Journal of Bodywork and Movement Therapies, Volume 14 (2010)

Journal of

Official journal of the: ® Association of Neuromuscular Therapists, Ireland ® Australian Pilates Method Association ® National Association of Myofascial Trigger Point Therapists, USA ® Pilates Foundation, UK

Volume 14 Issue 1 2010

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 John Hannon DC San Luis Obispo, CA, USA ( [email protected])

Dimitrios Kostopoulos PhD, DSc, PT Hands-on Physical Therapy, New York, NY, USA ([email protected])

Glenn M. Hymel EdD, LMT Department of Psychology, Loyola University, New Orleans, LA, USA ([email protected])

Craig Liebenson DC Los Angeles, CA, USA ([email protected])

ASSOCIATE EDITORS: PREVENTION & REHABILITATION Matt Wallden MSc, Ost, Med, DO, ND London, UK ([email protected])

Warrick McNeill MCSP London, UK ([email protected]) International Advisory Board D. Beales MD (Cirencester, UK) G. Bove DC, PhD (Kennebunkport, ME, USA) 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, NCTMB (Boulder, CO, USA) R. Schleip MA, PT (Munich, Germany) J. Sharkey MSc, NMT (Dublin, Ireland) D. G. Simons MD (Covington, GA, USA) D. Thompson LMP (Seattle, WA, USA) E. Wilson BA MCSP SRP (York, UK) A. Vleeming PhD (Rotterdam, The Netherlands)

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Journal of Bodywork & Movement Therapies (2010) 14, 1e2

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EDITORIAL

Has osteopathy a role to play in treatment of flu? H1N1 influenza (also referred to as swine flu)e for most people who contract it e is no more aggressive or dangerous than regular seasonal influenza. (CDC 2009) And yet for some the infection has proved fatal, with reports suggesting that the majority of fatalities, related to H1N1 infection, have occurred in individuals who are immune compromised, or who have serious secondary pathologies, including diabetes, liver and/or heart disease. Most fatalities occur when the infection moves from the standard influenza-like symptoms, to a severe acute respiratory syndrome (SARS), leading to pneumonia. This is a similar pattern to those who contracted Avian H5N1 influenza, several years ago. (MMWR 2003)

Osteopathic possibilities? The Spanish flu outbreak of 1918 was the first of its kind to have a variety of modern treatment approaches applied. These included osteopathic, naturopathic and chiropractic care, in addition to standard medical care. The U.S. Dept Health & Human Services lists three reasons why, at that time, standard medical care was ineffective. First, physicians mistakenly believed Pfeiffer’s bacillus (rather than a virus) was responsible, despite a lack of supportive scientific evidence. Secondly, masks were relied upon despite their ineffectiveness with viruses (masks CAN prevent bacterial spread). Lastly, although few physicians believed in miasmas and imbalances in the humours, their remedies derived from these theories. (U.S. Dept Health & Human Services 2009) Magoun (2004) has presented a well-documented approach to osteopathic care at that time e with implications for those who have influenza nowadays, whether regular seasonal, Avian H5N1, or the current model, H1N1. Magoun (2004) discusses osteopathic manipulative approaches: In the United States, more than 28% of the population succumbed (Kolata, 2001) In US military hospitals, the mortality rate averaged 36%, while the mortality rate in US medical hospitals fell between 30% and 40%, with the exception of a rate of 68% in medical hospitals in New York City. (Patterson 2000) . the American School of 1360-8592/$36 ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.09.001

Osteopathy, now the Kirksville College of Osteopathic Medicine . contacted all their alumni. This effort culminated in 2445 osteopaths responding in treating 110,122 patients with influenza, with a resulting mortality of 0.25%. One of the few osteopathic medical hospitals, 400- bed Massachusetts Osteopathic Hospital, in Boston, also reported a mortality of 0.25% for that period. (Walter 1992) Building on this historical evidence, Hruby & Hoffman (2007) note that, although there were no controlled studies (and no descriptive comparisons between MD and DO patients), osteopaths achieved a high success rate perhaps due to osteopathic manipulative therapy

What treatment did osteopaths use OMT (osteopathic manipulative treatment) comprised a series of modalities that attempted to enhance thoracic mobility and lymphatic drainage, as well as liver, spleen and abdominal function. Hruby & Hoffman have described the range of approaches used e not as a specific protocol, but, ‘‘as a listing of OMT procedures as a resource for use in an overall treatment plan for a given patient ... These include thoracic, hepatic, splenic, abdominal and pedal lymphatic pump procedures, as well as rib raising procedures. Also included are other OMT procedures that, although not thoroughly researched, have been clinically observed to provide similar effects. These procedures include soft tissue procedures, pectoral traction, mandibular drainage, frontal and maxillary lifts, and diaphragm doming .[as well as]., muscle energy techniques that can help to improve rib cage biomechanics.’’ Most such approaches would be familiar to osteopathic practitioners.

Belief It may be useful to reflect on the effects of the strong and widespread conviction, held by many osteopaths (and chiropractors) e that manipulative methods are capable of encouraging the self-regulating functions of the body e and how such convictions e(possibly more widely held in 1918

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Editorial

than 2010?) were able to translate to their flu-ridden patients? Paulus (2006) articulates this view when he says that the ‘‘quintessential goal’’ of the osteopath should be to: ‘‘diagnose the lack of motion and to help restore any quality of motion to the disordered region .. restoration of motion, not alignment of the musculoskeletal system, activates the therapeutic process that bring about healing.’’

Current evidence? Interestingly, although PubMed lists 956 H1N1 citations during the past six months, not one includes these keywords: manual therapy, lymphatic or even physical therapy. (PubMed, 2009) However recent research supports the possibility that general OMT is beneficial in enhancing immune function, particularly with respect to upper respiratory infections. For example:  Sleszynski and Kelso (1993) demonstrated that prevention of post surgical atelectasis, using osteopathic thoracic manipulation was just as successful as incentive spirometry  Jackson et al. (1998) found lymphatic and splenic pump techniques enhanced the antibody response to hepatitis B vaccination  Noll et al. (1999, 2000) provided clear evidence of the value of OMT in care of elderly hospitalized pneumonia patients. Manual methods were applied to elderly hospitalized patients with pneumonia, Hospital time was reduced from a mean of 8.6 days without OMT to 6.6 days for those receiving OMT. Additionally OMT patients required less intravenous antibiotics  Nicholas & Oleski (2002) Described a four-step protocol, composed of rib raising and treatment of the thoracic inlet, respiratory diaphragm, and pelvic diaphragm e for postoperative pain. ‘‘Patients who receive morphine preoperatively and OMT postoperatively tend to have less postoperative pain and require less intravenously administered morphine. In addition, OMT and relief of pain lead to decreased postoperative morbidity and mortality and increased patient satisfaction. Also, soft tissue manipulative techniques and thoracic pump techniques help to promote early ambulation and body movement.’’  Knott et al. (2005) demonstrated that osteopathic thoracic pump, and abdominal pump techniques, increased the flow of lymph through the thoracic ducts of mongrel dogs.

The potential value of such methods, applied in appropriate situations, alongside standard medical care, by osteopaths, physiotherapists, chiropractors, or other suitable trained therapists/practitioners, deserves further study, and not just in relation to H1N1.

References CDC, 2009. http://www.cdc.gov/h1n1flu/sick.htm (accessed 14. 09.09.). Hruby, R., Hoffman, K., 2007. Avian influenza: an osteopathic component to treatment. Osteopat Med Primary Care 1, 10. Jackson, K., et al., 1998. Effect of lymphatic and splenic pump techniques on the antibody response to hepatitis B vaccine: a pilot study. J. Am. Osteopath. Assoc. 98, 155e160. Knott, M., et al., 2005. Lymphatic pump treatments increase thoracic duct flow. J. Am. Osteopath. Assoc. 105, 447e456. Kolata, G., 2001. Flu e the Story of the Great Influenza Pandemic of 1918 and the Search for the Virus that Caused It. Simon & Schuster, New York. Magoun, H., 2004. More about the use of OMT during influenza epidemics. J Am Osteopathic Assoc 104 (10), 407. Morbidity & Mortality World Report, Mar 28, 2003. Outbreak of Severe Acute Respiratory SyndromedWorldwide. Centers for Disease Control. 52:241e246, 248. Nicholas, A., Oleski, S., 2002. J. Am. Osteopath. Assoc. 102 (Suppl. 3), S5eS8. Noll, D., et al., 1999. Adjunctive osteopathic manipulative treatment in the elderly hospitalized with pneumonia: a pilot study. J. Am. Osteopath. Assoc. 99, 143e152. Noll, D., et al., 2000. Benefits of osteopathic manipulative treatments for hospitalized elderly patients with pneumonia. J Am Osteopath Assoc. 100, 776e782. Patterson, M., 2000. Osteopathic methods and the great flu pandemic of 1917e1918. J. Am. Osteopathic. Assoc. 100, 309e310. Paulus, S., 2006. Concerning osteopathy: vital motions and material forms 2006. http://www.interlinea.org/ (viewed September 18, 2009). PubMed, 2009. http://www.ncbi.nlm.nih.gov/pubmed?termZ %28swineþORþH1N1%29þANDþ%28fluþORþinfluenzaþORþvirus þORþoutbreakþORþpandemic%29þANDþ%22lastþ6þmonths%22 [edat] (viewed September 16, 2009). Sleszynski, S.L., Kelso, A.F., 1993. Comparison of thoracic manipulation with incentive spirometry in preventing postoperative atelectasis. J. Am. Osteopathic. Assoc. 93, 834e838. 843e845. U.S. Dept Health & Human Services, 2009. http://1918.pandemicflu. gov/the_pandemic/03.htm (viewed September 16, 2009). Walter, G., 1992. The First School of Osteopathic Medicine. The Thomas Jefferson University Press at Northeast Missouri State University, Kirksville, Mo, p. 95.

Leon Chaitow New Medicine Group, 144 Harley Street, London W1, United Kingdom E-mail address: [email protected]

Journal of Bodywork & Movement Therapies (2010) 14, 3e12

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CLINICAL HYPOTHESIS

Fascia: A missing link in our understanding of the pathology of fibromyalgia Ginevra L. Liptan a,b,* a

Dept. of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, United States b Legacy Good Samaritan Pain Management Center, 1130 NW 22nd Ave, Suite 345, Portland, OR 97210, United States Received 26 January 2009; received in revised form 7 August 2009; accepted 11 August 2009

KEYWORDS Central sensitization; Myofascial release; Manual therapy; Inflammation; Connective tissue; Growth hormone

Summary Significant evidence exists for central sensitization in fibromyalgia, however the cause of this process in fibromyalgiadand how it relates to other known abnormalities in fibromyalgiadremains unclear. Central sensitization occurs when persistent nociceptive input leads to increased excitability in the dorsal horn neurons of the spinal cord. In this hyperexcited state, spinal cord neurons produce an enhanced responsiveness to noxious stimulation, and even to formerly innocuous stimulation. No definite evidence of muscle pathology in fibromyalgia has been found. However, there is some evidence for dysfunction of the intramuscular connective tissue, or fascia, in fibromyalgia. This paper proposes that inflammation of the fascia is the source of peripheral nociceptive input that leads to central sensitization in fibromyalgia. The fascial dysfunction is proposed to be due to inadequate growth hormone production and HPA axis dysfunction in fibromyalgia. Fascia is richly innervated, and the major cell of the fascia, the fibroblast, has been shown to secrete pro-inflammatory cytokines, particularly IL-6, in response to strain. Recent biopsy studies using immuno-histochemical staining techniques have found increased levels of collagen and inflammatory mediators in the connective tissue surrounding the muscle cells in fibromyalgia patients. The inflammation of the fascia is similar to that described in conditions such as plantar fasciitis and lateral epicondylitis, and may be better described as a dysfunctional healing response. This may explain why NSAIDs and oral steroids have not been found effective in fibromyalgia.

* Legacy Good Samaritan Pain Management Center, 1130, NW 22nd Ave, Suite 345, Portland, OR 97210, United States. Tel.: þ1 503 413 7513; fax: þ1 503 413 7503. E-mail address: [email protected] 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.08.003

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G.L. Liptan Inflammation and dysfunction of the fascia may lead to central sensitization in fibromyalgia. If this hypothesis is confirmed, it could significantly expand treatment options to include manual therapies directed at the fascia such as Rolfing and myofascial release, and direct further research on the peripheral pathology in fibromyalgia to the fascia. ª 2009 Elsevier Ltd. All rights reserved.

Introduction The etiology of fibromyalgiada disorder characterized by widespread muscle pain and tenderness at specific soft-tissue tender pointsdremains unclear. However, in the past decade evidence for abnormal pain processing in fibromyalgia has significantly advanced our understanding of this disorder. In 2002, a functional MRI study demonstrated that it took much less thumbnail pressure in fibromyalgia patients to activate the pain sensing areas of the brain compared to controls (Gracely et al., 2002). Another study found that fibromyalgia patients experienced stronger pain and larger areas of referred pain after intramuscular injection of hypertonic saline (Sorensen et al., 1998). Other research has shown abnormal temporal summation and wind-up of pain in fibromyalgia (Staud et al., 2004). These findings demonstrate that in fibromyalgia the central nervous system has an exaggerated response to pain, a phenomenon called central sensitization. Central sensitization is caused by repeated or sustained noxious input to the dorsal horn neurons leading to increased neuronal responsiveness or central sensitization. In fibromyalgia, however, no evidence of muscle pathology has been described, leading to speculation that the central sensitization in fibromyalgia may occur spontaneously though some as yet unknown mechanism (Ji et al., 2003). Others argue that myofascial trigger points cause the central sensitization in fibromyalgia (Staud, 2008). However recent biopsy studies have found increased levels of collagen and inflammatory mediators in the fascia of fibromyalgia patients. This paper proposes that dysfunction and inflammation of the intramuscular connective tissue, or fascia, leads to the central sensitization seen in fibromyalgia.

Central sensitization Central sensitization, a state of heightened sensitivity in the spinal cord, is thought to be a physiologic adaptation of the nervous system to sustained painful input. It is the end result of a complex neuronal response to peripheral nerve injury or tissue inflammation. Recent studies support an important role for dorsal horn glial cells (support cells for neurons) and NMDA receptors in producing abnormal pain sensitivity in the spinal cord (Watkins et al., 2001; Dickenson and Sullivan, 1987). In lab animals, central sensitization can be induced by injecting inflammatory chemicals into muscle, and by damaging peripheral nerves. Central sensitization has also been described in many chronic pain conditions, including endometriosis (Bajaj et al., 2003), peripheral arterial disease (Lang et al., 2006), and chronic low back pain (O’Neill et al., 2007). In these conditions there is a known source of persistent nociceptive input that keeps the CNS in a continued state of sensitization. One group showed that central sensitization associated with painful hip

osteoarthritis normalized following successful hip replacement surgery (Kosek and Ordeberg, 2000).

What causes central sensitization in fibromyalgia? Since patients with fibromyalgia complain of sore, painful muscles, investigators have long been searching for muscle pathology in fibromyalgia. These studies have included muscle biopsies with structural and ultra-structural observation, magnetic resonance imaging and metabolic studies, electromyography, and studies of blood flow and muscle strength. For the most part these studies have not shown consistent differences between healthy and fibromyalgia muscles. In Simm’s rigorous review of 32 studies of muscle in fibromyalgia he states ‘Although controversy persist, the weight of evidence from studies that are methodologically sound suggests that muscles are not abnormal’ (Simms, 1996). Others still argue that peripheral pain mechanisms must play an important role in fibromyalgia pain. ‘Central sensitization has to have an initial genesis and nociceptive stimuli from painful foci in muscle are increasingly recognized as being relevant to the development of fibromyalgia’ (Bennett, 2004). Supporting the idea that there are softtissue abnormalities in fibromyalgia is the distribution of pain, which is not uniform as one would expect if the pain was generated solely from a spontaneous central nervous system hypersensitivity, but is most prevalent in certain areas of the soft-tissue, especially the shoulders, chest, and lower back (Starz et al., 2008). The often observed worsening of fibromyalgia pain after an episode of muscle overuse also argues for a peripheral pathology in FM. Myofascial trigger points have been suggested as the peripheral source of painful input leading to central sensitization in fibromyalgia. Myofascial trigger points are discrete painful spots located in a palpable taut band of skeletal muscle, classified as active if they cause pain at rest, and latent if they are painful only with palpation (Simons et al., 1999). However, attributing the central sensitization seen in fibromyalgia solely to trigger points is problematic. Not all patients with fibromyalgia have trigger points, and not all patients with trigger points have fibromyalgia. One study found 68% of fibromyalgia patients had identifiable trigger points (Granges and Littlejohn, 1993), and another found trigger points in only 38% of fibromyalgia subjects examined (Wolfe et al., 1992). Myofascial trigger points are also quite commond33e54% of completely asymptomatic individuals have latent trigger points (Sola et al., 1955; Schiffman et al., 1990).

Background The symptoms of fibromyalgia have historically been described by many different terms, including ‘Chronic

Fascia: a missing link Rheumatism’ and ‘Muscular Rheumatism’. In a review article in 1904, Stockman described the symptoms of chronic rheumatism as ‘pain, aching, stiffness, a readiness to feel muscular fatigue, interference with free muscular movement, and very often a want of energy and vigour’ (Stockman, 1904). Chronic rheumatism was not thought by Stockman to affect the joints themselves, but rather the fibrous tissues structures of the muscles. He attributed chronic rheumatism primarily to infectious causes, particularly rheumatic fever and influenza, but also noted some cases with no infectious etiology. Stockman notes the work of Balfour and Scudamore, two British physicians who separately in the early 19th century put forward the idea that the pain of muscular rheumatism occurs as a result of thickenings developing in the fibrous connective tissue of muscle. Sir William Gowers attributed symptoms of muscular rheumatism to the ‘inflammation of fibrous tissue’, and proposed that the condition should be called ‘fibrositis’ (Gowers, 1904). Due to lack of evidence of peripheral inflammation, in 1976 the term ‘fibromyalgia’ was proposed, and ultimately adopted by the American College of Rheumatology when they released formal diagnostic criteria for the condition in 1990 (Wolfe et al., 1990). However the current terminology still reflects the concept of connective tissue abnormality in fibromyalgia, as the name is composed of the Latin words for fiber, muscle, and pain. Allopathic medicine has historically regarded fascia as relatively inert. According to a recent article in Science magazine ‘medical books barely mention fascia and anatomical displays remove it’ (Grimm, 2007). However in osteopathic medicine, the fascia has long been recognized as a potential cause of pain and soft-tissue dysfunction. As one osteopath writes ‘The whole of OMT [osteopathic manipulative treatment] has been concerned, purposefully or not, with manipulation of the fascia’ (Danto, 2003).

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Figure 1

Published with kind permission of Ron Thompson.

to its roles in regulation of inflammation and wound repair. Fibroblast activation is induced by various stimuli that occur with tissue injury. Activated fibroblasts isolated from the site of a healing wound will continue to secrete higher levels of ECM and proliferate more rapidly than fibroblasts obtained from normal tissue. Fibroblasts are also an important source of ECM degrading proteases, and have

Fascia Fascia is the dense connective tissue that envelopes muscles grossly, and also surrounds every bundle of muscle fibers and each individual muscle cell. This connective tissue is inextricably linked with the muscle, and is continuous with the tendons and periosteum (Figures 1 and 2). The fascia is composed of cellsdincluding fibroblasts, macrophages and mast cellsdand extracellular matrix. The extracellular matrix (ECM) is composed of ground substance and collagen and elastin fibers. Fascia is essentially a dense gel (the ground substance) in which cells and fibers are suspended, giving it colloidal properties. Fascia is richly innervatedda histological study found nerve fibers in all specimens of the deep fascia, including a variety of both free and encapsulated nerve endings, especially Ruffini and Pacini corpuscles (Stecco et al., 2006). In fact muscle innervation is primarily located in the fascia: consisting of 25 percent stretch receptors of muscle cells, and 75 percent free nerve endings in intramuscular fascia, and in the walls of blood vessels and tendons (Bonica, 1990). The principal cell of the connective tissue is the fibroblast, which produces the extracellular matrix, in addition

Figure 2 Structure of skeletal muscle, illustrating the layers of surrounding connective tissue known as the fascia, which includes the deep fascia, epimysium, perimysium and endomysium.

6 a crucial role in maintaining homeostasis and repair in the ECM (Kalluri and Zeisberg, 2006). Fascia has been demonstrated in vitro to have some contractile behavior. Some fibroblasts, called myofibroblasts, express alpha-smooth-muscle actin and are able to contract (Schleip et al., 2005, 2006). Increased expression of smooth-muscle actin is thought to be triggered by mechanical stimulation and inflammation in order to promote wound healing and tissue repair. Fibroblasts also respond to mechanical stretch with hyperplasia and secretion of inflammatory cytokines (Skutek et al., 2001). Using in vitro models, Dodd et al. demonstrated that fibroblasts respond to acyclic mechanical strain by altering shape and alignment, undergoing hyperplasia and secreting inflammatory cytokines, including IL-6 (Dodd et al., 2006). Fibroblasts have a vital role in the regulation of inflammation. Dysregulation of fibroblasts has been implicated in the chronic inflammation seen in rheumatoid arthritis. Synovial fibroblasts isolated from rheumatoid arthritis joints were found to secrete increased amounts of NF-kB, a transcription factor that ‘appears to play a critical role in perpetuating both tissue hyperplasia and the inflammatory response at sites of chronic inflammation’ (Miagkov et al., 1998; Buckley et al., 2001).

Fibrosis and adhesions One of the hallmarks of connective tissue, including fascia, is its mutability and remodeling in response to mechanical stress. However, under certain conditionsdexcess mechanical stress, inflammation or immobilitydthis process can result in excessive and disorganized collagen and matrix deposition resulting in fibrosis and adhesions (Langevin, 2008). In plantar fasciitis and tendinitis of the elbow these types of changes have been reported. Two series of surgical biopsies in patients with plantar fasciitis reported fascial thickening, collagen disorganization and increased fibroblasts. Jarde et al. (2003) in a report on 38 cases of plantar fasciitis noted ‘collagen degeneration with fibers losing their longitudinal arrangement and presenting with a haphazard orientation, with an increase in fibroblastic cellular density’. They also noted microcalcifications in the fascia of a few of the surgical specimens. The authors found that these lesions were similar to those found in cases of tendon injury. Tendons are essentially a denser version of intramuscular fascia with the same components of fibroblasts, collagen and extracellular matrix. According to a review of the histopathological changes found in lateral epicondylitis, the most common findings were hypertrophy of fibroblasts and abundant disorganized collagen (Kraushaar and Nirschl, 1999). A biopsy study of the thoracolumbar fascia in chronic mechanical low back pain found evidence suggestive of fascial inflammation, in particular degenerative changes in the collagen fibers and microcalcifications in the fascia (Bednar et al., 1995). In an ultrasound-based comparison, chronic low back pain patients had approximately 25% thicker perimuscular connective tissue in the

G.L. Liptan thoracolumbar fascia than healthy controls (Langevin et al., 2009). Eosinophilic fasciitis, a rare condition resulting in widespread eosinophilic infiltration and inflammation of the fascia results in significant fibrosis of the fascia. ‘Adhesions seen in eosinophilic fasciitis, which develops grossly thickened fascia and fibrosis are indicative of the potential for fascial inflammation to cause adhesions’ (Franklyn-Miller et al., 2009).

Evidence for fascial dysfunction in fibromyalgia When Stockman examined muscle biopsy studies of patients with ‘chronic rheumatism’ in 1904, he found inflammatory hyperplasia of the connective tissue. Specifically he described a section of inflamed perimysium which on light microscopic evaluation consisted of a ‘proliferated and oedematous fibrous tissue with an amorphous matrix’, leading him to conclude that ‘the essential pathological changes in chronic rheumatism are confined to white fibrous tissue’ (Stockman, 1904). However, Collins later examined Stockman’s published illustrations and noted ‘scarcely more variation in fibrous tissue structure than can be encountered normally in different situations in the human body’. Collins also examined 7 ‘typical fibrositic’ nodules under light microscopy and found no evidence of inflammation (Collins, 1940). Both of these early studies suffered from methodological flaws including lack of controls groups and poorly defined diagnostic criteria. More recent studies of FM muscle using standard histopathology techniques under light microscopy have not shown any consistent pathology (Lindh et al., 1995; Drewes et al., 1993). However one group described a ‘network of reticular fibers connecting muscle fibers’ causing a ‘rubberband like’ constriction of muscle fibers seen under light microscopy (Bartels and Danneskold-Samsoe, 1986). Electron microscopic studiesdwhich examine the myofibrils and sarcomeres that make up individual muscle cellsdhave also not shown any differences between fibromyalgia muscles and controls (Yunus et al., 1989a). While no consistent abnormalities have been found at either the ultrastructural or structural level of muscle cells using standard techniques, two recent studies using specialized immuno-histochemical staining techniques focused on the intramuscular connective tissue have discovered some intriguing abnormalities. Spaeth et al. describe an increase in collagen IV surrounding the muscles of fibromyalgia patients. Comparing immuno-stained muscle biopsies from 25 fibromyalgia patients to 26 healthy controls, they described a ‘slight, but significant increase in collagen surrounding the muscle cells of the fibromyalgia patients’ (Spaeth et al., 2005). Ruster et al. also found increased levels of collagen in the endomysium in fibromyalgia muscles, and in addition describe evidence for endomysial inflammation and tissue damage. Specifically, they note elevated levels of N-carboxymethyllsine (CML), an advanced glycation end-product (AGE) that is considered to be a marker of oxidative stress and tissue damage, in the fascia of fibromyalgia patients.

Fascia: a missing link ‘CML staining was stronger in the fibromyalgia patients, and was detected primarily in the interstitial tissue between the muscle fibers’ (emphasis added). They reported increased staining of collagen types I, II, and VI in the interstitial tissue compared to healthy subjects and found ‘the collagens and CML were co-localized, suggesting that the AGE modifications were related to collagen’. In addition, they found increased levels of CD-68 positive macrophages and activated NF-kB in the interstitial tissue of fibromyalgia muscles (Ruster et al., 2005). As described earlier, NF-kB is a transcription factor that plays an important role in the regulation of fibroblast hyperplasia and cytokine release, and high levels of NF-kB have also been reported in synovial fibroblasts from rheumatoid joints (Miagkov et al., 1998). This immuno-histochemical evidence is suggestive of fascial inflammation in fibromyalgia. As described earlier, focal fascial inflammation has been described in other conditions as plantar fasciitis and low back pain. Giesecke et al. found evidence for central sensitization in idiopathic chronic low back pain patients (Giesecke et al. 2004). Since local myofascial inflammation as described in chronic low back pain could be a trigger of central sensitization, it is possible that a more generalized fascial inflammation could lead to central sensitization as well. In fact peripheral afferent nociceptors of muscle, the majority of which reside in the fascia, have been shown to be highly effective at causing central sensitization (Wall and Woolf, 1984).

Growth hormone and sleep abnormalities Moldofsky was able to cause symptoms of fibromyalgiadwidespread muscle pain and fatiguedin healthy patients by depriving them of deep (slow-wave) sleep experimentally (Moldofsky and Scarisbrick, 1976). These symptoms resolved once subject were again allowed deep sleep. Sleep studies have demonstrated that fibromyalgia patients experience reduced deep sleep that is frequently interrupted with alpha-waves which are normally associated with states of wakefulness (Moldofsky et al., 1975). Growth hormone is primarily secreted during deep sleep and after exercise, and is responsible for regulating the healing and maintenance of tissues. Nearly 70% of total GH secretion occurs at night, and GH secretion ‘will not occur if sleep stage III or IV is prevented by awakening the subject’ (Felig et al., 1995). Reduced 24 h secretion of GH in FM has been reported, with the decrease most noticeable during the night when GH secreted in the patients was much lower than in controls (Leal-Cerro et al., 1999). Another group also found reduced GH secretion during sleep compared to controls (Landis et al., 2001). More than 90% of fibromyalgia patients have inadequate growth hormone response to exercise (Paiva et al., 2002) and one third have significantly low circulating IGF-1 levels (Bennett et al., 1992). Human growth hormone replacement in FM patients resulted in significant improvement of symptoms and reduction in tender points in one study (Bennett et al., 1998). Some of the clinical features of FM are similar to those described in adult GH deficiency syndrome including fatigue, muscle weakness, impaired exercise tolerance and

7 depression. Unlike FM, pain is not a major feature described in adult GH deficiency syndrome. However treatment with GH has been reported to improve pain levels in adult GH deficient patients (Cuneo et al., 1998). These conditions may not be directly comparable, however, because true adult GH deficiency is usually acquired due to pituitary damage and is generally accompanied by multiple other pituitary hormone deficiencies. In contrast, fibromyalgia patients have normal pituitary responses but have subtle alterations in hypothalamic control of growth hormone release (Leal-Cerro et al., 1999). Fibroblasts have growth hormone receptors, and in response to growth hormone secrete many important locally acting growth factors, such as IGF-1 (Murphy et al., 1983; Oakes et al., 1992). Fibroblasts play a central role in wound healing, and IGF-1 is a major physiological mediator of normal wound healing (Suh et al., 1992) A study of wound healing in rats revealed increased IGF-1 immunoreactivity in fibroblasts, epidermal cells and macrophages in the incisional area (Todorovic et al., 2008). Improved wound healing and increased staining for IGF-1 in healing tissue have been reported after administration of recombinant human growth hormone (Gilpin et al., 1994; Herndon et al., 1995). Local IGF-1 administration has also been found to improve wound healing (Suh et al., 1992; Beckert et al., 2007). An intriguing study of gamma-hydroxybutyrate, a medication known to increase slow wave sleep, was found to both increase growth hormone levels and improve wound healing in rats (Murphy et al., 2007). This medication has also shown benefit in recent human studies of patients with FM as well, and the improvements in sleep significantly correlated with improvements in pain scores (Russell et al., 2009).

Hypothesis Fascial dysfunction and inflammation may lead to the widespread pain and central sensitization seen in fibromyalgia. This paper proposes that the fascial dysfunction in fibromyalgia could be caused by chronic tension in the fascia and an impaired fascial healing response due to inadequate growth hormone stimulation. In genetically prone individuals, a trauma may trigger prolonged dysfunction of the stress response. This chronic autonomic arousal and hypervigilance may cause excess fascial tension, interfere with deep sleep and impair growth hormone release (Figure 3). There seems to be a genetic component to fibromyalgiadfirst-degree relatives of patients with fibromyalgia are 8.5 times more likely to have fibromyalgia than relatives of patients with rheumatoid arthritis (Arnold et al., 2004). An association between trauma and fibromyalgia has also been reported, with one study finding that ‘physical trauma in the preceding 6 months is significantly associated with the onset of FM’ (Al-Allaf et al., 2002). Hyperactivity of the stress response has also been described in fibromyalgia, with dysfunction of both hypothalamicepituitaryeadrenal axis and of the autonomic nervous system (Adler et al., 1999; Cohen et al., 2000). Hyperactivity of the HPA axis can also cause a blunted growth hormone response (Jones et al., 2007). Chronic sympathetic dominance of the nervous system may also promote chronic tension in the fascial system.

8

G.L. Liptan mechanical stress from daily activities, and thus have higher levels of fascial inflammation. The areas near muscle/tendon junctions are particularly susceptible to microinjuries from mechanical forces. In fact, six of the 18 tender points used to define the condition occur in or near areas of tendinous insertions, namely those at the suboccipital muscle insertions, near the epicondyles and at the medial fat pad of the knee (Figure 4a and b).

Anti-inflammatories in fibromyalgia If fascial inflammation exists in FM, why are non-steroidal anti-inflammatory medications (NSAID) and corticosteroids ineffective? No improvement in fibromyalgia symptoms was reported with prednisone 15 mg per day for two weeks, or with the NSAID medications ibuprofen and naproxen (Clark et al., 1985; Goldenberg et al., 1986; Yunus et al., 1989b). This paper argues that there is indeed fascial inflammation in fibromyalgia, but that it is a type of inflammation that is not responsive to oral NSAIDs or corticosteroids. The fascial inflammation proposed to exist in fibromyalgia is similar to that described in chronic overuse injuries such as lateral epicondylitis and plantar fasciitis. This inflammation is attributed to cumulative microtrauma that overwhelms the tissue’s ability to repair itself, resulting in a chronic inflammatory reaction that may be more appropriately termed a ‘dysfunctional healing response’. The response to injury of connective tissue, including fascia, ligaments and tendons, occurs in three phases (Kumar, 1999).

Figure 3 Proposed etiology of central sensitization in fibromyalgia.

1) Inflammatory phasedinvasion of polymorphonuclear cells and monocytes/macrophages, and release of prostaglandin and cytokines 2) Proliferative phasedfibroblasts activated to produce collagen and extracellular matrix that is laid down in disorganized fashion 3) Remodeling phasedprogressive maturation and alignment of collagen fibers and remodeling of extracellular matrix

Fascia has recently been shown to be able to have significant contractile force in vitro, and this fascial contractility is though to contribute to the incredible feats of strength humans can perform in emergenciesdsituations in which the sympathetic nervous system is also dominant (Schleip et al., 2005; Schleip et al., 2006). In response to chronic excess fascial tension, fibroblasts would likely overproduce collagen and extracellular matrix in a continuous attempt to respond to the increased mechanical stress. However due to inadequate growth hormone stimulation of fibroblast there may be an impaired fascial healing response resulting in chronic fascial inflammation; there is ‘a critical role for fibroblasts in regulating the switch from acute to chronic inflammation in tissues’ (Buckley et al., 2001). This widespread dysfunctional fascial healing response could be considered a ‘bodywide fasciitis’ as compared to the more focal fasciitis seen in other conditions such as plantar fasciitis. The tender points of fibromyalgia may reflect areas that suffer the greatest microtrauma and

The anti-inflammatory effect of NSAIDs is due to their interference with prostaglandin production, thus they are effective in the initial inflammatory phase of injury repair. NSAIDs have been shown to be helpful in decreasing pain and swelling in acute soft-tissue injuries, but not in chronic soft-tissue inflammation (Heere, 1987). A randomized controlled trial of NSAIDs in plantar fasciitis found that both placebo and NSAID group improved over time, and there was no statistical difference between the groups at 1, 2 or 6 months (Donley et al., 2007). Another randomized controlled study found no difference between placebo and NSAID treatment in chronic achilles tendinopathy (Astrom and Westlin, 1992). Local corticosteroid injections have shown effectiveness in overuse injuries but this effect tends to be short-lived. A randomized controlled trial of steroid injections in plantar fasciitis found a statistically significant pain reduction at 1 month in the treatment group that had disappeared by 3 months post treatment (Crawford et al., 1999). In lateral epicondylitis steroid injections also provide

Fascia: a missing link

Figure 4

9

a and b: 18 tender points of fibromyalgia as established by 1990 ACR criteria (Wolfe et al., 1990).

only temporary improvement, and ‘the significant shortterm benefits of corticosteroid injections are paradoxically reversed after six weeks with high recurrence rates’ (Bissett et al., 2006). In an animal model of chronic muscle inflammation created by injecting inflammatory stimulants into the hamstrings of mice, neither NSAIDs nor high-dose oral corticosteroids were effective in reducing inflammation. The inflammation could only be reduced by local corticosteroid injection directly into the muscle (Green and Mangan, 1980). Notably, while NSAIDs and oral steroids have been tested in FM, the effectiveness of local steroid injections in FM has not been assessed. NSAIDs and corticosteroids are not only ineffective in relieving chronic soft-tissue inflammation but may actually hinder the healing process. Two studies reported slowed muscle repair in animals treated with an NSAID (Obremsky et al., 1994; Almekinders and Gilbert, 1986). Indomethacin added to repetitively stretched fibroblasts in vitro reduced the secretion of prostaglandins but also inhibited the synthesis of DNA, an effect that may be detrimental in the remodeling phase of repair (Almekinders et al., 1995). Corticosteroids are also notorious for impairing surgical wound healing (Suh et al., 1992). Thus NSAIDs and corticosteroids may actually worsen an already dysfunctional tissue repair response in fibromyalgia.

Manual therapy in fibromyalgia treatment In 1904 Stockman recognized the potential of manual therapy in treating chronic rheumatism (what is now called fibromyalgia) and noted that ‘indurated fibrous tissue can

however only be removed by local and well-directed manipulations’ (Stockman, 1904). This idea was reiterated recently by a leading fascia researcher, ‘Treatments involving direct mechanical stimulation of connective tissue can potentially reverse connective tissue fibrosis’ (Langevin, 2008). Myofascial fibrotic changes can theoretically be treated by breaking up excessive collagen adhesions through soft-tissue and myofascial release techniques (Ward, 2003). If there is excess tension in the fascial system in fibromyalgia due to chronic sympathetic nervous dominance, manual therapy may also help reduce that tension. A randomized controlled pilot study demonstrated that osteopathic manipulative treatment (OMT), in conjunction with medication, was more effective in relieving symptoms of fibromyalgia than medication alone (Gamber et al., 2002). A total of 24 patients were included in the study, and the treatment group received once weekly OMT sessions for 23 weeks. The control group received either moist heat packs at each visit or no additional treatment beyond their usual medications. The osteopathic manipulative techniques used in this study were individualized for each patient, so it is difficult to assess how much treatment directed specifically at the fascia that each patient received. Each patient received Jones strain/counterstrain techniques and other modalities per provider discretiondincluding myofascial release, muscle energy, softtissue treatment and craniosacral manipulation. A Swedish study on connective tissue massage in fibromyalgia found a pain-relieving benefit of 37% in addition to reduced use of analgesics and positive effects on quality of life. The treatment group consisted of 23 patients who received 15 treatments over 10 weeks, while the control

10 group participated in weekly discussion groups. The connective tissue massage is described as a ‘manual techniques to detach dense connective tissue’, but no further description of the technique is provided. Interestingly, this treatment was chosen for the study because ‘experienced massage therapists who were surveyed prefer connective tissue massage for the treatment of individuals with fibromyalgia’ (Brattberg, 1999). However, for manual therapies to be effective in fibromyalgia, they must take into account the colloidal properties of fascia, and according to Chaitow and DeLany ‘the amount of resistance colloids offer increases proportionally to the velocity of force applied to them. This makes a gentle touch a fundamental requirement . when attempting to produce a change in, or release of restricted fascial structures which are all colloidal in their behavior’ (Chaitow and DeLany, 2000). Therefore, only slow and sustained pressure will effect changes in the fascial tissue. Appropriate manual therapy must allow for the state of reduced growth hormone and thus reduced capacity for tissue repair in fibromyalgia by allowing for sufficient rest between sessions. Utilizing the growing body of knowledge on the properties of fascia can help manual therapists treat fibromyalgia patients with techniques that don’t cause further injury and inflammation, but rather gently break apart existing fascial restrictions and adhesions and promote tissue healing.

Conclusion This paper presents the hypothesis that fascial dysfunction in fibromyalgia leads to widespread pain and central sensitization. Using other known abnormalities in fibromyalgia, a proposed mechanism leading to fascial dysfunction in fibromyalgia is described. The in vivo microdialysis techniques developed by Shah’s group to assess myofascial trigger points could also be used to evaluate the chemical composition of fascial interstitial fluid for evidence of inflammation (Shah et al., 2005). In vitro examination of fibroblasts removed from fascial tissues in fibromyalgia could look for evidence of activation, such as excess secretion of extracellular matrix and inflammatory mediators. Comparing fascial IGF-1 levels in fibromyalgia to controls may also be useful. Finally, clinical studies of manual therapies that target the fascia, like Rolfing and myofascial release, could help define the role of fascia in producing fibromyalgia pain. Directly comparing a therapy aimed at releasing fascial restriction such as myofascial release to a massage therapy that focuses primarily on muscle relaxation would be informative. If there is clinical improvement with manual therapies targeting the fascia, this could significantly improve our ability to treat fibromyalgia, and guide further research on the peripheral pathology of fibromyalgia towards the fascia.

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Journal of Bodywork & Movement Therapies (2010) 14, 13e18

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APPLIED PHYSIOLOGY

Skin distraction at select landmarks on the spine midline in the upright and fully flexed postures Paul J. Moga, D.O., Ph.D Post Office Box 4088, Ann Arbor, Michigan 48106e4088, USA Received 31 January 2008; received in revised form 13 March 2008; accepted 28 April 2008

KEYWORDS Skin distraction; Spinal motion; Spinal angles; Hamstring tightness; Fascia; Manual medicine; Spine

Summary Background: This study was aimed at quantifying superoinferior and mediolateral skin distraction over the spine’s midline for the purpose of designing a unique surface marker for use in a study originally proposed by Wojtys and Ashton-Miller. It was also aimed at testing the null hypotheses H01: There is no difference in the amount of skin distraction between hamstring normal and hamstring tight subjects and H02: There are no age or gender differences of skin distraction. Methods: Nine male and twelve female volunteers served as the convenience subjects for this IRB-approved study. Eight subjects were classified as hamstring ‘‘tight’’ (short) using the Finger-to-Floor Reach Test. Skin distraction was measured at five spine midline landmarks palpated on the subjects’ bared backs: T1, T10, L3, S1, and the posterioresuperior iliac spine (PSIS). A pattern of four dots was placed at each landmark using a rectangular template and non-toxic, water-soluble ink. Measurements were taken between superoinferior and mediolateral pairs of template points with subjects in both upright (‘‘initial’’) and fully flexed (‘‘final’’) postures. Between-measurement differences were then calculated, expressed as percent strain, and pooled for mean percent strain values. Repeated measures produced a maximum strain error of about 1.7%. Results: With the exception of the skin over the T10 landmark, distraction in the superoinferior direction was greater than that in the mediolateral direction. There were no significant differences in skin distraction between age or gender groups. However, hamstring short males had significantly smaller superoinferior skin distraction at L3 than their hamstring normal counterparts [35% (5.2) vs. 46% (4.6), pZ0.049), while hamstring short females had a smaller mean mediolateral distraction at the same level that approached significance [2.5% (2.5) vs. 7.6% (5.4), pZ0.080). At this landmark, there was a moderately strong, inverse correlation (rZ 0.720) between mediolateral percent strain and reach distance in hamstring tight subjects. Conclusion: In general, superoinferior percent strain increased and mediolateral percent strain decreased from thoracic to sacral regions, likely reflecting the relative increase in spine segment motion from thoracic to lumbar region. The larger mean mediolateral

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14

P.J. Moga distraction at the T10 level was probably the result of traction on the skin at that level by the dependence of appendicular structures in forward flexion. Finally, the negative value at the T1 landmark was probably the result of the cervical spine extension that occurred during flexion as the subjects lifted their heads to look up. ª 2008 Elsevier Ltd. All rights reserved.

Introduction The accuracy of the spine angle measurements based on skin surface markers depends on the marker’s ability to withstand skin distraction during subject movement, as this movement may introduce error (e.g., Vanneuville et al., 1994). Quantification of such movement is therefore essential to surface marker design. Because such information is lacking in the literature, a small study was performed to answer two questions: first, how much does the skin distract over the midline of the spine at select landmarks and second, are there significant differences in the amount of distraction between landmarks? The answers to these questions would be incorporated into the design of a unique surface marker for use in an optoelectronic study (Moga, 2002) that compared the spine angles of subjects who were hamstring normal (able to touch the ground in sagittal plane flexion) and hamstring short (unable to touch the ground in sagittal plane flexion). In keeping with the hamstring category comparison, the following null hypotheses were advanced:

Primary null hypothesis

methods measure the angle between two lines that demarcate the spine segment of interest. In the Cobb technique (1948), the most cephalad vertebra of the spine segment of interest is demarcated by a line tangential to its superior endplate. The most caudad vertebra of the same spine segment is similarly marked by a tangent to its inferior endplate. The angle between the two tangents at their intersection represents the spine segment angle (Figure 1). In Ferguson’s method (1949), the intersecting lines of the spine segment are based on three centroids, rather than two vertebral endplates. Centroids are points ‘‘at the geometric center of a polygon’’, which ‘‘.can be used to represent a polygon as a point’’ (Gregory, 2002). In this case, the polygon is the vertebral body or centrum. The vertebrae selected are at the cephalad aspect, the apex, and the caudad aspect of the spine segment of interest (Figure 2). Centroids are determined as the intersection of two lines drawn on each vertebral body from a corner to the opposite corner. Then two lines are drawn, one from the cephalad vertebral centroid to that of the apical vertebra, and the other from the caudad vertebral centroid to that of the apical vertebra. As in the Cobb method, the angle between the intersection of two lines represents the spine segment angle.

H01: There is no difference in the amount of skin distraction between hamstring normal and hamstring short subjects. It was expected that hamstring short subjects would have less skin distraction than hamstring normal subjects, which would reflect a reduced flexion range of motion.

Secondary null hypothesis H02: There are no age or gender differences of skin distraction.

Background There are primarily two approaches used to determine spine segment angles: contact and non-contact. The contact approach requires the application of goniometric measuring devices directly to the skin over palpated landmarks. These devices include Loebl’s pendulum goniometer (1967); Debrunner’s kyphometer (1972), and Willner’s pantograph (1981). The non-contact approach may be subdivided into two basic categories: radiographic and non-radiographic. The radiographic approach utilizes X-ray exposure to identify specific vertebral landmarks. The angles between these landmarks are then determined generally by using either the Cobb or, less commonly, the Ferguson method. Both

Figure 1 Cobb method (after Riseborough and Herndon, 1975) angle q, representing the angle of the spine segment, is measured as the angle between tangents to vertebral endplates (image ª Paul John Moga, 2002).

Skin distraction at select landmarks on the spine midline

15

Figure 3 Balsa template horizontal base: 2.8 cm1.8 cm 0.6 cm; vertical stanchion: 4.4 cm1.2 cm0.6 cm; image ª Paul John Moga, 2002. Figure 2 Ferguson method angle q, representing the angle of the spine segment, is measured as the angle between centroidbased lines (image ª Paul John Moga, 2002).

Non-radiographic, non-contact techniques used to measure spine segment angles include photogrammetric methods that mitigate the need for X-ray exposure. Like contact goniometric methods, non-radiographic techniques generally require both demarcation and labeling of spine segment landmarks. However, rather than relying on radiographic landmarks, surface-mounted markers are placed at manually palpated structures that define spine segment endpoints. Once the spine segment is defined, techniques similar to those of Cobb and Ferguson may be used to determine the spine angle. A modification of the Ferguson method was used in the photogrammetric method as described by Wojtys et al. (2000). In that study, flat, adhesive markers were placed on the skin’s surface at either end of the spine segment of interest. A test platform having cameras with photographic axes perpendicular to the plane of the subjects’ backs was used. A custom software program was developed to measure spine angles from the photographs as the angle of intersection between lines tangential to the skin’s surface landmarks. A modification of the Cobb method was utilized in the optoelectronic method as described by Moga (2002). In that study, specially designed platform markers were positioned on the skin over select spine landmarks at either end of the spine segment of interest. A commercially available, electronic videographic system having camera axes parallel to the skin surface was used to record marker position. Using the system’s software, spine angles were then calculated as the intersection of the angles between lines perpendicular to the skin’s surface, as demarcated by the skin markers’ perpendicular arms. At least one problem exists with the use of surfacemounted markersdDo the markers accurately reflect the position of bony landmarks? Authors such as Thurston and

Harris (1983) or Stokes et al. (1987) have shown that the error between skin mounted targets and true skeletal motion ranges from 8% to 10%. Leroux, et al. (2000) determined correlation coefficients of 0.94 and 0.91 for kyphosis and lordosis, respectively, between radiographic Cobb measurements and ‘‘spatial localization’’ of markers placed superficial to spinous processes. Troup et al. (1968) obtained correlation coefficients of 0.91 between surface marker and X-ray spine angles for erect and fully flexed postures for 14 observations, with no significant differences between the methods (Student’s t-test, p<0.001). Despite the strong correlation and similar marker system, they observed that ‘‘displacements of the skin in the long axis of the spine. proved to be considerable’’, and added that such displacement was a particular source of errors, especially in the lumbar region. Skin markers utilized at the lumbar area are less reliable, primarily because of soft tissue thickness (Willner, 1981; Bryant et al., 1989). When using non-radiographic methods, special care must be taken when placing surface markers at this region, as the thickness of the superficial tissues can affect marker position relative to the bony reference point. So, skin surface motion must be incorporated into a marker’s design. If not, the marker’s base may be dislodged during torso movement. Also, the protrusion of vertebral spinous processes during torso flexion must be considered,

Table 1 Landmark

T1 T10 L3 S1 PSIS

Mean percent strain at various spine landmarks. Superoinferior

Mediolateral

Mean

s.d.

Mean

s.d.

3.7 10.7 41.7 49.7 53.9

13.1 10.2 7.1 9.7 11.8

0.0 20.5 6.1 1.6 0.1

6.1 10.2 6.5 6.3 4.9

s.d.Zstandard deviation. Note: mean length % strain increases from T1 to S1.

16

P.J. Moga

Table 2 Mean differences of percent strain between landmark points. Superoinferior T1eT10 T10eL3 L3eS1 S1ePSIS

14.4 31 8 4.2

Mediolateral 20.5 14.4 4.5 1.5

groups. Repetition of the measurements produced an error which, with the exception of two outliers, ranged from an underestimation of 1.5 mm to an overestimation of the initial value by 1.5 mm. The mean error was an underestimation of 0.07 mm. This measurement error, similar to that found by van Weeren and Barneveld (1986), was propagated as a maximum strain error of approximately 1.7%.

Results lest the perpendicular orientation of the markers’ vertical arm relative to the skin’s surface be affected. In this event, the result would be inaccurate spine angle measurements.

Methods Nine male and twelve female (nZ21) volunteers served as the subjects for this Human Use Committee-approved study. They had no gross kyphoscoliosis, a mean age of 26.9 (10.5) years, a mean height of 1.73(0.09) m, and a mean weight of 67.68(9.71) kg. Approximately one-half exhibited hamstring tightness (shortness) by the Finger-to-Floor Reach Test. Skin distraction was measured at five landmark points on each subject’s bared back. These points were the first and the tenth thoracic vertebrae (T1, T10), the third lumbar vertebra (L3), the first sacral segment (S1), and the posterior-superior iliac spine (PSIS). The skin over these landmark points was marked using non-toxic, water-soluble ink. Four dots were placed in a rectangular pattern at each corner of a balsa wood template (Figure 3). Distraction over the each landmark site was determined by comparing the distances between two pairs of points measured with subjects in two positions. The four skin surface dots were paired as superoinferior and mediolateral template points. The two postures were upright and fully flexed positions. Each participant was asked to flex (bend forward) in the sagittal plane to the best of his or her ability. Each set of measurements were then repeated and averaged. The differences between the initial and final measurements at all landmark points for each subject were calculated and expressed as percent strain, with mean strains calculated for both hamstring normal and hamstring short

Figure 4 Superoinferior skin surface strain by gender (image courtesy of L.J. Huston, MSE).

Mean superoinferior and mediolateral percent strains for each spine landmark are listed in Table 1. With the exception of the skin over the T10 landmark, distraction in the superoinferior direction was greater than that in the mediolateral direction. In the superoinferior direction, percent strain ranged from 3.7% at T1 to 53.9% at the PSIS landmark. The negative value at the T1 landmark was likely the result of cervical spine extension that may have occurred during flexion as the subjects lifted their heads to look up. Mean percent strain differences between adjacent landmarks are displayed in Table 2. The greatest change in superoinferior strain was between the T10 and L3 levels, and was more than twice that of the T1 T10 difference. The greatest difference in mediolateral strain was between T1 and T10, almost twice that of T10 L3. These findings were exhibited by both gender groups (Figures 4 and 5). Independent groups’ t-tests were then used to compare the means of the skin distraction percent strains at the various landmarks between hamstring normal and hamstring short subjects. There were no significant differences of percent strains between the two groups (calculated t-test statistic valueZ0.1140; pZ0.88, using two-tailed distribution for heteroscedastic samples with a set at the 0.05 level of significance). However, after dividing the subjects according to gender, t-tests revealed a significant difference of superoinferior percent strain at the L3 landmark between hamstring groups for males (calculated t-test statistic valueZ2.8000; pZ0.049) and a difference that approached significance (calculated t-test statistic valueZ1.9519; pZ0.080) of the mediolateral percent strain at the L3 landmark between hamstring groups for females (Table 3). Although no inferential analysis was done to determine its statistical significance, there was a moderately strong, inverse correlation (Pearson

Figure 5 Mediolateral skin surface strain by gender (image courtesy of L.J. Huston, MSE).

Skin distraction at select landmarks on the spine midline

17

Table 3 Skin distraction (mean percent strain) at l3 for hamstring normal and Hamstring short subjects, along with calculated independent groups t-test statistic values and p-values. Hamstring normal

Females Mediolateral n Males Superoinferior n

Hamstring Tight

Statistical value

p-value

2.51

1.9519

0.080

5.18

2.8000

0.049

Mean

s.d.

Mean

s.d.

7.62 7

5.42

2.49 5

46.33 3

4.61

35.12 3

s.d.Zstandard deviation.

rZ 0.720) between mediolateral percent strain and reach distance in hamstring short subjects at this landmark. These findings led to the failure to reject the first null hypothesis. The data were then examined for significant differences of skin distraction by age and between genders. Subjects were divided into two age groupsdunder 30 years old and over 30 years old (Table 4). Contrary to what was expected, there were no significant differences of percent strains between age groups (calculated t-test statistic valueZ0.0531; pZ0.94). Nor were there significant differences of percent strains between genders (calculated t-test statistic valueZ0.1609; pZ0.84), even though males were significantly taller and heavier than females (Table 5). These findings led to the failure to reject the second null hypothesis.

Discussion How did skin distraction in the two directions compare? At every spine landmark level, with the exception of T10, mean skin distraction in the superoinferior direction was greater than mean distraction in the mediolateral direction. The superoinferior strains increased consistently from cephalad to caudad along the spine, with the greatest mean distraction over the PSIS and S1 (53.9% and 49.7% strain, respectively). Although it is speculation, the 4% difference in strain over PSIS and S1 may reflect an anatomic relationship of these landmarks and the lumbodorsal fascia. Grossly, fascial fiber direction at PSIS appears to be more parallel with that of the Latissimus dorsi, and, because of that relation, may be more susceptible to the distraction when the back is stretched and the upper limbs are dependent in the flexed posture. In contrast, load over the pre-S1 fascia may be more symmetrical (along the midline), and the fascia might be more fixed over that landmark point.

The increase of the skin’s percent strain from thoracic spine (about 11% over T10) to lumbar spine (about 42% at L3) was in keeping with each segment’s relative contribution to overall flexion range of motion (6 of flexion at T9 10 vs. about 16 at L3 4 (White and Panjabi, 1978 in Nordin and Frankel, 1989). Mean mediolateral strains diminished from T10 to PSIS. A larger mean mediolateral distraction at the T10 level may have been the result of traction on the skin by the dependence of osseous and soft tissue structures in forward flexion, such as the upper extremities, shoulder girdle, and breast tissue. Tissue dependence was likely also the explanation for the large difference in mediolateral strain between T1 and T10. How did the differences of percent strain from landmark to landmark compare? There was a pronounced difference in mean superoinferior strain between the T10 and L3 landmarks. This likely reflected the greater flexion range of motion of the superior lumbar spine as compared to the inferior thoracic spine, which, of course, is relatively fixed due to costal attachments. The greater flexion range of motion may also be the explanation for the moderately strong inverse correlation between reach distance and mediolateral distraction at L3 in hamstring short subjects. These results have some clinical implications. As distraction was determined over boney prominences and not muscle, it is likely that distraction occurred in the skin and subdermal tissues. The increase of superoinferior distraction in a cephalocaudad manner corresponds to the increase in sagittal plane, flexion range of motion of the spine from the thoracic to the lumbar region. Skin distraction was greatest at the lumbosacral regiondwhere the distal spine range of motion is at its peak. The study design prohibits any cause-and-effect conclusions. However, it may be possible that the converse of these findings is truedthat motion restrictions in these same soft Table 5

Mean weight and height for females and males. Weight (kg)

Table 4 Mean ages of subjects grouped as over 30 years and under 30 years of age.

<30 years >30 years

Mean years

s.d.

n

23.72 46.00

2.82 19.92

18 3

s.d.Zstandard deviation.

Females Males p-value

Height (m)

n

Mean

s.d.

Mean

s.d.

61.51 75.91 0.000

4.70 8.50

1.67 1.81 0.000

0.06 0.06

12 9

s.d.Zstandard deviation. Males were significantly larger than females.

18 tissues may impair overall flexion range. The findings of a significantly smaller distraction in hamstring-short subjects lend support to this notion. In addition, it has already been demonstrated that tissues such as the lumbodorsal fascia contribute to load transfer in the lower trunk (Vleeming et al., 1995). Because of the functional importance of these soft tissues, manual treatment of the low back and pelvis must go beyond boney and articular somatic dysfunction or subluxation. It must address not only muscle tightness issues (e.g., Hamstrings, Latissimus, Gluteal group), but should include treatment of the more superficial, soft tissue structures, such as the lumbodorsal fascia as well.

Conclusions Several important findings resulted from this small study. Quantification of the relative amounts of skin distraction at several landmark points along the human spine’s midline in sagittal plane flexion helped to augment the current knowledge base. From thoracic to sacral regions, superoinferior percent strain was found to increase in sagittal plane flexion, in keeping with the spine’s ‘‘stretching’’ while bending forward. Mediolateral percent strain was found to decrease, which was thought to be the result of an approximation of paravertebral tissue that became prominent during flexion. Another finding was that hamstring normal subjects who were able to touch the floor in a Finger-to-Floor Reach Test had significantly larger superoinferior and mediolateral skin distraction changes than hamstring short individuals, or those unable to touch the floor in sagittal plane flexion. This finding was believed to reflect the restricted lumbopelvic flexion that has been shown to occur in hamstring short subjects (Gajdosik et al., 1994).

Disclosures This project was part of a larger study sponsored in part by a Grant from the Orthopedic Research and Education Foundation, Rosemont, IL, USA.

Acknowledgments The author would like to thank University of Michigan faculty Drs. E.W. Wojtys and J.A. Ashton-Miller for their support during the data collection phase of this work, and Laura Huston, M.S.E., for her assistance.

References Bryant, J.T., Reid, J.G., Smith, B.L., Stevensen, J.M., 1989. Method for determining vertebral body positions in the sagittal plane using skin markers. Spine 14 (3), 258e265.

P.J. Moga Cobb, J.R., 1948. Outline for the study of scoliosis. AAOS Instructional Course Lecture 5, 261e275. Debrunner, H.U., 1972. The kyphometer (German). Zeitschrift fuer Orthopaedic und Ihre Grenzgebiete 110 (3), 389e392. Ferguson, A.B., 1949. Roentgen diagnosis of the extremities and spine. In: Annals of Roentgenology: A Series of Monographic Atlases, vol. XVII, second ed. Paul B. Hoeber, Inc., NY, pp. 364e365. Gajdosik, R.L., Albert, C.R., Mitman, J.J., 1994. Influence of hamstring length on the standing position and flexion range of motion of the pelvic angle, lumbar angle, and thoracic angle. Journal of Orthopaedic and Sports Physical Therapy 20 (4), 213e219. Gregory, I., 2002. A place in history: a guide to using geographical information systems in historical research. In: Arts and Humanities Data Service Guides to Good Practice. University of Essex, Colchester, UK. Leroux, M.A., Zabjek, K., Simard, G., Badeux, J., Coillard, C., Rivard, C.H., 2000. A noninvasive anthropometric technique for measuring kyphosis and lordosis: an application for idiopathic scoliosis. Spine 25 (13), 1689e1694. Loebl, W.Y., 1967. Measurements of spinal posture and range of spinal movements. Annals of Physical Medicine 9, 103e110. Moga, P.J., 2002. On the relation between thoracic kyphosis, athletic training, hamstring shortness, and anthropometry in the developing spine. Doctoral Dissertation, University of Michigan, Ann Arbor, MI. Nordin, N., Frankel, V.H., 1989. Basic Biomechanics of the Musculoskeletal System. Lea and Febiger, Philadelphia. Riseborough, E.J., Herndon, J.H., 1975. Scoliosis and other Deformities of the Axial Skeleton. Little, Brown, Boston. Stokes, I.A., Bevins, T.M., Lunn, R.A., 1987. Back surface curvature and measurement of lumbar spinal motion. Spine 12 (4), 355e361. Thurston, A.J., Harris, J.D., 1983. Normal kinematics of the lumbar spine and pelvis. Spine 8 (2), 199e205. Troup, J.D.G., Hood, C.A., Chapman, A.E., 1968. Measurement of the sagittal mobility of the lumbar spine and hips. Annals of Physical Medicine 9, 308e321. van Weeren, P.R., Barneveld, A., 1986. A technique to quantify skin displacement in the walking horse. Journal of Biomechanics 19 (10), 879e883. Vanneuville, G., Kyndt, T., Massaux, M., Harmand, Y., Garcier, J.M., Monnet, J.P., Guillot, M., Cluzel, P., Escande, G., Poumarat, G., 1994. Preliminary opto-electronic study on vertebral movement. Surgical and Radiologic Anatomy 16 (4), 385e391. Vleeming, A., Pool-Goudzwaard, A.L., Stoeckart, R., van Wingerden, J.P., Snijders, C.J., 1995. The posterior layer of the thoracolumbar fascia. Its function in load transfer from spine to legs. Spine 20 (7), 753e758. White, A.A., Panjabi, M.M., 1978. Clinical Biomechanics of the Spine. J.B. Lippincott, Philadelphia. Willner, S., 1981. Spinal pantographda noninvasive technique for describing kyphosis and lordosis in the thoracolumbar spine. Acta Orthopedica Scandinavica 52, 525e529. Wojtys, E.M., Ashton-Miller, J.A., Huston, L.J., Moga, P.J., 2000. The association between athletic training time and the sagittal curvature of the immature spine. American Journal of Sports Medicine 28 (4), 490e498.

Journal of Bodywork & Movement Therapies (2010) 14, 19e26

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INVESTIGATIVE STUDY: HUMAN PHYSIOLOGY

Relationship between hand-grip isometric strength and isokinetic moment data of the shoulder stabilisers Dimitris Mandalidis, PT, Ph.D.*, Moira O’Brien, FRCPI Department of Anatomy, Trinity College Dublin, Dublin 2, Ireland Received 4 March 2008; received in revised form 1 May 2008; accepted 2 May 2008

KEYWORDS Hand grip; Isokinetic strength; Shoulder musculature

Summary The purpose of this study was to examine the relationship between hand-grip (HG) isometric strength and isokinetic moment of the shoulder musculature in 18 healthy male volunteers. HG isometric strength at 0 , 90 and 180 of shoulder flexion and isokinetic peak and average concentric moments of the shoulder rotators and abductors and the elbow flexors at 60 s1 were measured on both the dominant and non-dominant sides. Pearson correlation coefficients revealed statistically significant positive relationships between HG isometric strength and isokinetic moments of the shoulder external rotators (rZ0.40e0.54), the shoulder abductors (rZ0.42e0.71) and the elbow flexors (rZ0.45e0.66) regardless of hand dominance. The positive relationships between HG isometric strength and isokinetic strength of the shoulder stabilisers was probably attributed to mechanisms providing stability to the elbow and shoulder joints either by force transmission via myotendinous and myofascial pathways or by ‘‘overflow’’ of muscular activity via neural circuits. The results of the present findings suggested that HG isometric strength can be used to monitor isokinetic strength of certain muscle groups contributing to the stability of the shoulder joint; however, HG strength may account only for approximately 16e50% of the variability in isokinetic strength of these muscle groups. ª 2008 Elsevier Ltd. All rights reserved.

Introduction

* Corresponding author at: Avlonos 41-104 43, Athens, Hellas, Greece. Tel.: þ30 3201 51122344. E-mail address: [email protected] (D. Mandalidis).

Strength improvement of the shoulder’s muscles is a major goal of every rehabilitation exercise programme concerning functional restoration of the injured shoulder as it plays a significant role in the stability of the shoulder joint. Constant monitoring of such changes enables clinicians to

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20 modify the preventive/rehabilitation exercise programme whenever it is required and assist them, at least in part, in decision making regarding patients’ return to previous athletic or working activities. The increased use of isokinetic dynamometers over the last few years has provided more accurate and reliable information regarding the functional status of the shoulder musculature than other tools, such as manual muscle testing, strain gauges, and hand held dynamometers (Mandalidis et al., 2001a, b; Mandalidis and O’Brien, 2001). However, factors such as (i) the low availability of isokinetic dynamometers probably due to the high cost of these devices, (ii) the high level of proficiency, as far as the testing procedure is concerned, which is required by the examiner, (iii) the high motivation which is necessary by the examinee, and (iv) the fact that isokinetic testing procedures, particularly those concerning the shoulder musculature, are time consuming, make isokinetic strength assessments of the shoulder impractical if not difficult. Furthermore, in order to ensure adequate stabilisation of the joint and to avoid articular range limitations and pain inhibition of the shoulder musculature, many authors have performed isokinetic assessment of the shoulder several months after surgical repair (Walker et al., 1987; Walmsley and Hartsell, 1992; Leroux et al., 1994). These restrictions prevent postoperative evaluation of the shoulder’s isokinetic strength for several months after surgery. Hand-grip (HG) dynamometry, a relatively inexpensive, simple and clinically useful method that has been mainly used in the evaluation of hand’s functional capacity, has also been utilised by several authors as a valid estimate of total upper limb strength (Bohannon, 1998; Adams et al., 2004), as well as total body’s (Niebuhr and Marion, 1990), back extensors (Sinaki, 1989) and pulmonary muscles strength (Sahin et al., 2004). Its validity in relation to the total upper limb strength has been determined based on the significant correlations revealed between HG strength measurements and manual muscle testing of specific shoulder, elbow and hand muscles (Bohannon, 1998) and self-report of upper limb functional assessments (Adams et al., 2004), in elderly people receiving home care (Bohannon, 1998) and in patients suffering injuries (Goldman et al., 1991), chronic stroke (Boissy et al., 1999) and early rheumatoid arthritis (Adams et al., 2004). No such correlation has been established between HG strength and isokinetic moment data of the shoulder stabilisers. The purpose of this study was to investigate the relationship between HG isometric strength and isokinetic moment of the shoulder rotators, shoulder abductors and elbow flexors in a healthy male population.

Methods Subjects HG isometric strength and isokinetic concentric moments of the shoulder rotators, shoulder abductors and elbow flexors of both dominant and non-dominant upper extremity were measured in a convenience sample of 18 collegiate-level male athletes. All individuals were invited and agreed to participate in the study after they read and signed an

D. Mandalidis, M. O’Brien informed consent form. Subjects with shoulder pathology or present shoulder/neck pain were excluded from the study. The mean and standard deviation of age, body mass, and height were 25.74.8 years, 78.410.0 kg and 1.80.1 m, respectively. Fifteen volunteers were right and three were left handed. Appropriate ethical approval granted prior to the study.

HG strength measurements HG strength measurements of both dominant and nondominant side were performed prior to isokinetic assessment with each subject standing, the shoulder at 0 , 90 , and 180 of flexion (see Figure 1aec), and the elbow in full extension using a standard HG dynamometer (Lafayette Instruments, Lafayette IN, US). The arm was halfway between internal and external rotation of the shoulder (the palm was facing towards the body) and the elbow was extended. The opening of the handle was adjusted prior to testing so that the crease of the proximal interphalangeal joints of the subject rested on top of the adjustable handle allowing 90 of flexion. Each volunteer was instructed to perform one submaximum and one near maximum effort attempt for warm up following by three attempts of maximum efforts, squeezing the handle of the instrument as hard as possible. Before each attempt the indicator needle of the instrument was set at the zero mark. Fifteen to twenty seconds rest was allowed between each attempt. One-minute break was the interval between testing of the dominant and nondominant hand. The best of the three maximum efforts was used in the statistical analysis. In order to avoid bias, hand dominance and arm position (0 , 90 , and 180 of flexion) were randomly assigned.

Isokinetic strength measurements Gravity corrected peak and average concentric moments of the dominant and non-dominant internal and external rotators and abductors of the shoulder as well as the flexors of the dominant and non-dominant elbow were measured using a Kin Com II dynamometer (Chattecx Corporation Chattanooga, TN, USA) at 60 s1. The internal and external rotators of the shoulder were measured between 0 (horizontal level) and 60 of external rotation with each subject seated upright with the arm at 45 of abduction and 30 of horizontal adduction (scapular plane). The elbow was set at 90 of flexion and the forearm was pronated (see Figure 2). Isokinetic testing of the shoulder abductors was performed between 30 and 90 of shoulder elevation with each volunteer seated and set at an angle of 30 anterior to the frontal plane (scapular plane), so that the scapular plane was parallel to the plane of rotation of the dynamometer’s actuator arm. The elbow was in extension and the forearm in pronation (see Figure 3). Isokinetic strength of elbow flexion was tested over a range of 60 (20e80 of elbow flexion) with each volunteer seated and strapped onto a chair with the arm placed at 90 of forward flexion and the forearm midway between supination and pronation (see Figure 4). Stabilisation of the subject’s trunk and body part under investigation as well as proper alignment between

Relationship between hand-grip isometric strength and isokinetic moment data of the shoulder stabilisers

Figure 1

21

Subject’s positioning for hand-grip isometric strength assessment at 0 (a), 90 (b), and 180 (c) of shoulder flexion.

the biological and motor centres of rotation was performed according to the isokinetic testing procedures described in previous studies (Mandalidis et al., 2001a, b; Mandalidis and O’Brien, 2001). A 10-min warm up which was consisted of 5-min arm cranking on an arm cycle ergometer at a low work load and 5-min of specific mobility and stretching exercises of the shoulders, performed by each subject before each testing session. Familiarisation with the isokinetic device was achieved by allowing each subject to perform three submaximum concentric actions, with at least one of the action at/or near maximum effort. After 1-min rest, each volunteer performed three maximum intermittent concentric actions (20-s interval between actions). An attempt was deleted if the volunteer reported a lack of effort or if a significant difference was observed on the screen between two consecutive torque curves. In this case, an

additional attempt was allowed. Five minutes break was allowed between each side tested. To minimise learning effects and bias due to fatigue, the order of limb dominance (dominant, non-dominant side) and muscle group tested (shoulder internal and external rotators, shoulder abductors and elbow flexors) was randomly assigned. No verbal encouragement was given and no visual feedback from the screen was allowed during isokinetic testing. All isokinetic testing procedures were considered reliable based on the ICC values calculated in previous studies (Mandalidis et al., 2001a, b; Mandalidis and O’Brien, 2001).

Statistical analysis The relationship between HG tests and isokinetic measurements was examined using the one-tailed Pearson

22

D. Mandalidis, M. O’Brien productemoment correlation coefficients (r). The coefficient of determination was presented as a percentage of r2.

Results

Figure 2 Subject’s positioning for isokinetic strength assessment of the internal and external rotators of the shoulder.

Grip strength of the dominant hand was not statistically significant greater than grip strength of the non-dominant hand measured at 0 (46.37.0 kg vs. 45.57.5 kg), 90 (42.76.3 kg vs. 41.76.6 kg), and 180 of shoulder flexion (47.06.5 kg vs. 42.96.6 kg). HG strength development was also greater when the shoulder was at 180 compared with 0 and 90 of shoulder flexion; however, the differences were also not statistically significant either for the dominant or the non-dominant side. The mean and standard deviation of isokinetic moment data of the shoulder internal and external rotators, shoulder abductors and elbow flexors of both dominant and non-dominant side are listed in Table 1. Pearson correlation coefficients between HG strength and isokinetic average and peak moments of the shoulder internal and external rotators, shoulder abductors and elbow flexors ranged between 0.06 and 0.62 (Table 2) for the dominant and between 0.28 and 0.71 for the nondominant upper extremity (Table 3). However, HG strength was statistically significant related only with isokinetic moments of the shoulder external rotators, the shoulder abductors and the elbow flexors (see Tables 2 and 3 for levels of statistically significant relationships). In general, better relationships were obtained between HG strength and average moments compared with peak moments and between isometric HG strength and isokinetic strength of the shoulder abductors compared with shoulder external rotators and elbow flexors. The majority of the correlation coefficients were also greater when isokinetic moments were related with HG measured at 90 and 180 of shoulder flexion compared with 0 , for both the dominant and nondominant side.

Discussion The findings of our study revealed a statistically significant positive correlation between HG force measured at 0 , 90 , and 180 of shoulder flexion and isokinetic average and

Figure 3 Subject’s positioning for isokinetic strength assessment of the abductors of the shoulder.

Figure 4 Subject’s positioning for isokinetic strength assessment of the elbow flexors.

Relationship between hand-grip isometric strength and isokinetic moment data of the shoulder stabilisers Table 1 Means and standard deviations (in brackets) of isokinetic average and peak concentric moment (N m) of dominant (D) and non-dominant (ND) shoulder internal and external rotators (SIR, SER), shoulder abductors (SAB), and elbow flexors (EF), nZ18. Average moment D SIR SER SAB EF

35.1 24.0 54.2 44.6

Peak moment

ND (7.4) (4.9) (7.9) (10.1)

33.2 23.1 52.2 43.0

D (9.1) (4.3) (8.4) (6.9)

ND

39.2 27.8 59.3 51.1

(8.2) (5.8) (9.4) (11.9)

36.8 27.2 57.2 48.6

(4.5) (10.2) (10.2) (7.5)

peak moments of the shoulder external rotators (rZ0.40e 0.54), shoulder abductors (rZ0.42e0.71), and elbow flexors (rZ0.45e0.66) for the dominant and non-dominant side. Similar relationships have been reported in a previous study between dynamometer-measured HG and manually tested strength of the shoulder abductors (rZ0.57 and 0.72 for the right- and left-hand side, respectively) and elbow flexors (rZ0.58 for the right- and rZ0.54 for the left-hand side) in a group of 37 home-care patients with a mean age of 78 years (Bohannon, 1998). The relationship between HG strength and isokinetic moment of the shoulder stabilisers can partly be explained based on the mechanism by which an efficient action of the muscles that act at a distal joint can be performed only when the proximal joint or joints to it are also efficiently stabilised by the surrounding musculature. HG is a dynamic task which requires a delicate and efficient action of the majority of the extrinsic muscles of the hand and wrist aided by some intrinsic muscles of the hand (Long et al., 1970). The closure of the fingers around an object, such as the handle of the dynamometer that was used in our study, is performed by the long flexors of the fingers in association with the extensors of the wrist (Smith et al., 1996; Johanson et al., 1998). The contribution of the wrist extensors to the development of isometric strength during HG, however, is of great importance as these muscles stabilise the wrist in extension opposing the action of the long finger flexors to move the joint into flexion (Smith et al., 1996). Johanson et al. (1998) have reported that apart from a high EMG activity the long flexors of the fingers (flexor digitorum supeficialis and profundus), the majority of the forearm muscles (extensor carpi radialis longus and brevis, the extensor carpi ulnaris, the extensor digitorum communis and the brachioradialis) were also active during power grip in

23

order probably to position and stabilise the carpal, midcarpal and metacarpophalangial joints of the hand. The forces developed by these muscles during HG may further be transmitted to the more proximally located areas both via myotendinous and myofascial pathways providing stability to the elbow and shoulder joints. Force transmission via the myotendinous pathway is enabled by the proximal tendinous attachments of the long extensors and flexors of the wrist onto the humerus. It may also be possible via myofascial sequences formed by muscle fibres that are inserted into the overlying fascia and septa, and fascial components. According to the Fascia Manipulation model that proposed by Stecco (2004), there are six such sequences that are arranged in the upper limb according to the three spatial planes. Three of these myofascial sequences, the antemotion, the mediomotion and the intra-rotation sequence are located in the anterior portion of the upper limb and literally connect the palmar muscles and fascia of the hand with those of the shoulder. The antemotion myofascial sequence distally begins with the muscles and fascia of the thenar eminence and continues with the flexor carpi ulnaris muscle and the biceps brachii, via the bicipital aponeurosis, which provides continuity between the anterior antebrachial and brachial fasciae. The brachial fascia, in turn, continues proximally with the fascia of the pectoralis major. The mediomotion sequence connects the hypothenar muscles, the flexor carpi ulnaris muscle, the medial intermuscular septum and coracobrachialis muscle. The intra-rotation sequence begins with the lumbricals, which are inserted into the tendons of the flexor digitorum profundus, and continues with the pronator teres, medial intermuscular septa and subscapularis. Recent anatomical studies, which revealed numerous tendinous insertions from the muscles of the arm and forearm onto the deep fascia of the upper limb, supported Stecco’s model (Stecco et al., 2007, 2009). Based on these findings the bicipital aponeurosis is merged with the antebrachial fascia and the palmaris longus is inserted into the palmar fascia and, via tendinous expansions, is connected with the fascia overlying the thenar eminence muscles. The pectoralis major fascia also is connected with the anterior brachial fascia (via a clavicular expansion), and the medial brachial fascia and the medial intermascular septum (via a costal expansion). Stecco et al. (2007, 2009) have also shown that at the posterior aspect of the upper limb the fascia of the latissimus dorsi is connected with the triceps brachii fascia via a fibrous lamina. The triceps tendon is inserted partially into the antebrachial fascia and the extensor carpi ulnaris sent a tendinous expansion to the

Table 2 Pearson correlation coefficients (r) and percentages of the coefficients of determination (r2) between hand-grip strength (HG) at 0 , 90 , and 180 of shoulder flexion and concentric average and peak moment (in brackets) of the shoulder internal and external rotators (SIR, SER), shoulder abductors (SAB), and elbow flexors (EF) of the dominant side. SIR HG-0 HG-90 HG-180 a b

SER 2

SAB 2

EF 2

R

%r

r

%r

r

%r

0.27 (0.21) 0.29 (0.23) 0.12 (0.06)

7.3 (4.4) 8.4 (5.3) 1.4 (0.4)

0.53b (0.43b) 0.54b (0.45b) 0.41b (0.36)

28.1 (18.5) 29.2 (20.3) 16.8 (13.0)

0.59a (0.58b) 0.62a (0.62a) 0.56a (0.55a)

34.8 (33.6) 38.4 (38.4) 31.4 (30.3)

p<0.01. p< 0.05 (nZ18).

r

%r2

0.45b (0.47b) 0.51b (0.52b) 0.37 (0.38)

20.3 (22.1) 26.0 (27.0) 13.7 (14.4)

24

D. Mandalidis, M. O’Brien

Table 3 Pearson correlation coefficients (r) and percentages of the coefficients of determination (r2) between hand-grip strength (HG) at 0 , 90 , and 180 of shoulder flexion and concentric average and peak moment (in brackets) of the shoulder internal and external rotators (SIR, SER), shoulder abductors (SAB), and elbow flexors (EF) of the non-dominant side. SIR HG-0 HG-90 HG-180

SER

SAB

EF

r

%r2

r

%r2

r

%r2

r

%r2

0.29 (0.28) 0.34 (0.34) 0.37 (0.36)

8.4 (7.8) 11.6 (11.6) 13.7 (13.0)

0.45c (0.39) 0.33 (0.28) 0.40c (0.43c)

20.3 (15.2) 10.9 (7.8) 16.0 (18.5)

0.50c (0.42c) 0.61b (0.52c) 0.71a (0.69a)

25.0 (17.6) 37.2 (27.0) 50.4 (47.6)

0.52c (0.56b) 0.52c (0.54c) 0.66b (0.64b)

27.0 (31.4) 27.0 (29.2) 43.6 (41.0)

a

p<0.001. p<0.01. c p<0.05 (nZ18). b

fascia of the hypothenar muscles). These anatomical findings confirmed also, at least in part, the Anatomy Trains Model introduced by Myers (1997b), by which force transmission may be possible via two myofascial chainsd‘‘train lines’’dthat run in the front and the back of the upper limb connecting the proximal with its more distal regions. Myers’ concept (1997a) was based on the ontogeny and disposition of the fascial net during its embryonic development by which is constituted one large and unified organ that allows constant transmission of tension and compression forces throughout the human structure. Force may also be transmitted towards the proximally located regions of the upper limb, along a myofascial pathway that permits force transmission between the sarcomeres and the endomysium (Huijing, 2003). Experimental animal studies have shown that force that originates (at least in part) from the endomysium, not from the sarcomeres in series, as a result of its counteraction to the shortening of the active or passive sarcomeres, may be transferred within a muscle, either longitudinally or onto neighbouring fascicles and then to the epimysium (intramuscular force transmission) (Huijing, 2003). Force may further be transmitted between the intramuscular connective tissue of a muscle and the extramuscular connective tissues, such as the fascia that constitutes the boundaries within a compartment (extramuscular force transmission), and between intramuscular layers of connective tissue of two adjacent muscles within a muscle group (intermuscular force transmission) (Huijing, 2003). However, it should be noted that myofascial force transmission was explored in these experimental laboratory studies under contractions of extremely lengthened muscles (Huijing and Baan, 2003; Maas et al., 2001) and therefore should be distinguished from the force that may be transmitted along a myofascial pathway under maximum muscular contractions that performed by a living individual. Furthermore, the relationship between HG and isokinetic moment of the shoulder and elbow musculature may be explained based on the mechanism by which muscular activity is ‘‘overflowed’’ to muscles beyond the essential prime movers or synergists that take part in a particular movement. Carey et al. (1983) using the term muscular or excitation overflow to describe this mechanism reported that, among other muscles, the EMG activity of the biceps brachii was increased during precision HG. Sporrong et al. (1995, 1996, 1998) have also shown an increased EMG activity of the supraspinatus and infraspinatus during intermittent 30e50% of maximum HG force production and

during light manual precision work particularly when the shoulder and the elbow joints were in various degrees of flexion. This mechanism is probably mediated by neural circuits located in the spinal cord and in cortical and subcortical areas of the central nervous system which increase the neural drive to agonists and synergists muscle in order to execute a specific task more effectively (Carroll et al., 2006). The better relationship between HG strength obtained at 90 and 180 compared with 0 of shoulder flexion and isokinetic moment of the shoulder external rotators, the shoulder abductors and the elbow flexors was probably attributed to the dynamic state of the entire upper limb when HG was performed with the shoulder in elevation. Shoulder flexion requires the action of the primary movers (anterior part of the deltoid) as well as the contribution of the rotator cuff muscles (infraspinatus and teres minor) and the long head of the biceps brachii (shoulder abductor and elbow flexor) in order to provide dynamic stability to the joint (Sigholm et al., 1984; Kronberg et al., 1990; Sakurai et al., 1998). The muscles around the elbow should also contract in order to maintain the joint fully extended. It has been proposed that muscle contraction during flexion of the upper limb may stretch the continuity of the myofascial structures located anterior to it, allowing more effective force transmission via myofascial pathways (Stecco et al., 2007a, b), resulting probably in a better relationship between HG and shoulder muscle’s strength. Correlation coefficients in this study were calculated between HG strength and both average and peak isokinetic moment of the shoulder stabilisers. Average moment in isokinetic dynamometry is a measure of muscle strength that is equal to the sum of moment values obtained at every sampling point of a specific range of motion divided by the number of points. Peak moment, on the other hand is the highest moment that is produced by a muscle group at a single point in this range. Many authors have recommended the use of average instead of peak moment because it is more reliable (Mandalidis et al., 2001a, b) and it is less affected by artefacts usually occurring during isokinetic assessment of muscles operating on heavy segments like the shoulder joint (Dvir, 1995). The present findings suggested that the average isokinetic moment of the shoulder stabilisers, not the peak, may be reflected more accurately with HG as the majority of correlation coefficients were greater when HG was related with average instead of peak isokinetic moment.

Relationship between hand-grip isometric strength and isokinetic moment data of the shoulder stabilisers The lack of consistency regarding the positions used for HG and shoulder isokinetic testing was one of the limitations of our study. HG strength has been measured by several authors in a wide variety of positions in order to assess whether its level can be influenced by the position of the individual under investigation and the position of the shoulder and elbow joints (Richards, 1997; Su et al., 1994; Balogun et al., 1991). In our study, HG was assessed in the standing position with the elbow fully extended as previous studies revealed that isometric strength of the HG in this position was greater compared with either standing or sitting position with the elbow at 90 of flexion (Balogun et al., 1991). Isokinetic testing, particularly of the shoulder rotators and abductors, has also been carried out in several different positions, revealing different moment outputs (Soderberg and Blaschak, 1987). Internal and external rotation of the shoulder in the present study was assessed at 45 of abduction in the scapular plane. Shoulder abductors were also assessed in the scapular plane. Rathbun and Macnab (1970) in a previous study have shown that when the shoulder is abducted the vascularity of the supraspinatus tendon is enhanced. Anatomical and biomechanical data have also revealed that when arm movements are performed in the scapular plane the stresses placed on the anterior capsuloligamentous structures are lower, the impingement of the greater tuberosity under the acromion is prevented, better congruency between the articular surfaces of the glenohumeral joint is provided and optimum lengthetension relationship of the rotator cuff muscles is achieved (Johnston, 1937; Greenfield et al., 1990; Kuhlman et al., 1992). Furthermore, previous studies have shown good reliability of the isokinetic testing procedures of all the muscle groups tested (Mandalidis et al., 2001a, b; Mandalidis and O’Brien, 2001). The range of HG isometric strength or isokinetic strength of the shoulder stabilisers may also have affected the correlation coefficients calculated in the present study and therefore the obtained relationships were limited to the study group. It is known that if a correlation exists between two variables, restricting the range of either of the variables will reduce the correlation (Pagano, 1994). The participants in the present study were healthy males between 17 and 35 years of age with a range of HG strength between 29.0 and 60.5 kg. This range was narrower compared with the range reported by Mathiowetz et al. (1985) for a healthy male population 20e94 years of age (12.2e79.8 kg). Therefore, the participants in our study should be considered as a subgroup and although the correlation coefficients calculated were considered acceptable for biological studies (Pagano, 1994) they could be greater if the study group was more representative of the general healthy male population.

Conclusions The findings of the present study revealed a statistical positive correlation between HG isometric strength and isokinetic moment produced by the shoulder external rotators and abductors and the elbow flexors. It is suggested that HG isometric strength measurements could be used to monitor strength levels of the shoulder stabilisers.

25

However, HG isometric strength should be treated with caution as an indicator of shoulder muscles’ strength as it accounts only for a 16.0e29.2% of the variability in isokinetic strength of the shoulder external rotators, a 17.6e 50.4% of the variability in isokinetic strength of shoulder abductors and a 20.3e43.6% of the variability in isokinetic strength of the elbow flexors regardless of hand dominance.

Conflict of interest All authors deny any conflicts of interest including personal, financial, or other related to the submitted manuscript entitled ‘‘Relationship between HG isometric strength and isokinetic moment data of the shoulder stabilizers’’.

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26 Kuhlman, J., Iannotti, J., Kelly, M., Riegler, F., Gevaert, M., Ergin, T., 1992. Isokinetic and isometric measurement of strength of external rotation and abduction of the shoulder. Journal of Bone and Joint Surgery 749, 1320e1333. Leroux, J., Codine, P., Thomas, E., Pocholle, M., Mailhe, D., Blotman, F., 1994. Isokinetic evaluation of rotational strength in normal shoulder and shoulders with impingement syndrome. Clinical Orthopaedics 304, 108e115. Long II, C., Conrad, P., Hall, E., Furler, S., 1970. Intrinsiceextrinsic muscle control of the hand in power grip and precision handling: an electromyographic study. Journal of Bone and Joint Surgery 52, 853e867. Maas, H., Baan, G., Huijing, P., 2001. Intermascular interaction via myofascial force transmission: effects of tibialis anterior and extensor digitorum longus length on force transmission from rat extensor digitorum longus muscle. Journal of Biomechanics 34, 927e940. Mandalidis, D.G., O’ Brien, M., 2001. Isokinetic strength of the elbow flexors with the forearm in supination and in the neutral position. Isokinetics and Exercise Science 9, 111e117. Mandalidis, D., O’ Reagan, M., Donne, B., O’ Brien, M., 2001. Reliability of isokinetic shoulder rotation in the scapular plane. Isokinetics and Exercise Science 9, 65e72. Mandalidis, D., O’ Reagan, M., Donne, B., O’ Brien, M., 2001. Effect of transient moment-oscillations on the reliability of isokinetic shoulder elevation in the scapular plane. Isokinetics and Exercise Science 9, 101e109. Mathiowetz, V., Kashman, N., Volland, G., Weber, K., Dowe, M., Rogers, S., 1985. Grip and pinch strength: normative data for adults. Archives of Physical Medicine and Rehabilitation 66, 69e72. Myers, T., 1997a. The anatomy trains. Journal of Bodywork and Movement Therapies 1, 134e145. Myers, T., 1997b. The anatomy trains: part 2. Journal of Bodywork and Movement Therapies 1, 91e101. Niebuhr, B., Marion, R., 1990. Voluntary control of submaximal grip strength. American Journal of Physical Medicine and Rehabilitation 69, 96e101. Pagano, R.R., 1994. Understanding Statistics in the Behavioural Sciences. West Publishing Company, Minneapolis, St. Paul. 149pp. Rathbun, J., Macnab, I., 1970. The microvascular pattern of the rotator cuff. The Journal of Bone and Joint Surgery 52B, 540e 553. Richards, L., 1997. Posture effects on grip strength. Archives of Physical Medicine and Rehabilitation 78, 1154e1156. Sahin, G., Ulubas, B., Calikoglu, M., Erdogan, C., 2004. Handgrip strength, pulmonary function tests, and pulmonary muscle strength in fibromyalgia syndrome: is there any relationship? South Medical Journal 97, 25e29.

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Journal of Bodywork & Movement Therapies (2010) 14, 27e34

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CLINICAL FASCIA RESEARCH

Changes in the structure of collagen distribution in the skin caused by a manual technique Helga Pohl, Ph.D.* Centre for Bodytherapy, Tassiloweg 2, D 82319 Starnberg, Germany Received 15 March 2008; received in revised form 1 June 2008; accepted 3 June 2008

KEYWORDS Functional disorders; Connective tissue; Collagen dermis; Manual treatment; Ultrasound study; Treatment effects

Summary Objective: When treating patients with functional disorders using a special manual technique, tissue changes can be felt by the therapist and the patient. This study was conducted to objectively document these changes. Method: In the author’s practice for body therapy, 30 patients were measured with highfrequency ultrasound (22 MHz) immediately before and after their first treatment in the area where they experienced pain or other discomfort and/or movement restriction. Results: Highly significant differences can be seen in the structure of the collagen matrix in the dermis before and after treatment. These changes reflect the differences in tension, softness and regularity, which can be palpated before and after treatment and are thought to be caused by changes in the mechanical forces of fibroblasts and increased microcirculation. ª 2008 Elsevier Ltd. All rights reserved.

Background In the author’s practice for body therapy, patients who mainly have chronic complaints that are referred to by the author as sensory motor disorders are treated. This means patients have unpleasant sensations such as chronic pain, nausea, dizziness, anxiety, depression, numbness, tingling, globus pharynges, burning feet, etc. At the same time they have movement disorders such as restriction, stiffness, instability, cramps, sudden weakness, voice disorders, speech disorders, restless legs, etc. The majority of these

* Tel.: þ49 8151 78171; fax: þ49 8151 3743. E-mail address: [email protected]

patients suffer from chronic pain and movement restriction and have several complaints. Their disturbances are often called functional, psychosomatic, neurogenic, or agerelated disorders. It is usually assumed that there is no bodily source for these complaints or it exists only in the central nervous system, or that it involves degeneration of the bones. From the clinical experience of the author, these disorders originate from the surface of the body. There is always a bodily basis of these disorders that can be found in the muscles, muscle fasciae (e.g. trigger points) or in the connective tissue of the skin. These changes can be palpated, and observed. Patients can pinpoint the site of their discomfort (for example anxiety at the front of their ribcage) although they may feel this discomfort as coming

1360-8592/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2008.06.001

28 from within. A movement restriction (in breathing, for example) can be seen where patients show their complaints, and more often than not also a dimpling in the skin. Structural changes in the muscles, in muscle fasciae, or in the skin can commonly be palpated at these locations. Besides the changes in the area of their complaints, patients may have patterns of heightened tension in other surface areas throughout their body, of which they may be completely unaware prior to treatment. For treatment of all these bodily changes, Sensory Motor Bodytherapy was used, which consists of several hands-on techniques, movement, and body awareness trainingdcombined with treating heightened tonus in muscles and connective tissue, thereby changing sensory impressions, movement, and posture. One of the manual techniques employed is a treatment of the connective tissue of the skin using rolling and pressing movements of the fingers (Figure 1). This is not the common technique of skin rolling over large areas of skin. Rather, treatment is carried out in a very localised area, going back and forth in all directions with a pressing and squeezing of the connective tissue between the thumb and the index finger and then moving to the next small area only a few millimetres distant from the first one. After a short while, treatment is repeated at the first location. Via this method, the tissue is thoroughly worked through, 1 mm after the other (Figure 2). At the beginning of the treatment, the afflicted area of the skin feels hard, firm, and cold to the therapist. The skin is not easy to move in this area and it has an irregular structure. Skin fold thickness is greater. For the patient it feels (very) painful when treating the afflicted area and the pressure used during treatment is perceived to be very strong. Patients regularly overestimate the power of the pressure. The same pressure used in a healthy area is estimated as being much less. In addition, treatment is not painful in non-afflicted areasdthere seems to be oversensitivity to pressure in the affected area. After a few minutes of treatment, the therapist feels the tissue becoming softer, warmer, and easier to move. A skin fold becomes thinner. This relaxation response is often very abrupt, from one moment to the next. At the moment of relaxation, patients report treatment to be less painful and sense the pressure as markedly reduced. Oversensitivity seems to have disappeared and this is when treatment at this site is considered complete. Immediately after treatment, the patient feels the treated area as warm and more alive and as having lost the previous pain or discomfort. In the treated area, a reddening can be seen and sometimes a little swelling without other signs of lasting oedema. There is also a larger range of movement along with more stability in movement in this area.

H. Pohl

Figure 1

Treatment of the connective tissue of the skin.

Subjects Thirty patients who came for body therapy, 16 females, 14 males, 23e80 years old. The mean age was 52 years.

Criteria for inclusion The afflicted area was easy to measure and had no trigger points or muscle tenderness under pressure.

Treatment Patients were treated in the area of one of their complaints. Treatment lasted for 4e29 min with an average of 14 min.

Method A Minhorst Collagenosonª was used for measurement. This is a high-resolution high-frequency ultrasound (22 MHz),

Method In a first step to objectively document the immediate changes caused by the treatment of the connective tissue of the skin, we conducted an ultrasound study.

Figure 2

Ultrasound measurement with Collagenoson.

Changes in the structure of collagen structure

Figure 3

29

Distribution of collagen in afflicted areas before treatment.

Figure 3 shows four examples of the measurements obtained before treatment. In general, the distribution of bundles of collagen fibrils can always be seen as a picture BZbrightness scan and

a diagram AZamplitude scan. The latter shows the curve of summed collagen density in the various layers of the skin. The following characteristics of normal skin can be seen in all our subjects: On the left side of the pictures (in the B Scan), there is always a thin dark band showing the high echo coming from the epidermis. This is regularly the highest peak of the entire curve in the A Scan. On the right is the dermis, which always contains a lot of collagen, which is seen in the B pictures as the high density of dark points and in the A scans as an elevated curve with several peaks. The second highest peaks of the graphs are often seen at the transition from the dermis to the subcutis. In the subcutis on the right side of the pictures, the density of dark points is reduced; consequently, the curve is flatter and the peaks are less high. This reflects subcutis containing markedly less collagen.

Figure 4 32-year-old female, pain felt in the inferior left abdomen.

Figure 5 shoulder.

reaching 4 mm beneath the surface. It makes visible objects the size of micrometres, that are dense enough to give an echo, in this case, bundles of collagen. For measurement, a probe is moved along a 2.5 cm path of the skin.

Measurement Patients were measured immediately before and after their first treatment in one of their afflicted areas.

Results

56-year-old male, pain felt at the front of the right

30

H. Pohl

Figure 6 foot.

64-year-old female, pain felt on top of the left

Besides these general traits, large differences between the different specimens can be seen. Thickness of the skin and quantity of collagen are known to depend on the following:          

area of the body (e.g. Smalls et al., 2006) gender (e.g. Roberts et al., 1975) age (e.g. Roberts et al., 1975; Hall et al., 1981) hormonal status (e.g. Quatresooz et al., 2006) diseases (e.g. Pitt et al., 1986; Collier et al., 1986) medication (e.g. Cossmann and Welzel, 2006) mechanical forces (e.g. Kligman and Takase, 1988) exposure to sun (e.g. Kligman and Takase, 1988) dominance of an extremity (e.g. Smalls et al., 2006) and many other factors.

Figure 7 abdomen.

41-year-old female, nausea felt in superior

Figure 8

57-year-old male, instability felt in the left calf.

For a summary of factors influencing thickness of the skin, see Krackowizer (2007). Due to these differencesdboth by individual and betweendthere were no baseline data available, no matched control group could be established, and only pre/ post comparisons were possible.

Individual pre/post comparisons Qualitative description of differences before and after treatment At first glance there is a high congruence of what can be palpated and what the ultrasound pictures show. It looks as it feels.

Figure 9 anterior.

60-year-old female, pain felt on the left tibialis

Changes in the structure of collagen structure

Figure 10

31

37-year-old female, breathing restriction upper right abdomen.

Epidermis does not seem to change with this sort of treatment (B scan and A scan). Dermis: After treatment the dermis looks broader. In the B pictures, there seems to be more fluid within the dermis than before and collagen is more distributed in the surrounding fluid. There is a more homogeneous structure with less high densities and a less-marked border to the subcutis. These differences are reflected in the A scans: after treatment the highest peaks in the dermis are lower than before and the curves are smoother. Subcutis: Since the dermis seems to have broadened and the Collagenoson measures only at a depth of 4 mm, there is less of the subcutis seen after the treatment. Hence, direct comparisons are not possible. For a qualitative description of pre/post differences, see Figures 4e9.

In the last example (Figure 10), an extreme densification in the papillary layer of the dermis (next to the epidermis) can be seen, which disappears over the course of treatment.

Statistical analysis and results For measuring the differences in collagen distribution before and after treatment, two measurements of the A scans (curves) were taken: height of the highest peak in the dermis (second highest peak of the entire curve) and thickness of the skin. Both were measured before treatment (at T1) and after treatment (at T2). Measurement was done by an independent observer. For the variable height of the highest peak in the dermis, the distance of the highest point in the dermis from the xaxis was measured. The difference of the mean height of the highest peak in the dermis before (MZ3.72, SDZ.68) and after (MZ2.59, SDZ.55) treatment was highly

5 4,5 4

Mean

3,5 3 2,5 2 1,5 1 0,5 0 Highest Peak T1

Figure 11 Example for the measurement of the height of highest peak in the dermis.

Highest Peak T2

Figure 12 Mean difference in the height of the highest peak in the dermis before and after treatment.

32

H. Pohl Table 1 Differences in thickness of skin by gender and results of t-test for matched pairs. T1

Female Male

T2

M

SD

M

SD

2.01 1.63

.67 .79

2.08 1.99

.66 .70

N

t-ratio

p<

16 14

.90 3.52

n.s. .01

Table 2 Differences in thickness of skin by age separated for younger and older patients and results of t-test for matched pairs. T1 Figure 13 the skin.

N

t-ratio

p<

M

SD

M

Younger Female Male

1.94 1.59

.62 .74

2.20 1.93

.61 .48

6 9

6.68 2.21

.01 .10

Older Female Male

2.05 1.71

.73 .94

2.00 2.40

.70 1.06

10 5

.50 4.14

n.s. .05

Example of the measurement of the thickness of

significant (t-test for matched pairs, t-ratioZ8.03, DFZ29, p<.0001) (see Figures 11 and 12). No gender or age influence could be found for this variable. The variable thickness of the skin (epidermis and dermis, without subcutis) was determined as length of the x-axis, where the first time the curve from the y-axis cuts the line by 15% in height. The difference of the mean height of the highest peak in the dermis before (MZ1.83, SDZ.74) and after (MZ2.04, SDZ.67) treatment was highly significant (t-test for matched pairs, t-ratioZ3.06, DFZ29, p<.01) (see Figures 13 and 14). There was a gender and age influence on the change of thickness of the skin. It was not significant for women, whereas the increase of thickness for men was highly significant (see Table 1). In a more fine-grained analysis, it turns out that only younger female patients (up to 55 years) showed a highly significant change (see Table 2 and e.g. Figures 4 and 7) whereas older female patients remained unchanged. Male patients showed the opposite finding with a highly significant change for older men and a statistical trend for younger men. Differences in homogeneity before and after treatment are likely, as can be seen from the graphs (B pictures).

T2 SD

Unfortunately, up to now we do not have a measure for homogeneity to support this observation statistically.

Treatment in non-afflicted areas As mentioned earlier, we have no real control group, but in 10 cases (six females, four males, mean age 49 years), the same treatment was administered to patients in nonafflicted areas of their skin. There were no complaints in these areas, specimen tissue felt soft from the very beginning and the treatment was not painful. After treatment, neither reddening nor swelling could be seen. No pre/post differences could be found when measuring

5 4,5 4

Mean

3,5 3 2,5 2 1,5 1 0,5 0

Thickness T1

Thickness T2

Figure 14 Mean difference in the thickness of the skin before and after treatment.

Figure 15

43-year-old male, non-afflicted area (forearm).

Changes in the structure of collagen structure

Figure 16

21-year-old female, non-afflicted area (neck).

patients in non-afflicted areasdeither in terms of height of the highest peak in the dermis nor in the thickness of the skin (see Figures 15 and 16).

Conclusions The changes seen in ultrasound scans seem to mirror the differences in tension, density, and homogeneity in the skin, palpable immediately before and after treatment. It looks as it feels. The main differences in the distribution of collagen that were measured, showed:  a reduction of the highest densifications in the dermis (found mainly in the transition zone with the subcutis);  an increase in thickness of the dermis. To date, we can only speculate about the causes of the changes we could observe. It may be an interaction of two overlapping processes: relaxation of fibroblasts and increase in microcirculation. Fibroblasts are very numerous in the dermis. A count of dermal fibroblasts produced numbers between 2100 and 4100 mm3 in the midst of the dermis (Miller et al., 2003) and 1106 cells per cm2 in a 100 mm thickness of papillary dermis, respectively (Randolph and Simon, 1998). Fibroblasts and their dendrites have been shown to form a network (Novotny

Figure 17

33 and Gnoth, 1991) that exerts active mechanical forces in many fascial tissues like subcutis (Langevin and Cornbrooks, 2004; Langevin et al., 2005), muscle fascia (Schleip, 2006), and dermis (Fray et al., 1998; Grinnell et al., 2003). It has also been shown that fibroblasts of the skin are able to contract collagen lattices and that their ability to contract can be changed by various substances (Coulomb et al., 1984; Adams and Priestley, 1988). Before treatment there may be a contracture of the fibroblasts in the skin, which can be felt as tension in the tissue and may be seen in the echoes of the ultrasound as somewhat higher densities of dermal collagen fibres. This contraction may also exert a pressure on receptors in the skin, causing feelings of discomfort. The manual treatment of the skin may influence mechanoreceptors, causing processes leading to relaxation of the fibroblasts. In the transition zone of the dermis to the subcutis and in the papillary dermis, where we found the highest densities of collagen (see Figure 17, right side), there are also the plexus of blood vessels of the dermis (see Figure 17, left side, and Braverman, 2000)daround blood vessels there is the highest concentration of fibroblasts (Randolph and Simon, 1998). Therefore, contracture of fibroblasts may restrict microcirculation. Pericytes may also be involved in this process. Thus relaxation of fibroblasts may lead to:    

widening of the skin, reduction of the highest collagen densities, facilitation of movement of interstitial fluid, mechanical and chemical changes influencing blood and lymph vessels,  increased microcirculation and a thickening of the skin. Relaxation of fibroblasts and increased microcirculation may also lead to the clinical phenomena of:    

less-restricted movement, reddening and swelling, sensations of softness and warmth, feelings of wellbeing.

Further research is needed to find out how long-lasting the immediate changes are and what their contributions to healing processes may be.

Blood vessels in the skin (left) and collagen distribution (right).

34 Since every manual treatment directly or indirectly also treats the skin, the connective tissue of the skin should become a focus of scientific attention, especially in functional sensory motor disorders.

Acknowledgments The author expresses her appreciation to all her patients making this work possible, to Prof. Dr. Erhard Mergenthaler and Dr. Robert Schleip, both with the University of Ulm, Germany, for their helpful comments and suggestions.

References Adams, L.W., Priestley, G.C., 1988. Contraction of collagen lattices by skin fibroblasts: drug induced changes. Archives of Dermatological Research 280, 114e118. Braverman, I.M., 2000. The cutaneous microcirculation. Journal of Investigative Dermatology Symposium Proceedings 5, 3e9. Collier, A., Matthews, D.M., Kellett, H.A., Clarke, B.F., Hunter, J.A., 1986. Change in skin thickness associated with cheiroarthropathy in insulin-dependent diabetes-mellitus. British Medical Journal 292 (6525), 936. Cossmann, M., Welzel, J., 2006. Evaluation of the atrophogenic potential of different glucocorticoids using optical coherence tomography, 20-MHz ultrasound and profilometry; a doubleblind, placebo-controlled trial. British Journal of Dermatology 155 (4), 700e706. Coulomb, B., Dubertret, L., Bell, E., Touraine, R., 1984. The contractility of fibroblasts in a collagen lattice is reduced by corticosteroids. Journal of Investigative Dermatology 82, 341e344. Fray, T.R., Molloy, J.E., Armitage, M.P., Sparrow, J.C., 1998. Quantification of single dermal fibroblast contraction. Tissue Engineering 4 (3), 281e291. Grinnell, F., Ho, C.H., Tamariz, E., Lee, D.J., Skuta, G., 2003. Dendritic fibroblasts in three-dimensional collagen matrices. MBC Online 14 (2), 384e395. Hall, D.A., Blacket, A.D., Zajac, A.R., Switala, S., Airey, C.M., 1981. Changes in skinfold thickness with increasing age. Age and Ageing 10 (1), 19e23.

H. Pohl Kligman, A.M., Takase, Y. (Eds.), 1988. Cutaneous Aging. University of Tokyo Press, pp. 47e60. Krackowizer, P., 2007. Sonographische Dickenmessung der Cutis. Grundlage fu ¨demdiagnostik. ¨r die sonographische Lympho Dissertation Universita ¨t Innsbruck. Langevin, H.M., Cornbrooks, C.J., 2004. Fibroblasts form a bodywide cellular network. Histochemistry and Cell Biology 122, 7e15. Langevin, H.M., Bouffard, N.A., Badger, G.J., Iatridis, J.C., Howe, A.K., 2005. Dynamic fibroblast cytoskeletal response to subcutaneous tissue stretch ex vivo and in vivo. American Journal of PhysiologydCell Physiology 288, C747eC756. Miller, C.C., Godeau, G., Lebreton-DeCoster, C., Desmoulie `re, A., Pellat, B., Dubertret, L., Coulomb, B., 2003. Validation of a morphometric method for evaluating fibroblast numbers in normal and pathologic tissues. Experimental Dermatology 12 (4), 403e411. Novotny, G.E.K., Gnoth, C., 1991. Variability of fibroblast morphology in vivo: a silver impregnation study on human digital dermis and subcutis. Journal of Anatomy 177, 195e207. Pitt, P., O’Dowd, T.M., Brincat, M., Moniz, C.J., Studd, J.W.W., Berry, H., 1986. Reduction of skin collagen with increased skin thickness in postmenopausal women with rheumatoid arthritis. Rheumatology 25, 263e265. Quatresooz, P., Pie ´rard-Franchimont, C., Gaspard, U., Pie ´rard, G.E., 2006. Skin climacteric aging and hormone replacement therapy. Journal of Cosmetic Dermatology 5 (1), 3e8. doi:10.1111/j.1473-2165.2006.00215.x. Randolph, R.K., Simon, M., 1998. Dermal fibroblasts actively metabolize retinoic acid but not retinol. Journal of Investigative Dermatology 111, 478e484. Roberts, M.A., Andrews, G.R., Caird, F.I., 1975. Skinfold thickness on the dorsum of the hand in the elderly. Age and Ageing 4 (1), 8e15. Schleip, R., 2006. Active fascial contractility. Implications for muscoskeletal mechanics. Dissertation, Faculty of Medicine, Ulm University, Ulm. Smalls, L.K., Wickett, R.R., Visscher, M.O., 2006. Effect of dermal thickness, tissue composition, and body site on skin biomechanical properties. Skin Research and Technology 12 (1), 43e49.

Journal of Bodywork & Movement Therapies (2010) 14, 35e39

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journal homepage: www.elsevier.com/jbmt

PATIENT CARE: CASE STUDY

Glove use and the HIV positive massage therapy client Sarah Elizabeth Welch, HBOR/BA, RMT a,*, Judah Bunin, B.Sc.H., M.Sc., N.D. b a

Time Out Massage Therapy, 1714 Rothesay Road, Saint John, New Brunswick E2H 2J4, Canada Research Coordinator and instructor, Atlantic College of Therapeutic Massage, 440 King Street, Fredericton, New Brunswick E3B 5H8, Canada b

Received 29 July 2008; received in revised form 22 January 2009; accepted 27 January 2009

KEYWORDS HIV/AIDS; Gloves; Skin-to-skin; Touch; Stress; Stigma; Universal precautions

Summary Massage therapy is often used to treat stress, and other symptoms of HIV/AIDS. Massage therapy standards of practice require the use of gloves only when contact with blood and bodily fluids is expected. Health care professionals often mistrust universal precautions and use gloves when their use is not indicated, especially when dealing with HIV positive clients. This case report explored the effects of un-indicated glove use on stress levels, satisfaction with treatment, perception of the therapist, and perceived stigma during a massage therapy treatment. In this case, gloved treatments were only 80% as effective at reducing stress as ungloved treatments. No difference was found in sense of stigma, perception of the therapist, or overall satisfaction in ungloved compared to gloved treatments. Suggestions for future considerations and additional research are made. ª 2009 Elsevier Ltd. All rights reserved.

Introduction UNAIDS (2007) currently estimates that there are more than 1.3 million people living with the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in North America. Studies show that complementary and

* Corresponding author at: 145-3 Orange Street, Saint John, New Brunswick E2L 1M7, Canada. Tel.: þ1 506 635 7883; fax: þ1 506 635 0206. E-mail address: [email protected] (S.E. Welch).

alternative health care (CAHC), and massage therapy in particular, are treatment modalities that individuals living with the HIV/AIDS often seek. Gore-Felton et al. (2003) found that 67% of people living with HIV/AIDS supplement their HIV-related medication use with CAHC. It was estimated in Gore-Felton et al’s (2003) study that 23% of those HIV positive individuals using CAHC chose to use massage therapy out of the many other CAHC modalities. With the increasing interest in, and availability of massage therapy, Baskwill et al. (2003) note that, ‘the likelihood, as massage therapists, that we will treat a client living with HIV (whether the client is aware, or not) is almost assured’

1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.01.008

36 (p. 13). Treating a client who is infected with HIV/AIDS is an area in which all Registered Massage Therapists (RMTs) should be trained and comfortable. The issue of HIV/AIDS and stigma is not new. Numerous research studies have been conducted in an effort to understand the extreme sense of stigma that surrounds this condition. Of particular interest are the studies that highlight the perceived stigma HIV positive patients feel from health care professionals (HCPs). This sense of stigma is often associated with the practice of double gloving, lack of touch, and overuse of universal precautions. Fourn and Duci (1993) found that although nursing students have an excellent understanding of the routes of HIV transmission, and use of universal precautions, 77.4% were fearful of contracting the disease during their hospital training. That study also notes that the fear of HIV infection decreased as knowledge levels rose. McCann and Sharkey (1998) note in a similar study that following an educational intervention with nurses regarding HIV transmission routes, participants were more willing to work with a colleague who was HIV positive, and to treat patients who are HIV positive. These same participants, however, would, ‘take additional precautions for fear of contracting HIV in the workplace’ (p. 267). This brings to light the fact that HCPs are not confident that universal precautions will protect them from becoming infected with HIV. Chapman (2000) reports that the HIV positive patient may internalize the actions of HCPs who are not comfortable working with an HIV positive patient as stigma. One participant in Chapman’s (2000) study stated, ‘even though she’s a nurse.that’s with people who understand all the facts e they still are frightened of it even though they know’ (p. 846). Current Canadian massage therapy standards of practice in Ontario indicate adherence to universal precautions to manage the transmission of infectious disease through blood and bodily fluids (CMTO, 2006). The massage therapy standards of practice follow the Infection Control Guidelines for Regulated Professionals (COTO, 2008). These guidelines recommend that gloves are only to be used if clients or practitioners have open wounds that will be contacted during the treatment. The use of universal precautions assumes that every client or practitioner could potentially be carrying a blood-borne pathogen. For this reason, in theory, all clients are treated equally, regardless of actual health status. Trends have been found in RMT student opinions regarding the use of gloves with HIV positive clients. Ivany (2008) reports that some RMT students express strong attitudes regarding the use of gloves, even when they are not indicated, if a client has disclosed positive HIV status. Again, this highlights the fact that RMTs, like nurses, are not confident that only using universal precautions when indicated by current standards of practice will protect them from HIV infection. Present research in the area of glove use is focused on tactile discrepancy, frequency of puncture/tearing, and adverse dermatological effects on HCPs who use gloves on a regular basis (Tiefenthaler et al., 2006; Noonan and Moyle, 2004; Nayer and Gottrup, 2000). Some research supports the notion that touch is a particularly important aspect in HIV/AIDS care. Butts (1995) indicates the

S.E. Welch, J. Bunin importance of skin-to-skin contact in the treatment of HIV positive individuals, as described below. Low self-esteem is often attributed to feelings of guilt and shame, and a sense of being punished for past behaviours. In fact, health care workers’ attitudes may even reinforce the sense of worthlessness in patients with AIDS. As a result, these patients often see themselves as repulsive to other people, which may interfere with successful coping.

Using latex gloves when dealing with blood and bodily fluids is a necessity in caring for all patients. In situations not requiring protective clothing, however, patients with AIDS should have as much skin-to-skin contact with nurses as other patients.

Patients with AIDS also have a special need for comfort touch in light of their many losses (p. 63).

The lack of cutaneous stimulation derived from skin-toskin comfort touching compounds sensory deprivation and magnifies the complexity of psychosocial problems experienced by these patients (p. 64). Chapman (2000) also highlights the importance of touch and satisfaction of tactile hunger for HIV positive individuals. Rattray and Ludwig (2000) note that, ‘As HIV/AIDS may be seen as an ‘‘untouchable’’ disease, touch itself can be healing’ (p. 1037). It seems that research has completely neglected the patient’s feelings about HCP glove use, and the effects of glove use on treatments. To the researchers’ knowledge there has been no study conducted regarding the effects of glove use on massage therapy treatment outcomes. Exploration as to the potential negative effects of unindicated glove use is necessary. This case report was designed to determine if un-indicated glove use during a massage therapy treatment on an HIV positive participant has a negative effect on stress levels, satisfaction with treatment, client perception of the RMT, or perceived stigma.

Methods Profile of participant The following information was gathered from the client through an intake survey, a health history form, and through verbal communication with the therapist throughout the massage treatments. The participant is a 45-year-old female who was diagnosed with HIV more than 25 years ago by a family physician via blood test. The medical prognosis after diagnosis was not disclosed. The client did not reveal any health history issues other than being HIV positive, and being under significant amounts of stress due to family dynamics, employment issues, and financial constraints. In the years following the diagnosis, the client has never required the use of medication to manage the condition. The client holds strong belief that

Glove use and the HIV positive massage therapy client CAHC is an effective way to manage HIV. Due to financial restrictions, and frequency of relocation, the participant has been unable to receive massage therapy treatments regularly in recent years. In the past, the participant had used massage therapy on a regular basis for stress management. The client currently lacks a family doctor, and receives blood tests infrequently due to lack of symptoms, difficulty in finding a family physician, and lack of interest in participating in conventional health care. Massage therapy precautions for treating a client who is HIV positive include, as with any client, the use of universal precautions. This recommends that the therapist use protective barriers (i.e., gloves, masks), if either the client or the therapist has an open wound, or there is potential for the exchange of blood/HIV carrying bodily fluids between the therapist and the client. Other precautions include not treating the client if they have a cold or flu, or if the therapist has a cold, flu, or other infection that could have an effect on the client’s immune-status (Rattray and Ludwig, 2000). The client’s desired outcomes from the massage included reduction of stress, time for self, opportunity for mindebody connection, and general enjoyment.

Treatment plan The case report was designed to treat an HIV positive client for stress using relaxation massages, and to evaluate the outcome of each massage to establish if there was any change in stress level, satisfaction with treatment, perception of the therapist, or perceived stigma between the gloved and ungloved treatments. In order to derive measurable results from the study, treatments, outcome measurement and location were kept consistent. An intake survey, posttreatment survey and final survey were used to gather data. The intake survey gathered demographic information from the participant, and evaluated the participant’s experience with: massage therapy; glove use in massage therapy; and experiences of perceived stigmatization from health care professionals. The post-treatment survey was derived from the Attitudes towards HIV Health Care Providers (AHHCP) scale, with some additional questions regarding current stress levels and satisfaction with treatments. The questions used both positive and negative wording, and required the participant to answer on a five point Likert-style scale ranging from do not agree to agree strongly. The AHHCP scale was created to evaluate an HIV positive person’s attitude towards their medical team, and takes into account HIVrelated stigma. It has been reported to have an excellent internal consistency of .92 (Bodenlos et al., 2004). The final survey was subjectively structured and allowed the participant to respond to open-ended questions regarding their satisfaction with the series of massage treatments, feelings related to gloves being used during treatments, sense of stigmatization during the treatments, and feelings towards the massage therapist, rather than the more quantitative structure of the post-treatment, Likertstyle survey. In summary, the intake survey was used to collect data on demographics and past experiences, the post-treatment survey was used to evaluate any change in quantitative effectiveness of treatments from gloved

37 treatments to ungloved treatments, and the final survey was used to derive subjective information from the participant after completion of all six treatments. Six 45-minute relaxation massages were performed to the back, arms and neck of this HIV positive participant. The massage treatments were consistent in type, duration and series of techniques used. Massage techniques used included effleurage, muscle squeezing, prolonged tapotement, scooping, wringings, fist compressions, palm spreading, light circular kneading and occipital origininsertion technique. All techniques were performed in a slow, predictable manner as to increase relaxation. These relaxation techniques were chosen due to their effects on stimulating the parasympathetic nervous system, and decreasing sympathetic nervous system firing, thus leading to increased levels of relaxation and decreased levels of stress (Rattray and Ludwig, 2000). The first treatment was ungloved, with each additional treatment alternating between being an ungloved or gloved treatment. Before each treatment the participant was asked to determine their current stress level on a five point Likert scale. Following each massage the client was asked to complete a post-treatment survey that evaluated her satisfaction with the treatment, feelings towards the therapist, views on stigmatization, and stress level. The client was also invited to add comments at the end of the survey for any additional feedback. Following the series of massages the client completed the final survey.

Results The final survey revealed that overall, the participant felt less stressed than when she was not receiving the treatments. She was aware of the treatments where the therapist wore gloves, and felt that the quality of the touch changed with glove use. She reported that when HCPs use gloves to treat, there is a feeling of ‘coldness’. The participant was satisfied and grateful for the massages, regardless of glove use. The participant stated that she could have let the use of gloves during the treatments affect her in a negative way, but she chose not to do so. She stated that, ‘people who are still attached to their status would feel the ‘‘dirty syndrome’’. I don’t have the capacity to allow myself that ugliness’. The participant also commented that, ‘if I had come in here in the first year of my diagnosis, I would have felt it (the shame of being dirty due to the therapist wearing gloves)’. She explained that the participant’s reaction to the therapist wearing gloves is dependant on their progression through accepting their HIV status, and how they choose to deal with stigmatization. Table 1 outlines descriptive data related to the changes in stress level before and after each treatment. All treatments yielded a decrease in stress level, with ungloved treatment number 3 showing the most difference at 2.5 marks on the Likert scale. Changes in stress level with each treatment ranged from 1 to 2.5 marks on the Likert scale. When pre-treatment stress levels were 3.5, the ungloved treatment was more effective in decreasing the stress level. Effectiveness of the ungloved treatments ranged from decreasing stress level by 1e2.5 marks. Gloved treatment effects on stress ranged from 1 to 1.5 marks.

38

S.E. Welch, J. Bunin

Table 1

Changes in stress level by treatment session.

Treatment number

Pre-treatment stress level

Post-treatment stress level

Change in stress level

1 2 3 4 5 6

3 3 3.5 2.5 2.5 3.5

2 1.5 1 1.5 1 2

1 1.5 2.5 1 1.5 1.5

Ungloved Gloved Ungloved Gloved Ungloved Gloved

The mean pre-treatment stress level for both gloved and ungloved treatments was 3. The mean post-treatment stress level for gloved treatments was 1.67, while the mean post-treatment stress level for ungloved treatments was 1.33. Ungloved treatments, therefore, lead to a mean decrease in stress of 1.67. Gloved treatments resulted in a mean decrease in stress level of 1.33. Figure 1 below reflects these data.

Discussion Outcomes of this case report show that relaxation massage may be an effective way to lower stress levels in individuals living with HIV/AIDS. In this case report, gloved treatments were only 80% as effective as ungloved treatment in reducing one participant’s stress levels. For some individuals, the use of gloves when not indicated may lead to negative internalization of stigma, and feelings of contamination. These findings coincide with the material previously published by Butts (1995). Somewhat unexpectedly, there was no change in overall satisfaction with treatments related to glove use in this study. It is important to note that, as a case study, the applicability of these results to the population as a whole is limited. The purpose of this case study is to bring to light the topic of improper use of universal precautions in massage therapy sessions with HIV

Mean Pre Treatment Stress Level Mean Post Treatment Stress Level

3 2.5

positive clients, and to explore the notion that the improper use of universal precautions may potentially have a negative effect on several different dependant variables or outcomes. One shortcoming in the design of this case report is that the client turned in the completed surveys and reports to the same RMT who performed the massage, which might have biased the client’s responses. Thus, it is possible that the overall benefits of the treatments on stress levels may be somewhat exaggerated, but this does not explain the apparent differences observed between the gloved and ungloved treatments. Future work on this subject should include a third party researcher collecting the data, with the RMT being kept unaware of their client’s remarks. Having this design, and advising the client that the therapist will not know his/her responses, is one method of reducing such demand characteristics. Further research with larger participant numbers at various stages of acceptance of HIV status seems prudent. Research on the effectiveness of gloved treatments among participants with other infectious diseases (i.e., Hepatitis C), and without infectious diseases will lead to a greater understanding of the effects of un-indicated glove use on treatment outcomes and perceptions, satisfaction with treatments, and perceived stigma in massage therapy sessions. It is time for health care research to focus on the effects of treatment-related variables on client perception and treatment outcomes. Not only does un-indicated glove use have the potential to have negative effects on a client emotionally, and psychosocially, but it appears that it may decrease the effectiveness of treatments. It is hoped that the next time an RMT or HCP reaches for a pair of gloves when they are not indicated, that they will reconsider, and choose skin-toskin contact.

Acknowledgments

2 1.5 1 0.5 0 Ungloved Treatment

Gloved Treatment

Figure 1 Mean pre- and post-treatment stress levels for ungloved vs gloved treatments.

The authors wishe to extend thanks to instructors Nadine Currie-Jackson, Lisa Ivany, and Candace Gilmore for their contribution to the study when it was in its early stages. Special thanks to Dr. Julie McKeen for her enthusiasm, encouragement, and assistance in finding a participant. Also special thanks to Dr. Janie Butts at the University of Southern Mississippi for sharing her knowledge of gloves and touch as related to the HIV positive client. Dr. Matthew Alexander, thank you for your tireless editing skills, and expertise in English grammar.

Glove use and the HIV positive massage therapy client

References Baskwill, A., Kilty, M., Hamilton, A., Atkinson, H., 2003. Massage therapy and immune measures in HIVþ clients: a critique of the current research. The Journal of Soft Tissue Manipulation 10 (4), 3e5. Bodenlos, J.S., Grothe, K.B., Kendra, K., Whitehead, D., Copeland, A.L., Brantley, P.J., 2004. Attitudes towards HIV health care providers scale: development and validation. AIDS Patient Care and STDs 18 (12), 714e720. Butts, J.B., 1995. Transcending the latex barrier: the therapeutics of comfort touch in patients with acquired immunodeficiency syndrome. Holistic Nursing Practice 10 (1), 61e67. Chapman, E., 2000. Conceptualisation of the body for people living with HIV: issues of touch and contamination. Sociology of Health & Illness 22 (6), 840e857. CMTO College of Massage Therapists of Ontario, 2006. Communication/Public Health Standard 5: Risk Identification and Management for an Outbreak of Infectious Diseases Available online: http://www.cmto.com/pdfs/CPH%205.pdf Retrieved June 2, 2008. COTO College of Occupational Therapists of Ontario, 2008. Infection Control for Regulated Health Professionals Available online: http://www.coto.org/pdf/InfectionControlforRegulatedHealthProfessionalsFederationGuide.pdf Retrieved June 2, 2008. Fourn, L., Duci, S., 1993. AIDS: knowledge and fear of contagion in nursing students during their hospital training. Medecine Tropicale 53 (3), 315e319.

39 Gore-Felton, C., Vosvick, M., Power, R., Koopman, C., Ashton, E., Bachmann, M.H., Israelski, D., Spiegel, D., 2003. Alternative therapies: a common practice among men and women living with HIV. Journal of the Association of Nurses in AIDS Care 14 (3), 17e27. Ivany, L., 2008. Personal Communications. RMT Student Attitudes Towards Treating HIV Positive Clients. January 16, 2008. McCann, T.V., Sharkey, R.J., 1998. Educational intervention with international nurses and changes in knowledge, attitudes, and willingness to provide care to patients with HIV/AIDS. Journal of Advanced Nursing 27 (2), 267e273. Nayer, L., Gottrup, F., 2000. Incidence of glove perforations in gastrointestinal surgery and the protective effect of double gloves: a prospective, randomized controlled study. European Journal of Surgery 166 (4), 293e296. Noonan, M., Moyle, M., 2004. Latex glove allergy in health care. Australian Nursing Journal 12 (3), 1e3. Rattray, F., Ludwig, L., 2000. Clinical Massage Therapy: Understanding, Assessing, and Treating over 70 Conditions. Talus Incorporated, Elora, 1178 pp. Tiefenthaler, W., Gimpl, S., Wechselberger, G., Benzer, A., 2006. Touch sensitivity with sterile standard surgical gloves and single-use protective gloves. Anesthesia 61 (10), 959e961. UNAIDS, 2007. 2007 AIDS Epidemic Update Available online: http://www.unaids.org/en/KnowledgeCentre/HIVData/ EpiUpdate/EpiUpdArchive/2007/ Retrieved June 2, 2008.

Journal of Bodywork & Movement Therapies (2010) 14, 40e49

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

STATISTICAL MEASUREMENT OF FUNCTIONAL PATHOLOGY

Range of normality versus range of motion: A functional measure for the prevention and management of low back injury Serge A. Gracovetsky Concordia University, Montreal, Q.C, Canada Received 20 September 2008; received in revised form 26 January 2009; accepted 1 February 2009

KEYWORDS Low back pain; Range of motion; Range of normality; Lordosis; Intersegmental mobility; Skin markers; Z score; Safe zone; Return to work

Summary The Range of Motion (ROM) is a popular measurement used in the determination of disability for low back pain subjects in spite of serious objections to its clinical usefulness. It is proposed to consider a different index called the Range of Normality (RON) which is defined to be the portion of the ROM that an injured subject is able to do quasi-normally. This permits a direct assessment of the return to work parameters and the restrictions that ought to be placed on activities. It also allows follow up since the RON is expected to fill up the ROM as the injured subject recovers from his injury. ª 2009 Elsevier Ltd. All rights reserved.

Introduction Back pain is the most costly ailment of working-age adults, with economic consequences exceeding $50 billion per annum in the USA alone (Deyo et al., 1991; Frymoyer and Cats-Baril, 1991). The most prevalent of these are low back injuries incurred in the workplace (Fathallah et al., 1998); approximately 2% of all workers sustain back injuries each year (Sontag, 1991). Snook (1978) has shown that only a very small percentage of the workforce is classified as

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outright malingerers. The pertinent medical issue in evaluating dysfunction of the spine is to objectively quantify the severity of the disability (Gracovetsky et al., 1997). The Range of Motion (ROM) of the trunk is one of the variables used by the clinician to rate the disability of the back-injured patient (Fitzgerald et al., 1983). Many believed that a correlation between the ROM for a subject could be related to pathology (Mayer and Gatchel, 1988) because the average ROM of a large population correlates with impairment of the spine. Subjects diagnosed with stenosis, degenerative disk disorders or disk prolapse tend to reduce their ROM, whereas those with spondylolisthesis or non-specific low back pain show a trend of greater ROM than the normal population.

1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.02.001

Range of normality versus range of motion The ROM depends on such a large number of factors introducing variability and limiting reproducibility, that many investigators have discounted its diagnostic importance (Lea and Gerhardt, 1995; Samo et al., 1997; Mayer et al., 1997). ROM is under voluntary control and dependent upon the cooperation of the patient. It is not entirely objective. Nevertheless, ROM is readily observable and continues to be a popular measurement used by the American Medical Association and the American Academy of Orthopedic Surgeons in determining impairment ratings (Venditti, 1991). ROM is a parameter recognized as being indicative of functional pathology in spite of the fact that the existing models of trunk motion characteristics and musculoskeletal capacity still require formal validation (Marras et al., 1995) and that ROM has yet to be shown to be a good predictor of job performance or injury occurrence (Venditti, 1991). The ROM of the trunk does not take into account the allocation of work between spine and pelvis and cannot account for the distribution of motion between the different levels of the lumbar spine. For example, a patient suffering from facet joint stiffness at the lower lumbar spine may produce a normal ROM by either increasing pelvic mobility (Mayer et al., 1984) or by increasing the mobility of the thoraco lumbar junction. Thus, in spite of the presence of spinal dysfunction, the ROM appears normal. According to Horn et al. (1991), the reality is that ‘‘ROM in the lumbar spine cannot distinguish between normal individuals and those with a true impairment due to pathological conditions.’’ There is not a single blind study with controls proving that the spinal impairment or disability of a subject can be derived with reasonable certainty from his/her ROM. ROM provides a non-specific index of spinal function and measurements of dynamic motion are more informative than static ROM (McGregor et al., 1997). For example, consider the unstable patient who, in the erect stance, has a normal ROM and a near normal radiograph. As the patient flexes, there is a moment at which the radiograph reveals an abnormal spinal motion. The dynamic changes in the motion betray the presence of pathology and influence the clinician’s diagnosis far more than the magnitude of the ROM. There is a deeper mathematical reason for the failure of ROM to account for a specific diagnostic. It is rooted in the statistical distribution of the ROM of the so-called normal and abnormal populations. The variance of these populations is so large that it does overlap both averages (see Figure 1a, b). Even if the average normal is distinct from the average abnormal, that finding is clinically useless because the clinician is not dealing with averages but with a single patient. Indeed, the clinical diagnosis is a reverse identification problem: given that the ROM of my patient is 63 , what is the probability that this is due to an injury at L4/L5 There is no known answer to that question. This difficulty is exacerbated by the fact that 90% of LBP is non-specific (Spratt et al., 1990) and the argument becomes circular. If the clinician is unable to reliably distinguish between the normal and the abnormal, what is the credibility of any statistics collected of these populations? Regrettably, in many studies, a normal subject is arbitrarily defined to be an asymptomatic subject, thereby introducing a bias from the start. In addition, load places local strain on the ligaments, muscles and disc tissues of intervertebral segments

41 (Anderson et al., 1985). Thus, when the same patient repeats the flexion while lifting a load, the point at which the instability appears on the radiographs changes. Segmental stability is responsible for maintaining the equilibrium of dynamic motion parameters within the ROM (Ogon et al., 1997). The measurement of segmental function is more informative than measuring ROM, which correlates poorly with the radiographic ‘‘gold standard’’ (Samo et al., 1997). Radiography is traditionally used as the ‘‘gold standard’’ for evaluating low back intersegmental function (Gianturco, 1944; Pearcy, 1985) even if low back dysfunction does not correlate well with either pain or radiological imaging (Waddell, 1987) and that diagnostic radiology is of limited value in the first evaluation of the majority of spinal disorders (Spitzer et al., 1987). Since function cannot be deduced from radiology or pain, it must be directly measured. Yet, reported pain is still the single most important factor in the clinical diagnosis of LBP (Gracovetsky et al., 1998). During dynamic lifting, there are specific stresses such as torque, compression, and shear forces corresponding to the trunk flexion and load weight (Chaffin and Andersson, 1984; Davis et al., 1998). Minimizing or limiting these stresses requires finding that portion of the ROM within which it is safe to operate. By definition, movements executed outside of the individual’s safe functional arc of motion increase the risk of back injury. The part of the ROM during which spinal coordination remains close to the normal average represents a more appropriate measure defining safety and disability parameters. This region of ‘‘safe’’ functionality is termed the ‘‘Range of Normality’’ (RON). This section introduces the concept of RON as a statistical measure of normal function and defines its differences with ROM. The practical applications of RON to the occupational risk management of low back disorders will now be investigated.

