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 ineffectiveness versus lack of evidence of benefit); although, it is hard to cite an example because of the lack of research. The bottom line is that practitioners should use common sense and be willing to change what they do if there is good evidence to do so.

Question: From your point of view: What is the essence of art in osteopathy? This is a hard one. I change my answer every time I think about it. I think the art encompasses a range of skills. It includes the way we interact with the patient (listening ability, empathy, support, encouragement, etc) and our intuitive interpersonal responses. Then there is the art associated with palpation and manual treatment, and this aspect may largely be intuitive (not supernatural, however not resulting from analytic conscious processes, but assimilated from experience and observational cues) and may complement the analytical approach. This is probably no different from the art associated with other manual and bodywork disciplines, except perhaps the philosophical emphasis on the ‘whole body’ approach in osteopathy may help promote intuitive leaps in a whole body context (in the postural, ergonomic, or psychological spheres). But I admit when talking about art I0 m completely out of my depth!

Question: Are the art of the osteopathy and the knowledge of science necessarily contradictory? I would say complementary, rather than contradictory. The ‘art’ is the manner in which the ‘science’ is applied. For example, the science may tell us that there is short-term

307 benefit in using manipulation to the lumbar spine in low back pain; the art may include the identification of lumbar segments that appear restricted, the application of techniques (such as soft tissue used firmly enough to produce a change in compliance of the muscle mass, but not enough to provoke pain and reactive guarding), and the patiente practitioner interaction that fosters trust and confidence in the treatment, dispels irrational fear and counterproductive behaviours, and instils realistic optimism.

Question: Is it more important to be free in the therapeutic decision-making process or do osteopaths need more guidelines? I don’t have any problem with clinical guidelines provided that they are used as guidelines and do not restrict practice options. Relevant evidence is there to inform and guide our choices for the benefit of our patients. By working within the recommendations of guidelines, our treatments are more likely to be consistent with the best current research, but there should always be the flexibility to use treatments according to the judgment of the clinician (which may be based on previous experience, awareness of patient values or preferences, etc). Guidelines can provide recommendations about treatment approaches that have the best supporting evidence. Practitioners may use these guidelines to add approaches and techniques to what they already use to ensure the best patient care, rather than removing treatments that may currently have only anecdotal or theoretical rationale, but this depends on the individual situation. So I think we can benefit from guidelines without the removal of our clinical judgment or freedom to make decisions.

Question: If you compare the development of research in osteopathy in Europe, USA and Australia e what are the common points and what are the differences? Research began in the US, with early researchers, such as Louisa Burns, F.P. Millard, and Wilbur Cole. It gained momentum with the Kirksville research team, which included J.S. Denslow and Irvin Korr, in the 1940s and 1950s. After the 1960s, the momentum appears to have been lost e with the exception of a few researchers e and only in the past decade have we seen renewed interest and allocation of resources towards osteopathic research. I0 m not aware of any substantial osteopathic research efforts in the UK or Australia until relatively recently, and the same is true of Europe and Canada (particularly given the emerging state of the professions there). Lack of access to funding is a common problem for osteopathic researchers outside the US (and probably within the US). In the UK, the profession has a longer history and is more established than in continental Europe, but few researchers have access to Medical Research Council funds (the UK BEAM trial being an exception). Much of the current research consists of small-scale student projects that are limited by the funding and resources of private colleges and are complicated by an ever increasingly complex Ethics

308 approval process. On the positive side, the establishment of the National Council for Osteopathic Research in 2003 shows a commitment to research, with a number of projects on adverse events in progress. There are also a growing number of osteopathic PhDs and doctoral students. The situation in Australia is similar, with smallscale projects conducted with limited funding from osteopathic departments at state universities, but with few PhDs within the profession. The state of research in Europe and Canada shows great potential. There has been extraordinary growth in smaller clinic-based projects e often associated with the requirements of fulfilling a Master’s degree or similar e resulting in innovative and quality research. I have noticed that researchers in countries, such as Germany and Italy, often investigate treatment (with an emphasis on visceral techniques) of non-musculoskeletal conditions, which is a research area that is not as apparent in the UK or Australia. The main barriers to research in Europe are lack of access to Ethics approval committees and limited resources and funding from private colleges, but because of the post-graduate structure of osteopathic training in some countries (such as Germany), research is being performed by osteopaths with established practices in their own clinics, which does not occur in the UK and Australia because students train in undergraduate programs. There is increasing professionalization taking place in Europe, with Master’s and doctoral programs in progress in several countries. It looks very promising for the future.

References BMJ Evidence Centre 2009 How much do we know? Retrieved 14.01.2010, from http://clinicalevidence.bmj.com/ceweb/ about/knowledge.jsp. Cleland, J.A., Childs, M.J.D., McRae, M., Palmer, J.A., Stowell, T., 2005. Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial. Man. Ther. 10 (2), 127e135. Clements, B., Gibbons, P., McLaughlin, P., 2001. The amelioration of atlanto-axial rotation asymmetry using high velocity low amplitude manipulation: is the direction of thrust important? J. Osteopath. Med. 4 (1) 8e4. Denslow, J.S., 1975. Pathophysiological evidence for the osteopathic lesion: the known, unknown and controversial. J. Am. Osteopath. Assoc. 75 (4), 415e421. Denslow, J.S., Clough, G.H., 1941. Reflex activity in the spinal extensors. J. Neurophysiol. 4, 430e437. Denslow, J.S., Hassett, C.C., 1942. The central excitatory state associated with postural abnormalities. J. Neurophysiol. 5, 393e402. Denslow, J.S., Korr, I.M., Krems, A.D., 1947. Quantitative studies of chronic facilitation in human motorneuron pools. Am. J. Physiol. 150 (2), 229e238. Ferna ´ndez-de-las-Pen ˜as, C., Alonso-Blanco, C., Cleland, J.A., Rodrı´guez-Blanco, C., Alburquerque-Sendı´n, F., 2008. Changes

H. Franke in pressure pain thresholds over C5eC6 zygapophyseal joint after a cervicothoracic junction manipulation in healthy subjects. J. Manipulative. Physiol. Ther. 31 (5), 332e337. Fryer, G., Alivizatos, J., Lamaro, J., 2005. The effect of osteopathic treatment on people with chronic and sub-chronic neck pain: a pilot study. Int. J. Osteopath. Med. 8 (2), 41e48. Fryer, G, Bird, M, Robbins, B, Johnson, J. Resting electromyographic activity of deep thoracic transversospinalis muscles identified as abnormal with palpation. J. Am. Osteopath. Assoc., in press. Fryer, G., Morris, T., Gibbons, P., 2004. Paraspinal muscles and intervertebral dysfunction. Part 1. J. Manipulative. Physiol. Ther. 27 (4), 267e274. Fryer, G., Morris, T., Gibbons, P., 2004. Paraspinal muscles and intervertebral dysfunction. Part 2. J. Manipulative. Physiol. Ther. 27 (5), 348e357. Fryer, G., Morris, T., Gibbons, P., Briggs, A., 2006. The electromyographic activity of thoracic paraspinal muscles identified as abnormal with palpation. J. Manipulative. Physiol. Ther. 29 (6), 437e447. Fryer, G., Ruszkowski, W., 2004. The influence of contraction duration in muscle energy technique applied to the atlantoaxial joint. J. Osteopath. Med. 7 (2), 79e84. Hundscheid, H.W., Pepels, M.J., Engels, L.G., Loffeld, R.J., 2007. Treatment of irritable bowel syndrome with osteopathy: results of a randomized controlled pilot study. J. Gastroenterol. Hepatol. 22 (9), 1394e1398. Kanlayanaphotporn, R., Chiradejnant, A., Vachalathiti, R., 2009. The immediate effects of mobilization technique on pain and range of motion in patients presenting with unilateral neck pain: a randomized controlled trial. Arch. Phys. Med. Rehabil. 90 (2), 187e192. Korr, I.M., Wright, H.M., Thomas, P.E., 1962. Effects of experimental myofascial insults on cutaneous patterns of sympathetic activity in man. J. Neural. Transm. 23, 330e355. Lenehan, K.L., Fryer, G., McLaughlin, P., 2003. The effect of muscle energy technique on gross trunk range of motion. J. Osteopath. Med. 6 (1), 13e18. 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. Lombardini, R., Marchesi, S., Collebrusco, L., et al., 2009. The use of osteopathic manipulative treatment as adjuvant therapy in patients with peripheral arterial disease. Man. Ther. 14 (4), 439e443. Noll, D.R., Shores, J.H., Gamber, R.G., Herron, K.M., Swift Jr., J., 2000. Benefits of osteopathic manipulative treatment for hospitalized elderly patients with pneumonia. J. Am. Osteopath. Assoc. 100 (12), 776e782. Sackett, D.L., Rosenberg, W.M., Gray, J.A., Haynes, R.B., Richardson, W.S., 1996. Evidence based medicine: what it is and what it isn’t. Br. Med. J. 312 (7023), 71e72. Schwerla, F., Bischoff, A., Nurnberger, A., Genter, P., Guillaume, J., Resch, K., 2008. Osteopathic treatment of patients with chronic non-specific neck pain: a randomised controlled trial of efficacy. Forsch Komplementmed 15, 138e145.

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 Number 4 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) P. W. Tunnell DC, DACRB (Ridgefield, CT, USA) E. Wilson BA MCSP SRP (York, UK) A. Vleeming PhD (Rotterdam, The Netherlands)

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Journal of Bodywork & Movement Therapies (2010) 14, 309e311

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EDITORIAL

Italian osteopathy e An exciting European example Osteopathy in Europe e particularly in Italyeis evolving its own professional shape e independent of the long-established United Kingdom model (which is itself changing), and different from osteopathy’s roots in the USA. In the UK, since the initiation of state regulation, and the establishment of the profession’s regulating body, the General Osteopathic Council, there appears to have been an emerging trend towards a more biomechanical/musculoskeletal, evidence-based, focus for the profession. Obvious conditions such as low back pain, and neck and shoulder issues (as examples), seem to be what UK’s close to 4000 osteopaths treat, most of the time, encouraged by the GOC, and the BOA (British Osteopathic Association) the profession’s virtual ‘trade-union’. While those UK trained osteopaths who have had, as part of their training, a broader philosophical and practical exposure e for example where naturopathic subjects are part of the training, or where ‘classical osteopathy’ has been taught e still treat patients with general health conditions, this is not the direction either the GOC, BOA, or the colleges, are encouraging. In the USA the majority of DO0 s no longer employ manipulation as part of their patient care; their work being almost indistinguishable from standard medical practice. Those DO0 s who do use manual approaches in patient care are finding an ever more hostile environment in which, in many States, payment for time spent on such treatment is being denied, or drastically reduced, by health insurance providers. Participation in the 2nd Italian Congress of Osteopathic Medicine, in Rome, in June (June 17e20), demonstrated that an energetic and exciting osteopathic profession is alive and thriving in Italy (as it is in many other European countries e including Spain, France, Belgium, Austria, Germany and Russia). The conference, efficiently organised under the direction of Paulo Tozzi DO, brought together many young (mainly) Italian osteopaths, who appear to have found ways of initiating and/or collaborating in a range of research projects, details of which were presented to an enthusiastic conference audience of around 200. Two veteran American osteopaths were also presenting, Professor Michael Patterson e who in his address confirmed many of the trends discussed above e as well as Viola 1360-8592/$36 ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.07.005

Frymann DO, who continues her teaching and clinical work as she approaches 90. Dr Frymann spoke about her work with infants and neonates, some of it collaboratively with Italian osteopaths. Some of the projects reported on by Italian osteopaths (see selection of summaries below), involved only small number of patients e making it impossible to draw definitive conclusions e however what seems at least as important as the results of such studies (and arguably far more important), is the fact that they are taking place at all.

Dr Viola Frymann, Rome, June 2010

310 A dynamic Italian osteopathic profession is emerging, with an enthusiastic desire to explore osteopathic efficacy in many areas of health concern. One result is a cohort of osteopaths, whose research skills are being refined, offering new insights as to the mechanisms and methods that osteopathic treatment can produce. A brief summary of selected research reports from the Congress include:

Osteopathy in neonatology clinical approach, treatment protocol, statistical study Craighero Germano DO presented a report on 5 years of study of approximately 2000 neonates at Villa Salus Hospital in Venice. A summary report was given involving 1000 infants who had been examined and treated e 772 vaginal births and the remainder caesarean. Based on assessments of these infants the following summary of findings emerged: Infants born vaginally most commonly demonstrated lateral cranial strains and occipital and cranial axis compressions. Infants born by caesarean section demonstrated a greater head circumference with more frequent injuries to the occiput. Based on his years of experience with neonates it was suggested that “osteopathic rebalancing” might prevent adverse structural and functional developmental effects of the observed cranial distortions.

Cancer related fatigue syndrome (CRFS) Members of the research team that investigated the effects of osteopathic care given to patients with CRFS, (Gugliemo Donniaquio, Luca Brema, Marino Pietro, Patrizia Boero) reported on a study conducted at San Paolo Day Hospital, Savona, Italy. The study was conducted by 6th (i.e. final) year osteopathic students from the European School of Medical Osteopathy in Genoa, under the supervision of faculty. The aim was to evaluate whether osteopathic treatment could be helpful in producing objective and effective results in patients with CRFS. Each of the 50 cancer patients (male and female), aged between 40 and 60, received 1 h of osteopathic treatment, every 3 months for 15 months. Treatment involved a cranial osteopathic protocol, as well as “‘multidimensional technique’ involving craniosacral, visceral, somatic-structural and neurovegetative rebalancing methods”. The findings of improved CRFS-related symptoms, and life quality improvements, suggested that a larger study would be justified.

Infertility, endometriosis and osteopathy Two small trials, initiated in a collaboration between surgeons and osteopaths, were reported on. The lead osteopath involved in the study, Alexandre Belloni DO, reported that in both trials, osteopathic treatment involved “elongation, manipulation, inhibition, stimulation” following on

Editorial from “assessment for joint dyskinesia, asymmetry of myofascial tonus and posture.” In her presentation the collaborating surgeon, Anastasia Ussia MD, reported on one study, involving 4 patients, aged between 20 and 40, who had demonstrated idiopathic infertility for over 2 years, accompanied by superficial endometriosis. The osteopathically treated patients were compared with those for whom a ‘wait and see’ approach, was adopted. Three one hour, osteopathic treatments were given at fortnightly intervals. At six-month follow-up three members of the infertile group were pregnant. In a separate pilot study, five patients aged 20e45, who had previously had surgery for serious endometriosis, and who subsequently suffered persistent pain, “not attributable to gynaecological problems”, also received three one hour, osteopathic treatments at fortnightly intervals. At 6 months follow-up, two patients were pain free, and two others showed significant reductions in pain. No conclusions could be drawn due to the small numbers involved in these trials, however the researchers suggest that the encouraging results highlight a need for further studies, with the objective of developing a randomized controlled research project.

Osteopathic manipulative treatment as adjuvant therapy in patients with peripheral arterial disease (PAD.) This study (Lombardini et al., 2009), conducted at the University of Perugia, evaluated and compared endothelial function and lifestyle modifications in 15 intermittent claudication patients who received both medical and osteopathic treatment (OMT group) and 15 intermittent claudication patients, matched for age, sex and medical treatment e the control group e who received standard medical attention. Compared to the control group, the OMT group had a significant increase in brachial flow-mediated vasodilation, ankle/brachial pressure index, treadmill testing, and physical health component of life quality (all p < 0.05), assessed at 2 months and 3 months from the start of the study. A report on this research initiative was published in Manual Therapy in August 2009. Many other reports were delivered at the Rome congress, on topics as varied as:  Possible correlations between performance and rebalancing of osteopathic pivots in athletes (Feliziani C Moretti M)  Clinical and kinematic evaluation of osteopathy-vsspecific exercise in obese non-specific chronic low back pain patients (Vismara L et al)  OMT and epicondylitis (Giacomo S et al)  The importance of deglutition in athletic performance (Desiro P)  Pain in patients with spinal injuries: OMT effects associated with drug therapy (Arienti C et al)  Dynamic Ultrasound evaluation of sliding motion of organs related to fascia layers, before and after osteopathic techniques are applied (Bongiorno D Tozzi P) These examples of research initiatives from Italy suggest a bright future for osteopathy in that country.

Editorial

Reference Lombardini, R., et al., 2009. The use of osteopathic manipulative treatment as adjuvant therapy in patients with peripheral arterial. Man. Ther. 14 (4), 439e443.

311 Leon Chaitow, ND DO 144 Harley Street, London W1G7LE, United Kingdom E-mail address: [email protected]

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CONFERENCE REPORT

Lessons from the conference: “Highlighting Massage Therapy in Complementary and Integrative Medicine” Geoffrey M. Bove, DC, PhD a,*, Susan L. Chapelle, RMT b,1 a University of New England College of Osteopathic Medicine, 208A Stella Maris Hall, 11 Hills Beach Road, Biddeford, ME 04005, United States b Squamish Therapeutic Massage, #108-41105 Tantalus Road, Squamish, BC V8B-0A8, Canada

Received 4 June 2010; accepted 4 June 2010 A landmark conference, Highlighting Massage Therapy in Complimentary and Integrative Medicine, was held in Seattle, Washington, on May 13the15th, 2010. The conference was designed to address the status of research related to massage therapy, as well as to have an open discussion regarding attitudes towards research and professional issues. Leaders from diverse manual therapy professions presented interesting and important data. The itinerary and summaries of the meeting can be found at http://www. massagetherapyfoundation.org/researchconference2010. html. In this brief report, rather than summarizing the presentations, we will share a combination of our observations and impressions, as well as suggestions for the direction of massage therapy research. Diana Thompson, LMP, opened the conference by stressing the need for mutual respect and collaboration between clinicians and researchers, and pointed out the overarching need to determine possible mechanisms of action of massage therapy. Helene Langevin, MD, re-emphasized the need for mechanistic understanding. Perhaps more importantly, she

* Corresponding author. Tel.: þ1 207 602 2921 (Lab); fax: þ1 207 602 5931. E-mail addresses: [email protected] (G.M. Bove), slchapelle@me. com (S.L. Chapelle). 1 Tel.: þ604 567 2666.

pointed out that the majority of treatments provided by massage therapists are for conditions where the etiologies are unknown. While this is true for other providers as well, it is a critical point, and is not usually discussed. If we do not know the etiologies of the problems we are treating, how can we design treatments based on anything but experience? And if a treatment works, can we move backwards to the etiology? Moreover, how can we look for mechanisms without etiologies? These are critical questions to think about and discuss. Dr. Langevin also discussed that while the histology of connective tissue is well understood, the physiology of it is not. It is commonly held that connective tissues are passive. She presented evidence that undifferentiated and pluripotent fibroblasts within connective tissue respond to stresses by migration to injured areas, where they transformation into contractile elements. More data presented showed that fascia is innervated with neuronal processes consistent with those that may mediate pain (such innervation is present in virtually all other structures). Such neurons “police” the structures they are in and mediate inflammatory responses. Dr. Langevin concluded by showing that the thoracolumbar fascia in humans with back pain is thicker than in humans without back pain. While preliminary, these data in combination document that fascia is not only responsive to stresses, but is more so in pathological states. These data have the potential to form a foundation for much future research into the mechanisms of back pain and its treatment.

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Lessons from highlighting massage therapy

Helene Langevin, MD

Dan Cherkin, PhD, shared data from his recent studies. In a study of acupuncture compared to massage, it was shown that massage therapy led to better outcomes. In another study, both “relaxation” and “structural” massage therapy improved function for back pain patients better than normal care. These data constitute good evidence that massage therapy has significant effects for low back pain, and needs further research. Dr. Cherkin pointed out that critical issues such as provider type and training, dosage, technique, and patient type need to be addressed. Willem Fourie, PT, discussed the use of manual therapy in recovery from breast cancer, specifically post-surgical scarring due to mastectomy, which very often leads to chronic pain and lymphedema. The current lack of understanding of the response of connective tissues to surgery became clearer, as did the potential role of manual therapists in post-surgical complications. Mr. Fourie included data from Antonio Stecco to stress the importance of inflammation in surgically disrupted connective tissue. Research into the physiology of postsurgical complications and the effects of treatments directed to the scarring are necessary and seem to be of high priority. This is an excellent example of where therapists could be and should be directly involved in all facets of both laboratory and

Willem Fourie, PT

313 clinical efforts. This particular area seems fertile for studying the potential effects of manual therapy at a cellular level. The first panel discussion involved public health and professional issues that are critical to massage therapy research. It was presented that although there are many thousands of massage practitioners, and that more than 8% of the US population uses their services, the educational standards and licensing of massage practitioners are diverse. The discussion also involved questions of whether massage therapy is a profession or a discipline. Should massage therapy work towards integration into mainstream healthcare, or should it remain largely separate? In many provinces in Canada, massage therapy has enjoyed the respect of being a registered health care profession. Massage therapists in three provinces are governed by the same rules and regulations as other health care providers, and this allows for accountability within the system. In the USA, the licensing is inconsistent between states, and there remain a few states without licensing. The discussion supported the efforts of the associations and educators to standardize education. Such efforts would be expected to lead to uniform licensing, and would also increase the possibility of developing more extensive and collaborative research efforts. The second panel discussion emphasized “translational research.” This phrase is now used along with “from bench to bedside” to describe the reciprocal need of sharing information between the clinic and the laboratory. For clinical science to advance most efficiently, clinicians will need to better inform scientists of their pressing questions, and the scientists will need to develop clinically relevant approaches to answer these questions. Such communication is typically initiated during meetings such as this one. In the breakout sessions, science related to massage therapy was presented. Space does not allow coverage of each presentation. The diversity of the backgrounds of the presenters was striking, and consisted of professional researchers as well as practitioners giving their first presentations. We applaud the newcomers, who should inspire others to feel confident to make such an effort. In the first session, challenges in methodological designs were clearly presented, and this seemed to be somewhat of a revelation to the audience. The presentations accentuated that performing meaningful research is very difficult, time consuming, and expensive, and that a supportive, collaborative, and multidisciplinary environment is of utmost importance. A presentation by Laurel Finch, LMT, CNMT was more about the process than the data, and we found this most inspiring. She reminded us that the foremost skills for performing research are tenacity and the belief that one can succeed. This research meeting for massage therapy can be considered a call to arms for the profession. However, many challenges need to be overcome. We see the two major challenges as being funding and formal education. Funding remains a primary problem for massage therapy research, as it is for all research. In the US, the National Institutes of Health has designed grant mechanisms specifically for manual therapy research. The funds go to the best applications as judged by peer review and the program priorities of the institute. We do not know what resources are potentially available worldwide. Organizations like the

314 Massage Therapy Foundation, as well as other smaller massage therapy associations, have made some funds available for research, despite limited resources. A general impediment to being awarded grants is that advanced degrees are required. Until a cadre of therapists attain such degrees, the profession needs to develop more partnerships with universities and laboratories interested in the effects of manual treatments as provided by massage therapists. The profession is urged to identify and sponsor interested therapists to complete advanced training in research methods. It is our belief that the massage therapy profession needs to develop a standardized education system, designed to give a deeper knowledge of anatomy and pathology as well as to promote critical thinking. Schools must seek degree-granting accreditation, necessary for academic advancement. Besides aiding research efforts, such changes will lead to deeper communication with and respect among health care professionals. Of course, all such changes will positively impact patient care, which is the ultimate goal. As for the direction that massage therapy research might take, it is clear that clinical trials based on case studies need to identify treatment effects on larger cohorts. As for

G.M. Bove, S.L. Chapelle all modalities, animal models need to be developed that resemble the conditions that massage therapists treat. The profession needs to identify research priorities through consensus to ensure that the research proceeds in the most efficient manner possible, and with the most benefit to the public health care system. Perhaps with more of an evidence base, massage therapy can enter the public health system and ultimately be supported as a health care modality for both prevention and treatment of soft tissue pathology. Luata Bray, a shaman and massage therapist, gave a beautiful closing prayer. It is fitting to quote her: “May stones be lifted from your path more easily in the upcoming years. Let us continue to lead the way in offering our communities with solid and acceptable evidence that massage therapy is indeed a medical modality for all people.” The road ahead is indeed rocky, but not impassible.

Acknowledgement Partial funding for GMB to attend the meeting was provided by Elsevier.

Journal of Bodywork & Movement Therapies (2010) 14, 315e317

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CONFERENCE REPORT

Highlighting Massage Therapy in CIM Conference: A massage therapist’s perspective Michael Hamm, LMP CCST Cortiva Institute e Seattle, 425 Pontius Ave North, Seattle, WA 98109, USA

Introduction

Major themes

In May of 2010, the second Highlighting Massage Therapy in CIM Research Conference took place in Seattle, WA. The conference attracted 350 attendees, including massage therapists, allied healthcare practitioners, researchers, and public health administrators. 291 attendees traveled from within the United States, 46 came from Canada, and a handful arrived from Australia, New Zealand, Italy, Greece, South Africa, and the United Kingdom (C. Leeders, personal communication, June 14, 2010). This article is a brief synopsis from the perspective of one attendee. Major themes are highlighted and implications discussed, but a comprehensive overview is not intended in this report.

Like any good conference, it was impossible to witness every worthwhile presentation. A brief scan of the daily agenda revealed an array of compelling subjects and thoughtful speakers. The following are four major themes that emerged:

Purpose/Intent of the Conference In organizing the conference, the Massage Therapy Foundation (MTF) had four primary goals. First was the dissemination of new research to attendees, which included clinical trials, basic mechanistic studies, educational research, case reports, and high-level reviews. Second, the MTF hoped to encourage translational research e that is, empowering both scientist and massage practitioner with knowledge from the other’s field. Third (and perhaps most interestingly), the conference was to incorporate live demonstrations of technique and thus foster more creative research design. Fourth was to facilitate productive collaborations between manual therapists and CIM researchers through focused breakout sessions and theme lunches. (Massage Therapy Foundation, 2009)

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Science as a social enterprise To the newly initiated bodyworker, it is easy to conceive of science as a monolithic entity, churning out its judgments without outside input. Conversely, a scientific investigator may imagine manual therapists as uninterested in his/her work and incapable of constructive discourse. Outgoing MTF President Diana Thompson addressed these misconceptions in her conference-opening talk by encouraging both practitioners and researchers to recognize the creative potential in both domains. She cautioned against the use of insular terminology, described the passion that underlies both kinds of work, and set a tone of mutual curiosity that carried through the conference. During a breakout session on the next day, Menard & Weeks (2010) presented qualitative interview findings on what factors give rise to successful collaborations between CIM providers and research institutions. (These include diligent preparation, personal initiative, and the persistent cultivation of funders and institutional allies.) Overall, the impression given was that a healthy massage research community includes active exchange between researchers and practitioners, and that each group must strive to be accessible to the other. Clinical findings The bulk of the content presented was focused on the effects of manual therapy in practice, and did not attempt to establish new physiological models or to redefine the

316 bodywork field. These clinical presentations spanned the range of evidence, including case reports, pilot studies, clinical trials, and high-level reviews. Haraldsson (2010) updated a 2006 Cochrane Review on massage for mechanical neck disorders, finding that positive evidence remains modest at best, and that studies must be strategically crafted to determine risk, placebo effects, optimum dosage, etc. Moyer (2010) presented a comprehensive quantitative review on cortisol reduction in massage therapy, concluding that cortisol reduction is mostly insignificant (with the major exception being children receiving multiple massage treatments), and that other mechanisms should be proposed for effects on anxiety, depression, and pain. On the other end of the evidence spectrum, a survey of recent case reports highlighted some creative approaches to examining massage in practice. This included an innovative body diagram for concisely describing massage techniques (Larson, 2010) and the use of pupil position for the accurate measurement of postural change in photographs (Goral and Burkett, 2010). Better measures lead to clearer mechanisms The basic science of bodywork can be hard to conduct with appropriate rigor. The multivariate nature of human contact e combined with a relative paucity of scientists who are also trained in manual therapy e make for an anemic literature on physiological mechanisms (Langevin 2010a). Large-scale clinical trials of massage therapy are being conducted without knowledge of how effects are produced. The result is studies whose conclusions are not useful to clinicians. Dr. Helene Langevin summarized this state of affairs with her usual clarity, portraying basic research and clinical trials as two interdependent pursuits. She specifically called for developing better biomarkers in clinical trials (Can we devise more measures that are clinically relevant, non-invasive, and predictive of therapeutic response?)(Langevin 2010b). Willem Fourie, a physiotherapist from South Africa, gave an illuminating talk on the use of ultrasound in measuring the success of manual therapy for scar tissue mobilization (Fourie 2010). In a patient recovering from shoulder surgery, Fourie showed a series of ultrasound scans taken at different times in the course of manual therapy treatment. In the early slides, Fourie pointed out a thick adhesion between superficial and deep layers, and then showed the adhesion dissipate in later scans, until it had mostly normalized. The obvious conclusion was that manual therapy was successful. “Do you agree with me?,” Fourie asked his audience, and after receiving approval from the friendly crowd, proceeded to dismantle his own prior argument. Despite the exciting findings, there were major weaknesses in his methods and the ensuing implications. The scans were taken by multiple people with varying styles of application, the scans themselves were not positioned precisely, and the visual plane of each scan varied somewhat between readings. All of these inconsistencies may have accounted for the apparent reduction in scar, and thus they severely limited the conclusions to be drawn from Fourie’s investigation. Such studies are all too common in the manual therapy field, and too often the clinicians reading those studies fail to recognize the methodological limitations. In offering his own work as a cautionary tale, Fourie exposed some of the pitfalls of incomplete outcomes measures.

M. Hamm Translational research and the future of massage science If the 2005 Highlighting conference was organized around promoting research literacy and participation, this second installment sought to make emerging research more effective. How swiftly can a published finding make its way into a typical massage practice? What makes for sound clinical reasoning? How do the various hunches of bodyworkers become testable hypotheses? Several speakers attempted to address these questions. Julie Ann Day (2010) discussed the work of Italian physiotherapist Luigi Stecco, who developed a fascial manipulation technique through the painstaking extrapolation of a central hypothesis. He proposed that the myofasciae have a proprioceptive function, and that this function is divided into discrete segments throughout the body. As more complex movements are assembled, the body uses retinacula and septa between antagonists to coordinate action. Stecco’s assertions are similar to those of later (contemporary) fascial theorists, but the specificity of his concepts allowed for meaningful histological study to be conducted. Day’s presentation was an urgent appeal to innovative clinicians to hone their treatment models into testable hypotheses. Equally urgent was the call for research that is designed with clinical relevance in mind. In a panel discussion on translational research, Leon Chaitow (2010) listed examples

Figure 1

Diane Thompson LMT and Julie Ann Day PT.

Figure 2

Geoff Bove PhD DC.

Highlighting massage therapy in CIM conference of scientific studies that fail to translate into practice. These include studies that e for practical reasons e are conducted on asymptomatic patients and/or normal tissues. In other studies, conclusions are muddled with too many variables or with clumsy research questions. Dr. Chaitow lamented the lost opportunity in such endeavors. Panelists Geoffrey Bove (2010) and Dan Cherkin (2010) both described their experiences in conducting research with a translational goal. Dr. Bove reported on the effects of mechanical stress on nerve tissue, and delineated three types of peripheral pain (nociceptive, ectopic nociceptive, and neuropathic). It became clear during Bove’s talk that our understanding of pain is undergoing rapid revision, and that the treatment models used in manual therapy must be updated accordingly. Dr. Cherkin, a researcher of low back pain, spoke of the importance of collaborative relationships during the design phase of a clinical trial, and offered a fresh perspective on placebo effects: “Placebo is a reflection of healing. We need to learn how to capitalize on it, and not [merely] control for its effects.” Once concrete findings have been published, it is important to incorporate them into practice. Whitney Lowe (2010) gave the last keynote address, summarizing the concepts from several other presentations into an insightful discussion of “knowledge translation”. The bodywork profession has a number of obstacles e educational, institutional, and cultural e to overcome if it will make full use of the evidence available to it. Lowe offered practical advice on how to manage information overload, how to read articles critically, and how to reform the continuing education model that currently prevails. At the core of the conference was an excitement about the possibility that bodyworkers can find a wider audience, build effective research collaborations, and relieve more suffering within integrative healthcare settings. Along with that excitement came a growing maturity about the role of research in clinical practice. Bodywork remains an art form, and manual therapists make frequent use of compassion and improvisation in their work. In years past, there was a suspicion among some therapists that scientific investigation would undermine the intuitive nature of bodywork. The overall impression from the 2010 Highlighting conference was that science and artistry cannot only coexist, but will thrive in each other’s presence.

317

References Day, J.A., 2010. First the hypothesis: How a biomechanical model can influence fascial anatomy research description. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA. Bove, G., 2010. Translational research panel. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA. Chaitow, L., 2010. Translational research panel. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA. Fourie, W., 2010. Translational research panel. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA. Cherkin, D., 2010. Translational research panel. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA. Goral, K., Burkett, M., 2010,). Massage-induced postural change as a mechanism of effect for reduction of anxiety: related procedures and findings from two case studies. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA Haraldsson, B.G., 2010. Massage for mechanical neck disorders: A systematic review e 2009 update. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA. Langevin, H.M., 2010a. Connective tissue physiology and its relevance to manual therapies. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA. Langevin, H.M., 2010b. Translational research panel. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA. Larson, E., 2010. Massage therapy effects in a long-term prosthetic user with fibular hemimelia. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA. Lowe, W., 2010. Knowledge translation: Key skills for highly successful clinicians. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA Massage Therapy Foundation. 2009. R13 Conference grant proposal to NCCAM, section 5: Conference plan. (PHS 398 Research Plan). Evanston, IL. Menard, M. and Weeks, J., 2010. Developing research collaborations: A “how-to” guide for CAM schools. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA. Moyer, C.A., 2010. Cortisol reductions in response to massage therapy: A comprehensive quantitative review. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA.

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FASCIA RESEARCH

How much time is required to modify a fascial fibrosis? Borgini Ercole, MD a, Stecco Antonio, MD b, Day Julie Ann, PT c, Carla Stecco, MD d,* a

Borgini Medical Center, Cesenatico, Italy Physical Medicine and Rehabilitation Clinic, University of Padova, Italy c Centro Socio Sanitario dei Colli, Physiotherapy, Azienda Ulss 16, Padova, Italy d Department of Human Anatomy and Physiology, University of Padova, Via A Gabelli 65, 35127 Padova, Italy b

Received 9 October 2009; received in revised form 18 January 2010; accepted 10 April 2010

KEYWORDS Connective tissue; Fascia; Manipulation; Plasticity; Low back pain; Manual therapy

Summary The perception of what appears to be connective tissue fibrosis, and its consequent modification during therapy, is a daily experience for most manual therapists. The aim of this study was to evaluate the time required to modify a palpatory sensation of fibrosis of the fascia in correlation with changes in levels of patient discomfort in 40 subjects with low back pain utilizing the Fascial Manipulation technique. This study evidenced, for the first time, that the time required to modify an apparent fascial density differs in accordance with differences in characteristics of the subjects and of the symptoms. In particular, the mean time to halve the pain was 3.24 min; however, in those subjects with symptoms present from less than 3 months (sub-acute) the mean time was lesser (2.58 min) with respect to the chronic patients (3.29 min). Statistically relevant (p < 0.05) differences were also evidenced between the specific points treated. ª 2010 Elsevier Ltd. All rights reserved.

Introduction Many authors (Myers, 2001; Schleip, 2003; Stecco, 2004; Hammer, 2007; Chaitow, 2008; Masi and Hannon, 2008)

* Corresponding author. Tel.: þ39 049 8272327; fax: þ39 049 8272319. E-mail address: [email protected] (C. Stecco).

suggest that trauma or overuse syndromes can alter the connective tissue and that, in particular, it could become tighter, altering its histological, physiological and biomechanical characteristics. The process that induces pathological modification of myofascial tissue is still not clear. Some authors (De Deyne et al., 2000; Matsumoto et al., 2002) suggest it could be due to an alteration of the collagen fibre composition. Others (Schleip et al., 2005, 2006; Chiquet et al., 2007; Grinnell, 2008) evidence the

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How much time is required to modify a fascial fibrosis? alteration of the fibroblasts with their transformation into myofibroblasts, while others (Whatmore and Kholi, 1974; Staubesand and Fischer, 1980; Scott, 2003; Hammer, 2007; Stecco and Stecco, 2009) suggest an alteration in the ground substance due to neurophysiological influences and changes in biochemical fluid relationships could be involved. There is some agreement that when fascia loses its pliability and becomes restricted, it could be a source of body misalignment and that, over time, this can potentially lead to poor muscular biomechanics (Barker et al., 2006), altered structural alignment, and decreased strength and motor coordination (Stecco, 2004; Fourie, 2008). Subsequently, patients may experience pain and functional deficit. It is also theorized that different manual and physical techniques could restore the normal physiological state of the fascia, but there is very little scientific evidence about the mode of action of manual therapies in general. The Cyriax method (1980) of deep transverse massage and similar manual therapies, such as the Graston Technique (Hammer, 2003, 2004) and Rolf (1963), propose modification of connective tissue mobility using the force of cross fibre friction. According to the Myofascial Release technique (Barnes, 1990), a sustained pressure applied into a restricted tissue barrier will cause this tissue to undergo histological length changes, and after 90e120 s, a sensation of perceivable release is noted and the tissue softens and becomes more pliable. Other authors claim that restoration of length and health to the myofascial tissue could relieve pressure on pain sensitive structures such as nerves (Sucher, 1993) and blood vessels (Quere ´ et al., 2009), as well as restoring alignment and mobility to the joints (Day et al., 2009). The Fascial Manipulation technique (Stecco, 2004; Stecco and Stecco, 2009) proposes to restore impeded gliding of collagen and elastic fibres within the ground substance by exploiting heat generated from the friction of deep manipulation. According to the law of Van t’Hoff (Haynie, 2001), which describes the relationship between temperature and the velocity of chemical reactions, this process could be established only if friction is applied where rigidity of the fascial tissue is perceived. By applying localized friction in an area of palpable rigidity, the therapist creates local heat and this may increase certain chemical reactions such as the attenuation of the secretion of inflammatory cytokines (Standley and Meltzer, 2008). When connective tissue is heated, it stretches more easily (Lehmann et al., 1970). However, no definitive explanation for the biomechanical bases of these transformations exists. While manual therapists often report perceptions of altered segmental tissue texture and its modification during therapy (Evanko, 2009), and correlations between changes in pain thresholds and perceived changes in tissue consistencies are at the basis of different therapies (Cyriax, 1980; Typaldos, 2002; Chaitow, 2003; Hammer, 2007; Stecco and Stecco, 2009) little direct evidence for these correlations exists (Fryer et al., 2004). Furthermore, a calculation of the mean time required for such changes to occur and the correlation between different patient subgroups with different degrees of altered fascial tissue is still lacking. De Bruijn (1984) described the application of deep transverse massage to soft tissue pain in 13 subjects. The time

319 required to produce a pain relief during application of this massage varied from 0.4 to 5.1 min, with a mean time of 2 min. Carreck (1994) evaluated the effect of a light stroking massage, applied for a total of 15 min in 20 healthy subjects, and demonstrated that this manoeuvre increased pain threshold levels, elicited by transcutaneous electrical stimulation. Kelly (1945, 1946) applied deep transverse massage for 5 min in 46 volunteers using a minimal amount of pressure that did not cause any pain and demonstrated that this particular modality did not produce a significant modification in the pain perception. The aim of this study is to evaluate the time required to modify the palpatory sensation of fibrosis of the fascia in correlation with changes in levels of patient discomfort in 40 subjects with low back pain utilizing the Fascial Manipulation technique. We selected low back pain because it is a leading cause of disability with a significant economic impact, not only on lost productivity but also on healthcare expenditures, approximately a fifth of patients will see multiple physicians in their quest for relief of low back pain (Jerymyn, 2001) and most manual therapies present specific treatment of this pathology. Furthermore, the fascial planes of the thoracolumbar fascia have been hypothesised to play a role in the pathogenesis of low back pain (LBP) (Langevin and Sherman, 2007; Schleip et al., 2007) and there is some initial evidence of correlations between altered connective tissue structures and LBP (Langevin et al., 2009), as well as preliminary studies indicating possible differences in motion between fascial layers in the thoracolumbar fascia in subjects with LBP as compared to a no-LBP groups (Fox et al., 2009). Three small areas over the thoracolumbar fascia that, according to Fascial Manipulation theory (Stecco and Stecco, 2009), are primarily involved in LBP mechanisms have been selected for treatment: - The area located at the level of the first lumbar vertebra, approximately 3 cm laterally to the spinous process of L1 for the paravertebral muscles. Note: in Table 1 this point is indicated with the abbreviation relu (retro-lumbi), which is an abbreviation used in the Fascial Manipulation technique to indicate this specific area (Stecco, 2004). - The area located at the level of the third lumbar vertebra at approximately 5 cm laterally to the spinous process of L3 for the quadratus lomborum. Note: this point is indicated with the abbreviation la-lu (laterolumbi). - The area immediately below the twelfth rib is for the latissimus dorsi, posterior inferior serrati and external oblique muscles. Note: this point is indicated with the abbreviation er-lu (extra-lumbi).

Materials and method Three operators (B.E., S.A., D.J.A.), each one with more than five years of experience in this method, analysed the time required to reduce the pain provoked during the application of this technique by half. Prior to this study, the 3 operators evaluated the three points considered for this study in 10 patients with low back pain and compared

320

B. Ercole et al.

Table 1 The main characteristics of the treated subjects and the initial and final pain, evaluated with the Verbal Numeric Scale, are reported.

a

These patients were treated only on one side because in the opposite side no fascial alteration was detected during comparative palpation.

How much time is required to modify a fascial fibrosis? fibrosis evaluation after each patient until 95% level of agreement was reached (Bland and Altman, 1986). Forty subjects suffering from acute or chronic mechanical low back pain were selected for this study. The research was conducted on 17 males and 23 females with ages ranging from 15 to 67 years (mean age 39.1 years old, SD  13.85). All of the subjects were evaluated with radiography and MRI prior to participation in this study in order to satisfy the inclusion/exclusion criteria for the study. Subjects who showed evidence of clinical neurological deficit, disc herniation, lumbar spine canal stenosis, systemic inflammatory disease such as rheumatoid arthritis, or had suffered either direct trauma or surgery to the back were excluded to avoid the possibility that excessive adherence between subcutaneous planes could influence the results of this study. Symptoms of mechanical low back pain were present for a period ranging from several months (m) to several years (y) and, in general, pain was discontinuous with recurrent exacerbating episodes being common (Table 1). In order to quantify the time required to halve the pain perceived during the application of this technique, the fasciae of three muscular groups often implicated in low back pain were chosen for treatment. These three groups include the paravertebral muscles, the quadratus lumborum muscles, and the muscles that insert onto the inferior border of the twelfth rib. Within each of these muscle groups, a small area of the fascia of approximately two square centimetres, known as the Centre of Coordination,1 was identified and evaluated. According to Fascial Manipulation methodology (Stecco, 2004; Stecco and Stecco, 2009), comparative palpation was then applied to examine all these small areas. This process involves operator skills in palpation and detection of altered fascial tissue, while simultaneously questioning the subject about perceived pain or discomfort. By means of continuous verbal feedback, the patient’s perception of pain and the palpatory sensation of fibrosis by the therapist were correlated and the most altered small area among the three evaluated points was selected. Treatment was bilateral in most cases, however, in some subjects, only a unilateral alteration of the fascia was noted. Consequently, in these cases, treatment was applied unilaterally to the altered or fibrotic Centre of Coordination. On each point selected for treatment, the operator exercised the minimal amount of pressure necessary to create friction against the fasciae of the abovementioned muscle groups. According to a previous study (Pedrelli et al., 2009), a mean force of 73.5 N over the CC of re-lu was required to produce a piercing pain sensation; in the CC of la-lu a mean force of 61.9 N and over the CC of erlu a mean force of 35.8 N. The operators all used pressure applied with the olecranon process and upper part of the ulna to perform the treatments, alternating between right and

1 A Centre of Coordination (CC) is a small area on the deep muscular fascia where force exerted by the muscular fibres of a specific region converge. The resultant myofascial forces appear to be transmitted to the surface of the deep fascia via its continuity with the endomysium, perimysium and epimysium. The CC has the role of coordinating the motor units that are located within this region.

321 left elbows according to the side of the body treated. The direction of the therapeutic manoeuvres varies according to the underlying structure: in a longitudinal direction with respect to the muscular fibres of the erector spinae (Fig. 1b); in a transverse direction for the quadratus lumborum (Fig. 1c); and in an oblique direction for the muscles below the 12th rib (Fig. 1a). All subjects were instructed how to report any experienced pain correctly, and were asked to inform the operator about the progression of pain provoked during treatment utilizing a verbal numeric scale (VNS). The verbal numeric scale (VNS) is a simple scale for the evaluation of pain, quite similar to the VAS (Visual Analogical Scale), with which it has a moderate correlation (Fosnocht et al., 2005). Subjects easily understand the VNS, as they are requested to choose a number from 0 to 10 that represents the level of their pain: zero corresponds to the absence of pain and ten corresponds to the most intense pain imaginable. This scale was chosen for this study because immediate and progressive reporting of pain levels was required and the verbal aspect was more functional than the VAS scale. Subjects were also instructed that they could ask for brief rest periods of a maximum of 10 s during manipulation to avoid extended interruptions that may have influenced results. A chronometer, which was activated at the beginning of each manipulation, was used to evaluate the time required to halve the pain according to pain levels reported by the subject. Prior to commencing treatment, the subjects were asked to report the exact moment in when either a minimal decrease or an important reduction in pain occurred. Subjects were also encouraged to report pain levels regularly (approximately every 30 s) and to indicate when the pain became less than 50% of the initial pain. All these variations in the pain/time curve were noted and reported in the Table 1. The time within which the therapist perceived a consistent change in sliding between the tissue layers was also noted. The mean value of the VNS scale measurements at the beginning and at the end of the treatment was calculated. The analysis of the differences in pain resolution among different subgroup of patients and among the three different evaluated points were compared with nonparamentric tests: KruskaleWallis test and Dunn’s multiple comparison test and ManneWhitney test for double comparisons.

Results At the beginning of treatment, the mean measurement of pain as reported by subjects was 7.9 on the most altered side and 6.7 on the contralateral side, while at the end of treatment it was of 3.2 and 3.0 respectively. The mean time necessary to reduce the referred level of pain to 50% was 3.24 min (SD 1.3), but specific differences could be evidenced among the different patients. In the subjects with sub-acute pathologies (<3 months), the mean time to halve the pain (SD) is 2.20 min (1.1), while in the chronic subjects this time increases (3.29 min  1.3). In a few cases (16%), the reduction in pain occurred slowly (>5 min), while in 36%, the reduction occurred more quickly (<2.5 min). In 54% of cases the pain diminished

322 progressively (Fig. 2), while in 46% one distinctive phase was noted (Fig. 3), with pain passing in less than 30 s from a high score (8 or 9) to a sensation of mere pressure (approximately 3). No specific correlation between a sudden or a slow reduction in pain was noted in any particular area. The therapists noted a marked increase in tissue mobility more or less at the same time the patients perceived a reduction in pain. Differences among the evaluated areas are also evident. In the CC of the fascia of the serratus posterior inferior muscle (er-lu), the mean time is 2.56 min (0.9); in the CC of the fascia over the quadratus lumborum muscle (la-lu) the mean time is 3.73 min (1.3), and in the CC corresponding to the fascia over the muscular mass of the lumbar erector spinae (re-lu) the mean time is 2.91 min (1.1). The mean time to halve the pain is different between the dominant and the opposite side, but this difference is not significant (p Z 0.355). The time to halve pain at the 75 percentile is in younger subjects (<25 years old) 3.3 min (SD  1.2 min), in adults (26e55 years) 3.8 min (SD  1.4 min) whereas in older subjects (>55 years) 3.4 min (SD  1.2 min). The statistical analysis with KruskaleWallis test does not show significant differences between younger and adult (p Z 0.833), between adult and older (p Z 0.91) and between younger and older (p Z 0.767). Also the mean time to half the pain is not statistically different (p Z 0.123) between males and

B. Ercole et al. females, in particular in males, the mean time to half the pain was 3 min, in the females 2.45 min.

Discussion This study evidenced, for the first time, that the time required to modify an apparent fascial fibrosis differs in accordance with the site and the differences in characteristics of the subjects and of the symptoms. In particular, the difference in the time to halve the pain level between sub-acute and chronic patients, and the differences between the specific small areas that were treated, was statistically significant (p Z 0.006). The therapists noted a marked increase in tissue mobility more or less at the same time the patients perceived a reduction in pain. It is hypothesised that pain reduction and increase in sliding of the tissue layers coincides with a sufficient increase in temperature that permits the transformation of the ground substance from its densified state (gel) to fluid (sol), as discussed in Introduction. It could be that an increased fluidity of the extracellular matrix permits the nerve endings within the fascia to adapt to the pressure exercised by the therapist, resulting in a reduction in perceived pain. Both the right-sided (re-lu, la-lu, er-lu) and the leftsided area were often (87.5%) palpably altered in the same subject, even though the time for the pain to be halved in

Figure 1 A: Centre of Coordination of ER-LU, localized over the inferior border of the twelfth rib, where the fasciae of latissimus dorsi, posterior inferior serrati and external oblique muscles join together. B: Centre of Coordination of RE-LU, located over the fascia of the paravertebral muscles at the level of the first lumbar vertebra, approximately 3 cm laterally to the spinous process of L1. C: Centre of Coordination of LA-LU, located over the fascia of the quadratus lumborum muscle, at the level of the third lumbar vertebra, approximately 5 cm laterally to the spinous process of L3. D: schematic representation of the localization of the three Centres of Coordination considered in this study.

How much time is required to modify a fascial fibrosis?

Figure 2

Pain level vs time graph, overlaid for each of the subjects that had a slow decrease of the pain.

the two areas was not always the same. While this difference is not statistically significant (p Z 0.355) it could nevertheless signify that the fasciae, on the two sides of the body, may not always be altered in the same manner. These differences could cause postural imbalances, determining involvement of different muscle groups. Tensional anomalies caused by fascial alterations do not usually cause pain within the muscular fascia itself but could alter joint movements, causing pain at this level. Pain associated with mechanical low back dysfunction is often felt in the lumbosacral region, which is an important pivot zone for the lumbar muscles, however, according to the biomechanical model adopted in Fascial Manipulation, the areas of the fascia that require treatment are generally located at a distance from the site of pain.

Figure 3

323

There are not statistically significant differences in the duration of the treatment between young, adult and old patients and between males and females. Different studies have highlighted the atrophy of paraspinal, quadratus lumborum, psoas and, most prominently, multifidus muscles in chronic low back pain (Kamaz et al., 2007; Hides et al., 2008a,b), although the paraspinal component is arguable (Kalichman et al., 2009). Other studies show evidence of atrophy of multifidus in chronic neck pain (Ferna ´ndez-de-las-Pen ˜as et al., 2008) as well as a reduced capacity to perform voluntary isometric contractions in some of these muscles (Wallwork et al., 2009). This does appear to be a localized phenomenon and asymmetry between sides in chronic LBP patients presenting with a unilateral pain distribution has been evidenced (Hides

Pain level vs time graph, overlaid for each of the subjects that had a sudden decrease of the pain.

324 et al., 2008a,b). Therefore, it is probable that on palpation the muscular structure of these sub-groups is very different. While motor control impairment is an important aspect in chronic low back pain, this study has focused on the overlying fascia, and its response to localized pressure. Apart from Langevin et al.’s study (2009), which focused on an area 2 cm lateral to the midpoint of the L2-3 interspinous ligament, in literature, specific studies analysing eventual variations of the fasciae, for example in thickness or resistance, among different groups and subgroups are still lacking. Our present study highlighted the differences in time as indicated by Cyriax (Stasinopoulos and Johnson, 2004) for the mobilisation of tendons (about 15 min), as compared to the time required to halve the pain and to apparently produce a palpable difference in the connective tissue by acting specifically on altered fascia (3 min). According to the Fascial Manipulation technique (Stecco, 2004; Stecco and Stecco, 2009), a tendinous irritation or inflammation is often a consequence of poorly coordinated muscle fibre recruitment, and emphasis is given to identifying small areas of altered fascia as the possible cause. In general, a connective tissue alteration is not an isolated phenomenon but distributes along muscle chains or myofascial sequences. Therefore, where necessary, it is important to act along the different points of a dysfunctional chain in the same treatment session. If therapists are able to re-create a global balancing of connective tissue mobility, then it is possible to have interesting results with a single session of Fascial Manipulation. Certainly, the perceived pain that is experienced at the beginning of the treatment is a relatively negative aspect and clinical research exploring less painful alternatives is encouraged. Nevertheless, rapid and effective resolution of chronic low back pain is advantageous. All subjects were advised about procedure prior to commencement and were active participants during all phases of treatment. In our experience, when the technique is applied appropriately, exercising a focused pressure and respecting the individual levels of pain tolerance and general health condition, the benefits from this type of treatment often outweigh the disadvantages of the discomfort experienced. The role of psychological distress in these patients was not evaluated. Further studies are necessary to evaluate if an alteration in central nervous system processing (such as somatisation, anxiety, depression), often evident particularly in chronic pain groups, may have had bearing on the outcomes.

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325 Schleip, R., 2003. Fascial plasticity, a new neurobiological explanation: part I. Journal of Bodywork and Movement Therapies 7, 11e19. 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. Medical Hypotheses 65, 273e277. 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. Medical Hypotheses 66, 66e71. Schleip, R., Vleeming, A., Lehmann-Horn, F., Klingler, W., 2007. Letter to the editor concerning “A hypothesis of chronic back pain: ligament subfailure injuries lead to muscle control dysfunction” (M. Panjabi). European Spine Journal 16, 1733e1735. Scott, J.E., 2003. Elasticity in extracellular matrix ‘shape modules’ of tendon, cartilage, etc. A sliding proteoglycan-filament model. The Journal of Physiology 1, 335e343. Standley, P.R., Meltzer, K., 2008. In vitro modeling of repetitive motion strain and manual medicine treatments: potential roles for pro- and anti-inflammatory cytokines. Journal of Bodyweight and Movement Therapies 12, 201e203. Staubesand, J., Fischer, N., 1980. The ultrastructural characteristics of abnormal collagen fibrils in various organs. Connective Tissue Research 7, 213e217. Stecco, L., 2004. Fascial Manipulation. Piccin Ed, Padova. Stecco, L., Stecco, C., 2009. Fascial Manipulation: Practical Part. Piccin Ed, Padova. Stasinopoulos, D., Johnson, M.I., 2004. Cyriax physiotherapy for tennis elbow/lateral epicondylitis. British Journal of Sports Medicine 38, 675e677. Sucher, B.M., 1993. Myofascial release of carpal tunnel syndrome. Journal of the American Osteopathic Association 93 (92e4), 100e101. Typaldos, S.P., 2002. Clinical and Theoretical Application of the Fascial Distortion Model within the Practice of Medicine and Surgery, fourth ed. Typaldos Publishing Company. Wallwork, T.L., Stanton, W.R., Freke, M., Hides, J.A., 2009. The effect of chronic low back pain on size and contraction of the lumbar multifidus muscle. Manual Therapy 14, 496e500. Whatmore, G.B., Kholi, D.R., 1974. The Physiopathology and Treatment of Functional Disorder. Grune & Stratton, New York.

Journal of Bodywork & Movement Therapies (2010) 14, 326e333

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

CLINICAL METHODS

The effects of manual treatment on roundedshoulder posture, and associated muscle strength* Christopher Kevin Wong, PT, PhD, OCS a,*, Denise Coleman, PT, DPT b, Vincent diPersia, PT, DPT c, Judi Song, PT, DPT d, Dennis Wright, PT, DPT, ATC/L e a

Columbia University, 710 West 168th Street, NI8, New York, NY 10032, USA New York Presbyterian Hospital, New York, NY, USA c Palisades Rehabilitation Center, Cresskill, NJ, USA d New York City Department of Education, New York, NY, USA e One-On-One Physical Therapy & Sports Rehabilitation, Brooklyn, NY, USA b

Received 9 January 2009; received in revised form 30 April 2009; accepted 3 May 2009

KEYWORDS Posture; Strength; Pectoralis minor; Soft tissue mobilization

Summary A relationship between pectoralis minor muscle tightness and rounded shoulder posture (RSP) has been suggested, but evidence demonstrating that treatment aimed at the pectoralis minor affects posture or muscle function such as lower trapezius strength (LTS) remains lacking. In this randomized, blinded, controlled study of the 56 shoulders of 28 healthy participants, the experimental treatment consisting of pectoralis minor soft tissue mobilization (STM) and self-stretching significantly reduced RSP compared to the pre-treatment baseline (Friedman test, p < .001) and the control treatment of placebo touch and pectoralis major self-stretching (ManneWhitney U-test, p < .01). RSP remained significantly reduced 2 weeks after the single treatment. Both control and experimental treatments resulted in increased LTS (Friedman test, p < .01) with no significant difference in LTS noted between treatments (p > .05). This study demonstrated that STM and self-stretching of the pectoralis minor can significantly reduce RSP. ª 2009 Elsevier Ltd. All rights reserved.

