Journal of Bodywork and Movement Therapies Official journal of the: ® Association of Neuromuscular Therapists, Ireland ® Australian Pilates Method Association ® Hands On Seminars, USA ® National Association of Myofascial Trigger Point Therapists, USA ® Pilates Foundation, UK Volume 15 Number 3 2011 EDITOR-IN-CHIEF
Leon Chaitow ND, DO c/o School of Life Sciences, 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 Geoffrey M. Bove, DC, PhD Kennebunkport, ME, USA (
[email protected]) John Hannon DC San Luis Obispo, CA, USA (
[email protected]) Glenn M. Hymel EdD, LMT Department of Psychology, Loyola University, New Orleans, LA, USA (
[email protected])
Dimitrios Kostopoulos PhD, DSc, PT Hands-on Physical Therapy, New York, NY, USA (
[email protected]) Craig Liebenson DC Los Angeles, CA, USA (
[email protected])
ASSOCIATE EDITORS: PREVENTION & REHABILITATION Warrick McNeill MCSP London, UK (
[email protected])
Matt Wallden MSc, Ost, Med, DO, ND London, UK (
[email protected])
International Advisory Board D. Beales MD (Cirencester, UK) C. Bron PT (Groningen, The Netherlands) I. Burman LMT (Miami, FL, USA) J. Carleton PhD (New York, USA) F. P. Carpes PhD (Uruguaiana, RS, Brazil) Z. Comeaux DO FAAO (Lewisburg, WV, USA) P. Davies PhD (London, UK) J. P. 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 LMT (Walpole, ME, USA) C. Norris MSc CBA MCSP SRP (Sale, UK) N. Osborne PhD DC (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 PhD, MA, PT (Munich, Germany) J. Sharkey MSc, NMT (Dublin, Ireland) D. Thompson LMP (Seattle, WA, USA) C. Traole MCSP, SRP, MAACP (London, UK) P. W. Tunnell DC, DACRB (Ridgefield, CT, USA) E. Wilson BA MCSP SRP (York, UK) A. Vleeming PhD (Schoten, Belgium)
Officially recognised and supported by: The Alliance of Massage Therapy Education The American Massage Therapy Association Associated Bodywork and Massage Professionals The British Orthopaedic Association The Institute of Sport and Remedial massage The International Association of Structural Integrators The International College of Applied Kinesiology USA The International Society of Clinical Rehabilitation Specialists The New Zealand Manipulative Physiotherapists Association The Organisation of Chartered Physiotherapists in Private Practice The Rolf Institute The Sports Massage Association The Upledger Institute
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Journal of Bodywork & Movement Therapies (2011) 15, 255e256
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EDITORIAL
Third International Fascia Research Congress 2012 Registration and abstract submission is now open for the Third International Fascia Research Conference e Vancouver, March 28e30 2012 http://www.fasciacongress.org/2012/. As with the first two conferences (Boston 2007, Amsterdam 2009) The Journal of Bodywork & Movement Therapies, together with its publisher Elsevier, are supporting and sponsoring the 2012 event, which is being organised by The Massage Therapy Association of British Columbia (MTABC) on behalf of the Ida P Rolf Research Foundation (IPRRF). We believe that it is vital that clinicians, who form the bulk of JBMT’s readership, and who made up the majority of delegates attending previous Fascia Research congresses, should be kept informed regarding the major scientific advances in this field. And this demands that scientists, and those clinicians, who are involved in either pure or clinical research e the source of the information that moves our clinical and wider understanding forward e are supported and encouraged. We will know a great deal more about what is currently being researched in the field of fascia, when abstracts are received and reviewed e and submission of these is now open. The topics and categories suggested for those wishing to submit abstracts are listed as: 1. Basic science a. Anatomy of Fascia b. Biomechanics of Fascia c. Cytology/Histology of Fascia d. Modelling and Fascia e. Pathology and Fascia f. Biological Fluid dynamics 2. Clinical mechanistic research, or clinical findings suggesting directions for basic research a. Manual and movement Therapy directed at Fascia b. Tool assisted therapy directed at Fascia (including try needling) c. Fascia in Surgery and recovery from Surgery d. Low Back Pain and Lumbar Fascia e. Fascia related research on special populations (e.g. women, persons with disabilities) f. Scars and adhesions 3. Research methodology 1360-8592/$36 ª 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2011.04.004