Method Subject selection Subjects with mechanical low back dysfunction were selected according to a very rigid inclusion/exclusion criteria (Gracovetsky et al., 1998).

Subject evaluation Each subjects’ performance was evaluated according to previously published methods (Gracovetsky et al., 1989; Gracovetsky et al., 1995). In brief, kinematic data were obtained by tracking the motion of light-emitting diode markers placed on the skin over spinous processes and iliac crests of the lumbar spine, while the activity of the multifidus over the L5 level was recorded by surface electromyography (EMG). Patients underwent the standard evaluation protocol, performing sagittal flexion, recoveryfrom-flexion, and lateral bending movements with incremental load increases. The kinematic data were used to estimate the spinal curve and spinal levels and several spinal coordination

42

S.A. Gracovetsky

Figure 1 a. The Gaussian approximation. The ROM of a given population can be approximated by a Gaussian distribution. The standard deviations away from the average are indicated. b. Normal and abnormal populations. The ROM distributions of the normal and abnormal populations overlap significantly. Hence, given the ROM of a patient, it is not possible to determine with a reasonable certainty whether that ROM belongs to the normal or to the abnormal population. The false positives AND negatives are simultaneously unacceptably high. This is why ROM alone cannot be useful in diagnosing LBP.

parameters such as trunk flexion and the intersegmental motion (EISM), in subjects with spinal pathology. Each subject’s parameters were compared to those of a matched normal population (age, sex, occupation) extracted from a robust normative database.

The normative database A validated normative database of 40 normal subjects selected according to stringent inclusion/exclusion criteria was previously generated (Gracovetsky et al., 1995). This database is representative of sex, age (20e30, 30e40, 40e50 and 50þ) and load lifted. Using various parameters derived from external measurements of spine motion (including estimated intersegmental mobility (EISM), lumbar lordosis/pelvic range of motion ratio and EMG pattern), normal function was characterized with appropriate standard deviations. These particular physiological parameters were chosen because their normal behavior turned out to be highly predictable and correlated with pathology.

Statistical analysis

amplitude of the total movement, regardless of the quality of the movement, whereas the portion of the ROM that is executed close enough from the normal average corresponds to the RON. Consider the problem of determining the range of normality of the lordosis’ variation of a 30 years old male lifting 22 kg. The term ‘‘lordosis’’ used in the text is the estimated lumbosacral angle derived from the correlation between radiographic studies and skin markers’ kinematics (Figure 3a). The normative database will generate the reference against which the subject performance will be assessed (Figure 3b). Although the normalized estimated lordosis’ variation as the loaded trunk flexes is the physiological parameter chosen to illustrate the definition of the RON, there are many other relevant parameters (Gracovetsky, 2009). The normal zone (2 SD) around the average is the shaded area. Figure 3c demonstrates that the measured lordosis remains within the shaded area for the first arc of motion of the trunk (zero to 50 ). Beyond 50 , the normal unfolding of the lordosis slows down for unknown reasons, but the restricted motion can be clearly detected. The conclusion from this experiment is that although the subject has a functional anomaly, his response is essentially normal

It was assumed that the distribution of the population can be approximated by a Gaussian. Even if the distribution of the physiological parameters of the normal population is not truly Gaussian, over 95% of the subjects fall within the interval of 2 SD around the average (Newman et al., 1996). For every physiological parameter measured, there was a corresponding normative value with its variance and the corresponding probabilities of normality were calculated using the Z-descriptor (Newman et al., 1996).

Definition of range of normality As illustrated in Figure 2, the RON is defined to be the part of the ROM during which the patient’s spinal coordination remains close enough (2 SD) from the normal average. By definition, the RON equals the ROM for the normal. The situation is quite different for the abnormal in which the ROM is greater than the RON. The ROM characterizes the

Figure 2

Range of Normality versus Range of Motion.

Range of normality versus range of motion

43

Figure 3 a. Definition of the estimated lordosis J and the true lumbosacral angle J*. The angle J is calculated from the skin markers while the angle J* is calculated from radiographs. The relationship J/J* is described in Gracovetsky (2009). The angle J is termed ‘‘lordosis’’ in the text. b. From the normative database. The statistics of the variation of the normalized estimated lordosis for a 22 kg load lift for a population of 30 years old male subjects is represented by its average and the 2 SD spread. By definition, to have a normal lordosis for a given angle of trunk flexion, a 30 years old male subject lifting 22 kg subject must control his lordosis to remain within the shaded area. c. Definition of RON. The subject measured response remains within the shaded area only when the trunk angle remains smaller than 50 . That is the RON. For trunk flexion angles greater than 50 , the spine is restricted and the response escapes the shaded normal zone. The maximum flexion angle is 70 , which is the subject’s ROM. d. Definition of RON. The same data of Figure 3b is represented as function of the distance to normality expressed in term of Z score. The normal range is now a rectangle with a height of 2 SD. The lordosis remains within the normal range for up to 50 of trunk flexion and is restricted. The advantage of this representation is that the range of normality is always a rectangle of fixed size.

from zero to 50 when lifting 22 kg. That is a very specify information with direct application in the workplace. Figure 3d contains the same data as Figure 3b but represented as a function of the distance to normality expressed in Z score. The same analysis is repeated for each physiological parameter detected by the system (see Figure 10).

Results Recall that a variation of a physiological parameter is considered normal as long as its distance to the average remains within 2 SD, corresponding to a 95% probability of normality. The corresponding range of trunk flexion was termed the Range of Normality (RON). Figure 4a depicts a Gaussian interpretation of ROM of the spine, showing the probability of exceeding a distance of one or two standard deviations from the mean or average value of the distribution. In this theoretical model, a deviation from the mean ROM value is interpreted as

pathology of various degrees, manifested as either a hypomobile or a hypermobile joint. Only the pathologies corresponding to a distance greater than 2 SD are relevant. The mechanics of assigning a probability of normality to a given response, depicted in Figure 4b, are straightforward, requiring only a basic statistical manipulation of the trunk flexion data. For example, when the trunk flexes by 80 , the distance between the patient’s response and the average normal was 1.5 times the standard deviation. This corresponded to a probability of abnormality of 6.7%. Accordingly, the patient’s probability of normality is: (1  0.067) Z 93.3% By repeating this evaluation for each angle of trunk flexion, the probability of normality for the entire ROM was determined. Figure 5a further demonstrates this statistical treatment of ROM data as a Gaussian distribution. Again, the probability of normality is a function of the trunk flexion angle

44

S.A. Gracovetsky

Figure 4 a. ROM distribution. The Gaussian distribution approximates the distribution of ROM of the normal population. Pathology manifested as a hypomobile or a hypermobile joint causes a deviation from the mean value. b. Deviation from normality. To transform the patient’s response into a probability of normality, the distance between the response and the average normal must be determined.

and the direction of the deviation from normal distinguished between hypomobile and hypermobile joints. The important issue for return to work decision is not whether the patient is hypermobile or hypomobile but whether the patient is normal for the task. Hence, the factor of interest is the absolute value of the distance to the mean and not its sign. When considering the distance from the mean rather than specifying a hyper or hypomobile condition, the sum of the probabilities must be added. In this example, for a distance from normality of 1.5 times the standard deviation, the probability that the subject was normal was the sum of the areas on each side of the bell curve. In other words, the corresponding probability was doubled to account for the symmetry of the Gaussian curve (Figure 5b). Figure 6a shows the normal variation of the estimated intersegmental mobility (EISM) of the lumbosacral (L5/S1) spinal articulation as the trunk flexes. This particular parameter is clinically noteworthy since the L5/S1 joint is subjected to a substantial amount of biomechanical stress during flexion and lifting (Anderson et al., 1985; Thompson, 1991) and is thus a common site of injury. When the response of an injured patient was compared to the normal (Figure 6b), it was apparent that the ‘‘quality’’ of the motion throughout the ROM deviated substantially from that of the normal average. This injured response was characteristic of a hypomobile joint, as the function fell below that of normal levels. Because the distance between

the subject’s response and the mean value was considered without distinguishing between hypermobility and hypomobility, the probabilities on each side of the mean were doubled. The probability of normality shows that the quality of motion was not consistent throughout the entire ROM, supporting the tenet that spinal dysfunction is far more complex than a simple deviation from the mean ROM value of the normal population. The relationship between RON and ROM is further highlighted in Figure 7a. Here, the subject’s probability of normality for EISM of the L5/S1 joint began to decrease at 20 of trunk flexion. It became unmistakably suggestive of abnormal spinal coordination by 40 of flexion, where it fell below 25% probability of normality. Furthermore, as shown in Figure 7b, the performance was affected by load. As the load lifted increases, the RON decreases, as demonstrated by the leftward shift in the probability function. This shows that spinal dysfunction reveals itself more clearly at higher levels of biomechanical stress, and that a proper assessment of spinal function requires putting the spine under stress.

Discussion The Range of Motion (ROM) characterizes the amplitude of the total movement and depends on the collaboration of the subject. Although low back pain sufferers demonstrate a reduction in ROM in all planes of motion and often exhibit

Figure 5 a. Probability of normality. A distance of greater than 1.5 times the standard deviation occurs with a probability of 6.7%. The minus sign signifies that the motion is hypomobile. b. Gaussian symmetry. The probability that an abnormal response is at a distance of 1.5 times the standard deviation is twice the initial hypomobile value of 6.7, which is 13.4%.

Range of normality versus range of motion

45

Figure 6 a. Changes in the L5/S1 estimated intersegmental angle during trunk flexion. Average normal (n Z 40) unloaded measured effective intersegmental angle at L5/S1 during trunk flexion. The probability of normality is plotted against the angle of trunk flexion. b. Comparing the unloaded injured with the normal. The injured response is near normal up to 40 of trunk flexion, at which point it deviates from normality.

slow, guarded motion (McGregor et al., 1997), very few individuals are actually impaired to such an extent that their entire ROM is abnormal. An impaired subject is not necessarily a functionally disabled subject (Marriott et al., 1998). An injured subject may not be able to do heavy manual labor; however, the same subject could handle less demanding tasks. The question that arises is ‘‘What is the appropriate level of disability for that person?’’ If the individual can find a desk job suited to his educational level, then he is clearly NOT disabled with respect to that particular occupation. If the person does not have the skills to handle such a job, then he will be classified as disabled since he is unable to perform in an occupation matched to his skills. Conversely, some individuals may have an abnormally small ROM. Yet, within that restricted ROM, they may nevertheless be capable of performing their required duties at a near normal level. This is why the pertinence of ROM measurements for the assessment of levels of dysfunction and disability in low back injury remains controversial and limited in clinical practice (McGregor et al., 1997). Dynamic motion characteristics differ between healthy individuals and those with low back impairment (Ogon et al., 1997). However, unlike ROM, the coordination between spine, pelvis and vertebrae is a characteristic of the human species that is relatively independent of voluntary controls (Gracovetsky et al., 1995). The inter-joint synergy of the spine is systematically coordinated by a complex neural proprioceptive system (Ogon et al., 1997; Mitnitski et al., 1998). Lumbar and pelvic coordination

patterns are useful physiological parameters in the objective evaluation of spinal pathology (Newman et al., 1996). This study examined spinal coordination patterns to evaluate the quality of motion over the entire ROM (Gracovetsky et al., 1989). This technology provided an accurate fingerprint of the coordination of the unconstrained spine during loaded or unloaded movements. The biomechanical parameters of subjects with spinal pathology were measured and compared to those of a normative database (Gracovetsky et al., 1995). The main feature of this normative database is the surprisingly small variance for the physiological parameters measured, which include EISM, spinal and pelvic contributions to the task, and percentage elongation of the posterior ligamentous system. This small variance indicates that important physiological parameters, such as the rate of decrease of lordosis during flexion, deviate little from one normal individual to the next. Thus, coordination between the spinal segments to execute a motion is relatively independent of voluntary control and represents a desirable objective measure of spinal function. Pathology displays abnormal coordination patterns (Newman et al., 1996). Assessing the degree of a disability requires the determination of the portion of the ROM that is executed at a normal or near normal level of spinal coordination for all measured physiological parameters. That is the purpose of the Range of Normality (RON). In this context, the definition of normality is primarily functional; that is a subject is classified as normal if able to

Figure 7 a. RON versus ROM. The quality of the motion during trunk flexion is not the same throughout the entire ROM. b. Effect of load. As the load lifted increases, the ROM and RON decrease.

46

Figure 8 RON and safety. For a given level of normality, the relationship between load (arbitrary units) and trunk flexion (angle) divides the plane into safe and unsafe zones.

function within 2 SD of the matched control asymptomatic, even if he is clinically injured (Newman et al., 1996). The relationship between the load and the RON permits to specify the maximum safe range of activity for an injured worker. Figure 8 shows that the relationship between load and the RON for a given probability of normality divides the plane into two zones. Using a 25% level of normality as the criteria, it is possible to measure the RON for a given load for a specific individual. The area below the 25% level of normality probability curve corresponds to the safe zone within which the subject can assume any combination of loads and postures. The performance of tasks outside of the functionally safe range incurs an increased risk of low back injury. For ergonomists and risk managers, the logical implementation of this relationship between load and RON is the determination of safe loading configurations for workers injured or not. The load lifted may be small enough to maintain the worker in the safe zone. An injured worker may still be employable for tasks involving low loads that he can lift normally in spite of his injury (Gracovetsky et al., 1998). From the measured characteristic response of a subject, it is possible to solve specific ergonomic problems. For instance, Figure 9a shows the characteristic response of a subject in a two dimensional plane with the load on the vertical axis and the RON on the horizontal axis. Suppose a particular job requires a trunk flexion of 40 to bend over a conveyor belt while holding a given load. For a level of normality set at 25%, the maximum load that can be safely manipulated is ‘‘3’’ (arbitrary units). The selection of a different level of normality will result in a different loading configuration (Figure 9b). For example, lifting a load of ‘‘3’’ at a 25% level of normality demands that the subject avoids flexing his trunk more than

S.A. Gracovetsky 40 . At the reduced level of normality of 10%, the trunk will be allowed to flex up to 70 . The issue of determining what level of normality is desirable depends upon the acceptable level of risk for the specific worker and workplace setting. To estimate risk levels, the occupational biomechanist must assess both the requirements of the job and the capacity of the individual (Chaffin and Andersson, 1984). An industrial surveillance study demonstrated that ‘‘there seems to be a threshold of sagittal flexion at which, if surpassed, simultaneous complex dynamic motions could be distinguished among risk groups’’ (Fathallah et al., 1998). The RON measure is one tool to evaluate the complex kinematics of the spine in occupational risk reduction. Large compressive loads during the lifting of weight increase the probability of work-related injuries. Numerous guidelines have been suggested in an attempt to diminish lumbar spine injuries (NIOSH, 1981). However, due to the number of variables involved, the rules regarding back safety and lifting have been of a speculative nature and may be overly conservative. The factors influencing safe lifting include load, lifting technique (Anderson and Chaffin, 1984), lordosis and intersegmental mobility (Mitnitski et al., 1998), speed and acceleration, and the interplay of muscles and ligaments (Anderson et al., 1985). Instead of limiting the back safety decision-making process to isometric, isokinetic, and ROM measures, it is suggested that the ‘‘quality’’ of the motion also be considered is assessing work-related risk. The ability to measure the RON under natural loaded conditions permits a more precise approximation of workplace lifting requirements, and is relevant for those formulating back safety guidelines for occupational risk reduction. Indeed, since dysfunction may reveal itself only at higher levels of spinal stress, evaluating the range of normal function of the spine under conditions of loading ought to be a better indicator of normality than that of unloaded function (Gracovetsky et al., 1998). Functional capacity testing and outcome measures for musculoskeletal disorders are assessed when returning the injured worker to the workplace or when determining their level of disability (Liebenson and Yoemans, 1997). RON may readily be employed to determine the type of movements that a worker is capable of performing quasi-normally, in spite of a pre-existing spinal dysfunction. By defining the functionally safe postural and loading parameters for a given individual and task, RON may be used to delineate

Figure 9 a. Determining safety parameters. The characteristic curve of the individual determines the trunk flexion angle and maximum load parameters for a given probability of normality. b. Safety and risk levels. The safe zone within which a given task can be accomplished is larger as the probability of normality decreases however greater risk is incurred.

Range of normality versus range of motion

47

Figure 10 The variations in estimated intersegmental mobility of the five lumbar segments and T12/L1 when the trunk flexes under load is represented by their distances to normality in the Z score diagram (see the definition of Figure 3). In this example, the ROM is about 70 . Note that the RON varies for each level. The minimum RON is obtained for L4/L5. By definition, the RON of that subject is the smallest RON that is about 15 . From a clinical perspective, the L4/L5 joint is the limiting factor in the movement.

safe work practice guidelines and reduce the incidence and cost of low back injuries. The RON is a statistical measure used to ascertain the ‘‘quality’’ of a motion, with or without load, and is a function of trunk flexion angle. Endurance, lateral bending and

other work-specific functions are also desirable parameters to be included into RON estimates to enhance its applicability to occupational risk management. There is nothing preventing the extension of the RON concept to models other than that of low back dysfunction.

Figure 11 a. The RON of each level in Figure 10 is regrouped to show the minimum RON occurring at L4/L5 for a value of 15 . That is the RON of the most restricted level and it sets the pattern of return to work restrictions. b. When the ROM is compared with each RON, the loss in normality becomes apparent (shaded area). This illustrates the direct impact of the pathology on the function of the spine.

48 Each physiological parameter measured has its own local RON (that is a RON for lordosis, for pelvic motion, for each EISM etc.) (Figure 10). The overall RON of the subject is defined to be the smallest of all the measured RONs since it is the most restricted parameter that will set the upper limit of the safe load (Figure 11). In particular, the actual reduction of normality for each level can be measured objectively. Knowing which physiological parameter is more restricted represents a clue as to the underlying pathology. Note that the system interprets all deviations from the normative data as being mechanical disorders. Since about 10% of the LBP is non-mechanical, it is imperative that this test be complemented by a full clinical examination to rule out non-mechanical causes of low back pain.

Conclusion The concept of Range of Normality and a methodology to measure it was compared to the familiar Range of Motion. This simple statistical measure permits the quantitative evaluation of the normal functional limits of the lumbar spine, with applicability to safe work practice guidelines, conservative care and disability measurement.

Acknowledgements The design of the machine used in the study was made possible by the support of the National Research Council of Canada (NRCC-IRAP program) and the Agence Que ´becoise de la Valorisation Industrielle de la Recherche (AQVIR). The normative database was calculated from the original data collected on 40 normal individuals as part of a research project supported by the Institut de Recherche en Sante ´ et Se ´curite ´ du Travail (IRSST), the research division of the Quebec Workers’ Compensation Board. The work of Martha Cox is herby acknowledged together with the collaboration of W. McIlwain M.D., E. Shapter M.D., K. Swan D.O.

References Anderson, C.K., Chaffin, D.B., Herrin, G.D., Matthews, L.S., 1985. A biomechanical model of the lumbosacral joint during lifting activities.’’. J. Biomech. 18 (8), 571e584. Anderson, C.K., Chaffin, D.B., 1984. A biomechanical evaluation of five lifting techniques. In: Proceedings of the 1984 International Conference on Occupational Biomechanics, pp. 313e317. Chaffin, D.B., Andersson, G.B.J., 1984. Mechanical work capacity evaluation. In: Occupational Biomechanics. Wiley Interscience Publications, John Wiley & Sons, Toronto, pp. 78e110. Davis, K.G., Marras, W.S., Waters, T.R., 1998. Evaluation of spinal loading during lowering and lifting processes. Clin. Biomech. 13 (3), 141e152. Deyo, R.A., Cherkin, D., Conrad, D., Volinn, E., 1991. Cost, controversy, crisis: low back pain and the health of the public. Annu. Rev. Public Health 12, 141e156. Fathallah, F.A., Marras, W.S., Parniapour, M., 1998. The role of complex, simultaneous trunk motions in the risk of occupationrelated low back disorders. Spine 23 (9), 1035e1042. Fitzgerald, G.K., Wynveen, K.J., Rheault, W., Rothschild, B., 1983. Objective assessment with establishment of normal values for lumbar spinal range of motion. Phys. Ther. 63 (11), 1776e1781.

S.A. Gracovetsky Frymoyer, J.W., Cats-Baril, W.L., 1991. An overview of the incidence and costs of low back pain. Orthop. Clin. North Am. 22, 263e271. Gianturco, C., 1944. A roentgen analysis of the motion of lumbar vertebrae in normal individuals and in patients with low back pain. Am. J. Roentgenol. Rad. Ther. 52, 261e268. Gracovetsky, S., Kary, M., Levy, S., Ben Said, R., Pitchen, I., Helie, J., 1989. Analysis of spinal and muscular activity during flexion/extension and free lifts. Spine 14, 327e331. Gracovetsky, S., Marriott, A., Richards, M., Newman, N., Asselin, S., 1997. The impact of inefficient clinical diagnosis on the cost of managing low back pain. J. Healthc. Risk Manag. 17 (3), 21e31. Gracovetsky, S., Newman, N., Pawlowsky, M., Lanzo, V., Davey, B., Robinson, L., 1995. A database for estimating normal spinal motion derived from non-invasive measurements. Spine 20 (9), 1036e1046. Gracovetsky, S.A., Newman, N.M., Richards, M.P., Asselin, S., Lanzo, V.F., Marriott, A., 1998. Evaluation of clinician and machine performance in the assessment of low back pain. Spine 23 (5), 568e575. Gracovetsky, S.A., 2009. The Spinal Engine, pp. 103e239-ISBN: 978 1 4276 2997 5. Horn, T.J., Lowery, W.D., Jr., Wiesel, S.D., 1991. Impairment evaluation based on spinal range of motion. In: Presented at the Annual Meeting of the International Society for the Study of the Lumbar Spine, Heidelberg, Germany, pp. 73. Lea, R.D., Gerhardt, J.J., 1995. Range of motion measurements. J. Bone Joint Surg. 77A (5), 784e798. Liebenson, C., Yoemans, S., 1997. Outcomes assessment in musculoskeletal medicine. Man. Ther. 2 (2), 67e74. Marras, W.S., Parnianpour, M., Ferguson, S.A., Kim, J.-Y., Crowell, R.R., Bose, S., Simon, S.R., 1995. The classification of anatomic- and symptom-based low back disorders using motion measure models. Spine 20 (23), 2531e2546. Marriott, A., Gracovetsky, S.A., Newman, N.M., Richards, M.P., Asselin, S., 1998. Improving clinical examinations by incorporation objective measurements of functional limitations. Rehab. Manag. Dec/Jan, 70e74. Mayer, T., Gatchel, R., 1988. Functional Restoration for Spinal Disorders: the Sports Medicine Approach. Lea & Febiger, Philadelphia, PA. Mayer, T.G., Kondraske, G., Brady Beals, S., Gatchel, R.J., 1997. Spinal range of motion: accuracy and sources of error with inclinometric measurement. Spine 22 (17), 1976e1984. Mayer, T.G., Tencer, A.F., Kristoferson, S., Mooney, V., 1984. Use of non-invasive techniques for quantification of spinal range-ofmotion in normal subjects and chronic low-back dysfunction patients. Spine 9 (6), 588e595. McGregor, A.H., McCarthy, I.D., Dore, C.J., Hughes, S.P., 1997. Quantitative assessment of the motion of the lumbar spine in the low back pain population and the effect of different spinal pathologies on this motion. Eur. Spine J. 6, 308e315. Mitnitski, A.B., Yahia, L.H., Newman, N.M., Gracovetsky, S.A., Feldman, A.G., 1998. Coordination between the lumbar spine lordosis and trunk angle during weight lifting. Clin. Biomech. 13 (2), 121e127. Newman, N., Gracovetsky, S.A., Itoi, M., Zucherman, J., Richards, M., Durand, P., Xeller, C., Carr, D., 1996. Can the computerized physical examination differentiate normal subjects from abnormal subjects with benign mechanical low back pain? Clin. Biomech. 11 (8), 466e473. NIOSH, 1981. Work Practice Guide for Manual Lifting. Department of Health and Human Services, National Institute for Occupational Health and Safety, Cincinnati, Ohio. Publication no. 81e122. Ogon, M., Bender, B.R., Hooper, D.M., Spratt, K.F., Goel, V.K., Wilder, D.G., Pope, M.H., 1997. A dynamic approach to spinal instability: part I: sensitization of intersegmental motion

Range of normality versus range of motion profiles to motion direction and load condition by instability. Spine 22 (24), 2841e2858. Pearcy, M.J., 1985. Stereo radiography of lumbar spine motion. Acta Orthop. Scand. 56 (212(Suppl.)). Samo, D.G., Chen, S.-P.C., Crampton, A.R., Chen, E.H., Conrad, K.M., Egan, L., Mitton, J., 1997. Validity of three lumbar sagittal motion measurement methods: surface inclinometers compared with radiographs. J. Occup. Environ. Med. 39 (3), 209e216. Snook, S.H., 1978. The design of manual handling tasks. Ergonomics 21 (12), 963e985. Sontag, M.J., 1991. Scientific basis of functional assessment of the lumbar spine patient. In: White, A.H., Anderson., R. (Eds.), Conservative Care of Low Back Pain. Williams and Wilkins, Baltimore, MD. Spitzer, W.O., Leblanc, F.E., Dupuis, M., 1987. Scientific approach to the assessment and management of activity-related spinal disorders. Spine 12 (7 Suppl.), 1e59. Spratt, K.F., Lehmann, T.R., Weinstein, J.N., Sayre, H.A., 1990 Feb. A new approach to the low-back physical examination.

49 Behavioral assessment of mechanical signs. Spine 15 (2), 96e102. Thompson, D.A., 1991. Ergonomics. In: White, A.H., Anderson., R. (Eds.), Conservative Care of Low Back Pain. Williams and Wilkins, Baltimore, MD. Venditti, P.P., 1991. Functional and work capacity evaluation. In: White, A.H., Anderson, R. (Eds.), Conservative Care of Low Back Pain. Williams and Wilkins, Baltimore, MD. Waddell, G., 1987. Clinical assessment of lumbar impairment. Clin Orthop Relat. Res. 221, 110e120.

Abbreviations EMG: Electromyography; EISM: Estimated Intersegmental mobility; ROM: Range of Motion; RON: Range of Normality; SD: Standard deviation

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WORKSITE HEALTH PROMOTION

Functional fitness improvements after a worksite-based yoga initiative Virginia S. Cowen, Ph.D.* Department of Health, Physical Education and Dance, Queensborough Community College, The City University of New York, 222-05 56th Avenue, Bayside, NY 11364, USA Received 9 September 2008; received in revised form 14 February 2009; accepted 24 February 2009

KEYWORDS Yoga; Mind-body; Exercise; Worksite health promotion

Summary This study explored the benefits of yoga on functional fitness, flexibility, and perceived stress. A quasi-experimental design was used to measure benefits of yoga in sample of firefighters from a major metropolitan fire department. Yoga classes were conducted on-shift, in the fire stations over the period of 6 weeks. The classes included pranayama (breathing), asana (postures), and savasana (relaxation); 108 firefighters enrolled in the study, most were physically active but had no prior experience with yoga. Baseline and post-yoga assessments were completed by 77 participants. Paired t-tests revealed significant improvements in the Functional Movement Screen, a seven item test that measures functional fitness. Improvements were also noted in trunk flexibility and perceived stress. Participants also reported favorable perceptions of yoga: feeling more focused and less musculoskeletal pain. These findings e along with the retention of the majority of the participants e indicate that participants benefited from yoga. ª 2009 Elsevier Ltd. All rights reserved.

Background Firefighting operations require superior physical fitness including strength (Gledhill and Jamnik, 1992), endurance (Adams et al., 1986), aerobic fitness (Adams et al., 1986), and balance (Punakallio, 2003). In addition to ability to physically perform job-related duties, it is important for

* Tel.: þ1 718 631 6322; fax: þ1 718 631 6333. E-mail address: [email protected]

firefighters to be able to respond to stressful situations (Blimkie et al., 1977) and traumatic events (Beaton et al., 1999). Within the past few decades, there has been growing interest in promoting physical fitness for firefighters (Garver et al., 2005). General health promotion (Barnard and Anthony, 1980) and exercise programs (Adams et al., 1986; Barnard and Anthony, 1980; Roberts et al., 2002) have noted improvements in physical fitness. Research has also found correlations between overall physical fitness and performance of job-related (functional) tests (Punakallio et al., 2004; Rhea et al., 2004).

1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.02.006

Functional fitness improvements Mindful activities, such as yoga, have not been explored in this population. Yoga is traditionally a non-competitive and mindful activity. Breathing and awareness are integral parts of yoga practice (Birkel and Edgren, 2000), and important aspects of firefighter job performance. Yoga postures are performed in a relaxed manner (Kerr, 2000) and sequenced to emphasize balance between strength and flexibility (Brust, 1993). Research indicates that yoga practice is associated with improvements in overall physical fitness (Cowen and Adams, 2005; Tran et al., 2001), along with increases in muscular strength, endurance, and flexibility (Raju et al., 1997; Telles et al., 1993; Tran et al., 2001). Research also supports the belief that yoga is beneficial in reducing perceived stress (Berger and Owen, 1988; Cowen and Adams, 2005) and improving physiological measures of stress (Murugesan et al., 2000; Telles et al., 1993). This study was undertaken to evaluate the benefits of yoga in a sample of firefighters. The overall hypothesis was that improvements in functional fitness, flexibility and perceived stress would be noted after participation in a series of yoga classes. A secondary hypothesis was that yoga would be favorably perceived and of interest to the firefighters as a worksite-based program.

Methods Recruitment and enrollment A quasi-experimental design was used for this study. Volunteers were recruited to participate in yoga classes. In order to enroll in the study all potential participants were required to be: employed as firefighters, age 18e65, able to engage in physical activity, and not regular yoga practitioners. Nineteen fire crews volunteered to participate in the study, 108 firefighters from these crews enrolled as participants. The Physical Activity Readiness Questionnaire (PAR-Q) was used to screen potential study volunteers. Prior to engaging in any of the assessments, all participants were required to read and sign an informed consent form detailing the study procedures and their rights as a research participant. This study was approved by the Arizona State University and the Queensborough Community College Institutional Review Boards. Demographic, behavioral, and physical data were collected for each participant in the study prior to the first yoga class, and after the last yoga class. Attendance was recorded for all yoga classes. The Functional Movement Screen was used to measure functional fitness (Cook, 2001). This seven item test (See Appendix A) was designed to measure quality of movement. Stability, mobility, and flexibility are evaluated when the subject performs multijoint movements: squat, hurdle step, lunge, shoulder mobility, leg raise, push-up, and trunk rotation,. Each item is scored on a scale of 0e3. Zero is awarded when subject fails to perform the movement or reports pain, three is awarded when subject executes movement without error, one and two are awarded when subject has some degree of difficulty but is able to partially execute the movement.

51 Total score can range from 0 to 21 with a higher score considered to be optimal. Psychological stress was measured using the Perceived Stress Scale (Cohen et al., 1983). This 14-item scale considered to provide a reliable and valid assessment of stress. Total scores range from 0 to 56 with a lower score considered to be optimal. Participants were asked for additional descriptive data including their current physical activity habits, recent musculoskeletal pain, and previous experience with yoga. At follow-up yoga participants were invited to express their opinions about yoga and their experience as participants in the study.

Yoga class The yoga classes included pranayama (breathing), asana (postures), and savasana (relaxation). Yoga classes were conducted in stations, on-shift, at times and in locations agreed upon by the participants. All firefighters who were on shift in the stations at the time of class were welcome to participate, this included firefighters temporarily assigned to crews (called ‘‘rovers’’). Firefighters who were not enrolled in the study were informed of the purpose of the class and the study. If they chose to participate, their attendance was recorded by the instructor. No other data were recorded for nonparticipants. Data were analyzed using SPSS version 11.0. Paired ttests were used to compare measurements prior to yoga (baseline) and after 10 yoga sessions (follow-up). The alpha level was set equal to .05.

Results One hundred and eight career firefighters were enrolled in the study. Study participants attended an average of four yoga classes during the study. The majority of the

Table 1

Pre- and post-yoga means. Pre-yoga

Functional Movement Screena Baseline perceived stressb Trunk flexibilityc a

Post-yoga

Mean

S.D.

Mean

S.D.

13.25

2.255

16.55

2.131

17.70

5.168

16.17

5.048

26.46

9.814

28.06

9.577

The Functional Movement Screen (Cook, 2001) is a seven item test designed to measure functional fitness by evaluating quality of movement. Each item is scored on a scale of 0e3. Test scores can range from 0 to 21. Higher score is considered to be optimal. b Measured with the Perceived Stress Scale (Cohen et al., 1983). Fourteen items are scored on a scale of 0e4. Test scores can range from 0 to 56. Lower score is considered to be optimal. c Trunk flexibility was measured in centimeters with a Sit and Reach Box. Higher score indicates more flexibility of trunk, and posterior leg.

52

V.S. Cowen

Table 2

Pre- and post-yoga paired sample t-test.

Functional Movement Screena Baseline perceived stressb Trunk flexibilityc

Pre-and post-yoga difference

95% confidence interval

t

p-Value

Mean

S.D.

Lower

Upper

3.30

2.317

3.82

2.77

12.491

.000

1.53

4.596

0.49

2.58

2.926

.005

1.60

4.350

2.59

.62

3.235

.002

a

The Functional Movement Screen (Cook, 2001) is a seven item test designed to measure functional fitness by evaluating quality of movement. Each item is scored on a scale of 0e3. Test scores can range from 0 to 21. Higher score is considered to be optimal. b Measured with the Perceived Stress Scale (Cohen et al., 1983). Fourteen items are scored on a scale of 0e4. Test scores can range from 0 to 56. Lower score is considered to be optimal. c Trunk flexibility was measured in centimeters with a Sit and Reach Box. Higher score indicates more flexibility of trunk, and posterior leg.

participants (N Z 104, 96%) were male, and four were female (4%). Participants ranged in age from 22 to 60 (mean age 40.6 years, S.D. 9.2). Most (81.8%, N Z 88) had no prior experience with yoga. The participants in the study were physically active off-the-job. At baseline, 75% of the participants (N Z 63) reported that they engaged in moderate or vigorous exercise at least four of the seven days prior to the study. Complete follow-up tests were completed by 77 participants. None of the participants formally withdrew from the study, but 31 were not available during the follow-up period (due to alarm calls, transfer to another job or station, or scheduled time off.) Paired t-tests revealed significant improvements in functional fitness as measured by the overall score on the Functional Movement Screen: pre-yoga mean 13.3 (S.D. Z 2.3), post-yoga mean 16.5 (S.D. 2.2), t(76) Z 12.49, p < .0005. The 95% confidence interval for the mean difference was 3.82 to 2.77. Significant improvements in trunk flexibility were noted on the Sit and Reach test: pre-yoga mean 26.46 cm (S.D. Z 9.814), postyoga mean 28.06 (S.D. Z 9.577), t(76) Z 3.24, p Z .002. The 95% confidence interval for the mean difference was 2.59 to .62. Significant reduction in stress was found on the Perceived Stress Scale: pre-yoga mean 17.7 (S.D. Z 5.2), post-yoga mean 16.2 (S.D. Z 5.0), t(76) Z 2.93, p Z .005. The 95% confidence interval for the mean difference was .49e2.58 (Tables 1 and 2). These findings support previous research supporting the physical benefits of yoga practice. All participants who completed follow-up assessments stated that they felt that yoga participation had some benefit for them either professionally or personally. Responses were clustered into general topic areas: 56% reported that they felt yoga had a positive impact on their job performance: 62% of the participants felt more flexible, 41% calmer/more focused, 17% reported less musculoskeletal pain, 16% improved breathing control, and 15% better balance/core strength. Additionally participants reported that they found the relaxation techniques helpful and useful outside of class. Several participants indicated that they anticipated more pronounced

benefits from yoga if classes were offered more frequently.

Discussion Improvements in functional fitness, flexibility, and perceived stress indicated that this study was successful. The on-shift delivery of the yoga classes enabled a large number of firefighters to participate. In addition to the firefighters enrolled in the study, 129 rovers attended one or more yoga classes. Although it is not standard practice in research to allow outside participants in an intervention, it was acceptable in this project for two reasons. First, goal of the program presented in this paper was to evaluate how yoga would be perceived by firefighters. Attendance and participation by firefighters would provide an additional means of addressing this question in a general manner. Second, teamwork (Murphy et al., 1994) and social support (Regehr et al., 2003) have been identified as important aspects of the firefighter’s workplace. Including, rather than excluding, these individuals seemed both logical and feasible given characteristics of the setting and the participants. Little is known about the possible dose response relationship for yoga, which offers another investigative opportunity. Overall, yoga was favorably received by the firefighters and the findings of the study indicate that yoga offers physical and perceptual benefits for this population.

Appendix A Functional Movement Screen Seven items comprise the Functional Movement Test (See Figure 1aeg) The test aims to measure functional mobility, stability, and flexibility (Cook, 2001). The scores for each item on the test range from 0 (unable to properly execute movement, or pain is present on movement) to 3 (able to execute movement without difficulty or compensation.) Possible composite scores for the overall test range from 0 to 21, with 21 indicating optimal performance.

Functional fitness improvements

53

Figure 1

Appendix B Pranayama is the practice of breathing exercises that aims to improve mental focus and cleanse the body. A variety of

techniques may be used including: regulating by lengthening or shortening the breath, retaining the breath, alternating the use of the nostrils or mouth, engaging accessory muscles of respiration, and adding vocalizations to the breath. Asana is the physical practice of yoga exercises. Dynamic movements and static postures are performed with the

54 body in sitting, standing, supine, and prone positions. The dynamic movements warm the joints of the body and the static postures require mental focus. Breathing during the exercises helps to improve mental focus. Practice of asana aims to balance strength and flexibility of the body and mind. Savasana is relaxation that may be performed before, during, or after yoga practice. The term savasana refers to corpse pose when the body is supine, motionless, yet still mentally aware. Progressive relaxation of the body and regulation of breathing is performed to promote conscious relaxation. Savasana aims to refresh the body and mind and promote lifestyle stress reduction.

References Adams, T., Yanowitz, F., Chandler, S., Specht, P., Lockwood, R., Yeh, M., 1986. A study to evaluate and promote total fitness among firefighters. Journal of Sports Medicine 26 (4). Barnard, R., Anthony, D., 1980. Effect of health maintenance programs on Los Angeles City firefighters. Journal of Occupational Medicine 22 (10), 667e669. Beaton, R., Murphy, S., Johnson, C., Pike, K., Corneil, W., 1999. Coping responses and posttraumatic stress symptomatology in urban fire service personnel. Journal of Traumatic Stress 12 (2), 293e308. Berger, B.G., Owen, D.R., 1988. Stress reduction and mood enhancement in four exercise modes: swimming, body conditioning, Hatha yoga, and fencing. Research Quarterly for Exercise and Sport 59 (2), 148e159. Birkel, D.A., Edgren, L., 2000. Hatha yoga: improved vital capacity of college students. Alternative Therapies in Health and Medicine 6 (6), 55e63. Blimkie, C., Rechnitzer, P., Cunningham, D., 1977. Heart rate and catecholamine responses of fire fighters to an alarm. Canadian Journal of Applied Sport Sciences 2 (3), 153e156. Brust, H.A., 1993. The Yoga of Mindfulness: a Buddhist Path for Body and Mind. Editions Duang Kamol, Bangkok, Thailand. Cohen, S., Kamarck, T., Mermelstein, R., 1983. A global measure of perceived stress. Journal of Health and Social Behavior 24 (4), 385e396. Cook, G., 2001. Baseline sports-fitness testing. In: Foran, B. (Ed.), High-Performance Sports Conditioning. Human Kinetics, Champaign, IL, pp. 19e48.

V.S. Cowen Cowen, V.S., Adams, T.B., 2005. Physical and perceptual benefits of yoga asana practice: results of a pilot study. Journal of Bodywork and Movement Therapies I9, 211e219. Garver, J.N., Jankovitz, K.Z., Danks, J.M., Fittz, A.A., Smith, H.S., Davis, S.C., 2005. Physical fitness of an industrial fire department vs. a municipal fire department. Journal of Strength and Condtioning Research 19 (2), 310e317. Gledhill, N., Jamnik, V., 1992. Characterization of the physical demands of firefighting. Canadian Journal of Sport Sciences 17 (3), 207e213. Kerr, K., 2000. Relaxation techniques: a critical review. Physical and Rehabilitation Medicine 12, 51e89. Murphy, S., Beaton, R., Cain, K., Pike, K., 1994. Gender differences in fire fighter job stressors and symptoms of stress. Women and Health 22 (2), 55e69. Murugesan, R., Govindarajulu, N., Bera, T., 2000. Effect of selected yogic practices on the management of hypertension. Indian Journal of Physiology and Pharmacology 44 (2), 207e210. Punakallio, A., 2003. Balance abilities of different-aged workers in physically demanding jobs. Journal of Occupational Rehabilitation 13 (1), 33e43. Punakallio, A., Lusa, S., Luukkonen, R., 2004. Functional, postural and perceived balance for predicting the work ability of firefighters. International Archives of Occupational and Environmental Health 77, 482e490. Raju, P.S., Prasad, K.V., Venkata, R.Y., Murthy, K.J., Reddy, M.V., 1997. Influence of intensive yoga training on physiological changes in 6 adult women: a case report. Journal of Alternative and Complementary Medicine 3 (3), 291e295. Regehr, C., Hill, J., Knott, T., Sault, B., 2003. Social support, selfefficacy and trauma in new recruits and experienced firefighters. Stress and Health 19, 189e193. Rhea, M.R., Alvar, B.A., Gray, R., 2004. Physical fitness and job performance of firefighters. Journal of Strength and Condtioning Research 18 (2), 348e352. Roberts, M., O’Dea, J., Boyce, A., Mannix, E., 2002. Fitness levels of firefighter recruits before and after a supervised exercise training program. Journal of Strength and Conditioning Research 16 (2), 271e277. Telles, S., Nagarathna, R., Nagendra, H.R., Desiraju, T., 1993. Physiological changes in sports teachers following 3 months of training in Yoga. Indian Journal of Medical Sciences 47 (10), 235e238. Tran, M.D., Holly, R.G., Lashbrook, J., Amsterdam, E.A., 2001. Effects of hatha yoga practice on the health-related aspects of physical fitness. Preventive Cardiology 4 (4), 165e170.

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TRADITIONAL JAPANESE MASSAGE STUDY

Effects of Anma therapy (traditional Japanese massage) on body and mind Nozomi Donoyama, MS a,*, Tsunetsugu Munakata, Ph.D. b, Masanao Shibasaki, MD, Ph.D. c a Course of Acupuncture and Moxibustion, Department of Health, Faculty of Health Sciences, Tsukuba University of Technology, 4-12-7 Kasuga, Tsukuba, Ibaraki 305-8521, Japan b Graduate School of Comprehensive Human Sciences, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki 305-8577, Japan c Allergy and Immunology, Department of Health, Faculty of Health Sciences, Tsukuba University of Technology, 4-12-7 Kasuga, Tsukuba, Ibaraki 305-8521, Japan

Received 6 September 2007; received in revised form 5 June 2008; accepted 11 June 2008

KEYWORDS Anma therapy; Traditional Japanese massage; Muscle stiffness in the neck and shoulder; Visual Analogue Scale (VAS); State anxiety; Salivary cortisol; Secretory immunoglobulin A (s-IgA)

Summary Introduction: Anma therapy is a traditional style of Japanese massage, one of touch and manual therapies, and one of the most popular CAM therapies in Japan. It was brought from China in the 6th century and, while based on the theory of Chinese medicine, it developed in Japan according to Japanese preference and has recently come to include theories of Western medicine. The purpose of this study was to clarify the physical and psychological effects of Anma therapy. Participants and methods: Fifteen healthy female volunteers in their fifth decade, with chronic muscle stiffness in the neck and shoulder, received two interventions: 40-min Anma therapy and 40-min rest intervention. The design was cross-over design. Participants were randomly divided into two groups. Group A was started on Anma therapy from the first day followed by the rest intervention after a 3-day interval. The order of the Anma therapy and the rest intervention reversed for Group B. Visual Analogue Scale (VAS) score for muscle stiffness in the neck and shoulder, state anxiety score, and salivary cortisol concentration levels and secretory immunoglobulin A (s-IgA) were measured pre- and post-interventions. Results: Anma therapy significantly reduced VAS scores and state anxiety scores. S-IgA concentration levels increased significantly across both groups. Conclusion: Anma therapy reduced muscle stiffness in the neck and shoulder and anxiety levels in this pilot study of 50-year-old females. ª 2008 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: þ81 29 858 9631; fax: þ81 29 855 1745. E-mail address: [email protected] (N. Donoyama). 1360-8592/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2008.06.007

56

Background What is Anma therapy? Anma therapy is a traditional Japanese massage brought from China as ‘‘Do-in and Ankyo’’ in the 6th century at approximately the same time as acupuncture, moxibustion, and Chinese medicine were introduced. ‘‘Do-in and Ankyo’’ were a kind of touch and manual therapy including movement and breathing exercises that were designed to stimulate the flow of ki, or life energy, throughout the body. This therapy is considered to be capable of rebalancing the flow of vital energy through the meridians. It originated as a way to prevent disease, maintain and promote good health. The art developed according to Japanese preferences, supported by public confidence, and at present, it is called Anma therapy (‘‘an’’ is the Japanese term for applying pressure and kneading, and ‘‘ma’’ the term for stroking), one of the most popular therapies in Complementary and Alternative Medicine (CAM) in Japan. Recently, Shiatsu (literally, in Japanese, ‘‘pressing with the thumb’’) has become famous worldwide, although it is only one technique of many in Anma therapy. In Japan, a massage practitioner license is given only to those who have passed a national examination, which allows the practice of all kinds of touch and manual techniques, including Anma therapy, Shiatsu, and other massage therapies such as Western and other Asian massage styles. In modern day Japan, the terms ‘‘Anma therapy’’ and ‘‘massage therapy’’ are commonly used synonymously. The public call Anma therapy ‘‘massage’’; however, scholastically there are differences between Anma therapy, or traditional Japanese massage and Western style massage. Anma therapy is composed of seven techniques (Kimura et al., 2003), including stroking, kneading, and pressing, with kneading being used most frequently. These stimuli are applied to the deep muscle, usually through clothes, to achieve tactile and pressure sensation, whereas Western style massage is applied directly to the skin using stroking technique more frequently with softer superficial tactile stimulation and lubrication. In the classical works of traditional Japanese medicine, the stimulation produced by Anma therapy was claimed to affect the functions of not only the body but also of the mind because it was based on traditional Chinese medicine. In traditional Chinese medical theory, it is hypothesized that the body and the mind are associated with each other; disorders of the seven emotionsdanger, joy, worry, grief, melancholy, fear, and fright result in injury to physical organs, and physical and psychological strain were thought to be etiology (Simple Question; Spiritual Axis). According to one classical work (Simple Question), Anma therapy is effective in the treatment of muscle stiffness when stressful hassles cause the flow of ki in the meridians to stagnate. Modern Anma therapy has come to embrace a wider acceptance of aspects of Western medicine, such as in anatomy and physiology. Some studies (Sato and Schmidt, 1971; Cao et al., 1992; Sato et al., 1996, 1997, 2002) have revealed that tactile and pressure stimulation given to the surface of the body in anesthetized rats elicited a somatovisceral reflex, which is currently believed to be the

N. Donoyama et al. mechanism of the clinical effect of Anma therapy: For example, in anesthetized rats, abdominal pressure stimulation inhibited gastrointestinal motility and the excitatory gastric response elicited by pressure stimulation of a hind paw, which are reflex responses. Moreover, cutaneous stimulation by brushing produced a reflex inhibition of the sympathetic nervous system to the adrenal medulla that resulted in decreased secretion of catecholamines. Thus, tactile and pressure stimulation affects the autonomic nervous system and internal secretion through the brain to act on physical modulation. Tactile and pressure stimulation to skin and muscles are important methods in Anma therapy, so organ reactions to somatosensory input (‘‘somato-autonomic reflexes’’) are considered to be the effective mechanism of Anma therapy. Anma therapy has been empirically shown to maintain well-being, promote health, treat illness, and prevent disease. It has often been used to treat symptoms which are not treated by medical doctors, such as muscle stiffness in the neck and shoulder, lower back pain, musculoskeletal or arthritic pain, chronic pain, neuralgia, autonomic nerve disorders, fatigue and so on (Donoyama and Katahira, 2002; Oride et al., 2002; Yamashita et al., 2002).

Introduction Recently, the use of CAM therapies has increased around the world, and the prevalence of massage therapy has rapidly increased, particularly because of its emphasis on stress reduction and increased physical and psychological relaxation (Lovas et al., 2002). According to the surveys, the rate of persons who have used some form of CAM therapy in the past 1 year is 42% of the individuals in the USA (Eisenberg et al., 1998), 20% in the UK (Ernst and White, 2000), and 76% in Japan (Yamashita et al., 2002). Among these, individuals who received massage therapy were 11%, 1%, and 15% in the USA (Eisenberg et al., 1998), the UK (Ernst and White, 2000), and in Japan (Yamashita et al., 2002), respectively. Moreover, in Sweden, 17% of respondents (patients) reported having consulted a CAM provider during the preceding year and 40% reported that the most frequently used CAM therapy was massage (Al-Windi, 2004). The main goal of Anma therapy in Japan is to treat musculoskeletal symptoms (Yamashita et al., 2002), among which, muscle stiffness in the neck and shoulder is one of the most frequent (Donoyama and Katahira, 2002; Oride et al., 2002). In addition, according to national surveys in Japan (Health and Welfare Statistics Association, 1996, 2001), the most frequent symptoms reported by the public were muscle stiffness in the neck and shoulder and lower back pain, and the number of people receiving Anma/ massage therapy increased. Thus, Anma therapy is one of the most popular CAM therapies in Japan, a therapy from which patients expect much. In spite of its long history and popularity, Anma therapy only has anecdotal evidence for its effectiveness and no evidence resulting from studies employing scientific methodology can be found from Medline searches. As for Western style massage therapy, many scientific studies aimed at verifying its effectiveness have been

Effects of Anma therapy (traditional Japanese massage) on body and mind published recently. Previous studies on massage therapy (Field, 1998, 2000; Field et al., 1992, 1997, 1998; Hart et al., 2001; Hernandez-Reif et al., 2000) have indicated that anxiety scores, salivary stress hormone (cortisol) levels and catecholamine levels in blood decrease significantly, and physical symptoms improve, after massage treatment compared to control groups. In addition, some studies on the effects of massage therapy on immunological function have been published, using secretory immunoglobulin A in saliva (s-IgA) as an indicator (Green and Green, 1987; Groer et al., 1994). Results show s-IgA concentration increase in massage groups. Thus, a preliminary study on the effect of Anma therapy was undertaken; Visual Analogue Scale (VAS) of clients’ symptoms, state anxiety, salivary cortisol, and s-IgA were measured (Donoyama et al., 2005). In the study, three female clients participated in five Anma therapy sessions (two times per week for two and one-half consecutive weeks) of 40 min’ duration. Immediate changes between pre- and post-therapy, and longer-term changes between first and last session were observed. According to the results, the degree of all chief complaints and state anxiety scores exhibited both immediate and longer-term decreases across all three women. Another immediate change seen in Anma therapy was an increase in s-IgA levels in saliva. Salivary cortisol concentrations, however, remained unchanged. These results suggested that Anma therapy may be effective in ameliorating physical symptoms and anxiety, and in enhancing immune function. Changes of salivary cortisol concentration by Anma therapy were different from those of Western style massage. However, these statements were premature because sample size was small and the conditions were varied. In the present study, a larger sample size was prepared, sample conditions were controlled, and the effects of Anma therapy were examined utilizing the VAS of participants’ symptoms, state anxiety, salivary cortisol, and s-IgA, using statistical analyses.

Materials and methods Participants Seventeen healthy volunteers were recruited for participation in this study, by three part-time female workers employed at the university. Inclusion criteria for gender, age, and physical conditions were as follows: (i) to be a female in the fifth decade of life; (ii) to feel chronic muscle stiffness around neck and shoulder; (iii) to have no disease requiring medical intervention; (iv) to desire Anma therapy; (v) and especially to eliminate the influence from sexual hormones suggested in the study by Kirschbaum et al. (1999) showing that salivary cortisol levels are affected by menstrual cycle, to be a few years post-menopause; and (vi) to feel no current symptoms of menopause. Muscle stiffness in the neck and shoulder is defined as symptoms which produce a feeling of annoyance, an

57

unpleasant sensation, strain, stiffness, ache, and/or pain in the regio axillaris and/or regio scapularis muscles (Hirabayashi, 2002; Ishii and Hirasawa, 2002). All participants gave their informed consent, were screened for conditions of chronic muscle stiffness in the neck and shoulder, and the absence of medical disease was confirmed by a doctor. Participants were asked to avoid strenuous exercise on the days of participation in the study and to avoid eating and drinking within 2 hours of participation in the study.

Interventions All participants received two interventions on 2 different days. One was Anma therapy and the other was a rest intervention. The 40-min Anma therapy was performed by a female therapist in possession of a national massage practitioner license with greater than 15 years’ treatment experience. On the massage table, Anma therapy was performed on the body, except the face, head and abdomen, with a focus on the neck and specific points of shoulder stiffness. Anma therapy techniques were standard versions composed mainly of kneading and lesser amounts of stroking and pressing, with intensity of stimulation applied within the range of comfort. Outline of the procedure of the Anma therapy is described briefly in Box 1. In the Rest Intervention (controls), participants lie on the massage table and rest for 40 min, without Anma therapy.

Design and setting The design of this study was cross-over. Participants were assigned randomly to two groups: Group A (nine subjects); Anma therapy was performed on the first day, and the rest intervention was performed 3 days after. Group B (eight subjects); received the rest intervention on the first day, and Anma therapy after a 3 days interval. The participants did not know to which group they had been assigned until the first intervention. Two persons in Group B withdrew from participation on the first day due to family circumstances. Therefore, the subject number in Group B decreased to six subjects prior to the beginning of the study. No subjects withdrew from participation during the study. The mean agestandard deviation (S.D.) of participants in the study was 55.42.1 years of age and the mean Body Mass Index (BMI)S.D. was 21.21.8. In Group A, the mean ageS.D. was 55.12.2 years of age and the mean BMIS.D. was 21.22.0, and in Group B, the mean ageS.D. and BMIS.D. were 55.82.1 years of age and 21.31.4, respectively. Unpaired (independent samples, two-tailed) t-test was performed in order to determine the differences in basic physical attributes between the two groups, and it was confirmed that there were no significant differences in age (t (d.f. 13)Z0.6, pZ0.54) or BMI (t (d.f. 13)Z0.09, pZ0.93).

Procedure Upon presentation to the laboratory, participants washed their mouths out with water from a disposable paper cup

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Box 1. Summary description of Anma procedure I. Lying down on one side for 17 min A. Procedure for the back including the shoulder, the back, and the lower back (1) Stroking starts at the base of the neck along the upper shoulder to the shoulder joint (2) Downward strokes along the full length of the back, starting at the base of the neck down to the waist (3) Thumb kneading by circular or linear (back and forth) movement: the upper shoulder from the side of the 7th cervical vertebra (Cv7) to the acromion along the trapezius (4) Thumb kneading by circular or linear movement: from Cv7 via the superior angle of the scapula and the supraspinous fossa to the acromion, on the levator scapulae, rhomboid, and supraspinatus (5) Thumb kneading by linear movement along the spine: from the side of Cv7 to the side of the 5th lumbar vertebrae (Lv5) on the erector spinae and the quadratus lumborum (6) Thumb or other four-finger kneading by circular or linear movement on the medial and lateral border of scapula (7) Heel of the hand kneading by circular movement on the infraspinous fossa (8) Downward strokes again along the length of the back, starting at the base of the neck down to the waist (9) Stroking again starting at the base of the neck along the upper shoulder to the shoulder joint B. Procedure for the upper limb and the hand (1) Stroking down from the shoulder to the fingertips (2) Palm grasp kneading over the upper limb on the deltoid (3) Palm grasp kneading over the upper front limb on the biceps brachii (4) Palm grasp kneading over the back of the upper limb on the triceps brachii (5) Thumb kneading on the back of the forearm (6) Palm grasp kneading on the front and the side of the forearm (7) Thumb kneading on the hand (8) Knead and squeeze each finger along the full length using the thumb and the index (9) Stroking down from the shoulder to the fingertips C. Procedure for the neck (1) Stroking starting at the superior nuchal line along the neck to the base of the neck (2) Thumb kneading over the back of the neck on the semispinal capitis, the splenius capitis, and the trapezius descending part (3) Thumb, two-finger (thumb and index), or four-finger kneading to the side of the neck, on the sternocleidomastoid (4) Apply four-finger kneading to the front of the neck (5) Thumb kneading and pressure along the superior nuchal line (6) Stroking again starting at the superior nuchal line along the neck to the base of the neck D. The cycle starts again with item A E. Procedure for the lower limb and the foot (1) Stroking from the buttock to the toes (2) Kneading over the buttock with the heel of the hand (3) Palm kneading on the front thigh, on the quadriceps femoris muscle (4) Palm grasp kneading to the back thigh or hamstrings (5) Palm grasp kneading on the patella (6) Thumb kneading on the front lower leg (7) Palm grasp kneading on the calf muscles (8) Palm grasp kneading of the Achilles tendon (9) Finger kneading over the top of the foot (10) Thumb kneading and pressure on the sole (11) Knead and squeeze each toe along the length using thumb and index finger (12) Intermittent palm pressure on the entire leg (13) Stroking again from the buttock to the toes II. Lying down on the opposite side, repeat A B C D E for 17 min III. Conclusion: in the prone position for 6 min (All the techniques in this concluding section are done simultaneously on the left and right side of the subject) (1) Stroking starts at the superior nuchal line along the sides of the neck and the upper shoulders to the shoulder joints (2) Downward strokes along the full length of the back, starting at the base of the neck down to the waist

Effects of Anma therapy (traditional Japanese massage) on body and mind

(3) (4) (5) (6) (7) (8) (9)

59

Grasp hand kneading, thumb kneading, and pressure over the back of the neck Four-finger kneading and pressure on the sides of the neck Grasp hand kneading, thumb kneading, and pressure on the upper shoulder Thumb kneading and pressure along the spine Palm grasp hand kneading over the sides of the back, from the waist to the shoulder jointsdlatissimus dorsi Downward strokes again along the full length of the back Stroking again from the superior nuchal line along the sides of the neck and the upper shoulders to the shoulder joints

Note: It is recommended that the guide book by Kimura et al. (2003) should be referred to for more detailed information on the basic techniques of Anma therapy.

and took a 15-min rest. Then, a saliva sample was obtained, and participants answered self-assessments of the neck and shoulder stiffness condition and feeling of anxiety. A 40-min intervention was then performed. After the session, assessments were performed again. Each time, the experiments began at 5 p.m. in consideration of the circadian rhythms of cortisol and s-IgA in saliva (Walker et al., 1984; Dimitriou et al., 2002). This study was approved by Human Ethics Committee of the Institute of Health and Sport Sciences, University of Tsukuba and performed according to the ethical standards set forth in the Helsinki Declaration in its revised version of 1975 and its amendments of 1983, 1989, and 1996.

Measurements (i) The VAS was used to assess the severity of the subjective symptom, muscle stiffness in the neck and shoulder. A sheet of paper (width 100 mmheight 40 mm) was given to the subject and it was explained that the left edge of the paper represented no symptoms and the right edge represented the most serious symptoms that the subject could imagine. The subject was then asked to indicate how serious the degree of their neck and shoulder stiffness was at that time and to record it as a tick on the paper. Length from the left edge to the tick on the paper was measured and treated as the VAS score. (ii) The state anxiety score was measured by the Japanese version of the State Trait Anxiety Inventory by Spielberger, Gorsuch, and Leshene (Mizuguchi et al., 1991), a self-report Likert scale, to assess the degree of anxiety being felt by participants at that time. The State Anxiety scale consists of 20 items that assess how the individual feels at that very moment, on a scale of severity including, 1 ‘‘not at all’’; 2 ‘‘somewhat’’; 3 ‘‘moderately so’’; and 4 ‘‘very much so’’; and the scores of items are added. The range of obtained scores is from 20 to 80. The higher the score obtained, the stronger the state anxiety. The reliability and validity of this scale has been repeatedly demonstrated (Mizuguchi et al., 1991). Cronbach’s alpha coefficients of this scale in the present study were 0.94, 0.91, 0.77, and 0.82 for pre-AI, post-AI, pre-RI, and post-RI, respectively. (iii) Two milliliter unstimulated saliva was collected at preand post-interventions, into serum-tubes, sealed and frozen immediately in a freezer on the night when the

intervention was conducted. On the next morning, they were delivered to the assay company (SRL Inc., Tsukuba, Japan). Assays were conducted for concentration levels of salivary cortisol and s-IgA in samples by g-cortisol and Enzyme Immunoassay (EIA) s-IgA test, respectively.

Statistical analysis To assess the immediate effects of Anma therapy comparing to those of rest without Anma therapy, VAS, state anxiety, salivary cortisol concentration level, and s-IgA concentration level were analyzed by repeated measures analyses of variance (ANOVA). To assess the longer-term effects of Anma therapy, repeated measures ANOVA were performed again. Moreover, to clarify differences between Anma therapy and the rest intervention effects on each item of the state anxiety, significant differences between pre- and post-intervention scores for each of the 20 State Anxiety items were determined by paired (two-tailed) t-test. All statistical analyses were performed by SPSS 15.0. Alpha was set equal to 0.05, thereby implying that any statistical outcome that had a p<0.05 would indeed be statistically significant.

Results To assess immediate changes of Anma therapy, differences of intervention order by the cross-over design, i.e., differences between group A (Anma therapy was performed on the first day) and Group B (the rest intervention was performed on the first day) were not effective (VAS FZ0.2, pZ0.652; state anxiety FZ1.2, pZ0.277; cortisol FZ0.5, pZ0.479; s-IgA FZ0.012, pZ0.913) (Table 1). Post-intervention VAS scores were significantly lower than those obtained pre-intervention (FZ42.4, pZ0.0005); there was significant difference between Anma therapy and the rest intervention (FZ20, pZ0.0005). Further, post-intervention state anxiety scores were significantly lower than those obtained pre-intervention (FZ15.0, pZ0.001); difference between Anma therapy and the rest intervention was FZ4.1, pZ0.053. For concentration levels of salivary cortisol, no significant differences between Anma therapy and the rest intervention (FZ0.8, pZ0.383) and within preintervention and post-intervention (FZ1.1, pZ0.301). Concentration levels of s-IgA post-intervention were

60 Table 1

N. Donoyama et al. Immediate intervention comparison (repeated measures analyses of variance ANOVA) nZ15.

Pre-/post-intervention measures Values

Visual Analogue Scale Anma therapy Rest intervention State anxiety Anma therapy Rest intervention Cortisol (mg/dL) Anma therapy Rest intervention s-IgA (mg/mL) Anma therapy Rest intervention

Effect

Pre

Post

Pre vs post

Pre/post Anma/rest

Pre/post Groups A/B

MeansS.E. (95% CI)

MeansS.E. (95% CI)

F

F

F

59.64.3 (50.4e68.8) 52.95.0 (42.2e63.7)

25.85.8 (13.1e38.6) 46.75.2 (35.4e57.9)

35.61.9 (31.9e39.4) 35.01.9 (31.1e38.8)

28.31.7 (24.8e31.7) 32.71.7 (29.3e36.1)

0.2290.022 (0.183e0.275) 0.1960.022 (0.149e0.242)

0.2100.020 (0.169e0.251) 0.1940.020 (0.153e0.235)

582.969.5 (439.9e725.4) 586.069.5 (443.3e728.8)

1082.8131.4 (812.8e1352.9) 1156.3131.4 (886.3e1426.4)

p

p

p

42.4 0.0005*** 20 0.0005*** 0.2

0.652

15.0 0.001**

4.1 0.053

1.2

0.277

1.1 0.301

0.8 0.383

0.5

0.479

63.9 0.0005*** 0.3 0.605

0.012 0.913

Group A: nZ9, first interventionZAnma therapy, second interventionZrest. Group B: nZ6, first interventionZrest, second interventionZAnma therapy. ** p<0.01. *** p<0.001.

increased significantly compared with those obtained preintervention (FZ6.39, pZ0.0005); however, there was no difference between Anma therapy and the rest intervention (FZ0.1, pZ0.756) (Table 1). To assess the longer-term effects of Anma therapy, prefirst intervention values and pre-second intervention values were compared between Group A and the B (Table 2). In Group A, pre-second intervention VAS scores, 47.25.7 were lower than those obtained pre-first intervention, 60.76.0, but not statistically significantly different (FZ3.4, pZ0.087); whereas in Group B, those obtained pre-second intervention, 58.57.0 was not almost changed as those obtained pre-first intervention, 58.77.3; there was no significant difference between Groups A and the B (FZ3.3, pZ0.094). Pre-second intervention state anxiety scores were significantly lower than those obtained pre-first intervention (FZ4.8, pZ0.048); however, there was no significant difference between Groups A and the B (FZ0.1, pZ0.740). For concentration levels of salivary cortisol, there were no significant differences within pre-first intervention and pre-second intervention (FZ1.8, pZ0.198) and between Groups A and the B (FZ2.5, pZ0.135). Moreover, for concentration levels of s-IgA, there were no significant differences within pre-first intervention and pre-second intervention (FZ0.1, pZ0.756) and between Groups A and the B (FZ0.004, pZ0.951) (Table 2). Table 3 shows the results of an examination of the significant differences between pre- and post-interventions on each of the 20 items of state anxiety. After Anma therapy, the scores improved significantly in 10 items: ‘‘I feel at ease’’; ‘‘I feel rested’’; ‘‘I feel anxious’’; ‘‘I feel comfortable’’; ‘‘I feel self-confident’’; ‘‘I am relaxed’’; ‘‘I feel content’’; ‘‘I am worried’’; ‘‘I feel joyful’’; and ‘‘I feel pleasant’’; on the other hand, after the rest intervention,

the score for the item ‘‘I am tense’’ improved significantly. There were no items that revealed significant differences between pre-Anma therapy and pre-rest intervention start lines.

Discussion The immediate change in the post-Anma therapy VAS scores verified that Anma therapy, distinguished from rest lying on the massage table, can improve subjective symptoms of muscle stiffness in the neck and shoulder. The effectiveness of Chinese and Western massage therapies for similar symptoms was discussed in previous studies: Can et al. (2003) suggested that traditional Chinese massage was effective for neck pain. In some studies on fibromyalgia (Sunshine et al., 1996; Field et al., 2002, 2003), improvement of muscle pain and stiffness were demonstrated by Western style massage. On the therapeutic effective mechanism of massage therapy, Field (2002a, b) hypothesized that massage therapy may reduce muscle tension, facilitate the removal of toxic metabolites and waste products, and allow oxygen and nutrients to reach the cells and tissues. In a study by Mori et al. (2004), it was revealed that massage increased the blood flow although it was performed on the lower back. In the present study, it is suggested that manual mechanical stimuli by Anma therapy also increase blood flow, remove metabolites and waste products that may in turn, result in the alleviation of the subjective symptoms in the neck and shoulder. Gregory and Mars (2004) showed that mean external cross-sectional diameter increased on microscopic examination by 8% immediately after compressed air massage of muscle and suggested that compressed air massage of muscle caused vasodilation of skeletal muscle capillaries

Effects of Anma therapy (traditional Japanese massage) on body and mind Table 2

61

Longer-term intervention comparison (repeated measures analyses of variance ANOVA).

Pre-/post-intervention measures Values

Visual Analogue Scale Group A Group B State anxiety Group A Group B Cortisol (mg/dL) Group A Group B s-IgA (mg/mL) Group A Group B

Effect

Pre-first

Pre-second

Pre-first/ pre-second

Pre-first/ pre-second Groups A/B

MeansS.E. (95% CI)

MeansS.E. (95% CI)

F

p

F

p

3.4

0.087

3.3

0.094

4.8

0.048*

0.1

0.740

1.8

0.198

2.5

0.135

0.1

0.756

0.004

0.951

60.76.0 (47.7e73.6) 58.77.3 (42.8e74.5)

47.25.7 (34.8e59.6) 58.57.0 (43.3e73.7)

41.82.3 (36.7e46.9) 32.52.9 (26.3e38.7)

37.42.4 (32.2e42.7) 29.33.0 (22.9e35.7)

0.2630.035 (0.187e0.339) 0.1900.043 (0.097e0.283)

0.2010.020 (0.159e0.243) 0.1950.024 (0.143e0.247)

528.981.5 (352.9e704.9) 656.699.8 (441.0e872.1)

515.593.8 (312.8e718.2) 636.5114.9 (388.2e884.7)

Group B: nZ6, first interventionZrest, second interventionZAnma therapy. Group A: nZ9, first interventionZAnma therapy, second interventionZrest. * p<0.05.

that persisted for a minimum of 24 h after treatment. VAS score reduction in the present study was also found 3 days after Anma therapy, though there was no statistically significant difference. It is implied that Anma therapy reduces muscle tension, causes vasodilation of skeletal muscle capillaries, and boosts circulation, resulting in the alleviation of symptoms of annoyance, unpleasant sensation, strain, stiffness, ache, and pain in muscles, and that the effectiveness of this may continue for a minimum of 3 days. Further studies are needed to verify these points. It was thought that sample size in the present study was too small to analyze two factor repeated measures ANOVA; the number of the participants who had been given Anma therapy on the first day was nine, and that of those who had been given the rest intervention on the first day was six. In the immediate change in the post-Anma therapy state anxiety scores, it was verified that Anma therapy can reduce state anxiety, however significant probability differed from rest lying on the massage table was 0.053. This result was the same as results obtained in previous studies on Western style massage therapy (Field et al., 1992, 1997, 1998, 2002, 2003; Hart et al., 2001; HernandezReif et al., 2000, 2001, 2003, 2005, 2007). However, it is not meaningful to compare state anxiety scores 3 days after Anma therapy with scores obtained pre-Anma therapy, because the State Anxiety scale assesses the degree of anxiety being felt at that moment. Further studies, using an appropriate measurement (i.e., the Trait Anxiety Inventory, designed to assess susceptibility to long-term feelings of anxiety), are needed to clarify consecutive effect on anxiety by Anma therapy. From the results of analysis on the 20 items for state anxiety, it is thought that Anma therapy can eliminate emotional discomfort, induce psychological relaxation and enjoyment, and improve the anxious condition. On the other hand, the score for the item ‘‘I am tense’’ improved significantly after rest, while the score after Anma therapy

was not changed. A close relationship between the client and the therapist is created in the usual clinical setting for Anma therapy. A client usually chooses a person as therapist whom they can trust based on the personality and technique. In this study, however, participants did not know the personality of the therapist or what techniques the practitioner could perform, because they were recruited only for the study. On the other hand, rest is not necessarily associated with a given individual. It is presumed that this is the reason why rest could alleviate the feeling of tension more than Anma therapy could in the study. This implies that it is important for Anma therapists to develop a good relationship with clients for more effective treatment. Cortisol is a major steroid hormone secreted by the adrenal cortex via reactions in the hypothalamus-pituitaryadrenal axis and autonomic nervous system, and is used commonly as an index of stress (Fukuda and Morimoto, 2001). In this study, salivary cortisol concentration was reduced only marginally after Anma therapy. This is in contrast to results obtained in previous studies on Western massage therapy (Field, 1998, 2000; Field et al., 1992, 1997, 1998; Hart et al., 2001; Hernandez-Reif et al., 2000), in which salivary cortisol levels decreased significantly after massage sessions. We can consider two reasons for these results at present. One is an equation on a method to collect saliva. In this study, 2 mL unstimulated saliva was collected directly from the mouth into the serum-tube by the participants, themselves. The difficulty of saliva collection may have varied among participants, requiring more time for some participants to perform and causing some to feel a psychological burden. It is possible that these circumstances prevented the reduction of cortisol. Further studies, using easier means of collect saliva, are needed to verify these points. Another possibility is that there was a baseline effect with cortisol levels being so low that any intervention, no matter how effective would cause

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Table 3 Meanstandard deviation for pre-/post-intervention measures for immediate intervention comparison for each of the 20 state anxiety items nZ15.

Effects of Anma therapy (traditional Japanese massage) on body and mind these levels to become significantly lower. Further studies are necessary to clarify these points on salivary cortisol. In immediate changes by both of Anma therapy and rest, in the present study, s-IgA concentration levels were significantly increased. Several studies demonstrate that relaxation by the watching of a humorous movie (Dillon et al., 1985), imagery (Jasnoski and Kugler, 1987), and massage (Green and Green, 1987) lead to highly significant increases in s-IgA concentrations. Dillon et al. (1985) showed that a humorous movie led to increases in s-IgA, suggesting that increases in well-being are accompanied by increases in s-IgA. Groer et al. (1994) also demonstrated an elevation in s-IgA concentration after a 10-min back rub and provided the rationale for the holistic benefits. On the other hand, during overtraining, athletes are susceptible to upper respiratory tract infection (URTI) because of decreases in s-IgA (Mackinnon et al., 1993; Mackinnon and Hooper, 1994). S-IgA, the predominant immunoglobulin type in mucosal secretion is a major effector of resistance against pathogenic microorganisms causing URTI (Mackinnon et al., 1993; Mackinnon and Hooper, 1994). These results, therefore, indicate that Anma therapy as a holistic treatment may increase s-IgA by increasing well-being, enhance immunological function, and contribute to the prevention of illness, although the immediate changes by therapy are no more effective than the control and other previous interventions in increasing s-IgA levels. In addition, s-IgA concentration changes could not be demonstrated for long-term periods. Further studies measuring sIgA concentration levels over time are needed to clarify this point. In conclusion, it is found that Anma therapy by which stimulation is applied to the surface of the body can reduce muscle stiffness in the neck and shoulder and anxiety.

Acknowledgments The present study, No. 17653125, was supported by a science study program grant from the Education and Science Ministry of Japan, 2005. Principal Investigator was Nozomi Donoyama.

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Japan Society of Acupuncture and Moxibustion 52, 296 (in Japanese). Donoyama, N., Shoji, S., Munakata, T., 2005. Effect of traditional Japanese massage, Anma therapy on body and mind: a preliminary study. The Journal of the Japanese Society of Balneology, Climatology and Physical medicine 68 (4), 241e247. Eisenberg, D.M., Davis, R.B., Ettner, S.L., Appel, S., Wikey, S., Van Rompay, M., Kessler, R.C., 1998. Trends in alternative medicine use in the United States, 1990e1997: results of a follow-up national survey. The Journal of the American Medical Association 280, 1569e1575. Ernst, E., White, A., 2000. The BBC survey of complementary medicine use in the UK. Complementary Therapies in Medicine 8 (1), 32e36. Field, T., 1998. Massage therapy effects. The American Psychologist 53, 1270e1281. Field, T., 2000. Touch Therapy. Churchill Livingstone, Edinburgh. Field, T., 2002. Massage therapy. The Medical Clinics of North America 86 (1), 163e171. Field, T., 2002. Massage therapy research methods. In: Lewith, G., Jones, W. (Eds.), Clinical Research in Complementary Therapies. Harcourt Publishers Limited, Edinburgh. Field, T., Morrow, C., Valdeon, C., Larson, S., Kuhn, C., Schanberg, S., 1992. Massage reduces depression and anxiety in child and adolescent psychiatric patients. Journal of the American Academy of Child and Adolescent Psychiatry 31, 125e130. Field, T., Hernandez-Reif, M., Seligman, S., Krasnegor, J., Sunshine, W., 1997. Juvenile rheumatoid arthritis: benefits from massage therapy. Journal of Pediatric Psychology 22, 607e617. Field, T., Schanberg, S., Kuhn, C., Field, T., Fierro, K., Henteleff, T., Mueller, C., Yando, R., Shaw, S., Burman, I., 1998. Bulimic adolescents benefit from massage therapy. Adolescence 33, 555e563. Field, T., Diego, M., Cullen, C., Hernandez-Reif, M., Sunshine, W., Douglas, S., 2002. Fibromyalgia pain and substance P decrease and sleep improves after massage therapy. Journal of Clinical Rheumatology 8 (2), 72e76. Field, T., Delage, J., Hemandez-Reif, M., 2003. Movement and massage therapy reduce fibromyalgia pain. Journal of Bodywork and Movement Therapies 7, 49e52. Fukuda, S., Morimoto, K., 2001. Lifestyle, stress and cortisol response: review 1. Environmental Health and Preventive Medicine 6, 9e14. Green, R.G., Green, M.L., 1987. Relaxation increases salivary immunoglobulin A. Psychological Reports 61, 623e629. Gregory, M.A., Mars, M., 2004. Compressed air massage causes capillary dilation in untraumatised skeletal muscle: a morphometric and ultrastructural study. Society of Physiotherapy 91 (3), 131e137. Groer, M., Mozingo, J., Droppleman, P., Davis, M., Jolly, M.L., Boynton, M., Davis, K., Kay, S., 1994. Measures of salivary secretory immunologlobulin A and state anxiety after a nursing back rub. Applied Nursing Research 7, 2e6. Hart, S., Field, T., Hernandez-Reif, M., Nearing, G., Shaw, S., Schanberg, S., Kuhn, C., 2001. Anorexia nervosa symptoms are reduced by massage therapy. Eating Disorders 9, 289e299. Health and Welfare Statistics Association, 1996. Movement of the Public Health, Tokyo (in Japanese). Health and Welfare Statistics Association, 2001. Movement of the Public Health, Tokyo (in Japanese). Hernandez-Reif, M., Field, T., Krasnegor, J., Theakston, H., 2000. High blood pressure and associated symptoms were reduced by massage therapy. Journal of Bodywork and Movement Therapies 4, 31e38. Hernandez-Reif, M., Field, T., Krasnegor, J., Theakston, H., 2001. Lower back pain is reduced and range of motion increased after massage therapy. The International Journal of Neuroscience 106, 131e145. Hernandez-Reif, M., Ironson, G., Field, T., Katz, G., Diego, M., Weiss, S., Fletcher, M., Schanberg, S., Kuhn, C., 2003. Breast

64 cancer patients have improved immune functions following massage therapy. Journal of Psychosomatic Research 57, 45e52. Hernandez-Reif, M., Field, T., Ironson, G., Beutler, J., Vera, Y., Hurley, J., Fletcher, M., Schanberg, S., Kuhn, C., Fraser, M., 2005. Natural killer cells and lymphocytes increase in women with breast cancer following massage therapy. The International Journal of Neuroscience 115, 495e510. Hernandez-Reif, M., Field, T., Diego, M., Fraser, M., 2007. Lower back pain and sleep disturbance are reduced following massage therapy. Journal of Bodywork and Movement Therapies 11 (2), 141e145. Hirabayashi, S., 2002. Cervico-omo-brachial syndrome (including muscle stiffness of shoulder). In: Ogata, E. (Ed.), Today’s Therapy. Igakushoin, Tokyo (in Japanese). Ishii, S., Hirasawa, Y. (Eds.), 2002. Standard Textbook Orthopedics and Traumatology: Locomotive Quality of Life. Igakushoin, Tokyo (in Japanese). Jasnoski, M.L., Kugler, J., 1987. Relaxation, imagery, and neuroimmunomodulation. Annals of the New York Academy of Sciences 496, 722e730. Kimura, A., Yokoyama, E., Takahashi, F., 2003. Japanese Anma: A Step-by-Step Guide of Japanese Traditional Massage. Ounkai Social Welfare for the Blind, Tokyo. Kirschbaum, C., Kudielka, B.M., Gaab, J., Schommer, N.C., Hellhammer, D.H., 1999. Impact of gender, menstrual cycle phase, and oral contraceptives on the activity of the hypothalamus-pituitary-adrenal axis. Psychosomatic Medicine 61 (2), 154e162. Lovas, J.M., Graig, A.R., Raison, R.L., Weston, K.M., Segal, Y.D., Markus, M.R., 2002. The effects of massage therapy on the human immune response in healthy adults. Journal of Bodywork and Movement Therapies 6 (3), 143e150. Mackinnon, L.T., Hooper, S., 1994. Mucosal (secretory) immune system responses to exercise of varying intensity and during overtraining. International Journal of Sports Medicine 15, 179e183. Mackinnon, L.T., Ginn, E., Seymour, G.J., 1993. Decreased salivary immunoglobulin A secretion rate after intense interval exercise

N. Donoyama et al. in elite kayakers. European Journal of Applied Physiology and Occupational Physiology 67, 180e184. Mizuguchi, K., Shimonaka, Y., Nakazato, K., 1991. The Japanese Translation Version of STAI. Sankyobo, Kyoto (in Japanese). Mori, H., Ohsawa, H., Tanaka, T.H., Taniwaki, E., Leisman, G., Nishijo, K., 2004. Effect of massage on blood flow and muscle fatigue following isometric lumbar exercise. Medical Science Monitor 10 (5), CR173eCR178. Oride, T., Kimura, K., Saito, S., Sakai, T., 2002. The role of Anma/massage therapy in the company: the first report. The Journal of Japanese Association of Manual Therapy 13, 14e18 (in Japanese). Sato, A., Schmidt, R.F., 1971. Spinal and supraspinal conponents of the reflex discharges into lumber and thoracic white rami. The Journal of physiology 212 (3), 839e850. Sato, A., Sato, Y., Suzuki, A., Uchida, S., 1996. Reflex modulation of catecholamine secretion and adrenal sympathetic nerve activity by acupuncture-like stimulation in anesthetized rat. The Japanese Journal of Physiology 46 (5), 411e421. Sato, A., Sato, Y., Schmidt, R.F., 1997. The impact of somatosensory input on autonomic functions. Reviews of Physiology Biochemistry and Pharmacology 130, 1e328. Sato, A., Sato, Y., Uchida, S., 2002. Reflex modulation of visceral functions by acupuncture-like stimulation in anesthetized rats. International Congress Series 1238, 111e123. Simple Question. Yellow Emperor’s Inner Classic (in Japanese). Spiritual Axis. Yellow Emperor’s Inner Classic (in Japanese). Sunshine, W., Field, T.M., Quintino, O., Fierro, K., Kuhn, C., Burman, I., Schanberg, S., 1996. Fibromyalgia benefits from massage therapy and transcutaneous electrical stimulation. Journal of Clinical Rheumatology 2, 18e22. Walker, R.F., Joyce, B.G., Dyas, J., 1984. Salivary cortisol: 1. Monitoring changes in normal adrenal activity. In: Read, G.F., Riad-Fahmy, D., Walker, R.F., Griffiths, K. (Eds.), Immunoassays of Steroids in Saliva. Alpha Omega, Cardiff. Yamashita, H., Tsukayama, H., Sugishita, C., 2002. Popularity of complementary and alternative medicine in Japan: a telephone survey. Complementary Therapies in Medicine 10 (2), 84e93.

Journal of Bodywork & Movement Therapies (2010) 14, 65e72

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PERFORMING ARTS MEDICINE

Performing arts medicine e Instrumentalist musicians, Part II e Examination Jan Dommerholt, PT, DPT, MPS* Bethesda Physiocare, Inc./Myopain Seminars, LLC, 7830 Old Georgetown Road, Suite C-15, Bethesda, MD 20814-2440, USA Received 24 November 2008; received in revised form 11 February 2009; accepted 12 February 2009

KEYWORDS Musicians; Performing arts medicine; Posture; Range of motion

Summary Part I of this article’s series included background information on performing arts medicine with a special focus on musicians. It covered in detail what questions need to be included in the history, when healthcare providers first examine musicians. In part II of the series, the emphasis is on the physical examination, including posture, range of motion and hypermobility, ergonomics, and instrument-specific examination procedures. The final article in the series will describe three case histories of musicians with hand pain. ª 2009 Elsevier Ltd. All rights reserved.

Introduction

Examination

This article is the second installment of a series of three articles on performing arts medicine with an emphasis on musicians. Part I covered general background information and outlined the components of the history-taking process indicated when examining musicians. In this article the emphasis is on the examination of musicians. During the history, clinicians will start formulating clinical hypotheses, which subsequently are confirmed or denied by the physical examination. A unique aspect of the examination of musicians is the evaluation with the musical instrument

Each musician needs to be approached on the basis of professional and personal demands and not every musician requires a full examination, including an assessment of pain, posture, strength, and range of motion. (Brandfonbrener, 1990; De Smet et al., 1998). The predominant symptom of musicians is pain, which usually involves muscles (Fry, 1984; Lambert, 1992; Moulton and Spence, 1992). There is little evidence that musicians suffer frequently from tendonitis or tenosynovitis, although these diagnoses are often made (Amadio and Russoti, 1990; Bengtson et al., 1993; Bejjani et al., 1996). Most musicians have developed inefficient movement patterns not only when they play their instruments, but also during other activities or functions (Williamson et al., 2007). Based on

* Tel.: þ1 301 656 5613; fax: þ1 301 654 0333. E-mail address: [email protected]

1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.02.004

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J. Dommerholt

empirical evidence, many musicians develop overuse syndromes with clinically relevant myofascial trigger points, even after brief periods of playing (Bryant, 1989; Meador, 1989; Chen et al., 2000; Davies, 2002). The examination for the presence of relevant myofascial trigger points will be included in part III of the series.

Posture The influence of posture on musical performance is well recognized (Dommerholt and Norris, 1997; Brandfonbrener, 1998; Dommerholt, 2000). Musicians’ postures may not be all that different from others, but the combination of deficient posture and playing an instrument may become problematic (Cailliet, 1990; Eijsden-Besseling et al., 1993; Dommerholt, 2000; Kapandji, 2000), which is why musicians’ postures should be evaluated with and without the musical instrument. In this context, it is important to realize that frequently the musical instrument has become an extension of professional musicians (Ostwald, 1992). Wind instrumentalists with forward head posture may experience difficulty with their embouchure and breathing, and may suffer from frequent headaches (see Figures 1 and 2) (Samama, 1981; Brouw, 1983; Balfoort, 1985; Ferna ´ndez

Figure 1 French horn player with forward head posture, who complained of episodic tension-type headaches, neck and shoulder pain, low back pain, decreased air volume, and difficulty with his embouchure (ª 2008 e Jan Dommerholt).

Figure 2 Same French horn player with winging of the right scapula, elevation of the left shoulder, and scoliosis of the spine (ª 2008 e Jan Dommerholt).

de las Pen ˜as et al., 2006; Ferna ´ndez de las Pen ˜as et al., 2007). Postural asymmetries as a result of instrument design are common for example, with the violin, guitar, flute, or double bass (Norris and Dommerholt, 1996). Violinists with forward head posture and poor axial extension may have difficulty with prolonged bowing and with positioning the fingers of the left hand in the strings, due to excessive internal rotation of the left arm. Violinists often play with their head tilted to the left and left rotation of the cervical spine, elevation of the left shoulder, and a scoliotic curve of the thoracic spine, combined with a preference to carry the weight of the body on the right foot, which in turn induces a downward shift of the left pelvis, and a scoliotic curvature of the lumbar spine (see Figures 3 and 4) (Kapandji, 2000). The question remains when asymmetry becomes problematic. Not all musicians have musculoskeletal problems and clinicians need to assess ease of movement, constraints, and coordination. The combination of awkward postures and repetitive motions has been shown to be particularly stressful and may contribute to muscle damage, tendonitis, or nerve damage (Larsson et al., 1988; Feuerstein and Hickey, 1992; Kuorinka and Forcier, 1995). The more a clinician is familiar with the characteristics and demands of musical instruments, the more accurate the assessment will be (Blanken et al., 1991; Ackermann and Adams, 2004a). Interestingly, many musicians consult with posture and movement specialists before consulting with a physician or physical therapist (Williamson, 1998). Physical therapists tend to have a predominant biomechanical orientation, which may not always be adequate in the treatment of musicians (Hullegie, 1995). Biomechanical approaches

Performing arts medicine e Instrumentalist musicians

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Figure 3 Common incorrect posture of a violinist (ª 2008 e Jan Dommerholt).

Figure 4 Correct posture of a violinist (ª 2008 e Jan Dommerholt).

employ hypothetico-deductive methods and focus mainly on the external aspects of human movement (Hullegie, 1995), whereas somatic approaches, such as the Alexander technique or Feldenkrais, recognize the unique context in which musicians work and move (Dommerholt, 2000). The Alexander technique is not really a form of movement education, but aims to help musicians and others to become aware of habitual movement patterns, which are corrected by increasing self-awareness and thought through processes referred to as inhibition and direction (Williamson, 2003). Through inhibition, musicians may learn to restrain the habitual patterns, while direction refers to the actual learning of new patterns (Mayers and Babits, 1987; Knebelman et al., 1994). Posture should be seen as relational and intentional movements through which musicians can express their musical dialogue (Batson, 1996, 1997).

at times be indicated, such as measuring limb lengths in relation to the musical instrument to identify those musicians at greater risk for injury. Violinists with relatively short arms were found to be at greater risk unless they modified their head position or the way they hold the instrument (Ackermann and Adams, 2003). Some musicians may need to be examined for localized or systemic hypermobility, which can be problematic for some, while advantageous to others (Brandfonbrener, 1990; Larsson et al., 1993; Brandfonbrener, 2002). The Beighton Scale of Hypermobility is useful as an initial screening. The test assesses hypermobility at the fingers, elbows, spine, knees, and thumb for a total of nine joints. A score of 4 out of 9 may indicate systemic hypermobility (Russek, 1999, 2000). The Modified Beighton Scale provides more detailed information. It is important to understand that not all persons with hypermobility have systemic hypermobility (Keer and Grahame, 2003). Sometimes, hypermobility is seen only in the upper extremities. For example, an 11-year-old cellist experienced much difficulty when playing vibrato, because of hypermobility of her finger joints. During the evaluation, she was asked to play the cello and demonstrate how she would play with vibrato. It was evident that she could not stabilize her fingers adequately and she was not able to avoid hyper-extending her interphalangeal joints (see Figure 5).

Range of motion Musicians may present with characteristic differences in range of motion. For example, experienced violinists may display greater range of motion of their left hand when compared to the right, which most likely can be attributed to functional adaptation (Ackermann and Adams, 2003). Special tests to identify involved structures or tissues may

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Figure 5 Eleven-year-old cellist with hyperextension of the distal interphalangeal joints of the left fingers. The musician was referred to physical therapy by her music teacher to determine whether there were any physical reason why she was not able to play vibrato (ª 2008 e Jan Dommerholt).

An eighteen-year-old violinist with hypermobility of the left thumb was not able to play the instrument until she started using a custom-made splint (see Figures 6 and 7).

Ergonomics Musical instruments were designed without incorporating any ergonomic principles and in spite of some efforts to improve the design, playing a musical instrument may physically be challenging (Wagner, 1995; Norris and Dommerholt, 1996; Markison, 1998). The design of an instrument may require excessive reach beyond the musician’s anthropometric capabilities (Wagner, 1988). Young players’ hands may be too small to comfortably reach the keys of their instruments. Observing a child’s play on an instrument that is too large will reveal excessive reaching to cover the keys of the instrument or to depress the keys on the keyboard. Violins come in different sizes to accommodate

Figure 6 Eighteen-year-old college student with painful hypermobility of the left thumb interfering with her ability to play violin. She was referred to physical therapy by her music teacher (ª 2008 e Jan Dommerholt).

J. Dommerholt

Figure 7 Correction of thumb hypermobility with a custommade splint* enabling the violinist to return to playing the instrument without any discomfort (ª 2008 e Jan Dommerholt). *Silver Ring Splint Company, Charlotteville, VA, USA.

the young player’s smaller hand size, but for other instruments such as the flute, clarinet, or oboe one size is supposed to fit all (Kopfstein-Penk, 1994). Kopfstein-Penk developed a measurement system to match players’ hands to the appropriate size guitar (Kopfstein-Penk, 1994). She relates the size of the hand to the size of the instrument. Norris designed a pediatric flute with an angled head joint and modified keys, which would allow young players to play the instrument without intrinsic hand strain (Norris and Dommerholt, 1996). One of the world’s leading authorities on adapting musical instruments is Maarten Visser, who out of his Amsterdam-based studio (www.flutelab.com) has modified instruments to accommodate individual musicians (see Figures 8 and 9) (Nabb, 2006). Some musical instruments have specific characteristics that may predispose musicians to injury (Hopmann, 1998). Evaluating the physical interface with the musical instrument can provide valuable insights. Therefore, all musicians should be encouraged to bring their instrument to the clinic. A unique aspect of performing arts medicine is that as part of the initial examination, the patient is examined

Figure 8 Flute key modification to accommodate a musician with an unusual short fifth finger (photograph courtesy of Maarten Visser, www.flutelab.com).

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Figure 11 Contact pressure of the left index finger against the flute increasing the risk of nerve compression (ª 2008 e Jan Dommerholt).

Figure 9 One-handed flute (photograph courtesy of Maarten Visser, www.flutelab.com).

while playing the instrument. Every performing arts medicine clinic should have a piano on the premises to examine keyboard players while playing. Those musicians who cannot bring in their instrument, such as organ players or vibraphonists, may need to be evaluated playing their instrument outside the clinical setting, if the nature of the problem cannot be identified satisfactorily in the clinic. Video recordings of the musician playing the instrument can be very useful especially when evaluated in slow motion (Norris and Dommerholt, 1995). Since healthcare providers do not have the same experience and insights of music

Figure 10 Contact pressure at the right thumb of an 11-yearold clarinetist (ª 2008 e Jan Dommerholt).

teachers or pedagogists, they should be cautious with questioning technique or musical performance, even though it has been established that different playing techniques may have distinctly different biomechanical demands (Bejjani et al., 1989). A pianist who was able to play with different styles of technique underwent an extensive kinetic and kinematic analysis of the different techniques and some were found to be much more demanding than others (Bejjani et al., 1989). Clinicians must analyze localized contact stresses caused by compression of the musical instrument against body parts. Examples include the clarinet, English horn, and oboe, which rest on the player’s right thumb, potentially leading to tendonitis and overuse injury (see Figure 10) (Fry, 1987; Smutz et al., 1995). Compression of the flute against the lateral aspect of the left index finger may cause nerve compression (see Figure 11) (Cynamon, 1982; Wainapel and Cole, 1988; Norris, 1996). Visser has modified the keys on the flute to avoid excessive reach and added a finger support to reduce direct compression of the finger against the instrument (see Figure 12).

Instrument-specific examination Clinicians will be better able to develop evidence-informed treatment strategies by actively engaging musicians in the

Figure 12 Key modification and finger support to avoid compression against the flute (photograph courtesy of Maarten Visser, www.flutelab.com).

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Figure 13 e Double bass German bow and bowing technique; note how the fifth finger supports the bow (photograph courtesy of Barbara Fitzgerald).

diagnostic process (Ackermann and Adams, 2004b; Brandfonbrener, 2006). Awareness of the demands of playing musical instruments greatly improved the interrater reliability of postural examinations by physical therapists (Ackermann and Adams, 2004a). For most instruments, the extrinsic forearm, upper arm, shoulder and trunk muscles are used for producing the sound, and for holding,

J. Dommerholt supporting, and carrying the instrument. The intrinsic hand muscles are used for playing the instrument, including manipulation of the keys, valves, or strings, and fine-tuning the sound (Meinke, 1998; Dawson, 2005). For some instruments, musicians will have to use a combination of extrinsic and intrinsic muscles to play the instrument, for example with the right (bowing) arm of double bass players. The actual bowing is performed with extrinsic muscles, but holding the bow requires the use of the intrinsic hand muscles. Double bass players may have a preference for the so-called German or French bow and bowing technique, which have different biomechanical demands. A German bow is held with a side-hand grip. The bow tends to be lighter, but has a taller frog. With the German bowing technique, the bow rests on the fifth finger, which may contribute to intrinsic muscle strain of the palmar interosseus muscle between digits 4 and 5, and the opponens digiti minimi muscle (see Figure 13). A French bow is similar to bows in the violin family, but it is thicker and heavier. With the French bowing technique, the bow is held with an overhand grip and the bow rests on digits 2e5 (see Figure 14). As healthcare providers may not be familiar with the demands of each instrument, musicians may need to educate clinicians about different techniques or approaches.

Summary and conclusions The examination of musicians needs to expand considerably beyond the general aspects of the physical examination used with all patients. Healthcare providers need to become familiar with the demands of each instrument and their impact on posture, range of motion, injury patterns, and ergonomic demands. All musicians should be examined while playing their instruments, which frequently points the clinician toward the correct diagnosis and injury pattern. Performing arts clinics should have at least a piano available to examined keyboard players. Frequently, musicians may need to educate healthcare providers about certain aspects of their instrument, repertoire, or playing techniques.

References

Figure 14 e Double bass French bow and bowing technique; the bow is supported by fingers 2e5 (photograph courtesy of Barbara Fitzgerald).

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Journal of Bodywork & Movement Therapies (2010) 14, 73e79

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

REVIEW AND HYPOTHESES

Qi Gong’s relationship to educational kinesiology: A qualitative approach Paul Posadzki a,*, Sheetal Parekh b, Marie-Luce O’Driscoll b, Dariusz Mucha c,1 a

University of East Anglia, School of Medicine, Health Policy and Practice, United Kingdom University of East Anglia, School of Allied Health Professions, United Kingdom c Radom Politechnic, Malczewskiego 29, 26-600 Radom, Poland b

Received 27 February 2008; received in revised form 25 November 2008; accepted 27 November 2008

KEYWORDS Qi Gong; Educational kinesiology; Complementary and Alternative Medicine

Summary This paper qualitatively reviews two complementary therapies; Qi Gong and educational kinesiology (EK). It is being suggested that Qi Gong and EK may be united through a qualitative convergence and a shared underlying concept. The authors hypothesize that a coherent rationale can be formed through this conceptual synthesis and propose that to some extent Qi Gong movements and EK can be considered to work in unison with each other. The logical synthesis of these two therapies is being presented to identify Qi Gong movements with concepts of brain gymnastics and also to explain how this new construct can be developed and implemented into practice. When verified, this hypothesis will allow individuals to better understand Chinese health exercises from the modern science perspective such as neuroanatomy, neurophysiology and psychoneuroimmunology. Crown Copyright ª 2008 Published by Elsevier Ltd. All rights reserved.

Introduction There is a growing body of evidence, which suggests the usefulness of Qi Gong; a Complementary and Alternative Medicine therapy. Qi Gong practitioners claim to be able to influence the functional status of the central nervous * Corresponding author. Tel.: þ44 1603 591223. E-mail addresses: [email protected] (P. Posadzki), [email protected] (S. Parekh), [email protected] (M.-L. O’Driscoll), [email protected] (D. Mucha). 1 Tel.: þ48 (0) 601 482162.

system, through the use of movement, to improve cognitive functioning, emotional well-being and self-awareness. Educational kinesiology (EK) therapy, is a relatively modern approach compared to Qi Gong, but also has some evidence underpinning claims about its efficacy. EK is a method and form of brain gymnastics that can be defined as an enhanced ability to process information and learn more effectively due to certain types of movements (Prashnig, 2004). EK and brain gymnastics can be used interchangeably insofar as the concentration and focused movements embodied by their direction and technique may facilitate neuroplasticity. This is a qualitative study that offers a new

1360-8592/$ - see front matter Crown Copyright ª 2008 Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2008.11.002

74 way of looking at Qi Gong and EK. To be more precise, from the viewpoint of various systems of the body, this article reviews in narrative manner the clinical applications of these two modalities, examines their beneficial effects and the concepts that underpin both approaches. Ultimately, the article aims to present an argument for combining Qi Gong and EK through a coherent construct. The authors aim to explore the qualitative convergence of both Qi Gong and EK through a common conceptual neuroscientific lens, with a view of identifying the similarities and differences between these two techniques. However, it is important to emphasize that the level of abstraction presented within the scope of this article is grounded in the qualitative approaches. This approach offers a range of epistemological, theoretical and methodological possibilities for knowledge building, that can be unique in content, focus, and form (Hesse-Biber and Leavy, 2005). Therefore, during the discourse, analysis of some information regarding Qi Gong’s and EK’s essence will be derived from the presented data to reveal the underlying core principles and the congruent essence of both practices.

Brief characteristics of Qi Gong Qi Gong is a therapeutic Chinese practice that has been used and developed over thousands of years to restore energy (Qi) to the body, mind, and spirit (Litscher et al., 2001). The Taoist and Buddhist philosophies, which promote health and vitality through gentle exercises for breath, body and mind form the foundation for the Qi Gong theory (McCaffrey and Fowler, 2003). Basic principles of Qi Gong are grounded in traditional Chinese medicine (Dorcas and Yung, 2003). Qi Gong in Chinese means Qi (vital energy) and Gong (skill or art) and is essentially regarded by practitioners as a way of working with energy. Western science considers Qi Gong as a combination of meditation, controlled breathing and gentle physical movements designed to manage the vital energy (Qi) of the body and consequently a way to improve spiritual, physical and mental health (Jones, 2001). Qi Gong uses specific movements in order that psychological concentration may be directly channeled to particular parts of the body. The Qi Gong experts frame it as a ‘‘mind-in-body’’ practice rather than mindebody interaction. It is a form of complementary therapy and a method of health improvement that is both efficient and effective (Sancier, 2003). This form of fluent movements, with harmonic breathing techniques tranquilizes the mind and is known to reduce the psychosomatic tensions (Skoglund and Jansson, 2007).

Physiological effects of Qi Gong It is suggested that the practice of Qi Gong leads to significant improvements in physical health, which are discussed below. However, the limitation of narrative review may relate to the quality of included studies, because these results may or may not have been critically assessed with or without focusing on their methodological quality. Nevertheless, the purpose of this section is to present to the reader Qi Gong’s ‘multidimensionality’ and its potential effects on health in order to facilitate and

P. Posadzki et al. promote deeper insights and better understanding of this therapeutic modality through concentrating on what can be known from these studies. The physiological effects of Qi Gong exercises include changes in electroencephalogram (EEG), electromyography (EMG), respiratory movement, heart rate, skin temperature, fingertip volume, and sympathetic nerve function. It also includes changes in the functioning of the stomach and intestine, metabolic activities, and endocrine and immunity systems (Lee et al 2003b; Lee et al 2005a) (Xu, 1994) as a result of soft body movements. As theta rhythm has been suggested to be one of the normal EEG patterns occurring in mental concentration, it is concluded that the theta rhythm is an indicator of mental concentration during Qi Gong state (Pan et al., 1994). In addition neuromonitoring during Qi Gong appears to objectify the accompanied cerebral modulations with a 22.2% increase in mean blood flow velocity (vm) in the posterior cerebral artery (Litscher et al., 2001). As a result the increased blood circulation after Qi Gong exercises brings ‘warmness’ in the body (Agishi, 1998). Moreover, significant differences were found in the volume of oxygen consumed, carbon dioxide produced, frequency of breath and expired ventilation. The study also showed an improvement of nearly 20% in ventilatory efficiency for oxygen uptake and carbon dioxide production suggesting that Qi Gong may have useful therapeutic value (Lim et al., 1993). Qi Gong is valuable and reliable as described by Mayer (1999) in a study that took place over 20 years ago and reported significant differences between a group practicing Qi Gong and a control group in a variety of outcome measures including reduction in total mortality rate. The evidence further suggests that practicing Qi Gong may have a positive effect on hypertension (Mayer, 1999). Qi Gong exercises can cause bradycardia (Skoglund and Jansson, 2007). Qi Gong is beneficial for lowering blood pressure and pH (Lee et al., 2007; Lee et al., 2003c), and increasing aerobic endurance (Lan et al., 2004; Lee et al., 2004b). The physical symptoms of stress including levels of norepinephrine and cortisol were lowered after Qi Gong exercises (Skoglund and Jansson, 2007). Similarly, heart rate and body temperature were also decreased after Qi Gong exercises (Lee et al., 2003c). This brief overview of Qi Gong and its physiological benefits on the body’s performance emphasizes the existence of considerable potential that can be utilized by the practitioner on a regular basis to prevent diseases and develop positive health states. Additionally, all the above data may suggest that gentle activation of the body’s muscles, through Qi Gong exercises, may have positive impact on homeostasis (Lee et al 2003a). These findings can be interpreted as further support to the value of Qi Gong in optimizing the body’s status for more balanced structure and function. Therefore, holistic harmony may be achieved as a result of such more effective and efficient interference of the physiological systems with one another. Consequently, optimal or total well-being with the highest life quality is achievable.

Psychological benefits of Qi Gong exercises Psychological outcome of Qi Gong practice includes perceptual changes such as individuals’ experience of

Qi Gong’s relationship to educational kinesiology warmness, chilliness, relaxation, tension and the perception of floating (Xu, 1994). It also positively affects the mood changes and relieves exhaustion and tension (Jung et al., 2006). Qi Gong helps to normalize and stabilize positive and pleasant emotional states of human mind (Lee et al., 2003a; Lee et al., 2006) and improves the overall well-being of an individual. It also relieves depression in chronic physical illness sufferers by improving the individual’s self-identity, social well-being and quality of life (Tsang et al., 2003, 2006). In this context, Bandura’s Social Learning Theory a development of the perception of self-efficacy was observed (Lee et al., 2004a; Lee et al., 2005b). From a health resource perspective, Qi Gong may improve an individual’s sense of coherence, regain a sense of safety and active control, and can be a specific stress coping strategy (Siu et al., 2007). Qi Gong training was found to result in transient long-term anxiety and pain reduction (Wu et al., 1999). This can be partially explained by Ryu et al. (1996) as the authors observed the effects of Qi Gong training on the levels of human endogenous opioid peptides, such as beta-endorphin, and other stress hormones adrenocorticotrophic hormone (ACTH). The level of beta-endorphin was significantly increased during the mid-time of training while the level of ACTH declined at the mid and post-time of training. The result suggests that Qi Gong training, when used as a stress coping method, affects and plays a role in hormonal regulation related to the maintenance of homeostasis in humans (Ryu et al., 1996). Results obtained by Jones (2001) have indicated that blood levels of the stress-related hormone cortisol may be lowered by short-term practice of Qi Gong as well. Another study showed that the practice of Qi Gong helped in the rehabilitation of drug addicts (Sancier, 1999). Evidence also suggests that Qi Gong may be an effective alternative for heroin detoxification without side effects (Li et al., 2002). A few positive impacts on various dimensions of human mind functioning proposes a huge potential of Qi Gong in maintaining health related goals. Furthermore, various states and processes of the mind can be consciously affected due to Qi Gong exercises. This may include cognitive processes (memory, attention), emotional reactions (including positive feelings), intelligence (emotional and spiritual) or creativity. From the psychological perspective, Qi Gong exercises may help practitioners to influence the body’s homeostasis via brain gymnastics and thus help to expand own capacities and broaden the horizons. As a result, the structure of one’s consciousness could be developed thanks to self-realization and self-actualization during Qi Gong practice.

Clinical applications of Qi Gong Qi Gong can have a broad spectrum of clinical applications. It has been suggested that in hypertensive patients, combining Qi Gong practice with drug therapy (combination therapy) resulted in reduced risk of stroke incidence and related mortality and reduced dosage of drugs required for blood pressure maintenance (Mayer, 1999). It is an efficient method of improving quality of life in cardiac disease patients (Hui et al., 2006) and decreasing systolic blood pressure in hypertensive patients (Lee et al., 2007). Body mass index, waist circumstance, level of cholesterol and albumin excretion can be controlled by means of Qi Gong

75 resulting in an overall health improvement. Qi Gong can also modulate the level of triglycerides, HDL-cholesterol and apolipoproteins in disorders of lipid metabolism (Xin et al., 2007). Qi Gong walking reduced plasma glucose after lunch without inducing a large increase in the pulse rate in patients with diabetes (Iwao et al., 1999). It has been suggested that Qi Gong exercises may also alleviate asthma symptoms, as well as modulate wound healing and inflammation processes (Chen and Turner, 2004). In asthma patients, the combination therapy resulted in reduced drug dosage, sick leaves, duration of hospitalization, and costs of therapy. An improvement in airway capability and a decrease in illness severity can be achieved by regular self-conducted Qi Gong exercises (Reuther and Aldridge, 1998). Qi Gong may also have a role in cancer management Lee et al 2005b (Yan et al., 2006); other authors have suggested a significant reduction in tumor size (Chen and Yeung, 2002). It can be useful in the advanced stages of cancer as it helps to reduce vomiting, insomnia, anorexia, and facilitates serenity and emotional control as well as minimizes distress and helplessness (Lee et al., 2006). In cancer patients, the combination therapy reduced the side effects of cancer therapy. However, the reported studies do not necessarily measure up to the strict protocols required for randomized controlled clinical trials (Sancer, 1999). From the clinical perspective, Qi Gong exercises have been shown to improve activities of daily living, social interactions and quality of interpersonal relations in elderly patients (Tsang et al., 2003). In the same group of patients other authors have reported increased balance parameters, which resulted in decreased risk of fractures (Yang et al., 2007). Qi Gong may be successfully incorporated into orthodox physiotherapy, as it is known to improve motor function (Schmitz-Halbsch et al., 2006) and movement coordination (Mannerkorpi and Arndorw, 2004). It is worth emphasizing that pain was diminished significantly among low back pain sufferers, woman with pre-menstrual symptoms (Jang and Lee, 2004), and chronic pain patients (Chen et al., 2006). Moreover, Qi Gong’s multidimensional influence on the whole person should be acknowledged as a standard method of rehabilitation, health promotion and prevention. For these reasons Qi Gong can be named as the art of selfhealing (Lee et al., 2003a). It can be suggested to the reader or the practitioner that the existence of complex mechanisms that influence various functions of the holistic body is embedded in Qi Gong exercises. A practitioner’s homeostatic mechanisms, on different levels, and with different intensity may be affected constructively. Additionally, these compound mechanisms that social and life scientists are trying to comprehend, can mobilize the individuals’ positive health resources, selfregulatory mechanisms and adaptive capacities. At the end of the Qi Gong section of this article, the reader is asked to form his or her own opinion on Qi Gong’s qualities, attributes and ‘mechanisms’ beyond the description provided and ask why it works, how and on what level it works? The answers for these questions may enhance self-education, increase the level of knowledge and own understanding of Qi Gong’s underlying principles. In the following section another therapeutic modality-EK will be discussed. Finally, fusion on the conceptual level

76 will occur with some practical examples to follow up. These examples will include specially designed Qi Gong movements embedded in the principles of EK to stimulate a flow of information within the holistic body.

Brief characteristics educational kinesiology EK is applicable to various cognitive skills, i.e. memory, attention, thinking and entails a number of techniques to enhance hemispheric communication and functioning (Gallo, 2005). EK’s exercises were originally derived from the work of neuro-rehabilitation specialists and include kinesthetic experience such as movement with new learning. The concept of EK is based on the assumption that specific movements (similar to those performed naturally by children as part of the process of brain development) can improve bodyemind integration. This integration can be obtained through brain gymnasticsestrategy that implements the concept of EK (Northey, 2005). Cammisa (1994) explained EK as a method that uses specific movements to examine the quality of various levels of brain function. In other words during testing of particular muscles, responsible for certain movements, the examiner is able to understand the structural and functional status of the central nervous system, of the individual, due to the wide and complex connections between the muscular and nervous system. This is because such examinations may reveal the extent to which there are wide and complex connections and other (not fully understood) neurophysiological systems. If we accept this premise then moving and examining muscles may provide significant insight into how the body is working as a whole. As it can be noticed human muscle movements might have various positive health effects and hence muscle function may be related with the body’s integrity. If so, then using specific muscles precisely and appropriately may bring individual benefits to the brain and the whole body. From the Qi Gong perspective, a practitioner may realize how specific movements generated by the muscles may influence his or her brain levels. To be more precise, during Qi Gong exercises, motor abilities such as coordination, agility, movements’ perception itself as well as cognitive and social functioning, personal development, emotional well-being and self-awareness can be influenced through the use of these muscles. While working, these muscles ‘create’ neuroanatomical and neurophysiological connections with other parts of the CNS, this is not as yet fully understood. This may have various clinical and non-clinical applications. Some of them will be presented below.

Main applications of educational kinesiology There is a limited evidence of EK’s clinical efficacy. However, the existence of its health potential can be easily noticed. For example, Sifft and Khalsa (1991) investigated the influence of the integrated movements in EK, on reaction time to visual stimuli. The results showed statistically significant improvement in agility where EK was used to develop whole body movement. This could mean enhanced synchronisation of movement responses due to EK. Further efficacy of EK is evident in coordination tests as Morris et al. (1998) claim that this modality can influence the quality of

P. Posadzki et al. motor skills such as movement smoothness (Morris et al., 1998). This could have powerful practical implication, i.e. movement therapists could use EK’s movement patterns and directions in order to improve their patient’s function, or develop more adaptable movement patterns. Another EK study showed significant improvement in an ability involving the interaction of perception and voluntary movement of those examined. This analysis has indicated a significant improvement in perceptual motor skills in individuals following the EK program (Cammisa, 1994). Therefore, it is suggested that EK may positively affect changes in the time taken to initiate and complete movement sequences, as well as changes in the features of movement sequences themselves (Ericsson et al., 2006). Nevertheless, further quantitative research is inevitably needed in order to investigate EK’s efficacy in various clinical and non-clinical settings. Additionally, more qualitative designs could find out why and how it works?

Qi Gong viewed through the lens of educational kinesiology Through the synthesis of these two areas of Complementary Medicine e Qi Gong and EK, it is possible to make a number of deductions. First of all EK can view Qi Gong movements as the ‘final effects’ of the central nervous system functioning. Secondly, similarly to EK, Qi Gong exercises consist of various and complex body movements utilizing a wide range of muscles. From the neuroanatomical and neurophysiological perspective, this association between muscular and nervous system and the potential benefits of such a relationship may be regarded as a common dimension of Qi Gong and EK. As an explanation it can be suggested that some Qi Gong exercises may combine effects of lateralization (L), focusing (F) and centering (C) during precisely performed sequences of movements. In terms of EK, in order to provide more reasonable explanation during Qi Gong exercises, the practitioner may and should perform his or her movements in such a manner that the central or mid-line of the body (sagittal line that is parallel to vertical axis and separates the human body into left and right equal parts) may be crossed, as this would facilitate experience of functional integration between the right and left hemisphere. To be more explicit in this statement both upper and lower extremities’ directions of movements in Qi Gong exercises indicate that the mid-line is being crossed. As a justification of this argument the authors give the example of a basic breathing technique used in Qi Gong exercises, where during the exhalation the practitioner moves his or her upper extremities in the cephalo-caudal direction (from the top of the face down to the lower abdominal region) passing central line several times in the front of the body simultaneously. Coordination between thought and movement may improve as a result, and in social context the ability to communicate with others and the quality of interpersonal relationships may also improve (Masgutowa and Akhmatova, 2004). Subsequently, in Qi Gong exercises, movements may contain components of crossing between anterior and posterior, as well as upper and lower parts of the body. In Qi Gong movements, in the superioreinferior directions within the sagittal plane, using upper extremities, and posterioreanterior ones, using lower

Qi Gong’s relationship to educational kinesiology extremities, within the same plane are similar to EK movements. This might suggest that the brain cortex, which is responsible for innovative ideas and creativity, is being stimulated in Qi Gong in a manner similar to that found in EK. Additionally, integration can be observed between rational thinking and emotions, feelings and movements in both Qi Gong and EK. Furthermore, the limbic system and its interrelations with autonomic nervous system can be stimulated during Qi Gong exercises. This may balance the functioning of heart, lungs, liver or blood vessels. During Qi Gong exercises posture stability is increased and the reaction pattern for environmental stimulus can change (orientation reflex). A Qi Gong practitioner is able to concentrate his or her attention on both the detail and the wholeness of a visible object, and this causes a better understanding of the reality (Masgutowa and Akhmatova, 2004). From the psychological point of view, both Qi Gong and EK have the potential to improve human’s self-awareness, sense of coherence, level of optimism, self-esteem, self-appraisal, emotional awareness and sharpen cognitive processes such as attention, memory, imagination and thinking. Ideally a Qi Gong practitioner may concentrate on combination of all three components (Lateralization (L) þ Focusing (F) þ Centering (C)) simultaneously during the movement performance and potentially benefit from such a ‘three dimensional strategy’. On the other hand an individual may also choose particular elements that he or she intends to develop, i.e. rational thinking and emotions together with attention focused on both the detail and the wholeness of a visible object as this would require a combination of F and C respectively. Conversely, it can be suggested that EK practitioner may incorporate Qi Gong movements’ characteristic (consciousness, smoothness, softness, effortless concentration, breathing and energy management) into his or her ‘session’ in order to generate potential biopsychosocial benefits. To some extent it can be concluded that, although Qi Gong and EK have their roots in different cultures and different historical timeframes, they may share a common conceptual background. If verified, this hypothesis may be a useful adjunct both to Qi Gong practitioners, permitting further development of their psychological or social awareness, and to educational kinesiologists, who might consider expanding their ‘therapeutic toolkit’ by using Qi Gong movements. The authors suggest that the assumptions presented within the scope of this article may not necessarily induce change of the existing paradigm in which Qi Gong and EK are embedded. Therefore, it is being recommended that within the proposed worldview through which knowledge is filtered, one may or may not acknowledge the other modality’s attributes or qualities, intend to incorporate them into practice and subjectively judge the effects of this convergence and its relevance. This model, if verified by the future research may promote change of the existing ontological, epistemological and methodological questions (Guba and Lincoln, 1998).

Conclusions Qi Gong is regarded as a therapy that harmonizes the wellbeing of an individual through simultaneous integrity of structure and function, such as unity of breathing, movement, attention (concentration), memory, positive

77 emotions, knowledge and self-consciousness. On the other hand EK therapy, quite a contemporary approach compared to Qi Gong, refers to the resources that an individual possesses and is able to ‘materialize’ them through movement (Masgutowa and Akhmatova, 2004). The main purpose of this article was to combine the evidence from Qi Gong and EK studies and investigate the underlying mutual processes and the essence of these two therapeutic modalities. By looking at Qi Gong and EK through the lenses of one coherent construct, it has been possible to raise an argument that Qi Gong and EK share a number of basic underlying principles. Additionally, the benefits of undertaking both Qi Gong and EK can be seen to be broadly similar. The effects and the concepts that underpin both approaches suggest that consciously performed movements can be beneficial through their influence on various systems of the body such as the immunological, cardio-respiratory, nervous, endocrine, and musculoskeletal systems and that these results in better self-perception and personality integration. The principles of EK complement those of Qi Gong’s insofar as the individual performs movements form that comprise elements of lateralization (L), concentration or focusing (F) and centering (C) (Masgutowa and Akhmatova, 2004). Furthermore, Qi Gong, like EK can be used as a form of brain gymnastics insofar as the concentration and focused movements embodied by the techniques may facilitate neuroplasticity. Qi Gong and EK can also ‘mobilise’ similar, not fully understood neuroanatomical and neurophysiological pathways (Ashe et al., 2006; Haaland, 2006). Qi Gong practitioners, like EK practitioners, might therefore be able to influence the functional status of the central nervous system, through the use of movement to improve cognitive functioning, emotional well-being and self-awareness. Qi Gong practitioners may also be able to facilitate personal development, better social functioning via interpersonal relationship improvement and whole personality integrity. Moreover it may also be successfully used in health promotion, disease prevention through social comparisons and/or modeling. From the EK point of view, Qi Gong may be regarded as an appropriate way of using muscles that offers enhanced mindebody integration as well as various psychophysiological benefits. Conversely, from Qi Gong’s perspective EK may be thought as a form of movements that encourages selforganization in social, pscychological and biological spheres. If Qi Gong and EK practitioners could entertain the proposed notion that the two practices share conceptual roots there might be an opportunity for both disciplines to draw upon the other’s understandings. Of course one may argue that this study may have limitations such as diverse quantity and various quality and scientific rigor of the presented studies. The first author (PP) also acknowledges that his interest in the topic could have shaped findings presented within the scope of this article. However, the discussion regarding the concept itself is open and the authors will be keen on accepting any thoughts and insights in order to modify or develop the presented concept.

Future research Future research could comprise the definite and exact (also quantitative) analysis of Qi Gong and EK’s movement

78 patterns and their influence on various bodies’ systems. If similar effects of the movement patterns on the body were detected, this could be an indirect but trustworthy indicator of congruence of these modalities on the biopsychosocial level. Unquestionably, further conceptual development, as well as more both qualitative and quantitative designs would be desirable in order to expand our knowledge on these therapies and their essence.

Acknowledgements The authors wish to thank Dr Simon Donell and Mr James Hands for their contribution to this article. Sincere thanks to Professor Tadeusz Kasperczyk for his support and Dr Chen Yong Fa for his efforts to promote Qi Gong around the world.

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Qi Gong’s relationship to educational kinesiology Ryu, H., Lee, H.S., Shin, Y.S., Chung, S.M., Lee, M.S., Kim, H.M., Chung, H.T., 1996. Acute effect of qigong training on stress hormonal levels in man. Am. J. Chin. Med. 24 (2), 193e198. Sancer, K.M., 1999 Aug. Therapeutic benefits of qigong exercises in combination with drugs. J. Altern. Complement. Med. 5 (4), 383e389. Sancier, K.M., 2003 Apr. Electrodermal measurements for monitoring the effects of a qigong workshop. J. Altern. Complement. Med. 9 (2), 235e241. Schmitz-Halbsch, T., Pyfer, D., Kielwein, K., Fimmers, R., Klockgether, T., Wu ¨llner, U., 2006 Apr. Qigong exercise for the symptoms of Parkinson’s disease: a randomized, controlled pilot study. Mov. Disord. 21 (4), 543e548. Sifft, J.M., Khalsa, G.C., 1991 Dec. Effect of educational kinesiology upon simple response times and choice response times. Percept. Mot. Skills 73 (3 Pt 1), 1011e1015. Siu, J.Y., Sung, H.C., Lee, W.L., 2007 Apr. Qigong practice among chronically ill patients during the SARS outbreak. J. Clin. Nurs. 16 (4), 769e776. Skoglund, L., Jansson, E., 2007 May. Qigong reduces stress in computer operators. Complement. Ther. Clin. Pract. 13 (2), 78e84. Epub 2006 Nov 28. Tsang, H.W., Mok, C.K., Au Yeung, Y.T., Chan, S.Y., 2003 May. The effect of Qigong on general and psychosocial health of elderly

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Journal of Bodywork & Movement Therapies (2010) 14, 80e83

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PREVENTION & REHABILITATION: EDITORIAL

PREVENTION & REHABILITATIONdEDITOR: WARRICK MCNEILL

Core stability is a subset of motor control Warrick McNeill, MCSP, Associate Editor United Kingdom Love it or hate it the term ‘core stability’ is ubiquitous, and is a firm part of the lexicon of modern life. While preparing to write this editorial I asked many people, from therapists, to clients, to the non-injured and healthy ‘man-in-the-gym’ what they thought of the term and what it meant. ‘‘I don’t use the term when I am talking to my patients,’’ said Chris Dorgu, an elite football Osteopath, working in the UK, ‘‘I prefer to talk about the specifics of what I am working on with them. The term core stability is imprecise and open to interpretation.’’ Suzy Barton, a London based Pilates Teacher said that, ‘‘The term core stability is used by everyday people and, to most, it means a strong centre while moving the arms and legs. People often have no idea about the science behind the concept.’’ Phillip O’Callaghan, currently working hard with a Personal Trainer in a late stage rehab of an ACL reconstruction said, ‘‘It’s all about the abdominals, isn’t it?’’ In this Prevention and Rehabilitation section, the JBMT is publishing an article by Eyal Lederman, entitled ‘‘The myth of core stability.’’ It is likely to be an interesting, perhaps challenging, read for clinicians who use the concepts of core stability in their everyday practice. Lederman reflects a current increase in the popular press, including the ‘New York Times’ (nytimes.com) and the United Kingdom’s ‘The Times’ (timesonline.co.uk) newspapers, questioning aspects of core stability theory. Lederman’s approach to this article looks at identifying assumptions within core stability theory and applying research findings to see if the assumptions bear scrutiny. In Lederman’s article the term core stability particularly relates to the mid 1990s work of Hodges and Richardson (1996), Richardson et al., 2004 from Australia’s Queensland University, and the identification of a timing delay in the firing of the transversus abdominis (TrA) during rapid

shoulder movement in subjects with low back pain. In the notes given out at a course I attended in 1996, presented by Paul Hodges (Richardson et al., 1996), the term core stability was not used. ‘Motor control’ was consistently referred to, as was ‘local joint stabilization.’ The term core stability appears to have developed, concurrently or later and seems to have become the default term applied to all motor control training around the trunk, through to (possibly!) ‘a clean and jerk then squatting a water filled Swiss ball’ (youtube.com). There does seem to be consensus that there may be some differences in the meaning of core stability as the term core strengthening is also frequently found in the literature and on the web. Comerford and Mottram (2001), Comerford (2004) points out that some therapeutic exercises are aimed at strengthening weak muscles around the core, and others are designed to improve the recruitment of muscles that may be underactive and not fulfilling their role in the synergy of neuromuscular control about the trunk and girdles. The difference Comerford suggests is related to the threshold of the recruitment required for each type of exercise, with ‘core strengthening’ needing to bias the fast fatiguing, fast motor unit to effectively strengthen, and ‘motor control core stability’ training of smaller postural loads, aimed at improving the recruitment and endurance of the slow motor unit. The clinical problem is in providing the assessment of the clients’ faults so that the correct threshold of exercise is given (Mottram and Comerford, 2008).

Do we need a model of muscle function? Regardless of how a model of muscle function is created, the construction of a model is important for clinicians to use to try and better understand the complexities of the brains control of muscle, both voluntary and sub-conscious.

E-mail address: [email protected] 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.10.001

For me local muscles such as ‘Hodges’ TrA, (Hodges and Richardson, 1996), or ‘Hides’ deep fibres of Multifidus (DM) (Hides et al., 1996, 2001) have helped me build a concept (however flawed?) of how the deeper muscles may work to control joint translation which, if uncontrolled, may lead to micro-trauma, wear and tear and possible injury (Panjabi, 1992). This led me, in my practice, to offer to those who I felt would benefit from having the deeper muscle structures brought to their attention, an ‘educational’ session identifying those muscles and a ‘muscle recruitment’ quiz to see if they can ‘turn them on.’ Muscle inhibition due to pain is identified in the literature (Hides et al., 1996), as is increased activation (van Dieen et al., 2003). If pain does cause DM inhibition and leads to eventual DM atrophy over an affected motion segment, I feel justified in teaching a client in the clinic how to recruit this muscle. I have read MacDonald et al.’s (2006) ‘The lumbar multifidus: does the evidence support clinical beliefs?’ in which a review of data about the DM and superficial multifidus (SM) is applied to the Queensland approach, and though some beliefs are supported by the data (for example: SM and DM are both segmental motion controllers, DM can work as a translational movement controller without having an antagonist), others are not (for example: SM is not solely a rotator or extensor, DM is not tonically active during static postures). The paper advises that the findings have implications in clinical practice. It appears, in my reading of the paper, that the DM remains an important component of the integrated musculature of the body, so I will continue to address its under-activation. I certainly do not believe that any one muscle is any more important than another in the so-called ‘core.’ ‘All muscles are created equal’ but this does not mean we are not allowed to shine a spotlight on a single cog in the clockworks to discuss its role. All the cogs in a clockwork mechanism need to work together to show the passing of time. In my practice not all of my clients get a ‘Queensland’ approach. History and presenting pain will inform my clinical decisions. Some clients do not appear to have any difficulty in proving a voluntary contact with their trunk muscles, superficial or deep, statically, or dynamically. They have a ‘flow’ while performing whole body movements that appears to be a smooth sequencing of muscles working in an efficient order, with no one muscle being more dominant than another, or more correctly, no one movement more dominant e as the ‘body knows movements, not muscles’ (Siff, 2009a). If no indicators suggest I use a ‘Queensland’ approach then I need to look for another technique in my toolkit for an appropriate treatment for the problems I do identify.

Explain muscles If Butler and Moseley (2003) can ‘Explain Pain’ to a chronic pain sufferer and a year later, with no other intervention, improve their pain, perhaps an ‘Explain Muscles’ approach could have a similar effect? In researching Complex regional pain syndrome ‘motor imagery’ has proved (Moseley, 2004) to be an effective tool. I feel that connecting a client to under-recruited muscles using visual feedback, self

81 handling, imagery, or anatomical or pathological explanations, gives the client raw material for their Central Nervous System (CNS) to process and to come up with its own solution(s) to the presenting motor control problems. Hodges (2004) identifies that there are multiple strategies available to the CNS for motor control and considerable redundancy within this system. This means that there may well be many correct solutions to ‘fix’ a motor control problem, and each individual may need a different approach to get to a solution that works for them. This identifies to me a key difference between research and the clinic. When a client comes in I have to provide a reasoned approach to address the problems I find. Doing ‘something’ may only provide a placebo effect, though this can help (Wittink and Michel, 2002), but it may also be doing something positive that changes the situation and assists the client back to a healthier footing than they were before their presentation. What I think I am doing, may produce the desired result, however, it may conceivably be by an entirely different process! Furthermore, in the clinic we don’t just do ‘one’ thing to the client, we provide multimodal treatment regimes which result in the clients eventual outcome. We may reflect and discard for an individual, or all our clients, some approaches that may not have appeared to work, but it is difficult to know with certainty, that we are discarding the ineffective technique. Often, through good luck, good management or the natural history of a condition, the client improves to a greater or lesser extent. The problem for the Researcher is to identify which modality, or which combination of modalities had what effect, which bears up to the rigour of evidence based practice and which do not. This is clearly exceptionally difficult. Being a clinician seems to be the easier choice. For me, the choice to use ‘core stability’ techniques remains valid under the current body of evidence.