* This study was completed at: Touro College, 27-33 West 23rd Street, New York, NY 10010, USA. * Corresponding author. Tel.: þ1 212 305 0683; fax: þ1 212 305 4569. E-mail address: [email protected] (C.K. Wong).

Introduction The habitual slouched postural common in everyday tasks can be brought on by, or lead to, rounded shoulder posture

1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.05.001

The effects of manual treatment on RSP, and associated muscle strength

Possible clinical relevance:  Soft tissue mobilization and stretching of the pectoralis minor muscle can reduce rounded shoulder posture.  Soft tissue mobilization and stretching of the pectoralis minor muscle is no more effective than passive touch and pectoralis major stretching in increasing lower trapezius muscle strength.  The 2.5 cm threshold for the supine measure of rounded shoulder posture may not detect dysfunction.

(RSP) (Magee, 1992; Chansirinukor et al., 2001). Characterized by protracted, downwardly rotated, and anteriorly tipped scapula position with increased cervical lordosis and upper thoracic kyphosis, RSP has been identified as a predisposing factor leading to upper quarter pain (Greenfield, 2001; Greenfield et al., 1995; Sahrman, 2002; Wang et al., 1999; Lukasiewicz et al., 1999). The cause of RSP is multifactorial. One factor that can contribute to RSP is tightness of the pectoralis minor muscle (Wang et al., 1999; Sahrman, 2002; Lukasiewicz et al., 1999; Borstad and Ludewig, 2005), which can occur with decreased scapular posterior tilt, retraction, and upward rotation during arm raising (Lukasiewicz et al., 1999). Treatment for a tight pectoralis minor is an important component in the rehabilitation of those with shoulder pathology and RSP (Sahrman, 2002; Kisner and Colby, 1990). Treatments suggested for RSP include stretching (Lukasiewicz et al., 1999; Wang et al., 1999; Kisner and Colby, 2002) and soft tissue mobilization (STM) to restore pectoralis minor length (Cantu and Grodin, 2001; Andrade and Clifford, 2001). Strengthening of the lower trapezius and serratus anterior muscles have also been used to actively counteract the strength and movement loss associated with RSP (Ekstrom et al., 2003; Ludewig et al., 2004; Hall, 2005; Smith et al., 2002). However, the effect on RSP of stretching, strengthening, or STM directed to the pectoralis minor muscle remains unknown. The scapular position related to RSP has been measured using x-rays (Greenfield et al., 1995) and with two- and three-dimensional video analysis (Plafcan et al., 1997; Johnson et al., 2001). Clinicians, however, need a reliable physical assessment method to utilize in a clinical setting. A supine method has been described using the distance of the acromion to the supporting table as a simple measurement for RSP (Kendall et al., 1993; Magee, 2002; Sahrman, 2002). While questioned as a measure of pectoralis minor muscle length (Borstad, 2005; Lewis and Valentine, 2007), use of the supine measure as an assessment of scapular position related to RSP has been demonstrated to have good reliability (ICC > 0.90) in both symptomatic and non-symptomatic shoulders (Lewis and Valentine, 2007). The supine RSP measure has also been shown to be comparable to a seated method of scapular posture assessment (Wang, 2006), but should be performed in a consistent degree of humeral rotation position for consistency (Borstad, 2006). The purpose of this study was to determine the effects of STM and self-stretch of the pectoralis minor muscle on

327

RSP and lower trapezius strength (LTS) compared to passive placebo touch and self-stretch of the pectoralis major muscle.

Methods Design Individual shoulders of each participant were considered separately and randomly assigned to the control or experimental group, using a random number table. Participants attended three sessions with 1e7 days between the first and second session, and 2 weeks between the second and third or follow-up session. The first session included completion of a questionnaire and an assessment for RSP and LTS of each shoulder. On the second session, the following were applied to each shoulder: (1) RSP and LTS measurements; (2) the experimental or control treatment; and (3) repeated RSP and LTS measurements. The follow-up outcome measures of RSP and LTS were reassessed on the third session 2 weeks later. One investigator provided all manual interventions and additional investigators provided self-stretch instruction and supervision. Investigators providing treatment did not perform assessments; investigators performing assessments were blinded to group assignment. Separate investigators assessed RSP and LTS without knowledge of each other’s findings and all investigators were blinded to past results. In addition, participants were blinded to the assignment of their shoulders to the control or experimental group. A research coordinator kept the confidentiality of all data and maintained the blinded environment by guiding participants to and from separate treatment rooms.

Study sample Volunteer participants of either gender between the ages of 20 and 40 years old were recruited from a college campus by announcement for this study. Participants were included if they exhibited RSP, as indicated by a distance 2.5 cm from the posterior aspect of the acromion to the table in supine (Sahrman, 2002). Participants were excluded if they had shoulder pain, pathology, or history of shoulder surgery; neurologic or cardiac symptoms; or prescriptions for any medication that altered muscle function. All participants gave informed consent before participating in this study, approved by the Institutional Review Board of the Touro College School of Health Sciences in New York, and participated without expectation of compensation or credit. In total, the study sample included 28 healthy participants with 56 shoulders. Individual shoulders were treated as independent entities and randomized to experimental or control groups. As a result, six participants had both shoulders assigned to the experimental condition, three had both shoulders assigned to the control condition, and 19 had one shoulder in each condition. Sagital plane scapular position has been demonstrated to vary between asymptomatic and symptomatic subjects with a difference between mean seated RSP of 7  2.5e3.2 mm respectively (Lewis et al., 2005). Scapular position has been shown to

328 influence isometric shoulder strength in healthy volunteers measured in kilograms with mean differences of 2.6e3.3 kg with standard deviations of 3.3e4.0 kg between the neutral and protracted or retracted positions (Smith et al., 2002). For the purposes of power analysis, expected mean changes and standard deviations based on these studies were used with a two-tailed power analysis with power set at 80%, a Z .05, and common standard deviation of 5 kg/mm, revealing that 25 shoulders were needed for each group to demonstrate a significant difference for a potential treatment effect size of 4 kg LTS strength or 4 mm RSP. The sample size of 56 shoulders was considered sufficient with 25 shoulders assigned to the control and 31 to the experimental groups.

Measures The demographic, anthropometric, and activity related information of each participant was collected by questionnaire. Rounded shoulder posture (RSP) With the participant lying at rest in supine on an unpadded examination table, scapular position related to RSP was measured with the shoulder positioned in neutral to avoid measurement variations due to humeral rotation (Borstad, 2006). The investigator palpated and marked the height from the examining table to the posterior aspect of the lateral acromion process on an unmarked plastic right angle positioned perpendicular to the table surface as described by others (Kendall et al., 1993; Lewis and Valentine, 2007; Magee, 1992; Sahrman, 2002). The distance was then measured using a separate straight ruler and recorded in millimeters. It has been noted that the supine RSP measure does not correlate well with an index of pectoralis minor length (Borstad, 2006) nor is the RSP measure an effective diagnostic predictor of shoulder symptoms (Lewis and Valentine, 2007). The current study, however, used the supine RSP measure as a measure of scapular position not of pectoralis minor length. In a study that assessed the concurrent validity of the supine RSP measure and a seated assessment of scapular posture, no significant difference between the measures of RSP was observed (Wang et al., 2006). Lower trapezius strength (LTS) To assess LTS, the participant was positioned in supine with hips and knees flexed to approximately 45 and 90 degrees respectively, the chest strapped to the table through the lowest anterior ribs, the shoulder positioned in 160 degrees flexion and abduction using a standard goniometer, the elbow extended, and the distal forearm just proximal to the posterior wrist placed in contact with the padded digital muscle tester (Liebler et al., 2001). The MicroFET2 Muscle Tester (Kom Kare Company, Middletown, OH), which is reported to be accurate with a 2% error for up to 150pound loads (http://www.rehaboutlet.com/manual_ muscle_test.htm, accessed 12/21/2008) was securely mounted on an adjustable platform that allowed the described arm position. A practice trial was performed to familiarize the participants to the testing method, followed by a 1 min rest. A different investigator then used the standard verbal directions ‘‘press as hard as you can’’ and

C.K. Wong et al. recorded the LTS measurement after the participant pressed against the digital muscle tester for 3 s for each shoulder with 10 s rest between two repetitions. The highest value was recorded as the peak strength. One study that reported LTS measure intra-rater reliability of ICC2,1 Z .89, also demonstrated significant construct validity with significantly greater lower trapezius muscle activity observed in the LTS test position compared to the upper and middle trapezius muscle testing positions (Michener et al., 2005). Reliability The reliability of pre-treatment RSP and LTS measurements from separate days of this study for all shoulders were analyzed using intraclass correlation coefficients (ICC) for absolute agreement of single measures with 95% confidence intervals using SPSS version 16.0. Portney and Watkins have suggested that ICC values above .75 indicate good reliability (Portney and Watkins, 1993, p. 514). Thus, the inter-day intra-rater reliability of the supine RSP measure in this study (ICC2,1 Z .80, 95% CI Z .68e.88) was considered good, although less than that of two studies (ICC3,1 Z .88e.93) that used the same RSP measure (Wang et al., 2006; Lewis and Valentine, 2007). Inter-day intra-rater reliability of the LTS measure (ICC2,1 Z .87, 95% CI Z .79e.92) was also considered good and comparable to previously reported intra-rater reliability (ICC Z .80e.95) for other shoulder muscle strength measurements using digital muscle testers (Phillips et al., 2000; Magnusson et al., 1990; May et al., 1997; Bohannon, 1990).

Treatments The experimental group received STM and performed stretching to the pectoralis minor muscle. The control group received passive light manual placebo touch and performed stretching to the pectoralis major muscle. All manual procedures were performed by a single licensed physical therapist certified as an orthopedic clinical specialist by the American Board of Physical Therapy Specialties. Self-stretch exercises were instructed and supervised by separate investigators. Experimental treatment For the STM portion of the experimental treatment, the participant was positioned in supine, anterior shoulder and chest exposed, and arm at the side. The STM procedure consisted of strumming perpendicular to the pectoralis minor muscle with the physical therapist’s fingers allowed to rebound across the muscle belly in a constant rhythm (Johnson, 2001, p. 597), producing muscle play or movement from side to side (Godges et al., 2003; Cantu and Grodin, 2001). Pectoralis minor STM was performed for 3 min with a force sufficient to move the muscle from side to side to the tolerance of the participant (see Figure 1). The STM was followed by a variation of supine pectoralis minor self-stretching described by others (Hall, 2005; Borstad and Ludewig, 2006) that incorporated spine extension/ ipsi-rotation/contra-sidebending with related rib motion. In the supine position with knees bent, the legs were rotated to the floor in the opposite direction of the arm to be

The effects of manual treatment on RSP, and associated muscle strength

329

Figure 1 Hand position and depth for strumming soft tissue mobilization of the pectoralis minor.

Figure 3 Hand position for the passive manual placebo touch of the control treatment.

stretched placing a stabilizing distal tension on the ribs (Sahrman, 2002). The subject then slowly brought the arm in a circular motion overhead pausing at points of tightness, maintaining close contact to the mat (see Figure 2). Overhead arm motion facilitated scapular posterior tipping, elevation, and retraction needed to stretch the pectoralis minor (Hall, 2005; Sahrman, 2002). The stretch was held for 30 s and repeated for a total of 3 min.

Statistical analysis

Control treatment The control treatment consisted of passive placement of the therapist’s fingers on the anterior shoulder over the lateral aspect of the pectoralis major muscle. Placebo touch was held for 3 min without applying tension or inducing movement (see Figure 3). After the passive placebo touch, participants performed a modified ‘door stretch’. With elbow extended, participants placed one hand on the door at waist level and leaned gently through the door, in a stretch intended to affect primarily the clavicular head of the pectoralis major (Kisner and Colby, 2002) (see Figure 4).

Figure 2 The pectoralis minor self-stretch of the experimental treatment.

The limited number of shoulders included in the sample and the finding that both initial LTS and RSP were skewed upward and tended to differ from a normal distribution (ShapiroeWilk p < .01 and p Z .06 for LTS and RSP, respectively), led to the use of non-parametric statistics in this studyda conservative choice since non-parametric tests are less sensitive than parametric tests with small samples (Portney and Watkins, 1993, p. 420). Statistical

Figure 4 The pectoralis major self-stretch or modified ‘‘door stretch’’ of the control treatment.

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C.K. Wong et al.

analysis was performed, using SPSS version 16.0 (SPSS-UK Ltd, St. Andrews House, West Street, Woking, Surrey, GU21 6EB, UK). Pre-treatment group comparisons were analyzed using ManneWhitney U-tests. To determine within-group treatment effects on the outcome measures through the post-treatment period, Friedman tests with statistical significance set at p < .05 and minimum significant differences (MSD) calculated with f Z .05 were performed. Comparisons of the between group treatment effects through the post-treatment period were performed using ManneWhitney U-tests (p < .05).

Results Descriptive data Descriptive statistics are presented in Table 1. No significant difference was found between the control and experimental shoulder groups prior to treatment. Pretreatment LTS and RSP measures revealed no significant difference between groups; means, standard deviations, and ranges for both groups were comparable. No significant change in RSP or LTS occurred in either group between the first and second pre-treatment measures (Friedman, p > .05). Overall, the control and experimental group shoulders were considered statistically equivalent prior to treatment (see Table 1). Treatment effects Experimental group RSP decreased significantly compared to the control group immediately after treatment, at the follow-up measure, and when average post-treatment measures were compared (ManneWhitney U-test: p Z .001, Z.015, <.001 respectively). The experimental group also demonstrated a significant within-group decrease in RSP (Friedman, p < .001, f < .05) compared to

Table 1

pre-treatment baseline. Immediately after treatment, experimental group RSP was significantly less than before treatment and the average post-treatment RSP was significantly less than the pre-treatment baseline. At the 2 week follow-up, RSP had increased from the immediate posttreatment RSP. Although the average RSP at follow-up was significant less than the pre-treatment baseline (Friedman, p < .001, f < .05), a significant difference in RSP could not be assumed with 95% confidence given that the confidence interval included zero (Sims and Reid, 1999). No withingroup change in RSP was observed for the control group (see Table 2). For both groups, within-group LTS increased significantly from pre-treatment to the initial post-treatment session and subsequently from initial post-treatment to follow-up session (Friedman, p < .001, f < .05). The average immediate post-treatment effect in the control group had a 95% confidence interval that included zero, however, and the chance that no difference occurred for any individual could not be excluded until follow-up (Sims and Reid, 1999). No significant difference in LTS increases existed between the groups (see Table 2).

Discussion Treatment directed to the pectoralis minor muscle consisting of STM and self-stretching significantly reduced RSP compared to the control group treatment consisting of passive placebo touch and a self-stretch of the clavicular head of the pectoralis major. While the control group RSP did not change from the pre-treatment baseline, experimental group RSP decreased significantly (p < .05) compared to the pre-treatment experimental group baseline period during which no intervention took place. The experimental shoulder group demonstrated a significant decrease in RSP immediately after treatment after

Group comparison.

Variable

Category/unit

Control

Experimental

p*

Gender

Men Women White Am African Am Asian Am Native Am Other Dominant Non-dominant 1e4 h 5e8 h 9e12 h years  SD cm  SD kg  SD kg  SD (range) cm  SD (range)

15 10 19 2 1 0 3 15 10 4 13 8 24.8  5.1 171.7  7.9 72.6  15.7 18.9  8.2 (8.9e46.1) 4.9  1.6 (2.8e8.3)

17 14 23 4 1 2 1 14 17 10 11 10 26.2  5.6 172.5  7.4 74.8  17.4 18.2  7.5 (7.6e39.8) 4.8  1.4 (2.6e9.3)

e

Race

Shoulder Daily sitting time

Age Height Weight Pre-treatment LTS Pre-treatment RSP

e

e .459

.377 .607 .608 .792 .902

Abbreviations: RSP, rounded shoulder posture; LTS, lower trapezius muscle strength; SD, standard deviation; cm, centimeter; kg, kilogram; h, hours. * denotes results of ManneWhitney U-tests.

The effects of manual treatment on RSP, and associated muscle strength Table 2

331

Treatment effects on rounded shoulder posture (RSP) and lower trapezius strength (LTS). Mean change  SD ,y

Median

95% CI

Experimental group RSP (cm)

Post-treatment Follow-up Average post-treatment

.65  .78* .19  .83*,y .42  .68*,y

.60 .50 .55

.37: .94 .49: .11 .67: .17

Control group RSP (cm)

Post-treatment Follow-up Average post-treatment

.02  .75 .17  .60 .09  .50

.15 .25 .00

.33: .29 .07: .42 .13: .29

Experimental group LTS (kg)

Post-treatment Follow-up Average post-treatment

1.2  3.1* 3.9  4.4* 2.5  3.1*

1.3 3.5 2.3

.03: 2.3 2.3: 5.5 1.4: 3.7

Control group LTS (kg)

Post-treatment Follow-up Average post-treatment

1.2  3.8* 4.3  4.0* 2.8  3.3*

1.5 3.5 3.3

.33: 2.8 2.7: 6.0 1.4: 4.2

Abbreviations: CI, confidence interval; SD, standard deviation; cm, centimeter; kg, kilogram. * Denotes significant within-group change from pre-treatment with Friedman tests (p < .05) and minimum significant differences calculated (a Z .05). y Denotes significant difference between groups with ManneWhitney U-tests (p < .05).

pectoralis minor STM and self-stretching and the average post-treatment RSP during the 2 week follow-up period remained improved compared to the baseline RSP measure, suggesting that the single experimental treatment produced a benefit beyond no treatment at all (see Table 2). Because participants were not monitored during the follow-up period, it is not known whether they continued to stretch on their own, avoid slouched postures, or engage in other activity that affected RSP. Regression towards the mean was observed in the experimental group at the follow-up, however, suggesting that more than one treatment may be necessary to maintain the decreased RSP for periods longer than 2 weeks. Although experimental group RSP was reduced after treatment directed to the pectoralis minor, more than 95% of the experimental shoulders in this study of healthy participants still had RSP greater than 2.5 cm. In a study that did not involve treatment of 135 subjects with and without symptoms, Lewis and Valentine found that none had a RSP less than 2.5 cm using the supine measure (Lewis and Valentine, 2007). The results of the current study support Lewis and Valentine’s notion that the 2.5 cm threshold for the supine RSP measure is not a sensitive predictor of dysfunction, since mean and median values are well above the 2.5 cm threshold (Lewis and Valentine, 2007). Future research may indicate a more useful threshold. Rounded shoulder posture is a multifactorial finding that may reasonably vary with hypomobility of any segment of the spine, rib articulation, or joint of the shoulder girdle including the acromioclavicular, sternoclavicular, and glenohumeral joints; tightness of the muscles related to any segment of the spine, ribcage, and shoulder girdle; as well as patient weight, height, position, and physical girth. A diagnostic choice for the treatment of an individual patient based on their RSP value as compared to the average RSP of people with mixed characteristics would be a questionable approach for a measure such as the supine RSP measure in this study.

The value of the supine RSP measure may be as an outcome measure that can demonstrate within subject change. The average difference in post-treatment reduction in RSP between the control and experimental groups was .51 cm, which was more than 10% of the pre-treatment RSP and double the SEM (SEM Z .12 cm). The results of this study suggest that the control treatment had no effect on RSP while the combination of STM and a pectoralis minor self-stretch reduced RSP to both a statistically and clinically significant degree. While treatment directed to the pectoralis minor reduced RSP in this study after intervention directed to the pectoralis minor, the supine RSP measure may not measure or predict pectoralis minor muscle length (Borstad, 2006). Supine RSP did not correlate strongly with a pectoralis minor index based on a seated pectoralis minor length measured from the coracoid process to the fourth rib adjacent to the sternum (Borstad, 2006), perhaps because of different test positions and the typically more lateral pectoralis minor attachment to the ribs. In the current study, RSP was used as a measure of scapular position not pectoralis minor length and the experimental treatment was directed to the pectoralis minor but may have affected other factors in RSP in addition to the pectoralis minor. While the placebo touch received by the control group could be isolated to the superficial pectoralis major, the pectoralis minor STM received by the experimental group may have affected the overlying pectoralis major. In addition, the self-stretch used in the experimental group incorporates spine and rib motion and does not isolate the pectoralis minor. Thus pre- and post-measures of RSP reflect the total affect of the experimental treatment not change in pectoralis minor length. The average post-treatment measures of LTS after the experimental and control treatments both increased significantly by comparable amounts (control 2.8 kg or 14.8%; experimental 2.5 kg or 13.7%), with no apparent differences between groups ‘see Table 2’. Friedman tests with MSD set at a Z .05 comparing the pre-treatment,

332 post-treatment, and follow-up LTS values revealed a significant increase (p < .001) between all three repeated measures suggesting that LTS increased immediately after treatment and increased further 2 weeks later in both groups. It is noted, however, that the post-treatment change in strength of the control group could not be assumed to be positive with 95% confidence (Sims and Reid, 1999) until the 2 week follow-up. The increase in the LTS of both groups throughout the study may have resulted from increased familiarity with the testing method or repetitive maximal voluntary testing, although no change was noted in the two pre-treatment baseline measurements (p > .05). It is possible that the placebo touch and self-stretch of the pectoralis major had an effect on LTS equivalent to the experimental treatment through the positive influence of human contact (Cheing and Cheung, 2002; Keller and Bzdek, 1986) or increased neuromuscular recruitment similar to that observed in an initial exercise program (Moritani and deVries, 1979). A variety of placebo treatments have been shown to affect 30% of patients (Winemiller et al., 2005; Lappin et al., 2003; Hoffman et al., 2005) with benefits in objective measures, such as blood flow (Martel et al., 2002) or tumor reduction, of less than 7% in a comprehensive metaanalysis of the use of placebos in oncology research (Chvetzoff and Tannock, 2003). This degree of change is comparable to the 6.3 and 6.6% changes in LTS observed in the present study immediately after treatment in both groups: control and experimental, respectively ‘see Table 2’. It is noted, however, that the control treatment, which included passive placebo touch, had no effect on RSP.

Study limitations The results of the present study must be considered in the context of several limitations. First, the practice of using the shoulders of each participant as independent entities raised two potentially problematic possibilities: that the 19 participants who received different treatments could have distinguished between the control and experimental treatments and responded differently based on group assignment; and that outcomes of one shoulder may have affected the other. For the 19 participants who had a shoulder in each group, ManneWhitney U-tests were conducted to determine whether there was a difference in shoulder performance. There was no significant difference between the control and experimental shoulders of these 19 participants (p > .05), suggesting that participants’ performance with different shoulders may not have depended on the group assignment of their shoulders. Analysis with Friedman’s test was conducted to determine whether any difference in outcomes existed among the participants whose shoulders: (1) received different treatments on each shoulder; (2) received the experimental treatment on both shoulders; or (3) received the control treatment on both shoulders. The results revealed that the six participants whose shoulders were both in the experimental group had greater reductions in RSP than the three whose shoulders were both

C.K. Wong et al. in the control group (Friedman p < .05, MSD f < .05). Though the small number of participants prevents firm conclusions, it is possible that one shoulder may have affected the other undermining the assumption that individual shoulders are independent entities. Future studies should assign individual people, not shoulders, to groups. Second, this study used a small healthy sample of convenience derived from a single college campus precluding generalization of the results beyond the sample population. Lastly, the control and experimental treatments both combined a manual touch or technique with a self-stretch procedure, thus results should not be interpreted as resulting from an individual procedure. While limiting the treatments to a single procedure may have demonstrated the outcome of a specific technique, the procedures were combined in this study to replicate a realistic clinical approach to excessive RSP. The use of passive placebo touch in the placebo-controlled design, while complicating the research design and introducing its own potential effect, remains vital to research involving manual therapy to differentiate manual therapy from simple human touch (Cheing and Cheung, 2002).

Conclusion This study has shown that a single session of STM paired with self-stretching to the pectoralis minor muscle reduced RSP for up to 2 weeks compared to passive manual touch and a pectoralis major self-stretch. Overall, the results of this study support the notion that treatment aimed at the pectoralis minor can benefit shoulder posture and muscle function and may be an important component of shoulder rehabilitation (Sahrman, 2002; Lukasiewicz et al., 1999; Borstad and Ludewig, 2005; Wang et al., 1999; Kisner and Colby, 1990).

Acknowledgements The authors wish to acknowledge the contributions of Limone Paljevic who coordinated this research.

Disclosure statement The authors have no conflict of interest to disclose.

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FASCIA CONGRESS ABSTRACT

Neurocognitive enhancement for the treatment of chronic pain Peter Przekop, DO, PhD a,b,*, Allison Przekop, DO b, Mark G. Haviland, PhD a, Matt L. Riggs, PhD c a Department of Psychiatry, Loma Linda University Medical School, 11374 Mountain View Avenue, Loma Linda, California 92354, United States b Department of Pediatrics, Loma Linda University Medical School, Coleman Pavilion, Room A1109 Loma Linda, California 92350, United States c Department of Psychology, California State University, San Bernardino, California 92407, United States

Received 12 July 2009; received in revised form 11 October 2009; accepted 19 October 2009

Abstract Chronic pain remains at epidemic levels in the United States, affecting approximately 20% of the population (Breivik et al., 2006). At present, treatments generally target symptom relief and seldom address improvements in quality of life and overall healing. Recent insights in neurobiology have demonstrated that chronic pain is a degenerative disease of cortical and sub-cortical structures (Tracy, 2008). Thus, treatments can be designed to enhance specific areas of the brain affected by chronic pain and, thereby, improve patients’ cognitive and emotional abilities. For example, specific treatments can be designed that normalize function of frontal lobe areas negatively affected by the effects of chronic pain.

Method 21 patients who had been detoxified from opiate therapy (13 women and 8 men; average age Z 48.5; average time opiate

* Corresponding author. Department of Psychiatry, Loma Linda University Medical Center, 11374 Mountain View Avenue, Loma Linda, California 92354, United States. Tel.: þ1 909 558 4505; fax: þ1 909 558 6090. E-mail address: [email protected] (P. Przekop).

dependent Z 8 years) with various chronic pain complaints (post laminectomy syndrome, post cancer pain, fibromyalgia, chronic headache, osteoarthritis; average time in pain Z 9 years) were enrolled in a 12-month comprehensive pain management program designed to enhance brain areas affected by pain. Treatments included group process, mindfulness exercises, movement exercises (Tai Chi, Qi Gong, and Yoga), manual treatments (Qi Gong and Neurofascial release), and the establishment of a treatment community. Patients met weekly for group process that addressed emotional and cognitive decision-making strategies, cognitive change, and movement. Patients received monthly manual treatments that consisted of Qi Gong and Neuro-fascial release. All chronic pain patients received the same management program. All were assessed at intake and at months 3, 6, 9, and 12, with a visual analogue pain scale, the Beck Depression Inventory, the McGill Pain Scale (short form), and the Perceived Stress Scale.

Results By month 12, patients’ scores declined dramatically on all tests (growth curve analysis), and these improvements were statistically significant (p < .01); (p < .01, dependent t tests). Mean reductions: visual analogue (7.0 / 2.3), depression (26.4 / 4.6), McGill-somatic (22.7 / 5.4), McGill-affective (7.7 / 1.5), and perceived stress (26.5 / 12.8).

1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.10.003

Neurocognitive enhancement treatment for chronic pain

335

Discussion

References

Targeted treatments appear effective in restoring several aspects of chronic pain patients’ lives. Future studies could be designed to address specific pain complaints or test larger populations.

Breivik, H., Collett, B., Ventafridda, V., Cohen, R., Gallacher, D., 2006. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. European Journal of Pain 10, 287e333. Tracy, I., 2008. Imaging pain. British Journal of Anaethesia 101 (1), 32e39.

Journal of Bodywork & Movement Therapies (2010) 14, 336e345

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

CASE REPORT

Rhythmic exercises in rehabilitation of TBI patients: A case report Yigal Goldshtrom, MS*, Gregory Knorr, PT, Iris Goldshtrom, PT, DPT Pillar of Light, Physical Therapy, Address 37-03 Berdan Ave, Fair Lawn, NJ 07410, USA Received 12 January 2009; received in revised form 20 May 2009; accepted 5 June 2009

KEYWORDS Traumatic brain injury; Rehabilitation; Rhythm; Exercise; Cognitive; Motor; Neuroplasticity

Summary Patients who have sustained traumatic brain injury (TBI) often present with a multiplicity of dysfunctions making rehabilitation challenging. Patients who have taken part in studies of rehabilitation exercises that incorporated monotonous timed auditory cues (using a metronome) following cerebrovascular events demonstrated improvement in gait and motor functions. The purpose of this case report is to describe the efficacy of Rhythmic Exercises with Auditory Cues (REAC) to improve functions in a patient, years after their traumatic brain injury. Methods: A single case report of a 24-year-old female patient, nine years post hemispherectomy following TBI that resulted in right hemiparesis. The patient was taught to perform REAC exercises at home. These exercises were designed to activate the body while Alternating hands and feet Bilaterally with Cross-midline movements for a short Duration while synchronizing the movements with a metronome as a Rhythm regulator. Outcome measurements included gait and functional assessment and cognitive and psychological instrument scores that were compared pre and post treatment. Clinical improvement was observed in the patient’s gait pattern with reduced hip hiking motion and increased cadence. There was a decrease in spasticity in the right arm and leg with some isolated volitional movements of the hand and fingers returning. She also regained sensation in her right arm and leg. Cognitive improvement was demonstrated by increased IQ scores from 78 to 94. Published by Elsevier Ltd.

Introduction

* Corresponding author. Tel.: þ1 201 797 8028. E-mail address: [email protected] (Y. Goldshtrom). 1360-8592/$ - see front matter Published by Elsevier Ltd. doi:10.1016/j.jbmt.2009.06.002

Traumatic Brain Injury (TBI) is a disorder of major personal and public health significance. A study in the United States has reported that among hospitalized TBI survivors in 2003, forty-three percent remained in long-term disability

Rhythmic exercises in rehabilitation (Selassie et al., 2008). Since 2001 there has been sharp increase in the number of TBI as result of the deployment of 1.5 million military personnel to Iraq or Afghanistan. TBI since the start of military operations have become an important source of morbidity in the Iraq and Afghanistan wars (Warden, 2006). A recent study of a U.S Army brigade had found that as many as 4.9% of the U.S. military personnel reported injuries with loss of consciousness (Hoge et al., 2008). Historically, motor recovery is not expected beyond 6e12 months after injury (DeLisa et al., 1999), leaving TBI patients with a wide range of limitations, including cognitive deficits, motor disabilities, emotional and social dysfunctions, personality changes, and changes in appearance (Chesnut et al., 1999). Patients with neuromuscular involvement have difficulty in executing motor actions because of the reduction in movement capabilities and sensations of the paretic limbs, which results in nonrhythmic and asymmetrical sensorimotor control feedback that limits recovery and function (Sibley et al., 2008). Some injuries require craniotomy (removal of part or the entire hemisphere) with result in loss of motor and sensory awareness in the affected limbs. Loss of sensory awareness such as tactile discrimination is an indication of damage to brain area corresponding to the affected body part. Increased tactile discrimination after brain injury corresponds with brain plasticity (brain reorganization) in primary sensory and motor cortices as result of an enlargement of the representations of the trained body parts (Hodzic et al., 2004).

Brain plasticity Brain plasticity refers to adaptations of the neural network or a restructuring of the network both functionally and hemisphericaly (Doidge, 2007). Functional restructuring happens when a cortical area that has a known function assumes additional function, while hemispherical restructure is the adaptation of the function into the opposite hemisphere. The hemispheres exhibit unique and bilateral functions. The right hemisphere, for example, generally process the nonverbal elements of communications like reading facial expressions, while the left hemisphere process the verbal-linguistic elements of communication like speech (Doidge, 2007). Many functions in the brain occur bilaterally like motor, sight, sound and tactile sensations, and some of those functions, like motor functions occur in the contralateral hemisphere (on the opposite side) of the affected limb. TBI can result in loss of motor function contralateral to the injured hemisphere; while many areas of the brain can be involved in TBI we are limiting the discussion here to the cerebral cortex. Regaining motor function depends on neuroplastic processes that can re-establish the function in the opposite hemisphere, ipsilateral of to the paretic limb, which is known as function lateralization. The recent use of brain scanning technologies offer direct evidence of significant neuroplastic restructuring in the cortical motor area of the brain for patients receiving rehabilitation after stroke or cerebral hemispherectomy (Richards et al., 2008). For example, studies of children after cerebral hemispherectomy reported increased cortical activation both contralaterally and ipsilaterally post hemispherectomy in

337 the primary sensorimotor (S1M1) and the secondary motor areas in the remaining hemisphere. These results were noted following intense gait training using Body WeightSupported Treadmill Training (BWSTT) on a treadmill with rhythmic passive/active activation for two weeksd60 h total training (de Bode et al., 2007). Evidence of brain reorganization under functional MRI (fMRI), specifically ipsilateral to the affected limb, have also been reported in several studies with chronic stroke patients (Calautti and Baron, 2003; Gerloff et al., 2006) with patients recovering from motor deficit after stroke using traditional rehabilitation methods (Dong et al., 2007; Green, 2003; Jang et al., 2007). Multiple studies revealed under fMRI and positron emission tomography (PET) scans that hemispheric adaptation occurs naturally when movement is combined with rhythm. When fingers of one hand are tapped, the activity will be detected in the contralateral hemisphere. However, multiple studies have shown that when finger tapping is combined with an external auditory rhythmic beat the activity had been detected in the ipsilateral hemisphere (Del Olmo et al., 2007; Horenstein et al., 2009; Thaut, 2003). Using PET, increased blood flow to the brain was visualized during rhythmic tapping, like tapping one finger, which activates parietothalamic and premotor activity, predominantly ipsilateral to the finger that is tapping (Thaut, 2003). These studies demonstrated that simple rhythmic finger movement has the effect of developing awareness bilaterally (Horenstein et al., 2009), which is precursor to re-learning motor and cognitive function deficits after brain injury.

Rhythmic exercises with auditory cues (REAC) in rehabilitation The effect of rhythmic activation of the extremities during exercises with resultant brain plasticity and recovery have been proposed in multiple studies; some were studying movement patterns while others have used fMRI to study how the brain is activated in response to timed movements. This case report describes a rehabilitation process with rhythmic exercise program called Rhythmex, a REAC program using exercises with a metronome. Each exercise is guided by five principles labled ABCD & R: A. B. C. D. R.

Alternating hands and feet in movements Bilateral activation of the body and extremities Cross-midline movements Duration of exercise Rhythmic auditory cues (via metronome)

The following studies demonstrate these principles:  Bilateral alternating hand and feet exercises foster bilateral cortical activation which generates multisensory crossmodal spatial mapping of vision and touch (Gray and Tan, 2002). The expected result is greater awareness unilateral of the affected limb as a precursor for functional lateralization.  Bilateral or bimanual movement training as a single modality or in combination with other modalities has

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Y. Goldshtrom et al. been found to be effective in stroke rehabilitation protocols during the sub-acute and chronic phases of recovery (Cauraugh et al., 2009; Cauraugh and Summers, 2005; Stewart et al., 2006). Bilateral training has been found to improve motor coordination in the affected limb in patients with central or peripheral impairments (Cauraugh and Summers, 2005; Luft et al., 2004; Mudie and Matyas, 2000; Whitall et al., 2000). Some studies did not find bilateral movement training alone to be effective with stroke patients (Desrosiers et al., 2005). Bilateral Arm Training With Rhythmic Auditory Cueing (BATRAC), a repetitive bilateral arm movement exercise has been found to be effective for upper extremity rehabilitation after stroke (Waller and Whitall, 2008; Whitall et al., 2000) Walking exercises with Rhythmic Auditory Stimulation (RAS) have been shown to improve gait with Parkinson’s patients (Ellis et al., 2008; Password, 2007; Thaut et al., 2007, 1997, 1996), and another study with Parkinson’s patients used spatial and temporal rhythmic visual cues to change and improve the patients’ walking speed on a treadmill (van Wegen et al., 2006). Another study using RAS protocol with children diagnosed with Cerebral Palsy reportedly improved their gait performance (Kwak, 2007). Active-Passive Bimanual Therapy (APBT) using passive rhythmical flexion-extension repetitions has been proposed for upper extremities among stroke patients (Stinear et al., 2008) Body Weight-Supported Treadmill Training (BWSTT) with rhythmic cues has been proposed for lower extremity rehabilitation among children after hemispherectomy (de Bode et al., 2007). Cross-midline movement activation creates dynamic multisensory crossmodal integration that can restore body-part perception, improve motor action execution, and body-part self-awareness (Maravita et al., 2003). Body-part awareness and motion activation occur contralaterally in each hemisphere, where sensory information (vision, tactile and audio data) integrates into a dynamic baseline spatial map which then develops into sensory, movement, and overall self-awareness. Studies of cross-limb actions have revealed cross-cortical cooperation in remapping of visual space that occurs while tracking the hand’s positions as it crosses midline (Macaluso and Driver, 2005; Spence et al., 2001). Brain exercises are learning activities, as the brain learns a new task from a novice state to improved performance, different areas of the brain become active. As the neural networks switch from controlled activation into automatic activation a reduction in the general neural activities occurs (Grill-Spector et al., 2006). The ‘‘learned’’ movement is distinguished from a novice conscious movement by its being automatic, rapid, and stereotyped (Thach, 1996). Learning (i.e. movement) for more than 15 min switches the activities in the cortex to an automatic process that prohibits new learning (Raichle et al., 1994).

The use of rhythmic auditory cues in rehabilitation was first proposed in a study among stroke patients (Whitall et al., 2000) which facilitated bilateral arm training using

two levers in a push/pull uniform motion regulated by a metronome. This approach has since been replicated elsewhere (Luft et al., 2004; Stinear and Byblow, 2004; Waller and Whitall, 2004). Even a short period of rhythmic walking among patients with incomplete spinal cord injuries has demonstrated improvements in the gait parameters of cadence, velocity, and stride length (de l’Etoile, 2008). However, when a bilateral training exercise was used with stroke patients but without auditory cues, it did not result in better outcomes compared to the regular exercise protocol (Desrosiers et al., 2005). The purpose of this paper is to report the effect of rhythmic exercises, and in particular on Rhythmex REAC protocol with a single patient with TBI who has improved significantly nine years post hemispherectomy (partial removal of her left hemisphere) for 12 months of Rhythmex exercises. Studies that use REAC protocol have been limited by the extremity they activate; upper extremities in BATRAC and APBT, and lower extremities in RAS and BWSTT, and the devices they use for these activities. Rhythmex is a natural all body movement exercise with the goal of restoring functional movement patterns using rhythmic motions, however small in amplitude, and is adaptable to many dysfunctions, their severity, and exercise settings.

Method Profile of the patient Jill (assumed name) is a 24-year-old female who is presented with Traumatic Brain Injury (TBI) as result of a sledding accident at age 15. She suffered an intracranial hemorrhage, brain contusion, and left open depressed skull fracture that required hemispherectomy twice. Post-operatively, she experienced increased intracranial pressure with hydrocephalus and excess Cerebral Spinal Fluid collection that required shunting on two occasions. Her recovery was complicated by seizures. She presented with refractory seizures that were moderate in intensity and was taking anti seizure medications, to reduce the number of episodes. Motor control As in most cases of patients with TBI and stroke with damage to the motor control centers, her gait demonstrated a combination of deviationsdincluding hip hiking and circumduction, and lack of active dorsiflexion that required a correction by Ankle Foot Orthotics. Her right upper extremity had strong flexor spasticity; no volitional motion below the elbow, and her right hand was fisted and therefore she had to wear a splint. During walking the flexor spasticity in the right upper extremity increased with the elbow gradually flexing to 100 degrees. Dorsiflexion of the affected ankle was minus two degrees when passively ranged, and she had strong clonus when the ankle was forcibly dorsiflexed. She was unable to negotiate stairs functionally and she also had poor balance standing and walking, even with the use of a cane. Her hip joint on the affected side was moderately retracted, as was the shoulder.

Rhythmic exercises in rehabilitation Sensory awareness Jill displayed deficit in her tactile awareness of the affected limbs. She had a complete loss of her sensation to touch from the elbow to the fingers in the right arm and from the knee to the toes in the right foot. She also had right hemianopsia (blindness in one half of the visual field), and expressive aphasia, with resultant difficulty reading, and impaired comprehension and speech. Rehabilitation history In the first two years after the accident, Jill received intensive inpatient physical therapy, and thereafter weekly physical therapy in residential programs. According to her physical therapy reports she received passive and active stretching and gait training. She was discharged from physical therapy completely in 2005 two years before she came to our clinic. She also received occupational therapy, and had participated in a cognitive program to improve her reading ability. Currently, Jill lives in a supervised residential community for individuals with chronic TBI. She sought services in our clinic looking for improvement in her gait, spasticity and functioning of her right hand.

The treatment plan The guidelines in choosing an effective treatment modality for Jill were governed by several factors. One, the chronic stage of her dysfunction nine years post trauma, second, the history of her rehabilitation in the past including passive range of motion, muscle strength, and gait training, and third, the significance of the existing limitations of the involved extremities; the high level of spasticity and low level of mobility and functionality. These limitations preclude the use of techniques like Constraint-Induced (CI) movement therapy for her upper extremities (Taub et al., 2006) due to lack of function in her right hand, BATRAC was excluded due to the spasticity in the shoulder, RAS and similar techniques because of spasticity in the right leg. Rhythmex exercises were chosen because they can be utilized and beneficial even with minimal range of motion. Treatment guidelines and procedures Treatment guidelines followed the ABCD&R principles of the Rhythmex method. A. Alternating upper and lower extremities (like in walking; left leg movement is synchronized with right arm movement and vice versa) B. Bilateral activation of both sides of the body in a reciprocal movement C. Cross midline, hands should cross the midline in movement D. Duration, each exercise was executed 30e90 s before a break R. Rhythmic auditory cue with the metronome Each session starts with an assessment of current limitations, matching the limitations with an appropriate exercise. During each exercise movements must be self

339 generated by the patient and actively executed, regardless of the amplitude of the motion. For example, at the beginning of Jill’s rehabilitation the movement of the affected right arm was limited to the shoulder joint at a range of 10e15 degrees flexion with horizontal adduction and strong elbow flexion to 100 degrees, while the left arm had a normal swing. The rhythm’s tempo was determined by the patient. Once the activity started the clinician observes the actual tempo the patient was able to perform and sets the metronome accordingly. There was no goal tempo or course of progression goals for the tempo. The auditory cue serves as an attention grabber and the tempo should be set comfortably for the patient’s ability. Exercise duration was limited to allow the patient to be active but not fatigued, to prevent the brain switching from control activation to automatic activitation. The duration of each exercise for this case varied between exercises in the range of 30e90 s following 30e60 s resting and about 10 repetitions for each set. The Rhythmex exercises When we began with the Rhythmex exercises, we modified the principles of alternating upper and lower extremities to address Jill’s limitations due to her tightness and increased spasticity. Jill was presented with exercises that activated upper extremities only and separately exercises that activate the lower extremities. The goal was to synchronize upper and lower extremities. The following are examples from Jill’s exercise regimen in the last six months of the rehabilitation including 4 exercises targeting her pelvic area and right shoulder spasticity, 2 of them performed lying on an exercise mat to avoid abnormal gait activation and loss of rhythm, one exercise was performed while standing in place, and one while in the quadruped position. Wag-the-tail The exercise was performed in quadruped position offering distal stability while activating the core muscles. Jill was instructed to side bend the pelvis from left to right with the metronomed40 beats/min for 1 min followed by a rest with 10 repetitions. Upside down bicycle The patient was lying on her back with her feet off the mat, and hips and knees flexed 90 degrees. This position allowed stability of the torso and mobility of the legs. She simulated riding a bicycle, with one leg extending while the other was flexing, with the metronome set ond42 beats/min for 90 s, with a brief 30 s rest the sequence repeated 10 times (Fig. 1). Cross-over bicycle The patient was lying on her back with the feet on the floor, alternately bending each knee and touching it with the opposite hand (Figs. 2 and 3). In this position she benefited from the stability of the trunk and the resting foot. The goal was to achieve 2e5 min of continuous activity per day with the metronomed40 beats/min for 90 s, with a brief 30 s rest repeating the sequence 10 times. This exercise

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Figure 1

Upside down bicycle.

accomplished all the ABCD&R principles; Alternating arms and legs, bilateral activation, crossing midline, sustaining the duration and keeping up with the rhythmic beat. When Jill began the exercise, she could not bring the right (paretic) hand to touch the left leg, but over time her arm became more functional to the point where she now stretches her hand to touch the knee.

Figure 3

Right-hand (paretic) touches left knee.

Results This case report documents a year in Jill’s rehabilitation using Rhythmex, a rhythmic exercises program. Over that period, Jill came to the office every 2e3 weeks and most of

Dancing Starting position is standing with hips and knees slightly bent. The instructions were to shift the weight to the right leg maintaining the hip and knee in flexion while rotating the torso to the left and at the same time allowing the arms to cross midline (Fig. 4). The same movement is then repeated to the opposite side, shifting the weight to the left foot and rotating to the right (as in a dancing motion) keeping the beat with the rotation. Metronome was set to 30 beats/min for 90 s, with a brief 30 s rest and the sequence repeated 10 times. Initially, Jill was not able to shift her weight sideways and rotate her upper body. We began with gentle weight shift, rocking the pelvis side to side to the metronome, within the range allowed by her spasticity. Gradually the spasticity in her hips decreased and Jill gained control over the lateral weight shift. As she progressed in the activity, she gained control over the upper body rotation and with it the ability to cross midline with her arms.

Figure 2

Cross-over bicycledleft-hand touches right knee.

Figure 4 Jill shifting her weight to the left rotating her upper body to the right and crossing midline with her left arm e dancing.

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her workout was done as a home program by herself. During the office visit, she performed all of her exercises while the team modified her exercises (i.e., changing target range of motion, or beat rate) based on her progress and the specific functional goals (see Appendix A). She reportedly spends 20e30 min a day (not counting set up time and rests) 4e5 days a week for 12 months practicing Rhythmex exercises. During that time Jill has shown gradual improvements in several key areas including gait and independent mobility, functional use of the right paretic arm, cognition, and psychological factors.

Gait and independent mobility Jill’s primary goals were to improve her gait and independent mobility. Gait was assessed by her walking pattern and cadence (number of steps per minute), while independent mobility was assessed by balance reactions and coordination of the upper and lower extremities and the trunk. Jill has improved her balance and coordination while in motion as result of reduced spasm in the pelvic area and increase of pelvic stability and isolated hip function, resulting in less hip hiking of the right hip during the swing phase of gait. The improved coordination carried through to her gait pattern, with improvement in cadence, from about 4 steps per 10 s with foot brace (0.4 m/s), to 12 steps per 10 s without a brace and 14 steps with a brace (1.4 m/s). According to the Speed-Based Classification System, Jill’s walking speed has improved from the lowest category of ‘‘household’’ speed to the highest category of ‘‘community’’ speed (Bowden et al., 2008). An additional parameter of improvement of the leg was the return of sensation to touch that was impaired from the knee to the toes since the injury.

Figure 5 The spasticity in her fingers decreased and the fist began to open spontaneously at rest.

2003 her Full Scale rose by merely 2 points to 78 (7th percentile) with Verbal IQ of 78 and Performance IQ of 83. In repeated evaluations in 2005 her WAIS-III Full Scale IQ scores did not change. In April 2008, a few months into the rhythmic exercises, Jill requested to be tested again as part of the application for accommodations during GED testing, because of her difficulty in reading due to the hemianopsia. This time, all of her scores rose markedly: Full Scale rose to 94 (34th percentile) with Verbal IQ of 89 and Performance IQ of 100 (VIQ and PIQ difference of 32.4%).

Levels of agitation

Hand function and ADL Jill’s goals for her right hand were to reduce the spasm and need of the splint, and to gain function. When treatment began Jill wore a hand splint stabilizing her right wrist in approximately 10 degrees of extension. With the splint removed the strong flexor spasticity dominated her posture with wrist flexion and tight fisted fingers. At the present time Jill no longer wears a splint, the hand is held in a relaxed posture (see Fig. 5) and there is reduced tone in the finger and wrist flexors. Jill began gaining isolated function of the hand and fingers (see Fig. 6), being able to pick up a small object between the thumb and index fingers of the right hand. Jill has been using her right hand in ADL activities such as washing dishes and fastening her seat belt. In addition, when initially seen, Jill had no sensation in her right hand from the elbow to fingers. Over the year she experienced sporadic returns of sensation to touch with the ability to discriminate the location. At present she has regained full sensation to touch from the elbow to the fingers.

One of the instruments available for measuring the severity of the brain injury is agitation; and the level of engagement in TBI patients is the Agitation Behavioral Scale (Corrigan, 1989; Lequerica et al., 2007). An instrument with

Cognitive skills Jill has been given several neuropsychological evaluations since her accident in 1999. Her WAIS-III Full Scale IQ evaluation in 2000 was measured at 76 (5th percentile) and in

Figure 6

Picking up an object with relaxed fingers.

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three subscales: Disinhibition, Aggression, and Lability (adaptability to change). A comparison between her state of agitation as measured by the Agitation Behavioral Scale, completed by her parent to reflect Jill’s behavior at the beginning of our treatment in 2007 with a second observation after a year in the program have showed improvements in all of its subscales (See Fig. 7).

Discussion This case report describes the use of Rhythmex, a rhythmic exercise program with auditory cues (REAC) protocol in treating a TBI patient nine years post craniotomy. Several studies in the last decade have showed the benefit of REAC in rehabilitation of patients after stroke and Parkinson’s disease, and with children with Cerebral Palsy. Rhythmex promotes five exercise principles labeled: ABCD & R to inspire spontaneous brain reorganization and re-learning of functions that have been impaired or lost due to brain injury. Exercises must activate the body extremities in an Alternating fashion Bilaterally, while the movements should Cross midline, and with each exercise Duration should only last 30e90 s before resting. The individual exercising must synchronize the movement to a constant Rhythm (such as a metronome). Brain training exercises are learning modalities and unlike muscle training, learning occurs in small windows (the ‘‘novice’’ phase) and intends to bring diminishing results with increase in the length of practice, as the brain switches from control to an automatic activation. Rhythmex training adapts to the ‘‘novice’’ windows in two ways. First it limits the practice to 20 min a day while breaking down each exercise to 30e90 s units, and second by adapting the exercises as their novelty wears off. Options for changing the exercise include increasing the tempo or changing one or all of the movement parameters (i.e., direction, distance, position, etc.).

Rehabilitation with rhythmic exercises When Jill arrived in the clinic she complained she had reached a plateau in her progress toward function using traditional rehabilitation programs. She demonstrated no

ABS Subscale Scores 25

Disinhibition Aggression Lability

20

15

10

5

0 2007

Figure 7

2008

Agitation behavioral subscales scores.

functional improvement since she was released from a rehabilitation program at a university hospital two years after the accident and was sent to live in community residency. When she arrived in our clinic in 2007 she was nine years post TBI. Two years earlier she had been released from all out patient physical therapy services, yet she still showed multiple impairments. The specific disabilities Jill presented in 2007 excluded her as a candidate for rehabilitation methods such as Constrained Induces therapy or any of the REAC (rhythmic) based methods such as BATRAC or RAS because walking was labored for her and she had minimal range of motion in the paretic arm. Rhythmex was suggested because of its flexibility and versatility. For example, after analyzing her level of spasticity and her movement restrictions, it was decided that the best beginning posture for her is in supine (lying on the back) which allows her the highest degree of control over her movement, and although her trunk was supported she could freely move her extremities. Rhythmex allows any small movement to inspire brain reorganization if the motion is active and the individual coordinates the movement with a metronome. Jill started her rehabilitation in our clinic in 2007, her goals were to gain independent mobility and improve the function of her right hand. During the year Jill practiced Rhythmex exercises and regained independent mobility and function (see Appendix A). Her progress covered gross motor functions, sensory awareness, cognitive and psychological functions. Motor improvement included decreased spasticity of the right hand with improved spontaneous movement that allowed the use of the hand to assist in ADL. Spasticity decreased at the right pelvis and hip improving Jill’s gate pattern and cadence. Jill’s balance reactions had improved and she is able to perform activities like walking without her cane, climbing stairs independently and walking backwards. Jill regained her sensation to touch on the right arm and leg. Her cognitive function as measured on standardized IQ tests has improved raising from the 7th percentile to an average level of 34th percentile and opening her possibilities in education. She passed the GED exam and is currently in courses to improve her reading ability in preparation to enroll in college. There has been improvement in her stress level as evident by lowering the agitation level as measured by the ABS scores. Jill is now looking to leave the community residency, find an apartment and planning to get a job. She feels confident taking a train or a bus to a major city or to school by herself, and she enjoys going out with friends. We find that some of the physiological and cognitive improvements in the past year can be attributed to the rhythmic exercises. We recognize that rehabilitation through rhythm has the potential to facilitate changes in brain organization even in patients who have plateaued. The use of rhythmic exercises in this case has correlated with improved motor and cognitive functions bilaterally, regaining movement patterns that were lost or impaired due to the severe brain injury, suggesting that brain reorganization was still able to occur, even this long after her injury. Furthermore, this case shows that rhythmic exercises carried out as home program with sporadic follow up sessions every 2e3 weeks, can be effective in bringing about significant improvements in a multitude of functions

Rhythmic exercises in rehabilitation that include: physiological, psychological, and cognitive, even in a patient nine years post injury. More studies of rhythmic exercises are needed to explore and confirm the effect of rhythmic movement under REAC protocol on brain reorganization and function lateralization.

Appendix A Assessment of outcomes summary

Observation/test Gross Motor Upper Extremities Paretic right hand

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References Bowden, M.G., Balasubramanian, C.K., Behrman, A.L., Kautz, S.A., 2008. Validation of a speed-based classification system using quantitative measures of walking performance poststroke. Neurorehabil. Neural. Repair 22 (6), 672e675. Calautti, C., Baron, J.-C., 2003. Functional neuroimaging studies of motor recovery after stroke in adults: a review. Stroke 34 (6), 1553e1566.

Pre intervention evaluation 2007 Goal: Functional ADL Right upper extremity under the influence of a strong flexor spasticity; no volitional motion below the elbow Right hand splinted in 10 degrees extension

Lower Extremities Climbing stairs

Goal: Independent Mobility Unable to climb stairs without holding the rail or using a cane

Ambulation

Difficulty in ambulating and often use of a cane Unable to ambulate backwards

Cadence

4 per 10 s with ankle foot orthotics (0.4 m/s) e ‘‘household’’ speed

Hip hiking

Marked hiking of the right hip during the swing phase of gait

Sensory Awareness/Fine Motors Tactile discrimination

No discrimination to superficial finger touching in right arm from the shoulder to fingers

No discrimination to superficial finger poking touch in the right leg from knee to toes Cognitive WAIS-III Full Scale IQ evaluations

Psychological Agitation Behavioral Scale (ABS) - An instrument with three subscales: Disinhibition, Aggression, and Lability.

Post intervention evaluation 2008

Spasticity of fingers has decreased and the fist has begun to open spontaneously. Right arm used more in ADL functions like washing dishes and strapping the safety belt in the car. Can climb stairs without assistance, holding the rail, or a cane Ambulating freely without any assistance Able to ambulate backwards without assistance at least 60 feet 12 per 10 s without a brace and 14 with a brace (1.4 m/s) e ‘‘community’’ speed Increased pelvic stability and isolated hip flexion resolving hip hiking Consistent awareness to superficial finger touching of right arm between the shoulders and wrist Consistent awareness to superficial finger poking touch in the right leg from knee and ankle Partial awareness to touch in fingers and toes

Jill’s WAIS-III Full Scale IQ evaluation in 2000 was measured at 76 (5th percentile), repeated tests in 2003 and 2005 show that her Full Scale rose by merely 2 points to 78 (7th percentile) with Verbal IQ of 78 and Performance IQ of 83.

In 2008 her Full Scale rose to 94 (34th percentile) with Verbal IQ of 89 and Performance IQ of 100 (VIQ and PIQ difference of 32.4%).