4. New Hypotheses 5. Fascial considerations for, women, minorities and persons with disability, such as pelvic pain, keloid formation, spasticity 6. Other For a comprehensive description of submission details (and downloadable examples of abstracts from previous congresses) go to: http://www.fasciacongress.org/2012/ abstract-submissions/. There is a student registration rate for the Fascia Congress that is open to all students enrolled in any professional or academic training program. An additional $200 scholarship e awarded by the primary initiators of the Fascia Congresses, The Ida P Rolf Research Foundation (IPRRF) e is available to the first 25 graduate students enrolled in any doctoral degree granting program (MD, PhD, DO, DC, DPT, DPH, DAc, etc.) with accepted abstracts, based on date of abstract submission. Students who are awarded the scholarship will receive them when they attend the Congress. For more detail see: http:// www.rolfresearchfoundation.org/graduatestudent. IPRRF will also host a gratis evening program for graduate students, during the Fascia Congress (following the regular conference presentations on Thursday 29th March 2012). This evening event will feature speakers on such topics as obtaining fellowships and grant funding, preparing manuscripts and research proposals, and how to find a good mentor, as well as opportunities for networking. http://www.fasciacongress.org/2012/traineesymposium/. A high attendance of both scientists as well as clinicians of all backgrounds is anticipated e attracted by: 1. A stellar lineup of keynote speakers, abstract presentations and panel topics: http://www.fasciacongress. org/2012/program-at-a-glance/ 2. The pre-conference dissection workshop: http://www. fasciacongress.org/2012/pre-conference-dissectionworkshop/ 3. The post-event workshops: http://www.fasciacongress. org/2012/workshop-descriptions/
256 And if your interest in fascia research is growing, and you want to look back at the truly amazing amount of information e much of it of major clinical relevance e that has emerged from the 2007 and 2009 congresses. Proceeding books and DVDs of the entire proceedings are available from IPRRF: http://www.fasciacongress.org/dvd-book-purchase.htm. Professor Tom Findley offers an additional perspective: “The number of papers in peer-reviewed journals, relating to fascia, continues to rise, from 200 per year in the 1970s and 1980s to almost 1000 in calendar year 2010! Each fascia congress adds to the body of knowledge and practitioner networking for fascia research. I am particularly excited by the addition of fluid dynamics to the
Editorial third fascia congress, as we learn how fascia affects fluid flow, and remodels in response to fluid flow in tissues. And having purchased a musculoskeletal ultrasound machine recently myself, I can speak highly for the imaging of fascia and fascial motion this allows. So scientists and clinicians can expect another stimulating congress e don’t worry if you don’t understand everything, we will record it so you can review it later.” Leon Chaitow ND DO Honorary Fellow, University of Westminster, 144 Harley Street, London W1G7LE, UK
Journal of Bodywork & Movement Therapies (2011) 15, 257e258
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LETTER TO THE EDITOR
Re: The Fall of the postural-structural-biomechanical model in manual therapy: Exemplified by lower back pain. A response to reviewers and further thoughts. “The Fall of the PSB model” was first published on CPDO’s Online Journal in March 2010 (Lederman, 2010). This article raised much interest and JBMT’s editor invited me to submit it in a shortened version for publication. The JBMT version (Lederman, 2011) contains only some of the main points from the original article. Following the reviewers’ published feedback I was given a limited right to reply. Hence, providing a counter-argument for all the specific issues raised by each reviewer is beyond the scope of this letter. The reason for writing the “Fall of PSB model” article is for ‘the love’ of manual therapy. It seeks to revitalize and modernize it. In the last two decades the effectiveness of manual therapy has been questioned, in particular as a clinical tool for treating common musculoskeletal conditions, such as LBP. There is a serious paradigm shift out there. A five hundred year-old view of the body as a mechanical entity, where disease, health and musculoskeletal conditions are ruled by biomechanics, is rapidly changing. We can either integrate the new knowledge gained from the sciences, evolve or become marginalized. My original professional orientation was firmly within the boundaries of a PSB model. For many years I have worked as a structural osteopath. First doubts emerged when I started my PhD research at King’s (1991), looking at the effects of manual therapy techniques on movement control. My drift away from a PSB model was slow (and painful) as my initial knowledge base was severely challenged. It has taken fifteen years to research, come to terms with the upheavals of change and to finally write about it. This period was also spent looking for an alternative approach that can integrate traditional manual therapy with current and changing scientific trends. This has led to the development of a Process Approach. This model values many ‘hands on’ therapeutic skills and practices but places them within the context of biological processes such as repair and adaptation, pain processes, motor learning and psychosocial and behavioral sciences.