Core robustness exercises Is ‘core stability’ new? Is it a re-badging of other concepts? Wallden (2009), My Co-Editor of this section, in his recent ‘Neutral spine principle’ Wallden (2009) discusses ‘neutral’ which is an integral component of ‘core stability’ yet there is not a mention of core stability in his piece. Why is this? Perhaps its because neutral concepts aren’t exclusive to core stability? Siff (2009b) suggests that at one time we had kinaesthetic, proprioceptive, or motor skill training, but now it is core stability training, he suggests that this is not a suitable modern substitute. He opines that the core, in most instances, operates in a world where peripheral contact with a surface is important and peripheral stabilization is more important than the stabilization of the core. In relation to knee injury risk, however, Zazulak et al. (2007a,b, 2008) show that deficits in neuromuscular control of the trunk predicts knee injury, in female, but not male athletes. Forces affecting the body from foot contact up the kinetic chain are clearly important, but, so too, it appears, are centre down forces. ‘Stability’ itself is poorly understood (Reeves et al., 2007), differentiating between static and dynamic systems is important. Reeves states that ‘static stability

PREVENTION & REHABILITATIONdEDITOR: WARRICK MCNEILL

Core stability commentary

PREVENTION & REHABILITATIONdEDITOR: WARRICK MCNEILL

82 explanations’ account for the findings ‘that there is a potential for injury under low level loading’ (Cholewicki and McGill, 1996) and ‘that a lack of stiffness was associated with injury’ and that this led to the development of concepts of core stability. Reeves suggests that this was taken from a static understanding of spinal stability where increasing stiffness does increase stability. In a dynamic model of stability, however, there are times when less stiffness is desirable to help in the precision of motor controlled activities such as standing, balancing or gait by providing a more supple spine. The ‘central controller’ needs to exhibit a variable control and efficient feedback, and this continues in a loop. Reeves goes on to say that a system is either stable or unstable, but it is the robustness (how well the system copes with uncertainties and disturbances) of the system that is important. Reeves comments that stability is often confused with robustness, ‘‘Core stabilizing exercises do not make the spine more stable, they make it more robust, thus reducing risk of injury.’’ Perhaps the next new hot exercise fad to take over from core stability training will be ‘core robustness exercise!’

Canada Vs. Australia Within the world of core stability research there appears to be two schools of thought perhaps best personalised by Stuart McGill from Canada and Paul Hodges from Australia. Their work frequently references each other as it appears they both produce good science with interesting results that can be applied to the theoretical models that they propose. Both are passionate (Chaitow, 2005), and if you have to identify the key area of research for each you may possibly choose spinal biomechanics for McGill and spinal motor control for Hodges, though the distinctions between them would be blurred. Both advocate exercise regimes for the prevention or treatment of spinal pain. Some of Hodges exercises are regarded as isolationist (Siff, 2009a), this could be interpreted, and has been, according to Lederman, in that the TrA and Mf are to be exercised and strengthened in isolation. This is reminiscent of the fitness (gym) worlds isolated exercise of the ‘biceps curl’ (not truly just a biceps brachii exercise, it is the synergy of elbow flexion/extension that is actually exercised). Admittedly the TrA and Mf muscles are identified and recruited in isolation, (not strengthened!) but this immediately precedes integrating those muscles into function, so it may be fair to say ‘isolationist’ but only until functional movement is added to the regime. McGill’s exercises reflect his opinion that ‘‘the relative contribution from every muscle source is dynamically changing’’ (McGill, 2007). His exercises, such as bird dog (see a description of this exercise in Leibenson’s ‘The missing link in protecting against back pain’ later in this editions Prevention and Rehabilitation section), and side bridge could be called co-contraction exercises as they recruit all muscles in the trunk, though will bias different muscle groups, and are aimed at promoting control of spinal posture in positions that are bio-mechanically sound. Liebenson (2007) reports on Koumantakis et al. (2005) study that demonstrated the ‘‘general’’ approach (McGill’s) was superior to the Australian ‘‘deep’’ local stabilization.

W. McNeill Liebenson therefore advocates an abdominal co-contraction (bracing) exercise regime in this paper. Tsao and Hodges (2008) in their study on subjects with low back pain, reported validating a motor control training strategy that improved TrA timing (feedforward) and maintained it for the follow up at six months. It was the first study to show such a finding. The authors took care to emphasise that the study, ‘‘does not advocate that repeated isolated voluntary contractions is sufficient to treat low back pain (LBP). Rather, the study indicates that one impairment often identified in LBP (i.e., delayed activity of TrA) can be changed with training.’’ A similar study by Hall et al. (2009) (including in the authorship Tsao and Hodges), looked at the co-contraction exercises favoured by McGill and showed that a single session of this type of training did not change the feedforward timing of the TrA in low back pain subjects. Admittedly both these studies had a low number of subjects but the findings are very interesting and may show there still is life in the theory of core stability. It is very possible that in the future we will look back and say that McGill and Hodges’ theories both had merit and were looking at the same problem; that their views and exercises were not mutually exclusive, as the CNS has many strategies to deal with movement control. In the clinic, where distinctions are blurred, I am happy to use both commentators’ ideas at different times. I contend that McGill and Hodges, in the field of low back biomechanics and motor control, may have more common ground they agree on than ground over which they do not.

Future research Chronic low back pain (CLBP) is a complex subject to investigate, not least because of the many various influences that may cause the pain. Hebert et al. (2008) attempted to subgroup patients with non-specific low back pain (LBP) to place them into various treatment categories including specific exercise, stabilization exercise, manipulation and traction. It appears that subgrouping LBP may help in future experimental design and provide cleaner results for interpretation. Where is core stability research going? In fact is that the real question we should be asking? If Lederman is effective in his argument the term core stability will be phased out and research funding placed elsewhere. McGill, Hodges and others are perhaps less likely to think they are specifically undertaking core stability research but would refer to their work as research in motor control. Core stability has really only ever been a subset of the broader church of ‘motor control’. So where is motor control research going? It seems that the assessment of movement control is starting to show interesting results Luomajoki et al. (2008) looked at 6 motor control tests of the lumbar spine with a study size involving 210 subjects, half with LBP and the control half without. The study showed a significant difference in the ability between the groups to actively control the movements of the low back. The LBP groups control was poorer. Roussel et al. (2009) has shown in dancers that two lumbo-pelvic movement control tests (standing bow and

a crook lying single knee lift) are predictive of injury risk to the low back or lower limb. Roussel’s findings suggest that motor control or strengthening interventions may reduce the chance of an injury happening at all.

Conclusion Is the term ‘core stability’ limiting? I believe it is. Lederman’s article shows how some ideas around core stability have become part of the problem and not part of the solution, and it is definitely time to move on from there. If this topic and this edition provokes a response from you, please email me as I would like to report back to the readership in my next editorial what your views are. The last word comes from the Pilates Teacher Suzy Barton we met earlier. ‘‘If the public are asking for core stability exercises, don’t send them away saying we don’t do that any more, take their request and give them exercises to fit their individual issues!’’

References Butler, D., Moseley, G.L., 2003. Explain Pain. Noigroup Publications, Adelaide. Chaitow, L., 2005. Melbourne conference. Journal of Bodywork and Movement Therapies 9, 85e87. Cholewicki, J., McGill, S., 1996. Mechanical stability in the vivo lumbar spine: implications for injury and chronic low back pain. Clinical Biomechanics 11 (1), 1e15. Comerford, M.J., Mottram, S.L., 2001. Functional stability retraining: principles and strategies for managing mechanical dysfunction. Manual Therapy 6 (1), 3e14. Comerford, M.J., 2004. Core stability: priorities in rehab of the athlete. SportEx Medicine 22, 15e22. Hall, L., Tsao, H., MacDonald, D., Coppieters, M., Hodges, P.W., 2009. Immediate effects of co-contraction training on motor control of the trunk muscles in people with recurrent low back pain. Journal of Electromyography and Kinesiology 19, 763e 2773. Hebert, J., Koppenhaver, S., Fritz, J., Parent, E., 2008. Clinical prediction for success of interventions for managing low back pain. Clinics in Sports Medicine 27 (3), 463e479. Hides, J.A., Richardson, C.A., Jull, G.A., 1996. Multifidus recovery is not automatic after resolution of acute, first-episode low back pain. Spine 21 (23), 2763e2769. 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 (11), 243e248. Hodges, P.W., Richardson, C.A., 1996. Inefficient muscular stabilisation of the lumbar spine associated with low back pain: a motor control evaluation of transversus abdominis. Spine 21 (22), 2640e2650. Hodges, P.W., 2004. Motor control of the trunk. In: Boyling, J.D., Jull, G.A. (Eds.), Grieves Modern Manual Therapy the Vertebral Column. Churchill Livingstone, pp. 119e139. Koumantakis, G.A., Watson, P.J., Oldham, J.A., 2005. Trunk muscle stabilization training versus general exercise only: randomized controlled trial of patients with recurrent low back pain. Physical Therapy 85, 209e225. Liebenson, C., 2007. A modern approach to abdominal training. Journal of Bodywork and Movement Therapies 11, 194e198. Luomajoki, H., Kool, J., de Bruin, E.D., Airaksinen, O., 2008. Movement control tests of the low back: evaluation of the

83 difference between patients with low back pain and healthy controls. BMC Musculoskeletal Disorders 9, 170. MacDonald, D.A., Moseley, G.L., Hodges, P.W., 2006. The lumbar multifidus: does the evidence support clinical beliefs? Manual Therapy 11, 254e263. McGill, S., 2007. Low back disorders evidence-based prevention and rehabilitation. Human Kinematics. Moseley, G.L., 2004. Graded motor imagery is effective for long standing complex regional pain syndrome: a randomised controlled trial. Pain 108, 192e198. Mottram, S.L., Comerford, M.J., 2008. A new perspective in risk assessment. Physical Therapy in Sport 9, 40e51. Panjabi, M., 1992. The stabilising system of the spine. Part 1. Function, dysfunction, adaptation and enhancement. Journal of Spinal Disorders 5, 383e389. Reeves, N.P., Narendra, K.S., Cholewicki, J., 2007. Spine stability: the six blind men and the elephant. Clinical Biomechanics 22, 266e274. Richardson, C., Hodges, P., Hides, J., 2004. Therapeutic Exercise for Lumbopelvic Stabilization. Churchill Livingstone. Richardson, C., Jull, G., Hodges, P., Hides, J., 1996. Local joint stabilisation: specific assessment and exercises for low back pain. Course notes. Roussel, N.A., Nijs, J., Mottram, S., Van Moorsel, A., Truijen, S., Stassijns, G., 2009. Altered lumbopelvic movement control but not generalized joint hypermobility is associated with increased injury in dancers. Manual Therapy. doi: 10.1016/j.math.2008.12.004. Tsao, H., Hodges, P.W., 2008. Persistence of improvements in postural strategies following motor control training in people with recurrent low back pain. Journal of Electromyography and Kinesiology 18 (4), 559e567. van Dieen, J.H., Selen, L.P.J., Cholewicki, J., 2003. Trunk muscle activation in low-back pain patients, an analysis of the literature. Journal of Electromyography and Kinesiology 13, 333e351. Wallden, M., 2009. The neutral spine principle. Journal Bodywork and Movement Therapies 13, 350e361. Wittink, H., Michel, THoskins, 2002. Chronic Pain Management for Physical Therapists, second ed. Oxford, New York. Zazulak, B., Hewett, T.E., Reeves, N.P., Goldberg, B., Cholewicki, J., 2007. The effects of core proprioception on knee injury: a prospective biomechanical-epidemiological study. American Journal of Sports Medicine 35, 368e374. Zazulak, B., Hewett, T.E., Reeves, N.P., Goldberg, B., Cholewicki, J., 2007. Deficits in neuromuscular control of the trunk predict knee injury risk: a prospective biomechanicalepidemiologic study. American Journal of Sports Medicine 35, 1123e1131. Zazulak, B., Cholewicki, J., Reeves, N.P., 2008. Neuromuscular control of trunk stability: clinical implications for sports injury prevention. Journal of the American Academy of Orthopaedic Surgeons 16, 497e5025.

Web sources http://www.youtube.com/results?search_queryZcleanþjerkþSwissþ Ball&;search_typeZ&aqZf. Siff, 2009. http://drmelsiff.wordpress.com/2009/07/31/ transversusabdominus-and-core-training-part-i/. Siff, 2009. http://drmelsif85.blogspot.com/2009/06/dr-mel-siffon-core-stability.html. http://women.timesonline.co.uk/tol/life_and_style/women/ diet_and_fitness/article6068862.ece. http://well.blogs.nytimes.com/2009/06/17/core-myths/ ?apageZ4.

PREVENTION & REHABILITATIONdEDITOR: WARRICK MCNEILL

Core stability commentary

Journal of Bodywork & Movement Therapies (2010) 14, 84e98

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

CRITICAL REVIEW

The myth of core stability Eyal Lederman* CPDO Ltd., 15 Harberton Road, London N19 3JS, UK

PREVENTION & REHABILITATIONdCRITICAL REVIEW

Received 26 October 2008; received in revised form 3 May 2009; accepted 4 August 2009

KEYWORDS Core stability; Spinal stabilisation; Transversus abdominis; Chronic lower back and neuromuscular rehabilitation

Summary The principle of core stability has gained wide acceptance in training for the prevention of injury and as a treatment modality for rehabilitation of various musculoskeletal conditions in particular of the lower back. There has been surprisingly little criticism of this approach up to date. This article re-examines the original findings and the principles of core stability/spinal stabilisation approaches and how well they fare within the wider knowledge of motor control, prevention of injury and rehabilitation of neuromuscular and musculoskeletal systems following injury. ª 2009 Elsevier Ltd. All rights reserved.

Introduction

back, and influences from Pilates, have promoted several assumptions prevalent in CS training:

Core stability (CS) arrived in the latter part of the 1990s. It was largely derived from studies that demonstrated a change in onset timing of the trunk muscles in back injury and chronic lower back pain (CLBP) patients (Hodges and Richardson, 1996, 1998). The research in trunk control has been an important contribution to the understanding of neuromuscular reorganisation in back pain and injury. As long as four decades ago it was shown that motor strategies change in injury and pain (Freeman et al., 1965). The CS studies confirmed that such changes take place in motor control of the trunk muscles of patients who suffer from back injury and pain. However, these findings combined with general beliefs about the importance of abdominal muscles for a strong

* Tel.: þ44 207 263 8551. E-mail address: [email protected]

 That certain muscles are more important for stabilisation of the spine than other muscles, in particular transversus abdominis (TrA).  That weak abdominal muscles lead to back pain  That strengthening abdominal or trunk muscles can reduce back pain  That there is a unique group of ‘‘core’’ muscle working independently of other trunk muscles  That back pain can be improved by normalising the timing of core muscles  That there is a relationship between stability and back pain As a consequence of these assumptions, a whole industry grew out of these studies with gyms and clinics worldwide teaching the ‘‘tummy tuck’’ and trunk bracing exercise to athletes for prevention of injury and to patients as a cure

1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.08.001

for lower back pain (Jull and Richardson, 2000; Richardson et al., 2002). In this article some of these basic assumptions will be re-examined.

Assumptions about stability and the role of TrA and other core muscle In essence the passive human spine is an unstable structure and therefore further stabilisation is provided by the activity of the trunk muscles. These muscles are often referred to in the CS approach as the ‘‘core’’ muscles, assuming that there is a distinct group, with an anatomical and functional characteristics specifically designed to provide for the stability. One of the muscles in this group to have received much focus is TrA. It is widely believed that this muscle is the main anterior component of trunk stabilisation. It is now accepted that many different muscles of the trunk contribute to stability and that their action may change according to varying tasks (see further discussion below). The TrA has several functions in the upright posture. Stability is one, but this function is in synergy with every other muscle that makes up the abdominals wall and beyond (Hodges et al., 1997, 2003; Sapsford et al., 2001). It acts in controlling pressure in the abdominal cavity for vocalisation, respiration, defecation, vomiting, etc. (Misuri et al., 1997). TrA forms the posterior wall of the inguinal canal and where its valve-like function prevents the viscera from popping out through the canal (Bendavid and Howarth, 2000). How essential is TrA for spinal stabilisation? One way to assess this is to look at situations where the muscle is damaged or put under abnormal mechanical stress. Would this predispose the individual to lower back pain? According to Gray’s Anatomy (36th edition 1980, page 555) TrA is absent or fused to the internal oblique muscle as a normal variation in some individuals. It would be interesting to see how these individuals stabilise their trunk and whether they suffer more back pain. Pregnancy is another state that raises some important questions about the role of TrA or any abdominal muscle in spinal stabilisation. During pregnancy the abdominal wall muscles undergo dramatic elongation, associated with force losses and inability to stabilise the pelvis against resistance (Fast et al., 1990; Gilleard and Brown, 1996). Indeed, in a study of pregnant women (n Z 318) they were shown to have lost the ability to perform situps due to this extensive elongation and subsequent force losses (Fast et al., 1990). Whereas all non-pregnant women could perform a sit-up, 16.6% of pregnant women could not perform a single sit-up. However, there was no correlation between the sit-up performance and backache, i.e. the strength of abdominal muscle was not related to backache. Despite this, CS exercises are often prescribed as a method for retraining the abdominal muscles and ultimately as a treatment for LBP during pregnancy. There is little evidence that localised musculoskeletal mechanical issues, including spinal stability play a role in the development of LBP during pregnancy. Often cited predisposing factors are, for example, body mass index, a history of hypermobility and amenorrhea (Mogren

85 and Pohjanen, 2005), low socioeconomic class, existence of previous LBP, posterior/fundal location of the placenta and a significant correlation between foetal weight and LBP (Orvieto et al., 1990). Another interesting period for us, concerning the role of abdominal muscles and stabilisation is immediately after delivery. Postpartum, it would take the abdominal muscle about 4e6 weeks to reverse the length changes and for motor control to reorganise. For example, rectus abdominis takes about 4 weeks postpartum to re-shorten, and it takes about 8 weeks for pelvic stability to normalise (Gilleard and Brown, 1996). It would be expected that during this period there would be minimal spinal support/stabilisation from the slack abdominal muscles and their fasciae. Would this increase the likelihood for back pain? In a recent study, the effects of a cognitive-behavioural approach were compared with standard physiotherapy on pelvic and lower back pain immediately after delivery (Bastiaenen et al., 2006). An interesting aspect of this research was that out 869 pregnant women suffering from back pain during pregnancy, 635 were excluded because of their spontaneous unaided recovery within a week of delivery. This spontaneous recovery was during a period, well before the abdominal muscles had time to return to their pre-pregnancy length, strength or control (Gilleard and Brown, 1996). Yet, this was a period when back pain was dramatically reduced. How can it be that back and pelvic pain is improving during a period of profound abdominal muscle inefficiency? Why does the spine not collapse? Has the relationship between abdominal muscles and spinal stability been over-emphasised? Similarly studies on weight gain and obesity and LBP challenge the CS theory. One would expect, as in pregnancy, the distension of the abdomen to disrupt the normal mechanics and control of the trunk muscles, including TrA. According to the CS model this should result in an increased incidence of back pain among this group. Yet, epidemiological studies demonstrate that weight gain and obesity are only weakly associated with lower back pain (LeboeufYde, 2000) According to the CS model we should be seeing an epidemic of back pain in over-weight individuals. Another area that can shed light on the control and stability of the abdominal muscles is the study of abdominal muscles that have been damaged by surgery. Would such damage affect spinal stability or contribute to back pain? In breast reconstruction after mastectomy, one side of the rectus abdominis is used for reconstruction of the breast. Consequently, the patient is left with only one side of rectus abdominis and weakness of the abdominal muscles. Such alteration in trunk biomechanics would also be expected to result in profound motor control changes. Despite all these changes there seems to be no relationship to back pain or impairment to the patient’s functional/movement activities, measured up to several years after the operation (Mizgala et al., 1994; Simon et al., 2004). One area for further study would be that of subjects who have had inguinal hernia repair. In this operation the TrA is known to be affected by the surgical procedure (Berliner, 1983; Condon and Carilli, 1994). To date there is no known epidemiological study linking such surgery and back pain.

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E. Lederman In summary we can conclude:

 That abdominal musculature can demonstrate dramatic physiological changes, such as during pregnancy, postpartum and obesity, with no detriment to spinal stability and health.  Damage to abdominal musculature does not seem to be detrimental to spinal stability or contribute to LBP.  No study to date has demonstrated that LBP is due to spinal instability. Despite a decade of research in this area it remains a theoretical model.

PREVENTION & REHABILITATIONdCRITICAL REVIEW

The timing issue In one of the early studies it was demonstrated that during rapid arm/leg movement, the TrA in CLBP patients had delayed onset timing when compared with asymptomatic subjects (Hodges and Richardson, 1996, 1998). It was consequently assumed that the TrA, by means of its connection to the lumbar fascia, is dominant in controlling spinal stability (Hodges et al., 2003). Therefore any weakness or lack of control of this muscle would spell trouble for the back. This assumption is a dramatic leap of faith. Firstly, in our body all structures are profoundly connected in many different dimensions, including anatomically and biomechanically. You need a knife to separate them from each other. It is not difficult to emphasise a connection that would fit the theory, i.e. that the TrA is the main anterior muscle that controls spinal stability. In normal human movement postural reflexes are organised well ahead in anticipation of movement or perturbation to balance. TrA is one of the many trunk muscles that takes part in this anticipatory organisation (Hodges and Richardson, 1997). Just because in healthy subjects it kicks off before all other anterior muscles (in one particular posture), does not mean it is more important in any way. It just means it is the first in a sequence of events (Cresswell et al., 1994a,b). Indeed, it has been recently suggested that earlier activity of TA may be a compensation for its long elastic anterior fasciae (Macdonald et al., 2006). It can be equally valid to assume that a delay in onset timing in subjects with LBP may be an advantageous protection strategy for the back rather than a dysfunctional activation pattern. Furthermore, it could be that during the fast movement of the outstretched arm the subject performed a reflexive pain evasion action that involved delayed activation of TrA, an action unrelated to stabilisation (Moseley et al., 2003a,b, 2004). An analogy would be the reflex pulling of the hand from a hot surface. One could imagine that a patient with a shoulder injury would use a different arm withdrawal pattern from a normal individual. This movement pattern would be unrelated to the control of shoulder stability but would be intended to produce the least painful path of movement, even if the movement is not painful at the time. A similar phenomenon has been demonstrated in trunk control where just the perception of a threat of pain to the back resulted in altered postural strategies (Moseley and Hodges, 2006). In the original studies of CS onset time differences between asymptomatic individuals and patients with CLBP

were about 20 ms, i.e. one fiftieth of a second difference (Hodges and Richardson, 1996, 1998; Radebold et al., 2000). It should be noted that these were not strength but timing differences. Such timings are well beyond the patient’s conscious control and the clinical capabilities of the therapist to test or alter. Often, in CS exercise there is an emphasis on strength training for the TrA or low velocity exercise performed lying or kneeling on all fours (Richardson and Jull, 1995). It is believed that such exercise would help normalise motor control which would include timing dysfunction. This kind of training is unlikely to help reset timing differences. It is like aspiring to play the piano faster by exercising with finger weights or performing push-ups. The reason why this is ineffective is related to a contradiction which CS training creates in relation to motor learning principles (similarity/ transfer principle) and training principles (specificity principle, see further discussion below). In essence these principles state that our bodies, including the neuromuscular and musculoskeletal systems will adapt specifically to particular motor events. What is learned in one particular situation may not necessarily transfer to a different physical event, i.e. if strength is required e lift weights, if speed is needed e increase the speed of movement during training and along these lines if you need to control onset timing switch your movement between synergists at a fast rate, and hope that the system will reset itself (Lederman, 2005, in press). To overcome the timing problem the proponents of CS came up with a solution e teach everyone to continuously contract the TrA or to tense/brace the core muscle (O’Sullivan, 2000; Jull and Richardson, 2000). By continuously contracting it would overcome the need to worry about onset timing. What is proposed here is to impose an abnormal, non-functional pattern of control to overcome a functional reorganisation of the neuromuscular system to injury: a protective strategy that is as old as human evolution. We now know that following injury, one motor strategy is to co-contract the muscles around the joint (amongst many other complex strategies, Figure 1). This injury response has also been shown to occur in CLBP patients (Nouwen et al., 1987; Arena et al., 1991; Hubley-Kozey and Vezina, 2002a,b; Marras et al., 2005), who tend to co-contract their trunk flexors and extensors during movement (van Dieen et al., 2003a,b). This strategy is subconscious, and very complex. It requires intricate interactions between the relative timing, duration, force, muscle lengths and velocities of contraction of immediate synergists (Shirado et al., 1995a,b; Radebold et al., 2000, see Table 1). Further complexity would arise from the fact that these patterns would change on a moment-to-moment basis and with different movement/postural tasks (McGill et al., 2003; Cordo et al., 2003; Moseley et al., 2003a,b). This pattern of muscle activity observed in standing with the arm outstretched is likely to change in bending forward or twisting. Indeed, in the original studies of the onset timing of TrA delays in onset timing were observed during fast but not during slow arm movements (Hodges and Richardson, 1996). Even during a simple trunk rotation or exercise the activity in TrA is not uniform throughout the muscle (Urquhart and Hodges, 2005; Urquhart et al., 2005a).

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Skills

Motor complexity

Composite abilities Balance, coordination, Transition time, motor relaxation

Synergetic abilities C Co o-contraction & reciprocal activation

Parametric abilities

Figure 1 Motor control of movement is composed of several underlying factors which include force, velocity, range and endurance (parametric group of abilities); co-contraction and reciprocal activation which represent the synergistic level of control and the more complex composite motor abilities that include coordination, balance transition time between different activities and motor relaxation. All these motor components play a part during movement. By altering one, all the other control factors will also change. Adapted from: Lederman E, Neuromuscular rehabilitation in manual and physical therapy, to be published 2010. London, Elsevier.

These studies demonstrate the complexity that a patient re-learning trunk control may have to face. How would a person know which part of the abdomen to contract during a particular posture or movement? How would they know when to switch between synergists during movement? How would they know what is their optimal co-contraction force? If CLBP patients already use a co-contraction strategy why increase it? It is naı¨ve to assume that by continuously contracting the TrA it will somehow override or facilitate these patterns. Furthermore no study to date has demonstrated that core stability exercise will reset onset timing in CLBP patients (Hall et al., 2007). In summary we can conclude:  That there is motor reorganisation of the trunk muscles in response to the experience or the fear of spinal pain  There is no evidence that such motor reorganisation is the cause of spinal pain or recurrence of back pain  Most prescribed CS exercise/manoeuvres are not well designed to challenge onset time of synergists and are therefore unlikely to reset the onset timing of the trunk muscles  No study to date have as demonstrated that core stability exercise will reset onset timing in CLBP patients.

The strength issue There is more confusion about the issue of trunk strength and its relation to back pain and injury prevention. What we do know is that trunk muscle control including force losses can be present as a consequence of back pain/injury. However, from here several assumptions are often made:

 That loss of core muscle strength could lead to back injury,  That increasing core strength can alleviate back pain To what force level do the trunk muscles need to co-contract in order to stabilise the spine? It seems that the answer is e not very much (Figure 2). During standing and walking the trunk muscles are minimally activated (Andersson et al., 1996). In standing the deep spinal erectors, psoas and quadratus lumborum are virtually silent! In some subjects there is no detectable EMG activity in these muscles. During walking rectus abdominis has an average activity of 2% maximal voluntary contraction (MVC) and external oblique 5% MVC (White and McNair, 2002). During standing ‘‘active’’ stabilisation is achieved by very low levels of co-contraction of trunk flexors and extensors, estimated at less than 1% MVC rising up to 3% MVC when a 32 kg weight is added to the torso. With a back injury it is estimated to raise these values by only 2.5% MVC for the unloaded and loaded models (Cholewicki et al., 1997). During bending and lifting a weight of about 15 kg co-contraction increases by only 1.5% MVC (van Dieen et al., 2003a,b). These low levels of activation raise the question why strength exercises are prescribed when such low levels of co-contraction forces are needed for functional movement. Such low co-contraction levels suggest the strength losses are unlikely ever to be an issue for spinal stabilisation. A person would have to lose substantial trunk muscle or force control before it will destabilise the spine. These low levels of trunk muscle co-contraction also have important clinical implications. It means that most individuals would find it impossible to control such low

PREVENTION & REHABILITATIONdCRITICAL REVIEW

Force, velocity, length, endurance

PREVENTION & REHABILITATIONdCRITICAL REVIEW The complexity of motor reorganisation during spinal/trunk injury and pain. All the levels of motor abilities are affected. It is an overall control reorganisation rather than failure of particular motor components. A therapeutic error is to focus on single issues such as force or co-contraction. Conditions

Parametric motor abilities Force

Lower Force losses in back pain trunk muscles in acute and CLBP patients (Airaksinen et al., 1996; Hides et al., 1994, 1996; Ng et al., 1998; Shirado et al., 1995a)

Synergistic

Composite

Velocity

Endurance

Co-contraction/ reciprocal activation

Coordination

Balance/postural stability

Transition time

Relaxation

Loss of flexion relaxation in the spinal muscles during flexion in patients with CLBP.Extensors activation prevents full forward bending (Shirado et al., 1995b). Individuals with high painrelated fear had smaller excursions of the lumbar spine for reaches to all targets at 3 and 6 weeks, but not at 12 weeks following pain onset (Thomas et al., 2008). Smaller stride length (Lamoth et al., 2008)

Reduced velocity of trunk movement during induced back pain (Zedka et al., 1999)Individuals with high painrelated fear had smaller peak velocities and accelerations of the lumbar spine and hip joints, even after resolution of back pain (Thomas et al., 2008). Walking velocity significantly lower in LBP patients (Lamoth et al., 2006a,b, 2008)

Increased fatigability trunk muscles in patient with CLBP (Roy et al., 1989; Shirado et al., 1995a,b; Suter and Lindsay 2001)

Impaired postural control of the lumbar spine is associated with delayed trunk/ abdominal muscles response times in CLBP patients (Hodges and Richardson, 1999; Hodges et al., 2003a,b; Hodges and Richardson 1996, 1998; MacDonald et al., 2006; O’Sullivan et al., 1997a,b; Radebold et al., 2001; Thomas and France, 2007; Thomas et al., 2007).Increase in trunk cocontraction in CLBP patients (Cholewicki et al., 2005; van Dieen et al., 2003a)Increased co-contraction in trunk during walking and additional cognitive demands (Lamoth et al., 2008)

Lumbar spineehip joint coordination altered in back pain subjects (Shum et al., 2005)Discoordination in pelvisethorax coordination in LBP (Lamoth et al., 2006a,b)

Changes in postural control in CLBP (Leinonen et al., 2001; Popa et al., 2007)Impaired postural control of the lumbar spine associated with delayed muscle response times in CLBP patients (Radebold et al., 2001)Changes in postural control unrelated to pain in CLBP (della Volpe et al., 2006)Postspinal surgery postural control changes both in pain and pain-free subjects. However, more evident in the symptomatic subjects (Bouche et al., 2006)Hip strategy for balance control in quiet standing is affected in CLBP (Mok et al., 2004)Experimental muscle pain changes feedforward postural responses of the trunk muscles (Hodges et al., 2003)

Not studied Compared to (but should be) healthy controls, persons with LBP exhibited a reduced ability to adapt trunkepelvis coordination and spinal muscle activity to sudden changes in walking velocity (Lamoth et al., 2006a,b)Slower reaction time in LBP patients. Demonstrated recovery of reaction time with training (Luoto et al., 1996)

E. Lederman

Length

88

Table 1

The myth of core stability Increase co-contraction

89 Increase spinal stability Increase spinal compression Reduce range of movement Increase energy expenditure

Range of active stability

Diminish co-contraction

Optimal level

Reduce spinal stability Reduce spinal compression Increase range of movement Reduce energy expenditure

Figure 2 Co-contraction has several roles during movement such as to help stabilise the joints and refine movement. The cocontraction levels in the trunk are kept at optimal low levels e an increase in co-contraction will raise the compression force on the disc and it is more energy consuming. It also tends to rigidify the trunk which is an unsuitable control strategy where range of movement or flexibility is required.

is unlikely that during CS exercise abdominal muscle would reach this force level (Stevens et al., 2007). We can conclude that:  There is no evidence that reduced trunk muscle strength or endurance will predispose the individual to LBP (Hamberg-van Reenen, 2007)  There are inconclusive finding regarding loss of trunk muscle strength and atrophy in response to CLBP  CS exercises do not provide an overtraining challenge that is expected to result in strength or endurance gains in these muscles.

The single/core muscle activation problem One of the principles of CS is to teach the individuals how to isolate their TrA from the rest of the abdominal muscles or to isolate the ‘‘core muscle’’ from ‘‘global’’ muscles. It is doubtful that there exists a ‘‘core’’ group of trunk muscles that are recruited operate independently of all other trunk muscles during daily or sport activities (McGill et al., 2003; Kavcic et al., 2004). Such classification is anatomical but has no functional meaning. The motor output and the recruitment of muscles are extensive (Hodges et al., 2000; Cholewicki et al., 2002a,b), affecting the whole body. To specifically activate the core muscles during functional movement the individual would have to override natural patterns of trunk muscle activation. This would be impractical, next to impossible and potentially dangerous; as stated by Brown et al. (2006) ‘‘Individuals in an externally loaded state appear to select a natural muscular activation pattern appropriate to maintain spine stability sufficiently. Conscious adjustments in individual muscles around this natural level may actually decrease the stability margin of safety’’. Training focused on a single muscle is even more difficult. Muscle-by-muscle activation does not exist (Georgopoulos, 2000). If you bring your hand to your mouth the nervous system ‘‘thinks’’ hand to mouth rather than flex the biceps, then the pectorals, etc. Single muscle control is relegated in the hierarchy of motor processes to spinal motor centres e a process that would be distant from conscious control (interestingly even the motor neurons of particular muscles are intermingled rather than being distinct anatomical groups in the spinal cord) (Luscher and

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levels of activity or even be aware of it. If they are aware of it they are probably co-contracting well above the normal levels needed for stabilisation. This would come at a cost of increasing the compression of the lumbar spine and reducing the economy of movement (see discussion below). Is there a relationship between weak abdominals (e.g. TrA) and back pain? A common belief amongst therapists and trainers who use CS is that trunk strength will improve existing back pain. It has been shown that a muscle such as multifidus (Hides et al., 1994) can undergo atrophy in acute and CLBP (although this is still inconclusive). Furthermore, it is well established that the motor strategy changes in the recruitment of the abdominal muscles in patients with CLBP (Ng et al., 2002a,b; Moseley et al., 2003a,b), with some studies demonstrating weakness of abdominal muscles (Helewa et al., 1990, 1993; Shirado et al., 1995a,b). However, strengthening these muscles does not seem to improve the pain level or disability in CLBP patients (Mannion et al., 2001a). Improvement appeared to be mainly due to changes in neural activation of the lumbar muscles and psychological changes concerning, for example, motivation or pain tolerance (Mannion et al., 2001b). To date there are no studies that show atrophy of abdominal muscles or that strengthening the core muscles, in particular the abdominal muscle and TrA, would reduce back pain (see discussion below). There are also examples where abdominal muscle activity is no different between asymptomatic and CLBP subjects. For instance, in studies of elite golfers, abdominal muscle activity and muscle fatigue characteristics were similar between asymptomatic and CLBP subjects after repetitive golf swings (Horton et al., 2001). Yet, this is the type of sportsperson who would often receive CS exercise advice. Doubts have also been raised concerning the effectiveness of many of CS exercise in helping to increase the strength of core muscles. It has been shown that during CS exercise, the maximal voluntary contraction (MVC) of the ‘‘core muscles’’ is well below the level required for muscle hypertrophy and is therefore unlikely to provide strength gains (Souza et al., 2001; Vezina and Hubley-Kozey, 2000; Hubley-Kozey and Vezina, 2002a,b). Furthermore, in a study of fatigue in CLBP, four weeks of stabilisation exercise failed to show any significant improvement in muscle endurance (Sung, 2003) A recent study has demonstrated that as much as 70% MVC is needed to promote strength gains in abdominal muscle (Stevens et al., 2008). It

PREVENTION & REHABILITATIONdCRITICAL REVIEW

90 Clamann, 1992). Indeed, it has been demonstrated that when tapping the tendons of rectus abdominis, external oblique and internal oblique the evoked stretch reflex responses can be observed in the muscle tapped, but also spreading extensively to muscles on the ipsilateral and contralateral sides of the abdomen (Beith and Harrison, 2004). This suggests sensory feedback and reflex control of the abdominal muscles is functionally related and would therefore be difficult to separate by conscious effort. This simple principle in motor control poses two problems to CS training. First, it is doubtful that following injury only one group or single muscles would be affected. Indeed, the more EMG electrodes applied the more complex the picture becomes (Cholewicki et al., 2002a,b). It is well documented that other muscles are involved e multifidus (Carpenter and Nelson, 1999), psoas (Barker et al., 2004), diaphragm (Hodges et al., 1997, 2003), pelvic floor muscles (PoolGoudzwaard et al., 2005), gluteals (Leinonen et al., 2000), etc. Basically in CLBP we see a complex and wide reorganisation of motor control in response to damage or pain. The second problem for CS is that it would be next to impossible to contract a single muscle or specific group. Even with extensive training this would be a major problem (Beith et al., 2001). Indeed, there is no support from research that TrA can be singularly activated (Cholewicki et al., 2002a,b). The novice patient is more likely to contract wide groups of abdominal muscles (Sapsford et al., 2001; Urquhart et al., 2005a,b). So why focus on TrA or any other specific muscle or muscle group? We can summaries that:  The control of the trunk (and body) is whole. There is no evidence that there are core muscles that work independently from other trunk muscle during normal functional movement.  There is no evidence that individuals can effectively learn to specifically activate one muscle group independently of all other trunk muscles.

CS and training in relation to motor learning and training issues Further challenges for the CS model arise from motor learning and training principles. CS training seems to clash with three important principles:  The similarity (transfer) principle in motor learning and specificity principle in training  Internaleexternal focus principles  Economy of movement.

Similarity/specificity principles When we train for an activity we become skilled at performing it. So if we practice playing the piano we become a good pianist, hence a similarity principle. We can’t learn to play the piano by practicing the banjo or improve playing by lifting weight with our fingers. This adaptation to the activity is not only reserved to learning processes, it has

E. Lederman profound physical manifestations e hence a weight trainer looks physically different to a marathon runner (specificity principle in training, Roels et al., 2005). If a subject is trained to contract their TrA or any anterior abdominal muscle while lying on their back (Karst and Willett, 2004), there is no guarantee that this would transfer to control and physical adaptation during standing, running, bending, lifting, sitting, etc. Such control would have to be practiced during some of these activities (Lederman, in press, see Figure 3). Anyone who is giving CS exercise to improve sports performance should re-familiarise themselves with this basic principle. It seems that such basic principles can escape many of the proponents of CS. This is reflected in one study which assessed the effect of training on a Swiss ball on core stability muscles and the economy of running (Stanton et al., 2004)! In this study it was rediscovered that practicing the banjo does not help to play the piano. The subjects got very good at using their muscles for sitting on a large inflatable rubber ball but it had no effect on their running performance. An often quoted study by Tsao and Hodges (2008) does show transfer of learning from CS training to postural activity. However, this is a low quality study, carried out on a small number of subjects (n Z 9) without any control/sham. The transfer observed in this study is in conflict with the vast knowledge of motor control that suggests that such transfer is highly unlikely (see Schmidt and Lee, 2005 for extensive review of transfer of learning). Trunk control will change according to the specific activity the subject is practicing. Throwing a ball would require trunk control, which is different to running. Trunk control in running will be different in climbing and so on. There is no one universal exercise for trunk control that would account for the specific needs of all activities. Is it possible to train the trunk control to specific activity? Yes, and it is simple e just train in that activity and don’t worry about the trunk. The beauty of it all is that no matter what activity is carried out the trunk muscles are always specifically exercised.

Internal and external focus in training CS has evolved over time in response to many of the model’s limitations described above. Currently, the control of TrA is attempted in different standing and moving patterns (O’Sullivan, 2000). Speed of movement, balance and coordination has been introduced to the very basic early elements of CS. The new models encourage the subjects to ‘‘think about their core’’ during functional activities. One wonders if David Beckham thinks about the ‘‘core’’ before a free kick or Michael Jordan when he slam-dunks or for that matter our patient who is running after a bus, cooking or during any other daily activities. How long can they maintain that thought while multitasking in complex functional activities? Maybe thinking about the core is not such a good idea for sports training. When learning movement a person can be instructed to focus on their technique (called internal focus) or on the movement goal (called external focus). When a novice learns a novel movement focusing on technique (internal focus) could help their learning (Beilock et al., 2002) For a skilled person, performance improves if training focuses on tasks outside the body (external focus) but it

The myth of core stability

91

Highly transferable

Least transferable

Trunk control during walking

Dissimilar out of context

Similar out of context

Dissimilar within context

Similar within context

Lumbro-pelvic tilts practiced on the floor Core tensing or bracing Extension exercise on the floor

Laying on the floor moving both legs in a walking-like pattern

Core tensing or bracing in Walk walking (this may seem surprising. However, as long as the person is walking they are practicing walking. The dissimilar movement is redundant as far as motor learning)

Figure 3 Similarity and context principle. Training and practice of movement can be dissimilar and out of context, similar but out of context, dissimilar within context or similar and within context. Ideal neuromuscular organisation to movement occurs when the movement is in similar patterns to the goal movement and practiced in context of the particular movement. Most CS training regimes contain movement patterns that are dissimilar and out of context to the trunk patterns used during normal activities. Adapted from Lederman E, Neuromuscular rehabilitation in manual and physical therapy, to be published 2010. London, Elsevier.

reduces when the focus is on internal processes within the body (McNevin et al., 2000, 2003). For example, there is greater accuracy in tennis serves and football shots when the subjects use external focus rather than internal-focus strategies (Wulf et al., 2002, 2003). This principle strongly suggests that internal focus on TrA or any other muscle group will reduce skilled athletic performance. Interestingly, tensing the trunk muscle has even been shown to potentially degrade postural control (Reeves et al., 2006). What about movement rehabilitation for CLBP patients? Would internal focus on specific muscles improve functional use of trunk muscles? Let’s imagine two scenarios where we are teaching a patient to lift a weight from the floor using a squat position. In the first scenario, we can give simple internal-focus advice such as bend your knees, and bring the weight close to your body, etc (van Dieen et al., 1999; Kingma et al., 2004). This type of instruction contains a mixture of external focusing (e.g. keep the object close to your body and between your knees) and internal focus about the body position during lifting. In the second scenario which is akin to CS training approach, the patient is given the following instructions: focus on co-contracting the hamstrings and the quads, gently release the gluteals, let the calf muscles elongate, while simultaneously shortening the tibialis anterior etc. Such complex internal focusing is the essence of CS training, but applied to the trunk muscles. It would be next to impossible for a person to learn simple tasks using such complicated internal-focus approach.

Economy of movement The advice given to CS trainees is to continuously tighten their abdominal and back muscles. This could reduce the

efficiency of movement during daily and sports activities. Our bodies are designed for optimal expenditure of energy during movement. It is well established that when a novice learns a new motor skill they tend to use a co-contraction strategy until they learn to refine their movement (Lay et al., 2002). Co-contraction is known to be an ‘‘energy waster’’ in initial motor learning situations. To introduce it to skilled movement will have a similar ‘‘wasteful’’ effect on the economy of movement. Minetti (2004) states: ‘‘to improve locomotion (and motion), mechanical work should be limited to just the indispensable type and the muscle efficiency be kept close to its maximum. Thus it is important to avoid: .. using co-contraction (or useless isometric force)’’. Such energy wastage is likely to occur during excessive use of trunk muscles as taught in CS. In sporting activity this would have a detrimental effect on performance. Anderson (1996) in a study on the economy of running states: ‘‘At higher levels of competition, it is likely that ‘natural selection’ tends to eliminate athletes who failed to either inherit or develop characteristics which favour economy’’. We can conclude for the evidence that:  CS exercises are in conflict with motor learning and training principles  CS exercises are dissimilar and out of context to normal physiological movement. This represents the most ineffective approach to learning motor skills  The internal-focus approach on individual muscles in CS is likely to degrade motor learning as well as skilled performance  Additional tensing of trunk muscles during daily activities or sports are likely to be more energetically taxing on the body

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Rehabilitating:

92

CS in prevention of injury and therapeutic value Therapist and trainers have been exalting the virtues of CS as an approach for improving sports performance (Kibler et al., 2006), preventing injury and as the solution to lower back pain. No matter what the underlying cause for the complaint CS was going to save the day. However, these claims are not supported by clinical studies:

PREVENTION & REHABILITATIONdCRITICAL REVIEW

Abdominal/stability exercise as prevention of back pain In one study, asymptomatic subjects (n Z 402) were given back education or back education þ abdominal strengthening exercise (Helewa et al., 1999). They were monitored for lower back pain for one year and the number of back pain episodes were recorded. No significant differences were found between the two groups. There was a curious aspect to this study, which is important to the strength issue in CS. This study was carried out on asymptomatic subjects who were identified as having weak abdominal muscles. Four hundred individuals with weak abdominal muscles and no back pain! Another large-scale study examined the influence of a core-strengthening programme on low back pain (LBP) in collegiate athletes (n Z 257). In this study too, there were no significant advantage of core strengthening in reducing LBP occurrence (Nadler et al., 2002).

CS a treatment for recurrent LBP and CLBP At first glance, studies of CS exercise for the treatment of recurrent LBP look promising e significant improvements can be demonstrated when compared to other forms of therapy (O’Sullivan et al., 1997a,b; Hides et al., 2001; Moseley, 2002; Rasmussen-Barr et al., 2003; Niemisto et al., 2003; Stuge et al., 2004; Goldby et al., 2006). Indeed, systematic reviews found stabilisation exercise to be better than general practitioner care, but not from any other form of physical therapy (Rackwitz et al., 2006; Ferreira et al., 2006; Macedo et al., 2009). However is could be argued that none of these studies actually showed a relationship between improvement in LBP and spinal stabilisation or core control. In all the studies there was no attempt to effectively identify patients who had timing or other control issues or had underlying instability. There was no attempt to evaluate how well the subjects learned CS manoeuvres and whether they were able to maintain that learning throughout the duration of the studies. Furthermore, there was no attempt to evaluate if there is a correlation between improvement of the condition and the recovery of stabilisation. It should also be noted that many of these studies did not have a control group. This means that although CS training may be better when compared to another form of therapy, we still don’t know if it is any better than a placebo/sham treatment. An interesting trend emerges when CS exercise are compared to general exercise (Table 2). Both exercise

E. Lederman approaches are demonstrated to be equally effective (Ariyoshi et al., 1999; van der Velde and Mierau, 2000; Franke et al., 2000; Reeves, 2006; Nilsson-Wikmar et al., 2005; Koumantakis et al., 2005; Cairns et al., 2006). Systematic reviews repeat this message (van Tulder et al., 2000; Abenhaim et al., 2000; Hurwitz et al., 2005). These studies strongly suggest that improvements are due to the positive effects that physical exercise may have on the patient rather than on improvements in spinal stability (it is known that general exercise can also improve CLBP) (Ariyoshi et al., 1999; van der Velde and Mierau, 2000). So why give the patient complex exercise regimes that will both be expensive and difficult to maintain? Perhaps our patients should be encouraged to maintain their own preferred exercise regime or provide them with exercises that they are more likely to enjoy. This of course could include CS exercise. But the patient should be informed that it is only as effective as any other exercise. We can thus conclude:  That CS exercise may better than general medical care (which is not difficult to achieve)  CS exercise is no better than other forms of manual or physical therapy or general exercise  Find out what exercise the patient enjoys and add it to the management plan.

CS in relation to aetiology of back pain Why has CS not performed better than any other exercise? In part, due to all the issues that have been discussed above. More importantly, in the last decade our understanding of the aetiology of back pain has dramatically changed. Psychological and psychosocial factors have become important risk and prognostic factors for recurrent back pain and the transition of acute to chronic pain states (Hasenbring et al., 2001). Genetic factors (MacGregor et al., 2004) and behavioural/‘‘use of body’’ are also known to be contributing factors. Localised, structural factors such as trunk/spinal asymmetries, have been reduced in their importance as contributing factors to back pain (Dieck, 1985; Nadler, 1998; Franklin and Conner-Kerr, 1998; Levangie, 1999; Fann, 2002; Norton, 2004; Poussa, 2005; Reeves, 2006; Mitchell et al., 2008). This shift in understanding LBP would include stability issues which are an extension of a biomechanical model. It is difficult to imagine how improving biomechanical factors such as spinal stabilisation can play a role in reducing back pain when there are such evident biopsychosocial factors associated with LBP conditions. Even in the behavioural/biomechanical spheres of spinal pain it is difficult to imagine how CS can act as prevention or cure. This can be clarified by grouping potential causes for back injury into two broad categories:  Behavioural group: individuals who use their back in ways that exert excessive loads on their spine, such as bending to lift (Gallagher et al., 2005) or repetitive sports activities (Fairclough et al., 1986; Renstro ¨m, 1996; Reid and McNair, 2000).

The myth of core stability CS studies, description of study, CS compared to other therapeutic modalities and outcome. Description of condition

CS compared to

Result

Notes

O’Sullivan et al., 1997a,b

CLBP (spondylolysis/ spondylolisthesis)

General exercise consisted of swimming, walking and gym work þ pain relief including heat application, massage and ultrasound

CS better

General exercises were not of the same duration as CS exercise.The pain relief methods chosen are known to have little effect on back pain

Hides et al., 2001

First episode LBP

CS better

Moseley, 2002

CLBP

General practitioner care þ medication CS þ MT compared to medical management

Rasmussen-Barr et al., 2003

CLBP

CS better in the short term but not long-term

Stuge et al., 2004

LBP in pregnancy

Manual therapy (muscle stretching, segmental traction, soft tissue and facet mobilisation Physical therapy

Niemisto et al., 2003

LBP

CS þ MT þ physician care compared to: physician care

CS/MT better

Goldby et al., 2006

CLBP

Back education and MT

CS > MT > education

Bastiaenen et al., 2006

LBP postpartum

Cognitive-behavioural therapy (CBT)

CBT better

Nilsson-Wikmar et al., 2005 Franke et al., 2000 Koumantakis et al., 2005

LBP in pregnancy

General exercise

Same

CLBP Sub-acute or CLBP

General exercise General exercise

Same General exercise slightly better Same SM and CS same outcome but slightly better than general exercise in the short but not long term

Cairns et al., 2006 Ferreira et al., 2007

Recurrent LBP CLBP

Exercise þ MT CS þ CBT compared to: 1. General exercise þ CBT þ stretching and strengthening all main muscles groups in body, þ cardiovascular exercise 2. Spinal manipulation (SM)

Critchley et al., 2007 1. MT 2. Pain management þ CBT 3. General exercise

 Bad luck group: individuals who had suffered a back injury from sudden unexpected events, such as falls or sporting injuries (Fairclough et al., 1986). In the behavioural group, bending and lifting is associated with a low level increase in abdominal muscle

CS/MT better than medical care

We still don’t know if CS is better because it was combined with MT The duration of MT was shorter than the CS exercise

CS better We still don’t know if CS is better because it was combined with MT Generally considered to be poor quality study

Other studiers suggest that CS is better than MT..

No difference between the groups

activity, which contributes to further spinal compression (de Looze et al., 1999). In patients with CLBP lifting is associated with higher levels of trunk co-contraction and spinal loading (Marras et al., 2005). Any further tensing of the abdominal muscles may lead to additional spinal compression. Since the spinal compression in lifting

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Table 2

93

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94 approaches the margins of safety of the spine, these seemingly small differences are not irrelevant (Biggemann et al., 1988). It is therefore difficult to imagine how CS can offer any additional protection to the lumbar spine during these activities. Often in CS advice is given to patients to brace their core muscle while sitting to reduce or prevent back pain. Although sitting is not regarded as a predisposing factor for LBP (Hartvigsen et al., 2002), some patients with existing back pain find that standing relieves the back pain of sitting. This phenomenon has been shown in CLBP patients who during sitting exhibit marked anterior loss of disc space in flexion or segmental instability (Maigne et al., 2003). Sitting, however, is associated with increased activity of abdominal muscles (when compared to standing) (Snijders et al., 1995). Increasing the co-contraction activity of the anterior and back muscles is unlikely to offer any further protection for patients with disc narrowing/pathology. Conversely, it may result in greater spinal compression. It is unknown whether core tensing can impede the movement of the unstable segments during sitting. This seems unlikely because even in healthy individuals creep deformation of spinal structures will eventually take place during sitting (Hedman and Fernie, 1997). The creep response is likely to be increased by further co-contraction of trunk muscles. In the bad luck group, CS will have very little influence on the outcome of sudden unexpected trauma. Most injuries occur within a fraction of a second, before the nervous system manages to organise itself to protect the back. Often injuries are associated with factors such as fatigue (Gabbett, 2004) and overtraining (Smith, 2004). These factors when combined with sudden, unexpected high velocity movement are often the cause of injury (Fairclough et al., 1986). It is difficult to see the benefit of strong TrA, abdominals or maintaining a constant contraction in these muscles in injury prevention.

Potential damage with CS? Continuous and abnormal patterns of use of the trunk muscles could also be a source of potential damage for spinal or pelvic pain conditions. It is known that when trunk muscles contract they exert a compressive force on the lumbar spine (van Dieen et al., 2003a,b) and that CLBP patients tend to increase their co-contraction force during movement (Cholewicki et al., 1997). This results in further increases of spinal compression (Marras et al., 2005; Brown et al., 2006). Another recent study examined the effects of abdominal stabilisation manoeuvres on the control of spine motion and stability against sudden trunk perturbations (Vera-Garcia et al., 2007). The abdominal stabilisation manoeuvres were e abdominal hollowing, abdominal bracing and a ‘‘natural’’ strategy. Abdominal hollowing was the most ineffective and did not increase stability. Abdominal bracing did improve stability but came at a cost of increasing spinal compression. The natural strategy group seems to employ the best strategy e ideal stability without excessive spinal compression. An increase in intra-abdominal pressure could be a further complication of tensing the trunk muscle (Cresswell et al., 1994a,b). It has been estimated that in patients with pelvic girdle pain, increased intra-abdominal pressure

E. Lederman could exert potentially damaging forces on various pelvic ligaments (Mens et al., 2006). Maybe our patients should be encouraged to relax their trunk muscle rather than hold them rigid? In a study of the effects of psychological stress during lifting it was found that mental processing/stress had a large impact on the spine. It resulted in an increase in spinal compression associated with increases in trunk muscle co-contraction and less controlled movements (Davis et al., 2002). Psychological factors such as catastrophising and somatisation are often observed in patients suffering from CLBP. One wonders if CS training colludes with these factors, encouraging excessive focusing on back pain and re-enforcing the patient’s notion that there is something seriously wrong with their back. Perhaps we should be shifting the patient’s focus away from their back. (I often stop patients doing specific back exercise). Furthermore, CS training may shift the therapeutic focus away from the real issues that maintain the patient in their chronic state. It offers a simplistic solution to a condition that may involve complex biopsychosocial factors. The issues that underline the patient’s condition may be neglected, with the patient remaining uninformed about the real causes of their condition. Under such circumstance CS training may promote chronicity.

Conclusion  Weak trunk muscles, weak abdominals and imbalances between trunk muscles groups are not a pathology just a normal variation.  The division of the trunk into core and global muscle system is a reductionist fantasy, which serves only to promote CS.  Weak or dysfunctional abdominal muscles will not lead to back pain.  Tensing the trunk muscles is unlikely to provide any protection against back pain or reduce the recurrence of back pain.  Core stability exercises are no more effective than, and will not prevent injury more than, any other forms of exercise or physical therapy.  Core stability exercises are no better than other forms of exercise in reducing chronic lower back pain. Any therapeutic influence is related to the exercise effects rather than stability issues.  There may be potential danger of damaging the spine with continuous tensing of the trunk muscles during daily and sports activities.  Patients who have been trained to use complex abdominal hollowing and bracing manoeuvres should be discouraged from using them.

Epilogue Many of the issues raised in this article were known well before the emergence of CS training. It is surprising that the researchers and proponents of this method ignored such important issues. Despite a decade of extensive research in

this area, it is difficult to see what contribution CS had to the understanding and care of patients suffering from back pain.

Acknowledgement I would like to thank Prof. Jaap H. van Diee ¨n, for his kind help in writing this article.

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E. Lederman Sung, P.S., 2003. Multifidi muscles median frequency before and after spinal stabilization exercises. Arch. Phys. Med. Rehabil. 84 (9), 1313e1318. Suter, E., Lindsay, D., 2001. Back muscle fatigability is associated with knee extensor inhibition in subjects with low back pain. Spine 26 (16), E361eE366. Thomas, J.S., France, C.R., 2007. Pain-related fear is associated with avoidance of spinal motion during recovery from low back pain. Spine 32 (16), E460eE466. Thomas, J.S., France, C.R., Sha, D., et al., 2007. The effect of chronic low back pain on trunk muscle activations in target reaching movements with various loads. Spine 32 (26), E801eE808. Thomas, J.S., France, C.R., Lavender, S.A., et al., 2008. Effects of fear of movement on spine velocity and acceleration after recovery from low back pain. Spine 33 (5), 564e570. Tsao, H., Hodges, P.W., 2008. Persistence of improvements in postural strategies following motor control training in people with recurrent low back pain. J. Electromyogr. Kinesiol. 18 (4), 559e567 [Epub 2007 Mar 2]. Urquhart, D.M., Hodges, P.W., 2005. Differential activity of regions of transversus abdominis during trunk rotation. Eur. Spine J. 14 (4), 393e400. Urquhart, D.M., et al., 2005a. Abdominal muscle recruitment during a range of voluntary exercises. Man. Ther. 10 (2), 144e153. Urquhart, D.M., Hodges, P.W., Story, I.H., 2005b. Postural activity of the abdominal muscles varies between regions of these muscles and between body positions. Gait Posture 22 (4), 295e301. van der Velde, G., Mierau, D., 2000. The effect of exercise on percentile rank aerobic capacity, pain, and self-rated disability in patients with chronic low-back pain: a retrospective chart review. Arch. Phys. Med. Rehabil. 81 (11), 1457e1463. van Dieen, J.H., Cholewicki, J., Radebold, A., 2003a. Trunk muscle recruitment patterns in patients with low back pain enhance the stability of the lumbar spine. Spine 28 (8), 834e841. van Dieen, J.H., Kingma, I., van der Burg, P., 2003b. Evidence for a role of antagonistic cocontraction in controlling trunk stiffness during lifting. J. Biomech. 36 (12), 1829e1836. van Dieen, J.H., Hoozemans, M.J., Toussaint, H.M., 1999. Stoop or squat: a review of biomechanical studies on lifting technique. Clin. Biomech. (Bristol, Avon) 14 (10), 685e696. van Tulder, M., et al., 2000. Exercise therapy for low back pain: a systematic review within the framework of the cochrane collaboration back review group. Spine 25 (21), 2784e2796. Vera-Garcia, F.J., et al., 2007. Effects of abdominal stabilization maneuvers on the control of spine motion and stability against sudden trunk perturbations. J. Electromyogr. Kinesiol. 17 (5), 556e567. Vezina, M.J., Hubley-Kozey, C.L., 2000. Muscle activation in therapeutic exercises to improve trunk stability. Arch. Phys. Med. Rehabil. 81 (10), 1370e1379. White, S.G., McNair, P.J., 2002. Abdominal and erector spinae muscle activity during gait: the use of cluster analysis to identify patterns of activity. Clin. Biomech. (Bristol, Avon) 17 (3), 177e184. Wulf, G., et al., 2002. Enhancing the learning of sport skills through external-focus feedback. J. Mot. Behav. 34 (2), 171e182. Wulf, G., et al., 2003. Attentional focus on suprapostural tasks affects balance learning. Q. J. Exp. Psychol. A 56 (7), 1191e1211. Zedka, M., Prochazka, A., Knight, B., et al., 1999. Voluntary and reflex control of human back muscles during induced pain. J. Physiol. 520 (Pt 2), 591e604.

Journal of Bodywork & Movement Therapies (2010) 14, 99e101

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SELFeMANAGEMENT: PATIENT SECTION

The missing link in protecting against back pain Craig Liebenson* L.A. Sports & Spine, 10474 Santa Monica Blvd # 304, Los Angeles, CA 90025, USA Accepted 14 October 2009

Whether you suffer from lower back pain or merely wish to improve your fitness odds are you have been told to build up your abdominals. While the abdominals are important, studies have shown that the often ignored spinal extensors (your back muscles) are at least as important (BieringSorensen, 1984; Luoto et al., 1995). Yet, most people do not know how to train these vitally important muscles. Think for a second about your upright posture e or lack thereof! It is easy to become slouched, stooped, or slumped. After all, we tend to sit way too much. The most popular abdominal exercise is the sit-up which actually makes us bend forward even more. Scientific investigations have discovered that normally our back muscles have onethird more endurance than our abdominals. But, in back pain patients this endurance is equal to the abdominals. So the message from the latest scientific evidence is clear e to protect your back strengthen it! Besides helping low back pain, spine extensor training is an ideal way to build up bone density in the spinal column of pre-menopausal women. In fact, whereas sit-ups have been shown to be dangerous for osteoporotic women, back extensor exercises have been shown to be safe. Here are a few excellent trunk extensor exercises that you can perform with a gymnastic ball.

Bird Dog Start:

* Tel.: þ1 31047 02909; fax: þ1 31047 03286. E-mail address: [email protected] 1360-8592/$ - see front matter ª 2009 Published by Elsevier Ltd. doi:10.1016/j.jbmt.2009.10.002

 Kneel on your hands on knees  Hands directly under your shoulders and knees directly under your hips  Round your back up and then let your spine relax down to the floor into a natural slightly arched position (see Figure 1)  Hold this slightly arched down position and ‘‘brace’’ your back by slightly tensing the muscles in 360 around your back to stiffen your spine  Hold this ‘‘braced’’ position while breathing normally (this takes a little practice!) Technique:  Keep your spine ‘‘braced’’ and reach with 1 arm all the way in front of you while simultaneously reaching with your opposite leg all the way behind you  Push with your support hand down into the floor so that your head/neck and upper back push off the floor slightly (see Figure 2)  Hold this position for a few seconds  Then return to the start position  Alternate arms and legs Avoid:  Poking your chin out  Letting your shoulder blade stick out (see Figure 3)  Flattening or rounding your back  Dropping your pelvis on one side  Holding your breath

PREVENTION & REHABILITATIONdSELF-MANAGEMENT: PATIENT SECTION

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PREVENTION & REHABILITATIONdSELF-MANAGEMENT: PATIENT SECTION

100

C. Liebenson

Figure 1

Figure 5

Start Position on All 4’s.

Figure 2

Quad Leg Reach.

Bird Dog.

Figure 6

(a) start position (b) final position

Sets/reps/frequency:  Perform 1 set  8e12 repetitions  1e2/day

Figure 3

Incorrect and Correct Shoulder Blade Position.

Troubleshooting:  If the Bird Dog is hard to control then perform the easier Quad Arm Reach and progress to the Quad Leg Reach (see Figures 4 and 5)

Superman

Figure 4

Quad Arm Reach.

Start:  Kneel on the floor with your feet against a wall  Pull a gymnastic ball in tight against your thighs and place your abdomen over the ball  Arch your back slightly so that you are sticking your buttocks out  Raise your arms so your hands are next to your hips (see Figure 6a)

The missing link in protecting against back pain

Technique:  Push off the wall until your body straightens up  Balance on the ball until you are on the tips of your toes (see Figure 6b)  Hold this position for a few seconds  Then return to the start position Avoid:  Slouching over the ball  Poking your chin out  Arching up so much you are creating a sway back

Sets/reps/frequency:  Perform 1 set  8e12 repetitions  1e2/day

References Biering-Sorensen, F., 1984. Physical measurements as risk indicators for low-back trouble over a one-year period. Spine 9, 106e119. Luoto, S., Heliovaara, M., Hurri, H., Alaranta, H., 1995. Static back endurance and the risk of low-back pain. Clin Biomech 10, 323e324.

PREVENTION & REHABILITATIONdSELF-MANAGEMENT: PATIENT SECTION

 Turn your palms so they are facing down and spread your fingers apart

101

Journal of

Official journal of the: ® Association of Neuromuscular Therapists, Ireland ® Australian Pilates Method Association ® National Association of Myofascial Trigger Point Therapists, USA ® Pilates Foundation, UK

Volume 14 Issue 2 2010

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 John Hannon DC San Luis Obispo, CA, USA ( [email protected])

Dimitrios Kostopoulos PhD, DSc, PT Hands-on Physical Therapy, New York, NY, USA ([email protected])

Glenn M. Hymel EdD, LMT Department of Psychology, Loyola University, New Orleans, LA, USA ([email protected])

Craig Liebenson DC Los Angeles, CA, USA ([email protected])

ASSOCIATE EDITORS: PREVENTION & REHABILITATION Matt Wallden MSc, Ost, Med, DO, ND London, UK ([email protected])

Warrick McNeill MCSP London, UK ([email protected]) International Advisory Board D. Beales MD (Cirencester, UK) G. Bove DC, PhD (Kennebunkport, ME, USA) 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, NCTMB (Boulder, CO, USA) R. Schleip MA, PT (Munich, Germany) J. Sharkey MSc, NMT (Dublin, Ireland) D. G. Simons MD (Covington, GA, USA) D. Thompson LMP (Seattle, WA, USA) E. Wilson BA MCSP SRP (York, UK) A. Vleeming PhD (Rotterdam, The Netherlands)

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Journal of Bodywork & Movement Therapies (2010) 14, 103e105

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EDITORIAL

Thoughts on the Amsterdam Fascia Congress: October 2009 In this and subsequent issues of JBMT during 2010, papers will be published that have emerged from the 2nd Congress of Fascia Research, held at the Free University, Amsterdam, during the last week of October 2009. For those wishing to share in the rich experience, a comprehensive immersion is possible through several invaluable resources, in the form of Proceedings books, as well as DVDs, from the 2007 and the 2009 Congresses. These are available from: http://www. fasciacongress.org/2009/dvd-book-purchase-pub.htm One major change from the first Congress, was the inclusion of two 90 minute plenary sessions, in which experts presented briefly on an assortment of manual (high velocity manipulation, connective tissue manipulation, neurodynamics, positional release techniques, structural integration, and manually induced oscillation) and toolassisted modalities (acupuncture, functional fascial taping, Fulford percussion/vibration, Graston technique, dry needling) e with the intention of informing scientists, and other practitioners/therapists, about the methods used, and the theories that underpin them e and most importantly the presumed fascial connections. Three eminent researchers/scientists were invited to comment on both demonstrations/presentations. For the manual therapy session these were Professors Moshe Solomonow, Michael Kuchera and Walter Herzog. For the Tool-assisted presentation the scientific panel comprised Professors Helene Langevin, Andry Vleeming and Siegfried Mense. The topics and presenters of the manual demonstration session are shown in Figure 1.

Impressions of Fascia 2 Stephanie Prendergast MPT ‘‘This meeting was truly multi-disciplinary, both in the presentations, ranging from basic science through clinical practice, and in the audience. This made interactions on and off stage valuable. I had the opportunity to meet professionals I would not have met otherwise. The 1360-8592/$36 ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.01.001

knowledge presented and the off-conference conversations have given me more knowledge regarding my own clinical practice and the use of connective tissue manipulation. My ‘wow’ may be an overall insight into research I naively did not know existed. For starters, I was completely unaware that people even studied fascia on a basic science level. Michael Hicks’ presentation taught me external loading on the fascia acts on fibroblasts e and his lecture discussed the differentiation of myoblasts for repair. I had not thought about the impact of our work on a cellular level e perhaps ever e and as a writer, lecturer, teacher and clinician I should have. Helen Langevin pointed out the difference between ‘areolar connective tissue’ and ‘loose connective tissue’. I also became aware of Rolfing literature. and in general, I am pleased to see fascia and therapies studied at cellular levels to help explain our clinical research findings.’’

Zachery Comeaux DO ‘‘I recognized the high calibre of the conference and appreciated knowing what experts were paying attention to, and not paying attention to. I appreciated the interdisciplinary mix of participants both in informal conversation, and during the clinical demonstration. From the content point of view, I was most impressed by Dr. van der Waal’s anatomical presentation including the potential role of the connective tissue matrix, including mechanoreceptor function, in coordination of regional motion. Aside from that I felt that the primary research was still largely directed toward the mechanical properties rather than responsiveness of the connective tissue matrix. The next generation of research, I hope, will be more in tune with clinical practice, by defining hypotheses more along the lines of natural process development, injury and therapeutic intervention with the living system in mind. I was excited and surprised to find a communality of ideas with the work of Luiz Fernando Bertolucci (Muscle Repositioning), in the Saturday workshops. His thoughts were able to

104

Editorial

Figure 1 Left to right: Leon Chaitow ND DO, Geoffrey Bove PhD DC, Zachary Comeaux DO, Michel Coppieters PhD PT, Stephanie Prendergast MPT, Robert Schleip PhD.

add both new considerations and new moves in my approach to manipulation.’’

Geoff Bove PhD DC ‘‘Overall there seems to be a schism between clinicians and scientists, this is not necessarily what it is typically thought to be. Many clinicians were thinking that scientists were trying to prove or disprove that what they do has an effect, or not. This is far from the truth. In fact what emerged is that scientists are interested in HOW the methods work, since most of them seem to work, at least to some degree. Finding the common denominators will be very helpful. Specifically I was very interested in the concept of using massage methods to ameliorate lymphedema post-mastectomy, and found Willem Fourie’s presentation illuminating.’’ (See Figure 2).

JBMT’s editor’s high points  Probably the most dramatic new information that has emerged from the two Fascia Research congresses,

Figure 2

Willie Fourie PT.

Figure 3 Area of ‘densification’ being treated, during Fascial Manipulationª workshop.

relates to the dynamic reconfiguration potential of the collagen network. This virtually instantaneous reconfiguration e occurring within seconds e suggests that the effect of manual therapy can be immediate and significant. ‘‘This work is a serious challenge to the classical representation and modelling of biomechanical systems’’ (Gracovetsky, in press, Guimberteau, 2007).  Helene Langevin (2009) provided elegant evidence regarding the speed of change in behaviour of loose (areolar) connective tissue (a matter of seconds e see above) when load is reduced following light static stretching. ‘‘Loose connective tissue fibroblasts are dynamically responsive to tissue stretch ex vivo and in vivo.’’  Some of clinical relevance of this new understanding of connective tissue behaviour came from South African physiotherapist, Willie Fourie, who gave an insightful therapist’s view of the management of surgical (mainly post-mastectomy) scar problems. and of the dramatic effect of regularly applied, brief, mild stretching

Figure 4 Julie Ann Day PT and Carla Stecco MD during Fascial Manipulationª workshop.

Editorial









methods e on Transforming Growth Factor b1 (TGF-b1) production and collagen deposition (see Figure 2). Jaap van der Wal offered a terminology lesson e virtually instructing the delegates that ‘‘ligaments don’t exist’’ because they are so enmeshed with connective tissue that the pictures we see in anatomy texts are science fiction. His preferred term, (that may not catch on, I fear, despite his sound argument), is ‘dynament’, to replace ligament. Carla Stecco’s rich presentation offered many insights, including how connective tissue resists traction/elongation, but allows itself to be lifted relatively easily, i.e. to be separated from ‘underlying/parallel structures’. A further Stecco illumination related to the ample presence of intra-fascial nerves, oriented perpendicularly, therefore more likely to be stimulated by collagen stretch. The Fascial Manipulationª workshop (Julie Ann Day and Carla Stecco) was fascinating and instructive. (See Figures 3 and 4) Space does not allow for a full description e suffice to say that the explanations offered, based on years of dissection and research, at the University of Padua, were impressive.

The clinical implications of the evidence in relation to stretch and compression, as well the previously mentioned revelations regarding fascia’s responsiveness to adaptation demands, as provided by Langevin, Stecco. Schleip, Fourie and others, will require many months of personal processing,

105 with some clarity possibly emerging in time for the 3rd Fascia Research Congress, which will take place in Vancouver, in 2012. The hosts for the 3rd congress are the Massage Therapists’ Association of British Columbia (MTABC) http:// www.massagetherapy.bc.ca/. The theme in 2012 will be the Practical Application of Research to Practice. JBMT will carry advance notice of the event, and will once again be publishing papers from key presenters.

References Gracovetsky, S. The coupled motion of the spine Bipedalism versus human gait. JBMT, in press. Guimberteau, J.C., October 2007. Strolling Under the Skin. In: Video Presented at the First Fascia Congress. Harvard Medical School, Boston. Langevin, H.M., 2009. Fibroblast Cytoskeletal Remodeling Contributes to Viscoelastic Response of Areolar Connective Tissue Under Uniaxial Tension. In: Fascia Research, vol. II. Elsevier, Munich.

Leon Chaitow, ND DO, Editor-in-Chief, 144 Harley Street, London W1 G 7LE, UK E-mail address: [email protected]

4 January 2010

Journal of Bodywork & Movement Therapies (2010) 14, 106e107

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EDITORIAL

2nd International Fascia Research Congress, Amsterdam, October 27e30 2009 a Clinicians Review. ¨hrl* Peter Wu Osteopathic Center Martinistrasse, Martinistrasse 11, 20251 Hamburg, FRG Accepted 2 February 2010 Having heard so much about the success of the first Fascia Research Congress, at Harvard (October 2007) attending the second Congress in Amsterdam involved feelings of curiosity and expectation. These feelings were fully realised. There was no resisting the atmosphere and the feeling of excitement that filled the conference hall. Researchers and clinicians from all continents came to the Free University in Amsterdam and joined together to discuss new ideas as well as to rediscover and appreciate old ones. 550 people attended the congress. Just observing the wide range of topics discussed in the halls, and on the floor, left no room for doubt: something has happened in the field of fascia research and practice. The organizers presented a 325-page manual to help delegates navigate through the different layers of the connective tissue of this five-day event. The conference brought together researchers, clinicians, old time fans of fascia, recent converts and sceptics (like myself).

Resistance As a clinician (Osteopath) I have an idea about the importance and limitations of fascia in the body. I also had some resistance and felt the role of fascia is sometimes overstated in Osteopathy. For example, if two phones are

* Tel.: þ49 (0)170 34 14 742. E-mail address: [email protected]

connected through a cable, the cable is important (until we all use cellular phones) but the message is created somewhere else and the fascia only transmits a message others created. Fascia re-acts, but as a clinician I want to know who acts. On the other hand, the research presented at the conference clearly showed that restrictions in fascia play a key role in loss of function and pain; if the cable is not able to slide smoothly on adjacent tissues transmission is compromised.

Compliance The palpable enthusiasm, for the subject of fascia, of those attending and presenting from such diverse backgrounds engendered in this observer a sense of compliance. The conference days started with keynote presentations on the basic scientific research on fascia: cytology, anatomy, biomechanics, innervation, pathology and surgery. Just listening to the concise questions asked of the speakers showed how well informed and prepared the audience was. One of the most impressive presentations was by Jaap van der Wal (University of Maastricht). He is interested in gross anatomy and calls himself a ‘‘dinosaur’’ in a world that is all about cytoskeleton, fibroblasts and molecular biology. Van der Wals’ research led him to talk about the proprioceptive function of connective tissue architecture, a statement that resonates with movement therapist and bodyworkers. Van der Wal and his colleagues in Maastricht have developed a special form of dissection

1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.02.002

Editorial that conserves the connective tissue. In traditional dissections the fascia is cut away, creating disconnected structures as objects of anatomy; one of the reasons, is suggested, that fascia has been relatively neglected in research until now.

Critique The afternoons were filled with presentations of research papers: sometimes boring, sometimes exciting, sometimes hard to understand, and sometimes bordering on being sales pitches. This was, for this reviewer, the least inspiring aspect of the conference. In contrast the most enjoyable sessions were those in which researchers commented on the presentation of clinical application (Rolfing, osteopathic manipulation, Positional-Release-Technique). The researchers were frank in their criticism and well focused. Walter Herzog from the Human Performance Lab at the University of Calgary, pointed to the disconnect between doing and explaining. Most clinicians show mechanics, but talk neurology. They act mechanically in their hands-on approach, but if it comes to talking about the effects of the technique, they refer to neurological relationships.

Friction The panel encounters between researchers and clinicians provided a valuable challenge during the conference. For the most part they treated each other with respect and a curiosity to learn from each other. A healthy friction seemed to dominate. Sometimes it was a bewildered question by a nonresearcher that added excitement to the discussion: why e for example e are most experiments done with stretching fascia, and not with compression? Most research focused on fibers and fibroblasts and not so much on the fluid volume of connective tissue. Both compression and stretch impact the fluid compartment. For a manual approach, working with the three-dimensional expression of forces, the mechanical properties of the fluid compartment of fascia are as important as the mechanical properties of fibers. The closing panel acknowledged this bias and promised to put more emphasis on it next time (Vancouver 2011). Refreshingly for this reviewer, most presenters were researchers, a fact some people complained about,

107 Clinicians offered competing perspectives as to which group had been responsible for reigniting interest in the topic. Fascia used to be a contentious issue. Historically the interest in fascia research was kept alive by hands-on practitioners and fringe researchers. Helene Langevin, another conference highlight, explained that in the Seventies even a Conference on Rheumatology no longer had special panels on connective tissue. Everything was dominated by immunology and molecular biology.

Osteopaths and other characters Of particular interest to this reviewer were the views of osteopathic presenters, especially how they made the split between lab research and clinical application. Some seemed to be quite comfortable in bridging the gap as Leon Chaitow did. Others defended eloquently the clinical experience as paramount to the lab. The conference involved some outstanding characters, who provided both humour and depth in their observations, including Moshe Solomonow (University of Colorado). He spoke with the voice of a grandfather telling fairy tales. An embodiment of the fluidity and softness of connective tissue, he was never afraid to challenge the consensus with his well-thought-of and sceptical remarks. At the end of the conference it was his job to remind everyone that we should not forget that life is beautiful outside the lab. It was also a pleasure to hear Helene Langevin (University of Vermont) present and engage in a discussion that provided delegates with the vision that the complexity of the connective tissues might in time be understood. Another outstanding presenter was fellow-German Robert Schleip. Schleip runs the Fascia Research Project at the Department for Applied Physiology, University of Ulm. From within his height and lankiness, his forward leaning demeanor and positive attitude, he can talk about the most complicated research with an uplifting voice filled with joy, e a symbol of the way ahead in fascia research. Finally the two Dutch organizers, Peter Hollander and Peter Huijing, both with a bone-dry sense of humor. Peter Hollander, the grey eminence of the conference, never in the spotlight always present backstage, without him nothing would have worked. Peter Huijing, always onestep ahead, never short of new ideas and a joke. Those two and all the others put an amazing program together, that resulted in a rekindled excitement for fascia.

Journal of Bodywork & Movement Therapies (2010) 14, 108e118

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SPECIAL REPORT: MODIFYING THE EFFECTS OF CEREBRAL PALSY

Modifying the effects of cerebral palsy: The Gregg Mozgala story Leon Chaitow, ND DO a,*, Tamar Rogoff, Choreographer b, Gregg Mozgala, Actor, Dancer c, Stefan Chmelik, MSc, Physician of Traditional Chinese Medicine d, Zachary Comeaux, DO, Professor of Osteopathic Principles and Practice e, John Hannon, DC, Associate Editor JBMT f, Eyal Lederman, PhD, DO, Professor g, Tom Myers, LMT, Anatomist, Rolfer h a

University of Westminster, UK Tamar Rogoff Performance Projects, 170 Avenue C, #19G New York, NY 10009 c No Affiliation d New Medicine Group, London, UK e West Virginia School of Osteopathic Medicine, USA f 1141 Pacific Suite B, San Luis Obispo, CA 93401, USA g Centre for Professional Development in Osteopathy and Manual Therapy, UK h Kinesis, 318 Clarks Cove Rd, Walpole, ME 04573, USA b

KEYWORDS Rehabilitation; Movement therapy; Dance; Cerebral palsy

Summary In response to a news report of the rehabilitation of a New York-based dancer/ actor with cerebral palsy, to the point where a ballet performance was scheduled, it was determined that a report based on the individuals involved would be commissioned. The resulting reports from the choreographer responsible for the rehabilitation exercises, and the dancer, were circulated to an interdisciplinary selection of physical medicine experts, for commentary as to what clinicians might learn from the case, and what mechanisms might be involved. ª 2010 Elsevier Ltd. All rights reserved.

* Corresponding author. E-mail addresses: [email protected] (L. Chaitow), [email protected] (T. Rogoff), [email protected] (G. Mozgala), [email protected] (Z. Chmelik), [email protected] (J. Comeaux), feldenkrais@ digitalputty.com (J. Hannon), [email protected] (E. Lederman), [email protected] (T. Myers).

In early 2008, a young actor with cerebral palsy, Gregg Mozgala, was appearing as Romeo in a Theater Breaking Through Barriers’ production in New York, which involved a mix of actors, some with disabilities and some without. In the audience was choreographer Tamar Rogoff e who decided that she would explore the idea of producing a performance, with this same young man dancing e despite

1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.02.001

The Gregg Mozgala story

109 This is followed by commentaries from experts who were selected from a variety of disciplines.

Tamar Rogoff

Figure 1 Tamar Rogoff during rehabilitation of dancer, Gregg Mozgala ª2009-2010 by LORI GRINKER.

the fact that he was totally untrained, and could not walk without exceptional distortion and effort. Mozgala has described his walking style at that time as looking like ‘‘a human velociraptor.’’ He walked on his toes, with his lower extremities turned in, wobbling from side to side to maintain balance. Genzlinger (2009), writing in the New York Times report on the Mozgala/Rogoff story, quotes him as saying: ‘‘My knees were going in, my hips were totally rotated inward. Gravity was just taking me down. So my upper body d arms and chest d overcompensated, curling back and up.’’ Some 9 months later, from December 3rd to 20th, Mozgala appeared in New York, in a production (Diagnosis of a Faun) choreographed by Rogoff, at the La Mama Experimental Theater Club. How was Mozgala able to go from his previous dysfunctional walk, to be able to appear on stage as a dancer? The early press reports offered only a few clues. It seems that Tamar Rogoff possesses other skills e that do not involve formal training in health care, but which she has acquired over the years of training and directing dancers. The particular methods and approaches that she used with Gregg Mozgala, are described below. In the text that follows, Tamar Rogoff and Gregg Mozgala describe aspects of the process in their own words.

‘‘I began the work in order to prepare Gregg to dance the role of the Faun in a new work I was choreographing. I first saw him as an actor and his body energy called out to me as it was interestingdstrong and active and responsive to the text. I liked how his passion ignited and was in direct contradiction to his physical condition. He seemed to act his way out of his c.p. leaving me unaware while watching him do Romeo and Juliet that he had it and I knew he could dance his way beyond it as well. I used a lifetime of body learningdeverything from decades of dance techniques (Ballet-Graham-Bharata Natyam) to bodywork. My bodywork teachers were Allan Wayne and Monica and Harmon Hathaway both of whom taught me ultimately never to listen to them but find my own way. I’ve never studied Feldenkrais or Trager or Alexander or Yoga. For the last 26 years I have given a laboratory class at PS 122 and now at La Mama in New York. Many students have been with me for all these yearsdthey are mostly actors and they agree to being there while I investigate whatever interests me movement-wisedthis is an experiential anatomy approach where I can spend a year behind the sternum or the rib cage, for exampledthen include any landmarks in the body that interest medbones-joints muscles-spaces between thingsdthe class speaks my idiosyncratic language dalignment issuesdmine and theirs often spark investigation. In my class at New York University’s Experimental Theater Wing I add how this investigation can be the origin of a choreographic vocabulary and how it can enliven actingdthis is not at all academic, as I haven’t studied the body in an organized course but have picked up information everywhere. I tend to start where I am or from what I see and let the class follow where the body takes usda class can’t ever be replicated. The first order of business with Gregg was to steady him enough so he could transcend his main concern which was balance and introduce him to new ways other than his set in stone movement vocabulary which seemed designed to compensate for the inward rotation of his legs and hips He was locked in to a very specific body vise and felt at the mercy of the signals from his brain which were telling him to tense updwe sat on chairs and stamped the feetdI offered imagerydthe horse shoe heeldwe opened the kneesdtucked him into the foetal position which rounded the lumbar spine and changed the curves he needed for balance once standingdintroduced opposition walking rather than the seesaw side to side lurch which was the way he got around, and after a few weeks I taught him the shaking technique. Shakingdwe started lying down on the back e legs bent feet on the floordarms outstretched to the sidesdpalms upeopening and closing the legs (knees) waiting until involuntary shaking and trembling took overdit took several sessions and ended up starting in thumps of the chest against the floor, the head doing an uncomfortable looking lifting and noddingdall very violent and not where I

110 was expecting it to come fromdeach time he lay down the body took off in this same way until it ran its coursedany time I put my hand on Gregg’s chest I could elucidate a thumpingdlater came other lightning bolts of zigzag energydmonth by month we worked out pattern after patterndmy finger under his lips could cause enormous gaggingdhis arms pounded the matsdhis hands clapped together until they hurt and I had to put something between themdat some point what you might call shaking beganda bit quieter but still intensedthru the thighs and sacrumdthen a vibrato took hold of his bellydhis stomach muscles had never served him as the way his upper body met his lower was disconnected from the body’s original design e then came more pounding, now thru the lumbardall this we followed as the body led us through. I selected a position from which to start sometimes lying on the back and sometimes on the belly or sitting in a chairdI selected a movement to begin getting us to the involuntary part and then we dedicated an hour or two to follow its courseewe were in a gym so we had mats and blocks and everything you might use for yogadI built him structures to get his pelvis up off of the floor so his legs could be tossed over his chest and his hamstrings could stretch and he could access his stomach musclesdnow that his body had experienced the shaking it constantly went to that mode in any stretch. Standing and hanging over fingers near toesdwe used this to stretch out and access the lumbar and open it updhere we got seizing up and a great deal of feardI bypassed the fear many a time by using my body against hisdalmost like lending him my nervous systemdmy sense of flowdthroughout I used my body to teach hisdhe could relax onto me in different waysdthe little Reiki I know I used to quiet him as well e my hands sent messages and new patternsdnow one sweep of my hand can elicit a 20 min reaction and instil a new or even a permanent understandingdmore and more he asks me to move aside as his body is telling him something directly and he must be left alone to follow his internal clues. Walkingdfrom the beginning he walked at every session and I gave him a small message often connected to an image to take on the street with himdwe had to watch his exiting on to the street as he tended to revert to a prior more protective ehistorically more familiar modedmostly I just watched his walk and saw where energy didn’t flowdwhere the body was uneven or where the foot didn’t touch the floordas his abilities grew he could feel when his sacrum was rigid or not. Attitudes e Gregg is now addicted to the way feelings and information come through his bodydhe’s in awe when he feels space in the hip sockets or connections from one place or anotherdor when he can just slow downethis is a reversal of his former attitude which was a slave to his condition ealways taking orders from the Bully (Oliver Sacks’ term for the lesion on the brain in C.P.)ealways using tons of fast frenetic energy to muscle him through everything from walking to sexdhis mind which functioned in a more nuanced way was at odds with the pace and lack of modulation in his body. What he thought in his minddwas not do-able in his bodyetherefore immense frustration as his hyper-vigilance governed the resonance of his body making known its limitations.

L. Chaitow et al.

Figure 2 Gregg Mozgala dancing in ‘‘Diagnosis of a Faun’’. Gregg Dancing ª2009 Julie Lemberger.

IdentitydGregg evolved his personhood ebody and mind to fit into his C.P. bodydthru that body he felt every emotion and in that body was stored all memories pleasurable and painfuldhis body rhythms ewalking and running were the sound score to his lifedthe drag of his footdhis particular toe walkdas his alignment changeddhis patterns changed and he became a stranger to himself and in fact to medit was the original walk that housed the person I was interested indthe new neutral was exciting because it proved that change was possible but a bit blah and devoid of any personalitydI often noticed when Gregg was drunk, or stoned, that his happiness reverted into the old home base of his original alignmentdhe reports that when he is being an actor the same happens. Going forward the questions are:  How will his new body house him?  What parts of the changes he’s elicited in his body will remain with him irrespective of his actively being conscious of them?  What amount of consciousness will be necessary to keep a healthier alignment?

The Gregg Mozgala story  For how long and how much will he have to continue the bodywork process?  We are planning a phase two of this project which will include bringing another person with C.P. on board so Gregg can both watch me teach and teach this person himself. Will teaching the work keep him involved and help preserve his new patterns?  How far will we be able to go towards a permanent positive alignment?  How will Greggs’ personality e emotional balance e identity and world view evolve to meet his new needs in his changing body?

Gregg Mozgala: with cerebral palsy ‘‘I’m sitting on a stool. Tamar is in front of me and has her hands on my feet. She’s placing them into proper alignment and pressing my pinkie toes, forever raised like the true aristocrats they are, into the ground. They were caught unawares by the revolution and need to learn what it means to do an honest day’s work. Tamar instructs me on how to get my feet into proper alignment. She uses her hands at first to show me the path my foot should travel up and down. She lists all the joints in the foot: heel/talus/ankle/ ball/etc. and encourages me to think of the foot in its many pieces as opposed to a heavy, single slab. I ask her to let me try the motion on my own and input the suggestion of the feet as a mutli-faceted unit. There’s an increase in sensation almost immediately. My body is in conflict with itself. It wants to discover these new routes, new ways of moving, which is actually the way it was originally designed to move, but it takes time and effort to release it from it’s old modes of behavior. I’m working on my right foot alone. As I focus to raise and lower my foot, I can feel my left leg grabbing in the hip flexor, the knee wanting to turn in, the heel coming off the ground. I stop. I ask Tamar for a yoga block. With my left foot on the block and supported the ‘‘bully reflex’’ is interrupted and I can put all my attention and focus into my right foot. The simple action of raising and lowering my foot takes an incredible amount of focus and is physically strenuous. After a few minutes I am shaking. Not just in my legs, but my entire pelvis starts undulating. All this movement, termed ‘‘shaking’’ is purely involuntary. As my body discovers the correct pathways and what I assume are new neural connections as a result of positive alignment, my body learns that it can utilize these new pathways and release the old mechanism that had previously allowed for standing, hind-limb ambulation, running, jumping and general mobility with the effective, but less efficient, C.P. alignment. What the shaking does is soften my otherwise tense or spastic musculature to receive basic instructions such as; point your sternum down, tuck your tailbone under, close the front ribs/open the back ribs, etc. What’s more, as my right leg and entire right side begins to learn proper alignment my resting leg begins to respond similarly. Not nearly with the same intensity, but it’s as if one side is teaching the other- like a game of ‘‘Follow the Leader.’’ As my body reroutes I often times also experience a physiologicaleemotional response. In this case, I experienced waves of nausea and became

111 very emotional to the point of tears. Tamar and I never stop or get bogged down with the psychological or emotional ramifications of this. This would kill our progress. We soldier on through. Both of us realize that what’s happening when this occurs is that my body is opening up areas that have been previously unavailable or inaccessible for over thirty years. It is what it is, and this too shall pass. I’d like to digress for a moment here and talk a little bit about my body’s relationship with fear. Tamar has said that my hyper-vigilance is due to my body being in a constant state of emergency. I have come to understand this as a constant fear of falling. During some of our most recent studio sessions as I experience release in my lower body, specifically in the leg below the knee, I’ve noticed that my arms- shoulders, forearms, wrists and hands get extremely tense. I believe this is a compensation that my body does automatically as a protective measure. As I move my pelvis, hips, legs and feet into proper alignment- into an alignment that my body has never felt- my body tenses. This is because I believe IT believes I’m going to fall down. This is a new and fascinating concept to me. I first became aware of my body’s fear response during the rehearsal period. The first day I was working on the set piece we affectionately refer to as, ‘‘The Rock,’’ I couldn’t even sit on it without waves of physical terror coursing through me. I was flanked by Tamar on my left and Sharon, our stage manager, on my right. As I moved around on it and eventually tried to stand up, I held on to them for balance and support. Initially I couldn’t stand up on it without their help. My body would tense so much that it would literally drop me to my knees for a more supported base. If they let go of me the waves of terror would return and I would simply ask- or scream or cry out- for one of them to touch me. This simple action both comforted and grounded me. During our opening week of performance I was experiencing so much pain as a result of tension in my hip flexors that I was convinced it was only a matter of time before I was going to injure myself. Tamar stressed the importance of a focused warm-up. As I increased my warm up and internal focus the pain first moved from my left side to my right and then disappeared completely. By the end of the first week of shows it was gone. It didn’t return for the remainder of the run. As we work in the studio, I’ve realized that I can actually counter this fear response by slowing down and convincing my body that it’s okay- that it’s not in a state of emergency. The grip we call, ‘‘The bully reflex’’ is the grip of fear. If I stay focused and connected to my body as I move into proper alignment, using my mind, I can show my body that there’s an alternative to falling that’s better, safer, more productive. I’m still working on developing this theory but could this be me willing my body to change? We work on my right side for a good forty-five minutes to an hour. I’m shaking. I’m gagging. I’m nauseous. I feel great. It’s time for me to stand up and walk around to see how my body has integrated these latest changes with movement. Tamar slowly removes my left foot from the block, being careful to place it down on the ground in the proper alignment. I ask to try and replicate what I have just done on my right foot with my left for a few times before I stand up. Tamar acquiesces. My left foot is considerably more rigid and less responsive then my right foot in general. It’s harder to lift and place down properly but I manage to do it about half a dozen times before Tamar assists me with standing up. With the first few steps it’s

112 as if my brain has caught fire. My feet are on the floor like never before. I have a roll to my walk that involves the entire foot that I’ve never utilized until this very moment. It’s incredible. I walk for a bit. I allow my body to integrate all the new information we have just fed it. I try to let my new walk walk me. I listen to my body. Before we know it our work has come to an end for the day. Neither of us had this planned when we arrived at the studio this morning. We never have an agenda. It just happened. This progress with the feet however, would not have been possible if we had not been working so intensively over the last eight to ten months. Tamar and I continue to talk as we change clothes and prepare to reenter the world at large. I have to head to the West Village to rehearse for a reading I am doing later that evening. Before we exit the studio Tamar gives me a few basic directions to carry with me throughout the day. I listen. I try and put them into practice as we climb the studio steps and exit out onto the street. Tamar returns the keys to Teddy at the gym. I cross the street and enter my building. As I enter my apartment and hit the stairs I remind my body of the work we have just done and take each step slowly and deliberately, careful to make sure I am landing half-toe/heel/with the outside of my heel pressing down. As I walk up the steps I think for the first time ever, ‘‘I love walking up stairs,’’ as I fight back the urge to throw up in my mouth.’’

Invited commentaries Stefan Chmelik The description of the interaction and partnership between Tamar and Gregg is a fascinating insight into the nature of the body-mind. In Traditional Chinese Medicine (TCM) mind, body (and spirit) are regarded as linked and inseparable. This is reflected in the association between structure, physiology and emotion, often in a circular, non-linear event pattern: in which anything affecting the body will affect the mind, and vice versa. CP is a profound neurological developmental or traumarelated condition. In TCM this level of pathology is almost always associated with the ‘Water element’ and the ‘Kidney’ viscera, as well as the Wood element and the Liver. This requires some interpretation for the Westerntrained mind. The ‘Kidneys’ have several important areas of association, including foetal development, DNA expression, the spine, the bone marrow and brain. The emotional association is fear and shock. Gregg Mozgala discusses his fear response ‘‘Tamar has said that my hyper-vigilance is due to my body being in a constant state of emergency. I have come to understand this as a constant fear of falling.’’ The ‘Liver’ is associated with the tendons and sinews and the free flow of energy (‘Qi’) and blood throughout the body as well as ‘Wind’ (Feng), the idea of either uncontrolled movement or lack or movement:‘ All this movement, termed ‘‘shaking’’ is purely involuntary.’ ‘What the shaking does is soften my otherwise tense or spastic musculature to receive basic instructions.’. Neurons that fire together, wire together, and by allowing the Qi and Blood to circulate through shaking, a new neural

L. Chaitow et al. network is created that seems able to compensate for the dysfunctional messages due to the brain lesions.

Zachary Comeaux This is exciting but not surprising. Couple bravery with determination and insightful intuition, and good things can happen. Many years ago at the Institute for the Achievement of Human Potential, Glen Doman and others formulated a program called patterning, for working with children with cerebral palsy and other congenital conditions disrupting the development of normal locomotion. By passively putting the child through a series of positions replicating the sequence of stages involved in evolving locomotor skills, the children progressed. The process described here reminds me of such treatment. More recently, with the instrumentation of Functional MRI we have gained an increased appreciation for the role of certain brain centers into the coordination of motion, and its association with cognitive processes, including expectations, body image. In other words, the divide between physical and ‘‘psychosomatic’’ aspects of human behavior is narrowing. Additionally, we have learned that this psychomotor system is plastic, changeable, and that learning is a physical as well as behavioral event. The case of Rogoff and Mozgala is interesting to me, not simply as an accomplishment, but as a process. Most bodywork disciplines rely heavily on a conceptual base and prescribed routines. Ms Rogoff and her client have approached the challenge of optimizing locomotor function from a phenomenological point of view. It is my long held belief that this is a valid dimension to any bodywork, and is maximized according to the perceptive capacity of the patient and therapist. An admonition of Dr. Still, the founder of osteopathy, was to ‘‘find the unnatural and return it to the natural.’’ Certainly there are standardized criteria for assessing and guiding treatment. But, especially with experience, clear observation, empathic communication, the will to succeed can serve to replace or complement conceptual analysis and decision making. I salute Rogoff and Mozgala, and expect they should share credit for the accomplishment. I would also expect readers to be motivated to broaden their perspective on dealing with limitations of physical mobility, regardless of practice discipline. Creativity, flexibility and openness to dealing with problems in an existential, rather than simply mechanical and prescriptive way, is legitimate and often fruitful.

Tom Myers, Author of Anatomy Trains (2nd edition, Elsevier, 2010) When this story appeared in the papers, I was very interested in the method employed, so I am glad to have this level of detail from both teacher and recipient. How wonderful that the method has no name! It reminds us that the path of healing is not restricted by specific approaches, but wends its way upward in switchbacks. It reminds us that

The Gregg Mozgala story our ‘name brands’ in bodywork e dear to us if they are our own, or raising our interest or suspicion (or both) if they seem to run counter to our beliefs - are but signposts along this path, and not the path itself. Secondly, I was impressed with the emphasis on what Gregg can do. So much of medical rehabilitation starts with what the patient cannot do, striving to make the currently impossible possible again. It was Emilie Conrad (of Continuum fame), herself a dancer originally, who first introduced me to the very liberating concept of: Start with what they can do. Explore that, and the novelty will arise, and then explore that, which leads on to more novel movements. Emphasis on the problem, difficulty, lack, and inability e even with a ‘helpful’ attitude e can leave a patient frustrated and depressed. Tamar’s method seems to owe much to the dancer’s sure knowledge that everyone has limitations, and yet everyone has a world within his body. Gregg’s Bully had limited his movement range, and then he himself had limited it further by adopting and constantly reverting to his CP stance, his rolling gait, his locked-in legs. By exploring an unrelated but possible movement within his range, he was led naturally up the switchbacks rather then going for the straight line uphill e which can be an effective path for the simple injury rehab, but not for a complex and enduring ‘condition’ such as Gregg presented. Seeing the situation as an opportunity instead of a problem is the artist’s prerogative, and one that more therapists would do well to adopt. Thirdly, we can note that everyone of these conditions has a somatoemotional component, very much evident in Gregg’s self-disclosing comments e he loves this and he’s about to gag; he’s standing and crying out in his fear of failure (falling). Those who undertake these deep structural healing processes should be prepared for cognitive dissonance, for not believing everything you think, for contrary emotions that occupy brain and belly together, for deep swoops and giddy highs that follow each other. Gregg clearly had the strength for such a journey and not everyone is willing. The shaking is an essential part of such releases, when the ‘accelerator/brake’ (combined excitatory and inhibitory signals, autonomic and somatic) lets go its grip and neuromuscular patterns (in my experience) let go, shake for some time, and then normalise. From the sounds of it, there was a ‘whole lotta shakin’ goin’ on’, indicative of both how deep Gregg’s patterns ran, but also how deep he was prepared to go to free them. Finally, we must note how much time and attention it took to stage Diagnosis of a Faun e and to complete even this stage of healing. There is no indication of how many hours the two spent together in the nine months, but on the basis of my own experience with similar journeys, I can easily believe that both were engaged pretty full-time on this project. How lucky for Gregg to have such a dedicated teacher! How lucky for Tamara to have such a willing student! Most professionals in the healing trade cannot set aside so much time for one person. But it is in these journeys that the possibilities of healing a revealed, which are later refined and fitted into protocols by others who follow. Thank you Tamara, and thank you Gregg for the glimpse into deep and path-breaking healing via the arts.

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Eyal Lederman Rehabilitation and re-abilitation Movement rehabilitation and motor normalization following central nervous system or musculoskeletal injury occurs naturally in varying degrees for most individuals. Following injury most humans will take physical actions that will support their spontaneous and unaided recovery. This would happen without any special knowledge or understanding of the underlying physiological principles underpinning their recovery. This recovery behaviour is the basis of functional neuromuscular rehabilitation. In this form of rehabilitation the individual is attempting to, partially or fully, execute the movement that has been lost. As in Gregg’s process, attempting to walk becomes the rehabilitation for the person who lost the ability to walk. The focus in this form of movement recovery is on the overall skill of performing the particular movement (skill rehabilitation). The therapist’s role (or Tamar’s in this situation) is to provide feedback/guidance about the ‘‘correctness’’ of the movement, e.g. the placement of the foot on the ground or overall posture in movement. However, this approach does not always lead to the intended results. Individuals who have motor losses may develop movement patterns that circumvent their losses. As in Greggs’ condition he presented with walking difficulties due to losses in the control of balance and coordination (as well as other factors). Using the skill rehabilitation principle, one would imagine that by encouraging the individual to increase their walking, ‘‘walking would train balance and coordination during walking’’. However, what may happen is that the individual will get better at using their compensatory pattern as were Gregg’s pre-training walking patterns. He tended to have slower walking speed or use shorter steps, rather than truly improving his control of balance and coordination during walking. Balance and coordination are part of several control building blocks that make up skilled movement. These building blocks are called sensory-motor abilities (Figure 3). A therapeutic approach that targets the various motor abilities is called ‘‘Re-Abilitation’’. At this level of rehabilitation the aim is to recover control losses associated with particular abilities. Hence, in Gregg’s case Tamar focused on challenging balance and coordination in dynamic and upright postures during the training. As we see in this case-study, skill rehabilitation and reabilitation are both therapeutically important and are often used in combination. However there may be a shift of focus towards one of these particular approaches depending on the individual’s condition and their phase of recovery. This is seen in Tamar’s and Gregg’s journey. The code for neuromuscular adaptation Neuromuscular rehabilitation is a straightforward process e anyone can do it. Indeed, we all do it all the time. Every day we take actions that result in movement and behaviour changes; we can self-modify our motor control. Furthermore, the neuromuscular system has the capacity for selfrecovery and to reorganize. It means that within our behaviour there are certain elements that facilitate the recovery of movement control.

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L. Chaitow et al. could help to reduce the overall duration of the treatment/ training programme. Skill Rehabilitation Composite abilities

Re- Abilitation

Further reading: Lederman, E., 2010. Neuromuscular Rehabilitation in Manual and Physical Therapy. Elsevier, Edinburgh. Internet resources: http://www.cpdo.net/shop/lederman_neuromuscular_ rehabilitation_ch01.pdf http://www.cpdo.net/shop/lederman_neuromuscular_ rehabilitation_ch14.pdf

Synergetic abilities

John Hannon

Parametric abilities

Figure 3 Rehabilitation of movement control can be at skill or ability level. Skill-level rehabilitation aim to recover movement losses by practicing the movement affected. Ability-level rehabilitation (re-abilitation) focuses on challenging underlying motor ability changes/losses. (from: Lederman E 2010 Neuromuscular rehabilitation in manual and physical therapy. Elsevier).

In functional rehabilitation we identify five such elements that optimize neuromuscular adaptation: cognition, being active, feedback, repetition and similarity (Figure 4). Hence in order to learn a new task, modify our behaviour or help our system recover we need to be aware of what we are doing (cognition) and we have to actively perform the action that we aim to recover (being active). In order to correct our movement we rely on internal information from our senses or depend on guidance by someone (feedback) and we have to practice the task many times (repetition). Furthermore, the practice has to closely resemble the movement we aim to recover (similarity). These principles are evident throughout Tamar’s description of her work with Gregg. She is intuitively facilitating Greggs movement control by introducing these adaptive code element into the training/dance programme. This approach will promote a functional recovery that is more likely to benefit the individual in their daily activities. The results are more likely to be maintained in the long term and

The artists She: a choreographer who found the young actor interesting and knew he could dance beyond cerebral palsy with his body energy that was active, strong and responsive (and, she felt, in direct contradiction to his hampered movements). He: the actor both articulate and willing to learn (and to endure the intensity of learning and not knowing). He describes his constant fear of falling (strong enough at times to provoke tears and severe nausea). He finds himself in the grip of the ‘‘bully reflex’’ that perpetuates his damaged movement patterns. Together, they find a way to transform these movements into capable and expressive ones; this process is emotional and arduous in large part because, as he puts it, he involuntary tenses when placed in better alignment because he believes the Bully reflex believes he must fall. Putting aside the enormous willingness of both parties to be vulnerable and honest. Putting aside the vast resources of creativity and intelligence both applied to these day-today challenges. What draws admiration is the pleasure they take in persistence. Tamar Rogoff in her persistence in a lifetime of body learning (and the courage to move past her teachers and find her own way). Gregg Mozgala in his moment-by-moment anguish as he painfully transcends his fear of falling to access his untapped capacity for balancing upon strong bones, intact nerves and a sharp intelligence. Together, they persisted and moved past the illusions, the delusions and the coarse muscle habits.

Cognition Being active Feedback Repetition Similarity

Figure 4 Experiences that contain the five code elements are more like to promote adaptive changes within the neuromuscular system resulting in movement and behavioural changes. (from: Lederman E 2010 Neuromuscular rehabilitation in manual and physical therapy. Elsevier).

The Gregg Mozgala story What are some of the things we can learn and be inspired by their actions? For one, there are our own illusions and delusions; another is to not let our training hamper our work. Current illusions William James (1890) questioned the then-current perception of the human body as ‘‘the same old body always there.’’ Since then, more nuanced views of the body have arisen but the reliability and validity of palpatory findings continues to be a worrisome reminder that much remains to be learned. There are interesting pilot studies of the vagaries of touch perception and the potential for illusion. Even though this seems but a dry wasteland when compared to the marvellous (and fluid) duet of learning/moving as presented in Diagnosis of a Faun, here are some intriguing items. Rock and Victor (1964) presented people with objects whose visual shape was vastly distorted experimentally from their tactile shape. They found that, after simultaneously grasping and viewing these objects, the subjects were strongly biased in favour of the visual sense and unaware of any conflict between the senses.1 This idea that visual assessments take precedence over tactile findings suggests that therapist training must include methods of recognizing (and extinguishing) visual bias. This is particularly relevant when bridging the gap between anatomical book-knowledge2 and that of the moving, breathing and utterly responsive clients we care for. In other studies,3 the subjects often ‘know’ their body is different than their illusory perceptions; they are not in delusion4 but they find the illusion inescapable. Longo et al. (2010) quote Lhermitte (1942) as noting the

1

Carter et al. (2009) extended this exploration of visual versus tactile dominance; their findings suggest the presence of tactile ambiguity. By using a grid of discrete stimulators, they found a tactile equivalent of the visual apparent motion illusion where the subject was unable to decode a solitary stimulation pattern. This implies the possibility for palpatory touch, at times, to lead treatment astray. 2 Huijing (2009) regrets the lack of detail in current texts in the descriptions of the ‘‘rapport’’ between adjacent muscles found in many French anatomy texts of the 19th century. This disappearance of detail pales when compared to the lack of consideration in kinesiology texts of the nuanced movements championed by dancers, mimes, gymnasts, circus acrobats, martial artists, musicians and athletes in general. 3 For instance, Longo et al. (2010), describe the Pinocchio illusion where the experimenter vibrates the subject’s arm that is holding the subject’s nose. (Vibration of the muscle tendons triggers the brain to consider the muscles as lengthening.) Thus a perceptual dilemma; the hand is perceived to be moving yet it is in continuous contact with the nose. Many subjects experience their noses as growing longer from this illusion while remaining perfectly aware their noses are not changing. 4 As compared to patients with certain brain lesions; there are people that experience ’numbsense’ (similar to blindsight) where they can localize touches that they are unable to detect. 5 Sacks (1995) states that it is not enough to apprehend something. The mind must be able to accommodate and retain a discovery and its possible connections. It is this second process that would benefit from careful study of the Rogoff:Mozgala process.

115 importance of ‘‘distinguishing between how we perceive our body to be, and how we remember or believe that it is.5’’ They note this challenge is all the more poignant when we realize there is no equivalent to a GPS satellite signal in the body that telling us where our body parts are in space. Parallel touch systems Myers (1998) points out that the English words ‘blind’ and ‘invisible’ define the incapacity of seeing and of being seen; and, although ‘numb’ describes the inability to feel, there is no word for not being able to be felt. This inadequacy of our common language for mapping what Lea (2009) calls ‘‘the messy corporeal geographies of learning a skill’’ make it all the more important study how people learn to move well. This marvellous exploration of the possible as seen in Diagnosis of a Faun is in sharp contrast to what Lewit (2010) describes as the plight of modern medicine deftly using complicated equipment while neglecting communication and the evidence of our eyes and our hands. Longo et al. (2010) note evidence of two parallel touch systems. In addition to the myelinated afferents serving the skin, they note the unmyelinated tactile C-fibres form a parallel system also serving the skin. This they describe as a system for ‘affective touch.’’ Serino and Haggard (2010) also discuss the dual nature of touch. They note that touch is a crucial agent in the construction of our self-consciousness6 and that tactile perception may vary depending on the mental representation of the involved body part. McGlone et al. (2007) continue to study the C-tactile afferents which they hypothesize drive the ‘‘emotional somatic system’’. They regret that although most acknowledge somatic sensation drives the subjective experience of pain, it is not often appreciated it also provides the emotional pleasure of touch. Tremblay and Elliott (2003) also discuss dual sensory processing. They describe two distinct visual streams; the ventral stream functioning for form perception and object recognition and the dorsal stream associated with actionbased perceptual judgments. To explore this further, they studied visualevestibular illusions; interestingly, they explain the kinesthetic system as also being stimulated by motor involvement and frame of reference orientation. Another dual sensory system proposed by Mittelstaedt (1996) discusses postural perception as being affected by previously unknown graviceptors located in the trunk. The first input enters the spinal cord at the 11th thoracic level. He hypothesizes the second follows either the phrenic or vagus nerves yielding gravity information through sensing changes in inertia of the blood contained within the great vessels. Vaitl et al. (2002) corroborated these findings with additional evidence that afferent inputs from the cardiovascular system are significant in postural perception. Decety and Gre `zes (2006) note yet another relevant dual system: that of a person perceiving the actions of another. They cite studies that suggest when individuals perceive the actions and the emotions produced by others, they use the same neural mechanisms as when they produce the

6

This resonates with Seitz (2000) who believes there is a bodily system of thought: ‘‘we do not simply inhabit our bodies; we literally use them to think with.’’

116 actions and emotions themselves. Moreover, a number of neuroimaging studies have shown that similar brain areas are activated while imagining one’s own actions or those of another. It may be possible to yoke in our minds these multiple sensory systems and cobble together some speculations about the magic and mystery of Rogoff:Mozgala. For instance, it is striking how emotional concerns are portrayed in the excerpts from both Mozgala and Rogoff. If we acknowledge the existence of multiple perceptual pathways, perhaps we will find additional ways of using them in ourselves as we help those we serve. Further considerations Cordo and Gurfinkel (2004) examined the sit-up. They used this action to illustrate that complex movements have associated movements not consciously controlled but essential for successful function. They state that since complex movements typically require a great deal of mobility (which makes instability likely), anticipatory postural adjustments (APA) are used to regulate posture. This implies for us to understand the capacity for humans to move, particularly those with impairments, we must track both APAs and associated movements as well as make judgments regarding their quality and appropriateness. In fact, we may have to map apprehensive APAs as well. Horstmann and Dietz (1990) suggested that in upright posture, a gravity-dependent mechanoreceptor system was needed (in addition to visual, vestibular and muscle proprioceptive systems) to signal the position of the body’s centre of gravity relative to the feet. They further suggested that these force-dependent receptors are pressure receptors within the joints and the vertebral column. Pozzo et al. (1998), while studying subjects both weightless and in normal gravity, found that gravity either initiates or brakes arm movements indicating that gravity may be represented in the planning of motor commands. Carson et al. (2009) devised a robotic system to reverse the effect of gravity upon the arms of participants.7 They found that in normal gravity, movements made on the downbeat were more stable than those on the upbeat; they also found this relationship was reversed when gravity was neutralized. They concluded that the ubiquitous tendency for downward movement on a musical beat arises ‘‘not from the perception of gravity but as a result of the economy of action that derives from its exploitation.8’’

7 Carson et al. had noted (while we find our arms being moved by music) that ‘‘invariably we will coordinate our movements so that the end of the downward phase of our gesture coincides with the beat of the movement.’’ 8 This echoes Massion (1994) who noted that after training the postural control system, the goal is to be as economical as possible in terms of energy consumption. This is accomplished by using passive forces (such as gravity) when possible. He noted that the ‘‘overall picture of postural organization that emerges from recent investigations is a long way off the picture of classical postural reflexes presented by the Sherrington School. While the old description of these reflexes is still valid and their analysis is still a useful means of experimentation and neurological evaluation, the emphasis is now on the flexibility of postural control and its adaptability to different contexts.’’

L. Chaitow et al. Taken together, these suggest we should look at how Rogoff arranged Mozgala; how she used stamping and shaking. Perhaps part of their success is based upon her seeing not only his movement but seeing where he could better ‘‘root’’ (with the help of gravity) his stance and his actions. Metaphorically, if we imagine a joint or muscle as a ‘‘tree’’ and the whole body’s action as a ‘‘forest’’ perhaps we can simultaneously see not only the forest and the trees but also the roots. And, lastly, perhaps we can formulate answers to the question of how quickly is it possible for improvement to happen? And how to make gravity trustworthy and taking the terror out of the distance between ourselves and the ground? Consider a well-designed study of the quality of postural balance: Tsang et al. (2004),9 found elders practicing Tai Chi improved stance control under reduced or conflicting sensory conditions with better balance than non-Tai Chi elders similar in age and gender. They also found the elder Tai Chi practitioners behaved similar to the young healthy subjects in terms of controlling body sway in their experimental design. Questions abound. How fast can a person learn movement excellence? Does it take more than a year to achieve balance? Just what is the quality of movement of healthy students? Let us use the experience of Rogff & Mozgala; let us choose to believe there is much more possible in the fields of movement quality and motor control than current studies suggest. What then can we learn from bodyworkers and movement therapists? From the wealth of published wisdom there is only room to consider a few wise examples: Maitland (2002) describes treatments as being of three kinds: relaxation; obtaining correction or, thirdly, integrating the subject as a whole. Browne (2006) notes three characteristics of what he calls qualitative exercise. 1. Self-awareness (‘‘know what you’re doing to do what you want.’’). 2. Make the exercise look like the behavior you want. 3. Link the exercise to real-life movements. Rywerant (2003) recommended a continuous, creative series of evaluative responses to what the teacher saw and felt in his or her pupil. He states: ‘‘The outcome of the process may be considered to be an answer to a question or problem concerning the subject. In some instances, a question may be proposed uniquely for the purpose of having it answered, as in the case, consciously or unconsciously, with most creations of art’’. Blackburn and Price (2007) suggest being present with the client. Instead of ‘‘spacing out’’ where both therapist and client drift in their own separate worlds, they present ways for the therapist to stay present as well as ways for the therapist to encourage the quality of presence in the client. In this they agree with Rywerant (2003) who notes that when the pupil is excessively alert to a possible infringement on its security, start by lessening this concern.

9 Tsang et al. used computerized dynamic posturography to study (in groups of about twenty) (1) young healthy students naı¨ve to Tai Chi, (2) elderly Tai Chi practitioners (training at least 3 times weekly for at least a year) and (3) healthy elders without Tai Chi experience.

The Gregg Mozgala story Speculative conclusions The very existence of the splendid collaboration of Mozgala & Rogoff inspires us to move beyond scientific experiments. Their success suggests the need to revamp our own selftraining in observation, palpation and motivation. We can re-learn how to listen, how to touch, how to feel and how to move. We need to be aware of the possible illusions that face us when we reach out and touch someone. Perhaps we also need to find an inner well of somatic empathy to internalize a more accurate representation of what our clients/pupils/patients are feeling and how they are moving. This means a three-dimensional living anatomy constructed of volumes rather than a lifeless sheaf of plane images. Also note these volumes must move to be representative. This movement includes the sloshing of liquids such as synovial fluid, lymph, blood and inflammation. Somehow we must sense the spring of bone and cartilage. Somehow we must tell the difference between resting muscle’s heft and drape versus the stiffness and solidity of a tightened/shortened/contracted muscle. We need to sense layers; we need to identify those places that do not compress or elongate or glide well. We need to learn to think for ourselves. Margaret Mead10 is reputed to have said ‘‘that the ways to get insight are to study infants; to study animals; to study primitive people; to be psychoanalysed; to have a religious experience and to get over it; to have a psychotic episode and get over it. .’’ Let us get exposed to the many wonderful ways of seeing and treating people. Let us reach basic competencies in a formal method of bodywork or movement therapy and then ‘get over it’. Learn another way and get over that one as well. Once we have confidence in our own competence, perhaps then we may think for ourselves. We need to debate our methods and our rationales. We need to translate the research in related fields to our own purposes and then we need to debate our rationales. We need to welcome temperate yet incisive criticism from our colleagues and develop a common language in what could be termed ‘‘spatial medicine’’. For instance, we benefit from learning of altered movement patterns appearing before the onset of pain as observed by Szeto et al. (2005).11 We further learn after observing if we find similar findings in our own practices. We vastly learn more when we share our findings. Towards this end, we would do well to learn from those who seek movement excellence, whether teachers or artists. We need to learn from the best. There is a place for dual sensory streams and tactile illusions but let us not allow the dusty academics to spoil the view of the possible. Let us harness the body’s capacity to exploit multiple sensory channels in ways utterly novel to scientists and clinicians alike. With eyes freshened by seeing the Rogoff:Mozgala transformation, let us develop confidence in methods of our own.

10 Margaret Mead quote (viewed 1.26.10) at http://www. goodreads.com/quotes/show/170824. 11 Szeto et al. (in a pilot study of 23 office workers) found that altered muscle recruitment patterns were observed in symptomatic subjects before the task became uncomfortable.

117

References Blackburn, J., Price, C., 2007. Implications of presence in manual therapy. Journal of Bodywork and Movement Therapies 11, 68e 77. Browne, G., 2006. A Manual Therapist’s Guide to Movement: Teaching Motor Skills to the Orthopedic Patient. Churchill Livingstone Elsevier, Edinburgh. p.20. Carson, R.G., Oytam, Y., Riek, S., 2009. Artificial gravity reveals that economy of action determines the stability of sensorimotor coordination. PLoS ONE 4 (4), e5248. Carter, O., Konkle, T., Wang, Q., Hayward, V., Moore, C., 2009. Tactile rivalry demonstrated with an ambiguous apparentmotion quartet. Current Biology 18 (14), 1050e1054. Cordo, P.J., Gurfinkel, V.S., 2004. Motor coordination can be fully understood only by studying complex movements. Progress in Brain Research 143, 29e38. Decety, J., Gre `zes, J., 2006. The power of simulation: imagining one’s own and other’s behavior. Brain Research 1079, 4e14. Genzlinger, N., 2009. Learning his body, learning to dance. New York Times November 24 2009. Huijing, P.A., 2009. Epimuscular myofascial force transmission: a historical review and implications for new research. International Society of Biomechanics Muybridge award lecture, Taipei, 2007. Journal of Biomechanics 42, 9e21. Horstmann, G.A., Dietz, V., 1990. A basic posture control mechanism: the stabilization of the centre of gravity. Electroencephalography and Clinical Neurophysiology 76, 165e176. James, W., 1890. Principles of Psychology, vol. I. Henry Holt, New York, p. 242(1918 copyright edition viewed at Google Books: 1.26.10). Lea, J., 2009. Becoming skilled: the cultural and corporeal geographies of teaching and learning Thai Yoga massage. Geoforum 40, 465e474. Lhermitte, J., 1942. De l’image corporelle. Revue Neurologique 74, 20e38. Longo, M.R., Azan ˜o ´n, E., Haggard, P., 2010. More than skin deep: body representation beyond primary somatosensory cortex. Neuropsychologia 48 (3), 655e668. Lewit, K., 2010. Manipulative Therapy: Musculoskeletal Medicine. Elsevier, p. 380. McGlone, F., Vallbo, A.B., Olausson, H., Loken, L., Wessberg, J., 2007. Discriminative touch and emotional touch. Canadian Journal of Experimental Psychology 61 (3), 173e183. Maitland, J., 2002. Cultivating the vertical: the Rolf method of structural integration. In: Coughlin, P., Micozzi, M.S. (Eds.), Principles and Practice of Manual Therapeutics, pp. 88e99. Massion, J., 1994. Postural control system Current Opinion in Neurobiology 4 (6), 877e887. Mittelstaedt, H., 1996. Somatic graviception. Biological Psychology 42 (1e2), 53e74. Myers, T., 1998. Kinesthetic dystonia: what bodywork can offer a new physical education. Journal of Bodywork and Movement Therapies 2 (2), 101e114. Pozzo, T., Papaxanthis, C., Stapley, P., Berthoz, A., 1998. The sensorimotor and cognitive integration of gravity. Brain Research. Brain Research Reviews 28 (1e2), 92e101. Rock, I., Victor, J., 1964. Vision and touch: an experimentally created conflict between the two senses. Science 143, 594e596. Rywerant, Y., 2003. The Feldenkrais Method: Teaching by Handling. Basic Health Publications, Laguna Beach, p. 81, 210. Sacks, O., 1995. Scotoma: forgetting and neglect in science. In: Silvers, R.B. (Ed.), Hidden Histories of Science. New York Review Book, New York, p. 159. Seitz, J.A., 2000. The bodily basis of thought. New Ideas in Psychology 18, 23e40.

118 Serino, A., Haggard, P., 2010. Touch and the body. Neuroscience and Biobehavioral Reviews 34, 224e236. Szeto, G.P.Y., Straker, L.M., O’Sullivan, P.B., 2005. A comparison of symptomatic and asymptomatic office workers performing monotonous keyboard workd1: neck and shoulder muscle recruitment patterns. Manual Therapy 10, 270e280. Tremblay, L., Elliott, D., 2003. Contribution of action to perception of self-orientation in humans. Neuroscience Letters 349, 99e102.

L. Chaitow et al. Tsang, W.W., Wong, V.S., Fu, S.N., Hui-Chan, C.W., 2004. Tai Chi improves standing balance control under reduced or conflicting sensory conditions. Archives of Physical Medicine and Rehabilitation 85, 129e137. Vaitl, D., Mittelstaedt, H., Saborowski, R., Stark, R., Baisch, F., 2002. Shifts in blood volume alter the perception of posture: further evidence for somatic graviception. International Journal of Psychophysiology 44 (1), 1e11.

Journal of Bodywork & Movement Therapies (2010) 14, 119e126

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

SPINAL REHABILITATION

Preliminary investigation into a seated unloading movement strategy for the lumbar spine: A pilot study Jerome Fryer, BSc DC (Hons)*, William Zhang, MA, MSc University of Northern British Columbia, Prince George, BC, Canada V2N 4Z9 Received 28 February 2008; received in revised form 14 June 2008; accepted 16 June 2008

KEYWORDS Lumbar; Hydraulic; Nutrition; Sitting; Unload; Posture

Summary This study was a preliminary investigation into a seated unloading movement strategy for the lumbar spine using the upper extremities. With the economic burden of LBP estimated in the billions worldwide, and also with a trend towards more jobs related to sitting, a simple distraction exercise coined chair-care is presented. An attempt to objectify using stadiometry was used to measure standing height changes after 15 min of sitting and after the exercise. The results showed significant standing height gains post-exercise when compared to post-sitting and initial standing (2.4 and 2.7 mm, respectively). No significant standing height changes were seen after 15 min of sitting. It is therefore likely that this simple seated exercise creates standing height gains of the spine. Proposed mechanisms are discussed with an emphasis on spinal hydraulics and intervertebral disc nutrition. Reproducible studies are required. ª 2008 Elsevier Ltd. All rights reserved.

Introduction In the description of low back pain (LBP), many have suspected the intervertebral disc as a probable source (Podichetty, 2007) with its degenerative cycle curiously intertwined in the etiology. Typical degeneration findings include: radial fissures, prolapse, endplate damage, annular protrusion, internal disc disruption, and disc space

* Corresponding author. #2-1551 Estevan Road, Nanaimo, BC, Canada V9S 3Y3. Tel.: þ1 250 753 5351; fax: þ1 250 714 0162. E-mail address: [email protected] (J. Fryer).

narrowing. A common theme in these findings is a compartmental disturbance of water: dessication and/or displacement. Whether it is lack or severe displacement as in herniated forms, water (with its solutes) plays an integral role on the mechanobiology of the intervertebral discs (Fortuniak et al., 2005). The fundamental role of the disc is to resist compression (Adams and Roughley, 2006) and maintain vertebral spacing in spinal motion. And when water is properly contained and directed, it critically supports the disc structurally and nutritionally. Prolonged sitting has been shown by some as deleterious to the low back (Beach et al., 2005) especially when combined with awkward postures (Lis et al., 2007). With the

1360-8592/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2008.06.008

120 rapid development of modern technology, sitting is now the most common posture in today’s workplace (Li and Haslegrave, 1999). Investigative tools like that of positional MRI has shown that sitting induces flexion in the lumbar spine as well as posterior nuclear migration (Alexander et al., 2007) and dural sac swelling (Hirasawa et al., 2007). Others using this technology have found a positive correlation to the level of degeneration and anterior and middle disc height loss in sitting (Karadimas et al., 2006). Many LBP syndromes appear to be curiously related to prolonged sitting with a common clinical reporting of stiffness or pain during and/or after the act. But under what mechanism is still unresolved. In 2005, in vitro static flexion disc loading showed greater movement of vertebrae when compared to cyclic loading (Little and Khalsa, 2005). Obviously, sitting without shifting is a constant gravitational load on spinal discs and correspondingly, it is speculated here that the efflux of water from discs predominates over the influx in sustained sitting. With the worldwide economic burden of LBP estimated in the billions (Maniadakis and Gray, 2000; Luo et al., 2004), interest remains high in discovering successful therapeutic interventions. In many scientific treatment circles, decompression or unloading of the discs is a common theme in this pursuit. These interventions range from conservative to surgical treatments with outcomes of varying success. Recently, potential evidence supporting the role of distraction in disc regeneration and hydration (through improving disc nutrition via the endplates) has been published (Guehring et al., 2006; Crock and Yoshizawa, 1976) suggesting that distraction seems to make the most probable sense from a therapeutic standpoint (Schnake et al., 2006). With newer understandings of disc physics relating to endplate pressures (Huber et al., 2007), fluid-flow (Van der Veen et al., 2005) and static versus dynamic loads (Huang and Gu, 2008), this preliminary paper looks at a seated decompression/recompression strategy utilizing the upper extremities in the treatment and prevention of LBP related to intervertebral discs. In 1998, this movement strategy was conceived and coined chair-care by the author. It was then prescribed in private practice to those with LBP and dysfunction related to sitting during the periods of 2000e2008. The outcomes have demonstrated consistent patterns of varying improvement. Here, an introduction to the movement strategy is presented, together with an attempt to objectify results seen in private practice.

Materials/methods This study included 49 subjects acquired primarily from visiting patients to a chiropractic/naturopathic clinic in Nanaimo, BC, Canada. Subjects were asked if they wanted to participate in a study evaluating a newly designed exercise for LBP. Additional participants were recruited by way of a posting in the local paper. Participants were of ages ranging from 12 to 85 (mean age of 54.9 years). Forty-nine percent of the participant were females (24/49) and 51% were males (25/49). Height measurements were taken using a 235 Heightronic digital stadiometer (accuracy to 0.01 cm) using a capacitive incremental encoding system by accurate technology. The stadiometer was installed on a stable interior wall in the waiting room of a clinical office. The surface under the stadiometer was leveled concrete with an

J. Fryer, W. Zhang industrial grade carpet glued down without underlay. Informed written consent was obtained for all subjects.

Measuring procedure Each subject approached the stadiometer with their backs facing the wall. To ensure the specific feet position of the subject for a standing height measure, the examiner placed his or her index fingers on the border of a piece of tape that was securely fastened 4.6 cm from the bottom of the wall on the carpet. Each subject was asked to bring their feet together (with shoes removed) and slowly shuffle each foot back to the point where symmetrical pressure was felt by the examiner’s fingers in contact with the heels of each subject. Subjects rested their back on the vertical plexiglass plate of the stadiometer. Subjects head position was determined as follows: if the subject was able to rest the head against the wall comfortably, then resting the head on the vertical column of the stadiometer was preferably chosen as a standard measuring position for that subject. If the subject had significant kyphosis and was not able to rest the head easily back onto the stadiometer, the subject was asked to look straight ahead. Examiners were trained in standardized measurement procedures. Three examiners were used in this study with one performing all measurements within each subject. Minimal pressure was induced on the top of the stadiometer head unit when measures were obtained with an attempt for consistency within each examiner. Each measurement was recorded in 5e10 s upon rising from the chair. Three standing height measurements were taken on all subjects: an initial standing, a post-sitting, and a postexercise measurement (see Figure 1). After the initial measurement, the subject was asked to sit for 15 min and instructed not to shift or use the armrests. The chair used was a standard office chair and was located approximately 1.2 m from the standing measuring site. A timer with an audible chime was utilized to identify the 15 min duration. At the 12e14 min mark of sitting, the participant was explained the exercise both procedurally and verbally by way of demonstration by the examiner (see Figure 2a and b) with subjects only watching the examiner. After 15 min of sitting, subjects got up (without using the armrests) and approached the stadiometer for the postsitting measurement. Immediately following this (post-sitting) measurement, the subject returned to the same chair and performed the exercise. After four repetitions of 5 s with a return to relative neutral for 1e3 s between each repetition (Figure 2a), the subject stood up and the third (post-exercise) standing measurement was taken. Measurements were recorded within 5e10 s after the last distraction component of chair-care. This was the conclusion of the study for that participant. The outcome measures of interest were the height differences between each of the three standing heights within each subject. The descriptive statistics were evaluated with stem and leaf analysis with QQ in determining normal distribution (see Table 1). Paired t-test was performed on each pair of standing height differences (initialepostsitting, initialepost-exercise, post-sittingepost-exercise). The influence of age and gender was also investigated with

Investigation into a seated unloading movement strategy for the lumbar spine

Figure 1

several ANOVA models, including General Linear Model (GLM) with repeated measurements and age and sex as factors, and ANOVA model with the height change as response/dependent variable. Here, only the GLM with repeated measurements will be discussed, which is further refined with age removed.