2007 ABS scores e Disinhibition (22.55), Aggression (17.5), and Lability (18.6)

2008 ABS scores e Disinhibition (17.5), Aggression (14), and Lability (14) e lower agitation level.

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Journal of Bodywork & Movement Therapies (2010) 14, 346e351

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

PHYSIOLOGY

Maximal clenching effort influence on the electromyographic activity of the trapezius muscle in healthy subjects* Fabiano Politti a,b,*, Cesar Ferreira Amorim d, ´via Dare ´ Guerra a, Luis Henrique Sales Oliveira b,c, Fla Ivan Luis Souza Pieres a, Evanisi T. Palomari a a

Departments of Anatomy, Cell Biology and Physiology and Biophysics, State University of Campinas (Unicamp) Brazil Department of Physical Therapy, Rehabilitation Sciences Biomechanics Lab, University of Vale do Sapucaı´ (Univa´s), Brazil c Department of Plastic Surgery, Federal University of Sa˜o Paulo (UNIFESP), Brazil d Department of Mechanical Engineering, State University of Sa˜o Paulo (Unesp-FEG), Brazil b

Received 28 January 2009; received in revised form 29 May 2009; accepted 5 June 2009

KEYWORDS Electromyography; Masticatory apparatus; Clenching; Trapezius muscle

Summary Alteration of the occlusion and the position of the jaw can affect the muscles of the neck, due to a relationship between the masticatory and cervical systems. Thus, the objective of this study was to verify whether the bite in maximal clenching effort, in centric occlusion, in individuals with clinically normal occlusion, and without a history of dysfunction in the masticatory system, influences the electromyographic activity of the upper trapezius muscle. A total of 19 normal individuals participated in the study, 14 of which were women (average age of 25.4  4.14 years), and 5 were men (average age of 24.11  3.28 years). The root mean square (RMS) amplitude and median frequency (MF) of the upper trapezium muscle with 40% and 60% of maximal voluntary contraction were analyzed under pre- and post-maximal clenching effort conditions in centric occlusion. The electromyographic signal was collected with a sampling frequency of 2 kHz and the value in RMS was obtained by a moving window of 200 ms. The paired Student’s t-test was used to compare RMS amplitude and MF under preand post-maximal clenching effort conditions. The level of significance for each comparison

* ´S, Department of Physical Therapy, Rehabilitation Sciences Work accomplished at the University of Vale do Sapucaı´ e UNIVA Biomechanics Laboratory. * Corresponding author. Universidade Estadual de Campinas, UNICAMP, Depto de Anatomia, Instituto de Biologia, Cx Postal 6109, CEP 13084-971, Campinas e SP, Brazil. E-mail address: [email protected] (F. Politti).

1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.06.001

Maximal clenching effort

347 was set to p < 0.05. This study concluded that in individuals without a history of dysfunction of the masticatory system, maximum clenching effort in centric occlusion does not alter the electromyographic signal of the upper trapezius. ª 2009 Elsevier Ltd. All rights reserved.

The trigeminal system is composed of neurons with peripheral extensions that connect to the neuromuscular shafts of the masticatory musculature, to receptors in the temporomandibular joint and to the teeth. These peripheral extensions have the function of informing the position of the jaw and the bite force through the synapses with the neurons of the motor nucleus of the trigeminal nerve, thus forming the simple myotactic reflex arches, also called mandibular reflex (Costacurta, 1979). The existing reflex arch in the trigeminal system allows the afferent relationship of the trigeminal nerve with proprioception of the dental occlusion, vision and standard corporal posture (Gangloff and Perrin, 2002). Furthermore, it also has an important functional relationship with the cervical system, through the inhibition and reciprocal coactivation of the mandible, neck and shoulder during the performance of upper limb positioning, as verified in specific tests (Ferrario et al., 2003; Ciuffolo et al., 2005). Dysfunctions in the masticatory system can induce in the trapezius muscle a condition of hyper-contraction in response to the nociceptive signal in the acting area of the trigeminal nerve (Gola et al., 1995). This muscle is recruited systematically to produce stability at the neck and frequently it can be activated by pain reflexes as a protective mechanism. This increased recruitment of the trapezius muscle may change its ability to sustain prolonged contractions in patients with temporomandibular joint disorders (TMD), which may lead to significant changes in body posture. A relationship between increased muscle EMG activity in the neck muscles and myofascial pain has been observed in subjects with TMD (Pallegama et al., 2004; Tecco et al., 2008). This myofascial pain might not be limited just to these neck and masticatory muscles, but might spread out to several body parts, for example to the shoulder region (Pedroni et al., 2006; Munhoz et al., 2004). These findings, associated with the complex anatomical and biomechanical interaction between the stomatognathic system and the head and neck regions, have led many scientists to discuss these relationships (Mannheimer and Rosenthal, 1991; Darling et al., 1994). As demonstrated by many studies, regardless of the known relationships between the masticatory system, the neck muscles and the scapular waist, it is hypothesized that the activity of these muscles is altered only in cases of dysfunction of the masticatory system (Pedroni et al., 2006; Ciuffolo et al., 2005; Munhoz et al., 2004; Ferrario et al., 2003; Gola et al., 1995). Thus, the objective of this study was to verify whether the bite, in maximal clenching effort, in centric occlusion, in individuals with clinically normal occlusion and without a history of dysfunction in the masticatory system, influences the electromyographic activity of the upper trapezius muscle, as happens in individuals with disturbances in the masticatory apparatus mentioned by the literature.

Material and methods Subjects The subjects of this study are 19 volunteers, 14 of whom were women (average age of 25.4  4.14 years), and 5 were men (average age of 24.11  3.28 years), all were undergraduate and graduate students in the University of Vale do ´S, Minas Gerais State, Brazil. Eligible Sapucaı´ e UNIVA subjects were screened for TMD according to Axis I of the Research and Diagnostic Criteria e RDC/TMJ (Dworkin and LeResche, 1992). To be included in the study, the subject had to meet the following criteria: (a) adult age (>18 years); (b) pain-free active mouth opening >40 mm (including overbite), pain-free active protrusion and laterotrusion >7 mm; (c) difference between active and passive opening 62 mm; (d) positive overjet and overbite between 0 and 4 mm; (e) willingness to participate in the study and to sign a written informed consent. Exclusion criteria were: (a) any TMD diagnosis; (b) chronic pain conditions (>3 month duration) in other parts of the body; (c) current orofacial inflammatory conditions; periodontal diseases; (d) removable dental prostheses; (e) absence of any teeth (except third molars); (f) neurological and movement disorders; and (g) habitual intake of drugs influencing the activity of the central nervous system. Shoulder and cervical spine normality of was determined by these specific tests: (a) Neer’s Test (Neer, 1983): the test is performed by placing the arm in forced flexion with the arm fully pronated. The scapula should be stabilized during the maneuver to prevent scapulothoracic motion. Pain with this maneuver is a sign of subacromial impingement; (b) Hawkins’ Test (Hawkins and Kennedy, 1980): it is performed by elevating the patient’s arm forward to 90 while forcibly internally rotating the shoulder. Pain with this maneuver suggests subacromial impingement or rotator cuff tendonitis; (c) Instability Testing (Harryman et al., 1990, 1992): the tests described in this section are useful in evaluating for glenohumeral joint stability. Because the shoulder is normally the most unstable joint in the body, it can demonstrate significant glenohumeral translation (motion). Again, the uninvolved extremity should be examined for comparison with the affected side; (d) Posterior Apprehension and Instability (O’Driscoll, 1991): with the patient supine or sitting, the examiner pushes posteriorly on the humeral head with the patient’s arm in 90 of abduction and the elbow in 90 of flexion; (e) Spurling’s Test (Palmer and Epler, 1998): the patient’s cervical spine is placed in extension and the head rotated toward the affected shoulder. An axial load is then placed on the spine. Reproduction of the patient’s shoulder or arm pain indicates possible cervical nerve root compression and

348

Figure 1 Test position as the individual elevates the shoulder ipsi-lateral to the dominant arm (A) against the resistance of the load cell (B).

warrants further evaluation of the bony and soft tissue structures of the cervical spine. 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 ´S. Each subject from the University of Vale do Sapucaı´e UNIVA 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 4-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 2 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 Muscle activity was recorded from the upper trapezius, selected because it can be affected by a masticatory dysfunction (Gola et al., 1995) and is always related to tension pain of the head and neck. The bipolar surface circular electrodes (Ag/AgCl e Medical Trace) with 10 mm diameter, were used for the surface recording of EMG with a center to center distance of 20 mm. The electrode was positioned with the medial

F. Politti et al. recording area 20 mm lateral to the midpoint of the line between the C7 spinous process and the acromion (Jensen et al., 1993). A reference electrode was fastened in the C7 spinous process of the volunteers. Before beginning the recording of EMG signals, each individual subject was asked to carry out a series of three maximum force elevations of the shoulder of the dominant arm, with duration of 3 s each, against the resistance offered by the load cell (Figure 1). A 2-min rest period was given between efforts. The mean value from the three trials obtained against the resistance offered by the load cell, represented a subject’s 100% maximum force (MaxForce) elevation of the shoulder. The two sub-maximal force (40% and 60% MaxForce) were used in the analysis activity of upper trapezium muscle in the situation pre- and post-maximal clenching effort (MCE). Initially, the data was collected as the subject tractioned a load cell by elevating the shoulder at 0 upper limb adduction, until reaching 40% and 60% of previously determined MaxForce (pre-MCE). After a 10 min rest, data was collected (post-MCE) under the same sub-maximal conditions (40% and 60% of the upper trapezium MaxForce) as the individual bit two cotton rolls (8 mm thick), positioned in the first and second molar as done by Ferrario et al. (2000) in a similar study. The criteria for the recording of the EMG signals were always the same for all stages of the experiment. At each moment (pre- and post-MCE), 40% and 60% MaxForce samples were collected and maintained through visual feedback provided by a line drawn on the computer screen. The duration of each EMG signal sample was 5 s. In order to avoid a learning effect, the order of the sample collection (40% or 60% MaxForce) was 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 should always be maintained in the same position, so as to avoid interference from the upper trapezius muscle in the activity.

Processing and analysis of the signals Amplitude signal analysis The EMG signals was obtained during the 40% and 60% of MaxForce contractions under the conditions pre- and postMCE. Each sample lasted 5 s with a rest interval of 2 min. The root mean square (RMS) was calculated using a 200 ms moving window. Frequency signal analysis A power spectral analysis was performed on the 5 window for upper trapezius muscle. A fast Fourier transform of 512 points (Hanning window processing) was performed on 19 consecutive, 512 ms segments, overlapping each other by half their length (256 ms), for each 5 s contraction. The Median frequency (MF) was determined from each of the 19 overlapping windows. The mean and standard deviation of the FM during each contraction were calculated for upper trapezius muscle. EMG Analysis Software, Version 1.01 (EMG System do Brasil, Ltda) was used. The basic assumption for the use of spectral characteristics of the signal for inferring motor control strategies or changes in fiber membrane

Maximal clenching effort

349

Figure 2 Mean (standard deviations) of RMS of the upper trapezius muscle at pre- and post-MCE conditions during the elevation of the shoulder at 40% and 60% of MaxForce. Not significant difference was found between the pre- and postMCE (Paired Student’s t-test: p > 0.05).

Figure 3 Mean (standard deviations) of Median Frequency (MF) of the upper trapezius muscle during the elevation of the shoulder. No significant difference was found between pre- and post-MCE, with 40% (t Z 1.44, p Z 0.16) and 60% (t Z 0.83, p Z 0.41) of MaxForce (Paired Student’s t-test).

properties is the scaling effect that muscle fiber conduction velocity has on the power spectrum of the signal (Lindstrom and Magnusson, 1977; Stulen and DeLuca, 1981).

between the masticatory and cervical muscles (Zafar, 2000; Milanov et al., 2001). According to the results of this study, this is reflex is absent which means that MCE in centric occlusion, does not cause a widespread excitation of the trapezius muscle in individuals without a history of dysfunction in the masticatory system. Similar results were also found in subjects with normal mandibular divergence and lower and higher mandibular angles (Tecco et al., 2007). However, a significantly higher EMG activity in sternocleidomastoid and upper trapezius muscles has already been verified during maximal voluntary clenching in retrusive occlusal position, as well as no significant differences in EMG activity between intercuspal position, ipsi-lateral, contralateral and protrusive positions (Zuniga et al., 1995). The EMG pattern observed suggests that the position of the mandible can interfere in the functional link between the masticatory and cervical muscles. The performance of the upper member positioning can also be influenced by mandibular positioning (Ferrario et al., 2003; Ciuffolo et al., 2005). The observations about the mandibular positioning, and the fact that the EMG signal readings were carried out only in centric occlusion, demonstrate that the methodology used in this study affected the results. A possible functional link between the masticatory and cervical muscles is more evident in individuals with dysfunction of the masticatory system. In situations of dysfunction of the masticatory system, the trapezius muscle receives afferent nociceptive signal via the trigeminal system, remaining hyperactive while the nociceptive stimulus lasts. Changes in shoulder position could develop because the masticatory muscle hyperactivity leads to cervical muscle hyperactivity, with contraction of the muscles responsible for shoulder elevation and protrusion (Mannheimer and Rosenthal, 1991). This hyperactivity, which can be related to occlusion dysfunction can also affect neck muscles (Ferrario et al., 2003; Ciuffolo et al., 2005). These observations are clear indications that a modulating activity of muscles such as the trapezius can be altered by the nociceptive signal caused in the activity

Statistical analysis Data of EMG activity from the upper trapezius muscle are presented as means and standard deviations (SD). The parametric Student t-test for paired data was used to compare the difference of the RMS amplitude and MF between pre- and post-MCE recording during elevation of the shoulder at 40% and 60% of MaxForce. 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).

Results The values obtained in RMS demonstrated that a postmaximal clenching effort, as contrasted with a pre-maximal clenching effort, does not alter the amplitude of EMG signal under conditions with 40% (t Z 1.0, p Z 0.32,) and 60% (t Z 0.1, p Z 0.91) of MaxForce as demonstrated in Figure 2. The median frequency value demonstrates that MCE does not alter motor control strategies. This result was obtained when comparing pre- and post-MCE conditions with 40% (t Z 1.44, p Z 0.16) and 60% (t Z 0.83, p Z 0.41) of MaxForce in elevation of the shoulder (Figure 3).

Discussion Although these investigations confirm the physiological and anatomic relationships between the masticatory system and the cervical spine (Gola et al., 1995; Zafar, 2000; Milanov et al., 2001), the result of this study demonstrates that the MCE in centric occlusion does not influence the activity of the upper trapezius muscle in individuals without a history of dysfunctions in the masticatory system. The existence of a trigemino-cervical reflex is well known and it may bring about the possible functional link

350 area of the trigeminal nerve, generated by a masticatory system dysfunction, as related by Gola et al. (1995). It has been demonstrated that the masseter muscle and the upper trapezius are a frequent source of pain. This leads to an increase in their fatigability and a reduction in their endurance in response to a given load (Clark et al., 1993). It has been shown that the most painful body site is the cervical spine, followed by the scapular region and the temporomandibular joint (Pedroni et al., 2006). These facts support the idea that nociceptive feedback from the jaw muscles may interact with systemic nociceptive mechanisms, and play a role in musculoskeletal disorders involving pain distributed throughout the head, neck, and limbs. However, it is possible that in situations of dysfunctions in the masticatory system, the trapezius muscle receives afferent nociceptive signals from the trigeminal system, staying hyperactive while the nociceptive stimulus lasts. This can be a possible cause of hyperactivity and the presence of a trigger point (Gola et al., 1995; Fryer and Hodgson, 2005) in this muscle, an issue that should be investigated in future studies.

Limitations The first limitation of this study is related to the sample size, which is considered too small to quantify a possible interaction involving the physiological and anatomic relationships between the masticatory system and the cervical spine. A second limitation was caused by the fact that the results pertained only to healthy individuals. If individuals with dysfunctions in the masticatory systems were included, the results could possibly have been different, which would allow for a more extensive discussion. A third limitation might have been the collection of the EMG signal without altering the positioning of the mandible. Future studies should be conducted with variations (intercuspal, ipsi-lateral, contralateral, protrusive and retrusive occlusal contact positions) regarding the positioning of the mandible.

Conclusions It was possible to determine in this study that in individuals without a history of dysfunction of the masticatory system, maximum clenching effort in centric occlusion does not alter the electromyographic signal of the upper trapezius. This result is not sufficient to disregard a link between the masticatory system and the trapezius muscle.

Acknowledgements This study was partly supported by the FAPESP and CAPES/ PROEX, Brazil.

References Ciuffolo, F., Manzoli, L., Ferritto, A.L., et al., 2005. Surface electromyographic response of the neck muscles to maximal voluntary clenching of the teeth. Journal of Oral Rehabilitation 32, 79e84.

F. Politti et al. Clark, G.T., Browne, P.A., Nakano, M., et al., 1993. Co-activation of sternocleidomastoid muscles during maximum clenching. Journal of Dental Research 72, 1499e1502. Costacurta, L., 1979. Anatomia microsco ´pica buco-dental humana. Atheneu/Universidade de Sa ˜o Paulo, Sa ˜o Paulo. Darling, D.W., Krauss, S., Clasheen-Wray, M.B., 1994. Relationship of head posture and the rest position of the mandible. Journal of Prosthetic Dentistry 52 (1), 111e115. Dworkin, S.F., LeResche, L., 1992. Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and specifications, critique. Journal of Craniomandibular Disorders: Facial and Oral Pain 6, 301e355. Ferrario, V.F., Sforza, C., Colombro, A., et al., 2000. A electromyographic investigation of mastigatory muscles symmetry in normoocclusion subjects. Journal of Oral Rehabilitation 27, 33e40. Ferrario, V.F., Sforza, C., Dellavia, C., et al., 2003. Evidence of an influence of asymmetrical occlusal interferences on the activity of the sternocleidomastoid muscle. Journal of Oral Rehabilitation 30, 34e40. Fryer, G., Hodgson, L., 2005. The effect of manual pressure release on myofascial trigger points in the upper trapezius muscle. Journal of Bodywork and Movement Therapies 9 (4), 248e255. Gangloff, P., Perrin, P.P., 2002. Unilateral trigeminal anaesthesia modifies postural control in human subjects. Neuroscience Letters 330, 179e182. Gola, R., Chossegros, C., Orthlieb, J.D., 1995. Syndrome algodysfonctionnel de l’appareil manducateur. Masson, Paris. Harryman, D.T., Sidles, J.A., Clark, J.M., et al., 1990. Translation of the humeral head on the glenoid with passive glenohumeral motion. The Journal of Bone and Joint Surgery 72, 1334e1343. Harryman, D.T., Sidles, J.A., Harris, S.L., et al., 1992. Laxity at the normal glenohumeral joint: a quantitative in-vivo assessment. Journal of Shoulder and Elbow Surgery 1, 66e76. Hawkins, R.J., Kennedy, J.C., 1980. Impingement syndrome in athletes. The American Journal of Sports Medicine 8, 151e157. Jensen, C., Vasseljen, O., Westgaard, R.H., 1993. The influence of electrode position on bipolar surface electromyogram recordings of the upper trapezius muscle. European Journal of Applied Physiology 67, 266e273. Lindstrom, L., Magnusson, R., 1977. Interpretation of myoelectric power spectra: a model and its applications. Proc IEEE 65, 653e662. Mannheimer, J.S., Rosenthal, R.M., 1991. Acute and chronic postural abnormalities as related to craniofacial pain and temporomandibular disorders. Dental Clinics of North America 35 (1), 185e209. Milanov, I., Bogdanova, D., Ishpekova, B., 2001. The trigeminocervical reflex in normal subjects. Functional Neurology 16, 129e134. Munhoz, W.C., Marques, A.P., Siqueira, J.T.T., 2004. Radiographic evaluation of cervical spine of subjects with temporomandibular joint internal disorder. Brazilian Oral Research 18 (4), 283e289. Neer, C.S., 1983. Impingement lesions. Clinical Orthopedics 173, 70e77. O’Driscoll, S.W., 1991. A reliable and simple test for posterior instability of the shoulder. The Journal of Bone and Joint Surgery 73B (Suppl. 1), 50. Pallegama, R.W., Ranasinghe, A.W., Weerasinghe, V.S., et al., 2004. Influence of masticatory muscle pain on electromyographic activities of cervical muscles in patients with myogenous temporomandibular disorders. Journal of Oral Rehabilitation 31 (5), 423e429. Palmer, M.L., Epler, M.E., 1998. Fundamentals of Musculoskeletal Assessment Techniques. Lippincott Williams & Wilkins, Philadelphia. Pedroni, C.R., Oliveira, A.S., Berzin, F., 2006. Pain characteristics of temporomandibular disorder e a pilot study in patients with cervical spine dysfunction. Journal of Applied Oral Science 14 (5), 388e392.

Maximal clenching effort Stulen, F.B., DeLuca, C.J., 1981. Frequency parameters of the myoelectric signal as a measure of muscle conduction velocity. IEEE Transactions on Biomedical Engineering Letters 28, 515e523. Tecco, S., Caputi, S., Tete, S., et al., 2007. Electromyographic activity of masticatory, neck and trunk muscles of subjects with different mandibular divergence. The Angle Orthodontistic 77 (2), 260e265. Tecco, S., Tete, S., D’Attilio, M., et al., 2008. Surface electromyographic patterns of masticatory, neck, and trunk muscles in

351 temporomandibular joint dysfunctions patients undergoing anterior repositioning splint therapy. The Eruropean Journal of Orthodontics 30 (6), 592e597. Zafar, H., 2000. Integrated jaw and neck function in man. Studies of mandibular and headeneck movements during jaw opening e closing tasks. Swedish Dental Journal Supplement 143, 1e41. Zuniga, C., Miralles, R., Mena, B., et al., 1995. Influence of variation in jaw posture on sternocleidomastoid and trapezius electromyographic activity. Cranio 13 (3), 157e162.

Journal of Bodywork & Movement Therapies (2010) 14, 352e360

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

CASE SERIES

Clinical and MRI findings after high dosage medical exercise therapy in patients with long lasting subacromial pain syndrome: A case series on six patients ˚vard Østera ˚s a,b,*, Gunnar Myhr c, Lasse Haugerud d, Ha Tom Arild Torstensen e a Sør-Trøndelag University College, Faculty of Health Education and Social Work, Department of Physical Therapy, Ranheimsv 10, N-7004 Trondheim, Norway b Rosenborg Sport Clinic, Lerkendal, N-7492 Trondheim, Norway c Unilabs Røntgen Trondheim, 7030 Trondheim, Norway d Moholt Physical Therapy Institute, Trondheim, Norway e Holten Institute, Lidingo¨, Sweden

Received 8 January 2009; received in revised form 14 May 2009; accepted 16 June 2009

KEYWORDS Medical exercise therapy; Pain; Shoulder; Subacromial pain syndrome; MRI

Summary Background and purpose: The primary aim of this case series was to investigate the effect of a high dosage medical exercise therapy program on shoulder pain in patients with subacromial pain syndrome. Subjects: Six subjects were assigned to a medical exercise therapy group. Methods: They received three treatments a week over three months. Outcome measures were descriptions of the subacromial space including supraspinatus tendon diameter, function, pain, and active range of motion in the shoulder girdle. Results: The subjects showed improvement posttest compared to pretest with respect to pain, function, range of motion, and isometric strength. An MRI demonstrated no change in tendon thickness after the treatment. Inflammatory signs such as fluid in the subacromial bursa decreased in some patients.

* Corresponding author. Sør-Trøndelag University College, Faculty of Health Education and Social Work, Department of Physical Therapy, Ranheimsv 10, N-7004 Trondheim, Norway. Tel.: þ47 73 55 93 05; fax: þ47 73 55 93 51. E-mail address: [email protected] (H. Østera ˚s). 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.06.004

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353

Discussion and conclusion: In patients with uncomplicated subacromial pain syndrome, high dosage medical exercise therapy might be an efficient treatment approach. The clinical effects might be explained by morphological changes in the subacromial space. ª 2009 Elsevier Ltd. All rights reserved.

Introduction Shoulder pain is relatively common in the general population (Pope et al., 1997), and the longstanding painful shoulder is well known to be hard to treat (Desmeules et al., 2003). Subacromial impingement syndrome is commonly associated with chronic pain symptoms, but the source of this pain has not been scientifically clarified (Cohen and William, 1998). Theories vary on the origin of the pain in this condition. Khan et al. (1999) suggest that it may come from the subacromial bursa, the rotator cuff tendons, the acromion, or from a combination of pathologies in these various tissues. In the chronic stadium, surgical treatment, such as acromionplasty, is often instituted (Hyvonen et al., 1999). To gain a better understanding of the etiology of the pain in a patient with shoulder impingement, it may be necessary to consider some subacromial anatomical issues. The main blood supply to the rotator cuff comes from the anterior humeral circumflex, the posterior humeral circumflex, the suprascapular and the subscapular arteries (Rothman and Parke, 1965). At a point approximately 1 cm from its insertion on the greater tubercle, the supraspinatus tendon is hypovascular, as demonstrated by various vascular injection studies (Fu et al., 1991). This area is known as the ‘‘critical zone’’. Adduction compounds this hypovascularity by winding the insertional end further around the humeral head. Scheib (1990) suggests that this ‘‘wringing-out’’ further diminishes the blood to the tendon. It is difficult to understand why the supraspinatus tendon has an area of diminished blood supply. Rathburn and MacNab (1970) suggest that since these are flat tendons and the blood vessels run the length of the tendons they are susceptible to traction and direct pressure. The avascular zone therefore might result, and is not a result of degenerative changes. The scientific effect of exercise treatment in patients with impingement is unclear, but exercise as treatment is widely used among physiotherapists. Clinically, medical exercise therapy is believed to increase local circulation in this condition, though this has never been investigated. Inconsistent findings in the literature as to the treatment effects of exercise therapy in subacromial pain syndrome might be explained by the overall low intervention dosages used. The hypothesis is that there are benefits to be gained by increasing the dosages of exercise training for patients with subacromial pain The primary aim of this case series was to investigate the effect of a high dosage of a medical exercise therapy program on subacromial structures and shoulder pain in patients with subacromial pain syndrome.

Materials and methods Subjects. Five men and two women participated in the study. One man was excluded from the study during the intervention period due to surgery. The participants were

recruited by orthopedic surgeons in a regional hospital and by general practitioners. Ethical approval was acquired from the Human Review Committee and all participants provided written consent. Individuals between the ages of 18 and 60 with a unilateral primary shoulder impingement syndrome were assigned if they had: signs of positive impingement, a minimum of three months since the onset of shoulder symptoms, not undergone previous shoulder surgery, normal neck, elbow and thoracic spine function (no positive neurology tests), no neurological diseases, no history of shoulder dislocation, subluxation or fracture, no vestibular or visual disturbances (which would make it impossible to perform the intervention), and no chiropractic, osteopathic or physiotherapy sessions within the last six months prior to entering the study. Individuals were also excluded if they had any cardiovascular, respiratory, systemic, or metabolic conditions limiting exercise tolerance. No subjects refused to participate in the study. The subjects went through a one-day testing procedure before and after the experiment period. They were preliminarily informed about the length of the study and the test parameters that were going to be used. They were asked not to perform strength training the two days before the experiments to avoid the influence of non-restituted musculature. The averages of the subjects’ physical and physiological characteristics before the training period are presented in Tables 1 and 2.

Instrumentation Magnetic resonance imaging (MRI) was performed in a private radiology institute. Coronal T1dweighted turbo spin echo (TSE) and T2dweighted fat saturated TSE, transversal T2dweighted gradientecho and oblique sagittal T2dweighted fat saturated imaging sequences were performed on a Siemens 1.5 Tesla magnet (Symphony) before starting treatment. The coronal images were angulated along the main direction of the superior rotator cuff tendons. This protocol was repeated in a control MR examination three months later. The control MRI was performed one week after the end of treatment. The images were evaluated in a routine clinical setting by two experienced MR radiologists with consensus on configuration of the acromion, subacromial space reduction, degeneration in the acromioclavicular joint, lesions in the rotator cuff, and other soft tissue abnormalities. They agreed on each finding. The subacromial space was measured in the oblique sagittal plane at the lateral edge of the acromion, from the under surface cortical line to the cranial cortical line of the humeral head. The thickness of the supraspinatus tendon was measured in a coronal image located along the central part of the tendon at a point one centimeter lateral to the edge of the acromion. The measurement result was compared in the two MR examinations.

354 Table 1

H. Østera ˚s et al. Baseline values at inclusion of background data.

Case

Age/sex (M Z male, F Z female)

Height (cm)

Mass (kg)

Number of treatments

Durations of symptoms (years)

Subacromial diameter (mm)

1 2 3 4 5 6

49/M 50/M 67/M 44/F 49/F 37/M

181 183 170 170 174 193

75 94 80 70 69 80

35 31 36 28 36 25

0,4 5 0,3 5 15 3

8 10 9 7 7 8

Pain scores The subjective pain score was a composite score of the visual analog scale (VAS). The pain responses were recorded on a 0e100 mm line used for each test. The extreme limits were marked with perpendicular lines using the verbal descriptors of ‘‘no pain’’ or ‘‘worst pain I can imagine’’. The subjects were blinded to their previous markings when follow-up measurements were taken. Measurements were expressed in millimeters. The same rater for all subjects tested the active range of motion (ROM), performed in a standing position with extended elbows. The subjects were asked to flex their shoulder as far as possible. Range of motion was noted with a digital inclinometer (Dualer, JTech Medical Industries, Salt Lake City, Utah, USA). The same procedure was performed measuring active abduction. Function was measured using a functional assessment questionnaire. The functional outcome measures included the self-completed Shoulder Rating Questionnaire (SRQ) for which uniform instructions were given. The five main components are pain (VAS), pain in specific components, activity in daily living, activity level in sports and leisure, and work ability. Psychometric properties (reliability, validity and responsiveness to change) of the SRQ have been previously reported for patients with shoulder pathology (L’Insalata et al., 1997; Williams et al., 1995). The SRQ was scored using the method described by L’Insalata et al. (1997), resulting in a scores rating from 17 to 90, with higher scores indicating better shoulder function with less shoulder symptoms.

Experimental procedures Patient history, symptoms, and clinical findings were the basis for choosing starting positions, range of motion, and Table 2 Case

1 2 3 4 5 6

weight resistance for the patient being able to do three sets of 30 repetitions. Each exercise was tested using a specific clinical test procedure developed in medical exercise therapy (Torstensen, 2004). Note: An example of the exercise protocol will be found in Box 1. Thus, each patient had an individual tailored exercise program. The patient exercised within the comfortable range of motion with normal humeroscapular rhythm, and in the early phase the weight from the pulley apparatus was used to unload some of the weight off the arm, making it possible to perform the high number of repetitions in sets (three sets of 30 repetitions) with good kinetic control. As the patient improved, experiencing less pain, the range of motion and weight resistance were increased and the starting position was changed according to the progression ladder developed in medical exercise therapy (Torstensen, 2004). The number of repetitions and sets was kept constant during the treatment period, which involved three treatments a week for 12 weeks. The intervention program was a combination of 20 min of global aerobic exercises using a stationary bike, treadmill, or step machine, and eight semiglobal and local shoulder exercises using medical exercise therapy equipment. All subjects used the same eight exercises, working with all shoulder muscles.

Remedial exercise program The patients’ history and clinical tests, including muscle tests, specific joint tests and functional tests, are the basis for choosing the correct grading of the exercises focusing on the appropriate weight resistance and range of motion. As an example of the test methodology a patient with 80 degrees of active flexion, 45 degrees of active abduction,

Pain (VAS), range of motion (ROM), shoulder function (SRQ) and supraspinatus tendon diameter with treatment. VAS

ROMdflexion

ROMdabduction

SRQ

Supraspinatus tendon diameter (mm)

Pretest

Posttest

Pretest

Posttest

Pretest

Posttest

Pretest

Posttest

Pretest

Posttest

7,2 7,0 7,5 4,0 6,0 4,0

5,0 2,5 2,0 0,5 4,5 1,0

70 120 90 120 170 180

170 180 170 180 180 180

60 100 90 80 90 180

170 130 160 100 90 180

56 47 45 67 38 45

80 61 79 80 58 69

5 4 6 6 6 4

5 4 6 6 6 4

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355

Box 1. Exercise protocol. For treatment purposes the patient is performs 3 sets of 30 repetitions with a 30 s break between each set, making it a total of 90 repetitions for each exercise. The test methodology is as follows:  From the chosen starting position, range of motion and weight resistance the patient is asked to perform as many repetitions as possible. The patient then starts the exercise, at a speed of approximately 1 repetition every 2 s.  When the patient reaches 8e9 repetitions the test is stopped and the patient is asked whether he/she feels it will be possible to complete at least 40 repetitions.  Depending on the response the regime is modifieddThe response is either ‘‘yes I think I can reach 40 repetitions’’, in which case the patient continues to at least 40 repetitions.  If the report is that it is too easy, the weight resistance is increased or the starting position can be changed.  If however the answer is that the effort is too great or that pain in the shoulder is being provoked the weight resistance is lowered and/or the starting position and range of motion modified.  When the patient reaches 40 repetitions, and starts to tire, or becomes uncoordinated, or starts to feel some pain or discomfort, the exercise is stopped, 20% is deducted from the 40, ending up with 3 sets of 30 repetitions.  The goal is to involve the patient in the test making the patient understand that the goal is to find a baseline regarding range of motion and weight resistance, doing 3 sets of 30 repetitions. The exercise is then continuously monitored, increasing range of motion and weight resistance, but keeping the 3 sets of 30 repetitions constant.  The grading of the exercises is a mirror image of the functional ability the patient. internal rotation to the gluteal fold, and external rotation to 35 degrees, the exercises are tested out within these active ranges of motion. Hence the initial starting positions of the exercise program is a mirror image of the available functional level the patient has. When testing out one exercise, the goal is 40 repetitions and then 20% is deducted from the 40 repetitions ending up with 32 being rounded down to 30 repetitions. To be able to do 3 sets of 30 repetitions, 30e60 s breaks are taken between each set, ending up with a total of 90 repetitions. To be able to accomplish at least 40 repetitions, the physiotherapist (based on the clinical assessment) chooses a range of motion, and weight resistance that is likely to achieve this objective. However this is trial end error and each exercise is tested out the following way;  The patient is told to complete as many repetitions as he/she can manage.  When the patient reaches 8e9 repetitions he/she is told to stop, and the following three questions are asked. 1. Do you think you will be able to reach 40 repetitions, based on the starting position, range of motion, and the degree of effort you have been repeating so far?, 2. Or, is this too easy for you to do? 3. Or, Is this too difficult, causing an increase in symptoms? If the patient says that the loading feels acceptable to reach 40 repetitions, no changes are made and the patient continues the test counting 10, 11 and so forth, up to 40 repetitions. However if the patient says that the exercise is too easy, or too heavy, the exercise is modified, involving either the starting position, the range of motion, or the weight resistance. Thus this is a test, within in the exercise series, that involves the patient in the grading of the degree of effort, so ensuring, as best possible, a positive experience. As the treatment proceeds, and the patient is

improving, the exercises are modified accordingly, changing first the range of motion and then the weight resistance, so that the weight is optimal for doing the sets of 30 repetitions. A change in the exercise program is made at least every 4th to 5th treatment. This system ensures that the patients’ exercise is as pain free as possible. Subjects were informed that, while the exercises might result in muscle fatigue, there should not be an increase in the shoulder pain. It was possible to get the patient to exercise in the pain free range of motion with good coordination, and with the humeroscapular rhythm as close to normal as possible. The subjects performed eight exercises, each of three sets of 30 repetitions, three times a week for three months, making a total of 36 treatments. It is possible that this high exercise dosage results in pain modulation, stimulating the gate control mechanism in the posterior horn, as well as the release of neuropeptides such as endorphins and encephalin from the pituitary gland, into the central nervous system. There was no attrition. Prior to the semiglobal and local exercises the experimental group warmed up for 15e20 min on an ergometer cycle. Half way through the exercise program (four exercises each of three sets of 30 repetitions) the patients cycled for 10 min. After the last four exercises, the patients spent another 10 min on stationary ergometer cycling. The intensity during cycle exercises was moderate to high, i.e. a heart rate frequency of 70e80% of the maximal heart rate, determined as 220 beats per minute, minus age. All patients were treated over a three-month period with three treatments a week. For all patients a physiotherapist was present in the exercise room motivating, supporting and re-grading the exercises according to the patients’ clinical presentation and change in function and symptoms over the three-month treatment period. Thus, all patients received the same amount of attention while they were in the exercise room. The patients were treated in medical exercise therapy groups, where the therapist is in the exercise room, for one hour. Thus the patients were under continuous supervision while exercising. The variables that were continuously

356 regraded were range of motion and weight resistance, while the number of exercises, repetitions, sets, and time performing aerobic work, using a stationary bike, were kept constant. After each treatment the physiotherapist filled in a compliance log for each patient.

Case reports These several case reports constitute a case series type of research methodology.

Case 1 A 49-year-old male visited our clinic five months after he developed shoulder pain. He had problems performing his job as a postman, due to increasing pain during the day, but he was not on sick leave. While he did not perform very much work above shoulder height with the affected arm, he still did much carrying and lifting during an ordinary working day. The subacromial diameter on the affected arm was eight mm. The MRI showed an acromion type 1 and a light degree of calcification in the area 5 mm cranial to the supraspinatus insertion on tuberculum major. After 35 treatments the MRI did not show any changes. He had improved both function and range of motion, and the pain level was decreased.

Case 2 This case is a 50-year-old male working with a moderate degree of physical strain on the upper body, but not with work over shoulder height. As in case 1, this man did not perform any specific kind of physical activity in addition to his work. His shoulder pain had developed gradually, starting approximately five years ago. There was no obvious reason for the initial pain. The MRI at pretest showed a type 1 acromion, no calcification, 10 mm subacromial diameter, but a light degree of liquid between lateral parts of the supraspinatus tendon and the deltoid muscle. A small benign subcortical cyst in ventral parts of the tuberculum major was also found at pretest. After 31 treatments over 12 weeks the radiologist found a normalization of the supraspinatus tendon and no cyst. The patient had marked pain relief; from 7.0 to 2.5 on the VAS, along with increased function and range of motion.

Case 3 A 67-year-old male was seen four months after the initial shoulder symptoms. He had worked as a bureaucrat his entire career, and had never done strenuous overhead physical activities, and had no known shoulder or arm injury. His acromion configuration was type 2, with a subacromial diameter of 9 mm. The MRI showed a light degree of tendinosis in both the supraspinatus and the subscapularis tendons. Despite failing standardized protocols describing quantification tendinosis in these areas, the MRI at posttest, with the same radiologist and corresponding MRI procedure, showed less tendinosis after 36 treatments. He was the patient in the present study that improved most with respect to pain, from 7.5 to 2.0 on the VAS. However, he had only had

H. Østera ˚s et al. shoulder pain for four months. The active range of motion and function also had a marked increase.

Case 4 A 44-year-old female with five years of symptoms did not use her arms much at work, and was not on sick leave. She had previously been a handball player, but with no known shoulder injuries, and she fulfilled the inclusion criteria. At pretest she complained of shoulder pain during light upper body strength training, and she also had a certain degree of pain at rest and in the night. The pretest MRI showed type 2 subacromial configuration, with a subacromial diameter of 7 mm. After 28 treatments her pain level decreased from 4.0 to only 0.5, along with an increase in overall shoulder function. At posttest her active shoulder range of motion was completely normal.

Case 5 The 49-year-old woman had pain in different levels for 15 years, with no pinpointed onset, and no injury. The MRI at pretest showed a type 2 acromion, with an 8 mm subacromial diameter. Structural changes in the transition between muscle and tendon tissue in the supraspinatus were also found. At her office workplace she had a moderate degree of shoulder strain, but no specific physical activity in her leisure time. She needed almost a month to be able to complete the recommended intervention level due to pain, but she was able to train the last two thirds of the medical exercise treatment period as prescribed. After 36 treatments the MRI found normalization in the tissue changes found in the supraspinatus at pretest, and no extra-tendinous oedema in the same area. Her range of motion did not change, but she had less pain and increased function.

Case 6 This 37-year-old male with three years of shoulder pain also had some pain in the other shoulder, but he fulfilled the inclusion criteria. He worked as a physiotherapist, but did not do heavy work due to shoulder strain. However, he had been an active cross-country skier, and he was still performing upper body physical activities on a daily basis. The initial MRI showed acromion type 2, with an 8 mm subacromial diameter. After 25 treatments 12 weeks later, a thin layer between the supraspinatus tendon and the deltoid muscle disappeared, corresponding to a pain relief from 4.0 to 1.0 on the VAS. His function also improved. The range of motion was not affected in the beginning. He was able to increase the frequency of his cross-country skiing, but at posttest he still had increased shoulder pain through strength training in a more than 90-degree flexion or abduction. Each participant’s compliance categorization was determined by averaging the compliance reported on four compliance logs. The compliance level was 83%%, with the number of sessions expected at the outset. The results from the testing of active range of motion in the shoulder girdle are presented in Table 2, which showed an increase in both active abduction and flexion in all subjects from pretest to posttest. The results from the MRI are illustrated in Figures 1e3.

Effects of exercise therapy in impingement patients

357

Figure 1 Longitudinal rupture of the supraspinatus tendon at the musculotendinous junction. 1A and 1B: Pretreatment coronal and sagittal T2 weighted fat saturated images shows irregular signal and high-signal intensity oedema in the superficial part of the tendon (arrow). 1C and 1D: The same images after treatment. The tendon is normal.

 Four subjects had type 2 acromial configuration and three had type 1 according to the Bigliani classification (1986).  The subacromial diameter was unchanged from pretest to posttest images for all subjects.  The thickness of the supraspinatus tendon pretest and posttest is given in Table 1.  The thickness changed in three patients, two increased by 1 mm and one decreased by 1 mm.  In addition to the measurement values that were found during the MRI, some qualitative soft tissue findings changed during the study period. They included reduced fluid in the subdeltoid bursa in four cases and increased fluid in one case.  A partial intratendinous longitudinal rupture normalized during the study, see Figure 1a and b.  A small intrasubstance rupture in the supraspinatus tendon was not visible on the follow up in one patient.  A calcified tendinosis remained unchanged in one case.  One patient with extensive osteoarthritis of the acromioclavicular joint, bursitis of the subdeltoid bursa and penetrating rupture of the supraspinatus tendon was

referred to surgical treatment and was therefore excluded from the study group.

Discussion In this case series, we found reduced pain, improved active range of motion and function, in a group of patients with shoulder impingement syndrome treated with high dosage exercise therapy. In five of the six patients, the subjective qualitative evaluation of the MRI findings suggests a normalization of the subacromial soft tissue structures. Due to the low number of subjects, we do not know whether the high dosage medical exercise therapy correlates with the specific soft tissue findings on the MRI. The shape of the acromion has been classified into three anatomical types by Bigliani et al. (1986). 1. In type 1, the acromial under the surface has a flat shape.

358

Figure 2

H. Østera ˚s et al.

The standard measurement of tendon thickness. 2A: Distance from the tip of acromion. 2B: The measurement.

2. In type 2 the acromial shape is gently curved with the majority of the inferior cortex parallel to the curvature of the humerus head in the oblique sagittal plane. 3. The type 3 acromial shape has an anterior hook that abruptly narrows the anterior acromiohumeral distance (Crues and Fareed, 1991). Type 3 acromion has been found to predispose for impingement syndrome and might be associated with rotator cuff tears in the ‘‘critical zone’’ (Wolin and Tarbet, 1997). In the present study, the number of subjects is too small to suggest a correlation between acromial shape and symptoms, which might be of interest in subjects who are candidates for surgery. Shoulder pain and the shoulder impingement syndrome are third in frequency of visits to general practitioners, only less frequent than headaches and backaches (Bland et al., 1977). The shoulder impingement syndrome is the most common shoulder problem seen in sports medicine. This syndrome may be caused by repetitive overhead use of the arm causing microtrauma to the subacromial tissues. These microtraumas provoke a local inflammatory response, partial tearing, and thickening of the rotator cuff. The subacromial bursa may also become irritated with resultant thickening of its wall, accumulation of fluid, and adhesion formation (Jackson and Graf, 1985). Correct rehabilitation is the key to successful conservative treatment. Nirschl (1989) suggests that intrinsic muscle contractile tension overload is the major factor in rotator cuff tendinosis rather than primary impingement. This, according to him, is why stage 1 and 2 lesions respond positively to exercise therapy. The qualitative MRI evaluation of soft tissue changes in patients with shoulder pain is subjective. Subtle differences in tendon signal intensity and small intrinsic or surface ruptures may be difficult to detect in the first place. Changes between two consecutive studies may be more difficult to objectify. The same problem is apparent when measuring thickness of tendon plates that normally is

in the 4e7 mm range. Intraobserver variability may have been a source of error. The small change in diameter cannot be related to treatment. We would expect a treatment effect on tendon inflammation to lead to a decrease in thickness. Some of the qualitative differences seen in the soft tissue structures may be related to a decrease in local inflammation, e g. decrease in bursal fluid. It is difficult to decide if this is a real treatment response or just a reparative response over time, because of a change in physical activity patterns, regardless of the treatment. The present study used a high number of repetitions in the treatment program. In vitro studies of shoulders have demonstrated an avascular zone in the supraspinatus tendon, located approximately one cm proximal to the insertion of the tuberculum majus (Wolin and Tarbet, 1997;

Figure 3 The acromion shape extrapolated from Bigliani et al. (1986). Sagittal fat saturated T2 weighted image shows the Type 2 acromion with the surface parallel to the head of the humerus.

Effects of exercise therapy in impingement patients

Figure 4

359

Standing unloaded shoulder flexion 3  30 repetitions, 3 kg.

Hawkins and Abrams, 1987). This avascular zone may be a predisposing factor in tendon degeneration and tendonitis with pain and reduced function (Lyons and Orwin, 1998). A positive effect from the medical exercise therapy might be an increase in revascularization and regeneration of the rotator cuff tendons through a biomechanical stimulus from performing dynamic exercises with a concentric and eccentric phase (Torstensen, 2004; Torstensen et al., 1994). This fits well with the move from tendinitis to tendinosis (Khan et al., 2002). In patients with tendinosis of the Achilles tendon, a vasculo-neural growth in the tendon has been registered and may be a possible explanation for pain in patients with longstanding Achilles tendinosis ¨ hberg, 2003). O ¨ hberg (2003) has (Alfredson et al., 2003; O also documented that eccentric training resulted in a decrease in the neovascularization of the tendon and that the tendon infrastructure changed from having ultrasonographically hypoechoic areas and irregular fiber structure in a normal tendon. Even though the function of the shoulder is different compared to the lower leg, there are relevant clinical and functional similarities. A case study by Torstensen et al. (1994) showed that a supraspinatus tendon (tendinosis) regenerated after HD medical exercise therapy. More research is needed into any positive effects on tissue structures that are causing shoulder pain. Pain source? Even after eliminating shoulder pain caused by structures in the neck and thoracic area, it is still difficult to pinpoint exactly which structure in the shoulder is causing the subacromial pain. When the pain is caused by structures within the shoulder joint, there is a very low correlation between structural changes in soft tissues in the shoulder and the pain experience (Needell et al., 1996;

Khan et al., 1998). Adding to the problem of making a true and correct tissue-at-fault diagnosis, health professionals generally find it difficult to agree on a common diagnosis and treatment for patients who have a painful shoulder (Bamji et al., 1996). To avoid these problems the basis for choosing exercises and their grading in medical exercise therapy is strictly based on the patient presentation. This includes the patient history, the patient’s pain reaction, and such clinical findings as active and passive range of motion, palpation, isometric tests, provocation tests, impingement tests, and so on, and not on structural changes of tissues. Another factor that clinicians must take into account is the fact that the more complex and chronic a shoulder problem is, the more complex and diverse the pain mechanisms, the more futile the effort is to direct treatment at a ‘‘specific’’ target tissue. The exercise therapy in this trial did not have the ‘‘single-bullet-therapy’’ effect, as, for example, a cortisone injection; rather the total exercise dosage has the effect of a shotgun hitting all structures in the shoulder, shoulder girdle and the arm. In a systematic review by Michener et al. (2004) on the effectiveness of rehabilitation for patients with subacromial impingement syndrome they concluded that therapeutic exercise was the most thoroughly investigated form of rehabilitation. Controlled trials indicate that therapeutic exercise is more effective in reducing pain and improving functional loss than a placebo in both short- and long-term follow up (Brox et al., 1993; Brox et al., 1999), and more effective than no intervention in short-term follow up (Ludewig and Borstad, 2003). Given the evidence from the last systematic review by Michener et al. (2004),

360 therapeutic exercise is indicated as an effective intervention for patients with subacromial impingement syndrome as opposed to no treatment or placebo treatment. However, the interventions were vaguely described, making the exercise techniques difficult to replicate. It is also unclear what the optimal exercise regimen is or the frequency and intensity of an exercise program. One shortcoming in the present case series is the differences in the number of sessions attended (Table 1). Further research with a time-series analysis could shed some light on this discussion of dosage. It would be interesting and useful to compare symptomatic with asymptomatic subjects in a future study. Further research in this area should address a larger group of patients in randomized clinical trials. Imaging methods such as diagnostic ultrasound should also be included. Randomized clinical trials should also be used to further investigate the therapeutic effects of different exercise therapy regimens in patients with longstanding subacromial pain.

Conclusion The primary purpose of this clinical trial was to investigate whether there might be pain, active ROM or morphological changes after medical exercise regimens in non-operated patients with subacromial pain syndrome. The subjects showed clinically improved results after twelve weeks of medical exercise training for overall pain and function, though further research is needed for this to be more conclusive. In patients with uncomplicated subacromial pain syndrome, medical exercise therapy might be an efficient treatment approach Figure 4a and 4b.

Acknowledgement The authors received no funding in the writing or preparation of this manuscript and have no conflicts of interest.

References ¨ hberg, L., Forsgren, S., 2003. Is vasculo-neural Alfredson, H., O ingrowth the cause of pain in chronic Achilles tendinosis? An investigation using ultrasonography and colour doppler, immunohistochemistry, and diagnostic injections. Knee Surg. Sports Traumatol. Arthrosc. 11, 334e338. Bamji, A.N., Erhardt, C.C., Price, T.R., Williams, P.L., 1996. Clinical audit. The painful shoulder: can consultants agree? Br. J. Rheum. 35, 1172e1174. Bland, J.H., Merrit, J.A., Boushey, D.R., 1977. The painful shoulder. Semin. Artrithis Rheum. 7, 21e47. Bigliani, L.U., et al., 1986. The morphology of the acromion and its relationship to rotator cuff tears. Orthop. Trans. 10, 216. Brox, J.I., Staff, P.H., Ljunggren, A.E., Brevik, J.I., 1993. Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome). BMJ 307, 899e903. Brox, J.I., Gjengedal, E., Uppheim, G., et al., 1999. Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease (stage II impingement syndrome): a prospective, randomized, controlled study in 125 patients with a 2 1/2-year follow-up. J Shoulder Elbow Surg. 8 (2), 102e111. Cohen, R., William, G., 1998. Impingement syndrome and rotator cuff disease as repetitive motion disorder. Clin. Orthop. 351, 95e100.

H. Østera ˚s et al. Crues III, J.V., Fareed, D.O., 1991. Magnetic resonance imaging of shoulder impingement. Top Magn. Imaging. 3, 39e49. Desmeules, F., Cote, C.H., Fremont, P., 2003. Therapeutic exercise and orthopedic therapy for impingement syndrome: a systematic review. Clin. J. Sport Med. 13, 176e182. Dualer IQ. J Tech Medical Industries, Salt Lake City, Utah, USA. Fu, F.H., Harner, C.D., Klein, A.H., 1991. Shoulder impingement syndrome. Clin. Orthop. 269, 162e173. Hawkins, R.J., Abrams, J.S., 1987. Impingement syndrome in the absence of rotator cuff tear (stages 1 and 2). Orthop. Clin. North Am. 18, 373e382. Hyvonen, P., Lohi, S., Jalovaara, P., 1999. Open acromionplasty does not prevent the progression of an impingement syndrome to a tear. J. Bone Joint Surg. Br. 8, 813e816. Jackson, D., Graf, B., 1985. Decompression of the coracohumeral arch. In: Jackson, D. (Ed.), Shoulder Surgery in the Athlete. Aspen Publications, Rockville, MD, pp. 51e63. Khan, K.M., Tress, B.W., Hare, W.S.C., Wark, J.D., 1998. Treat the patient, not the x-ray: advances in diagnostic imaging do not replace the need for clinical interpretation. Clin. J. Sports Med. 8, 1e4. ˚strøm, M., 1999. Khan, K.M., Cook, J.L., Bonar, F., Hardcourt, P., A Histopathology of common tendinopathies. Sports Med. 27, 188e201. Khan, K.M., Cook, J.L., Kannus, P., et al., 2002. Time to abandon the ‘‘tendinitis’’ myth. Painful, overuse tendon conditions have a non-inflammatory pathology. BMJ 324, 627e628. L’Insalata, J.C., Warren, R.F., Cohen, S.B., et al., 1997. A selfadministered questionnaire for shoulder assessment of symptoms and function of the shoulder. J. B. Joint Surg. Am. 79, 738e748. Lyons, P.M., Orwin, J.F., 1998. Rotator cuff tendinopathy and subacromial impingement syndrome. Med. Sci. Sports Exerc. 30 (4), 12e17. Ludewig, P.M., Borstad, J.D., 2003. Effects of a home exercise programme on shoulder pain and functional status in construction workers. Occup. Environ. Med. 60 (11), 841e849. Michener, L.A., Walsworth, M.K., Burnet, E.N., 2004. Effectiveness of rehabilitation for patients with subacromial impingement syndrome: a systematic review. J. Hand. Ther. 17 (2), 152e164. Nirschl, R.P., 1989. Rotator cuff tendinosis: basic concepts of pathoetiology. Am. Acad. Orthop. Surgeons, Instructional Course Lectures 38, 439e445. Needell, S.D., Zlatkin, M.B., Sher, J.S., et al., 1996. MR imaging of the rotator cuff: peritendinous and bony abnormalities in an asymptomatic population. AJR 166, 863e867. ¨ hberg L., 2003. The chronic painful achilles and new methods for O treatment. PhD thesis, Umea ˚ University, Umea ˚, Sweden. Pope, D.P., Craft, P.R., Pritchard, C.M., Silman, A.J., 1997. Prevalence of shoulder pain in the community: the influence of case definition. Ann. Rheum. Dis. 56, 308e312. Rothman, R.H., Parke, W.W., 1965. The vascular anatomy of the rotator cuff. Clin. Orthop. 41, 176e186. Rathburn, J.B., MacNab, I., 1970. The microvascular pattern of the rotator cuff. J. Bone. Joint. Surg. 52-B, 540e553. Scheib, J.S., 1990. Diagnosis and rehabilitation of the shoulder impingement syndrome in the overhead and throwing athlete. Rheum. Dis. Clin. North Am. 16, 971e988. Torstensen, T.A., 2004. A software programmer and sportsman with low back pain and sciatica. In: Jones, M.A., Rivett, D.A. (Eds.), Clinical Reasoning for Manual Therapists. Elsevier Ltd, London, pp. 275e311. Torstensen, T.A., Meen, H.D., Stiris, M., 1994. The effect of medical exercise therapy on a patient with chronic supraspinatus tendinitis. Diagnostic ultrasound e tissue regeneration: a case study. JOSPT 20 (6), 319e327. Wolin, P.M., Tarbet, J.A., 1997. Rotator cuff injury: addressing overhead use. Phys. Sports. Med. 25 (6). Williams, J.W., Holleman, D.R.J., Simel, D.L., 1995. Measuring shoulder function with the shoulder pain and disability index. J. Rheumatol. 22, 727e732.

Journal of Bodywork & Movement Therapies (2010) 14, 361e366

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

PHYSIOLOGY

Effect of low back pain on postural stability in younger women: Influence of visual deprivation ˆnio Renato Pereira Moro a, Luana Mann a, Julio F. Kleinpaul a, Anto Carlos Bolli Mota b, Felipe P. Carpes c,* a

Laboratory of Biomechanics, Federal University of Santa Catarina e Floriano´polis, SC, Brazil Laboratory of Biomechanics, Federal University of Santa Maria e Santa Maria, RS, Brazil c Exercise Research Laboratory, Federal University of Rio Grande do Sul e Porto Alegre, RS, Brazil b

Received 24 October 2008; received in revised form 19 June 2009; accepted 26 June 2009

KEYWORDS Body balance; Pain; Sensory feedback; Visual information; Motor control; Lumbar spine; Postural balance

Summary This study investigated the effect of low back pain (LBP) on body balance during normal and visual deprivation during standing in a LBP group (10 women) and a control group (10 women). A 3-D force plate was used to measure the center of pressure (COP) anteroposterior and mediolateral displacements, and resultant velocity. ANOVA was used to compare situations. LPB group presented higher amplitudes of COP for anterioposterior direction (p < 0.01) in conditions of open (3.07  0.53 cm) and closed eyes (3.70  0.71 cm) than healthy women (1.39  0.17 cm and 1.75  0.36 cm, for open and closed eyes, respectively). Similar results were found for COP involving mediolateralsway. The resultant COP velocity was larger for LBP group (p < 0.05) when visual information was removed (3.03  0.68 m/s and 3.63  1.33 m/s for LBP and healthy women, respectively). LBP influenced the stability of young women during quiet standing, and the visual deprivation appears to reinforce LBP effects. ª 2009 Elsevier Ltd. All rights reserved.