Results Stem and leaf plot and QQ plot did not find sufficient evidence against the assumption that the data follows normal distribution, therefore, paired t-tests for each pair of standing height differences (initialepost-sitting, initiale post-exercise, post-sittingepost-exercise) were performed. The post-exercise standing height measurements differed significantly (p<.001) from both post-sitting and initial standing heights (Table 2) with mean height increases seen (2.4 and 2.7 mm, respectively). Significant changes were not seen comparing standing heights before and after sitting. The same conclusions were found when the data were evaluated, stratified by gender. A general linear model with

121

Study flow.

three measurements as repeated measurements, patient as subject, gender as a fixed factor and age as a covariate was performed. The SAS code is

proc glm dataZtest.Data; class sex; model start postchcar postsitZsex age/nouni; repeated Time 3 contrast(1); run;

In the above SAS code, the repeated measurements form the factor ‘‘time’’. The results of the tests of hypotheses for between subjects effects are shown in Table 3. The p-value for sex is .0006, indicating the average of three height measurements is significantly different between man and woman, while the average of three height measurements does not change due to age changing. The results of hypotheses test for within subjects effects are shown in Table 4. As the age and timeage are both

Figure 2 (a) Chair-care. (b) A seated anti-axial creep movement strategy, chair-care. Instructions: press into the seat cushion with your hands and relax the lower back while creating a distraction moment in the lumbar spine. The majority (approximately 60e80%) of your full weight should be supported by the shoulder girdles. Be sure to keep the chin retracted and arms externally rotated. Hold for 5 s. Most people feel a stretching in the lower back while performing. Gently return to neutral sitting posture for 1e3 s allowing the full weight to be resupported by the spine. Repeat four times.

122 Table 1

J. Fryer, W. Zhang Descriptive statistics for three standing measurements in the study cohort.

Initial

Gender

N

Minimum

Maximum

Mean

S.D.

Female Male

25 24 49

142.76 150.27 142.76

177.75 196.10 196.10

164.00 173.73 168.77

7.49 10.32 10.16

Female Male

25 24 49

142.01 150.34 142.01

178.15 196.15 196.15

164.04 173.76 168.80

7.58 10.39 10.22

Female Male

25 24 49

142.85 150.40 142.85

178.30 196.38 196.38

164.29 173.99 169.04

7.52 10.36 10.18

Whole group Post-sitting Whole group Post-exercise Whole group

insignificant, the covariate age is taken out and the model is refined as  model start postchcar postsitZsex/nouni; Following is the result of the tests of hypotheses for within subject effects (see Table 5). The result indicates that time is significant (p<.0001), i.e., the mean of the heights are different between three measures. It also confirms that gender has no impact on how heights/measurements are changed across different measuring time, i.e., the interaction between time and sex is insignificant (pZ.9746). The results for the tests of contrast specified in the refined model are listed in Table 6. It indicated the same conclusion about the two pairs (post-exercise height measurements versus the initial height, the height after sitting versus the initial height) as the paired t-test in Table 6 did.

Discussion In the first part of this study, standing heights were measured before and after 15 min of sitting without significant changes seen. We expected to see standing measures decrease after 15 min of sitting. Other researchers have found height increases in standing height postures after a period of 30 min of sitting (Althoff et al., 1992) with greater attention to subject positioning compared to this pilot study. It is unknown whether we would have seen the same, as our protocols were different. We believe that a measure of increased joint space width (JSW) occurs in the hips, knees and ankles likely resulting in height gains in the lower extremity when standing heights Table 2

were measured (both in this and Althoff’s study) which was not discussed in detail in the research of Althoff et al. Heel pad swelling was considered but intrasynovial swelling in other joints were not considered and assumptions were made with the influence on stature considered negligible. We disagree and believe the influence from the lower synovial joints is not negligible. They found that the act of supported sitting contributed to greater statural heights but this was looked at with 30 min of sitting versus our study of 15 min of sitting therefore, it is difficult to compare. Swelling within other joints in the lower extremities may have occurred to a greater extent with 15 more minutes of unloading. For example, the meniscus in knees has been found to be involved significantly in load-bearing MRI studies in the calculation of JSW (Hunter et al., 2006). Obviously, when someone sits, the spine continues to be under load while the lower extremities are relieved of the large axial forces of gravity. Height gains may have occurred between epiphyseal plates/hyaline cartilage/ meniscus within joints in the lower extremities during sitting in conjunction of height loss in the spine when standing heights were measured after 15 min of sitting. Deformation of all biological tissues, not only heel pad swelling, in lower extremity changes during sitting must be accounted for when standing heights are of interest to help assess tissues involved in standing measures. Therefore, in future spinal studies of events related to height changes, it is suggested that measuring sitting heights would help eliminate the lower extremity influence on data as has been done by Magnusson et al. (1990). If height increase of intervertebral discs are related to a period of unloading (Kourtis et al., 2004), then could it be possible that this occurs in other cartilaginous structures, like that of the hip, knee and ankle? Could the common experienced relief in

Paired t-test for each pair of the three measurements: initial, post-sitting and post-exercise. Paired differences

Pair 1: Post-exerciseepost-sitting Pair 2: Post-exerciseeinitial Pair 3: Post-sittingeinitial

Mean

S.D.

.24367 .27633 .03265

.27836 .31780 .29784

t-test

d.f.

Significance (two-tailed)

6.128 6.086 .767

48 48 48

<.0001 <.0001 .447

95% confidence interval of the difference Lower

Upper

.16372 .18504 .05290

.32363 .36761 .11820

Investigation into a seated unloading movement strategy for the lumbar spine Table 3 effects.

Tests of hypotheses for between subjects

Source d.f. Type III SS Sex Age Error

1 1 46

Mean square F-value Pr>F

3366.54954 3366.54954 11.49442 11.49442 11467.28381 249.28878

13.50 0.05

0.0006 0.8309

the lower extremities when someone sits down after a period of standing be related to JSW? The act of ‘‘standing-up’’ after a period of 15 min of sitting did not demonstrate standing height gains in this study when compared to the seated distraction technique looked at in part 2. This finding suggests that the commonly encouraged action to get out of a seated position (McGill, 2002) may not have the same spinal benefits as the spinal unloading technique looked at in this study. In the second part of the study, initial and post-sitting heights were compared to post-exercise heights. Postexercise heights were found to be significantly increased. This supported the hypothesis that height increases are associated with this exercise. There were many possible limitations in the study. Positioning of the subject may have influenced the data; however, standardized measurement procedures were used to minimize this error although not tested rigorously for reliability. Even though the subjects were blinded from measures, positioning changes may have occurred, even if a subject’s intent was objective. Future studies using the 235 Heightronic stadiometre should consider the use of the spectalevel to help minimize cervical flexion/extension variances within subjects in future stadiometric studies. This device was simply created with an attached site level on the arm of a pair of universal glasses although not used in this study. Some researchers have implicated heel pad swelling as a factor in stature measures (Foreman and Linge, 1989) reporting that 2 min of standing pressure on the heels were required for reliable standing height measures. But as individual differences were looked at with the same amount of heel-time pressure before measures were obtained (5e10 s) after a period of unloading, this was considered a relative constant; with the likelihood of seeing even greater significant height gains post-exercise if subjects remained seated to allow the heel pads to swell even more before the final measure was taken. Diurnal changes in height happen most quickly in the early morning hours so the measurements recorded in a window of approximately 17 min within each individual between the hours of 10 a.m. and 5 p.m. should have not influenced the

Table 4 effects.

Univariate tests of hypotheses for within subject

Source

d.f. Type III SS Mean square F-value Pr>F

Table 5 The result of the tests of hypotheses for within subject effects. Source

0.24529072 0.00168957 0.00394495 4.26872260

0.12264536 0.00084479 0.00197248 0.04639916

2.64 0.02 0.04

0.0765 0.9820 0.9584

d.f. Type III SS

Time 2 Timesex 2 Error (time) 94

Mean square

F-value Pr>F

2.23054469 1.11527234 24.54 0.00234333 0.00117166 0.03 4.27266756 0.04545391

<.0001 0.9746

data with any significant weight. It was presumed that most of the subjects had been up for at least 1 h before commencing the study which has been shown in previous studies to have the greatest height variances (Tyrrell et al., 1985). Preloading histories of entering subjects were not known on the day of testing and it is uncertain whether this would have interfered with the results. The 235 Heightronic stadiometer is reliable with very little calibration required (.01 cm over 200 clinical uses). It is therefore unlikely that the unit itself posed any significant error. The investigators taking the measurements with the stadiometer had extensive training and experience with the unit but unfortunately were not blinded. Pressures on the top of the stadiometer during recordings may have influenced the data even if care was taken. Additionally, no other known studies using this stadiometer with these protocols were done previously; therefore, it is difficult to compare this pilot study to others. In this study, the screws were loosened with only very minimal friction of the sliding apparatus. It is suggested that in future studies utilizing the 235 heightronic, that the adjustment screws be loosened completely so the weight of the stadiometer head be the only factor in pressure induced on the top of a subject’s head. This study did not investigate the duration that the observed changes in height were retained. Interestingly, when the third measurement (post-exercise) was taken, it was noticed that the numerical digital reading was descending, almost as though the subject’s height was ‘‘settling down’’. The quicker a measurement could be acquired after the exercise, the greater the height was for that subject. This is why a 5e10 s restriction was implemented after the last unloading repetition to record the height. Utilizing this sensitive stadiometer revealed the dynamic nature of standing posture (especially immediately after the exercise) that was otherwise unknown to the author. Other areas of possible error might be the chair-care procedure itself. How to perform the exercise (Figure 2a and b) is explained and demonstrated to the subject at the 12e14 min mark during the sitting phase of the experiment but having subjects perform this exercise for the first time brought some queries. Table 6 Source

Time 2 Timesex 2 Timeage 2 Error (time) 92

123

Analysis of variance of contrast variables. d.f. Type III SS

Post-exercisee 1 initial Post-sittinge 1 initial

Mean square

F-value Pr>F

3.73467516 3.73467516 36.24

<.0001

0.05205355 0.05205355 0.57

0.4522

124

J. Fryer, W. Zhang

Figure 4

Chair-care proposed hydraulic model.

down from the gleno-humeralescapular complexes. A comparison study of differing postural relief strategies would prove to be useful in the future. No known risks are associated with this movement strategy although it is speculated that minor cervical compression may occur. The optional use of fists, in chairFigure 3 Chair-care with armrests. Press into the armrests with the elbows to unload the lumbar spine.

This exercise requires some practice and it is expected that greater height gains would have been seen with more experienced performers. A recent literature review in people with non-specific chronic LBP suggested that there was strong supportive evidence in improving pain and function when comparing unloading movement facilitation to no exercise (Slade and Keating, 2007). This chair-care exercise (both without and with armrests (see Figure 3)) is thought to incorporate components of several common unloading therapeutic strategies for LBP (Cox flexion distraction, intermittent traction/distraction, and the McKenzie protocols) into a simple-seated vertical unloading format in which most people should be able to perform. It is also similar (in some respects) to the popular orthopedic sign called minors, but with an extension moment instead of the flexed unloading position as it often demonstrates in discogenic related syndromes. Chair-care also appears to be similar in posture to Brugger’s relief position (Lewit, 1996) as the lumbar spine is repositioned into an erect (lordotic) posture. The critical difference chair-care offers is the added component of lower spinal unloading through the act of pressing

Figure 5

Proposed decompression hydraulics.

Investigation into a seated unloading movement strategy for the lumbar spine

125

Conclusion This was a pilot/preliminary investigation to objectify a simple seated exercise, coined chair-care, that has demonstrated varying degrees of clinical success in private practice. Individual standing height differences were not seen after 15 min of sitting but were seen after the performance of the exercise. Future stadiometric investigations should include the use of a spectalevel to help with the invasive nature of positioning error using the 235 Heightronic. Were the changes seen due to the lumbar angle and/or disc heights or something else? Positional MRI should be used to anatomically investigate. The ease of application makes this exercise potentially useful for many with LBP related to sitting. Optimal loading and unloading rates still require investigation in defining the most favorable microenvironments of human lumbar intervertebral discs in sitting.

Conflict of interest declaration Figure 6

Proposed compression hydraulics.

care, should help those with symptoms related to the carpal tunnel. With the diurnal loading recovery cycle of these structures suggested in the mechanobiology and degenerative paradigm (Johannessen et al., 2004), it is proposed here that this decompression/recompression exercise aids in the drawing of water and essential solutes across endplates in and out of discs in an ebb and flow fashion (see Figures 4e 6). Some forms of mechanical loading have demonstrated the ability to induce highly specific metabolic responses (Iatridis et al., 2006) and with a yet to be determined optimal loading/unloading rate, this exercise is thought to encourage metabolism through an active cyclic osmotic mechanism, providing a relief of the effects of axial load over time while sitting. The height increase in this study is believed to be due to (in part) by increasing the exposure of the fixed negative charges of sulphated GAG chains (Maroudas and Evans, 1974) in discs to the large dipole moments of influxing water. With a greater number of water bound aggrecans, this is expected to contribute towards a greater disc volume. These height gains seen after chair-care in this preliminary study must be reproduced. Improvements to minimize measurement error using the 235 heightronic stadiometer should be implemented to help with issues of measurement validity and reliability. Future studies might consider positional MRI to help discern why height increases were seen with chair-care in this study. The continuing investigation of the compressive effects of weight on intervertebral discs while sitting should help cast light on associated disc rheology and sitting. Optimal low back unloading and re-loading rates while sitting require attention in the scientific pursuit of corresponding optimal osmotic transportation to and from intervertebral discs. Water carries both nutrients and structure to these large avascular structures.

No grants, technical support or corporate support have been requested or utilized in this study. There are no conflicts of interest.

Acknowledgments The lead author would like to thank John A. Dufton, DC MSc MD; Mitch Haas, DC MA; David Panzer DC; and James Carollo MS for the editing of this paper. I must also thank my dear wife, Nichole.

References Adams, M.A., Roughley, P.J., 2006. What is intervertebral disc degeneration, and what causes it? Spine 31, 2151e2161. Alexander, L.A., Hancock, E., Agouris, I., Smith, F.W., MacSween, A., 2007. The response of the nucleus pulposus of the lumbar intervertebral discs to functionally loaded positions. Spine 32, 1508e1512. Althoff, I., Brinkmann, P., Frobin, W., Sandover, J., Burton, K., 1992. An improved method of stature measurement for quantitative determination of spinal loading. Application to sitting postures and whole body vibration. Spine 17, 682e693. Beach, T., Parkinson, R., Stothart, P., Callaghan, J., 2005. Effects of prolonged sitting on the passive flexion stiffness of the in vivo lumbar spine. The Spine Journal 5, 145e154. Crock, H.V., Yoshizawa, H., 1976. The blood supply of the lumbar vertebral column. Clinical Orthopaedics and Related Research 115, 6e21. Foreman, T.K., Linge, K., 1989. The importance of heel compression in the measurement of diurnal stature variation. Applied Ergonomics 20, 299e300. Fortuniak, J., Jaskolski, D., Tybor, K., Komunski, P., Zawirski, M., 2005. Role of proteoglycans in the intervertebral disc degeneration. Neurologia i Neurochirurgia Polska 39, 324e327. Guehring, T., Omlor, G.W., Lorenz, H., Engelleiter, K., Richter, W., Carstens, C., Kroeber, M., 2006. Disc distraction shows evidence of regenerative potential in degenerated intervertebral discs as evaluated by protein expression, magnetic resonance imaging, and messenger ribonucleic acid expression analysis. Spine 31, 1658e1665.

126 Hirasawa, Y., Basir, W., Smith, F., Magnusson, M., Pope, M., Takahashi, K., 2007. Postural changes of the dural sac in the lumbar spines of asymptomatic individuals using positional stand-up magnetic resonance imaging. Spine 32, E136eE140. Huang, C.-Y., Gu, W.Y., 2008. Effects of mechanical compression on metabolism and distribution of oxygen and lactate in intervertebral disc. Journal of Biomechanics 41, 1184e1196. Huber, G., Morlock, M.M., Ito, K., 2007. Consistent hydration of intervertebral discs during in vitro testing. Medical Engineering and Physics 29, 808e813. Hunter, D.J., Zhang, Y.Q., Tu, X., LaValley, M., Niu, J.B., Amin, S., Guermazi, A., Genant, H., Gale, D., Felson, D.T., 2006. Change in joint space width: hyaline articular cartilage loss or alteration in meniscus? Arthritis and Rheumatism 54, 2488e2495. Iatridis, J.C., Maclean, J.J., Roughley, P.J., Alini, M., 2006. Effects of mechanical loading on intervertebral disc metabolism in vivo. The Journal of Bone and Joint Surgery. American Volume 88, 41e46. Johannessen, W., Vresilovic, E.J., Wright, A.C., Elliot, D.M., 2004. Intervertebral disc mechanics are restored following cyclic loading and unloaded recovery. Annals of Biomedical Engineering 32, 70e76. Karadimas, E.J., Siddiqui, M., Smith, F.W., Wardlaw, D., 2006. Positional MRI changes in supine versus sitting postures in patients with degenerative lumbar spine. Journal of Spinal Disorders and Techniques 19, 495e500. Kourtis, D., Magnusson, M.L., Smith, F., Hadjipavlou, A., Pope, M.H., 2004. Spine height and disc height changes as the effect of hyperextension using stadiometry and MRI. The Iowa Orthopaedic Journal 24, 65e71. Lewit, K., 1996. Role of manipulation in spinal rehabilitation. In: Liebenson, C. (Ed.), Rehabilitation of the Spine: a practItioners Manual e-dition, first ed. Williams and Wilkins, pp. 195e196. Li, G., Haslegrave, C.M., 1999. Seated work posture for manual, visual and combined tasks. Ergonomics 42, 1060e1086.

J. Fryer, W. Zhang Lis, A.M., Black, K.M., Kom, H., Nordin, M., 2007. Association between sitting and Occupational LBP. European Spine Journal 16, 283e298. Little, J., Khalsa, P., 2005. Human lumbar spine creep during cyclic and static flexion: creep rate, biomechanics, and facet joint capsule strain. Annals of Biomedical Engineering 33, 391e401. Luo, X., Pietrobon, R., Sun, S.X., Lui, 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. Magnusson, M.L., Hult, E., Lindstrom, I., Lindell, V., Pope, M.H., Hansson, T., 1990. Measurement of time dependent height-loss during sitting. Clinical Biomechanics 5, 137e142. Maniadakis, N., Gray, A., 2000. The economic burden of back pain in the UK. Pain 84, 95e103. Maroudas, A., Evans, H., 1974. A study of ionic equilibria in cartilage. Connective Tissue Research 1, 69e79. McGill, S., 2002. Reducing the risk at work. In: McGill, S. (Ed.), Low Back Disorders: Evidenced-Based Prevention and Rehabilitation e-dition, first ed. Human Kinetics, pp. 161e186. Podichetty, V.K., 2007. The aging spine: the role of inflammatory mediators in intervertebral disc degeneration. Cellular and Molecular Biology 53, 4e18. Schnake, K.J., Putzier, M., Haas, N.P., Kandziora, F., 2006. Mechanical concepts for disc regeneration. European Spine Journal 15, S354eS360. Slade, S.C., Keating, J., 2007. Unloaded movement facilitation exercise compared to no exercise or alternative therapy on outcomes for people with non-specific chronic low back pain: a systematic review. Journal of Manipulative and Physiological Therapeutics 30, 301e311. Tyrrell, A.R., Reilly, T., Troup, J.D., 1985. Circadian variation in stature and the effects of spinal loading. Spine 10, 161e164. Van der Veen, A.J., Mullender, M., Smit, T.H., Kingma, I., Van Dieen, J.H., 2005. Flow-related mechanics of the intervertebral disc: the validity of an in vitro model. Spine 30, E534eE539.

Journal of Bodywork & Movement Therapies (2010) 14, 127e138

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

PERFORMING ARTS MEDICINE

Performing arts medicine e Instrumentalist musicians: Part III e Case histories Jan Dommerholt, PT, DPT, MPS* Bethesda Physiocare, Inc./Myopain Seminars, LLC, 7830 Old Georgetown Road, Suite C-15, Bethesda, MD 20814-2440, USA Received 24 November 2008; received in revised form 11 February 2009; accepted 12 February 2009

KEYWORDS Case reports; Performing arts medicine; Physiotherapy; Musicians; Ergonomics; Trigger points

Summary In parts I and II of this article series, the basic principles of examining musicians in a healthcare setting were reviewed [Dommerholt, J. Performing arts medicine e instrument alist musicians: part I: general considerations. J. Bodyw. Mov. Ther., in press-a; Dommerholt, J. Performing arts medicine e instrumentalist musicians: part II: the examination. J. Bodyw. Mov. Ther., in press-b]. Part III describes three case reports of musicians with hand pain, interfering with their ability to play their instruments. The musicians consulted with a performing arts physiotherapist. Neither musician had a correct medical diagnosis if at all, when they first contacted the physiotherapist. Each musician required an individualized approach not only to establish the correct diagnosis, but also to develop a specific treatment program. The treatment programs included ergonomic interventions, manual therapy, trigger point therapy, and patient education. All musicians returned to playing their instruments without any residual pain or dysfunction. ª 2009 Elsevier Ltd. All rights reserved.

Introduction Parts I of this article series outlined the basic principles of the history and examination of musicians within the context of healthcare (Dommerholt, in press-a, in press-b). While many aspects of the examination and treatment outlined in this article are applicable to other professions as well, the focus of this article is on the physiotherapy assessment and management. Readers are encouraged to place the case reports within their own discipline. Because musculoskeletal

* Tel.: þ1 301 656 5613; fax: þ1 301 654 0333. E-mail address: [email protected]

injuries are the most common disorder among musicians, it follows that physiotherapists would play an important role in the management and prevention of injuries (Dommerholt and Norris, 1997; Brandfonbrener, 2000). Yet, in a study commissioned by the International Conference of Symphony and Opera Musicians only 13% of 2212 musicians associated with 48 major symphony orchestras in the United States had consulted with physiotherapists (Fishbein et al., 1988). In 1994, the American Physical Therapy Association established the Performing Arts Special Interest Group [PASIG], which aims to be ‘‘a leading authority in performing arts physical therapy [.] through professional development and dissemination of current information/trends, current practice, research initiatives and outreach programs with performing

1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.02.005

128 artists and performing arts groups’’ [https://www.orthopt. org/sig_pa.php, accessed February 11, 2009]. In 2004, the PASIG published a practice analysis survey to initiate the development of clinical guidelines, which showed that after dancers, musicians are the second most common population treated by performing arts physiotherapists (Gamboa et al., 2004). The PASIG includes dancers, instrumentalists and vocal musicians, ice skaters, and gymnasts in its definition of performing arts physiotherapy. In spite of the efforts of the PASIG and other performing arts medical associations, relatively few articles have appeared in the physiotherapy literature about the specific physiotherapy management of musicians (Gamboa et al., 2004). Performance-related injuries are almost always preventable (Wynn Parry, 2003; Fjellman-Wiklund and Chesky, 2006). Physiotherapists can educate musicians, music students, teachers, and managers of performing arts organizations, which has been shown to be very effective (Dommerholt and Norris, 1997; Hildebrandt and Nubling, 2004). Most music teachers have not received any education on care of the physical body of musicians (Redmond and Tiermman, 2001). Musicians need to learn and accept that their physical body is part of the instrument and deserves and requires the same level of attention and care (Dommerholt et al., 2000). Teachers familiar with injury mechanisms and prevention strategies are essential in instructing students accordingly (Hildebrandt and Nubling, 2004). Physiotherapists and other healthcare providers can initiate prevention programs in music schools or orchestras. Preventative exercise program or movement re-education classes have proven track records in reducing playing-related musculoskeletal problems (Spaulding, 1988; Chong et al., 1989; Wakely, 1998; Ackermann et al., 2002; de Greef et al., 2003). For example, a fifteen-week self-awareness program to reduce injuries and improve musicians’ perceived physical competence demonstrated a significantly reduced injury rate compared to a control group. Forty-five percent of the decrease in injuries was a direct result of an increase in physical competence (de Greef et al., 2003). An injury prevention program at a Norwegian conservatory was very effective (Spaulding, 1988). A Dutch symphony orchestra contracted with a physiotherapist to conduct a weekly consultation clinic available to all members of the orchestra. The program has been well received, and has been shown to reduce the rate of musculoskeletal disorders (Wakely, 1998). Strength and especially endurance programs directed at music students reduced their perceived exertion of playing (Ackermann et al., 2002). Musicians do not necessarily make regular exercise part of their daily routine, which increases their risk of injury. Poor proximal strength, endurance, and stability result in poor posture, increased stress on distal muscles, and overuse injuries. The combination of poor and constrained postures, flawed practice habits, repetitive movements, poor physical conditioning, stressful work conditions, faulty ergonomics, and poor awareness are direct causes of injury (Lowe, 1992; Quarrier, 1993; Dommerholt and Norris, 1997; Dommerholt, 2000; Brandfonbrener, 2006). Shafer-Crane emphasized trunk stabilization, shoulder stabilization, upper quadrant strengthening, stretching, and overall conditioning as the main components of a prevention program for musicians (Shafer-Crane, 2006).

J. Dommerholt

Case histories This article documents the physiotherapy management of three musicians with hand pain. Each case illustrates different aspects of the physiotherapy evaluation process and physiotherapy management. Although the article is written from the perspective of a performing arts physiotherapist, the principles are applicable to other healthcare providers as well.

The bassoonist The patient was a 19-year-old male college student who experienced disabling pain in the left index finger, but only when he played the bassoon. He was on a full music scholarship and played in the university’s symphony orchestra and in other school ensembles. During his high school years, he had switched from saxophone to bassoon at the recommendation of his music teacher, who had advised him that colleges have much difficulty in finding high-level bassoon players and the likelihood of getting music scholarships would be considerably greater for bassoon players than for saxophonists. The patient had played the bassoon for only three years. In preparation of his college auditions, he had increased his practice time considerably and often would play 6e8 h daily. Since he had been accepted to the school on a full scholarship, he practiced approximately 5 h daily in addition to orchestra rehearsals, private lessons, and other ensemble engagements. When asked about his practice habits, he admitted playing nearly continuously without regular breaks. He did not use any practice methods without playing the instrument, such as shadow-playing or mental practice. During the period that he prepared for the auditions, he had experienced similar pain in his left index finger, but the pain was not constant and did not interfere with his ability to play. Upon entering college, he started studying with a new teacher, but with few significant changes in his playing technique. After approximately six weeks in the music school, he started experiencing frequent pain in his left index finger. Two months later he consulted with a performing arts physiotherapist. The onset of pain started after approximately 5e10 min of playing the bassoon. The pain would increase unless he stopped playing. Rest periods did not seem to make much difference. When he would start playing again, the pain would start again after 5e10 min. At its worst, he rated his pain as a ‘‘8’’ on a visual analog scale ranging from 0 to 10, with ‘‘0’’ being equal to ‘‘no pain’’ and ‘‘10’’ the ‘‘worse level of pain he could imagine.’’ When he stopped playing, the pain would subside within minutes. The musical repertoire did not have any impact on the onset of pain. Other activities of daily living did not evoke the patient’s pain complaint. He did not experience any pain in his finger unless he played the bassoon. There were no other pertinent findings from the history (for a review of pertinent questions, see part I of this series). The patient was examined with and without the bassoon. The examination without the bassoon revealed normal muscle strength of the finger flexors, extensors, and interossei using manual testing. Range of motion was

Performing arts medicine significant for the finding of hypermobility of the metacarpophalangeal joints of all his fingers. Passive extension was measured at 80 degrees and was not painful. Palpation of the extensor digitorum muscle and the finger flexors did not trigger the patient’s familiar pain. Local palpation of the intrinsic hand muscles and the wrist and finger extensors did not reveal any discomfort either. He did not have systemic whole-body hypermobility. Hypermobility was limited to the upper extremity. Examination of the patient while playing the bassoon showed a mismatch between the patient’s hand size and the size of the instrument. In order to wrap his fingers around the bassoon, he kept his hand and fingers tightly against the instrument, which caused excessive passive hyperextension of the metacarpophalangeal joints (see Figure 1). At the same time, he held his left arm closely against his trunk in an adducted position of the shoulder. The patient did not present with any other obvious impairments, which would explain the onset of disabling pain. Discussion From a music medicine perspective, the patient’s status was rated as a grade 1 on the Functional Grading of Severity of Injury scale (Fry, 1986). As mentioned in part I of this article series, the Functional Grading of Severity of Injury scale is commonly used to determine the impact of pain on playing musical instruments. In this case, the pain was limited to one site and the onset of pain was brought on by playing the instrument. The pain did not persist away from the instrument and did not persist on rest. From a US physiotherapy perspective, it is recommended to use the Guide to Physical Therapy Practice to classify and diagnose patients’ problems (American Physical Therapy Association, 2001). The Guide is developed by the American Physical Therapy Association and is based on Nagi’s disablement model (Nagi, 1965, 1969, 1991; American Physical Therapy Association, 2001). In this model, four interrelated concepts are identified, including pathology/pathophysiology, impairments, functional limitations, and disability (American Physical Therapy Association, 2001). Pathology refers to a disease, disorder, or

Figure 1 Hyperextension of the metacarpophalangeal joint due to a mismatch between hand anthropometry and size of the instrument (ª 2008 e Jan Dommerholt).

129 condition and usually corresponds to the medical diagnosis. Impairments are the consequence of disease, pathological processes, or lesions, and are defined as ‘‘abnormalities of structure or function.’’ When impairments result in the inability to perform a physical activity, task, or activity in an efficient, typically expected, or competent manner, physiotherapists formulate functional limitations. Disability according to the model is defined as ‘‘the inability or restricted ability to perform actions, tasks, and activities related to self care, home management, work (job/school/ play), community, and leisure roles in the individual’s sociocultural context and physical environments’’ (American Physical Therapy Association, 2001). The patient did not present with a clear pathological or pathophysiological condition. He had not seen a physician for this problem and did not have a medical diagnosis. The patient’s hypermobility of the metacarpophalangeal joint appeared to be causative of the pain he experienced during playing the bassoon and as such, hypermobility was diagnosed as an impairment. Hypermobility was particularly problematic, because of a mismatch between the patient’s hand anthropometry and the size of the bassoon. As a result of the impairment, the patient was functionally limited as he was no longer able to play the bassoon without pain. Because he could not overcome his functional limitation and was not able to play his instrument and meet the expectations of his work as an orchestra musician in the college symphony orchestra, he was considered disabled. Following the examination, physiotherapists categorize each patient into specific practice patterns, which direct the management plan. The Guide identifies four categories of conditions: musculoskeletal, neuromuscular, cardiovascular/pulmonary, and integumentary. Each category consists of several sub categories (American Physical Therapy Association, 2001). The patient was categorized into musculoskeletal practice patterns B (Impaired Posture) and D (Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Connective Tissue Dysfunction). As hypermobility was thought to be the primary impairment, pattern D was the primary musculoskeletal pattern. The Impaired Posture during playing the instrument was considered a secondary pattern. The therapeutic management of this patient posed several interesting challenges. The Guide distinguishes three intervention strategies: coordination, communication, and documentation (American Physical Therapy Association, 2001). The patient had not consulted with other healthcare providers, which limited the coordination and communication to the physiotherapist and the patient. Patients who are being seen by other practitioners require a more comprehensive level of coordination and communication. Because the patient did not present with distinct pathological findings, his treatment plan was mostly functionally oriented. Initially, the patient was instructed to position his left upper arm into scaption, which positioned his hand in a more relaxed position at the instrument. Unfortunately, with his arm in scaption, he was not able to maintain good contact with the instrument and he was not able to play at all. As the patient was full-grown and bassoons do not vary much in size, there were limited options of modifying the fit

130 between the patient’s hand and the instrument. We considered modifying the keys and extend the keys toward the player’s hand. As an alternative, we considered using a so-called plateau key, which is a covered key with a pad for the third finger of the left hand. A plateau key replaces the traditional ring key and allows small hands to more comfortably close a finger hole. The patient was however, quite concerned about making modifications to his instrument, and he preferred other less permanent modifications, which is a common response of musicians faced with modifying their instruments (Ostwald, 1992). Placement of a few layers of gauze in between the left hand and the instrument did correct his hand and shoulder positions reasonably well, but was not a permanent position (see Figure 2). After two months of searching for a suitable solution, the problem was finally corrected using Silopad pressure sensitive dots. The dots feature an adhesive, which made it possible to attach the dots directly to the instrument, without damaging the veneer of the bassoon. Silopad pressure sensitive gel dots were originally designed for the treatment of pressure or friction induced lesions, such as blisters or calluses, but they proved ideal to correct the patient’s hypermobility and to eliminate the direct pressure of the hand on the instrument (see Figure 3). Prior to discharge from physiotherapy, the patient was educated regarding proper practice habits. With the Silopad, he was able to return to playing the bassoon full-time without any pain or other restrictions. He received a small supply of dots for future use. Three years after discharge, the patient contacted the physiotherapist. He reported that his pain had not returned. However, he had run out of pressure sensitive dots and ordered an additional set. In summary, the patient returned to playing the bassoon on a full-time basis without any restrictions or residual pain. Although his music career was seriously threatened, the problem was corrected after only one physiotherapy examination and treatment.

The guitarist The patient was a 30-year-old male amateur classical guitarist, who had not been able to play the guitar due to

Figure 2 Correction of hyperextension at the metacarpophalangeal joints using several layers of gauze (ª 2008 e Jan Dommerholt).

J. Dommerholt

Figure 3 Correction of hyperextension and direct pressure using Silopad pressure sensitive dots (ª 2008 e Jan Dommerholt).

severe pain and limited range of motion of the left thumb. During a hiking trip two-and-a-half years earlier, a backpack fell on his outstretched left thumb, causing immediate pain. He reported that the thumb and the thenar prominence were swollen for several days following the accident. He did not seek medical attention for several weeks, but he did consult eventually with a physician who diagnosed him with having a muscle strain and prescribed non-steroidal anti-inflammatories. After two months, he continued to have severe pain with movement and limited range of motion of the left thumb, at which point he consulted with a hand surgeon. The hand surgeon made a diagnosis of ‘‘scar tissue’’ and referred him to a hand therapist. The patient reported that he did not see any obvious signs of scar tissue, but the hand therapist confirmed the diagnosis of scar tissue. He had several weeks of occupational therapy/hand therapy, but he did not gain much progress. He was informed that due to the scar tissue, he would not be able to play the guitar anymore. He was not able to position his left thumb behind the neck of the guitar and play the instrument. He discontinued hand therapy and stopped playing guitar. Occasionally, he tried to play the instrument, but his limited thumb range of motion prevented him from playing comfortably. The pain in the thumb eventually subsided somewhat, but was always present especially with any use of his thumb. After reading a newspaper article about music medicine, the patient consulted with a performing arts physiotherapist. He reported that he had been playing guitar since high school. He started taking private classical guitar lessons approximately 8 years before the accident. He had always studied with the same teacher. As he was unable to play guitar at all, questions about his repertoire, playing, and practice habits were only relevant to gain a better understanding of his pre-injury status and his potential return-toplay objectives. At the time of the initial evaluation, he rated his pain as a ‘‘5’’ on a visual analog scale ranging from 0 to 10, with ‘‘0’’ being equal to ‘‘no pain’’ and ‘‘10’’ the ‘‘worse level of pain he could imagine.’’ Any activity involving the thumb, including playing the guitar, increased his pain levels immediately. He suffered from persistent movement-activated pain in the thumb region. The pain was located in the thenar prominence and in the thumb. He

Performing arts medicine characterized the pain as a deep, aching pain, but he was unable to identify the location of the pain exactly. Visual inspection of the left hand did not reveal any abnormalities. The examination of his left hand revealed significantly decreased active abduction and extension of the first carpometacarpal joint of no more than 15 degrees. Passive range of motion was 25 degrees for abduction and extension and painful in the patient’s end range. Pain was located over the thenar eminence. The right thumb had full range of motion in all planes. Wrist range of motion was within normal limits. Resisted abduction, circumduction, adduction, flexion, and extension of the thumb were painful. Palpation of the thumb musculature revealed taut bands with myofascial trigger points in the abductor pollicis brevis, the opponens pollicis, the adductor pollicis, and the first dorsal interosseus muscles. Palpation of the trigger points elicited a familiar pain to the patient. The patient did not bring his guitar to the initial physiotherapy appointment. Discussion The patient’s status was rated as a grade 4 on the Functional Grading of Severity of Injury scale (Fry, 1986). He had persistent pain irrespective of playing the musical instrument. The pain increased with any use of the thumb, including activities of daily living. A grade 5 was considered, because he was no longer able to play the instrument. However, because he did still had functional use of his hand, a grade 5 seemed inappropriate. Following the Guide to Physical Therapy guidelines, the patient’s active myofascial trigger points were considered his pathology. His impairment was restricted range of motion. His functional limitation was not able to play guitar without pain, leading to disability. The patient was categorized into musculoskeletal practice patterns C (Impaired Muscle Performance) and D (Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Connective Tissue Dysfunction) (American Physical Therapy Association, 2001). Although myofascial pain has been reported as the most common diagnosis responsible for chronic pain and disability in other populations, few reports on musicians’ specific soft tissue dysfunctions have considered myofascial pain in the differential diagnosis (Rosomoff et al., 1989a,b; Skootsky et al., 1989; Fricton, 1990; Hendler and Kozikowski, 1993; Rosen, 1993; Dommerholt and Norris, 1997; Davies, 2002; Dommerholt et al., 2006a,b; Gerwin and Dommerholt, 2006). A survey of physician members of the American Pain Society showed general agreement that myofascial pain and trigger points exist as distinct clinical entities (Hendler and Kozikowski, 1993; Harden et al., 2000). Yet, generally speaking, physiotherapists do not pay much attention to myofascial pain. Very few articles about muscle dysfunction and trigger points have been published in the physiotherapy literature, and few physiotherapists have received training and education in pain management strategies (Dommerholt, 2005; Dommerholt et al., 2006a,b). The term ‘‘myofascial pain’’ is sometimes used without referring to trigger points and their characteristic features, which can be confusing (Wee and Brandfonbrener, 2005). Myofascial trigger points are the hallmark characteristic of myofascial pain and have been described as

131 ‘‘hyperirritable spots in skeletal muscle that are associated with hypersensitive palpable nodules in taut bands (Simons et al., 1999). An active trigger point is a symptomproducing point, which can trigger local and referred pain or other paresthesia. Active trigger points cause muscle weakness and decreased range of motion. A latent trigger point does not trigger pain without being stimulated, but may alter muscle activation patterns and limit range of motion (Lucas et al., 2004; Lucas, 2008). Gentle palpation of a trigger point can trigger a patient’s familiar pain, which indicates that trigger points contribute to peripheral and central sensitization (Ferna ´ndez-de-las-Pen ˜as et al., 2007). Normally, skeletal muscle nociceptors require high intensities of stimulation and they do not respond to moderate local pressure, contractions, or muscle stretches (Mense, 2003). Trigger points cause persistent noxious stimulation, which results in an increase of the number and size of the receptive fields to which a single dorsal horn nociceptive neuron responds, and the experience of spontaneous pain and referred pain (Mense, 1994). Myofascial trigger points are identified through either a pincer palpation technique, in which a muscle is palpated between the clinician’s fingers, or a flat palpation technique, in which a clinician applies finger or thumb pressure to muscle against underlying bony tissue (Simons et al., 1999; Dommerholt et al., 2006a,b). Several recent studies have determined excellent intrarater and interrater reliability for identifying myofascial trigger points (Gerwin et al., 1997; Sciotti et al., 2001; Al-Shenqiti and Oldham, 2005; Bron et al., 2007). Many studies have confirmed that myofascial trigger points are common not only in persons attending pain management clinics, but also in internal medicine and dentistry (Graff-Radford, 1984; Fricton et al., 1985; Rosomoff et al., 1989a,b; Skootsky et al., 1989; Gerwin, 1995; Chaiamnuay et al., 1998). In fact, myofascial trigger points have been identified with nearly every musculoskeletal and other pain diagnoses (Dommerholt et al., 2006a). For example, a study of adults with frequent migraine headaches diagnosed according to the International Headache Society criteria showed that 94% of the patients reported migraineous pain with manual stimulation of cervical and temporal trigger points, compared with only 29% of controls (Headache Classification Subcommittee of the International Headache Society, 2004; Calandre et al., 2006). In 30% of the migraine group, palpation of trigger points elicited a ‘‘full-blown migraine attack which required abortive treatment.’’ The researchers found a positive relationship between the number of trigger points and the frequency of migraine attacks and duration of the illness (Calandre et al., 2006). In a study of 110 adults with low back pain, myofascial pain was the most common finding affecting 95.5% of patients (Weiner et al., 2006). There are no controlled studies of the incidence or prevalence of myofascial pain among musicians. One retroactive study reported that 73% of musicians diagnosed with overuse syndrome had in fact myofascial pain, however, this study did not include a control group (Moran, 1992). Facial myofascial pain was most prevalent among violists, violinists and brass players (Bryant, 1989; Taddey, 1992). Meador reported the treatment of a viola player with

132 myofascial pain with trigger points in the latissimus dorsi and teres major muscles (Meador, 1989). Back to the guitarist, the initial focus of the physiotherapy intervention was on inactivating myofascial trigger points in the abductor pollicis brevis, the opponens pollicis, the adductor pollicis, and the first dorsal interosseus muscles. Trigger points can be inactivated manually with muscle energy techniques, trigger point compression or transverse frictions, with ultrasound or laser, or invasively using trigger point dry needling or injections (Majlesi and Unalan, 2004; Ferna ´ndez-de-las-Pen ˜as et al., 2005, 2006; Dommerholt et al., 2006a,b; Rickards, 2006; Srbely and Dickey, 2007; Blikstad and Gemmell, 2008; Dearing and Hamilton, 2008; Gemmell et al., 2008; Srbely et al., 2008). Several recent studies, including a Cochrane review, have confirmed that trigger point needling is an effective intervention (Hong, 1994; Furlan et al., 2005; Dommerholt et al., 2006a,b; Ga et al., 2007a,b; Giamberardino et al., 2007; Hsieh et al., 2007).1 As part of the physiotherapy program, musicians can learn self-treatment strategies for myofascial trigger points (Davies, 2002). The reader is referred to two recent review articles on myofascial pain and dry needling (Dommerholt et al., 2006a,b). The patient consented to being treated with trigger point dry needling. Myofascial trigger points were inactivated with solid filament needles with a diameter of 0.16 mm and a length of 20 mm (see Figure 4). Multiple local twitch responses were elicited per trigger point. A local twitch response is an involuntary spinal cord reflex of the muscle fibers in a taut band following snapping palpation or needling procedures (Hong and Torigoe, 1994; Hong et al., 1995). Eliciting local twitch responses are essential when trigger points are inactivated with either dry needling or injections (Hong, 1994; Dommerholt et al., 2006a,b). They are unique to trigger points. The dry needling procedures were followed with manual trigger point therapy (Dommerholt and Issa, 2003; Dommerholt et al., 2006a,b). After three treatments, the patient had full, but still painful range of motion of the thumb in all directions. After five sessions, he was pain-free with all movements of his left thumb. He was seen for five more sessions spread out over several weeks, during which only manual techniques were used in combination with patient education. The patient had to learn that he could start playing guitar again, after having been convinced that playing would never be possible again. During that period, he was asked to bring in his instrument for an instrumentspecific evaluation.

1 Trigger point dry needling is within the scope of physical therapy in many countries, including Australia, Canada, Ireland, the Netherlands, New Zealand, Norway, South Africa, Spain, and the United Kingdom, among others. Currently, physical therapy boards of eleven US states have ruled that dry needling is within the scope of physical therapy practice, including Alabama, Colorado, Georgia, Kentucky, Maryland, New Hampshire, New Mexico, Ohio, South Carolina, Virginia, and Texas. A few state boards ruled that dry needling would not fall within the scope of physical therapy practice, including Hawaii, Nevada, New York, North Carolina, and Tennessee. In most other states, it has not been determined at this point in time (Dommerholt et al 2006).

J. Dommerholt

Figure 4 Trigger point dry needling of the adductor pollicis muscle (ª 2008 e Jan Dommerholt).

The most striking finding of the instrument-specific evaluation was that the neck of his guitar was much too narrow for the size of his hands (see Figure 5). To position his hand around the neck, he had to use a forced pincer grip, requiring prolonged isometric muscle contractions. This was interpreted as a significant risk factor for future overuse injuries. The patient was advised to replace his instrument if at all possible, or to at least limit playing and practice time to very brief episodes. The patient decided to replace his instrument and he commissioned a guitar builder to construct a new instrument. Physiotherapy was discontinued at that time. Once the instrument maker was ready to complete the neck of the instrument, the patient returned to physiotherapy to determine the ideal thickness of the neck for his hand anthropometry in close coordination with the instrument

Figure 5 Narrow neck of the guitar compared to the size of the player’s hand (ª 2008 e Jan Dommerholt).

Performing arts medicine

Figure 6 Ergonomically improved interface with a broader neck of the guitar matching the size of the player’s hand (ª 2008 e Jan Dommerholt).

maker. After the instrument was completed, he returned for three additional physiotherapy sessions, during which he was educated about gradually returning to playing the guitar. The new guitar fit his relatively large hand size (see Figures 6 and 7). He was discharged from physiotherapy after a total of thirteen sessions. Five years later, he was still pain-free and continued playing guitar without any restrictions. He even recorded a demo CD of his music. In summary, this patient had been erroneously diagnosed with ‘‘scar tissue’’. In spite of not having played at all for a period of two-and-a-half years, he was able to resume playing the guitar once he was treated for myofascial trigger points in combination with correcting the ergonomic aspects of the playereinstrument interface.

The organist The patient was a 26-year-old female professional organ player, who complained of severe pain in the radial aspect

Figure 7 Comparison of the old and new guitar (ª 2008 e Jan Dommerholt).

133 of the right wrist and thumb. The pain started approximately three months before her visit to a performing arts physiotherapist. She was still able to play the organ and piano, but had to stop playing the organ after less than 10 min and the piano after approximately 20 min, due to the onset of severe pain. The pain decreased away from the instruments, but never resolved. The pain significantly impacted her ability to use her right hand with other activities of daily living. She was no longer able to meet the demands of her job as church organist, choir director, and music teacher. The pain had started insidiously and she could not identify any precipitating event. Within two months following the onset of pain, she was no longer able to play. As her career was seriously threatened, she consulted with three orthopedic surgeons, who were unanimous in their diagnosis of de Quervain’s syndrome. Two of the three surgeons recommended immediate surgical repair and informed her that delaying the surgery would jeopardize her ability to ever play the organ again. The third orthopedic surgeon recommended a course of physiotherapy combined with pharmacological management, but did not rule out surgical intervention if physiotherapy would not resolve her pain. The patient was reluctant to submit to surgery and consulted a performing arts physiotherapist for another non-surgical opinion. She reported that she started playing piano at the age of six. She switched to organ when she was fourteen. She had a variety of music teachers until she went to college, where she got a bachelor’s degree in organ. She planned to pursue graduate studies in organ, but the current pain levels had shattered that dream. More urgently, she was very concerned about not meeting the demands of her job as church organist. In that function, she was expected to not only play during church services, but she was also responsible for playing during any other church function, including funerals, weddings, and other special occasions. She was also the director of several church choruses and responsible for selecting the music repertoire for the church services and the choruses. Her job demanded her playing several hours daily. In addition, she was an organ and piano teacher with 15 weekly students. She played several organ recitals throughout the year. The patient received free housing from the church and she was afraid that she would be forced to move if she would not be able to perform the duties of her job. The patient reported that the repertoire made no difference in her pain. She did admit practicing several hours without regular breaks, but did not feel that her practice habits contributed to the onset of pain. The patient could easily identify the area of pain over the radial aspect of the right wrist and thumb. She rated her pain as an ‘‘8’’ on a visual analog scale ranging from 0 to 10, with ‘‘0’’ being equal to ‘‘no pain’’ and ‘‘10’’ the ‘‘worse level of pain he could imagine.’’ Visual inspection of the hand, thumb, wrist, arm, shoulders, and neck did not reveal any obvious deficiencies. There were no signs of swelling in the wrist and thumb, including the anatomical snuff box region. She did have relatively small hands considering that she was an organist. In spite of her smaller hand size, she had been able to meet the demands of the instrument. She did present with forward head posture, protracted shoulders, internal rotation of the upper extremities, and overall poor core stability (slouched

134 posture), but her posture did not seem to contribute to the sudden onset of pain. The patient presented with hyperabduction and hyperextension of both thumbs. Measurements of strength of the thumb muscles in adduction, extension, flexion, abduction, and circumflexion were within normal limits and did not cause any additional pain. The patient tested positive for the Finkelstein test and she confirmed that the orthopedic surgeons had performed the same test. Surprisingly, when the Finkelstein test was performed with the elbow in extension, the test was negative with the patient reporting having no pain in the wrist and thumb. She did complain of the familiar pain with pronation of the forearm combined with ulnar deviation of the wrist. This suggested that the pain she experienced was not due to stenosis of the first dorsal compartment or inflammation or irritation of the extensor pollicis brevis or abductor pollicis longus. The position of the elbow and forearm has no mechanical effect on the first dorsal compartment. The patient was also examined for other possible causes of pain in the thumb, including referred pain from myofascial trigger points. She presented with latent myofascial trigger points in the right infraspinatus, supraspinatus, medial scalene, brachioradialis, supinator, and extensor carpi radialis longus muscles. It was not clear however, whether these trigger points contributed to the pain complaint as she did not recognize the pain patterns associated with trigger point palpation, which is why these trigger points would be classified as latent trigger points (Dommerholt et al., 2006a). Discussion The patient’s status was rated as a grade 5 on the Functional Grading of Severity of Injury scale (Fry, 1986). She had persistent pain irrespective of playing the organ or piano. The pain increased with any use of the thumb and hand, including activities of daily living, and seriously threatened the patient’s musical career at the time of the initial physiotherapy evaluation. The physiotherapy diagnosis was more challenging, as it appeared that the patient did not have the correct medical diagnosis. Keyboard players with smaller hand sizes are at increased risk for developing overuse syndromes and occupational palsies, including de Quervain’s syndrome (Sakai et al., 2006). Small-handed keyboard players have to play with a greater abduction angle of their thumbs, which increases the risk of developing de Quervain’s syndrome (Sakai et al., 2006). In a study of 200 Japanese pianists, 35% of the players developed overuse problems. In 74% of all cases the pain was attributed to practicing octaves and chords (Sakai, 1992, 1993, 2002). Brown identified a direct correlation between awkward postures of pianists and wrist injuries (Brown, 2000). Paying much attention to postures of musicians is critical (Lister-Sink, 1993, 1994). In keyboard playing excessive thumb abduction is often combined with maximum radial deviation (Sakai et al., 2006). In spite of the patient being at increased risk, the diagnosis of de Quervain’s syndrome did not match the physical findings of the physiotherapy examination. For example, the patient’s thumb strength was well within normal limits. Studies of strength measurements in de Quervain’s syndrome have demonstrated significant loss of

J. Dommerholt strength (Fournier et al., 2006; Forget et al., 2008). Active thumb range of motion was increased, while in persons with de Quervain’s syndrome, active range of motion is usually decreased (Forget et al., 2008). The increase in range of motion may be a functional adaptation, as sometimes is seen in musicians, but it is nevertheless inconsistent with a diagnosis of de Quervain’s syndrome (Ackermann and Adams, 2003). In 1895, Swiss physician Fritz de Quervain first described the disorder, which later became known as de Quervain’s syndrome (de Quervain, 1997; Ahuja and Chung, 2004). The syndrome is usually defined as pathology of the tendons of the extensor pollicis brevis and the abductor pollicis longus muscles secondary to stenosis of the first dorsal compartment of the wrist. The Finkelstein test, during which the clinician grasps the patient’s thumb and quickly deviates the hand and wrist ulnarly, is the classic diagnostic test for de Quervain’s disease. The Finkelstein test was first described by surgeon Harry Finkelstein in 1930 (Finkelstein, 1930). A few years earlier, Eichhoff described a similar test for de Quervain’s syndrome in 1927 (Eichhoff, 1927). Many clinicians erroneously refer to Eichhoff’s recommendation to place the thumb within the hand and subsequently bring the hand into ulnar abduction as the Finkelstein test. Interestingly, recent biomechanical analysis has shown that the Finkelstein test has a bias toward the extensor pollicis brevis tendon over the abductor pollicis longus, and it was suggested that de Quervain’s syndrome may in fact be a pathology of the extensor pollicis brevis tendon and subsheath (Kutsumi et al., 2005). Surgical releases of the subsheath have resulted in complete relief of symptoms (Louis, 1987). Physiotherapy intervention following surgical intervention has been shown to be important and effective (Robinson, 2003). The differential diagnoses for de Quervain’s syndrome include a scaphoid fracture, osteoarthritis of the carpometacarpal joint of the thumb, Kienbock disease, and Wartenberg’s syndrome. Kienbock disease is characterized by wrist pain, sclerosis and collapse of the lunate due to avascular necrosis. Wartenberg’s syndrome, sometimes referred to as cheiralgia paresthetica, is an entrapment of the sensory branch of the radial nerve (Carlson and Logigian, 1999). The patient had no history of falls or other trauma, which increased the likelihood that she could have a superficial radial neuropathy or Wartenberg’s syndrome. The patient had increased pain with ulnar deviation and pronation of the forearm, which supported the diagnosis of Wartenberg’s syndrome (Carlson and Logigian, 1999). Some authors have suggested that Wartenberg’s syndrome and de Quervain’s syndrome may be correlated (Rask, 1978). Lanzetta and Foucher emphasized the importance of identifying Wartenberg’s syndrome before performing a surgical release of the first dorsal compartment to avoid poor surgical outcome, aggravation of neuritis, and potential legal action against the surgeon (Lanzetta and Foucher, 1993). Rask maintained that superficial radial neuritis may actually be the result of contiguous inflammation of de Quervain’s disease (Rask, 1978). Patients with superficial radial neuropathy or Wartenberg’s syndrome often present with numbness or pain over de dorsolateral aspects of the hand, wrist and thumb, and the index, middle,

Performing arts medicine and ring fingers (Plancher et al., 1996; Fontes, 2004). Some patients experience a poorly localized burning or shooting pain into the dorsum of the thumb, first web, or index finger (Eaton and Lister, 1992). At the recommendation of the physiotherapist, a neurologist confirmed the clinical diagnosis of Wartenberg’s syndrome. To better direct the physiotherapy program, it seemed important to investigate the cause or causes of the nerve entrapment. Superficial radial neuropathies can be caused by nerve entrapment in the forearm, wrist, or in the distal nerve branches in the hand. The site and nature of entrapment determine the therapeutic intervention. Some patients presenting with compression of the radial nerve are relatively easy to treat, by removing the compressive agent (Rask, 1979; Plancher et al., 1996). For example, when a tight wristband causes sensory radial nerve entrapment, the treatment would consist of removing the band (Rask, 1979; Plancher et al., 1996). Entrapments in the forearm are more challenging. One possible entrapment site is in between the two slips of a split brachioradialis tendon, which was observed in 5 out of 150 dissected arms in 4 out of 74 cadavers (Turkof et al., 1994). An in-vivo study of patients with Wartenberg’s syndrome found this kind of entrapment in 7 out of 143 patients (Turkof et al., 1995). Other entrapment sites at the elbow include compression underneath an accessory brachioradialis muscle (Spinner and Spinner, 1996a), in between the tendons of the brachioradialis and extensor carpi radialis longus (Kleinert and Mehta, 1996), or as the result of surgical tendon transfers (Spinner and Spinner, 1996b). Because the Finkelstein test was negative when performed with the patient’s elbow in extension, the possibility of a nerve irritation secondary to stretch could not be excluded. The role of the observed myofascial trigger points seemed relevant as well. Trigger points have been associated with nerve entrapments and it seemed conceivable that taut bands and trigger points in the brachioradialis and extensor carpi radialis longus muscles could potentially contribute to nerve compression (Dommerholt et al., 2006a,b). The referred pain patterns of trigger points in the right infraspinatus, supraspinatus, medial scalene, brachioradialis, supinator, and extensor carpi radialis longus muscles do include the area of the pain complaint, even though the pain was not elicited with palpation (Simons et al., 1999). The possible contributions of latent trigger points are still largely unknown (Lucas et al., 2004; Lucas, 2008). Although the exact location of the nerve entrapment could not be identified, a physiotherapy treatment plan was developed and implemented. Following the Guide to Physical Therapy guidelines, the patient’s sensory radial nerve entrapment was considered her primary pathology. Her impairment was pain. Her functional limitation was not able to play organ or piano without pain. The patient was clearly disabled as she was not able to meet the demands of her job. The patient was categorized into musculoskeletal practice patterns B (Impaired Posture), C (Impaired Muscle Performance), and neuromuscular pattern F (Impaired Peripheral Nerve Integrity and Muscle Performance Associated with Peripheral Nerve Injury) (American Physical Therapy Association, 2001). The first step in treating this patient was explaining why she could not possibly have de Quervain’s syndrome, even

135 though three orthopedic surgeons had made that diagnosis. She needed to understand that surgery of the first dorsal compartment would most likely not resolve her pain and restore her function. Instead, physiotherapy consisted of soft tissue mobilizations of the muscles around the elbow, including the brachioradialis, supinator, and wrist extensor muscles. Myofascial trigger points were treated with a combination of trigger point dry needling and manual trigger point therapy. She was instructed in gentle nerve gliding exercises for the radial nerve within a pain-free range. After six sessions of physiotherapy twice per week, the patient started noticing a modest improvement. She was instructed to start playing piano again, but only during 5e10 min per day. According to the patient, playing piano was less involved than playing the organ. A friend of the patient took photographs while she was playing the piano and organ to allow the physiotherapist to evaluate playing her playing postures. At that time, the physiotherapy clinic did not yet have a piano at the premises. The photographs were reviewed with the patient. She presented with poor posture at both instruments with the same postural problems identified during the initial evaluation. The organ is particularly challenging from a postural perspective. Organ players use their feet and their hands and balance their trunk on the bilateral ischial tuberosities, which makes it difficult to keep the trunk aligned in a spine neutral position. The focus of the physiotherapy program changed slowly from the pain management phase to the conditioning phase with more emphasis on proper posture, correction of forward head posture, core stabilization, and functional training to reduce disability. During the pain management phase, reduction in pain is the main objective and physiotherapists may employ manual therapy, dry needling (where legally allowed), electro-therapeutic modalities, and emphasize the basics of posture training and early improvement in physical functioning. During the conditioning phase, the focus shifts to advanced exercises and training to further improve physical function and reduce disability (Dommerholt, 2005). Musicians must learn that successful rehabilitation requires self-pacing during activities, for example when the musician returns to playing the instrument, and setting appropriate and achievable goals, including physical, functional, and social goals (Norris and Dommerholt, 1995; Harding et al., 1998). The patient was instructed in proper practice habits, emphasizing regular and frequent breaks, shadow-playing, mental practice, relaxation, and visualizations of the music. Physiotherapy was continued for a total of four months at which point the patient was nearly pain-free. She rated her pain as a ‘‘1’’ on a visual analog scale ranging from 0 to 10, with ‘‘0’’ being equal to ‘‘no pain’’ and ‘‘10’’ the ‘‘worse level of pain she could imagine.’’ She had no pain with activities of daily living and was able to play the organ and piano. Several months after being discharged from physiotherapy, the patient pursued her dream and started her graduate studies in organ. Two years later, she graduated from the program with a master’s degree in organ. Since her graduation, she returned twice to physiotherapy for other non-related musculoskeletal problems. By her own report, she never experienced the pain in her wrist and thumb again.

136 In summary, this patient was diagnosed incorrectly with de Quervain’s syndrome. Instead, based on the physiotherapy examination she was eventually diagnosed with a sensory radial nerve entrapment. Even though the actual entrapment was not identified, the physiotherapy treatment regimen was very successful and returned the patient to full function. Not only was she able to meet the demands of her job, she was able to complete graduate studies in organ.

Summary and conclusions Physiotherapists are essential providers in the field of performing arts medicine. As illustrated by the case reports, physiotherapists can play a substantial role in the prevention, diagnosis, and management of performance-related musculoskeletal injuries of musicians. The case reports of the guitarist and organist illustrate that patients may not always have the proper medical diagnosis. The guitarist presented with myofascial pain and dysfunction, but was previously diagnosed with ‘‘scar tissue.’’ The organist was almost exposed to surgical correction of a presumed de Quervain’s syndrome, which she did not have. The case reports of the bassoonist and guitarist highlight particular ergonomic challenges. Through specific individualized instrument modifications both musicians were able to return to playing their instruments. Other ergonomic measures within the scope of physiotherapy practice may include the evaluation of orchestra chairs, which often are poorly designed and not suitable for the task. Musicians often have musical instruments that do not match their anthropometry, as illustrated in the guitarist and bassoonist’s case reports. Many string instruments, including violins and guitars, are available in different sizes, which should be considered as part of injury prevention and treatment programs (Kopfstein-Penk, 1994). Familiarity with musicians’ backgrounds, musical instruments, and work conditions is helpful and clinicians who do not have a musical background may need to develop the necessary skills and knowledge (Wagner, 1995). Few publications have documented the actual physiotherapy treatments of musicians (Warrington, 2003; Winspur, 2003). This article included three case reports, but more systematic research is needed to determine the outcome of physiotherapy intervention in the treatment of musicians. Physiotherapists interested in treating musicians can start with expanding the history component of the initial evaluation as outlined in part I of this article series. By asking specific questions about the instrument, practice habits, education, repertoire, and employment much pertinent information will direct the physiotherapist and musician toward a solution of otherwise career-threatening injuries. In the end, attending concerts by former patients, who at one time were convinced that their musical careers has ended due to injury, is one of the most gratifying outcomes of performing arts physiotherapy.

References Ackermann, B., Adams, R., 2003. Physical characteristics and pain patterns of skilled violinists. Med. Probl. Perform. Artists 18 (2), 65e71.

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Journal of Bodywork & Movement Therapies (2010) 14, 139e151

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

ERGONOMICS

Proper body mechanics from an engineering perspective Edward G. Mohr, CPE, CSP, NCTM 1581 Oneida Trail, Lake Orion, MI 48362-1243, USA Received 27 June 2008; received in revised form 24 February 2009; accepted 5 March 2009

KEYWORDS Massage; Body mechanics; Ergonomics; Computer modeling; Injury risk; Strain

Summary The economic viability of the manual therapy practitioner depends on the number of massages/treatments that can be given in a day or week. Fatigue or injuries can have a major impact on the income potential and could ultimately reach the point which causes the practitioner to quit the profession, and seek other, less physically demanding, employment. Manual therapy practitioners in general, and massage therapists in particular, can utilize a large variety of body postures while giving treatment to a client. The hypothesis of this paper is that there is an optimal method for applying force to the client, which maximizes the benefit to the client, and at the same time minimizes the strain and effort required by the practitioner. Two methods were used to quantifiably determine the effect of using ‘‘poor’’ body mechanics (Improper method) and ‘‘best’’ body mechanics (Proper/correct method). The first approach uses computer modeling to compare the two methods. Both postures were modeled, such that the biomechanical effects on the practitioner’s elbow, shoulder, hip, knee and ankle joints could be calculated. The force applied to the client, along with the height and angle of application of the force, was held constant for the comparison. The second approach was a field study of massage practitioners (n Z 18) to determine their maximal force capability, again comparing methods using ‘‘Improper and Proper body mechanics’’. Five application methods were tested at three different application heights, using a digital palm force gauge. Results showed that there was a definite difference between the two methods, and that the use of correct body mechanics can have a large impact on the health and well being of the massage practitioner over both the short and long term. ª 2009 Elsevier Ltd. All rights reserved.

E-mail address: [email protected] 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.03.001

140

Introduction Massage therapy is a profession that can bring much needed relief to clients suffering from a variety of soft tissue injuries and illnesses. From pain associated with tight muscles, to joints that are dysfunctional due to physical activities, massage is a modality that is pursued by many people. The skilled massage therapist is the one who offers relief to such people’s pain and suffering (Ernst and Fialka, 1994; Rich, 2002). The irony is that in providing relief to others, many massage therapists cause injury to themselves. Sometimes in their zeal to help their client, they put themselves in an awkward posture and attempt to apply excessive degrees of force. Repetitive degrees of biomechanical load, commonly associated with poor body use, appears to affect many massage therapists, resulting in them leaving the profession (Greene, 1995). In all occupations, it is important to use ergonomic principles when designing jobs involving muscle strength and movement (Kodak Ergonomics Group, 1987). The purpose of this paper is to explore how the use of body mechanics impacts the massage therapist, both physically and economically. The hypothesis is that proper body mechanics can lessen the chance of injury or illness, and the main approach will be to look at this issue from a scientific and an engineering perspective.

The need According to 2007 data from the American Massage Therapy Association, there are approximately 267,000 people in the United States who are involved in the massage therapy profession. Based on their survey (n Z 838 therapists), 15% are male and 85% are female, with an average of 6.5 years in the profession and an average age of 42. The average time actually performing (paid) massage is 15.1 h/week. There is an average turnover of 20% per year in the profession, and although more research is needed to determine the cause, 11% of respondents stated that avoiding personal injury was the top challenge facing massage therapists (AMTA, 2008). Since the majority of the massage population is female, data for the 50th percentile female will be utilized in all analyses using calculations or computer modeling. The U.S. Bureau of Labor Statistics and the National Safety Council gather injury data from a variety of occupations. According to 2006 injury data for massage therapists (code 319010), 56% of the injuries were due to ‘‘sprains/strains’’, and 57% of the injury sources were from ‘‘worker motion/position’’. The upper extremities (including hand/wrist) accounted for 51% of the injuries, followed by the trunk at 16%. (See Appendix A for a breakdown of all the massage therapist injury statistics.)

The human body as a system of levers and pulleys The human body is composed of muscle, bone, tendons and ligaments, all of which make up its load bearing and force

E.G. Mohr generating components. In engineering terms, these components can be equated to levers, fulcrums, pulleys, etc. Some massage therapy textbooks (Fritz, 2009a) make reference to these terms, but, to our knowledge, no one has made an attempt to actually calculate the forces involved with massage, to mathematically show the advantages of using proper body mechanics. To understand the forces that occur at the joints of the human body, a brief description and example is necessary. The one main descriptor of any joint in the human body is movement, more specifically rotational movement. A ‘‘moment’’ is an engineering term used to defined rotational movement around an axis. This term adequately describes the forces that occur at a joint. For example, in order to hold a weight in one’s hand with the forearm parallel to the ground, there are two forces trying to rotate the arm in a downward motion, and simplistically speaking one counteracting force trying to rotate the forearm upward, thus keeping it steady. The two downward forces are the weight of the forearm (including the hand) and the weight of the load being held. The upward, stabilizing force, comes from the muscles of the upper arm (biceps brachii and brachialis). Figure 1 (Chaffin et al., 2006) shows what happens at the elbow joint when this occurs. A moment is calculated by multiplying the force acting on a rotational axis (in this case the pivot point of the elbow) with the distance that force is from the axis. Using the anthropometry for a 50th percentile female, the total distance from the elbow joint to the center of the hand is 12.2 inches (w31 cm), and the center of mass (CM) of this arm/hand segment is 5.3 inches (w13.5 cm) from the elbow. The weight of this body segment is 3.0 pounds (1.35 kg). If a person were holding a load of 20 pounds (w9 kg) in the hand, the downward moment created at the elbow would be: MðelbowÞ Z ð5:3 inch  3:0 lbÞ þ ð12:2 inch  20 lbÞ ð13:5 cm  1:35 kgÞ þ ð31:0 cm  9:0 kgÞ MðelbowÞ Z 15:9 inch-lb þ 244:0 inch-lb 18:2 cm-kg þ 279:0 cm-kg MðelbowÞ Z 259:9 inch-lb 297:2 cm-kg If the arm is stationary, then the counteracting moment of the muscle must also equal 259.9 inch-pounds (297.2 cmkg). Knowing that the attachment point for the biceps brachii and brachialis muscles is 1.97 inches (5.0 cm) from the rotational axis of the elbow, the muscle force required to hold this load can be calculated as follows: FðmuscleÞ Z 259:9 inch-lb = 1:97 inch 297:2 cm-kg = 5:0 cm FðmuscleÞ Z 132 lb 59:4 kg Thus, in this example, it takes 132 pounds (59.4 kg) of muscle force to hold a 20 pound (9.0 kg) object in the hand. This information can then be compared to research which was conducted to determine population muscle strength moments (Stobbe, 1982), in order to determine the percent of the given population that could withstand this rotational force on the elbow.

Proper body mechanics from an engineering perspective

141

Figure 1 Free body diagram of the forces acting on the elbow joint while holding a load in the hand. ME is the sum of the moments at the elbow, determined by the load in the hand (LH), weight of the forearm and hand (WF&H), the force of the muscle (FM), and the attachment distance of the muscle (m). (From Chaffin et al., 2006, p. 116, used by permission).

As can be seen, even this most basic calculation can be very complex. As one starts to work further through the body, all the forces acting on the elbow, in addition to those acting on the upper arm, come into play to calculate the shoulder moments. Calculations for the hip, knee and ankle become increasingly complex. Also, this example is two-dimensional, and all forces are acting at 90 degrees. In the real world, postures are three-dimensional and forces act at varying angles, requiring a great deal of trigonometry to make the calculations. The above description is provided to show that it is possible to determine the effect that a given posture and forces can have on the human body. Fortunately, there is human modeling software available that can make all of these calculations and compare the results to the strength moment data for the population selected. However, it must be noted that both the above calculations and the modeling software make assumptions about the human anatomy and function. All of the complex dynamics of human motion (such as the affect of synergistic muscles) cannot be completely accounted for, but these models can provide a good approximation, especially for comparative purposes. This human modeling software will be utilized to make the comparisons between proper and improper body mechanics in a later section.

Proper body mechanics e general concepts All massage therapists, to varying degrees, learn how to apply forces to their clients in order to affect some neurological, physiological or mechanical change. Some schools may also teach the therapist how to use their body in order to make the massage visually appealing by giving it a certain flow. However, very few schools teach

the therapist how to use their body in a manner that will reduce the chance of the therapist becoming fatigued and possibly injured over the long term. Fritz (2009b) dedicates a chapter to the use of proper body mechanics. Some of these concepts will be discussed in order to understand, and ultimately compare the effects of body mechanics. Whenever the body utilizes muscle force, energy must be expended. When a joint is stacked (in straight alignment), forces acting on the joint go straight through, and do not generate any rotational force that must be counteracted by the muscle. The other key principle in massage is that body weight and gravity are free. Making movements in a downward direction, the weight of the body can be used to increase the force (Konz, 1995). Normally, whenever the center of gravity of the body moves past the base of the feet, some muscles contract to counteract and stabilize the body. However, when that force generated by body weight can be transferred through the hand onto another stationary object, this force transfer requires only minimal muscle activity. Also, since the majority of the force is generated through body weight, the force can be applied for a longer time period without generating undue fatigue. This can be achieved by ‘‘stacking’’ body segments in such a way that the rotational effects of moments at the joints are minimized and the majority of force is applied through body weight (Figure 2).

Proper body mechanics e computer modeling approach As was shown in the section on ‘‘The human body as a system of levers and pulleys’’, the forces acting on the

142

E.G. Mohr Whereas 99% of the selected female population has the capability to generate the necessary strength moments at all of the joints using the ‘‘Proper’’ body mechanics posture, only 40% has the capability using the ‘‘Improper’’ posture, with the limiting factor being the ankle joint. (Note: because the ankle cannot be rotated in the 3D Program, small weight and balance adjustments that a person would use are difficult to model, thus the results for the ankle should be used with caution). The elbow was also a significant limiting joint, with only 60% having the required capability. In addition, the ‘‘Improper’’ posture put 13% more compressive force on the L5/S1 joint.

Proper body mechanics e field study approach

Figure 2 p. 224).

Diagram of stacked joints (from Fritz, 2009b,

joints of the body can be mathematically calculated and these calculations can by aided by existing computer software models. The University of Michigan 3D Static Strength Prediction Program (3DSSPP) was utilized to compare what was hypothesized to be ‘‘Improper’’ versus ‘‘Proper’’ body mechanics in a massage application. The following photographs (Figure 3) show two contrasting methods for applying a compressive force to a client. The ‘‘Improper’’ posture in Figure 3a, the massage practitioner is standing in a more upright posture and bending at the torso, at approximately 55 degrees. The left elbow is bent, thus requiring a majority of the force to be exerted using arm strength, and causing a rotational movement (moment) at the elbow joint. In contrast, the ‘‘Proper’’ posture in Figure 3b, shows the massage practitioner using ‘‘stacked joints’’ where the opposite leg, torso, neck and head are in alignment. The force generating arm is also straight, transferring the force straight through the elbow joint and thus not requiring any additional muscle force to counteract a rotational movement. Instead of using arm strength as in the previous posture, the practitioner can lean on the client and thus use her body weight to assist in generating the majority of the force applied to the client. The massage practitioner’s posture (body segment angles) was loaded into the 3DSSPP software, using the anthropometry of the 50th percentile female and the applicable muscle strength moments. The computer generated posture output is shown for both postures in Figure 4 and the free body diagram of the joint segment analysis in Figure 5. A load of 40 pounds (w18.2 kgm) was chosen as the compressive force to be applied to the client, applied at a height of 33.3 inch (84.5 cm) and at a downward angle of 45 degrees. Utilizing these two postures with the same magnitude and angle of force, capabilities were calculated for the elbow, shoulder, hip, knee and ankle joints. The actual computer results are shown in Appendix B, and are summarized here in Table 1.

In addition to the 3D modeling discussed above, a strength test protocol was developed to test three different applications of body mechanics. Eighteen (18) massage practitioners, with varying levels of experience (normal distribution with median of 2e3 years e see Table 2), were asked to apply a compressive force using what was hypothesized to be ‘‘Poor’’ (standing arm push), ‘‘Good’’ (stacked joints but without locking the back knee), and ‘‘Best’’ (stacked joints with a locked back knee) body mechanics. Applications using counterpressure were also recorded for the ‘‘Poor’’ and ‘‘Best’’ positions. (Note: in this study, the ‘‘Poor’’ and ‘‘Best’’ postures, correspond to the ‘‘Improper’’ and ‘‘Proper’’ postures used in the computer modeling section). The subjects were outfitted with an Ergo-FET digital palm force gauge, which could record a maximum force of 150 pounds (w68 kg) (see Figure 6). Static strength assessments must be kept to less than 10 s to keep from fatiguing the muscle, with the recommended duration being between 4 and 6 s (Sanders and McCormick, 1993). All test durations were less than 10 s, with the majority being within the recommended range. The subjects were tested applying compressive force at a 45 degree angle to the edge of massage tables, at vertical heights of 39.5 inch (100 cm), 34.5 inch (w87.5 cm), and 29.0 inch (w73.5 cm) (see Figure 7). The surfaces were wooden frames, covered with a thin layer of foam and a vinyl covering. All subjects had been previously trained in the use of the ‘‘Good’’ and ‘‘Best’’ postures. For the ‘‘Poor’’ posture (Figure 7a), the subjects were instructed to stand at a comfortable location from the table, and to apply maximal pressure by pushing with their arm. The subjects were intentionally not given more than this general instruction, so as to allow them to find their most natural position. There was a tendency to still lean in with the body to some degree, thus pure arm strength forces would be generally even lower than recorded. Five data points were collected at each of the three vertical heights. These data points were as follows. (A) (B) (C) (D) (E)

Standing arm push (Figure 7a) Standing arm push with counterpressure Stacked joints, not locking the knee Stacked joints, with locked knee (Figure 7b) Stacked joints, with locked knee and counterpressure

The raw data collected are shown in Table 2, with references AeE corresponding to the above postures.

Proper body mechanics from an engineering perspective

Figure 3 method.

143

Photographs of two contrasting methods for applying compressive force to a client. (a) Improper method. (b) Proper

Figure 4 Computer modeling of application methods (from University of Michigan 3DSSPP, ver. 5.0.8, used by permission). (a) Improper method. (b) Proper method.

Figure 5 Computer modeling of application methods (from University of Michigan 3DSSPP, ver. 5.0.8, used by permission). (a) Improper method. (b) Proper method.

144 Table 1

E.G. Mohr Results from computer modeling analysis, comparing the Proper and Improper methods. Compression Force on the L5/S1 Disk:

Percent of Females Able to Apply the 40 Pound Force – by Joint Location 100

99

98 98

93 86

99 97 100

75 50

Proper 91 lbs. Improper 103 lbs.

60 Summary of analysis results from The University of Michigan 3D Static Strength Prediction ProgramTM

40

25 Ankle

Knee

Hip Shoulder Elbow Proper Improper

locked posture averaged 49.0 pounds (w22 kg). By looking in the table at the intersection of these two postures, it shows that this comparison generated 51% more force for the stacked and locked posture. Table 3 compares the effects of the different test heights. Test 1 (with H Z 39.5 inch (w100 cm)) has the largest percentage increases in all categories. By contrast Test 3 (with H Z 29.0 inch (w73.5 cm)) has the smallest percentage increases in all categories. Thus, while proper

Comparisons were performed using the average forces generated at each of the three table heights (Table 3), and using the combined averages for all three tests (Table 4). The results in both tables are interpreted as follows. A percentage figure in the table compares the description in the column on the left with the row description above. Using for example ‘‘standing arm push’’ (poor) versus ‘‘stacked and locked’’ (best) at a height of H Z 39.5 inch (w100 cm), the arm push posture averaged 32.5 pounds (w14.7 kg) and the stacked and

Table 2 Raw data showing subject’s years of massage experience (also see distribution below table), height, and weight. Data within the table are maximum applied forces recorded (in pounds) at the three test heights using the five application methods (AeE). The last three rows contain the average, minimum and maximum force for each column (n Z 18). Demographics

Test 1: H Z 39.5 inch

Test 2: H Z 34.5 inch

Test 3: H Z 29.0 inch

Years

Height Weight (lb.) A (inches) (1 inch Z 2.54 cm; 1lb Z.45 kg)

B

C

D

E

A

B

C

D

E

A

B

C

D

E

2e3 2e3 0e1 >5 2e3 1e2 3e5 1e2 2e3 3e5 1e2 2e3 0e1 3e5 >5 2e3 2e3 2e3

62 63 63 63 64 65 66 66 66 66 66 67 67 67 67 72 69 68

145 130 170 173 130 125 185 130 170 285 130 170 165 205 150 165 140

25 31 17 32 21 26 47 40 32 30 60 39 22 32 32 42 24 33

48 47 26 73 75 52 84 48 66 56 68 61 35 42 34 82 69 55

26 35 18 38 51 34 65 30 52 25 45 50 33 29 34 52 35 39

32 41 28 42 59 46 78 46 64 43 70 48 38 39 43 56 50 59

63 58 28 87 104 61 92 61 71 73 82 81 49 60 67 97 71 96

36 53 18 40 28 45 62 52 49 28 55 36 26 35 29 47 35 34

56 55 35 71 80 70 86 69 77 65 66 56 43 43 40 79 57 62

31 48 25 44 43 51 71 46 48 33 63 38 31 38 32 58 40 52

40 59 31 45 56 53 80 50 57 44 69 49 42 42 41 69 51 62

72 68 40 88 82 77 84 70 78 57 76 66 61 59 69 95 74 98

58 63 33 48 46 54 72 61 40 28 67 39 34 36 48 57 32 49

67 68 41 64 88 64 93 72 68 48 69 62 49 38 60 87 48 76

44 68 39 55 48 57 75 51 70 32 76 49 35 37 46 59 33 59

51 70 42 58 59 51 86 53 71 47 89 51 45 54 58 66 40 75

72 73 49 89 98 59 83 62 73 57 97 78 59 77 71 95 51 110

Average 66 Minimum 62 Maximum 72

163 125 285

32.5 56.7 38.4 49.0 72.3 39.3 61.7 44.0 52.2 73.0 48.1 64.4 51.8 59.2 75.2 17 26 18 28 28 18 35 25 31 40 28 38 32 40 49 60 84 65 78 104 62 86 71 80 98 72 93 76 89 110

Years of massage experience Number of subjects

0e1 2

1e2 3

2e3 8

3e5 3

>5 2

Proper body mechanics from an engineering perspective

145

Proper body mechanics e general tips for massage therapists Although the main purpose of this paper is to validate the concept that proper body mechanics do indeed reduce stress on the massage practitioner, it would be remiss to leave the topic without providing some useful suggestions. Fritz (2009b) dedicates an entire chapter in her book explaining and demonstrating various techniques. The following is a very brief summary of some of the major concepts. Referring back to Figure 2, in addition to the photos in Figure 8, will assist in visualizing these concepts.

Weight transfer Figure 6

Photo of Ergo-FET digital palm force gauge.

body mechanics allow the subject to generate higher forces in all cases, it has the most impact when the point of application is higher off the floor. Overall comparisons for the data are in Table 4, and can be summarized as follows. Tables are in Imperial measures: to convert to decimal use 2.54 cm Z 1 inch, and 0.45 kg Z 1 pound/lb)  Counterpressure increases forces for both methods (standing arm push increases by 53% and stacked and locked increases by 37%)  Counterpressure is higher with proper body mechanics (by 21%)  Stacked and locked (best) body mechanics is better than stacked not locked (good) body mechanics (by 20%)  Stacked not locked (good) and stacked and locked (best) are both better than standing arm push (poor) body mechanics (by 12% and 34%, respectively)

Figure 7

Leveraging body weight, as opposed to utilizing muscle force, will significantly reduce the stress on the practitioner. Pushing with upper body strength can cause neck and shoulder problems. Stand in an asymmetric stance with the back leg and torso in a straight line, keep the hips and shoulders aligned and facing the client, and lock the back knee to generate pressure coming from the back heel. Note how in Figure 8a, the table is too low causing the therapist to rock back and bend at the waist. In Figure 8b, the higher table allows the therapist to leverage all of his body weight. Also, Figure 8e shows the therapist’s weight improperly on the front foot, versus the proper posture in Figure 8g with the pressure coming from the back heel.

Perpendicular application of force Align the client and practitioner such that force is applied at a 90 degree angle. This makes the force application more efficient by directing 100% of the pressure into the client’s tissue (refer back to Figure 2).

Photo of test subject performing: (a) poor posture and (b) best posture at 34.5 inch test height.

146 Table 3

E.G. Mohr Comparison of force differentials at each test height, presented as a percentage (1 inch Z 2.54 cm; 1lb Z .45 kg).

Test 1: H Z 39.5 inch Compression force (lbs.) Standing arm push SAP with C/pressure Stacked not locked Stacked and locked Test 2: H Z 34.5 inch Compression force (lbs.) Standing arm push SAP with C/pressure Stacked not locked Stacked and locked Test 3: H Z 29.0 inch Compression force (lbs.) Standing arm push SAP with C/pressure Stacked not locked Stacked and locked

Standing arm push

SAP with C/pressure

Stacked not locked

Stacked and locked

S and L with C/pressure

32.5

56.7 75%

38.4 18%

49.0 51%

72.3 27%

28% 48% 39.3

61.7 57%

52.2 33%

73.0 18%

19% 40% 48.1

64.4 34%

51.8 8%

59.2 23%

75.2 17%

14% 27%

Stacked joints As discussed previously, joints that are not stacked and locked require additional muscle force to hold the joint steady and counteract rotational forces in the joint while applying pressure (refer to Figure 8ceg).

Core stability Having good core stability is essential to eliminate fatigue and possible injury. If the core is not working, the psoas and rectus abdominis take over core responsibility. Also, the body over breathes in order to cause the lumbar dorsal fascia to tighten, in an attempt to stabilize the core.

Point of contact The practitioner must use caution to protect their hands and wrists. Whenever possible, force should be applied using the forearm. If the hand is used, the wrist should remain in the mid-range of motion, avoiding any extreme extension of the wrist which puts undue stress on the

Table 4

44.0 12%

structures of the carpal tunnel. The hand and fingers should be relaxed whenever possible, to keep from transferring stress to the forearm and shoulder.

Economic impact There is no current research which delves into why approximately 50,000 massage therapists leave the profession each year, in the USA (AMTA, 2008). As was stated earlier, the majority of the injuries which require massage therapists to lose time from work are related to ‘‘sprains and strains’’, and the most common cause is ‘‘worker motion or position’’. Also, 11% of therapists surveyed cite ‘‘avoiding personal injury’’ as their top challenge in the profession. Since the use of proper body mechanics has been shown to reduce the strain on the therapist’s body and improve their motions and positions, the data suggest that there is some number of therapists who have left the profession due to injury, who would still be working today if they had used proper body mechanics. The ramifications are personal injury and loss of income (especially since very few massage therapists have health benefits from their employers or are self-employed). The

Comparison of the average force differentials from all test heights, presented as a percentage. Composite averages at all heights (1 inch Z 2.54 cm; 1lb Z.45 kg)

Compression force (lbs.) Standing arm push SAP with C/pressure Stacked not locked Stacked and locked

Standing arm push

SAP with C/pressure

Stacked not locked

Stacked and locked

S and L with C/pressure

40.0

60.9 53%

44.7 12%

53.5 34%

73.5 21%

20% 37%

Proper body mechanics from an engineering perspective

Figure 8

147

Examples of correct vs. incorrect postures (from Fritz, 2009b, pp. 217e237).

economic impact can also affect the profession in a more subtle way. If strain and soreness from improper body mechanics is the limiting factor in the number of clients that a therapist can see on a daily basis, then the use of

proper body mechanics can increase their daily output. Using an industry average of 15 paid massages per week (in the USA), and an average wage of $39 per hour (AMTA, 2008), and assuming a therapist works 5 days per week

148

E.G. Mohr proper body mechanics being greatest at the highest point of application. However, one cannot use the actual dimensions used in this study to set a table height. The practitioner must evaluate their own body type and massage style (majority hand or forearm work) and make adjustments accordingly.

(equating to 3 massages per day) and 48 weeks per year, the therapist would theoretically make $28,080 per year. If the therapist, by improving their body mechanics, could increase their workload by only 1 client per day, their annual income could increase by $9360 to a total of $37,440. If they could now physically perform 2 additional massages per day the annual income would be $46,800, an increase of $18,720. Further research would be required to put an exact number on the injured therapists leaving the profession and the potential for increased client workload, as well as the impact that proper body mechanics would have. However, there is enough data here to suggest that a relationship does exist, and for the good of the profession it is one that should be explored further.

Key concepts Certain general concepts assist in the application of good body mechanics. A few of these concepts are as follows.  Leveraging body weight as opposed to using muscle force  Applying forces at 90 degree angles  Stacking joints to avoid rotational forces in the joints  Locking the back knee and pushing from the heel to generate more force  Application of force using the forearm wherever possible and keeping the hand and fingers relaxed  Keeping the wrist within the mid-range of motion when necessary to use the hand to apply force  Having a good breathing pattern and core stability.  Although not proven, the data suggest that the reduced strain from proper body mechanics can have a positive effect on the therapist’s economic well being, either from the ability to increase client workload, or from the ability to avoid injury and stay in the profession.  Setting the correct massage table height, and using proper body mechanics, will allow the massage/manual therapy practitioner to generate higher compressive forces, while at the same time using less force and strain on their own body.

Summary Poor body mechanics can affect both the client and the practitioner. If a certain amount of compressive force is required to deal with the client’s symptoms, and the massage practitioner cannot deliver that force, then the client’s treatment will not be as effective as possible. If the practitioner can deliver the required force, but they are working at or near their maximum strength, then the practitioner may suffer either an acute or chronic injury. The physical effects of the massage on the massage practitioner can be quantified. In the computer modeling comparison, use of the improper posture showed that only 40% of the 50th percentile female population would have the strength moment capability at the ankle, and only 60% would have the capability at the elbow. In contrast, using proper body mechanics, that same population would have 99% capability at the ankle and 100% capability at the elbow. All other joints showed the same trend, but the range of capability was less significant. In the field study of massage practitioners (n Z 18), it was found that proper body mechanics correlated with an overall 34% increase in applied maximal force, as compared with the improper posture. When counterpressure was used with both postures, the increase was 21%. This trend held true for all three test heights, with the impact of using

Appendix A Injury data for massage therapists from the U.S. Department of Labor (2006), Bureau of Labor Statistics (http:// www.bls.gov/iif/oshwc/osh/case/ostb1801.pdf) and the National Safety Council. Note: data reformatted by author.

Number of nonfatal occupational injuries and illnesses involving days away from work. Source: National Safety Council, 2006 data for Massage Therapists, based on data from the U.S Department of Labor, Bureau of Labor Statistics (code 319010). Sex

Age

Race

Length of service

32% Men 68% Women

47%, 25e34 32%, 35e44 21%, 45e54

48% White 14% Hispanic 38% Not reported

14%, 14%, 32%, 41%,

Injury

Event or exposure

Injury source

Time of day

56% 22% 11% 11%

26% 26% 11% 37%

57% 10% 10% 24%

19%, 19%, 14%, 48%,

Strain/sprain Soreness, pain Carpal tunnel Other

Overexertion Repetitive motion Contact with object Other

Worker motion/position Ground, floor surfaces Patient Other

<3 months 3e11 months 1e5 years >5 years

8:00 ame12:00 pm 12:00 pme4:00 pm 4:00 pme8:00 pm Not reported

(continued on next page)

Proper body mechanics from an engineering perspective

149

Table (continued) Body part affected

Hours worked

Time off-work

Day of week

35% Upr. extremities 19% Wrist 16% Trunk 10% Lwr. extremities 6% Hand 6% Shoulder 6% Back n Z 220

10%, <1 h 0%, 1e2 h 10%, 2e4 h 10%, 4e6 h 15%, 6e8 h 55%, Not reported

10%, 15%, 15%, 20%, 15%, 25%,

14% 14% 18% 23% 14% 18%

2 days 3e5 days 6e10 days 11e20 days 21e30 days >31 days

Monday Tuesday Wednesday Thursday Friday Saturday

Incidence rate of nonfatal occupational injuries and illnesses involving days away from work. Injuries per 10,000 workers Injury Event or exposure Injury source Body part affected 44.8 Strain/sprain 17.3 Soreness, pain 8.2 Carpal tunnel 8.4 Other

21.3 Overexertion 21.0 Repetitive motion 7.7 Contact with object 30.9 Other

50.2 Worker motion/position 10.1 Patient 7.1 Ground, floor surfaces 22.9 Other

25.9 Wrist 13.4 Lwr. extremities 11.0 Upr. extremities 10.0 Hand 8.3 Back 7.2 Shoulder 4.5 Trunk

In 2006, there were 1.2 million cases requiring days away from work in private industry. The 2006 rate for all industries was 128 per 10,000 workers. The 2006 rate for massage therapists was 93.8 per 10,000 workers. Rates ranged from 11 (computer and mathematical) to 301 (transportation and material moving).

Appendix B Joint capability data from University of Michigan 3D Static Strength Prediction Program (3DSSPP), used by permission

1) 3DSSPP analysis summary

Figure B1b

Proper method.

2) Low back analysis e sagital plane

Figure B1a

Improper method.

Figure B2a

Improper method.

150

E.G. Mohr

4) Fatigue analysis

Figure B2b

Proper method.

3) Strength capabilities Figure B4a

Figure B4b Figure B3a

Improper method.

Proper method.

Improper method.

Appendix C Computer software 3D Static Strength Prediction Program, version 5.0.8, copyrightª 2007, The Regents of the University of Michigan 2007, used with permission.

Equipment Ergo-FET digital palm force gauge, Hoggan Health Industries. Serial #22153 e Patent #5090421. 150# maximum capacity. New unit, calibrated 4 months prior by manufacturer.

References Figure B3b

Proper method.

American Massage Therapy Association (AMTA), 2008. Massage Industry Research Report. AMTA.

Proper body mechanics from an engineering perspective Chaffin, D., Andersson, G., Martin, B., 2006. Occupational Biomechanics, fourth ed. Wiley-Interscience. Ernst, E., Fialka, V., 1994. The clinical effectiveness of massage. Forsch Komplementarmed 1, 226e232. Fritz, S., 2009a. Essential Sciences of Therapeutic Massage, fourth ed. Mosby. Fritz, S., 2009b. Fundamentals of Therapeutic Massage, fourth ed. Mosby. Greene, L., 1995. Save Your Hands: Injury prevention for Massage Therapists. Gilded Age Press, Coconut Creek, Florida. Kodak Ergonomics Group, 1987. Ergonomic Design for People at Work, vol. 2. Van Nostrand Reinhold.

151 Konz, S., 1995. Work Design, Industrial Ergonomics, fourth ed. Publishing Horizons. Rich, G.J., 2002. Massage Therapy: The Evidence for Practice. Mosby, Edinburgh. Sanders, M., McCormick, E., 1993. Human Factors in Engineering and Design, seventh ed. McGraw-Hill. Stobbe, T., 1982. The Development of a Practical Strength Testing Program for Industry. Unpublished doctoral dissertation, The University of Michigan. U.S. Department of Labor, 2006. Occupational Injuries and Illnesses Report Involving Days Away From Work. Bureau of Labor Statistics.

Journal of Bodywork & Movement Therapies (2010) 14, 152e161

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

CLINICAL REVIEW

Paradigm for assessment and treatment of SIJ mechanical dysfunction Manuel F. Cusi* School of Medicine, Sydney University of Notre Dame, 160 Oxford Street, Darlinghurst, NSW, 2010, Australia Received 4 October 2009; received in revised form 15 December 2009; accepted 16 December 2009

KEYWORDS Sacro-iliac joint; Mechanical assessment; SPECT/CT; Self-bracing mechanism; Prolotherapy; Non-specific low back pain

Summary The sacroiliac joint (SIJ) is an integral part of both the lumbar spine and the pelvic girdle. It is frequently the source of low back pain and pelvic girdle pain. Recent research has permitted a deeper understanding of its function and assessment. The mechanical assessment of the SIJ as a transmitter of load between trunk and lower limbs, and as a means to absorb torsion stresses of the pelvis absorber of torsion is examined; history, clinical examination and imaging modalities are explored and the role of exercise and some interventional therapies are described in general terms. ª 2009 Elsevier Ltd. All rights reserved.

Introduction SIJ and Pelvic Girdle Pain in the context of ‘‘non specific low back pain’’ Low Back Pain (LBP) has been described as an epidemic of the 20th century, and the trend continues in the 21st century. In Australia up to 80% of the population will experience back pain in their lives, and 10% will experience significant disability as a result (Briggs and Buchbinder, 2009). The causes are not well understood, and therapies frequently fail. The very use of the term Low Back Pain as a ‘‘quasi diagnosis’’ e when pain is a symptom, not a disease e reflects a general lack of knowledge.

* 15 Vernon Street, Strathfield, NSW 2135, Australia. E-mail address: [email protected]

Lumbar spinal pain has been defined (Merskey and Bogduk, 1994) as pain perceived within a region bounded laterally by the lateral borders of the erector spinae, superiorly by an imaginary line through the T12 spinous process, and inferiorly by a line through the S1 spinous process. Sacral pain is defined as perceived pain within a region overlying the sacrum, bounded laterally by imaginary vertical lines through the posterior superior and posterior inferior iliac spines, superiorly by a line through the S1 spinous process, and inferiorly by a transverse line through the posterior sacrococcygeal joints. LBP is therefore pain arising from anywhere within the two areas described, independently of radiation to other areas of the body. It does not indicate at all the origin or cause of the pain. The ability to make a specific diagnosis in patients with LBP is the subject of debate. Often the diagnosis depends on the professional background of the diagnostician. Some authors consider that definite pathology can only be

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Assessment and treatment of SIJ mechanical dysfunction diagnosed in 15% of patients with LBP (Waddell, 1998). Research on LBP has focused for a long time on anatomical structures with a nerve supply that could explain the origin of pain. The study of pain generators has yielded objective findings. Nerve block procedures have identified a structure responsible for the pain in over 50% of cases (Mc Gill, 2002) The sacroiliac joint was first suggested as a source of lower back pain in 1905 by Goldthwaite and Osgood (1905) but largely ignored as the intervertebral disc became labelled as the major cause of back pain by Mixter and Barr in 1934. The sacro-iliac joint is a source of pain in the lower back and buttocks in up to 15e21% of the population (Dreyfuss et al., 1996). There is evidence that dysfunction of this joint could, similar to a herniated lumbar disc, produce pain along the same distribution as the sciatic nerve (Fortin et al., 1994aec, 2003). Using anaesthetic blocks of the sacro-iliac joint, Schwarzer (Schwarzer et al., 1995b) investigated the contribution of the SIJ in a low back pain population. They found that 18.5% were considered to have pain from the SIJ. As injections were given into the synovial part of the joint and did not involve the posterior ligaments, it is possible that the SIJ is responsible for LBP in a higher proportion of subjects. Identifying the anatomical source of pain does not automatically explain why a particular structure is painful. A functional diagnosis (understanding why tissues are painful) requires a different approach and a different model, with a focus on functional kinematic relations and the integration of structural constructs -bones, joints and ligaments- with movement generators and control systems -muscles, neural regulation- (Willard, 2007; Panjabi, 1992a, b; Lee, 2004). Willard (2007) provided the following description: ‘‘The lumbosacral spinal column performs a key role in the transfer of weight from the torso and upper body into the lower extremities, both in static positions and during movement. The primary bone structures involved in this force transduction are: five lumbar vertebrae, a sacrum, two innominate bones and the two femoral heads. Critical to the stability of these bony components is a complex arrangement of dense connective tissue. Although typically described as separate entities in most textbooks of anatomy, these fibrous, soft-tissue structures actually form a continuous ligamentous stocking, in which the lumbar vertebrae and sacrum are positioned. The major muscles representing the prime movers in this region e such as the multifidus, gluteus maximus and biceps femoris e have various attachments to this elongated ligamentous stocking. The muscular and ligamentous relationships composing the lumbosacral connection are of extreme importance in stabilising the lumbar vertebrae and arrangement has been termed a ‘self-bracing mechanism’ (Snijders et al., 1993a, b) and, as such, its dysfunction is critical to the failure of the lower back’’. The pelvic girdle is a closed osteo-articular ring composed of six or seven bones and the joints between them. Acting as a unit it supports the abdomen as well as the pelvic organs. It also provides a dynamic link between the spine and the lower limbs (Lee, 2004). Acknowledging the position of the pelvic girdle as the link between trunk and lower limbs can be the key to a better understanding of its function and the role of the structures that attach to it. The pelvis is part of both the trunk and as such of the spine and of the lower limbs.

153 Structures that attach to it directly and indirectly span as far as the shoulder and the proximal humerus via latissimus dorsi, and to the lower limbs as far as the foot through a combination of muscles (gluteus maximus, hamstrings, peronei) and fascia (thoraco-lumbo-dorsal). Pelvic girdle pain (PGP) is a specific form of low back pain that can occur separately or in conjunction with LBP (Vleeming et al., 2008). There is evidence that pelvic girdle pain in pregnancy was recognised in the ancient world. Hippocrates (circa 400 B.C.) mentioned symphysis pubis dysfunction in his theory of ‘‘disjunctio pelvica’’. PGP has been described by various authors in the past 20 years in the Scandinavian countries, United States, the Netherlands, South Africa, Israel, Australia and Nigeria. It generally arises in relation to pregnancy, trauma, osteoarthrosis and arthritis. Pain is experienced between the posterior iliac crest and the gluteal fold, particularly in the vicinity of the sacro-iliac joints (SIJ). It may radiate to the posterior thigh and can also occur with/or separately in the symphysis. The endurance capacity for standing, walking, and sitting is diminished. The diagnosis of PGP can be reached after exclusion of lumbar causes. The pain or functional disturbances in relation to PGP must be reproducible by specific clinical tests (Vleeming et al., 2008; Laslett et al., 2005). Three high quality prospective studies (Ostgaard et al., 1991; Larsen et al., 1999; Albert et al., 2000) report on incidence and point prevalence of PGP in pregnancy, in large cohorts totaling close to 2000 patients. The results indicate that around 20% of pregnant women suffer from PGP. The situation is different in non-pregnant patients. A large retrospective study by Bernard and Kirkaldy-Willis found a 22.5% prevalence rate in 1293 adult patients presenting with LBP. Diagnoses in this series were based predominantly on physical examination (Bernard and Kirkaldy-Willis, 1987). There is a growing body of evidence that points to the SIJ as an important source of PGP. The prevalence of sacroiliac joint pain would appear to be at least 13% and perhaps as high as 30% (Schwarzer et al., 1995a; Maigne et al., 1996). In our own small case series of 25 patients treated with prolotherapy for ligamentous failure of the SIJ (Cusi et al., 2008), the clinical history suggests that two thirds of patients are post pregnancy, and the remaining third are post injury, usually falls or direct trauma to the buttock area. The clinical diagnosis of pelvic girdle pain of SIJ origin is difficult, given the variety of clinical tests and the absence of a gold standard. Maigne claims that double anaesthetic blocks of the SIJ are the gold standard, but they are only effective to diagnose intra-articular pathology and do not cover the ligamentous apparatus that surrounds the joint, an important source of pain (Laslett et al., 2005). Murakami’s study (Murakami et al., 2007) confirmed Laslett’s opinion: following a pain provocation test, an intraarticular injection of local anesthetic (2% lidocaine) was performed on the first 25 consecutive patients with SIJ pain and a periarticular injection on another 25. The periarticular injections were given to one or more sections of the posterior periarticular area of the SIJ and to another section in the extraarticular portion. The periarticular injection was effective in all patients, but the intraarticular one was effective in only 9 of 25 patients.

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The sacro-iliac joint Anatomical and functional considerations A brief consideration of some anatomical functional and biomechanical aspects of the SIJ (Maigne et al., 1996; Van Der Wurff et al., 2000) will underpin the tests proposed for the clinical assessment of the SIJ, and recent developments in imaging studies. The long dorsal sacroiliac ligament can be palpated directly distal to the posterior superior iliac spine and inner lip of the iliac crest as a thick band that attaches distally and medially to the lateral sacral crest of S3 and S4. It lies posterior to the interosseous ligament and is covered by the fascia of the gluteus maximus muscle. The fibre tension varies with the movement of the sacrum. It is slack during nutation (from the Latin nutare -to nod-) and becomes taut in counternutation; localised pain within the boundaries of the long ligament could indicate a spinal condition with sustained counternutation of the SIJ (Vleeming et al., 1996). Nutation of the sacrum increases the tension of the major ligaments of the SIJ. In normal subjects it occurs in load-bearing situations (sitting, standing, walking, etc). Counternutation slackens them when the SIJ is minimally loaded (supine). The structure of the sacro-iliac joint and its purpose have been controversial for a long time. The small range of movement (Jacob and Kissling, 1995; Sturesson et al., 1989, 1999), the absence muscles that execute active movements of the joint and its position in the pelvic ring suggest that its function is one of stress relief for torsional forces across the pelvis (Bogduk, 2005), such as rotation during the gait sequence. In addition, it must be strong and stable to transmit forces from the vertebral column to the lower limbs and vice versa. This is possible with a combination of complementary fitting surfaces and strong ligaments. Pressure across the joint surfaces (compression) provides the stability that permits such load transfer. The amount of pressure required varies according to the functional activity

undertaken. Different strategies are required to provide varying degrees of pressure across the joint surfaces. Excessive, or insufficient, pressure across the SIJ can be identified as causes of deficient function and provide diagnostic clues (Vleeming et al., 1990b; Pool-Goudzwaard et al., 1998; Mens et al., 1999; Hungerford et al., 2003; O’Sullivan and Beales, 2007; Willard, 2007). Flat surfaces have been found to be best suited for transmission of large forces, but they are also less resistant to shear (Snijders et al., 1993a, b). Two mechanisms contribute to prevent shear. The cartilage is thicker and changes in the sacral surface are more prominent in women. This may be related to childbearing and to a different position of the centre of gravity in relation to the sacro-iliac joint. The ‘‘keystone-like’’ bony architecture of the sacrum, wedged between the two ilia, wider anteriorly and cranially than posteriorly and caudally, would be a second factor. Finally, Vleeming proposed the concepts of form and force closure of the sacro-iliac joint (Vleeming et al., 1990a, b). Shear is prevented by a combination of the specific anatomical features (form closure) and the compression generated by muscles and ligaments (force closure) that can accommodate to specific loading situations. Force closure (Figure 1) has been defined as the effect of changing joint reaction forces generated by tension in ligaments, fasciae, and muscles and ground reaction forces. In the ideal situation, force closure provides compression in a perpendicular plane to the sacro-iliac joint to overcome the forces of gravity. This has been termed a selfbracing mechanism (Snijders et al., 1993a, b). In the pelvis the self-bracing mechanism relies on the nutation of the sacrum. This movement is an anticipation for joint loading. Hodges et al use the terminology ‘‘preparatory motion’’ for the same phenomenon in the lumbar spine (Hodges and Richardson, 1996). Nutation tightens most of the SIJ ligaments, among them the interosseous and short dorsal sacro-iliac ligaments. The posterior parts of the iliac bones are then pressed together, thus increasing compression across the joint (Vleeming et al., 2008).

Force closure mechanism

Form closure mechanism

Self-bracing mechanism Figure 1

Diagrammatic representation of force closure, form closure and the self bracing mechanism of the SIJ.

Assessment and treatment of SIJ mechanical dysfunction Joint stability is the effective accommodation of the joints to each specific load through an adequately tailored joint compression, as a function of gravity, coordinated muscle and ligament forces, to produce effective joint reaction forces under changing conditions. Non optimal stability may be caused by altered laxity/stiffness of the joint, which results in increased joint translations or exaggerated joint compression. Experienced clinicians can now confidently diagnose mechanical derangement of the sacro-iliac joint. The diagnosis is based on the assessment of function, rather than the traditional medical model of anatomical pathology, which has been impossible to demonstrate to date. The Integrated Model of Function (Figure 2) proposed by Lee and Vleeming (1998) is an elegant summary of present day thinking. It has been expanded to include motor control and emotions, which have been known clinically to influence the transfer of load across the joint (Moseley et al., 2004).

Mechanical assessment of the SIJ Failure of load transfer through the SIJ (‘‘SIJ instability’’ or ‘‘SIJ dysfunction’’) can be diagnosed on the basis of history, clinical examination and imaging studies.

A. History The typical presenting symptom is LBP (Vleeming et al., 2008; Merskey and Bogduk, 1994). Pain maps have identified the distribution of symptoms related to the sacro-iliac joint. It is never above the level of L5, and includes the overlying area, buttock and posterior aspect of thigh and lower leg. There is evidence that dysfunction of this joint could, similar to a herniated lumbar disc, produce pain along the same distribution as the sciatic nerve (Fortin et al., 1994a, b, 2003). The presenting symptom is often described by the patient as ‘‘sciatica’’. Episodes of pain are typically recurrent, triggered sometimes by trivial actions such as bending

155 and twisting, without any substantial lifting involved. The initial episode can be either during or soon after pregnancy, or traumatic such as a fall, head on motor vehicle collision, ‘hard braking’ whilst driving a car or a transverse ‘crushing’ mechanism which compresses the pelvis. Pain is worse when the SIJ is loaded (sitting, standing, walking and negotiating stairs). Patients typically have difficulties turning in bed. Dyspareunia and changes in bladder habit are also common.

B. Clinical examination Historically mechanical tests for the sacroiliac joint can be divided into two broad categories: pain provocation tests and palpation tests (for assessment of position and movement) There appears to be no single mechanical test for the sacro-iliac joint that provides sufficient reliable information. Studies have shown that if considered in ‘clusters’ their reliability increases (Laslett et al., 2005; Van Der Wurff et al., 2006; Robinson et al., 2007). Manual tests attempt to identify structures and relationships that can give a clue to the cause of the pain. Manual tests rely heavily on the palpation skills of the examiner, and are ultimately ‘‘operator dependent’’. Other tests assess the onset timing of muscle activity patterns around a joint, which in turn reflect motion patterns. There is a parallel situation in the assessment of patello-femoral joint as a cause of anterior knee pain (Cowan et al., 2001). For instance, transversus abdominis (TA) activation precedes independent arm movement in normal subjects, but it lags behind in patients with low back pain (Hodges and Richardson, 1996). The following tests have been proven to appropriately assess different aspects of the function of the sacro-iliac joint. 1. The posterior pelvic pain provocation test (also known as thigh thrust) has been identified as reliable in the

Integrated Model of Function (Lee & Vleeming 1998)

Form Closure

Force closure

Bones, joints, ligaments

Muscles, fasciae

FUNCTION Motor control Neural recruiting patterns

Figure 2

Emotions Awareness

The integrated model of function of the SIJ (Lee and Vleeming, 1998).

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2.

3. 4.

5.

6.

M.F. Cusi diagnosis of pelvic girdle pain in pregnant women (Ostgaard et al., 1994) Palpation of the long dorsal sacro-iliac ligament (Vleeming et al., 1996, 2002). It becomes taut e and painful on palpation e when the sacrum is counternutated; it provides information on inappropriate patterns of relative motion between sacrum and ilium. The Trendelenburg test in its different forms indicates poor muscle activity of gluteals (Malanga and Nadler, 2006). The stork test (also known as Gillet test), assesses intrapelvic motion (Hungerford et al., 2003, 2007; Cusi et al., 2008). More importantly, it recognises changes in muscle activation patterns in the action of weight transfer and elevation of the contra-lateral knee. In patients with sacro-iliac joint pain there is early activation of biceps femoris and delayed contraction of internal oblique and multifidus (the opposite of normal subjects). The active straight leg raise (ASLR), tests the load transfer through the sacro-iliac joint, and has been shown to be reliable and reproducible (Mens et al., 1999, 2001, 2002, 1997; De Goot et al., 2008). Patrick’s Fabere and Gaenslen’s test are also useful when used in clusters (Laslett et al., 2005).

Other clinical manouvres have been used by a large number of clinicians, and provide valuable information of intraarticular motion, when compared from side to side, particularly the SIJ glide test as described by Lee (Lee, 2007). A number of these clinical manouvres have been tested in pregnancy-related back and pelvic girdle pain (Albert et al., 2002) and confirmed that the joints of the pelvic ring can be examined reliably in a clinical setting.

C. Imaging The sacro-iliac joint can be assessed with a variety of imaging modalities. Imaging of the SIJ has been

traditionally based on the diagnosis of sacroiliitis. Sacroiliitis can be differentiated into ankylosing spondylitis, reactive arthritis, psoriatic arthritis, arthritis of chronic bowel inflammatory disease and undifferentiated spondyloarthropathy (Braun et al., 2000). X-ray was historically the first modality used. Computerised Tomography (CT) scans are a superior modality to identify normal and pathological features (Lawson et al., 1982). However, degenerative changes are found sometimes in younger age group healthy individuals (Cohen et al., 1967). This questions whether normal development of symmetrical grooves and ridges can be considered as osteoarthritic changes, or rather normal changes within the life span (Dijkstra et al., 1989; Vleeming et al., 1992b). Magnetic Resonance Imaging (MRI) scans provide further information that can be matched with scintigraphic uptake (Hanly et al., 2000). Description of findings in normal and pathological joints is available, and caution is required to avoid existing pitfalls especially in the diagnosis of sacroiliitis. Nuclear medicine investigation is also a useful tool to assess the sacroiliac joint. Sacroiliitis, stress fractures and degenerative changes can be identified. Once again, caution is required because of the very low sensitivity and high specificity of nuclear imaging in the evaluation of ‘‘sacroiliac joint syndrome’’ (Slipman et al., 1996). In summary, inflammatory processes, degenerative changes, fractures and stress fractures have been identified with sound use of the available imaging modalities, but it has not been possible to identify mechanical changes within the joint. Most research and clinical experience have concentrated on the anterior -synovial- and to a certain extent cartilaginous portions of the joint. However the ligamentous apparatus of the joint -that plays an important role in its function as a load transmitter- has resisted accurate imaging to date.

Figure 3 SPECT-CT of SIJ. Increased uptake in the left SIJ soft tissue region and the intense sclerosis of both sacral and ilial margins of the joint (arrows), indicative of mechanical stress. (Image courtesy of M Cusi & H can der Wall).

Assessment and treatment of SIJ mechanical dysfunction The combination of Single Photon Emission Tomography and CT scan (SPECT-CT, Figure 3) offers exciting possibilities. Early preliminary work undertaken by the author and colleagues suggest that SPECT-CT of the sacro-iliac joint can provide a specific set of images that matches the clinical diagnosis of failure of load transfer. Those changes include increased uptake in the ligamentous (posterior) portion of the joint and attachment of the interosseous ligament to the surface of the ilium and loss of the ‘‘dumbell effect’’. The pattern of contrast uptake is quite different to the images of degenerative changes or inflammatory disease of the sacro-iliac joint. Improved understanding of the functional and biomechanical features of the sacroiliac joint provide the framework for the diagnosis of failure of load transfer through the sacroiliac joint, formerly termed ‘instability’. In the author’s opinion both terms could be used concurrently. Failure of load transfer is biomechanically more correct, but in a clinical setting the term instability refers to a constellation of signs and symptoms independent from the existing amount of movement within the joint, which is known to be minimal in any case (Sturesson et al., 1989).

Differential specific diagnosis In the daily clinical setting the diagnosis of failure of the SIJ to transfer load does not indicate whether the failure is of force closure (altered neural drive, deficient muscle strength or dynamic ligamentous failure), or form closure failure (joint surfaces, capsule and passive ligaments as passive structures). The specific diagnosis can only be made by exclusion, retrospectively. In cases where deficient stability of the sacro-iliac joint has been established, clinical experience suggests that exercise programs designed to increase appropriate compression have inconsistent results in terms of decreased pain and increased function. Exercise programs are successful when there is adequate ligamentous strength (Stuge et al., 2004, 2006). Patients who respond to a specific muscle strengthening program would qualify for the retrospective diagnosis of failure of force closure of neuromuscular origin. Response time can vary, but it can take three months for such programs to yield results (Stuge et al., 2004) (neuromuscular coordination, timing and onset of muscle activation and strength development).

Therapeutic alternatives A. Exercise therapy. Assessment of levels, criteria for stage progression Exercise therapy is considered the first therapeutic strategy once the diagnosis of load transfer failure has been made. A successful exercise programme needs to be specific, targeted and progressive (Hides et al., 2001; Mooney et al., 2001; Prather, 2003; Zelle et al., 2005). It can be divided into three stages (Isolation, Combination, Function). In each stage the patient learns to recruit the

157 particular muscle or set of muscles being trained and develop both strength and endurance. Contractions are usually light (10% of a maximal voluntary contraction), as stabilising muscles will be active for long periods of time. Each stage needs to be completed before the patient can be progressed to the next stage in a safe and effective manner. The use of a sacro-iliac belt may assist some patients, especially in the early stages (Vleeming et al., 1992a). Stage 1: isolation Patients need to develop the ability to recruit the targeted group of muscles independently of other groups. The initial target is the so called ‘‘inner unit’’ and includes transversus abdominis (TA), deep multifidus and pelvic floor. Neuromuscular training is often the first strategy as it is necessary to change existing muscle recruitment pattern strategies that compensate for the relative inactivity of the deep stabilisers. Common compensation patterns are the use of internal and external obliques, hip adductors and hamstrings. These and other global muscles need to be ‘‘downtrained’’ (Lee, 2004). Re-training motor control is difficult for some patients. Real time ultrasound is a good teaching tool that gives patients a useful visual cue. Once recruitment is achieved strength and endurance are developed gradually, to prevent fatigue and inappropriate compensating muscle recruitment patterns. Stage 2: combination In the second stage those muscles are recruited in various combinations to develop endurance. This is usually achieved by adding ‘challenging’ elements to the contraction, and incorporating progressively activation of the larger superficial ‘‘movement’’ muscles. Examples of this would be non weight bearing, weight bearing, closed chain and open chain movements whilst maintaining controlled contraction of the deep muscles (TA, multifidus, pelvic floor) without unnecessary compensatory strategies such as isolating hip abduction from combined lateral trunk flexion and hip abduction. Added movements should be slow and measured initially, and become faster as control and endurance improve. Stage 3: function In the third stage the patient progresses to functional activities; daily living, work or sport physical requirements. It requires tailoring the exercise programme to the patients’ needs and goals, whilst maintaining the guiding principles. It is always important to maintain good technique to prevent falling back to compensatory strategies. At higher level some muscles will change their mode of contraction from tonic to phasic, in keeping with functional demands (Saunders et al., 2005). The specific exercises a patient does in each stage can vary according to what ‘‘works for them’’ that also works for the treating therapist. It is more important to adhere to the principles outlined above, and ensure that the patient is not compensating in some way by using ‘the wrong muscles’ to carry out the prescribed exercise. In the author’s experience, failure to respond to an exercise programme carried out along these three stages

158 can be due to a variety of factors, intrinsic or extrinsic to the exercise programme. Intrinsic causes include: - Poor design (exercises are not specific enough), - Premature progression through the stages (neuromuscular patterns not established, insufficient endurance) - Poor compliance - Inappropriate exercise technique (exercises not done properly) The treating clinician needs to be aware of these pitfalls to ensure that patients obtain benefit from the therapy. Extrinsic causes are considered when a properly designed and executed exercise program is not sufficient to solve the problem, and the patient cannot reach the desired level of activity. It is reasonable to think that specific exercise programs fail when deficient ligament strength of the posterior elements of the sacro-iliac joint does not provide a sufficiently stable base to permit an effective muscle recruiting strategy (Pool-Goudzwaard et al., 1998). A mechanism that increases the passive stiffness of the joint would improve dynamic stability of the pelvis (force closure). In these cases the increased ligamentous stiffness would have the effect of providing a more stable anchor for specific strengthening programs to produce the desired outcome. Experimental work in rats indicates that prolotherapy may indeed be effective in building up collagen fibers and thus strengthening ligament (Dagenais et al., 2007a).

B. Prolotherapy Prolotherapy is an injection therapy used to treat chronic ligament, joint, capsule, fascial and tendon injuries. The goal of this treatment is to stimulate proliferation of collagen at the fibro-osseous junctions to promote nonsurgical soft tissue repair and to relieve pain (Klein and Eck, 1997). It has been defined by Hackett as ‘‘the rehabilitation of an incompetent structure (such as a ligament or tendon) by the induced proliferation of new cells’’ (Hackett, 1956). It is also called ‘‘Regenerative Injection Therapy (RIT) (Reeves et al., 2008), ‘‘Reconstructive Therapy’’, ‘‘Non-Surgical Tendon, Ligament, and Joint Reconstruction’’ and ‘‘Growth Factor Stimulation Injection’’(Alderman, 2007). The injection of various solutions aimed at producing a sclerosing effect to treat soft tissues injuries (e.g., inguinal hernia) has been used in modern times since the 1930s, when Schultz described a treatment for subluxation of the temporomandibular joint (Schultz, 1937). Prolotherapy has been used extensively in the USA since the 1930s (over 450,000 patients) and in other countries around the world, but it is not a recognized ‘main-stream’ therapy. Indeed the question has been raised: ‘‘Prolotherapy at the fringe of medical care, or is it at the frontier’’ (Mooney, 2003). The abundance of case series studies and anecdotal evidence has not been supported by a large body of randomised controlled trials (Yelland et al., 2004a; Dagenais et al., 2007b). Two systematic reviews of the use of prolotherapy for chronic musculoskeletal pain (Rabago et al., 2005; Dagenais et al., 2005) have found a variety of

M.F. Cusi randomised and non-randomised studies, but there is little standardisation of protocols, and generally limited highquality data supporting the use of prolotherapy in the treatment of musculoskeletal pain or sport related soft tissue injuries.

Application to spinal pain Prolotherapy is one of many interventional techniques applied to spinal pain. However, its published results have not been consistent (Klein et al., 1993; Yelland et al., 2004b; Linetsky and Manchikanti, 2005). A Cochrane Collaboration report concluded that: ‘‘There was no evidence that prolotherapy injections alone were more effective than control injections alone, but in the presence of co-interventions, prolotherapy injections were more effective than control injections, more so when both injections and co-interventions were controlled concurrently’’ (Yelland et al., 2004a). A large prospective, well designed randomised controlled trial of the injection of either normal saline or a mixture of 20% Dextrose with 0.2% lignocaine found that all patients with non-specific low back pain improved, irrespective of the solution injected or concurrent use of exercises (Dhillon, 1997; Yelland et al., 2004b). Most studies that involve the use of prolotherapy in the treatment of spinal pain do not consider a specific clinical diagnosis for patient selection. They instead take a ‘‘scattergun approach’’ to treating all forms of low back pain without the initial establishment of a firm working diagnosis. Patient selection is based mainly on pain location, and the injections are given in the painful sites. Injected volumes depend on the number of sites injected, and the number of injections depends on symptom response. A more functional approach has been used in a recently published case series. The population studied was 25 patients with failure of load transfer through the SIJ, who had not improved with a specific exercise programme along the guidelines outlined above. Patients underwent three CT guided injections of a small volume (1 ml) of 20% Dextrose in Bupivicaine 0.5% into the dorsal interosseous ligament. There was significant improvement both in the clinical examination parameters and in the functional questionnaires (Quebec Disability Scale, Roland Morris 24 and Roland Morris 24 Multi-form Questionnaires) at 3, 12 and 24 months (Cusi et al., 2008). This is a novel approach, as the indication for treatment was loss of function and a specific clinical diagnosis, not pain alone. The time between injections (six weeks) was based on the assumption that the inflammatory reaction and formation of collagen takes up to seven or eight weeks, and it is not necessary for the injections to follow each other closely. Three injections were considered sufficient to ensure a reasonable length of time for regeneration of collagen. This study suggests that (a) It is possible to make a clinical diagnosis of SIJ deficient load transfer of ligamentous origin. (b) Treatment with CT guided prolotherapy injections in the dorsal interosseous ligament of the affected SIJ e in combination with specific core stability training e can successfully correct the deficiency, reduce pain and improve function.

Assessment and treatment of SIJ mechanical dysfunction Further research is required to confirm these results with randomised control studies that compare prolotherapy to placebo injections.

C. Surgery Surgical stabilisation has been advocated in patients with SI joint pain unresponsive to more conservative measures. Unfortunately, all published reports on SI joint fusion have been small case series or retrospective studies. Whereas the primary indications for SI joint fixation are either joint instability or fractures (Waisbrod et al., 1987), successful arthrodesis has also been reported for degenerative joint disease. It can be done as an open technique or percutaneously, with CT guidance (Arand et al., 2004). The success rate of SIJ arthrodesis is around 70%, regardless of the underlying pathology. In the case of instability it must be considered as a measure of last resort (Cohen, 2005).

Conclusion The SIJ is potentially the source of LBP in a greater proportion of cases than previously anticipated. Mechanical assessment of the joint is now possible with a combination of specific historical findings, clinical manouvres and imaging tools. There are treatment strategies available to address mechanical dysfunction. A specific functional diagnosis is required to maximize their chance of successful outcomes.

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Journal of Bodywork & Movement Therapies (2010) 14, 162e171

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

MANUAL MANIPULATION FIBROBLAST RESEARCH

In vitro modeling of repetitive motion injury and myofascial release Kate R. Meltzer, M.S a, Thanh V. Cao, B.A a, Joseph F. Schad, M.S b, Hollis King, D.O, Ph.D. c, Scott T. Stoll, D.O, Ph.D. d, Paul R. Standley, Ph.D. a,* a

Department of Basic Medical Sciences, University of Arizona, College of Medicine, Phoenix, AZ 85004, USA Arizona College of Osteopathic Medicine, Midwestern University, Glendale, AZ 85308, USA c A.T. Still University, School of Osteopathic Medicine, Mesa, AZ, USA d University of North Texas Health Sciences Center, Texas College of Osteopathic Medicine, Fort Worth, TX 76107, USA b

Received 1 November 2009; received in revised form 12 November 2009; accepted 31 December 2009

KEYWORDS Cyclic strain; Human fibroblasts; Morphology; Myofascial release; Repetitive motion strain

Summary Objective: In this study we modeled repetitive motion strain (RMS) and myofascial release (MFR) in vitro to investigate possible cellular and molecular mechanisms to potentially explain the immediate clinical outcomes associated with RMS and MFR. Method: Cultured human fibroblasts were strained with 8 h RMS, 60 s MFR and combined treatment; RMS þ MFR. Fibroblasts were immediately sampled upon cessation of strain and evaluated for cell morphology, cytokine secretions, proliferation, apoptosis, and potential changes to intracellular signaling molecules. Results: RMS-induced fibroblast elongation of lameopodia, cellular decentralization, reduction of cell to cell contact and significant decreases in cell area to perimeter ratios compared to all other experimental groups (p < 0.0001). Cellular proliferation indicated no change among any treatment group; however RMS resulted in a significant increase in apoptosis rate (p < 0.05) along with increases in death-associated protein kinase (DAPK) and focal adhesion kinase (FAK) phosphorylation by 74% and 58% respectively, when compared to control. These responses were not observed in the MFR and RMS þ MFR group. Of the 20 cytokines measured there was a significant increase in GRO secretion in the RMS þ MFR group when compared to control and MFR alone. Conclusion: Our modeled injury (RMS) appropriately displayed enhanced apoptosis activity and loss of intercellular integrity that is consistent with pro-apoptotic dapk-2 and FAK signaling. Treatment with MFR following RMS resulted in normalization in apoptotic rate and cell morphology both consistent with changes observed in dapk-2. These in vitro studies build upon the cellular evidence

* Corresponding author. University of Arizona, College of Medicine- Phoenix, ABC Building 1, Room 324, 425 N. 5th Street, Phoenix, AZ 85004-2157, USA. Tel.: þ1 602 827 2107/2132; fax: þ1 602 827 2127. E-mail address: [email protected] (P.R. Standley). 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.01.002

In vitro modeling of MFR

163 base needed to fully explain clinical efficacy of manual manipulative therapies. ª 2010 Elsevier Ltd. All rights reserved.

Introduction Myofascial release (MFR) is a widely employed direct manual medicine treatment which utilizes specifically guided mechanical forces to manipulate and reduce myofascial restrictions of various somatic dysfunctions. MFR when used in conjunction with conventional treatment, is effective to provide immediate relief of pain and to reduce tissue tenderness (Hou et al., 2002; Fernandez de las Penas et al., 2005). Additional post-treatment clinical outcomes include attenuation of edema and inflammation, reduction of analgesic use, improved muscle recovery post trauma and increased range of motion in affected joints (Sucher, 1993; Andersson et al., 1999; Sucher et al., 2005). Despite these reports for clinical efficacy, no cellular or molecular mechanisms conclusively have been shown to be responsible. We previously reported that, in vitro, fibroblasts respond to repetitive mechanical strain with a delayed inflammatory response, upregulated nitric oxide secretions and increased cell proliferation (Dodd et al., 2006; Eagan et al., 2007; Meltzer and Standley, 2007). This response was not observed in counterstrain treated fibroblasts. Importantly, RMS-induced inflammatory responses were attenuated by counterstrain (Meltzer and Standley, 2007). Therefore, we focus here on the ability of fibroblasts to serve as a mechanotransducer by which they respond acutely to modeled repetitive motion strain (RMS) and modeled MFR. Specifically we will model repetitive motion strain and MFR in vitro by using human fibroblast tissue constructs and videomorphometric and palpometric data we have reported previously (Meltzer et al., 2007). Similar to what we

reported for counterstrain (Meltzer and Standley, 2007), here we hypothesize that human fibroblasts secrete inflammatory mediators in response to RMS, and that modeled MFR reduces such secretions. Further, we hypothesize that RMS acutely induces fibroplasias (increased fibroblast hyperplasia and hypertrophy), while MFR acutely reverses this effects. Importantly since clinical reports suggest that immediate pain relief is attained postMFR (Hou et al., 2002; Fernandez de las Penas et al., 2005), we will test the immediate effects of RMS and MFR strain paradigms on fibroblast cytokine secretion, morphology, proliferation and hypertrophy. This study will build upon cellular and molecular evidence to explain mechanisms underlying the immediate clinical outcomes associated with RMS and MFR.

Methods and material Human fibroblast cultures Normal human dermal fibroblasts (NHDF) from Cambrex Laboratories (East Rutherford, New Jersey) were used for all experiments. Cells were cultured in Fibroblast Basal Medium (FBM; Cambrex Laboratories) at 37  C, 5% CO2, and 100% humidity. FBM was changed every other day and NHDF were passed at confluence (usually 7e14 days). Experiments utilized passage numbers 2e6.

In vitro strain apparatus The Flexercell FX-4000 Tension Plus System (Flexcell International Corp, Hillsborough, NC) is a computer-based

Text box 1. Clinical relevance of study Under normal conditions the fascia moves with fluidity and is unrestricted to provide stability and structural support. However, the functional roles of the fascia may become impaired as a result of repetitive motion injury, physical trauma and inflammation. Traumatized fascia disrupts normal biomechanics of the body, increasing tension exerted on the system and causing myofascial pain and reduced range of motion. Myofascial release (MFR) is clinically effective to provide immediate pain relief and to improve physiologic functions that have been altered by somatic dysfunctions. Despite clinical efficacies, our understanding of the underlying mechanisms responsible is minimal. Here, we investigated the molecular and cellular effects of modeled repetitive motion strain (RMS) and MFR on human fibroblast constructs in vitro. Fibroblasts treated with modeled RMS responded with morphological changes as measured by cellular actin staining, reduction in area and perimeter ratios and increased focal adhesion kinase activity. Fibroblasts also displayed enhanced cellular apoptosis (programmed cell death), likely mediated by death-associated protein kinase. Fibroblasts strained by RMS followed by MFR displayed attenuation in these responses. Modification of these cellular properties may predispose to myofascial restrictions and tension and alleviation of symptoms with MFR noted in vivo. While clinical MFR directs force to fascial fibroblasts, indirect strains applied to nerves, blood vessels, lymphatic system, and muscles were not considered in this model. Despite the limitations of this in vitro modeling, these and other data from our laboratory suggest that fibroblasts, the primary cell type of the fascia, adapt specifically to mechanical loading in manners dependant upon strain magnitude, duration and frequency. This cellular strain model may prove useful to further investigate mechanisms and to build a cellular evidence base describing the positive outcomes of applied manual treatments in the clinical setting.

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Text box 2. Description of clinical MFR methodology Several challenges exist in order to effectively model MFR in vitro including accurately modeling strain directions, durations, frequencies and magnitudes. In an attempt to improve our modeling techniques, we have analyzed digital video data of several osteopathic manual treatments (OMTs) performed by osteopathic clinicians. Fig. 1 shows two still frames of a video segment illustrating the procedure used to analyze MFR strain direction, frequencies and durations. Fig. 1A shows the neutral, pre-treatment positioning of the patient and clinician’s hands prior to MFR. A clear Plexiglas sheet was immobilized approximately 24 inches above the patient in a manner that did not interfere with MFR. On the sheet were placed a series of three black dots, representing the neutral position and two arrows representing the strain direction in which the treatment will be applied. On the patient, a series of three red dots were applied to indicate the change in position of the skin, relative to neutral pre-strain, when strain is applied. In this pre-treatment frame, the dark and light dots are superimposed upon one another. In Fig. 1B, the direct MFR is applied (in a manner with sufficient force to engage the deep fascia as determined by clinician palpation) as shown by displacement of the two series of dots. The displacement indicates superior, lateral, and clockwise strains imparted to the fascia and underlying muscle. Data from these frames and several additional MFR sessions were captured digitally (Scion Image software suite) to analyze the superior and lateral strain (by measuring the inter-dot distances in the superior/inferior and lateral/medial fields) and the clockwise rotational strain (i.e., torque; by measuring angle of deviation from the pre-treatment parallel relationship of the two series of dots).’’ From these data, we utilized the following to generate our in vitro strain profile: time to load, duration of static strain, and time to unload. Strain magnitude used in the current study was equivalent to those studied in published reports. Strain direction, although equiradial in the current study, often includes heterobiaxial, uniaxial and shear in clinical settings.

system, which utilizes vacuum to strain cells adhered to flexible collagen-coated membranes arranged in a six-well per plate format. The deformation of the collagen causes the attached fibroblasts to also deform. Strain profiles are created by programming the magnitude, duration, direction and frequency of the negative pressure to create the desired profile. We have reported utilizing this apparatus to effectively model aortic pressure waveforms (Standley et al., 1999, 2001), injury (Meltzer and Standley, 2007), and counterstrain (Eagan et al., 2007; Meltzer and Standley, 2007).

Strain profiles NHDF were seeded (120,000 cells/well) onto collagen Icoated Bioflex plates, six wells per treatment group. Once cells were approximately 50e60% confluent (approximately 24 h post-seeding), FBM was replaced with a reduced-serum medium (0.2% FBS) to induce quiescence. After 24 hours, cells were subjected to mechanical strain profiles. Strain profiles were designed to simulate a repetitive motion injury (8 h of RMS; Fig. 2A) and a simulated myofascial release (60 s of MFR; Fig. 2B) based upon videomorphometric

Figure 1 Still images captured from video clips of a clinical MFR treatment. (A) Clinician’s hands and patient’s back before treatment, and (B) the same placements during a 90 s MFR. Note the simultaneous superior, lateral and clockwise strain directions.

In vitro modeling of MFR

165

A

1.6 s

Slope: 33.3% / sec

~10%

is used to denature cellular DNA with subsequent assessment of chromatin changes specific to apoptotic (and not necrotic) cells. The detection of denatured DNA was accomplished by using a monoclonal antibody to singlestranded DNA.

Intracellular signaling measurements

B

Slope: 1.5%/s for 4s

Slope: 3%/s for 2s

6%

60 s

Figure 2 Strain paradigm specifics for repetitive motion strain (RMS; A), and a complete 60 s cycle of modeled myofascial release (MFR; B).

analysis of clinical MFR treatments (Meltzer et al., 2007). The following four strain regimens were tested: 1. Control: cells were not subjected to any strain protocol for the duration of the experiments. 2. RMS (Repetitive Motion Strain): cells were subjected to the RMS profile (Fig. 2A) for 8 hours, and then sampled immediately upon cessation of RMS. 3. MFR (Myofascial Release): cells were subjected to the MFR profile (Fig. 2B) for 60 seconds, and then sampled immediately upon cessation of MFR. 4. RMS þ MFR: cells were subjected to the 8 hours RMS protocol followed three hours later by the 60 second MFR protocol and then sampled immediately after cessation of MFR.

Photomicrographs Fibroblast tissue constructs were analyzed microscopically for potential differences in cell morphology including lamellopodia elongation and/or truncation, cell membrane blebbing and removal from the collagen matrix. NHDF were also immunohistochemically stained with rhodamine-tagged phalloiden and subsequently observed for potential actin microfilament reorganization. Photomicrographs of each treatment group were also analyzed for cell counts per high powered field (HPF), cell area and cell perimeter using Image J 1.40 g (National Institute of Health, USA; http://rsb.info.nih.gov/ij/) and Prism 4.03 (GraphPad Software, Inc., San Diego, California).

Cell viability and growth measurements Cell viability was confirmed and proliferation was measured using the CellTiter 96Aqueous One Solution cell proliferation assay (Promega Corp.; Madison, WI).

Apoptosis measurements Apoptosis was measured using ssDNA Apoptosis ELISA kit (Chemicon International; Billerica, MA) in which formamide

Potential changes in intracellular signaling molecules were assessed pair-wise for selected treatment groups. Each treatment group was composed of one to two pooled sixwell plates. Cell lysates were obtained by treatment with ice-cold lysis buffer (5 ml lysis buffer, 15 ml pepstatin A, 1 mg/ml DMSO, 25 mg of a protease inhibitor cocktail (Roche Molecular Biochemicals, Indianapolis, IN) and 0.77 mg DTT). Lysates were centrifuged at 15,000 rpm at 4  C for 30 min and the supernatant was aspirated and collected and frozen at 80  C. Samples were then sent on dry ice for microarray processing (Kinexus Bioinformatics Corporation, Vancouver, B.C. Canada). Expression levels and phosphorylation states of cell signaling proteins were assessed in duplicate.

Cytokine secretion measurements Cytokine secretion was measured by testing the conditioned media on a quantifiable cytokine microarray (RayBiotech, Inc., Norcross, GA). Briefly, glass slides impregnated with antibodies of 20 cytokines in 16 replicate microarrays were incubated with blocking buffer, a six-sample standard curve cytokine cocktail and conditioned media samples obtained from the four strain groups described above. Slides were then incubated with a detection antibody cocktail (Alexa Fluor 555-conjugated streptavidin) and the signal was detected with an Agilent Scanner G2505B. Data were extracted from the image via GenePix Pro 4.0 (Molecular Devices, Sunnyvale, CA), and then further analyzed with Q-Analyzer v3.5 (RayBiotech, Inc., Norcross, GA;). All data were corrected for volume and cell number before statistical analyses.

Statistical analysis Two to four experiments (with two to four replicates each) were completed to obtain the proliferation, cell count, protein, DNA, apoptosis and cytokine data presented. NHDF area and perimeter measurements were derived from 42e48 random cells per experimental group. Intracellular protein measurements were derived from 6e12 pooled replicate wells and each array was completed in duplicate. Cytokine results were then evaluated by Grubbs’ Test to determine significant outliers from data set and further analyzed by a two-way ANOVA Bonferroni post-test. Additionally, all data were analyzed with a oneway ANOVA with post-hoc Tukey’s Multiple Comparison tests using Microsoft Excel (Microsoft Corporation) and Prism 4.03 (GraphPad Software, Inc., San Diego, California). Group means were considered significantly different if p < 0.05.

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Figure 3 Representative photomicrographs of human fibroblast construct morphology, growth patterns and actin architecture of the four treatment groups: control, repetitive motion strain (RMS), myofascial release (MFR), and RMS þ MFR.

Results RMS-induced morphologic changes appear mediated when followed three hours later by MFR Eight hours of RMS caused elongate lamellopodia, cellular decentralization, larger intercellular distances and reduced cell-cell contact area when compared to all other groups (Fig. 3). Sixty seconds of MFR did not appear to cause these morphologic changes. When RMS is followed three hours later by MFR, the degree of lamellopodia presence/elongation and cytoplasmic condensation was reduced while intercellular distances and cellecell contact area were mostly restored.

RMS causes NHDF area and perimeter changes NHDF from all three strain groups displayed significantly decreased cellular area when compared to control cells (one-way ANOVA p < 0.0001; Tukey post-hoc; Fig. 4, top). RMS caused a significant increase in cell perimeter compared to all other treatment groups (one-way ANOVA p < 0.0001; Tukey post-hoc; Fig. 3, middle), while MFR resulted in significantly reduced cell perimeters vs. control and RMS groups only. NHDF from the control group displayed significantly greater area to perimeter ratios than any other group, NHDF from the RMS group displayed significantly reduced area to perimeter ratios vs. any other group (One-way ANOVA p < 0.0001; Tukey post-hoc; Fig. 4, bottom).

Fibroblast proliferation does not appear to be strain regulated Cellular proliferation e as measured by cells per high powered field, the calorimetric proliferation assay, and DNA content e did not differ significantly among any of the four treatment groups (Figs. 5 and 6). Differences in protein concentration among RMS, MFR or RMS þ MFR were found to be insignificant. A ratio of protein to DNA (as a proxy of cell hypertrophy) also showed no significant differences among any treatment groups (Fig. 6d).

RMS causes apoptosis in fibroblasts Eight hours of RMS caused a significant increase in apoptosis compared to control, MFR and RMS þ MFR (One-way ANVOA p < 0.05; Tukey post-hoc; Fig. 7). There were no significant differences in apoptosis rates among control, MFR and RMS þ MFR groups.

Intracellular signaling protein results suggest support for morphologic and apoptotic changes Over 600 intracellular signaling proteins were identified and compared by microarrays among the four treatment groups. While many displayed significant differences among the strain groups (data not shown for brevity), we focused our analyses on those that might suggest potential mediators of the observed cell morphology and apoptosis differences (Table 1). Our intracellular signaling results in the RMS

In vitro modeling of MFR

A

120

B

B

B

0.0075 0.0050

100

Area:Perimeter

0.025

RMS+MFR

MFR

RMS

MFR

C

AC

RMS+MFR

A

RMS

0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0

B

Control

Perimeter (mm)

0.0000

Control

0.0025

A

0.020

C

0.015

C

B

0.010 0.005

RMS+MFR

MFR

RMS

Control

0.000

Figure 4 Cell area (top), perimeter (middle) and area:perimeter (bottom) assessed from photomicrographs via digital image capturing. Different letters denote significant relationships among groups (one-way ANOVA with post-hoc Tukey Multiple Comparisons Test); p < 0.05; N Z 42e48 cells analyzed per treatment group.

treatment group showed that tyrosine 576 phosphorylated focal adhesion kinase (FAKY576) is upregulated by 58% when compared to control nonstrained NHDF. We also observed a 55% upregulation of phosphorylated peptide in the RMS þ MFR group compared to RMS alone while there was only a 23% increase in the MFR group compared to control (averaged data from duplicate microarray spot analyses of 6e12 pooled lysate samples each). Death-associated protein kinase 2 (DAPK-2), a signaling protein that mediates apoptosis, is upregulated by 74% in the RMS group compared to control. The other two comparisons (MFR vs. Control and RMS vs. RMS þ MFR) revealed downregulation in this proapoptotic peptide of 12% and 10%, respectively. Serine 133 phosphorylated cyclic AMP response element binding protein (CREBS133) causes an upregulation in transcription

90 10 5 0

RMS+MFR

0.0100

110

MFR

0.0125

RMS

Area (mm 2)

0.0150

Pr oliferation Index (% of Contr ol)

0.0175

167

Figure 5 Proliferation indicies, as measured calorimetrically with the CellTiter 96aqueous one solution cell proliferation assay, of the treatment groups as a percent of non-strain control; N Z 3e4 (p > 0.05).

of numerous genes (Shaywitz and Greenberg, 1999). NHDF subjected to RMS displayed a 159% increase in this phosphorylated peptide when compared to control. NHDF strained with the MFR protocol displayed an increase of only 21% compared to control, and those treated with RMS þ MFR displayed only a 6% upregulation compared to the RMS group.

Analysis of cytokine secretion NHDF secretions of 20 human cytokines were assessed immediately after cessation of the four strain treatments (Table 2). Of the 20 cytokines measured, IL-6, IL-8, and VEGF were secreted from NHDF in concentrations in excess of 100 pg/mL and GRO and MCP-1 secretion was greater than 1000 pg/mL as measured in conditioned media. All other cytokines were measured to be minimal immediately after cessation of strain. There was a significant increase in GRO secretion in the RMS þ MFR group when compared to control and MFR group. All other cytokine secretions measured were found to be non significant among the four treatment groups.

Discussion To our knowledge, this is the first study to model MFR in an in vitro human fibroblast culture. While reports have shown various repetitive strain-induced changes in fibroblast proliferation, growth factor secretions and cellular alignment, ours is the first to show that several morphological changes in fibroblasts seen post repetitive strain are reversed if followed by modeled MFR. The lack of RMS-induced proliferation seen in this study may be masked by DAPK-2 associated apoptosis, an effect not seen in MFR or RMS þ MFR groups. While we observed no differences among a number of secreted inflammatory and growth promoting mediators with the strain paradigms tested, we can not rule out up- or downregulation of their receptors, intracellular effectors or expression/secretion differences in non-measured mediators. This in vitro strain model may be useful to further explore key cellular mechanisms that may underlie positive outcome of clinical MFR. Fascia is a tough connective tissue that contains elastic fibers and its elasticity contributes to its passive resistance

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D

200 150

150 100

MFR

R MS + M F R

MFR

R M S+ M FR

0

RMS

50

RMS

C

Pr olif er at ion Index [ DNA] ( % of Contr ol)

MFR

0

R MS + M F R

100

200

[ Pr ot ein] :[ DNA] ( % of Cont r ol)

B

200

RMS

Cell Count per HPF ( % of Cont r ol)

A

RMS +M FR

0

MFR

100

RMS

[Protien] (% of Contr ol)

200

100 50 0

Figure 6 Cell counts per high powered field (HPF; N Z 3e4 experiments), DNA, protein, and protein:DNA concentrations of treatment groups as a percent of control; N Z 2.

RMS+MFR

MFR

RMS

*

65 60 55 50 45 40 35 30 25 20 15 10 5 0 Control

Apoptosis Index

(% o f po si ti ve co n tro l )

to tensile forces. Under normal conditions the fascia tends to be fluid and move with minimal restrictions. However, injuries resulting from physical trauma, repetitive motion strain and inflammation can decrease fascia tissue length and elasticity resulting in fascial restriction. Physical strain has also been shown to influence the density of fibroblasts, connective tissue proteins such as collagen and fascial myofibroblasts which may be capable of active fascial contraction (Schleip et al., 2006). Injuries, such as repetitive motion strain, result in abnormal changes to tissue texture affecting passive and active resistance to motion which in turn leads to compromised joint articulation,

Figure 7 Apoptosis indices of treatment groups as a percent of positive control. Significance determined via one-way ANOVA with post hoc Tukey Multiple Comparisons Test; p < 0.05; N Z 2; *, significantly different from all other groups.

discomfort, pain and reduced range of motion. Improvement in these sign and symptoms are often seen post-MFR treatment (Sucher, 1993; Andersson et al., 1999; Hou et al., 2002; Fernandez de las Penas et al., 2005; Sucher et al., 2005). In our in vitro RMS model, NHDF tissue constructs displayed fibrotic looking cells with elongate actin-containing lamellopodia and general decentralization which are apparent in the enclosed photomicrograph. Significant decreases in area to perimeter ratio confirmed that substantial morphologic changes occurred in the RMS group that is indicative of cell elongation, increased intercellular distances and decrease cell-cell attachment area. If similar tissue changes occur in vivo in response to RMS, these findings may be characteristics of abnormal tissue texture change which, in turn, may attribute to fascia restriction. We have previously reported that acyclic strain causes morphological changes in fibroblasts (Dodd et al., 2006; Eagan et al., 2007) while others have found cyclic straininduced reorientation of fibroblasts (Jungbauer et al., 2008; Wen et al., 2009). Studies of fibroblast morphologic changes due to cyclic strain are scarce. However, in other cell types, cyclic stretching induced morphologic changes of HUVEC cells from a normal polygonal shape to elongated spindle-like shapes (Naruse et al., 1998) and cyclic stretching of vascular smooth muscle cells have been shown to cause a variety of phenotypic changes including causing cell elongation (Riha et al., 2005). To our knowledge this is the first study to investigate fibroblast morphology changes that may be consistent with fascial restrictions evident after repetitive motion injuries.

In vitro modeling of MFR

169

Table 1 Intracellular proteins of interest, their function, and percent change from control as assayed via Kinex Antibody Microarray. Protein or Phosphorylation Site

Function

Control vs. RMS

Control vs. MFR

RMS vs. RMS þ MFR

DAPK-2 FAKY576 CREB1S133

Positively mediates apoptosis Maximizes FAK activation Upregulates gene transcription

þ74% þ58% þ159%

12% þ23% þ21%

10% þ55% þ6%

found to pre-apoptotically stabilize stress fibers, but not maintain focal adhesions in quiescent murine embryonic fibroblasts (Kuo et al., 2003). DAPK also triggers uncoupling of the formation of stress fibers and focal adhesions, possibly predisposing cell to apoptosis which is found to occur after this uncoupling effect (Kuo et al., 2003). Specifically, DAPK-2 is involved in apoptotic signaling (Kawai et al., 1999), and its regulation influences overall fibroblast growth rates and, consequently, fibroplasia and alterations in tissue texture. Compared to control, RMS strained cells had a significant 21% increase in apoptosis concomitant with an upregulation of dapk-2 by 74%. Cyclic strain has been found to cause increases in apoptosis in mesenchymal stem cells (Kearney et al., 2008), vascular endothelial cells (Kou et al., 2009), and periodontal ligament cells (Zhong et al., 2008). Fibroblasts apoptosis in response to cyclic strain has been mixed with increases seen from minutes (Skutek et al., 2003) to days (Barkhausen et al., 2003), decreases (Danciu et al., 2004) and no change (Persoon-Rothert et al., 2002; Nishimura et al., 2007). Thus, the rate of apoptosis appears to be highly dependant on sampling time. Barkhausen et al. (2003) found an upregulation of apoptosis after one day, consistent with our

In addition to observing morphological changes we investigated several intracellular proteins that may be involved in the morphologic responses seen in the RMS group. We report upregulation of Focal Adhesion Kinase (FAK) phosphorylation at Tyrosine 576 by 58% in the RMS group compared to the control group. Focal Adhesion Kinase (FAK) is an important mediator of actin-extracellular matrix interaction and cell motility (Calalb et al., 1995; Schlaepfer et al., 2004) and the phosphorylation of FAK at Tyrosine 576 maximizes FAK activation (Calalb et al., 1995). Changes in physical morphology require modifications of cell extracellular matrix interactions and our result of increased FAK activity is consistent with our observed morphology changes allowing structural stabilization during actin-cytoskeleton remodeling. In a related study, cyclic strain has been found to increase FAK tyrosine phosphorylation from minutes to hours and decrease in time frames greater than 24 h (Naruse et al., 1998; Molina et al., 2001; Wang et al., 2001). We observe similar results and report immediate response changes in FAK tyrosine phosphorylation immediately upon cessation of an 8 h cyclic strain. Another intracellular protein that was accessed was death-associated protein kinase (DAPK). DAPK has been Table 2 Cytokine

NHDF secretion of select cytokines and growth factors from the four treatment groups described. Treatment groups Control

IL-1a IL-1b IL-2 IL-4 IL-5 IL-6 IL-8 IL-10 IL-12 IL-13 GM-CSF GRO IFNg MCP-1 MIP-1a MIP-1b MMP-9 RANTES TNFa VEGF

RMS

RMS þ MFR

MFR

Mean

SEM

Mean

SEM

Mean

SEM

Mean

SEM

0.4 0.6 5.4 21.3 0.4 107.7 146.4 11.3 6.6 1.5 0.4 1897.0 11.3 1467.0 8.3 1.6 3.2 10.9 7.2 256.9

0.3 0.2 0.4 10.5 0.0 82.9 1.5 5.1 3.9 0.6 0.0 297.9 9.5 551.0 4.7 1.0 0.1 7.3 1.1 44.3

28.9 0.3 5.0 4.3 0.4 13.1 226.3 9.2 5.8 4.1 1.3 2595.0 27.2 1509.0 11.6 2.8 3.2 2.2 7.3 275.2

17.6 0.0 0.1 0.4 0.0 5.8 71.6 0.4 0.1 1.5 0.5 921.5 13.6 617.7 5.4 2.0 0.1 0.7 1.1 14.4

18.8 0.3 5.2 10.4 0.5 84.1 91.4 13.1 0.7 4.6 0.3 1152.0 13.6 2225.0 5.3 3.8 3.0 13.2 7.3 800.9

10.2 0.0 0.5 4.5 0.1 46.6 5.9 5.3 0.1 2.2 0.1 127.8 5.9 952.0 1.7 1.5 0.1 8.3 1.8 126.3

0.9 0.3 5.4 4.9 2.2 92.0 123.7 9.8 13.6 5.3 0.4 3761.0* 59.53 2313.0 10.8 1.7 3.2 2.0 133.5 493.5

0.2 0.0 0.4 1.0 1.0 37.2 34.2 4.7 0.1 1.5 0.0 2037.0 12.6 566.4 4.1 0.7 0.1 1.0 59.5 129.0

Group means and SEMs are calculated with the exclusion of significant outliers determined by Grubbs’ Test. All data are expressed in pg/ml (N Z 2e3). *, Significant differences compared to control and MFR.

170 findings, however, after two days apoptosis decreased. Apoptotic response to strain may change over time as the cells adapt to modified environments as induced, for example, by additional injurious strains or by manually directed strain maneuvers such as MFR. Furthermore, we also observed a 159% increase in CREB phosphorylation at serine 133 in the RMS test group. CREB phosphorylation at serine 133 is essential for CREB-mediated transcription and studies have shown its involvement in key cellular processes that include proliferation, differentiation and adaptive response (Shaywitz and Greenberg, 1999). Upregulation in gene transcription may be associated with apoptotic, morphologic genes or cell surface receptor protein increasing NHDF sensitivity to select cytokine and growth factors. For example, studies have shown that fibroblasts cyclically strained resulted in an increase in cell proliferation (Webb et al., 2006; Eagan et al., 2007) but here we report that there were no significant changes in cell proliferation among the test groups. Cell proliferation was accessed by cell count per high powered field and confirmed be quantifying dsDNA. In addition, we have also shown that RMS treated cells resulted in an increase in apoptotic signaling. Significant increases in apoptosis should result in a decrease in total cell number however, this was not the case. Together, these data suggest that proliferation may have increased but the increase in apoptosis may have masked the proliferation rate resulting in no net gains. These data suggest that RMS in our NHDF tissue constructs bears many resemblances to injurious strain profiles noted in vivo. In clinical application, manual manipulative therapy is effective in immediate response changes in tissue texture and pain threshold with patients diagnosed with mechanical neck pain (Fernandez de las Penas et al., 2005). In a related report, MFR e when used with other treatment modalities e showed immediate reduction in pain and improved range of motion in patients with cervical myofascial dysfunction (Hou et al., 2002). Our in vitro RMS þ MFR model incorporated a three hour delay in between treatment to reflect the delay associated with patient seeking treatment at times after initially sustaining an injury. Although this delay may contribute to cell recovery after RMS, clinically this delay might be insignificant. In vitro analysis of the NHDF immediate proliferative response to a modeled MFR after injury showed a significant reduction in cellular apoptosis accompanied with a 10% decrease in DAPK-2 activation. To maintain non-fluctuation in cell numbers, as we did not observe changes in net cell proliferation in comparison to other treatment groups, the decrease in apoptosis may be correlated with a reduction in proliferation rate, as opposed to RMS. Morphological changes induced by RMS were not observed in the RMS þ MFR group. These data are complemented by results indicating significant increases in area to perimeter ratio in RMS þ MFR when compared to RMS alone. It is interesting to speculate that the change in morphology and increase in area to perimeter ratio could be a reflection of tissue texture changes and increase elasticity of the myofascial layer resulting in improved range of motion seen in clinical applications.

K.R. Meltzer et al. In this study we broadened the search of cytokines that may be involved in immediately post-treatment changes. Of the twenty cytokines measured we only observed a significant increase in GRO secretion in the RMS þ MFR group when compared to control and MFR. GRO has been classified as a neutrolphil chemotractant and although studies have shown that GRO is unresponsive to induce proliferation in fibroblasts there is evidence to support its effect on regulating fibroblast collagen expression (Unemori et al., 1993). This suggests that GRO may play a potential role in fibroblast actin-extracellular matrix remodeling as observed here in this study. All other cytokines secretion investigated were found to be non significant, however, we did observe an increasing trend in IL-1a in the RMS group compared to control which is consistent with our previous report (Meltzer and Standley, 2007). Interestingly, RMS-induced IL-1a expression was attenuated with the addition of MFR following RMS. The morphologic and apoptotic changes observed here appears to be independent of the cytokines we examined. However, the possibility of mechanical strain altering NHDF sensitivity to select cytokines through upregulating surface cell protein receptors is plausible. A 24 h posttreatment investigation of cytokines is out of the scope of this study; however it may elucidate delayed cytokines secretion in response to the stimuli. Future studies will examine delayed secretion of cytokines and the immediate mediators of the morphologic and apoptotic changes observed in this study. Clinically, temporal delays from hours to days in cytokine induction, inflammatory processes, and pain after a repetitive motion strain type injury or a soft tissue trauma are well documented (Smith et al., 2000; MacIntyre et al., 2001; Hildebrand et al., 2005). However, in this study we focused only on potential mediators of cellular changes that take place immediately post-treatments.

Funding sources and conflicts of interest Funding for these studies came from the National Institute of Health e National Center for Complementary and Alternative Medicine, the American Osteopathic Association and the Arizona Biomedical Research Collaborative. No authors declare any conflict of interest, financial or otherwise.

Acknowledgments We thank Chris Gooden, Diana Petitti, Michael Hicks and Shande Chen for their technical assistance.

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171 Naruse, K., Yamada, T., Sai, X.R., Hamaguchi, M., Sokabe, M., 1998. Pp125FAK is required for stretch dependent morphological response of endothelial cells. Oncogene 17 (4), 455e463. Nishimura, K., Blume, P., Ohgi, S., Sumpio, B.E., 2007. Effect of different frequencies of tensile strain on human dermal fibroblast proliferation and survival. Wound Repair Regen. 15 (5), 646e656. Persoon-Rothert, M., van der Wees, K.G., van der Laarse, A., 2002. Mechanical overload-induced apoptosis: a study in cultured neonatal ventricular myocytes and fibroblasts. Mol. Cell. Biochem. 241 (1e2), 115e124. Riha, G.M., Lin, P.H., Lumsden, A.B., Yao, Q., Chen, C., 2005. Roles of hemodynamic forces in vascular cell differentiation. Ann. Biomed. Eng. 33 (6), 772e779. Schlaepfer, D.D., Mitra, S.K., Ilic, D., 2004. Control of motile and invasive cell phenotypes by focal adhesion kinase. Biochim. Biophys. Acta 1692 (2,3), 77e102. Schleip, R., Naylor, I.L., Ursu, D., Melzer, W., Zorn, A., Wilke, H.J., Lehmann-Horn, F., Klingler, W., 2006. Passive muscle stiffness may be influenced by active contractility of intramuscular connective tissue. Med. Hypotheses 66 (1), 66e71. Shaywitz, A.J., Greenberg, M.E., 1999. CREB: a stimulus-induced transcription factor activated by a diverse array of extracellular signals. Annu. Rev. Biochem. 68, 821e861. Skutek, M., van Griensven, M., Zeichen, J., Brauer, N., Bosch, U., 2003. Cyclic mechanical stretching of human patellar tendon fibroblasts: activation of JNK and modulation of apoptosis. Knee Surg Sports Traumatol. Arthrosc. 11 (2), 122e129. Smith, L.L., Anwar, A., Fragen, M., Rananto, C., Johnson, R., Holbert, D., 2000. Cytokines and cell adhesion molecules associated with high-intensity eccentric exercise. Eur. J. Appl. Physiol. 82 (1,2), 61e67. Standley, P.R., Obards, T.J., Martina, C.L., 1999. Cyclic stretch regulates autocrine IGF-I in vascular smooth muscle cells: implications in vascular hyperplasia. Am. J. Physiol. 276 (4 Pt 1), E697eE705. Standley, P.R., Stanley, M.A., Senechal, P., 2001. Activation of mitogenic and antimitogenic pathways in cyclically stretched arterial smooth muscle. Am. J. Physiol. Endocrinol. Metab. 281 (6), E1165eE1171. Sucher, B.M., 1993. Myofascial release of carpal tunnel syndrome. J. Am. Osteopath. Assoc. 93 (1), 92e94. 100e101. Sucher, B.M., Hinrichs, R.N., Welcher, R.L., Quiroz, L.D., St Laurent, B.F., Morrison, B.J., 2005. Manipulative treatment of carpal tunnel syndrome: biomechanical and osteopathic intervention to increase the length of the transverse carpal ligament: part 2. Effect of sex differences and manipulative ‘‘priming’’. J. Am. Osteopath. Assoc. 105 (3), 135e143. Unemori, E.N., Amento, E.P., Bauer, E.A., Horuk, R., 1993. Melanoma growth-stimulatory activity/GRO decreases collagen expression by human fibroblasts. Regulation by CeXeC but not CeC cytokines. J. Biol. Chem. 268 (2), 1338e1342. Wang, J.G., Miyazu, M., Matsushita, E., Sokabe, M., Naruse, K., 2001. Uniaxial cyclic stretch induces focal adhesion kinase (FAK) tyrosine phosphorylation followed by mitogen-activated protein kinase (MAPK) activation. Biochem. Biophys. Res. Commun. 288 (2), 356e361. Webb, K., Hitchcock, R.W., Smeal, R.M., Li, W., Gray, S.D., Tresco, P.A., 2006. Cyclic strain increases fibroblast proliferation, matrix accumulation, and elastic modulus of fibroblastseeded polyurethane constructs. J. Biomech. 39 (6), 1136e1144. Wen, H., Blume, P.A., Sumpio, B.E., 2009. Role of integrins and focal adhesion kinase in the orientation of dermal fibroblasts exposed to cyclic strain. Int. Wound J. 6 (2), 149e158. Zhong, W., Xu, C., Zhang, F., Jiang, X., Zhang, X., Ye, D., 2008. Cyclic stretching force-induced early apoptosis in human periodontal ligament cells. Oral Dis. 14 (3), 270e276.

Journal of Bodywork & Movement Therapies (2010) 14, 172e178

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

MASSAGE THERAPY FOR HYPOCHONDROPLASIA

Improving mobility in a client with hypochondroplasia (dwarfism): A case report* Amy Axt Hanson, LMP* 923 N. Lawrence St., Tacoma, WA 98406-5510, USA Received 18 August 2009; received in revised form 4 January 2010; accepted 5 January 2010

KEYWORDS Myofascial release; Muscle fatigue; Achondroplasia; Structural bodywork; Climbing stairs; Compartment syndrome

Summary A client with hypochondroplasia dwarfism and a medical diagnosis of spinal stenosis had found that her ability to walk had decreased over the past 7 years from easily walking 6 miles (10 K) to now needing to rest every half block (171 ft/52 m) due to muscle fatigue. Such weakness is consistent with nerve impingement due to spinal stenosis, which would not be improved by massage. However, during a preliminary assessment, it was found that both lower legs had severe fascial adhesions, possibly compressing lower leg blood vessels and nerves. It was hoped that by using myofascial massage techniques to relieve the adhesions, her mobility would improve over the course of 8 sessions. Myofascial massage techniques showed positive results in reducing adhesions, improving circulation, and increasing the distance the client could walk before resting to 2 blocks (686 ft/209 m). Working with this client showed that Licensed Massage Practitioners (LMPs) can easily accommodate clients of very short height. ª 2010 Elsevier Ltd. All rights reserved.

Introduction Clients of very short height are a surprisingly large group, with a study done in 2003 by the advocacy group Little People of America finding that 1 in 277 US adults, or roughly a million people, were 4 feet 10 inches/147 cm or shorter. Most were thought to simply have a family history of short

* Winner of Massage Therapy Foundation’s 2009 Annual Student Case Report Contest. * Tel.: þ1 253 222 3651. E-mail address: [email protected] URL: http://www.amyhansonmassage.com

height. Although exact numbers of dwarfs are unknown, they are estimated to account for more than 200,000 people in the US (Adelson, 2005a). That figure seems to be low even for a baseline: the same study found that roughly 169,000 people in the US were 40 600 /137 cm or shorter, a height likely tied to a medical cause (Adelson, 2005a). To be considered a dwarf, a client must be 40 1000 or shorter due to a medical condition that limits growth. Those medical conditions identified to date include faulty mechanisms of cartilage and bone development, pituitary or thyroid hormone deficiencies, absent or incomplete chromosomes, genetic syndromes, malnutrition, extreme emotional neglect or abuse, and chronic diseases of the kidney, heart, liver, or gastrointestinal tract (Adelson, 2005b).

1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.01.003

Improving mobility in a client with hypochondroplasia The client in this report was diagnosed with the bone growth disorder hypochondroplasia (literally ‘under cartilage molding’), which produces defective conversion of cartilage into bone due to point mutations in the same fibroblast receptor protein linked to achondroplasia (literally ‘no cartilage molding’) (Francomano, 2005a; Hall, 2005). Hypochondroplasia is considered to be a less severe form of achondroplasia (Beighton, 1993; Francomano, 2005b; Greenfield, 1990a; Greenspan, 2000a). Achondroplasia is the most commonly diagnosed form of dwarfism, appearing in 1 of every 15,000e40,000 live births, and is thought to account for half of all cases of dwarfism (Francomano, 2005c; Greenfield, 1990a). The prevalence of hypochondroplasia is unknown but thought to be similar to achondroplasia, only less frequently diagnosed since body changes are milder and likely to be overlooked (Francomano, 2005c,d). Typical presentation of hypochondroplasia and achondroplasia includes normal trunk length but disproportionately short arms and legs. Hands and feet are broad and short (Francomano, 2005b,e; Spranger et al., 2002). Much is known about hypochondroplasia and achondroplasia from X-ray studies of skeletal features, with several issues being pertinent to discussions of mobility, including lumbar hyperlordosis, a squared, shortened ilia, a more horizontally tilted sacrum, short femoral neck, mild genu varum (bowed legs), and a reduced greater sciatic notch (Beighton, 1993; Bogumill and Schwamm, 1984; Francomano, 2005c,e; Greenfield, 1990b; Greenspan, 2000b; Spranger et al., 2002). These clients tend to have shorter than average pedicles, the bridges between vertebral bodies and the arch holding the transverse and spinous processes. With smaller than average vertebral and intervertebral foramina, any further narrowing due to injuries, herniated disks, bone spurs, or cartilage aging can produce pain, numbness, and weakness in the extremities, particularly the legs (Beighton, 1993; Francomano, 2005c; Greenfield, 1990b; Greenspan, 2000c; Spranger et al., 2002). According to orthopedic surgeon Dr. Steven E. Kopits, who specialized in dwarfism, ‘With progression of the severity, the patients have to make obligatory stops at periodic distances during gait because of numbness, pain, and weakness of the lower limbs’ (Kopits, 1976a). This accurately describes the client in this study, who was limited in the distance she could walk before having to stop and rest due to muscle weakness in her legs. In addition, she found climbing stairs difficult, and had to bring both feet to each step. After sitting at her desk for 4 or more hours, and on waking in the morning, various areas of her feet and toes tingled, which could be relieved by dorsiflexing and plantar flexing her feet, or by walking. During assessment it was discovered that the client had severe fascial restrictions in both lower legs, and the skin of her lower legs and feet felt significantly cooler to the touch than her thighs or arms. Fascial adhesions are considered to be a potential cause of blood and nerve flow impingement (Archer, 2007a; Travell and Simons, 1993). Layers of fascial connective tissue are found most superficially as a body stocking under the dermis, and also more deeply wrapping groups of muscles (compartments), each named muscle, each inner bundle (fascicle) within a muscle, and each individual muscle cell (fiber). Fascia separates various functional

173 groups yet holds them together (Smith, 2005a). In the lower leg, deep fascia divides muscles into anterior, lateral, deep posterior, and superficial posterior compartments, with major bundles of nerves, arteries, veins, and lymph vessels running between compartments, within compartments, and underneath the superficial fascial layer (see Figure 1). These nerves, blood and lymph vessels can become compressed due to contraction of surrounding muscles, from inelasticity in the fascial wrapping, or from a gluingtogether of fascial septa on either side of the nerves and vessels. Collagen fibers can lose elasticity and/or become bonded to collagen fibers in adjacent fascial layers from disuse, dysfunctional use, aging, or injury (Smith, 2005b). These adhesions, if severe enough, can produce muscle fatigue and pain, and at the most extreme, produce compartment syndrome in which underlying muscle tissue degenerates (Travell and Simons, 1993). In participating in this study, the client’s primary interest was to see whether massage could increase the distance she could walk before the onset of muscle fatigue. She was unconcerned with the tingling in her feet, and had no expectation of any other changes. It was suspected that fascial adhesions or inelasticity could be compressing nerves and blood vessels in her lower legs, creating or exacerbating her symptoms, and a series of sessions were planned in which myofascial techniques would be used along with other massage techniques. It was not known whether there might be undiagnosed cardiovascular issues; improvements could also be limited by spinal stenosis, a true neurological condition that produces pain and weakness in the legs (Mayo Clinic, 2008).

Methods Profile of client A 63-year-old librarian was, at 40 400 (132 cm), the only member of her family with hypochondroplasia. Her ability to walk had been normal until her 40s, allowing her to participate in 10-km (6-mile) fundraising walks. She was diagnosed with spinal stenosis 13 years ago and started experiencing muscle weakness in her legs 7 years ago, which had progressed to where she could only walk half a block (171 ft/ 52 m) before having to stop and rest for several minutes. Muscle weakness only occurred when walking, and was not associated with any pain or burning in her legs or lower back, although occasionally she felt tingling in her feet and toes at this time. She was not able to link the fatigue to any specific muscle or group of muscles. When she forced herself to keep

Deep posterior compartment Tibialis posterior Flexor digitorum longus Flexor hallucis longus Superficial posterior compartment Gastrocnemius Soleus

Tibia

Anterior compartment Tibialis anterior Extensor digitorum longus Extensor hallucis longus Lateral compartment Peroneus longus Peroneus brevis Fibula

Figure 1 Cross-section of the lower leg showing the major fascial divisions grouping muscles into the anterior, lateral, deep posterior, and superficial posterior compartments.

174 walking, her leg muscles no longer functioned and she fell. Use of a cane as a mobility aid did not improve her muscle fatigue or distance, but helped her walk faster and feel more balanced. Tingling in her toes and feet had become more pronounced over the past 5 years, especially when she woke up in the morning or sat at her desk at work for 4e5 h. She had not noticed a pattern to the tingling, which occurred in her toes, heels, and various areas of her feet (lateral, medial, and superior sides). The tingling was relieved by dorsiflexing and plantar flexing her foot, or by walking, and disappeared within 5 min. The client had a positive attitude toward life, adapting to her increasing limitations with good humor. She often used a cane when walking at work, home, and shopping, and for longer distances used a mobility scooter. She felt that her mobility would be improved by losing weight, and had been following a nationally franchised weight-reducing program for 3 years, losing 38 pounds (17 kg) to bring her to a current weight of 163 pounds (73 kg). The client had never received massage of any kind. She received physical therapy for low back pain 13 years ago for a term of 2 months. At that time, she had steroid injections to relieve low back pain caused by spinal stenosis. She also performed stretching exercises for her legs and back, and felt that it helped improve her mobility, but also felt that reduced pain from her steroid injections was more important in improving her mobility. At the outset of the study, she had no pain in her legs or low back, but sometimes felt tightness down the posterior muscles of her leg, especially when walking and climbing stairs. This tightness required her to bring both feet up to each stair before tackling the next. On initial assessment, the client was found to have fascial tension in both lower legs to the extent that skin moved very little in any direction. Muscles of the anterior and lateral compartments felt tight. She had light to moderate range of motion (ROM) limitations in all planes of the hips, knees, and ankles, with no limitation in knee extension. Of note was a moderate-plus limitation in dorsiflexion and plantarflextion of her ankles. Hip flexion had a firm active end point at 90 degrees, with no further gain in ROM on passive movement. The client stood with light lateral rotation of both femurs, low medial arches, lumbar hyperlordosis, and no other significant postural deviations. On initial assessment, her lower legs, feet, and toes felt significantly cooler in temperature than her thighs. She had no significant tension in the muscles of her lower leg posterior compartments, anterior thighs, or posterior thighs. The client was very interested to see if massage could improve her ease of movement and flexibility to the extent that it might increase her walking distance from half a block to two blocks between rest stops. She had no other goals for this study, but the author was interested to see whether easing the client’s myofascial restrictions might be accompanied by an increased ROM and reduction in the tingling of her toes and feet.

Treatment plan Eight massage sessions were conducted over the course of 15 weeks, with each session lasting 1.5 h (plus additional time

A.A. Hanson for assessment). The time between massages averaged 14 days, ranging from 11 to 21 days. Two weeks after session 8, final information was gathered on walking distance. Session 1 used whole-body Swedish massage and deep tissue techniques (focused work on deeper muscles, both with-fiber and cross-fiber, with the intent to release longstanding adhesions) for assessment, palpation, and to introduce the client to massage. Techniques in sessions 2e6 included prone broad-plane, linear shift, and horizontal-plane myofascial release techniques (Archer, 2007b) to the posterior compartment, plus Swedish and deep tissue techniques to posterior lower leg, hamstrings, iliotibial band, gluteals, and back. Supine techniques included broad-plane, linear shift, and horizontalplane myofascial release to anterior and lateral lower leg, plus Swedish and deep tissue techniques to anterior lower leg and quadriceps. Sessions 7 and 8 used the more specifically targeted, heavier-pressure techniques of structural bodywork using the finger chisel, dorsum of hand, and octopus-hand strokes intended to produce myofascial release of heavy adhesions and deep structures (Smith, 2005c). With the client standing and slowly flexing her knees, greater pressure was directed to the extensor retinaculum, anterior valley, and gastrocnemius/soleus. A small structural ball was placed under each medial arch with knee flexion while the client was standing. With the client supine and dorsiflexing and plantar flexing her feet, greater pressure was directed to the flexor retinaculum, anterior and lateral compartments. Muscle rolling was employed to help release muscle group adhesions (Archer, 2007b). Session 8 also included horizontal-plane release just superior to and inferior to each knee (supine and prone), and traction release to each femur was employed in order to help release fascia of the ankle, knee, and hip joints (Archer, 2007c). Side-lying contract-relax stretches of the iliopsoas were conducted in sessions 2, 4, 5, 6, 7; direct iliopsoas massage was performed in session 3 (Archer, 2007d). Hip and knee ROM were checked in sessions 2, 4, and 7; ankle ROM was checked at sessions 2, 4, 7, and 8. At the start of each session, the client reported the distance she could walk before symptom onset during the intervening two weeks. Results were encouraged to be average distances, not an unusual maximum for that time period. The client was assigned no stretching homework in order to monitor results from myofascial techniques alone.

Results Improved functional outcomes At the beginning of the series, the client’s feet and lower legs felt significantly cooler in temperature than her thighs before massage; during and after massage sessions, her calves and feet felt noticeably warmer and often changed color from uniformly pale to showing patches of pink. By session 8, her legs and feet felt significantly closer to thigh and trunk temperature prior to massage. Similarly, fascial restrictions noted in session 1 that resisted skin movement in any direction were eased throughout the course of this study so that by session 8, the skin on the client’s lower leg moved well in all directions. During sessions 1 and 2, when the client lay prone, the tingling in her feet increased and became uncomfortable.

Improving mobility in a client with hypochondroplasia

175

Semi-side-lying alleviated this. On session 3, the client found she could lie prone comfortably, which lasted for all subsequent sessions. After each session, the client reported a greater feeling of ease of movement in her lower legs, a feeling that she retained until the next session. At session 4, she reported that climbing stairs had become easier, as she could now ascend stairs with one foot per step. Previously, she had to bring both feet to each step before continuing. During sessions 1e6, the client’s ROM in her ankles (dorsiflexion and plantar flexion) were limited to a moderate-plus extent and did not change as a result of broad-plane myofascial techniques. After the more focused, deeper structural/myofascial work conducted during session 7, ankle dorsiflexion and plantar flexion improved significantly to only a light limitation. Structural myofascial work done in session 8 raised the medial arches of her feet. Walking distances before stopping were reported at the beginning of each massage session and are reported in Figure 2. Blocks were converted to feet/meters after the client walked with the author and pointed out where she usually had to stop. Distances were measured with a 25foot carpenter’s measuring tape. At the study’s outset, the client could only walk half a block (171 ft/52 m) before having to stop. Swedish techniques performed at session 1 allowed the client to walk three-quarters of a block (257 ft/ 78 m) before having to stop. No distance improvements were noted in conjunction with the broad-plane myofascial techniques performed during sessions 2 through 4. Broadplane myofascial work done at session 5 resulted in an improvement to 1 block (343 ft/104 m) before stopping; the same work done at session 6 resulted in her ability to walk 1.5 blocks (514 ft/157 m) before stopping. Structural bodywork techniques in sessions 7 and 8 improved the client’s ability to walk 2 blocks (686 ft/209 m) before having to stop (A year after the initial work, the client continues able to walk 2 blocks before having to stop.). Unchanged functional outcomes The tingling reported by the client in her toes and feet did not change during the course of this study, nor was there any change in the lateral rotation of her feet.

Figure 3 An 8-inch standard bolster held the client’s lower legs in significant flexion.

As a gauge of iliopsoas tension, the client had little femur extension beyond the frontal/coronal plane. This did not change with side-lying iliopsoas contract-relax stretches, or with direct iliopsoas massage. All other ROM limitations in her hips and knees were unchanged. It is not known how much change in muscle tension was achieved in the anterior and lateral compartments of the lower leg during the course of this study due to incomplete attention by the student LMP.

Discussion Adhesions of the intramuscular and superficial fascia can bring about decreases in circulation, leading in extreme cases to compartment syndromes and muscle necrosis (Travell and Simons, 1993). It was hypothesized that the client’s muscle weakness may have been due in part to fascial tension in her lower legs that was constricting nerve or blood flow to her calves and feet. As her fascial restrictions were reduced, circulation improved as observed by skin color change and a feeling of warmth to the practitioner’s hand (Smith, 2005d). Concurrent with this, the client reported steady improvements in ease of movement, stair-climbing ability, and walking distance. It is reasonable to assume that these improvements were due to the easing of fascial restrictions, but this can only be inferred because massage practitioners have no methods to quantitatively measure fascial restrictions.

8 7 6

Numbered massage session

5 4 3 2 1

prior to study 0

100

200

300

400

500

600

700

Distance walked (feet) before resting

Figure 2 The average distance the client could walk before needing to rest prior to the study and in the two-week period after each numbered massage.

Figure 4 A 4-inch bolster (in this case, a rolled-up yoga mat) reduced flexion in the client’s lower legs.

176 It was hoped that ROM change would be seen at each session as an indication of fascial easing, but this client’s ROM remained unchanged until session 7, when significant gains in dorsiflexion and plantar flexion occurred as a result of structural bodywork techniques. It is possible that these techniques are inherently more effective than lighter work, though it is also possible that the client responded well because her fascial restrictions had been released enough so that stronger work could be effective. The unchanged ROM limitations of her hips and legs may not have had a fascial origin, as it was later discovered that her initial assessment had been in comparison to LMP expectations learned from average-height clients. It may be that her ‘‘limitations’’ were in fact entirely within the normal range of motion for bone configurations inherent to the legs and hips of clients with hypochondroplasia. Measuring progress via the large-scale measurement of walking distance was also problematic because although there was a gain after the first massage, there seemed to be no change for the following 3 massages, with improvements only being seen in the 2-week period following session 5. Future studies would be better served by having the client walk in place or walk on a treadmill until the point of muscle fatigue in order to more finely gauge progress. Having the client self-report her average walking distances also adds uncertainty to the data in that city blocks are not standard units, and can vary widely. A measure of confidence in the data was obtained by the fact that the client trevelled the same route every day between home and work, making it possible for stopping locations to be determined. There still remains the possibility that the client might have wanted to please the practitioner by reporting results greater than those actually obtained. The author would always ask about changes in mobility and symptoms, making the point of saying that ‘no change is totally fine, too.’ Since the client consistently reported no change in walking distance for many sessions, nor a reduction in foot or toe tingling throughout the course of the study, the author is more confident with this data. The client’s greater ease of climbing stairs was an unexpected bonus to the work, and may be another indication of fascial easing given the client’s initial reports of

Figure 5 A set of folding steps can be used for clients to get up onto a fixed-leg table. This version has steps 8 and 10 inches (20 and 25 cm) high, which is still a challenge. An electric or hydraulic table eliminates problems for both clients and LMPs.

A.A. Hanson feeling tightness down the back of her legs when climbing stairs. It improved her quality of life in that she sometimes had to climb a flight of stairs at work to reach certain books. In addition, her home has stairs to the basement and to the second floor, and she used a stepstool in the kitchen to reach the countertops. The tingling in the client’s toes remained an unresolved issue. It was hoped by the LMP that these symptoms could be reduced, but such was not the case, and it is considered that these may be a symptom of spinal stenosis or undiagnosed cardiovascular or neurologic issues.

Changes in our assumptions of normal As the study progressed, the author found it refreshing to work with a client who allowed a re-examination of various assumptions of normality. For example, it is entirely normal for clients with hypochondroplasia and achondroplasia to have bone configurations that produce lumbar hyperlordosis that no amount of bodywork could change. Lumbar nerve difficulties are common due to their commonly shortened lumbar pedicles, and work to relieve false sciatica, while helpful, would not relieve symptoms of true sciatica. The author found it an interesting challenge to conduct the iliopsoas tension/length test (Thomas’ test). Lack of tension in the iliopsoas is seen when the client’s knee rests below horizontal, but a shorter leg length results in smaller angles below horizontal and potentially a more difficult test interpretation. Interestingly, predicting muscle issues by watching a client walk is impossible for

Figure 6 Stairs can be a challenge for even the most mobile dwarf clients, and a barrier to those in a wheelchair.

Improving mobility in a client with hypochondroplasia

Figure 7 Dwarf clients do not span the massage table as fully as clients of average height.

clients with hypochondroplasia because normal posture and gait patterns have not been documented. Normal gait has been determined for achondroplasia, with data available as a master’s thesis (Knudsen, 1993); it has been broadly described elsewhere as a ‘characteristic waddling gait’ (Greenspan, 2000d). Altered gait is expected due to significant differences in bone structures, including lumbar hyperlordosis, mild genu varum short neck of the femur, and hip changes including a more horizontal tilt to the sacrum.

Practical (office) considerations No matter what the cause of a client’s short height, LMPs will find they need to make only minimal changes in office equipment and routine to maximize client comfort. When lying supine, this client’s lower legs were held in significant flexion by an 8-inch bolster or pillow; a 4-inch bolster (in this case, a rolled-up yoga mat) worked best (see Figures 3 and 4). A low chair aided client comfort during intake and tests for true neurological conditions. Since this client was quite mobile, a footstool leading to an average-height chair helped her climb onto the table; later a set of folding stairs was used (see Figure 5). Less-mobile clients may require an electric or hydraulic table. Stairs are usually a challenge and/or a barrier, so massage space must be wheelchair accessible (see Figure 6).

Figure 8 For significant amounts of foot and leg work, the client should be positioned at the distal end of the table to optimize LMP body mechanics.

177 Since short-height clients do not span the massage table as fully as do average-height clients, LMP body mechanics benefit by positioning them at the distal end of the table when sessions include a substantial amount of lower extremity work (see Figures 7 and 8). Finally, to paraphrase orthopedic surgeon and dwarfism specialist Dr. Stephen E. Kopits (1976b) the challenge to LMPs is not to see the unusual bone structures of dwarfism as a problem. The only problem e and this is the case with all clients e comes from their long-term use patterns of these bones and muscles. LMPs fortunate enough to work with this population will find that massage therapy offers the possibility of improving range of motion and ease of movement in a supportive, non-clinical, and body-neutral environment.

Acknowledgements The author is grateful to the client for her participation in this study, to Dr. John E. Hanson for his support and technical expertise, and to the teachers at Cortiva InstituteSeattle School of Massage Therapy for their insights, suggestions, encouragement, and education in medical massage therapy.

References Adelson, B.M., 2005a. Dwarfism: Medical and Psychosocial Aspects of Profound Short Stature. The Johns Hopkins University Press, Baltimore, p. 22e23. Adelson, B.M., 2005b. Dwarfism: Medical and Psychosocial Aspects of Profound Short Stature. The Johns Hopkins University Press, Baltimore, p. 17e20 & 287e297. Archer, P., 2007a. Therapeutic Massage in Athletics. Lippincott Williams & Wilkins, Philadelphia, p. 232e234. Archer, P., 2007b. Therapeutic Massage in Athletics. Lippincott Williams & Wilkins, Philadelphia, p. 164e174. Archer, P., 2007c. Therapeutic Massage in Athletics. Lippincott Williams & Wilkins, Philadelphia, p. 171e172. Archer, P., 2007d. Therapeutic Massage in Athletics. Lippincott Williams & Wilkins, Philadelphia, p. 134. Beighton, P., 1993. McKusick’s Heritable Disorders of Connective Tissue. Mosby-Year Book Inc, St. Louis, p. 578. Bogumill, G.P., Schwamm, H.A., 1984. Orthopaedic Pathology: A Synopsis With Clinical and Radiographic Correlation. WB Saunders Co, Philadelphia, p. 43e49. Francomano, C.A., 2005a. Hypochondroplasia. GeneReviews Available from: http://www.ncbi.nlm.nih.gov/bookshelf/br. fcgi?bookZgene&partZhypochondroplasia, p. 4 [Internet] [cited 2008 August 4]. Francomano, C.A., 2005b. Hypochondroplasia. GeneReviews Available from: http://www.ncbi.nlm.nih.gov/bookshelf/br. fcgi?bookZgene&partZhypochondroplasia, p. 1 [Internet] [cited 2008 August 4]. Francomano, C.A., 2005c. Hypochondroplasia. GeneReviews Available from: http://www.ncbi.nlm.nih.gov/bookshelf/br. fcgi?bookZgene&partZhypochondroplasia, pp. 6e7 [Internet]. [cited 2008 August 4]. Francomano, C.A., 2005d. Hypochondroplasia. GeneReviews Available from: http://www.ncbi.nlm.nih.gov/bookshelf/br. fcgi?bookZgene&partZhypochondroplasia, pp. 6e7 [Internet] [cited 2008 August 4]. Francomano, C.A., 2005e. Hypochondroplasia. GeneReviews Available from: http://www.ncbi.nlm.nih.gov/bookshelf/br.

178 fcgi?bookZgene&partZhypochondroplasia, pp. 2e3 [Internet] [cited 2008 August 4]. Greenfield, G.B., 1990a. Radiology of Bone Diseases. JB Lippincott Co, Philadelphia, p. 276. Greenfield, G.B., 1990b. Radiology of Bone Diseases. JB Lippincott Co, Philadelphia, p. 272e276. Greenspan, A., 2000a. Orthopedic Radiology: A Practical Approach. Lippincott Williams & Wilkins, Philadelphia, p. 910. Greenspan, A., 2000b. Orthopedic Radiology: A Practical Approach. Lippincott Williams & Wilkins, Philadelphia, p. 908e909. Greenspan, A., 2000c. Orthopedic Radiology: A Practical Approach. Lippincott Williams & Wilkins, Philadelphia, p. 909e910. Greenspan, A., 2000d. Orthopedic Radiology: A Practical Approach. Lippincott Williams & Wilkins, Philadelphia, p. 908. Hall, B., 2005. Bones and Cartilage: Developmental and Evolutionary Skeletal Biology. Elsevier Academic Press, Amsterdam, p. 437. Knudsen, M., 1993. Range of motion and flexibility of adults with achondroplasia [master’s thesis]. Denton (TX), Texas Woman’s University.

A.A. Hanson Kopits, S.E., 1976a. Orthopedic complications of dwarfism. Clinical Orthopaedics and Related Research 114, 158. Kopits, S.E., 1976b. Orthopedic complications of dwarfism. Clinical Orthopaedics and Related Research 114, 154. Mayo Clinic, 2008. Spinal Stenosis. MayoClinic.com Available from: http://www.mayoclinic.com/health/spinal-stenosis/DS00515 (accessed 11.03.08.). p. 1e2. [cited 2008 August 8]. Smith, J., 2005a. Structural Bodywork. Elsevier, London, p. 58e62. Smith, J., 2005b. Structural Bodywork. Elsevier, London, p. 73e74, 84e89. Smith, J., 2005c. Structural Bodywork. Elsevier, London, p. 135e141. Smith, J., 2005d. Structural Bodywork. Elsevier, London, p. 136. Spranger, J.W., Brill, P.W., Poznanski, A., 2002. Bone Dysplasias: An Atlas of Genetic Disorders of Skeletal Development. Oxford University Press, Oxford, p. 90. Travell, J.G., Simons, D.G., 1993. Myofascial Pain and Dysfunction, The Trigger Point Manual, The Lower Extremities. Lippincott Williams & Wilkins, Philadelphia, p. 361e362, 443e444.

Journal of Bodywork & Movement Therapies (2010) 14, 179e184

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

COMPARATIVE STUDY

Osteopathic manual therapy versus conventional conservative therapy in the treatment of temporomandibular disorders: A randomized controlled trial A.M. Cuccia a,b,*, C. Caradonna a,b, V. Annunziata b, D. Caradonna a,b a b

Department of Dental Sciences ‘‘G. Messina’’, University of Palermo, Via del Vespro 129, 90128 Palermo, Italy School of Specialization in Orthodontics, University of Palermo, Via del Vespro 129, 90128 Palermo, Italy

Received 10 April 2009; received in revised form 1 August 2009; accepted 12 August 2009

KEYWORDS OMT; Physical therapy; Stomatognathic system; Occlusal splint; Masticatory muscle

Summary Objective: Temporomandibular disorders (TMD) is a term reflecting chronic, painful, craniofacial conditions usually of unclear etiology with impaired jaw function. The effect of osteopathic manual therapy (OMT) in patients with TMD is largely unknown, and its use in such patients is controversial. Nevertheless, empiric evidence suggests that OMT might be effective in alleviating symptoms. A randomized controlled clinical trial of efficacy was performed to test this hypothesis. Methods: We performed a randomized, controlled trial that involved adult patients who had TMD. Patients were randomly divided into two groups: an OMT group (25 patients, 12 males and 13 females, age 40.6  11.03) and a conventional conservative therapy (CCT) group (25 patients, 10 males and 15 females, age 38.4  15.33). At the first visit (T0), at the end of treatment (after six months, T1) and two months after the end of treatment (T2), all patients were subjected to clinical evaluation. Assessments were performed by subjective pain intensity (visual analogue pain scale, VAS), clinical evaluation (Temporomandibular index) and measurements of the range of maximal mouth opening and lateral movement of the head around its axis. Results: Patients in both groups improved during the six months. The OMT group required significantly less medication (non-steroidal medication and muscle relaxants) (P < 0.001).

* Corresponding author at: Department of Oral Sciences, University of Palermo, Via del Vespro 129, 90128 Palermo, Italy. Tel.: þ39 091 6552296/6811287; fax: þ39 091 214637. E-mail address: [email protected] (A.M. Cuccia). 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.08.002

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A.M. Cuccia et al. Conclusions: The two therapeutic modalities had similar clinical results in patients with TMD, even if the use of medication was greater in CCT group. Our findings suggest that OMT is a valid option for the treatment of TMD. ª 2009 Elsevier Ltd. All rights reserved.

Introduction Temporomandibular disorders (TMD) are a collective term that includes disorders of the temporomandibular joint (TMJ), of the masticatory muscles and their associated structures in the absence of other visceral pathology (for example ear disorder, pharyngeal tumour, or dental abscess). It is characterized by pain, joint sounds, and restricted mandibular movement (De Bont et al., 1997). The pathogenesis of the TMD, however, is unclear. Physical (trauma, muscles spasms, chronic malocclusion, bruxism causing grinding or clenching of teeth), biochemical (vitamin inadequacy), and physiological factors (anxiety, stress and depression) may all play a role (Levy and Gorlin, 1953; Haskin et al., 1995). Upledger (1987) stated that TMD may originate from sacral dysfunction (Upledger, 1987). Several types of treatment have been proposed in the literature by dentists, orthodontists, psychologists, physical therapists, and physicians, although with highly disparate results among the published studies (Cascos-Romero et al., 2009). non-invasive therapies should be attempted before pursuing invasive, semipermanent or permanent treatments (such as orthodontics or surgery) that have the potential to cause irreparable harm. Non-invasive therapies may include pharmacological treatment (non-steroidal anti-inflammatory drugs, muscle relaxants, antidepressants and corticosteroids), oral appliances, home care procedures, cognitive-behavioral information program, acupuncture, and dry needling, chiropractic, physical therapy, osteopathy, relaxation and meditation (Carlson et al., 2001; DeBar et al., 2003; Alcantara et al., 2002; Buescher ,2007). Physical therapy is intended to relieve musculoskeletal pain, reduce inflammation, and restore oral motor function. The American Academy of Craniomandibular Disorders and the Minnesota Dental Association have cited physical therapy (electrophysical modalities, therapeutic exercises, manual therapy techniques) as an important treatment to relieve musculoskeletal pain, reduce inflammation and restore oral motor function (Sturdivant and Fricton, 1991). Numerous physical therapy interventions are potentially effective in managing TMD. These therapies include: electrophysical modalities (shortwave diathermy, ultrasound, biofeedback, microwave, laser therapy and transcutaneous electrical nerve stimulation), acupuncture, therapeutic exercises for the masticatory or cervical muscles and manual therapy techniques. These interventions are commonly used to reduce pain and to improve mandibular range of motion (McNeely et al., 2006). Osteopathic treatment is a physical therapy intervention, characterized by fine manipulative techniques, less invasive than other interventions, individually adapted to

tissue quality, in order to maintain or restore the circulation of body fluids (Magoun, 1976). Osteopathic treatment is utilized by many practitioners of neuromusculoskeletal medicine and osteopathic manipulative medicine in many countries, including the United States of America, Australia, South Africa and the United Kingdom. The evidence regarding treatments is from clinical reports, patient outcomes and is largely anecdotal. Only a few studies evaluated the effect of osteopathic treatment in TMD (Larsen, 1976; Royder, 1981). Monaco et al., (2008) suggested that OMT can induce changes in the stomatognathic dynamics, offering a valid support in the clinical approach to TMD. The purpose of the current case-control study was to study the effects of OMT in adult subjects with TMD.

Methods The subjects in this study were recruited from among the patients with TMD who attended the Department of Orthodontics and Gnathology, University of Palermo, Italy, during a six-month period from September 2008 to February 2009. A total of 50 consecutive patients, aged 18e50 years, diagnosed with TMD were selected for the study. The subjects were randomly assigned to the OMT group (25 patients, 12 males and 13 females, age 40.6  11.03) and a conventional conservative treatments (CCT group, 25 patients, 10 males and 15 females, age 38.4  15.33). A standardized TMD examination was executed in all patients: joint pain, crepitation, uncoordinated movements of the head of the mandibular condyles during opening or closing the mouth were investigated by lateral and posterior palpation of each TMJ with both index fingers. Subjects were included if they had a temporomandibular index (TMI) reference value of 0.08  0.10, and a minimum pain intensity of 40 mm on a visual analogue scale (VAS). The TMI is a clinical measure used to determine the severity of the disorder. It is composed of a total index (TMI) with three sub-indices: function index (FI), muscle index (MI) and joint index (JI). The FI includes 12 items related to the range of motion of the mandible. The MI measures pain associated with bilateral digital palpation of selected masticatory muscles at a total 20 sites. The JI measures pain evoked by digital palpation of 2 sites for each TMJ and the incidence of noise in each TMJ. The FI, MI and JI are calculated by dividing the sum of positive findings for each subindex by the total number of items examined (respectively 12 for FI, 20 for MI and 8 for JI). The scores of all indices ranged from 0 to 1, with 1 being the highest score possible. The overall TMI score is the average of the scores for the FI, MI, and JI. (Pehling et al., 2002). The intensity of jaw pain was recorded on the visual Analogue (VAS) pain scale of 1e10 with 1 indicating mild pain, 5 moderate pain and 10 unbearable pain (Huskisson, 1974).

Osteopathic manual therapy versus conventional conservative therapy In addition, assessment of the range of maximal mouth opening (MOV) and lateral movement of the head around its axis were examined (ROM). Maximal mouth opening was measured using calibrated caliper with a 1 mm accuracy, as the maximal inter-incisal distance added to the vertical overlap of the incisors. Patients were asked to open their mouth as wide as possible to the point of pain, and were measured with their heads supported in a neutral position (Figure 1). The Cervical Range of Motion instrument (Performance Attainment Associates, 958 Lydia Drive, Roseville, MN 55113) was used in order to measure the rotation of the cervical spine on the transverse plane. This instrument consists of an eyeglass-shaped plastic frame with inclinometers. For the rotation measures (degrees), the inclinometer is magnetic and moves along the transversal plane (Neiva and Kirkwood, 2007). The exclusion criteria were: history of adverse effects with osteopathic treatment, being under orthodontic treatment or under treatment for TMD, previous treatment for TMD, making regular use of analgesic or anti-inflammatory drugs, use of dental prosthesis, presence of any other oro-facial pain condition, neurological or psychiatric disorders and systemic inflammatory disorder. The OMT group received osteopathic manipulation by a doctor of osteopathy (VA). Treatments lasted 15e25 min, and were gentle techniques such as myofascial release, balanced membranous tension, muscle energy, myofascial release, joint articulation, high-velocity, low-amplitude thrust and cranial-sacral therapy (Greenman, 2003; Magoun, 1976; Ge ´hin, 2007; Winkel et al., 1997). Treatment was directed to the cervical and TMJ regions. In particular, the specific manipulative procedures performed by the osteopath were designed both to reduce the dysfunction (pain and restriction) of the ligaments of the TMJ (stylo-mandibular and spheno-mandibular ligaments, lateral collateral ligament) and to retrain the involuntary neuromuscular, reflexive control of posture and balance.

Figure 1 Clinical measurement of maximal active mouth opening using calibrated caliper.

181

The CCT was provided by a gnathology specialist. Gnathology is the study of the masticatory system, including its physiology, functional disturbances and treatment. The treatment included use of an oral appliance, physical therapy (gentle muscle stretching and relaxing exercises), therapies such as hot or cold packs (or both), transcutaneous electrical nerve stimulation. Both groups could take a non-steroidal medication (antiinflammatory medication and analgesics) and/or muscle relaxants, when prescribed by their medical practitioner. The therapeutic protocol specified treatments at intervals of two weeks in both groups. At 24 (T1) and 32 (T2) weeks, the patients were assessed by an evaluator who was blinded to the treatment assignments. The Ethics Committee of the University Palermo approved the protocol. Written informed consent was obtained from each subject after a full explanation of the experiment.

Statistical method Chi-square tests were used to compare the age and sex of OMT and CCT groups. Scores of TMI, FI, MI JI, and VAS, age and range of MOV and ROM (mm) were presented as the means  standard deviation (sd). The t of Student was applied to compare the data between OMT patients and control group. The two-way mixed analysis of variance (ANOVA) with the Tukey Post test was performed in order to verify whether the differences in the measurements of VAS, MOV, ROM and TMI at T0, T1, and T2 between OMT and CCT groups were statistically significant. Data were analyzed using Primer of Biostatistics for Windows (version 4.02, McGraw-Hill Companies, New York) (Glantz, 2002). Significance for all statistical tests was set at P < 0.05.

Results The findings indicated that the OMT and CCT groups did not demonstrate any significant difference. The use of medication was greater in the CCT group than in the OMT group, with significant differences for non-steroidal anti-inflammatory drugs (X2 Z 4.083, P < 0.001) and muscle relaxants (X2 Z 4.878, P < 0.001). Non-steroidal medication was prescribed to 14 patients of the CCT group vs 6 patients of the OMT group. In addition, a muscle relaxant was prescribed in 8 patients in the CCT group and to 1 patient in the OMT group (Table 1). There were no differences in the mean pre-test values of VAS, MOV and ROM between OMT and CCT groups. When the two groups were compared at T1 and T2, the best results were obtained in the OMT group: only the VAS value at T2 was not statistically significantly different between two groups (3.80  1.26 vs 4.40  1.75, P > 0.05) (Table 2). Improvement in values of VAS, MOV and ROM in both groups was observed at T1 and at T2 than at T0. A statistically significant difference was observed in the OMT group between T1 values and T2 values for the VAS (1.5  0.85 vs 3.8  1.26, F Z 184.44, P < 0.000) and MOV (46  4.78 vs 42.9  2.69, F Z 48.19, P < 0.000), and in CCT group for the VAS (2.6  0.7 vs 4.4  1.75, F Z 48.66,

182

A.M. Cuccia et al.

Table 1 The ratio and number of distribution for sex, age and patients who took medication. Age y

OMT

Mean  SD Range

40.6  11.03 38.4  15.33 30e63 29e62

Age group (years), n (%) Women < 45 15 (60) Men  45 10 (40)

CCT

t

P NS NS

X2 16 (64) 9 (36)

P NS NS

X2

Sex Women Men

17 (68) 8 (32)

Medications n (%) Non-steroidal 6 (24) medication Muscle relaxants 1(4) Total number of 7 (28) medications used

P

15 (60) 10 (40)

NS NS

14 (56)

X2 P 4.083 0.001

8(28) 22 (88)

4.878 0.001 13.718 0.000

P < 0.000). These higher values at T2 indicate moderate worsening of symptoms and signs after 2 months (Table 3). Improvement in values of FI (F Z 3.72, P < 0.005) and MI (F Z 4.43, P < 0.015) was observed at T1 compared to T0 in OMT group (Table 4).

Discussion Osteopathic treatment is a form of manual medicine first applied by Still (1902). His principles and philosophy are based on an appreciation of human beings’ triune unity (body, mind, and spirit), the interrelationship between structure and function, and the body’s ability to heal itself (Ward et al., 2003). Still hypothesized that manipulative treatment stimulated the production of endogenous compounds that promoted homeostasis and healing. A study by Licciardone et al. (2005) indicated that OMT significantly reduces low back pain. The level of pain reduction was greater than expected from placebo effects alone and persisted for at least three months. OMT has been utilized not only in musculoskeletal disorders (e.g. low back pain, Table 2

fibromyalgia), but also in several pathologies such as recurrent acute otitis media, cerebral palsy, learning disorders, neurologic deficits, asthma, pneumonia, bronchiolitis, gastrointestinal disorders and headaches (Andersson et al., 1999; Mill et al., 2003; Duncan et al., 2004; Frymann, 1966, 1976; Degenhardt and Kuchera, 2006). It is likely that the benefits of osteopathic interventions in these conditions could extend to other pain conditions such as TMD. Results of this study suggest that reduction in pain and improved range of motion were reported after six months, suggesting that OMT and CCT provide relief for TMD related conditions. However, in the OMT group it was observed that the best values were for VAS, MOV and ROM at T1 and T2, and the reduction of FI and MI and the use of medications. Even if at T2 there was a mild worsening of MOV, ROM and VAS than at T1, MOV and ROM values remained within the normal range of motion, and the reduction of VAS was noteworthy in that, and however there was an improvement at T2 when compared to T0. Numerous mechanisms have been considered as sources of muscle and articular pain: local factors (microtrauma, local ischemia or hypoperfusion) can produce structural or functional consequences due to release of endogenous algesic substances (glutamate, histamine and others) from tissue cells and afferent nerve fibres leading to excitation or sensitization of nociceptors; central processes involving neuroendocrine factors (endogenous and exogenous hormones) as well as neurophysiological mechanisms (peripheral and central sensitization) also play a role in the pathophysiology of muscular pain (Sessle, 1999; Svensson and Graven-Nielsen, 2001). Researchers suggest that massage and manipulation trigger a release of neuropeptides in patients and have studied the relationship between OMT and the endocannabinoid system (Christian et al., 1988). The endocannabinoid system, like the better-known endorphin system, consists of receptors in the brain, nervous system and elsewhere (cannabinoid receptors) and their endogenous ligands (endocannabinoids). McPartland et al. (2005) inferred that the endocannabinoid system may be elicited by OMT, with sedative, anxiolytic, analgesic and hemodynamic effects (McPartland et al., 2005). There is also low evidence from a single case study that massage therapy and strain-counterstrain technique

Comparison of the VAS, MOV and ROM values between OMT and CCT groups (n Z 25) at T0, T1 and T2. OMT

T0

T1

T2

a b c

VASa MOVb ROMc VASa MOVb ROMc VASa MOVb ROMc

6.9 35.1 62.4 1.5 46.0 81.9 3.8 42.9 80.5

CCT 0.88 4.36 10.67 0.85 4.78 10.31 1.26 2.69 5.44

The visual analogue pain scale was scored from 0 to 10. Measure in millimeters. Measure in degrees.

6.40 34.9 64.5 2.6 41.3 71.9 4.4 40.4 72.4

t 1.42 34.5 9.55 0.7 4.52 9.05 1.75 2.41 2.95

P NS NS NS

4.995 3.572 3.654

0.000 0.000 0.000 NS

3.461 6.545

0.001 0.000

Osteopathic manual therapy versus conventional conservative therapy

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Table 3

Average values and SD of the VAS, MOV and ROM values, ANOVA for repeated measures and Tukey Post test results.

Group

TO

OMT VASa MOVb ROMc CCT VASa MOVb ROMc

T1

T2

F

P

Tukey Post test

Mean

SD

Mean

SD

Mean

SD

6.9 35.1 62.4

0.88 4.36 10.67

1.5 46.0 81.9

0.85 4.78 10.31

3.8 42.9 80.5

1.26 2.69 5.44

184.88 48.19 35.53

0.000 0.000 0.000

TO vs T1, TO vs T2, T1 vs T2 TO vs T1, TO vs T2, T1 vs T2 TO vs T1, TO vs T2,

6.40 34.9 64.5

1.42 34.5 9.55

2.6 41.3 71.9

0.7 4.52 9.05

4.4 40.4 72.4

1.75 2.41 2.95

48.66 23.6 8.07

0.000 0.000 0.000

TO vs T1, TO vs T2, T1 vs T2 TO vs T1, TO vs T2 TO vs T1, TO vs T2

a

The visual analogue pain scale was scored from 0 to 10. Measure in millimeters. c Measure in degrees. The mean values of VAS, MOV and ROM at T0, T1, and T2 in the OMT and CCT. For each parameter the Post test results are reported. If P < 0.05, difference between treatment at T0, T1 and T2 is statistically significant. b

tone or diminished neuromuscular coordination may have been associated with improvement of TMD in this study (Schleip et al., 2005). The favourable cost benefit ratio of physiotherapy over other treatment modalities seems to indicate that physiotherapy, in general, can be regarded as a first choice approach in selected TMD patients. OMT, in particular, had a positive effect on physical symptoms of TMD, and it is recommendable as an effective treatment in patients suffering from TMD. Further studies need to be conducted to evaluate whether the findings are reproducible, and if positive longterm outcomes can be achieved. If the findings of this study are reinforced by future research, OMT would prove to be a non-invasive solution for managing TMD, either alone or together with other therapies and/or medication as part of an overall treatment plan. In this regard, it would be desirable that in the management of disorders involving the TMJ and related musculoskeletal structures, dentist should work in close collaboration with osteopaths and physical therapists.

(positional release), stimulated parasympathetic activity, and reduced neuromuscular activity. These activities would engage the relaxation response and, in turn, reduce stress and anxiety associated with TMD (Eisensmith, 2007). In the current study, the positive therapy effect on TMD may be explained by neural plasticity which could have been induced by these therapeutic interventions. Plasticity is a property of a self-organizing central nervous system (changes in network, synaptic or cell intrinsic properties) that is continually optimizing its own performance. Therapies targeting the masticatory system (occlusal splints, physiotherapy, osteopathic manipulation and others) may have significant neurologic implication via sensorimotor integration with the brainstem, subcortical and cortical centers, cervical region, proprioception and body posture. If therapeutic approaches induce appropriate neural plasticity, then it is possible that considerable neurologic improvement of the patient may be achieved (Yin et al., 2007). It is also possible that manual therapies may influence myofascial tone. Thus, increased or decreased myofascial

Table 4 Average values and SD of the temporomandibular index and the associated subindex in OMT group and the CCT group, ANOVA for repeated measures and Tukey Post test results. Group

OMT Function index Muscle index Joint index Temporomandibular index CCT Function index Muscle index Joint index Temporomandibular index

TO

T1

Mean

SD

0.45 0.64 0.46 0.52

(0.12) (0.23) (0.28) (0.21)

0.34 0.44 0.38 0.39

0.47 0.62 0.47 0.52

(0.23) (0.41) (0.36) (0.33)

0.35 0.45 0.41 0.40

T2

Mean

SD

(0.12) (0.27) (0.24) (0.21)

0.39 0.51 0.43 0.44

(0.15) (0.22) (0.17) (0.18)

0.45 0.64 0.46 0.52

(0.14) (0.19) (0.37) (0.23)

0.40 0.52 0.44 0.45

(0.17) (0.18) (0.09) (0.15)

0.47 0.62 0.47 0.52

F

P

Tukey’s test P < 0.05

Mean

SD

(0.12) (0.23) (0.28) (0.21)

0.34 0.44 0.38 0.39

(0.12) (0.27) (0.24) (0.21)

0.39 0.51 0.43 0.44

(0.15) 3.72 0.005 TO vs T1 (0.22) 4.43 0.015 T0 vs T1 (0.17) NS (0.18) NS

(0.23) (0.41) (0.36) (0.33)

0.35 0.45 0.41 0.40

(0.14) (0.19) (0.37) (0.23)

0.40 0.52 0.44 0.45

(0.17) (0.18) (0.09) (0.15)

NS NS NS NS

The mean values of FI, MI, JI and TMI at T0, T1, and T2 in the OMT and CCT. For each parameter the Post test results are reported. If P < 0.05, difference between treatment at T0, T1 and T2 is statistically significant.

184

Acknowledgements The authors would like to thank Patrizia Rovere Querini, M.D., Ph.D. San Raffaele Scientific Institute, for her contribution to the design and development of this study.

Supplementary data The supplementary data associated with this article can be found in the on-line version, at doi:10.1016/j.jbmt.2009. 08.02

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A.M. Cuccia et al. Glantz, S.A., 2002. Primer of Biostatistics, fifth ed. McGraw-Hill Companies, New York. Greenman, P.E., 2003. Principles of Manual Medicine, third ed. Lippincott Williams & Wilkins, Philadelphia. Haskin, C.L., Milam, S.B., Cameron, I.L., 1995. Pathogenesis of degenerative joint disease in the human temporomandibular joint. Crit. Rev. Oral. Biol. Med. 6, 248e277. Huskisson, E.C., 1974. Measurement of pain. Lancet 2, 1127e1131. Larsen, N.J., 1976. Osteopathic manipulative contribution to treatment of TMJ syndrome. Int. J. Osteopath. Med. 3, 15e27. Levy, B.M., Gorlin, R.J., 1953. The temporomandibular joint in vitamin C deficiency. J. Dent. Res. 32, 622e625. Licciardone, J.C., Brimhall, A.K., King, L.N., 2005. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet. Disord. 6, 43. Magoun, H.I., 1976. Osteopathy in the Cranial Field, third ed. Northwest Printing Inc, Boise. McNeely, M.L., Armijo Olivo, S., Magee, D.J., 2006. Therapy interventions for temporomandibular disorders. Phys. Ther. 86, 710e725. McPartland, J.M., Giuffrida, A., King, J., Skinner, E., Scotter, J., Musty, R.E., 2005. Cannabimimetic effects of osteopathic manipulative treatment. J. Am. Osteopath. Assoc. 105, 283e291. Mill, M.V., Henley, C.E., Barnes, L.L.B., Carreiro, J.E., Degenhardt, B.F., 2003. The use of osteopathic manipulative treatment as adjuvant therapy in children with recurrent acute otitis media. Arch. Pediatr. Adolesc. Med. 157, 861e866. Monaco, A., Cozzolino, V., Cattaneo, R., Cutilli, T., Spadaro, 2008. Osteopathic manipulative treatment (OMT) effects on mandibular kinetics: kinesiographic study. Eur. J. Paediatr. Dent. 9, 37e42. Neiva, P.D., Kirkwood, R.N., 2007. Measurement of neck range of motion among mouth-breathing children. Rev. Bras. Fisioter. 11, 355e360. Pehling, J., Schiffman, E., Look, J., Shaefer, J., Lenton, P., Fricton, J., 2002. Interexaminer reliability and clinical validity of the temporomandibular index: a new outcome measure for temporomandibular disorders. J. Orofac. Pain 16, 296e304. Royder, J.O., 1981. Structural influences in temporomandibular joint pain and dysfunction. J. Am. Osteopath. Assoc. 80, 460e467. Schleip, R., Klingler, W., Lehmann-Horn, F., 2005. Active fascial contractility: fascia may be able to contract in a smooth muscle-like manner and thereby influence musculoskeletal dynamics. Med. Hypotheses 65, 273e277. Sessle, B.J., 1999. The neural basis of temporomandibular joint and masticatory muscle pain. J. Orofac. Pain 13, 238e245. Still, A.T., 1902. The Philosophy and Mechanical Principles of Osteopathy. Hudson-Kimberly Publication Co., Kansas City, MO. Sturdivant, J., Fricton, J.R., 1991. Physical therapy for temporomandibular disorders and orofacial pain. Curr. Opin. Dent. 32, 485e496. Svensson, P., Graven-Nielsen, T., 2001. Craniofacial muscle pain: review of mechanisms and clinical manifestations. J. Orofac. Pain 15, 117e145. Upledger, J.E., 1987. Craniosacral Therapy II: Beyond the Dura. Eastman Press, Seattle. Ward, R.C., et al. (Eds.), 2003. Foundations for Osteopathic Medicine, second ed. Lippincott Williams & Wilkins, Philadelphia. Winkel, D., Matthijs, O., Phelps, V., 1997. Diagnosis and Treatment of the Spine. Aspen Publishers, Gaithersburg. Yin, C.S., Lee, Y.J., Lee, Y.J., 2007. Neurological influences of the temporomandibular joint. J. Bodyw. Mov. Ther. 11, 285e294.

Journal of Bodywork & Movement Therapies (2010) 14, 185e194

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PREVENTION & REHABILITATION: EDITORIAL

Shifting paradigms

Received 6 January 2010; accepted 6 January 2010 Often a fad may be described, perhaps falsely, as a paradigm shift. In the rehabilitation and prevention section of the previous issue of JBMT, Lederman (2010) challenged what many would consider a paradigm shift that has occurred over the last decade or more as a result of the focus by many bodywork and movement therapists on ‘‘core stability’’. What Lederman’s (2010) article highlighted was the fact that, bodyworkers and movement educators have a number of tools in their tool-kit, and an important skill involves the ability to grow with the knowledge base, and not to succumb to trends as ‘‘panaceas’’; nor to become too dogmatic regarding beliefs. This is easier said than done, of course. Nevertheless, if such advances can be seen as emergent tools, which may, at some point, become usurped by other more current techniques, this may be judged an appropriate evolution. Equally, it is important to not become dogmatic in the way the tools used by others are judged; too narrow a focus usually results in collisions with unforeseen peripheral concepts and rationale. One rationale Lederman has previously used was to ask how the human body should function by looking for an evolutionary advantage (Lederman, 2000). Clearly, there is rarely a time when a primal human being would be found doing a prone transversus abdominis activation exercise with a biofeedback cuff! Nevertheless, there may be rationale to explain how human physiology could embrace ‘‘core stability’’ and other methods, as part of a primal environment (see Textbox 1). In a recent discussion with a sports medicine physician, a ‘‘tool’’ that the author of this editorial has been involved with for just over 2 years, was explained; a footwear

E-mail address: [email protected]

product called Vibram Fivefingers. This product is one of many on the market that claims to offer a functional benefit to users; fitting it into the emerging category of ‘‘functional footwear’’ alongside brands such as Masai Barefoot Technology (MBT), FitFlop, Nike Free’s, Vivo Barefoot and Newton running shoes, among others. The sports medicine physician commented that since there was little research to back use of the Vibram Fivefingers; and that what research there was seemed to suggest a dramatic change of the gait pattern, and the way the user runs (Squadrone and Gallozzi, 2009), they could be dangerous and might well cause as many injuries as might be prevented. This may, of course, be true. However, the fact that this new data correlated closely with barefoot data, but was distinct from shod data, meant that it could be interpreted either as a dramatic change to what the (shod) individual is used to; or a dramatic reversion to what the individual is designed for.

Evolving ideas Study of the foot offers an opportunity to consider factors such as the possible benefits of barefoot walking. Data searches suggest that there is an abundance of evidence in support of this. (Warburton, 2001; Wallden, 2008; Squadrone and Gallozzi, 2009). In recent years Masai Barefoot Technology shoes have gained ground in the market place as a new concept. At the same time Nike, the largest producer of sports shoes (originators of the concept of a ‘‘running shoe’’), recognized that in order to enhance running performance, and decrease running injuries, their top advisors were recommending that athletes should frequently train barefoot (McDougall, 2009). Objectively barefoot walking appears sensible, especially when it is appreciated that supporting a structure (in

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PREVENTION & REHABILITATIONeEDITOR: MATT WALLDEN

Matt Wallden, MSc Ost Med, DO, ND, Associate Editor

PREVENTION & REHABILITATIONeEDITOR: MATT WALLDEN

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M. Wallden

Textbox 1: The Survival Reflex (taken from Wallden (2008) Rehabilitation and re-education (movement) approaches in Chaitow (Ed) Naturopathic Physical Medicine. Elsevier) Chek (2000, 2004) has described what he terms a survival reflex where the body will reflexively recruit all muscles it can, to avoid an actual, or a perceived, catastrophic event. Certainly these observations seem to have good founding both in the clinical environment, and in the neurophysiological literature. For example, Davidoff (1992) explains that the capacity of the segmental myotatic reflex system to compensate for changing loads is only modest. What the Swiss ball does not tend to do is to place the body under significant load (as would occur in some sports or in weight-lifting). Davidoff goes on to say that reflexive adjustments at the segmental level may be effective at compensating for perturbation when the errors of position are small and the stretch is rapid. This is exactly what we tend to find with Swiss ball use; a small rapid need to correct the posture. Nitz and Peck (1986) also observe that a characteristic of the deeper, inner unit musculature is that they have an increased concentration of spindle cells making them particularly important for (and reactive to) stability challenges. As Panjabi et al. (1989) discuss, the typically shorter length of the inner unit muscles, and their lower threshold to stimulus, allow them to react more quickly; hence their response to anything that induces a stability challenge, such as a Swiss ball, wobble boards, or balance shoes. Additionally, Janda (1999) comments that a classic way of combating low back pain utilized by the aboriginal Indians of North America was to run in dried out river-beds. Anyone who has tried to run on the soft sand of a beach will recognize that this probably posed something of a perturbation and/or balance challenge to help reactivate their inner unit. In contrast, Hides et al. (1996) showed that even 1 year after resolution of low back pain, the lumbar multifidus had not recovered its normal function. They proposed that this may be a mechanism for the onset of chronic back pain. What Hides and co-worker’s research implies is that if someone has a pain problem, they cannot properly recover from it unless they see a trained therapist to teach them to consciously activate multifidus/transversus abdominis and other inner unit muscles. However, this may be a somewhat simplified view. Indeed the implication would be that prior to Hides’ research in 1996 e which would include the whole of human evolution e a single bout of low back pain or a back injury would result in compromised inner unit function and therefore presumably, compromised ability to move, to hunt or to evade predators. In short, the prognosis after even one bout of back pain wouldn’t be too good. In their paper, Hides et al. do not state how many of their experimental subjects were actively engaged in sports, how many were entirely sedentary e or any shade in between. In an unpublished meta-analysis of the available high-quality literature available on core rehabilitation in 1998, the author concluded that, since there are so many potential methodological flaws with most exercise prescriptions at that time, it would seem that the best way to effectively rehabilitate function of the core musculature, would be to play sports that involved multiple movement patterns. Since then, knowledge has moved on, and effective core activation can be progressed from floor based to Swiss ball based, to standing functional exercises. But to play interactive sports is still a very reasonable piece of advice for core conditioning e assuming that the patient is able to activate their deep stability system when they play their sport. The primal pattern system of assessment described above can be utilized to see if, when and in which movement patterns (motor chunks) the patient is able to activate their core. This conclusion seemed to coincide somewhat with the concept of the ‘‘survival reflex’’ and with the nature of existence in the great outdoors. There is little doubt that in running as fast as the body can manage would allow the climbing of the nearest tree e even perhaps then swinging through the vines to escape a big cat, would be enough to activate both Chek’s ‘‘survival reflex’’ and the perturbations described by Davidoff e and show some parallels to Janda’s river-bed running.

the same way one might support a broken arm in a cast) would ultimately result in weakening of the supporting musculature. To keep the feet strong, and the athlete injury-free, Nike were being encouraged by their advisors to consider a ‘‘barefoot’’ alternative, ultimately resulting in the birth of the ‘‘Nike Free’’.

The evolutionary experiment The foot evolved around 270 million years ago (Haines, 1999). In contrast, shoes have been around for a few thousand years at most, making their congruence with optimal biomechanical function of the foot more questionable. The primary counter argument posed by those who hold strongly to the notion that shoe support, or cushioning, is required, is that humans did not evolve on concrete roads and paths (Downey, 2009). The best available evidence implies that humans evolved in Africa, where great swathes of the land were baked

harder than concrete for at least 6 months of the year and, significantly, where most of the major fossil finds of our hominid ancestors were in rocky environments such as the Rift Valley, Olduvai Gorge or volcanic regions such as Laetoli. Indeed, the African palaeoecological record of the past 2þ million years shows a proliferation of drought-tolerant trees, with moisture-loving trees being less prevalent for the last 2þ million years than they are even today (Stringer and Andrews, 2005). All animals require sufficient functional dexterity so that they can survive and thrive in the environment in which they find themselves; which would rarely be one single substrate, but a combination of hard, soft, rugged, flat and inclined surfaces, and much more besides. Interestingly, Zipfel and Berger (2007) assessed lesions found in the metatarsals of the three recently evolved human groups (Sotho, Zulu and European) and found that they generally appeared to have more severe pathologies than those found in groups of 35 pre-pastoral (9720 and 2000 years

before present) remains. They suggest that this result may support the hypothesis that pathological variation in the metatarsus was affected by habitual behaviour e including the wearing of footwear e and exposure to modern substrates. However, since both recent and ancient groups presented with similar patterns of pathological variation, but notable differences in frequency, Zipfel and Berger (2007) interpret these changes as only, in part, a result of the environment, and to a greater extent ton be a result of differences in habitual behaviour e primarily the wearing of shoes. When shod versus unshod populations are compared, there is research confirming that unshod populations have better arch development (Rao and Joseph, 1992; Mauche et al., 2008), and that there is a lower prevalence of many of the most common running injuries in barefoot running populations, versus shod running populations including ankle sprain, shin splints, Achilles tendinopathy, plantar fasciitis, iliotibial band syndrome, peri-patella pain, back pain (Warburton, 2001). From this recognition, a new phenomenon has arisen; the emergence of a market for ‘‘functional footwear’’.

Functional footwear Six current brands of so-called ‘‘Functional Footwear’’ are discussed below (the Nike Free, the MBT, the FitFlop, Vivobarefoot, the Newtons, and the Vibram Fivefingers). It is acknowledged that this list is not fully comprehensive, and that there are other products such as Beech Sandals, Earth Shoes, Crocs, and many others besides, who claim (and may well have) functional benefits, however, journal space and the ability to provide a fully exhaustive review in such a growth sector would always dictate the need for a cut-off point.

Conflict of interest The author of this editorial is UK Distributor, Vibram Fivefingers, one of the six brands reviewed in this editorial.

Nike free (Contributor: M. Lafortune, Nike Inc.) Nike is closely connected with athletes and coaches at all levels, from beginners to elite athletes. At the time of the Sydney Olympics, we started to hear more and more about athletes either warming up for or cooling down from their runs, barefoot. These barefoot warm ups or cool downs typically took place on nice pristine soccer/football fields. In the opinions of coaches and athletes, this leads to better performance and less injury. ‘‘ I can’t prove this, but I believe that athletes that have been training barefoot run faster and have fewer injuries. It’s just common sense.’’ Vin Lananna, Track & Field, University of Oregon (McDougall, 2009; Lafortune, 2009) Considering that only few athletes (beginners to elites) have access to well maintained and safe grassy surfaces due to locations or climatic conditions, Nike decided to create a shoe that would allow athletes to run on pavement and have their feet function as they function when running barefoot on grass.

187 Nike developed the Nike Free running shoe in 4 phases: In Phase 1, they gathered information regarding barefoot function while running on grass; in Phase 2 they created a shoe to allow close mimicry of the barefoot kinematics observed in phase 1. For Phase 3, Nike decided to partner with Prof. Peter Brueggemann at the University of Koln to assess the potential benefits of warming up and walking around with the Nike FREE shoes. Brueggemann conducted an unpublished study in which 100 athletes participated. Athletes were randomly divided into a control group and an experimental group. Following 12 weeks of warming up and walking around with the Nike FREE, rather than warming in their own sport shoes (Control group), Brueggemann found that the Nike FREE group increased the flexibility and strength of their feet more than the control group (use of their own sport shoes). He also found that the Nike FREE group improved its balance score while standing on 1 foot (Personal Communication, Mario Lafortune, Nike Inc, 2009). Breuggemann was twice contacted with a request for further detail of this research but no response has been received to date. Nike concluded that trainers, coaches and athletes they were working with believed that this improvement in flexibility, strength and balance should lead to better performance and lower injury risk.

VivoBarefoot (Contributor: B. Le Vesconte, VivoBarefoot.) VivoBarefoot shoes are based on the simple principal, that being barefoot is the most natural and healthy way for our feet and bodies to be. Vivobarefoot shoes have an ultra thin, puncture resistant sole. In their marketing literature they explain that the human foot is a masterpiece complete with 200,000 nerve endings, 28 bones, 19 major muscles, 33 joint centres and 17 ligaments. Six million years of evolution created the perfect foot, then we started wearing shoes. VivoBarefoot claim that their shoes protect the foot with an ultra-thin (3 mm) puncture resistant sole; that they strengthen the foot naturally by encouraging the muscles of the feet to work; that they stimulate every nerve ending in the feet to enhance sensory perception; and that they realign posture. Editor’s note: Whilst there is no citation of medical references for these claims, there are examples of this kind of information in the medical literature that are easily obtainable, for example, see Warburton, (2001). Of particular interest in this section is the last claim that the shoes may realign posture. The paper by Siqueira et al., 2010. in this section of this issue of JBMT, looks at postural stability in those with knee hyperextension versus those with optimal knee alignment. Firstly, such hyperextension of the knee, based on Siqueira et al’s work, may, theoretically, be tempered by wearing shoe with inbuilt lability (as with the MBT’s and FitFlops), and secondly, hyperextension at the knee is, according to Barker (2005), the most common result of having a heel on a shoe, something deliberately avoided by the VivoBarefoot, the Vibram Fivefingers, and minimized in the Newton’s and the Nike Free.

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Shifting paradigms

PREVENTION & REHABILITATIONeEDITOR: MATT WALLDEN

188 Linking this to Liebenson’s contribution to this section of JBMT on sagittal plane curvatures, the most common biomechanical result of knee hyperextension is a concomitant increase in lumbar lordosis (Barker, 2005). As Janda has stated, an upper crossed syndrome is the ‘‘child’’ of a lower crossed syndrome (Chek, 1994). Any alteration in spinal curvature will impact on spinal mechanics (Wallden, 2009), on the function of the spine as an engine in gait (Gracovetsky, 1997), and thereby reduce overall locomotor efficiency and increase injury risk. It may be possible then, that shoes may be a causative factor in stooped posture, as discussed in Liebenson’s paper. Shoes translate loading toward the forefoot, which creates an excitatory response in the quadriceps group, or a quad-dominant muscle firing pattern. If this occurs, the quadriceps are firing in a dominant fashion over and above the gluteus maximus and the combination of these two factors results in an increased anterior tilt of the innominate and subsequent lumbar hyperlordosis. (Sahrmann, 2002) The potentially detrimental sequellae of this, range from increased hallux valgus due to aberrant load of the forefoot, increased stress to the anterior cruciate ligament due to quadriceps dominance (Neumann, 2002a), unlocking and relative instability of the sacroiliac joints due to decreased form closure (Lee, 2005), and facet impingement/irritation due to increased loading through the posterior load-bearing columns (Wallden, 2009). It has been observed that the fashion for high heels on shoes in Europe historically correlates consistently with climactic events; mini-ice-ages (Lafferty, 2008) The only other rationale for having a heel on a shoe, historically is that it is the part of the shoe that wears out the quickest due to the increased impact at heel strike when walking so a thicker heel means a longer lasting shoe (Neumann, 2002b), and perhaps a longer lasting shoe or being ‘‘well-heeled’’ was once perceived as equating with higher social status.

Masai Barefoot Technology (MBT) (Contributor: J. Wies, Director MBT Academy UK.) The concept behind the MBT is that the foot is not designed to walk on flat hard ground and so, by building a soft spongy heel component into the shoe ‘‘the MBT sensor’’, the heel sinks into the shoe (as it would do on sand or a soft forest floor) and that the contour of the sole of the shoe; a convex arch, makes the foot ‘‘roll’’ from heel to toe, decreasing impact forces, spreading the load across the foot more evenly and minimizing stresses higher up in the kinematic chain. Editor’s note: Similar to the FitFlop concept discussed below, the MBT creates a labile base of support; particularly, in this instance, in the sagittal plane, which will excite the tonic motoneurons (Davidoff, 1992) and hence the tonic or ‘‘inner unit’’/‘‘local system’’ musculature of the body. MBT: MBTs have been shown to change postural alignment to a more upright position by 10 due to equal changes occurring at the knees, hips, pelvis and lumbar spine; probably because of this capacity to excite the tonic musculature or postural musculature of the body. This in turn may lead to more efficient postural muscle and joint function. (New & Pearce, 2006) The regular wearing of MBTs improve both static and dynamic balance (Nigg, 2005)

M. Wallden Editor’s note: This presupposes sufficient mobility and elasticity in these joints, especially pelvic and spinal joints, to accommodate such demands, otherwise adaptative stresses could evolve. MBTs increase muscle activity in the lower limb which MBT claim will reduce joint loading whilst increasing calories burned in standing walking and jogging (Vernon, 2004; Nigg, 2004, 2009; Romkes, 2006; Mueller, 2007; Hoppeler, 2008). Editors note: This seems counterintuitive, as increased muscle contraction will always increase joint loading. However, it may be that the lability of the surface the MBT provides results in facilitation of the tonic musculature which, whilst designed to compress the joints, does so in a relatively gentle (usually at just around 1e10% of maximal voluntary contraction) and controlled manner (tonic motoneurons have a far fewer muscle fibres they communicate with, increasing their capacity for fine tuning) (Bompa, 1999) MBT: Clinical benefit have been shown using MBTs for reduction in low back pain, reduction in neck pain, reduction in knee pain secondary to osteoarthritis (Nigg et al., 2006 a,b), improvement in chronic ankle instability (Ka ¨lin, 2008), reduction in heel pain and improvements in quality of life measures for workers that stand at work. Editor’s note: MBT provide references for many of these claims, though most are unpublished. MBT suggest that the positive effect of their footwear is ‘‘based on the principle of natural instability. An effect which can, in fact, be achieved without the benefit of high-tech footwear: by simply walking barefoot on soft, uneven, natural ground such as sand or moss’’. However, they claim, in today’s modern world such barefoot walking on soft ground is not always easy to do and their footwear provides a solution. MBT say ‘‘From hard, flat surfaces to soft, natural, uneven ground, MBTs activate and strengthen the small supporting muscles which are the body’s natural shock absorbers’’.This is another way of describing what’s been already stated above, though the concept of shock absorbers is perhaps a little outdated; and exploitation of a specific energy niche may be a more effective and accurate way of viewing these muscles and their associated fascia. According to MBT ‘‘The mid-sole, with its integrated [convex] balancing area, requires an active and controlled rolling movement with every step.’’ This function of the MBT may be of use for those with functional hallux limitus; though it may equally inhibit the normal flexibility of the 1st MTP in those with ‘‘normally functioning feet; and will certainly curtail any benefits of the windlass1 mechanism which is most active as the toe hyperextends to around 65 .

1 Windlass mechanism Z classically, as the gait cycle moves from mid-stance to toe-off, the toes move into hyperextension, ideally reaching 65 degrees of extension, the plantar fascia is drawn tight increasing the arch along the medial aspect of the foot creating a spring like mechanism to push the person forward as they toe-off (Neumann c) 2002). Less commonly described, but equally valid, the windlass mechanism occurs in the open chain extension of the toes in the swing phase of gait prior to heel strike prepares the medial longitudinal arch of the foot for loading; and may also be engaged further in runners who forefoot strike, thereby storing elastic energy in the plantar fascia.

Shifting paradigms

Newton (Contributor: I. Adamson, Newton Running.) Editors note: Newton running shoes don’t so much try to mimic barefoot running as to encourage the wearer to run in a more ‘‘natural’’ running gait by promoting a forefoot strike in running gait, as opposed to the more commonly seen ‘‘heel strike’’ in those wearing running shoes (Squadrone and Gallozzi, 2009; De Wit et al., 2000). Newton: Newton claim that their improved shoe geometries encourage a natural running gait, resulting in lower impact to the body. Newton shoes have 4e5 mm heel lift compared to 12e13 mm for traditional running shoes (10 mm for racing flats.) Editor’s note: This, of course, correlates with one of the rationale described by VivoBarefoot in their shoe design (as well as the Nike Free’s and the Vibram Fivefingers). Newton: This allows users to run naturally by loading their leg when their centre of gravity passes over their foot and their joints are flexed. Traditional shoes with a 10e13 mm heel lift load the leg too early in the gait cycle when the joints are locked out and the foot strike is forward of the centre of gravity, resulting in high shock loads and braking. The small lift in Newton shoes allows runners to readjust the soft tissues in the back of their leg (stretch back to their natural length) without being too aggressive. Zero drop has proven too much of an adjustment for most runners.  Biomechanical top plate (inside the shoe) enhances afferent feedback from the ground to the foot, facilitating the runner’s ability to sense and react to the ground naturally. Traditional cushioning (foam, gel, air etc.) dampen afferent feedback, encouraging harder foot strikes.

 Greater shock absorption compared to leading brands. The Newton Active Membrane Technology (AMT) provides up to 80% greater displacement on impact, resulting in dramatically increased energy absorption (lower shock to the body.) Leading brands result in up to 100% high shock to the body (see Figure 1). Editor’s note: Newton also report other benefits less related to this discussion such as increased energy return and increased forefoot support, compared to other leading running shoe brands. They also go on to say that most people load the heel portion of their shoe at some point during the gait cycle and, depending on their running style and shoe geometry, this loading may vary from almost negligible to severe impact. Irrespective of this heel loading, significant midfoot forces are generated by all runners as their centre of mass moves anteriorly over the foot before push off. The standard heel-to-toe drop is just over 1 cm in most running shoes; meaning it is difficult to avoid hitting the heel portion of a regular running shoes. Newton’s along with some of the other brands of ‘‘functional footwear’’ in this discussion (VivoBarefoot, Nike Free & Vibram Fivefingers) have decreased or nullified the heel-to-toe drop; both allowing more of a midfoot strike (as if running in a natural barefoot state) and reducing shock loads associated with heel strike, see Figure 1.

FitFlop (Contributor: D. James, co-designer FitFlop.) The FitFlop was developed in 2006 with the brief to develop a shoe-based technology and concept that was biomechanically valid. Since the earlier Masai technology was designed from a sagittal plane perspective it seemed intuitive to approach development of a new shoe from

Figure 1 Forefoot strike versus Heel strike. The research conducted by Newton on the peak impact force when wearing their footwear versus other running shoe brands is congruent with other research (McDougall, 2009; Lieberman et al., 2010) suggesting that forefoot strike (which the Newton running shoes mechanically engender) minimizes impact force.

PREVENTION & REHABILITATIONeEDITOR: MATT WALLDEN

It does of course also raise the point that if the arches of a bare foot are concave, why would a shoe that is convex be called ‘‘barefoot’’? MBT’s answer is that they have attempted to recreate the way a barefoot moves through sand; not necessarily how it moves on harder surfaces, and so such kinematic analysis shows that the heel sinks somewhat, the midfoot pivots over the ridge created by the displaced sand, in a rocking style motion; and it is this motion that MBT have attempted to recreate in their shoe design. MBT say that in conjunction with the Masai Sensor, the body’s entire musculoskeletal system is activated and exercised, the muscles in the buttocks, stomach and back are strengthened, posture and gait are kept relaxed and upright and stress on the joints and back is relieved. These points are all of relevance to the bodyworker and movement therapist. It might be noted that the claims of ‘‘increased muscle contraction’’ with ‘‘relaxed posture and gait’’ would appear somewhat contradictory, though this does depend on which muscles are being assessed; the larger outer unit muscles like the hamstrings and gluteals, or the smaller intrinsic muscles such as the deep multifidus, the gemelli, vastus medialis obliquus, if it is the latter, then it makes more biomechanical and physiological sense and may not be contradictory.

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190 a medial-lateral standpoint. The concept they developed was what they term ‘‘Micro’wobbleboard’’ technology, its goal, to enhance muscle activation patterns. The FitFlop is constructed out of differing mid-sole densities in an innovative vertical arrangement. The concept is to slightly destabilise the user during the weight-bearing phase of the gait cycle, in a way similar to a soft, uneven forest floor or other ‘‘natural’’ surface; thus creating a more continuous tension in the supporting muscles in the foot and leg to correct this instability. Editor: This line of thought; an unstable surface creating increased tensioning of the musculature of the lower limb is consistent with the study presented in this section by Sequeira et al. and also with Janda’s description of ‘‘riverbed running’’, and the rocker shoes Janda promoted in the rehabilitation setting for the last few decades (Janda 2007). (see Textbox 1 above). FitFlop claims to improve posture, to reduce shock, to increase muscle activity and to reduce foot pain. Research supporting these claims include:  Improve posture. An independent investigation reported the ground reaction force vector during loading response to be directed more centrally towards the trunk in the FitFlop when compared to a control shoe

M. Wallden (unpublished data). Such a finding might have postural benefits. We have performed acceleration measures recorded at the lower leg and found a 53% increase in low frequency power when compared to a control shoe (p Z 0.006; n Z 10; unpublished data). This power is indicative of active kinematic strategies, and such adaptations have been noted in the literature in dealing with the forces associated with ground impact (De Wit et al., 2000).  Reduce shock. Our research has demonstrated a 22% decrease in impact-related shock (p Z 0.02; n Z 10) at the tibia compared to a control shoe using spectral analysis of the acceleration signal, see Figure 2 (unpublished data).  Increase muscle activity. Peroneus Longus (PL) activity consistently shows significantly increased muscle activity when tested against a control shoe. In our most recent study (n Z 17), RMS ratio was increased by 11% (p Z 0.007) (unpublished data). Such a repeatable measure demonstrates the validity of ‘Micro-Wobbleboard’ Technology. The PL acts as a stabilizer during mid-stance to assist in the maintenance of an upright posture (Schunk, 1982), and is accentuated further as the foot passes over the soft-density medial section of the mid-sole.

Figure 2 Pressure distribution Fitflop versus control shoe during walking gait. Compare and contrast these with the pressure distributions in Figure 3 below.

Shifting paradigms

 Reduce foot pain ‘Microwobbleboard’ Technology has been shown to reduce the pressure distribution under the plantar surface of the foot when compared to a control shoe, see Figure 2 (unpublished data). In particular, reductions have been demonstrated under the medial and lateral heel, and metatarsals (Figure 2). These observations support the efficacy of our technology along with the notable difference in centre of pressure trajectory. Interestingly pressure distribution is greater under the phalanges. The implications of these findings are not clear until a clinical population is tested; however, it appears that foot functionality is preserved in the FitFlop. Editor’s note: Similar to the MBT, the FitFlop can be seen to increase muscle activation in walking in, however, there are no claims that this increases gait efficiency; moreover that it stimulates greater muscle contraction in a way similar to walking over uneven ground (Vines, 2005).

Vibram Fivefingers (Contributor & Editor M. Wallden, UK Distributor, Vibram Fivefingers) In contradistinction to the other shoes in this range of functional footwear, the Vibram Fivefingers were not developed with any biomechanical intent in mind. The history of Vibram as the world’s leading sole manufacturer meant that, at its core, Vibram’s reputation was to produce hard-wearing, sure-gripping soles. The remit of the designers at Vibram was to use this protective grip technology to create a shoe that mimicked the sensation of being barefoot on a sailing boat with the grip and reassurance of a Vibram sole. However, when Vibram’s Fivefingers were taken to the US Market in 2006, it soon became clear that they were attracting attention from fields far outside the anticipated sailing market. With strength and conditioning coaches, running coaches, pilates instructors, yoga instructors, physical therapists and many podiatrists taking a keen interest in the Fivefingers product, Vibram knew that they had to look at providing an evidence base for their recommending customers to refer to. This first piece of research specifically detailing the biomechanical effect of wearing Fivefingers footwear was published in March 2009 (Squadrone and Gallozzi, 2009) comparing shod running, with barefoot running with ‘‘Fivefingered running’’ and, in brief, concluded with the following points:  Shod running creates significantly change in angles at ground contact, of the ankle, the knee and the hip compared to the natural barefoot state  Running in Vibram Fivefingers creates an almost identical posturing of ankle, knee and hip compared to the natural barefoot state

Significance: Barefoot running and running in Vibram Fivefingers results in more of midfoot or forefoot strike, whereas running shod results in more of a heel strike. Barefoot running and running in Vibram Fivefingers increases the stiffness requirement of the lower limb; this may have significant effects on sports performance as stiffness is a factor in top flight running speed and in effective load transfer.  Shod running is around 2e3% less efficient (in terms of oxygen consumption) compared to barefoot running  Running in Vibram Fivefingers is 0e1% more efficient (in terms of oxygen consumption) compared to barefoot running Significance: Running barefoot and in Vibram Fivefingers is more energetically efficient than running shod. This has been known about running barefoot for a long time (Warburton, 2001) but has been assumed to be due to the weight of the shoe on the end of a long lever e the leg. This finding, however, throws that interpretation into question.  Shod running spreads loading more broadly across the foot compared to the natural condition (see Figure 3)  Running in Vibram Fivefingers creates a pressure loading spike around the 2nd metatarsal head; almost identical to barefoot running. Significance: Switching from running shod to barefoot running may result in increased loading (and potential injury) of the 2nd metatarsal head; particularly if a period of adaptation is not built into the transition. However, in order to generate forward power, loading against the ground in toe off, where there is optimal leverage for forward propulsion is required. This may explain the increased efficiency of barefoot and Vibram Fivefingers, versus shod, running. A major difference between the Vibram Fivefingers footwear and the other shoes discussed are the separated toe compartments. The theory behind this is to allow the foot to function as nature intended; and in doing so, allow the toes to act more proprioceptively, through their entire range of motion and to allow lateral spread; affording greater frontal plane stability.

Discussion Some of the key discussion points in terms of the functional footwear products discussed are: 1) Labile sole, versus nonlabile; 2) Tactile sole versus non-tactile; 3) functional flex points in the sole; 4) Sole modifications to create a soft landing, versus shoe modifications to minimize any protection on landing; 5) Minimal or no heel raise. 1) Labile versus non-labile: The function of a labile sole (such as the MBT or Fitflop sole) may be of use in minimizing repetitive strain injuries, in facilitating the tonic system of the body and in training the tilting reflex (useful in most water sports or in any situation where the surface you’re standing on moves under you e.g. riding

PREVENTION & REHABILITATIONeEDITOR: MATT WALLDEN

Increased activation of Rectus Femoris (6%), Medial Gastrocnemius (4%), and Tibialis Anterior (5%) has previously been reported whilst wearing the FitFlop; however, these differences were not large enough to elicit a significant effect (p > 0.05) when compared against a control shoe.

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Figure 3 Pressure distribution barefoot versus Vibram Fivefingers versus control running shoe during running gait. Note the pressure spike near the 2nd metatarsal head, this may be optimal for forward propulsion, but may equally lead to metatarsalgia if transition from shod to barefoot (or minimalist footwear) is too rapid to allow for adaptive change.

a bus or an escalator). A non-labile sole, may be of more use in training for sports or activities in which the surface does not move under you; most ball sports, running, walking, dancing, climbing, activities of daily living; anywhere you’re using a righting reflex profile. 2) Tactile versus non-tactile: This function of the sole may be of use in facilitating proprioceptive feedback and may facilitate afferent neural pathways as well as optimizing efferent muscle recruitment strategies; in an ‘‘information out can only be as good as information in’’ way. 3) Functional flex points in the shoe: This function will allow a full range of motion at all 26 joints of the foot, rather than just the one or two of traditional supportive sports shoes; maintaining functional range of motion and biomechanical function. This may be of particular significance with regard to the metatarsophalangeal joints (esp 1st, 2nd and 3rd) which are so heavily involved in the windlass mechanism. 4) Sole modification to create a soft landing versus those that minimize protection: Research by Robbins and Waked (1997), as well as Divert et al. (2005) questions the validity of creating a soft landing through provision of ‘‘soft’’ sole materials as it appears that the nervous systems response to this is to ‘‘seek’’ for the stability of the ground through the soft sole; thereby increasing strike impact through the shoe to compensate for its softness. Minimalist soles (or going barefoot), on the contrary, evoke a change in biomechanical strategy; a shortening of the stride, a quickening of the cadence and an altered ground contact e usually a midfoot or

forefoot strike. This is considered the ‘‘natural’’ patterning as it is adopted almost instantaneously by subjects under biomechanical analysis; whereas it takes the same subjects as much as 4 min of running to ‘‘acclimatise’’ and adjust their gait to suit the running shoe they may be wearing (De Wit et al., 2000) 5) Minimal or no heel raise: As discussed above, the heels on shoes, sports shoe notwithstanding, is a historical (or fashion) artefact which has no biomechanical benefit e and probably only a biomechanical detriment. To draw this back to the research presented in this section of this issue of JBMT, by Siqueira et al. regarding flexing of the knees under perturbation; as well as the discussion by Liebenson of correcting the sagittal spinal curves, there is a further possible mechanism for the changes in knee flexion we see in the research. De Wit et al. (2000) confirm that knee flexion and leg stiffness is increased when subjects run barefoot versus shod. Squadrone and Gallozzi (2009) agree that this knee flexion occurred in their barefoot runners and their runners wearing Vibram Fivefingers; while Siqueira et al. also find increased flexion in their subject under balance challenge.

Hypotheses  It could be that flexion of the knee both brings the centre of gravity lower as well as increasing stiffness of the lower limb due to the prerequisite muscle contraction.

Shifting paradigms

Summary ‘‘Functional footwear’’ is just one of many of the useful tools that are available both to the bodyworker and movement therapist; as well as to their patient base. To be able to advise on which of these tools may be most appropriate for clients/patients, based on their needs, has relevance to the effectiveness and integrity of any healthcare practice. While it may be appropriate to recommend use of MBT to someone with hallux rigidus, the same recommendation to someone who needs to retain full ROM in their first MTP e or who has hallux limitus e may be inappropriate. It may be inappropriate to recommend barefoot training, or minimalist shoes for someone with metatarsalgia, whereas a runner with a history of plantar fasciitis or Achilles tendinopathy may benefit greatly from barefoot running, due to the lack of heel strike and lighter footfall. To recommend the wearing of shoes with inbuilt lability to someone who uses a righting reflex profile for their sport or activities of daily living (ie land-based activities) may be a less effective strategy than encouraging them to wear a shoe in which they can feel the ground. In contrast, someone engaged in a sport or activity in which the surface on which they stand moves (a boat, a bus, a surfboard, a horse, or a skateboard), may benefit greatly from a shoe with inbuilt lability. Duration is another factor that requires consideration. For someone with a longstanding pronation pattern, to introduce a rapid transition to minimalist footwear, would not be advisable. This is why Nike developed a sliding scale, moving from 10 being a standard fully supportive shoe to 0 being barefoot. The Nike Free currently encompasses a ‘‘near full support’’ (the Free 7.0) to ‘‘half support’’ (the Free 5.0), to ‘‘minimal support’’ (the

2 The spinal engine theory, (briefly explained in Wallden, 2009) was developed in the 1980s by Serge Gracovetsky and published in his book of the same name in 1988. The theory proposes that the spine optimizes efficacy of motion in the gravitational field by using the spine to propel the legs forwards by capturing the ground reaction force to de-rotate the spinal segments with each step of the gait cycle; storing the ground reaction force as potential energy in the viscoelastic tissues of the lower limb and spine, and then expressing that potential as kinetic energy as the spine derotates.

Free 3.0). The VivoBarefoot or Vibram Fivefinger would probably be somewhere between 0.1 and 1.0 on this scale. Recommendation of a long term active rehabilitation/re-strengthening strategy by means of transition from support to no support, in daily increments, combined with a parallel corrective exercise program to rebuild the arch, would be clinically appropriate, whereas the use of an acute ‘‘passive crutch’’ which an antipronation device offers, is probably only a short term solution. Similarly, it would make little clinical-sense to place someone on a labile surface all day, when most rehabilitation and conditioning specialists would advise against using a wobble board, or a Swiss ball, for lengthy periods; as the result would be fatigue in the tonic musculature, leaving the user vulnerable to injury or faulty compensatory recruitment patterns.

Conclusion Choice of functional footwear should not be dependent on products because of their appearance but should reflect clinical and practical needs. Since the human form spent somewhere between 4 and 7 million years in the making, and the foot a further 265 million years evolving, the recent model (40 years or so) of placing of feet on thick polyurethane soles (with various ingenious contours) between the plantar aspect of the foot, and the ground might be seen to be undesirable. The weight of evidence appears to be tipping towards that perspective (Stacoff et al., 2000; Richards et al., 2009; Mauch et al., 2008; Anderson, 1996; Divert, 2008; Squadrone and Gallozzi, 2009; Robbins and Waked 1997; Nigg et al., 1999; Wolf et al., 2008; De Wit et al., 2000; Divert et al., 2005). In much the same way that ‘‘core function’’ or motor control research can be seen to have correlates with the path we trod to get here (Texbox 1); so too can emerging research on the functional foot. This understanding may help us to select appropriate tools for intervention, based on each individual patient’s physiological needs.

References Anderson, T., 1996 Aug. Biomechanics and Running Economy. Sports Med 22 (2), 76e89. Barker, V., 2005. In: Posture Makes Perfect, third ed. Waiwera International Limited. Bompa, T., 1999. Periodization training for sports. Human Kinetics, 18e20. Chek, P., 1994. Scientific Back Training. Correspondence Course. CHEK Institue, Vista, CA. Chek, P., 2000. How to activate ‘‘survival reflexes’’ for improved strength. Published on. http://www.dragondoor.com/articler/ mode3/231/ Accessed 05.12.06. Chek, P., 2004. How to activate ‘‘survival reflexes’’ for improved strength and function. Published on. http://www.mercola. com/2004/jun/19/survival_reflexes.htm Accessed 05.12.06. Davidoff, R., 1992. Skeletal muscle tone and the misunderstood stretch reflex. Neurology 42, 951e963. De Wit, B., De Clercq, D., Aerts, P., 2000. Biomechanical analysis of the stance phase during barefoot and shod running. Journal of Biomechanics 33 (3), 269e278.

PREVENTION & REHABILITATIONeEDITOR: MATT WALLDEN

 And if this is the case, it might be that barefoot runners (or equivalent) drop their centre of gravity and flex their knees more due to the fact that they have a smaller base of support.  Additionally it is possible that MBT and FitFlop users do the same, due to the labile nature of their footwear?  A question remains as to why stiffness increases, and it may be hypothesised that this is merely an artefact of a flexed lower limb?  Another possible answer is that a cushioned sole and the increased loading through that sole requires less stiffness to achieve the appropriate raw energy pulse from the ground reaction force, to drive the spinal engine2, as described by Gracovestky (1997).

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194 Divert, C., Baur, H., Mornieus, G., Mayer, F., 2005. Stiffness adaptations in shod. Journal of Applied Biomechanics 21 (4), 311e321. Divert, C., Mornieux, G., Freychat, P., Baly, L., Mayer, F., Belli, A., 2008. Barefoot-Shod Running Differences: Shoe or Mass Effect? Int J Sports Med 29, 512e518. Downey, G., July 26, 2009. Lose your shoes: is barefoot better?. Posted on. www.Neuroathropology.net. http://neuroanthropology. net/2009/07/26/lose-your-shoes-is-barefoot-better/ Accessed 05.01.10. Gracovetsky, S., 1997. Linking the spinal engine to the legs. In: Vleeming (Ed.), Movement, Stability and Low Back Pain - the essential role of the pelvis. Churchill Livingstone. Haines, T., 1999. Walking with Dinosaurs. BBC Worldwide Ltd, pp. 8e13. Hides, J., Carolyn, A., Richardson, C., Jull, G., 1996. Multifidus muscle recovery is not automatic after resolution of acute, first episode low back pain. Spine 21, 2763e2769. Janda, V., 2007. Sensory motor stimulation. In: Liebenson: Rehabilitation of the Spine. Lippincott Williams & Wilkins, pp. 513e530. Janda, V., 1999. Personal Communication. Ka ¨lin, X., 2008. The MBT as a Therapeutic Device for Ankle Joint Instabilities. Poster presentation at the annual conference of the Association of Chartered Physiotherapists in Sports Medicine, 13-14. November, Belfast, 2008. Lafferty, F., 2008. Osteopathy for all international osteopathic forum. Evolutionary Athleticism. http://health.groups.yahoo. com/group/OsteopathyForAll/message/4479 Accessed 05.01.10. Lafortune, M. 2009. Nike Inc, USA. Personal Communication. Lederman, E., 2000. Facilitated segments: a critical review. British Osteopathy Journal 22, 7e10. Lederman, E., 2010. The myth of core stability. Journal of Bodywork and Movement Therapies 14 (1), 84e98. Lee, D., 2005. The Pelvic Girdle. Elsevier. Lieberman, D., Venkadesan, M., Werbel, William A., W., Daoud, A., D’Andrea, S., Davis, I., Ojiambo Mang’Eni, R., Pitsiladis, Y., 2010. Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature 463, 531e536. McDougall, C., 2009. Born to Run. Profile Books, pp. 168e183. Mauch, M., Mickel, K., Munro, B., Dowling, A., Grau, S., Steel, J., 2008. Do the feet of German and Australian children differ in structure? Implications for children’s shoe design. Ergonomics 51 (4), 527e529. Neumann, D., 2002a. Kinesiology of the Musculoskeletal System. Mosby, pp. 451. Neumann, D., 2002b. Kinesiology of the Musculoskeletal System. Mosby, pp. 553. Neumann, D., 2002c. Kinesiology of the Musculoskeletal System. Mosby, pp.506. New, P., Pearce, J., 2006. The effects of Masai Barefoot Technology footwear on posture: an experimental designed study. Physiotherapy Research International 12 (4), 202. Nigg, B., Hintzen, S., Ferber, R., 2006a. Effect of an unstable shoe construction on lower extremity gait characteristics. Clinical Biomechanics 21, 82e88. Nigg, B., Emery, C., Hiemstra, L., 2006b. Unstable shoe construction and reduction of pain in osteoarthritis patients. In: Medicine & Science in Sports & Exercise. American College of Sports Medicine.

M. Wallden Nigg, B.M., Nurse, M.A., Stefanyshyn, D.J., 1999. Shoe inserts and orthotics for sport and physical activities. Medicine and Science in Sports and Exercise 31 (7 Suppl.), 421e428. Nigg, B.M., Davis, E., Lindsay, D., Emery, C., 2009. The effectiveness of an unstable sandal on low back pain and golf performance. Clin J Sport Med. 2009 Nov 19 (6), 464e470. Nitz, A., Peck, D., 1986. Comparison of muscle spindle concentrations in large and small human epaxial muscles acting in parallel combinations. American Journal of Surgery 52 (5), 273e277. Panjabi, M., Abumi, K., Duranceau, J., Oxland, T., 1989. Spinal stability and intersegmental muscle forces. A biomechanical model. Spine 14 (2), 194e200. Rao, U., Joseph, B., 1992. The influence of footwear on the prevalence of flat foot. A survey of 2300 children. Journal of bone & joint surgery 74B, 525e527. Richards, C., Magin, P., Callister, R., 2009. Is your prescriptions of distance running shoes evidence-based? Br J Sports Med 43, 159e162. Robbins, Waked, 1997. Balance and vertical impact in sports: role of shoe sole materials. Archives of Physical Medicine and Rehabilitation 78 (5), 463e467. Robbins Romkes, J., Rudmann, C., Brunner, R., 2006. Changes in gait and EMG when walking with the Masai barefoot technique. Clinical Biomechanics 21, 75e81. Sarhmann, S., 2002. Diagnosis and Treatment of Movement Impairment Syndromes. Mosby. Schunk, M.C., 1982. Electromyographic study of the peroneus longus muscle during bridging activities. Physical Therapy 62 (7), 970e975. Siqueira, C.M., Moya, G.B.L., Caffaro, R.R., Fu, C., Kohn, A.F., Amorim, C.F., Tanaka, C., 2010. Misalignment of the knees: does it affect human stance stability? Journal of Bodywork and Movement Therapies 14 (2). Squadrone, R., Gallozzi, C., Mar 2009. Biomechanical and physiological comparison of barefoot and two shod conditions in experienced barefoot runners. Journal of Sports Medicine and Physical Fitness 49 (1), 6e13. Stacoff, A., Renschmidt, C., Nigg, B.M., Van, D., 2000. Effects of foot orthoses on skeletal motion during running. Clinical Biomechanics (Bristol, Avon) 15 (1), 54e64. Stringer, C., Andrews, P., 2005. The Complete World of Human Evolution. Thames & Hudson, pp. 50e51. Vines, G., 2005. Put a wild wobble in your walk. New Scientist 2531, 51. Wallden, M., 2008. Rehabilitation and Movement Re-education, in Chaitow: Naturopathic Physical Medicine. Elsevier. Wallden, M., 2009. The neutral spine principle. Journal of Bodywork and Movement Therapies 13 (4), 350e361. Warburton, M., 2001. Barefoot running. Sportscience 5 (3). sportsci.org. Wolf, S., Simon, J., Patikas, D., Schuster, W., Armbrust, P., Doederlein, L., 2008. Foot motion in children shoes: A comparison of barefoot walking with shod walking in conventional and flexible shoes. Gait & Posture 27 (2008), 51e59. Zipfel, B., Berger, L.R., 2007. Shod versus unshod: the emergence of forefoot pathology in modern humans? The Foot 17, 205e213.

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QUALITY OF LIFE RESEARCH

Brena Guedes de Siqueira Rodrigues, Esp., Prof. a,b,*, Samaria Ali Cader, ´li Valim Oliver Bento Torres, MSc., Prof. d, Dra., Prof. b,c, Nata ´a Monteiro de Oliveira, Esp., Prof. a,b, Este ´lio Henrique Martin Dantas, Edile a,b,e,f Dr., Prof. a

PROCIMH e Universidade Castelo Branco, RJ, Brasil LABIMH e UCB, RJ, Brazil c Universidade Nossa Senhora de Assunc¸a˜o e Paraguai d Universidade Federal do Para´ e UFPA, Bele´m-Pa, Brazil e Grupo de Desenvolvimento Latino-Americano para a Maturidade e GDLAM, Brazil f Bolsista de Produtividade em Pesquisa e CNPq, Brasil b

Received 26 August 2009; received in revised form 18 December 2009; accepted 20 December 2009

KEYWORDS Pilates; Personal autonomy; Balance; Quality of life

Summary Objective: The aim of this study was to evaluate the effects of the Pilates method on the personal autonomy, static balance and quality of life in healthy elderly females. Method: Fifty-two elderly females were selected and submitted to evaluation protocols to assess functional autonomy (GDLAM), static balance (Tinetti) and quality of life (WHOQOLOLD). The Pilates group (PG: n Z 27) participated in Pilates exercises twice weekly for eight weeks. Descriptive statistics were compiled using the ShapiroeWilk test. The level of significance was considered to be p  0.05. Results: The dependent Student-t test demonstrated significant post-test differences in the Pilates group in the following areas balance (D% Z 4.35%, p Z 0.0001) and General Index of GDLAM (D% Z 13.35%, p Z 0.0001); the Wilcoxon test demonstrated significant post-test differences in the quality of life Index (D% Z 1.26%, p Z 0.0411). Conclusion: The Pilates method can offer significant improvement in personal autonomy, static balance and quality of life. ª 2009 Elsevier Ltd. All rights reserved.

* Corresponding author. Brena Guedes de Siqueira Rodrigues, Rua Mundurucus 984/402, Jurunas, Bele ´m-Pa-Brazile 66025-660, Brazil. Tel.: þ55 91 8867 2002/3222 9946. E-mail addresses: [email protected] (B.G.de Siqueira Rodrigues), [email protected] (S. Ali Cader), natalivalim@ yahoo.com.br (N.V.O. Bento Torres), [email protected] (E.M.de Oliveira), [email protected] (E.H. Martin Dantas). 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.12.005

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Introduction

Methods and procedures

The aging process involves a series of degenerative, gradual and irreversible alterations of body systems culminating in complete loss of function (Matsudo et al., 2000). These alterations can cause losses of strength, flexibility, balance, coordination and memory, leading to considerable losses of personal autonomy and quality of life for elderly people (Heathcote, 2000; Rogatto and Gobbi, 2000). Loss of balance represents a significant difficulty in the lives of elderly people characterized by reduced postural control in dynamic and static situations and increased risk of falls and injuries (Montes-Castillo, 2006). This deficit has direct consequences for personal and functional autonomy related to individual capacity to complete daily activities, control will and feelings and hide physical and/or mental limitations (Heathcote, 2000; Dantas et al., 2004). Functional limitations due to age affect the capacity of each individual to carry out their activities and present direct challenges to well-being and quality of life for elderly people (Rebelatto et al., 2006; Siren and HakamiesBlomqvist, 2009). Quality of life is a subjective concept, although it can be understood as a measure of perfect physical, psychic and social well-being (Minayo et al., 2000). Several studies have been developed to examine the importance of health quality in old age. Many of them have emphasized the importance of physical activity or mobility as a way of improving organic conditions and slowing physical degeneration. (May, 2003; Kura et al., 2004; Pieron, 2004). Pilates consists of a physical exercise that uses resources such as gravity and the resistance of springs, either to resist or assist movement execution (Gagnon, 2005). It aims to prevent automatic movements, which are responsible for unwanted muscle activity that can cause injuries (Petrofsky et al., 2005). According to Anderson and Spector (2000), Pilates encouraged the importance of proprioceptive stimulation for motor learning improvement using the powerhouse exercise (transversus abdominus, obliques, and multifidi muscles) and repetition of correct movement to achieve the training standard, leading to a better motor performance and less risk of injuries. Pilates practice can be divided in phases: assistive movement (to inhibit improper muscles actions), disassociation, stabilization, mobilization, dynamic stabilization and functional reeducation (Anderson and Spector, 2000). Pilates method has been studied in relation to its effects on personal autonomy (Johnson et al., 2007), posture (Blum, 2002; Kaesler et al., 2007), pain control (Gladwell et al., 2006), improved muscle strength (Schroeder et al., 2002), flexibility (Segal et al., 2004) and motor skills (Lange et al., 2000); its effects in these areas have been proven. New research is needed on the Pilates method as a mechanism for the prevention and treatment of geriatric disorders. Thus, the aims of this study are to analyze the effects of the Pilates method on the personal autonomy, static balance and quality of life of healthy elderly females.