Introduction The ability to control of body balance during standing is dependent on the activity of central nervous system (CNS). The CNS plays a fundamental role for generation and regulation of proper muscle activity to control the * Corresponding author. Tel.: þ55 51 3308 5859; fax: þ55 51 3308 5842. E-mail address: [email protected] (F.P. Carpes).

relationship between the center of mass projection and the area of support (Winter et al., 1998). The postural stability usually is described by changes in the center of pressure e COP e excursion (Winter et al., 1998). The CNS regulates the body stability while standing or during locomotion mainly by means of afferent information from the visual system (Mergner et al., 2005), proprioceptors organs (Bove et al., 2003; Tresch, 2007), cutaneous inflow (Kavounoudias et al., 1998), and changes in vestibular input (Bacsi and Colebatch, 2005).

1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.06.007

362 When some restriction occurs, such as absence of visual feedback while standing with the eyes closed, the stability is expected to decrease (Schieppati et al., 1999). Elite gymnast athletes evaluated during bipedal, unipedal and handstand postures in different levels of complexity presented not only direct effect of visual deprivation on the stability evaluated by COP surface and COP mean velocity, but also, for example, the influence of the segment’s orientation (Asseman et al., 2005). Visual deprivation can also increase instability in dancers (Hugel et al., 1999). This supports the concept that visual information can influence postural stability mainly by changing the interaction with the environment. Fear or apprehension, for instance, while standing on platforms of various heights (0.8, 1.6, and 3.2 m) resulted in increased COP variation depending on the degree of fear of falling and anxiety detected (Davis et al., 2008). Additionally, subjects evaluated under a similar protocol also presented changes in H-reflex that could not be explained by the background muscle activation, but were dependent on presynaptic inhibitory mechanisms anxiety-related (Sibley et al., 2007). The authors suggested this theoretical mechanism is also possible due to pain. Indeed, young-trained gymnasts of normal weight and anxiety-free but with low back pain (LBP) presented increased variability of center of pressure (Harringe et al., 2008). The authors investigated whether athletes training and competing with LBP would change their strategies for postural control. The anteroposterior COP excursion while standing with eyes closed on a foam surface was greater in LBP subjects compared to subjects with lower extremity injury (Harringe et al., 2008). LBP affects the ability to control standing posture (Brumagne et al., 2008a, b). Studies suggest LBP as a public health problem with prevalence up to 20% in USA and up to 40% in European countries (Van Tulder, 1996). Nonspecific LBP has been considered resultant of articular and/or muscular imbalances of the lumbo-pelvic complex (Vogt, 2003) and is more frequent for women (Clarke and Buckley, 1980; Andersen et al., 2006). Among the factors underlying LBP are decrease of agility, coordination and postural control (Alaranta et al., 1994). The low muscular conditioning of muscles of the trunk and lumbo-pelvic complex has also been suggested as influencing the hip strategy for control of body balance in LBP subjects (Carpes et al., 2008). As a corollary, LBP is known to negatively influence the proprioceptive capacity (Mientjes and Frank, 1999; Brumagne et al., 2008a), which probably leads to increased dependence on the visual system (Brumagne et al., 2000, 2008a). This would be related to similar pre-synaptic inhibitory mechanisms similar those observed in fear/ anxiety situations (Sibley et al., 2007; Davis et al., 2008). In this regard, under both quiet stance and dynamic conditions, vision cannot be readily replaced by other sensory inputs in normal subjects (Schmid et al., 2007). If so, the ability to control the body balance in nonspecific LBP subjects, deprived of vision, should result only from nonvisual sensory feedback. Thus, visual deprivation in LBP patients may result in more remarkable effects on body balance than would be the case for healthy subjects. The purpose of this study was to investigate the effects of vision deprivation on the body balance of younger women reporting nonspecific LBP.

L. Mann et al.

Methods Subjects Institutional approval for all phases of this study was obtained from the Committee of Ethics in Research with Humans of the Institution where this study was developed (IRB number 23081.001276/2007-32). Subjects signed a consent form affirming voluntary participation in the study. The subjects were divided into two groups. The experimental group (LBP) comprised 10 women reporting chronic nonspecific LBP for more than three months (mean  standard-deviation age of 20.7  2.1 years old, body weight of 57.6  0.6 kg, and height of 1.65  0.04 m). The LBP group was paired to a control group (healthy) without any LBP episode and without history of lumbar surgery, spine abnormalities, neuromuscular, joint and reflex deficits, cauda equina, carcinoma, pregnancy, or radicular symptoms observed during functional evaluation. These 10 healthy women presented mean  standarddeviation age of 20.2  1.7 years old, body weight of 56.7  0.2 kg, and height of 1.66  0.03 m. The inclusion in the LBP group was based on LBP uni- or bilaterally with nonspecific origin for more than three months, which was confirmed by use of functional tests previously described in the literature for the low back (Gross et al., 1996). The subjects of both the groups had not been involved with regular physical activity during the six months prior to evaluation.

Pain evaluation LBP was rated by each subjects by means of a visual analog scale from 0 to 10, where 0 represented ‘no pain’, and 10 represented ‘unbearable pain’. The pain grade also suggested 0e2 as ‘light pain’, from 3 to 5 ‘light to moderate pain’, from 6 to 7 ‘moderate to intense pain’, and from 8 to 10 ‘unbearable pain’ (Bird and Dickson, 2001).

Body balance biomechanical assessment The biomechanical assessment of body balance followed the protocol described in a recent publication (Carpes et al., 2008). The changes in center of pressure (COP) displacement were measured using a biomechanical 3-D force plate (Advanced Mechanical Technology, Inc., Watertown, MA, USA) placed in the center of a quiet environment and calibrated as described by the manufacturer recommendations. The force plate was embedded at the level of the laboratory floor, and the room presented no visual or auditory distractions. The subjects had their feet positioning marked on the force plate surface in the first trial, and each individual used this template for all the subsequent trials. Subjects were oriented to stand quietly barefoot separated at a comfortable width (about shoulder-width apart) with their arms resting at their sides. The trials had a duration of 30 s with the subjects maintaining a static posture, and were repeated three times randomly with closed eyes (CE) or opened eyes (OE) in an attempt to minimize variability. The eyes closed characterized the visual deprivation, which was observed by the researcher to make sure that subjects

Effect of low back pain on postural stability

363

Statistical procedures Data were organized for mean and standard-deviation for each situation and group. The data normality was confirmed by means of Shapiro-Wilk’s test. The homogeneity of variances was verified using Hartley’s test. The comparison between situations within and between groups was accomplished by means of a two-way mixed model (between-within) ANOVA. Post-hoc Tukey’s test was applied where main interactions were found. All statistical procedures were conducted using the SPSS 11.5 for Windows (Statistical Package for Social Sciences, Chicago, IL, USA). The significance level was set at 0.05.

Results The LBP group presented scores of 6  2 concerning the pain ratio grade, which denotes moderate to intense pain. The Figures 1e3 depict the findings of the present investigation. The overall results were consistent with significant effects of LBP and visual deprivation on body balance. The visual deprivation was related to increase COPap magnitudes for both groups. LBP subjects presented higher COPap

¢

8

*

CE

8 CE OE 6

COPml (cm)

remained with the eyes closed during the trials. The COP was used to express the neuromuscular responses to postural stability due to changes of the position of center of gravity (Winter, 1990). Data regarding body balance were acquired in the same way for the two groups. The testing protocol was conducted in a quiet room with data being collected at sampling rate of 100 Hz via personal computer using specific software (data acquisition and off-line analysis) of the biomechanical force plate (NetForce, Advanced Mechanical Technology, Inc., Watertown, MA, USA). From COP data, the anterioposterior displacement (COPap), mediolateral displacement (COPml) and resultant velocity (COPvel) were considered for discussion.

¢ *

4 * 2

0 Healthy

LBP

Figure 2 Center of pressure displacement in mediolateral direction (COPml, in cm) for the two groups (healthy and low back pain e LBP) in the situations of closed (CE) and opened eyes (OE). For LBP subjects, the COPml was higher in the closed eyes situation (¢, F Z 9.33; p Z 0.007), and COPml was higher than found for healthy subjects for both closed and opened eyes situation (*, F Z 23.9 and F Z 97.6, respectively, for p < 0.001).

displacement in both situations (see Figure 1). COPap was statistically higher for the subjects, for CE (F Z 59.6; p < 0.001) and OE (F Z 91.35; p < 0.001). COPap was higher in the situation of closed eyes for healthy (F Z 7.85; p < 0.05) and LBP subjects (F Z 5.04; p < 0.05). COPml (Figure 2) did not differ between situation of closed and opened eyes for the healthy subjects (F Z 0.92; p Z 0.350). For low back subjects, the COPml was higher than found for healthy subjects for both closed and opened eyes situation (F Z 23.9 and F Z 97.6, respectively, for p < 0.001). Closed eyes situation elicited higher COPml than while standing with eyes open (F Z 9.33; p Z 0.007). The COPvel (see Figure 3) depicts the velocity of changes in resultant COP position for the different groups and situations. COPvel was not influenced by the visual condition in healthy subjects (F Z 0.01; p Z 0.91 for closed eyes, and F Z 1.28; p Z 0.27 for opened eyes). For opened eyes

OE 8 *

CE 4

¢

OE

*

6

COP vel (m/s)

COPap (cm)

6

2

0

4

2 Healthy

LBP

Figure 1 Center of pressure displacement in anteroposterior direction (COPap, in cm) for the two groups (healthy and low back pain e LBP) in the situations of closed (CE) and opened eyes (OE). COPap was statistically higher for the LBP subjects, for CE (¢, F Z 59.6; p < 0.001) and OE (¢, F Z 91.35; p < 0.001). COPap was higher in the situation of closed eyes for healthy (*, F Z 7.85; p < 0.05) and LBP subjects (*, F Z 5.04; p < 0.05).

0 Healthy

LBP

Figure 3 Center of pressure resultant displacement velocity (COPvel) for the two groups (healthy and low back pain e LBP) in the situations of closed (CE) and opened eyes (OE). Closed eyes situation present statistically significant difference between the groups (*, F Z 7.24; p Z 0.015).

364 condition, no difference was found between healthy and low back pain subjects (F Z 4.26; p Z 0.054). Closed eyes situation present statistically significant difference between the groups (F Z 7.24; p Z 0.015).

Discussion Vision is the sensory input of highest confidence for the CNS in postural stabilization (Latash, 1997). Postural control involves information processing from sensory stimuli deriving from the visual, vestibular and somatosensorial systems in an integrated way to accurately regulate body positioning and center of mass movements (Oie et al., 2002; Della Volpe et al., 2006). If one or more of these systems fail, or the sensoy information is not correctly processed, the risk of a fall or instability increases (Horak and Macpherson, 1996). LBP can alter the sensory input to postural control (Graven-Nielsen et al., 1997; Gill and Callaghan, 1998). It may be related to increased pre-synaptic inhibition of afferent muscles (Sibley et al., 2007) in this case due to pain, or for chronic LBP subjects could suggest an adaptation of cortical processing of proprioceptive information (Rossi et al., 2003). Additionally, the deficit in recovery from perturbations is suggested to be dependent on reduced proprioceptive information, which would elicit increased visual dependence (Nies and Sinnott, 1991; Mientjes and Frank, 1999; Brumagne et al., 2008a). In this regard, for normal subjects under both quiet stance and dynamic conditions, vision cannot be readily replaced by other sensory inputs (Schmid et al., 2007). Gymnasts performing specific movements in bipedal, unipedal and handstand postures were not only affected by visual deprivation, but also by visual deprivation combined with orientation (Asseman et al., 2005). Visual deprivation was suggested as affecting postural control in dancers (Hugel et al., 1999). LBP is known to decrease proprioceptive capacity (Mientjes and Frank, 1999; Brumagne et al., 2008a), which may lead to increased dependence on the visual system in an attempt to improve the interaction with the environment, providing stability (Gautier et al., 2007; Brumagne et al., 2000, 2008a). Therefore, the main purpose of this study was to assess body balance in young women, both healthy and with LBP, with and without visual information. Our results are consistent with increased dependence on visual information in LBP subjects (Mientjes and Frank, 1999; Radebold et al., 2001; Brumagne et al., 2008a; Mok et al., 2004; Nies and Sinnott, 1991; Speers et al., 2002). Subjects presented LBP ratio classified as moderate to intense. Visual deprivation was induced by standing posture while keeping the eyes closed. The results support the influence of LBP in general variables of body balance (Della Volpe et al., 2006; Brumagne et al., 2008a; Harringe et al., 2008). Additionally, we found visual deprivation increasing postural instability more significantly (higher magnitudes of COP displacements) for those with LBP. Among the factors for reduced postural control in LBP subjects is the limited ability for use of a hip strategy due to reduced force and flexibility of the lumbo-pelvic region (Carpes et al., 2008; Brumagne et al., 2008b). Our results eliciting higher variability in mediolateral direction,

L. Mann et al. support the deficit in hip strategy in LPB subjects. This relates to the number of degrees of freedom considering the anteroposterior oscillation when compared to the mediolateral direction that is mainly controlled by the hip strategy (Mochizuki et al., 2006). A hip strategy for postural control involves action of muscles across the trunk and hip with horizontal shear forces as results of torque produced at the hip joint, rather than ankle joint to maintain the body stability. On the other hand, an ankle strategy concerns action of muscles across the ankle joint producing torques that shift the center of vertical foot pressure to maintain the center of mass over the base of support provided by the contact of feet with the ground (Henry et al., 2006). Indeed, LBP subjects present deficits in the sense of position for the region of the hip (Gill and Callaghan, 1998; Brumagne et al., 2000, 2008a), and which evokes an ankle strategy to maintain the standing posture (Brumagne et al., 2004). The influence of muscle fatigue due to change in trunk position combined with pain may lead to increased instability in low back subjects, including subjects with chronic pain. Our results are also consistent with a posture of trunk shift forward in LBP subjects, as elicited by the greater COPap displacement (Brumagne et al., 2008a; Popa et al., 2007). According to Brumagne et al. (2008a) increased forward trunk inclination resultant from anticipation of postural instability may play a key role in the recurrence of LBP. This effect could be similar those resulting from fear and/or anxiety involving postural control while standing on platforms of different heights (Davis et al., 2008) when changes in H-reflex not explained by the muscle activity may also arise (Sibley et al., 2007). The present results and the results from previous studies have implications for the postural control in older subjects with LBP or hemiplegic subjects, as previous suggested (Sibley et al., 2007). Considering LBP as the only factor contributing to changes in postural control, changes in normal standing posture leads to increased activation of back muscles (Brumagne et al., 2008a), and therefore an increased the fatigue rate (Vogt, 2003). These changes in the pattern of back muscle activation have been suggested as a strategy to limit spine movements regardless of the pain intensity (Nies and Sinnott, 1991; Mientjes and Frank, 1999; Brumagne et al., 2008a). Our results for COPvel are consistent with LBP leading to decrease of spine mobility (Thomas et al., 1998) and increased reaction time for a stimulus in the spine (Jayaraman et al., 1994). It negatively affected postural control likely due to alterations in muscle recruitment (Wegener et al., 1997; Bouisset et al., 2002). In the situation of visual deprivation, the subjects with LBP present greater instability; with sensory-motor information insufficient to correct and avoid postural imbalances (i.e. spinal and cerebral reflexes, motor cortex processing and sensorimotor pathways) (for a review see Ebenbichler et al., 2001). Our results demonstrated that LBP subjects deprived of visual information present increased postural instability compared to healthy subjects while standing in the erect posture (Figure 3). This suggests that even the COP is not significantly dependent on visual information during dynamic

Effect of low back pain on postural stability challenging situations (Della Volpe et al., 2006), strong dependence on visual information arises during quiet standing situations. The present results when compared to previous reports reinforces the question as to the question: ‘how much pain’ is being experienced?. The different pain grades (different pain intensities) may affect results. A previous study has suggested the differentiation between intensities of pain as a topic of concern (Mientjes and Frank, 1999), as well as suggesting that conclusions using typical population (elderly people and acute LBP) should be avoided (Brumagne et al., 2008a). Our results suggest that even a moderate LBP can influence postural stability and that visual deprivation reinforce its effects.

Conclusion LBP degrades postural stability. When vision is supressed, our study of young women with moderate to intense pain was remarkable for significant findings. Subjects with LBP were more dependent on visual information for control of center of pressure oscillation during standing than healthy subjects. The LBP also influenced the ability to quickly react to changes in body position (i.e., center of pressure velocity) when the visual input was removed. Similar effects for men and for elderly people should be addressed in further investigations.

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L. Mann et al. Journal of Neurology, Neurosurgery, and Psychiatry 66 (3), 313e322. Schmid, M., Nardone, A., de Nunzio, A.M., Schmid, M., Schieppati, M., 2007. Equilibrium during static and dynamic tasks in blind subjects: no evidence of cross-modal plasticity. Brain 130 (8), 2097e2107. Speers, R.A., Kuo, A.D., Horak, F.B., 2002. Contributions of altered sensation and feedback responses to changes in coordination of postural control due to aging. Gait and Posture 16 (1), 20e30. Thomas, E., Silman, A.J., Papageorgiou, A.C., Macfarlane, G.J., Croft, P.R., 1998. Association between measures of spinal mobility and LBP. An analysis of new attenders in primary care. Spine 23 (3), 343e347. Tresch, M.C., 2007. A balanced view of motor control. Nature Neuroscience 10 (10), 1127e1128. Van Tulder, M.W., 1996. Diagnostics and Treatment of Chronic LBP in Primary Care, vol. 1. Free University, Amsterdam, 164 pp. Vogt, L., 2003. Neuromuscular control of walking with chronic LBP. Manual Therapy 8 (1), 21e28. Wegener, L., Kisner, C., Nichols, D., 1997. Static and dynamic balance responses in persons with bilateral knee osteoarthritis. Journal of Orthopaedic and Sports Physical Therapy 25 (1), 13e18. Winter, D.A., 1990. Biomechanics and Motor Control of Human Movement. Wiley, New York, 277 pp. Winter, D.A., Patla, A.E., Prince, F., Ishac, M., Gielo-Perczak, K., 1998. Stiffness control of balance in quiet standing. Journal of Neurophysiology 80 (3), 1211e1221.

Journal of Bodywork & Movement Therapies (2010) 14, 367e374

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HEAD POSTURE

Influence of forward head posture on scapular upward rotators during isometric shoulder flexion Jong-Hyuck Weon a, Jae-Seop Oh b, Heon-Seock Cynn c, Yong-Wook Kim d, Oh-Yun Kwon e,*, Chung-Hwi Yi e a Department of Rehabilitation Therapy, Wonju Christian Hospital, Wonju College of Medicine, Yonsei University, Wonju, Republic of Korea b Department of Physical Therapy, College of Biomedical and Engineering, Inje University, Gimhae, Republic of Korea c Department of Physical Therapy, Hanseo University, Seosan, Republic of Korea d Department of Physical Therapy, College of Alternative Medicine, Jeonju University, Jeonju, Republic of Korea e Department of Physical Therapy, College of Health Science, Yonsei University, Republic of Korea

Received 30 December 2008; received in revised form 25 June 2009; accepted 26 June 2009

KEYWORDS Electromyography; Forward head posture; Scapular upward rotator

Summary We assessed the effects of forward head posture in the sitting position on the activity of the scapular upward rotators during loaded isometric shoulder flexion in the sagittal plane. Healthy volunteers (n Z 21; 11 men, 10 women) with no history of pathology participated in the study. Subjects were instructed to perform isometric shoulder flexion with the right upper extremity in both the forward head posture (FHP) and neutral head posture (NHP) while sitting. Surface electromyography (EMG) was recorded from the upper trapezius, lower trapezius, and serratus anterior muscles. Dependent variables were examined by 2 (posture)  3 (muscle) repeated measures analysis of variance. Significantly increased EMG activity in the upper trapezius and lower trapezius and significantly decreased EMG activity in the serratus anterior were found during loaded isometric shoulder flexion with FHP. Thus, FHP may contribute to workrelated neck and shoulder pain during loaded shoulder flexion while sitting. These results suggest that maintaining NHP is advantageous in reducing sustained upper and lower trapezius activity and enhancing serratus anterior activity as compared with FHP during loaded shoulder flexion. ª 2009 Elsevier Ltd. All rights reserved.

* Corresponding author. Department of Rehabilitation Therapy, The Graduate School, Yonsei University, 234 Maji-li, Hungob-myon, Wonju, Kangwon-do 220-710, Republic of Korea. Tel.: þ82 33 760 2429; fax: þ82 33 763 2496. E-mail address: [email protected] (O.-Y. Kwon).

Introduction Work-related neck and shoulder pain are frequently reported in the workplace. Haughiee et al. (1995) found that forward head posture (FHP) is associated with neck and

1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.06.006

368 shoulder pain. In addition, Chiu et al. (2002) found that approximately 60% of individuals with neck pain had FHP. Several variables have been identified as risk factors for the development of shoulder pain, including highly abnormal sustained posture of the cervical spine, repetitive use of the arm, and work with the arm in an elevated position. Lifting and overhead work in the sagittal plane are often performed in construction and assembly line workplaces for loading and unloading, and FHP is the typically assumed posture during much work in construction and on assembly lines. Greenfield et al. (1995) reported that patients diagnosed with shoulder overuse demonstrated increased FHP in comparison with healthy subjects. Musculoskeletal pain occurs due to changes in muscle length when assuming a poor posture for a prolonged period and performing repetitive movements (Bergqvist et al., 1995). Spinal alignment is thought to affect scapular position and shoulder girdle function. Faulty cervical spinal alignment, such as FHP, is usually associated with shortening of the posterior neck extensor muscles and tightening of the anterior neck muscles, as well as the shoulder muscles, affecting scapular position and kinematics (Kebaetse et al., 1999). FHP is also considered to be an etiological factor in the pathogenesis of subacromial impingement syndrome. Postural deviations observed in FHP involve a downwardly rotated, anteriorly tilted, and protracted scapula leading to increased compression in the subacromial space during arm elevation (Lewis et al., 2005). Although there is evidence for an association between abnormal sustained forward posture of the cervical spine and the development of shoulder pain, there is a lack of evidence addressing the issue of how posture of the cervical spine contributes to shoulder pain. A biomechanical mechanism that may explain this association involves altered scapular and humeral kinematics, secondary to scapular upward rotator muscle imbalance. To prevent shoulder pain associated with abnormal neck posture, many researchers have stressed maintenance of a neutral head posture (NHP) during arm movement and functional activity (Edmondston et al., 2007; McLean, 2005). Many studies have been performed to determine the effects of head, thorax, and shoulder position on shoulder and scapular kinematics and the strength of the shoulders and hands. Ludewig and Cook (1996) investigated the effects of head position on scapular orientation and muscle activity during shoulder elevation in the scapular plane without an applied load. However, to our knowledge there have been no previous studies of the effects of head position on muscle activity of the scapular upward rotators during loaded shoulder flexion in the sagittal plane. It is generally believed that FHP is a contributor to the development of chronic neck, shoulder, and even jaw pain (Haughie et al., 1995). However, there is confusion in the literature regarding the impact of head posture on upper quadrant pain. We hypothesized that FHP during loaded isometric shoulder flexion would alter the muscular activation pattern of scapular upward rotator muscles. We assessed the effects of FHP on electromyographic activity of the upper trapezius, lower trapezius, and serratus anterior muscles during loaded isometric shoulder flexion (30 , 60 , 90 , 120 ) in the sagittal plane.

J.-H. Weon et al.

Methods Subjects Healthy subjects (n Z 21; 11 men, 10 women) were recruited from the Department of Physical Therapy, Yonsei University. The subjects had a mean age of 21.3 (3.1) years, a mean weight of 72.4 (2.2) kg, and a mean height of 174.6 (5.3) cm. Exclusion criteria were past or present neurological, musculoskeletal, or cardiopulmonary diseases that could interfere with shoulder flexion in the sitting position. Before the study, the principal investigator explained all procedures to the subjects in detail. All subjects signed an informed consent form, which was approved by the Yonsei University College of Health Science Human Studies Committee. A power analysis determined that 12 subjects were required to obtain a power of 0.8 at a < 0.05. This analysis was based on an estimated effect size (5% MVIC difference) derived from previous literatures (Perry, 1992; McLean and Urquhart, 2002). Perry (1992) has stated that 5% MVIC was an appropriate threshold for determining the onset and termination of muscle activity during gait cycle. And 5% MVIC was used as threshold to measure the level of upper trapezius muscle load in computer and production workers (McLean and Urquhart, 2002). Thus, we estimated the effect size by 5% MVIC. The proposed effect size may have been inflated because it was not derived from pilot data; therefore, 21 subjects were tested.

Equipments Electromyographic (EMG) data were collected using a Biopac MP100WSW and a Bagnoli EMG System. Skin preparation of electrode sites involved shaving and cleaning with rubbing alcohol, as described by Cram et al. (1998). Disposable AgeAgCl surface electrodes were positioned at an interelectrode distance of 2 cm. The reference electrode was attached to the styloid process of the right ulna. EMG data were collected for the following muscles on the right side: upper trapezius (2 cm lateral to the midpoint of a line drawn between the C7 spinous process and the posterolateral acromion), lower trapezius (placed on an oblique vertical angle with one electrode superior and one inferior to a point 5 cm inferomedial from the root of the spine of the scapula), and serratus anterior (placed vertically along the mid-axillary line at rib levels 6e8) (Cram et al., 1998; Nieminen et al., 1993). Each pair of electrodes was aligned along the line of underlying muscle fibers. EMG data were sampled at 1000 Hz. The EMG signals were amplified and digitized using AcqKnowledge 3.7.2 software. Band-pass (20e450 Hz) and band-stop filters (60 Hz) were used. The raw data were processed into root mean square (RMS) data using a moving window of 250 ms and converted to ASCII files for analysis. For normalization, 5-s reference contraction data were recorded while subjects performed three trials of maximal voluntary isometric contraction (MVIC) in the manual muscle testing position, as recommended by Kendall et al. (2005). A 1-min rest period was provided between trials. The mean RMS was calculated for each muscle. The EMG signals collected

Influence of forward head posture during each degree of shoulder flexion are expressed as percentages of the calculated mean RMS of MVIC (%MVIC).

Procedure Each subject was required to assume an upright position, sitting comfortably in a low-backed wooden chair. The height of the chair backrest was low enough (lower thoracic level) to allow movement of the scapula in all subjects. We performed this test on the right side to minimize artifacts from the electrocardiographic signal. While sitting in a chair, the subject was asked to raise the right upper extremity in the sagittal plane (30 , 60 , 90 , 120 ) in both the NHP and FHP in random order. Surface EMG was recorded from the upper trapezius, lower trapezius, and serratus anterior muscles (Figure. 1). A plumb line hanging from the ceiling was used to determine the subjects’ posture. In NHP, each subject’s external auditory meatus, acromion, and greater trochanter were aligned with a base plumb line that was perpendicular to ground level. In FHP, the subject was instructed to position his or her head anteriorly in a horizontal plane allowing the tragus to be aligned to a target plumb line, which was placed 5 cm anterior to the base plumb line. An inclinometer was used to determine when the shoulder was at 30 , 60 , 90 , or 120 flexion. A horizontal bar was placed at this level and provided feedback to the subject when instructed to flex his/her right shoulder with a 2-kg dumbbell in the hand until the upper aspect of the right wrist touched the bar and to hold the position without elbow flexion for 5 s. The EMG signal was recorded during this 5-s isometric contraction period. A 2-min rest period was provided between measurements to minimize muscle fatigue and the mean RMS of three trials was determined for comparison. Prior to

Figure 1

369 testing all subjects were familiarized with shoulder flexion in the sagittal plane with a 2-kg dumbbell. All subjects were comfortable, with standardized position and movement at the time of data collection.

Statistical analysis The data are expressed as the means  standard deviation. A 2  3 repeated measures ANOVA with one within-subject factor (posture) and one within-subject factor (muscle) was used to determine the main effects and interaction effects at each degree of flexion, with the significance level set at a Z 0.05. If statistical significance were found for a main effect of muscle, multiple comparisons were performed using paired t-tests with the appropriate Bonferroni adjustment.

Results There were significant posture-by-muscle interactions for EMG activity at 30 , 60 , 90 , and 120 loaded isometric shoulder flexion. There was a significant main effect of posture for the EMG activity in 30 , 60 , 90 , and 120 loaded isometric shoulder flexion. There was also a significant main effect of muscle on EMG activity in 30 , 60 , 90 , and 120 loaded isometric shoulder flexion (Table 1). Multiple comparisons among the three muscles are presented in Table 2. A significant posture-by-muscle interactions were further analyzed conducting separate repeated measures ANOVA for three 2  2 subtables in each shoulder flexion angle. There were significant interaction effects except for the interaction effects between upper trapezius and lower trapezius in 90 and 120 (Table 3).

Loaded isometric shoulder flexion at 90 shoulder flexion. (A) Neutral head position. (B) Forward head position.

370 Table 1

J.-H. Weon et al. Summary of analyses of the EMG data.

Degree of flexion

Effect

F value

p-Value

30

Posture Muscle Posture  muscle

F1,20 Z 29.702 F2,40 Z 16.815 F2,40 Z 35.685

.000 .000 .000

60

Posture Muscle Posture  muscle

F1,20 Z 39.502 F2,40 Z 21.982 F2,40 Z 26.309

.000 .000 .000

90

Posture Muscle Posture  muscle

F1,20 Z 37.885 F2,40 Z 7.567 F2,40 Z 30.383

.000 .002 .000

120

Posture Muscle Posture  muscle

F1,20 Z 20.744 F2,40 Z 8.452 F2,40 Z 31.629

.000 .001 .000

Discussion

Results of post hoc paired t-tests revealed that EMG activity in the upper trapezius and lower trapezius was significantly increased and EMG activity in the serratus anterior was significantly decreased during loaded isometric shoulder flexion with FHP in 30 , 60 , 90 , and 120 (P < 0.05) (Figure 2). Results of post hoc paired t-test for multiple comparisons between muscles are presented in Figure 3. In NHP, there were significant differences in EMG activity between serratus anterior and upper trapezius all shoulder flexion positions, and significant differences in EMG activity between upper trapezius and lower trapezius were found at 30 , 60 , and 90 shoulder flexion (Padj < 0.017). A significant difference in EMG activity between serratus anterior and lower trapezius was revealed at 90 and 120 shoulder flexion in NHP (Padj < 0.017). In FHP, the EMG activity between serratus anterior and upper trapezius was significantly different at 60 shoulder flexion, the EMG activity between upper trapezius and lower trapezius was significantly different at 30 , 60 and 90 shoulder flexion, and the EMG activity between serratus anterior and lower

Table 2

trapezius was significantly different at 30 and 60 shoulder flexion (Padj < 0.017).

Multiple comparisons between muscles.

Pain and stiffness in the shoulder and posterior neck lead to an inability to work or carry out household and leisure activities, burdening both patients and society (Nie et al., 2005). Postural neck pain is usually associated with sustained static loading of the cervical spine and shoulder girdle, induced by faulty posture and incorrect movement patterns. Although many previous studies have examined the relationship between FHP and pain, our study is the first to determine the effects of FHP on the upper trapezius, lower trapezius, and serratus anterior muscle EMG activity related to scapular upward rotation during loaded isometric shoulder flexion in the sagittal plane. In the present study, the activities of the upper trapezius and lower trapezius were increased significantly, while that of the serratus anterior was decreased significantly in FHP in comparison with those in NHP during all degrees of loaded isometric shoulder flexion. There are several potential mechanisms that may explain our results. First, FHP may alter the length and tension of the levator scapula muscle during scapular upward rotation. Significantly increased levator scapulae activity was reported previously in FHP vs. NHP (McLean, 2005). The upper trapezius is an agonist muscle for upward rotation of the scapulae, and the levator scapula is an antagonist for scapular upward rotation. Thus, increased tension of the levator scapula will prevent scapular upward rotation. To overcome this increased levator scapula tension, it is believed that the upper and lower trapezius should be activated to a greater extent in FHP than in NHP. Second, scapular or thoracoscapular position could be changed during the FHP condition. Clinicians have postulated that abnormal cervical spine alignment alters the

Table 3

Summary of interaction comparisons.

Degree Interaction of flexion

F value

pValue

30

Posture  muscle (UT vs LT) Posture  muscle (UT vs SA) Posture  muscle (LT vs SA)

F1,20 Z 16.656 .001 F1,20 Z 32.240 .000 F1,20 Z 52.740 .000

Degree of flexion

Muscle comparison

p-Value

30

Upper trapezius vs lower trapezius Upper trapezius vs serratus anterior Lower trapezius vs serratus anterior

.000 .002 .016

60

60

Posture  muscle (UT vs LT) Posture  muscle (UT vs SA) Posture  muscle (LT vs SA)

Upper trapezius vs lower trapezius Upper trapezius vs serratus anterior Lower trapezius vs serratus anterior

.000 .000 .010

F1,20 Z 39.502 .016 F2,40 Z 21.982 .000 F2,40 Z 26.309 .000

90

90

Posture  muscle (UT vs LT) Posture  muscle (UT vs SA) Posture  muscle (LT vs SA)

Upper trapezius vs lower trapezius Upper trapezius vs serratus anterior Lower trapezius vs serratus anterior

.008 .003 .929

F1,20 Z 37.885 .400 F2,40 Z 7.567 .000 F2,40 Z 30.383 .000

120

120

Upper trapezius vs lower trapezius Upper trapezius vs serratus anterior Lower trapezius vs serratus anterior

.548 .002 .001

Posture  muscle (UT vs LT) F1,20 Z 20.744 .155 Posture  muscle (UT vs SA) F2,40 Z 8.452 .001 Posture  muscle (LT vs SA) F2,40 Z 31.629 .000

NHP, neural head posture; FHP, forward head posture; SA, serratus anterior; UT, upper trapezius; LT, lower trapezius.

Influence of forward head posture

371 60 degrees

30 degrees 40

*

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Figure 2 Comparison of the EMG activity between NHP and FHP in 30 , 60 , 90 , and 120 loaded isometric shoulder flexion. Abbreviation: NHP, neural head posture; FHP, forward head posture; SA, serratus anterior; UT, upper trapezius; LT, lower trapezius. *P < 0.05.

resting position of the scapula (Greenfield et al., 1995). Previous studies have shown that sitting posture and thoracic spine position affect scapular kinematics (Finley and Lee, 2003; Kebaetse et al., 1999). Ludewig and Cook (1996) reported that the scapular upward rotation and posterior tilting were significantly decreased in the 20 flexed head position during humeral elevation without load. Although we did not measure scapular kinematics directly in this study, the FHP-related altered scapular position may have affected the movement pattern of the scapular upward rotation during loaded isometric shoulder flexion. Previous studies have also shown that shoulder positions affect shoulder muscle strength (Smith et al., 2002). Thus, these previous findings of position-induced changes in kinematics, muscle activation patterns, and length-tension relationship appear to be consistent with our findings. Third, it is possible that the changes in biomechanics of FHP influenced muscle activation. When the flexion moment of the cervical spine is increased in FHP, the level of neck extensor muscle activation is increased to counterbalance the increased flexion moment. This is consistent with our observation that upper trapezius muscle activity was increased in FHP. A previous study (Ludewig and Cook, 1996) indicated that scapular upward rotation and posterior tilting were significantly decreased in flexed head positions and there were no significant differences in the EMG activities of the upper and lower trapezius, levator scapula, or serratus

anterior according to head position (0 , 25 , 50 ) during humeral elevation in the scapular plane, without an applied load. In our study, however, EMG activities of the upper and lower trapezius and serratus anterior were significantly different between NHP and FHP. The different findings of the present study may have been due to the pattern of arm elevation (i.e., the plane of arm elevation or external load application) affecting the scapular movement pattern. In our study, subjects were asked to elevate their arm in the sagittal plane with a 2-kg weight to simulate a real work position, in contrast to the unloaded arm elevation in the scapular plane in the study of Ludewig and Cook (2000). Other groups have shown that differences in the pattern of arm elevation resulted in changes in scapular movement patterns. McQuade and Smidt (1998) reported that the scapulohumeral rhythm was significantly altered according to the external weight on the arm during dynamic humeral elevation in the scapular plane. Up to about 40% of maximum arm elevation, the lighter the load, the higher the scapulohumeral rhythm. Doody et al. (1970) also reported that the scapulohumeral rhythm decreased in the initial phase of motion with additional load during abduction in the scapular plane. In the present study, significant increases were observed in upper trapezius and lower trapezius muscle activity in FHP vs. NHP. Kinematic changes in scapular motion have been linked to muscle force imbalances between the upper and lower or between medial and lateral forces (Sahrmann,

372

J.-H. Weon et al. NHP

%MVIC

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LT

Figure 3 Comparison of the EMG activity between muscles in 30 , 60 , 90 , and 120 loaded isometric shoulder flexion. Abbreviation: NHP, neural head posture; FHP, forward head posture; SA, serratus anterior; UT, upper trapezius; LT, lower trapezius. *Padj < 0.017.

2002). Kinematic changes have been reported to occur in patients with shoulder impingement syndrome. Ludewig and Cook (2000) reported that construction workers with shoulder impingement syndrome showed increased upper and lower trapezius muscle activity and decreased serratus anterior muscle activity during humeral elevation in the scapular plane in comparison with subjects without shoulder impingement. Overactivity of the upper and lower trapezius and changes in scapular kinematics may contribute to neck and shoulder pain. Increased muscle activation to maintain a certain posture can result in localized muscle fatigue and may worsen signs and symptoms of repetitive injury in the cervical and shoulder regions (McLean, 2005). Continued muscle contraction has been shown to be reported to chronic cervical and shoulder pain syndrome (Larsson et al., 1988; Sluiter et al., 2001), and the progressive deterioration in posture of computer workers has also been shown to be associated with increased muscle activity in the trapezius during data entry task performance (Kleine et al., 1999). Previous studies have demonstrated that there is a trend toward higher muscle activation while performing similar tasks in individuals with musculoskeletal disorders, especially trapezius myalgia, in comparison with healthy subjects (Veiersted et al., 1990, 1993; Waersted et al., 1991). In the present study, maintenance of FHP induced stress in the intervertebral foramen and posterior structures at several cervical levels and possible injury to joint structures that may result in nociceptor stimulation, and consequently reflexive contraction of cervicobrachial muscles to protect tissues from further injury. Such increased muscle activity may then facilitate further tissue damage (Ha ¨gg and Astro ¨m, 1997; Ha ¨gg and Suurku ¨la, 1991; Hermens and Hutten, 2002).

Activation of scapular upward rotators during arm elevation is important for movement of glenohumeral joint as decreased scapular upward rotation has been suggested to be a mechanical risk factor contributing to the development of subacromial impingement syndrome by reducing the subacromial space and increased subacromial pressure (Flatow et al., 1994; Kibler and McMullen, 2003; Michener et al., 2003; Sahrmann, 2002). During glenohumeral elevation, the serratus anterior is required to work with the trapezius to rotate the scapula upward to allow free movement of the humeral head under the coracoacromial arch (McQuade et al., 1998). Ludewig and Cook (2000) reported decreased activity level of the serratus anterior and reduced upward rotation of the scapula in patients with subacromial impingement syndrome. In addition, decreased scapular upward rotation is thought to be associated with glenohumeral instability by altering glenohumeral joint alignment. Decreased muscle activity of the serratus anterior may reduce control or stabilization of scapular motion statically or dynamically. We found that serratus anterior muscle activity was significantly decreased during loaded isometric shoulder flexion with FHP in comparison with NHP, and this change in activity of the serratus anterior muscle may lead to alterations in scapular and glenohumeral kinematics. The serratus anterior muscle is an important scapular stabilizing muscle during arm movement. The serratus anterior is a scapular abductor and antagonist of the upper and lower trapezius, which are adductors of the scapula. Decreased activity of the serratus anterior muscle may cause scapular adduction during arm elevation in FHP. The serratus anterior may provide proximal stabilization of the scapula on the thorax

Influence of forward head posture during arm movement. Decreased activity of the serratus anterior muscle may cause winging of the scapula during arm elevation in FHP. Ludewig and Cook (2000) reported that the serratus anterior showed decreased activity in construction workers with impingement across all loads (2.3 kg, 4.6 kg loads) and all phases (31e60 , 61e90 , 91e120 ) during humeral elevation in the scapular plane in comparison with subjects without shoulder impingement. Prolonged FHP may cause shoulder impingement syndrome related to occupational or recreational exposure to lifting and overhead work, because of decreased serratus anterior muscle activity during lifting. The lower digitations of the serratus anterior that insert on a triangular area on the inferior scapular angle draw the lower angle of the scapula forward to couple with the upper trapezius and levator scapulae in forward rotation (Kent, 1971). Ludewig and Cook (1996) reported that scapular posterior tilting was significantly decreased in the 20 flexed head position during unloaded arm elevation in the scapular plane humeral elevation. The decreased serratus anterior muscle activity observed in the present study may have contributed to the reduction of scapular posterior tilting during arm elevation in the sagittal plane in FHP. Subjects with impingement syndrome showed less posterior tipping of the scapula in comparison to subjects without impingement (Sahrmann, 2002; Lukasiewicz et al., 1999). FHP may cause the anterior tilting of the scapula due to decreased serratus anterior muscle activity during working overhead or lifting a tool or loaded components in construction or assembly line work. Thus, FHP may contribute to the development of shoulder impingement syndrome or neck and shoulder pain. In a preliminary study, subjects were asked to flex their right shoulder while holding a 2-kg or 3-kg dumbbell until the upper aspect of the right wrist touched the bar and to hold the position for 5 s. Using the 3-kg weight, subjects complained of discomfort and fatigue in the right shoulder joint and muscles secondary to the increased load. Thus, we used the 2-kg dumbbell for the load in the present study. Our study has several limitations. First, to measure upward rotator muscle activity, we used surface EMG and assumed that the recorded EMG signal indicated the activity of each muscle. However, signal alterations could potentially be caused by muscle movements below the surface electrode or cross-talk from adjacent muscles. Second, it is difficult to conclude that increased upper trapezius and lower trapezius and decreased serratus anterior activity caused reduced scapular upward rotation during shoulder flexion in FHP without kinematic data for scapular upward rotation during isometric shoulder flexion. Further studies involving the collection of kinematic data are warranted to verify that scapular upward rotation occurs during shoulder flexion in FHP. Our results should not be generalized to other populations, because all the subjects in the study were young and healthy, with no cervicobrachial pathology. Thus, the benefits of NHP in this study should be confirmed in other patient populations. The results of the present study indicated significant increases in upper and lower trapezius activity and a significant decrease in serratus anterior activity with FHP during loaded isometric shoulder flexion in the sagittal plane. Thus, assuming NHP during loaded isometric shoulder flexion at different degrees can be advocated as

373 a biomechanically favorable posture to reduce excessive activity of the upper and lower trapezius and to increase the activity of the serratus anterior.

References Bergqvist, U., Wolgast, E., Nilsson, B., Voss, M., 1995. Musculoskeletal disorders among visual display terminal workers: individual, ergonomic, and work organizational factors. Ergonomics 38, 763e776. Chiu, T.T., Ku, W.Y., Lee, M.H., Sum, W.K., Wan, M.P., Wong, C.Y., et al., 2002. A study on the prevalence of and risk factors for neck pain among university academic staff in Hong Kong. Journal of Occupational Rehabilitation 12, 77e91. Cram, J.R., Kasman, G.S., Holtz, J., 1998. Introduction to Surface Electromyography. Aspen, Gaithersburg. Doody, S.G., Freedman, L., Waterland, J.C., 1970. Shoulder movements during abduction in the scapular plane. Archives of Physical Medicine and Rehabilitation 51, 595e604. Edmondston, S.J., Chan, H.Y., Ngai, G.C., Warren, M.L., Williams, J.M., Glennon, S., et al., 2007. Postural neck pain: an investigation of habitual sitting posture, perception of ‘good’ posture and cervicothoracic kinaesthesia. Manual Therapy 12, 363e371. Finley, M.A., Lee, R.Y., 2003. Effect of sitting posture on 3dimensional scapular kinematics measured by skin-mounted electromagnetic tracking sensors. Archives of Physical Medicine and Rehabilitation 84, 563e568. Flatow, E.L., Soslowsky, L.J., Ticker, J.B., Pawluk, R.J., Hepler, M., Ark, J., et al., 1994. Excursion of the rotator cuff under the acromion. Patterns of subacromial contact. The American Journal of Sports Medicine 22, 779e788. Greenfield, B., Catlin, P.A., Coats, P.W., Green, E., McDonald, J.J., North, C., 1995. Posture in patients with shoulder overuse injuries and healthy individuals. The Journal of Orthopaedic and Sports Physical Therapy 21, 287e295. Ha ¨gg, G.M., Astro ¨m, A., 1997. Load pattern and pressure pain threshold in the upper trapezius muscle and psychosocial factors in medical secretaries with and without shoulder/neck disorders. International Archives of Occupational and Environmental Health 69, 423e432. Ha ¨gg, G.M., Suurku ¨la, J., 1991. Zero crossing rate of electromyograms during occupational work and endurance tests as predictors for work-related myalgia in the shoulder/neck region. European Journal of Applied Physiology and Occupational Physiology 62, 436e444. Haughie, L.J., Fiebert, I.M., Roach, K.E., 1995. Relationship of forward head posture and cervical backward bending to neck pain. The Journal of Manual and Manipulative Therapy 3, 91e97. Hermens, H.J., Hutten, M.M.R., 2002. Muscle activation in chronic pain: its treatment using a new approach of myofeedback. International Journal of Industrial Ergonomics 30, 325e336. Kebaetse, M., McClure, P., Pratt, N.A., 1999. Thoracic position effect on shoulder range of motion, strength, and threedimensional scapular kinematics. Archives of Physical Medicine and Rehabilitation 80, 945e950. Kendall, F.P., McCreary, E.K., Provance, P.G., 2005. Muscles: Testing and Function with Posture and Pain. Williams and Wilkins, Baltimore. Kent, B.E., 1971. Functional anatomy of the shoulder complex. A review. Physical Therapy 51, 947. Kibler, W.B., McMullen, J., 2003. Scapular dyskinesis and its relation to shoulder pain. The Journal of the American Academy of Orthopaedic Surgeons 11, 142e151. Kleine, B.U., Schumann, N.P., Bradl, I., Grieshaber, R., Scholle, H.C., 1999. Surface EMG of shoulder and back muscles

374 and posture analysis in secretaries typing at visual display units. International Archives of Occupational and Environmental Health 72, 387e394. Larsson, S.E., Bengtsson, A., Bodega ˚rd, L., Henriksson, K.G., Larsson, J., 1988. Muscle changes in work-related chronic myalgia. Acta Orthopaedica Scandinavica 59, 552e556. Lewis, J.S., Green, A., Wright, C., 2005. Subacromial impingement syndrome: the role of posture and muscle imbalance. Journal of Shoulder and Elbow Surgery 14, 385e392. Ludewig, P.M., Cook, T.M., 1996. The effect of head position on scapular orientation and muscle activity during shoulder elevation. Journal of Occupational Rehabilitation 6, 147e158. Ludewig, P.M., Cook, T.M., 2000. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Physical Therapy 80, 276e291. Lukasiewicz, A.C., McClure, P., Michener, L., Pratt, N., Sennett, B., 1999. Comparison of 3-dimensional scapular position and orientation between subjects with and without shoulder impingement. The Journal of Orthopaedic and Sports Physical Therapy 29, 574e583. McLean, L., 2005. The effect of postural correction on muscle activation amplitudes recorded from the cervicobrachial region. Journal of Electromyography and Kinesiology 15, 527e535. McLean, L., Urquhart, N., 2002. The influence of psychological stressors on myoelectrical signal activity in the shoulder region during a data entry task. Work and Stress 16, 138e153. McQuade, K.J., Dawson, J., Smidt, G.L., 1998. Scapulothoracic muscle fatigue associated with alterations in scapulohumeral rhythm kinematics during maximum resistive shoulder elevation. The Journal of Orthopaedic and Sports Physical Therapy 28, 74e80. McQuade, K.J., Smidt, G.L., 1998. Dynamic scapulohumeral rhythm: the effects of external resistance during elevation of the arm in the scapular plane. The Journal of Orthopaedic and Sports Physical Therapy 27, 125e133.

J.-H. Weon et al. Michener, L.A., McClure, P.W., Karduna, A.R., 2003. Anatomical and biomechanical mechanisms of subacromial impingement syndrome. Clinical Biomechanics (Bristo., Avon) 18, 369e379. Nie, H., Kawczynski, A., Madeleine, P., Arendt-Nielsen, L., 2005. Delayed onset muscle soreness in neck/shoulder muscles. European Journal of Pain 9, 653e660. Nieminen, H., Takala, E.P., Viikari-Juntura, E., 1993. Normalization of electromyogram in the neck-shoulder region. European Journal of Applied Physiology and Occupational Physiology 67, 199e207. Perry, J., 1992. Gait Analysis: Normal and Pathological Function. Slack, Thorofare. Sahrmann, S.A., 2002. Diagnosis and Treatment of Movement Impairment Syndrome. Mosby, St. Louis. Sluiter, J.K., Rest, K.M., Frings-Dresen, M.H., 2001. Criteria document for evaluating the work-relatedness of upper-extremity musculoskeletal disorders. Scandinavian Journal of Work, Environment and Health 27 (Suppl. 1), 1e102. Smith, J., Kotajarvi, B.R., Padgett, D.J., Eischen, J.J., 2002. Effect of scapular protraction and retraction on isometric shoulder elevation strength. Archives of Physical Medicine and Rehabilitation 83, 367e370. Veiersted, K., Westgaard, R.H., Andersen, P., 1990. Pattern of muscle activity during stereotyped work and its relation to muscle pain. International Archives of Occupational and Environmental Health 62, 31e41. Veiersted, K.B., Westgaard, R.H., Andersen, P., 1993. Electromyographic evaluation of muscular work pattern as a predictor of trapezius myalgia. Scandinavian Journal of Work, Environment and Health 19, 284e290. Waersted, M., Bjørklund, R.A., Westgaard, R.H., 1991. Shoulder muscle tension induced by two VDU-based tasks of different complexity. Ergonomics 34, 137e150.

Journal of Bodywork & Movement Therapies (2010) 14, 375e381

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

BIOMECHANICS

The effect of patellar taping on joint reaction forces during squatting in subjects with Patellofemoral Pain Syndrome (PFPS) ¨ Hudson c Javid Mostamand a,*, Dan L. Bader b, Zoe a Department of Physiotherapy, Faculty of Rehabilitation Sciences, Isfahan University of Medical Sciences, Isfahan, 8174673461, Islamic Republic of Iran b Department of Engineering, Queen Mary University of London, Mile End Road, London, E1 4NS, UK c Centre for Sports and Exercise Medicine, Barts and the London Queen Mary’s School of Medicine and Dentistry, Mann Ward, Mile End Hospital, Bancroft Road, London, E1 4DG, UK

Received 24 March 2009; received in revised form 25 June 2009; accepted 1 July 2009

KEYWORDS Patellar dysfunction; PFJ biomechanics

Summary Introduction: The mechanisms of pain reduction have not completely been established following patellar taping in subjects with patellofemoral pain syndrome (PFPS); although it might be related to alteration in the kinetics of the patellofemoral joint. Methods: Patellofemoral Joint Reaction Force (PFJRF) of eighteen subjects with PFPS and eighteen healthy subjects as controls were assessed by a motion-analysis system and one force plate. This procedure was performed on the affected knee of subjects with PFPS, before, during and finally after patellar taping during unilateral squatting. A similar procedure was also performed on the unaffected knees of both groups. Results: The mean values of PFJRF prior to taping (2025 N, SD 347 N) were decreased significantly following a period of taping (1720 N, SD 303 N) (P < 0.05). There were no significant differences between the mean values of PFJRF among controls (1922 N, SD 398 N) and subjects with PFPS prior to taping (P > 0.05) which might be due to small sample size in both groups and large variability observed in the study. Interpretation: Decreased values of PFJRF may explain the mechanism of pain reduction following patellar taping in subjects with PFPS. ª 2009 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: þ98 (0) 311 792 2024; fax: þ98 (0) 311 6687270. E-mail addresses: [email protected] (J. Mostamand), [email protected] (D.L. Bader), [email protected] (Z. Hudson).

Introduction Although the aetiology of patellofemoral pain syndrome (PFPS) is not clearly understood, it has been suggested that the pain and discomfort is likely to be the result of

1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.07.003

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abnormal biomechanical factors that alter the distribution of shearing and compressive forces on the patellofemoral joint (PFJ) during normal activities (Sikorski et al., 1979). Patellofemoral pain is usually aggravated during activities associated with the flexed knee; such as stair stepping, (Crossley et al., 2002) or with prolonged sitting (McConnell, 1986). It is believed that these activities result in higher patellofemoral joint reaction force (PFJRF) and hence higher patellofemoral joint stress (PFJS) (Reilly and Martens, 1972; Wallace et al., 2002). It seems that increased level of PFJRF and consequently higher PFJS is related to the improper tracking of the patella through the trochlear groove during these activities (Hvid et al., 1981). It is therefore proposed that these forces and stresses may be increased in subjects with PFPS during these knee bent activities, which may cause the perception of pain. Patellar taping is known as an effective treatment method for improving the symptoms of PFPS (Crossley et al., 2002; Ng and Cheng, 2002). It is believed that this method affects the tracking of the patella and centralizing it within the trochlear groove (Powers et al., 1998; McConnell, 2002). The mechanism by which taping affects the PFJ is not completely clear; so, it has been proposed that the application of the tape alters the knee extensor moment and PFJRF of the various articulations associated with the knee joint during knee bent activities (Larsen et al., 1995; Somes et al., 1997). The effect of patellar taping on the knee moments of healthy subjects has previously been investigated during stair-stepping task (Selfe et al., 2008). Authors found that patellar taping reduced the range of coronal and transverse plane knee moments. Decreased level of knee extensor moment and consequently PFJRF and PFJS may therefore explain decreased level of pain following application of tape in subjects with PFPS. In addition, two previous studies assessed the effect of patellar taping on sagittal plane knee moments during a leg vertical jump, lateral step-up and stair-stepping task in subjects with PFPS (Ernest et al., 1999; Salsich et al., 2002). The results showed that the taping increased the range of sagittal plane knee moments in these subjects.

Table 1

Different values of moment in various planes in both healthy and PFPS subjects require more investigations to explain any kinetic changes following patellar taping in subjects with PFPS. As far as the authors know there have been no studies considering the effect of patellar taping on both sagittal plane knee moments and PFJRF of subjects with PFPS during squatting. Therefore, this study was aimed to measure these moments and consequently PFJRF, after application of the patellar tape in subjects with PFPS. This study was developed to establish methods that could indirectly explain the pain reduction mechanism of patellar taping.

Methods Subjects To determine the sample size for testing the hypotheses on subjects, it was important to establish the variability of the PFJRF. As this variable has not previously been reported, the sample size for this study was based on the quantitative data that were collected for PFJRF from subjects. Post hoc sample size analysis was therefore conducted after data collection on subjects recruited to this study. Based on the sample size analysis with a power of 80% and a two-sided significance level of 0.05, twelve samples were required to statistically compare the mean PFJRF differences of 302 N (SD 274 N) on the painful knee of subjects with PFPS before patellar taping (2052 N, SD 336 N) and after application of the tape (1750 N, SD 252 N). These values were derived from thirteen subjects with PFPS. Considering probable drop-outs, eighteen subjects with PFPS were recruited in the study from the physiotherapy department of Mile End Hospital of London (Tower Hamlet Primary Care Trust). These subjects were diagnosed by experienced physiotherapists, using the clinical examinations; although the final decision about entrance of participants into the study was made by the researcher on the basis of meeting all inclusion criteria (Table 1). Eighteen healthy subjects with no history of the knee pain were also selected from the

Inclusion and exclusion criteria for both groups of study. Inclusion criteria

PFPS group

1. Anterior or retropatellar pain, insidious in nature, which was aggravated by at least two of the following common functional activities of daily life: -

prolonged sitting stair climbing squatting running kneeling hopping/jumping

Exclusion criteria 1. Any traumatic, inflammatory or infectious pathology in the lower extremity 2. Dislocation or subluxation in the PFJ 3. History of surgery in the knee joint 4. Any signs of secondary osteoarthritis in the knee joint

2. Pain during an objective single leg squatting of 10-seconds 3. Aged less than 40 years (both genders) 4. Completed consent form Control group 1. Age, gender, weight and height matched to PFPS group 2. Completed consent form

As above

The effect of patellar taping on joint reaction forces students and staff of Queen Mary University of London as a control group. The age, sex, height and weight of control group was matched to those subjects in the PFPS group. For each PFPS subject a relevant control with maximum age difference of 2 years were selected. The difference of weight and height between each PFPS subject and his/her healthy control was supposed to be less than 2 kilograms and 3 centimeters, respectively. The study was approved by the East London and City Research Ethics Committee before recruiting both groups’ subjects. A written informed consent was taken from each subject.