Samples Fifty-two volunteer participants were selected by a simple random sampling. They were randomly divided by lottery into two groups: twenty-five in the control group (CG) and twenty-seven in the age-matched Pilates group (PG). They were all women, aged 60e78 years (66  4 years), with a height average of 1.55 (0.06), weight of 62 (14.12) and body mass index of 25.8 (5.64), participants of an Occupational Therapy group (twice weekly), sedentary for at least six months and none had been through a Pilates class before. All participants met the inclusion criteria, which included the following: capacity to carry out activities of daily living without physical support, physical aptitude for the practice of Pilates exercises, and no practice of any other type of physical activity during the study period. They also failed to meet the following exclusion criteria: pathologies that could cause physical limitations or that interfered with the functions of attention, understanding and cognition, and use of medication for the treatment of bone, muscle or joint injuries. All participants were required to complete the entire intervention program. All subjects gave their written consent according to the Regulations Governing Research on Human Subjects of (WMA, 2002), and this study was approved by the Institutional Ethics Committee under protocol number 0050/2008 e UCB/VREPGE/COMEP/PROCIMH. This research does not pose physical or psychological risks to participants, and all of the ethical rules of identity and image confidentiality were respected.

Procedures For the evaluations, the following equipment was used: a mechanical adult scale with a capacity of 330.7 lb (Instituto Sa ˜o Paulo/SP), a stopwatch with 30-lap memory (SL210 Oregon), a shirt (Hering size X), two obstacles to turn and one chair without arms (50 cm height). Both groups were submitted to a general evaluation of personal autonomy, static balance and quality of life. Personal autonomy was evaluated through the Latin American Development Group for Elderly (GDLAM) protocol (GDLAM, 2004), which consists of tests including 10 m walks (C10 m) (Spila ´ et al., 1996), standing up (LPS) (Guralnik et al., 1994), putting on and to taking off a shirt (VTC) (Vale et al., 2006) rising from the prone position (LPDV) (Alexander et al., 1997) and rising to walk through the house (LCLC) (Andreotti and Okuma, 1999). From the results of these tests, GDLAM (IG) is obtained, which represents the final test scores (Dantas et al., 2004). Balance was evaluated by the Tinetti test (Tinetti, 1986), wherein a source of mobility guides test performance that is specific for static balance. Quality of life was evaluated by the WHOQOL-OLD, the version for the elderly of World Health Organization’s quality of life questionnaire. It is comprised of twenty-four questions, divided into six domains, as follows: DOM1, sensory abilities; DOM2, autonomy; DOM3, past, present

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and future activities; DOM4, social participation; DOM5, death and dying; and DOM6, intimacy (Fleck et al., 2006).

After initial evaluation, the PG began the intervention, which consisted of practicing the Pilates method using a Bobath ball and the Cadillac, Wall Unit, Combo Chair and Reformer devices made by Metacorpus Pilates Studio (RJ/ Brazil). They voluntarily performed Pilates practice in a private clinic (Bele ´m-Para ´-Brazil). The subjects were supervised by a physical therapist certified as a qualified Pilates method instructor (Brazil). An explanation about Pilates and the apparatus was given to the subjects, as well as a practical demonstration of each exercise before they began their intervention. The same instructor taught all sessions, with the assistance of three volunteers at each session ensuring quality of supervision. The session was divided into the following stages: initial global stretching (10 min), a general conditioning (40 min) and relaxation (10 min), in accordance with protocols used in other studies (Lord et al., 1996; Barnett et al., 2003; Kaesler et al., 2007). The initial global stretching included two exercises: 1. Hamstring stretch (Combo Chair): standing tall position, feet apart, straight legs. Press through hands to push pedal down. Slowly control pedal return through trunk extension (Figure 1). 2. Mermaid (Reformer): sit tall, legs on table, one hand on foot bar. Pull foot bar and perform an arm arc over head (Figure 2). For exercise 1 two springs of 81 kilogram force/ meter (kgf/m) were used, and for exercise 2 one spring of 24.4 kgf/m and one of 10 kgf/m were used. The general conditioning phase included eight exercises: 3. Arms up and down (Reformer): supine position, pelvis neutral, hips flexed in 90 degrees. Holding the reformer handles, perform flexion and extension of both shoulders (Figure 3).

Figure 2

Mermaid.

4. Arms by the side (Cadillac/Wall Unit): standing tall position, pelvis neutral. Holding the spring handle, perform abduction and adduction of a shoulder (Figure 4). 5. Arms up and pull down (Cadillac/Wall Unit): supine position, straight legs, pelvis neutral. Holding the bar, perform flexion and extension of both elbows (Figure 5). 6. Supine lower leg series (Cadillac/Wall Unit): with foot caught in the handle, pelvis neutral, lift the leg up and down (flexion and extension of hip) (Figure 6). 7. Leg series on side, up and down (Cadillac/Wall Unit): lying on side, pelvis neutral, under leg in hip and knee flexion. With foot caught in the handle, lift the leg up and down (abduction and adduction of hip) (Figure 7). 8. Footwork toes and heels (Reformer): supine position, pelvis neutral. Firstly toes in foot bar, than heels in foot bar. Perform knees flexion and extension (Figure 8). 9. Sit ups (Cadillac/Wall Unit): supine position, pelvis neutral, straight legs. Pull the Cadillac/Wall Unit tower bar up and sitting using abdominal muscles (Figure 9). 10. Gluteus and trunk raises (Cadillac/Wall Unit): supine position, neutral pelvis, arms besides body, legs above a Bobath Ball (55 cm). Perform gluteus and trunk raises from table (Figure 10). For exercises 3, 4, 6 and 7 springs of 8.3 kgf/m were used; for exercise 5 two springs of 10 kgf/m were used; for

Figure 1

Hamstring stretch.

Figure 3

Arms up and down.

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Figure 6 Figure 4

exercise 8 springs of 29.8 kgf/m were used; for exercise 9 and 10 only gravity was employed. The springs used were the same for all the volunteers, however, to work on individual needs, adjustments were made to the angle in which they were inserted in the apparatus, in order to provide greater or lesser resistance, according to the physical capacity of each subject. The maximum angle chosen was the one that allowed the subject to achieve total range of motion. The implementation of exercise followed the principles of Pilates. The subjects were taught by the instructor to inhale through their nose during relaxation and gently exhale through the mouth during the movement. Thus, the movements were performed slowly, at the individual’s own pace. Each exercise was performed for a maximum of ten repetitions. The intervention occurred during a period of eight consecutive weeks, with frequency of two weekly and each session lasted 1 h, according to the protocol used by Kaesler et al. (2007). After the intervention, all the participants (PG and CG) were re-evaluated and the tests were compared. The control group was not submitted to any kind of intervention.

Statistical treatment The descriptive analysis was carried out by calculating mean, median, standard error and standard deviation. For

Figure 5

Supine lower leg series.

Arms by the side.

Arms pull up and down.

the normal distribution analysis, the sample ShapiroeWilk test was used. The statistical comparison method for variables was the paired Student-t test or the Wilcoxon test (intragroup) and ANOVA 2  2 or KruskaleWallis (intergroup), followed by the Post Hoc de Shefee ´ or Manne Whitney tests, respectively. For all hypothesis tests, the alpha level for significance was 0.05 for rejection of the null hypothesis, as previously defined. Microsoft Excel 2007 and the BioEstat 5.0 statistical package (Ayres et al., 2008) were used to analyze data.

Results Table 1 presents the descriptive and inferential analysis of the sample’s static balance (Tinetti) using ShapiroeWilk test. Notably, the PG shows a heterogeneous distribution of data (p < 0.05). The Graph 1 presents the absolute D values. The Wilcoxon test demonstrated significant difference (p < 0.05) in the PG’s balance (p Z 0.0001). According to ManneWhitney test in the intergroup comparison, a difference in baseline was found of p Z 0.0626. The PG had significant improvement in post-test relation (p Z 0.0002). The descriptive and inferential ShapiroeWilk analysis of the sample’s personal autonomy is displayed in Table 2. PG shows a heterogeneous data distribution (p < 0.05) in the

Figure 7

Leg series on side, up and down.

Pilates method in personal autonomy, static balance and quality of life

Footwork for toes and heels.

C10M, LPDV, and LCLC variables and in IG score; whereas in the CG the only heterogeneously distributed variable was VTC. Graph 2 shows absolute D values of the PG and CG in relation to IG. In the intergroup comparison the baseline equivalence was observed and the post-PG  post-CG significant differences were observed in all tests, namely: C10m (p Z 0.0103); LPS (p Z 0.0164); LPDV (p Z 0.0001); VTC (p Z 0.0401); LCLC (p Z 0.0011) e IG (p Z 0.0003). Table 3 shows the descriptive and inferential Shapiroe Wilk analysis of quality of life (WHOQOL-OLD). PG has a heterogeneous data distribution (p < 0.05) in the following domains: DOM1, DOM4, DOM6 and QVG; whereas CG shows heterogeneous data distribution only in domain DOM6. Graph 3 shows absolute D values of QVG for PG and CG. The Wilcoxon test showed significant improvement in QVG of PG (p Z 0.0411). In the intergroup comparison, Student-t test showed a baseline difference in DOM5 (p Z 0.0483) and DOM6 (p Z 0.0108). The ManneWhitney test showed significant post-test improvement in the PG following domains: DOM4 (p Z 0.0428), DOM5 (p Z 0.0349) and DOM6 (p Z 0.0286); and Student-t test in QVG (p Z 0.0378). According to Sigmound (1964), the Pearson correlation coefficient (r) was significant in: Tinetti  C10m (r Z 0.384); Tinetti  DOM2 (r Z 0.428); IG  LPS (r Z 0.679); IG  LCLC (r Z 0.676); IG  LPDV (r Z 0.579); IG  VTC (r Z 0.854); IG  DOM3 (r Z 0.396); VTC  LPS (r Z 0.481); VTC  LPDV (r Z 0.459); LCLC  VTC (r Z 0.382); DOM5  LPS (r Z 0.438); QVG  DOM2 (r Z 0.566); QVG  DOM3 (r Z 0.566); QVG  DOM4 (r Z 0.614);

Figure 10

Gluteus and trunk raises.

QVG  DOM6 (r Z 0.614); DOM2  DOM6 (r Z 0.387); DOM3  DOM4 (r Z 0.029); DOM6  DOM3 (r Z 0.501); DOM3  VTC (r Z 0.399) and DOM6  VTC (r Z 0.434). The b error calculated in this paper was of 0.18. This result corresponds to a power experiment of 82%, remaining above the minimum acceptable that is 80% to control the type II error.

Discussion The maintenance of physical, psychic and social independence, often impacted by aging, is important in the preservation of personal autonomy and quality of life for elderly people. This preservation, according to studies, can be obtained by regularly practicing physical activity, which functions as an important factor for maintaining motor skills, preventing falls and improving quality of life for geriatric populations (Rogatto and Gobbi, 2001; Reeves et al., 2004), as has been observed in this research. The Pilates method is a mode of physical activity that offers resistance work, either using the subject’s own body weight or the springs that are applied in the method, supported by a philosophy of body consciousness that searches for harmony between body and mind. The principles of the Pilates methods include: centralization, control, concentration, fluidity of movement, precision and breathing (Anderson and Spector, 2000), offering its practitioner a global practice in stability and flexibility. As

Table 1 Descriptive and inferential analysis using ShapiroeWilk tests of PG and CG for static balance, in pre- and post-test conditions.

PG CG

Figure 9

Sit ups.

Pre Post Pre Post

Average  SD

SE

Median

SW p-value

23.85  1.49 24.88  1.07 22.04  2.89 22.36  2.63

0.29 0.21 0.58 0.53

24 25 23 22

0.009 0.084

PG: Pilates group; CG: Control group; SW: ShapiroeWilk; SE: standard error; SD: standard deviation; the unit of measure was: score (Tinetti).

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Graph 2 Comparative analysis of absolute D of PG’s and CG’s IG. *p < 0.0001 (PG-post  CG-post).

PREVENTION & REHABILITATIONeQUALITY OF LIFE RESEARCH

Graph 1 Comparative analysis of absolute D of PG’s and CG’s static balance. * p < 0.05 (PG-post  CG-post).

stimulation and postural stability to analyze the effects of the method in relation to static balance as indicated by this study. Personal autonomy was evaluated using the GDLAM protocol, which was developed especially for elderly people and is composed of measures of activities of daily living such as walking, standing up, and getting dressed (Dantas et al., 2004). Although previous studies have not used this protocol for evaluating Pilates practice, the results of this research show that through this method it was possible to see significant differences in levels of personal autonomy of the elderly participants, whereas the control group did not present significant results. According to previously performed studies, personal autonomy is dependent on variables such as strength, flexibility, coordination, balance, interpretation of sensorial stimulations, and cognitive capacity. The preservation or improvement of autonomy demands work that incorporates these variables. It was also demonstrated that physical activities can improve strength (Sekendiz et al., 2007), resistance (Kloubec, 2005), flexibility (Vale et al., 2005), balance and motor abilities Lange et al., 2000, (Silva et al., 2008) since they improve neural function, and strengthen the muscles of posture and the interpretation of sensory stimuli (Orr et al., 2006).

a result of its known benefits such as improved muscle strength and flexibility, Pilates has come to be studied as a physical activity method for older adults. This research indicated that the Pilates method can offer positive benefits in relation to static balance in the elderly, since the group that practiced the method showed post-test results that were more significant than CG results. These results can be explained by diverse factors. It is known that loss of balance is related to many factors, including reduced speed of muscular responsiveness (Orr et al., 2006), of strength (Heathcote, 2000) and proprioceptive information (Westlake et al., 2007), characteristic of aging. In previous studies it was demonstrated that Pilates method promotes increased strength (Schroeder et al., 2002), improves resistance (Kloubec, 2005), and that with respect to principles such as concentration, precision and control, it supplies constant proprioceptive stimulation during practice (Lange et al., 2000). Moreover, studies such as Kaesler’s (2007) indicate that the effect in relation to static balance can be a consequence of postural stability, reached by the harmony of opposing muscle groups. In this way, the effects related to muscles can be associated with the proprioceptive

Table 2 Descriptive and inferential analysis using ShapiroeWilk test of the functional autonomy of PG and CG in pre- and posttest conditions. Average  SD

C10M LPS LPDV VTC LCLC IG

Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post

SE

Median

SW p-value

PG

CG

PG

CG

PG

CG

PG

CG

7.60  1.68 6.89  1.60 10.47  2.22 9.23  2.27 4.20  0.93 3.11  0.80 14.30  3.31 12.31  2.57 34.99  4.99 31.07  6.01 27.21  3.85 23.58  3.96

7.56  1.12 7.59  1.21 10.70  1.95 10.58  2.19 4.44  0.96 4.59  1.10 12.95  1.78 13.21  1.89 36.65  4.70 36.69  4.89 26.96  3.37 27.19  3.58

1.68 1.60 2.22 2.27 0.93 0.80 3.32 2.57 4.99 6.01 3.85 3.96

1.12 1.21 1.95 2.19 0.96 1.10 1.78 1.89 4.70 4.89 3.37 3.58

7.22 6.49 10.71 9.12 4.07 3.02 14.04 12.18 35.69 29.8 26.66 22.47

7.29 7.29 10.19 10.47 4.47 4.85 13.09 13.26 37.34 36.59 26.91 27.05

0.001

0.042

0.198

0.209

0.001

0.080

0.056

0.175

0.070

0.438

0.035

0.125

C10m: walked of 10 m; LPS: to rise from a seated position; LPDV: to rise from a ventral decubitus position; VTC: to put on and to take off a shirt; LCLC: to rise out of a chair and to move freely through the house; IG: Index GDLAM; PG: Pilates group; CG: Control group; SW: ShapiroeWilk; SE: error standard; SD: standard deviation.

Pilates method in personal autonomy, static balance and quality of life

201

Table 3 Descriptive and inferential analysis of quality of life of PG and CG in pre- and post-test conditions using the Shapiroe Wilk test.

DOM1 DOM2 DOM3 DOM4 DOM5 DOM6 QVG

Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post

SE

MEDIANA

SW p-value

PG

CG

PG

CG

PG

CG

PG

CG

04.23  2.87 14.69  2.43 13.74  2.82 14.18  3.21 15.70  1.61 15.85  2.82 15.88  1.77 16.35  2.17 12.92  4.06 12.96  3.49 15.18  2.99 14.96  3.80 88.23  6.19 89.35  9.38

13.44  4.34 13.24  4.85 13.88  2.49 13.64  2.81 15.00  2.52 15.00  2.35 14.52  3.51 14.20  3.90 10.84  4.81 10.88  4.90 17.16  2.32 17.16  2.52 84.84  10.6 84.16  11.0

0.56 0.78 0.54 0.62 0.31 0.54 0.35 0.42 0.78 0.67 0.57 0.73 1.21 1.84

0.87 0.97 0.50 0.56 0.50 0.47 0.70 0.78 0.96 0.98 0.46 0.50 2.11 2.20

15 15 14 15 16 16 16 16 12 12 15 15 89 89

13 14 14 13 15 15 14 15 10 10 17 17 85 86

0.001

0.225

0.466

0.293

0.026

0.272

0.009

0.277

0.254

0.224

0.070

0.044

0.010

0.910

PG: Pilates group; CG: Control group; SW: ShapiroeWilk; SE: standard error; SD:standard deviation; DOM1: sensorial abilities; DOM2: autonomy; DOM3: past, present and future activities; DOM4: social participation; DOM5: death and dying; DOM6: privacy; QVG: quality of life index.

The Pilates method has already had proven results related to variables such as strength (Sekendiz et al., 2007), flexibility (Segal et al., 2004), balance (Johnson et al., 2007) and postural stability (Kaesler et al., 2007). So, the positive results found in this research, from the improvement in daily activities to the improvement of measured variables as a whole, can be attributed to the Pilates method, which is important for the development of necessary motor control. Concerning quality of life, we observed that there was a meaningful improvement in ratings of quality of life in the Pilates group but no meaningful difference in the control group, which comprises the evaluation of this variable. Several factors could explain this result. One issue is that quality of life is a subjective concept that is not exclusively associated with physical performance, but also associated with emotional and social conditions, although these are not essential objectives in the practice of Pilates. Moreover, it is possible to find correlations between the evaluation instruments, the short period of time for re-evaluation, the evaluation modality and objectives of exercises, as well as the participant’s self-esteem (Velchia et al., 2005).

Relevance of findings of this study. The aging of the world’s population suggests there is a need to reduce the functional limitations arising from the degeneration of the systems of older people, in order to attempt to preserve physical, psychological and social independence. Therefore, any scientifically validated techniques and procedures, that positively influence the lives of elderly people, have undeniable relevance. The results of this study offer reliable data suggesting that Pilates exercise can be used to promote an improvement in functional capacity, offering a positive influence on static balance and, consequently, an improved quality of life for elderly females. These results reflect the scientific evidence that Pilates improves the motor performance of aging people, reducing the time required to perform activities of daily living and, therefore, suggests a resource that can improve function and quality of life for older individuals.

Conclusion Based on this study it is possible to conclude that the practice of the Pilates method can improve the functional autonomy and static balance of elderly individuals. However, in relation to quality of life, we suggest that further studies be carried out using a more representative sample, and a longer period of intervention, to more precisely evaluate the results of the method with respect to this variable.

Conflict of interest Graph 3 Comparative analysis of absolute D in PG’s and CG’s QGV index. *p < 0.0001 (PG-post  CG-post).

The authors have no conflict of interest.

PREVENTION & REHABILITATIONeQUALITY OF LIFE RESEARCH

Average  SD

202

PREVENTION & REHABILITATIONeQUALITY OF LIFE RESEARCH

References Anderson, B.D., Spector, A., 2000. Introduction to Pilates-based rehabilitation. Orthopaedic Physical Therapy Clinics of North America 9 (3), 395e410. Andreotti, R., Okuma, S.S., 1999. Validac ¸˜ ao de uma bateria de testes de atividades da vida dia ´ria para idosos fisicamente independentes. Revista Paulista de Educac ¸˜ ao Fı´sica 13 (1), 46e66. Alexander, N.B., Ulbrich, J., Raheja, A., Channer, D., 1997. Rising from the floors in older adults. Journal of American Geriatrics Society 45 (5), 564e569. Ayres, M., et al., 2008. Bioestat Versa ˜o 5.0. Sociedade Civil de Mamiraua ´, MCT e CNPq, Bele ´m, Para ´, Brazil. Barnett, A., Smith, B., Lord, S.R., 2003. Community based group exercise improves balance and reduces falls in at-risk older people: a randomized controlled trial. Age and Ageing 32 (4), 407e414. Blum, C.L., 2002. Chiropractic and Pilates therapy for the treatment of adult scoliosis. Journal of Manipulative Physiological Therapeutics 25 (4). Dantas, E.H.M., Vale, R.G.S., Pernambuco, C.S., 2004. GDLAM’s protocol of functional autonomy evaluation. Fitness & Performance Journal 3 (3), 175e183. doi:10.3900/fpj.3.3.175.e. Fleck, M.P., Chachamovich, E., Trentini, C., 2006. Development and validation of the Portuguese version of the WHOQOL-OLD module. Revista de Sau ´de Pu ´blica 40 (5), 785e791. Grupo de Desenvolvimento Latino-americano para Maturidade (GDLAM), 2004. Discussa ˜o de estudo: conceitos de autonomia e independe ˆncia para o idoso Rio de Janeiro. Gagnon, L.H., 2005. Efficacy of Pilates exercises as therapeutic intervention in treating patients with low back pain. Tese de Doutorado. The University of Tennessee, Knoxville. Gladwell, V., Head, S., Haggar, M., Beneke, R., 2006. Does a program of Pilates improve chronic non-specific low back pain? Journal of Sport Rehabilitation 15, 338e350. Guralnik, M., Simonsick, E.M., Ferrucci, L., Glynn, R.J., Berkman, L.F., Blazer, D.G., et al., 1994. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. Journal of Gerontology 49 (2), M85eM94. Heathcote, G., 2000. Autonomy, health and ageing: transnational perspectives. Health Education Research 15 (1), 13e24. Johnson, E.G., Larsen, A., Ozawa, H., Wilson, C.A., Kennedy, K.L., 2007. The effects of Pilates-based exercise on dynamic balance in healthy adults. Journal of Bodywork and Movement Therapies 11, 238e242. doi:10.1016/j.jbmt.2006.08.008. Kaesler, D.S., Mellinfont, R.B., Swete, K., Taaffe, D.R., 2007. A novel balance exercise program for postural stability in older adults: a pilot study. Journal of Bodywork and Movement Therapies 11 (1), 37e43. doi:10.1016/j.jbmt.2006.05.003. Kloubec, J.A., 2005. Pilatesexercises for improvementofmuscleendurance, flexibility, balance and posture. Universityof Minnesota. Kura, G.G., Ribeiro, L.S.P., Niquetti, R., Tourinho Filho, H., 2004. ı de forc ¸a muscular Nı´vel de atividade fı´sica, IMC e ´ndices esta ´tica entre idosas praticantes de hidrogina ´stica e gina ´stica. Revista Brasileira de Cie ˆncias do Envelhecimento Humano, 30e40. Lange, C., Unnithan, V., Larkam, E., Latta, P.M., 2000. Pilates inspired exercise for learning functional motor skills. Journal of Bodywork and Movement Therapies 4 (2), 99e108. Lord, S.R., Ward, J.A., Williams, P., 1996. Exercise effect on dynamic stability in older women. A randomized control trial. Archives of Physical Medicine and Rehabilitation 77 (3), 232e236. Matsudo, M.S., Matsudo, V.K.R., Barros Neto, T.L., 2000. Impacto do envelhecimento nas varia ´veis antropome ´tricas, neuromotoras e metabo ´licas da aptida ˜o fı´sica. Revista Brasileira de Cie ˆncia e Movimento 8 (4).

B.G.de Siqueira Rodrigues et al. May, B.J., 2003. Mobility training for the older adult. Topics inGeriatricRehabilitation 19 (3), 191e198. Minayo, M.C.S., Hartz, Z.M.A., Buss, P.M., 2000. Qualidade de vida e sau ´rio. Cie ˆnciae Sau ´de: um debate necessa ´de Coletiva 5 (1), 7e18. Orr, R., Vos, N.J., Singh, N.A., Ross, D.A., 2006. Power training improves balance in healthy older adults. Journal of Gerontology 61A (01), 78. Petrofsky, J.S., Morris, A., Bonacci, J., Hanson, A., Jorritsma, R., Hill, J., 2005. Muscle use during exercise: a comparison of conventional weight equipment to Pilates with and without a resistive exercise device. Journal of Applied Research 5 (1). Pieron, M., 2004. Lifestyle, practice, of physical activity and sports, life quality. Fitness& Performance Journal 3 (1), 10e18. doi:10.3900/fpj.3.1.10.e. Rebelatto Jr., , Calvo, J.I., Orejuela Jr., , Portillo, J.C., 2006. Influe ¸a ˆncia de um programa de atividade fı´sica de longa durac ˜o sobre a forc ¸a muscular manual e a flexibilidade corporal de mulheres idosas. Revista Brasileira de Fisioterapia 10 (1), 127e132. Reeves, N.D., Narici, M.V., Maganaris, C.N., 2004. Effect of resistance training on skeletal muscle-specific force in elderly humans. Journal of Applied Physiology 96 (4), 885e892. Rogatto, G.P., Gobbi, S., 2001. Efeitos da atividade fı´sica regular sobre para ˆmetros antropome ´tricos e funcionais de mulheres jovens e idosas. Revista Brasileira deCineantropometriae Desempenho Humano 3 (1), 63e69. Schroeder, J.M., Crussemeyer, J.A., Newton, S.J., 2002. Flexibility and heart response to an acute Pilates reformer session. Medicine and Science in Sports and Exercise 34 (5), 258. Segal, N.A., Hein, J., Basford, J.R., 2004. The effects of Pilates training on flexibility and body composition: an observational study. Archives of Physical Medicine and Rehabilitation 85 (12), 1977e1981. Sekendiz, B., Altuna, O., Korkusuza, B., Akinb, S., 2007. Effects of Pilates exercise on trunk strength, endurance and flexibility in sedentary adult females. Journal of Bodywork and Movement Therapies 11 (4), 318e326. Sigmound, R., 1964. Estatı´stica na ˜o-parame ´trica. McGraw-Hill, Sa ˜o Paulo. Silva, A., Almeida, G.J.M., Cassolhas, R.C., Cohen, M., Paccin, M.S., Tifik, S., Mello, M.T., 2008. Equilı´brio, coordenac ¸a ˜o e agilidade de idosos submetidos a ` pra ´tica de exercı´cios fı´sicos resistidos. Revista Brasileira de Medicina do Esporte 14 (2). Spila ´, S., Multanen, J., Kallinen, M., Eera, P., Suominen, H., 1996. Effects of strength and endurance training on isometric muscle strength and walking speed in elderly women. Acta Physiologica Scandinavica 156, 457e464. Siren, A., Hakamies-Blomqvist, L., 2009. Mobility and well-being in old age. Topics in Geriatric Rehabilitation 25 (1), 3e11. Tinetti, M.E., 1986. Performance-oriented assessment of mobility problems in elderly patients. Journal of American Geriatrics Society 34, 19e26. Vale, R.G.S., Novaes, J.S., Dantas, E.H.M., 2005. Efeitos do treinamento de forc ¸a e de flexibilidade sobre a autonomia de mulheres senescentes. Revista Brasileira de Cineantropometriae Desempenho Humano 13 (2), 33e40. Vale, R.G.S., Pernambuco, C.S., Novaes, J.S., Dantas, E.H.M., 2006. Teste de autonomia funcional: vestir e tirar uma camiseta (VTC). Revista Brasileira de Cie ˆnciae Movimento 14 (3), 71e78. Velchia, R.D., Ruiz, T., Bocchi, S.C.M., Corrente, J.E., 2005. Qualidade de vida na terceira idade: um conceito subjetivo. Revista Brasileira de Epidemiologia 8 (3), 246e252. WMA - World Medical Association. Declaration of Helsinki. http:// www.wma.net/e/policy/b3.htm (acess in 04/06/2008). Westlake, K.P., Wuy, Y., Culham, E.G., 2007. Sensory-specific balance training in older adults: effect on position, movement, and velocity sense at the ankle. Physical Therapy 87, 560e568.

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SELF-MANAGEMENT: PATIENT SECTION

Postural exercises on the foam roll Craig Liebenson L.A. Sports & Spine, 10474 Santa Monica Blvd., # 304, Los Angeles, CA 90025, USA Accepted 14 December 2009 Upright posture is a challenge to maintain. Chairs, desks, and computers all conspire with gravity to round our back and shoulders forward. Stress also is often felt as a ‘‘weight of the world’’ on our shoulders. For all these reasons and more, upright posture is hard to maintain. Our upright posture develops gradually from the fetal position in the womb. By 1 month of life an infant can raise the head to look straight ahead. By 3 months, an infant arches the low back into extension away from the fetal, slumped forward posture. By the end of the first year, supported upright walking is possible and by 4 years old most young children can stand upright like an adult and balance on 1 leg. Unfortunately, excessive sitting at desks in our schools, and slouching on soft chairs and couches at home in front of the television poison this innate upright posture that we achieve. Slumping, slouching and stooping become a programmed habit. The effects of poor posture are seen everywhere, and include loss of energy, headaches, neck or back pain, pinched nerves, etc. This self-care hand-out will show you how to utilize a foam roll to gain better conscious awareness of good posture so that this will again become a subconscious habit in all your daily activities. These exercises are designed to help you compensate for the environmental pollution of prolonged sitting and sedentarism. They act like a computer anti-virus program!

Vertical Foam Roll Start Position (see Figure 1) - Start on your back - Hands at your sides and palms up - Breathe in and out from your abdomen - Reps: 2e3 breaths - What you should feel: B Feel your abdomen moving in with each exhalation, and out with each inhalation B Feel your shoulders falling back towards the floor

Basics of Exercise  Exercise is generally safe  Mild discomfort is alright  If you feel more pain, stop the exercise  Perform slowly, with good form  Breathe normally  Frequency: Twice/day E-mail address: [email protected] 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.02.003

Figure 1

Vertical Foam Roll e Start Position.

Arms Overhead (see Figure 2) - Raise your arms overhead - Be sure the back of your hands are on the floor - If not, then lower your arms - Reps: Hold for 1e2 breaths - What you should feel: B Feel your abdomen moving in with each exhalation, and out with each inhalation B Feel your chest and shoulders stretching - Note: If you feel excessive or persistent pain in the front of your shoulder(s) then lower your arms until you don’t feel discomfort

PREVENTION & REHABILITATIONeSELF-MANAGEMENT: PATIENT SECTION

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204

C. Liebenson

PREVENTION & REHABILITATIONeSELF-MANAGEMENT: PATIENT SECTION

Horizontal Foam Roll (see Figure 5) - Extend your back over the foam roll - Keep your chin tucked in - Stretch and roll - Reps: Roll back and 8e10 times - What you should feel: B Feel your upper back stretching backwards Figure 2

Vertical Foam Roll e Arms Overhead.

Chest Presses (see Figure 3) - Hold a medicine ball in your hands - Press the ball all the way up to the ceiling - Keep your neck relaxed on the foam roll - Reps: Perform 5e6 repetitions - What you should feel: B Feel your chest and arm muscles working Figure 5

Horizontal Foam Roll.

- Common mistake to avoid: B Not arching back far enough B Poking your chin out (see Figure 6)

Figure 6 Horizontal Foam Roll e Common Mistake e poking chin and not extending spine.

Upper Back Cat (See Figure 7) Figure 3

a,b e Vertical Foam Roll e Chest Presses.

- Common mistake to avoid: B Pressing up part way (see Figure 4)

Figure 4 Vertical Foam Roll e Chest Press e Common Mistake e failing to reach up all the way.

Figure 7

a,b e Upper Back Cat

205

- Place your wrists on the foam roll - Round your back up (letting your head hang relaxed) and breathe in - Let your chest drop down and breathe out. Hold this position for another breath in and out - Reps: Perform 5e6 repetitions - What you should feel: B Focus on feeling your upper back and chest stretching down towards the floor B Feel the front of your shoulders stretching - Common mistake to avoid: B Shrugging your shoulders up towards your ears (see Figure 8) - Note: If you feel excessive or persistent pain in the front of your shoulder(s) when you drop your chest down, then discontinue this stretch

Figure 8 a,b e Upper Back Cat e Common Mistake e shrugging the shoulders.

PREVENTION & REHABILITATIONeSELF-MANAGEMENT: PATIENT SECTION

Postural exercises on the foam roll

Journal of

Official journal of the: ® Association of Neuromuscular Therapists, Ireland ® Australian Pilates Method Association ® National Association of Myofascial Trigger Point Therapists, USA ® Pilates Foundation, UK

Volume 14 Issue 3 2010

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 John Hannon DC San Luis Obispo, CA, USA ( [email protected])

Dimitrios Kostopoulos PhD, DSc, PT Hands-on Physical Therapy, New York, NY, USA ([email protected])

Glenn M. Hymel EdD, LMT Department of Psychology, Loyola University, New Orleans, LA, USA ([email protected])

Craig Liebenson DC Los Angeles, CA, USA ([email protected])

ASSOCIATE EDITORS: PREVENTION & REHABILITATION Matt Wallden MSc, Ost, Med, DO, ND London, UK ([email protected])

Warrick McNeill MCSP London, UK ([email protected]) International Advisory Board D. Beales MD (Cirencester, UK) G. Bove DC, PhD (Kennebunkport, ME, USA) 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. G. Simons MD (Covington, GA, USA) D. Thompson LMP (Seattle, WA, USA) C. Traole MCSP, SRP, MAACP (London, UK) E. Wilson BA MCSP SRP (York, UK) A. Vleeming PhD (Rotterdam, The Netherlands)

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EDITORIAL

Clinical prediction rules A trend in manual therapy has been the development of Clinical Prediction Rules (CPR). CPRs are derived statistically e literally “translated” from research evidence e with the aim of identifying the combinations of clinical examination findings that can predict a condition or outcome. (Fritz et al., 2003; Fritz, 2009; Cook, 2008) Falk and Fahey (2009) summarise the key element of CPR as follows: “Clinical prediction rules quantify the contribution of symptoms, clinical signs, and available diagnostic tests, and stratify patients according to the probability of having a target disorder. The outcome of interest can be diverse and be anywhere along the diagnostic, prognostic, and therapeutic spectrum”. In manual and movement therapies, this might translate into a focus on particular problems, such as nonspecific low-back pain (LBP), as well as those patients enduring this condition. This would allow a degree of categorization e so predicting which forms of treatment would be most likely to be of benefit to LBP in general, and/or which specific subgroups of patients with LBP should be targeted with particular therapeutic approaches. What though is the reliability of such prediction? And what is the reliability of the tests involved in producing categorization? Paatelma et al. (2009) examined Inter-tester reliability in classifying sub-acute low-back-pain patients, comparing specialist and non-specialist examiners. They observed that: “Although a number of LBP classification systems have been proposed, such as a pathoanatomical/pathophysiological classification system, the McKenzie classification, treatment-based classification, and the movement-impairment classification, what is still unclear is which clinical tests between two assessing clinicians are sufficiently reliable to allow subgroup categorization. The reliability and validity of the overall classification systems has been tested and has been reported as moderate or good”. Not surprisingly, the better trained the individual practitioners, the more accurate the findings. As to the reliability of tests used for placing types of low-back pain, into separate groupings, the evidence is variable. Paatelma et al. (2009) summarise the current situation as follows: 1360-8592/$36 ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.04.005

   

Discogenic and sacroiliac joint pain: fair to good Segmental dysfunction/facet pain: poor Clinical lumbar instability: poor to good Clinical central or lateral stenosis: no reliable clinical tests, however a self-reported history questionnaire has been shown to be a useful diagnostic tool for lumbar spinal stenosis

A further obvious question is whether or not classification of different types of low-back pain actually improves clinical outcomes? In a study involving over 2000 patients with ‘mechanical low-back pain’, in which there was no direct reference to anatomic site, or pathological process, Hall et al. (2009) observed that: “The identification of clinical syndromes directed treatment; there was no reference to specific pathology. This approach had a strong positive effect on outcomes for pain relief, reduced medication use, improved function, and shortened length of treatment”. Lee and Lee (in press), caution that while useful as part of decision making CPRs should not replace clinical judgement e and should be seen as complementary to that process e which needs to involve experience, clinical opinion, intuition as well as research evidence. It is important to acknowledge that while statistical evidence tells us about the average response of a group, defined by the characteristics used in design of the study, in practice, individual symptoms and circumstances may be identified to a greater or lesser degree than such averages suggest would be the case e or might even present quite differently. Most experienced clinicians are well aware of patients they have seen who display symptoms and characteristics that are not the same as those suggested by data from clinical trials e and that these individual cases may indeed offer insights that can lead to research questions being generated. It is also useful to acknowledge that information deriving from research may at times be subject to bias during the process of interpretation as conclusions are drawn. It is a truism to state that a lack of evidence does not invalidate a technique, or an approach that has been shown by

208 experience to have clinical value, even if it does not quite fit with clinical prediction rules.

References Cook, C., 2008. Potential pitfalls of clinical prediction rules. Journal of Manual & Manipulative Therapy 16 (2), 69. Falk, G., Fahey, T., 2009. Clinical prediction rules. British Medical Journal 339, b2899. Fritz, J.M., Delitto, A., Erhard, R., 2003. Comparison of a classification-based approach to physical therapy and therapy based on clinical practice guidelines for patients with acute low back pain: a randomized clinical trial. Spine 28, 1363e1372. Fritz, J.M., 2009. Clinical prediction rules in physical therapy: coming of age? JOSPT 39 (3), 159.

Editorial Hall, H., McIntosh, G., Boyle, C., 2009. Effectiveness of a low back pain classification system. The Spine Journal 9, 648e657. Lee, D., Lee, L.-J. Differential diagnosis and management of chronic pelvic pain. In: Chaitow, L., Lovegrove, R. (Eds.), Chronic Pelvic Pain & Dysfunction, Churchill-Livingstone, Edinburgh, in press. Paatelma, M., Karvqnen, E., Heinqnen, A., 2009. Inter-tester reliability in classifying acute and subacute low back pain patients into clinical subgroups: a comparison of specialists and nonspecialists. Journal of Manual & Manipulative Therapy 17 (4), 221e229.

Leon Chaitow, ND DO, Editor-in-Chief, University of Westminster, London, UK E-mail address: [email protected]

Journal of Bodywork & Movement Therapies (2010) 14, 209e218

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

DANCE: PSYCHO-PHYSICAL EFFECTS

Greek traditional dances and quality of old people’s life Fotios H. Mavrovouniotis*, Eirini A. Argiriadou, Christina S. Papaioannou Sports Medicine Laboratory, Department of Physical Education & Sport Science, Aristotle University, Str. Makrigianni 20, Thessaloniki 54635, Greece Received 14 June 2008; received in revised form 16 September 2008; accepted 11 November 2008

KEYWORDS Elderly; Aerobic exercise; Psychosomatic responses; Mood state; State anxiety

Summary The aim of the present study was to examine the effect of Greek traditional dances on the improvement of old people’s quality of life. A hundred and eleven subjects (75 women and 36 men) 60e91 years old, were divided into an experimental group (n Z 76) which participated in Greek traditional dances and a control group (n Z 35) which was discussing and watching television, both for 1 h. The Subjective Exercise Experiences Scale [McAuley, E., Courneya, K., 1994. The Subjective Exercise Experiences Scale (SEES): development and preliminary validation. Journal of Sport and Exercise Psychology 16, 163e177] was used to measure positive well-being, psychological distress, and fatigue and the State-Trait Anxiety Inventory [Spielberger, C.D., Gorsuch, R., Lushene, R., 1970. Manual for the State-trait Anxiety Inventory. Consulting Psychologists, Palo Alto] to measure state and trait anxiety respectively. Correlational analyses, between the various measures taken postdance, showed that the overall set of relations between the SEES subscales and the SAI-Y1 subscale supports the criterion-related validity of this measure of exercise-induced psychological responses. The independent groups t-tests showed that the control group in comparison to experimental group, at rest as well as on the second measurement, has significantly higher levels of state anxiety (t Z 4.45, p < 0.001 & t Z 6.56, p < 0.001), psychological distress (t Z 4.30, p < 0.001 & t Z 5.46, p < 0.001), and fatigue (t Z 3.16, p < 0.01 & t Z 3.46, p < 0.001), while it has significantly lower levels of positive well-being (t Z 4.23, p < 0.001 & t Z 6.90, p < 0.001). After dancing approximately 63% of maximum heart rate of experimental group was activated, while from paired t-tests significant decreases in state anxiety (t Z 5.02, p < 0.001) and psychological distress (t Z 3.14, p < 0.01) were observed, as well as significant increases in positive well-being (t Z 4.44, p < 0.001) and fatigue (t Z 2.15, p < 0.05). On the other hand, no significant difference in control group was observed. Consequently, Greek traditional dances may be used as a functional psychophysical activity, to produce both physical and mental benefits for elderly individuals. ª 2008 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: þ30 32310707410/32310992184/32310992187, 6947521795 (mobile); fax: þ30 32310992183/32310707410. E-mail address: [email protected] (F.H. Mavrovouniotis). 1360-8592/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2008.11.005

210

Introduction Lifestyle modulates health state and blunts the changes that derive as a result of old age. However, most old people acquire the habit of sedentary life, which is characterized by intense lack of any form of physical activity (Berger and Hecht, 1989; Berger and McInman, 1993; Duda and Tappe, 1988; Smith and Serfass, 1981). Thus, the functional ability low level, that is observed in many old people, is not the result of old age, but the result of their lifestyle (Vuori, 1995), and certainly of sedentary life. Physical activity, on the other hand, is necessary for the maintenance of physical health and psychological wellbeing (Berger, 1996; Blair, 1995). The body should move and, an active lifestyle that leads to adaptations allows individuals to move comfortably (Theodorakis, 1990). Today, more and more people learn and understand the importance of regular physical exercise in their life, particularly the importance of remaining physically active throughout their life span. The participation in physical activities constitutes an important factor that contributes to psychological balance, promotes psychological state (Berger et al., 1993, 1998; Craft, 2005; Dimeo et al., 2001; International Society of Sport Psychology, 1992; Landers and Arent, 2001; Lawlor and Hopker, 2001; Morgan and O’Connor, 1988) and is the best preventive means for chronic diseases such as arteriosclerosis, hypertension, cardiovascular diseases, mellitus diabetes type II, osteoarthritis, osteoporosis, obesity, some forms of cancer, disturbances in the peptic system, as well as for premature mortality, functional limitations, and disability (Antonakoudis and Antonakoudis, 2003; Nelson et al., 2007; Paffenbarger, 1996). Consequently, regular, moderate physical activity contributes positively to the maintenance not only of physical, but, also, of mental and psychological health of children and adults, as well as that of middle-aged and elderly people (Berger and Hecht, 1989; Berger and McInman, 1993; Ekkekakis et al., 2000; Duda and Tappe, 1988; Ostrow, 1989; Smith and Serfass, 1981; Tucker, 1990). More specifically, the old people who participate in kinetic and not competitive activities have higher levels of mood state, mental alertness and physical improvement, are satisfied with their life, rejoice bigger intervals of independence and autonomy, and generally live more happily (Mahon and Searle, 1994). In addition the physical well-being feeling that exercise ensures also results in psychological balance, leading to relaxation, absence of unnecessary anxiety and to a feeling of completion (Spantideas, 2003). Therefore, it is imperative for a healthy person to remain active and vivid throughout his life and especially after his 60s in order for him/her to delay the loss of his/her organ function (Avlonitou, 2002). Consequently, with a view to promoting health and wellbeing, such programs have been implemented in the Centres of Old People’s Open Protection (C.O.P.O.P.) and health care centres in the U.S.A. as well as in Europe (Kerr and Van den Wollenderg, 1997). The purpose of these centres is to prevent old people’s physical, psychological and social problems, in order for them to remain independent and active (http://www.thessalonikicity.gr/

F.H. Mavrovouniotis et al. Koinonikes-ypiresies/koinonika/kaph.htm). As far as the choices of exercise forms are concerned, there is fortunately a variety of training options for the elderly participating in exercise programs. These include group or individual walking programs, aerobic-exercise classes, chair-seated exercises, personal training, balance training, aquatics, relaxation classes, and active hobbies such as gardening or square dancing, or simply integrating more physical activity into the daily routine of the elderly (American Council on Exercise, 1998). Similar exercise programs in Greece offer aerobic activities and traditional dance learning (Alexandris et al., 2007). However, in fact only few old people take part in these activities in Greece (Harahousou, 1999). The statistics of Eurobarometer (http://www.ec.europa.eu) indicate that older Greek individuals’ (more than 65 years old) participation rates in physical activities are on the average of the European Union members, with around 50% of them reporting no participation in any form of moderate physical activity in the contexts of work, home, and leisure. However, the percentage of physical inactivity during leisure time for older people in Greece is among the highest in the European Union. Less than 9% of the individuals reported regular participation in leisure time physical activities/recreation. In this direction, the C.O.P.O.P., these important capitularies give a chance to the elderly and via social care, to make their free time productive, cultivate their interests, participate in the life of the community and maintain active living (Kostaridou-Efklides, 1999). The C.O.P.O.P. provide leisure and recreation opportunities and a variety of activities for middle-aged and old individuals. The members can choose from a variety of activities, such as social gatherings, seminars, leisure trips, exercise programs and programs of Greek traditional dances (Alexandris et al., 2007). Dancing plays an important role for the old people because they have the chance to enjoy, as they used to when they were young (Atchley, 1993). Additionally, dancing has been their basic social activity from their adolescence to their aging (Cooper and Thomas, 2002). Since Greek traditional dancing is an integral part of Greek culture. Moreover, it is one of the most indicative characteristics of temperament, history and cultural identity of Greeks because it is connected with the same spontaneous, instinctive expression of human mind and body. Greek traditional dance, music and singing are not just social life expressions and depictions, but also organic and integral elements of social life (Filias, 1999). At the same time, the Greek traditional dance is a familiar and popular activity with elderly Greek people. In relation to exercise intensity, for safety reasons, lowimpact rather than high-impact modes of aerobic activity are recommended for older-adult participants, so that possible orthopedic problems and cardiovascular implications are avoided (Pollock et al., 1991). An intensity level of 30%e75% VO2max (with a Rate of Perceived Exertion of 12e 14 on the Borg 6-to-20 Perceived Exertion Scale) sustained for 30e60 min is recommended for older adults (American College of Sports Medicine, 1995; Pollock et al., 1994). In fact, lower-intensity but longer-duration aerobic exercise is much more beneficial compared to higher-intensity but shorter-duration exercise (American College of Sports Medicine, 1991; Swart et al., 1996).

Greek traditional dances and quality

211

Dancing is a recreational activity and leads to a calorie loss that amounts to 300e360 kcal/h, when dancing in a low intensity pace. On the contrary, when dancing in a more intensive way we may burn from 420 to 480 kcal/h (Byrne, 1991; Klissouras, 2004; Papanikolaou, 1993). Moreover, it is a fact that dancing in the form of a physical activity of moderate intensity, of approximately 3e5 METs, contributes to the improvement of physical fitness (Balady and Weiner, 1987; Klissouras, 2004). It appears, therefore, that dancing is advisable as an appropriate form of physical activity in the application of programs for the elderly. However, although the effects of aerobic exercise on people’s psychological state have been studied adequately (Colussi, 2002; Ekkekakis and Petruzzello, 1999; Maroulakis and Zervas, 1993; Ritter and Low, 1996), the effects of dance, and more specifically the acute effects of Greek traditional dances, have not been studied sufficiently, yet especially with reference to old people’s psychological state. Concluding, the purpose of this study is to address this issue to old people’s psychological state, by examining the pre- and post-dancing levels of mood and anxiety. Moreover, the present study examines the effects of Greek traditional dances on old people’s physical state by measuring the heart rate not only pre- and post- the dancing session, but also in the middle of it.

Finally, a hundred and eleven (111) healthy members of the five different C.O.P.O.P. (75 women and 36 men) participated in the research. The subjects ranged from 60 to 91 years of age (M Z 69.79, SD Z 7.18). They were, then, divided into an experimental (Group A) (n Z 76) and a control group (Group B) (n Z 35), according to the following criteria: a) the subjects who were visiting the C.O.P.O.P. in order to socialize with other members, watch television, have fun and enjoy themselves, as well as participating in one group dancing program for learning and performing Greek traditional dances to the C.O.P.O.P. and no other dancing or exercise program, constitute Group A, b) the subjects who didn’t participate in any program of dancing or exercise, but were visiting the C.O.P.O.P. only in order to socialize with other members, watch television, have fun and enjoy themselves, constitute Group B. Chatting and watching TV are the main activities for the members of a C.O.P.O.P. Consequently, the two different groups were in all respects identical, and the control group was a group matched with the experimental group, except for the participation in the dancing program for learning and performing Greek traditional dances, which however is the factor who have been willing to investigate. It should, also, be noted that the subjects of the experimental group on the time of the research conducted have managed to complete almost a 10-week traditional dancing course.

Method

Procedure

Sample

An approval for the conduct of the research was given from the committee of each C.O.P.O.P., after the aim and the design of the research were described. Procedures were in agreement with ethical standards of the Declaration of Helsinki of the World Medical Association (2000). Before the beginning of the research, a description of general requirements was given and, still, the aim of the research was described to the participants without any briefing relative to previous research findings. The psychological instruments were also presented and the instructions were explained for each one of them. The need for absolute honesty and precision was particularly emphasized. Moreover, the subjects of the experimental group received one-hour preparatory session, on methods of heart rate (HR) measurement and procedural details (Zervas et al., 1993). During this session, the subjects were trained to self-measure their HR using the palpation method, the most popular and practical method of HR measurement. The palpation method is appropriate for the HR measurement at rest and also after exercise, as in healthy individuals HR and pulse are exactly similar sizes (Corbin et al., 2001; McArdle et al., 2001). The wrist location (radial artery) was chosen, instead of the neck (carotid artery), because if a subject (especially if older than 65) press too hard on the carotid artery may become lightheaded and fall. The subjects learned to place their index and middle fingers, not the thumb, together on the wrist of the other hand, about ½ inch on the inside of the joint, in line with the index finger, so they could feel the pulse (Corbin et al., 2001; Nagashio et al., 2003). After the subjects practiced taking HR, the accuracy of their HR measurement was checked by pre-trained assistants.

Elderly people from five different C.O.P.O.P. from the city of Thessaloniki, were used. We randomly selected 50 people from each centre who fulfilled all the inclusion criteria such as participating only in a dancing program for learning and performing Greek traditional dances at the C.O.P.O.P. or/and visiting the C.O.P.O.P. in order for them to socialize and discuss with other members, watch television, have fun and enjoy themselves. A communication/ invitation to each chosen member, with regard to the research was made. After the above, a total of a hundred and twenty-five (125) members volunteered to participate in the research. A written informed consent for the participation in the research was obtained from each subject. All the subjects, prior to the beginning of the research, underwent medical control so that it could be certified that they do not suffer from any cardiovascular or other disease and, also, that they do not take any medication. Additionally, they answered a questionnaire about their personal medical history and any health problem, while a research assistant was present in order to give any essential clarifications if he was asked to. Fourteen subjects who were found to fulfil the exclusion criteria, that is health problems, such as recent complicated myocardial infarction, unstable angina, serious dysrhythmias, acute pericarditis or myocarditis, endocarditis, severe aortic or mitral stenosis or other forms of acute cardiopulmonary illness, etc. (American College of Sports Medicine, 1995; Hanson, 1984) or/and medication that could affect the results, or/and extra participation in exercise programs, were excluded from the research.

212 In continuity, the subjects of the experimental group participated in a group program of Greek traditional dances performance, at the C.O.P.O.P. where they were members. Each session of Greek traditional dances was conducted by teachers of physical education with extensive practical experience and was exactly the same in all C.O.P.O.P., with regard to the dances, the number of dances, their duration and the accompanying music, as well as the number and duration of breaks. The performed Greek traditional dances were from different areas of Greece. In order to begin to dance the subjects were holding each other from the hands, creating a hemi-cycle. The performed dances included a variety of simple kinetic patterns with music accompaniment. The dances intensity ranged from low to moderate, with frequent rhythm alternations, so that the subjects could keep dancing continuously throughout the dance session. Essential breaks of approximately 10 s in between dances in order to change dance were made. The duration of each dance was about 2.5e3 min. The session duration was 60 min in total. The subjects of the control group, on the other hand, were asked to stay in a room all together, free to discuss with each other or watch television. The discussing and watching TV session duration was 60 min in total.

Scales of measurement The Subjective Exercise Experiences Scale (SEES; McAuley and Courneya, 1994), which constitutes a measurement of global psychological responses, to the stimulus properties of exercise, was used. The scale facility and brevity allows its fast and repeated use by the researchers even during exercise. The scale is composed of 12 items that represent three factors. Two of these factors, positive well-being and psychological distress, correspond to the positive and negative poles associated with psychological health, whereas the third factor represents subjective indicants of Fatigue. The three-factor structure originally established by exploratory factor analysis using young adults was also supported in middle-aged exercising adults (McAuley and Courneya, 1994), as well as in the present sample. Additionally, SEES, in the present study, demonstrated acceptable internal consistency (a ranges from 0.73 to 0.90). SEES was completed about 5 min before and after the Greek traditional dances performance and the discussing and watching TV session. Moreover, State-Trait Anxiety Inventory (SAI; Spielberger et al., 1970) was used, for the measurement of anxiety. All subjects completed the 20-item trait anxiety subscale, SAIY2, for trait anxiety measurement once, just about 5 min before the Greek traditional dances session and the discussing and watching TV session, with score ranging from 20 to 80 degrees. The 20-item state anxiety subscale, SAI-Y1 was also completed about 5 min before and after the Greek traditional dances performance and the discussing and watching TV session, for state anxiety measurement, with score ranging from 20 to 80 degrees. SEES and SAI were administered in a counterbalanced order, which was reversed at the posttest and translated in Greek following a standard procedure involving the discussion of multiple alternative wordings by a group of five bilingual experts.

F.H. Mavrovouniotis et al.

Heart rate measurement HR response to dancing was monitored for assessing workout intensity. So, just before the dancing session the subjects self-measured their baseline HR during two 10-s periods. On the 30th minute, the performance of the Greek traditional dances was interrupted for a period of no longer than 1:00e1:30 min, during which the subjects measured their HR. Moreover, the subjects self-measured their HR immediately after the end of the Greek traditional dances session during two 10-speriods, too. The teachers of physical education and pre-trained assistants supervised the HR measurements after averaging the two HRs. The intensity of Greek traditional dances was estimated by comparing individual HRpeaks to age-predicted HRmax according to Tanaka et al. (2001) formula.

Data analysis For the statistical analysis the statistic packet SPSS/PC Version 15.0 for windows was used. Descriptive analysis was used. The non-parametric test KolmogoroveSmirnov was used to evaluate the normal distribution of the sample. In addition, the paired t-test was used to evaluate significant differences between measurements, that is before and after the Greek traditional dances, and before and after the discussing and TV watching session, while the independent groups’ t-test was used to evaluate significant differences between groups. Moreover, correlational analyses between the various measures taken postdance for experimental group were conducted to determine the degree to which such measures were or were not associated, thereby providing an index of both convergent and discriminant validity for the SEES and SAI-Y1. The level of significance was set to p < 0.05.

Results In Table 1 the anthropomorphological characteristics and, also, trait anxiety of the subjects of both groups are presented. From SAI-Y2 elaboration, it was found out that Group A had low trait anxiety, while Group B had more increased trait anxiety (see Table 1). In Figure 1 the minimum, maximum, and mean values of the HR of subjects of Group A at rest, as well as at 30 and 60 min of the Greek traditional dances bout, are presented. With this way, the subjects’ HR alteration during Greek traditional dances bout is shown. As it is observed, while at

Table 1

Sample’s characteristics.

Parameters

Group A (experimental) Mean  SD

Group B (control) Mean  SD

Age (years) Height (cm) Weight (kg) Body Mass Index (kg/m2) Trait anxiety (degrees)

67.62  6.29 163.32  8.33 74.55  10.40 28.03  3.94 32.01  10.16

74.51  6.78 169.34  5.50 77.57  8.57 27.04  2.79 43.46  11.40

Greek traditional dances and quality mean

Before the dancing session

maximum

140 130 120 110 100 90 80 70 60

25

rest

30min

60min

20 15 10 5 0

Figure 1 HR alteration during Greek traditional dances bout (Group A).

State Anxiety

Figure 2

rest the subjects presented HR 75.6 bpm and reached at the end of the Greek traditional dances bout, that is after 60 min, 103.92 bpm a HR that is within the range of training zone for the age of 70 (American College of Sports Medicine, 1991; Chase http://plu.edu/wchasega/main.htm). This increase represents approximately 63% of HRmax (see Figure 1). Descriptive statistics for each measure assessed prior to and following the dance bout and the significance of any demonstrated change of Group A are shown in Figure 2 and Table 2. In regard to SEES, according to data processing, it was obvious that there was an increase in the positive factor positive well-being, while there was a decrease in the negative factor psychological distress. Furthermore, the subjective indicators of fatigue showed an increase, while the state anxiety score from the SAI-Y1 presented a decrease, after the Greek traditional dances performance (see Figure 2). Moreover, from paired t-tests it was found out that all factors of the SEES, as well as the state anxiety score from the SAI-Y1, were significantly influenced by the Greek traditional dances bout (see Table 2). As it can be seen, these changes that are observed after the performance of the Greek traditional dances generally reflect increases in positive responses and fatigue and decreases in negative responses. Although all of these changes are relatively modest in magnitude, they are all statistically significant. More specifically, the greatest influence on psychological responses noted to be evidenced in the psychological distress dimension (12.79% decrease, t Z 3.14, p < 0.01), state anxiety (10.50% decrease, t Z 5.02, p < 0.001) and fatigue (9.55% increase, t Z 2.15, p < 0.05). However, the increase in positive well-being, although relatively small

Table 2 dances.

After the dancing session

30

degrees

bpm

minimum

213

Pos. well-being

Psychol. distress

Fatigue

Alterations to SAI-Y1 and SEES factors for Group A.

(6.28%), was, also, statistically significant (t Z 4.44, p < 0.001). Descriptive statistics for each measure assessed prior to and following the discussing and TV watching session and the significance of any demonstrated change of Group B are shown in Figure 3 and Table 3. In regard to SEES, according to data processing, it was obvious that small changes were recorded in the positive factor positive well-being, the negative factor psychological distress, the subjective indicators of fatigue, as well as in the state anxiety score from the SAI-Y1, after the discussing and TV watching session (see Figure 3). Additionally, paired t-tests between the various measures taken before and after the discussing and TV watching session were then conducted to determine possible differences between the measurements. It was found out that all factors of the SEES, that is positive wellbeing (t Z 0.18, p > 0.05), psychological distress (t Z 0.14, p > 0.05), and fatigue (t Z 0.84, p > 0.05), as well as the state anxiety score from the SAI-Y1 (t Z 1.03, p > 0.05), were not significantly influenced by the discussing and TV watching session, but they stayed quite unchangeable (see Table 3). In Figure 4 the differences between the two groups are presented. As can be seen, there are differences in all the studied variables, at rest as well as after the dancing and the discussing and TV watching session. The independent groups’ t-tests which used to evaluate significant differences between the two groups showed that the observed differences are significant differences both at the first measurement (rest) and at the second measurement (after the dancing and after the discussing and TV watching).

Descriptive data, and degree of change for SAI-Y1, and SEES for Group A, before and after the Greek traditional

Affect Measure

Pretest

Posttest

Change

t

p

M

SD

M

SD

M

SD

SAI-Y1 State anxiety

29.80

10.76

26.67

8.69

3.13

5.44

5.02

<0.001

SEES Positive well-being Psychological distress Fatigue

24.49 6.41 8.17

4.70 4.08 5.99

26.03 5.59 8.94

3.79 3.43 5.38

1.54 0.82 0.78

3.02 2.26 3.15

4.44 3.14 2.15

<0.001 <0.01 <0.05

214

F.H. Mavrovouniotis et al. Before the discussing and tv watching session

After the discussing and tv watching session

40 35

Affect Measure

30

degrees

Table 3 Descriptive data, and degree of change for SAIY1, and SEES for Group B, before and after the discussing and TV watching session.

25

Posttest

Change

M

M

M

SD

SD

15 10 5 0 State Anxiety

Pos. well-being

Psychol. distress

Fatigue

Alterations to SAI-Y1 and SEES factors for Group B.

More specifically, at rest there were observed statistically significant differences between the two groups in terms of trait anxiety (t Z 5.30, p < 0.001), state anxiety (t Z 4.45, p < 0.001), positive well-being (t Z 4.23, p < 0.001), psychological distress (t Z 4.30, p < 0.001), and fatigue (t Z 3.16, p < 0.01). After the dancing and the discussing and TV watching session there were observed statistically significant differences between the two groups in terms of state anxiety (t Z 6.56, p < 0.001), positive well-being (t Z 6.90, p < 0.001), psychological distress (t Z 5.46, p < 0.001), and fatigue (t Z 3.46, p < 0.001). Besides, it is important to note that Group B in comparison to Group A has higher levels of trait anxiety, state anxiety, psychological distress and fatigue while it has lower levels of positive well-being at rest, a state that is recorded not only unchangeable but, also, more intense on the second measurement. However, the state of Group A has been recorded improved after the Greek traditional dances as long as state anxiety and psychological distress were significantly decreased and positive well-being was significantly increased (see Figure 4). Correlational analyses between the various measures taken postdance for Group A were then conducted to determine the degree to which such measures were or were not associated, thereby providing an index of both convergent and discriminant validity for the SEES and SAIY1. These relationships are shown in Table 4. From the results in Table 4, it appears that statistically significant correlations exist between the studied variables. In particular, positive well-being correlated negatively with the measures of negative affect, such as psychological distress (r Z 0.69, p < 0.01), state anxiety (r Z 0.61, p < 0.01), and fatigue (r Z 0.26, p < 0.05), while the psychological distress factor correlated positively with indicants of negative states, such as state anxiety (r Z 0.48, p < 0.01), and fatigue (r Z 0.33, p < 0.01). Moreover, statistically significant negative correlation was observed between state anxiety and positive well-being (r Z 0.61, p < 0.01), while statistically significant positive correlations were observed between state anxiety and the other variables, that is psychological distress (r Z 0.48, p < 0.01), and fatigue (r Z 0.33, p < 0.01). So, it can be said that the overall set of relations between the SEES subscales and the SAI-Y1 subscale supports the criterionrelated validity of this measure of exercise-induced psychological responses (in this case dances).

t

p

SD

SAI-Y1 State anxiety 39.57 10.72 39.11 10.47 0.46 2.61

20

Figure 3

Pretest

1.03 NS

SEES Positive 20.14 5.67 20.05 5.08 0.08 2.72 0.18 NS well-being Psychological 10.37 5.33 10.25 5.50 0.11 4.77 0.14 NS distress Fatigue 12.02 5.94 12.91 6.11 0.88 6.22 0.84 NS NS: p > 0.05.

Discussion The primary objective of the present study was to examine whether a Greek traditional dance session results in positive effects on old people’s psychosomatic state. Moreover, the effectiveness of the Greek traditional dances session was contrasted with that of a discussing and watching TV session. Thus, elderly people taking Greek dance classes were compared to elderly people who only spent their time chatting and watching TV. The results overall indicate that Greek traditional dances possess properties improving old people’s psychosomatic state, which are not comparable to those of a chatting and watching TV session. More specifically, in the present study was found out that Greek traditional dances increased well-being, as well as decreased stress, and anxiety of old participants. In agreement, other authors suggest that dancing causes anxiety and neuromuscular tension reduction, and, also, causes psychological and physical calm (Garnet, 1974; Leste and Rust, 1984; Payne, 1992; Stanton-Jones, 1992; Steiner, 1992). Thus, it can be said that via dancing the old people’s psychological state is generally improved. It has, indeed, ascertained that the participation in dancing programs, of 45 min duration, once a week, for five months, improved the psychological state of old people who suffered from stroke, traumatic brain injury and cerebral vascular accidents (Berrol et al., 1997). It has been, also, found out that the elderly women with senility who participated in a program with social/traditional dances could reconstruct their remaining faculties and present with personal style their kineticdancing learning and experiences, communicate as a team and try positive sentiments (Palo-Bengtsson et al., 1998). Additionally, exercising in Greek traditional dances increased old people’s HR from 75.6 bpm at rest to 96.4 bpm in 30 min, and to 103.92 bpm in 60 min, that is the end of Greek traditional dances bout. Thus, old people’s HR was increased significantly and approximately 63% of their HRmax was activated. This exercise intensity can develop and maintain older people’s cardiorespiratory fitness (American College of Sports Medicine, 1991). In particular, the HR exercise benefit range (EBR) for people older than 61 years old is fluctuated from 85 to 139 bpm (Chase http://www.plu.edu/wchasega/main.htm). Consequently, the physical load from the Greek traditional dances is found

Greek traditional dances and quality

215

Trait anxiety Positive well-being before Psychological distress after

State anxiety before Positive well-being after Fatigue before

State anxiety after Psychological distress before Fatigue after

45 40 35

degrees

30 25 20 15 10 5 0 Group A

Figure 4

Group B

Alterations to SAI-Y1 and SEES factors for Groups A and B.

to be within the EBR for the specific age group. Therefore, the Greek traditional dances as performed in the present study, could constitute a part of a regular exercise program aiming at improvement in physical fitness, and thus physical benefits for old people. Similarly state anxiety decrease, together with mood state improvement was observed in young adults, after one session of traditional Greek dance, lasting approximatelty 1.5 hours. (Argiriadou and Mavrovouniotis, 2001, 2002). Likewise, Konstantinidou et al. (2000) studied the effects of a program of Greek traditional dances on old women’s subjective perception for life satisfaction. The results of the study showed a strengthening in satisfaction and a significant improvement in all the parameters that delimit the quality of life generally. In another study a program of practice with movements of traditional Korean dances. More specifically, after the program moral satisfaction, self-confidence and psychological state in old women participants (Kim et al., 2002). Furthermore, Berryman-Miller (1988) found out that the 8-month application of a dancing program in individuals aged 55e85 years old, affected self-esteem and well-being positively and led to mood state improvement. A possible explanation for the relation between the improved mood state and dancing, as a form of aerobic exercise, is that the improvement in mood state is related to the improvement in cardiovascular functioning and in physical fitness that occurs by exercising

Table 4

(Cox, 2002). So, while exercising many systems of the body as cognitive, skeletal-muscular or cardiovascular, interact in a somewhat general or holistic manner together with positive and negative moods (Thayer et al., 1994). Moreover, McGowan et al. (1996) showed that changes in affect were correlated with average HR. Higher HR was associated with reductions in negative affect and increases in positive affect. Moreover, this sense of psychological well-being is connected with endorphin excretion that has a morphineeffect in the exercising individual. The general euphoria that endorphins produce reduces depression, anxiety, confusion and different negative mood states levels (Cox, 2002; Dishman, 1989). Besides, old people who are engaged as dancers feel the benefits in their health, in a more intense way, physically and mentally, feel a sense of achievement, and accomplishment, define their health in positive terms and also, feel much better, compared to their age peers (Barkoukis et al., 1998; Konstantinidou et al., 1998; Ransford and Palisi, 1996). This happens, possibly, not only because they have higher expectations from this activity, but also because the involvement in dancing as a physical activity reduces their feelings of vulnerability to illness. Therefore, dancing as a physical activity may be especially beneficial to maintain and boost positive definitions of health (Pikoula et al., 2005; Ransford and Palisi, 1996). Moreover, it has been found out that the old people who participate in

Correlations between SEES subscales and the state anxiety measures. State anxiety

SAI-Y1 State anxiety SEES Positive well-being Psychological distress Fatigue

Positive well-being

Psychological distress

Fatigue

1.00

0.61**

0.48**

0.33**

0.61** 0.48** 0.33**

1.00 0.69** 0.26*

0.69** 1.00 0.45**

0.26* 0.45** 1.00

*Correlation is significant at the 0.05 level; **Correlation is significant at the 0.01 level.

216 Greek traditional dances programs have a better picture for their body limbs and functions, as well as bigger satisfaction than their age peers that do not participate in similar programs (Barkoukis et al., 1998; Konstantinidou, et al. 1998). This fact was, also, proven in the preset study, where the subjects of the control group, that didn’t participate in a dance or other exercise form program, had higher levels of trait anxiety, state anxiety and fatigue, while they had lower levels of positive well-being at rest. So it can be said that they taste greater levels of negative and smaller levels of positive feelings, or else that subjects of the experimental group taste smaller levels of negative and greater levels of positive feelings. This state may have been a function of the dance context, as the subjects of the experimental group at the time of the measurements completed almost a 10-week participation in the Greek traditional dances program, showing that the elevated predance states may be reflective of anticipatory effect, while the subjects of the control group didn’t participate in any program. Nevertheless, further examination is essential in order for us to ensure that these results have to do with the participation to the dance program. Moreover, after the chatting and TV watching session the subjects’ state remained unchanged, while the state of the subjects of the experimental group improved significantly after dancing Greek traditional dances, indicating the significant positive effects of Greek traditional dances on old individuals’ psychological state. Consequently, it could be said that dancing is an effective factor of mood state improvement of old people, as it contributes to the creation of a special stream state of consciousness which is related to various ecstasy levels, or, in other words, to a state of enthusiasm (Dimoulas and Karatolias, 1990; Schott-Billmann, 1997). Therefore, it appears that dancing is not simply and only the means of bodyespirit reconnection. It is a kinetic activity that can, as the primitive, ritual dances, use brain properties in order to connect, via the conceiving rhythm, the internal and the external, that is the individual and the world, a fundamental element in psychotherapy (Schott-Billmann, 1997). In addition, via dancing a safety and confidence climate is created in which sentiment expression is attained via movement. An environment, absolutely adapted to old people’s faculties was offered and corresponded to their real needs (Cooper and Thomas, 2002). This happened because the Greek traditional dances included a variety of simple kinetic patterns, was of low to moderate intensity, depending on the participants’ capacities, with appropriate intervals and frequent rhythm alternations. Moreover, dancing and movement with the help of music provide an improvement of psychological well-being and a clear reduction of anxiety symptoms (Herman and Renzurri, 1978; Ritter and Low, 1996). Actually, music helps in the expression of movement (Chen, 1985; Spilthoorn, 1986), reinforces mood state positively (Karageorghis and Terry, 1997, 1999), and can decrease anxiety (Csikszentmihalyi, 1991). Additionally, the Greek traditional dances that the old people performed in the present study, as an aerobic exercise of moderate intensity with music accompaniment, are considered a pleasant exercise type that helps the

F.H. Mavrovouniotis et al. participants to escape from their problems. Besides, pleasure (from exercise or any other activity) appears to be a main factor in the improvement of psychological wellbeing and quality of life, which is closely related to the concept of flow (Berger, 1993; Wankel, 1993). When a person is in the condition of flow, he/she concentrates on a limited field of stimuli, loses the sense of time, forgets personal problems, makes a ‘‘time out’’ from the daily routine, feels capable and in control, and has a sense of harmony with the environment (Colussi, 2002; Csikszentmihalyi, 1991). These are, probably, some of the reasons explaining the observations in the present study. In conclusion, Greek traditional dances of moderate intensity, with music accompaniment, could lead to significant improvements in old people’s psychological and physical well-being. Consequently, Greek traditional dances, as a form of aerobic activity, could produce not only physical but also mental benefits, and should constitute a part of exercise programs that aim both to the improvement of old people’s psychological state and quality of life. Of course these observations about the value of Greek traditional dances are preliminary. Besides, they concern the acute effects of a Greek traditional dances session and cannot be generalized to assess long-term participation in a dance program, although there have been indications for the positive effects. In order to support these observations further validation research is necessary. As a first systematic attempt to assess the effects of dancing Greek traditional dances on psychological and physical well-being, our study was limited to a sample old, healthy and mostly physically active individuals. Despite the fact that the dancing intensity involved was moderate and the results were indicating positive effects on our sample’s psychosomatic state, whether the findings reported here will generalize to other populations, such as the sedentary, the overweight, or various patient and medically vulnerable populations, remains unknown. Future research could extend the investigation to such populations.

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218 Leste, A., Rust, J., 1984. Effect of dance on anxiety. Perceptual and Motor Skills 58, 767e772. Mahon, M., Searle, M., April 1994. Leisure education: it’s effect on older adults. The Journal of Physical Education, Recreation and Dance, 36e41. Maroulakis, E., Zervas, Y., 1993. Effects of aerobic exercise on mood of adult women. Perceptual and Motor Skills 76, 795e801. McArdle, W.D., Katch, F.I., Katch, V.L., 2001. Exercise Physiology, second ed. Paschalidis Medical Publishers, Athens. McAuley, E., Courneya, K., 1994. The Subjective Exercise Experiences Scale (SEES): development and preliminary validation. Journal of Sport and Exercise Psychology 16, 163e177. McGowan, R.W., Talton, B.J., Thompson, M., 1996. Changes in scores on the profile of mood states following a single bout of physical activity: heart rate and changes in affect. Perceptual and Motor Skills 83, 859e866. Morgan, W., O’Connor, P., 1988. Exercise and mental health. In: Dishman, R.K. (Ed.), Exercise Adherence: Its Impact on Public Health. Human Kinetics, Champaign, pp. 91e121. Nagashio, M., Suzuki, Y., Onishi, Y., Tomatsu, A., Shimada, Y., Okamura, S., Shirai, M., 2003. Post-operative cardiac rehabilitation programs for early returning to daily life activities: selfmeasurement of heart rate and blood pressure during staying at home trial. Journal of Cardiology 41 (2), 91e95. Nelson, M.E., Rejeski, W.J., Blair, S.N., Duncan, P.W., Judge, J.O., King, A.C., Macera, C.A., Castaneda-Sceppa, C., 2007. Physical activity and public health in older adults. Recommendation from the American College of Sports Medicine and the American Heart Association. Medicine and Science in Sports and Exercise 39 (8), 1435e1445. Ostrow, A.C., 1989. Aging and Motor Behavior. Benchmark Press, Indianapolis. Paffenbarger, R., 1996. Physical activity and fitness for health and longevity. Research Quarterly for Exercise and Sport 67 (3), 11e30. Palo-Bengtsson, L., Winblad, B., Ekman, S.I., 1998. Social dancing: a way to support intellectual emotional and motor functions in persons with dementia. Journal of Psychiatric and Mental Health Nursing 5 (6), 545e554. Papanikolaou, G., 1993. Up-to-date Nutrition & Dietetics, third ed. Lorenzo DeGiorgio Publishers, Athens. Payne, H., 1992. Dance Movement Therapy: Theory and Practice. Tavistock/Routledge, London. Pikoula, I., Mavrovouniotis, F., Argiriadou, Eir, 2005. Traditional dance and subjective health. In: A presentation at the 8th Panhellenic Congress of Physical Education and Sport, 8-10/4 Thessaloniki, Greece. Pollock, M.L., Graves, J.E., Swart, D.L., Lowenthal, D.T., 1994. Exercise training and prescription for the elderly. Southern Medical Journal 87 (5), S88eS95. Pollock, M.L., Carroll, J., Graves, J.E., Leggett, S.H., Braith, R.W., Limacher, M., Hagberd, J.M., 1991. Injuries and adherence to walk/jog and resistance training programs in the elderly. Medicine and Science in Sports and Exercise 23, 1194e1200.

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Journal of Bodywork & Movement Therapies (2010) 14, 219e226

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

NEUROPHYSIOLOGY

The use of surface electromyography for the study of auricular acupuncture* Fabiano Politti a,b,*, Cesar Ferreira Amorim c, Lilian Calili a, Adriano de Oliveira Andrade d, Evanisi T. Palomari a a

Department of Anatomy, University of Campinas (Unicamp), Brazil Department of Physical Therapy, Rehabilitation Sciences Biomechanics Lab, University of Vale do Sapucaı´ (Univa´s), Brazil c Department of Mechanical Engineering, Sa˜o Paulo State University (UNESP - FEG), Guaratingueta´ - SP, Brazil d Biomedical Engineering Laboratory (BioLab), Federal University of Uberlandia, Brazil b

Received 13 June 2008; received in revised form 11 November 2008; accepted 22 November 2008

KEYWORDS Electromyography; Auricular acupuncture; Neurophysiology

*

Summary The advancement of knowledge in neurophysiology has demonstrated that acupuncture is a method of peripheral neural stimulation that promotes local and systemic reflexive responses. The purpose of this study was to determine if surface electromyography can be used as a tool to study the action of auricular acupuncture on striated skeletal muscle. The electromyographic amplitudes of the anterior, middle and posterior deltoid muscle and the upper trapezium muscle with 20%, 40% and 60% of maximal voluntary contraction of 15 healthy volunteers, were analyzed after the individuals were submitted to the auricular acupuncture treatment. The non-parametric Friedman test was used to compare Root Mean Square values estimated by using a 200 ms moving window. Significant results were further analyzed using the Wilcoxon signed rank test. In this exploratory study, the level of significance of each comparison was set to p < 0.05. It was concluded in this study that a surface electromyography can be used as a tool to investigate possible alterations of electrical activity in muscles after auricular acupuncture. However there is still a lack of adequate methodology for its use in this type of study, being that the method used to record the electromyographic signal can also influence the results. ª 2008 Elsevier Ltd. All rights reserved.

Work accomplished at the State University of CampinaseUNICAMP, Institute of Biology, Department of Anatomy. * Correspondence to: Fabiano Politti, Universidade Estadual de Campinas, UNICAMP, Depto of Anatomia, Instituto de Biologia, Cx Postal 6109, CEP: 13084-971, Campinas - SP, Brazil. E-mail address: [email protected] (F. Politti).

Introduction Acupuncture has recently been recognized by western science as a procedure that can be used supplementary to medicine, especially in the treatment of chronic pain syndrome (NIH, 1998). Advances in the knowledge of

1360-8592/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2008.11.006

220 neurophysiology have made it possible to establish that this is a neural peripheral stimulation method that promotes local and systemic reflexive responses, mediated by endocrine and immune systems and by superior centers of central control (Mayer, 2000; Carlsson, 2002). A reflexive response is caused by a gauging stimulus located in the somatic nerve fibers, which is triggered by insertion of a needle (Andersson and Lundeberg, 1995) in specific points of the skin and muscles, called acupoints (Li et al., 2004). These acupoints, found in greater concentration in specific areas such as the ear, can be used in a combined fashion with points on the body (Ellis, 1994). The most frequent use of acupuncture treatment is in muscular relaxation (Lewith and Kenyon, 1984); in the systemic regulation of motor dysfunctions (Ulett et al., 1998) and in the control of skeletal muscle pain, considering that its analgesic effects are mediated by central mechanisms that involve neural standards (Sim, 1997; Pomeranz, 2001). However, results are still questionable regarding acupuncture’s action in pain control. Studies carried out on the effects of chronic pain have indicated that individuals who received treatment with sham acupuncture, demonstrated better results than the individuals receiving real treatment (effective treatment of chronic pain), generating much criticism about the methodology applied in these types of studies (Ezzo et al., 2000). In general, the methodology utilized to demonstrate the effects of acupuncture has concerned several authors (Birch, 2003; Hopwood and Lewith, 2003), who rate many of these studies inconsistent, partial and likely to overestimate the positive effects of the treatment (Moher et al., 1996; Jadad and Rennie, 1998; Ezzo et al., 2000). Due to the existence of different techniques for the insertion of the needle, combined with different strategies for the localization of the insertion points and the existence of several treatment methods for the same type of diseases (Birch, 2003), it is essential for this type of study to consider the appropriate selection of a specific treatment for each type of pathology, and the selection of the control group, the choice of the participants and the choice of the acupuncturists (Sherman and Cherkin, 2003). Recent review articles have concluded that acupuncture still requires investigation. This is due to the fact that the neuromodulating mechanisms of nociception resulting from the stimulus caused by acupuncture, which happen at the three levels of the central nervous system (spinal, troncoencephalic and diencephalic), needs greater clarification (Moya, 2005), as do the methodological standards such as appropriate sample sizes, well-defined inclusion and exclusion criteria, and collection of data on safety and side effects (Sherman and Cherkin, 2003). An important note of observation about these revision articles is that, as of yet, there exists no standardized method for each area of investigation into acupuncture activity. Since it is an acceptable method in the investigation of muscular function in various types of analysis such as in muscular biomechanics (Finley et al., 2005), muscular skeleton fatigue (Ebaugh et al., 2006), strength (Kamibayashi and Muro, 2006), rehabilitation (Barak et al., 2006) and neuromuscular disorders (Hogrel, 2005), surface electromyography can be a reliable tool to validate the

F. Politti et al. effects of acupuncture, because it is then possible to investigate the amplitude and occurrence of electrical activity in the muscle while a task is being performed (Robertson et al., 2004) The aim of the present study was to determine if surface electromyography can be utilized as a tool to study the action of auricular acupuncture on striated skeletal muscles. Additionally, the behavior of the electrical activity was verified from anterior, middle and posterior deltoid muscles and upper trapezium muscle at different levels of exertion in a single test position.

Methods Subjects The volunteers taking part in the study were selected by means of a blind draw from the population of undergraduate and graduate students from the Anatomy Department of the University of Campinas Biology Institute. Fifteen volunteers, between ages 20 and 28, were selected and of those, eight were females (average 20.63  2.97) and seven were males (average 26.33  5.68). Included in the study were healthy, non-obese, sedentary volunteers having no history of previous shoulder pain. The volunteers were examined by a physical therapist familiar with musculoskeletal disorders of the upper limbs and scapular waist and neck. All volunteers signed a Term of Consent as required by resolution 196/96 issued by the National Health Council and previously approved by the Ethical Committee in Research from the State University of Campinas. Each subject was informed of the purpose and potential risks of the study before their written voluntary consent was obtained.

Equipment Myoelectric signals were obtained using an 8-channel module (EMG System do Brazil Ltda.), consisting of a band pass filter of 20e500 Hz, an amplifier gain of 1000, and a common rejection mode ratio >100 dB. All data were acquired and processed using a 16-bit Analog to Digital converter (EMG System do Brazil Ltda), with a sampling frequency 1.33 kHz. The system was composed of active bipolar electrodes displaying a pre-amplification gain of 20. A channel of the acquisition system was enabled for the utilization of the load cell (Alfa Instruments), having an output between 0 and 20 mV and a range up to 1 kN.

Procedure and data collection In western culture, the use of the auricular microsystems developed in France by neurologist and acupuncturist Paul Nogier gave another perspective to the understanding of some of the mechanisms by which acupuncture works. The concept of the technique is based upon the somatotopic organization of the external auricular pavilion and principally on its direct relation to the central nervous system, which is hypothesized to function through the branches of pairs of cranial nerves innervating the whole auricular pavilion (Nogier, 1969, 1972, 1983).

The use of surface electromyography Nogier’s original discovery led to the identification of the body mapping on the auricle which presented remarkable consistency with respect to anatomic and embryological considerations. Thus, the ‘‘inverted fetus’’ presents with the musculoskeletal (mesodermal) projections in the upper aspect of the ear, including the anti-helix, scaphoid fossa, and triangular fossa (Nogier, 1969). According to the theory and body mapping proposed by Nogier, it is possible to conclude that the needle stimulus in the specific external auricular pavilion can influence in a reflexive manner specific regions of the body. However, this hypothesis is yet to be tested in a blind, placebocontrolled clinical trial. In order to verify this hypothesized reflexive action of auricular acupuncture on the musculoskeletal activity, we used the acupuncture point referring to the scapular waist and shoulder, as proposed by Nogier (Figure 1). Consequently, the possible reflexive action of the scapular waist and shoulder acupuncture point was verified through activity from the upper trapezius and deltoid muscles respectively. Muscle activity was recorded from the upper trapezius, selected because they are the primary muscles used to elevate the arm (Michels and Boden, 1992; Campos et al., 1994) and because they are commonly related to tension pain of the head and neck. The anterior, middle and posterior deltoid muscles were chosen because they assist in the elevation and stabilization of the shoulder during this elevation (Hagberg, 1981; Kronberg et al., 1991; McCann et al., 1993). Self-adhesive disposable surface electrodes (Ag/AgCl e Medical Trace) of 10 mm of diameter were used for the surface recording of electromyography with a center to center distance of 20 mm. Prior to the fixation of the

Figure 1 Insertion points of the acupuncture needle in the ear, corresponding to the shoulder (a) and the scapular waist (b) used in the experimental group and the point located in the shell of the ear (c) used for the placebo group.

221 electrodes, the skin was cleansed with 70% alcohol for the elimination of residual fat; cleansing was followed by exfoliation using a specific sand paper for skin (Bio-logic Systems Corp) and a second cleaning with alcohol. The electrodes were affixed 2 cm laterally in reference to the mid point of a line traced from the posterior lateral edge of the acromion to the 7th cervical vertebra (Matthiassen et al., 1995) in the upper trapezium muscle. For the anterior, middle and posterior deltoid electrodes were positioned in the lower half of the distance from the acromion to the deltoid tuberosity (Nannucci et al., 2002). A reference rectangular electrode (3 cm  2 cm), was lubricated with electro-conductor gel (Pharmaceutical Innovations) and fastened to the left wrist of the volunteers. During the experiments, the individuals remained comfortably seated in the test chair. Before beginning the recording of electromyographic signals, each individual subject was asked to carry out a series of three maximum force elevations of the shoulder ipsi-lateral to the auricular acupuncture treatment, with duration of 3 s each, against the resistance offered by the load cell (Figure 2). A 2-min rest period was given between efforts. Verbal encouragement was given to the subject especially during the task. The mean value from the three trials represented a subject’s 100% maximum voluntary contractions (MVC) force, and the 20%, 40% and 60% values of MVC were calculated from that number. Mean muscle output was used to determine MVC as it was believed to be a more accurate representation of a subject’s strength than a single contraction. The three sub-maximal contractions (20%, 40% and 60% MVC) were used in the analysis of the auricular acupuncture action on the shoulder muscle.

Figure 2 Test position as the individual elevates the shoulder ispi-lateral to the auricular acupuncture (A) against the resistance of the load cell (B).

222 Due to the necessity of having an appropriate control group for this type of study, the same volunteers served as the control. Consequently, the experiment was run in two stages with a fixed, 7-day interval between the two tests. The results obtained with the needles placed in the points specific to the treatment of shoulder region problems were assigned to the experimental group and the placebo group served as the control. A blind draw determined the order of the individual subjects sampled. As suggested by Sherman and Cherkin (2003), the real function of each acupuncture point was masked from the participants. Likewise, the participants were requested not to visualize the application site of the needle. Communication with the patient was not permitted during the experiment, and the acupuncturists were not aware of the specific purpose of the study. Questions about the study were noted by one of the authors, but were answered only at the conclusion of the research, when all data had been collected. Electromyographic signals were recorded at three distinct moments, the first, pre-acupuncture (ACP), served as comparison to the signal obtained after the insertion of the acupuncture needle. Five minutes after the first sample (ACP), disposable sterile acupuncture needles 0.25  13 mm (Suchou Huanqiu Acupuncture Medical Appliance Co. Ltd.) were inserted at previously established points of the outer ear and were maintained without manipulation until the end of the experiment. After a 1-min interval, a second electromyographic signal sample was recorded with acupuncture (ACP1), and after 5 min, the third and last sample electromyographic signal (ACP2) was recorded, followed by immediate removal of the needle. The criteria for the recording of the electromyographic signals were always the same for all stages of the experiment. At each moment (ACP, ACP1 and ACP2), 20%, 40% and 60% sub-maximum MVC samples were collected and maintained through visual feedback provided by a line drawn on the computer screen. The duration of each electromyographic signal sample was 5 s. In order to avoid a learning effect, the order of the sample collection was also determined by blind draw. Possible risks of bodily compensation during the traction of the load cell and of patterning in the whole experiment were prevented through training before all the tests. Of greatest concern during the experiment was that the head and neck be always maintained in the same position, so as to avoid interference from the upper trapezius muscle in the activity.

F. Politti et al. waist (Nogier and Boucinhas, 2001). Asepsis by means of alcohol was provided at the location of the acupuncture needle insertion. A physical therapist certified in the Nogier Method of Auricular Acupuncture by the Regional Physical Therapy Council (CREFITO-4) and having 5 years of clinical experience with the Nogier Method, performed the auricular acupuncture treatment.

Processing and analysis of the signals For this study, the EMG signals obtained during the 20%, 40% and 60% sub-maximal MVC contractions under the conditions ACP, ACP1 and ACP2, were normalized by the medium values of the three repetitions at maximal effort with fixed resistance for each muscle analyzed, as used by McLean (2005). Each sample lasted 4 s with a rest interval of 2 min. The position and action of each muscle studied was thus: i) upper trapezium and medium deltoid: individual subject seated, performing static contraction of the limb in abduction of 90 and neutral rotation of the shoulder, against the resistance of a strap positioned near the elbow joint (McLean et al., 2003); ii) posterior deltoid: individual subject seated, with a slight abduction, extension and medial rotation of the shoulder, performing extension of the limb with isometric contraction during the traction of a fixed strap attached near the elbow joint (Kendall et al., 1993); iii) anterior deltoid: individual subject seated, with slight abduction, flexion and lateral rotation of the shoulder, performing flexion of the limb in isometric contraction during the traction of a fixed strap attached near the elbow joint (Kendall et al., 1993). After data were normalized for each muscle the root mean square (RMS) was calculated using a 200 ms moving window technique. Electromyographic Analysis Software, Version 1.01 (EMG System do Brasil, Ltda.) was used.

Statistical analysis Data are presented as means and standard deviations (SD). The non-parametric Friedman test was used to compare intraclass results in root mean square amplitude (RMS). Significant results were further analyzed using the Wilcoxon signed rank test. In this exploratory study, the level of significance of each comparison was set to p < 0.05. The entire analysis was conducted using the software SPSS (Version 12.0).

Needle insertion points on the ear

Results In the experimental group, the needles were inserted on the ear at the points corresponding to the scapular waist, located in the sixth of seven spaces contained between the posterior fold of the anti-tragus (in the region of its junction with the anti-helix and the second depression located on the anti-helix), and to the shoulder, located approximately 3 mm above the furrow which separates the anti-helix from the anti-tragus as indicated in Figure 1 (Nogier and Boucinhas, 2001). In relation to the placebo group, the needles were inserted on the shell of the ear as placebo treatment (Figure 1), being that this region does not present any somatotropic relationship to the shoulder and the scapular

The intraclass analysis (Friedman test) of anterior, middle and posterior deltoid muscle (Table 1) did not present a statistically significant difference (p > 0.05) of the values of RMS amplitude, under pre-acupuncture conditions and post-acupuncture, tested under each sub-maximum force level (20%, 40% and 60% of MVC). The same analytical criteria were adopted for the upper trapezium muscle, which, in accordance with the Friedman test displayed significant difference (p < 0.003) for values corresponding to 60% of the MVC in the experimental group. In the multiple comparisons, using the Wilcoxon test, a significant difference (p < 0.003),

The use of surface electromyography

223

Table 1 Mean and standard deviation (SD) of RMS (mV) from the anterior, middle and posterior deltoid muscle from experimental group and placebo group. ACP indicates the pre-acupuncture condition and ACP1 and ACP2 indicate the acupuncture condition tested under three levels of sub-maximum force (20%, 40% and 60% MVC). Muscles

ACP

ACP1

ACP2

Mean (SD)

Mean (SD)

Mean (SD)

60% 40% 20%

0.29 (0.18) 0.18 (0.12) 0.14 (0.09)

0.28 (0.18) 0.21 (0.12) 0.14 (0.11)

0.32 (0.22) 0.17 (0.14) 0.15 (0.11)

0.76 0.42 0.54

Middle Deltoid

60% 40% 20%

0.83 (0.58) 0.52 (0.49) 0.47 (0.41)

0.80 (0.59) 0.56 (0.42) 0.46 (0.41)

0.86 (0.55) 0.54 (0.42) 0.48 (0.40)

0.81 0.81 0.62

Posterior Deltoid

60% 40% 20%

0.88 (0.56) 0.58 (0.52) 0.28 (0.16)

0.86 (0.68) 0.49 (0.43) 0.28 (0.19)

0.90 (0.69) 0.52 (0.41) 0.31 (0.19)

0.93 0.12 0.48

60% 40% 20%

0.21 (0.06) 0.17 (0.06) 0.10 (0.03)

0.20 (0.10) 0.21 (0.19) 0.11 (0.04)

0.20 (0.06) 0.20 (0.19) 0.10 (0.03)

0.72 0.28 0.76

Middle Deltoid

60% 40% 20%

0.67 (0.39) 0.42 (0.17) 0.35 (0.15)

0.63 (0.36) 0.47 (0.22) 0. 39 (0.20)

0.67 (0.35) 0.46 (0.21) 0.38 (0.19)

0.62 0.62 0.86

Posterior 2Deltoid

60% 40% 20%

0.71 (0.68) 0.43 (0.23) 0.27 (0.12)

0.62 (0.51) 0.41 (0.28) 0.26 (0.11)

0.63 (0.41) 0.43 (0.23) 0.28 (0.12)

0.63 0.21 0.70

Experimental Group Anterior Deltoid

Placebo Group Anterior Deltoid

% MVC

*p value

*A Friedman test did not show a significant difference (p > 0.05) in the intraclass comparison.

was identified in the RMS values corresponding to the ACP and ACP2 (Figure 3). These results indicate an increase of the RMS amplitude in the upper trapezium muscle at 60% MVC, after 5 min of the insertion of the acupuncture needle in the ear. For values regarding 20% and 40% MVC in the experimental group, no significant differences were found (Friedman test, p > 0.05). Under these same test conditions, no statistically significant differences were found in the analysis of the trapezium muscle in the placebo group (Figure 3).

Discussion Based on the advances in neurophysiology, it is possible to define acupuncture as a neural peripheral stimulation method aimed at promoting changes in the sensorial, motor, hormonal and cerebral functions (Nishijo et al., 1997; Mayer, 2000). Such changes originate from the reflex response caused by the afferent stimuli in the somatic nerve fibers after the insertion of the needle (Andersson and Lundeberg, 1995).

Figure 3 Mean of the RMS (mV) value computed over 5 seg from the upper trapezium muscle. The intraclass tests accomplished in the placebo group, did not demonstrate significant statistical differences (Friedman test, p > 0.05) between the pre-acupuncture (ACP) and with acupuncture (ACP1 and ACP2) in each one of the tree tested levels of sub-maximum force (20%, 40% and 60% MVC). * Indicates a significant difference between ACP and ACP2 (Wilcoxon, p < 0.003).

224 Knowledge about the reflex response is concentrated in experimental studies carried out on the pathways of the sensory nerve system responsible for the modulation and inhibition of pain (Mayer, 2000; Carlsson, 2002) in the three levels of the central nervous system: spinal cord (Lewith and Kenyon, 1984; Cao, 2002), encephalic trunk (Cao, 2002) and cerebral cortex (Zhang et al., 2004). However, the action of auricular acupuncture on the motor apparatus is not frequently discussed in scientific studies, which makes a difficult discussion of the results presented in this work. With respect to the results obtained by means of the methodology used in this study, it is not possible to state that auricular acupuncture can influence the activity of the muscles studied because, although a significant increase (p < 0.05) in electromyographic activity of the upper trapezius muscle was observed in the experimental group with 60% of MVC there was no alteration of the electromyographic signal with 20% and 40% of MVC. The significant alteration observed only in the upper trapezius muscle in the experimental group with 60% of MVC, requires extra care in its interpretation. To affirm a possible effect of auricular acupuncture on the muscle activity would be possible only if statistically significant alterations of the electromyographic signal with 20% and 40% of MVC had been found. Factors such as type (Tarkka, 1984) and time duration of contraction (DeVries et al., 1982; Tarkka, 1984) can also alter the muscle activity and should be considered in the analysis of the results obtained in this study. In general, during an isometric exercise at constant load, there is a time related increase of the electromyographic signal (Tarkka, 1984) which could be related to changes in the recruiting pattern of motor units after the first seconds of contraction, as well as to the increase of the amplitude of the action potential and to the recruitment of motor units or the firing of the motor neurons (DeVries et al., 1982; Tarkka, 1984); however, this fact is not enough to justify the increased amplitude of the electromyographic signal in the experimental group, since the same experimental conditions were maintained for the two groups studied. Another argument that would contradict this outcome is that acupuncture has as one of its more frequent clinical uses, muscular relaxation (Lewith and Kenyon, 1984) and, in this case, the electromyographic signal is reduced. All the consulted therapists using the Nogier method relate muscle relaxation and a reduction or an elimination of pain as principle therapeutic effects. As such, the results of this study open to questioning the affirmation that auricular acupuncture has muscular relaxation as one of its effects. This contradiction indicates that the clinical treatment results are not the same as those present in the controlled study, suggesting that further investigation is necessary. One possible explanation for the appearance of the significant difference found in the experimental group at 60% of MVC could be related to the methodology employed during the experiment. Since the collection sequence of electromyographic signal was by blind draw, the data referring to the sub-maximum contraction of 60% of MVC could have randomly been the last to be collected under the ACP2 condition of the experimental group, but there is

F. Politti et al. no way of proving this, each possibility of sub-maximum contraction (20%, 40% and 60% MVC) having been determined by the draw which preceded each of the samples. If this really occurred, the increased electromyographic signal amplitude could be related to the onset of fatigue (Masuda et al., 1999), which can happen during a repetitive or sustained activity (Mannion & Dolan, 1996), as was the case during the experiment. This points to a possible fault in the method used in this study. Thus, the duration of data collection and the number of repetitions of the experiment also need to be well planned to avoid alterations of the amplitude electromyographic signal as a result of biological factors such as muscular fatigue. During the development of this study, a constant source of concern for the authors was the use of methodological rigor in the collection and treatment of data. This concern arose mainly after the literature review indicated potential problems involving sample size, nature of the study, inadequate control groups and absence of long-term responses (Mclellan et al., 1993; Moher et al., 1996; Ezzo et al., 2000; Sherman and Cherkin, 2003; Moya, 2005). To ensure confidence in the results obtained, a blind clinical trial was carried out by means of a draw. The trial aim was to compare the action of the true points in the treatment experimental group versus the action of the false points in the placebo group, in random distribution, as suggested in the literature (Carroll et al., 1996; Filshie and White, 1998) and described in the methodology of the present study. The use of false points is possible due to the fact that points on the ear are highly specific and there are differences between the stimuli effect from the real and false points (Farber et al., 1995; Tavares et al., 1996). It is important to mention that is impossible to carry out a double blind study in acupuncture since the acupuncturist cannot be blinded (Filshie and White, 1998; Carlsson, 2002). Consequently, the volunteers who participated in this study, as well as the author of the evaluations of the electromyographic signals, were not informed of the specific function of the auricular acupuncture treatments adopted in the experiment, as suggested by Filshie and White (1998) and Carlsson et al. (2000). Even with all these cautionary measures, it was observed that the methodology used for electromyographic signal recording of the deltoid muscle was not the most appropriate. Previous studies indicate that the action of the three portions of the deltoid muscle is directly related to the movements of abduction, flexing and the dislocation of the upper limb in different angular movements (Michels and Boden, 1992; Campos et al., 1994). Since this experiment was conducted without angular shoulder movement (Figure 2), the electromyographic signal amplitude obtained from the three portions of the deltoid muscle was very low and possibly not sufficient to show a possible influence of auricular acupuncture on this muscle. With relation to the upper trapezius muscle, the position adopted for the tests (Figure 2) permitted that this muscle performed its functions as a prime mover during elevation and rotation of the scapula and as a stabilizer of the scapula during glenohumeral movements (Schenkman and De Cartaya, 1987) and during glenohumeral torque production (Mathiassen and Winkel, 1990). Consequently, it

The use of surface electromyography is important to respect the muscular function because the firing frequency of the motor units varies according to the levels of force exerted during the isometric contraction (Maton, 1981) and it is possible that the greater the motor engagement, the greater the chance that alterations will be observed in the pattern of the electromyographic signal.

Conclusions Based on the results found, it is not yet possible to state that auricular acupuncture can influence the electrical activity of the muscle. A suitable methodology needs to be developed to allow the utilization of auricular acupuncture as a research tool in the investigation of the action of auricular acupuncture on the electrical activity of the muscle. Factors such as the duration of collection, main action of the muscle and the number of test repetitions during the same experiment can influence the amplitude of the electromyographic signal leading to wrong conclusions about the answers obtained from the tests. To avoid misleading results in future investigations that involve the use of surface electromyographic in the analysis of the effects of auricular acupuncture, the experiments should be carried out while the muscles perform their main action to increase the chances of detecting any alteration of the electromyographic signal caused by the use of auricular acupuncture. However, it is important to mention that this work is an initial study that focuses only on the auricular acupuncture as proposed by the Nogier method. For this reason, the results found in the study are specific to the Nogier method and should not be considered for other methods of treatment by acupuncture.

Acknowledgements This study was partly supported by the FAPESP (2002/ 13559-1) and FAEPEX/Unicamp (0098/02), Brazil.

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Journal of Bodywork & Movement Therapies (2010) 14, 227e233

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

REVIEW AND HYPOTHESIS

Qi Gong exercises and Feldenkrais method from the perspective of Gestalt concept and humanistic psychology ¨ckl a,1, Dr. Dariusz Mucha b,2 Dr. Paul Posadzki a,*, Dr. Andrea Sto a b

School of Medicine, Health Policy and Practice, University of East Anglia, Norwich NR4 7TJ, UK Health and Physical Education Institute, Radom Polytechnic, 26-600 Radom, Poland

Received 11 April 2008; received in revised form 15 December 2008; accepted 16 December 2008

KEYWORDS Qi Gong; Feldenkrais; Gestalt concept; Humanistic psychology

Summary This study describes two similar approaches to human movement: Qi Gong exercises and the Feldenkrais method. These systems are investigated in terms of Gestalt concepts and humanistic psychology. Moshe Feldenkrais created the concept known as Awareness Through Movement. This concept assumes that by becoming more aware of one’s movements, one functions at a higher level. In similar ways to those using the Feldenkrais method, individuals may become more aware of their own movements by performing Qi Gong exercises: A therapeutic modality that facilitates mindebody integration. Qi Gong exercises commonly lead to increased personal awareness accompained by enhanced quality, fluency and smoothness of movement. These two methods of movement therapies are explored in terms of their relations with Gestalt concept and humanistic psychology. Crown Copyright ª 2008 Published by Elsevier Ltd. All rights reserved.

Introduction Feldenkrais is an educational system designed to use movement and perception of one’s own self to foster individualized improvement in function. Moshe Feldenkrais, its originator, believed his method enhanced people’s * Corresponding author. Tel.: þ44 01603591223. E-mail addresses: [email protected] (P. Posadzki), [email protected] (A. Sto ¨ckl), [email protected] (D. Mucha). 1 Tel.: þ44 01603 591879. 2 Tel.: þ48 601 482 162.

ability to discover flexible and adaptable behaviour, which are, as he argued, self-organized (Buchanan and Ulrich, 2001). It could therefore be claimed that Feldenkrais’ methods are somatic education techniques designed to establish a heightened awareness of movements (Jain et al., 2004). Feldenkrais method also describes excellence in motor control and it provides encouragement towards developing awareness of body movements (Hannon, 2000a,b, 2001a,b). A self-awareness exploration principle is presented to help to deepen this understanding and to encourage a visceral comprehension of another principle: Control follows awareness (Hannon, 2000a,b). It is worth

1360-8592/$ - see front matter Crown Copyright ª 2008 Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2008.12.001

228 mentioning that the Feldenkrais approach has in common with phenomenology of bodyemind approaches a general philosophy of enhancing natural processes system to improve function and decrease pain (Lusky and Devlin, 2001). Therefore, persons who seek out these practices and incorporate them into their daily lives and expressions of physical activity are often motivated to maintain or establish an optimal state of well-being and function (Schlinger, 2006). The author believes that Chinese Qi Gong exercises and Feldenkrais method are based on similar principles: both approaches consist of conscious movements that are performed with precision and full concentration: an effortless permission of flow (Levey and Levey, 2005). In addition, both Qi Gong exercises and Feldenkrais method may have principles of Gestalt concept and humanistic psychology in common, such as, firstly, a feeling of presence in the reality that can be defined as a mental process-act in the present, embedded in the structure of the actuality (Perls, 1951, p. 67); secondly, consciousness: a place from which acceptance and committed action can occur (Strosahl, 2002); and thirdly, self-development: the tendency of the organism to move in the direction of maturation (Rogers, 1951, p. 488). They also share a similar approach to describe the various processes that a person with motivational progression towards ultimate self-actualization develops: once the basic needs are completely gratified, step by step, the person moves onto the next higher one and eventually emerges into consciousness (Maslow, 1968, p. 32); 4). Self-realization brings a value of richness of existence that expands horizons and maximises potential through movements. The aim of this study is to describe Qi Gong exercises and Feldenkrais method in the context of humanistic and Gestalt concept and explore how patients and therapists can benefit from this fusion.

Benefits of Feldenkrais therapy Psychological and social benefits of Feldenkrais therapy Laumer et al. (1997) reported that participants of the Feldenkrais course showed increased contentment with regard to problematic zones of their body and their own health as well as concerning acceptance and familiarity with their own body. Other results showed open and self-confident behaviour, a decrease of feelings of helplessness, heightened sense of self-confidence, and a general process of maturation of the whole personality (Laumer et al., 1997). The participants in the group with well-developed body awareness described an enhanced attitude towards the body, and they gave clearer descriptions about their experiences of emotions (Ryding et al., 2004). Additionally, the results showed significant positive changes over time in all three treatment groups with regard to reduced psychological distress, pain, and improved self-image (Malmgren-Olsson et al., 2001). Some analyses of variance for repeated measures revealed mood improvement following Feldenkrais method (Netz and Lidor, 2003) and a sense of well-being (Stephens et al., 1999). These findings can be interpreted as further support for the efficacy of the Feldenkrais method in reducing states of anxiety and

P. Posadzki et al. symptoms of depression (Kerr et al., 2002; Kolt and McConville, 2000; Huntley and Ernst, 2000), and improving self-esteem (Huntley and Ernst, 2000). It has been suggested that Feldenkrais method can facilitate voice projection (Emerich, 2003) and therefore that it may be useful in various social interactions. These results suggest that this type of motor learning intervention can be effective in improving a variety of physical and psychological parameters related to balance confidence and selfefficacy (Stephens et al., 2001).

Clinical effectiveness of Feldenkrais Studies suggest that Feldenkrais may be more effective than conventional treatment in patients with non-specific musculoskeletal disorders (Malmgren-Olsson et al., 2001). It can be thought that this kind of therapy encourages individuals to explore various, more effective movement patterns. For instance, fibromyalgia patients showed improvement in balance and trends to better lower extremity muscle function after the Feldenkrais intervention (Kendal et al., 2001). It should be noted that Feldenkrais therapy participants reported increased joint mobility of neck and shoulders in 97 female industrial workers (Lundblad et al., 1999). Other studies reported that Feldenkrais participants improved significantly in measurements of flexibility (sit and reach test) as opposed to their control group counterparts (Hopper et al., 1999). Likewise, Feldenkrais therapy patients stated decreased perception of pain, both immediately after the program and in a one-year follow-up (Bearman and Shafarman, 1999). Results from analyses of variance showed that the Feldenkrais intervention was effective in reducing the affective dimension of pain for people experiencing chronic lower back problems (Smith et al., 2001). From a social perspective, the Feldenkrais group showed significant decreases in complaints from neck and shoulders and in disability during leisure time (Lundblad et al., 1999). From physiological point of view, for example, an endurance score, and exertion capacity according to a dynamic endurance test of the shoulder flexors with simultaneous surface EMG were improved (Lundblad et al., 1999). In their social survey Junker et al. (2004) sent 180 questionnaires to members of the German Dystonia Society. Functional Integration (FI) and Awareness Through Movement (ATM) are aspects of the Feldenkrais method that have been used successfully in the rehabilitation of these patients. Clinical effectiveness of Feldenkrais has been confirmed among orthopedic patients (Stephens, 2000). Both FI and ATM can influence various body spheres and dimensions and facilitate improved neuromuscular organization and coordination, range of movement or soft tissue flexibility. Pain free movements are possible with decreased muscle tension and joint stiffness, leading to less fatigue as a consequence. Other outcomes suggest that ATM is beneficial for some people with multiple sclerosis (Stephens et al., 1999). Feldenkrais method includes approaches to motor learning that can be used to facilitate change and integration in postural and general musculoskeletal control (Stephens, 2000; Stephens et al., 2001). In addition, it can be used in postural education or reeducation in children’s ‘back school’. Seegert and Shapiro (1999) support this point of

Qi Gong exercises and Feldenkrais method view as they described that only the exercise group of 25 college students showed statistically significant changes in quality and harmony of posture and simple movement such as postural sway after Feldenkrais intervention. Other outcomes show that two broad areas of improvement were ease and steadiness of daily movements (Stephens et al., 1999).

Brief characteristics of Qi Gong According to Chinese Medicine, Qi is the energy that simultaneously pervades the macro-cosmos e the Universe and the micro-cosmos e the human body. Followers of Qi Gong believe that within the human body Qi energy flows in channels called meridians. Gong may be translated as a way of development, enhancement and improvement. As such, Qi Gong means augmentation of the body’s energy. Qi Gong are Chinese health exercises that have been used and developed for thousands of years to optimize energy within the body, mind, and spirit (Litscher et al., 2001). Qi Gong is a combination of meditation, controlled breathing and gentle, physical movements designed to control or mobilize the vital energy (Qi) of the body. It consequently may improve spiritual, physical and mental health (McCaffrey and Fowler, 2003; Jones, 2001). Qi Gong exercises may either sedate or ‘speed up’ the functioning of the human brain, depending on the Qi Gong methods practiced by different individuals (Zang et al., 1993). Qi Gong can be seen as a usage of specific movements to direct mental attention to specific areas of the body. The Qi Gong master frames it as a ‘mind-in-body’ practice rather than minde body interaction (Kerr, 2002). Qi Gong practitioner may experience various body sensations due to enhanced Qi flow within the body (Xu, 1994). These sensations may include warmness in hands, state of relaxation, sense of harmony with movements and universe simultaneously, chillness, and state of tranquility and serenity (Agishi, 1998). Evidence shows that Qi Gong exercises may be beneficial for various ‘civilization’ diseases such as hypertension or diabetes (Iwao et al., 1999; Mayer, 1999). For example, Iwao et al. (1999) have, shown that both Qi Gong and conventional walking decreased plasma glucose levels in comparison to control groups, however in the Qi Gong group no increase in pulse rate was observed. Longitudinal studies over 20 years have shown that Qi Gong exercises promote longevity (Kuang et al., 1991; Wang et al., 1993). There is some encouraging evidence of Qi Gong for lowering systolic blood pressure, nevertheless rigorously designed trials are needed to confirm this (Lee et al., 2007).

Qi Gong and health Qi Gong exercises can affect many functions of the body and improve health in a beneficial manner (Sancier, 1996). From the perspective of a mind-body approach, the psycho-social effect of Qi Gong was hypothesized by Tsang et al. (2002) as they argued that Qi Gong, as a form of Chinese therapeutics, has the effect of improving life quality and overall wellbeing. Chow and Tsang (2007) have suggested that Qi Gong can be considered as an alternative therapy to help to meet the increasing demand for non-pharmacologic modalities in achieving holistic health for those suffering from anxiety in

229 the general population (Chow and Tsang, 2007). Mental wellbeing can be achieved due to Qi Gong movements as they may reduce tensions, and regulate the body’s internal balance (Ryu et al., 1996, 1997; Wu et al., 1999; Jones, 2001). From the perspective of Western science, physiological effects of Qi Gong may be taken into account such as changes in brain functioning, i.e. theta rhythm frequencies, level of concentration (Pan et al., 1994), and increase in blood flow velocity in the posterior cerebral artery (Litscher et al., 2001). The respiratory movements can be improved by changing the volume of oxygen consumed, the carbon dioxide that is produced, and changes in the frequency of breath (Lim et al., 1993). The sympathetic nervous system functions, such as heart rate, skin potential, skin temperature, stomach and intestine metabolism, endocrine and immunity systems can also be influenced positively (Xu, 1994; Ryu et al., 1995; Jones, 2001). It can be assumed that consequences of regular Qi Gong exercises are overall on health and longevity. It seems to be a valuable and reliable method to enhance the individual’s health awareness (Mayer, 1999).

Gestalt concept Gestalt theory (GT) is the result of investigations in psychology, logic, and epistemology and is a palpable convergence of concepts ranging through the sciences, and various philosophic points of views of modern times (Ko ¨hler, 1940; Koffka, 1935; Wertheimer, 1944). Gestalt theory of perception draws on existential and various Eastern philosophies and aims to enable the individual to seek his or her own solutions to personal problems. Literally translated as ‘form’, Gestalt focuses the individual to appreciate and experience the present (Jones, 1992). Gestalt Psychology (GP), founded by Max Wertheimer at the beginning of the 20th century, was to some extent a rebellion against the paradigm of molecularism that was in fashion at the time. In fact, the word Gestalt means a unified or meaningful whole. GP focuses on understanding of essentials of reality within ‘here and now’. Similarly to phenomenology, Gestalt theory penetrates the problem itself and therefore it can be regarded as ‘applied phenomenology’ (Koffka, 1935, pp. 9e10). Frederick Perls introduced the Gestalt concept into psychotherapy, and it was then developed by Paul Goodman (Perls et al., 1951). As a psychotherapy method, Gestalt concept was used to facilitate an integration of life and to give the person a sense of balance in life through the restoration of awareness, which allows for increased choice and flexibility in all aspects of living (Zahm and Gold, 2002, p. 863). Gestalt may also mean recognizing the communication between thoughts and feelings as they appear in our reality during the course of actions. Healthy functioning requires self-regulation in which the person becomes aware of needs which are contingent on a given situation. The person expresses himself to satisfy those needs and to ‘complete’ his or herself (Mosher, 1977). The perception of self is widely used in Gestalt concept (Schnake Silva, 1981). The natural process of self-regulation cannot be interrupted by the self and further personal growth requires experimenting with new solutions for unsolved problems (Mosher, 1979a,b).

230 Gestalt practitioners believe that wholeness is a complex system in which some parts are determined by the behaviour of other parts (Zimbardo, 1999, p. 307), therefore it can be regarded as a unity of basic perception and experiences. In Gestalt concept, an encounter with the self may take place, when one realizes that a precious aspect of life can be created by concentrating on introception and extraception simultaneously within the here and now. A powerful source of life can occur and bring change to an individual’s way of life, while being closer to experiences of living because of heightened awareness (Moreau, 1980). Some principal concepts are then elaborated more fully such as the cycle of awareness (Corbeil and Poupard, 1978). Mosher (1979a,b) claims that awareness is conceived to be selective, curative, a method, a prescription for ideal living, and a ground for human existence. The same author presents more Gestalt awareness methods such as continuum of awareness, awareness questions, bio-behavioral feedback, directed awareness, concentration, present-centering, and being more responsible for one’s own and others’ lives (Mosher, 1979a,b). Enhanced self-realization, self-development, and self-acceptance, new ways of approaching and solving problems, coherence with self-awareness, and unity with the Universe can be achieved by a sense of ‘grounding’ in the reality. Experimenting and trying to find meaning via full awareness contribute to this sense of grounding. In Qi Gong exercises and the Feldenkrais session some Gestalt method principles could be applied: the continuum of movements’ awareness, constant feedback from body as a whole, effortless concentration on movements, and the sense of grounding in the presence (reality). Equally, Feldenkrais stated that at any single moment the whole system achieves a kind of general integration that the body will express at that moment when it acts (moves) (Feldenkrais, 1972, p. 38). The body’s position in space, positive thoughts and emotions, as well as chemical and neuro-hormonal processes combine to form a whole that cannot be separated out into its various parts during the movements. The nature and essence of movements could be therefore ‘penetrated’ and explored by the individual. Gestalt would be similar to the explorations of Qi Gong and/or Feldenkrais in the sense that unity of movements’ perception, its experience and expression could be an open door to enhanced self-realization and self-development. However, a discussion should be opened and further explorations may bring some insights into the relationships between Qi Gong exercises and Feldenkrais method in the light of Gestalt concept. Chiropractors, osteopaths, naturopaths or physiotherapists may take inspiration from such synthesis of these concepts for patients’ best benefits. Researchers can obtain valuable and additional arguments through such cross-fertilization of ideas across presented studies that may be united by shared assumptions.

Humanistic psychology Humanistic psychology emphasizes the functioning of the holistic body (Zimbardo, 1999, p. 702). Carl Rogers emphasized the world of individual experiences, and called

P. Posadzki et al. it the phenomenal field, arguing that individual perception of reality and its interpretation determines further behavioral patterns (Rogers, 1946). During the life span-development, an individual focuses on the role of external relationships in the shaping and maintenance of selfconcept and personal identity that entails an integration of self-acceptance and new positive and realistic selfperceptions (Rogers, 1961). Maslow (1968: p. 15) believed that the self-actualization drive of the organism’s potentialities towards a more effective basis for further growth stands at the top of the hierarchy of individual’s needs and is the most powerful impulse and internal motivation that individuals possess. Self-actualization (SA) is a concept of the integrity of a person’s nature: the organism spontaneously reorganizes its capacities to actualize its potential through whichever avenues are available (Maslow, 1971, p. 168). SA could be seen as a final state of affairs and a human’s goal and a dynamic process, active during a lifetime of ‘Being and Becoming’. It has also been argued that a person will choose the right path of development when she or he distinguishes and properly interprets the specific current development opportunities (Perls, 1948; Rogers, 1964). In addition to a personality’s integrity, wholeness can be achieved via the drive to self-development. Generally, humanistic psychology emphasizes the individuals’ strengths and tries to find optimistic aspects of peoples’ nature, their positive self-esteem that allows them to adjust to environmental demands (Rogers, 1964; Maslow, 1971). Additionally, an individual should possess an increasing openness to experience, tendency to live fully in each moment, trust in his or her organism as a means of arriving at the most satisfying behaviour in each existential situation and psychological freedom to move in any direction (Rogers, 1961, p. 186). Similarly, Feldenkrais (1972: pp. 16e18) pointed to different stages of development which can be found in each individual and there is no limit to improvement and the boundaries of the possible should be expanded in order to reach its fullest potential through movements. The more an individual advances his development through movements, the greater will be his ease of action with harmonious self-organization. On the other hand, through Qi Gong movements one can maximize his or her potential as a human being, freedom of expression and fulfillment of awareness. Finally, it can be suggested that Qi Gong movements facilitate self-actualization and further continuous personal growth.

Psychological approach to Qi Gong exercises and Feldenkrais method Qi Gong practitioners and Feldenkrais patients could focus their attention on more passive and calm introspection as a sine qua non condition for having the sense of control, which is awareness of the body (Vollmer, 1998). Such attentive awareness of the body would allow them to focus on various kinds of body movements: quick and rapid, as well as slow, soft and relaxed ones. Vollmer (1999: pp. 34e35) also suggested that we do not have to try to find the mental cause of the movements, but simply pointed to the fact that, since we move naturally, we know how to start to move. He argued that this attempt consists of something

Qi Gong exercises and Feldenkrais method we can do without trying because we never do more than move our bodies. Qi Gong exercises could be regarded as an aware intention to perform fluent movements combined with the of knowledge how to move our bodies in practical ways. Similarly to the Feldenkrais method, it can be suggested that a constant development through movements can be achieved following Qi Gong practice. Qi Gong exercises could mean to the practitioner a persistent selfexploration in the direction of enhanced self-organization at the level of personality characteristics. This could imply further changes in psychological well-being (positive mood, emotions and/or optimal self-esteem), social functioning (quality and quantity of interpersonal relationship) and spiritual growth beyond the self. Both Qi Gong and Feldenkrais could be considered in broader conceptual field: awareness mechanisms such as ‘communication’ between thought and movement, emotions and movement, relaxation of the whole body, and effortless concentration within the here and now would facilitate personal growth, selfactualization and self-realization. Such combination of concepts could allow an individual to reach his or her fullest potential as a human being. During Qi Gong exercises and Feldenkrais method the receptive mind should be tuned into harmony with nature and life within reality. Likewise, Qi Gong exercises and Feldenkrais classes are based on the assumption that the human body possesses positive resources which enable individuals to obtain maximum potential through movements so enhancing the body’s selfregulatory processes. Jain et al. (2004) suggested that more efficient movements are developed in the learning process and a person’s system can function better as a result. A person’s awareness is a valuable tool that can be used when an trying to express his or her potential through Qi Gong movements or Feldenkrais method. However, being truly aware and attentive to the subtleties of our movements requires effortless concentration, systematic and persistent efforts via practice (Jain et al., 2004). Equally, Feldenkrais suggests that once people mature their movements, further function becomes automatic and does not require concentration and systematic and persistent effort. Nevertheless, Qi Gong movements could and should be constantly developed in order to achieve the perfection of precision and personal growth through such ‘movements of self-realization’. The conscious process of self-exploration and realization through movements might be and should be pleasant, fascinating and passionate. Similarly, Maslow (1971: p. 43) proposed that people working on something which is very precious to them and which they love makes the work-joy dichotomy in their lives disappear. Both Qi Gong and Feldenkrais can be regarded as potential methods or ways of aware self-development and self-realization through movements. Qi Gong and Feldenkrais practitioners may potentially have ‘better’ perception of reality than non-practitioners due to movements performed with full awareness and concentration on the ‘here and now’. Perfectly fluent movements can be obtained in Qi Gong exercises through self-awareness and concentration. Correspondingly, Feldenkrais method allows an individual to increase or develop consciousness and improve perception of reality through the perception of his or her own body and body movements. Both Qi Gong exercises and Feldenkrais method can be regarded as a way of obtaining

231 knowledge of one’s own self and the structure of one’s consciousness (Zimbardo, 1999, p. 26). Additionally, Ryding et al. (2004) claim that body awareness has two dimensions: one which is expressed in posture and movement and a second that pertains to the introspective dimension. Both in Qi Gong exercises and Feldenkrais practice introspective and perceptive awareness should coalesce with each other in a unity of the present moment. It means that an individual should simultaneously be aware of both psychological processes (attention, thoughts, feelings) and surrounding circumstances including his or her own body and its movements in the current moment (Armstrong, 1989). Feldenkrais suggested that we have to learn to use the parts of out bodies separately and the major difficulty is differentiation of movement that includes all temporal and spatial changes in the state and configurations of the body and its parts (Feldenkrais, 1972, p. 32). Indeed, first of all Qi Gong practitioner should learn how to use the trunk, head, upper and lower extremities ‘separately’. Later on, one should consider the entire body full of consciousness, which allows for freedom and continuity of movements within here and now. From the exercise perspective it has been suggested that Qi Gong exercises should be the ‘mixture’ of appropriate muscle usage in order to promote the body’s balance, i.e. relaxation and tension, interchangeably. Appropriate rhythm and adjustment in time and space is equally important (Feldenkrais, 1972, p. 34). Such movement quality influences the nervous system positively. Body movements performed with full awareness, state of unity within reality and self may be an optimal way for self-discovery, self-exploration and overall development. Rogers (1961: p. 173) wrote that the individual should move towards living in an open, friendly, close relationship to his own experience-movements. Therefore, the Gestalt concept and humanistic psychology can be major ‘modalities’ applicable to movement therapy.

Conclusions The goal of Feldenkrais method and Qi Gong exercises is to teach the individual to become more aware of his or her own movements in a functional and kinesthetic way. As a result of these approaches, the improvement of posture or liberation of muscle tension may occur (Jain et al., 2004). It is suggested that observation of our experience indicates that consciousness is closely related to movement and the muscular sense. From concrete examples from the Feldenkrais method and Qi Gong exercises, it can be shown that changes in the organization of movement and functioning are intimately related (mind and the body are an inseparable whole during movements) and that one cannot change without conscious experience of the other (Ginsburg, 1999). Therefore, through exploration and association of awareness and movements, functional patterns can be modified. Gestalt concept of presence and humanistic psychology approach to self-development opportunities should therefore be incorporated into Qi Gong exercises and Feldenkrais practice. It can be suggested that such incorporation could enable a better understanding of both Gestalt concept and humanistic psychology from the perspective of a person’s movements and vice versa. Qi

232 Gong and Feldenkrais method can further be explored and developed according to principles of humanistic psychology and Gestalt psychotherapy. More research is needed to better assess and understand the effect of adding Qi Gong exercises and Feldenkrais method principles into an integrated, multifaceted program that selectively incorporates diet, relaxation training, and socio-psychological dimensions (Mayer, 1999). Considering all these suggested arguments, one can conclude that physiotherapy or/and rehabilitation process can also benefit from incorporating Qi Gong exercises, principles of Feldenkrais method and humanistic psychotherapy into clinical practice.

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Journal of Bodywork & Movement Therapies (2010) 14, 234e238

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

COMPARATIVE STUDY

Behavior analysis of electromyographic activity of the masseter muscle in sleep bruxers ´sar Ferreira Amorim a,*, Lilian Chrystiane Giannasi b, Luciano Maia Alves Ce ´rcio Magini b,1, Claudia S. Oliveira d, Luis Vicente Franco de Ferreira c, Ma Oliveira d, Tamotsu Hirata a, Fabiano Politti e a

Department of Mechanical Engineering (FEG), Sa˜o Paulo State University - UNESP, Guaratingueta - SP, Brazil Institute of Research and Development IP&D, University of Vale do Paraı´ba e UNIVAP, Sa˜o Jose´ dos Campos, SP, Brazil c Biomechanics of Movement Laboratory, University Center Claretiano e CEUCLAR, Batatais, SP, Brazil d Rehabilitation Sciences Master’s Program, Nove de Julho University e UNINOVE, Sa˜o Paulo, SP, Brazil e Department of Anatomy, University of Campinas (Unicamp), Brazil b

Received 18 February 2008; received in revised form 27 November 2008; accepted 28 December 2008

KEYWORDS Electromyography; Sleep bruxism; Masseter muscle

Summary The effects of occlusal splint on the electric activity of masseter were studied in 15 women who presented sleep bruxism using surface electromyography. Sleep bruxism was defined by its clinical characteristics. The signal acquisition was done during mandible occlusion without clenching and maximum voluntary contraction in two situations. The first was after a workday without using the occlusal splint; and the second, after a sleeping night using occlusal splints. Evaluating masseter muscles during mandible occlusion without clenching, it could be observed that lower values were noticed after splint wearing in both sides. The same results were verified in maximum voluntary contraction (MVC). These results confirmed that the use of occlusal splints reduced the electromyographic activity of the right and left masseters, showing its myorelaxing effect. ª 2009 Elsevier Ltd. All rights reserved.

Introduction The International Classification of Sleep Disorders defines sleep bruxism (SB) as a disease characterized by tooth clenching and grinding harmful movements during the * Corresponding author. Tel.: þ55 12 3942 4736. E-mail address: [email protected] (C.F. Amorim). 1 Current address: Universidade Camilo Castelo Branco, Nu ´cleo Parque Tecnolo ´gico, Rodovia Presidente Dutra, Km 138, Euge ˆnio de Melo, Sa ˜o Jose ´ dos Campos, Sa ˜o Paulo, Brazil, 12247-004.

sleep. It could be clinically observed by signs like abnormal tooth wear; orofacial pain; temporal headache; tooth hypersensibility to cold foods and drinks. Noises and hinge in the temporomandibular joints are also related to sleep bruxism (Tosun et al., 2003). SB is considered an idiopathic disease since innumerous physiological and pathological motor activities could involve the orofacial muscles during sleeping. The masticatory activity consists of mimic, lips protrusion, and tongue and swallow movements, which are completely physiological during sleep (Kato et al., 2003).

1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2008.12.002

Behavior analysis of electromyographic activity Sleep bruxism is a controversial phenomenon regarding its etiology. Its diagnosis is described as a complex process composed by peripheral and central factors (Lobbezoo and Naeije, 2001). The peripheral factors, morphological, like occlusion and anatomical differences of the bone structures of orofacial region, were considered as being involved in sleep bruxism etiology (Lobbezoo et al., 2006a; Lobbezoo et al., 2006b). Other factors such as chronic alcohol use, drug use, smoking, diseases and trauma could also be involved in sleep bruxism etiology, as well as pathological and psychological factors which appear as central factors (Lobbezoo et al., 2006a,b). More specifically, disturbances in the central dopaminergic system had been recently described as being involved in sleep bruxism etiology (Lobbezoo et al., 1997). The effects of SB are not limited to the temporomandibular joints, head or neck areas. It can also be related to physiological and psychological health. Disturbances related to SB include insomnia, headaches, muscle stiffness in the morning, congestion of facial sinuses, cervicodynia, arthrosis and vertigo (Treacy, 1999). In other study, the authors showed that SB was found in 8% of a sample of 846 subjects with clinical signs of tooth wear, associated with rhythmical masticatory muscle activity. Its consequences include tooth destruction, mandibular pain and tooth grinding (Lavigne et al., 1998). Occlusal splint (OS) wear is considered an effective and non-invasive treatment for many sleep bruxism patients and those with temporomandibular disorders. Several studies have been proposed to elucidate the splint action such as the modulation of neuromuscular function, relief of temporomandibular joints’ loads and psychological effects (Hiyama et al., 2003). Glaros and Rao (1977) suggested that some studies had demonstrated changes in the masticatory muscular activity after the sear of OC wear in awaken patients. Those studies used systems of conventional electromyographic signs registration to monitor the electric activity of masticatory muscles. SB was also studied using polissonographic methods, including surface electromyography of the mandibular muscles. The presence or absence of SB and its frequency was determined using a match of EMG pattern and amplitude of the masseter and temporal muscles (Lavigne et al., 1996). Electromyography (EMG) has been widely used as an auxiliary method on temporomandibular disorders diagnosis. Its use allows evaluating the functional and biomechanical responses of masticatory muscles in rest, chewing and grinding (Michelotti et al., 2005). The study of muscular function by EMG is defined by the analysis of electric signal produced during the muscular contraction, and allows interpretations in pathological and normal conditions (De Luca, 1997). The present study aims to analyze the electromyographic signs of masseter muscle in women who presented SB, after a working day, correlating stress factors, psychological and intellectual conditions, and after the OS wearing during a sleeping night.

Method The sample consisted of 15 (fifteen) women with average age of 26.5  3 years, who worked for 8 (eight) hours per day, 40 hours per week.