Instrumentation A two camera (DCR-VX2000E, Sony, Japan) motion-analysis system (SIMI Motion e 2D & 3D Motion Analysis, version 7.0, Reality Motion Systems, GmbH, Germany), was used to record three dimensional coordinates of superficial reflective markers of thigh, shank and foot (Figure 1), at a rate of 60 Hz. Unilateral ground reaction force data were also collected from one force plate (Figure 1) (Kistler, 2812A1-3, version 3.20, Switzerland) at a rate of 600 Hz.

Preparation of subjects Anthropometric data of subjects in both PFPS and healthy control groups were measured (Winter, 1990) after they met all inclusion criteria. To collect the kinematic data of subjects using double-sided tape, superficial reflective markers (2.5-cm spheres) were placed on specific bony landmarks, namely, the second metatarsal head, lateral malleolus, lateral shank, lateral femoral epicondyle and lateral thigh of both legs (Wallace et al., 2002). After preparing the subjects, they were instructed to perform several practices for single leg squats, although the subjects with PFPS were warned to practice to a minimum level with the affected knees to avoid exacerbating the pain before the main study. To control any trunk forward flexion or deviation, all subjects were asked to keep their foot in full contact with

Figure 1 Setup used to measure kinematics and kinetics during single leg squatting.

377 the floor during single leg squatting, while verbal feedback was used to encourage subjects to hold their trunks in a vertical position. The first leg to be tested for each subject in both groups of study was selected in a randomized order, even and odd, selected from a container. To implement randomization, forty numbered tags (twenty evens and twenty odds) were put inside a container and each subject drew a tag from the container. Note that labeling was blind to the subjects drawing the tags.

Test procedures Biomechanical assessment of subjects with PFPS in the untaped condition Subjects with PFPS were asked to perform a shallow single leg squat of approximately 45 of knee flexion on the affected leg (to ensure that the knee flexion angle is 30 ) and hold it for approximately 10 s to record any resulting pain on the standard 100 mm visual analogue scale (VAS). Then they were instructed to stand on one leg on the force plate and to keep the contralateral leg off the floor. Each subject was then asked to execute a single leg squat from a neutral position (0 degree of knee flexion) to a depth of approximately 45 of knee flexion (to ensure that the knee flexion angle is 30 ), while maintaining heel in contact with the floor (Figure 1). The duration of squatting functions were constrained to about 3 seconds measured by a stop watch; the measurement was from the initiation of knee flexion to return to full knee extension. Thus a maximum period of 12 seconds was assigned to three repetitions, including the first 3 seconds of test period for concordance of subjects with the activity. Verbal feedback regarding both depth and duration of the function were provided after several practice squats. When the subjects had familiarized themselves with the timing and depth of this single leg squat, testing would commence. Data were simultaneously recorded with the camera system and force plate. Data collection was stopped when the subjects completed the three single leg squats. On completion of this procedure, an identical test procedure was repeated on the contralateral leg.

Figure 2

Medial glide taping technique.

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Biomechanical assessment of subjects with PFPS in the taped condition After recording data, the patellar tape was immediately attached over the affected patellar region in subjects with PFPS in the order of medial glide (Figure 2), according to patellar orientation tests (McConnell, 1986). The choice of taping methods was partly based on assessment of the patella position and partly on the attainment of pain reduction. After application of tape over the patella, each subject was asked to perform a single leg squat and hold it for about 10 s for evaluating the pain level on a separate VAS sheet. The taping method was acceptable if the level of pain was decreased by approximately 50% compared to the untaped condition (Crossley et al., 2002). Then the same test procedures for collecting both kinematic and kinetic data were conducted in taped condition in the same session. Biomechanical assessment of subjects with PFPS after removal of the tape After finishing the measurements in the taped condition, the subjects in PFPS group were instructed verbally and also with illustrated diagrams to be able to independently apply the taping corrections on a daily basis during the follow-up period (Crossley et al., 2002) (see Appendix). At each evaluation session, subjects were asked to apply the patellar tape to check if they can perform it correctly. The subjects were evaluated during 7 days of follow-up period, using the VAS, until they became symptom-free; a period that based on previous studies predicted to last a maximum of 6 weeks (McConnell, 1986; Crossley et al., 2002; Clark et al., 2000; (Eburne and Bannister, 1996); Harrison et al., 1999; Kowall et al., 1996). Once the subjects became symptom-free, they were instructed to remove the tape before coming to the human performance laboratory. At that time, each subject was asked to repeat the testing procedure, in an identical method described in two previous tests, for the third time on the affected knee. Biomechanical assessment of healthy control subjects Subjects in the control group underwent a similar testing procedure as subjects in the PFPS group. One testing session was allocated to these subjects to measure the kinematic and kinetic data of both legs without applying any additional intervention during single leg squatting.

(Winter, 1990). Sagittal- plane knee joint angles and net knee moments (Mk) were calculated from the inertial properties, segmental kinematics, and force platform data using inverse dynamics equations (Winter, 1990). The PFJRF was calculated using a biomechanical model of the PFJ (Salem and Powers, 2001). Based on the model, quadriceps muscle force (Fq) was calculated as the net knee moment (Mk) divided by the moment arm for the quadriceps (Lq). Fq ZMk =Lq The moment arm was estimated using the following nonlinear equation, based on the curve fitting to the data of van Eijden et al. (1987): Lq Z8:0e5 X 3  0:013X 2 þ 0:28X þ 0:046 where, X is the tibiofemoral joint angle. PFJRF was calculated as the product of the quadriceps force (Fq) and a constant (k) as follow: PFJRFZFq $k The constant k was estimated for knee joint angle (X ) using the following non-linear equation, based on the curve fitting to the data of van Eijden et al. (1986): 3:8e5 X 2 þ 1:5e3 X þ 0:462 kZ 7:0e7 X 3 þ 1:6e4 X 2  0:016X þ 1 For each test, kinetic data (Mk, PFJRF) were averaged through the 3 repetitions of single leg squatting. Data were analyzed in the eccentric phase of this activity at 30 of knee flexion.

Data analysis A parametric test (Two-way analysis of variance Z ANOVA) was then chosen to compare data between subjects with PFPS and healthy control in different tape conditions. Though bilateral kinetic data of healthy control subjects were collected, paired sample t-tests revealed that the differences between the mean values of Mk and PFJRF of right and left knees were not statistically significant (P > 0.05). Data sets were therefore combined to compare the results between the affected and unaffected knee of subjects with PFPS. For all tests, a 0.05 level was used to determine statistical significance. SPSS statistical software, version 13.0 was used to perform all statistical analysis.

Data reduction

Results Marker-coordinate and force data were processed by the SIMI motion-analysis system. Using this system, the segmental kinematics for the foot, shank and thigh were computed. The inertial properties for the foot, shank and thigh were determined from the subject’s total body weight, segment geometry and anthropometric data Table 2

Table 2 demonstrates the demographic and anthropometric data obtained from both groups of PFPS and control subjects. As Mk and PFJRF were inter-related by constant values and therefore followed the same patterns during

Anthropometric and demographic data of the PFPS and control groups (mean (SD)).

PFPS group Control group

Number

Gender

Age (years)

Weight (kg)

Height (cm)

18 18

11 men, 7 women 11 men, 7 women

27.9 (6.3) 26.4 (4.9)

71.5 (9.5) 71.6 (11.1)

171.3 (5.9) 171.9 (7.5)

The effect of patellar taping on joint reaction forces

379

Table 3 The mean values (SD) of knee extensor moment (Mk) and patellofemoral joint reaction forces (PFJRF) in subjects with PFPS and healthy control in five different conditions of taping. Significant differences of PFJRF values have been shown between three paired comparisons. Condition of patellar taping

Mk (Nm/kg)

PFJRF (N)

Significant difference between PFJRF values (N)

UnNTa BTb WTc ATd NTHSe

1.51 1.61 1.43 1.37 1.53

1895 2025 1796 1720 1922

UnNTa- BTb Z 130 BTb e WTc Z 229 BTb e ATd Z 305

a b c d e

(0.17) (0.19) (0.18) (0.19) (0.22)

(286) (347) (297) (303) (398)

UnNT, no-tape unaffected knees. BT, affected knees before applying the tape. WT, affected knees with tape. AT, affected knees after application of the tape. NTHS, no-tape knee of healthy control subjects.

eccentric phase of single leg squatting in 30 degrees of knee flexion, the results of PFJRF measurements were reported as final products of the Mk. The Mk values are summarized in Table 3. The mean value of PFJRF of the affected knee in subjects with PFPS before applying the tape (2025 N, SD 347 N) was greater than the mean PFJRF for the corresponding values of the unaffected knees (1895 N, SD 286 N) (P < 0.05). The mean value of PFJRF in the before-taped condition was also greater than the taped condition (1796 N, SD 297 N) and after applying the tape (1720 N, SD 303 N) in the affected knees. However, there was no significant difference between the mean values of PFJRF in the before-taped condition and no-tape condition, in both knees of healthy control subjects (1922 N, SD 398 N) (P > 0.05) (Table 3). Two-way ANOVA revealed that there were significant differences between the mean values of PFJRF in five different conditions of taping in subjects with PFPS and healthy controls (F4, 85 Z 2.65, P < 0.05). The multiple comparison tests using the least significant difference (LSD) demonstrated that these values between the conditions of before taping and taped, before and after taping and also before taping and no-tape of unaffected knees were significantly different (P < 0.05), while there were no significant differences comparing these values for taped and after taping condition and also for before taping and no-tape condition of healthy control subjects (P > 0.05). The magnitude of PFJRF differences between before taping and taped condition and also between taped and after taping, in affected knees was 11.3% and 4.2%, respectively. The mean levels of pain with tape (31 mm, SD 9 mm) and after application of the tape in the last test session (16 mm, SD 9 mm) were lower than the level of pain before application of the tape (60 mm, SD 10 mm) in subjects with PFPS. The differences between these mean values were significant (F2, 51 Z 101, P < 0.001). An immediate pain reduction of approximately 50% occurred among the subjects with PFPS, after using a patellar tape in the first session of test. The similar percentage of pain reduction also occurred in the last test session, compared with the taped condition. Pain reduction

of approximately 50% during each test session, revealed that the magnitudes of these differences were similar.

Discussion Several null hypotheses related to the kinetic data were tested in the current study. The first hypothesis was that Mk and PFJRF will not change immediately after application of patellar tape in PFPS subjects, during single leg squatting. Additionally, that Mk and PFJRF would not change with daily application of patellar tape for at least 6 weeks. The results indicate that after immediate application of the patellar tape and also during less than 6 weeks of follow-up, the knee extensor moment and PFJRF decreased in the affected knee of PFPS subjects. The secondary null hypothesis on similarity of kinetic values in both knees was also rejected by the results; indicated that values were statistically greater in the affected knees of PFPS subjects before application of the tape than unaffected knees. In the present study the reduction of pain following application of patellar tape in subjects with PFPS was associated with a decrease in Mk (from 1.61, SD 0.19 Nm/kg to 1.37, SD 0.19 Nm/kg) and consequently reduction in PFJRF. Conversely, two previous studies reported an increase in these variables following immediate application of patellar tape during different functional activities. Ernest et al. (1999) showed that the taped condition resulted in a greater Mk (1.73, SD 0.36 Nm/kg and 1.40, SD 0.27 Nm/ kg) than the no-tape (1.40, SD 0.46 Nm/kg and 1.21, SD 0.33 Nm/kg) and placebo tape conditions (1.38, SD 0.32 Nm/kg and 1.28, SD 0.28 Nm/kg) during a single leg vertical jump and lateral step-up. In another study, Salsich et al. (2002) also reported the similar increase in Mk, following application of patellar tape during trials of stair ascent and descent. In the no-tape condition, during stair ascent and descent the Mk was 0.12 (SD 0.17) Nm/kg and 0.37 (SD 0.13) Nm/kg, respectively. This variable after applying the tape during stair ascent and descent was 0.30 (SD 0.17) Nm/kg and 0.55 (SD 0.14) Nm/kg, respectively. There is a possible explanation for the decreased kinetic values with patellar taping in the current study. This is related to the quadriceps moment arm which may change during patellar taping. As the PFJRF are the final product of

380 Mk, any potential change in the quadriceps moment arm may result in changes in the Mk and therefore the PFJRF. Smidt (1973) found that the maximum length of quadriceps moment arm is at 30e45 of knee flexion and this length reaches a minimum when the knee is in the full flexion where the patella is located distally in the intercondylar groove. The quadriceps moment arm and Mk may be altered by any potential movement or position of the patella. A radiographic study showed that application of an infrapatellar strap could displace the patella proximally and anteriorly compared to the case without the strap in the extended knee (Levine, 1978). The proximal displacement of the patella may prevent the patella sinking distally into the intercondylar groove and thus maintain a longer quadriceps moment arm. In an optimal condition, the patella is situated parallel to the femur in both frontal and the sagittal planes, so that it is equidistant between the two condyles in a slightly flexed knee (McConnell, 1986). In the current study however, the patellar tape was used across the middle of patella to correct the lateral glide or tilt of the patella, holding it in the centre of intercondylar groove. This corrective taping might have therefore improved patellar position and limited any proximal displacement of the patella, facilitating its distal displacement into this groove during knee flexion. This condition would decrease the quadriceps moment arm and produce a smaller Mk and thus decreased PFJRF. Although the knee extensor moment in sagittal plane in subjects with PFPS was measured in the present and previous studies, the reason of differences in the results may be sought in different functional activities recruited in these studies. This difference may be explained in two ways. Firstly, the muscle recruitment strategies for various activities may be changed, leading to altered muscle activities. For example, the isokinetic leg press exercise has been shown to place a greater demand on the knee extensors than other kinds of closed kinetic chain exercises, including stair-stepping task (Wilk et al., 1996). Therefore in the present study it is possible that squatting placed less demand on the knee extensor moment than stair stepping or vertical jump exercises recruited by the Ernest et al. (1999) and Salsich et al. (2002). Indeed, the taping might have contributed to the recruitment of the quadriceps muscle based on the less muscle demand during squatting, thus produced enhanced muscle efficiency. Secondly, generating the necessary muscle forces to propel the body and control the centre of body mass may be different during various functional activities. It is evidential that during stair-stepping task, the individual must be able to activate the muscles properly and generate the necessary forces to propel the body upstairs and downstairs and control the constantly changing centre of body mass (Shumway-Cook and Woollacott, 1995). It seems that displacement of centre of body mass is very smaller during squatting than the stair-stepping task, because during squatting, the body is not required to be lifted to overcome a height and control the constantly changing centre of body mass. Considering the lesser muscle force required for squatting than stair-stepping task, patellar tape might have decreased the quadriceps muscle force more, hence decreased knee extensor moment during this activity.

J. Mostamand et al.

Conclusion Taping technique aims to align the PFJ and consequently to reduce the pain level in subjects with PFJS. This study showed that PFJRF values in the affected knee of subjects with PFPS were greater than those related to the unaffected knee, although these values were not different from healthy control subjects. This may be related to the small sample size recruited in both groups to compare their kinetic values. It is possible that a true difference in PFJRF existed between the affected knee of subjects with PFPS before using the tape and the knees of healthy control subjects but was not detected, given the large variability associated with the eighteen subjects. It was also revealed that patellofemoral taping reduced the PFJRF values and corresponding pain level during single leg squatting. Reduction of pain in subjects with PFPS may be therefore attributed to the effect of tape in decreasing the value of PFJRF, although this claim would have been verified using only a randomized controlled trial. The reduction of kinetic values may be as a result of alteration in the quadriceps moment arm following patellar taping.

Acknowledgements This article was provided as a part of the study leading to the degree of PhD, which was financially supported by Isfahan University of Medical Sciences and Ministry of Health and Medical Education of Islamic Republic of Iran.

Conflict of interest statement The authors confirm that there are no conflicts of interests regarding this paper.

Appendix Patellar taping techniques

Medial glide technique: To control lateral glide, one end of the tape is secured to the lateral patellar (kneecap) border and the therapist (patient) glides the patella medially with his thumb while maintaining tension in the tape. Then, he lifts the medial soft tissue (skin) toward the patella so that several skin folds appears, and secures the tape medially and across the knee (Crossley et al., 2002).

The effect of patellar taping on joint reaction forces

Medial tilt technique: In order to correct lateral tilt of the patella, the tape is secured at the upper middle portion of the patella (kneecap) and the therapist (patient) pulls the tape medially to lift the lateral border of the patella, correcting the tilt, then he lifts the medial soft tissues (as indicated before) and secures tape (Crossley et al., 2002).

References Clark, D.I., Downing, N., Mitchell, J., Coulson, L., Syzpryt, E.P., Doherty, M., 2000. Physiotherapy for anterior knee pain: a randomized controlled trial. Annals of the Rheumatic Diseases 59, 700e704. Crossley, K., Bennell, K., Green, S., Cowan, S., McConnell, J., 2002. Physical therapy for patellofemoral pain: a randomized, double blinded, placebo-controlled trial. The American Journal of Sports Medicine 30, 857e865. Eburne, J., Bannister, G., 1996. The McConnell regimen versus isometric quadriceps exercises in the management of anterior knee pain. A randomized prospective controlled trial. The Knee 3, 151e153. Ernest, G.P., Kawaguchi, J., Saliba, E., 1999. Effect of patellar taping on knee kinetics of patients with patellofemoral pain syndrome. Journal of Orthopaedic and Sports Physical Therapy 29, 661e667. Harrison, E.L., Sheppard, M.S., McQuarrie, A.M., 1999. A randomized controlled trial of physical therapy treatment programs in patellofemoral pain syndrome. Physiotherapy Canada 51, 93e100. Hvid, I., Anderson, L.I., Schmidt, H., 1981. Chondromalacia Patellae, the relation to abnormal patellofemoral mechanics. Acta Orthopedia Scandinavia 52, 661e666. Kowall, M.G., Kolk, G., Nuber, G.W., Cassisi, J.E., Stern, S.H., 1996. Patellar taping in the treatment of patellofemoral pain. A prospective randomized study. The American Journal of Sports Medicine 24, 61e66. Larsen, B., Andreasen, E., Urfer, A., Mickelson, M.R., Newhouse, K.E., 1995. Patellar taping: a radiographic examination of the medial glide technique. The American Journal of Sports Medicine 23, 465e471. Levine, J., 1978. A new brace for chondromalacia patella and kindred conditions. The American Journal of Sports Medicine 6, 137e139.

381 McConnell, J., 1986. The management of chondromalacia patellae: a long-term solution. Australian Journal of Physiotherapy 32, 215e223. McConnell, J., 2002. The physical therapist’s approach to patellofemoral disorders. Clinics in Sports Medicine 21, 363e387. Ng, G.Y.F., Cheng, J.M.F., 2002. The effects of patellar taping on pain and neuromuscular performance in subjects with patellofemoral pain syndrome. Clinical Rehabilitation 16, 821e827. Powers, C.M., Lilley, J.C., Lee, T.Q., 1998. The effects of axial and multi-plane loading of the extensor mechanism on the patellofemoral joint. Clinical Biomechanics 13, 616e624. Reilly, D.T., Martens, M., 1972. Experimental analysis of the quadriceps muscle force and patellofemoral joint reaction forces for various activities. Acta Orthopedia Scandinavia 43, 126e137. Salem, G.J., Powers, C.M., 2001. Patellofemoral joint kinetics during squatting in collegiate women athletes. Clinical Biomechanics 16, 424e430. Salsich, G.B., Brechter, J.H., Farwell, D., Powers, C.M., 2002. The effects of patellar taping on knee kinetics, kinematics, and vastus lateralis muscle activity during stair ambulation in individuals with patellofemoral pain. The Journal of Orthopaedic and Sports Physical Therapy 32, 3e10. Selfe, J., Richards, J., Thewlis, D., Kilmurray, S., 2008. The biomechanics of step descent under different treatment modalities used in patellofemoral pain. Gait and Posture 27, 258e263. Shumway-Cook, A., Woollacott, M., 1995. Motor Control Theory and Practical Applications. Williams & Wilkins, Baltimore, MD, U.S.A. Sikorski, J.M., Peters, J., Watt, I., 1979. The importance of femoral rotation in chondromalacia patellae as shown by serial radiology. The Journal of Bone and Joint Surgery-British 61, 435e 442. Smidt, G.L., 1973. Biomechanical analysis of knee flexion and extension. Journal of Biomechanics 6, 79e92. Somes, S., Worrell, T.W., Corey, B., Ingersol, C.D., 1997. Effects of patellar taping on patellar position in the open and closed kinetic chain: a preliminary study. Journal of Sports Rehabilitation 6, 299e308. van Eijden, T.M.G.J., Kouwenhoven, E., Verburg, J., Weijs, W.A., 1986. A mathematical model of the patellofemoral joint. Journal of Biomechanics 19, 219e229. van Eijden, T.M.G.J., Weijs, W.A., Kouwenhoven, E., Verburg, J., 1987. Forces acting on the patella during maximal voluntary contraction of the quadriceps femoris muscle at different knee flexion/extension angles. Acta Anatomica 129, 310e314. Wallace, D.A., Salem, G.J., Salinas, R., Powers, C.M., 2002. Patellofemoral joint kinetics while squatting with and without an external load. Journal of Orthopaedic and Sports Physical Therapy 32, 141e148. Wilk, K.E., Escamilla, R.F., Fleisig, G.S., Barrentine, S.W., Andrews, J.R., Boyd, M.L., 1996. A comparison of tibiofemoral joint forces and electromyography during open and closed kinetic chain exercises. American Journal of Sports and Exercise Medicine 24, 518e527. Winter, D.A., 1990. Biomechanics and Motor Control of Human Movement, second ed. A Wiley-Interscience Publication, New York NY.

Journal of Bodywork & Movement Therapies (2010) 14, 382e390

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

PAIN PHYSIOLOGY

The influence of age and physical activity on the pressure sensitivity of soft tissues of the musculoskeletal system Waldemar Andrzejewski, Krzysztof Kassolik, Marcin Brzozowski*, Katarzyna Cymer Department of Physiotherapy, University School of Physical Education, Faculty of Physiotherapy, 51-612 Wroclaw, al. Paderewskiego 35/p-4, Poland Received 30 January 2009; received in revised form 2 July 2009; accepted 6 July 2009

KEYWORDS Pressure sensitivity; Physical activity; Age

Summary Background: The pressure sensitivity of soft tissues is defined as the slightest pressure causing pain. Sex, movement system illnesses, pain ailments may influence the pressure sensitivity. However, there have been few studies on factors determining the level of pressure sensitivity of skeletal muscles. Objective: The authors have determined to study the influence of age and physical activity on the pressure sensitivity of skeletal muscles. Methods: The examination of pressure sensitivity of trigger points and muscle insertions was carried out using algometry. Results: 76 volunteers (38 students and 38 individuals aged 50e75) participated in the study. The differences in pressure sensitivity between students and people aged 50e75 were not statistically significant. Pressure sensitivity of students differed depending on their level of physical activity. Conclusions: The level of physical activity influenced the pressure sensitivity of skeletal muscles. Age did not significantly influence pressure sensitivity. ª 2009 Elsevier Ltd. All rights reserved.

Introduction

* Corresponding author. Tel.: þ48 071 3473091; fax: þ48 071 3473016. E-mail address: [email protected](M.Brzozowski).

The pressure sensitivity of soft tissues is defined as the smallest degree of pressure that causes pain (Fischer, 1988). Among the factors influencing the pressure sensitivity are gender, musculoskeletal conditions, painful ailments, and mental health disorders. So far there have

1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.07.004

The influence of age and physical activity been few studies which demonstrate the influence of these factors on the level of pressure sensitivity of skeletal muscles. Some studies measured pressure sensitivity in relation to fibromyalgia, myofascial pain syndrome, or nonspecific spinal pain (Mikkelsson et al., 1992; Offenbacher and Stucki, 2000).

Clinical relevance Therapists who use palpation as a diagnostic tool should take into account factors determining pressure sensitivity. The results of the research described in this paper suggest that physical activity can influence the level of pressure sensitivity of muscles, potentially modifying pain threshold. An additional finding is that there appears to be little influence of age on pressure sensitivity. Fischer researched both pressure sensitivity, and maximum pressure tolerance, of skeletal muscles with an algometer. He demonstrated higher pain sensitivity (lower pain threshold) of muscles in a group of men in comparison with a group of women, as well as different sensitivities of different muscles (Fischer, 1987a). Fischer found that pain caused by a pressure of up to 3 kg/cm2 is characteristic of unhealthy tissue. Additionally, he concluded that a difference in sensitivity of tissues on both sides of the body greater than 2 kg/cm2 is proof of a disease state within the tissue limits (Fischer, 1986). This comparison of the pressure sensitivity of tissues, on both sides of the body, seems to be more reliable for diagnostic purposes than comparing results with population standards, which are individually variable. In the case of double-sided pathological sensitivity, Fischer suggested comparing the results with those taken from neighboring tissues, or the upper limits of norms established for healthy tissues. Mikkelsson carried out a study on pressure sensitivity in women with fibromyalgia. The measurements were performed on the tibial and deltoid muscles. The pain threshold in women with fibromyalgia was lower than in healthy matched controls (Mikkelsson et al., 1992). Measurements are commonly performed on muscles, including myofascial trigger points, and on fascias, tendons, ligaments, and bone tissues. There are two ways to examine pressure sensitivity: manual palpation (Andrzejewski et al., 2007b, 2006; Kassolik et al., 2005) and examination with an algometer, which was designed specifically for this purpose1 (Andrzejewski et al., 2007a, 2005; Fischer, 1987a,b, 1984, 1986; Offenbacher and Stucki, 2000; Reeves et al., 1986; Ronat et al., 2003). The evaluation of pressure sensitivity is a relatively easy and quick diagnostic method. It can be used by various healthcare providers, including physicians, occupational therapists, physical therapists, bodyworkers, etc. Examining sensitivity with an algometer makes the assessment of a patient’s condition more objective, as it limits the patients’ subjectivism and their indecision regarding pain 1 ZAKqAD USqUG ELEKTRONICZNYCH, Niedziałkowskiego Street 22, 51-507 Wrocław, Poland.

383 levels. On the other hand, manual palpation is less objective but, due to its ease, quickness, and availability, it is used more frequently than employment of an algometer. Both methods can be used clinically, with no need to create a special measurement site. Assessing sensitivity assists not only in determining which muscles are extra sensitive, but also in planning a treatment regimen, and monitoring the effectiveness of therapy. The influence of such factors as gender, musculoskeletal system conditions, and mental health disorders, on the pain threshold level has been noted in few studies examining sensitivity (Fischer, 1987a; Mikkelsson et al., 1992). There are however no reports of the influence of age and the level of physical activity on the pressure sensitivity of muscles, knowledge of which can be helpful in treating patients of different ages, or different levels of physical activity. Therefore the aim of this study was to evaluate the influence of age and physical activity on the pressure sensitivity of skeletal muscles using algometry.

Material Seventy-six volunteers participated in the study. They were divided into four groups on the basis of answers in a questionnaire. The first criterion of the division into groups was the age of the participants and the other was the level of physical activity stated in the questionnaire. In group I were 38 individuals aged 50e75 (mean age: 65 years). All subjects in group I were students of The Sudetes University of Third Age, in Wałbrzych, Poland. In the questionnaire, 34 members of the group (90%) declared they engaged in moderate physical activity, 2 (5%) in light physical activity, and the remaining 2 (5%) in vigorous physical activity. The people in this group were relatively healthy and fit for their age, as they were students of the University of the Third Age, which demands quite a lot of activity within the course of the study. All students attended sport classes at least once a week, e.g. group gymnastics in a gym, strolling, Nordic walking or swimming at an indoor swimming pool. In Poland, such an intensity of physical activity is above average for the age group of 50e75. In group II were 38 individuals aged 20e26 (mean age: 22 years). All subjects in group II were students of The University School of Physical Education in Wroclaw, Poland. The members of this group were healthy and fit as they were students of the University School of Physical Education and both before being admitted to the university and during the course of study they had undergone several medical examinations, which were essential to pass an exam on motor fitness in order to continue their studies. In the questionnaire, 16 members of this group (42% of group II) declared they engaged in vigorous physical activity, 16 individuals (42% of group II) moderate physical activity, and the remaining 6 (16% of group II) light physical activity. Out of group II, two further study groups were created: group III, which consisted of 16 students from group II declaring vigorous physical activity, and group IV, consisting of 16 students from group II who declared moderate physical activity. Groups I (University of the Third Age students) and II (University School of Physical Education students) were

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created to see if age influenced pressure sensitivity. Groups III (University School of Physical Education students with vigorous physical activity) and IV (University School of Physical Education students with moderate physical activity) were created to check if a different level of physical activity influenced the pressure sensitivity of soft tissues. Because of the small differences between the levels of physical activity in the group of University of the Third Age students, group I was not taken into account when evaluating the influence of physical activity on pressure sensitivity.

Methods The study consisted of two parts: a questionnaire (Figure 1) and an examination of the pressure sensitivity of muscles. First the study participants completed the questionnaire, than they underwent an examination of pressure sensitivity with an algometer. The algometer used in this study was developed through a joint venture between Wroclaw University of Technology and the Department of Physical Therapy and Massage at the University School of Physical Education in Wroclaw under the supervision of Waldemar Andrzejewski Ph.D. The algometer features a 1 cm2 application head, a shut-off button for subjects, and a reset button (Figure 2). Measurements are displayed in units of pressure (kg/cm2) with a sensitivity of 1 g. Prior to the measurement, all the participants were informed about procedures and were given instructions on how to behave during the measurement. Before the actual measurements three trials were performed so that subjects could easily distinguish the sensations of pressure and pain and were able to stop the measurement at the proper moment. Each subject heard the same instruction: ‘During the measurement, certain points on your body will be pressed. The moment you feel the first pain sensation in the measured area, and not only the sensation of pressure without any pain, please simultaneously say ‘stop’ and press the button you are holding in your hand.’ First the therapist palpated the point in the tissue to be examined and then put the head of the algometer at a right angle and pressed it gradually into the tissue at a rate of 100 g/s. Only the therapist could see the display unit of the algometer. Subjects stopped the measurement by pressing the button at the exact moment when they feel a sharp pain in the area where the head of the algometer had been placed. First and last name : ................................................................................. Age (years) : ................................................................................. Physical activity : 1. light (up to 2 times per week) 2. moderate (at least 3 times per week for 30 minutes) 3. vigorous (at least 5 times per week for 30 minutes or professional sport) Taking painkillers within the recent three months 1. yes 2. no Painful ailments – if present, where exactly

Figure 1

The research questionnaire.

Figure 2

Algometer.

The value of the measurement was then recorded and the device reset, by pressing the button on the upper surface of the main part of the instrument. The therapist successively pressed attachment sites and trigger points of fifteen chosen muscles which, from the authors’ experience, frequently present overstrain changes and, therefore, are most often subject to therapeutic activities. Table 1 includes all the points of the attachments of the tested muscles. Localization of latent trigger points was performed according to Travell and Simons (Travell and Simons, 1992; Simons et al., 1999). Muscles on both body sides were evaluated. During the measurement the subjects were lying relaxed, on one side, with the legs supported, while the other side was being examined. Right limbs of patients were placed on massage cushions. Subjects held the shut-off button of the algometer. Each point was measured bilaterally. The maximum applied pressure was 10 kg/cm2 to minimize the risk of damaging the tissue at higher pressures. The subjects had refrained from any kind of physiotherapeutic treatment, or the use of painkillers, for a period of at least three months before the study. All the subjects were examined by the same therapist, and the measurement was taken using the same instrument. All the individuals had agreed to participate in the study. The study was approved by the local University Ethics Committee. The researchers adopted the hypothesis that age and physical activity influenced pressure sensitivity of skeletal muscles. In order for the hypothesis to be accepted, at least 60% (clear majority) of muscles tested needed to

The influence of age and physical activity Table 1 The points of pressure sensitivity measurement on chosen muscles. Name of muscle

Place of insertion

Superior fibular retinaculum Peroneus longus Biceps femoris Gluteus maximus Gluteus medius

Lateral surface of calcaneum Base of first metatarsal Linea aspera of femur Gluteal tuberosity Superior surface of greater trochanter Lateral surface of anterior superior iliac spine Labium externum of crest of iliac bone Posterior superior iliac spine Greater tubercle of humeral bone Superior angle of scapula Crest of greater tubercle of humerus Coracoid process Pisiform Base of second metacarpal Medial femoral epicondyle

Tensor fasciae latae Latissimus dorsi Erector spinae Infraspinatus Levator scapulae Pectoralis major Pectoralis minor Flexor carpi ulnaris Flexor carpi radialis Adductor magnus

demonstrate a significant difference between values of pressure sensitivity in the compared groups.

Results The mean of the pressure sensitivities for a given body side for each muscle in all groups was calculated. The results were analyzed using Student’s t test for independent samples with a probability of 0.05. For groups I and II a t test for large samples was used and for groups III and IV a t test for small samples. The aim was to check if there were statistically significant differences in sensitivity between groups I (University of the Third Age students) and II (University School of Physical Education students) and groups III (University School of Physical Education students, vigorous physical activity) and IV (University School of Physical Education students, moderate physical activity). The results are presented in Tables 2e9. Tables 2e5 present the comparison of pressure sensitivity between groups I and II. Of a total 60 point to point comparisons, 44 (73.3%) did not reach statistical significance. Table 2 presents the mean values of the pressure sensitivity and the statistical significance of the differences between groups I and II at muscle insertions on the left side of the body. In the majority of muscles (60% of all the researched muscles) there were no statistically significant differences between the two groups. In six of the muscles (peroneus longus muscle, biceps femoris muscle, gluteus maximus muscle, flexor carpi ulnaris muscle, flexor carpi radialis muscle, adductor magnus muscle) there was a statistically significant increased pressure sensitivity in group I. Table 3 presents the mean values of the pressure sensitivity of the muscles and the level of statistical significance of differences between groups I and II at trigger

385 points of the muscles on the left body side. Statistically significant differences (p < 0.05) were found in only two muscles, namely the flexor carpi radialis and the adductor magnus (13.3% of all the researched muscles). Table 4 presents the mean values of the pressure sensitivity and the level of statistical significance of the differences between groups I and II at muscle insertions on the right side of the body. Statistically significant differences in pressure sensitivity were found in only four muscles, namely peroneus longus muscle, biceps femoris muscle, gluteus maximus muscle, and adductor magnus muscle (26.7% of all the researched muscles). Table 5 presents the mean values of pressure sensitivity and the statistical significance between groups I and II at trigger points of the muscles on the right body side. Statistically significant differences (p < 0.05) were found in the following muscles: the peroneus longus, infraspinatus, flexor carpi radialis, and adductor magnus (26.7% of all the researched muscles). Tables 6e9 present the comparison of pressure sensitivity between groups III and IV. Of a total 60 point to point comparisons, 55 (91.7%) reached statistical significance. Table 6 presents the mean values of the pressure sensitivity of the muscles and the statistical differences between groups III (University School of Physical Education students with vigorous physical activity) and IV (University School of Physical Education students with moderate physical activity), at muscle insertions of the left side of the body. In the majority of the muscles (80% of all the researched muscles), the difference was statistically significant (p < 0.05). An increased pain threshold was observed in all the muscles of those in group III. Table 7 presents the mean values of the pressure sensitivity of the muscles and the statistical differences between groups III and IV at trigger points of the left side of the body. In all the muscles the difference was statistically significant (p < 0.05). An increased pain threshold was characteristic of those in group III. Table 8 presents the mean values of the pressure sensitivity of the muscles and the statistical difference between the groups III and IV at muscle insertions of the right side of the body. In fourteen muscles (93.3% of all the researched muscles) the difference was statistically significant (p < 0.05). The difference observed in the erector spinae was not statistically significant. An increased pain threshold was characteristic of those of group III. Table 9 presents the mean values of the pressure sensitivity of the muscles and the statistical differences between groups III and IV at trigger points of the right side of the body. In fourteen muscles (93.3% of all the researched muscles) the difference was statistically significant (p < 0.05). The difference observed in the tensor fasciae latae muscle was not statistically significant. Similar to the above measurements, an increased pain threshold was characteristic of the muscles of those in group III.

Discussion So far, there have been no reports in the literature of the influence of age and physical activity on the pressure sensitivity of muscles.

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Table 2 Mean values of the pressure sensitivity (kg/cm2) at muscle insertions on the left side of the body for groups I (University of the Third Age students) and II (University School of Physical Education students). No

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Researched site e insertion left side

Group I

Superior fibular retinaculum Peroneus longus muscle Biceps femoris muscle Gluteus maximus muscle Gluteus medius muscle Tensor fasciae latae muscle Latissimus dorsi muscle Erector spinae muscle Infraspinatus muscle Levator scapulae muscle Pectoralis major muscle Pectoralis minor muscle Flexor carpi ulnaris muscle Flexor carpi radialis muscle Adductor magnus muscle

5.015 5.012 4.706 5.182 5.296 4.583 4.691 5.129 3.660 3.970 4.007 3.086 4.430 4.447 3.347

kg/cm

2

Group II kg/cm

2

5.212 6.479 5.967 6.611 5.986 4.271 4.557 4.897 4.100 4.138 4.364 3.600 5.177 5.760 4.599

Statistically significant NS * * * NS NS NS NS NS NS NS NS * * *

NS e no statistically significant differences. * e statistically significant difference (p < 0.05).

This study demonstrates that the differences in pressure sensitivity between students and people aged 50e75 were not statistically significant in 73.3% of all the researched muscles. In the majority of cases, age does not significantly influence pressure sensitivity, which is surprising considering the distinct difference in fitness and physical efficiency between the young and participants aged 50e75. The observed increased values of pressure sensitivity in some muscles of the younger people may be the result of static

and dynamic overloading which could be a result of overtraining. The relatively low pressure sensitivity in the group of the people aged 50e75 may be the result of their quite high, for this group age, levels of fitness and physical activity. Generally, in Poland only a few percent of people over the age of 50 regularly attend organized recreation and sports activities. It is commonly known that physical activity influences all human body systems in a positive way. Also the musculoskeletal system and, more precisely, skeletal muscles are influenced very positively. It has been

Table 3 Mean values of the pressure sensitivity (kg/cm2) at the trigger points of the muscles on the left body side for groups I (University of the Third Age students) and II (University School of Physical Education students). No

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Researched site e trigger point left side

Group I

Superior fibular retinaculum Peroneus longus muscle Biceps femoris muscle Gluteus maximus muscle Gluteus medius muscle Tensor fasciae latae muscle Latissimus dorsi muscle Erector spinae muscle Infraspinatus muscle Levator scapulae muscle Pectoralis major muscle Pectoralis minor muscle Flexor carpi ulnaris muscle Flexor carpi radialis muscle Adductor magnus muscle

4.225 4.740 5.421 5.119 5.668 4.566 4.129 5.115 4.406 2.102 2.578 2.934 4.185 3.516 2.624

NS e no statistically significant differences. * e statistically significant difference (p < 0.05).

kg/cm

2

Group II kg/cm 4.867 5.244 6.204 5.211 5.280 3.946 4.696 4.990 5.119 2.499 2.574 3.339 4.245 4.321 4.407

2

Statistically significant NS NS NS NS NS NS NS NS NS NS NS NS NS * *

The influence of age and physical activity

387

Table 4 Mean values of the pressure sensitivity (kg/cm2) at muscle insertions on the right side of the body for groups I (University of the Third Age students) and II (University School of Physical Education students). No

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Researched site e insertion right side

Group I kg/cm

Superior fibular retinaculum Peroneus longus muscle Biceps femoris muscle Gluteus maximus muscle Gluteus medius muscle Tensor fasciae latae muscle Latissimus dorsi muscle Erector spinae muscle Infraspinatus muscle Levator scapulae muscle Pectoralis major muscle Pectoralis minor muscle Flexor carpi ulnaris muscle Flexor carpi radialis muscle Adductor magnus muscle

5.073 4.946 4.458 5.042 5.369 4.942 5.002 5.364 3.967 4.028 3.779 3.248 4.660 4.809 3.127

2

Group II kg/cm

2

5.275 6.136 6.392 6.626 6.198 4.986 4.372 4.642 4.690 3.795 4.455 3.848 5.274 5.239 5.359

Statistically significant NS * * * NS NS NS NS NS NS NS NS NS NS *

NS e no statistically significant differences. * e statistically significant difference (p < 0.05).

shown that, under the influence of physical activity, the number of capillary vessels in skeletal muscles is increased and thus tissue metabolism and tissue efficiency is improved (Jasko ´lski et al., 2002). However, from the authors’ own observations, there are some muscles which, during a lifetime, are subject to greater wear than other muscles. Among basic factors influencing ‘‘greater wear’’ are recurrent minor injuries and lesions occurring while performing everyday activities. This situation is mostly characteristic of muscles stabilizing ankle joints: long peroneal muscle and short peroneal muscle, and muscles stabilizing the brachiocarpal joint: the

ulnar flexor muscle of the wrist, and radial flexor muscle of the wrist. Due to recurrent ankle or wrist sprains, microinjuries in the above mentioned muscles may be triggered and, consequently, sensitivity of the muscles in middle-aged and elderly people may be increased. This possibility is reflected in the research, as the differences in the pressure sensitivity between young participants and University of the Third Age students, were evident only in the case of the above-mentioned muscles. Greater muscle sensitivity may also be increased by degenerative changes in venous and arterial vessels e.g.

Table 5 Mean values of the pressure sensitivity (kg/cm2) at trigger points of the muscles of the right body side for groups I (University of the Third Age students) and II (University School of Physical Education students). No

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Researched site e trigger point right side

kg/cm

Superior fibular retinaculum Peroneus longus muscle Biceps femoris muscle Gluteus maximus muscle Gluteus medius muscle Tensor fasciae latae muscle Latissimus dorsi muscle Erector spinae muscle Infraspinatus muscle Levator scapulae muscle Pectoralis major muscle Pectoralis minor muscle Flexor carpi ulnaris muscle Flexor carpi radialis muscle Adductor magnus muscle

4.244 4.282 5.264 5.250 5.692 4.959 4.322 5.050 4.439 2.336 2.535 2.923 4.078 3.803 2.368

NS e no statistically significant differences. * e statistically significant difference (p < 0.05).

Group I 2

Group II kg/cm 4.564 5.983 6.204 5.585 5.698 4.415 4.442 4.844 5.300 2.690 2.801 3.065 4.717 4.970 3.921

2

Statistically significant NS * NS NS NS NS NS NS * NS NS NS NS * *

388

W. Andrzejewski et al.

Table 6 Mean values of the pressure sensitivity (kg/cm2) at muscle insertions on the left side of the body for groups III (University School of Physical Education students, vigorous physical activity) and IV (University School of Physical Education students, moderate physical activity). No

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Researched site e insertion left side Superior fibular retinaculum Peroneus longus muscle Biceps femoris muscle Gluteus maximus muscle Gluteus medius muscle Tensor fasciae latae muscle Latissimus dorsi muscle Erector spinae muscle Infraspinatus muscle Levator scapulae muscle Pectoralis major muscle Pectoralis minor muscle Flexor carpi ulnaris muscle Flexor carpi radialis muscle Adductor magnus muscle

Group III

Group IV

kg/cm2

kg/cm2

Statistically significant

6.109 7.765 7.172 8.129 7.249 5.310 5.069 5.557 4.793 4.992 5.263 4.614 6.339 6.723

4.441 5.605 5.008 5.560 5.242 3.452 4.413 4.337 3.468 3.630 3.676 2.980 4.469 5.338

* * * * * * NS * * NS * * * NS

5.428

4.219

*

NS e no statistically significant differences. * e statistically significant difference (p < 0.05).

the deep femoral artery and deep veins of the thigh. The vessels are located in the adductor canal (Hunter’s canal) and, therefore, their degenerative changes lead to an increase in a rest tonus of muscles of the adductor canal and, therefore, also of the adductor magnus muscle. This is also reflected in the research as the adductor magnus muscle of University of the Third Age students, despite its physical activity, presents greater pressure sensitivity in

comparison with the same muscle of younger participants in the study. Moreover, there is also an increased sensitivity of the gluteus maximus muscle which, through the sacrotuberous ligament, remains in structural contact with the adductor magnus muscle, attaching to the ischial tuberosity. Any increase in the rest tonus of the adductor magnus muscle is balanced by an increase in the resting tonus of the

Table 7 Mean values of the pressure sensitivity (kg/cm2) at the trigger points of the left side of the body for groups III (University School of Physical Education students, vigorous physical activity) and IV (University School of Physical Education students, moderate physical activity). No

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Researched site e trigger point left side

kg/cm

Superior fibular retinaculum Peroneus longus muscle Biceps femoris muscle Gluteus maximus muscle Gluteus medius muscle Tensor fasciae latae muscle Latissimus dorsi muscle Erector spinae muscle Infraspinatus muscle Levator scapulae muscle Pectoralis major muscle Pectoralis minor muscle Flexor carpi ulnaris muscle Flexor carpi radialis muscle Adductor magnus muscle

5.668 6.415 7.531 6.549 6.407 4.521 5.839 6.011 6.162 2.944 3.228 3.969 5.342 5.361 5.075

NS e no statistically significant differences. * e statistically significant difference (p < 0.05.

Group III 2

Group IV kg/cm 4.381 4.216 5.255 4.188 4.332 3.325 3.644 4.103 4.357 2.043 1.997 2.878 3.533 3.752 3.911

2

Statistically significant * * * * * * * * * * * * * * *

The influence of age and physical activity

389

Table 8 Mean values of the pressure sensitivity (kg/cm2) at muscle insertions of the right side of the body for groups III (University School of Physical Education students, vigorous physical activity) and IV (University School of Physical Education students, moderate physical activity). No

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Researched site e insertion right side

Group III

Group IV

kg/cm2

kg/cm2

Statistically significant

Superior fibular retinaculum Peroneus longus muscle Biceps femoris muscle Gluteus maximus muscle Gluteus medius muscle Tensor fasciae latae muscle Latissimus dorsi muscle Erector spinae muscle Infraspinatus muscle Levator scapulae muscle Pectoralis major muscle Pectoralis minor muscle Flexor carpi ulnaris muscle Flexor carpi radialis muscle Adductor magnus muscle

6.548 7.212 7.515 8.157 7.519 5.837 5.575 5.299 5.514 4.868 5.645 4.760 6.550 6.146 5.135

4.282 5.207 5.267 5.457 5.082 4.179 3.404 4.189 3.996 3.104 3.812 3.333 4.367 4.729 3.945

* * * * * * * NS * * * * * * *

NS e no statistically significant differences. * e statistically significant difference (p < 0.05).

sacrotuberous ligament, and of gluteus maximus (Myers, 2001). Physical activity is commonly regarded as a factor prolonging youth, simultaneously retarding the aging process. In the questionnaire, 90% of the group of University of the Third Age students declared a moderate level of physical activity. In the group of University School of Physical Education students, 42%

declared a moderate level of physical activity, while a further 42% of the group declared a high level. It is considered that the lack of statistically significant differences in pressure sensitivity of most tissues between the age groups may be caused by the relatively high level of physical activity reported by the University of the Third Age students and the University School of Physical Education students.

Table 9 Mean values of the pressure sensitivity (kg/cm2) at trigger points of muscles of the right body side for groups III (University School of Physical Education students, vigorous physical activity) and IV (University School of Physical Education students, moderate physical activity). No

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Researched site e trigger point right side

Group III

Superior fibular retinaculum Peroneus longus muscle Biceps femoris muscle Gluteus maximus muscle Gluteus medius muscle Tensor fasciae latae muscle Latissimus dorsi muscle Erector spinae muscle Infraspinatus muscle Levator scapulae muscle Pectoralis major muscle Pectoralis minor muscle Flexor carpi ulnaris muscle Flexor carpi radialis muscle Adductor magnus muscle

5.569 7.319 8.022 7.185 7.040 5.318 5.339 5.896 6.584 3.096 3.570 3.883 5.891 6.257 4.878

NS e no statistically significant differences. * e statistically significant difference (p < 0.05).

kg/cm

2

Group IV kg/cm 3.882 4.912 4.774 4.253 4.458 3.771 3.661 3.868 4.245 2.257 2.172 2.454 3.755 4.218 3.251

2

Statistically significant * * * * * NS * * * * * * * * *

390 In group III (University School of Physical Education students with vigorous physical activity) there was statistically significantly lower pressure sensitivity in most of the studied muscles (91.7%) compared to group IV (University School of Physical Education students with moderate physical activity). This may have been caused by the difference in the level of physical activity between the two groups. No muscle, apart from one, had a sensitivity threshold under 3 kg/cm2. Only the levator scapulae muscles on the left side of the body, at a trigger point, had a sensitivity level of 2.944 kg/cm2, which only slightly diverges from the accepted level of 3 kg/cm2. According to Fischer’s criteria, this level may be described as the norm under which tissues present increased pressure sensitivity. It can therefore be concluded that physical activity influences the pressure sensitivity of muscles in a very positive way. In group IV there were muscles whose sensitivities were below this level. These muscles were the levator scapulae, pectoralis major, and pectoralis minor. The muscles are very frequently characterized by some pain relating to trigger points, which may be observed in the findings of the study on both body sides. The presented findings cannot serve as precise norms for the populations of young and elderly people, or of populations of people performing moderate or vigorous physical activity, but they can help in an approximate determination of pressure sensitivity in similar research groups. Despite attempts to determine norms for the sensitivity of given muscles, it is difficult, or even impossible to determine these very precisely, as several factors may influence them, such as posture, gender, and the emotional state of the subject (Merskey and Spear, 1964). However, it seems important to determine more precisely what factors may influence the pressure sensitivity of muscles and up to what level. This would allow using this knowledge in the clinical practice, where the evaluation of pressure sensitivity of muscles plays an important role in determining the general condition of a patient, as a measure of the effectiveness of therapy. This study may act as a stimulus to do more research in a larger group, taking into consideration the influence of diverse factors on the pressure sensitivity of muscles. The results of studies on pressure sensitivity in different age or professional groups with an additional division into the gender of the subjects could be of great interest.

Conclusions 1. The level of physical activity influences the pressure sensitivity of skeletal muscles. The higher the level of activity, the higher the pain threshold (less sensitivity). 2. Age does not appear to influence the pressure sensitivity of skeletal muscles in spite of the fact that there is a tendency for the pain threshold to be lower in older age.

W. Andrzejewski et al.

References Andrzejewski, W., Kassolik, K., Czaplicka, A., Czaplicki, P., Pia˛tkowski, P., 2007a. Algometryczna ocena efektywnos´ci fizjoterapii w zespołach bo ´lowych kre˛gosłupa le˛dz´wiowo-krzy_ zowego. Kwartalnik Ortopedyczny 2, 152e161. Andrzejewski, W., Kassolik, K., Steciwko, A., Rakus, J., 2007b. Skutecznos´´ c masaz_ u medycznego w bo ´lach kre˛gosłupa u oso ´b w wieku starszym. Family Medicine & Primary Care Review 9 (2), 195e203. Andrzejewski, W., Kassolik, K., Karas´, A., Karas´, G., Trze˛sicka, E., 2006. Ocena efektywnos´ci masaz_ u medycznego u oso ´b z bo ´lami dolnego odcinka kre˛gosłupa. Fizjoterapia Polska 6 (4), 150e156. Andrzejewski, W., Kassolik, K., Stodo ´łka, J., Marcinkowski, q, Mucha, A., Migasiewicz, J., Błach, W., 2005. Ocena dolegliwos´ci bo ´lowych narza˛du ruchu wyste˛puja˛cych u studento ´w Akademii Wychowania Fizycznego. Medycyna Sportowa 21 (5), 358e365. Fischer, A.A., 1987a. Pressure algometry over normal muscles. Standard values, validity and reproducibility of pressure threshold. Pain 30, 115e126. Fischer, A.A., 1988. Documentation of myofascial trigger points. Archives of Physical Medicine and Rehabilitation 69, 286e291. Fischer, A.A., 1984. Diagnosis and management of chronic pain in physical medicine and rehabilitation. In: Ruskin, A.P. (Ed.), Current Therapy in Psychiatry. Saunders, Philadelphia. Fischer, A.A., 1986. Pressure threshold meter: its use for quantification of tender spots. Archives of Physical Medicine and Rehabilitation 67, 836e838. Fischer, A.A., 1987b. Tissue compliance meter for objective, quantitative documentation of soft tissue consistency and pathology. Archives of Physical Medicine and Rehabilitation 68, 122e125. Jasko ´lski, A., Jasko ´lska, A., Adach, Z., 2002. Podstawy fizjologii wysiłku fizycznego. AWF, Wrocław. Kassolik, K., Andrzejewski, W., Trze˛sicka, E., Ostrowska, B., 2005. _ medycznego w zespole bolesnego Ocena skutecznos´ci masazu barku. Fizjoterapia Polska 5 (2), 201e206. Merskey, H., Spear, F.G., 1964. The reliability of the pressure algometer. British Journal of Social and Clinical Psychology 3, 130e136. Mikkelsson, M., Latikka, P., Kautiainen, H., Isomeri, R., Isomaki, H., 1992. Muscle and bone pressure pain threshold and pain tolerance in fibromyalgia patients and controls. Archives of Physical Medicine and Rehabilitation 73, 814e818. Myers, T.W., 2001. The Anatomy Trains: Myofascial Meridians for Manual and Movement Therapies. Churchill Livingstone, Edinburg. Offenbacher, M., Stucki, G., 2000. Physical therapy in the treatment of fibromyalgia. Scandinavian Journal of Rheumatology 29 (Suppl. 113), 78e85. Reeves, J.L., Jaeger, B., Graff-Radford, S., 1986. Reliability of the pressure algometer as measure of myofascial trigger points sensitivity. Pain 24, 313e320. Ronat, A., Defrin, R., Ravid, A., Peretz, C., 2003. Spatial summation of pressure pain: effect of body region. Pain 106, 471e480. Simons, D.G., Travell, J.G., Simons, L.S., 1999. Travell and Simons’ Myofascial Pain and Dysfunction; the Trigger Point Manual, second ed., vol. 1. Williams & Wilkins, Baltimore. Travell, J.G., Simons, D.G., 1992. Myofascial Pain and Dysfunction: the Trigger Point Manual. Williams & Wilkins, Baltimore.

Journal of Bodywork & Movement Therapies (2010) 14, 391e396

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Referred pain areas of active myofascial trigger points in head, neck, and shoulder muscles, in chronic tension type headache ˜as, PT, PhD a,b,c,*, Hong-You Ge, MD, PhD b, ´sar Ferna ´ndez-de-las-Pen Ce ´lez-Iglesias, PT e, Cristina Alonso-Blanco, PT, MSc d, Javier Gonza Lars Arendt-Nielsen, DMSc, PhD b a Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation of Universidad Rey Juan Carlos, Alcorco´n, Madrid, Spain b Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Aalborg University, Aalborg, Denmark c Esthesiology Laboratory of Universidad Rey Juan Carlos, Alcorco´n, Madrid, Spain d Department of Health Sciences II, Universidad Rey Juan Carlos, Madrid, Spain e Centro de Fisioterapia Integral, Candas, Asturias, Spain

Received 2 April 2009; received in revised form 27 June 2009; accepted 28 June 2009

KEYWORDS Tension type headache; Muscle trigger points; Referred pain areas

Summary Our aim was to analyze the differences in the referred pain patterns and size of the areas of those myofascial trigger points (TrPs) involved in chronic tension type headache (CTTH) including a number of muscles not investigated in previous studies. Thirteen right handed women with CTTH (mean age: 38  6 years) were included. TrPs were bilaterally searched in upper trapezius, sternocleidomastoid, splenius capitis, masseter, levator scapulae, superior oblique (extra-ocular), and suboccipital muscles. TrPs were considered active when both local and referred pain evoked by manual palpation reproduced total or partial pattern similar to a headache attack. The size of the referred pain area of TrPs of each muscle was calculated. The mean number of active TrPs within each CTTH patient was 7 (95% CI 6.2e8.0). A greater number (T Z 2.79; p Z 0.016) of active TrPs was found at the right side (4.2  1.5) when compared to the left side (2.9  1.0). TrPs in the suboccipital muscles were most prevalent (n Z 12; 92%), followed by the superior oblique muscle (n Z 11/n Z 9 right/left side), the upper trapezius muscle (n Z 11/n Z 6) and the masseter muscle (n Z 9/n Z 7). The ANOVA showed significant differences in the size of the referred pain area between muscles (F Z 4.7, p Z 0.001), but not between sides (F Z 1.1; p Z 0.3): as

* Corresponding author: Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Avenida de Atenas s/n, 28922 Alcorco ´n, Madrid, Spain. Tel.: þ34 91 488 8884; fax: þ34 91 488 8957. E-mail address: [email protected] (C. Ferna ´ndez-de-las-Pen ˜as). 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.06.008

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C. Ferna ´ndez-de-las-Pen ˜as et al. determined by a Bonferroni post hoc analysis the referred pain area elicited by levator scapulae TrPs was significantly greater than the area from the sternocleidomastoid (p Z 0.02), masseter (p Z 0.003) and superior oblique (p Z 0.001) muscles. Multiple active TrPs exist in head, neck and shoulder muscles in women with CTTH. The referred pain areas of TrPs located in neck muscles were larger than the referred pain areas of head muscles. Spatial summation of nociceptive inputs from multiple active TrPs may contribute to clinical manifestations of CTTH. ª 2009 Elsevier Ltd. All rights reserved.

Introduction Headache is one of the most prevalent neurological disorders (Bendtsen and Jensen, 2009). Tension-type headache is the most common form of headache and its chronic form (chronic tension-type headache: CTTH) is one of the most neglected (Bendtsen and Jensen, 2006) and is difficult to treat. It has been reported a prevalence rate of 38.3% for episodic tension type headache and 2.2% for CTTH (Schwartz et al., 1998). The prevalence of this headache has increased over the years (Lyngberg et al., 2005). CTTH may cause substantial levels of disability, not only to patients and their relative families, but also to the global society due to very high prevalence (Stovner et al., 2007). Although there has been an increasing interest in the pathogenic mechanisms of CTTH, the real patho-anatomical mechanisms remain to be fully elucidated (Fumal and Schoenen, 2008). It seems clear that hyper-excitability of nociceptive pathway plays an important role in CTTH (Bendtsen and Schoenen, 2006). It has been recently postulated that CTTH pain, at least in part, may be associated with referred pain elicited by trigger points (TrPs) in head, neck and shoulder muscles (Ferna ´ndez-de-las-Pen ˜as et al., 2007a). A myofascial TrPs is defined as a hypersensitive spot within a taut band of a skeletal muscle that elicits a referred distant pain (Simons et al., 1999). From a clinical point of view, TrPs may be active or latent. Active TrPs cause symptoms and both their local and referred pain evoke a familiar pain for the patient. In CTTH, active TrPs evoke symptoms similar to those patients perceive during their headache attacks. We have demonstrated that CTTH is associated with active TrPs in the suboccipital (Ferna ´ndez-de-las-Pen ˜as et al., 2006a), upper trapezius (Ferna ´ndez-de-las-Pen ˜as et al., 2007b), superior oblique (Ferna ´ndez-de-las-Pen ˜as et al., 2005), sternocleidomastoid (Ferna ´ndez-de-las-Pen ˜as et al., 2006b), temporalis (Ferna ´ndez-de-las-Pen ˜as et al., 2007c), and lateral rectus of the eye (Ferna ´ndez-delas-Pen ˜as et al., 2009) muscles. Additionally, we also formulated an updated pain model for CTTH involving both peripheral sensitization from active muscle TrPs and central sensitization in which active TrPs located in those muscles innervated by C1eC3 segments or the trigeminal nerve may be responsible for peripheral nociception producing a continuous afferent barrage into the nucleus caudalis of the trigeminal nerve sensitizing the central nervous system in CTTH (Ferna ´ndez-de-las-Pen ˜as et al., 2007d). Previous studies in patients with CTTH have shown larger referred pain areas elicited from TrPs in the upper trapezius (Ferna ´ndez-de-las-Pen ˜as et al., 2007b) and the temporalis (Ferna ´ndez-de-las-Pen ˜as et al., 2007c) muscles as compared to controls. In addition, there are a number of

muscles in which TrPs can refer pain to the head and hence contribute to CTTH (Figure 1), e.g. masseter, splenius capitis, levator scapulae (Simons et al., 1999), which have not been included in recent published studies. Therefore, the aim of this study was to analyze the differences in the referred pain patterns and size of the areas of those muscle TrPs involved in CTTH including a number of muscles not investigated in previous studies.

Material and methods Patients Thirteen women diagnosed with CTTH, aged from 30 to 50 (mean age: 38  6 years) years of age participated in this study. Patients were recruited from an advertisement in a local newspaper. All subjects were right-handed. Patients were interviewed by an experienced clinician to be certain that they fit the inclusion criteria of the International Headache Society (IHS) criteria for CTTH (IHS, 2004). Headache pain features, temporal profile, family history, and past and current medications were ascertained from the history. To be included, patients had to describe all the characteristics typical of this headache: bilateral location, pressing and tightening pain, mild or moderate intensity (6 on a 11-point numerical pain rate scale from 0 to 10) and no aggravation of headache during physical activity. No patient reported photophobia, phonophobia, vomiting or evident nausea during headaches. In addition, patients had to have headaches for at least 15 days/month. Other primary headaches were excluded. Each patient fulfilled the criteria for CTTH, and there was no apparent evidence of secondary headaches. Medication-overuse headache as defined by the IHS was also ruled out. Furthermore, patients completed a headache diary for 4 weeks in order to substantiate the diagnosis (Phillip et al., 2007). All patients had received several prophylactic drugs several years ago, but none of them were taking any prophylactic drug at the time the study was conducted. Furthermore, patients who received any non-pharmacological treatment (physical therapy, relaxation) within 6 months prior to the study were not considered for the study. Ethical approval of the study was granted by the Local Ethics Committee (VN 2005-0041). Informed consent was obtained from all subjects, and all procedures were conducted according to the Declaration of Helsinki.

Headache characteristics An 11-point numerical pain rating scale (Jensen et al., 1999) (NPRS; range: 0 Z no pain, to 10 Z maximum pain)

Referred pain areas of active TrPs in head, neck, and shoulder muscles, in CTTH

393

Figure 1 Referred pains from upper trapezius, sternocleidomastoid, suboccipital, splenius capitis, splenius cervicis, semispinalis capitis and temporalis muscle TrPs as described by Simons et al. Reprinted with permission from Simons, D., Travell, J., Simons, L., 1999. Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol. 1, second ed. Williams & Wilkins, Baltimore.

was used to assess headache intensity. The headache diary was used to calculate the following variables: (1) headache intensity, calculated from the mean of the NPRS of the days with headache; (2) headache frequency, calculated by dividing the number of days with headache by the number of analyzed weeks (days/week); and (3) headache duration, calculated by dividing the sum of the total hours of headache by the number of days with headache (hours/ day). Patients also drew their headache pattern on an anatomical map.

Muscle trigger point examination Patients were asked to avoid any analgesic or muscle relaxant 48 h prior to the examination, and they were examined when their headache intensity was less than 4 on the NPRS. Myofascial TrPs were bilaterally explored in upper trapezius, splenius capitis, sternocleidomastoid, masseter, superior oblique, levator scapulae and suboccipital muscles by an observer assessor who had more than 8 years of experience in TrP diagnosis. For the upper trapezius, sternocleidomastoid, splenius capitis, masseter and levator scapulae muscles, TrP diagnosis was conducted following the diagnostic criteria described by Simons et al.

(1999): (1) presence of a palpable taut band within a skeletal muscle; (2) presence of a hypersensitive tender spot in the taut band; (3) local twitch response elicited by snapping palpation of the taut band; and (4) reproduction of the typical referred pain pattern of the TrP in response to compression. For suboccipital and superior oblique muscles we adopted the previous published guidelines (Ferna ´ndezde-las-Pen ˜as et al., 2005, 2006a). Briefly, the diagnosis of suboccipital TrPs was made when there was tenderness in the suboccipital region, referred pain evoked by maintained pressure for 10 s, and increased referred pain with muscle contraction [extension of the headeneck] (Ferna ´ndez-de-las-Pen ˜as et al., 2006a). For the diagnosis of superior oblique muscle TrPs, we searched for both local and referred pain elicited by palpation of the superiorinternal corner of the orbit and increased referred pain with both contraction [infra-adduction of the eye] and stretching [supra-abduction of the eye] of the muscle (Ferna ´ndez-de-las-Pen ˜as et al., 2005). TrPs were considered active if both the local and the referred pain evoked by manual palpation reproduced total or partial pattern of the headache (Simons et al., 1999). Muscle TrPs were searched in each muscle with a 1-min interval between two consecutive points. After TrP

394

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examination on each point, patients were asked to draw the distribution of referred pain (if it was elicited during examination) on an anatomical map. The referred pain area of muscle TrPs was calculated with a digitizer (ACECAD D9000, Taiwan).

between head pain areas and pain clinical parameters (intensity, duration or frequency) were found.

Statistical analysis

The mean number of active TrPs within each CTTH patient was 7 (95% CI 6.2e8.0). A greater number (T Z 2.79; p Z 0.016) of active TrPs was found on the right side (4.2  1.5) when compared to the left side (2.9  1.0). TrPs in the suboccipital muscles were most prevalent (n Z 12; 92%), followed by the superior oblique muscle (n Z 11 [85%]/n Z 9 [69%] right/left side), the upper trapezius muscle (n Z 11 [85%]/n Z 6 [46%]) and the masseter muscle (n Z 9 [69%]/n Z 7 [54%]). The distribution of active muscle TrPs was significantly different between sides for the upper trapezius (c2 Z 4.792; p Z 0.045), the sternocleidomastoid (c2 Z 4.524; p Z 0.045) and the levator scapulae muscles (c2 Z 5.406; p Z 0.0354). In such a way, active TrPs were mostly located in the right side in both upper trapezius and sternocleidomastoid muscles, whereas levator scapulae TrPs were mostly located in the left side. The distribution of active TrPs in the analyzed muscles is shown in Table 1, and referred pain areas of particular muscles in Table 2. The ANOVA showed significant differences in referred pain areas between muscles (F Z 4.7, p Z 0.001), but not between sides (F Z 1.1; p Z 0.3). Based on a Bonferroni post hoc analysis, the referred pain area elicited from levator scapulae TrPs was significantly greater than the referred pain from the sternocleidomastoid (p Z 0.02), the masseter (p Z 0.003) and the superior oblique (p Z 0.001) muscles. Referred pain areas of upper trapezius, splenius capitis, suboccipital, and levator scapulae were not significantly different (p > 0.3).

Data was analyzed with SPSS version 14.0 (SPSS Inc, Chicago, IL) Results are expressed as mean and 95% confidence interval in the text. The KolmogoroveSmirnov test showed a normal distribution of quantitative data (p > 0.05). The differences in the number of active TrPs between both sides were assessed with the non-parametric Wilcoxon Signed-Rank test. The chi square (c2) test was used to assess the differences in the size of the distribution of active TrPs within each muscle on each side. A two-way ANOVA was used to detect the differences in referred pain area (cm2) between muscles and sides. The Bonferroni test was conducted as post hoc analysis. The Pearson (r) test was used for the correlation analysis between referred pain areas and clinical variables relating to headache (intensity, frequency, duration, history). The statistical analysis was conducted at a 95% confidence level. A p value-less than 0.05 was considered statistically significant.

Results Clinical features of the sample In this CTTH sample, mean duration of the headache history was 11.5 years (95% CI 7.2e15.8 years). The mean headache period per day was 7.2 h (95% CI 5.8e8.5 h), the mean intensity per episode was 4.8 (95% CI 4.4e5.2), and the number of days per week with headache was 4.5 (95% CI 4.1e5.0 days/week). The day of the examination mean headache intensity was 2.3 (95% CI 2.0e2.6). Headache intensity was positively associated with the headache duration of individual attacks (r Z 0.65; p Z 0.02): the greater the intensity, the longer the duration of the headache. The mean head pain area reported by the patients during their attacks was 4.1 cm2 (95% CI 2.6e5.6) in the frontal region, 5.9 (95% CI 4.7e7.2) in the occipital region (including the posterior part of the neck region), 3.3 (95% CI 2.5e4.1) in the left side of the head, and 2.8 (95% CI 1.9e 3.8) in the right side of the head (Figure 2). No correlation

Figure 2

Muscle TrPs in CTTH: number, location and referred pain areas

Discussion This study showed the existence of multiple active TrPs in different head, neck and shoulder muscles in patients with CTTH. Both the local and referred pain elicited by active TrPs reproduced the headache pattern in all the patients. The presence of bilateral active TrPs in trigemino-cervical muscles provides a plausible explanation for the symmetrical bilateral distribution of pain observed in patients with CTTH.

Symptom area of the patients with chronic tension type headache included in the current study.

Referred pain areas of active TrPs in head, neck, and shoulder muscles, in CTTH Table 1

Number of patients with chronic tension type headache (n) with active trigger points (TrPs) located in each muscle.

Active TrPs (n) No TrPs (n)

Active TrPs (n) No TrPs (n)

Upper trapezius muscle

Sternocleidomastoid muscle

Masseter muscle

Left side

Right side

Left side

Right side

Left side

6 7

11 2

2 11

6 7

Right side

7 6

9 4

Splenius capitis muscle

Levator scapulae muscle

Superior oblique muscle

Left side

Left side

Left side

4 9

Right side 4 9

8 5

We found up to seven active muscle TrPs within each headache patient, supporting the assumption of spatial summation of TrP activity in CTTH, as we have previously suggested (Ferna ´ndez-de-las-Pen ˜as et al., 2007a,b,d). Our results underscore the importance of searching for multiple active TrPs in different muscles in patients with CTTH. This finding increases the relevance of multiple TrPs because active TrPs constitute an important source of peripheral nociception since higher concentrations of chemical mediators (bradykinin, calcitonin gene-related peptide, substance P, and serotonin) may be present in active muscle TrPs (Shah et al., 2005). This hypothesis would be related to previous assumptions that peripheral nociception and sensitization mechanisms would play a crucial role in the evolution from episodic to chronic tension type headache (Bendtsen and Schoenen, 2006). Therefore, clinicians should search and treat active muscle TrPs in the musculature which receives a trigemino-cervical innervation in patients with CTTH and try to treat those which referred pain TrP reproduced the headache attack. We also calculated the referred pain areas elicited by active TrPs and found that referred pain areas of suboccipital and levator scapulae muscle TrPs were the commonest ones. It is interesting to note that neck (suboccipital, levator scapulae or splenius capitis), instead of head muscles (masseter or superior oblique), showed the greatest referred pain areas. These findings claim for the relevance of neck muscles in pain perception in CTTH.

Table 2

395

Right side 4 9

9 4

Right side 11 2

Previously we assessed referred pain areas from the upper trapezius (Ferna ´ndez-de-las-Pen ˜as et al., 2007b) and temporalis (Ferna ´ndez-de-las-Pen ˜as et al., 2007c) muscles, but not from the remaining muscles included in the current study. The current study increases the number of muscle TrPs which referred pain is contributing to headache pain pattern in CTTH. Additionally, we also showed that the referred pain areas of the analyzed muscles covered the extension of the entire headache pain pattern of the patients, although we should consider that the referred pain areas of some muscle TrPs, e.g. suboccipital, splenius capitis, and upper trapezius, are located in the same region of the head (frontal or lateral side of the head or neck). In addition, we should take into account that the referred pain pattern of the levator scapulae muscle did not reach the head. Nevertheless, since all CTTH patients reported neck pain symptoms, active TrPs in this muscle are related to the neck pain pattern present in CTTH. Finally, the referred pain patterns elicited by active TrPs in the current study were very similar to those previously reported by Simons et al. (1999) and by Beat de Jung (2006). Nevertheless, some slight differences may be observed, probably due to the pathology of the patients included, or due to the sensitization state in which the patients were explored. An interesting finding was that active TrPs in the upper trapezius and sternocleidomastoid muscles were mostly located in the right side, whereas levator scapulae TrPs were mostly located in the left side. These results are

Referred pain areas of active trigger points on each muscles in patients with chronic tension type headache.

Patients with chronic tension type headache Upper trapezius Sternocleidomastoid Masseter Splenius capitis Levator scapulae Superior oblique Suboccipital

Right side (n Z 11) Left side (n Z 6) Right side (n Z 6) Left side (n Z 2) Right side (n Z 9) Left side (n Z 7) Right side (n Z 4) Left side (n Z 4) Right side (n Z 4) Left side (n Z 8) Right side (n Z 11) Left side (n Z 9) n Z 12

Referred pain areas (cm2) are expressed as means  standard deviation (95% confidence interval).

3.4  1.2 2.9  1.2 2.5  0.7 1.8  0.4 2.2  0.5 2.8  1.0 3.8  0.5 3.1  1.5 4.9  1.1 4.1  2.0 2.5  1.1 2.7  1.6 4.5  1.3

(2.5e4.2) (1.7e4.2) (1.8e3.2) (1.4e2.6) (1.8e2.6) (1.9e3.8) (3.1e4.6) (1.0e4.4) (3.1e6.6) (2.4e5.8) (1.7e3.2) (1.5e4.0) (3.7e5.4)

396 similar to those found in a previous study (Ferna ´ndez-delas-Pen ˜as et al., 2007b) in which TrPs in the upper trapezius muscle were also located in the dominant side. A greater prevalence of TrPs in the right side may be related to the fact that all patients were right-hand dominant. Bernard (1997) found that highly repetitive work and forceful arm or hand movements cause neck and shoulder pain. Repetitive use of the muscle in the dominant side may be a factor to the development of TrPs (Simons, 2004). Nevertheless, this hypothesis does not explain why active TrPs in the levator scapulae were more prevalent on the non-dominant side. Future studies should investigate this topic. We should recognize some limitations of the study. Firstly, we only included women with CTTH; therefore our results cannot be extrapolated to men with CTTH. Future studies should include men with CTTH for a more generalization of the results of the current study. Secondly, we included a small sample size, so future studies with a greater number of patients is recommended. Thirdly, since active TrPs are not found often in healthy controls we only included patients, in the current study. The reason was that we wanted to investigate referred pain areas in active TrPs in a patient population.

Conclusions The present study showed the existence of multiple active TrPs in different head, neck and shoulder muscles in women CTTH. Both the local and referred pain elicited by active TrPs reproduced the headache pattern in patients. The referred pain areas of TrPs located in neck muscles were greater than the referred pain areas of head muscles. Spatial summation of nociceptive inputs from multiple active TrPs may contribute to both peripheral and central sensitization in CTTH.

References De Jung, B., 2006. Triggerpunkt-therapie, second ed. Verlag Hans Huber, Bern. Bendtsen, L., Jensen, R., 2006. Tension type headache: the most common, but also the most neglected headache disorder. Curr. Opin. Neurol 19, 305e309. Bendtsen, L., Jensen, R., 2009. Epidemiology of tension-type headache, migraine and cervicogenic headache. In: Ferna ´ndez-de-lasPen ˜as, C., Arendt-Nielsen, L., Gerwin, R. (Eds.), Tension Type and Cervicogenic Headache: Patho-physiology, Diagnosis and Treatment. Jones & Bartlett Publishers, Baltimore, pp. 7e13. Bendtsen, L., Schoenen, J., 2006. Synthesis of tension type headache mechanisms. In: Olesen, J., Goasdby, P., Ramdan, N.M., Tfelt-Hansen, P., Welch, K.M.A., 2006. The Headaches, third ed. Lippincott Williams & Wilkins, Philadelphia, 2006. Bernard, B., 1997. Musculoskeletal Disorders and Workplace Factors: a Critical Review of Epidemiologic Evidence for Workrelated Musculoskeletal Disorders of the Neck, Upper Extremity, and Low Back, second ed. US Department of Health and Human Services, NIOSH, Cincinnati, OH, pp. I-C-59.

C. Ferna ´ndez-de-las-Pen ˜as et al. Ferna ´ndez-de-las-Pen ˜as, C., Cuadrado, M.L., Gerwin, R.D., Pareja, J.A., 2005. Referred pain from the trochlear region in tension-type headache: a myofascial trigger point from the superior oblique muscle. Headache 45, 731e737. Ferna ´ndez-de-las-Pen ˜as, C., Alonso-Blanco, C., Cuadrado, M.L., Gerwin, R.D., Pareja, J.A., 2006a. Trigger points in the suboccipital muscles and forward head posture in tension type headache. Headache 46, 454e460. Ferna ´ndez-de-las-Pen ˜as, C., Alonso-Blanco, C., Cuadrado, M.L., Gerwin, R.D., Pareja, J.A., 2006b. Myofascial trigger points and their relationship with headache clinical parameters in chronic tension type headache. Headache 46, 1264e1272. Ferna ´ndez-de-las-Pen ˜as, C., Ge, H.Y., Arendt-Nielsen, L., Cuadrado, M.L., Pareja, J.A., 2007a. Referred pain from trapezius muscle trigger point shares similar characteristics with chronic tension type headache. Eur. J. Pain 11, 475e482. Ferna ´ndez-de-las-Pen ˜as, C., Ge, H.Y., Arendt-Nielsen, L., Cuadrado, M.L., Pareja, J.A., 2007b. The local and referred pain from myofascial trigger points in the temporalis muscle contributes to pain profile in chronic tension-type headache. Clin. J. Pain 23, 786e792. Ferna ´ndez-de-las-Pen ˜as, C., Simons, D.G., Cuadrado, M.L., Pareja, J.A., 2007c. The role of myofascial trigger points in musculoskeletal pain syndromes of the head and neck. Curr. Pain Headache Rep 11, 365e372. Ferna ´ndez-de-las-Pen ˜as, C., Cuadrado, M.L., Arendt-Nielsen, L., Simons, D.G., Pareja, J.A., 2007d. Myofascial trigger points and sensitisation: an updated pain model for tension type headache. Cephalalgia 27, 383e393. Ferna ´ndez-de-las-Pen ˜as, C., Cuadrado, M.L., Gerwin, R.D., Pareja, J.A., 2009. Referred pain from the lateral rectus muscle in subjects with chronic tension type headache. Pain Med 10, 43e48. Fumal, A., Schoenen, J., 2008. Tension-type headache: current research and clinical management. Lancet Neurol 7, 70e83. IHS. 2004. Headache Classification Subcommittee of the International Headache Society: The International Classification of Headache Disorders, second ed. Cephalalgia 24(Suppl. 1), 9-160 Jensen, M.P., Turner, J.A., Romano, J.M., Fisher, L., 1999. Comparative reliability and validity of chronic pain intensity measures. Pain 83, 157e162. Lyngberg, A.C., Rasmussen, B.K., Jorgensen, T., Jensen, R., 2005. Has the prevalence of migraine and tension-type headache changed over a 12-year period? A Danish population survey. Eur. J. Neurol 20, 243e249. Phillip, D., Lyngberg, A.C., Jensen, R., 2007. Assessment of headache diagnosis: a comparative population study of a clinical interview with a diagnostic headache diary. Cephalalgia 27, 1e8. Schwartz, B.S., Stewart, W.F., Simon, D., Lipton, R.B., 1998. Epidemiology of tension type headache. JAMA 279, 381e383. Shah, J.P., Phillips, T.M., Danoff, J.V., Gerber, L.H., 2005. An in vitro microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J. Appl. Physiol 99, 1977e1984. Simons, D.G., 2004. Review of enigmatic MTrPs as a common cause of enigmatic musculoskeletal pain and dysfunction. J. Electromyogr. Kinesiol 14, 95e107. Simons, D.G., Travell, J., Simons, L.S., 1999. Travell and Simons’ Myofascial Pain and Dysfunction: the Trigger Point Manual, second ed., Vol. 1. Williams & Wilkins, Baltimore. Stovner, L., Hagen, K., Jensen, R., et al., 2007. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia 27, 193e210.

Journal of Bodywork & Movement Therapies (2010) 14, 397e402

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

CASE STUDY

Diagnosis and treatment of posterior interosseous nerve syndrome using soft tissue manipulation therapy: A case study John Saratsiotis, BSc, BA, DC a,*, Emmanouil Myriokefalitakis, MD b a b

Doctor of Chiropractic, Private Practice, Roupel 9, Peristeri, Athens, Attiki 121-34, Greece Orthopaedic Resident, A’ Orthopaedic Department, General Hospital ‘‘G. Gennimatas’’, Athens, Greece

Received 29 September 2009; received in revised form 22 October 2009; accepted 11 November 2009

KEYWORDS Peripheral nerve entrapment; Posterior interroseous nerve; Posterior interroseous nerve syndrome; Active release technique; Peripheral nerve release

Summary Peripheral nerve entrapments of the upper and lower extremity are commonly seen in practice. Chronically repetitive movement patterns lead to constriction of the nerve due to the development of local fibrosis within the soft tissues surrounding the nerve which also affects nerve traction, mobility, and function. A case is presented of a patient with motor weakness in the wrist and hand in order to illustrate the diagnosis and treatment of posterior interosseous nerve (PIN) syndrome. Using Active Release Techniques Soft Tissue Management and Peripheral Nerve Release Systems the patient’s symptomatology was resolved. Soft tissue-based management in conjunction with neural gliding may be beneficial in the conservative management of PIN syndrome. Further research into the pathophysiology of nerve entrapments will have immediate impact on the management of neuropathies and likely result in emphasizing conservative management and rehabilitation rather than surgical intervention particularly in cases not involving denervation or paralysis. ª 2009 Elsevier Ltd. All rights reserved.

Introduction Peripheral nerve entrapments of the upper and lower extremity are commonly seen in practice. An entrapment can occur anywhere along the course of a peripheral nerve (even though usually entrapment occurs at specific sites). The etiology of these syndromes is typically traumatic

(crush) injury or chronic injury. In both cases, the pathophysiology is similar (local ischaemia due to mechanical pressure), however the pathogenesis differs according to current research (Pham and Gupta, 2009; McKinnon, 2002). Acute injuries (crush injuries) are characterized by axonal injury (triggering Schwann cell dedifferentiation) and subsequent Wallerian degeneration (Pham and Gupta, 2009). In chronic nerve compression injuries simultaneous

* Corresponding author. Tel.: þ30 695 506 9285. E-mail address: [email protected] (J. Saratsiotis). 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.11.002

398 Schwann cell proliferation and apoptosis are induced leading to localised demyelination and remyelination at the injury site as well as axonal sprouting (Pham and Gupta, 2009). Interestingly, these changes occur in the absence of both morphological and electrophysiological evidence of axonal damage (Pham and Gupta, 2009; McKinnon, 2002). Depending on the nerve involved, the symptoms of nerve entrapment syndromes generally involve pain, sensory and motor changes. Most entrapment syndromes involve mixed sensory and motor nerves and consequently present with all the aforementioned symptoms. However, there are some exceptions such as the posterior interosseous nerve (PIN) which is a pure motor branch of the radial nerve. The PIN is an exception for another reason as well. While most entrapments occur usually due to an osseoligamentous tunnel narrowing, in the case of a PIN entrapment, the compression occurs within the musculo-tendinous radial tunnel. Specifically, in up to 69.4% of the cases, the nerve is compressed by the fibrous arcade of Frohse (Ritts et al., 1987; Ferdinand et al., 2006). The arcade is absent in fetuses and is thought to develop from repetitive rotational (supinationepronation) movements of the forearm (overuse) (Links et al., 2009). Anatomic studies have revealed a variable rate of occurrence which ranges between 30% and 80% of the population (Spinner, 1968; Clavert et al., 2009). Compression of the posterior interosseous nerve within the radial tunnel yields two different clinical pictures that are believed to reflect two distinct clinical entities: posterior interosseous nerve syndrome and radial tunnel syndrome (Ferdinand et al., 2006). Posterior interosseous nerve syndrome is characterized by motor deficits in the distribution of the posterior interosseous nerve. Consequently, it is important for the practitioner to understand the etiology and symptomatology in order to create an effective treatment protocol. Treatment of a PIN syndrome consists of either conservative or surgical management. Initially, wrist and/or elbow splints may be used, physical therapy, use of NSAIDs, or a corticosteroid injection in order to reduce local inflammation and swelling around the nerve (Hyde and Gengenbach, 2007). Therapy should continue for approximately 3e6 months with regular re-assessment of signs and symptoms. If there is no response to therapy, evidence of denervation, or persistent paralysis, surgical decompression should be considered (Stanley, 2006). Physical therapy involves the use of cryotherapy, ultrasound, TENS, and strengthening exercises for weakened musculature. However, recent literature has advocated the effectiveness of deep soft tissue mobilization techniques (myofascial release, Active Release Technique, Graston Technique) in conjunction with neural gliding (‘‘flossing’’) in order to achieve optimal results (Hyde and Gengenbach, 2007; Agrios and Crawford, 1999; Buchberger et al., 1996; Coppieters et al., 2004). A case is presented to illustrate the treatment of posterior interosseous nerve syndrome using Active Release Techniques Soft Tissue Management and Peripheral Nerve Release Systems.

J. Saratsiotis, E. Myriokefalitakis the course of time to right wrist and finger extension weakness. The complaint originally started insidiously 4 months previously with pain in the lateral aspect of the upper forearm (closer to the elbow). During that period the patient was otherwise in good health. The pain was rated as 5 out of 10 on an 11-point Numeric Rating Scale-Pain Intensity (NRS-PI) where 0 represents ‘‘no pain’’ and 10 represents ‘‘worst possible pain.’’ The pain did not radiate into the forearm but was localised approximately 6e7 cm distal to the elbow crease (lateral aspect). The patient did not report any hypesthesia, but did indicate an inability to extend digits 2 through 5, as well as noticing a weakness in wrist extension. No other symptoms were reported. The patient had been diagnosed with right lateral epicondylopathy early-on in his symptomatology (prior to motor weakness presentation). Electromyography and nerve conduction velocity (NCV) testing revealed no particular findings (Figures 1 and 2), except for a mild sensory loss and possible C8 radiculopathy on the right. MRI imaging indicated mild degenerative changes and a disc bulge at the C6/C7 vertebral level. X-ray imaging of the right elbow was unremarkable. Previous treatment included physiotherapy (TENS, ultrasound, massage to lateral forearm, stretching exercises to extensor muscle group) which according to the patient had produced very little benefit. Upon observation no swelling was evident in the forearm, however, a finger drop was observed in the right hand. Active and passive ranges of motion of the cervical spine, elbow, wrist, and fingers were performed and were painfree and symmetrical except for a notable weakness of the metacarpalphalangeal joints (MCP) on the right side. Specifically, active and resisted extension of the right wrist was graded as 4/5 with a slight radial deviation of the wrist. Resisted finger extension was graded as 3/5 for fingers 3e5, while the index finger was graded 2/5 (all at the metacarpalphalangeal e MCP-joints). Elbow flexion was within normal limits and tested 5/5 in both flexion and extension. Resisted supinationepronation caused discomfort in the latter. Orthopaedic testing of the cervical spine (compression, distraction, Jackson’s test) were unremarkable except for mild pain during Jackson’s compression test on the right. Bilateral sensation was tested and the result was bilateral and symmetrical, while reflexes were graded 2þ bilaterally for the upper extremity. Palpation revealed

Muscle

Duration

Height

Phase

Comment_

Deltoid (R)

WNL

WNL

WNL

Small involvement

WNL

WNL

WNL

Small involvement

WNL

WNL

WNL

Involvement

WNL

WNL

WNL

Small involvement

WNL

WNL

WNL

Small involvement

WNL

WNL

WNL

Small involvement

_

Biceps Brachii (R) Extensor Digitorum (R) Abductor Pollicis Brevis (R) 1st dorsal Interosseus (R) Abductor

Case study A 62 year old office worker presented with right lateral forearm pain (4 month duration) that had progressed over

Digiti min. (R)

Figure 1 EMG results of patient indicating weakness in extensor digitorum on the right.

Diagnosis and treatment of PIN syndrome

399

Motor Nerve Conduction Study Distance

NCV

Median (R)

Site

Latency (ms) 4.44

Amplitude 7.42mV

19.4mVms

Area

205mm

51m/s

-

8.46

7.92mV

20.0mVms

147mm

0m/s

Ulnar (R)

3.26

5.88mV

18.9mVms

125mm

60m/s

-

5.34

7.67mV

24.5mVms

180mm

49m/s

_

Sensory Nerve Conduction Study Area

Distance

NCV__

Ulnar (R)

Site

Latency (ms) 2.90

Amplitude 8.90uV

5.34uVms

152mm

52m/s

Median (R)

3.26

10.7uV

2.80uVms

168mm

51m/s

Radial (R)

1.34

27.6uV

11.8uVms

80mm

59m/s

Figure 2 Nerve conduction velocity (sensry and motor) of the upper extremity indicating neuropathy (hypoaesthesic) and possible C8 radiculopathy.

tender areas of nodular consistency within the supinator, while tissue tension was identified in both the extensor carpi radialis longus and supinator on the right, as within the extensor carpi ulnaris. Palpation over the anterior radiohumeral joint and lateral epicondyle did not cause any pain or tenderness. The Rule of Nine test was then performed where a large squared box was drawn over the anterior aspect of the right proximal forearm. The sides of the square were determined by the width of the elbow crease with a fully extended elbow and a fully supinated forearm and the square was further divided into nine smaller equal squares giving three columns and three rows (Loh et al., 2004). It has been suggested that the PIN travels through the lateral column, the median nerve travels through the middle column, while the medial column is traversed by neither (Loh et al., 2004). The areas of pain have been identified in Figure 3. According to Loh et al., the presence of the fibrous bands connecting brachialis and brachioradialis overlying the PIN at the level of the radial head is most likely to

Figure 3 Rule of Nine test and areas of pain upon palpation of patient’s right upper lateral forearm.

involve the lateral 1 square (Loh et al., 2004; Tubbs et al., 2006). The leash of Henry, the tendinous medial edge of the extensor carpi radialis brevis, the arcade of Frohse, and the distal tendinous edge of the supinator or bands within the two heads of supinator make the involvement of lateral 2 and 3 squares most likely (Loh et al., 2004; Tubbs et al., 2006). As seen from Figure 3, the patient’s symptoms localised in the lateral squares 2 and 3. This area, which measured 6e7 cm from the elbow crease, is below the proposed superficial landmark for the leash of Henry (approximately 5 cm from lateral epicondyle), which would indicate an entrapment by most likely the ECRB, the supinator, or the arcade of Frohse. At this point, a diagnosis of posterior interosseous nerve syndrome was made, ruling out the possibility of lateral epicondylopathy, radiculopathy, or radial tunnel syndrome.

Methodology and results The patient was treated using Active Release Techniques applied to the extensor carpi radialis brevis, supinator, and Arcade of Frohse. The treatment of these structures corresponds to protocols 30, 32, 33 from the manual of the Active Release Techniques Soft Tissue Management System of the Upper Extremity. The intended purpose of this treatment was to decrease tissue tension as well as to normalize tissue function. Following soft tissue therapy, nerve traction techniques were performed to the posterior interosseous nerve, once again according to protocol 8 from the Active Release Techniques Soft Tissue Management System for Nerve Entrapments (Figure 4). The purpose of nerve gliding/traction is to maximize the movement of the nerve in relation to the anatomic structures adjacent to it, in this case the supinator muscle and the Arcade of Frohse. After nine visits (with 1 day between visits) the patient reported lateral upper forearm pain rated as 1 out 10 on the 11-point NRS-PI scale. Motor deficits observed with wrist and finger extension resolved and resisted muscle testing was graded 5/5 bilaterally for wrist

Figure 4 Neural gliding using the Active Release Techniques Soft Tissue Management System for Nerve Entrapments of the posterior interosseous nerve: at this point in the technique, the nerve is lengthened proximal to the contact site and shortened distal to the contact site.

400 extension and finger extension of digits 2e5. The patient was given strengthening exercises for wrist and finger extension and asked to return in 1 months time for reassessment. During re-assessment the patient reported no pain in his forearm and noted full strength in his right wrist and hand. At 6 months following treatment the same results were observed.

Discussion The posterior interosseous nerve is a branch of the radial nerve. The radial nerve is the main continuation of the posterior chord (C6eC8, and occasionally T1) of the brachial plexus (Moore and Dalley, 1999; Sellards and Kuebrich, 2005). The radial nerve enters the arm posterior to the brachial artery, medial to the humerus, and anterior to the long head of the triceps (Moore and Dalley, 1999). At mid arm, the radial nerve descends behind the humerus, deep to the long head of the triceps, and then spirals around the humerus in between the medial and lateral heads of the triceps in the spiral groove. Approximately 10 cm above the lateral humeral epicondyle, the nerve pierces the lateral intermuscular septum and enters the anterior compartment of the arm (Moore and Dalley, 1999; Sellards and Kuebrich, 2005). Here, it immediately enters the deep, muscular groove bordered medially by the biceps and laterally by the brachioradialis, the extensor carpi radialis longus (ECRL), and the extensor carpi radialis brevis (ECRB). The nerve then courses immediately in front of the radiocapitellar joint capsule, where it divides into the motor PIN and the sensory superficial radial nerve (see Figure 5). Branches innervating the brachioradialis and ECRL come off before the bifurcation while the ECRB is innervated by either the radial nerve or the PIN (Moore and Dalley, 1999). The PIN enters the radial tunnel underneath a musculo-

Figure 5 The radial nerve courses immediately in front of the radiocapitellar joint capsule, where it divides into the deep motor (PIN) and the sensory superficial radial nerve. [Reproduced with kind permission by Elsevier from Spinner, M., 1968. J. Bone Joint Surg. Br. 50, 809e812].

J. Saratsiotis, E. Myriokefalitakis tendinous arch, the arcade of Frohse. Formed by the upper free border of the superficial head of the supinator, the arcade of Frohse is a semicircular fibrous arch that remains fibrous medially and is found in 30e80% of anatomical specimens (Spinner, 1968; Clavert et al., 2009). Just before the arcade of Frohse, a number of arterial branches (leash of Henry) that arise from the recurrent radial artery cross over the PIN (Moore and Dalley, 1999; Sellards and Kuebrich, 2005). Within the radial tunnel, the PIN rests on the deep head of the supinator. After emerging from the tunnel beneath the supinator, the PIN lies posteriorly to the interosseous membrane of the forearm and innervates the extensor digiti minimi, extensor carpi ulnaris, medially the extensor digitorum communis, and laterally the extensor indicis proprius, extensor pollicis longus and brevis, and abductor pollicis longus (Ferdinand et al., 2006; Moore and Dalley, 1999; Sellards and Kuebrich, 2005). Entrapment of the PIN can occur right at the division of the radial nerve into motor and sensory branches, within the radial tunnel, or after the nerve bifurcates into medial and lateral branches (Ferdinand et al., 2006; Moore and Dalley, 1999). Consequently, depending on where the entrapment is, the presenting signs and symptoms will slightly vary (depending on which muscles have lost innervation). With respect to the radial tunnel, entrapment can occur due to compression from fibrous bands attached to the radiocapitellar joint, the radial recurrent vessels (branches of Henry), the tendinous origin of the extensor carpi radialis brevis, the tendinous origin of the supinator (arcade of Frohse), and fibrous thickenings within and at the distal margin of the supinator (Clavert et al., 2009; Moore and Dalley, 1999; Sellards and Kuebrich, 2005; Konjengbam and Elangbam, 2004). Compression of the posterior interosseous nerve (PIN) within the radial tunnel yields two different clinical pictures that are believed to reflect two distinct clinical entities: PIN syndrome and radial tunnel syndrome (Ferdinand et al., 2006). Both are considered entrapments of the PIN, however, the latter involves pain along the radial aspect of the proximal forearm (mimics lateral epicondylitis) and is characterized by the absence of neurological findings (motor deficit) (Ferdinand et al., 2006; Lister et al., 1979). Electrodiagnostic examination findings fail to demonstrate any abnormality of the PIN, and are not useful in confirming the diagnosis for radial tunnel syndrome, which is generally made on the basis of a physical examination (Ferdinand et al., 2006). One theory suggests that the PIN, while mainly a motor nerve, carries sensory afferent fibres from the wrist as well as group IIA afferent fibres from the muscles along its distribution (Ritts et al., 1987; Lister et al., 1979). It is possible that only afferent fibres are affected with radial tunnel syndrome, whereas only the motor fibres are affected with PIN syndrome (Ritts et al., 1987). Some authors believe radial tunnel syndrome may represent an early posterior interosseous nerve syndrome (Ritts et al., 1987). In the case presented, this might potentially explain the unremarkable results from the electrodiagnostic testing which was performed on the patient early-on in his symptomatology. Most likely, the condition had started as a radial tunnel syndrome that

Diagnosis and treatment of PIN syndrome progressed to a PIN syndrome due to repetitive compression of the nerve. The repetitive overuse (supinationepronation) of the patient’s right forearm potentially promoted histological changes to the radial tunnel structures, particularly the supinator and arcade of Frohse, with progressive development of a local fibrous zone (Clavert et al., 2009). The Active Release Technique Soft Tissue Management System (ART) has proven to be clinically promising in treating conditions related to overuse (Spina, 2007; Leahy, 1995). Within the rehabilitation arena, cumulative trauma disorders are often treated with ART. These types of disorders follow the law of repetitive motion developed by P. Michael Leahy, D.C.:

401 neuropathies (neural tension test). Similarly, rehabilitation techniques used to stretch the nerves and restore neural gliding are frequently successful in relieving patient symptoms (Hyde and Gengenbach, 2007; Coppieters et al., 2004). Consequently, Active Release Techniques Peripheral Nerve Release Systems was used on the posterior interosseous nerve in order to increase gliding motion of the nerve. Overall improvement in symptomatology was observed in this patient with restoration of motor deficits and decrease in pain. The patient was also given strengthening exercises in order to re-educate and strengthen soft tissue structures affected by compression of the PIN.

Conclusion

IZNF=AR where, I Z insult to tissues, N Z number of repetitions, F Z tension of each repetition as percentage of maximum muscle strength, A Z amplitude of each repetition, and R Z relaxation time between repetitions (Leahy, 1995). It is obvious from the above equation, that if the number of repetitions ‘‘N’’ is increased, such as in a case of cumulative trauma, the insult to the tissues also increases. According to Leahy, this soft tissue insult will reduce circulation in the area of concern ultimately leading to tissue hypoxia (Leahy, 1995). Related research has indicated that as the partial pressure of oxygen (PO2) begins to decrease, due to hypoxic conditions, fibroblasts are stimulated by such conditions and start to proliferate at the site of injury (Falanga et al., 2002). This results in abnormally high amounts of collagen deposition causing excessive fibrosis (scar tissue formation). Studies have suggested that deep tissue mobilization techniques induce a controlled amount of microtrauma in an area composed of excessive scar tissue, which in turn appears to stimulate connective tissue remodelling through resorption of excessive fibrosis, along with inducing repair and regeneration of collagen secondary to fibroblast recruitment (Melham et al., 1998; Gehlsen et al., 1999). A preliminary report on the use of ART for a variety of upper extremity overuse syndromes found a 71% efficacy rate (Schiottz-Christensen et al., 1999). Furthermore, localised fibrosis around a nerve leads to compression of the nerve and consequent compressioninduced neuronal swelling, even 1 week after compression is applied (Chien et al., 2003). The swelling occurs proximal to the constriction site and studies show it might be the result of either abnormal cytoplasmic axonal transport or ischemic conditions (McKinnon, 2002; Chien et al., 2003). Histopathologic studies have indicated the swelling is associated with perineural and epineural fibrosis rather than nerve fibre pathology (McKinnon, 2002; Chien et al., 2003). Once the nerve is released in these situations, axonal diameter equalizes a few days later (Chien et al., 2003). The rapid recovery of motor deficiency following treatment in the case presented would indicate chronic nerve compression due to fibrosis rather than axonal nerve injury. Furthermore, this fibrosis would prevent the nerve fibres themselves from going through a full range of movement, without traction, and decreased gliding. Clinical tests that put a stretch on the nerve will provoke patient symptoms and have been used to diagnose specific compression

Posterior interosseous nerve syndrome is an entrapment neuropathy that is not common in the upper extremity, however it can be debilitating due to symptoms of pain and motor deficiency in the wrist and hand. This condition should not be confused with radial tunnel syndrome which involves compression of the same nerve. Chronically repetitive movement patterns lead to constriction of the nerve due to the development of local fibrosis within the soft tissues surrounding the nerve which also affects nerve traction and mobility. Frequently, according to literature, conservative treatment of such conditions involves very little manual therapy. In the case presented, a conservative treatment protocol that included deep soft tissue mobilization techniques (ART) as well as neural gliding (‘‘flossing’’) techniques was introduced with positive results even 1 and 6 months following treatment. Histological studies support the decision to use such treatment methods while the results of this study confirm the need to introduce new effective conservative techniques prior to considering nerve decompression surgery. Further research into the pathophysiology of nerve entrapments will have immediate impact on the management of neuropathies and likely result in emphasizing conservative management and rehabilitation rather than surgical intervention particularly in cases not involving denervation or paralysis.

References Agrios, P., Crawford, J.W., 1999. Double crush syndrome of the upper extremity. J. Sports Chiropr. Rehab. 13 (3), 111e114. Buchberger, D.J., Rizzoto, H., McAdam, B.J., 1996. Median nerve entrapment resulting in unilateral action tremor of the hand. J. Sports Chiropr. Rehab. 10 (4), 176e180. Chien, A.J., Jamadar, D.A., Jacobson, J.A., Hayes, C.W., Louis, D.S., 2003. Sonography and MR imaging of posterior interosseous nerve syndrome with surgical correlation. AJR 181, 219e221. Clavert, P., Lutz, J.C., Adam, P., Wolfram-Gabel, R., Apr 2009. Frohse’s arcade is not the exclusive compression site of the radial nerve in its tunnel. Orthop. Traumatol. Surg. Res. 95 (2), 114e118. Coppieters, M., Bartholomeeusen, K., Stappaerts, K., Nov 2004. Incorporating nerve-gliding techniques in the conservative treatment of cubital tunnel syndrome. J. Manip. Physiol. Ther. 27 (9), 560e568. Falanga, V., Zhou, L., Yufit, T., Apr 2002. Low oxygen tension stimulates collagen synthesis and COL1A1 transcription through the action of TGF-beta1. J. Cell. Physiol. 191 (1), 42e50. Ferdinand, B.D., Rosenberg, Z.S., Schweitzer, M.E., Stuchin, S.A., Jazrawi, L.M., Lenzo, S.R., Jul 2006. MR imaging features of

402 radial tunnel syndrome: initial experience. Radiology 240 (1), 161e168. Gehlsen, G.M., Ganion, L.R., Helfst, R., April 1999. Fibroblast responses to variation in soft tissue mobilization pressure. Med. Sci. Sports Exerc. 31 (4), 531e535. Hyde, T.E., Gengenbach, M.S., 2007. Conservative Management of Sports Injuries. Jones and Bartlett Publishing, Sudbury, MA. Konjengbam, M., Elangbam, J., Jan 2004. Radial nerve in the radial tunnel: anatomic sites of entrapment neuropathy. Clin. Anat. 17 (1), 21e25. Leahy, P.M., 1995. Improved treatments for carpal tunnel and related syndromes. Chiropr. Sports Med. 9, 6e9. Links, A.C., Graunke, K.S., Wahl, C., Green, J.R., Matsen, F.A., JaneFeb 2009. Pronation can increase the pressure on the posterior interosseous nerve under the arcade of Frohse: a possible mechanism of palsy after two-incision repair for distal biceps rupturedclinical experience and a cadaveric investigation. J. Shoulder Elbow Surg. 18 (1), 64e68. Lister, G.D., Belsole, R.B., Kleinert, H.E., Jan 1979. The radial tunnel syndrome. J. Hand Surg. Am. 4 (1), 52e59. Loh, Y.C., Lam, W.L., Stanley, J.K., Soames, R.W., June 2004. A new clinical test for radial tunnel syndrome e the-rule-ofNine test: a cadaveric study. J. Orhtop. Surg. 12 (1), 83e86. McKinnon, S.E., May 2002. Pathophysiology of nerve compression. Hand Clin. 18 (2), 231e241. Melham, T.J., Sevier, T.L., Malnofski, M.J., Wilson, J.K., Helfst Jr., R.H., June 1998. Chronic ankle pain and fibrosis

J. Saratsiotis, E. Myriokefalitakis successfully treated with a new non-invasive augmented soft tissue mobilization technique (ASTM): a case report. Med. Sci. Sports Exerc. 30 (6), 801e804. Moore, K.L., Dalley, A.F. (Eds.), 1999. Clinical Oriented Anatomy, fourth ed. Lippincott Williams and Wilkins, Baltimore. Pham, K., Gupta, R., Feb 2009. Understanding the mechanisms of entrapment neuropathies. Review article. Neurosurg. Focus 26 (2), E7. Ritts, G.D., Wood, M.B., Lindscheid, R.L., 1987. Radial tunnel syndrome. A ten-year surgical experience. Clin. Orthop. 219, 201e205. Schiottz-Christensen, B., Mooney, V., Azxad, S., Selstad, D., Gulick, J., Bracker, M., 1999. The role of Active Release Manual Therapy for Upper Extremity Overuse Syndromes e a preliminary report. J. Occup. Rehab. 9 (3), 201e211. Sellards, R., Kuebrich, C., 2005 Mar. The elbow: diagnosis and treatment of common injuries. Prim. Care 32 (1), 1e16. Spina, A.A., 2007 Mar. External coxa saltans (snapping hip) treated with active release techniques(R): a case report. J. Can. Chiropr. Assoc. 51 (1), 23e29. Spinner, M., 1968. The arcade of Frohse and its relationship to posterior interosseous nerve paralysis. J. Bone Joint Surg. Br. 50, 809e812. Stanley, J., ApreJun 2006. Radial tunnel syndrome: a surgeon’s perspective. J. Hand Ther. 19 (2), 180e184. Tubbs, R.S., Salter, E.G., Wellons, J.C., Blount, J.P., Oakes, W.J., May 2006. Superficial surgical landmarks for identifying the posterior interosseous nerve. J. Neurosurg. 104 (5), 796e799.

Journal of Bodywork & Movement Therapies (2010) 14, 403e410

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PREVENTION & REHABILITATION: EDITORIAL

Chains, trains and contractile fields Matt Wallden, MSc Ost Med, DO, ND, Associate Editor In the film, Planes, Trains and Automobiles, the underlying theme is that two men are trying to get home in time for a major social celebration. The story is focused around the challenges these men face as the route from a to b became increasingly convoluted and indirect. In animal locomotion, this same theme of getting from a to b in the most efficient way is often a key aspect of organismal evolutionary fitness. However, there may be some cases in which a more convoluted, indirect route may be of survival benefit; for example, if you were to track a course of musculature around the body in a spiral fashion (Beach, 2007; Wallden, 2008; Myers, 2001), the longer your route from a to b, the more muscle fibres can be utilised, and therefore the more power can be generated. This is why when power generation occurs in sports, such as when hitting, throwing, kicking or punching, it typically involves a rotary twist of the body; to access this fast twitch spiral musculature coursing from the lower limb through and around the trunk, and back out via a different limb to its extremity. Of course, the more powerful a movement, the less efficient it generally is; this applies as much to the human body as it does to planes trains and automobiles. If a Ferrari competes with smart car, the Ferrari may win, but in the long run, the Smart car will go further on the same amount of fuel. Equally, there is little sense in a creature retaining fuel if it is to be some other creatures dinner as a result. Organismal biological design still seems to have the edge on synthetic counterparts; especially in terms of versatility. Going even further back, prior to human evolution, may provide even deeper insight; for this, it is necessary to look back into deep time.

Deep time Early life on Earth exhibited poor or limited motility; nevertheless, such motility was sufficient to satisfy survival

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within the presenting ecological niche that single-celled, photosynthesising organisms found themselves in. Early animal forms, such as sponges, anemones and jellyfish all showed very primitive circumferential movement patterns. These movement patterns have been described as the “radial chain” musculature (Beach, 1989, Personal Communication) or “radial contractile field” (Beach, 2008; Wallden, 2008). Later animal forms, such as flat worms and round worms also exhibit this circumferential movement pattern, but do so sequentially across body segments. It was not until the evolution of vertebrates in the form of fish that effective longitudinal contraction down the body wall could take place (Kardong, 2002; Wallden, 2008). Subsequent development merely elaborated on the established fish-based body plan (Erwin et al., 1997); this was the premise of Gracovetsky’s (1988) Spinal Engine theory, the concept that the spine is what drives the legs forward; the limbs simply amplifying spinal motion in steady-state gait.

Recent times Various thinkers from the exercise and rehabilitation fields have made attempts to understand these developments in the musculoskeletal function of organisms; among them early pioneers including Raymond A. Dart’s Double Helix Mechanism of the Spine, Phillip Beach’s Muscle Chains (1989), which evolved into a concept now called Contractile Fields (2007/2008), Andry Vleeming’s and Diane Lee’s Slings (Vleeming et al., 1997) and Thomas Myer’s Anatomy Trains (2001). In short, these people e and many others alongside e were all doing “joined-up-thinking” in the field of human locomotor anatomy. In the last issue of this Journal, the co-editor of this section of JBMT, Warrick McNeill PT, included a paper on the importance of the deep longitudinal sling in hamstring strain (Panayi, 2010). This sling, described by van Wingerden et al. (1996), Vleeming et al. (1997) and Gracovetsky

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404 (1997) is key in both stabilization of the lumbopelvic complex and, Gracovetsky argues, in utilising ground reaction force to de-rotate the spine in gait. Further research, such as Hungerford et al.’s (2003) paper suggest that this sling may also become facilitated as a result of sacroiliac joint (SIJ) pain; the deeper, intrinsic or “inner unit” musculature being somewhat inhibited or delayed in response in SIJ pain patients e when compared with controls e and the biceps femoris firing ahead of these muscles in a feed-forward mechanism. This may have a logical cross-over to the issues discussed in the paper in this section, by Hashemirad et al. (2010), on the flexor-relaxation phenomenon. They describe how a lumbar spine which has undergone creep due to prolonged flexion (for just 7 min or more) will create a statistically significant delayed flexor-relaxation phenomenon. For those unfamiliar with this response, the typical clinical response being observed is a switch from a “muscular” trunk strategy (erector spinae) to a “ligamentous” trunk strategy (transversus abdominis pulls on the thoracolumbar fascia and whole posterior ligamentous system of the spine tightens) at around 45 degrees of trunk flexion or around 90% of lumbar flexion. This reflex is stimulated by mechanoreceptors in the posterior ligamentous system of the spine inhibiting the lumbar erectors. An implication of Hashemirad et al.’s findings, is that the normal stretch does not activate the flexor-relaxation of the lumbar erectors at the usual time; this means that the hamstrings, the transversus abdominis (and it’s tensioning of the deep layer of the thoracolumbar fascia) which normally become dominant at this point in the movement, are delayed in their action. The upshot is decreased intra-abdominal pressure (due to delayed TrA contraction), decreased force closure at the sacroiliac joints (due to TrA not activating the nut-cracker phenomenon of force closure at the SIJ), decreased extensor moment action of the diamond-shaped middle layer of the thoracolumbar fascia, extended lumbar erector contraction in a position of increased flexion and therefore greater risk of posterior annular loading and potential injury. In short, from one simple act of flexing the lumbar spine for a little too long, the ability of the body to effectively transfer loads during lifting or squatting, via a posterior myofascial chain incorporating the hamstrings, sacrotuberous ligaments, thoracolumbar fascia, posterior ligamentous system, lumbar erectors and transversus abdominis, is compromised. This means that the SIJ’s and the discs become more vulnerable to injury; and the ramifications may be greater than that. The later that the hamstrings become dominant in this movement pattern, for example, the greater the leverage on their proximal insertion due to the angle of trunk inclination. Might this influence their risk for becoming strained? If the loading on the hamstring changes its realtime orientation based on the body’s long-established reflex mechanisms, could this have ramifications further down the deep longitudinal sling e as far as the arch of the foot and its role in absorption, storage and recoil of ground reaction forces? At this point the answers are unclear, but what is known is that a change in the spatiotemporal relationships of the

M. Wallden body; especially if this occurs under load or velocity, such as in a sporting event, creates significant computational stress onto the nervous system, to adapt to a situation that it isn’t reflexively equipped for. Perhaps a clinical realisation arising from this is that not only are ergonomics key, but also paying attention to other causes of creep on the ligamentous system, such as the hypnotic effect of computer and TV screens, the sedative effects of alcohol consumption or of chronic sleep deprivation; potentially switching the body off from its own mechanoreceptive feedback, may offer greater understanding in preventing low back injury.