235 Clinical diagnosis was made under world standards of diagnosis, based upon patient history and orofacial examination. Tooth wear was evaluated with a dental mirror and adequate light. Upper and lower casts were made to analyze the degree of tooth wear (Seligman and Pullinger, 1995). Diagnosis of muscular hypertrophy was also considered bearing in mind the age of patients and dental/facial morphology (Raadsheer et al., 1996). All of those evaluated used flat and plane, myorelaxing occlusal splints during sleep, to avoid tooth wear, and temporomandibular joint overload, for at least 30 days. Biological signals were obtained using an eight channel module (EMG System do Brasil LTDA), consisting of a signal conditioner with a band pass filter with cut-off frequencies at 20e500 Hz, an amplifier gain of 1000 and a common mode rejection ratio >120 dB. All data were processed using specific software for acquisition and analysis (Tool Box BR V1.0 by EMG System do Brasil LTDA) (Figure 1), a converting plate for A/D 16 bits signal to convert analog to digital signals with a sampling frequency of anti-aliasing 2.0 kHz for each channel. The differential double electrodes used consisting of three rectangular parallel bars of Ag/AgCl (1 cm in length, 0.2 cm in width and separated by 1 cm) were used and were coupled to a rectangular acrylic resin capsule 2.2 cm in length, 1.9 cm in width and 0.6 cm high with an internal amplifier in order to reduce the effects of electromagnetic interference and other noise (Amorim et al., 2006). Electrodes were fastened to the skin where it was previously cleaned with alcohol 70%, to reduce the impedance, and guided by bone prominences and the route of the muscle fibers (Dornelas de Andrade et al., 2005). This system obtained data, in root mean square (RMS), of each sample participant. Surface silver electrodes were positioned in the motor point, located in the muscular womb center, indicated by masseter muscle hypertrophy in contraction. In all procedures the capture and analysis of EMG signals were carried out as recommended by the International Society Electrophysiology Kinesiology (ISEK) (Solomonow, 1995). The EMG evaluation occurred in the mandibular resting position, and after a maximal voluntary contraction (MVC), isometric muscle contraction, biting a chewing gum placed bilaterally. Chewing gum was used to eliminate the discomfort of tooth contact. Patients were placed sitting safely on a comfortable chair, staring the computer screen, which was exhibiting the electromyographic signs. A clear and precise verbal command was given to the patients concerned about muscles’ contractions and signs acquired. The utilization of a computer screen, like a biofeedback, was used to control the intensity of maximum voluntary contraction, in order to eliminate subjective muscular effort. The data were collected twice per patient: after a work period without occlusal splint wearing (before occlusal splint wear) and after a night’s wearing the occlusal splint (after occlusal splint wear). The signal treatment was performed by complete wave rectification, linear cover by Butterworth of fourth level, with 5 Hz frequency of cut, normalized in time base and amplitude, where the amplitude was normalized by mean.

236

C.F. Amorim et al.

Figure 1

Software acquisition and signal processing.

The intensity variability of the EMG signs in the different muscular situations was made by ManneWhitney’s Test and Wilcoxon’s Test based on the values of rectified signal of paired samples. The level of significance adopted was 0.05.

Results Figure 2 shows the values concerning to electromyographic signs acquired on left and right masseter muscles in rest position. It could be observed that the comparative values of EMG signs measured respectively on right and left masseter muscle in mandibular rest position. Both masseter muscles show EMG signs verified after a work journey before and after wearing occlusal splint. Figure 3 and Table 2 demonstrate the values concerning to electromyographic signs acquired on left and right masseter muscles in maximal volunteer contraction (MVC), isometric muscle contraction. It shows the comparative values of EMG signs measured respectively on right and left

masseter muscle in maximal volunteer contraction before and after occlusal splint wear.

Discussion Sleep bruxism is a parafunctional oral habit characterized by harmful tooth clenching and grinding movements during sleep, which result in excessive tooth wear, periodontal disease and temporomandibular disturbances (Xhonga, 1977). Recently, the relationships between stress, muscular hyperactivity and painful symptoms have been studied using EMG. The clinical use of EMG in orofacial pain, muscular hyperactivity and specific daily activities shows considerable variations among patients (Rugh and Harlan, 1988). EMG signs evaluated on the right masseter in rest (Figure 2) showed reduction of the electromyographic activity with a significant statistical difference in 15 of the

Figure 2

8 7 6 5 4 3 2 1 0

Left Masseter Muscle Amplitude µV RMS

Amplitude µV RMS

Right Masseter Muscle

1

2

Before occlusal splint

After occlusal splint

8 7 6 5 4 3 2 1 0

1

2

Before occlusal splint

After occlusal splint

Values of EMG signs of the masseter muscle in rest, with statistically significant difference to p < 0.05.

Figure 3

237

Right Masseter Muscle

200 180 160 140 120 100 80 60 40 20 0

Amplitude µV RMS

Amplitude µV RMS

Behavior analysis of electromyographic activity

1

2

Before occlusal splint

After occlusal splint

Left Masseter Muscle

200 180 160 140 120 100 80 60 40 20 0

1

2

Before occlusal splint

After occlusal splint

Values of EMG signs of the masseter muscles in MVC, with statistically significant difference to p < 0.05.

subjects analyzed. The Average of the EMG sign obtained on the left masseter at rest (Figure 2 and Table 1) also showed a significant statistical difference in 15 subjects, with all 15 presenting a reduction in the myoeletric activity. One of the subjects tested presented no significant statistical difference on EMG signs measured on the right masseter but showed significant differences on EMG values on the left. In another patient it could be observed an inverse situation: significant differences on EMG signs on the right masseter and no significant differences on EMG signs on the left masseter. This situation of different results found in masseter muscles of the same individual can be explained by (Baba et al., 2000), which showed that inadequate force distribution of the masticatory muscles and temporomandibular joints, can lead to occlusal asymmetry. EMG signs obtained on the right masseter in maximum voluntary contraction (MVC) showed that 2 subjects presented no significant statistical differences between signs measured before and after occlusal splint use. EMG signs on the left masseter in maximum voluntary contraction (MVC) (Figure 3) showed that 13 subjects presented significant statistical differences, with all 13 showing reduction of the sign values. Two subjects presented no statistical differences. Another study showed a significant difference in the distribution of masticatory forces on muscles and temporomandibular joints. During tooth clenching, small jaw movements occur and it affects the temporomandibular joints loading. In an experimental situation, the maximum level of force could differ depending on jaw movement, which affects the clenching force and the EMG activity. The results from this study indicate that the distribution of clenching forces in sleep bruxism could be influenced by occlusal patterns of the subject (Baba et al., 1996). Our findings related to electric potential produced by right and left masseter during occlusion, without clenching,

Table 1 Average of EMG signs of the masseter muscles in rest, with statistically significant difference to p < 0.05.

are in accordance with scientific literature. Our results showed a significant statistical decrease of electromyographic activity for muscles of both sides. Only one subject presented no significant result. The efficacy of OS and placebo was compared during 6 weeks, and the authors found no statistical difference between the 2 types of devices, but the findings showed that there was statistically significant reduction of the masseter EMG activity immediately after the insertion of splints. However, there were no significant changes in 2, 4 and 6 weeks after the insertion of either splint (Baba et al., 2000). The results of our study also are in agreement with those found by Landulpho et al. (2002), which showed a significant reduction (p < 0.05) in the EMG activity of masseter during isometric muscle contraction in occlusal splint wearers, indicating decrease of electromyographic activity. A randomized cross-over study using 10 patients, compared the masseter EMG effects of two types of occlusal splint: a nociceptive trigeminal inhibitory splint providing occlusion only on the front teeth and a standard occlusal splint. Each patient received both splints and the study lasted 7e8 weeks including the washout period. The authors concluded that the significant decrease of EMG activity is not associated with a reduction in temporomandibular disorders’ signs or symptoms, once 5 of 10 patients perceived pain at baseline (Baad-Hansen et al., 2007). Armijo-Olivo and Magee (2007) evaluated the electromyographic activity of the masticatory (masseter and anterior temporalis) and cervical (upper trapezius and splenis capitis) muscles during resisted jaw opening in awake patients, and found that EMG activity of these 4 muscles significantly increased during resisted jaw opening.

Table 2 Average of EMG signs of the masseter muscles in MVC, with statistically significant difference to p < 0.05. Before splint using

After splint using

Before splint using

After splint using

Right

Left

Right

Left

Right

Left

Right

Left

8.23  2.6 mV

7.40  1.6 mV

6.59  1.5 mV

5.82  1.3 mV

178.90  7.6 mV

170.60  6.6 mV

120.40  6.5 mV

129.37  5.3 mV

238 Therefore, more investigative studies are necessary to verify the relationship among peripheral and central factors, and sleep bruxism etiology. Different investigative methods may also be tested, comparing the control and pathological groups after situations of induced stress or electroencephalographic exams correlating sensitive-motor activities during the sleep.

Conclusion Occlusal splints wearing as a prevention or treatment of sleep bruxism should decrease electric activity of right and left masseter in situation of mandibular rest and maximal isometric muscle contraction in women. Stress factors during a work period can influence the increase of electric activity of masseter muscles in sleep bruxism bearers.

Acknowledgments The authors are grateful to Thiago R. Amorim for his help in developing the software of analysis. The amplifier system and the differential double electrodes, were made available by EMG System do Brasil, Sa ˜o Jose ´ dos Campos e Sa ˜o Paulo, Brazil. This study was supported by FAPESP e Fundac ¸˜ ao de Amparo a Pesquisa do Estado de Sa ˜o Paulo and CNPq e Conselho Nacional de Desenvolvimento Cientl´fico e Tecnolo ´gic.

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C.F. Amorim et al. Dornelas de Andrade, A., Silva, T.N., Vasconcelo Ket, A.L., 2005. Inspiratory muscular activation during threshold therapy in elderly healthy and patients with COPD. J. Electromyogr. Kinesiol. 15 (6), 631e639. Glaros, A.G., Rao, S.M., 1977. Bruxism: a critical review. Psychol. Bull. 84 (4), 767e781. Hiyama, S., Ono, T., Ishiwata, Y., Kato, Y., Kuroda, T., 2003. First night effect of an interocclusal appliance on nocturnal masticatory muscle activity. J. Oral Rehabil. 30 (2), 139e145. Kato, T., Dal-Fabbro, C., Lavigne, G.J., 2003. Current knowledge on awake and sleep bruxism: overview. Alpha Omegan 96 (2), 24e32. Landulpho, A.B., e Silva, W.A., e Silva, F.A., Vitti, M., 2002. The effect of the occlusal splints on the treatment of temporomandibular disorders e a computerized electromyographic study of masseter and anterior temporalis muscles. Electromyogr. Clin. Neurophysiol. 42 (3), 187e191. Lavigne, G.J., Rompre ´, P.H., Montplaisir, J., 1996. Sleep bruxism: validity of clinical research diagnostic criteria in a controlled polysonographic study. J. Dent. Res. 75 (1), 546e552. Lavigne, G.J., Rompre ´, P.H., Poirier, G., et al., 1998. Rhythmic masticatory muscle activity (RMMA or chewing-automatism) during sleep in normal controls. J. Sleep Res. 7, 229. Lobbezoo, F., Naeije, M., 2001. Bruxism is mainly regulated centrally, not peripherally. J. Oral Rehabil. 28 (12), 1085e1091. Lobbezoo, F., Van Der Zaag, J., Naeije, M., 2006a. Bruxism: its multiple causes and its effects on dental implants e an updated review. J. Oral Rehabil. 33 (4), 293e300. Lobbezoo, F., Brouwers, J.E., Cune, M.S., Naeije, M., 2006b. Dental implants in patients with bruxing habits. J. Oral Rehabil. 32 (2), 152e159. Lobbezoo, F., Soucy, J.P., Hartman, N.G., et al., 1997. Effects of the D2 receptor agonist bromocriptine on sleep bruxism: report of two single-patient clinical trials. J. Dent. Res. 76 (9), 1610e1614. Michelotti, A., Farella, M., Gallo, L.M., et al., 2005. Effect of occlusal interference on habitual activity of human masseter. J. Dent. Res. 84 (7), 644e648. Raadsheer, M.C., Kiliaridis, S., Van Eijden, T.M., et al., 1996. Masseter muscle thickness in growing individuals and its relation to facial morphology. Arch. Oral Biol. 41 (4), 323e332. Rugh, J.D., Harlan, J., 1988. Nocturnal bruxism and temporomandibular disorders. Adv. Neurol. 49, 329e341. Seligman, D.A., Pullinger, A.G., 1995. The degree to which dental attrition in modern society is a function of age and of canine contact. J. Orofac. Pain 9 (3), 266e275. Solomonow, M.A., 1995. Practical Guide to Electromyography. International Society of Biomechanics Congress XV, Jvaskyla, Finland. 1995. Treacy, K., 1999. Awareness/relaxation training and transcutaneous electrical neural stimulation in the treatment of bruxism. J. Oral Rehabil. 26 (4), 280e287. Tosun, T., Karabuda, C., Cuhadaroglu, C., 2003. Evaluation of sleep bruxism by polysomnographic analysis in patients with dental implants. Int. J. Oral Maxillofac. Implants 18 (2), 286e292. Xhonga, F.A., 1977. Bruxism and its effect on the teeth. J. Oral Rehabil. 4 (1), 65e76.

Journal of Bodywork & Movement Therapies (2010) 14, 239e244

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CLINICAL INFLUENCES

Differences in practitioners’ proficiency affect the effectiveness of massage therapy on physical and psychological states Nozomi Donoyama a,*, Masanao Shibasaki b a Course of Acupuncture and Moxibustion, Department of Health, Faculty of Health Sciences, Tsukuba University of Technology, 4-12-7, Kasuga, Tsukuba 305-8521, Ibaraki, Japan b Allergy and Immunology, Department of Health, Faculty of Health Sciences, Tsukuba University of Technology, 4-12-7, Kasuga, Tsukuba 305-8521, Ibaraki, Japan

Received 24 March 2008; received in revised form 16 January 2009; accepted 27 January 2009

KEYWORDS Massage therapy; Proficiency; Practical training; Muscle stiffness in the neck and shoulder; Visual analogue scale (VAS); State anxiety; Salivary cortisol; Secretory immunoglobulin A (s-IgA)

Summary Objective: An examination was made of how differences in the proficiency of massage practitioners had different physical and psychological effects on clients. Method: Eight healthy 50-year-old females, suffering from chronic neck and shoulder stiffness, were recruited and four interventions were conducted: three 40-minute massage therapy interventions, one each by a freshman and a sophomore student studying massage therapy, and one by their instructor, and one rest on the massage table. Visual analogue scale score for muscle stiffness in the neck and shoulder, state anxiety score, and salivary cortisol concentration levels and secretory immunoglobulin A, were measured pre- and post- interventions. Results: Visual analogue scale of neck and shoulder stiffness after massage by the instructor was significantly lower than that after the other interventions, and the score of state anxiety was lower than that after resting. ª 2009 Elsevier Ltd. All rights reserved.

Introduction Recently, the use of complementary and alternative medicine (CAM) therapies has increased around the world, and the prevalence of and expectations for massage

* Corresponding author. Tel.: þ81 29 858 9631; fax: þ81 29 855 1745. E-mail address: [email protected] kuba-tech.ac.jp (N. Donoyama).

therapy have rapidly increased, particularly because of its emphasis on stress reduction and increased physical and psychological relaxation (Lovas et al., 2002). In Japan, practitioners of massage therapy, including traditional Japanese massage called Anma therapy, foreign-style massage, and shiatsu, should undergo professional training for at least three years after finishing high school, and then they should pass the national examination to obtain a national license for massage practitioner. In Japan, hands-on therapies, including those mentioned above, are often collectively called ‘‘massage’’ and are not properly

1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.01.007

240 distinguished from each other. In this case, traditional Japanese Anma therapy is the most widely used form of ‘‘massage’’. Thus, in this manuscript, the term, ‘‘massage’’ is used to refer to the traditional Japanese Anma therapy. (It is recommended that the previous study (Donoyama et al., 2010) be referred to for more detailed information on the traditional Japanese Anma therapy.) Japanese law stipulates that students who are in schools for professional education for at least three years, have to pass 77 units of coursework (one unit includes 15e30 lecture hours and 30e45 practical training hours), including basic massage studies (e.g. anatomy, physiology, basic kinesiology, pathology, hygiene and public health, general clinical medicine, clinical medicine, rehabilitation medicine, medical systems overview), professional massage studies (e.g. oriental medicine, meridian and treatment points, massage theory, clinical oriental medicine, clinic management), and practical training (e.g. basic practical training, clinical training, clinical clerkship at massage clinics and medical settings). Special emphasis is placed on 10 units that involve about 450 h of practical training and clinical clerkship (Japan Association of Massage and Acupuncture Teachers, 2003). In spite of this hard study and intensive practical training, the public and the government seem to believe that it is easy for anyone to treat physical symptoms, relieve mental stress, and induce relaxation. As evidence of that, it is easy in Japan for persons without a national license for massage therapy to practice illegally and almost none of them have been punished by the government. It is thought to be dangerous for therapists who are not adequately familiar with human body structures and functions, formation of diseases, and principles of massage therapy to treat clients. There is a review that has reported incidents of massage therapy practiced by unlicensed therapists and students that resulted in aggravation of lower back pain, induction of pain in part or even all of the body, infection through massage oil, and even rib fracture, among other adverse effects (Donoyama, 2002). Even given the occurrence of such harmful mistakes, is it true that any practitioner can use massage therapy to treat clients? Massage therapy is composed of tactile, pressure, and mechanical stimuli given from the surface of the body to muscles and other soft tissues. Can massage therapy always have the same effect on clients, regardless of the proficiency or experience of the practitioner? In order to answer this question, the present study examined the results of massage sessions conducted by practitioners with differing levels of experience and the different physical and psychological effects these sessions had on clients, by measuring the visual analogue scale (VAS) of participants’ symptom of the neck and shoulder stiffness, state anxiety, salivary cortisol, and secretory immunoglobulin A (s-IgA).

Materials and methods Participants Ten healthy females were recruited randomly from a volunteer list, in which about 150 persons are registered as volunteers for the massage experiments in the

N. Donoyama, M. Shibasaki laboratory. Requirements for participants’ gender, age, and physical condition were: (i) to be a female in the fifth decade of life; (ii) to feel chronic muscle stiffness around the neck and shoulders;, (iii) to have no disease requiring medical intervention; (iv) to desire massage therapy; and especially to eliminate the influence of sexual hormones, as suggested in the study by Kirschbaum et al. (1999) showing that salivary cortisol levels are affected by the menstrual cycle, (v) to be a few years post-menopause, and (vi) to feel no current symptoms of menopause. Muscle stiffness in the neck and shoulders is defined by symptoms which produce a feeling of irritation, an unpleasant sensation, strain, stiffness, ache and/or pain in the Regio axillaris and/or Regio scapularis muscles (Hirabayashi, 2002; Ishii and Hirasawa, 2002). All participants gave their informed consent, were screened for conditions of chronic muscle stiffness in the neck and shoulders, and the absence of medical disease was confirmed by a doctor. They were asked to avoid strenuous exercise on the days they were participating in the study and to avoid eating and drinking within one hour of participating in the study.

Interventions All participants received four interventions, conducted on different days. Three 40-minute massage therapy sessions, one each conducted by a freshman student (60-h practical training, 6-month educated) and a sophomore student (240h practical training, 15-month educated) who were majoring in acupuncture and massage therapy at a university, one session conducted by an instructor who taught them and had more than 15 years of experience in massage therapy and its education, and one session consisting of a 40-minute rest on the massage table without massage therapy. Student therapists (five freshmen and five sophomores) were recruited to conduct two interventions each. Participants were randomly assigned to the students but in a way that would guarantee that each participant would receive one intervention by a freshman and one by a sophomore. They did not know the academic year of the students. The instructor treated all 10 participants. Interventions were conducted at one-week intervals. The massage procedure essentially consisted of basic and clinical versions of traditional Japanese massage taught at the university, Anma therapy, which is composed primarily of massage techniques that are commonly used in Japan. Anma therapy is usually administered through clothing or using a piece of cloth; here, it was administered through clothing. Practitioners were given leeway with their massage sessions in order to deal adequately with individual participants’ symptoms of neck and shoulder stiffness. However, all practitioners in this experiment were required to use at least the following massage procedure: have the participant lie down on one side and stroke, knead, and press her neck, shoulder, back, lower back, arm, hand, leg and foot. Next, have the participant lie down on the opposite side and repeat the same procedure on the other side of her body. Finally, with the participant in a prone position for several minutes, stroke, knead, and press her whole body except the head. This massage procedure was the same as in our previous study,

Practitioners’ proficiency and effectiveness of massage therapy on physical and psychological states so please refer to our previous article for details (Donoyama et al., 2010).

Procedure of the experiment Upon arrival at the laboratory, participants rinsed their mouths out with water from a disposable paper cup and took a 15-minute rest. Then, a saliva sample was obtained, and participants wrote self-assessments of their neck and shoulder stiffness using the visual analogue scale and feelings of anxiety using the State Trait Anxiety Inventory. A 40-minute intervention was then performed. After the session, assessments were made again. Each time, the experiments began at 3:00 p.m. in consideration of the circadian rhythms of cortisol and s-IgA in saliva (Walker et al., 1984; Dimitriou et al., 2002). This study was approved by the Medical Ethics Committee of Tsukuba University of Technology and was performed according to the ethical standards set forth in the Helsinki Declaration of 1964 and its amendment of 2000.

Measurements (i) The visual analogue scale (VAS) was used to assess the severity of the subjective symptoms, muscle stiffness in the neck and shoulders. A sheet of paper (width 100 mm  height 40 mm) was given to each subject and it was explained that the left edge of the paper represented no symptom and the right edge represented the most serious symptom that the subjects could imagine. The subjects were then asked to indicate how serious the degree of their neck and shoulder stiffness was at that time by ticking the corresponding location on the paper. The length from the left edge of the paper to the tick was measured and treated as the VAS score. (ii) The state anxiety score, which was measured by the Japanese version of the State Trait Anxiety Inventory (STAI) by Spielberger et al. (Mizuguchi et al., 1991), was a self-report Likert scale consisting of 20 items to assess the degree of anxiety being felt by participants at that time. The scores obtained ranged from 20 to 80, with higher scores representing stronger states of anxiety. (iii) Saliva was collected pre- and post-interventions. Each time, a swab was removed from a Salivette (Sarstedt, Aktiengesellschatt & Co., Germany), chewed 60 times gently for a minute in synch with a metronome, then returned to the Salivette. It was sealed and frozen immediately in a freezer on the night when the intervention was conducted. The next morning, the Salivettes were delivered to the assay company (SRL Inc, Tsukuba, Japan). Assays were conducted to determine the concentration of salivary cortisol and s-IgA in samples by g-cortisol and enzyme immunoassay (EIA) sIgA test, respectively.

Statistical analysis In the present study, data for eight participants who could take part in all four of the interventions were analyzed; two persons withdrew from one intervention due to family circumstances.

241

To compare the immediate changes by interventions, repeated measures analyses of variance (ANOVA) with Bonferroni correction were performed. Next, values before interventions were converted into scores based on 100, values after interventions were calculated, and each intervention group was compared by repeated measures ANOVA with Bonferroni correction. All statistical analyses were performed by SPSS 15.0. Alpha was set equal to 0.05, thereby implying that any statistical outcome that had a p < 0.05 would indeed be statistically significant.

Results The repeated measures ANOVA with Bonferroni correction were performed to clarify differences among massage therapy sessions by the freshman students, the sophomore students, and the instructor, and the rest (control), and results are shown in Table 1. Post-intervention VAS scores were significantly lower than those obtained pre-intervention (F Z 38.2, p Z 0.0005). There were significant differences among the four interventions (F Z 9.7, p Z 0.017); the VAS scores were significantly lower after massage therapy sessions by the instructor than those by freshman students (p Z 0.041) and after the rest sessions (p Z 0.043). Post-intervention state anxiety scores were significantly lower than those obtained pre-intervention (F Z 16.7, p Z 0.005); however, there were no significant differences among the four interventions (F Z 0.7, p Z 0.448). For concentration levels of salivary cortisol, post-intervention values were significantly lower than those obtained pre-intervention (F Z 16.4, p Z 0.005); however, there were no significant differences among the four interventions (F Z 1.5, p Z 0.264). Concentration levels of s-IgA post-intervention were increased significantly compared with those obtained pre-intervention (F Z 23.1, p Z 0.002); however there were no significant differences among the four interventions (F Z 1.7, p Z 0.237). Second, values before interventions were converted into scores based on 100, values after interventions were calculated, and each intervention group was compared by repeated measures ANOVA with Bonferroni correction (Table 2). The VAS scores of neck and shoulder stiffness were found to be significantly lower after massage therapy sessions by the instructor than after the other interventions (the instructor vs. the freshman students, p Z 0.017; the instructor vs. the sophomore students, p Z 0.049; the instructor vs. the rest, p Z 0.004), and the value of state anxiety was lower after massage therapy sessions by the instructor than after resting on the massage table (p Z 0.002).

Discussion In the post-massage therapy by all three kinds of practitioners, VAS scores were lower than the pre-massage therapy VAS scores, whereas the rest-sessions did not reduce the scores. Despite their relatively brief period of academic learning, the students could fractionally improve the symptoms of muscle stiffness in the neck and shoulders. In previous studies on anesthetized rats (Cao et al., 1992; Sato et al., 1996, 2002) tactile and pressure stimuli, from

242

N. Donoyama, M. Shibasaki

Table 1 Comparison of temporal changes in values among four interventions (repeated measures analyses of variance ANOVA with Bonferroni corrections). Time

Effect Pre

Post

Group

Time

Group  time

Mean  SE (95% CI)

Mean  SE (95% CI)

F

F

F

Visual analogue scale Freshmen 75.8  5.9 (62.6e86.9) 57.4  8.3 (40.5e74.3) Sophomores 70.8  5.9 (58.6e82.9) 54.9  8.3 (38.0e71.8) Instructor 72.5  5.9 (60.3e84.7) 23.3  8.3 (6.3e40.2) Rest (control) 58.4  5.9 (46.2e70.5) 57.1  8.3 (40.2e74.0) State anxiety Freshmen 36.8  2.7 (21.1e42.4) 30.0  2.1 (25.8e34.2) Sophomores 37.5  2.7 (31.9e43.1) 28.4  2.1 (24.1e32.6) Instructor 36.4  2.7 (30.8e42.0) 26.8  2.1 (22.5e31.0) Rest (control) 34.1  2.7 (28.5e39.7) 30.3  2.1 (26.0e34.5) Cortisol (mg/dL) Freshmen 0.239  0.020 (0.198’e0.279) 0.219  0.019 (0.179e0.258) Sophomores 0.276  0.020 (0.236-0.317) 0.240  0.019 (0.209-0.279) Instructor 0.234  0.020 (0.202e0.283) 0.199  0.019 (0.159e0.238) Rest (control) 0.230  0.020 (0.190e0.270) 0.205  0.019 (0.166e0.244) s-IgA (mg/mL) Freshmen 417.8  54.1 (307.0e528.6) 819.6  142.7 (527.3e1111.8) Sophomores 355.7  54.1 (244.9e466.5) 813.5  142.7 (521.2e1105.7) Instructor 389.3  54.1 (278.5e500.1) 571.8  142.7 (279.5e864.1) Rest (control) 434.1  54.1 (323.2e544.9) 719.0  142.7 (426.7e1011.2)

p

p

9.7 0.017* 38.2 0.0005*** 7.8

p 0.027*

p Z 0.041* p Z 0.043* 0.7 0.45

16.7 0.005 ** 0.2

0.69

1.5 0.26

16.4 0.005 ** 1.8

0.23

1.7 0.24

23.1 0.002 ** 3.8

0.09

*p < 0.05; **p < 0.01; ***p < 0.001.

the surface of the body affected the autonomic nervous system and induced reflexive motions, somato-visceral reflexes, which are thought of as a massage therapeutic mechanism. In previous studies (Field, 2002a,b; Mori et al., 2004), it was found that manual mechanical stimuli by massage increase blood flow, remove metabolites and waste products. This suggests that massage stimuli by even unskilled students may be able to induce autonomic nerve reflexes and cause some alleviation of physical symptoms of muscle stiffness in the neck and shoulders. Nevertheless, the massage therapy by the instructor was significantly different from that by freshman students and the resting session (Table 1). The comparison of values after interventions, when values before interventions were converted into scores based on 100 among the four interventions, clearly indicates that VAS scores after the massage therapy by the instructor were significantly lower than those by the other three types of interventions (Table 2). As a result, it was concluded that the massage therapy by the experienced and skilled practitioner was much more effective in improving the physical subjective symptoms than that by the unskilled practitioners. The changes in the post-intervention state anxiety scores indicated that massage therapy by all three kinds of practitioners and the resting session could reduce state anxiety compared with before interventions, although the differences among the four interventions were not clear (Table 1). Next, a comparison of values after interventions, when values before interventions were converted into scores based on 100 among the four interventions, showed that the score of state anxiety after massage therapy by the instructor was significantly lower than after resting on the

massage table (Table 2). The results imply that massage therapy by an experienced and skilled practitioner can greatly improve not only the physical symptoms of the muscle stiffness in the neck and shoulders but also psychological conditions, and state anxiety. Moreover, in the present study, salivary cortisol concentrations in the post-interventions were decreased significantly (Table 1). The significant decreases in salivary cortisol levels after massage sessions were the same as in previous studies (Field, 1998, 2000; Field et al., 1992, 1997, 1998; Hart et al., 2001; Hernandez-Reif et al., 2000). Cortisol is a major steroid hormone secreted by the adrenal cortex via reactions in the hypothalamusepituitarye adrenal axis and autonomic nervous system that is commonly used as an index of stress (Fukuda and Morimoto, 2001). This result suggests that stimulation from the surface of the body can affect the autonomic nervous system and help to release psychological stress through the hypothalamusepituitaryeadrenal axis. In our previous study, in which saliva had been collected directly, rather than with Salivettes, salivary cortisol concentration levels after massage therapy by the same practitioner participating in the present study were not reduced significantly compared with those before the massage sessions (Donoyama et al., 2010). It is thought that the use of Salivettes to obtain saliva without distress could increase the accuracy of measurements taken of cortisol concentration levels before and after massage therapy. However, there were no significant differences among the four interventions (Tables 1 and 2). S-IgA concentration levels were significantly increased after interventions, however, there were no significant

Practitioners’ proficiency and effectiveness of massage therapy on physical and psychological states

243

Table 2 Comparisons of values after interventions when values before interventions were converted into scores based on 100 (repeated measures analyses of variance ANOVA with Bonferroni corrections).

differences among the four interventions (Tables 1 and 2). Previous studies not only on massage therapy (Green and Green, 1987; Groer et al., 1994) but also on relaxation by watching a humorous movie (Dillon et al., 1985) and imagery (Jasnoski and Kugler, 1987) showed the same results, i.e. increase of s-IgA after interventions. These findings in previous studies suggested that increases in wellbeing (Dillon et al., 1985) and holistic benefits (Groer et al., 1994) caused s-IgA to increase. The present study implies that all four kinds of interventions could enhance wellbeing and provide holistic benefits to participants and, in the results, s-IgA concentrations were increased. This in turn may enhance immunological functions and help prevent illness. However, massage therapy is no more effective for increasing s-IgA than resting, watching humorous movies, or viewing images. In conclusion, this study has verified that massage therapy practiced by a competent experienced practitioner can greatly alleviate subjective symptoms of muscle stiffness in the neck and shoulders and state anxiety, and lower salivary cortisol as an index of psychological stress. It is thought that the differences in effectiveness between an experienced practitioner and unskilled student depend on the proficiency of the practitioner, which has been cultivated by experience. Massage instructors have the responsibility to educate students to become professionals who can attend to clients’ needs. The results presented here strongly suggest that practical training and clinical clerkship should be an integral part of massage therapy education. The limitations of this study should be noted. Since it was too difficult to recruit massage professionals with the

same experiences and the same skills, one instructor was used across all eight subjects in the study. This was not the case with the freshman and sophomore interventions. All eight subjects should have been treated by each and every freshmen and sophomore. In the absence of this type of control, it is possible that variances across the five freshmen and across the five sophomores might have been a factor influencing the outcomes of the study. In the present study, repeated measures ANOVA was performed twice to clarify differences among the four interventions, as shown in Tables 1 and 2. The first analyses using ANOVA were expected to reveal differences among the four interventions; however, they could not clearly indicate significant differences among the interventions. Therefore, values before interventions were converted into scores based on 100, values after interventions were calculated, and each intervention group was compared by repeated measures ANOVA with Bonferroni correction. As a result, statistically significant differences among the four interventions finally became clear. This suggests that our sample size was too small to perform statistical analyses. It would thus be advisable to try the study again with a sufficiently large sample size to confirm the results.

Acknowledgement The present study, No. 17653125, was supported by a science study program grant from the Education and Science Ministry of Japan, 2006.

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Journal of Bodywork & Movement Therapies (2010) 14, 245e254

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QUALITATIVE STUDY

The experiences of basic body awareness therapy in patients with schizophrenia Lena Hedlund, RPT, MSc*, Amanda Lundvik Gyllensten, RPT, PhD Department of Health Sciences, Division of Physiotherapy, Faculty of Medicine at Lund University, PO Box 157, 221 00 Lund, Sweden Received 13 October 2008; received in revised form 3 March 2009; accepted 31 March 2009

KEYWORDS Physiotherapy; Affect regulation; Self-esteem; Cognitive function; Rehabilitation

Summary Background: Basic Body Awareness Therapy (BBAT) is a physiotherapeutic treatment method that is commonly used in Scandinavian mental health services. However, for patients with schizophrenia, there are few studies that verify the effectiveness of BBAT, or explain which dysfunctions or disabilities BBAT has an effect on in this group of patients. The aim of the present study was thus to describe patients’ experiences of BBAT, focusing on perceived main treatment effects. The areas of perceived effects are to be investigated in future research. Method: In a qualitative study, eight patients with schizophrenia were interviewed. The interview transcriptions were analysed with content analysis methodology. Result: Patients with schizophrenia report positive treatment effects of physiotherapy with BBAT. Four main categories were identified: affect regulation, body awareness and self-esteem, effects described in a social context and effects on the ability to think. These should be targeted in a future randomized and controlled study. ª 2009 Elsevier Ltd. All rights reserved.

Background Schizophrenia is a severe mental disease which causes great suffering for the afflicted individual and renders large costs for society. It involves a variety of symptoms, including both negative symptoms (blunted affects, passivity and isolation) and positive symptoms (hallucination) (McGorry, 2005) as well as cognitive dysfunctions that include a broad variety of impairments concerning attention, memory, verbal fluency, psychomotor speed * Corresponding author. Tel.: þ46 46 222 00 00. E-mail address: [email protected] (L. Hedlund).

and executive functions (Helldin et al., 2006). These negatively affect the daily life of the individual (McGorry, 2005) and the link between cognitive dysfunction and negative symptoms is well supported (Helldin et al., 2006). Blunted or flattening of affects is a common major symptom in schizophrenia and is associated with difficulties in engaging in social activities (McGorry, 2005; Brune, 2005). Alexithymia is a term reflecting the difficulties in verbalizing and apprehending your own and others’ emotions and mental states and is more common among patients with different kinds of psychoses, especially those with schizophrenia (Maggini and Raballo, 2004a).

1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.03.002

246 Another aspect of the disease concerns insecure identity, a lack of self-esteem, depression and anxiety (Van Dongen, 1998; Pallanti et al., 2004). Furthermore, many patients suffer from symptoms of disembodiment, body image disturbances and deficits in the feeling of being an agent in their own bodies and lives (Priebe and Ro ¨hricht, 2001; Maggini and Raballo, 2004b). One theoretical ‘‘starting point’’ for almost all bodyemind physiotherapeutic treatments is the psychomotor developmental aspects of movement and cognition, mainly based on Piaget’s theory of psychomotor development, focusing on the child’s activity as a central aspect in development (Gebhardt et al., 2008). Lately researchers have focused on unconscious processes and the interplay between different areas in the brain and the connection between the body and thought processes. From this perspective, our cognition is to a large extent dependent on acting and sensory motor experiences, in relation to environmental and social contexts. Roth and Lawless describe this embodied form of cognition as ‘‘basic level schemata’’ and suggest that these are (a) generally selfexplanatory and (b) basic elements of cognitive functioning (Roth and Lawless, 2002). One main physiotherapeutic treatment, in the Scandinavian mental heath services, is Basic Body Awareness Therapy (BBAT) with roots in the eastern tradition of body movement, Tai Chi Chuan (Gyllensten et al., 2003a). In the treatment process, the basic goals include establishing better contact with the living body, increasing the feeling of ‘‘ownership’’ of the body and increasing the tolerance for different sensory motor and affective sensations. The psychomotor interplay is trained through different body functions; the ability to have a stable and relaxed posture, to be grounded, to be able to coordinate movement with breathing, the ability to be well-defined in movements and interpersonal relations and finally the ability to be mentally present or mindful (Gyllensten et al., 2003a). The patients take part in various exercises where they are asked to be mentally present and observe their own activities, reactions and other experiences within or without the body (Gyllensten et al., 2003a). For a further description of BBAT, see Appendix B. BBAT has been shown to be effective and relevant as part of the treatment for several groups of patients with mental illness (Mattsson et al., 1997; Grahn et al., 1998; Eriksson et al., 2007; Gyllensten et al., 2003a), but there are few studies concerning patients with schizophrenia or other severe psychoses. In a controlled prospective study, 17 patients with schizophrenia who were treated with BBAT for 6 months were compared with nine patients with schizophrenia who only received treatment as usual. The results revealed that patients, treated with BBAT, significantly improved their quality of movement, body image, gaze, sexual interest and suffered less from anxiety compared with the control group (Roxendal, 1985). In a qualitative study, focusing on the perceived and most important aspects of treatment, six patients with schizophrenia reported that they experienced better own control and that this feeling was important for them (Gyllensten et al., 2003b). It is thus important to continue to evaluate the effects of BBAT and a relevant first step is to describe the patients’ own experiences of the method. The aim of the present study was thus to describe patient experiences of BBAT, focusing on

L. Hedlund, A.L. Gyllensten perceived main treatment effects. The areas of perceived effects are to be investigated in future research.

Method Participants Two physiotherapists, who were experts in the BBAT method, nominated 10 physiotherapists who had experience of work with patients with schizophrenia or similar diseases for at least 2 years and had an adequate education in BBAT, at level two or higher. All the physiotherapists worked at community psychiatric clinics for patients with schizophrenia and other severe mental illnesses. They all agreed to participate in the study, engaging at least one patient, a person who in writing declared that he or she was willing to participate in an interview with one of the researchers. The inclusion criteria for the patients were that they were diagnosed with schizophrenia or similar diseases and had received BBAT for at least 1 year. Twelve patients agreed to participate in the study, one of whom later declined thus resulting in 11 available informants. One patient did not appear for the interview. After eight interviews, no new information was communicated, with the same information being received. The decision was thus made to end the data collection and consequently two of the 11 patients who had agreed to participate were not called for an interview. The patients lived in three different towns in Sweden and were diagnosed by their psychiatrists, in accordance with ICD-10, as having schizophrenia (three patients), unspecified schizophrenia (two patients), undifferentiated schizophrenia (two patients) and paranoid schizophrenia (one patient). All of the patients received other treatments, pharmacological and various verbal therapy forms, mostly of a supportive nature, over and above the BBAT. Four of the patients were male and four were female, the ages ranged from 29 to 56, with an average of 45.5 years, median 48.5 years. Their duration of illness ranged from 4 to 30 years, averaging 16.3 years, median 16 years and had received BBAT for 2e 7 years, averaging 3.3 years, median 3 years. All patients were single and lived alone except for one who lived with her parents. One patient had only received BBAT individually, while the others had started individually and then continued in small groups.

Interview technique and interview process The study utilized a qualitative method with interviews as the source of information (Burnard, 1991). The first author used an interview guide focusing on the experienced effects of the BBAT treatment. The interview guide consisted of open questions with follow-up questions (see Appendix A). The interviews were characterized as only allowing short periods of silence and not having the ambition of attaining higher levels of abstraction due to the patients’ varying cognitive disabilities and sensitivity to stress. In seven cases, the interview took place at the patients’ ordinary community psychiatric clinic, while one interview was carried out at the patient’s home. The interviews were recorded, transcribed and then sent back to the patients

The experiences of basic body awareness therapy for an approval of the content, together with prepared envelopes. None of the patients commented on the transcribed content of the interview, while three patients wrote a letter about their treatment progress after the interview.

The process of analysing the transcriptions The main interest of the present study was the different experiences of treatment effects. A cross-case analysis was thus performed, based on a manifest content analysis and triangulation in order to increase validity (Burnard, 1991; Farmer et al., 2006). The total number of transcribed pages of text was 160, written with double line spacing. Manifest content analysis is a qualitative method, which can include a quantitative strategy for organizing the transcribed text. The text is systematically reduced into meaning units in distinction to latent analysis, where the underlying meaning of the text is interpreted and used (Graneheim and Lundman, 2003). A meaning unit is an existing word in the text that represents or is central to the meaning of the sentence, e.g. ‘‘I get more strength after training with BBAT’’. The meaningful unit here is ‘‘strength’’. These meaning units are then categorized in several stages and organized quantitatively (Burnard, 1991). In the present study, four persons e one psychiatrist, one psychiatric nurse, the first author and another physiotherapist e read and identified the meaning units separately. In a comparison, the level of agreement between the four persons was good, except for a few cases that eventually resulted in either disqualification or changes of the meaning unit. The first author and the physiotherapist, who is also trained in BBAT, then continued the process of analysis by comparing their own separate categorization of transcriptions from three patient interviews. The analysis revealed that the agreement was very good between the two physiotherapists. Approval was granted by the Regional Ethical Committee in Lund, Sweden, registration number 108/2008.

Result All informants reported some positive treatment effects, both in the short as well as the long term. Their contributions to the result, the number of meaning units, differed greatly, due to their varying capacity to verbalize their experiences in the interviews. For example, one informant contributed 18 meaning units while another informant’s transcribed text consisted of 150 units. Four different main categories were identified; affect regulation, body awareness and self-esteem, effects described in a social context, and effects on the ability to think. Each of the main categories contained a number of subgroups, shown in Table 1.

Affect regulation All the informants described how the treatment resulted in a change of their emotional state towards more subjectively pleasant feelings (see Table 1). The treatment

247 increased the experience of vitality and interest, and also the ability to accept and tolerate more unpleasant experiences, such as discomfort and distress. They mostly felt stronger or more vigorous, alert and relaxed after the BBAT sessions. An informant who had suffered from a painful tiredness for many years explained: Well, yes, often you feel a sense of well-being afterwards, life feels easier and the well-being increases. Mostly I feel more alert afterwards, in fact, I don’t get tired. Often when you feel more relaxed, you may feel tired but that doesn’t happen so often to me. I usually get more alert (8). Another informant described how she found her strength when training her strength to protect her body boundaries and integrity: . and when I say NO! Then I get the strength . I have a living soul, I own my body and can say NO! (6). When unpleasant feelings occurred, the patients were encouraged to deal with them. Five informants had experienced that the difficult moments had become easier and easier when continuing with BBAT and three of them thought that it might be beneficial to specifically train those moments that were difficult to deal with. As one informant said: . and I don’t want to escape the difficult moments because one of these moments may give you the greatest benefits. No, it is rather that I suspect that it can be like that, the fact that it hurts a little bit, or is strenuous shows that you are untrained and really need the training (8). The exercises offered the opportunity to get in contact with oneself, which sometimes can be difficult. It addresses one of the main problems with having a false or low sense of self that is common in this group of patients. Ehm, well, the fact that you are left alone with your own way of dealing with time . and there’s no other way. You didn’t have any tools to use, instead you had to just deal with the time. And the exercises were a little bit . prickly for one’s psyche, quite simply (3). Six informants used the exercises in BBAT in order to be able to feel better in their everyday lives, noted in the subgroup as better coping (see Table 1). Two of them described that they could deal more successfully with anxiety and were able to prevent it from developing into panic. Another informant described how she now deals with her psychotic anxiety: I become aware of my breathing, my body and stretch in situations where I otherwise would have felt that my body was disconnected (5). A further four informants said they suffered from generalized anxiety to a lesser extent, and that stress and fears were reduced in the long run. Three of them felt calmer and in greater control by focusing on being mentally present and in contact with their bodies. One informant said that, by using the exercise and focusing on his centre of coordination in the solar plexus region, he was able to prevent himself from being overwhelmed.

248

Body awareness and self-esteem Seven of eight informants reported improvements in their ability to be mentally present, to be in better contact with their bodies, to have increased awareness of their movement behaviour and changes in body posture, balance and movability (see Table 1). Increased ability to be more mentally present and in better contact with their bodies were reported by six informants. They experienced an increased sensory awareness and were in better contact with the surroundings. One informant who used to be preoccupied by her illness said: I was too focused on my own brain, my head, the voices and my illness, unaware of how I dressed myself, if it was warm or cold . I’ve opened up for a bigger room, with clothes and warmth and everything, And see the nature and trees and birds (6). The exercise made it possible for the informant to experience a greater sense of being grounded in the self, and to meet the stillness inside. Well, I think so, when we do this exercise, lying on the mattress, then I feel my breathing and that I am in my body and I feel this stillness within myself (6).

L. Hedlund, A.L. Gyllensten Six of the informants described an increased activity level, ranging from a minor change to a more thorough change. When talking about BBAT and the standing exercise, one informant said: Well, one change I’ve noticed is that, before, I used to lie down on my sofa, when watching TV. Now I sit instead, in fact. Actually, I don’t know why. It has just become like that (1). After many years of disliking moving her body, one informant described that she nowadays liked to do it: Well, yes it is, and then another positive effect it has had is that I’ve started to be more interested in becoming physically active. Actually, I did like to take a walk even before but now I’ve started to train in a gym and practice Yoga and Tai Chi. I’ve never been interested in that before (8). The importance of good balance and posture is often connected with increased self-esteem and feelings of security. This is described by five informants. One informant tries to explain what it meant to him, to get a better posture and also raise his head: Well, symbolically you think of an emperor, a king in China or something, or an old King from the North,

Table 1 Main categories and subcategories in the order of how many informants reported a certain effect, with the frequency of the meaning units in the transcribed text and, in parentheses, the number of informants contributing to each category or subcategory (range and medians are also reported). Main categories and subcategories, total number of meaning units in main category (number of informants)

Affect regulation, 184 (8) Increased sense of well-being and a better mood Finding it difficult and disliking some parts of the treatment Calmer Better coping Relaxed and positively tired More alert and strengthened Increased interest Decreased anxiety, stress and fear Body awareness and self-esteem, 201 (7) More mentally present and in better contact with the body and body sensations More active Better self-esteem Increased awareness of their own behaviour Better balance and posture Movability Effects described in a social context, 36 (6) More relaxed and natural in social situations, greater ability to have eye contact with others Greater integrity Less shame Effects on the ability to think, 28 (5) Better concentration and ’’calmer or clearer’’ thoughts

Total number of meaning units in each subcategory (number of informants)

Range (median)

46 (8) 28 (8) 20 (6) 23 (6) 21 (6) 26 (5) 13 (5) 7 (4)

1e10 (4) 1e5 (4) 1e9 (3) 1e7 (3) 1e6 (3) 3e9 (3,5) 1e5 (2) 1e3 (1,5)

73(6)

1e18 (4)

17 60 18 18 15

2e4 (2,5) 2e20 (8,5) 1e6 (4) 2e6 (5) 1e6 (2)

(6) (6) (5) (4) (4)

17 (5)

1e6 (3)

12 (3) 7 (3)

2e8 (2) 1e4 (2)

28 (5)

4e9 (5)

The experiences of basic body awareness therapy without political involvement I mean, and to be elevated, to be more satisfied with life, I think, as in ‘‘I’ve got enough, I don’t have to fight for it’’. A King doesn’t have to do that. They know that they will get it if they just ask for it. . It’s a kind of relaxation (3). One informant who thought he had a better postural stability, spontaneously reflected on the mental consequences of this: I think it is that I feel much calmer and more stable. It is as if I’ve got better self-esteem (4).

Effects described in a social context Most of the informants received their treatment in small groups and described several advantages of this. In addition to the effects of the group treatment itself, six informants described effects in a social context that they thought could be attributed to the effects of BBAT. The effects were better ‘‘coping’’, increased feelings of integrity and ability to be in contact with others. Some informants carried out BBAT exercises before socializing with friends. One informant, who had struggled with her feelings of shame, described her benefits from the exercise: I think when you have felt so insecure, and ashamed, it’s very important to get your self-esteem back and if you dare to look people in their eyes, then they look down if you hold your gaze still. Sometimes it’s very hard but I try. And I try to straighten myself up, sometimes I don’t manage, but I try to think about it and not look down, but straight ahead instead (6). The informants reported that they were more relaxed when socializing with other people, due to better awareness and acceptance of their true selves: Today I allow myself to be quiet. Before I forced myself to be more talkative, I couldn’t accept that I was quiet, I felt like a failure. So it was. So I forced myself to talk in situations where I didn’t want to, which hurts you in the long run (8). Another aspect of recovery is the need to be and behave like ‘‘normal’’ people. One informant described the importance of the erect posture in a social context: It’s important to me, to be like other people mentally, psychologically and socially, to be like others. That is one of my main goals as a psychiatric patient, so to speak (3).

Effects on the ability to think Five informants reported an increased ability to concentrate, and an experience of a ‘‘calmer activity level’’ in the brain, clearer thoughts or having the feeling of being mentally awake. When doing sitting BBAT exercises one informant experienced the following: I look down and focus my eyes there and experience a stillness, sometimes there’s a lot of babble, but

249 sometimes it stops and becomes quiet and that feels very good, I feel clear in my head (6). Another informant said: Well, what shall I say . the possibility of hearing voices decreases when I.when I’ve been to physiotherapy. I feel clearer in my head . so it feels very good (5). The informant who suffered from tiredness said that her thoughts did not become calmer: Instead, when I get more alert it affects how I feel in my head. My thoughts become maybe a little bit more alive, it feels like my level of thinking gets ‘‘more vital’’ or how shall I put it (8).

Discussion Discussion of methods This study is a qualitative approach describing the treatment effects of BBAT, as told by patients with schizophrenia. The number of informants was small, only eight patients were interviewed about their experiences. The main purpose was, however, to get patient-based suggestions of variables, that could be examined further in a planned randomized controlled study, and in such studies there are limited possibilities for following up all the effects that were experienced, except for the main ones. The decision to end the data collection after eight interviews was based partly on the fact that the same treatment experiences were reported several times and no new themes were conveyed in the last interviews and partly on the first author’s 20 year experience of working with BBAT and patients with schizophrenia providing a certain preunderstanding of treatment effects. However, there may be some bias regarding this decision. The informants had a positive attitude, showed interest and made efforts to be understood by the interviewer. As a group, patients with schizophrenia are considered to be difficult to motivate to participate in studies, in part due to their negative symptoms. Therefore, patients with less positive experiences of BBAT probably did not participate in this study. Instead, the patients who participated in this study can be considered to be well motivated. This may be due to positive treatment responses or other reasons, for example, a desire to tell their personal story once more. Another possibility could be that a positive therapeutic encounter had been established between them and their physiotherapist. The patients included in the study were offered the opportunity to participate by their own physiotherapist. This also may have influenced the selection of participants, resulting in a positive sample of patients. In order to increase the internal validity, three methods for validity check were used (Farmer et al., 2006). First the transcriptions were returned to the informants, with prestamped envelopes. There were no comments on the transcriptions, but three informants replied with personal comments about their ongoing progress. Another check of validity was the use of ‘‘triangulation by researcher’’ (Farmer et al., 2006). Three other persons were engaged in the sorting of meaning units, and two of

250 them had a different professional background. In this comparison, there was a high level of agreement. Then, when categorizing the meaning units to a higher abstraction, a comparison was made between the first author and another qualified physiotherapist. The level of agreement was very high. Finally, the first author used different theoretical frameworks, such as physiotherapeutic, psychological and neurocognitive, when discussing the results. This broadened the discussion and decreased the use of narrow-minded interpretation (Farmer et al., 2006). Most of the informants also met other caregivers at the same time. Many of the described effects are therefore probably a result of the influence of several therapists. Different kinds of psychotherapy and medication can make it possible for other interventions to work and vice versa. However, some effects are described by the informants themselves as a direct result of BBAT, related in time and connected to different exercises. This is true for most of the experienced treatment effects, categorized under ‘‘affect regulation, effects on the ability to think, body function and self-esteem’’. When it comes to the effects described in a social context and an increased activity level, these effects are not experienced close to the BBAT session and therefore more likely to be influenced by a number of different factors. After a psychotic episode, there are normally different recovery phases that also influence the remission Andersen et al., 2003. On the other hand, there are several studies within different areas concerning the effects of BBAT that have shown similar effects, irrespective of diagnosis (Mattsson et al., 1997; Grahn et al., 1998; Gyllensten et al., 2003a). This increases the possibility of these results being related to the effects of BBAT.

Discussion of results According to the content analysis, certain experienced effects of the BBAT treatment were reported frequently, by most of the informants. This indicates that the experienced treatment effects might be rather general and common experiences, shared by many. Recovery from schizophrenia is a complex and truly individual process (Sells et al., 2004). Today there is a widening interest in the recovery process, what hinders and what initiates/ stimulates recovery (Onken et al., 2002). According to the philosophy of BBAT, little attention is paid to different symptoms and difficulties. Instead the therapist looks at the patients’ own view of their problems, the status of the body functions and individual strengths and resources (Gyllensten et al., 2003a). Therefore, in the long run, it is especially interesting to find out if BBAT offers the patients increased recovery potentials by matching their individual needs.

Affect regulation All of the eight informants reported changes of different affects and emotions from BBAT. They experienced themselves as vitalized, with increased feelings of interest (five of eight). Those changes must be considered as very important for patients with negative symptoms who

L. Hedlund, A.L. Gyllensten struggle with a lack of interest and motivation. Without a basic vitality and feelings of interest, the ability to make changes in life is limited. Patients with schizophrenia are known to have symptoms such as blunted affects, and difficulties in how to discriminate and communicate them (McGorry, 2005; Brune, 2005). In this study the patients could describe different affects/emotions. Whether this was also the case from the beginning of the treatment cannot be answered in the present study, but the informants described that their emotional state changed when using BBAT. Some informants had even learned how to use the exercises to regulate their affects/emotions outside the treatment sessions. They noticed that the more stressful feelings decreased with continued BBAT. It gave them a feeling of control and security and helped them to protect their integrity. Within the research field of affects and emotions, there is an interest in the developmental aspects of affect regulation, as a normal and pathological process. The connection between attachment and affect regulation is described in an article by Mikulincer et al. (2003). The authors present a theory of the child’s normal development of affect regulation, as an intimate process, linked to an emotionally present object. This ‘‘object’’ teaches the child how to regulate its affects, mostly in a subtle, unconscious way. In order for this to be true, certain conditions must prevail; a safe attachment to a successfully affect regulated object, stimulates the child to discover itself, actively deal with displeasure and to make use of the motivating force of pleasure. This leads to an increased ability to solve different emotional problems. The child’s self-image expands and the self-esteem increases due to the incorporation of the parents’ successful strategies to regulate affects and their own experiences of successful regulations. The child eventually develops a feeling of control, of being an agent with the capability to deal with emotions (Mikulincer et al., 2003). In comparison with this description, BBAT offers several similar components in the treatment process. One ambition is to encourage the patients to be curious about their bodily experiences and reactions. The physiotherapist is to be emotionally present and responsible for the intensity in experiences not overwhelming the patient. The regulation techniques, used in BBAT, arise both from theory and from the physiotherapist’s self-experienced knowledge about different ways to physically increase or decrease affective reactions, as well as the importance of verbalizing the experiences and mentally accepting different affects and body reactions. The physiotherapist also involves the patient in the decision-making concerning their own experiences so that the patients themselves learn to deal with their emotions. This is especially important when distressing and painful experiences occur. Low tolerance for stress and stimuli is a common symptom within patients with schizophrenia (McGorry, 2005) and in this study all eight informants reported experiences in BBAT that were unpleasant. However, they mostly understood the benefits of being exposed to the unpleasant feelings. Therapeutically, it is important to emphasize the normality in unpleasant experiences, not to be afraid of it but at the same time encourage the patients own integrity and respect the need for avoidance. When given these opportunities, the

The experiences of basic body awareness therapy tolerance often increases naturally and, if not, the physiotherapist guides the patients to a more acceptable experience.

Body awareness and self-esteem Body function, as described within the BBAT, includes the ability to have a stable and relaxed posture, to be grounded, to be able to coordinate movement with integrated breathing, to be well-defined in movements and interpersonal relations and finally, to be mentally present or mindful (Gyllensten et al., 2003a; Hofman and Asmundson 2008). These body functions are systematically trained for better functioning. Seven of eight informants reported improvements concerning body functions, as experienced in having better balance and posture, more flexibility in movement and more in contact with their bodies and surroundings. Moreover, the reports of better balance and posture are linked to security and better self-esteem. The intimate connection between self-awareness, self-esteem and the ability to feel secure in our bodies is clearly shown by these statements and also described by Dropsy (1999). He postulates that when the person is ‘‘rooted’’ to the ground, with a better balance between the two forces, gravity and the postural reflexes, there is a better ability to relax, feel calm and be mentally present and alert. The increased contact with body functions is often followed by a deeper feeling of existence and a better contact with the true self and agency. Dropsy declares that many people have a threefold contact problem, with the body, with the physical reality (the room, spatial orientation and time) and with other people. If there is a problem with one of the contact domains, it also has an effect on the other domains and vice versa. ‘‘Opening up’’ in one domain leads also to improvement in the other two (Dropsy, 1999; Gyllensten, 2004). Furthermore, five informants described moments in BBAT that had led them to reflect on their own behaviour. They have ‘‘become aware of, observed and noticed’’ different aspects of movement. The ability to reflect is a very fundamental function of the ‘‘observing self’’ that is essential for self-regulation, to take good care of yourself and the ability to change (de Vigemont and Fourneret, 2004). For one informant, his erect posture was important so that he could look like ‘‘normal’’ people do. Patients with schizophrenia often make odd gestures and have restricted body movements and facial expressions, due to both the illness and the side effects of medication, such as tardive dyskinesia (McGorry, 2005). This probably contributes to the process of stigma. By normalizing the posture, movements and gestures, you can to some extent protect your integrity and minimize the risk of being exposed to discrimination. The importance of better body control, in this context, is also presented by another qualitative study, also concerning patients with schizophrenia (Gyllensten et al., 2003b). Six informants had increased their level of activity. Passivity is one of the major negative symptoms of schizophrenia and there is a strong association with cognitive dysfunction (McGorry, 2005; Helldin et al., 2006). However, there are probably several reasons for passivity. It could be

251 explained as a part of a more depressive symptomatology which often includes lack of vitality, anxiety, feelings of hopelessness, worthlessness and loss of meaningfulness. The informants in the present study described increased alertness and strength, increased interest, decreased anxiety, better self-esteem and a better ability to ‘‘think’’. Moreover, BBAT contains soft exercises that allow the informant to adapt to physical activity at their own pace and this contributes finally to a change of behaviour. All these effects may explain the increased activity level which must be considered as an important change within the schizophrenia symptomatology.

Effects described in a social context Patients with schizophrenia are known to have difficulties in social contexts, such as withdrawal and passivity (Brune, 2005; McGorry, 2005) In addition to the cognitive dysfunctions, a concurrent existence of social anxiety, low tolerance of stress and low self-esteem, with easily aroused feelings of shame, contributes to the need for withdrawal. In this study, six informants described experiences that included increased opportunities for participation in social activities. They talked about shame, integrity, acceptance of the self and the need to be like others. One important aspect of social interaction is the ability to separate yourself from others, to filter the impressions of others and be able to defend your integrity when needed. The exercises of the body function ‘‘delimitation of movement’’ leads to the experience of limits with the need to accept and respect limitations, but also to ‘‘be safe’’ within the limits. This is a ‘‘basic level schemata’’, generally self-explanatory, and of great importance to later social functioning (Roth and Lawless, 2002).

Effects on the ability to think Five of the eight informants described experiences of a better ability to ‘‘think’’ after treatment sessions. The ability to concentrate increased, thoughts became calmer and the feeling of clarity of the mind increased. Attention difficulties are common in patients with schizophrenia (Helldin et al., 2006). The treatment process with BBAT constantly appeals to the awareness of surroundings, the body and bodily sensations and emphasizes the efforts to make voluntary movements that emanate from the body functions and this stimulates attention in a very direct, concrete and personal manner. The feeling of having greater clarity of thought might also be a result of greater alertness. A specific cognitive function is ‘‘vigilance’’, important for the ability to sustain the attention over time and is partly regulated by the reticular formation, restraining the ‘‘wakefulness’’ in the central nervous system (Helldin et al., 2006). The exercise with BBAT may have a specific influence on this function, resulting in clearer thoughts as well as increased ability to be mentally present and in better contact with the body etc. As defined in ‘‘embodied cognition’’, this is one of the ‘‘basic elements of cognitive functioning’’ that is intimately linked to the body and its function (Roth and Lawless, 2002). Furthermore, another explanation for ‘‘clearer thoughts’’

252 might be that BBAT regulates muscular tension and anxiety and thereby decreases the disturbance on the cognitive processes. Consequently, there are at least three different mechanisms that may explain the better ‘‘ability to think’’ which might be stimulated or activated with BBAT.

Conclusion This qualitative study focused on possible treatments effects of Basic Body Awareness Therapy, as they were experienced by eight patients with schizophrenia. Four main categories were identified; Affect regulation, body awareness and self-esteem, effects described in a social context and effects on the ability to think. These results should be targeted in future randomized controlled studies.

Conflict of interest statement There are no conflicts of interest in this study.

Acknowledgements This study was funded by the Swedish Council for Working life and Social Research (FAS) and the County Council of Scania, Sweden.

Appendix A. Interview guide (1) Tell me if and how the treatment with BBAT has helped you in any way? - In the short term - In your every day life - In the long term (2) What feels good about doing the BBAT exercise? (3) Are there exercises that feel bad or are difficult to do? (4) Tell me more about your experiences of working with BBAT.

Appendix B. Description of body awareness therapy Therapists’ education Basic Body Awareness Therapy is a physiotherapeutic treatment, developed in Scandinavia. The education to be a certified body awareness therapist requires a five step educational programme. The programme consists of theoretical, practical and clinical training, with considerable emphasis on one’s own treatment experience and process. The students have homework to do between the four 1week training sessions. The first two levels focus on developing body awareness and an understanding of the process from an inside perspective. The theoretical framework and history of body awareness, as well as how to verbalize goals and motivational aspects in patients work, are also focused on. In the third level, students work with and write a report on the individual process with a patient going through BBAT. The fourth level focuses on treatment

L. Hedlund, A.L. Gyllensten with a group where the student also writes a report on the dynamics in the BBAT group processes and the role of the therapist in BBAT. The student also reads about 2000 pages of relevant literature that are processed and critically evaluated from a clinical perspective. This is done in two literature reports. All reports are evaluated by a teacher who approves and gives feedback. The fifth level consists of a written project paper of clinical interest. Education in BBAT is offered both as private education at the Institute for Basic Body Awareness Therapy in Sweden or public education e.g. examination in BBAT methodology at the University College of Bergen, Norway (60 EC credits). After this students become certified BBAT therapists. The full education is available only for registered physiotherapists. Other professionals are accepted for steps one and two. A typical therapist’s training consists of 30 weeks during 4e5 years. Today, there are around 150 certified BBAT therapists in Europe (Sweden, Norway, Denmark, Finland, Island, Switzerland, UK and Spain). In this study, the experts in BBAT were certified BBAT therapists, teachers at the private institute, educating therapists with more than 20 years of clinical practice within psychiatric physiotherapy.

The methodology of BBAT History BBAT is inspired by Western movement practice, like Feldenkrais, Alexander technique and the European movement tradition (Gindler and Selver), the expressive arts, like dance (Graham and Laban) and theatre (Stanislavski). Body-oriented psychotherapy (Reich and Lowen) also influences BBAT. From the East, Zen meditation and Tai-chi Chuan (Tai Chi), are important sources of inspiration. BBAT was developed to be starting exercises for Tai Chi and tends to follow the same principles. A French psychotherapist and actor, J. Dropsy, synthesized the aforementioned traditions and published two books describing the method (Gyllensten, 2004). A Swedish physiotherapist used the method in the treatment of patients with schizophrenia and published the results in a thesis at the medical faculty of Gothenburg University, 1985 (Roxendal, 1985). Since then, the methodology has been used within physiotherapy mainly in psychiatric physiotherapy, but also in the rehabilitation of prolonged pain. Today, there are 12 theses using BBAT or the Body Awareness Scale (BAS). Eleven of them have been written by physiotherapists and one by a medical doctor (http://www.ibk.nu). Methodology In BBAT one uses movement, breathing, massage/hands-on guiding and awareness to try to restore balance, freedom and the unity of body and mind. BBAT is described as resource-oriented which in this case means working with the resources of the body as a whole. Turning attention both to the doing and to what is experienced in the movements is central and stimulates awareness and movement performance. BBAT differs from Tai Chi in the way that movements are quite simple, focused on the experience of stability, ease and intension (Gyllensten,

The experiences of basic body awareness therapy 2004). The therapist encourages the patients to move in ways more optimal for postural control, balance, free breathing and coordination. The relation to the ground, vertical balance in the centre line, centring of movements and coordination from the trunk and the solar plexus area, breathing, flow and awareness are seen as important aspects of the body-ego, trained in BBAT (Gyllensten, 2004). BBAT can be executed both individually and in a group. It is performed lying, sitting, standing, walking and running. BBAT also includes partner work, in structured massage or push-hand exercises from Tai Chi. The treatment takes the starting point in an assessment, the Body Awareness Scale (BAS), where strengths and weakness of functional capacities and activities are assessed. This means that every treatment is individually created and no protocol, common for all patients is used. However, the treatments are alike, using a common number of structured movements, in different starting positions that can be individually applied according to the patients’ need. Compared to other body-oriented or mindfulness-oriented treatments, there is a systematic training of the ‘‘physical level of the self’’, originating from the specific body functions above and the intentional and observing self, on a mental level. The number of BBAT sessions needed depends on both the medical diagnosis and the functional capacities of the individual patient. For example, patients with moderate depression or anxiety demonstrate a significant improvement of symptoms, self-efficacy, attitude to the body and body awareness after about 12 sessions (Gyllensten et al., 2003a). Patients with schizophrenia often need considerably more sessions, about 9 months or more (Roxendal, 1985). The equipment needed in BBAT is a rather spacious room without a lot of furniture. For sitting exercises a stool or meditation cushion are needed. For lying exercises a ground sheet can be used. No music is used since the individual’s own rhythm is central and the connection between movements and breathing is emphasized. Teamwork Physiotherapists working with BBAT for patients with schizophrenia are usually an integrated member of a professional team including psychiatrists, psychologists, social workers, psychiatric nurses and occupational therapists. In order for a patient to receive BBAT there has commonly been a discussion in a team conference, in the presence of the patient’s psychiatrist. Usually, if the patient receives BBAT, it has been initiated by either the patient complaining of bodily symptoms or functional deficits related to the body or by the patient’s casemanager. Each patient usually receives different interventions from different professionals, e.g. case-management, psychotherapy and BBAT. In some rural regions of Sweden, the physiotherapists are not connected to a team but treat the patients at a private clinic after psychiatrist referral. Patients who have active delusions or hallucinations can receive treatment with BBAT and the treatment will then be adjusted to the patient’s ability to be mentally present. The BBAT can often decrease hallucinations and delusions by increasing the contact with the body.

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References Andersen, R., Oades, L., Caputi, P., 2003. The experience of recovery from schizophrenia: toward an empirically validated stage model. Australian and New Zealand Journal of psychiatry 37, 586e594. Brune, M., 2005. ‘‘Theory of mind’’ in schizophrenia: a review of the literature. Schizophrenia Bulletin 31, 21e42. Burnard, P., 1991. A method of analysing interview transcripts in qualitative research. Nurse Education Today 11, 461e466. de Vigemont, F., Fourneret, P., 2004. The sense of agency: A philosophical and empirical review of the ‘‘who’’ system. Consciousness and Cognition 13, 1e19. Dropsy J, 1999. Human expression: the coordination of mind and body, in: Skjaerven LH (Ed.), Quality of Movement e the Art and Health. Reportno 1/99, Bergen University College Department of Health and Social Sciences, Norway. Eriksson, E.M., Mo ¨ller, I.E., So ¨derberg, R.H., Eriksson, H.T., Kurlberg, G.K., 2007. Body awareness therapy: a new strategy for relief of symptoms in irritable bowel syndrome patients. World Journal of Gastroenterology 13 (23), 3206e3214. Farmer, T., Robinson, K., Elliott, S.J., Eyles, J., 2006. Developing and implementing a triangulation protocol for qualitative health research. Qualitative Health Research 16, 377e394. Gebhardt, S., Grant, P., von Georgi, R., Huber, M.T., 2008. Aspects of Piaget’s cognitive developmental psychology and neurobiology of psychotic disorders e an integrative model. Medical Hypotheses 71, 426e433. Grahn, B., Ekdahl, C., Borgquist, L., 1998. Effect of multidisciplinary rehabilitation programme on health related quality of life in patients with musculoskeletal disorders. Disability and Rehabilitation 20, 285e297. Graneheim, U.H., Lundman, B., 2003. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today 24, 105e112. Helldin, L., Kane, J.M., Karilampi, U., Norlander, T., Archer, T., 2006. Remission and cognitive ability in a cohort of patients with schizophrenia. Journal of Psychiatric Research 40, 738e745. Gyllensten AL, 2004. Basic Body Awareness Therapy. Thesis, Lund. Gyllensten, A.L., Hansson, L., Ekdahl, C., 2003a. Basic outcome of basic body awareness therapy. a randomized controlled study of patients in psychiatric outpatient care. Advances in Physiotherapy 5, 179e190. Gyllensten, A.L., Hansson, L., Ekdahl, 2003b. Patient experiences of basic body awareness therapy and the relationship with the physiotherapist. Journal of Bodywork and Movement Therapies 7, 173e183. Maggini, C., Raballo, A., 2004a. Alexithymia and schizophrenic psychopathology. Acta Bio Medica Ateneo Parmense 75, 40e49. Maggini, C., Raballo, A., 2004b. Self-centrality, basic symptoms model and psychopathology in schizophrenia. Psychopathology 37, 69e75. Mattsson, M., Wikman, M., Dahlgren, L., Mattsson, B., Armelius, K., 1997. Body awareness therapy with sexually abused women. Part 2. Evaluation of body awareness in a group setting. Journal of Bodywork and Movement Therapies 2, 38e45. McGorry, P., 2005. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders. Australian and New Zealand Journal of Psychiatry 39, 1e30. Mikulincer, M., Shaver, P.R., Pereg, D., 2003. Attachment theory and affect regulation: the dynamics, development and cognitive consequences of attachment-related strategies. Motivation and Emotion 27, 77e102. Onken, J.S., Durmont, J.M., Ridgway, P., Dornan, D.H., Ralph, R.O., 2002. Mental health recovery: what helps and what hinders? A National Research Project for the Development of

254 Recovery Facilitating System Performance Indicators. National Technical Assistance Centre. Pallanti, S., Quercioli, L., Hollander, E., 2004. Social anxiety in outpatients with schizophrenia: a relevant cause of disability. The American Journal of Psychiatry 161, 53e58. Priebe, S., Ro ¨hricht, F., 2001. Specific body image pathology in acute schizophrenia. Psychiatry Research 101, 289e301. Roth, W., Lawless, D.V., 2002. How does the body get into the mind? Human Studies 25, 333e358.

L. Hedlund, A.L. Gyllensten Roxendal G, 1985. Body awareness therapy and the body awareness scale, treatment and evaluation in psychiatric physiotherapy. Gothenburg Thesis. Sells, D., Stayner, D.A., Davidson, L., 2004. Recovering the self in schizophrenia: an integrative review of qualitative studies. Psychiatric Quarterly 75, 87e97. Van Dongen, C., 1998. Self-esteem among persons with severe mental illness. Issues in Mental Health Nursing 19, 29e40.

Journal of Bodywork & Movement Therapies (2010) 14, 255e261

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FASCIA RESEARCH: VISCERAL ADHESIONS

Notes on visceral adhesions as fascial pathology Gil Hedley

Received 25 April 2009; received in revised form 13 October 2009; accepted 19 October 2009

Summary Fascia is introduced as an organizing anatomical category for visceral mesothelia. Normal tissue relations are discussed in order to frame the presentation of abnormal visceral adhesions as fascial pathology, 4 types of which are identified. Laboratory dissections of fixed and unembalmed human cadavers provide the basis for insights into these pathologies as regards self-care and therapeutic technique. ª 2010 Elsevier Ltd. All rights reserved.

Intent Many clinicians assess and treat perceived limitations of visceral mobility which are attributed, among other things, to visceral adhesions. This article notes some of the lines between normal and pathological adhesions of various types. The intent is to illuminate this inner world of visceral adhesions considered as fascial pathology, in the hope of providing useful information for those who carefully consider the same in their therapeutic practices.

Anatomical background It is hard to overstate the value of undertaking many gross human dissections for establishing a baseline understanding of normal tissue relations. Such experience enables one to differentiate more readily between a normal presentation, a healthy but anomalous presentation, and a pathological presentation of visceral relationships. Exactly how to

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perceive these same differences when palpating the living is left to the skilled teachers of visceral manipulation. This paper simply reports what has been found in the laboratory by the present author. Conventional anatomical literature and study is founded on a regional approach. Because of this focus on particular regions as distinct subjects of study from other regions of the body, generalizations regarding common tissue textures and analogous functions sometimes escape the regional method. The author has developed and subscribes to a method of study which he calls ‘‘integral anatomy.’’ While these notes do not permit a full explication of the object and methods of integral anatomy, suffice it to say that the approach places particular emphasis on the whole person while emphasizing the textural layers of the body in their continuities and relationships across purported regional boundaries. This having been said, the author synthesizes the disparate information regarding the anatomical structures of the visceral regions by introducing the general and commonly recognized category of ‘‘fascia’’ as an organizing principle referent. The membranes and fibrous layers which surround the organs of the body do in fact represent various specialized types of the more

1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.10.005

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G. Hedley

general category of ‘‘fascia,’’ the general properties and anatomy of which this author gives a more thorough accounting elsewhere (Hedley, 2005a,b, 2006, 2009). In that prior resource is introduced the notion of ‘‘visceral fasciae.’’ According to this account, the notion of ‘‘visceral fasciae’’ is observed to include, in a manner that repeats across regions, a fibrous outermost layer, a parietal serous layer, and a visceral serous layer. Careful and considerate attention to these tissues is given by Barral in his several volumes of work, upon which the present author relies, especially in so far as they provided foci of interest for more direct explorations in the laboratory. (Barral and Mercier, 1988; Barral, 1989,1991,1993) In order simply to convey from an integral perspective the various structures, already known and identified in a disparate manner through the conventional regional approach, the author developed Table 1. (Hedley, Vol. 3, 2006.) In Table 1, a schematization of the various structures by region is offered, including the membranes of the CNS for the sake of analogical completeness, in a manner that organizes them according to analogous tissue textures.

Normal adhesion of the parietal layer to the fibrous layer It is the author’s experience that it is normal for the parietal, or ‘‘wall’’ layer, to be adherent to the outermost fibrous layer. The parietal serous membranes are relatively well fixed to the fibrous layer in normal tissue presentations, though they can be manually ‘‘peeled’’ apart and thus differentiated in gross dissection in a manner which clearly demonstrates the distinctness of the two layers. The degree to which the parietal layer is fixed is somewhat predictable based on region. The parietal peritoneum, for instance, is considerably more firmly fixed with fibers at the anterior midline to the transversalis fascia than it is more lateral to this line. The two layers can be peeled apart manually along most of their shared surface, but at the midline a scalpel is required to differentiate them (Photo 1).

Normal adhesion of the visceral layer to the viscera It is also the author’s experience that it is normal for the visceral layer of serous membrane to be adherent to the underlying parenchymal tissues of the given organ which it covers. Because of their complete adherence to the tissue of the organs they cover, this author refers to the visceral serous membrane as the ‘‘skin’’ of the organ. The pelvic ‘‘space’’ is technically sub-peritoneal and outside of this Table 1

Photo #1 Above, we see the entire parietal peritoneum presenting after the more superficial transversalis fascia has been differentiated and reflected superiorly. The visibly yellowish midline tissues represent the normal locus of higher degrees of normal fibrous fixation to the overlying transversalis fascia. Image Copyright Gil Hedley, 2006. Used with permission.

typology. For the sake of anatomical accuracy then, it should be said that the rectum, uterus and bladder are all invested/covered superiorly by parietal rather than visceral peritoneum (Photo 2). Proceeding from the deep aspect of the visceral layer of the serous membrane, there are fibers that are continuous with the connective tissue matrix of the underlying tissues. Therefore the ‘‘skin’’ of an organ, despite its obvious continuity as a fascial ‘‘wrap,’’ cannot be very readily ‘‘peeled’’ from the enveloped organ itself, with which it exists in perfect continuity. The visceral serous membranes rather shred when an attempt is made to differentiate them, much as the periosteum does, when the deeper connections are severed and the thin fabric of the surfacing layer recoils upon itself. In this manner then, the degree of normal ‘‘adhesion’’ of the visceral serous membrane to the organ exceeds the tenacity of the relationship of the fibrous outermost layer and the parietal serous layer, whether pleural, pericardial or peritoneal. The pia mater of the central nervous system is the least substantial as compared to its visceral membranous fascial analogues. It does not manifest enough depth in itself, or enough fibrous matter, being only a two or three cell-deep covering over the brain, even to ‘‘shred’’ in the fashion of the visceral pleura, for instance. It is soft enough to easily push a finger through, which is not the case for the visceral layer of the serous membranes in general. The pia simply cannot be differentiated as a layer except histologically.

Schematization of cranial and visceral fasciae.

Visceral Spaces

Fibrous outermost layers

Parietal serous layers

Visceral serous layers

Intracranial Thoracic Cardiac Abdominal

Dura mater Endothoracic fascia Fibrous pericardium Transversalis fascia

Arachnoid Parietal pleura Parietal pericardium Parietal peritoneum

Pia Visceral pleura Visceral pericardium Visceral peritoneum

Table 1 is taken from The Integral Anatomy Series, Vol. 3: Cranial and Visceral Fasciae, Copyright Gil Hedley, 2006, on DVD. Used with permission.

Fascia research: Visceral adhesions

257

Adhesion distinguished from ligamentous distortion

Photo #2 Above we see the visceral peritoneum covering the hepatic flexure of the colon. Image Copyright Gil Hedley, 2009. Used with permission.

Normal relations of parietal and visceral layers to each other The parietal and visceral layers of the various serous membranes form a continuity of tissue: the fascia is continuous, but it reflects off of the organs and then doubles-back around them to form an enveloping ‘‘balloon’’ around them as well. (Gray, pp. 459, 901, 970, 1901/1977) Within the parietal layer, then, the viscera, themselves covered in their ‘‘skins,’’ ideally slide one against another in perpetual motion in their ranges of normal mobility. They also slide against the parietal layer which surrounds them and with which they have varying degrees of contact throughout their range of motion. Further, in certain areas, the parietal layer is in sliding contact with itself.

Normal sliding surfaces So normal sliding surfaces can be said to include visceral serous membranes against one another, parietal serous membranes against themselves, and finally visceral serous membranes against parietal serous membranes. A few examples of these three categories of sliding surfaces are schematized in Table 2.

Definition of pathological adhesion A pathological adhesion, for the purposes of this conversation, is defined as a fixed connection between tissues which would normally slide relative to each other. Such adhesions are ‘‘pathological’’ to the extent that the normal range of motion of the tissues is inhibited by the abnormal relations of the visceral fascia. The normal motion of the organs in their own right, as well as in their relationships with one another, are an essential aspect of the proper physiological functioning of the organs. Therefore the disruption of normal motion via fascial pathology in the form of adhesions is potentially disruptive of highest organ function (Photo 3).

An adhesion is distinguished by the author for the purposes of these notes from the phenomena of distortions of visceral ligaments. ‘‘Ligaments’’ in anatomical nomenclature most generally indicate literally a form of ‘‘tying’’ of one structure to another. (from Latin, ligare, to bind or tie) Ligaments ‘‘tie’’ bone to bone, but they also ‘‘tie’’ organ to organ, and so on. Visceral ‘‘ties,’’ or ligaments, most often consist of various reflections, folds and spannings of the serous membranes (mesothelia) as they envelop the complex but interrelated forms of the viscera themselves and the convolutions of the spaces wherein the viscera move. In the author’s experience, the serous membranes are found to be highly elastic, which property is demonstrable not only in unfixed but also in fixed tissue samples, evidenced insofar as they recoil in various degrees when incised. The elastic property derives anatomically from the ample presence of both simply elastic as well as actively contractile fibers within the membranes. (Schleip, 2006, p.3) The causes of tissue shortening are various and beyond the scope of the present article. It is sufficient for now to simply distinguish for conversation’s sake between adhesions, where normal sliding surfaces are stuck to one another, and ligamentous distortion, where abnormal shortening or lengthening of the relationships of organs through their various ‘‘tyings’’ represent a different kind of fascial pathology of the viscera.

Types of pathological adhesion by cause Table 2, therefore, can serve equally well to outline potential loci of adhesions, because any normal sliding surface contacts also have the potential to become stuck: that is, to adhere, to one another. It is the author’s observation of clinical evidence in the laboratory that the circumstances which give rise to the adhesion of normally sliding surfaces are multiple. They include, but are not exhausted by, the following causes: 1) inflammation from infections or other types of disease processes 2) inflammation and scarring as the sequelae of surgical intervention 3) the sequelae of prior limitations upon movement cycles 4) intentional therapeutic adhesion

Inflammation from infections or other types of disease processes Serous membranes, like other tissues of the body, being highly vascular and innervated, are subject to inflammation from a variety of causes. Any ‘‘-itis’’ in the region of the viscera could potentially, though not necessarily, result in an adhesion. For instance, a lung infection could result in one or more points of fibrous connection of varying degrees of density between the visceral and parietal pleura. Pericarditis may result in a broad fixation of the visceral and parietal

258 Table 2

G. Hedley Examples of normal sliding surfaces.

Visceral layers against each other

Parietal layers against themselves

Visceral layers against parietal layers

Stomach to liver

Diaphragmatic aspect of parietal pleura to costal aspect of parietal pleura Diaphragmatic aspect of parietal pleura to mediastinal aspect of parietal pleura Uterus to rectum

Visceral pleura to parietal pleura Visceral pericardium to parietal pericardium Visceral peritoneum to parietal peritoneum

Loops of small intestine to themselves Ovaries to loops of small intestines Table 2 Copyright Gil Hedley, 2009. Used with permission.

pericardium. The normally free border of a cystic ovary may become adherent to the adjacent parietal peritoneum of the posterior abdominal wall (Monk et al., 1994). The author regularly dissects these types of ovarian adhesions as they appear commonly in cadaver specimens (Photo 4). This author has directly observed in the laboratory how other disease processes can result in adhesions beyond those deriving from straightforward inflammatory processes. Cysts and tumors can have the effect of binding two organs or two sliding surfaces together with the aberrant growth serving as the focal point of adhesion between the membranes. Ulcers, cancerous metastases and pancreatitis exemplify more extreme types of inflammation where strong adhesions may result from the disruption of the local tissues (Troitskii, 1968).

Inflammation and scarring as the sequelae of surgical intervention Surgery offers so many advantages that we are prone to forgive some of the problems that it can cause, among which can be counted visceral adhesions, and scarring. Where there are surgical scars observed on the outside of a human form, one can almost unerringly predict some manifestation of adhesions and scarring within the form. Scarring is defined by this author, for the sake of this discussion and based on

Photo #3 Arrow identify the adhesion of the visceral peritoneum of the small intestine to the parietal peritoneum of the ascending colon: these normally have a sliding relationship with each other. Image Copyright Gil Hedley, 2009. Used with permission.

direct observation, as aggregations of fibrous matter that result when surgical incisions or other types of wounds heal, leaving tissue layers (skin, superficial fascia, deep fascia, and membranes) pinned to each other with reduced play and elasticity. This author has also observed how the fiber direction of scars so defined is usually plaited in a multidirection manner, distorting the normal vectors of elasticity and tension native to the tissue. Scars can also be evident within the visceral spaces wherever incisions have been made, and in these cases they sometimes have as sequelae the adhesion of local tissues. (Zong et al., 2004) For instance, this author has directly observed how open heart surgeries will often result in major adhesions of the left lung to the chest wall, i.e., the visceral to the parietal pleura, as well as considerable adhesion of the visceral to the parietal pericardium. Because the incisions of surgery necessarily cause inflammation of the local tissues, in combination with scarring this can result in the formation of a seemingly progressive adhesion of visceral fasciae (Liakakos et al., 2001) (Photos 5 and 6).

The sequelae of prior limitations upon movement cycles Visceral ligaments and the spatial relationship of the organs to one another define the normal range of motion of the

Photo #4 Above the arrows indicate the whole inferior margin of the liver adherent to the greater omentum as the likely sequela of inflammatory processes. Image Copyright Gil Hedley, 2009. Used with permission.

Fascia research: Visceral adhesions

259 subsequent irritation of the membranes will initiate the formation of adhesions between the membranes which when fully progressed will have the effect of mitigating further collapse: the adherent membranes serve to sustain the inflation of the lung. (Montes et al., 2006) The loss of the sliding surface between the visceral and parietal pleura is the price willingly paid for the higher good of the lung’s permanent inflation. This author has directly observed how surgeons will suture tissues together in a manner demanding fixed relationships of tissues which might otherwise prolapse or spread apart. Thus sometimes tissues are adherent because it is demanded of them to be so (Wong and King, 2004).

Varying impact of adhesions Photo #5 Adhesions of visceral to parietal pericardium following upon open heart surgery. Image Copyright Gil Hedley, 2006. Used with permission.

viscera as they respond to the breath cycle. A scar or initial adhesion represents an abnormal limit cycle upon the phases of movement characteristic within the visceral spaces. It is this limitation of movement which is at the heart of the type of progressive adhesion noted above. Adhesions beget adhesions, as the initial limitation of normal motion extends like a growing cloud of stillness in the immediate tissues. This type of progressive adhesion will form as a diffused and general fixed relationship of the tissues across a broad surface, rather than as a cluster of single-pointed fibrous linkages. In dissection, one ‘‘peels’’ these adhesions apart, as opposed to cutting or ‘‘popping’’ them at individual points of relationship. The author has dissected many human forms where numerous precedent abdominal surgeries have resulted in virtually the entire visceral contents becoming adhered into a single common mass (Photos 7 and 8).

Intentional therapeutic adhesion

The adhesion of normally sliding surfaces in any of the manners described range on a continuum of impact upon normal organ function from inconsequential to debilitating. Where the abdominal organs are reduced to a virtually solid and immobilized mass as a result of repeated major surgical interventions, the physiology of the organs are necessarily affected by their lack of mobility over time. On the other hand, a minor and singular adhesion of a fatty epiploic apendage of the descending colon to the adjacent parietal peritoneum is unlikely to have any particularly untoward effect, given the normally relatively fixed position of the colon along the posterior wall of the abdomen by the parietal peritoneum (Photo 9).

Palpating for adhesions Part of the process of careful dissection of the viscera involves visually observing and manually palpating the tissues. This inspection process often reveals a variety of adhesions in the mostly elderly forms which donor programs provide. Often it is possible to deduce or infer the causes of the adhesions based on the evidence at hand, and given a lack of explicit medical history, these inferences are all

In the instance of a repeatedly collapsing lung, talc may be introduced between the visceral and parietal pleura. The

Photo #6 After the removal of the adhesions of the visceral and the parietal pericardium shown above. Image Copyright Gil Hedley, 2006 used with permission.

Photo #7 Above is a specific fibrous adhesion of the visceral pleura of the right lung at its most inferior tip, to the parietal pleura in its mediastinal aspect. Image Copyright Gil Hedley, 2009. Used with permission.

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Photo #8 Above a progressive adhesion of the entire visceral surface of the lung to the mediastinal pleura is being manually peeled apart in dissection: the arrows indicate the still undifferentiated adhesions at the margins of the lung. Image Copyright Gil Hedley, 2009. Used with permission.

there is to go by. Many of the adhesions discovered, when not obviously associated with evident disease processes or surgical interventions, would likely have escaped the knowledge of the donors and their doctors. Nonetheless, they may have been subtly affecting optimal visceral motion and health. The question then remains open as to how a therapist trained in visceral manipulation might facilitate the visceral motion in the living in a manner that might relieve some of the adhesions revealed in the dissection process.

Direct vs indirect approaches to releasing adhesions In the process of differentiating the viscera it becomes necessary to release adhesions as they are found. Many

G. Hedley adhesions can simply be directly pulled apart manually in dissection. The author has often imagined that the same could probably have been accomplished manually in vivo as well, given the appropriate leveraging of the tissues in question. However, though this type of direct technique seems possible, it does not, upon careful consideration, appear to be the most advisable approach. Fibrous adhesions when broken abruptly can result in small wounds to the tissues related by them, which wounds themselves would be likely sources of inflammation. So a cycle of adhesion could easily be re-introduced with such a strategy, creating little progress, or even exacerbating the problem. A more indirect technique for releasing adhesions in vivo would appear to be desirable. By manually facilitating movement towards the normal range of motion of the fixed tissues with gentle traction, timed with several fulsome breath cycles on the part of the client, the expanding range of motion may itself induce the dissolution of the adhesions, not necessarily in the moment, but over time. In the same way that restrictions upon movement from adhesions may progress into greater levels of adhesion over time, enhancements of movement may progress into greater levels of movement and the restoration of normal sliding relationships of tissues.

Hypothetical examples of indirect release of adhesions in vivo These examples are hypothetical and are not meant to serve as medical advice. They could serve as sample protocols for researching the impact of interventions with respect to post surgical adhesions.

Self-care example An individual might help themselves to release adhesions from progressing after thoracic surgery with a practice of simple variations on thoracic twists. For instance, with hands grasping on a pull-up bar positioned at a height within easy reach, an individual could introduce gentle torques into their thorax, accompanied by several deep breath cycles at each position explored. Such could be a daily practice for a few minutes a day post-surgery. The external torsion accompanying the internal breath could literally stretch and mobilize fixed but normally sliding tissues of the thorax. The reiteration of larger cycles of motion thus introduced could have the effect over time of gently dissolving adhesions, slowing the progression of further adhesion, or at least increasing the elasticity and range of motion of the individual’s visceral relationships, both normal and pathological.

Practitioner-supported example

Photo #9 Epiploic appendage of descending colon adhering to parietal peritoneum. Image Copyright 2009 Gil Hedley. Used with permission.

In instances where the support of a practitioner is warranted, taking the same example as above, a trained bodywork practitioner could gently introduce torsions into the patients thorax while coaching their position and breath cycles, with an intent on varying the presenting

Fascia research: Visceral adhesions motion patterns which may be reflecting underlying adhesions. By increasing the factors which thus increase demand for the gliding of sliding surfaces which may be fixed, greater movement cycles may reiterate and accrue to the advantage of the client in the manner described above.

References Barral, J.-P., Mercier, P., 1988. Visceral Manipulation. Eastland Press, Seattle. Barral, J.-P., 1989. Visceral Manipulation II. Eastland Press, Seattle. Barral, J.-P., 1991. The Thorax. Eastland Press, Seattle. Barral, J.-P., 1993. Urogenital Manipulation. Eastland Press, Seattle. Gray, Henry, 1901/1977. Anatomy, Descriptive and Surgical. Gramercy Books, New Jersey. Hedley, G., 2005a. The Integral Anatomy Series, on DVD. In: Skin and Superficial Fascia, vol. 1. Hedley, G., 2005b. The Integral Anatomy Series, on DVD. In: Deep Fascia and Muscle, vol. 2. Hedley, G., 2006. The Integral Anatomy Series, on DVD. In: Cranial and Visceral Fasciae, vol. 3.

261 Hedley, G,, 2009. The Integral Anatomy Series, on DVD Viscera and their Fasciae. Liakakos, T., Thomakos, N., Fine, P.M., Dervenis, C., Young, R.L., 2001. Peritoneal adhesions: etiology, pathophysiology, and clinical Significance. Dig. Surg. 18, 260e273. PMID 11528133. Monk, Bradley J, Berman, Michael L, Montz, F.J., 1994 May. Adhesions after extensive gynecologic surgery: clinical significance, etiology, and prevention. Am. J. Obstet. Gynecol. 170 (5), 1396e1403. Montes, J.F., Garcı´a-Valero, J., Ferrer, J., 2006 Sept. Evidence of innervation in talc-induced pleural adhesions. Chest 130 (3), 702e709. PMID: 16963666. Schleip, R., 2006, Active Fascial Contractility. Implications for Musculoskeletal Mechanics, Dissertation, Ulm University, Ulm, Germany. Troitskii, R.A., 1968 April. Abdominal adhesions and tumor growth. Bull. Exp. Biol. Med. 65 (4), 441e443. Wong, S.W., King, D., 2004 Aug. Sutureless intestinal plication. ANZ J. Surg. 74 (8), 681e683. Zong, Xinhua, et al., 2004. Prevention of Postsurgery-induced abdominal adhesions by electrospun bioabsorbable nanofibrous poly(lactide-co-glycolide)-based membranes. Ann. Surg. 240 (5), 910e915. 2004 Nov.PMID: PMC1356499.

Journal of Bodywork & Movement Therapies (2010) 14, 262e271

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CLINICAL INFLUENCES

Extensor coxae brevis: Treatment strategies for the deep lateral rotators in pelvic tilt Thomas Myers 318 Clarks Cove Rd, Walpole, ME 04573, USA Received 5 December 2008; received in revised form 26 November 2009; accepted 8 December 2009

KEYWORDS Myofascial; Pelvic neutral; Hip joint; Postural assessment; Piriformis

Summary The group of myofascial units known as the deep lateral rotators are considered in light of their role as postural hip extensors, resulting functional and palpatory assessments of pelvic neutral are presented, and treatment strategies for anterior and posterior pelvic tilt are discussed. ª 2009 Elsevier Ltd. All rights reserved.

Our Uniquely Human Hip The differing roles of five small but important myofascial units e the gluteus medius, piriformis, obturator internus, obturator externus and quadratus femoris e within the unified fascia of the posterior hip are here examined. This group of muscles, commonly named as ‘deep lateral rotators of the hip’, can be seen alternatively as postural extensors of the coxofemoral (hip) joint. Within this perspective, we propose informal assessments and treatment strategies for these structures in anterior and posterior pelvic tilt (Fig. 1). One of the many unique features of human plantigrade carriage is that our femur in standing posture is in general coronal alignment with the spine. Comparatively, few other quadrupeds or even primates are accustomed to such hip extension; their mid-range positions for the femur are

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substantially flexed, usually at 90 or more to the angle of the sacrum (Fig. 2). Bring the leg of any cat or dog into such full extension; and one is likely to get an unmistakable non-verbal response before reaching the angle required for human standing. Even our closest relatives, the chimpanzee and gorilla, who can achieve fuller extension when necessary, seem to drop gratefully (in this author’s observation) back toward hip flexion, whereas humans routinely spend the day standing ‘naturally’ in what would be for most other primates or quadrupeds the more extreme end of the flexioneextension range. One can say ‘extreme’ even in the human, given that there is very little additional extension left for the femur in most of us, due to the twisting of the coxofemoral ligament complex, specifically the pubofemoral ligament under (or blended with, in our limited but repeated dissection observation) the iliopsoas tendon. Even the minor hyperextension required for our gait can be observed at a certain point to incur lumbar hyperextension rather than further extension of the femur relative to the hip (Fig. 3). The

1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.12.003

Extensor coxae brevis

Figure 1 The ‘extensor coxae brevis’ group. Art courtesy of John Hull Grundy, used with permission..

posturally lazy can thus shift the pelvis forward over the feet to ‘lean’ against these ligaments, whereas the yogically or acrobatically trained, or those with a naturally loose ligamentous bed, can achieve greater than normal coxofemoral hyperextension before the movement is transferred from hip to spine. Attaining and maintaining our upright posture in either phylogenetic or ontogenetic terms requires approximating the ischial tuberosity (IT) to the femur. Hip extension can involve either extending the femur away from the front of the pelvis and spine, as we just did with our cat, or bringing the posterior aspect of the pelvis closer to the shaft of the femur. Human standing requires the latter: swinging the pelvis posteriorly around the stationary head of the nearly vertical femur, as in Fig. 3. Coupled with the erector spinae above and the soleus below in keeping the body upright, the author contends that the hip extensors are the muscles that must shorten, over evolutionary time, to extend the

Figure 2 Human standing involves a uniquely extended hip joint where the femur is generally aligned with the axis of the spine, compared to other mammals, even primates, where the coxofemoral relation is 90 or less.

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Figure 3 In human standing the hip bone must make a powerful movement around the femur to approximate the ischial tuberosity to the femur and lift the spine (After Molliere).

hip. A relaxed body out of gravity will assume the ‘dead man’s float’ position, with the hips flexed into a more quadrupedal position. The primary hip extensors are usually considered to be the hamstrings, pulling directly inferior from the posterior surface of the IT, with fascial extensions onto the sacrum. These muscles are also fascially continuous with both the erectors and the triceps surae (fellow travelers in the Superficial Back Line (Myers, 2009) e Fig. 4). While the role of these ischiocrural muscles as hip extensors is unassailable, they have two disadvantages in performing the postural1 part of this uniquely human hip extension: 1) All three hamstrings are two-joint muscles, flexing the knee as well as extending the hip. This author’s clinical finding is that the body’s brain primarily uses the deeper, single-joint muscles to maintain posture whenever possible, leaving the more superficial multijoint muscles to modulate and coordinate movement.1 How do the hamstrings mediate between their pivotal postural and dual movement roles? I.e.: how do the hamstrings maintain hip extension without also flexing the knees? Having this tendency constantly opposed by the quadriceps would be energetically inefficient. 2) All the hamstrings are very long. Because of the linear alignment of myosin and actin elements, maintaining posture via such long muscles (despite the extensive membranes and tendon arrangements within them) is mechanically and physiologically disadvantageous (Fig. 5).

1 We can avoid the controversy concerning whether muscle activity is or should be involved in human standing posture by positing that a) human standing involves constant low-amplitude shifting and resulting tonic muscle activity, and b) muscle activity in hip extensors would be necessary to prevent hip flexion during loading, i.e. when carrying a child on the front of the trunk or it’s postural equivalent such as a pot belly.

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Figure 4 A dissection of the Superficial Back Line laid over a classroom skeleton. The hamstrings e part of this myofascial continuity e pull down on the ischial tuberosity. Photo courtesy of the author and the Laboratories for Anatomical Enlightenment.

Which are single-joint muscles whose tonus might maintain human hip extension against the force of gravity, any myofascial tension in the numerous hip flexors, or any recoil of the pubofemoral ligaments? In answer, we find the long portion of the adductor magnus e a single-joint extensor of the hip just deep to the hamstrings e and the deep lateral rotators. (Fig. 6) In fact, every one of the muscles behind the coronal midline of the femur can help extend the hip: in addition to the posterior fibers of adductor magnus, we can include portions of the gluteus medius and gluteus minimus, piriformis, gemellus

T. Myers superior and inferior, obturator internus, and quadratus femoris (see Fig. 1). This list constitutes the posterior portion of what can be seen as a ‘fan’ of muscles, or a set of myofascial ‘spokes’ around the ‘hub’ of the greater trochanter (Myers, 2004a). The tensor fasciae latae, and anterior portions of gluteus medius and minimus constitute the anterior e and thus hip flexor as well as abductor and medial rotator e part of this fan. The fact that the muscles named above are commonly named the ‘deep lateral rotators’ (of the femur) demonstrates that their role as extensors of the hip has been under-appreciated in our consideration of hip biomechanics. The ‘lateral rotator’ designation implies that the pelvis is the stable origin and the greater trochanter of the femur is the moveable insertion. For the remainder of this article, we will be reversing the emphasis, taking the femur of the standing leg (or both legs) as origin and the posterior aspects of the os coxae and sacrum as the insertion e hence extensor coxae brevis. Any of the hamstrings, save the short head of biceps femoris, would thus be ‘extensor coxae longus’. Both groups, we are hypothesizing, share the workload of extending the hip and preventing unwanted hip/trunk flexion Though the two tasks of lateral femoral rotation and hip extension are related (think of the push-off phase of rollerblading or ice-skating as extensions of similar smaller movements in walking), their role as lateral rotators is subordinate, in this writer’s opinion, to their postural role in keeping the hip extended.2 If we concur with that role, these muscles become crucial to any strategy for dealing with an anterior or posterior pelvic tilt, as these postural positions could be alternatively described as hip flexion and extension respectively. In hip flexion/anterior pelvic tilt, these muscles will tend to be eccentrically loaded (neuromyofascially ‘locked long’); in hip extension/posterior tilt, they will tend to be concentrically loaded (‘locked short’) e though the precise parameters of such designations are yet to be defined. The extremes of both anterior and posterior pelvic tilt may involve a functional weakness in terms of these surrounding muscles’ ability to generate forceful contraction on any attachment or across the hip joint itself. Eccentrically loaded muscles have less overlap between the myosin and actin proteins, and thus cannot generate a strong contraction. Concentrically loaded muscles have plenty of overlap (so it is more difficult to generate relaxation in them), but are so near the end of the ‘ratchets’ that they cannot generate significant further contraction.3 Even though there is a certain amount of adjustability in tonal length within the muscles, neither of these ‘out of

2 This is an assumption not universally shared: No less an authority than Serge Gracovetsky says: ‘‘As a rule of thumb, the muscles must be considered as ‘‘gas guzzlers’’ and, to execute any tasks with minimum energy consumption or minimum stress in all joints, the musculoskeletal system will always attempt to use its ligaments first, and fire a muscle as a last resort.’’ (Gracovetsky, 1986). 3 Again, this is a presumption based on clinical palpation only. Hoyle found most striated muscle to be heterogeneous (Hoyle, 1967).

Extensor coxae brevis

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Figure 6 The adductor magnus assists the hamstrings and the deep lateral rotators in maintaining hip extension. Art courtesy of John Hull Grundy, used with permission.

Figure 5 Given that they are very long two-joint muscles, the hamstrings are ill-equipped to be postural muscles.

neutral’ positions would seem to provide efficient and strong muscle contraction in functional movement. If so, we speculate that those clients whose characteristic postural position tends toward one or the other of these extremes have neither a strong and adjustable initiator for leg movement, nor a stable but responsive foundation for spinal movement.

Assessing pelvic tilt If the treatment option employed varies with pelvic tilt, how shall we define pelvic neutral? Opinions abound as to what

constitutes a ‘neutral pelvis’. Ida Rolf suggests that when the superior surface of the pubic bone and the tip of the coccyx are in horizontal alignment, the pelvis is in a proper neutral (Rolf, 1977). Hiramoto and Kendall and McCreary posit that pelvic neutral is when the ASIS and the front surface of the pubic bone are in the same coronal plane (Hiramoto, 2000; Kendall and McCreary, 1983). Others suggest an ideal angle between the ASIS and PSIS (Shamberger, 2002). This author finds such markers objectionably geometric and fixed, as they fail to account for individuated dynamic relations between the femur and the lumbar spine through the pelvis. A more complete goniometric method might yield more convincing and less cut-and-dried measures with further research (Sprigle et al., 2003). We have been using a more individually responsive test, which has its own problems, but produces, in our opinion, a truer overall result than these simple geometric visual measures. Again, more research with such measuring devices as a laser or balance beam might be possible to introduce objectivity and

266 eliminate ideomotor bias from the following subjective (but nonetheless interesting and sensitive) assessment method. With the subject in relaxed standing, place your hand ever so gently on their head, with a cranial touch e no more than a nickel’s worth of pressure. Resting in the hair will suffice to feel what you are looking for. From whatever pelvic position is ‘normal’ for this person, have them tilt the pelvis a bit anteriorly. Does the head rise into or shrink away from your hand? If they increase the forward tilting of the pelvis toward their end-range of hip flexion, at some point the body will shorten away form your hand. Have them return to their normal. Now have them tilt the pelvis posteriorly a little. Same question: does the head bloom into your hand or shrink away? Again, if they continue into more extreme posterior tilt toward the end-range of hip extension, the spine will eventually shorten. Have the subject slowly oscillate through the top of the movement until you are sure where the ‘highest’ point in the cycle occurs. In this model, pelvic neutral e the postural ideal e is when the head is at its highest, indicating that the spine is at its longest. The operating presumption for this test is that the pelvis should rest in the position where the spine is ‘living its full length’. Repeat the exercise in each direction a few times to make sure you are reading the results correctly. This test is more accurate the more differentiated the client’s pelvic movement can be, such that they can isolate the movement of the pelvis from compensatory movement in the rib cage, legs and lumbars. In individuals who are challenged with excessive stiffness, injury, or surgery, the test will be less effective, as the spine will shorten due the forward or backward displacement of the head or rib cage. In most cases, however, the anterior or posterior tilt of the pelvis reveals that ‘highest point’, often only a few degrees from where they habitually rest, and that is where you should aim for having the patient rest in normal. This angle of the pelvis where the spine lives its fullest length, for the purposes of this paper, is defined as their particular ‘pelvic neutral’. Periodically retest over time, as the results can shift a little as greater balance is achieved. Please note that we are not suggesting that you should instruct your clients to ‘put’ themselves in this normal; if you do good work, the subject will arrive naturally and without effort at his own ‘personal best’ normal.

T. Myers muscle is a distinct slip running on the oblique line between the posterior superior iliac spine (PSIS) and the superior aspect of the greater trochanter. By strumming across this line, the trailing edge of this muscle and its fascia can usually be distinctly felt as if it were a separate muscle.

Piriformis The only two-joint muscle of this group, as it also crosses the sacroiliac joint, passes from the top of the greater trochanter through the greater sciatic foramen to attach to the anterior aspect of the middle three segments of the sacrum (Fig. 7). The piriformis is thus the sole axialappendicular muscle of this group, with the ability to create ‘force closure’ on the sacroiliac joint during gait (Vleeming et al., 2007). This function combines with its contribution to stabilizing the sacrum at the bottom of the spinal ‘lever’ in lateral tilts, bends, and rotations of the spine, as well as the more familiar one of laterally rotating the femur (or preventing medial rotation), or teaming up with the pectineus to create pelvic rotation e stretching the poor piriformis among multiple roles (Myers, 2004b). This muscle can be most easily palpated (though sometimes it is not easily palpated at all) in the center of a triangle made from the top and bottom of the sacrum along the midline and the posterior aspect of the greater trochanter. Strumming up and down over the center of this triangle will often (but not always) reveal the small but potent piriformis. Whether it can be distinctly felt or not, this is where piriformis is most easily touched manually (given that we are not entering the body cavities). Proximal to this point, it disappears deep to the sacrum, and distal to this point the tendon can be lost in the general ‘glom’ of connective tissue around the trochanter. Of course piriformis can be ‘reached’ using the femur as a lever to

Anatomy A brief review of the anatomy will be helpful before discussing treatment options. Precise palpation directions are offered as all of these muscles lie deep to the large and thick gluteus maximus, which can make easy palpation challenging. All but a small portion of this muscle (deep and parallel to the quadratus femoris, according to Janda) is quiescent in standing, so its role in hip extension is limited to running and stair-climbing, and not, like the rest of this list, in relaxed standing (Janda, 1986). We proceed from superior to inferior.

Gluteus medius, posterior portion The posterior portion of the gluteus medius is a combination of a hip extensor and abductor. The posterior edge of this

Figure 7 The unique piriformis performs multiple roles, and should be considered from both sides, as one myofascial continuity, as suggested in this art from John Hull Grundy. Used with permission.

Extensor coxae brevis induce a general stretch, though this author finds far more specificity for each of the three slips by means of the direct manual approach.

Gemellus superior This small muscle passes from the lateral end of the sacrospinous ligament to the trochanteric fossa, and may thus provide muscular reinforcement to the ligament in its role of stabilizing the side-to-side movement of the sacrum. In this way, this muscle is, in effect, a two-joint muscle as well, helping to reinforce the sacroiliac joint via the sacrospinous ligament. Palpate this muscle, if it can be distinguished, along a line just superior to obturator internus.

Obturator internus This fascinating muscle also inserts into the trochanteric fossa, but it passes behind the ischium to take a 90 turn over a bursa, fanning out to cover the whole inside of the lower flange of the hip bone within the true pelvis, completely covering the medial side of the obturator membrane. This muscle is thus much larger and stronger than it appears from a posterior view of the hip. It also provides an attachment for the iliococcygeus of the pelvic floor. Take these two muscles together on both sides, and one can see a fascial ‘hammock’, strung from trochanter to trochanter (Fig. 8). This author agrees with Grundy’s view in Fig. 8: this complex can provide a resilient ‘spring’ for the forces transferring from the spine to the legs, sparing the full force from the coxofemoral joint itself (Grundy, 1982).

Figure 8 The obturator internus, again considered from both sides, and when coupled with the pelvic floor (not pictured), forms a sling to cushion the shock of the upper body’s weight on the hip joint. Art courtesy of John Hull Grundy, used with permission.

267 To find the obturator internus (OI), locate the ischial tuberosity (IT) from below on your prone client. ‘Walk’ your fingers up the ‘mountain’ of the ischial bone toward the head until you find a soft ‘meadow’ of muscle e this is the OI, which can usually be felt as a distinct muscle if you strum up and down. From here go directly lateral to find the distal tendinous portion of this muscle, which may blend with one or both gemelli to produce a single large tendon, or may remain palpable as two or three distinct tendons. Following Humphry4 we could see the obturator and the gemelli as a single five-stem ‘bouquet’ of muscles arising from the trochanteric fossa, with the two gemelli forming the upper and lower (and shorter) portions over to the upper and lower ischium, while the obturator internus rounds the tuberosity to divide into three portions e one reaching up toward the iliac portion near the anterior sacroiliac joint, one reaching straight across the obturator membrane for the suprapubic ramus, and one reaching downward toward the ischioubic ramus (Humphry, 1872). To find this larger, internal, and more muscular proximal part of OI requires courage and a willing client e and even then you are limited to the lower two of the three parts just described. Place three fingertips just inside the IT, using the sacrotuberous ligament as a guide for the index finger. Slide in the direction of the navel, lateral to the anal verge and parallel to the ischium. Your fingerpads will feel the IT/ischial ramus at first, but as you pass into the ischiorectal fossa, you will encounter a softer area that is

4

Humphry, 1872, p. 34 ‘The three flattened, closely adjusted tendons which the obturator internus presents as it passes over the smooth surface of the ischium, have often attracted attention. They are the result of a division of the muscle within the pelvis into three flat fan-shaped portions. Of these, one, lying internal to the others (in a superficial plane when dissected from the inner side), arises from the inner surface of the angle formed by the horizontal and the descending portions of the os pubis. It is situated internally to the obturator vessels and nerve, and the arch of fascia which covers them, and therefore away from the obturator foramen. The tendon proceeding from this is the middle tendon of the three. The second division of the muscle, from which the lowest tendon proceeds, arises from the ossa pubis and ischii bounding the lower half of the obturator hole, and from the surface of the obturator ligament. The third division arises from the upper half of the obturator ligament, and from the ossa pubis and ilii above the obturator hole and beneath the brim of the pelvis. It extends upon the ilium nearly to the sacroiliac synchondrosis. This tendon is the upper of the three. It occupies a groove commonly seen just below the spine of the ischium; and it sometimes presents a division into two for a short distance, giving the appearance of four tendons upon the internal surface of the muscle. The two last-mentioned divisions, which may be called respectively ‘‘pubischiatic’’ and ‘‘pubiliac’’, approach one another upon the obturator ligament beneath the first-mentioned, which may be called the ‘‘pubic’’ division. Having passed over the ischium, the tendons unite into one, the edges of which are joined above and below by the gemelli. If traced backwards from the trochanter, the tendon of the obturator gives off, first, in a penniform manner, the fibers of the gemelli; then, in like manner, those of the ‘‘pubiliac’’ and ‘‘pubischiatic’’ portions; and lastly, in like manner, the fibers of the pubic portion’.

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T. Myers

comprised of the lower fibers of OI. You will be stopped in your upward and forward progress by the pelvic floor/iliococcygeus, which crosses over from the midline to attach to the OI fascia at the arcuate line. Have the client contract the pelvic floor and you will be able to assess its relative strength from the contraction against your fingertips.

Gemellus inferior This small muscle reinforces the obturator internus from below, extending from the distal end of the sacrotuberous ligament on the ischial tuberosity to blend in its attachment with the tendon of the obturator internus. Though this muscle shares with all the others in this list the roles of hip extensor and lateral rotator of the femur, any additional role e such as possibly providing an adjustable reinforcement to the sacrotuberous ligament complex e is as yet unclear (Van der Wal, 2009).

Quadratus femoris The last but not least of our group extends from the lateral aspect of the IT laterally to the posterior trochanter. This muscle is a powerful postural extensor of the hip (or, more accurately, a powerful resistor to hip flexion as well as medial femoral rotation), given its ability to approximate the IT to the posterior aspect of the femur, and will be short and bunched in most clients with a pronounced posterior tilt. Because the muscle is quadrate, it rarely presents as a twangy bit of myofascia, but more often as a graduated mound of tissue. Quadratus can be found and assessed above a line running lateral to the lower end of the IT e frequently just above the line of the superficial gluteal fold. Do not confuse this with the similar mound more distally located on the femur, below the gluteal fold, which is the fleshy attachment of the gluteus maximus.

Obturator externus (OE) This muscle is usually included in the deep lateral rotator group, but is not an ‘extensor coxae brevis’ because it acts e alone in this group e as a hip flexor. This rogue muscle is hard to palpate and difficult to treat in its entirety. Originating from the lateral surface of the lower flange of the hip bone, covering the outer surface of the obturator membrane, the OE passes under the neck of the femur from anterior to posterior to attach into the trochanteric fossa deep to the quadratus femoris. Obturator externus counterbalances the OI in hip flexion and extension, though both combine to resist the medial rotation of the femur (Fig. 9). In running closely under the neck of the femur, it also offers a muscular reinforcement to the neck when it is under extra strain (in landing after a jump, for instance). It is probably not a powerful hip flexor, given the competition it finds in the more advantageously positioned iliacus, pectineus, and rectus femoris, etc., but chronic shortness in its myofascia could conceivably prevent the ischial ramus from moving forward and thus the pubic bone from lifting.

Figure 9 Obturator externus is included in the deep lateral rotator group, but not in our extensor coxae brevis group, as it is a weak hip flexor. Hard to reach and difficult to treat, it is nevertheless a major stabilizer of the pelvis on the leg. Art courtesy of John Hull Grundy, used with permission.

The two obturator tendons arise from the same area of the trochanteric fossa, and can, in this author’s limited dissection observation and Humphrey’s more extensive documentation, blend at their distal end (Humphry, 1872). Together, the two muscles could be seen to reach out from the femur like two hands holding the inner and outer aspects of the lower flange of the pelvis in a close but adjustable grip. This is one of the more obscure muscles of the pelvic area to palpate, but it can be felt by the knowledgeable practitioner on a willing client by entering the femoral triangle of the client lying supine with the knees up. Find the small fascial ‘window’ between the medial edge of the pectineus origin and the lateral edge of the adductor longus tendon and press in superiorly and posteriorly with fingertips or your thumb pad. The tough and generally sensitive tissue beyond these two muscles is the OE, running from the lateral surface of the ischium and obturator membrane back and under the neck of the femur to the trochanteric fossa. Only a small portion of this muscle can be directly palpated.

Treatment Having come this far, treatment options abound. The one sentence pre ´cis is that in cases of a chronic postural set of anterior pelvic tilt/hip flexion the fascia of this muscle group needs to be taken inferiorly individually and as a whole, while in cases of posterior pelvic tilt these myofascial units need to be neuro-muscularly and fascially released and allowed to lengthen and hopefully reset at lower standing tension. In anterior tilt, these muscles will be eccentrically loaded, so any or all of them present in our clinic as twangy, tight, and sore with active trigger points. In posterior tilt, they often present as bunched, often seemingly tied together, with primarily passive trigger points.

Extensor coxae brevis

Figure 10 Treatment of these muscles in posterior tilt generally involves lengthening the myofascial units, and usually from pelvic origin to femoral insertion. Art courtesy of John Hull Grundy, used with permission.

Posterior tilt In posterior tilt, a variety of treatment options may be used to ease standing tension, including neuromuscular therapy techniques, active isolated stretching, strain-counterstrain, or proprioceptive neuromuscular facilitation. In terms of more commonly-used fascial release techniques, working slowly along each individual muscle from pelvic origin toward the femoral insertion, using the guidelines for specificity outlined above, will usually result in lengthened fascia and lower standing tone (Fig. 10). The posterior edge of the gluteus medius is easily located between the superior trochanter and the PSIS. Beneath this muscle, the harder-to-feel but equally potent gluteus minimus can be contacted (usually to the client’s initial horror) by passively abducting the side-lying client’s thigh with one hand or forearm, while working deeply into the posterior hip tissue with the other elbow. The piriformis is harder to locate on some clients, but following the direction to the center of the triangle described above will guarantee that you are on the piriformis whether it can be detected or not. Work laterally and inferiorly toward the insertion to lengthen this muscle (at least temporarily e modulating pelvic tilt is only one of piriformis’s many roles, which include antagonizing the lower psoas over the sacroiliac joint (Myers 2004b), reinforcing the sacrospinous ligament, and preventing excess movement in the sacroiliac joint due to forces descending from spinal movements above, not to mention force closure of the SI joint in walking e therefore treatment of the

5

Resetting the standing tonus of muscles is an elusive concept in research. As a clinician, we ‘know what we feel’, but the science is not yet fully in agreement here (Mori et al., 1982; Asanoma et al., 1998; Bouret and Sara, 2005).

269 piriformis often reverts over a short time until the body reaches sufficient balance in all these forces for the piriformis to retain any new tonal ‘set point’.5) Gemellus superior and inferior are usually addressed with the obturator internus rather than individually, again working along the muscles from the lateral side of the upper ischial tuberosity laterally toward the fossa at the back of the greater trochanter. Work deeply and slowly for best results. For the intrepid practitioner and the willing client, the larger portion of OI can be reached by sliding the fingertips up into the ischiorectal fossa in the direction of the navel, using the sacrotuberous ligament as a guide, as detailed above. Once well onto the muscular fibers of the OI proper, hook the myofascia and bring the issue inferiorly and posteriorly (bring your hand back the same way it went in, but with the fingertips hooked into the fascia), as the client medially rotates the femur. This one technique can result in a substantial reorientation of the pelvis in the direction of an anterior tilt (as well as easing the overlytight pelvic floor, in our experience), helping to restore a neutral lumbar lordosis when the client stands after treatment. The quadratus femoris is a tough square of myofascia that can be worked quite strongly and needs to be worked quite thoroughly in these cases, mostly along the posterior side of the trochanter superior to the gluteal fold. If you are working this muscle with the client prone, ask them to arch their lumbar spine slowly into a lordosis as you work, thus adding an active release component into your technique. Release of this muscle e again along the grain of the fibers, deeply and slowly e often results in the ability to more properly fold the hip joint into flexion without binding.

Anterior tilt For anterior tilt, this entire set of myofascial units needs to be pulled caudad. One fascial portion of this treatment can be accomplished most easily behind the greater trochanter, where they all terminate. With your client prone and the hip relaxed as possible, hook the fascia at the top of the trochanter with an elbow and bring it down along the back of the trochanter (Fig. 11). Several passes and significant weight are often required to effect a change, as you are working with the tendons of all these muscles in the fascial fabric behind the trochanter. Similar work can be done nearer the origin of these muscles by hooking tissue slowly along the posterior iliac crest, just lateral to the PSIS, and along the lateral lower sacrum and ischial tuberosity. Cross-fiber work across each of these individual muscles seems to be helpful in unlocking the eccentric loading in the fibers of these muscles, helping to create (but not guaranteeing) a shorter standing tonus.6 Work slowly back

6 This could be a useful area for future ultrasound research: what is the architecture of fascia, particularly the endomysium, in an eccentrically loaded muscle? And what is the effect of cross-fiber work on this ‘locked long’ myofascial architecture? See Van der Wal, 2009; Purslow 2002; Passerieux et al., 2006 and Huijing 2007.

270

Figure 11 Treatment in anterior tilt generally involves pulling the fascial plane caudally while stimulating the muscles to shorten via cross-fiber work. Art courtesy of John Hull Grundy, used with permission.

and forth across the muscle you wish to focus on, slowly enough not to ‘twang’ the muscle, but to soften and differentiate the myofascia without allowing it to jump beneath your applicator (fingers, knuckles, or elbow). Of course, this work needs to be accompanied by the release of the hip flexors and spinal extensors for best results. Including the OE, the renegade of our group, can be helpful in this regard. Again, this requires a willing client and a certain skill by the practitioner. With your client supine and the knees up, sit next to her hip and cup her knee in your axilla. Find the obvious adductor longus tendon in the groin and place your thumb just anterolateral to its junction with the pubic bone. Insinuate your thumb between the adductor longus and the pectineus. OE lies deep to these two, and is usually distinctly harder than the pectineus, and deeper than the adductor longus or brevis. Contacting it will often elicit a surprised reaction from the client, but with sensitive communication, you can get a release from the portion of the muscle you can touch, which is by no means all of it. This is only one access point to a fairly large attachment, but by changing the angle of the thumbprint slightly from directly superior to inferior and medial against the pubic bone, or superior and lateral, and calling for a slow pelvic rock, more of the muscle belly can be contacted. Most clients with a fixed anterior tilt will find more freedom after this release, which can be repeated as often as time (and the client) allow. Continuing our journey caudad from here, we would encounter the adductor minimus, which due to its positioning and innervation is probably, like the OE a hip flexor. The remaining portions of the large adductor magnus running from the more posterior ischial ramus to the linea aspera and medial femoral epicondyle do appear to participate in hip extension, but are often stuck in

T. Myers a dormant ‘sensori-motor amnesia’, and will benefit from the kinds of muscle-activation techniques such as MET and PNF mentioned above. In cases where the two innominates are in a different angle, the two sides will require different degrees of treatment to ease locked nutation or counter-nutation of the sacroiliac joint. In general however, the inclusion of these ‘extensori coxae brevi’ in your treatment plans for excessive anterior or posterior pelvic tilt will be rewarded. In considering the postural balance of the pelvis on the femur, the hip flexors get a lot of attention and for very good reason: 1) they are large and strong muscles, 2) which must lengthen significantly for full maturational development, and 3) which can be subject (in our observation) to increased tension in common fear or post-traumatic situations, as well as in chronic torsion or rotational patterns not addressed by this article. Here we have made the case that the ‘deep lateral rotators’ may act as postural antagonists to these hip flexors, not leaving the entire job to the long, bi-articular, and often over-worked hamstrings. We offered a test for determining the client’s personal ‘pelvic neutral’, and suggested techniques for this ‘extensor coxae brevis’ group to help move the client toward their functional norm.

References Asanoma, et al., March 1998. Augmentation of postural tone induced by the stimulation of the descending fibers in the midline area of the cerebellar white matter in the acute decerebrate cat. Neurosci. Res. 30 (3), 257e269. Bouret, S., Sara, S., 2005. Network reset: a simplified overarching theory of locus coeruleus noradrenaline function. Trends Neurosci. 28 (11), 574e582. 1 November 2005. Gracovetsky, S., 1986. Determination of safe load. Br. J. Indust Med. 43, 120e133. Grundy, J., 1982. Human Structure and Shape. Noble Books, Chilbolton UK. Hiramoto, Y., 2000. Morpho-metrical features of the pelvis in standing posture. Kaibogaku Zasshi 75 (2), 223e230. Hoyle, J., 1967. Diversity of striated muscle. Am. Zool. 7 (3), 435e 449. doi:10.1093/icb/7.3.435. Huijing, P., 2007. Epimuscular myofascial force transmission between antagonistic and synergistic muscles can explain movement limitation in spastic paresis. J. Biomech. 17 (6), 708e724. Humphry, G.M., 1872. Lectures on human myology. Br. Med. J. 2 (602), 33e35. Janda, V.,1986. ‘‘Muscle weakness and inhibition (pseudoparesis) in back pain syndromes’’ in ‘‘Modern Manual Therapy of the Vertebral Column’’ edited by GP Grieve, New York, ChurchillLivingston, p. 197e201. Kendall, F., McCreary, E., 1983. Muscles, Testing and Function, third ed.. Williams & Wilkins, Baltimore, p. 25. Mori, et al., 1982. Setting and resetting of level of postural muscle tone in decerebrate cat. J. Neurophysiol. 48, 737e748. Myers, T., 2009. Anatomy Trains, second ed.. Churchill Livingstone, Edinburgh. Myers, T., 2004a. Fans of the hip joint. originally published in Massage Magazine 1998, self published 2004 as ‘Body3’. Available from: www.anatomytrains.com. Myers, T., 2004b. Psoas-piriformis balance. originally published in Massage Magazine 1999, self published 2004 as ‘Body3’. Available from: www.anatomytrains.com.

Extensor coxae brevis Passerieux, et al., 2006. Structural organization of the perimysium in bovine skeletal muscle: junctional plates and associated intercellular domains. J. Struct. Biol. 154 (2), 206e216. Purslow, P., 2002. The structural and functional significance of variations of connective tissue within muscle. Comp. Biochem. Phys. 133 (4), 947e966. Rolf, I., 1977. Rolfing. Healing Arts Press, Rochester, VT, p. 87. Shamberger, W., 2002. The Malalignment Syndrome. Churchill Livingstone, Edinburgh.

271 Sprigle, S., Flinn, N., et al., June 2003. Development and testing of a pelvic goniometer designed to measure pelvic tilt and hip flexion. Clin. Biomech. 18 (5), 462e465. Van der Wal J 2009 The Architecture of the Connective Tissues in the Musculoskeletal System e based on a doctoral thesis ‘‘The Organization of the Substrate of Proprioception in the Elbow Region of a Rat’’ published in 1988, reprinted in Journal of Bodywork and Movement Therapies, 2009 (2), 4. Vleeming, A., Mooney, V., Stoeckart, R., 2007. Movement, Stability & Lumbopelvic Pain: Integration of research and therapy.

Journal of Bodywork & Movement Therapies (2010) 14, 272e279

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

MICROCURRENT ELECTROTHERAPY

The efficacy of frequency specific microcurrent therapy on delayed onset muscle soreness Denise Curtis, MSc, NMT a,*, Stephen Fallows, PhD a, Michael Morris, MSc a, Carolyn McMakin, MA DC b a b

Centre for Exercise & Nutrition Science, University of Chester, Parkgate Road, Chester CH1 4BJ, England, UK Fibromyalgia and Myofascial Pain Clinic of Portland, 69 SW Hampton Street, Portland, OR 97223, USA

Received 6 October 2008; received in revised form 11 January 2010; accepted 24 January 2010

KEYWORDS Frequency specific microcurrent therapy; Delayed onset muscle soreness; Eccentric; VAS

Summary This study compared the effects of frequency specific microcurrent (FSM) therapy versus sham therapy in delayed onset muscle soreness (DOMS) in order to determine whether specific frequencies on two channels would produce better results than single channel single frequency microcurrent therapy which has been shown to be ineffective as compared to sham treatment in DOMS. 18 male and 17 female healthy participants (mean age 32  4.2 years) were recruited. Following a 15-min treadmill warm-up and 5 sub-maximal eccentric muscle contractions, participants performed 5 sets of 15 maximal voluntary eccentric muscle contractions, with a 1-min rest between sets, on a seated leg curl machine. Post-exercise, participants had one of their legs assigned to a treatment (T) regime (20 min of frequency specific microcurrent stimulation), while the participant’s other leg acted as control (NT). Soreness was rated for each leg at baseline and at 24, 48 and 72 h post-exercise on a visual analogue scale (VAS), which ranged from 0 (no pain) to 10 (worst pain ever). No significant difference was noted at baseline p Z 1.00. Postexercise there was a significant difference at 24 h (T Z 1.3  1.0, NT Z 5.2  1.3, p Z 0.0005), at 48 h (T Z 1.2  1.1, NT Z 7.0  1.1, p Z 0.0005) and at 72 h (T Z 0.7  0.6, NT Z 4.0  1.6, p Z 0.0005). FSM therapy provided significant protection from DOMS at all time points tested. ª 2010 Elsevier Ltd. All rights reserved.

Introduction Delayed onset of muscle soreness (DOMS) has been described as damaged muscle tissue membranes combined with

a secondary inflammatory condition (Gleeson et al., 1995; Wilmore and Costill, 2004; Connolly et al., 2003) resulting from unaccustomed eccentric contractions (Taleg, 1973; Newman et al., 1983a,b; Armstrong, 1984; Denegar and Perrin, 1992) and maximal isometric contractions (Clarkson

* Corresponding author. Tel.: þ353 46 9059095. E-mail address: [email protected] (D. Curtis). 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.01.009

The efficacy of FSM therapy on DOMS et al., 1986). Although many variables are reported in the quantification of muscle damage, the typical symptoms associated with DOMS are loss of strength, pain, muscle tenderness, stiffness, swelling and elevated levels of the enzyme creatine kinase (McHugh et al., 1999). Symptoms can vary from mild muscle tenderness to severe debilitating pain (Cheung et al., 2003). DOMS is a well researched phenomenon and the morphological injury to the muscle has been well described, however the mechanism underlying the injury remains poorly understood. For many years, DOMS was attributed to an accumulation of the metabolic end products of exercise resulting in elevated muscle lactate. This assumption is now understood to be unconnected to DOMS. It is now proposed that the soreness may be the result of, amongst others, mechanical (Newman et al., 1983a,b; Armstrong, 1984; Stauber et al., 1990) or biochemical (Armstrong, 1984; McIntyre et al., 1995) factors. Research suggests that the soreness typically appears between 8 and 24 h post-exercise, peaks at 24e48 h and can last for up to 7 days (Cleak and Eston, 1992; Howell et al., 1993). Although the precise details of muscle damage following eccentric exercise remains unknown, it appears that even a single bout of eccentric muscle contractions can offer significant protection against muscle soreness in subsequent performances of the same exercise. This phenomenon, which has been known to last for several months, was termed the ‘‘repeated bout effect’’ by Nosaka and Clarkson (1995). DOMS is a universal symptom familiar to most athletes that usually occurs after an extended layoff from exercise or unfamiliar, predominantly eccentric exercise. Athletic performance is typically impaired when an athlete is sore. Research by Proske et al. (2003) implied that muscle soreness, following a bout of unaccustomed eccentric exercise, may also contribute to muscle weakness, possibly as a result of reduced excitability of the motor cortex. Thus, any practice or therapy that limits soreness and restores the maximal function of the muscles as quickly as possible would be of interest and practical value to the athlete. Numerous treatment strategies, both prophylactic and rehabilitative, have been introduced to help relieve the severity of DOMS. Some of the proposed treatments include pre- and post-exercise static stretching (Herbert and Gabriel, 2002; Cornwell et al., 2002; Yamaguichi and Ishii, 2005), pharmacological treatments using non-steroidal anti-inflammatory drugs (NSAIDs) (Grossman et al., 1995; O’Grady et al., 2000; Sayers et al., 2001; Connolly et al., 2003; Lanier, 2003), nutritional supplements (Kaminski and Boal, 1992; Warren et al., 1992; Jakeman and Maxwell, 1993), massage therapy (Tiidus and Shoemaker, 1995; Lightfoot et al., 1997), continuous compression (Kraemer et al., 2001) and ice-water immersion (Sellwood et al., 2007). However, little scientific evidence exists to support the effectiveness of any of these therapeutic interventions. The following study compared the effects of FSM therapy versus sham therapy on DOMS in order to determine if the use of certain specific frequencies would produce better results than simple single frequency microcurrent therapy which had been shown by Allen et al. (1999) to be ineffective when compared to sham treatment in DOMS. Allen et al. (1999) determined that 20 min of single channel,

273 single frequency microamperage current using 30 Hz at 200 mA for 10 min and 0.3 Hz at 100 mA for 10 min was not effective in reducing pain or increasing range of motion 24, 48 and 72 h after DOMS induction in the biceps muscle in a group of 18 subjects (3 males, 18 females). The sham group in the Allen paper received treatment from a unit that had been disabled by the manufacturer to provide no electrical stimulation and both the subjects and experimenter were blinded. In the present study the sham treatment was provided by a unit that was not turned on and only the subjects were blinded. To the authors’ knowledge, no controlled studies to date have examined the effects of FSM therapy on DOMS.