Muscle, fascia and force transmission A second paper appearing in this edition’s Rehabilitation and Prevention section is titled “Muscle fascia and force transmission” by Peter Purslow, (2010a) PhD. This paper explains in great detail how the inner fascial components of the muscle; the endomysium, which surrounds the myofibril, and the perimysium, which surrounds the muscle fibre bundles, form a network to create fascial continuity between different contractile units; even if one unit is fatigued, damaged, being repaired or, indeed, is simply growing. A muscle can be imagined to behave a little like a bridge, connecting one piece of land (bone) to another piece of land (bone) while traversing some kind of ditch or gap (joint). In this way the bridge (muscle) would be built of hundreds of units e perhaps bricks e (sarcomeres) placed both end to end (in series) and alongside each other (in parallel). These bricks (sarcomeres) are designed to both withhold and to generate great forces. In the structure of the bridge, this is a relatively static role, but in the structure of the muscle, this is a far more complex dynamic interplay between resting tone, and various contractile states (concentric, eccentric, isometric and so on). If one or more bricks were to become damaged, or be knocked out of the structure of the bridge, its integrity and ability to both withstand and to generate force would be significantly impaired. However, in both muscles and in bridges this happens regularly, and reconstruction and maintenance is an ongoing feature of such a functional load-bearing structure. In order to be able to safely repair the bridge while it can still allow loads to be taken, some kind of extrinsic scaffolding needs to be in place; probably across the whole bridge (the epimysium), and it is likely that a more focused brace (perimysium) will need to be placed under the section of bridge that is to be repaired; while, specifically, the bricks (sarcomeres) in contact with the actual brick to be repaired (damaged sarcomere) may need a very specific, localised brace to hold them, while the stone mason is doing his work. This allows replacement of the damaged brick (sarcomere) and effective force transmission between the adjacent bricks (sarcomeres) so that the bridge (muscle) doesn’t lose much, if any functional capacity. This is critical to maintain motility of the system of which the muscle (bridge) is a part (Fig. 1). As Purslow goes on to discuss, there is more to these systems than just biomechanics. He illustrates, for example

405

Figure 1 Muscle, fascia and force transmission. The 3 key components of the fascia which envelops a muscle; the endomysium, perimysium and epimysium, can be seen a little like the struts that may support a brick bridge that is under repair. Since muscle tissue is constantly under conditions of growth, damage and repair, there must be mechanisms in place to allow continued function of the muscle when required. The endomysium and perimysium appear to allow for this, and for intra-muscular force transmission, while the epimysium may be more involved in intermuscular force transmission.

that additional crosslinks may form through advanced glycation end products (AGEs); typical of the changes in connective tissues in those with blood sugar dysregulation, from smoking and from aging. Connective tissue function is not just, then, about how the body is used biomechanically, but what it is exposed to biochemically. Purslow’s work is also relevant to the concept of slings discussed by Panayi (2010) in JBMT issue 14(1), by Myers (1997a, b) many times in this Journal and in his book Anatomy Trains, as well as by Beach (2007, 2008). These slings are, important in providing a whole-body appreciation of dysfunctional states, helping us to track back to where a problem may have arisen from and, indeed, as McNeill (2010) and Chaitow (2010) have discussed, to predict where a future problem may arise. What Purslow’s work seems to indicate is that contractile forces passing through the sarcomeres and direct into the myotendinous junction are route-1 for force generation, but that if a given line of sarcomeres has a damaged unit in series (or “brick” in the line), then this doesn’t stop every other sarcomere in that series from working; but simply allows contractile forces to be transmitted laterally across to a parallel series of sarcomeres (line of bricks) allowing continued function of the muscle,

without significant compromise to performance or to repair. Interestingly, Hunter (2005) presented prospective research on English Premiership soccer players which demonstrated that those players with greater measurable stiffness in their hamstrings at the beginning of the season were the least likely to suffer a hamstring strain during that season. Muscle stiffness is known to be generated by the series elastic components, which act like springs in between each sarcomere (Sarhmann, 2002). Therefore, the more sarcomeres (bricks) in parallel, the more series elastic components, the greater the stiffness, and the more possible pathways for force transmission e as well as for running repairs during play and across the season in general. As to whether these forces can pass out of the contracting muscle and into the surrounding fascia (epimysium), Purslow is uncertain, but explains that it would seem entirely feasible and that there is certainly evidence of a hydraulic amplifier mechanism occurring between agonist muscles within a compartment. Purslow (2010b, Personal Communication) states: “Whether epimysium in some muscles at least can also act in the same way to hydraulically stiffen the muscle so that

Text box 1. Evidence for hydraulic amplification between agonists in muscle compartments “.compartmentalisation increases the efficiency of muscle contraction. The contraction of one muscle within the group pressurises the compartment (from 15 mmHg in normal contractions up to approx. 80 mmHg in tetanic conditions), and even a small elevation in pressure raises the contractile efficiency of all members in the muscle group. Cutting the fascia releases 50% of this normal pressure generation and decreases contractile force for a given extension by 16% (Garfin et al., 1981). The interactions of the contractile proteins actin and myosin in muscle are known to be sensitive to high pressures, but very large pressures (10 MPa, or 100 atm) are required, and the effect of these are to reduce the active tension generated (Knight et al., 1993). Perhaps the more useful explanation of the effect observed at such low pressures is the lateral constraint effect proposed by Aspden (1990), which argues that the reduction in lateral expansion that pressurisation of neighbouring muscles may cause increases the effective muscle stiffness in active contraction, thus leading to increased force production for a given length of contraction.”

PREVENTION & REHABILITATIONdEDITOR: MATT WALLDEN

Chains, trains and contractile fields

406 it produces more force for a given length change is, as far as I know, not known, but in some muscles with heavy sheets of tendon-like epimysium it certainly looks a possibility.”

M. Wallden Adolescents from two schools in the Rift Valley Province were also compared: one group (4) who have never worn shoes; and another group (5) who have been habitually shod most of their lives.

PREVENTION & REHABILITATIONdEDITOR: MATT WALLDEN

Load transfer Research conducted by Vleeming et al. (1997) supports this notion of the capacity of the epimysium to transfer load across compartments into adjoining muscle groups. Research conducted both on the transfer of load between the gluteus maximus and the contralateral latissimus dorsi via the thoracolumbar fascia, and on the peroneus longus through to the tendon of biceps femoris, showed that a percentage (approximately 18%) of forces applied to the cadaveric myofascial system were, indeed, transferred across muscle groups. The most likely explanation for this (as had been hypothesized by authors such as Myers, Beach and others) is the direct fascial attachments; but specifically of the epimysium (as opposed to contributions from the endomysium or perimysium). The limitations of these studies are clear, inasmuch as the subjects were not living, had been prepared as cadavers (factors which will both significantly alter tissue properties) and were assessed on a dissection table (ie not in a functional load-bearing or sports-specific position), and using extrinsic application of force rather than intrinsic myogenic contractile forces. Nevertheless, such research allows the bodyworker and movement therapist the possibility of making associations between the apparent “functional anatomy” and what they see clinically.

Time to rewrite the biomechanics books? One such example is the biomechanics of gait. For the last 10 years or so, the running community has been in debate about whether running with a heel strike is functional or not. Many running coaches have suspected that the natural state is to strike the ground with the forefoot since a higher proportion of elite distance runners forefoot strike, than those in the lower echelons of the sport. Yet, despite this, heel striking runners still outnumber the forefoot strikers by some significant margin (Downey, 2009). This is why the research from Lieberman et al. (2010) published earlier this year met with so much interest from the world’s media and, in particular with the biomechanics and podiatry communities. What Lieberman et al. (2010) did, for the first time, was to assess groups of habitually unshod runners, versus habitually shod runners, from different cultures, comparing their running style both barefoot and in running shoes. Adults were sampled from three groups of individuals who run a minimum of 20 km per week: (1) habitually shod athletes from the USA; (2) athletes from the Rift Valley Province of Kenya (famed for endurance running), most of whom grew up barefoot but now wear cushioned shoes when running; and (3) US runners who grew up shod but now habitually run barefoot or in minimal footwear.

Subject

Condition

RFS

MFS

FFS

Habitually shod adults, USA

Barefoot Shod

83 100

17 0

0 0

Recently shod adults, Kenya

Barefoot Shod

9 29

0 18

91 54

Habitually barefoot adults, USA

Barefoot Shod

25 50

0 13

75 37

Barefoot adolescents, Kenya (never)

Barefoot Shod

12 e

22 e

66 e

Shod adolescents, Kenya

Barefoot Shod

62 97

19 3

19 0

RFS Z Rearfoot strike. MFS Z Midfoot strike. FFS Z Forefoot strike. What these results seem to clearly demonstrate is that, while humans are able to rearfoot, midfoot or forefoot strike, it would appear that the primary discriminating factor in this behaviour, is more to do with whether they are shod, rather than their genetic or biomechanical heritage (Figure 2). At this early stage in the research, it would seem that the working conclusion is that the natural state for running appears to be a forefoot strike, while adorning the foot with a running shoe seems to be the primary causative factor in rearfoot strike behaviour.

Clinical implications Assuming further ongoing research seems to support this notion, what may be the clinical implications for such an understanding? Firstly, of course, the biomechanics books may have to be re-written with respect to running gait. Interestingly, of course, most such texts have been written since people started wearing running shoes in 1970s and beyond; and therefore have used data from shod groups. Secondly, other findings, both within this research from Lieberman and from other groups suggest that barefoot running and shod running differ with respect to lower limb joint angles, muscle activation firing patterns, leg stiffness, joint torques, and so on (DeWit et al., 2000; Divert et al., 2005; Kerrigan et al., 2010). Weaker epidemiological studies suggest the possibility that these factors may reduce injury profiles (Warburton, 2001). While research from the strength and conditioning field suggests that increasing leg stiffness; something that happens naturally when running barefoot, is a key way to increase top flight running speed (Peak Performance, 2009).

Figure 2 Rearfoot Strike and Forefoot Strike (adapted from Lieberman et al., 2010). When running in supportive trainers, the majority of runners will strike the ground with their heel. This changes the gait cycle, the cadence, the biomechanics and the loading profile. When running barefoot, the majority of runners will strike the ground with their forefoot. Since cushioned shoes are a recent phenomenon, it is likely that the barefoot condition is more akin to the “natural condition” and to the way human biomechanics have evolved to function.

Back to the fusion If we are to place this research regarding the natural biomechanical state into the context of “joined-upanatomy”, or the fusion of musculature hitherto regarded as “separate” entities, it may be possible to identify a dual speed system: one for low-speed gait (walking) and one for supra-walking pace gait (running, to include jogging, and sprinting). The reason for this is that there is a potential problem with the deep longitudinal system, as described by van Wingerden (2006), Vleeming (1997), Panayi (2010), in the context of this new research on the forefoot strike; it can only really work if you heel strike. Though it wasn’t explicitly discussed by Panayi (2010), the lower portion of the deep longitudinal sling, namely the tibialis anterior and the peroneus longus, which form a connective tissue stirrup around the arch of the foot, to control pronation of the medial longitudinal arch, will work very well if the foot is dorsiflexed before heel strike, as it means that the leverage of the ground

407 reaction force against the heel, in tandem with the descending load of the bodyweight through the talocrural joint, will result in a very strong eccentric load through this lower portion of the sling (which is when a muscle is strongest); effectively controlling both plantar flexion of the ankle and pronation of the medial longitudinal arch. But, if the natural state of running is to plantarflex the foot and to forefoot strike, then this system suddenly becomes very inefficient; not serving to control pronation, nor to translate forces up the sling to provide force closure to the load-bearing sacroiliac joint. In forefoot strike, the deep longitudinal sling’s appears to be practically nullified. Since this forefoot strike appears to be the natural state; and this in tandem with the prevailing theory of human evolutionary nutrition, for the last 2 million years, it seems relied heavily on the persistence hunt where the prey is literally run to exhaustion (Lieberman et al., 2010; Liebenberg, 2006), it would seem that effective load transfer through the myofascial net would be key in allowing our ancestors to optimally exploit their ecological niche. So what is the answer? Perhaps there is another means of explaining the efficiency of natural state human running gait. The stability of a moving object increases as its velocity increases. Similar to a cyclist moving at a very slow speed, versus at high speeds, gait may also be recognized for the fact that there is greater transverse plane motion; translated into greater pronation stresses during walking, than there is during sprinting. Indeed, the efficacy with which the human body can create sagittal plane or forward momentum is key in its ability to get from a to b quickly and without energy “leakage” into the frontal or transverse planes. Hence it would be reasonable to assume that the laterally placed (and therefore counter-pronation) musculature of the deep longitudinal system (peroneus longus, tibialis anterior and biceps femoris into sacrotuberous ligament), may be more important at slower, walking velocities, but that it may become usurped in a higher velocity activities such as running, but another sling mechanism. Myers’ superficial back line or “train” has been described in earlier editions of JBMT (Myers, 1997a, b) and in his book “The Anatomy Trains”, Myers depicts this myofascial sling as running from the deep toe flexors (active eccentrically in forefoot strike) and plantar fascia and, direct through the connective tissues into the Achilles tendon and into the triceps surae. The ankle being plantarflexed before heel strike means that as the forefoot strikes the ground, the triceps surae will be eccentrically loaded (where they are at their strongest) and, interestingly, it is eccentric loading that is missing from the gait cycle if someone rearfoot strikes. Could there be a correlation between a lack of forefoot striking and Achilles tendinopathy, after all, since the work of Alfredson (1998), one of the primary methodologies for treating tendinopathic injury has been to prescribe an eccentric loading protocol. Following the anatomy up, the two heads of the gastrocnemius run medially to their super-incumbent hamstrings, the semimembranosus/tendinosus and the two heads of biceps femoris; sweeping around laterally to insert on the condyles of the femur.

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3 2 1 Myers Superficial Back Line. Myer’s description of the superficial back line runs from 1) the deep toe flexors into, 2) theplantar fascia to, 3) the junctional fascia between the plantar fascia and Achilles tendon. 4) is the triceps surae and 5) is where the two head of the gastrocnemius wrap around the tendons of 6) the medial and lateral hamstring groups. The hamstrings course up and are continuous and are continuousboth with each other and with 7) the sacrotuberous ligament, which spans from 8) the ischial tuberosity up to 9) the sacroiliac joint, where it blends with 10) the deep fibres of the multifidus and the erector group _ finally running all the way up to 11) epicraneus and 12) the frontalis muscle.

The functional relevance of this is that if there is a strong contraction of the triceps surae complex, as would be expected during landing with a forefoot strike, this will create a sudden sharp pull on the hamstring tendons; akin to a tendon-jerk reflex. This will stimulate a strong and bilateral contraction of both hamstring groups (in contrast to just the laterally placed biceps femoris of the deep longitudinal sling), which will transfer loads into the sacrotuberous ligament and across the load-bearing sacroiliac joint. It has been reported by Vleeming et al. (1997), as though it is only the tendon of the biceps femoris which blends with (and therefore transfers load into) the sacrotuberous ligament, yet to quote Gray’s Anatomy 37th edition (1989), the biceps femoris has two proximal attachments: a long head, attached to . the ischial tuberosity by a tendon common to it and the semitendonosis, which blends with the lower part of the sacrotuberous ligament. This edition of Gray’s goes on to say of the proximal semimembarnosus that its fibres are partly interwoven with the biceps femoris and semitendinosus, so it would seem quite logical to deduce that all three muscles may contribute something to the force closure described by

Vleeming et al. (1997) in their description of the deep longitudinal sling.

A possible parallel field of investigation In the field of podiatry, there is an emerging concept around a similar dual mechanism focused around the foot mechanics; termed biaxial propulsion- see Textbox 2 below (Curran, 2010a). In summary, the high and low gear axis really only works during the propulsive phase, so it may be that during a forefoot strike, the autosupport of the foot may gain high gear (a functionally pronated forefoot) and appropriate calcaneocuboid stability as a result. If this were correct, then with the toe-heel-toe loading of forefoot stike runners, it would seem to imply that the high gear mechanism may be engaged to provide stability “in both directions” both receiving load and expressing load. The same may be said of the windlass mechanism; that it may both store up energy on toe strike and recoil energy on toe-off. It

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During the late 1970s, the Danish anatomist Finn Bojsen-Møller described the interrelationship of the loading mechanism of the calcaneocuboid joint that is secondary to the timely tightening of the plantar fascia. Reliant on weight flow through to the first web space, the overall effect of this complex, yet essential mechanism produced stability of the rearfoot and midfoot via compression of the calcaneocuboid joint prior to heel lift. During his investigations, Bojsen-Møller also examined the metatarsal parabola (2 > 1 > 3 > 4 > 5 or 2 > 1 Z 3 > 4 > 5), which revealed an anterior protrusion of the 2nd metatarsal; a seemingly consistent feature associated with the normal foot. In effect, two different axes of propulsion at the MTP joints were observed to exist. One passing transversely through the heads of the first and second metatarsal (transverse or high gear axis) and the other passing obliquely through the second through to the fifth metatarsal heads as the (oblique or low gear axis). Further investigation of these propulsive axes revealed a number of functional advantages, and in particular the transverse axis. By evaluating the distance between each axis from a central point of the ankle joint, the distance to the perpendicular bisection of the transverse axis was documented as being greater (approximately 15e20%) when compared to the same distance to the perpendicular bisection of the oblique axis. Therefore, during high gear (transverse axis) propulsion in which weight flow is directed medially, the forefoot was observed to be functionally pronated (partly through the action of the peroneus longus). It is hypothesized that the position of the forefoot brings the dorsal border of the calcaneus and calcaneal process of the cuboid together. This in turn, provides an osseous block to further motion creating stability and is referred to as the “closed-packed position.” The greater distance from Bojsen-Møller’s central point of the ankle joint to the perpendicular bisection of the transverse axis was assumed to produce a taut attitude of the plantar fascia. This provides further compression of the cuboid on the calcaneus that results in the crucial stability required for propulsion. Conversely, during lateral weight flow (oblique axis or low gear propulsion), it was hypothesized that because of the inverted position of the foot, the calcaneocuboid joint failed to obtain the closed-packed position as previously described. This is thought to be coupled with an insufficient tightening of the plantar fascia due to the shortened distance associated with oblique axis propulsion. As a result, it can be assumed that the lateral aspect of the forefoot would absorb the majority of the forces. is worth noting that biaxial propulsion is just one of the many autosupport mechanisms of the foot, and is dependant on timely motions and activation of other mechanisms. For example, if someone had a limited first MTP joint then it is likely to disrupt weight flow and failure of appropriate support - and of course this will happen whether barefoot or shod if the biomechanical dysfunction is already present (Curran 2010b). Nevertheless, barefoot gait poses no restriction on MTP range of motion; so decreases likelihood of compromise to this mechanism. Perhaps some of these mechanisms go some way to explain why unshod gait is typically more biomechanically efficient.

Conclusion The body is majestically complex e even in its biomechanical make-up alone. If I were a mechanic working, as fascinating as it may be, with planes, trains and automobiles, I think I would look over my shoulder with some envy at the biomechanics who worked with chains, trains and contractile fields.

References Alfredson, H., Pietila ¨, T., Jonsson, P., Lorentzon, R, 1998. Heavy load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. The American Journal of Sports Medicine 26 (3), 360e366. Aspden, R.M., 1990. Constraining the lateral dimensions of uniaxially loaded materials increases the calculated strength and stiffness-application to muscle and bone. J. Mater. Sci. Mater. Med 1, 100e104. Beach, P., 1989. Development of muscle chains theory. Personal communication.

Beach, P., 2008. The contractile field e a new model of human movement e part 3. Journal of Bodywork and Movement Therapies 12, 158e165. Beach, P., 2007. The contractile field e a new model of human movement. Journal of Bodywork and Movement Therapies 11, 308e317. Chaitow, L., 2010. Clinical prediction rules. Journal of Bodywork and Movement Therapies 14 (3), 7e8. Curran, S., 2010a. Sagittal plane facilitation of motion theory and associated pathologies. In: Albert, S.F., Curran, S.A. (Eds.), Lower Extremity Biomechanics: Theory and Practice. Volume 1. BiPedMed Press, Denver, USA. Curran, S., 2010b. Biaxial propulsion and calcaneo-cuboid locking mechanism. Personal communication. Divert, C., et al., 2005. Stiffness adaptations in shod running. Journal of Applied Biomechanics 21 (4), 311e321. DeWit, B., et al., 2000. Biomechanical anlaysis of the stance phase during barefoot and shod running. Journal of Biomechanics 33 (3), 269e278. Downey, G., 2009. Lose your shoes. Is barefoot better? http:// neuroanthropology.net/2009/07/26/lose-your-shoes-isbarefoot-better/ (accessed 30.06.10). Erwin, D., Valentine, J., Jablonski, D., 1997. The origin of animal body plans. American Scientist 85, 126e137. Garfin, S.R., Tipton, C.M., Mubarak, S.J., Woo, S.L.Y., Hargens, A.R., Akeson, W.H., 1981. Role of fascia in maintenance of muscle tension and pressure. Journal of Applied Physiology 51, 317e320. Gracovetsky, S., 1988. The Spinal Engine. Springer, Vienna. Gracovetsky, S., 1997. Linking the spinal engine with the legs: a theory of human gait. In: Vleeming, A., Mooney, V., Dorman, T., Snijders, C., Stoeckart, R. (Eds.), Movement, Stability and Low Back Pain e The Essential Role of the Pelvis. Churchill Livingstone, New York, pp. 243e252. Hashemirad, F., Talebian, S., Olyaei, G., Hatef, B., 2010. Compensatory behaviour of the postural control system to

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410 flexion-relaxation phenomena. Journal of Bodywork and Movement Therapies 14 (2). Hungerford, B., Gilleard, W., Hodges, P., 2003. Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain. Spine 28 (14), 1593e1600. Hunter, G., 2005. Hamstring strain in professional football. Football Association Medical Society Non- League Conference, Lilleshall, UK, October 2005. Kardong, K., 2002. Vertebrates. McGraw-Hill, New York. Kerrigan, D., Casey, M.D., Jason, F., Geoffrey, S., Keenan, M., Dicharry, J., Della, U., CroceWilder, R., 2010. The effect of running shoes on lower extremity joint torques. PM&R 1 (12), 1058e1063. Knight, P.J., Fortune, N.S., Geeves, M.A., 1993. Effects of pressure on equatorial X-ray fiber diffraction from skeletal muscle fibers. Biophysical Journal 65, 814e822. Liebenberg, L., 2006. Persistence hunting by modern huntergatherers. Current Anthropology 47 (6), 1017e1025. 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, 531ee536. McNeill, W., 2010. Journal of Bodywork and Movement Therapies 13 (3), 272e275.

M. Wallden Myers, T., 1997a. The ‘anatomy trains’. Journal of Bodywork and Movement Therapies 1 (2), 91e101. Myers, T., 1997b. The ‘anatomy trains’: part 2. Journal of Bodywork and Movement Therapies 1 (3), 135e145. Myers, T., 2001. The Anatomy Trains. Churchill Livingstone. Panayi, S., 2010. The need for lumbar-pelvic assessment in resolution of chronic hamstring strain. Journal of Bodywork and Movement Therapies 14 (1), 294e298. Peak Performance, 2009. Training for Sprinting, Speed & Acceleration. Purslow, P., 2010a. Muscle, fascia and force transmission. Journal of Bodywork and Movement Therapies 14 (2). Purslow, P., 2010b. Personal communication. Sarhmann, S., 2002. Diagnosis and Treatment of Movement Impairment Syndromes. Mosby. Vleeming, A., Snijders, C., Stoeckart, R., Mens, J., 1997. The role of the sacroiliac joins in coupling between spine, pelvis, legs and arms. In: Vleeming et al. (Eds.), Movemen, Stability & Low Back Pain. Churchill Livingstone, 53–71. Wallden, M., 2008. Rehabilitation and Movement Re-education Approaches. Naturopathic Physical Medicine. Elsevier. Warburton, M., 2001. Barefoot running. Sportscience 5 (3). sportsci.org. van Wingerden, J.P., Vleeming, A., Stoeckart, R., Raissadad, K., Snijders, C.J., 1996. Force transfer between biceps femoris and peroneus muscle; a proposal for a longitudinal spring mechanism in the leg.

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FASCIA PHYSIOLOGY

Muscle fascia and force transmission Peter P. Purslow, PhD Department of Food Science, University of Guelph, Guelph, Ontario N1G 2W1, Canada Received 13 October 2009; received in revised form 3 January 2010; accepted 7 January 2010

KEYWORDS Muscle; Connective tissue; Extracellular matrix; Mechanical function; Myofascial force transmission; Endomysium; Perimysium; MMPs; ECM turnover

Summary This paper reviews the major intramuscular extracellular matrix (IM-ECM) structures (endomysium, perimysium and epimysium) and their possible mechanical contributions to muscle functions. The endomysium appears to provide an efficient mechanism for transmission of contractile forces from adjacent muscle fibres within fascicles. This coordinates forces and deformations within the fascicle, protects damaged areas of fibres against over-extension, and provides a mechanism whereby myofibrils can be interrupted to add new sarcomeres during muscle growth without loss of contractile functionality of the whole column. Good experimental evidence shows that perimysium and epimysium are capable in some circumstances to act as pathways for myofascial force transmission. However, an alternative role for perimysium is reviewed, which involves the definition of slip planes between muscle fascicles which can slide past each other to allow large shear displacements due to shape changes in the whole muscle during contraction. As IM-ECM is continually remodelled so as to be mechanically adapted for its roles in developing and growing muscles, control of the processes governing IM-ECM turnover and repair may be an important avenue to explore in the reduction of fibrosis following muscle injury. ª 2010 Elsevier Ltd. All rights reserved.

Introduction The soft connective tissues associated with muscle tissue have been referred to as the intramuscular extracellular matrix (IM-ECM), intramuscular connective tissue (IMCT) and muscle fasciae (MF). Although these general names can be used interchangeably, the term IM-ECM will be used here. Substantial reviews of the structure, development, composition and function of IM-ECM exist (Purslow and Duance, 1990; Purslow 2002, 2008). The mechanisms and

pathways by which IM-ECM is remodelled and adapted due to changing functional demands during muscle growth and repair, and in response to exercise training or disuse, are addressed by Kjær and Magnusson (2008). Like most other soft connective tissue structures, the amount and composition of IM-ECM structures are not simply programmed during embryogenesis and subsequent post-natal maturation processes. The amounts and composition of the various IM-ECM structures in living tissue represent a dynamic balance between deposition, growth, remodelling and degradation, which is affected by the interplay between

E-mail address: [email protected] 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.01.005

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functional demands on the tissue and the mechanical environment. The cellular mechanisms of mechanotransduction in fibroblasts are reviewed by Chiquet et al. (2009). The purpose of the current review is to highlight information pointing to the crucial roles of IM-ECM in force transmission and accommodation of shape changes in functioning muscle.

General structure and biochemical composition of IM-ECM As schematically shown in Fig. 1, each muscle is surrounded by epimysium, a connective tissue layer that is continuous with the tendons that attach the muscles to the bones. In some long strap-like muscles the epimysium is composed of two parallel sets of wavy collagen fibres in a crossed-ply arrangement, embedded in a proteoglycan matrix (see Fig. 2). When the muscle is at its resting length, the two sets of collagen fibres are arranged at angles of approximately 55 to the long axis of the muscle fibres. In other muscles, and especially in pennate muscles, the arrangement of collagen fibres in the epimysium is parallel to the long axis of the muscle and forms a dense surface layer that functions as a surface tendon. The perimysium is a continuous network of connective tissue which divides the muscle up into fascicles or muscle fibre bundles. Fascicles run along the length of the muscle from tendon to tendon, and the ends of muscle fibres form highly folded interdigitating joints (the myotendinous junction) with the tendon at this point (Trotter, 1993). The perimysial network merges into the epimysium at the surface of the muscle and is mechanically connected to it. Within each fascicle or muscle fibre bundle, the endomysium is a continuous network of connective tissue that separates individual muscle fibres. Each of the epimysium, perimysium, and endomysium layers has its own structure and composition, but generally these connective tissue layers are composed of collagen fibres in an amorphous matrix of hydrated proteoglycans (PGs) which plays a crucial role in mechanically linking

Fig. 1 Schematic diagram of IM-ECM structures in a skeletal muscle. Epimysium delineates the surface of the muscle, perimysium separates muscle fascicles and endomysium separates individual muscle fibres. Also depicted are the contractile myofibrils within each muscle fibre. (Artwork: Dr. L.-T. Lim).

Fig. 2 Light micrograph of epimysium from bovine sternomandibularis muscle, showing arrangement of collagen fibres in crossed-plies. The fibres are in two parallel layers lying at þ55 and 55 to the muscle fibre axis. From Purslow (1999), with permission. In epimysium from other muscles the collagen is more aligned with the muscle fibre direction and acts as an exo-tendon or aponeurosis.

together the collagen fibre networks in these structures (Scott, 1990). Listrat et al. (1999, 2000) show that collagen types I, III, IV, V, VI, XII and XIV are all expressed in muscle development. Collagen typically represents 1e10% of the dry weight of adult skeletal muscle (Bendall, 1967). Fibres of elastin can be found in the IM-ECM of some muscles, principally in the perimysium. However, the amount of elastin is small in most muscles and is typically less than 1% of muscle dry weight (Bendall, 1967). Collagen fibres are stabilised by the formation of covalent crosslinks directed by a clear set of post-translational modifications which act on the collagen molecules extracellularly after assembly of the collagen molecules into the quarter-stagger overlapped arrangement characteristic of fibrils (Bruns and Gross, 1973). The formation of crosslinks is essential for the mechanical strength and stiffness of collagen fibres (Bailey et al., 1998). During gestation and post-natal maturation there are changes in the types and amounts of covalent crosslinks that stabilise the collagen molecules within all connective tissues in the body, including IM-ECM. There are also non-enzymatic reactions of collagen with glucose and other aldehydes. Formation of additional crosslinks through advanced glycation end products (AGEs) is typical of the changes in connective tissues in diabetes and during ageing and glycation, and is thought to be a significant contributor to changes in the mechanical properties of connective tissues with age (Paul and Bailey, 1996). Advanced glycation end products can be incorporated into the body from dietary sources (e.g. heat processing of some foods creates AGEs) and from tobacco smoke (Avery and Bailey, 2008). In this way, diet and lifestyle may affect the mechanical properties of IM-ECM via AGE-cross-linking of collagens.

IM-ECM changes during muscle development During embryonic development of intramuscular connective tissue, the amounts of the various collagens and PGs

changes (Velleman et al., 1999; Listrat et al., 1999; Lawson and Purslow, 2001). Spatial variations between the endomysium and perimysium within one muscle (Nishimura et al., 1997) and differences in expression of both collagen type I and PG components such as laminin between muscles (Lawson and Purslow, 2001) are both determined early in prenatal development. In bovine muscles, type I collagen expression is always higher than type III expression at all stages of gestation and post-natally (Listrat et al., 1999). Thus some differences in the composition of intramuscular connective tissue appear to be pre-programmed in embryogenesis. However, there are some variations in the amounts of collagens as muscle development progresses. In bovine psoas and triceps muscles the total collagen concentration and amounts of collagen type I is maximum at the point in gestation when the expression of myosin within muscle fibres changes from the embryonic to the adult form (Listrat et al., 1999). After this, the growing diameter of the muscle fibres dilutes out the connective tissue content of the muscle. In contrast, the pectoralis and quadriceps muscles of the chick show steady increases in collagen type I content and laminin content through gestation and post-natally (Lawson and Purslow, 2001). Whether these differences between bovine and chick muscle growth are due to avian versus mammalian phyla differences or due to functional differences in the muscles studied remains unclear.

The amounts and composition of endomysium and perimysium vary between functionally different muscles In fully developed adult animals, there are large differences in the amounts and composition of IM-ECM between different muscles in the body. Histological comparison (see Fig. 4 in Purslow, 2005) illustrates that the continuous perimysial network surrounds or separates fascicles of radically different sizes and shapes in different muscles from the same animal. This difference also results in different thicknesses of perimysial connective tissue. A comparison of the connective tissue content of 14 bovine muscles shows that the endomysial collagen content is between 0.47% and 1.2% of dry weight, but the perimysial collagen content in the same muscles ranges from 0.43% up to 4.6% of dry weight (Purslow, 1999). The amount of perimysium in muscles varies far more than the amount of endomysium. These variations, especially in the amount and spatial organisation of the perimysium have long been taken to show that IM-ECM must play strong roles in the normal physiological functioning of each muscle. As reviewed in the following two sections, some possible explanations of these roles are emerging but are far from complete.

Structure and functional roles of the endomysium As reviewed by Purslow and Duance (1990), each muscle cell is surrounded by its own plasmalemma and basement membrane. Filling the intervening region between the basement membranes of two adjacent muscle cells is the much more substantial reticular layer, which is comprised

413 of a network of collagen fibrils and fibres in a proteoglycan matrix. The thickness of the endomysium as a whole varies with muscle length, becoming thicker at short muscle lengths and thinner as the muscle is extended (see Trotter and Purslow, 1992). Transmission electron micrography of intact endomysium in situ confirms that all of the collagen fibres in the network layer lie in the plane of the layer (Trotter and Purslow, 1992). The only location where this does not hold true is in the junction zones between the perimysium and the endomysium of muscle cells that lie in the surface of the fascicle. Swatland (1975) concluded that the reticular layer was a single structure shared between adjacent muscle cells, and that this endomysial structure forms a continuous network that runs across the whole muscle fascicle. This interpretation is very strongly borne out by scanning electron microscopy of endomysial collagen networks prepared by NaOH-extraction of muscle to remove all cell components, PGs, plasmalemma, and basement membrane structures (Trotter and Purslow, 1992; Purslow and Trotter, 1994; Nishimura et al., 1994, 1995; Liu et al., 1995). This preparation technique was first demonstrated on connective tissues generally by Ohtani et al. (1988). Fig. 3 (from Purslow and Trotter, 1994) shows such a preparation. The structure of the endomysium appears broadly identical in all SEM preparations from skeletal muscle from different muscles and species, and also in cardiac muscle (Purslow, 2008). The planar network of collagen fibres in the thick reticular region of the endomysium is often described as a random or quasi-random network of irregularly wavy fibres. These collagen fibres run at almost every angle to the muscle fibre long axis, but the network is not truly random. Detailed image analysis of the distribution of fibre directions with respect to the long axis of adjacent muscle cells reveals that there is a preferred direction in the wide distribution of collagen fibre orientations, and that this preferred orientation changes with muscle length (Purslow and Trotter, 1994). At short muscle lengths, more of the collagen fibres in the endomysial network are aligned circumferentially, and at long muscle lengths there is a higher preference for fibres to be aligned longitudinally. The reorientation of collagen fibres in this network at short and long muscle lengths also involves some stretching out of the wavy fibres, but at all sarcomere lengths a very large proportion of the collagen fibres are still wavy. The mechanical consequence of this is that the planar network will be very compliant in tension at all physiologically relevant muscle lengths, and can easily deform to follow changing muscle lengths in vivo. Although this behaviour potentially provides overload protection at high deformations, such protection will only occur at muscle lengths well above those experienced in normal function. These implications are confirmed by detailed modelling of the in-plane tensile properties of the endomysium (Purslow and Trotter, 1994). Their models of the tensile properties of the endomysial network are in agreement with experimental forcelength measurements by Podolsky (1964) and Magid and Law (1985) who compared the tensile properties of relaxed single muscle fibres with and without endomysium. The difference that the removal of the endomysium makes to

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Fig. 3 Scanning electron micrographs of the collagen fibre scaffolding in IM-ECM structures in bovine sternomandibularis muscle as revealed by NaOH-digestion of myofibrils, cytoskeletal proteins, cell membranes, and proteoglycans. Upper panel; low-magnification view, showing thicker perimysial sheets surrounding fascicles. Lower panel; high-magnification oblique view, showing endomysial networks. From Purslow and Trotter (1994) with permission.

the passive elasticity of single fibres is very small at physiologically relevant sarcomere lengths, showing that the endomysium is extremely compliant in tension along the muscle fibre direction over normal working muscle lengths in vivo. Many muscles in species from many phyla contain muscle fibres that do not run along the entire length of fascicles, but terminate before reaching the myotendinous junction (Gans and Gaunt, 1991; Trotter, 1993; Trotter et al., 1995). Muscle fibres in series-fibred muscles are relatively short compared to the length of the fascicle except in humans, which appear to have relatively longer fibres in their seriesfibred muscles. Although some intrafascicularly terminating muscle fibres do seem to have attachments to connective tissue

P.P. Purslow bands internal to the muscle and occasionally have myomuscular junctions where two muscle fibres have interdigitating folded joints between them, the most common termination is a gentle tapering down to an end. These tapering fibres have no terminating structure that would link them directly to another muscle fibre or to the tendon (Trotter, 1993). The fibres are staggered by about one quarter of their length with respect to the adjacent muscle fibres, so that the tapering end of one fibre terminates with the endomysial network surrounding it forming a seamless connection to the endomysium of its neighbours (Purslow and Trotter, 1994). The endomysium is the only structure that links muscle fibres together within fascicles. In seriesfibred muscles, transmission of tension generated in intrafascicularly terminating fibres to the ends of the fascicles absolutely necessitates transmission of force through the endomysial network, as this is the only structure continuously linking the fibres (Trotter et al., 1995). Trotter and Purslow (1992) show that the endomysium is compliant in tension, so that force transmission is unlikely by this means, but they also suggest that force transmission is by shear through its thickness. The key idea is that the endomysium, while very compliant to tensile forces acting within the plane of the network, is much more efficient in providing a non-compliant linkage by shear through its thickness. A formal derivation from fibre composites theory shows that, for practical purposes, the stiffness of the endomysium in shear through its thickness varies only slightly with the orientation of the collagen fibrils in the plane of the endomysium (Purslow, 2002). Any linkage that transmits forces from intrafascicularly terminating muscle fibres to tendinous attachments must be non-compliant (i.e. high stiffness) in order to be efficient. Especially in isometric muscle contractions, any significant stretching in the length of the fascicle due to stretchy connections would result in a very poor transmission of contractile force. The serieselastic nature of this shear linkage can be represented as an apparent longitudinal stiffness Eapp (Purslow, 2002) given by  . 2 Eapp ZG L T

ð1Þ

where G is the translaminar shear modulus of the endomysium, T is its thickness and L the muscle fibre length. Even if we take a fibre as short as 1 cm in length, L/T is in the order of 2000, so that Eapp is going to be in the order of 4  106 greater than the true translaminar shear modulus of the endomysium. In a ‘‘composite’’ consisting of two parallel muscle cells with the endomysium sandwiched between them, the apparent longitudinal stiffness of endomysium as it deforms in shear will still be orders of magnitude higher than the tensile stiffness of the muscle fibres themselves. Due to this high value of Eapp the longitudinal stiffness of the entire assembly is going to be dominated by stretching in the muscle fibres themselves rather than in the linking endomysium. This shear linkage through the thickness of the endomysium provides a force transduction pathway from one muscle cell to its neighbours which is highly efficient. However, the endomysium can deform easily in the plane of the network, due to its low tensile stiffness, and so does not restrict changes in muscle fibre length and diameter as muscles contract and relax.

Lateral load sharing through the endomysium is an important concept that also explains how it is possible for muscles to grow and to repair damaged sarcomeres. Lateral load sharing and coordination of deformations means that a fibre can be interrupted for the addition of new sarcomeres necessary for muscle lengthening during growth, without loss of function of an entire contractile column. By the same mechanism, the contractile capacity of the weakness of a sarcomere in which damaged myofibrils are being broken down and remodelled during muscle repair does not lead to tearing of the fibre at this point, as the endomysial connections between adjacent fibres serve to keep the strains uniform throughout the tissue. In submaximal contractions not all the motor units in the muscle are recruited, so that many non-contracting fibres are usually adjacent to contracting fibres. Coordination by shear linkages through the endomysium explains how sarcomere lengths in non-contacting fibres keep in register with those in adjacent, contracting fibres. This maintains uniform sarcomere lengths in the muscle. The continuous meshwork of endomysium that connects adjacent muscle fibres together, therefore, forms a connecting matrix that coordinates force transmission between fibres in a fascicle and keeps fibres in uniform register (Purslow, 2008).

Functional anatomy of the perimysium Two sizes of fascicles and, therefore, two levels of perimysial structure can be distinguished in cross-sections of muscle. Small (primary) fascicles or muscle fibre bundles are delineated by primary perimysium. Groups of primary fascicles are then organised into larger, secondary fascicles by secondary perimysium, which tends to be thicker than primary perimysium. In porcine semitendinosus muscle, the thicker secondary perimysium is in the order of 10 mm thick at birth and increases to approach 50 mm in 55 month old pigs (Fang et al., 1999). The thickness of primary perimysium in cattle muscles ranges from 54.6 m to 133 mm (Brooks and Savell, 2004). Both of these perimysial layers form a fenestrated network that extends across the entire cross-section of the whole muscle. The perimysium does not form a distinct sheath that surrounds one fascicle, but rather is a shared structure lying between two fascicles (Purslow and Trotter, 1994). Nodes form at the junction between perimysial sheets and the fascicles occupy polygonal ‘‘holes’’ in this network, in a manner similar to muscle fibres occupying polygonal ‘‘holes’’ in the endomysial network (but at a larger scale). At the surface of the muscle the perimysium merges and seamlessly joins with the epimysium (Nishimura et al., 1994). The perimysial layer separating two fascicles is primarily comprised of crossed-plies of wavy collagen fibres in a proteoglycan matrix. In a few muscles (e.g. bovine semitendinosus) there are substantial amounts of elastin fibres associated with the collagenous network (Rowe, 1981). The collagen fibre bundles are far larger in diameter than the fine fibres and fibrils in the endomysium and have a regular sinusoidal waviness, with all collagen fibre bundles lying parallel to each other in each ply, and having the same wave periodicity. In porcine semitendinosus muscle the degree of waviness has been observed to increase with animal age

415 (Fang et al., 1999). The collagen fibres lie in the plane of the perimysium, do not run through its thickness, and all the collagen fibres in each ‘‘ply’’ are parallel to each other and lie at 55 to the muscle fibre axis at the resting length of the muscle. This angle changes with muscle length, varying from around 80 at an extremely short sarcomere length of 1.1 mm to approximately 20 at a long sarcomere length of 3.9 mm (Purslow, 1989). Mathematical modelling of the tensile properties in the plane of this network using fibrous composites theory (Purslow, 1989), and direct measurements of the tensile strength and stiffness of perimysial sheets dissected from muscle (Lewis and Purslow, 1989; Purslow, 1999), show that the perimysium is easily deformed in tension until the collagen fibres have become aligned along the stretching direction and the waviness in the fibres pulled out straight. This shows that the perimysium can build up a high tensile stiffness and carry large loads in tension, but only at very large extensions well beyond the range of working lengths in living muscle. The tensile properties of the perimysium are, therefore, similar is nature to the endomysium. Both are initially easily deformed networks that can follow length and diameter changes imposed by the muscle fibres and fascicles contracting and being lengthened by the action of antagonistic muscles. It is tempting to extend the analogy between endomysium and perimysium by proposing that the perimysium could also act to transmit the forces generated in fascicles to their adjacent neighbours by translaminar shear. Although it can be shown that force transmission by such a mechanism can be invoked in circumstances of extreme muscle damage or by cutting the tendinous attachments to some fascicles (Huijing, 2009), there are two considerations that we can raise that diminish the likelihood of this mechanism being involved in living muscle, at least under normal working conditions. Firstly, considering again that the series-elastic nature of a shear linkage can be represented as an apparent longitudinal stiffness Eapp and that Eapp given by Eq. (1) above then even if the perimysium can be up to 50 times thicker than endomysium, the (L/T )2 term in this equation could be up to 2500 times smaller for the same length of perimysium than for the endomysium. If the translaminar shear modulus of the perimysium and endomysium would even be within an order of magnitude of each other, this means that thicker perimysium would have a far smaller Eapp, i.e., it would be far more compliant in shear than the endomysium. This would represent a rather sloppy and inefficient force transmission pathway. The second consideration revolves around the observation that the amounts and structure of endomysium are relatively constant and only slightly vary between different muscles, whereas the amounts of perimysium, its thickness, and the size and shape of primary and secondary muscle fascicles vary tremendously. The endomysial structures providing tight shear linkages between adjacent muscle fibres are reasonably conservative and do not vary so much from muscle to muscle. So, if the perimysial network functions similarly, why should its amounts and spatial arrangement vary so much more? Schmalbruch (1985) cites a model originally proposed by Feneis which proposes that the perimysium provides ‘neutral’ connections between adjacent fascicles. These

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Muscle fascia and force transmission

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416 connections permit fascicles to slide past each other, and also facilitate shape changes in the muscle during contraction. All fan-shaped, fusiform, and especially pennate muscles change shape when contracting, and in order to accommodate this there must be slippage, or sliding, of some elements within the muscle (i.e. shear deformations). For pennate muscles it is easy to formally calculate the shear strains within the muscles as they contract and the pennation angles change. In ultrasonic images of human muscles, ‘‘boundaries’’ between fascicles can be seen, and measurement of changes in the angle of these during contraction allows shear strains to be predicted. Shear strains within working human muscles are substantial and vary considerably between human muscles such as quadriceps, vastus lateralis and gastrocnemius (Purslow, 2002). If the endomysium maintains adjacent muscle fibres in tight shear register, then where can these large and variable shear strains be accommodated? Simple observations on rigor muscle that is manipulated to produce internal shear show that deformations preferentially occur at the boundaries between fascicles, and that very little shear displacements occur within a fascicle (Purslow, 1999). If the theory that the division of muscle into fascicles is to facilitate shear deformations that are necessary for contracting muscle to change shape is correct, then it seems to offer an explanation of why the amount and distribution of perimysium changes so very markedly from muscle to muscle. Thin perimysia surrounding small fascicles in long strap-like muscles may be associated with relatively small shear displacements, whereas thicker perimysial sheets and larger primary fascicles may relate to larger shear displacements. However, comprehensive data on the relationship between perimysial thickness, fascicle size, and the actual distributions of shear strains in working muscles need to be collected to test this theory.

Control of turnover of IM-ECM as a possible treatment in muscle injury and repair of fibrosis Muscle growth, turnover, and repair necessitate remodelling of IM-ECM, principally under the control of matrix metalloproteinases (MMPs) and tissue inhibitors of MMPs (TIMPs). MMPs are expressed by muscle cells as well as by fibroblasts in the IM-ECM (Balcerzak et al., 2001). Adaptation of muscle, including muscle hypertrophy following exercise training is known to involve increased expression of a range of MMPs (Kjaer, 2004). Expression of MMPs is stimulated by mechanical forces, hormones, and growth factors as well as nutritional components. Myoblasts express almost as much MMP and total collagenase activity as fibroblasts in cell culture and tend to increase this expression more strongly than fibroblasts when mechanically stimulated by biaxial stretching (Cha and Purslow, unpublished data). Numerically, muscle cells vastly outnumber fibroblasts within normal muscle tissue. Epinephrine (adrenaline) is a general agonist of all types of adrenergic receptors, and in muscle principally acts to increase glycolysis via a signalling pathway involving AMP-activated protein kinase (Shen and Du, 2005). There is also adrenergic control of protein metabolism in skeletal muscle. Epinephrine acts to increase calpastatin levels, so reducing protein turnover by calpains and resulting in net muscle accretion (Navegantes

P.P. Purslow et al., 2009). Beta-adrenergic agonists (e.g. clenbuterol, ractopamine, cimaterol, salbutamol) mimic this effect and chronic administration of these growth promoters leads to muscle hypertrophy or amelioration of muscle wasting (Navegantes et al., 2002). Although some reports associate the effect of catecholamines on protein metabolism with c-AMP dependent kinase, Yamaguchi et al. (1997) showed that the p38 MAPK pathway can be activated by beta-adrenergic receptors in kidney cells. Expression of MMPs 1 and 13 is activated by the p38 MAPK pathway in keratinocytes (Johansson et al., 2000). Recent work in our laboratory (Cha and Purslow, unpublished data) shows that both skeletal muscle fibroblasts and myoblasts increase MMP expression in the presence of epinephrine, but with different time-courses and degrees of correlation with expression of AMP-activated protein kinase. Cardiac muscle is obviously different from striated muscle functionally and structurally, yet there are striking similarities about the organisation and function of ECM structures between the two muscle types (Purslow, 2008). A change in the balance between synthesis and degradation of ECM in the myocardium is a characteristic of many types of heart failure, including hypertensive heart failure and infarction/ ischemia (Berk et al., 2007; Graham et al., 2008). Banfi et al. (2005) reported increased plasma levels of MMPs 2&9 in patients with chronic heart failure and also a significant correlation between norepinephrine and MMP2 levels. Cardiac fibroblasts are known to react to both mechanical stimuli and catecholamines in terms of both proliferation and expression (Villareal and Kim, 1997), and cardiomyocytes from chick embryos are known to react to stimulation of the alpha-adrenergic receptor via noradrenaline by activation of p38 MAPK (Tsang and Rabkin, 2009). Ongoing studies to provide fundamental information about the control of expression of IM-ECM forming cells may have far-reaching impact on muscle ageing, injury, and repair.

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PREVENTION & REHABILITATIONdFASCIA PHYSIOLOGY

Muscle fascia and force transmission

Journal of Bodywork & Movement Therapies (2010) 14, 418e423

available at www.sciencedirect.com

PREVENTION & REHABILITATIONdSPINAL PHYSIOLOGY

journal homepage: www.elsevier.com/jbmt

SPINAL PHYSIOLOGY

Compensatory behavior of the postural control system to flexionerelaxation phenomena Fahime Hashemirad a,b,c,*, Saeed Talebian a, Gholam R. Olyaei a, Boshra Hatef c a Physical Therapy Department, Rehabilitation Faculty, Tehran University of Medical Sciences and Health Services, Tehran, Iran b Akhavan Spine Physical Therapy Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran c Sports Medicine Research Center, Tehran University, Tehran, Iran

Received 4 September 2009; received in revised form 16 February 2010; accepted 15 April 2010

KEYWORDS Creep; Erector spinae muscles; Flexionerelaxation; Lumbar spine

Summary Laxity of the passive tissues of the spine during prolonged spinal flexion has been shown to disturb spinal stability. This study investigated the effects of short periods of static lumbar flexion and short rest periods on the flexionerelaxation angle for the erector spinae muscles in 36 healthy female college students. The surface electromyographic activity of the erector spinae muscles was measured in three states before the onset of creep, immediately after 7 min of static lumbar flexion, and after a 10 min rest. The results showed that 7 min of static lumbar flexion will produce relaxation of the erector spinae muscles that occurs at greater absolute lumbar and trunk angles, during the forward bending activity (P < 0.05), while the corresponding relative angles did not change before and after creep. The results also indicate that postural compensations are dominant over the muscular compensations for load sharing in flexionerelaxation phenomena of asymptomatic healthy participants. This further highlights the importance of postural modulation in the control of movement and preservation of skeletal stability. Clinical relevance: Considering spinal posture in the upright condition, and its changes by phenomena such as creep, can reduce postural injuries by instructing subjects to approach a more vertical posture, after periods of bending, to compensate the stretching effects of the tissues and thus regaining the normal muscular activity pattern. ª 2010 Elsevier Ltd. All rights reserved.

* Corresponding author. Akhavan Spine Physical Therapy Center, University of Social Welfare and Rehabilitation Sciences, Shahid Jaafar Asadi Manesh Alley, After Monirie Square, Valie Asr Avenue, Tehran, Iran. Tel.: þ98 21 66467000. E-mail address: [email protected] (F. Hashemirad). 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.04.008

Introduction Creep deformation in the various passive tissues of the spine including ligaments, intervertebral discs, and joint capsule is thought to increase the laxity of the intervertebral joints, allowing increased relative motion, which destabilizes their natural alignment, with the potential for consequent injury and associated pain (Jackson et al., 2001; Solomonow et al., 1999; Wiliams et al., 2000). High incidence of low back pain (LBP) disorders is associated with occupations requiring sustained and repetitive lumbar flexion (Little and Khalsa, 2005). As the trunk is flexed from a standing position toward full lumbar flexion, lumbar extensor muscles exhibit myoelectric silence and this phenomenon is called flexionerelaxation (FRP) (Floyd and Silver, 1955; Kippers and Parker, 1984; Olson et al., 2004). In the fully flexed posture, the body weight is supported mainly by a passively generated extension moment from spinal ligaments, intervertebral discs and the passive components of the extensor muscle-tendon units (McGill and Kippers, 1994). If the flexed posture is maintained, the passive tissues will deform at a slow rate due to their viscoelastic material properties, and this creep deformation of the spinal tissues provides more laxity in the passive tissues and reduced resistance to forward flexion moment (Shin and Mirka, 2007). The change in the passive tissue stiffness is expected to affect the activation level of back extensor muscles because flexion moment generated by upper body weight is supported by cocontribution of both active and passive components. The creep response and recovery behavior of erector spinae is an interesting model to study the modulation of lumbar stability. Solomonow et al. (2003a) showed creep, developed during a short static lumbar flexion, elicited significant changes in the muscular activity pattern of the flexionerelaxation phenomenon. The effects of creep on the upright posture and considering this in EMG activity of erector spinae have not yet been fully identified. Understanding how the trunk and lumbar angles are affected by the creep phenomenon and how the erector spinae muscles activation pattern is influenced by these changes, can be helpful in the assessment of the creep phenomenon and choosing a preventive strategy for low back pain. The aims of this study were to investigate how a short static posture of 7 min affects the absolute and relative angles of flexionerelaxation response and how a short rest period of 10 min would moderate those effects. Since considering the starting posture while measuring range of motion is of great importance (Vachalathiti et al., 1995), it was presumed that using the two measures of “absolute” and “relative” angles would lead to different results, therefore in this study, we have chosen the latter to get a better estimate of the effect of creep phenomenon on spinal motion characteristics, while keeping the absolute value for comparative purposes.

Methods Subjects Thirty-six healthy female students without a history of back pain during the last 2 years were recruited from Tehran

419 university of Medical Science and Health Services to participate. All participants were free from chronic and current back problems and after being introduced to the nature of the study, signed consent forms that they were willing to take part. Previous studies have shown the creeprelated changes to be different in males and females (Solomonow et al., 2003a). Thus to neutralize the effect of gender and its consequent confounding factors, and also since they were more accessible, only females were studied. The mean (standard deviation) age, height and weight of the thirty-six participants were 22.3(3.4) years, 1.6(0.1) m and 56.7(6.3) kg, respectively.

Instrumentation Surface EMG data were collected using a 4-channel electromyography device (Medelec, Promiere model). The EMG signals were detected by pregelled AgeAgCl electrode pairs applied at the L3-4 level over the left erector spinae musculature (about 4 cm lateral from midline). Center to center electrode distance was 2.5 cm; electrodes were longitudinally oriented along the fibers of the erector spinae muscles. A reference electrode was taped on the left wrist. To identify the L3 level we first found the sacrum and followed the spinous processes of the lumbar vertebrae up to L3. L3 is located at the center of the lumbar curvature and due to its long transverse processes, provides mechanical advantage for the muscles so the investigation of muscular activity at this level is preferred (Bogduk, 1997) and it is more comparable to other research reports (Solomonow et al., 2003a). The EMG signals were amplified by 1000 with a frequency band pass of 20e500 Hz, Gain 100 mV/Div., 80 dB signals to noise ratio and CMRR of 90 dB. Maximum acceptable skin impedance level was set at 5 kU. Sampling rate of recording was 1000 Hz and the data were digitized and stored by a 12-bit A/D board. Angular variables were estimated by a digital camera (JVC-GZ-MG50AS) placed 1 m away from the subject at waist level with a direct view of the subject’s right side in the sagittal plane. The camera collected kinematics data at the rate of 25 frames per second. The markers used to measure the segment angles were attached to the subjects as follows: three circular markers were attached to the right greater trochanter, lateral midline along the iliac crest and the lower palpable edge of the rib cage (Solomonow et al., 2003a). Video and EMG data were synchronized by an electrical circuit which triggered them at the same time.

Protocol The skin was cleaned with alcohol preparation pads before attachment of the EMG electrodes. The electrodes and skin markers were placed as described above, and the signal was checked prior to test trials to make sure of proper marker detection and lack of EMG signal noises. The subjects stood just behind a horizontally drawn line on the ground barefoot with their feet pelvis-width apart, their wrists hooked together in the front of their body, and their

PREVENTION & REHABILITATIONdSPINAL PHYSIOLOGY

Compensatory behavior of the postural control system

PREVENTION & REHABILITATIONdSPINAL PHYSIOLOGY

420 knees kept straight and bent forward from the waist level as far as possible. After introducing the task to the subjects and making sure of the accuracy of the maneuver, subjects performed two trials separated by 30e50 s between them. Each trial consisted of an approximately 3 s of quiet standing followed by 3e5 s full forward flexion. The deep flexion was held for 4 s followed by 3e5 s extension to upright posture, and then static standing through the end of recording. Finally one of the trials was chosen depending on signal quality for data analysis (Hashemirad et al., 2009). After recording EMG and kinematics data, the subjects sat on the floor with their trunk in full lumbar flexion. A hemicylindrical foam bolster was placed under the thighs to tilt the pelvis posteriorly, and reduce hamstring stretch (Solomonow et al., 2003a) (Figure 1). The subjects stayed in this static flexion position for 7 consecutive minutes, immediately after which they stood up and performed another set of flexioneextension tasks similar to the one performed prior to the static flexion period. Following that the subjects sat on a chair to recover for 10 min and then the trial, and recordings of EMG and kinematics were all repeated.

Data analysis The recorded EMG signals were full-wave rectified and smoothed with the time constant of 50 ms to yield linear envelops. The EMG values were normalized using the peak EMG magnitude during the task. A threshold level of 5% of this magnitude was used to determine the onset and the end of the flexionerelaxation period. The onset of the flexionerelaxation phenomenon (EMG-Off) was defined as the point at which the magnitude of EMG signal got less than the threshold level and the end point of the phenomenon (EMG-On) during the extension phase was defined as the point at which EMG signals amplitude exceeded the threshold level (Olson et al., 2004) (Figure 2). The video data were analyzed using Ulead video studio software (version 7) to match the frame of the video with the corresponding EMG signals (frames of EMG-Off and EMGOn). Measurement of the angles of interest in each specific frame was done with Auto CAD software (2006). The trunk, hip and lumbar angles were measured by lateral markers. Trunk angle was defined as the angle between the vertical line crossing the ilium marker and the line connecting the rib and ilium markers. The hip angle

Figure 1 Schematic representation of a subject during the 7 min of static lumbar flexion.