History of frequency specific microcurrent (FSM) therapy Microcurrent electrical neuromuscular stimulation (MENS) was developed in the 1970s as a battery operated physical therapy modality delivering current in the microampere range. An ampere (amp) is a measure of the strength of electric current and measures the rate of flow of charge in a conducting medium. One micro amp (mA) equals 1/1000th of a milliamp (mA). By comparison, interferential, TENS, and high-volt pulsed galvanic stimulators deliver currents in the milliamp range causing muscle contraction, pulsing and tingling sensations. TENS applies an electrical force that stimulates pain suppressing A-beta afferent fibers which compete against A-delta and C fibers that transmit pain signals. Most TENS units deliver current around the 60 mA range (Kirsch and Lerner, 1998). Although microcurrent devices are approved in the category of TENS for regulatory convenience, in practical use they are in no way similar and cannot be compared to TENS in their effect. With microcurrent the patient cannot feel the current since there is not enough current to stimulate sensory nerve fibers (Mercola and Kirsch, 1995). Traditionally, microcurrent therapy has been used to increase the rate of healing in injured athletes, to treat and manage muscle pain and dysfunction and to increase the rate of fracture repair (Rowley et al., 1974; Bertolucci and Grey, 1995; Kirsch, 1996, 1997; Lambert et al., 2002). Current in the range of 10 up to 500 mA was observed to increase ATP production, amino acid transport, protein synthesis, and waste product removal in rat skin whereas ATP production leveled off between 500 and 1000 mA and decreased when the current was above 1000 mA (Cheng, 1982). TENS devices provide up to 60 times higher current levels than that seen to decrease ATP production which may explain why TENS units have not been found to be effective in treatment of DOMS (Craig et al., 1996). Typical microcurrent applications use only low and simple one channel frequencies such as 0.3 Hz, 3 Hz, 10 Hz, 30 Hz, and 300 Hz (Manley, 1994; Allen et al., 1999). The therapeutic use of frequencies and electrotherapy began in the early 1900s in the United States and England with thousands of medical physicians using a number of devices to treat a wide range of conditions from arthritis and tuberculosis to pneumonia (Kirsch and Lerner, 1998). The Electromedical Society and the journal Electromedical Digest served as a forum for physicians to share their

274 research and clinical findings. Copies of Electromedical Digest were found in the rare book room of the National College of Naturopathic Medicine in Portland containing frequencies and protocols for the above conditions and articles documenting clinical outcomes in every edition available published between 1920 and 1951. In 1934, as part of its effort to standardize medicine and medical education, the American Medical Association (AMA) decreed that pharmaceutical medications and surgery were the legitimate tools of medicine and that electromagnetic therapies, homeopathy, herbs and other treatments were ‘‘unscientific’’ (Berliner, 1975, Barzansky and Gevitz, 1992). The biophysics and medical research that would provide the mechanisms and science explaining electromedicine would not be done until the 1980s (Becker and Seldon, 1985; Oschman, 2000). The use of electromagnetic therapies and frequencies declined, the research being reported in Electromedical Digest ceased and the last edition of the journal available was published in 1951 (Electronic Medical Digest, 1951). The FDA made the original devices illegal around the same time. The frequencies used in this study were obtained in 1995 from a retired British osteopath who bought a practice in Vancouver, BC (Canada) in 1946 that came with a machine (manufacturer unknown) and a list of frequencies that were created in 1922 thought to address specific tissues and neutralize specific conditions. The list acquired from the osteopath included approximately 100 frequencies alleged to neutralize certain pathologies or conditions and over 200 frequencies thought to address certain tissues. The osteopath’s method of treatment included using a frequency on one channel to ‘‘remove a pathology’’ combined with a frequency on the second channel to ‘‘address a specific tissue’’. The device used by the osteopath has long since disappeared and has never been available for inspection. While it is thought to have plugged into the wall current which may have been DC in 1922, it is not known what current level it delivered and there is no reason to suspect that it delivered microamperage current which was not introduced until the early 1980s. Frequencies found on the back page of Electromedical Digest in a wall chart being sold by Albert Abrams were identical to those that came with the osteopath’s machine where the two lists overlapped. The use of microcurrent and frequencies for the treatment of nerve, muscle pain and injury repair was developed clinically using the osteopath’s two channel, condition and tissue treatment paradigm and has been taught as Frequency Specific Microcurrent (FSM) since 1997 (McMakin, 1998; McMakin, 2004; McMakin et al., 2005). The technique requires use of any microcurrent device that can provide a different frequency on each of two channels using a ramped square wave and alternating pulsed direct current. The devices used in this study are calibrated by the manufacturer (Precision Microcurrent, Newberg, Oregon, USA) and the company standards require that the frequencies be accurate to within 0.5 Hz on both channels. Frequencies on one channel are thought to be effective in neutralizing specific conditions such as hemorrhage, fibrosis, scar tissue, mineral deposits, histamine, and acute and chronic inflammation. These frequencies are combined with frequencies on a second channel thought to be specific for muscles, fascia, tendons, nerves and arteries and other tissues (McMakin, 2004).

D. Curtis et al. The frequency specific protocols were developed clinically through trial and error by one of the authors after it was determined through clinical use on volunteers that the use of a frequency combination that did not produce improvement also did no apparent harm. The descriptions of the frequencies from the list were taken at face value and used speculatively for various chronic and acute conditions in clinical practice to determine if they would produce a change in symptoms and clinical improvement (McMakin, 1998; McMakin, 2004; McMakin et al., 2005). For example, the frequencies described on the list as reversing ‘‘hemorrhage’’ in the ‘‘arteries’’ were used speculatively in acute injuries to reduce bruising ‘‘as if’’ it correctly represented the effect of the frequency. It was subsequently observed not only to prevent bruising and reduce pain but also coincidentally noted to stop bleeding for up to 12 h in patients who were menstruating at the time of treatment. No other frequency tried produced this effect. This frequency had no effect on any other condition. No formal research has been done to verify the effect of this frequency but it has been reproduced on numerous occasions by the authors and many of the 1200 clinicians using FSM worldwide including athletic trainers for the USA National Football League (NFA), surgeons and an obstetrician who use this frequency specifically to stop bleeding and bruising in medically appropriate settings. The other frequencies used in FSM therapy were explored in the same way. 40 Hz was described on the osteopath’s list and in Electromedical Digest as being useful to ‘‘reduce inflammation’’. Use of this frequency in a clinical setting suggested that it did only that and was not useful to change any other condition. Use of 40 Hz on channel A and 10 Hz on channel B was found to reduce pain in fibromyalgia patients and to reduce all of the inflammatory cytokines as measured by micro-immunochromatography (McMakin et al., 2005). One control patient treated with a protocol that did not include 40 Hz had no change in cytokines (McMakin et al., 2005). Clinical response to the frequencies over the last 14 years suggests that the conditions being treated and the tissues being addressed are accurately represented by the frequency descriptions although decades of research will be required to confirm and clarify these effects. Until such research is done no claims can be or are made by the authors for the specific effects of frequencies on biological tissues or conditions. Clinical research, such as this paper, may report the observed and reported effects in a research setting of certain frequency combinations without making specific claims for the frequencies used. Fortunately, medicine is pragmatic and it is not uncommon for apparently effective medications, such as aspirin, to be used for many years before the mechanism is understood.

Methods Participants Following the posting of an advertisement on the student notice board at the National Training Centre (NTC) in Dublin, Ireland, forty-four students volunteered to participate in the

The efficacy of FSM therapy on DOMS study. 18 male and 17 female students (mean age 32  4.2 years) were selected from these volunteers to take part in the study. Each of the participants had one of their legs assigned to a treatment group, while the opposite leg was assigned to a control group. The nomination of the participants’ leg (left or right) as treatment or control was randomized by the toss of a coin. Participants were required to meet the following inclusion and exclusion criteria to be eligible for the study. Inclusion Participants were: 1) aged between 20 and 40 years; 2) healthy and recreationally active; 3) required complete a health screening questionnaire prior to the study; 4) required to give written consent. Exclusion Potential participants were excluded if they were: 1) engaged in resistance training or eccentrically biased exercises for the lower body three months prior to the study; 2) suffering from unstable cardiovascular or pulmonary conditions or diseases; 3) suffering from any pain or injury in the legs or other health problems; 4) pregnant. Participants received a participant information sheet two weeks before the study commenced and were given three days to decide if they wanted to be involved in the research. The study was reviewed by the Ethics Committee of the School of Applied and Health Sciences, University of Chester, UK. A health screening questionnaire was completed by each of the participants on the day of the study to rule out any pathology that may have excluded them from taking part in the research. Participants were asked not to massage, stretch or treat the hamstring muscles in any way and to refrain from NSAIDs or supplements until the final set of data was completed. Massage, stretching, NSAIDs and supplements are common practices that exist for the treatment of DOMS and may therefore have affected the final results. Once the students agreed to participate in the study and had given written consent a phone call was made to each participant to confirm times and dates and also reconfirm inclusion criteria. During this phone conversation participants were verbally instructed to drink at least 2 l of water in the 2 h prior to their allocated time for participation in the study. During the warm-up and training session, a 500 ml bottle of water was provided to each participant to prevent dehydration.

275 themselves with the equipment. Participants were then instructed to perform five sets of 15 maximal eccentric contractions, with a 1-min rest between each set. Post-exercise, one of their legs, randomly chosen, underwent a 20-min FSM programme and the other leg was not treated. The frequencies delivered in the programme were chosen from a list provided by Frequency Specific Seminars, Inc. (Vancouver, Washington, USA) and are thought to be specific for tissues and conditions. The channel A frequency values that were used in this study were chosen because they were thought to be specific to some of the main pathologies induced by DOMS, while the channel B frequency values that were used were chosen because they were thought to be specific to some of the main soft tissues that are affected by DOMS. 18 Hz on channel A was combined with 62 Hz on channel B for 4 min. 124 Hz on channel A was combined with 62 Hz, 142 Hz and 191 Hz on channel B for 1 min each. 40 Hz on channel A was combined with 116 Hz on channel B for 4 min. 40 Hz on channel A was combined with 62 Hz, 142 Hz and 191 Hz on channel B for 2 min each. 49 Hz on channel A was combined with 62 Hz, 142 Hz and 191 Hz on channel B for 1 min each. The intensity was set at 200 mA and the waveslope was set at 10 for the entire 20-min programme.

Procedure for seated leg curl Participants were asked to sit into a Pulse Fitness leg curl machine and align the knee joint with the axis of the machine. The seat was then set so that their backs made full contact with the back rest and to ensure that the posterior aspect of the knee joint was positioned at the edge of the leg curl seat. Starting in full leg extension, their ankles were dorsi flexed and placed on the rollers with the feet no wider than hip distance apart. Subjects were asked to hold the side handles for support. The machine was set to allow for full range of movement (Figure 1). Subjects were instructed to curl the rollers downwards and backwards to full leg flexion (Figure 2) and then slowly return the rollers to full leg extension. Male participants began with a starting weight of 25 kg, whereas female participants started with a weight of 20 kg. Participants either performed 15 repetitions with their starting weight or continuous repetitions until they could no longer push or resist the weight. When participants could no longer push or resist the weight, the weight was reduced by 5 kg and the protocol continued either to fatigue or until the fifteen repetitions were completed. Participants were verbally encouraged to exert maximal resistance in the upward (eccentric) phase of the movement. To ensure consistency, participants were instructed to control the lifting velocity of the rollers by counting from one to five from the beginning to the end range of the eccentric action.

Procedure for FSM treatment Design Following a 15-min warm-up on an ascent Pulse Fitness treadmill, at a speed of 6 km/h, participants were instructed to perform five sub-maximal eccentric contractions on a Pulse Fitness seated leg curl machine to familiarize

Post-exercise, participants were instructed to lie in the prone position on a massage table. Each of the participants’ legs were attached to separate FSM machines (Precision Microcurrent, Newberg, Oregon, USA) that were placed on either side of the table in alignment with the hamstring

276

D. Curtis et al.

Figure 1

Eccentric end range on leg curl machine.

muscles and positioned so that the patient could not see the front panel of the device or determine which machine was turned on (Figure 3). As DOMS was induced in only the hamstring muscle group, the current was directed only through the soft tissues in this muscle group. The positive leads from the device were attached to graphite gloves that were wrapped in wet towels and placed on the upper portion of the participants’ thighs. The negative leads were attached to graphite gloves that were wrapped in wet towels and placed below the participants’ knees. This allowed the current to flow between the two leads through the soft tissues of the treated leg. One of the machines was turned off providing the sham treatment and the volume on the working machine was turned down. Rated soreness and tenderness were evaluated at baseline and 24, 48 and 72 h post-exercise using a visual analogue scale (VAS). The VAS consists of a 10 cm horizontal line with the two end points labeled 0 (no pain) to 10 (worst soreness ever) (Huskinson, 1974; Joyce et al., 1975). Participants were asked to make a vertical slash across the 10 cm line that corresponded to the level of pain intensity between the limits of no pain felt (left end of line) and worst soreness ever (right end of line). A blank scale was used each time to avoid bias from previous measurements.

Figure 3

Subject position for FSM treatment.

The VAS has been shown to be a valid and reliable measurement for determining the intensity of human pain, it is minimally intrusive and is easily and quickly administered (Lee and Kieckhefer, 1989; Mattacola et al., 1997).

Statistical analysis As the VAS falls into the ratio level of measurement (Myles et al., 1999), parametric tests were conducted to investigate significant differences within and between the groups. Changes in the VAS within the groups were analysed via a One Way repeated measures ANOVA and post hoc analysis utilising multiple paired t-tests tests. Differences between the groups were investigated using multiple Independent t-tests, one at each time point (baseline, 24, 48 and 72 h). Normality was assessed and confirmed prior to each test via the Shapiro Wilk statistic and data are presented as mean  standard deviation (SD). All data were analysed using SPSS for Windows (Version 14.0) and significance was set at the 0.05 level. A post hoc sample size calculation based on the data from this study revealed an effect size 0.08. Based on a significance level of 0.05, being a two tailed test with 80%, power, this provided a sample size of 26 participants in each group.

Results Perceived muscle soreness

Figure 2

Concentric end range on leg curl machine.

The baseline values for perceived muscle soreness before exercise as assessed by the VAS (Table 1) for each group revealed no significant difference (p Z 1.000). This indicated that the groups had no prior muscle pain and understood how to use the scale correctly. Once each group had undergone the exercise regime to induce the muscle damage the ratings on the VAS significantly increased. This was observed in both groups with the non-treatment group increasing from zero at baseline to 5.2  1.3 at 24 h (p Z 0.0005) and the treatment group increasing from zero to 1.3  1.0 (p Z 0.0005). This significant increase demonstrated that the exercise regime had worked at inducing muscle damage. It can also be seen that

The efficacy of FSM therapy on DOMS

277

Table 1 Perceived muscle soreness at baseline, 24, 48 and 72 h for each treatment. Baseline 24 h Treatment 00 Non-treatment 00 p Value (between 1.000 groups)

48 h

72 h

1.3  1.0a 1.2  1.1a 0.7  0.6 5.2  1.3a 7.0  1.1a 4.0  1.6a 0.0005 0.0005 0.0005

N.B.: Results presented as mean  SD. a Significant difference from baseline VAS score within each group (p < 0.05).

the non-treatment group reported a significantly greater (p Z 0.0005) increase in perceived muscle soreness than the treatment group. A similar trend existed between 24 and 48 h with both groups demonstrating significant increases in perceived muscle soreness (non-treatment p Z 0.0005; treatment group p Z 0.001). The perceived muscle soreness in the treatment group (1.2  1.1) was significantly less (p Z 0.0005) than in the non-treatment group (7.0  1.1). At 72 h the perceived muscle soreness in the treatment group had almost retuned to baseline levels (0.7  0.6) indicating an absence of any pain although the scores in the non-treatment group remained elevated (4.0  1.6) and significantly higher than baseline values (p Z 0.0005). A summary of the results is presented in Figure 4.

Discussion The aim of this investigation was to compare the effects of FSM therapy versus sham at 24, 48 and 72 h post-exercise. Allen et al. (1999) found that 20 min of single channel microcurrent therapy that was not frequency specific compared to sham treatment was not effective in reducing pain or increasing range of motion 24, 48 and 72 h after DOMS induction in the biceps muscle. Clinical evidence suggested that dual channel microcurrent using different frequency combinations was very effective in reducing the pain associated with muscle trauma and DOMS providing the motivation for conducting this study. This study was undertaken to provide a controlled trial evaluation of

Visual Analogue Scale (VAS) score

10 9

Treatment Leg Non Treatment Leg

8 7 6 5 4 3 2 1 0 Baseline

24hrs

48hrs

72hrs

Time (hrs)

Figure 4 VAS scores for TL and NTL over a period of 72 h. N.B.: Results expressed as mean  SD.

20 min of FSM therapy compared to sham treatment. It was hypothesized that FSM therapy would offer significant protection from post-exercise muscle soreness. The participants were blinded to which leg was being treated because they could not see the machine and because the current is subsensory. This reduced the possibility of a placebo effect while the treatment was been given. However it should be acknowledged that by using the participant’s opposite leg as a control, it is likely that participants could have guessed quite quickly (probably within hours of the treatment been given) which leg had been treated and which leg had not. As initial improvements in one leg may have had them guessing which leg had been treated, this would have meant that they were no longer blinded. The use of graphite gloves wrapped in wet towels as conductors was assumed to prevent the reduction in voltage seen in Petrovsky’s measurements of graphite electrodes in TENS devices (Petrofsky et al., 2006). The use of wet towels also ensures that the current will remain subsensory since graphite electrodes against dry skin may make even microamperage current sensible (Grimnes, 2008). The method selected for inducing DOMS was deemed successful, as the data collected at 24, 48 and 72 h postexercise differed significantly from the data collected at baseline. This pattern was similar to previous literature related to the time course and intensity of DOMS (Cleak and Eston, 1992; Howell et al., 1993; Nosaka and Clarkson, 1996) and suggests that the methodology was appropriate to create DOMS. The VAS was selected as a measurement for perceived pain because it is patient friendly, low cost, easy to administer and not too time consuming. However, although the VAS is a well established, valid and reliable measurement for determining the intensity of pain, the authors acknowledge the possibility that variations may have occurred in participant responses during the data collection period. As participants were required to independently perceive their soreness at four different time points over a 72 h period, it should be noted that how they perceived their pain may have altered over the 72 h, depending on how they were being affected by their pain at that specific moment. Also, individual tolerance for pain can vary greatly from person to person. Acknowledgement is also given to the possibility that reciprocal facilitation may have had an effect on the overall findings. The FSM units were set up so that the treated leg had current flowing between the positive and negative leads while the untreated leg had no current delivered as the machine on this leg was turned off. Although there is no evidence in any electrical theory or practice that suggests that the current will migrate to other areas outside the area between the two leads, because of the interconnectedness of the body there is no way of knowing what effect, if any, the FSM treatment had on the control leg. No attempt was made in the present study to control for the effects of environmental electromagnetic influences (‘‘electronic smog’’) since such influences would have had equivalent effects on both the treated and untreated leg. In future studies in which there is a sham control group being treated at another time and setting than the

278 treatment group consideration may need to be made for the possible effects of extraneous electrical interference. A possible limitation to the study was that only one marker, perceived muscle soreness, was used to assess muscle damage. Other markers such as maximal isometric strength, range of motion, angle of peak torque, leg circumference and plasma creatine kinase levels were not assessed. A suggestion for future research would be to use multiple markers as an assessment for DOMS. Future studies of FSM in DOMS or any condition may include a methodology that includes separate sham and active treatment groups and will also allow for double blinding the subjects and the experimenters. Even though the patients turned in their pain scores without any further contact with the un-blinded experimenter, the possibility of some experimental error due to lack of experimenter blinding cannot be excluded. To ensure double blinding it is suggested that future studies include a sham unit that is disabled by the manufacturer so that no electrical stimulation passes through it.

Conclusion The results of this study show that at the parameters selected for this investigation FSM therapy did provide significant protection from post-exercise muscle soreness.

Acknowledgements The authors would like to thank Bobby Fitzsimons for his help and assistance with this research project and also the students at the NTC who took part in the study. No funding of this study or incentive for publication was provided by any commercial interest.

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The efficacy of FSM therapy on DOMS Lambert, M.I., Marcus, P., Burgess, T., Noakes, T.D., 2002. Electromembrane microcurrent therapy reduces signs and symptoms of muscle damage. Medicine and Science in Sports and Exercise 34, 602e607. Lanier, A.B., 2003. Use of non-steroidal anti-inflammatory drugs following exercise-induced muscle soreness. Sports Medicine 33, 177e186. Lee, K.A., Kieckhefer, G.M., 1989. Measuring human responses using visual analogue scale. Western Journal of Nursing Research 11, 128e132. Lightfoot, J.T., Char, D., McDermott, J., Goya, C., 1997. Immediate post exercise massage does not attenuate delayed onset muscle soreness. Journal of Strength and Conditioning Research 11, 119e124. Manley, T., 1994. Microcurrent Therapy Universal Treatment Techniques and Applications. Manley and Associates, Corona, California. Mattacola, C.M., Perrin, D.H., Gansneder, B.M., Allan, J.D., Mickey, C.A., 1997. A comparison of visual analogue scale and graphic rating scales for pain and intensity following DOMS. Journal of Sport Rehabilitation 6, 38e46. McIntyre, D.L., Reid, W.D., McKenzie, D.C., 1995. Delayed muscle soreness: the inflammatory response to muscle injury and its clinical implications. Sports Medicine 20, 24e40. McHugh, M.P., Connolly, D.A.J., Eston, R.G., Gleim, G.W., 1999. Exercise-induced muscle damage and potential mechanisms for the repeated bout effect. Journal of Sports Medicine 27, 158e170. McMakin, C., Gregory, W., Philips, T., 2005. Cytokine changes with microcurrent treatment of fibromyalgia associated with cervical spine trauma. Journal of Bodywork and Movement Therapies 9, 169e176. McMakin, C., 2004. Microcurrent therapy: a novel treatment method for chronic low back myofascial pain. Journal of Bodywork and Movement Therapies 8, 143e153. McMakin, C., 1998. Microcurrent treatment of myofascial pain in the head, neck and face. Topics in Clinical Chiropractic 5, 29e35. Mercola, J.M., Kirsch, D., 1995. The basis for microcurrent electrical therapy in conventional medical practice. Journal of Advancement in Medicine 8 (2). http://therapyproducts.net Available on-line from:pages not numbered. Myles, P.S., Troedel, S., Boquest, M., Reeves, M., 1999. The pain in visual analogue scale: Is it linear or nonlinear? Anesthesia and Analgesia 89, 1517e1520. Newman, D.J., McPhail, G., Mills, K.R., Edwards, R.H., 1983a. Ultrastructural changes after concentric and eccentric contractions on human muscle. Journal of Neurological Science 61, 109e122. Newman, D.J., Mills, K.R., Quigley, B.M., Edwards, R.H.T., 1983b. Pain and fatigue after concentric and eccentric contractions. Journal of Clinical Science 64, 55e62.

279 Nosaka, K., Clarkson, P.M., 1995. Muscle damage following repeated bouts of high force eccentric exercise. Medicine and Science in Sports and Exercise 27, 1263e1269. Nosaka, K., Clarkson, P.M., 1996. Changes in indicators of inflammation after eccentric exercise of the elbow flexors. Medicine and Science in Sports and Exercise 28, 953e961. O’Grady, M., Hackney, A.C., Schneider, K., Bossen, E., Steinberg, K., Douglas, J.M., Murray, W.J., Watkins, W.D., 2000. Diclofenac sodium (voltaren) reduced exercise-induced injury skeletal muscle. Medicine and Science in Sports and Exercise 32, 1191e1196. Oschman, J., 2000. Energy Medicine, The Scientific Basis. Churchill Livingston, Edinburgh. Petrofsky, J., Schwab, E., Cuneo, M., George, J., Kim, J., Almalty, A., Lawson, D., Johnson, E., Remigo, W., 2006. Current distribution under electrodes in relation to stimulation current and blood flow: are modern electrodes really providing the current distribution during stimulation we believe they are? Journal of Medical Engineering and Technology 30, 368e381. Proske, U., Weerakkody, N.S., Percival, P., Morgan, D.L., Gregory, J.E., Canny, B.J., 2003. Force-matching errors after eccentric exercise attributed to muscle soreness. Clinical and Experimental Pharmacology and Physiology 30, 576e579. Rowley, B.A., McKenna, J.M., Wollcott, L.E., 1974. The use of low level electric current for the enhancement of tissue healing. Biomedical Scientific Instrumentation 10, 111e114. Sayers, S.P., Knight, C.A., Clarkson, P.M., van Wegan, E.H., Kamen, G., 2001. Effects of ketoprofen on muscle function and sEMG after eccentric exercise. Medicine and Science in Sports and Exercise 33, 702e710. Sellwood, K.L., Brukner, P., Williams, D., Nicol, A., Hinman, R., 2007. Ice-water immersion and delayed-onset muscle soreness: a randomized controlled trial. British Journal of Sports Medicine 41, 392e397. Stauber, W.T., Clarkson, P.M., Fritz, V.K., Evans, W.J., 1990. Extracellular matrix disruption and pain after eccentric muscle action. Journal of Applied Physiology 69, 868e874. Taleg, T.S., 1973. Residual muscular soreness as influenced by concentric, eccentric and static contractions. Research Quarterly 44, 458e469. Tiidus, P.M., Shoemaker, J.K., 1995. Effleurage massage, muscle blood flow and long-term post-exercise strength recovery. International Journal of Sports Medicine 16, 478e483. Warren, G.L., Jenkins, R.R., Packer, L., Witt, E.H., Armstrong, 1992. Elevated muscle vitamin E does not attenuate eccentric exercise-induced muscle injury. Journal of Applied Physiology 72, 2168e2175. Wilmore, J.H., Costill, D.C., 2004. Physiology of Sport and Exercise, second ed. Human Kinetics, Leeds. Yamaguichi, T., Ishii, K., 2005. Effects of static stretching for 30 seconds and dynamic stretching on leg extension power. Journal of Strength and Conditioning Research 19, 677e683.

Journal of Bodywork & Movement Therapies (2010) 14, 280e286

available at www.sciencedirect.com

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INVITED REVIEW

The biomechanics of spinal manipulation Walter Herzog, PhD* Faculty of Kinesiology, University of Calgary, Calgary, AB T2N 1N4, Canada Received 30 November 2009; received in revised form 19 March 2010; accepted 29 March 2010

KEYWORDS Spinal biomechanics; Chiropractic; Manipulative therapy; Vertebral artery; Stroke; Internal forces

Summary Biomechanics is the science that deals with the external and internal forces acting on biological systems and the effects produced by these forces. Here, we describe the forces exerted by chiropractors on patients during high-speed, low-amplitude manipulations of the spine and the physiological responses produced by the treatments. The external forces were found to vary greatly among clinicians and locations of treatment on the spine. Spinal manipulative treatments produced reflex responses far from the treatment site, caused movements of vertebral bodies in the “para-physiological” zone, and were associated with cavitation of facet joints. Stresses and strains on the vertebral artery during chiropractic spinal manipulation of the neck were always much smaller than those produced during passive range of motion testing and diagnostic procedures. ª 2010 Elsevier Ltd. All rights reserved.

Introduction Chiropractic spinal manipulations are mechanical events. Clinicians exert a force of specific magnitude in a controlled direction to a target site, typically on the spine. High-velocity, low-amplitude (HVLA) manipulations are more frequently used by chiropractors than other treatment modalities, and they are of special interest, as force magnitudes and the rates of force application are high. HVLA treatments cause deformations of the spine and surrounding soft tissues and often elicit a cracking sound that has been identified as cavitation of spinal facet joints (Cascioli et al., 2003; Conway et al., 1993; Haas, 1990;

* Tel.: þ1 403 220 8525; fax: þ1 403 220 2070. E-mail address: [email protected]

Herzog et al., 1993c; Meal and Scott, 1986; Miereau et al., 1988; Reggars, 1996). Despite the acknowledged nature of mechanical force application as a treatment modality (Triano, 2000), and the accepted idea that HVLA treatments produce mechanical effects (e.g., Triano and Schultz, 1997) at the treatment site, little is known about the biomechanics of spinal manipulation. Biomechanics is the science that deals with the external and internal forces acting on biological systems and the associated effects produced by these forces. Here, I will attempt to briefly review what is known about the external forces applied by chiropractors during HVLA manipulative treatments on patients, discuss selected effects of these forces, and then focus specifically on an increasingly important topic of internal force transmission: the stresses and strains experienced by the vertebral artery during HVLA neck manipulations.

1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.03.004

The biomechanics of spinal manipulation

External forces applied by chiropractors during HVLA spinal manipulations Wood and Adams (1984) and Adams and Wood (1984) were the first to quantify the forces exerted by chiropractors during spinal manipulation. Their work involved application of a HVLA manipulative thrust to a treatment dummy. Although a classic piece, the limitation of their work was that treatments were not performed on human subjects, thereby bringing into question the validity of the results for a clinical setting. Hessel et al. (1990) were the first to directly measure the forces applied by chiropractors on human subjects for a variety of different treatment modalities. They used a thin, flexible pressure pad that was placed under the thrusting hand of the clinician to measure the forces applied to the target site on patients. This pioneering work was followed by a series of similar studies, all aimed at obtaining information on the force-time histories of HVLA spinal manipulations (Conway et al., 1993; Herzog et al., 1993a,b; Kawchuk et al., 1992; Kawchuk and Herzog, 1993; Triano and Schultz, 1997; Triano, 2000; Triano and Schultz, 1990). When combining the results of selected force parameters during HSLA treatments, the following results emerged: Peak and Preload forces (Figure 1) varied dramatically depending on the location of treatment application (Herzog et al., 1993a). Peak forces for neck manipulations (on average about 100N) were substantially smaller than the peak forces applied during thoracic and lumbar spine and sacroiliac joint treatments ((all about 400N (Table 1)). Furthermore, the treatment forces varied dramatically between clinicians, and in our laboratory we have measured peak forces ranging from 200N to 1600N (Herzog et al., 1993a), which is an eightfold difference. Figure 2 shows a random sample of ten female and ten male chiropractors performing treatments on a small number of subjects (Forand et al., 2004). Interestingly, the average forces between males and females are about the same ((Forand et al., 2004) (Figure 3)), and so are the average forces between novice and experienced chiropractors (results not shown). From these direct measurements of the external forces applied by clinicians on patients, the following conclusions seem warranted: 1. The external forces applied during HVLA treatments vary dramatically depending on the treatment site Peak force Δf Preload force

Preload phase

Thrust phase time, Δt

Resolution phase

Figure 1 Definitions for the preload force, peak force and thrust time.

281 2. The external forces applied during HVLA treatments vary dramatically across clinicians These results suggest that local mechanical conditions might affect the amount of force applied by clinicians. For example, all clinicians apply substantially less force for treatments of the cervical spine compared to the thoracic spine (Herzog et al., 1993a). The reasons for this observation are not clear, although it makes intuitive sense that a relatively mobile part of the spine (cervical spine) would be treated differently than a relatively stiff segment of the spine (thoracic spine). The amount of force applied to patients by a given chiropractor varies dramatically as indicated above (Conway et al., 1993; Herzog, 1991; Herzog et al., 1993a,b; Kawchuk et al., 1992; Triano, 2000). Clinicians, who tend to adjust with great force, do so consistently and clinicians who use little force do so consistently as well. Some “soft” adjusting clinicians will not even reach the preload forces of some of the “hard” adjusting clinicians, thus it is questionable whether force magnitude is an important variable in the application of a HVLA chiropractic treatment. The thrust times (Figure 1) were approximately 100 ms for cervical and 150 ms for thoracic and lumbar spine treatments. Since the peak force magnitudes vary substantially and thrust times are similar across practitioners, it follows that the rate of force application varies substantially too (Table 1), and thus is likely not a relevant factor for the success of a chiropractic treatment. In the absence of consistent force-time histories for chiropractic manipulations, one may conclude that the detailed force magnitude might not be an important characteristic for the success of a treatment, while the thrust direction might be. Unfortunately, thrust force directions have not been studied systematically, thus this proposition must be considered a hypothesis at present.

Selected effects of HVLA spinal manipulative treatments There are many scientific and clinical publications advertising the efficacy of HVLA spinal manipulation. However, the number of publications investigating mechanical, physiological or neurological effects produced by such treatments is small, and a direct link between the treatment forces, the effects produced by these forces, and the beneficial effects created are almost completely missing. Here, I would like to discuss just some selected effects of HSLA treatments that have been debated intensely. Relative movements of the target segment in the paraphysiological zone One of the premises of HVLA spinal manipulative treatments has been that the target joint (typically a spinal facet joint) is brought to its end range of motion by the application of a directed and well described preload force ((Triano, 2000) (Figure 1)). Following application of the preload force, a force thrust is given that represents the actual treatment, and the idea has been that this thrust force takes the (facet) joint beyond its regular end range of motion into the para-physiological movement zone. Of course, when applying a thrust, every clinician can feel the

282

W. Herzog

Table 1

Preload forces (N) Peak forces (N) Thrust times (ms) Rate of force application (n/s)

Cervical spine

Thoracic spine

Sacroiliac joint

Activator instrument

27 107 81 1321

139 399 150 2660

88 323

22 41 32 1281

Force [N]

Forces on T4 by men

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Figure 2 Force-time histories of thoracic spinal manipulations performed by 10 male (left) and 10 female (right) chiropractors. Note the vast difference in force between clinicians.

deformation of the spine under the thrusting hand, however, it was not possible to decide if part of this movement arose from the target joint, or if the entire deformation was caused by joints neighbouring the target joint that were not brought to the end range of motion by preload force application. In order to study this question in detail, we inserted bone pins into three adjacent vertebral bodies of the thoracic spine in human cadavers, and then calculated the relative movements of the vertebral bodies during the preload and the thrust phase of HVLA anterior to posterior thrusts to the transverse process of a thoracic vertebra (Ga ´l et al., 1994, 1997a,b). There was substantial relative movement of the target and adjacent vertebrae during the preload phase, and there was further relative movement of target and adjacent vertebrae during the thrust phase of the manipulative treatment (Figure 4). This result illustrates that there is movement of the target (facet) joint during thrust application beyond the movement achieved by the preload force (Ga ´l et al., 1994, 1997a,b).

Reflex responses associated with HVLA spinal manipulative treatments Spinal manipulative treatments, although aimed primarily at restoring joint (including facet joint) mobility and function, had been thought to produce reflex responses in the muscles underlying the treatment area. In order to test this hypothesis, we measured the surface electromyogram (EMG) of back muscles at the treatment site. Typically, EMG activity was measured within 200e400 ms following the onset of the treatment thrust (Herzog et al., 1995). Muscle activity disappeared following the treatment thrust, and was not observed during preload application, suggesting that this was indeed a reflex response, and that the reflex response was associated with the speed of force application (Figure 5).

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Figure 3 Mean force-time histories of thoracic spinal manipulations across 10 male (dashed line) and 10 female (solid line) chiropractors.

Figure 4 Posterier-Anterior translation and sagittal rotation of thoracic vertebrae T10 and T11 during the thrust phase of a thoracic spinal manipulation. Note the approximate 2 degree difference in sagittal rotation during the treatment thrust indicating vertebral movement in the “paraphysiological” zone.

The biomechanics of spinal manipulation

Figure 5 Force-time and EMG-time histories measured during a thoracic spinal manipulation. Note the delayed onset of the EMG response suggesting a reflex activation of the muscles caused by the treatment thrust.

When applying a very short and precisely focused treatment force (using an activator instrument), a reflex response was elicited that had the visual shape of a single motor unit action potential. Furthermore, its delay from the onset of force application (50e100 ms) was such that it was suggested to be a muscle spindle reflex pathway (Herzog et al., 1995). Reflex responses produced by activator application were always restricted to the vicinity of treatment application. For HVLA spinal manipulations, the reflex responses were not restricted to the immediate treatment area, but formed characteristic activation patterns that depended on the site of force application ((Herzog et al., 1995, 1999) (Figure 6)). Finally, patients presenting with spastic muscles showed EMG activity in the muscles of the treatment area. When subjected to a HVLA treatment thrust, the muscles relaxed and EMG activity was abolished in some but not all of the patients (Herzog, 2000) (Figure 7). It is not known why treatments produced a relief of muscle spasticity in some patients but not in others. We conclude from these observations that HVLA spinal

283

Figure 7 EMG-time history for patient with spastic activation of the back musculature. The arrow indicates the time of the treatment thrust. Note the release of spasticity and EMG activation following the treatment thrust.

manipulative treatments elicit a reflex response that is not necessarily localized, and affects locations that are remote from the actual treatment site. Role of the audible release The audible release, or cracking sound, is an indicator of a successful treatment for many chiropractors, so much so, that when an audible release does not occur, many clinicians will immediately apply a second or even third treatment thrust. The role of the audible release has been a matter of intense debate (Brodeur, 1995; Sandoz, 1969) and one of the roles associated with the audible release has been the idea that it causes the reflex responses discussed above. However, there are a variety of observations that do not fit that idea. For example, every HVLA treatment thrust we have recorded was associated with an electromyographical response, but not all of these caused cavitation (Conway et al., 1993). That is, reflex responses were observed in the absence of cavitation. However, in order to address this question directly, we asked chiropractors to apply treatment forces at the exact location and exact direction as they would for a normal manipulative thrust,

Figure 6 EMG-time histories of 16 channels collected before and after spinal manipulation (left). The vertical line indicates the time of onset of the treatment thrust. Note the reflex activations elicited by the thrust for various EMG channels. Approximate placements of the EMG electrodes (open circles) and area of reflex response (enclosed areas 100% response, 80% response and 50% response for smallest, middle and largest area, respectively) for treatments of the left (left) and right (right) sacroiliac joint (filled circle).

284

W. Herzog Distance [mm] 15.5 neutral head position

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Figure 8 Stretch-shortening time history for a vertebral artery segment during neck flexion.

but to do so very slowly. With a slow force application, an audible release can be elicited, but this release is not associated with a corresponding EMG response (Conway et al., 1987), suggesting that the audible release is not responsible for the observed reflex responses during HVLA chiropractic spinal manipulations.

Internal stresses and strains during HSLA manipulative treatments of the cervical spine One major issue with the use of HVLA spinal manipulation is its safety, especially with respect to neck manipulation and the risk of stroke. Estimates of the risk of stroke vary from 1:5000 to 1:10 million (Cote et al., 1996; Frisoni and Anzola, 1991; Haldeman et al., 1999, 2002; Hurwitz et al., 1996; Lee et al., 1995). Although the proposed risk is extremely small, the serious and irreversible nature of vascular accidents makes this an important issue (Terrett and Kleynhans, 1980). The earliest documented reports of fatal vascular accidents following spinal manipulation can be traced back to the 1930s (Foster vs Thornton, 1934), and 1940s (PrattThomas and Beyer, 1947). The majority of these cases

Figure 10 Mean force-time histories of spinal manipulations of the neck averaged across 15 patients (normal) and 15 measurements from cadaveric specimens (cadaver). Note the force-time histories are virtually identical suggesting thrust treatment forces given to patients and in our cadaver work are very similar.

have involved the vertebrobasilar system, specifically the cephalad/distal loop of the vertebral artery, as it exits the foramen transversarium of C1 (Haldeman et al., 1999). Because of the unique configuration of the vertebral artery, it has been suggested that it experiences considerable stretch and associated tissue stress during extension and rotation of the neck which may lead to occlusion and damage to the arterial walls (Terrett and Kleynhans, 1980). Consequently, it has been hypothesized that HVLA spinal manipulation may also lead to stretch-induced vertebral artery damage, although our biomechanical evidence does not support this view (Herzog and Symons, 2002; Symons et al., 2002). Measurements of internal stresses of soft tissues caused by spinal manipulation are rare, and the only documented reports of such measurements on the vertebral artery are those by Herzog and Symons (2002), and

Length [mm] C2/C3 17 16

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Figure 9 Stretch-shortening time history for a vertebral artery segment during a neck manipulative treatment. The onset and end of the thrust phase of the treatment is indicated by the arrows.

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Figure 11 Stretch-shortening-time history for vertebral artery segments C2/C3 (top) and C3/C4 (bottom) for a rotational range of motion test. Note that the two segments show opposite behaviour: C2/C3 is stretched during neck rotation (as one would expect based on the anatomy) while segment C3/C4 shortens.

The biomechanics of spinal manipulation

285

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Figure 12 Stretch-shortening-time history for vertebral artery segments C2/C3 (top) and C3/C4 (bottom) for a chiropractic neck manipulation. Note that the two segments show opposite behaviour: C2/C3 is stretched during neck rotation (as one would expect based on the anatomy) while segment C3/C4 shortens.

Symons et al. (2002). In these studies, the strains of the vertebral artery were measured from the neutral length (head and neck in the neutral position) for a variety of range of motion and diagnostic testing, as well as for different HVLA cervical spine manipulations across all levels performed ipsi- and contralaterally to the target vertebral artery (Figures 8 and 9). They then excised the vertebral arteries carefully from the cadaveric specimens used for these studies and measured the corresponding forces experienced by the vertebral arteries for the strains (elongations) measured during the diagnostic and clinical procedures. Symons et al. (2002) and Herzog and Symons (2002) found that stretches to the vertebral artery during neck manipulative procedures (6% for the cephalad/distal segment) were much smaller than the stretches produced during range of motion and diagnostic testing (13%). They also found that the elongations produced during HVLA spinal manipulations did not produce any tensile forces in the vertebral artery, suggesting that the vertebral arteries were slack when the head and neck were in the neutral position and that this slack was not fully taken up during spinal manipulative treatments. Therefore, spinal manipulation did not cause any tensile stress in the vertebral arteries during the treatment procedures. However, the studies by Symons et al. (2002) and Herzog and Symons (2002) had several limitations. Most importantly, measurements were only made for two segments (cephalad to C1 and caudad to C6), forces during the spinal manipulations were not measured and the vertebral arteries of the unembalmed cadavers were devoid of fluid, thus possibly affecting their shape. In order to overcome these limitations, we performed a pilot study to measure the strains in the vertebral artery segments C1eC6 with the arteries filled with gel and while measuring the forces applied by two chiropractors during all diagnostic and treatment procedures. The

forces applied by the chiropractors during spinal manipulations were similar to those administered to patients, thus we may assume that the external mechanics were similar (Figure 10). The peak strain (elongation form neutral) that was measured for any of the 176 treatments procedures was 2.1% while strains for diagnostic procedures were in excess of 10% (flexion 10.1%, rotation 13.0% and Houle’s test 9.4%), suggesting, in agreement with our previous studies, that strains during HVLA cervical spinal manipulations were much smaller than those produced during diagnostic procedures. In contrast to our previous work, however, the strains measured in adjacent vertebral artery segments were not always intuitively apparent. For example, we found the repeatable (across multiple measurements and across clinicians) result that for some diagnostic and treatment procedures, one vertebral artery segment shortened while the adjacent segment was stretched. For example, in Figure 11, we show the right vertebral artery segments C2/C3 and C3/C4 for a left rotation of the neck. Textbook anatomical considerations would suggest that the vertebral artery segments should be stretched, which was observed for the C2/C3 segment, but not the C3/C4 segment which shortened consistently for both chiropractors and for all three repeat measurements. Similarly, these same segments behaved opposite during a HVLA neck manipulation (Figure 12). Again, this result was observed for all three repeat measurements of and both clinicians. Combined, the results of this study suggest that spinal manipulative treatments produce stretches of the vertebral artery that are much smaller than those that are produced during normal everyday movements, and thus they appear harmless. However, textbook anatomical considerations do not necessarily allow prediction of the direction of strain in different vertebral artery segments. Some non-intuitive behaviour was observed that cannot be explained at present but might be related to the intricate coupled motions of vertebral bodies and the complex fixation of the vertebral artery to the transverse foramen of C1eC6. In summary, there is little knowledge of the transmission of stresses and strains across hard and soft tissues during spinal manipulation. This is a vast field of investigation that needs careful attention so that the detailed mechanics of HVLA treatments can be understood and possible risks of these procedures may be identified.

Acknowledgements The Canadian Chiropractic Research Foundation, Canadian Chiropractic Protective Association, The Alberta College and Association of Chiropractors.

References Adams, A.H., Wood, J., 1984. Comparison of forces used in selected adjustments of the low back: A preliminary study. Res. Forum 1, 5e9. Brodeur, R., 1995. The audible release associated with joint manipulation. Journal of Manipulative and Physiological Therapeutics 18, 155e164.

286 Cascioli, V., Corr, P., Till Ag, A.G., 2003. An investigation into the production of intra-articular gas bubbles and increase in joint space in the zygapophyseal joints of the cervical spine in asymptomatic subjects after spinal manipulation. Journal of Manipulative and Physiological Therapeutics 26 (6), 356e364. Conway, B.A., Hultborn, H., Kiehn, O., 1987. Proprioceptive input resets central locomotor rhythm in the spinal cat. Exp. Brain Res. 68 (3), 643e656. Conway, P.J.W., Herzog, W., Zhang, Y., Hasler, E.M., Ladly, K., 1993. Forces required to cause cavitation during spinal manipulation of the thoracic spine. Clinical Biomechanics 8, 210e214. Cote, P., Kreitz, B.G., Cassidy, J.D., Thiel, H., 1996. The validity of the extension-rotation test as a clinical screening procedure before neck manipulation: a secondary analysis. J.Manipulative Physiol Ther 19 (3), 159e164. Forand, D., Drover, J., Suleman, Z., Symons, B., Herzog, W., 2004. The forces applied by female and male chiropractors during thoracic spinal manipulation. Journal of Manipulative and Physiological Therapeutics 27, 49e56. Foster vs Thornton, 1934. Medicolegal abstract. Malpractice: death resulting from chiropractic treatment for headache. Journal of American Medical Association 103, 1260. Frisoni, G.B., Anzola, G.P., 1991. Vertebrobasilar ischemia after neck motion. Stroke 22 (11), 1452e1460. Ga ´l, J., Herzog, W., Kawchuk, G., Conway, P.J.W., Zhang, Y., 1997a. Movements of Vertebrae during manipulative thrusts to unembalmed human cadavers. Journal of Manipulative and Physiological Therapeutics 20, 30e40. Ga ´l, J., Herzog, W., Kawchuk, G., Conway, P.J.W., Zhang, Y.T., 1994. Biomechanical studies of spinal manipulative therapy (SMT): Quantifying the movements of vertebral bodies during SMT. The Journal of the CCA 38, 11e24. Ga ´l, J., Herzog, W., Kawchuk, G., Conway, P.J.W., Zhang, Y.T., 1997b. Measurements of vertebral translations using bone pins, surface markers and accelerometers. Clinical Biomechanics 12 (5), 337e340. Haas, M., 1990. The physics of spinal manipulation. Part IV. A theoretical consideration of the physician impact force and energy requirements needed to produce synovial joint cavitation. Journal of Manipulative and Physiological Therapeutics 13, 378e383. Haldeman, S., Kohlbeck, D.C., McGregor, M., 2002. Unpredictability of Cerebrovascular Ischemia Associated With Cervical Spine Manipulation Therapy. Spine 27 (1), 49e55. Haldeman, S., Kohlbeck, F.J., McGregor, M., 1999. Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine 24 (8), 785e794. Herzog, W., 1991. Biomechanical studies of spinal manipulative therapy. The Journal of the CCA 35, 156e164. Herzog, W. 2000, Clinical Biomechanics of Spinal Manipulation Churchill Livingstone, Philadelphia. Herzog, W., Conway, P.J.W., Kawchuk, G.N., Zhang, Y., Hasler, E. M., 1993a. Forces exerted during spinal manipulative therapy. Spine 18, 1206e1212. Herzog, W., Conway, P.J.W., Zhang, Y.T., Ga ´l, J., Guimaraes, A.C. S., 1995. Reflex responses associated with manipulative treatments on the thoracic spine. Journal of Manipulative and Physiological Therapeutics 18, 233e236. Herzog, W., Kawchuk, G.N., Conway, P.J.W., 1993b. Relationship between preload and peak forces during spinal manipulative treatments. Journal of the Neuromusculoskeletal System 1 (2), 52e58.

W. Herzog Herzog, W., Scheele, D., Conway, P.J.W., 1999. Electromyographic responses of back and limb muscles associated with spinal manipulative therapy. Spine 24 (2), 146e152. Herzog, W., Symons, B., 2002. The mechanics of neck manipulation with special consideration of the vertebral artery. Journal of the Canadian Chiropractic Association 46 (3), 134e136. Herzog, W., Zhang, Y.T., Conway, P.J.W., Kawchuk, G.N., 1993c. Cavitation sounds during spinal manipulative treatments. Journal of Manipulative and Physiological Therapeutics 16, 523e526. Hessel, B.W., Herzog, W., Conway, P.J.W., McEwen, M.C., 1990. Experimental measurement of the force exerted during spinal manipulation using the Thompson technique. Journal of Manipulative and Physiological Therapeutics 13, 448e453. Hurwitz, E.L., Aker, P.D., Adams, A.H., Meeker, W.C., Shekelle, P., 1996. Manipulation and mobilization of the cervical spine. A systematic review of the literature. Spine 21, 1746e1759. Kawchuk, G.N., Herzog, W., 1993. Biomechanical characterization (fingerprinting) of five novel methods of cervical spinal manipulation. Journal of Manipulative and Physiological Therapeutics 16 (9), 573e577. Kawchuk, G.N., Herzog, W., Hasler, E.M., 1992. Forces generated during spinal manipulative therapy of the cervical spine: A pilot study. Journal of Manipulative and Physiological Therapeutics 15, 275e278. Lee, K.P., Carlini, W.G., McCormick, G.F., Albers, G.W., 1995. Neurologic complications following chiropractic manipulation: a survey of California neurologists. Neurology 45 (6), 1213e1215. Meal, G.M., Scott, R.A., 1986. Analysis of the joint crack by simultaneous recording of sound and tension. Journal of Manipulative and Physiological Therapeutics 9 (3), 189e195. Miereau, D., Cassidy, J.D., Bowen, V., Dupuis, P., Noftall, F., 1988. Manipulation and mobilization of the third metacarpophalangeal joint. Manual Med. 3, 135e150. Pratt-Thomas, H.R., Beyer, K.E., 1947. Cerebellar and spinal injuries after chiropractic manipulation. Journal of American Medical Association 133, 600e603. Reggars, J.W., 1996. Recording techniques and analysis of the articular crack. Australasian Chiropractic and Osteopathy 5 (3), 86e92. Sandoz, R., 1969. The significance of the manipulative crack and of other articular noises. Ann. Swiss Chiro.Assoc. 4, 47e68. Symons, B., Leonard, T.R., Herzog, W., 2002. Internal forces sustained by the vertebral artery during spinal manipulative therapy. Journal of Manipulative and Physiological Therapeutics 25, 504e510. Terrett, A.G.J., Kleynhans, A.M., 1980. Cerebrovascular complications of manipulation. In: Haldeman, S. (Ed.), in Principles and Practice of Chiropractic, second edn. Appleton & Lange, Connecticut, pp. 579e598. Triano, J., Schultz, A.B., 1997. Loads transmitted during lumbosacral spinal manipulative therapy. Spine 22, 1955e1964. Triano, J.J., 2000. The mechanics of spinal manipulation in Clinical Biomechanics of Spinal Manipulation. In: Herzog, W. (Ed.). Churchill-Livingstone, Philadelphia, PA, pp. 92e190. Triano, J.J., Schultz, A.B., 1990. Cervical spine manipulation: applied loads, motions and myoelectric responses. Proc.14th Mtg.Amer.Soc.Biomech. 14, 187e188. Wood, J., Adams, A.H., 1984. Forces used in selected chiropractic adjustments of the low back: A preliminary study. The Research Forum,. Palmer College of Chiropractic 1, 16e23.

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BOOK REVIEW Frank C, Lardner R, Page P. The assessment and treatment of muscular imbalance e The Janda Approach Hardback $64, Human Kinetics, Champlain, IL USA, ISBN-13:9780736074001

Vladimir Janda, MD, DSc (1923e2002) influenced generations of practitioners spanning many disciplines. This evidence-based book is written by three physical therapists, all of whom worked with Janda. It emphasizes various assessment and treatment procedures based on the existence of muscle imbalance e the combination of abnormal muscle inhibition (‘‘weakness’’) and hypertonic muscles (tightness). This would make a useful addition to every clinician’s library e especially physical therapists, chiropractors, osteopaths and all those using hands-on therapies. The book is divided into four parts: - The Scientific Basis of Muscle Imbalance includes chapters on the structural and functional approaches to muscle imbalance, and the ‘‘pathomechanics’’ of pain. - Functional Evaluation of Muscle Imbalance discusses posture, gait, muscle length testing and soft tissue assessment. - Treatment of Muscle Imbalance Syndromes describes the restoration of muscle balance and sensorimotor training. - Clinical Syndromes presents four common areas of musculoskeletal pain disorders: cervical, upper extremity, lumbar and lower extremity. Like many pioneers, Janda’s terminology and ideas evolved apart from the traditional clinical sciences. The author’s state: ‘‘There are several schools of thought regarding muscle imbalance. Each approach uses a different paradigm as its basis. Vladimir Janda’s paradigm was based on his background as a neurologist and physiotherapist.’’ The Janda Approach provides more than an introduction of his material for practitioners and students. In the preface the author’s state: ‘‘We wanted to write a text that both preserves and supports Janda’s teaching. This book is only a tool for everyday practitioners; it is not meant to address all chronic pain syndromes or even all muscle imbalance syndromes. Instead, we wanted to provide practical, relevant, and evidence-based information

doi:10.1016/j.jbmt.2009.11.003

arranged into a systematic approach that could be implemented immediately and used along with other clinical techniques.’’ An important concept presented well is the interplay between injuries and muscle imbalance. Janda’s ‘‘muscle imbalance continuum’’ describes tissue damage, pain and altered gait as potential causes of imbalance, while emphasizing that the reverse can also exist. The book’s wide range of topics associated with neuromuscular function is as impressive as the therapeutic options offered e from acupuncture and trigger point therapy to the works of Florence and Henry Kendall, and George Goodheart. All the topics are well researched with 40 pages of references. Janda’s view of muscle imbalance is presented well e the combination of tight/short muscles and weak ones, mediated by the central nervous system with important stimuli from the peripheral nervous system (in particular, proprioception from joints). While the book references Sherrington, Janda often deviated in his approach by treating the tightness as the primary muscle problem rather than the weakness. The book’s side-by-side comparison is made between Janda’s clinical approach to muscle imbalance and that of physical therapist Dr. Shirley Sahrmann. However, to help address the common debate among clinicians regarding which side of muscle imbalance is primary, it might have been useful to also present the different perspectives adopted by physical therapist Diane Damiano (Damiano et al., 1995; Wiley and Damiano, 1998) or George Goodheart DC (Walther, 2000; Goodheart, 1964) whose clinical work focused mainly on muscle weakness. The interpretation of Sherrington’s law of reciprocal inhibition appears to be the difference. The Janda Approach does recommend using muscle testing in certain cases, and suggests, at times, treating the weakness side of muscle imbalance. The Janda Approach describes a full spectrum of muscle imbalance e from relatively common problems associated with aches and pains, including chronic low back syndrome, to the more serious mechanical distortions in brain and spinal cord injured patients. An important tenet is worded well by the authors: ‘‘[Janda] based his approach on his observations that patients with chronic low back pain exhibit the same patterns of muscle tightness and weakness that patients with upper motor neuron lesions such as cerebral palsy exhibit, albeit to a much smaller degree.’’

288 Janda believed that 80% of patient’s with low back pain could be shown to have minimal brain dysfunction. In our symptom-oriented healthcare world, it was refreshing to read Janda’s philosophy that the source of pain is rarely the cause. The book dedicates a chapter to this concept of interactions between the skeleton, muscles and nervous system, and the process of cause and effect. While the authors describe Janda’s many clinical models, clinicians are well aware that patients typically deviate from these patterns, creating their own unique neuromuscular patterns. Like many chapters, the one on posture, balance and gait is excellent. However, despite writing his first book on muscle testing, The Janda Approach describes only a few manual muscle tests, instead relying more on posture, gait, muscle length assessment and basic movement patterns to evaluate muscle imbalance. Because Janda felt that manual therapy was not sufficient by itself to successfully treat the neuromuscular system, the authors discuss his sensorimotor training as an important aspect of patient care. Rather than traditional strength training, Janda used sensorimotor training to promote whole-body neuromuscular activity with emphasis on incorporating certain areas of the brain. These include gently increasing proprioception from the sole of the foot, deep cervical musculature and the sacroiliac joint, as well as vestibular balance training. These physical activities

Book Review help activate/retrain the motor system, improve postural control and optimize gait. The last part of the book contains four chapters, each representing a common clinical syndrome by region: cervical, upper extremity, lumbar and lower extremity. Case histories offer good examples, but they don’t replace an effective assessment and the potential for a wide variety of therapeutic options e many of these are offered by The Janda Approach. Despite this reviewer’s many years of study of Janda’s work, this book provided much new information and ideas, largely because the authors present the material so well. Dr. Maffetone can be reached through his website (www. PhilMaffetone.com): [email protected]

References Damiano, D., Kelly, L., Vaughan, C., 1995. Effects of quadriceps femoris muscle strengthening on crouch gait in children with spastic diplegia. Phys Ther 75, 658e671. Goodheart Jr. G, 1964. Applied Kinesiology. Detroit: Privately Published. Walther, D., 2000. Applied Kinesiology Synopsis, second ed. Systems DC, Pueblo, CO. Wiley, M., Damiano, D., 1998. Lower-extremity strength profiles in spastic cerebral palsy. Dev Med Child Neurol 40, 100e107.

Philip Maffetone

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PREVENTION & REHABILITATION: EDITORIAL

Warrick McNeill, MCSP, Associate Editor* United Kingdom

What is prevention? About 4500 years ago, according to Chinese tradition, and Fletcher (1988), the Yellow Emperor, Huang-di, only paid his physician’s retainer when he was well and stopped paying when he was not. ‘The wise people (the sages) did not treat those who were already ill; they instructed those who were not yet ill.’ Preventative measures (nourishment, rest, exercise and sleep) consisted of 4 of the 5 modes of treatment espoused at that time. Serge Gracovetsky, reports in an interview published on YouTube, that he once, while suffering back pain, went to see seven different Orthopaedic or Neuro Surgeons but received seven different diagnoses. Gracovetsky appears to have applied a similar principle and didn’t pay any of them to proceed with their suggested treatments. Four recommended surgery, three did not. He decided that the best course of action was to do nothing, but go to the Library to find out what he could about back pain. Have we then come very far in the intervening four millennia? On the safetylit.org website, an online source of injury prevention literature, they state: ‘Injuries have causes e they don’t simply befall us from fate or bad luck. To prevent injuries it is necessary to have information about the factors that contribute to their occurrence. With this information we may understand the options for prevention. Effective injury prevention requires a multifaceted, multidisciplinary approach.’ It is also a very broad remit. Too broad perhaps? Health and Safety Directives seem to be impinging on society and the workplace. Enough so as to encourage the UK’s Health and Safety Executive to produce ‘Myth of the Month’ posters debunking ‘Great health and safety myths.’ November 2009s

* Tel.: þ44 7973 122996. E-mail address: [email protected]

poster points out that it is a myth that Health and Safety rules stop classroom experiments. The cartoon shows a rather sad teacher and pupils wearing safety goggles watching paint dry on a card propped up in a safety-glass cabinet. As a Physiotherapist I use the UK Health and Safety Regulations on Display Screen Equipment (1992) (based on the relevant EC directives) in the part of my practice which involves ergonomically assessing staff at their computer workstation, but even then, I’m a second tier external consultant e only brought in when the staff member is already reporting pain, and has usually already been seen by the in-house assessors. Is my role ‘preventative’? Prevention, as a concept of health management, appears to be wasted on the young. The hubris and indestructibility of youth becomes more glaring as one ages and becomes more risk adverse. The young appear not to listen to sound advice, they do not appear to learn by others mistakes rather they seem to want to sustain the injury to discover that they need to avoid injuring themselves in the first place. Being an Injury Prevention specialist working with the young might not possibly score highly on a job satisfaction questionnaire, but how much ‘prevention’ work actually occurs prior to first episode injuries? When my Physiotherapy colleagues discuss prevention it is usually about preventing recurrence of the injury, so it is after the fact of the original insult, and becomes part of rehabilitation. Mark Ford, a Pilates/Gyrotonic/Franklin Method instructor in Australia says, ‘To me rehabilitation and prevention can not be separated. Rehab is not complete if the client doesn’t understand causes, actions and consequences.’ (Ford, 2010). Chaitow (2010) says eloquently in a personal communication, ‘I work with a model in which dysfunction emerges from a background of failed adaptation (to overuse, misuse, abuse and disuse). In such a model prevention is seen to involve modifying or eliminating those stressors that can be

1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.04.001

PREVENTION & REHABILITATIONdEDITOR: WARRICK MCNEILL

About prevention

290

PREVENTION & REHABILITATIONdEDITOR: WARRICK MCNEILL

identified e so reducing adaptation demands bodywide, or locally. In addition, prevention entails enhancing functionality (bodywide and/or locally) so enabling the system or area to better cope with adaptation demands. Rehabilitation of existing dysfunction involves a similar model of care e with specifically focussed interventions and strategies, as well as generalised ones (better posture, breathing, nutrition, habits of use etc). Prevention therefore only differs from rehabilitation by virtue of the context and the objectives’. So it appears, in the context of therapy and therapists, that prevention and rehabilitation treatments or strategies could possibly be the same thing, but just be a question of timing, before or after an incident (or injury provoking behaviour), that may itself be an original insult, second or third.

Chronic low back pain Exciting advances made in motor control and pain research means that there is a diagnosis and management shift from a pathological and anatomical viewpoint to a dynamic systems approach according to Key (2010a). In the opening chapters of her recently published book, ‘Back Pain: A movement problem.’ Key neatly summarises Waddell who states that: only about 15% of patients with back pain show definite structural pathology, the relationship between imaging and symptoms is weak, and in the absence of a diagnosis Health professionals may look to psychological reasons for their pain, therefore, there is no surprise that the ‘biopsychosocial model’ has evolved. While not discounting the biopsychosocial model readers of the Journal of Bodywork and Movement Therapies may too realise that hands-on or therapeutic exercise answers may exist for their clients neuromusculo-skeletal problems. Key goes further and looks at classification systems for Chronic non-specific low back pain (CNLBP) or ‘ordinary’ back pain, quoting Riddle (1998) that current classification systems are confusing, looking at appropriate treatments, or prognoses, or pathology. She also quotes O’Sullivan (2005) who overviews 8 models, including the ‘Motor control model’ in which O’Sullivan bases his own work. Key suggests the ‘Functional movement model’ that combines many features of other CNLBP models including the biopsychosocial (Key’s own bolding) and Motor control. She suggests that ‘altered function of the posturo-movement system is the primary problem largely responsible for the development and perpetuation of most pain syndromes.’ I asked Key (2010b) about how she considers prevention in the therapeutic context, she said, ‘I certainly consider that prevention is an important aspect of comprehensive therapeutic care e yet this aspect seems to have been largely usurped by the ‘fitness’ and related industries who have little ‘real rehabilitation’ training e hence who knows what they base their ‘‘prevention programs’’ on. I consider that if prevention strategies are to be meaningful and functionally useful, they need to be built upon a well informed understanding around a number of related aspects concerning movement control: (a) What is ‘more ideal’ posturo-movement function? Appreciating this also enables better application of the

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(b)

(c)

(d)

(e)

available evidence; to put research outcomes into the clinical context; and even question the clinical utility of some findings The evidence is pointing more towards deficiencies in motor control being associated with spinal pain disorders and so, more beneficial programs should focus upon the quality of our patterns of movement control rather than the ubiquitous ‘strengthening’ and ‘stretching’ The practitioner needs to be cognisant of the fact that seemingly subtle changes in posturo-movement control are usually apparent before the onset of pain. These changes can tell us a lot about the potential or actual problems the patient may be/is experiencing and so this can also serve a certain predictive role e important for prevention programming. The practitioner needs to appreciate ‘‘what are the more likely patterns of dysfunctional response going to be’’? While evidence is giving us more answers in this area, at this point in time we need to rely more on our clinical pattern recognition and therapeutic skills to provide the substance of more meaningful prevention program. In essence, effective programs of care e therapeutic and preventative, depend upon a balance between artful clinical practice informed by the knowledge that science can offer.’

In summary Key said she ‘is trying to get the message out there that clients most probably need to work smarter not harder!’ We know that a marker for measuring the success of rehabilitation is in dropping recurrence rates, it is the underlining and exclamation point a researcher has when they publish their follow up study, see Hides et al. (2001) work on the deep multifidus.

The 3rd movement dysfunction conference 2009 During a dismally wet Edinburgh weekend Sahrmann (2009a) presented her Keynote Lecture on Low back pain: ‘Isolated or degenerative problem e what are the implications?’. She stated that ‘90% of people are expected to experience low back pain during their life’ with a high recurrence rate ‘between 30 and 80%’ These high incidence and recurrence rates, she says, ‘are consistent with low back pain being associated with the degenerative process’ and this process consists of ‘temporary dysfunction and 4 stages of hyper-mobility before the final stage of hypomobility and spinal stenosis. If the ‘‘acute episodes’’ are part of the pattern of temporary dysfunction associated with segmental hyper-mobility then treatment should be directed toward control and prevention of the progressive hyper-mobility that at a minimum should slow the degenerative process.’ She challenges physical therapists to ‘monitor the pattern of movement of the low back, designing and appropriately instructing the patient in corrective exercises and movement strategies rather than just providing episodic short-term treatment.’ Sahrmann reported that clinical examination is reliable, in trained

About prevention

      

a deep squat a hurdle step an in-line lunge shoulder mobility an active straight leg raise a trunk stability push up, and a rotation stability test.

Comerford (2009, 2004) in his presentation to conference discussed that in sport (where improving performance becomes a major goal of the support staff, as opposed to, in the clinic where the major goal is reducing pain and disablement) the significant ‘Recurrence of injury and pain’ indicates that something is missing in our current screening and prevention strategies. Comerford pointed out that assessments and screening of athletes is standard across the board. Screenings primarily look at testing joint range, muscle strength (power and endurance) and muscle extensibility. Comerford was clear that these are all relatively unsuccessful at predicting risk of re-injury or recurrence of pain. Like Cook, Comerford also identified that history of previous injury is the single most consistent and reliable predictor of high risk of re-injury. He identified that the isolationist testing of joint range of motion or normal muscle strength is not an adequate rehabilitation end point to prevent recurrence. Comerford suggested it is the assessment of the control of ‘real’ function that is the missing piece of the screening puzzle. He defines ‘real’ function as the influence of the multiple muscle interactions acting on multiple joints in functionally orientated tasks. Comerford advocates the Perfomance Matrix screen, that he presented to the conference. I personally teach a version of this to the pilates community. At the centre of the screen is the assessment of the motion segment (or regional) ‘hyper-mobility’ referred to by Sahrmann earlier. This may be directional (i.e. flexion, extension, rotation etc) and, equally importantly, relates to the threshold at

which it occurs (low or high). Comerford terms this ‘uncontrolled movement.’ Sahrmann refers to the same concept as the ‘direction susceptible to movement’, and O’Sullivan as a ‘control impairment.’ Comerford suggests it is the threshold at which the failure occurs which dictates whether the specific exercises required to improve the uncontrolled movement should be slow motor unit dominant (low threshold) thereby showing a Central Nervous System (CNS) led ‘recruitment’ failure of the muscles that should be providing the control, or a fast motor unit dominant (high threshold) ‘weakness’ e meaning the hyper-mobile area needs muscular strength to provide the control. This is the key differentiation between the FMS and Performance Matrix approaches.

In the real world Swart (2010), Physiotherapist for elite athletes in South Africa reports that ‘in the area of symptoms we mostly find uncontrolled movements with the low threshold tests which makes sense due to the fact that pain affects slow motor unit recruitment. With the Performance matrix or FMS we can determine risk factors for injury in other areas of the body before they occur preventing further time out due to injury. It is less time consuming to prevent injuries rather than treat the injuries, and athletes hate not being able to train. Once there is pathology it usually means the athlete has to rest for 6 weeks to allow for healing or at least I change their exercise program to allow them to perform unloaded training in water. Athletes usually start too quickly and try to progress too fast leading to recurrences of injuries or injuries in other areas due to compensation.’ Barr (2010), an Injury Prevention Specialist for the New York Knicks Basketball Team, confirms the requirement for interdisciplinary co-operation. Barr does not regard reactive injury prevention programs as injury prevention e this, he says, ‘is just an extension of injury rehab.’ Like the Yellow Emperor before him Barr believes that, ‘optimal nutrition, hydration and sleep quality are all essential aspects of injury prevention. If these obvious basics are not taken care of fully, then any other injury prevention strategy employed will have a lesser effect.’ Barr suggests the athlete needs to:  be specifically conditioned to perform in their specific sport,  after previous bouts of exercise be fully recovered to perform,  be in a ready state to perform physically (warmed up) and mentally (focused) and,  have optimal neuromuscular control, stability, mobility and strength for the demands of their specific sport. To ensure all these considerations are taken care of reliable screening and testing methods need to be frequently performed. ‘My area of expertise,’ says Barr, ‘and what I believe to be an essential part of the screening process, is the ‘‘analysis of the quality of movement.’’ In my experience screening for ‘‘movement control’’ and ‘‘producing injury

PREVENTION & REHABILITATIONdEDITOR: WARRICK MCNEILL

people, in identifying movement faults and that there is validity in identifying (movement) subgroups (Sahrmann, 2009b). Fass (1996), ‘Exercises: which ones are worth trying, for which patients, and when?’ found that more research on ‘different types of exercising’ in patients with chronic back pain was necessary. Sahrmann’s comments at the Movement Dysfunction conference suggests that there may eventually be a plethora of well reasoned, specific exercises for specific movement faults, identified by pattern recognition and clinical testing, that probably make up the 85% of CNLBP sufferers that do not have a structural pathology. ‘Movement screening’ was highlighted at the conference, first by Gray Cook who introduced his Functional Movement Screen (FMS). Cook (2009) identified that the strongest predictor of future injury is previous injury. The FMS, is a reliable (Minick et al., 2010) predictive system for those who do not have a known musculo-skeletal injury. It assesses functional movement patterns looking for asymmetries and movement limitations, and therefore, he suggests, indicates what ‘to do’ with the client. The test movements are relatively simple and include:

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prevention programs to improve the control of movement’’ have great success. Aside from traumatic injuries most other injuries can be related to ‘‘uncontrolled movement.’’ It is relating uncontrolled movement to the pathology that allows you to understand how uncontrolled movement is an injury risk and correcting uncontrolled movement is injury prevention.’

PREVENTION & REHABILITATIONdEDITOR: WARRICK MCNEILL

Crossover between pain and human performance It is interesting to note that Cook and Comerford, system developers, and Swart and Barr, users of a system of assessing movement control, are physical (or physio) therapists who originally trained to treat pain and injury but have moved out from a narrow focus to look at human performance as well. They have the remit, via their professional training, to look at both patients (those in pain) and athletes (concentrating on those with performance deficits). Not all who read the JBMT will be able to move easily between these two camps. Some movement disciplines such as Pilates or Yoga are not widely regarded as ‘treatment’ and therefore their teachers should not work without the co-operation of a suitably qualified health professional or without clearance from a doctor who is knowledgeable (both about the patients condition and the discipline they are referring to). Yet many who present to Pilates or Yoga Teachers do so because they are in pain, perhaps they do not identify themselves as having pain for fear of being excluded from the session or perhaps they do not see that it is important for the teacher to know about their pain. It is often the wording of the practitioners insurance policy that defines who a Teacher can see, however, it is becoming very clear that movement dysfunctions are responsible for the internal environment that leads to pain. Pain is probably just a late sequelae of the same movement faults that Pilates and Yoga teachers see in every class that they teach. The Teachers have the tools to alter these movement faults by their interventions, cueing and handling, thereby ‘preventing’ the ‘pain’ that could have otherwise have been expected to follow. It is the fact that exercise is often undertaken in group classes so that a teacher should ideally:    

keep the group size small, know the clients extremely well, have assistants, play to the lowest common physical denominator, or ‘sub-group’ their classes to fit those with similar problems together, to keep the individual in a group as ‘safe’ as possible.

Individual or ‘one to one’ sessions are a luxury that for many clients is imperative if they are to progress with the least risk of recurrence from being given an inappropriate exercise or trying too hard too soon or simply not working hard enough. In an individual session a teacher is able to discover the modifications that that client requires to zone a specific exercise into something that is maximally beneficial in that instance as opposed to performing

a ‘cheat’ in which the cheat becomes perpetuated. Criticism of the disciplines of Pilates and Yoga (Key, 2010a) to name but two disciplines is fair especially when poorly trained teachers, use exercise recipes and dogma instead of individual assessment, critical thought and exercise modification. In my personal opinion the nascent scientific research looking at Pilates or Yoga often lets itself down by not defining within the research question what part of the discipline it is looking at. The disciplines have varied practices of the same activities yet a broad brush stroke description of what is undertaken is often deemed enough. Describing every detail, especially modifications of exercises encouraged and cueing used, may help the disciplines develop a scientific credibility that at present appears to be unfortunately lacking. Careful thought as to what exercises should be excluded from a particular study might be more beneficial than performing all the available repertoire. The history of chronic low back pain research over the last one or two decades, and recent thoughts on motor control and sub-grouping that are now developing, could be applied to help accelerate research in Pilates or Yoga.

Call to action As this is the Prevention and Rehabilitation section of the Journal of Bodywork and Movement Therapies I would like to put a call out for papers with a focus on injury prevention or the prevention of injury recurrence. If we accept that motor control deficiencies eventually lead to pain and disability we want to know which movement strategies can be used as motor control tests, or whether those motor control tests currently in use are good predictors of injury risk. Gracovetsky’s (2010) paper discussing ‘Range of Normality’ and injury prevention is an excellent example of the type of paper that improves our knowledge of injury prevention.

Feedback: core stability is a subset of motor control Lederman’s (2010) Myth of core stability paper provoked a muted response in reply to my editorial (McNeill 2010), though it is currently, at the time of writing, the most downloaded article from the JBMT, via ScienceDirect. Comments made showed appreciation of a critical look at core stability, and reiterated that clinicians should be careful not to read too much into research that might not be there. In relation to Core Strengthening, Marcus (2009) quoted ´ me chose’. (The more ‘plus a change, plus c’est la mA things change, the more they stay the same). He identified that in his time as a pain medicine MD that several exercise approaches have come and gone, ‘they become jargonized and thus useless. New is not necessarily better.’ Marcus et al. (2010) points out that he currently uses the Kraus exercise program in his chronic pain treatment protocol. This system (of what we might now regard as non-specific exercise) was developed in the

1950s and reduced or eliminated back pain in 80% of those undertaking them. It seems that despite science and fashion appearing perhaps to be opposite fields of endeavour they both appear influenced by seasons!

In this edition In line with this editorials theme on prevention (and in this case ‘prevention of recurrence’), and with its prevalence in sports, Stephanie Panayi discusses the need for lumbarpelvic assessment in chronic hamstring strain. Josephine Key, who has written before for the JBMT, elaborates further on Vladimir Janda’s ‘Pelvic crossed syndromes’ for this issue. Craig Liebenson’s popular self management: patient section wraps up this editions Prevention and Rehabilitation section. As always, please feel free write to me in response to the Editorial, the papers, or the ongoing themes within the journal or affecting your own practice.

References Barr, A., 2010. Personal correspondence. Chaitow, L., 2010. Personal correspondence. Comerford, M.J., 2004. Core stability: priorities in rehab of the athlete. SportEx Medicine 22, 15e22. Comerford, M.J., 2009. Recurrence of injury and pain in sport e 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. Fass, A., 1996. Exercises: which ones are worth trying, for which patients, and when? Spine 21 (24), 2874e2878. Fletcher, G.F., 1988. Exercise in the Practice of Medicine, second revised ed. Futura Publishing, Mount Kisco, New York. Ford, M., 2010. Personal correspondence. Gracovetsky, S., 2010. Range of normality versus range of motion: a functional measure for the prevention and management of low back injury. Journal of Bodywork & Movement Therapies 14 (1), 40e49.

293 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 (11), 243e248. HSE Booklet L26 Display screen equipment work: Health and Safety (Display Screen Equipment) Regulations 1992: guidance on regulations. ISBN: 0-7176-2582-6. Key, J., 2010a. Back Pain: A Movement Problem. Churchill Livingstone Elsevier. Key, J., 2010b. Personal correspondence. Lederman, E., 2010. The myth of core stability. Journal of Bodywork and Movement Therapies 14 (1), 84e98. Marcus, N., 2009. Personal correspondence. Marcus, N., Gracely, E., Keefe, K., 2010. A comprehensive protocol to diagnose and treat pain of muscular origin may successfully and reliably decrease or eliminate pain in a chronic pain population. Pain Medicine 11 (1), 25e34. McNeill, W., 2010. Core stability is a subset of motor control. Journal of Bodywork and Movement Therapies 14 (1), 80e83. Minick, K.I., Kiesel, K.B., Burton, L., Taylor, A., Plisky, P., Butler, R.J., 2010. Interrater reliability of the functional movement screen. Journal of Strength Conditioning Research 24 (2), 479e486. O’Sullivan, P., 2005. Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control impairments as an underlying mechanism. Manual Therapy 10, 242e255. Riddle, D.L., 1998. Classification and low back pain: a review of the literature and critical analysis of selected systems. Physical Therapy 78 (7), 708e737. Sahrmann, S., 2009a. Low back pain: isolated or degenerative problem e what are the implications? Manual Therapy 14 (5), S1eS54. Swart, J., 2010. Personal correspondence.

Web sources Science & Humour with Dr. Serge Gracovestsky e Part 1. http:// www.youtube.com/watch?vZqgh2C8M50Iw. http://www.safetylit.org. http://www.hse.gov.uk/myth/nov09.pdf. Sahrmann, S., 2009b. http://www.webducate.net/icmd_blog/? pZ53. www.functionalmovement.com. www.performance-stability.com.

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About prevention

Journal of Bodywork & Movement Therapies (2010) 14, 294e298

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

REVIEW

The need for lumbarepelvic assessment in the resolution of chronic hamstring strain Stephanie Panayi* Shop 5/325 Centre Rd, Bentleigh, VIC 3204, Australia Received 24 June 2009; received in revised form 20 August 2009; accepted 23 August 2009

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KEYWORDS Hamstrings; Mobilisation; Sacroiliac joint; Arthrokinetic reflex

Summary A lumbarepelvic assessment and treatment model based on a review of clinical and anatomical research is presented for consideration in the treatment of chronic hamstring strain. The origin of the biceps femoris muscle attaches to the pelvis at the ischial tuberosity and to the sacrum via the sacrotuberous ligament. The biomechanics of the sacroiliac joint and hip, along with lumbarepelvic stability, therefore play a significant role in hamstring function. Pelvic asymmetry and/or excessive anterior tilt can lead to increased tension at the biceps origin and increase functional demands on the hamstring group by inhibiting its synergists. Joint proprioceptive mechanisms may play a significant role in re-establishing balance between agonists and antagonists. An appreciation of neuromuscular connections as well as overall lumbarepelvic structural assessment is recommended in conjunction with lumbare pelvic strengthening exercises to help resolve chronic hamstring strain. ª 2009 Elsevier Ltd. All rights reserved.

Introduction One of Dr. Ida Rolf’s frequent mantras to her students was ‘Where the pain is, it ain’t!’ According to Dr. Rolf, first and foremost in any evaluation of chronic pain is global assessment of structure. Localised evaluation is necessary for acute injury, however a global approach is often appropriate when addressing chronic musculoskeletal pain. While the etiology of hamstring strain is multifactorial and sometimes difficult to define, this article proposes that assessment of lumbarepelvic biomechanics may play * Tel.: þ61 434 919 487. E-mail address: [email protected]

a valuable part in the successful resolution of chronic hamstring strain. Hamstring injuries are the most prevalent muscle injury in sports involving rapid acceleration and sprinting (Hoskins and Pollard, 2005). At its simplest, treatment of hamstring strain might include stretching and soft-tissue work to increase flexibility and address scar tissue formation. Research into the value of stretching for injury prevention (Herbert and Gabriel, 2002), and the value of massage to effect muscle damage (Tiidus, 1997), does not however show significant effects of these interventions. Research suggests that lumbarepelvic alignment may play a significant role in hamstring strain (Cibulka et al., 1986; Hennessey and Watson, 1993; Hoskins and Pollard, 2005).

1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.08.004

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In the 1970s Dr Vladimir Janda (1978) developed a multifaceted approach to musculoskeletal pain. His treatment protocol included restoring postural alignment, correcting the biomechanics of joints, increasing the proprioceptive input to the central nervous system, and exercise to increase muscular endurance (Janda, 1978). Using Janda’s conceptual framework, research relating to assessment and treatment of hamstring strain is presented under the following headings: Posture, Joint Influences, and Lumbare pelvic Stabilisation Exercises.

Lumbar hyperlordosis, anterior tilt of the pelvis, and sacroiliac joint (SIJ) dysfunction have all been implicated in chronic hamstring strain (Cibulka et al., 1986; Hennessey and Watson, 1993; Hoskins and Pollard, 2005). Lumbar hyperlordosis often correlates with anterior pelvic tilt, placing strain on the origin of the hamstrings at the ischial tuberosity, resulting in hamstring tissue pathology (Cibulka et al., 1986). When no tissue pathology is present in the hamstrings, it has also been linked to lumbarepelvic myofascial pain referral, mimicking hamstring strain (Hoskins and Pollard, 2005). Van Wingerden et al. (1997) suggest that the high correlation between tight hamstrings and lower back pain might reflect a beneficial compensatory mechanism for people with pelvic instability. They point out that, in low back pain patients, bending forward is often painful because of the increase in spinal load during this movement. Increased hamstring tension prevents the pelvis from tilting forward, which diminishes the forward-bent position of the spine, thereby reducing spinal load Van Wingerden et al. (1997). SIJ dysfunction has been defined as pelvic asymmetry between the left and right innominates (Pool-Goudzwaard et al., 1998). The two innominates join anteriorly at the pubic symphysis, and posteriorly they border the sacrum. Joint play is movement within a synovial joint that is independent of, and cannot be introduced by, voluntary muscle contraction (Greenman, 1996). The amount of joint play at the SIJ is less than 1/8 of an inch in any plane but allows the innominates to rotate anteriorly and posteriorly during ambulation (Figure 1), causing side bending and rotation in the sacrum (Greenman, 1996). These movements are essential for the normal pain-free, nonrestricted movement of the joint and significant somatic dysfunction can occur if any of these movements are impeded (Greenman, 1996). Ideally, when standing or seated, the innominates do not differ in terms of anterior or posterior rotation. However, it is not uncommon for pelvic obliquity to develop, involving an anterior tilt on one side and a posterior tilt on the contralateral side. Rotation of the innominates and torsion of the sacrum can result from forces being transmitted to these bones from the spine, pelvic floor or lower extremities (Schamberger, 2002). In athletes, training error, or overtraining with unilateral loading, as in kicking or throwing, can exaggerate the normal sacroiliac movements (Ross, 2000). Over time, unilateral muscle tightness or contracture can produce a rotational force on the innominates. For example, a tight rectus femoris muscle could

Figure 1 When walking, as the right leg swings forward the right ilium rotates backward in relation to the sacrum. Simultaneously, the sacrotuberous and interosseous ligamentous tension increases to brace the sacroiliac joint (SIJ) in preparation for heel strike. Just before heel strike, the ipsilateral hamstrings are activated, thereby tightening the sacrotuberous ligament (into which they merge) to further stabilize the SI joint. Figure. 1 is figure 5.15 from A Massage Therapist’s Guide to Low Back and Pelvic Pain Chaitow L., Fritz S. 2007 Elsevier/ Churchill Livingstone, Edinburgh Redrawn from Vleeming et al. 1997 Movement, Stability and low back pain. 1st Edition Churchill Livingstone, Edinburgh.

produce anterioreinferior rotation force on the anterior superior iliac spine, while a tight biceps femoris muscle could produce posterioreinferior rotational force at the ischial tuberosity (Schamberger, 2002). Cibulka et al. (1986) investigated the role of SIJ dysfunction in hamstring strain. Results showed a significant increase in hamstring strength immediately following SIJ mobilisation. The researchers had noted a high correlation between hamstring muscle strains and an anterior tilt of the innominate bones, associated with sacroiliac dysfunctions. They concluded that mobilising the SIJ reduced the tilts of the innominates, releasing undue stress on the previously elongated biceps femoris. More recent research has also found SIJ mobilisation to increase hamstring flexibility (Fox, 2006). Hoskins and Pollard, (2005), found that improving lumbarepelvic biomechanics, including SIJ mobilisation, played a role in treatment and prevention of hamstring injury in Australian Rules footballers. Apart from producing a static stretch of the biceps femoris muscle, fixations of the SIJ can exacerbate pain upon ambulation. Ideally, during hip flexion the innominate on the same side rotates in a posterior and inferior

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direction (using the posterior superior iliac spine as the point of reference), moving the ischial tuberosity anteriorly and reducing hamstring strain. If however, the innominate is fixed in an anterior rotation, the ischium will not move anteriorly during hip flexion and this will increase stress at the origin of the hamstrings. This kind of stress is particularly relevant in sports involving rapid acceleration during running or sprinting (Gabbe et al., 2005). SIJ dysfunction has also been associated with piriformis spasm on the side of the posterioreinferior lateral angle, paravertebral spasm, iliopsoas spasm and gluteal and hamstring spasm (Dowling, 2004).

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SIJ dysfunction and muscle pathology e cause/ effect A primary function of the pelvis is to transfer the loads generated during standing, walking, sitting and other functional tasks (Lee, 2005). Effective load transfer requires optimal force and form closure of the SIJ. Form closure refers to the stable situation of the SIJ due to closely fitting joint surfaces where no extra forces are needed to maintain stability (Pool-Goudzwaard et al., 1998). However, since the sacrum does not fit the pelvis with perfect form closure and some mobility is required during ambulation, ligament and muscle-forces are needed to provide compression of the SIJ, especially during unilaterally loading of the legs when shear forces increase (Pool-Goudzwaard et al., 1998). Force closure refers to the stability of the SIJ produced by surrounding myofascia (Figure 2), particularly that with a fibre direction perpendicular to the SIJ, such as gluteus maximus (Pool-Goudzwaard et al., 1998). Weakness or underactivity of gluteus maximus may therefore predispose the SI joints to injury (Elphington, 2008). While contraction of the myofascia assists form closure of the SIJ, the question remains whether muscular contraction is able to influence the positioning of the sacrum and therefore have the potential for creating SIJ dysfunction. Based on research in which joint restrictions did not alter when myorelaxants were given to hypertonic muscles, Lewit (1985) defines the SIJ as one of three joints in the body where joint restrictions are not the result of soft-tissue changes. However recent research suggests that although the muscles crossing the SIJ are not described as prime movers of that joint, motion can occur at the SI joint as a result of their contraction (Schamberger, 2002; Vleeming et al., 1989a; Vleeming et al., 1989b; Wingerden et al., 2004). In a dissection study of 12 cadavers, Vleeming et al. (1989a) found that in all cases, gluteus maximus attached to the sacrotuberous ligament, and in 50% of cases unilateral or bilateral fusion of the sacrotuberous ligament with the tendon of the long head of biceps femoris was evident. In some specimens, fusion was so complete that there was no connection of this muscle to the ischial tuberosity itself. In a subsequent study, Vleeming et al. (1989b) found that load to the sacrotuberous ligament, either directly or via continuation with the long head of biceps femoris, significantly diminished the forward rotation of the base of the sacrum (Figure 3).

Figure 2 Posterior oblique system: latissimus dorsi, gluteus maximus and the lumbodorsal fascia (which links them). When latissimus and contralateral gluteus maximus contract there is a force closure of the posterior aspect of the SIJ. Figure 2 is figure 5.11 from A Massage Therapist’s Guide to Low Back and Pelvic Pain Chaitow L., Fritz S. 2007 Elsevier/Churchill Livingstone, Edinburgh Redrawn from Vleeming et al. 1997 Movement, Stability and low back pain. 1st Edition Churchill Livingstone, Edinburgh.

Joint influences Mobilisation is commonly utilised to ease joint pain and increase range of movement. Recent research also emphasises the role of joint mobilisation in reciprocal inhibition (Liebler et al., 2001; Makofsky et al., 2007; Yerys et al., 2002). Sherrington’s principle of reciprocal innervation states that during contraction of agonist muscles, the antagonists do not behave passively, but are actively inhibited by central nervous mechanisms (Day et al., 1984). This mechanism, long thought to be based in afferents from muscles or tendons, may also be mediated by the articular receptors; these can inhibit or facilitate muscle tone, and failure to recognise the importance of these arthrokinetic (AKR) circuits may explain the difficulty in neuromuscular re-education and strengthening of muscle groups (Makofsky et al., 2007). In relation to chronic hamstring strain, a tightened anterior hip capsule would facilitate the iliopsoas muscle while inhibiting the gluteus maximus through the arthrokinetic reflex (Yerys et al., 2002). Visible muscle wasting of the gluteal muscles is often seen when tightness is present in the iliopsoas. Since gluteus maximus is a prime mover in hip extension, its inhibition places undue loads on its hamstring synergists (Elphington, 2008), making them more prone to injury. Mobilisations performed on the anterior hip capsule have been shown to significantly increase gluteus maximus strength (Yerys et al., 2002). Muscle weakness may therefore be influenced by inhibition related to capsular hypomobility of the underlying joint (the gluteus

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Figure 3 Deep longitudinal system: erector spinae, deep laminae of the thoracodorsal fascia, sacrotuberous ligament and biceps femoris. When contraction occurs, biceps femoris influences compression of the SI joint and sacral nutation can be controlled. Figure. 3 is figure 5.12 from A Massage Therapist’s Guide to Low Back and Pelvic Pain Chaitow L., Fritz S. 2007 Elsevier/Churchill Livingstone, Edinburgh Redrawn from Lee D 1999 The Pelvic Girdle 2nd Edition Churchill Livingstone, Edinburgh.

maximus is inhibited each time the hip extends against its restrictive barrier of motion). During mobilisation, the alteration in mechanoreceptor discharge theoretically removes the neurally driven inhibition of the gluteus maximus muscle whilst simultaneously inhibiting the iliopsoas muscle through reciprocal inhibition (Yerys et al., 2002). Perhaps the therapeutic role of SIJ mobilisation (Cibulka et al., 1986; Fox, 2006) extends beyond normalising an anterior rotation of the innominate, to stimulating joint receptors involved in an AKR with the hamstrings. The timing, pattern and amplitude of the muscular contractions involved in force closure of the SIJ depend on an appropriate response of both the central and peripheral nervous systems which in turn rely on appropriate afferent input from the joints, ligaments, fascia and muscles (Lee, 2005). Unusual positioning of the SI joints can influence afferent output of the joint capsule and there may be a causal relationship between different afferent output of the joint capsule and changes in the motor programme of supporting myofascial tissue such as transversus abdominus and multifidus (Pool-Goudzwaard et al., 1998).

Lumbar/pelvic stabilisation exercises Lumbarepelvic stabilisation exercises are important to promote normal lengthetension relationships across the pelvis, optimal arthrokinematics, dynamic stability, and efficient kinetic chain muscle activation patterns (Elphington, 2008). The main muscles of lumbarepelvic stabilisation are the multifidus, transversus abdominus and internal obliques (Elphington, 2008). The oblique abdominals and transversus abdominus are particularly important in spinal stability due to their connections with the thoracolumbar fascia and their role in enhancing intra-abdominal pressure (Norris, 1995). Gracovetsky (2008) has described the important relationship between the transversus abdominus and the thoracolumbar fascia in extension of the spine, and how internal abdominal pressure, together with lordosis, controls the force transmission efficiency of the lumbodorsal fascia. The gluteal group is also an important contributor to dynamic pelvic stability and must activate effectively to produce the short foot contact times necessary for fast running (Elphington, 2008). In stability training, the client’s attention to the exercise is crucial. This is not only important so that the exercise is performed properly, but attention is likely to aid in the facilitation of muscles which have become relatively inactive. In a study by Day et al. (1984) conscious inhibition of the wrist flexor reflex was demonstrated with the radial nerve anaesthetised by injection of local anaesthetic at the elbow. Subjects were asked to try to contract the paralysed extensor muscles. Under this condition, attempted voluntary wrist extension inhibited the flexor reflex even though

PREVENTION & REHABILITATIONdREVIEW

When there are joint restrictions, mechanoreceptor inputs to the CNS can cause active weakening (or inhibition) of muscles whose action could take the joint beyond its restrictive barrier. Therefore, trying to strengthen a muscle that is being inhibited before mobilising the joint may be counterproductive. Much in line with Janda (1978), Makofsky et al., (2007) proposed a simple clinical rule of thumb: ‘Stretch what’s tight and mobilise what’s stiff prior to strengthening what’s weak.’ Joint mechanoreceptors can also be stimulated during tasks that maximise sensory input to the central nervous system and elicit subconscious and automatic responses in muscles. This is most effectively done by providing balancechallenging exercises which stimulate the sub-cortical systems which regulate movement and balance (Janda et al., 2006). Bullock-Saxton et al., (1993), found that gluteal muscles activated more affectively by stimulating the proprioceptive mechanism during walking. Subjects wore ‘balance shoes’, which acted as a labile surface, to facilitate cerebellovestibular circuits. This study showed significant increases in gluteal activity and faster contractions after one week of facilitation. Specific sensory motor tasks have been shown to be as effective for improving strength as traditional strength training (Risberg et al., 2007; Ihara and Nakayama, 1986), and lead to shorter latency of contraction (Ihara and Nakayama, 1986). Because the sub-cortical regulatory systems do not rely on conscious control, they are faster, and after time the stabilising process can become ‘second nature’ (Norris, 1995).

298 no extension occurred. Similar results were obtained by Duk Yang et al. (2005) showing that imagination of movement facilitated motorneurons of the agonist muscle while having an inhibitory effect on those of the antagonist muscle. This suggests that focussed attention to specific muscular contraction can play a significant role in muscle facilitation and reciprocal inhibition.

PREVENTION & REHABILITATIONdREVIEW

Summary The etiology of hamstring strain is multifactorial and often difficult to define. There is, however, evidence to suggest that hamstring strain may sometimes be reflective of lumbarepelvic imbalances. These imbalances increase the functional load on the hamstrings by defacilitating the gluteus maximus, and/or increasing the tensile stress on the biceps femoris origin. Apart from working to increase hamstring flexibility and address scar tissue formation, successful resolution of hamstring strain may involve the following: lengthening myofascial components that contribute to excessive lumbar lordosis, anterior pelvic tilt, and pelvic obliquity; mobilising the SIJ and/or the anterior hip joint to stimulate joint receptors and facilitate gluteus maximus and the hamstrings; balance-challenging exercises to further stimulate joint proprioceptor activity and enhance gluteal strength; and strengthening exercises for the lumbarepelvic stabiliser muscles to create and maintain a balanced pelvis. While research into structural alignment and hamstring strain is at this stage neither conclusive nor extensive, the information presented suggests that further research into this area is warranted.

References Bullock-Saxton, J.E., Janda, V., Bullock, M.I., 1993. Reflex activation of gluteal muscles in walking. An approach to restoration of muscle function for patients with low-back pain. Spine 18 (6), 704e708. Cibulka, M.T., Rose, S.J., Delitto, A., Sinacore, D.R., 1986. Hamstring muscle strain treated by mobilizing the SIJ. Physical Therapy 66 (8), 1220e1223. Day, B.L., Marsden, C.D., Obeso, J.A., Rothwell, J.C., 1984. Reciprocal inhibition between the muscles of the human forearm. Journal of Physiology 349, 519e534. Dowling, D.J., 2004. Evaluation of the pelvis. In: DiGiovanna, E.L., et al. (Eds.), An Osteopathic Approach to Diagnosis and Treatment. Lippincott Williams & Wilkins, Philadelphia. Duk Yang, H., Ki Minn, Y., Hong Son, I., Han Suk, S., 2005. Facilitation and reciprocal inhibition by imagining thumb abduction. Journal of Clinical Neuroscience 13 (2), 245e248. Elphington, E., 2008. Stability, Sport and Performance Movement: Great Technique Without Injury. North Atlantic Books, California. Fox, M., 2006. Effect on hamstring flexibility of hamstring stretching compared to hamstring stretching and SIJ manipulation. Clinical Chiropractic 9 (1), 21e32. Gabbe, B.J., Finch, C.F., Bennell, K.L., Wajswelner, H., 2005. Risk factors for hamstring injuries in community level Australian football. British Journal of Sports Medicine 39, 106e110. Gracovetsky, S., 2008. Is the lumbodorsal fascia necessary? Journal of Bodywork and Movement Therapy 12 (3), 194e197. Greenman, P., 1996. Principles of Manual Medicine, second ed. Williams and Wilkins, USA.

S. Panayi Hennessey, L., Watson, A.W., 1993. Flexibility and posture assessment in relation to hamstring injury. British Journal of Sports Medicine 27, 243e246. Herbert, R., Gabriel, M., 2002. Effects of stretching before and after exercising on muscle soreness and risk of injury: systematic review. British Medical Journal 325, 468e478. Hoskins, W.T., Pollard, H.P., 2005. Successful management of hamstring injuries in Australian rules footballers: two case reports. Chiropractic & Osteopathy 13 (4). doi:10.1186/1746-1340-13-4. Ihara, H., Nakayama, A., 1986. Dynamic joint control training for knee ligament injuries. American Journal of Sports Medicine 14 (4), 309e331. Janda, V., 1978. Muscles, central nervous motor regulation and back problems. In: Korr, I. (Ed.), The Neurobiological Mechanisms in Manipulative Therapy. Plenum Press, New York. Janda, V., Vavrova, M., Herbenova, A., Veverkova, M., 2006. Sensory motor stimulation. In: Liebenson, C. (Ed.), Rehabilitation of the Spine: a Practitioner’s Manual, second ed. Lippincott Williams & Wilkins, Philadelphia. Lee, D., 2005. Recent advances in the assessment and treatment of the SIJ: stability and the role of motor control. In: Presentation at the American Back Society Meeting, San Francisco. Liebler, E.J., Tufano-Coors, L., Douris, P., Makovsky, H.W., McKenna, R., Michels, C., Rattray, S., 2001. The effect of thoracic spine mobilisation on lower trapezius strength testing. The Journal of Manual & Manipulative Therapy 9 (4), 207e212. Lewit, K., 1985. The muscular and articular factor in movement restriction. Manual Medicine 1, 83e85. Makofsky, H., Panicker, S., Abbruzzese, J., Aridas, C., Camp, M., Drakes, J., Franco, C., Sileo, R., 2007. Immediate effect of grade IV inferior hip joint mobilization on hip abductor torque: a pilot study. The Journal of Manual & Manipulative Therapy 15 (2), 103e111. Norris, C., 1995. Spinal stabilisation: an exercise programme to enhance lumbar stabilisation. Physiotherapy 81 (3), 31e38. Pool-Goudzwaard, A.L., Vleeming, A., Stoeckart, R., Snijders, C.J., Mens, J.M.A., 1998. Insufficient lumbopelvic stability: a clinical, anatomical and biomechanical approach to ‘a-specific’ low back pain. Manual Therapy 3 (1), 12e20. Risberg, M.A., Holm, I., Myklebust, G., Engebretsen, L., 2007. Neuromuscular training versus strength training during first 6 months after anterior cruciate ligament reconstruction: a randomised clinical trial. Physical Therapy 87 (6), 737e750. Ross, J., 2000. Is the SIJ mobile and how should it be treated? British Journal of Sports Medicine 34, 226. Schamberger, W., 2002. The Malalignment Syndrome: Implications for Medicine and Sports. Churchill Livingstone, UK. Tiidus, P., 1997. Manual massage and recovery of muscle function following exercise: a literature review. Journal of Orthopaedic and Sports Physical Therapy 25 (2), 107e112. Van Wingerden, J.P., Vleeming, A., Kleinrensink, G.J., Stoeckart, R., 1997. The role of the hamstrings in pelvic and spinal function. In: Vleeming, A., et al. (Eds.), Movement, Stability and Low Back Pain. Churchill Livingstone, Edinburgh. Vleeming, A., Stoeckart, R., Snijders, D.J., 1989a. The sacrotuberous ligament: a conceptual approach to its dynamic role in stabilising the SIJ. Clinical Biomechanics 4, 204e209. Vleeming, A., Van Wingerden, J.P., Snijders, C.J., Stoeckart, R., Stijnen, T., 1989b. Load application to the sacrotuberous ligament influences SIJ mechanics. Clinical Biomechanics 4, 204e209. Wingerden, J., Vleeming, A., Buyruk, H., Raissadat, K., 2004. Stabilisation of the SIJ in vivo: verification of muscular contribution to force closure of the pelvis. European Spine Journal 13 (3), 199e207. Yerys, S., Makofsky, H., Byrd, C., Pennachio, J., Cinkay, J., 2002. Effect of mobilization of the anterior hip capsule on gluteus maximus strength. The Journal of Manual & Manipulative Therapy 10 (4), 218e224.

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POSTURAL PHYSIOLOGY

Josephine Key, MPAA, Musculoskeletal Physiotherapist* Edgecliff Physiotherapy Sports and Spinal Centre, Suite 505/180 Ocean Street, Edgecliff N.S.W. 2027, Australia Received 25 April 2009; received in revised form 14 January 2010; accepted 20 January 2010

KEYWORDS Back pain; Pelvic pain; Motor control; Posturo-movement dysfunction; Lumbo-pelvic-hip movement control; Therapeutic exercise; Core stability; Clinical sub-group classification

Summary Structurally, the sacrumecoccyx provides the dual roles of serving as the base of the spinal column while also forming part of the pelvic ring. Physiological movement control of the pelvis and the spine are functionally interdependent. In particular, intra-pelvic control, (that between the ilia and sacrum/coccyx in support and control of the forces and small movements within the pelvic ring) is fundamental to controlling its spatial organization as a whole and its control on the femoral heads, all of which directly influence spinal alignment and control mechanisms. This involves coordinated activity in the related neuro-myofascial systems in providing mechanisms of both intrinsic and extrinsic support and control. ª 2010 Elsevier Ltd. All rights reserved.

Janda proposed the concept of the Pelvic Crossed Syndrome as an underlying factor in the genesis and perpetuation of many low back pain syndromes (Janda, 1987; Janda and Schmid, 1987; Janda et al., 2007). Here, imbalanced muscle activity e tightness and overactivity of the hip flexors and low back extensors and a coexistent underactivity in the abdominals and glutei create a ‘crossed pattern’ of disturbed sagittal lumbopelvic posturo-

* Tel.: þ61 02 93261168; fax: þ61 02 93281695. E-mail address: [email protected]

movement alignment and control. While certainly evident in back pain populations, for the observant clinician it is not a universal finding. Like Janda, our group has been interested in the validity of clinical pattern recognition which appears to also delineate another different, yet broad subgroup within the back pain population who share in common similar features of changed postural alignment and control. This sub-group displays a relative hyperactivity in the upper abdominal wall and piriformis/hamstrings with underactivity in the lower abdominals, deep hip flexors and low back extensors. This also creates an altered ‘crossed pattern’ affecting

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PREVENTION & REHABILITATIONePOSTURAL PHYSIOLOGY

The Pelvic Crossed Syndromes: A reflection of imbalanced function in the myofascial envelope; a further exploration of Janda’s work

PREVENTION & REHABILITATIONePOSTURAL PHYSIOLOGY

300 sagittal lumbopelvic alignment and control and has been described by Key et al. (2008b). It is clinically apparent that most patients presenting with low back and pelvic pain syndromes display at least some of the features attributable to either of these two primary pictures of altered pelvic function. In Janda’ s originally proposed Pelvic Crossed Syndrome, the pelvis is more posterior and this is associated with imbalanced coactivation of the trunk muscles with more dominant activity observed in the extensors. Key et al. (2008b) proposed this syndrome be re-termed the Posterior Pelvic Crossed Syndrome (Figure 1C). Conversely, in the other broad group, the pelvis is postured more anteriorly and this is associated with a predominant tendency to more axial flexor activity e described by Key et al. (2008b) as the Anterior Pelvic Crossed Syndrome (Figure 1B). However, it is important for the clinician to also recognise that underpinning both primary pictures of pelvic posturo-movement dysfunction there is usually a related, common and clinically apparent fundamental deficit in the integrated and balanced control provided from the deep, innermost myofascial sleeve which sub-serves the foundations of lumbopelvic support and control. Key et al. (2008a) proposed that the muscles of the body could for practical purposes be conceptually viewed as essentially consisting of two systems e a deep and a superficial systemic muscle system. They termed the deep system the Systemic Local Muscle System and proposed that this plays a critical role in underlying postural support and control. It is hereby further proposed that in respect to healthy lumbopelvic function, an important part of this deep system is a continuous, largely internal three dimensional myofascial web, providing a scaffold of tensile inner

J. Key support and stability and contributing to a structural and functional bridge between the lower torso and legs. It is suggested that these collective myofascial aggregations be termed the ‘Lower Pelvic Unit’ (LPU). This includes the obvious contractile elements for which there is accumulating evidence of deficient function in subjects with low back and/or pelvic pain e the transversus abdominus (Hodges and Richardson, 1996, 1998, 1999) multifidus (Hides et al., 1996) the diaphragm and pelvic floor muscles (O’Sullivan et al., 2002; Hodges, 2006). Impressions from clinical practice suggest inclusion also of the obturators, iliacus, psoas, and all their related and interconnecting fascial sheaths. Sound activity within this myofascial ‘inner stocking’ sustains many functional roles: e providing deep anterior support to the lower half of the spinal column; with the spinal intrinsics it contributes to lumbopelvic control (Hodges, 2004); while also contributing to the generation of IAP (Cresswell et al., 1994), continence and respiration (Hodges and Gandevia 2000) (Figure 2). Importantly, it is further asserted that from a therapeutic perspective, co-operative activity within the LPU allows the modulation of discrete yet clinically apparent, fundamentally important intra-pelvic movements and spatial shifts. In helping to control our posturo-movements, it acts as the ‘collective internal agonist’ to balance the actions and forces created by activity of the ‘outer antagonists’. This balanced coactivation within the LPU and between it and the large more superficial muscles provides control of the myo-mechanics and movement force couples necessary to allow the pelvis to be the initiator and driver of functional posturo-movement control of the torso on the legs. Control initiated from the base of the spine through the pelvis, directed via the ischia and coccyx, is essential in being able to effectively manage the delicate neuromuscular balance involved in being upright against gravity. It also enables one to draw upon on an endless array of options in the fluid control of movement including being able to create kinematically sound patterns of movement which support basic activities of daily living e bending over, lifting, reaching squatting, jumping and so on e all possible when the pelvis can act in its prime role as the centre of weight shift in the body. Balanced coactivation from the LPU provides internal stability to the pelvis as it swings and swivels on the femoral heads which is necessary in weight shift, load transfer and in controlling equilibrium. This is ‘core control’.

Clinical relevance

Figure 1 Altered control of pelvic position changes the alignment and control mechanisms throughout the spine. Reproduced from ‘‘Back pain: A movement problem’’ by Key, publishing early 2010. With permission from Elsevier.

The experienced clinician knows that seemingly subtle changes and differences in pelvic posturo-movement control can mean a lot in the presenting symptom picture of those with spinal pain and related disorders. Appreciation of the Pelvic Crossed Syndromes and the common associated dysfunction in the LPU helps the practitioner ‘to see’ and better understand what is driving the patients underlying problem and the likely needs in terms of retraining appropriate functional motor control. In the author’s clinical experience, this is best addressed in the patient initially relearning specific activation of deficient elements within the LPU, establishing the important fundamental patterns of intra-pelvic control and

301

Figure 2 Much of the LPU involves a prevertebral and intra-pelvic myofascial web of support. Reproduced from ‘‘Back pain: A movement problem’’ by Key, publishing early 2010. With permission from Elsevier.

integrating these into basic functional patterns of movement control initiated from the pelvis. This will better ensure the likelihood of the patient achieving more functionally appropriate and ‘real core control’.

References Cresswell, A.G., Oddsson, L., Thorstensson, A., 1994. The influence of sudden perturbations on trunk muscle activity and intraabdominal pressure while standing. Exp. Brain Res. 98, 336e341. Hides, J.A., Richardson, C.A., Jull, G.A., 1996. Multifidus muscle recovery is not automatic following resolution of acute first episode low back pain. Spine 21, 2763e2769. Hodges, P., 2004. Abdominal mechanism and support of the lumbar spine and pelvis. In: Richardson, C., Hodges, P., Hides, J. (Eds.), Therapeutic Exercise for Lumbopelvic Stabilisation: a Motor Control Approach Foe the Treatment and Prevention of Low Back Pain, second ed. Churchill Livingstone, Edinburgh. Hodges, P.W., 2006. Low back pain and the pelvic floor. In: Carrie `re, B., Markel Feldt, C. (Eds.), The Pelvic Floor. Thieme, Stuttgart. Hodges, P.W., Richardson, C.A., 1996. Inefficient muscular stabilisation of the lumbar spine associated with low back pain: a motor control evaluation of transversus abdominus. Spine 21 (22), 2640e2650. Hodges, P.W., Richardson, C.A., 1998. Delayed postural contraction of transversus abdominus in low back pain associated with movement of the lower limb. J. Spinal Disord. 11 (1), 46e56.

Hodges, P.W., Richardson, C.A., 1999. Altered trunk muscle recruitment in people with low back pain with upper limb movements at different speeds. Arch. Phys. Med. Rehabil. 80 (9), 1005e1012. Hodges, P.W., Gandevia, S., 2000. Changes in intra-abdominal pressure during postural and respiratory activation of the human diaphragm. J. Appl. Physiol. 2000 (89), 967e976. Janda, V., 1987. Muscles and motor control in low back pain: assessment and management. In: Twomey, L. (Ed.), Physical Therapy of the Low Back. Churchill Livingstone, New York. Janda, V., Schmid, H.J.A., 1987. Muscles as a pathogenic factor in back pain. Proc. IFOMPT New Zealand 1980. Janda, V., Frank, C., Liebenson, C., 2007. Evaluation of muscular imbalance. In: Liebenson, C. (Ed.), Rehabilitation of the Spine: a Practitioner’s Manual, second ed. Lippincott Williams & Wilkins, Philadelphia. Key, J., Clift, A., Condie, F., Harley, 2008a. A model of movement dysfunction provides a classification system guiding diagnosis and therapeutic care in spinal pain and related musculoskeletal syndromes: a paradigm shift e part 1. J. Bodyw. Mov. Ther. 12 (1), 7e21. Key, J., Clift, A., Condie, F., Harley, C., 2008b. A model of movement dysfunction provides a classification system guiding diagnosis and therapeutic care in spinal pain and related musculoskeletal syndromes: a paradigm shift e part 2. J. Bodyw. Mov. Ther. 12 (2), 105e120. O’Sullivan, P.B., Beales, D., Beetham, J., Cripps, J., Graf, F., Lin, I., Tucker, B., Avery, A., 2002. Altered motor control strategies in subjects with sacroiliac joint pain during active straight leg raise test. Spine 27 (1), E1eE8.

PREVENTION & REHABILITATIONePOSTURAL PHYSIOLOGY

The pelvic crossed syndromes: A reflection of imbalanced function in the myofascial envelope

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PREVENTION & REHABILITATIONeSELF-MANAGEMENT: PATIENT SECTION

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SELF-MANAGEMENT: PATIENT SECTION

Improving trunk rotation D.C. Craig Liebenson* International Association for the Study of Pain, American Pain Society, Team Chiropractor, N.B.A. Los Angeles Clippers, L.A. Sports and Spine, 10474 Santa Monica Blvd., #304, Los Angeles, CA 90025, USA Received 5 April 2010; accepted 6 April 2010 Sports such as tennis, golf, baseball, and hockey each involve a tremendous amount of trunk rotation. It is not just striking sports, but also throwing, kicking, running, swimming, skiing, etc which all require your body to rotate through your core. In order to transmit forces from your bigger, stronger leg muscles to your arms, trunk rotation is needed. Back injuries, oblique abdominal strains, rotator cuff problems, and even reduced performance can directly result from diminished mobility in trunk rotation. This selfcare article shows a very simple trunk rotation exercise that can be performed as a warm-up or part of a daily stretching routine. Another benefit of trunk rotation training is that it can help improve to posture. A slouched posture with rounded shoulders will quickly straighten up with these simple stretches.

Kneeling trunk rotation (Fig. 1) Start
Kneel on the floor
Sit back on your heels
Place one hand behind your neck

Technique
Lift your head & torso up while simultaneously twisting your upper body

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Figure 1 position.

Kneeling trunk rotation (a) start position (b) final


Think about sticking your chest out
Hold this position for a few seconds
Then return to the start position

Avoid
Staying slouched

Troubleshooting
Use towel under forehead
Use rolled up towel or ½ foam roll behind knees
Be sure to stick chest out so that you are arching your back through your shoulder blades instead of from your lower back

Sets/reps/frequency
Perform 1 set
8e12 repetitions
1e2x/day

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Obituary: David Simons (1922e2010) e the next adventure Jan Dommerholt, PT, DPT, MPS* Bethesda Physiocare/Myopain Seminars, 7830 Old Georgetown Road, Suite C-15, Bethesda, MD 20814-2440, USA

On April 5, 2010, Dr. David Simons, co-author of the Trigger Point Manuals and author of many innovative and thoughtprovoking articles and research studies on myofascial trigger points, started what he described as “the next adventure”, when he passed away at the age of 87. Dave Simons was a pioneer not just in musculo-skeletal medicine, but also in aerospace explorations. After receiving his medical degree in 1946 from Jefferson Medical College in Philadelphia, PA, he served in the United States Air Force, initially as a researcher and during the Korean conflict as a flight surgeon. As project officer for balloon flights at the Aeromedical Field Laboratory at Holloman Air Force Base in New Mexico, he was particularly interested in the effects of galactic cosmic radiation on living tissue. On August 19, 1957, his career reached new heights, when he became the first man in outer space traveling 101,516 feet above the Earth in a pressurized gondola as part of the Man High Project. This 36-hour record-breaking high altitude balloon flight earned him a place on the cover of Life magazine and the title of “Father of Radiobiology”. When attending a two-day lecture and demonstration by Dr. Janet Travell in 1963, he was immediately intrigued by the concept of myofascial trigger points (MTrPs) and described her lectures and demonstrations as “a revelation” and “aweinspiring”. Following his 1965 retirement from the US Air Force, Dr. Simons became coordinator of research at the Veterans Administration and had the opportunity to meet with * Tel.: þ1 301 656 5613; fax: þ1 301 654 0333. 1360-8592/$ - see front matter doi:10.1016/j.jbmt.2010.04.007

and learn from Dr. Travell. Inspired by her teachings, he became certified as a physiatrist and started examining and treating patients with MTrPs. He continued to work with Dr. Travell, and in 1981, they published the first MTrP hypothesis. Eventually, Dr. Simons became the driving force behind writing the Trigger Point Manuals, which have been translated into many foreign languages. Perhaps the words of Hugh Elliot offer a good characterization of our mentor, friend, colleague and teacher Dave Simons: “I am not dying, not anymore than any of us are at any moment. We run, hopefully as fast as we can, and then everyone must stop. We can only choose how we handle the race.” Throughout his life, Dave Simons ran as fast as he could, trying to accomplish as much as possible. At age 85, he started writing a book about global warming out of concern for the well-being and future of the world. When asked why he would take on such an endeavor, he replied that since there are now enough clinicians and researchers in the world carrying on MTrP research and clinical practice, he was no longer concerned that MTrPs soon would be forgotten. “I think I can serve the world better by explaining the real threat of global warming,” he explained. In 2009, he decided not to publish the book after all, but the energy and fervor he displayed was truly inspiring. Instead, he returned to work on the next edition of the Trigger Point Manuals, which he continued until just a few days before his death. Dave Simons will be remembered by doctors, physical therapists, chiropractors, osteopaths, massage therapists, body workers and many other healthcare providers worldwide. His work has and will continue to inspire researchers and clinicians. Every day, thousands of clinicians treat even more thousands of patients based on the works by Travell and Simons. It gave David great pleasure realizing that so much unnecessary suffering was relieved as a result of his endeavors. It seems likely that in his next adventure, David Simons will once again reach new heights and continue to amaze us.

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INTERVIEW

Research and osteopathy: An interview with Dr Gary Fryer by Helge Franke Helge Franke*

Received 19 August 2009; received in revised form 12 January 2010; accepted 16 January 2010 Dr Gary Fryer is a Senior Lecturer at Victoria University, Melbourne, and Research Associate Professor with the A.T. Still Research Institute, Kirksville, Missouri. He graduated in 1991 and practiced osteopathy in Melbourne, Brisbane and rural Victoria. Dr Fryer has been extensively involved in osteopathic education and research. In 2007, he joined the A.T. Still Research Institute in Kirksville, Missouri, the birthplace of osteopathy, where during a two-year period he conducted research with and taught osteopathic manipulative medicine as Adjunct Assistant Professor at Kirksville College of Osteopathic Medicine. Dr Fryer has authored many articles in peer-reviewed journals, several book chapters, and has been an invited speaker at osteopathic conferences in the United States, United Kingdom and Europe.

Question: The English osteopath Eyal Lederman, said to me in an interview, that osteopathy lacks 50 years of research. Would you agree with that perception? Yes, I agree. I think the profession became complacent following the pioneering research of Denslow, Korr and colleagues in the 1940s and 1950s (Denslow and Clough, 1941; Denslow and Hassett, 1942; Denslow et al., 1947; Korr et al., 1962). The interpretation of these studies suited the profession, and many believed the osteopathic paradigm was proven and further research was not a priority. This early body of work (paraspinal electromyography [EMG] and

* Correspondence. E-mail address: [email protected]

electrical skin resistance) was groundbreaking in many ways and appeared to support the osteopathic paradigm, but by today’s standards it falls short in terms of methodology and analysis. These studies are often cited as demonstrating objective evidence of somatic dysfunction and supporting the rationale of osteopathic manipulative treatment (OMT), but most of them did not directly investigate palpatory findings or the effect of manipulation, and their results have not been re-examined or verified by later studies. I think it was unfortunate that there was little follow-up to this work and that a research culture did not develop in the osteopathic profession. We now see considerable research in the wider field of manual medicine, but the osteopathic profession cannot be considered at the cutting edge in many of these research areas. I have been interested in Denslow and Korr’s pioneering work at Kirksville, but the question of abnormal EMG activity associated with tissue texture abnormality is still uncertain. At the A.T. Still Research Institute, we have been examining intramuscular EMG activity associated with palpatory findings, but e unlike a previous study (Fryer et al., 2006) e have so far been unable to verify any abnormal EMG activity that might account for the abnormal texture at rest (Fryer et al., in press). Interestingly, years after the original EMG study, Denslow reported that abnormal spontaneous activity was not consistently detected on further attempts to reproduce his earlier findings (Denslow, 1975). My feeling is that these tissues appear abnormal due to increases in tissue fluid either from tissue inflammation or secretion of proinflammatory compounds. We have also been examining the EMG response of deep paraspinal muscles from various manual interventions and are currently processing and analysing these results.

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Research and osteopathy Although evidence exists that supports the plausibility of muscle dysfunction associated with minor trauma to the spinal segment (whether reflex contraction or inhibition, sensitized stretch reflexes, or more complex motor changes) (Fryer et al., 2004a,b), we still lack convincing research demonstrating that what we palpate is clinically meaningful. In other words, as a result of palpation, do we find things that are related to pain and dysfunction, that occur less frequently in people without pain or dysfunction, and that are reduced or eliminated by treatment? There is also a need to continue to investigate whether OMT produces relevant physiological and clinical outcomes. On the positive side, I think the osteopathic profession understands the importance of research e both politically and for improving patient care e and there are a growing number of small clinical trials examining osteopathic management of a range of patient complaints and conditions, somatic and non-somatic, and a small number of larger multicentre trials.

Question: Between A.T. Still and today are more than 100 years of development in medicine. In view of new knowledge over this time does it make sense to refer to A.T. Still when asking therapeutic questions? A.T. Still saw a connection between disturbed structure and altered function and through practical experience found that he could influence his patients’ health using manual techniques. I think in many ways we have moved on from Still’s original beliefs, particularly in regard to the physiological mechanisms underlying manipulative therapy. I see relevance in recalling Still’s words for historical perspective and to remind us to look at many aspects of the body (fascia, nerves, fluids, etc) and to not become too orthopaedic or pharmaceutically based. However, I don’t count myself among those who believe that scrutiny of Still’s books will reveal hidden meanings or secrets from the past. Although the structure/function interrelation concept has taken a beating from some quarters, I don’t think it should be dismissed entirely, but there are limits to its applicability. On one level, the connection is self-evident, such as the relationship between poor posture and mechanical strain on tissues, where altered structure results in physiological changes like inflammation or nociception. The possibility that mechanical strain on tissues alters cell physiology is also becoming evident from the process known as mechanotransduction, where fibroblasts have been shown to respond to mechanical forces, changing their physiological processes and even gene expression. This process raises potential new support for structure/ function interaction although the clinical implications of this research are still speculative. As a result of the increasing research and resulting knowledge of pain processing and pain pathophysiology, however, we have reason to further limit the general applicability of the structure/function interrelation concept. The process known as central sensitization may occur in response to a bombardment of noxious input, resulting in neuroplastic changes in the dorsal horn and higher centres to produce long term sensitization of

305 nociceptive pathways. The functional and structural changes in the nervous system result in hyperalgesia and allodynia, the later being pain evoked by stimuli that would not normally be painful. The peripheral tissue injury may resolve completely, but the neuroplastic changes e and the symptoms e remain as a source of pain generated entirely by the nervous system, which appears to be the process underlying many cases of chronic pain. There may also be effects on the peripheral tissue site because the activated nociceptors may secrete pro-inflammatory peptides, enhancing tissue inflammation. Additionally, these central processes may involve changes to motor strategies, activating and inhibiting different muscle groups. The osteopath typically works with the understanding that tissue tenderness and abnormal texture to touch or motion indicate tissue pathology or dysfunction, but in some individuals these symptoms and clinical findings may be generated by the central nervous system (allodynia and neurogenic inflammation), rather than the tissues. Add the importance of patient psychology to recovery and disability (biopsychosocial approach), and the violations to the structure/function interrelation paradigm may be substantial. How we determine that the structure/function concept is relevant in certain instances but not in others is an area that needs closer attention and exploration. Perhaps clinical experience is important for recognising patients who may respond better to treatment, but e from a scientific perspective e this is yet to be determined.

Question: You prefer the term ‘‘evidenceinformed therapy’’ in osteopathy instead of ‘‘evidence-based medicine’’. What is the difference? Due to the lack of high-quality research evidence in osteopathy, we cannot ‘base’ practice on evidence, or we would end up doing very little. I suspect there will never be a time when we can base every aspect of treatment on research literature because it is hard to imagine that there would ever be high-quality evidence for every procedure that we use in patient consultation. Instead, we use existing evidence to inform and guide our decisions in practice e hence, evidenceinformed practice e where we assess the relevance of the existing evidence with the needs of a given patient and make decisions by integrating this knowledge with our own experience, with other forms of evidence (expert opinion, physiological rationale, etc), and with the patient’s own expectations and individual needs. In short, evidenceinformed practice is using research evidence to make informed decisions; evidence-based medicine (EBM), in the strictest sense, disregards clinical judgment and is simply not possible in view of the limited relevant evidence available. The original definition of EBM reads much more like evidence-informed medicine (‘the judicious use of current best evidence by integrating individual clinical expertise with the best available external clinical evidence from systematic research’ (Sackett et al., 1996)), but some EBM purists appear to disregard the role of clinical judgment. There is also a justifiable fear that EBM may be applied for economic reasons, rather than for best care. Evidence from randomised controlled trials addresses average results from

306 large groups and may not necessarily inform a practitioner about individual patients. A treatment found to be effective for the majority of individuals with a similar complaint may not always be best for the individual for a variety of reasons, including the aetiology of their condition, and their past experience (negative or positive) and expectations of treatment. Some approaches or techniques are likely to be more effective in the hands of particular practitioners, related to their skill and experience. It is also likely that certain treatments will have much larger non-specific effects (placebo) for some patients, and these effects should not be dismissed lightly. Hence, there remains a need for balance and integration between external clinical evidence and clinical experience, and this applies, not just to osteopaths, but to all health practitioners.

Question: Evidence-based medicine means not only that we need evidence for decisions about treatment, but also transparency in the process of a decision, a trial or a position. In short, it means we have to deal with information and decisions on treatment in a different way. Therapists have to explain what they are doing. Do you agree with that side of view? Absolutely. We have moved away (I hope) from past practices where patients were told to remain silent because they would be incapable or unqualified to ask an intelligent question to practices where we actively engage the patient with the problem, explore the options with them, and empower them to participate in the solution. I think one positive trend from the EBM movement is the availability of information to empower patients in their treatment decision-making process. Therefore, we can discuss treatment management with a patient in an honest and intelligent way (with an encouraging and positive manner while addressing any inappropriate attitudes or pain behaviours), the merits of best evidence, and the most effective treatment in the experience of the practitioner. Although not every patient wants to be empowered or active in their management, I think those who do are more likely to be compliant in their aftercare management and have a better chance of recovery.

Question: At the ‘‘Fifth International Symposium on Advances in Osteopathic Research’’ last year you said, that there is a political imperative for osteopathy to be effective. What do you mean by that? We need to demonstrate that our approach is effective (assuming that it is). In Australia, we are seeing third party payers, such as our state-based Workcover and other health insurance agencies, begin to limit payments to manual therapists, justified on the basis of EBM. Payment for ‘passive’ treatments that are not well supported by evidence is being limited, and payment for treatment without demonstrated improvement in outcomes (using a validated

H. Franke measure) is also being limited. I actually think this is reasonable and appropriate e why should the state (or anyone) pay for treatments that don’t work or have no evidence of being effective? If we do not provide evidence of effectiveness, then third party payers will progressively withdraw funding. Lack of evidence of effectiveness is also a major hindrance for emerging osteopathic professions in some countries, where clear evidence of effectiveness would greatly assist their recognition and quest for state licensing. This is not to say that we have no evidence of effectiveness. We have a moderate level of evidence for the effectiveness of OMT for low back pain (Licciardone et al., 2005) and have a growing number of small trials that support the effectiveness of OMT for a variety of conditions, such as neck pain, pneumonia in the elderly, irritable bowel syndrome, and other conditions (Noll et al., 2000; Fryer et al., 2005; Hundscheid et al., 2007; Schwerla et al., 2008; Lombardini et al., 2009). Many of these studies involve limited participant numbers and may be criticised on various methodological grounds; but it is heartening to see a renewed interest in research within the profession, and as the profession and its researchers mature, we will see larger, more convincing studies. The growth in the number of osteopathic research studies, however, presents a problem with the compilation and accessibility of evidence relevant to osteopathic management. It would be helpful to have this research collated in a form that could be easily accessible to practitioners, but I am not aware of any such repository. I have often received requests from practitioners asking what studies have been done for a particular condition or treatment. The collection of studies (not to mention the interpretation of them) can be a tedious process when no reviews exist on a subject.

Question: You said also, if a therapist knows without any doubt that a treatment will have no success it’s better he does not treat in this way. This sounds good and I think many osteopaths would agree with you. But what in osteopathy do we really know without any doubt? At this stage, there is not much that we can say without any doubt, but this is probably true of most health professions. Rather, we make decisions as to what course of action is reasonable and rational and may be supported by good external evidence. Osteopathy is not alone in its struggle to support practice with high-quality external evidence. Some researchers have estimated that approximately 13% of medical treatments are based on evidence that supports the beneficial effect of the intervention and that 46% of practice has unknown benefit (BMJ Evidence Centre, 2009). I think I also said that we do not have quality evidence that clearly helps us to select the most appropriate technique, but we are beginning to see some effort in this direction. There is moderate evidence that some techniques produce measurable short-term changes (range of motion, pain thresholds) (Clements et al., 2001; Lenehan et al., 2003; Fryer and Ruszkowski, 2004; Cleland et al., 2005; Ferna ´ndezde-las-Pen ˜as et al., 2008; Kanlayanaphotporn et al., 2009)

Research and osteopathy and evidence that osteopathic management produces improved outcomes for low back pain and certain conditions, although some of these studies are not easily generalizable to all practice situations (Noll et al., 2000; Fryer et al., 2005; Licciardone et al., 2005; Hundscheid et al., 2007; Schwerla et al., 2008; Lombardini et al., 2009). Most of this evidence supports the rationale for the use of these techniques and the conditions or situations where the techniques may be beneficial. This is not to say that they produce benefit without any doubt (nothing in the manual therapy armamentarium, or probably in mainstream medicine, could promise that), but there is a rationale based on limited external evidence for the use of these techniques to achieve certain aims. I think this is the case for high velocity, muscle energy, and a few other techniques. There is also a good case for non-manual approaches, such as addressing inappropriate pain-related behaviours, as per the bio-psychosocial model. There are many manual techniques that are currently being used that have little or no supporting evidence or established efficacy, but I think it can be appropriate to continue using them (based on personal experience and anecdotal evidence) provided they are combined with approaches that have some research or guideline support. If a technique does not have a plausible physiological rationale e in addition to a lack of evidence of efficacy e then it is appropriate to question its use. When there is clear evidence of no effectiveness or evidence of harm, then these approaches should be abandoned (of course, debate will ensue over what constitutes clear evidence of i