F. Hashemirad et al.

Figure 2 Typical recording of EMG activity during the flexioneextension task. Raw EMG and the linear envelope data were used to estimate EMG-Off and EMG-On points. The extension phase used for normalization of the EMG linear envelope is also provided.

was defined as the angle between the vertical line crossing the ilium marker and the line connecting the greater trochanter and ilium markers while the angle of lumbar flexion was defined as the difference between the two previous ones (trunk angle  hip angle) (Solomonow et al., 2003a) (Figure 3). The angle measurements were done as absolute and relative. The relative angles were calculated with respect to the corresponding angles in the erect posture. The dependent variables included absolute and relative angles of the trunk and lumbar in full flexion, EMG-On and EMG-Off, in three conditions of before, immediately after and 10 min after the creep.

Figure 3 Schematic representation of a subject performing the forward bending task and the measured angles where a, b and g are the trunk, hip and lumbar angles, respectively.

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Parameters (absolute angles)

Before creep (condition I) X(SD)

After creep (condition II) X(SD)

After 10 min rest (condition III) X(SD)

P value Conditions I,II

Conditions I,III

Conditions I,III

Trunk angle Full flexion EMG-off EMG-on

103.3(17.1) 102.7(16.8) 83.9(14.8)

106.4(17.7) 106.1(17.9) 84.7(20.4)

106.1(17.7) 105.5(18.1) 87.1(22.2)

<0.001 <0.001 0.752

0.008 0.009 0.328

0.738 0.577 0.316

Lumbar angle Full flexion EMG-off EMG-on

48.6(9.0) 48.6(8.9) 45.6(8.7)

50.5(9.4) 50.4(9.4) 46.2(10.1)

50.1(9.7) 50.03(9.9) 46.8(9.8)

0.009 0.015 0.528

0.011 0.010 0.187

0.534 0.547 0.449

Statistical analysis Analysis of variance with repeated measures design (before vs. after 7 min of deep flexion and 10 min of rest) was used to evaluate the effect of static flexion on EMG activity pattern of erector spinae muscles. The alpha level was set at 0.05.

Results Thirty of the 36 subjects (or 83%) exhibited FRP in their erector spinae muscles before creep. Nine out of 30 subjects did not show FRP after the creep. The data from 21 of these subjects who also showed FRP after static lumbar flexion were subjected to statistical analysis. Since the focus of this study was on investigating the effect of creep on the flexionerelaxation phenomenon, the data from 15 subjects who did not exhibit this phenomenon were not analyzed here. Table 1 demonstrates the test results of the absolute trunk and lumbar angles in full flexion, EMG-On and EMGOff in three conditions of before, immediately after and 10 min after the creep. 7 min of static lumbar flexion increased trunk and lumbar angles for 3.4 (from 102.7 to 106.1 ) and 1.8 (from 48.6 to 50.4 ) at the EMG-Off point (P < 0.05). There was no difference between immediately after creep and after the 10 min rest period. After the creep, the erector spinae muscles remained active in larger degrees of flexion and the creep response was not fully recovered after 10 min of rest. Table 2 indicates of the trunk and lumbar angles in the erect posture in three conditions of before, immediately and 10 min after the creep. 7 min of static lumbar flexion led to 2.6 (from 13.5 to 10.9 ) and 1.7 (from 4.7 to 3.0 ) decrease in the trunk and lumbar angles, respectively (P < 0.05) and following this period of rest, the approximation of the angles to the reference vertical did not fully recover. Table 2

Table 3 shows the results related to the relative angles in three conditions of before, immediately and 10 min after the creep. To calculate the relative angles, the absolute trunk and lumbar angles at the EMG-Off and EMG-On points were compared to the corresponding values in the erect posture which yielded no significant difference between the relative angles before and after the creep. In other words according to the relative angles, the erector spinae muscles were relaxed at the same angles in the before and after creep conditions. According to Tables 1 and 3, there was no significant difference in EMG-On angles for both absolute and relative measures. In other words, 7 min of static lumbar flexion had no significant effect on re-activation of the erector spinae muscles in the extension phase.

Discussion Differences seen in the responses of FRP in angle measurements as absolute and relative, showed that the changes in the trunk and lumbar angles in the erect posture offset the creep-related increase in absolute angles of EMGOff so that relative angles did not show significant difference before and after the creep. Solomonow et al. (2003a) in a similar study found the changes in trunk and lumbar angles of the 25 female participants to be 7.3 and 2.7 , respectively at the EMG-off point. Our results follow the same trend with the absolute values of the corresponding angles to be 3.4 and 1.8 , respectively, while in both studies these changes were statistically significant. In contrast, the angular changes at the point of EMG-on in our study were not statistically meaningful while Solomonow found them significant in his study. Based on the results of this study, it seems that EMGOff angles were more sensitive than EMG-On angles because the shorter time of static lumbar flexion only provokes changes in the absolute angles at which the EMG turns off.

The effect of creep phenomenon on angles at erect posture in 21 subjects who exhibited FR before and after creep.

Parameters in erect position

Before creep (condition I) X(SD)

After creep (condition II) X(SD)

After 10 min rest (condition III) X(SD)

P value Conditions I,II

Conditions I,III

Conditions I,III

Trunk angle Lumbar angle

13.5(7.3) 4.7(6.6)

10.9(7.8) 3.0(7.7)

11.3(6.8) 2.1(7.2)

<0.001 0.001

0.002 0.001

0.714 0.235

PREVENTION & REHABILITATIONdSPINAL PHYSIOLOGY

Table 1 The effect of creep phenomenon on absolute angles at full flexion, EMG-Off and EMG-On in 21 subjects who exhibited FR before and after creep.

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Table 3 The effect of creep phenomenon on relative angles at full flexion, EMG-Off and EMG-On in 21 subjects who exhibited FR before and after creep.

PREVENTION & REHABILITATIONdSPINAL PHYSIOLOGY

Parameters (Relative angles)

Before creep (condition I) X(SD)

After creep (condition II) X(SD)

After 10 min rest (condition III) X(SD)

P value Conditions I,II

Conditions I,III

Conditions I,III

Trunk angle Full flexion EMG-off EMG-on

116.9(17.1) 116.3(16.9) 97.5(12.9)

117.4(18.7) 117.0(18.9) 95.7(20.7)

117.4(16.7) 116.8(17.1) 98.4(21.1)

0.519 0.389 0.520

0.680 0.733 0.768

0.992 0.878 0.163

Lumbar angle Full flexion EMG-off EMG-on

53.4(8.2) 53.4(8.4) 50.4(7.4)

53.5(8.8) 53.4(8.7) 49.2(9.2)

52.2(8.2) 52.1(8.3) 48.9(7.9)

0.867 0.962 0.277

0.109 0.088 0.143

0.241 0.240 0.852

It seems that static lumbar flexion for durations for as long as 7 min, will impose alterations in the spinal system which, if not compensated by the spinal stabilizing system (such as changing the erect standing posture as the starting and reference position) might challenge the stability of the system. Panjabi has divided the spinal stabilizing system into active, passive and neural sub-systems. In the normal state, the three sub-systems work together to provide the needed mechanical stability (Panjabi, 1992). Since the FRP is the product of interplay between active and passive elements of the spine, the unchanged behavior of the phenomenon indicates that the alterations in the erect starting position of the spine provides enough passive tension in the posterior elements for the FRP to occur, and the erector spinae muscles to relax at the same relative angles. Considering the effects of static lumbar flexion on erect posture, an important suggestion can be constructed from the findings of this study: when the lower back is exposed to static loading due to activities such as manual material handling, the process of muscle recovery can be substantially improved by modulating the starting erect posture to decrease the developed laxity in the passive tissues. The findings of this study confirm the results of previous ones, showing that creep and increased muscular activity that were developed during the 7 min of flexion, were not fully recovered by the 10 min rest period (Shin and Mirka, 2007; Solomonow et al., 2003b; Solomonow, 2004). Following these results, it emerges that the rest duration of 10 min is not capable of allowing full recovery, even if a static lumbar flexion of less than 10 min is applied to the lumbar spine. As elicited in the results of this study, six of the 36 subjects (or 17%) before creep and nine of the 30 subjects (or 30%) after creep despite being asymptomatic did not exhibit FRP. This heterogeneity in the healthy population might shed light on the predisposing factors and development mechanisms of LBP which seems worth studying in prospective studies. Further study on the neurophysiologic aspects and reflex mechanisms associated with the creep phenomenon will add to the findings of this study.

Summary Trunk and lumbar angles have achieved considerable attention in the assessment of body posture and spinal biomechanics. FRP has also been introduced as an effective factor

influencing spinal stability and injury tolerance which can also show the acuity of the spinal performance as lack of this phenomenon has been associated with LBP. In this study, the effect of a short period static flexion posture (being critically important from an ergonomic point of view) has been investigated on the FRP and erector spinae muscles activation pattern. The results included three major interesting findings: 1) As per previous studies, ES muscles remained active for longer periods but, when considering the alterations of the upright standing posture at the starting position, it was revealed that short periods of static flexion do not alter the range of motion during which ES muscles are active. 2) 10 min of rest is not sufficient to offset the biomechanical consequences of 7 min of static flexion posture. It seems that a longer period of rest is needed to offset the effects of creep. 3) It seems that not only LBP patients fail to exhibit FRP but there are also subjects without low back problems, in which FRP is absent. A follow-up study might show if lack of FRP is a predictive factor for the incidence of LBP or not.

Conflict of interest statement There is no conflict of interest regarding the publication of this paper.

Acknowledgements The authors gratefully thank Dr. Mohamad Parnianpour for his valuable comments on the manuscript and Amir H. Kahlaee for reviewing the manuscript. We also appreciate the financial support of rehabilitation faculty of Tehran University of Medical Sciences and Health Services which made this project possible.

References Bogduk, N., 1997. Clinical Anatomy of the Lumbar Spine and Sacrum, third ed. Churchill Livingstone, New York, p. 228(Appendix). Floyd, W.F., Silver, P.H.S., 1955. The function of the erectores spinae muscles in certain movements and postures in man. Journal of Physiology (London) 129, 184e203.

Hashemirad, F., Talebian, S., Hatef, B., Kahlaee, A.H., 2009. The relationship between flexibility and EMG activity pattern of the erector spinae muscles during trunk flexioneextension. Journal of Electromyography and Kinesiology 19, 746e753. Jackson, M., Solomonow, M., Zhou, B., Baratta, R., Harris, M., 2001. Multifidus EMG and tensionerelaxation recovery after prolonged static lumbar flexion. Spine 26, 715e723. Kippers, Y., Parker, A.W., 1984. Posture related to myoelectric silence of erectors spinae during trunk flexion. Spine 9, 740e745. Little, J.S., Khalsa, P.S., 2005. Human lumbar spine creep during cyclic and static flexion: creep rate, biomechanics, and facet joint capsule strain. Annals of Biomedical Engineering 33 (3), 391e401. McGill, S.M., Kippers, V., 1994. Transfer of loads between lumbar tissues during the flexionerelaxation phenomenon. Spine 19, 2190e2196. Olson, M.W., Li, L., Solomonow, M., 2004. Flexionerelaxation response to cyclic lumbar flexion. Clinical Biomechanics 19, 769e776. Panjabi, M.M., 1992. The stabilizing system of the spine, part I: function, dysfunction, adaptation, and enhancement. Journal of Spinal Disorders 5, 383e389. Shin, G., Mirka, G., 2007. An in vivo assessment of the low back response to prolonged flexion: interplay between active and passive tissues. Clinical Biomechanics 22, 965e971.

423 Solomonow, M., 2004. Ligaments: a source of work-related musculoskeletal disorders. Journal of Electromyography and Kinesiology 14, 49e60. Solomonow, M., Baratta, R.V., Banks, A., Freudenberger, C., Zhou, B.H., 2003a. Flexionerelaxation response to static lumbar flexion in males and females. Clinical Biomechanics 18, 273e279. Solomonow, M., Baratta, R.V., Zhou, B.H., Burger, E., Zieske, A., Gedalia, A., 2003b. Muscular dysfunction elicited by creep of lumbar viscoelastic tissue. Journal of Electromyography and Kinesiology 13, 381e396. Solomonow, M., Zhou, B.H., Baratta, R.V., et al., 1999. Biomechanics of increased exposure to lumbar injury caused by cyclic loading: part 1. Loss of reflexive muscular stabilization. Spine 24, 2426e2434. Vachalathiti, R., Crosbie, J., Smith, R., 1995. Effects of age, gender and speed on three dimensional lumbar spine kinematics. Australian Journal of Physiotherapy 41, 245e252. Wiliams, M., Solomonow, M., Zhou, B., Baratta, R., Harris, M., 2000. Multifidus spasms elicited by prolonged lumbar flexion. Spine 25, 2916e2924.

PREVENTION & REHABILITATIONdSPINAL PHYSIOLOGY

Compensatory behavior of the postural control system

Journal of Bodywork & Movement Therapies (2010) 14, 424e444

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

STRUCTURAL HIERARCHIES

Simple geometry in complex organisms Graham Scarr* 60 Edward Street, Stapleford, Nottingham NG9 8FJ, United Kingdom Received 12 August 2008; received in revised form 22 October 2008; accepted 22 November 2008

KEYWORDS Crystallography; Helix; Icosahedron; Natural law; Platonic solids; Symmetry; Structural hierarchies; Tensegrity; Tetrahedron

Summary Many cultures throughout history have used the regularities of numbers and patterns as a means of describing their environment. The ancient Greeks believed that just five archetypal forms e the ‘platonic solids’ e were part of natural law, and could describe everything in the universe because they were pure and perfect. The formation of simple geometric shapes through the interactions of physical forces, and their development into more complex biological structures, supports a re-appreciation of these pre-Darwinian laws. The selfassembly of molecular components at the nano-scale, and their organization into the tensegrities of complex organisms is explored here. Hierarchies of structure link the nano and micro realms with the whole organism, and have implications for manual therapies. ª 2008 Elsevier Ltd. All rights reserved.

Introduction Many cultures throughout history have used the regularities of numbers and patterns as a means of describing their environment. The ancient Greeks believed that just five archetypal forms e the ‘platonic solids’ e were part of natural law and could describe everything in the universe because they were pure and perfect (Figure 1) (Fuller, 1975, sec.820.00). This platonic conception of nature persisted up until the mid nineteenth century when Charles Darwin published his revolutionary ‘Origin of Species’, ‘‘After Darwin the whole lawful scheme was overthrown and organic forms came to be seen as contingent mutable assemblages of matter e ‘clever artefact like contrivances’ e put together gradually

* Tel.: þ44 115 9491753. E-mail address: [email protected]

during the course of evolution primarily by natural selection for biological function’’ (Denton et al., 2003). A recognition of natural patterns and shapes derived from physical laws seemed to reassert itself in 1917 when d’Arcy Thompson published his classic ‘On Growth and Form’ (Thompson, 1961), but in the scientific mainstream this remained little more than interesting. Using simple geometry to describe a complex organism is likely to generate a certain amount of skepticism, as esoteric and occult descriptions seem rather simplistic compared to modern scientific thinking. However, in 1928 Frank Ramsey proved that every complex or random structure necessarily contains an orderly substructure. His proof established the fundamentals of a branch of mathematics known as Ramsey theory, which is used to study the conditions under which order must appear, such as in large communication networks and the recognition of patterns in physical systems. The theory suggests that much of the essential structure of mathematics consists of extremely large

1360-8592/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2008.11.007

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Figure 1

The five platonic solids.

numbers (with very complicated calculations) derived from problems which are deceptively simple (Graham and Spencer, 1990; Fuller, 1975, sec.227.00). From the perspective of the human body, Ramsey theory implies that simple shapes might form part of that underlying substructure, and an examination of how these could arise through the interactions of physical forces is presented. This supports recent research which reinstates physical law, and not natural selection, as the major determinant of biological complexity in the subcellular realm (Denton et al., 2003). The development of these shapes into more complex structures, and how they model biology, with implications for manual therapy then follows.

Simple geometry One of the problems that nature seems to solve repeatedly is that of the most efficient ways of packing objects close together. A circle drawn on a piece of paper, i.e. in two dimensions (2D), demonstrates this. The circle encloses the

Figure 2

largest area within the minimum boundary, which makes it a ‘minimal-energy’ shape (requiring the least amount of energy to maintain). Circles enclose space, as well as radiate out into it, as can be seen in a drop of oil floating on water, the growth of fruit mould, and the ripples in a pond. However, this efficiency is severely compromised when several circles are put next to each other as gaps are left in between (Figure 2). Other shapes, such as squares and triangles will both fill the space completely, but the proportion of area to boundary is not as good as with the circle. A square is inherently unstable; while triangles are very stable, even with flexible joints (Figure 3). Structures that are not triangulated can generate torque and bending moments at their joints, and must be rigidly fixed to prevent them from collapsing. The best compromise between efficient space filling of the circle and stability of the triangle is the hexagon (Figure 2). Isolated hexagons are also liable to collapsing, but when several hexagons are packed together, they support each other as stresses balance at their 3-way

The tessellation of different shapes on a flat plane showing the appearance of the hexagon (shaded).

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Figure 3

G. Scarr

Diagram to show that square trusses are inherently unstable at their joints, whereas triangular trusses are rigid.

junctions (Figure 4). However, they are only fully stable when triangulated, with sides that form chords of a circle equal to the radius (Figure 4). Hexagons close-pack in an array that can self-generate to produce the same shapes at different size scales (Figure 5), and even non-uniform shapes approximate to hexagons as they pack together in sheets (Figure 7). Soap bubbles spontaneously join together with outside surfaces that always meet at 120 , just like hexagons, whether the bubbles are equal in size or not (Figure 6). This is because soap molecules hold together through their

surface tension, which tries to minimize itself and reduce the surface area (Fuller, 1975, sec.825.20; Stewart, 1998, p. 16). Some examples of naturally occurring hexagons are shown in Figure 7 (Bassnett et al., 1999; Weinbaum et al., 2003; Sanner et al., 2005). All this would seem to make the hexagon the obvious choice for close-packing in two dimensions. In 3D, however, a structure which fulfills the same purpose may not be so readily apparent. The ancient Greeks recognized the importance of the five regular polyhedra because of their

Figure 4 triangles.

Figure 5 hexagons.

The relationship between hexagons, circles and

Hexagonal close-packing and a hierarchy of

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427

Figure 6 (a) Diagram of bubbles joining with an external surface angle of 120 , the same as a hexagon; (b) three bubbles form an internal septum (bold lines), also with an angle of 120 .

intriguing properties (Figure 1) (Fuller, 1975, sec.820.00). Their outer faces are made from shapes which are all the same; a sphere circumscribed around each one will touch all the corners, while one inscribed within will touch the centre of all the faces; and they all have 3, 4 or 5 sides. Joining up the face centres creates the ‘dual’ of that shape, i.e. the octahedron and cube are duals of each other; and the dodecahedron and icosahedron similarly; the tetrahedron is unique in that it is a dual of itself. Not a hexagon in sight. yet! Just as the circle is the most efficient shape for enclosing space in 2D, so its equivalent in 3D is the sphere. Atoms, bubbles, oranges, and planets all approximate to spheres. Putting lots of spheres next to each other still leaves all those wasteful spaces in between, just like the circles did; but there is a more efficient solution. In order to tease out some of the consequences of packing spheres

closely together, plastic balls have been glued together (Figure 8). The same arrangements are also shown as lattices of steel balls, with coloured magnetic sticks representing the inherent ‘minimal-energy’ characteristic of close-packing (i.e. their centres of mass are at the minimum possible distance apart) (Connelly and Back, 1998). Adding more spheres to a particular shape creates higher-order structures of the same shape, numbered according to the [magnetic] connections on their outer edge (Figure 8) (Fuller, 1975, sec.415.55).

The tetrahedron (Figure 8) The simplest and most stable arrangement of spheres in 3D is a tetrahedron, because of its triangles (Fuller, 1975, sec.223.87). Methane and ice molecules configure as tetrahedrons; a pile of oranges and grains of sand are rough

Figure 7 Some examples of hexagons in natural structures: (a) honeycomb (Wikipedia); (b) close-packing of Polio virus (Fred Murphy & Sylvia Whitfield, Wikipedia); (c) Basalt blocks on the Giants Causeway in Ireland, formed from cooling lava (Matthew Mayer, Wikipedia); (d) stacked layers of carbon atoms in graphite (Benjah-bmm27, Wikipedia); (e) hexagonal close-packing of actin and myosin in a muscle fibril; (f) hexameric complexes of uroplakin covering the epithelial lining of the urinary bladder (redrawn after Sanner et al., 2005); (g) idealized diagram of the sub-cortical cytoskeleton (redrawn after Weinbaum et al., 2003); and (h) cells in the optic lens arranged as hexagons (redrawn after Bassnett et al., 1999).

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Figure 8

Closest-packing of spheres forms a tetrahedron (1st, 2nd, 3rd and 4th orders).

tetrahedrons; and in the early embryo, four cells arrange as a tetrahedron. Adding more spheres to the tetrahedron produces higher-order structures and the emergence of another shape e the octahedron.

The octahedron (Figure 9) The octahedron appears as an inevitable consequence of close-packing. It is naturally found in radiolarian structures (Fuller, 1975, sec.203.09), and is the basis of the octet truss used by structural engineers because of its stability. It does have 3 equatorial squares at 90 to each other, but their stability is maintained because of the triangles at each vertex (Fuller, 1975, sec.420.01). A good approximation of this truss appears in the bones of birds, probably due its strength and lightness (Thompson, 1961, p. 236).

The cuboctahedron (Figures 10e12) Increasing the tetrahedron to its 4th order (Figures 8 and 10) produces the first close-packing of spheres around a central nucleus, and the emergence of another shape e the cuboctahedron (which is not a platonic solid) (Fuller, 1975, sec.414.00). This shape is also contained within a 2nd order octahedron (Figure 11).

The cube (Figure 13) The addition of a tetrahedron to each of the 8 triangular faces of the 2nd order cuboctahedron turns it into a cube, or looking at it another way, the cuboctahedron is a cube with the corners cut off. If these were cut away further, it would end up as an octahedron. When four corners of a cube are connected diagonally, they enclose a 4th order tetrahedron (Figure 13b). The cuboctahedron and cube are not shapes which generally appear in biological structures, but they are still relevant to the discussion. Table 1 shows a comparison of the relative volumes of these shapes when taking each one as unity. It can be seen that the volume of the tetrahedron is the only standard where all the others can be expressed as integers; the other comparisons leave awkward fractions or irrational numbers which disguises their simple relationships. Man-made structures commonly use cubes with their 90 angles, but these shapes are relatively rare in the natural world where they are constructed from discrete components, and 60 geometry is more prevalent e an observation noted by Fuller (1975, sec.410.10). An architect of some renown, he formulated a complete system of geometry based on 60 , which applied to a wide diversity of the laws formulated in physics and chemistry.

Figure 9 (a) Emergence of octahedron (light) within 2nd order tetrahedron (dark). (b) 1st and 2nd order octahedra with construction of octet truss.

Simple geometry in complex organisms

Figure 10

Nuclear close-packing starts in the centre of a 4th order tetrahedron to form a cuboctahedron.

Figure 11

Nuclear close-packing forms cuboctahedron (a) and octahedron (b).

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Figure 12

Cuboctahedron (2nd order) and the same with front removed to show nuclear rays.

In crystallography, for example, two basic types of closepacking are described e cubic (Figure 14a) and hexagonal (Figure 14b) (Read, 1974, p. 21). The different ‘layers’ are described as parallel to the surface of a cube, but as already shown, the value of this shape as a standard in nature is dubious. In ‘cubic’ close-packing, the true layers are at 60 to the surface of the cube, and all the energy bonds in these layers are oriented in the same directions (Figure 13). (This can be observed in the external angles of the hexagon in Figure 13c, which are 60 .) In ‘hexagonal’ close-packing, however, every third layer is rotated by 60 around an axis perpendicular to the layer plane, and it doesn’t then produce simple shapes like those already described. In any case, there are plenty of hexagons in ‘cubic’ close-packing (Figures 13c and 15), and the tetrahedron, octahedron, cuboctahedron and cube are all examples of this (Read, 1974, p. 96). To illustrate this, diamond (the hardest natural substance) is constructed from carbon atoms arranged in a 3D hexagonal lattice; with complete hexagonal rings that form tetrahedral units; which crystallizes as an octahedron; and uniquely has

maximal cubic symmetry (Figure 16) (all these polyhedra have cubic symmetry) (Read, 1974, p. 83; Sunada, 2008). All these shapes naturally occur as inorganic crystals, and there is no suggestion that they can literally be observed in the human body. This new description, however, includes them in a unified and comprehensive approach to understanding natural forms, which are all influenced by the same energy-efficient ways of packing objects of similar size through the interactions of molecular forces. Before getting to more complex structural mechanisms, it is necessary to make a brief return to the cuboctahedron, where it will be noticed that it is constructed from 12 spheres that create four interlocking hexagons around a central nucleus (Figures 10, 11 and 17a). Pauling (1964) described it as a ‘coordination polyhedron’ because its minimal-energy configuration is the common denominator of the tetrahedron, octahedron and cube. Fuller (1975, sec.430.00) considered the links between spheres as energy vectors, and called it the ‘vector equilibrium’. This shape has radial and circumferential vectors which are all the

Figure 13 The layers in a cube. (a) 1st corner layer removed (white dotted). (b) 2nd layer removed to show one side of a tetrahedron (white dotted). (c) 3rd layer removed to show a hexagon (white dotted).

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Table 1 A comparison of the relative volumes of different shapes with the same edge length, when taking each one as unity. Tetrahedron

Octahedron

Cube

Cuboctahedron

1 0.25 0.1666666. 0.05

4 1 0.666666. 0.20

6 1.5 1 0.30

20 5 3.33333333. 1

same size. In terms of vectorial dynamics, the outward radial thrust from the nucleus is exactly balanced by the circumferentially restraining chordal forces (Figures 10 and 11). So, as well as the highest degree of symmetry (cubic), we have a coordinating shape (cuboctahedron) and a balance of forces (vector equilibrium), the significance of which will be explained later. It is even possible to pack spheres tighter and at a lower energy level by removing the nucleus. This allows 12 spheres to compact differently around a smaller central space as 12 interlocking pentagons (Figures 17b and 18a, b). Joining all the spheres together creates an icosahedron e another platonic solid, but this one is different (Figure 18c). Adding more spheres to the outside will not create a higher order, like in the previous shapes, because the spheres won’t all touch (Figure 18d). A 2nd order icosahedron won’t close-pack around the basic shape, or a 3rd order around a 2nd, because they would be unstable (Figure 18e and f), and can only exist in their own right as a single outer shell. The icosahedron enlarges by subdividing each of its faces into more triangles, which is why it remains stable (Figure 18g). (The relative volume compared to the tetrahedron in Table 1 is 18.51.) In order to understand the full significance of simple geometry, we must look at another way that the universe uses to deal with complexity, namely, integration.

Tensegrity The concepts of tensegrity [tensional integrity] have become increasingly recognized over the last thirty years as a useful model for understanding some of the structural properties of living organisms. Their appreciation follows from investigations in the 1940s by Snelson (website) who constructed sculptures with parts that appeared to defy gravity and float in the air. His structures so impressed the architect Fuller (1975) that he incorporated them into his developments in building design, and set about exploring the principles underlying their formation. Fuller defined two types of tensegrity structure based on the icosahedron, and termed them geodesic and prestressed.

The geodesic dome The outstanding feature of all geodesic structures is that they have a rigid external frame maintaining their shape, made from multiple struts or trusses arranged in geometric patterns. These are usually triangles, pentagons or hexagons, with triangulated structures being the most stable. The term ‘geodesic’ actually refers to the shortest path between two points on a surface (equivalent to the struts), so strictly speaking this definition should only refer to the triangulated structure. Aside from this, the ‘geodesic’ dome can enclose a greater volume with minimal surface area, with less material than any other type of structure apart from a sphere. When the diameter of a sphere doubles, the surface area increases 4-fold and the volume 8-fold, which makes such structures very efficient in terms of construction material. The 1st order tetrahedron and octahedron are geodesic structures which enlarge by adding more spheres to the outside, but they then cease to be hollow structures. In contrast the icosahedron, whose spheres enclose a small central space, creates an outer geodesic shell which enlarges by adding more triangular faces within it (Figures 18g and 19). The icosahedron has several attributes that are advantageous for biological structures (Levin, 1995). It is the closest of

Figure 14 (a) ‘Cubic’ close-packing in a cube. The orientation of energy bonds in each layer of spheres remains the same (compare Figure 13). (b) ‘Hexagonal’ close-packing shows the third layer of spheres (white dotted) rotated by 60 on the layer below.

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Figure 15 Hexagonal shape in (a) octahedron; (b) 1st order cuboctahedron; (c,d) 2nd order cuboctahedron; and (e) cube (viewed from edge).

all the regular polyhedra to being spherical e making it efficient in terms of construction material; and it is fully triangulated e giving it stability. It has 12 vertices, 20 triangular faces and 30 edges, with five faces and their edges meeting at each vertex; and demonstrates six 5-fold, ten 3-fold and fifteen 2-fold symmetries. Fuller introduced his geodesic domes during the 1950s; and because their strength increases as they get bigger, it has been possible to build some very large structures. Some of these can be seen in the Eden project in Cornwall, and protective coverings on radar installations. Some natural structures are: ‘Buckyballs’ e a form of carbon named after Fuller e with 60 atoms linked together to form 20 hexagons, interspersed with 12 pentagons e the same as the pattern

on a football (actually a spherical truncated icosahedron); viruses; the silica shells of radiolaria; pollen grains; clathrins (endocytic vesicles beneath the cell membrane); and the cellular cytoskeletal cortex (Figure 20). In 1956, Crick and Watson, the discoverers of DNA, pointed out that the only way to build a hollow protein shell out of identical subunits is a shape with cubic symmetry. Since then it has been amply confirmed that the icosahedron is the best shape for producing the outer capsid shell of the ‘spherical’ viruses, because it is a minimum free-energy structure, and spontaneously assembles through the actions of intermolecular forces (Figure 20b) (Crick and Watson, 1956; Kushner, 1969; Caspar, 1980; Van Workum and Douglas, 2006). These viruses form larger structures, which get

Figure 16 (a) Multi hexagonal lattice of carbon atoms in diamond, shown within the ‘standard’ cube; (b) octagonal diamond crystal; (c) enlarged lattice showing tetrahedral apexes (white, compare with (a)); and (d) tetrahedron viewed from apex (cross).

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Figure 17 (a) 12 spheres close-pack around a central nucleus to form a cuboctahedron with 4 interlocking hexagons; and (b) around a central space to form an icosahedron with 12 interlocking pentagons (front 3 spheres have been shaded for clarity).

Figure 18 Close-packing around a central space (a,b) forms an icosahedron with hexagonal outline (c). Packing more spheres around the icosahedron (d) forms an unstable dodecahedron (e) or icosahedron (f). An icosahedron enlarges by subdividing its surfaces into more triangles (g).

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Figure 19

Icosahedron subdivided into 2nd and 3rd order geodesic icosahedra.

even closer to a sphere, by using more protein subunits (capsomers) to subdivide their triangular faces (Figure 19). The maximum number of identical subunits which can be arranged is 60, and to become larger, some subunits must distort slightly in order to form stable bonds. This ‘quasiequivalence’ is necessary for preserving the icosahedral template, with multiples of 60 subunits allowing many more triangular faces, but there are always just 12 vertex pentagons (it is the 5-fold symmetry which creates the geodesic dome) (Caspar, 1980). (The icosahedron has also been found to play an important part in the structure of many electron-deficient substances, including metals and alloys Pauling, 1964, 1990; Teo and Zhang, 1991.) Multiple icosahedra can arrange neatly together in a thick planar sheet because of their hexagonal outline (Figures 7b and 18c), making the hexagon the link between space filling in 2D and the icosahedron in 3D. They can stack in a column or helix; branch or pack around each other (incompletely) to create curved surfaces; and form more complex patterns and shapes in 3D (Figure 21). In contrast, tetrahedral and octahedral based trusses are not omnidirectional in form and function; they have a smaller volume to surface area ratio; they do not closepack at all well and their shapes do not self-generate. Cubes and dodecahedra are also inherently unstable unless they are triangulated; and as they rarely feature in biology, will not be considered further at this point. However, they are still significant to later discussion. Applying pressure to any point of a geodesic dome causes force to be transmitted around the edges, with both

compression and tension operating within different parts of each strut, which means that they must be made of a material that can deal with both types of loading. Prestressed tensegrities, on the other hand, have these two components separated, optimizing the material properties of each (Ingber, 2003a).

Prestressed tensegrity The description of biological structures as tensegrities first appeared in the literature in the early 1980s, with independent contributions by Ingber et al. (1981) and Levin (1982). Prestressed tensegrities consist of a set of struts under compression, and an arrangement of cables under isometric tension. The resultant pull of the cables is balanced by the struts, providing structural integrity with the compression elements appearing to float within the tension network. A load applied to this type of structure causes a uniform increase in tension around all the edges and distributes compression evenly to the struts, which remain distinct from each other and do not touch (Skelton et al., 2001; Masic et al., 2006). Fuller described it as: ‘‘.continuous tension and discontinuous compression’’ (Fuller, 1975, sec.700). The geodesic icosahedron can be converted into a prestressed tensegrity structure by using six new compression members to traverse the inside, connecting opposite vertices and pushing them apart (Figure 22) (Fuller, 1975, sec.700; Levin, 1982). The edges can then be replaced with cables so that the outside is entirely under tension. (Some

Figure 20 Geodesic icosahedrons in (a) Radiolarian (Wikipedia); (b) Adenovirus (Wikipedia); and (c) Pollen grains (Dartmouth College, Wikipedia).

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Figure 21

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(a) Incomplete icosahedral packing; (b) icosahedral branching; and (c) icosahedral helix.

of the edges have disappeared in the transition to prestressed tensegrity because they are now redundant and not essential to this new structure.) To summarize the significant aspects of this type of design (Van der Veen, 2003): 1. Stability e achieved through the configuration of the whole network, and not because of the individual components. It is also omnidirectional, with the different elements maintaining their respective properties regardless of the direction of applied load. 2. Balance e the tension and compression components are separated and balanced mechanically throughout the

Figure 22

entire structure, which will optimize automatically so as to remain inherently stable. 3. Integration e a change in any one tension or compression element causes the whole shape to alter and distort, through reciprocal tension, distributing the stresses to all other points of attachment. 4. Energetically efficient e giving maximum stability for a given mass of material. In mechanical terms it cannot be anything other than in a balanced state of minimal energy throughout (Masic et al., 2006; Skelton et al., 2001). Since its discovery, the tensegrity concept has developed in four main areas e sculpture (Snelson); building

(a) Geodesic icosahedron; and (b) prestressed tensegrity icosahedron.

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(Fuller); space research and structural biology. Space research has shown a great deal of interest in tensegrities because of their lightness and other unusual structural properties. Defining their complex mathematics will probably lead to new developments in biological research, with physical and computerized modelling becoming valuable tools for exploring their potential in the future (Connelly and Back, 1998; Skelton et al., 2001; Coughlin and Stamenovic, 2003; Masic et al., 2006; Yu et al., 2008). The ‘geodesic dome’ has been considered distinct from ‘prestressed’ tensegrity for the purpose of description so far e one has all the struts touching, and the other has them all separated; although tension maintains their integrity in both cases, and they are really both prestressed (Fuller, 1975, sec.703.03). They seem to be poles at opposite ends of a continuum, although even this distinction is an illusion, and as will be explained. A definition which satisfies all researchers has so far remained elusive, particularly in biology, where distinctions become blurred, and the following examples use a broad and inclusive approach.

The complexity of shape Shape is a direct result of all the forces acting on the component structures during development, from a single molecule to the complete organism. At a ‘simple’ level, the arrangement of spheres (atoms) is through the spontaneous attraction (tension) of inter-atomic forces. Three spheres form a triangle and four spheres form a tetrahedron (Figure 8). More spheres can be added to create an octahedron, cuboctahedron or cube (Figures 11 and 13); but these distinct shapes are generally only stable as fixed inorganic crystals. In contrast, the molecular dynamics within living organisms is in continuous flux as conflicting forces attempt to resolve themselves. Eventually they can settle into a balanced and stable state of minimal-energy, at least until some other force exerts its influence. Prestressed tensegrities are a most attractive proposition in living systems, because they create an energy ‘sink’ for the interacting force fields (a ‘basin of attraction’ in dynamics terminology), and make possible an enormous number of flexible

Figure 23

and stable structures through changes in the lengths of their compression members (Connelly and Back, 1998; Skelton et al., 2001; Nelson et al., 2005; Ingber, 2006a,b, 2008). Their non-linear stressestrain curve is considered an essential element in biological materials, where it has been related to the differing properties of components in their nano and microstructures (Figures 24 and 29) (Gordon, 1978, p. 164; Lakes, 1993; Skelton et al., 2001; Puxkandl et al., 2002; Gao et al., 2003; Gupta et al., 2006); one of the smallest of these is the helix.

The helix The a-helix is a series of curves which all have the same radius, drawn out like a long spring (Figures 24e29). Probably the most famous of all is DNA e deoxyribonucleic acid e a double helix of two chains running in opposite directions. The discoverers of DNA rightly predicted that helixes would be one of the simplest of shapes to spontaneously assemble through intermolecular forces (Crick and Watson, 1956; Kushner, 1969; Caspar, 1980; Van Workum and Douglas, 2006). Helical structures are stabilized through a balance between the attractive (tensional) and resistant (compressional) forces within the molecule, which makes them tensegrities. They can also flex without buckling, lengthen without breaking, and are capable of rotation without deformation (Stecco, 2004, p. 185). All known filamentous viruses are helical (most of the rest are icosahedral) (Figures 20b and 21c). In proteins, sequences of amino acids can fold into ahelixes and further twist around each other to form double or triple coiled-coils (super-coils) (Figure 25), or fold with other a-helixes (or b-sheets) to form globular structures. Of the huge number of possible amino acid combinations, protein folding is limited to a set of about 1000 different forms because of some basic self-assembly rules, analogous to the laws of chemistry or crystallography, which correspond to an energy minimum (Denton et al., 2002).

The cytoskeleton Within the cytoplasm, the prestressed cytoskeleton is a lattice consisting of microtubules e tightly packed helices

Prestressed tensegrity models (a) icosahedron; (b) icosahedral chain; and (c) icosahedral thick planar sheet.

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Figure 24 Diagram to show hierarchies of different components in the structure of muscle e a-helix of tropomyosin, double coiled-coil of tropomyosin; globular g-actin, combined double helix of f-actin and tropomyosin; double a-helix of myosin molecule, myosin thick filament; hexagonal packing of actin and myosin in a myofibril, self-similar packing of myofibrils into a fibre, a fibre bundle and ultimately muscle.

of globular tubulin protein under compression (Figure 26); microfilaments e double helices of the protein F-actin under tension (Figure 27); and helical protein intermediate filaments which stabilize and integrate the whole structure, from cell membrane to the nucleus (Ingber, 2008; Maguire et al., 2007; Brangwynne et al., 2006). Experimental support for the cytoskeleton as a tensegrity structure now seems overwhelming (Ingber, 2008), although some studies have been unable to confirm it (Heidemann et al., 1999; Ingber et al., 2000).

The cellular cortex The cellular cortex is essentially made from triangulated hexagons of the helical protein spectrin (Figure 25), coupled to underlying bundles of the helical protein actin

Figure 25

(Figures 7g and 27) (Liu et al., 1987; Weinbaum et al., 2003; Li et al., 2005; Zhu et al., 2007). The erythrocyte, with a diameter of 8 mm, has a composite membrane which distorts as it flows through smaller capillaries, but allows the cell to recover its biconcave shape. The network is organized into w33,000 repeating units, each with a short central actin protofilament linked by 6 spectrin filaments under tension, to a lipid-bound suspension complex (Sung and Vera, 2003; Zhu et al., 2007). About 85% of these units appear as hexagons, with w3% pentagons and w8% heptagons, which suggests that the hexagonal arrangement is a preference, and not perfect (Liu et al., 1987). The erythrocyte membrane may be considered as many prestressed tensegrity actin/spectrin units within a geodesic dome, which is itself a bilayered structure of phospholipid molecules with outer heads under tension separated by

Spectrin tetramer e each strand of a- and b-spectrin consists of a series of double and triple coiled-coils (super-coils).

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Figure 26

Microtubule polymer of globular tubulin.

hydrophobic tails under compression. It has also been modelled around an icosahedron (Li et al., 2005). Deformation of the membrane network may cause turbining of the actin protofilaments through the suspension mechanism, thereby facilitating oxygen transfer from one side of the membrane to the other (Sung and Vera, 2003; Zhu et al., 2007). This arrangement of different components at varying size scales is a common feature in biology, where the functions of each one contribute to a higher collective function within a hierarchy of structures (Figures 24 and 29).

Structural hierarchies The nano-structures of collagen and spider silk have both been described as prestressed tensegrities (Skelton et al., 2001) within a hierarchical fibrous structure (Figure 28) (Termonia, 1994; Knight and Vollrath, 2002; Du et al., 2006). Collagen, the most abundant structural molecule based on the helix, is the main constituent of the extracellular matrix, fascia, tendons and ligaments. More than twenty different types have been described in different tissue specific combinations which are particularly able to resist tensional stresses. At the nano-scale three helical procollagen polymers wind around each other to form a triple helix of tropocollagen. These molecules then arrange laterally in a quasi-hexagonal configuration with cross-linking to form collagen microfibrils, and pack sequentially in a hierarchy to form a subfibril, fibril and collagen fibre (Figure 29) (Jager and Fratzl, 2000; Puxkandl et al., 2002; Gao et al., 2003; Gupta et al., 2006; Perumal et al., 2008). Collagens and spider silk are also examples of liquid crystal elastomers e different states, or mesophases of matter, that lie between liquids and solid crystals (Ho et al., 1996; Knight and Vollrath, 2002). They are flexible and malleable, with fibres that show a high degree of orientational order and varying degrees of translational

Figure 27

order, and are sensitive to mechanical loading and changes in electro-magnetic fields; which may influence their synthesis and define fibre orientation during morphogenesis and tissue remodelling. Even though spider web fibres are secured at their ends to what is effectively a continuous compression component, the whole web has been classed as a tensegrity on structural engineering grounds (Connelly and Back, 1998).

Fractals The self-similar geometrical structure of collagenous tissues has been demonstrated in the fractal character of their polarization properties, with degenerative-dystrophic changes revealed by alterations in these properties (Ho et al., 1996; Angelsky et al., 2005). This observation may be of value in pre-clinical pathological diagnostics, and a correlation between these findings and tissue palpation would be useful research in the future. Fractal analysis is commonly applied to natural structures, where similar shapes and patterns appear at different size scales, linking hierarchies throughout the body (Mandelbrot, 1983; Skelton et al., 2001; Jelinek et al., 2006); the branching patterns of blood vessels, the bronchial tree and nerve fibres all display this property (Zamir, 2001; Palagyia et al., 2006; Phalen et al., 1978; Thomas et al., 2005). These characteristic shapes are developmental remnants of non-linear dynamic systems which were sensitive to small changes in the local environment, created instabilities in growth and caused the typical branching pattern which extends from the micro to the macro scale. They are part of ‘deterministic chaos’ or chaos theory (Goldberger et al., 1990).

The matrix The extracellular matrix, surrounding virtually every cell in the body, provides a branching structural framework which extends through the fascia to the whole organism. It

F-actin polymer filament.

Simple geometry in complex organisms

Figure 28 A model fibre showing the prestressed tensegrity nano-structure with similarities to collagen and spider silk.

439 other cells at some distance. Long-distance transfer of mechanical forces between different tissues could then spatially orchestrate their growth and expansion, allowing complex multicellular tissue patterns to emerge through interactions among a hierarchy of different components. Multi-modular hierarchies of form and function can thus be linked, with simplicity evolving into complexity, and the whole system mechanically functioning as a unit (Stecco, 2004, p. 25; Nelson et al., 2005; Ingber, 2006a, 2008; Parker and Ingber, 2007). As a self-organizing tensegrity construction system, the matrix could repair and replace itself at a local level, by allowing small and incremental changes compatible with the mechanical demands of all its components. Stecco (2004, p. 31) described the fascia as a tensioned network which may coordinate the motor system in a way that the central nervous system is incapable of, although this work has yet to be confirmed.

Modelling icosahedral tensegrities attaches to the cellular cytoskeleton through adhesion molecules in the cell membrane, allowing a transfer of mechanical forces between them and changes in the cytoskeletal tension (Ingber, 2003a,b,2008). Multiple intracellular signalling pathways are activated as a result which provide multiplexed switching between different states such as cell growth, differentiation or apoptosis. Conversely, local tensional stresses within the cytoskeleton transfer to the extracellular matrix and produce effects on

The icosahedron is particularly useful in modelling the tensegrities of biological structures, because it demonstrates both geodesic and prestressed properties which can be connected to form an infinite variety of shapes (Figures 21, 23 and 31). Even the tension and compression elements can be made from interlinked icosahedra, themselves constructed from smaller icosahedra, repeating further in a self-similar structural hierarchy (Fuller, 1975, sec.740.21;

Figure 29 Diagram to show a hierarchy of components in the structure of tendon e a-helix of procollagen, triple coiled-coil of tropocollagen, collagen microfibril, and the self-similar packing arrangement in subfibril, fibril, fibre, fascicle and ultimately tendon.

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Wheel showing central hub suspended within outer rim; and wheels within wheels model successive joints in the arm.

Ingber, 2003a; Levin, 2007). Curved compression elements (Figure 32) differ from straight struts (Figure 22) because their outer convex surfaces are actually under tension and inner concave surfaces under compression, but like the struts in a geodesic dome, biological materials deal with both types of loading as a result of their nano and micro structures (Gordon, 1978; Lakes, 1993; Puxkandl et al., 2002; Gao et al., 2003; Gupta et al., 2006; Brangwynne et al., 2006). Inferences that this is ultimately due to their tensegrity construction have been made (Skelton et al., 2001; Levin, 2007; Ingber, 2008). In addition, when spheres are added to the outside of an icosahedron they do not close-pack completely, and an instability develops (Figures 18def and 21a). This apparent ‘flaw’ in the packing arrangement allows another possibility for modelling an infinite variety of shapes, as different parts of the structure branch outwards, and the spaces in between can fill with smaller icosahedra. It may now be seen that the distinction between ‘geodesic’ and ‘prestressed’ tensegrities is really just relative to the scale at which they are observed,

Figure 31 Right upper extremity modelled as a sequence of interconnecting icosahedral tensegrities with compression struts of different lengths.

a corollary which should be added to any definition. Even the close-packing of atoms (spheres) should be considered as a ‘tensegrity with invisible struts’ because their centres of mass are held a minimum distance apart (Connelly and Back, 1998). Distinctions of structure and function in biology may essentially be points on a continuum and artefacts of textbook classification. Although ‘geodesic’ structures appear limited to the cellular size level, ‘prestressed’ tensegrities almost certainly dominate beyond this. At the macro scale the fascia, muscles, ligaments and capsules provide the tension; while the bones and tissue bulk of muscles, organs and fluid-filled vessels resist compression.

Tensegrities within tensegrities Levin was the first to describe the higher complexities of the human body in terms of tensegrities, using the analogy of a bicycle wheel, where the compression elements of the central hub and outer rim are held in place by a network of wire spokes in reciprocal tension (Levin, 1997, 2005a; Connelly and Back, 1998). This type of wheel is a selfcontained entity, maintained in perfect balance throughout, with no bending moments or torque, no fulcrum of action, and no levers (Figure 30). He suggested that the scapula may function as the hub of such a wheel, in effect as a sesamoid bone, and transfer its load to the axial skeleton through muscular and fascial attachments (Levin, 1997, 2005a). The sterno-clavicular joint is not really in a position to accept much compressional load, and the transfer of compression across the gleno-humeral joint has been found to be at maximum only when loaded axially at 90 abduction (Gupta and van der Helm, 2004). As compression can only take place normal to the glenoid surface i.e. at 90 (it is essentially a frictionless inclined plane), the joint must rely heavily on ligamentous and muscular tension in all other positions. A humerus hub model would function equally well with the arm in any position. Similarly, the ulna could be a hub within the distal humeral ‘rim’ of muscle attachments, where load bearing across the joint may be significantly tensional, allowing compressional forces to be distributed through a tensioned network, and the hand to lift loads much larger than would otherwise be

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Figure 32

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A model of the cranial vault as a tensegrity structure (Scarr, 2008).

the case (Figure 31). In this respect, zero compression across the femur and meniscii has been observed during arthroscopy in an extended knee joint under axial loading in vivo (Levin, 2005b). The pelvis is also like a wheel with the iliac crests, anterior spines, pubis and ischia representing the outer rim; and the sacrum representing the hub, tied in with strong sacro-iliac, sacro-tuberous and sacro-spinous ligaments. Similarly, the femoral heads may function as hubs within the ‘spokes’ of the ilio-femoral, pubo-femoral and ischiofemoral ligaments (Levin, 2007). Most joint movements display helicoid motion around a variable fulcrum, and this is demonstrated in the simple tensegrity elbow in Figure 31, a physiological feature not found in most other models.

Omnidirectionality According to Wolff’s law, tensional forces remodel the bony contours and alter the positions and orientations of their attachments, contributing to the complexity of shapes apparent in the skeleton (Kushner, 1940; Kjaer, 2004). As part of a prestressed tensegrity structure, each attachment would influence all the others, distributing forces throughout the system and avoiding points of potential weakness (Skelton et al., 2001; Masic et al., 2006); in contrast to a pure geodesic chain or truss which is vulnerable to buckling (Figure 21c). Such a mechanism would be an advantage in long-necked animals such as giraffes and dinosaurs, where the load from the head is distributed throughout the neck (Figure 23) (Levin, 1982). The erect spine and bipedal weight bearing capability of humans have traditionally been viewed as a tower of bricks and compressed disc joints, transferring the body weight down through each segment until it reaches the sacrum, but this is a relative rarity amongst vertebrates. Most other species have little or no use for a compressive vertebral column, which is frequently portrayed as a horizontal truss and cantilever support system (Thompson, 1961, p. 245; Gordon, 1978, p. 239). As the main difference in vertebrate

anatomies is in the detail, it seems reasonable to suppose that they have some structural properties in common (Levin, 1982, 2002). Tensegrities are omnidirectional, i.e. they are stable irrespective of the direction of loading; and the spine, pelvis and shoulder all demonstrate this property (within physiological limits), enabling dancers to tip-toe on one leg, and acrobats to balance on one hand.

Continuums of structure Prestressed and geodesic tensegrities may coexist at the same level within a particular functional unit and have been described in the cranium, where the bony plates of the vault substitute for curved prestressed compression struts and do not touch each other; alongside a geodesic cranial base (Figure 32). Prestressed tension is provided by the dura mater e a tough membrane covering the brain e which regulates bone growth, maintains the separation of vault bones at the adjoining sutures, and integrates the whole structure into a single functional unit. It has been suggested that the brain influences the vault to grow outwards, through the dura mater, rather than physically pushing it out (Scarr, 2008).

Balanced mobility Balanced and symmetrical tensegrities automatically assume the configuration that minimizes their stored elastic energy, with changes in shape that require very little control energy; in contrast to classical structures where significant energy is required to work against the old equilibrium (Skelton et al., 2001; Masic et al., 2005). Their high yield strain allows large shape changes to be accomplished at no loss in stiffness (Masic et al., 2006), a distinctive feature in biological structures. The icosahedron has been described as an intermediary in a potential oscillating system (Fuller, 1975, sec.460.08) with similarities to an energy efficient pump (Levin, 2002). If the vector equilibrium (cuboctahedron) (Figure 11a) is constructed without radial vectors and joined with flexible connectors,

442 and is compressed between two opposite triangular faces, it will contract and rotate symmetrically (due to the instability of the square faces) and assume the shape of the slightly smaller icosahedron (each of the square faces now becomes a rhomboid, or essentially, two triangles). Further compression causes the equator to twist and fold, and the structure transform itself through an octahedron, to the tetrahedron, and back again. The icosahedron is at the lowest energy state within the system, and the point around which changes in shape occur. Fuller called this mechanism the ‘jitterbug’ (Fuller, 1975, sec.460.00). An organism utilizing such a system would be able to move with the minimum of energy expenditure, and remain stable whilst changing shape.

Symmetry and natural laws ‘‘The ability. to generate elaborate and beautiful forms. comes from a simple but fundamental principle which governs the deep structure of the physical universe: symmetry. .Albert Einstein. argued that truly fundamental laws of nature must be the same at all times and in all places: that is, the laws must be perfectly symmetric. Principles of symmetry govern the four forces of nature (gravity, electro-magnetism, and the strong and weak nuclear forces that act between fundamental particles).’’ (Stewart, 1998, p. 38) The ubiquitous nature of symmetry offers a simple explanation for stable crystal lattices and other regular patterns, because of the balance of forces. Instabilities in the dynamics of living systems also generate complex patterns and shapes within hierarchies of structure, as self-similar shapes (fractals) scale up through dilation e one of the four principal types of symmetry transformation. ‘‘Instability breaks the overall system symmetry, but it appears to be a localized fissure that is offset by. a balancing asymmetry elsewhere in the system. Essentially, the sum of all the asymmetries is symmetrical. Thus, we have patterns of symmetry that reflect the underlying symmetrical nature of the universe, and patterns (and forms) that are generated by instabilities in the system.’’ (Kreigh and Kreigh, 2003) That different structures should emerge at different levels in complex organisms is typical of evolutionary selection. Over hundreds of millions of years chance mutations in the genetic code occasionally gave rise to new characteristics which conferred an advantage to the organism, whilst existing traits which remained useful were retained, through natural selection. This bifurcation in development creates asymmetries which must be balanced in order to permit new higher-order symmetries (Stewart, 1978, p. 114). Organization is still part of the self-assembly capacity, but the resulting form may have a very different appearance from its component substructures (Figures 24 and 29) ‘‘.and be arranged into almost any contingent artifactual arrangement we choose’’ (Denton et al., 2003). Correlations with ‘60 geometry’ at the macro scale may then be more coincidental (Phalen et al., 1978; Thomas et al., 2005); and description such as ‘close-packing of the knee in full

G. Scarr extension’ means something different to ‘close-packing of spheres’.

Summary The tetrahedron is one of the simplest of shapes in 3D because of its close-packing efficiency, minimal-energy configuration and triangular stability. It gives rise to the octahedron and square in the octet truss, and nuclear closepacking in the cuboctahedron and cube; all manifesting within each other, and all resulting from ‘60 geometry’. The hexagon, and cubic symmetry of these shapes links them to the polyhedron most suited to fulfill structural evolution in biology, which is the icosahedron, possibly part of the substructure predicted by Ramsey (Graham and Spencer, 1990). All these polyhedra undergo a phase transition as they morph into prestressed tensegrity structures, giving endless shape possibilities, but their well-defined geometries are now obscured. The cuboctahedron links them to the ‘vector equilibrium’ and dynamic ‘jitterbug’, where energy efficient transformations of shape become significant. Self-assembling helical proteins carry the tensegrity principle into the nano-structures of the cell and extracellular matrix; and through structural hierarchies to the whole body. The genes orchestrate a battery of physical and chemical processes, but the natural laws of physics still provide the construction rules (Stewart, 1998, p. 25; Denton et al., 2003; Harold, 2005; Ingber, 2006b); and shape becomes determined more by Darwin’s ‘‘natural selection for biological function’’ (Denton et al., 2003).

Conclusion ‘‘.ideal geometries.pervade organic form because natural law favours such simplicity as an optimal representation of forces’’. Stephen Jay Gould (Thompson, 1961, xi) Energy consumption is the key to understanding the structural complexities of living organisms, and as energy-efficient structural mechanisms, tensegrities seem to apply at every level from the atom to the whole body. The icosahedron links the simple geometry of the platonic solids to the tensegrities of complex shapes, and lends itself to their modelling. It also becomes a transient in energy efficient transformations of shape, through the ‘jitterbug’ system described by Fuller. As a tensioned tensegrity network, the fascia may have a coordinating function throughout the body; and as manual therapies make contact at the whole body level, it provides a pathway for therapeutic interventions right down to the molecular scale.

Acknowledgements I wish to express my appreciation to Stephen Levin for information on the icosahedron which initiated this article, and to Nic Woodhead, Chris Stapleton and Andrea Rippe for the opportunity to discuss some of these concepts with helpful feedback. Also to Rory James for the photographs in Figures 9e12 and 15.

Simple geometry in complex organisms

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