DOI of original article: 10.1016/j.jbmt.2011.01.004. 1360-8592/$36 ª 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2011.03.001
The main principle of a Process Approach is to co-create with the patient environments in which their recovery can be optimized. For that we need to look at the patient’s underlying processes and match the intervention according to these needs. For example, tissue repair processes are optimized by movement, passive or active. Hence, an intervention after injury or surgery could include passive manual approaches and/or active movement rehabilitation. Neuromuscular processes are optimized by active movement (but not passive) as well as psychological, cognitive and behavioral factors. Hence, active interventions such as exercise therapy or active manual techniques, functional rehabilitation and cognitive-behavioral approaches are useful to regain control of movement. In the psychological-behavioral dimension change occurs through the psychological, cognitive, behavioral and relational aspects of the contact with the patient. In this dimension passive manual techniques can play an important role as well as active manual/exercise approaches. In a Process Approach the focus is on the patient’s needs and away from particular techniques or our vocational boundaries. The patient is involved, proactive and empowered and not a detached recipient of health. A Process Approach does not aim to adjust, correct, fix, balance, manipulate into place, passively switch off pain, turn on-off particular muscles, or mold the patient into some idealized structure or into a preconceived function (core stability). It does aim to be creative, experimental and to minimize being prescriptive by using what the patient already knows. In a Process Approach we acknowledge and work within the uncertainty and complexity of health care. I have spent over twenty years researching and describing the different body-mind processes, the dimensions in which they reside and identified the interventions required to promote a change. A Process Approach was analyzed and described in Fundamentals of Manual Therapy (Lederman, 1998) and expanded in a later edition, The Science and Practice of Manual Therapy (Lederman, 2005). A Process Approach is well-researched, malleable and a logical alternative to the PSB model. But work is still in progress; I am currently writing a paper on a Process Approach which will be published in 2012. Postural-structural-biomechanical and functional asymmetries are the norm not a pathology. Natural selection provided the greatest asymmetry of them all e side dominance. This involves movement behavior and postures that
258 are side preferential and associated with profound, unilateral imbalances in motor control and tissue loading. Do individuals develop their conditions due to these imbalances? Are their conditions related to a weaker or stronger side or the side more coordinated? Furthermore, there is a competition in adaptation which is behaviorally driven. Any attempt to “correct” structure or motor control will be overridden by the default, asymmetrical, dominant use. Concerning the reviewers’ responses, imagine a courtroom drama in which each side presents their contending evidence for a PSB model. There is no right or wrong but a ruling is reached by weighing the balance of evidence. I believe that in the “Fall of PSB” article the case for moving away from a PSB model was made clearly and robustly. I value the reviewer’s feedback; however they offer little scientific evidence to refute the conclusions of this article. Read the full article before making up your mind; it clarifies several of the issues raised by the reviewers. It can be downloaded from: http://www.cpdo.net/jour/jour1.html.
Letter to the Editor
References Lederman, E., 1998. Fundamentals of Manual Therapy: Physiology, Neurology and Psychology. Churchill Livingston, Edinburgh. Lederman, E., 2005. The Science and Practice of Manual Therapy. Elsevier, Edinburgh. Lederman, E., 2010. The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain. CPDO Online Journal March, 1e14. http:// www.cpdo.net/Lederman_The_fall_of_the_posturalstructural-biomechanical_model.pdf. Lederman, E., 2011. The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain. JBMT 15 (2), 130e152.
Eyal Lederman* CPDO Ltd., 15 Harberton Road, London N19 3JS, United Kingdom *Tel.: þ44 207 263 8551. E-mail address:
[email protected]
Journal of Bodywork & Movement Therapies (2011) 15, 259e261 available at www.sciencedirect.com
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LETTER TO THE EDITOR
Re: Is a postural-structural-biomechanical model, within manual therapy, viable? A JBMT debate
In a scientific discussion it is important to cite supporting references, so that readers can check whether the available evidence permits the conclusions offered by the authors. Stuart McGill refers several times to the large number of studies which would contradict Lederman’s position, but he does not cite these studies. This is not helpful. A scientific discussion is not based on what one believes, but on evidence that supports an argument or point of view. Lederman discloses his evidence, so everybody has the possibility of examining and judging this support. McGill quotes two studies of the knee. The study by McLean (McLean and Beaulieu, 2010) reports about the association between morphological factors and ACL injury risk, while Hewett (Hewett et al., 1999) evaluated the effect of neuromuscular training on the incidence of knee injury in female athletes. These are interesting studies but pathobiomechanics of the knee are very different to that of the spine. In the best case, an association of loading or neuromuscular training and knee injury can give plausibility to how morphological factors have possibly had an effect on the back. However, this does not indicate causality. Plausibility is helpful but it based always on the restricted current knowledge. Plausibility is neither necessary nor sufficient for causality (Fletcher and Fletcher, 2005). McGill quoted the study by Yates. In this study compressive loads in combination with 7000 repetitive cycles of flexionextension were applied to 22 porcine motion segments to examine the association between endplate size and shape, and the probability of a specific herniation type. The authors note that the shape of intervertebral discs is predictive of the pathway of herniation. However, this interesting biomechanical study is not an argument against Lederman’s position. An in-vitro study (!) does not represent biological complexity. Lederman consistently argues that physical load can be compensated in a biological system and that a disc prolapse does not automatically mean low back pain (LBP). Lederman mentions “the inability to identify/define the critical level where PSB factors contribute to the individuals back pain. This critical level is impossible to predict on an DOI of original article: 10.1016/j.jbmt.2011.01.004. 1360-8592/$36 ª 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2011.03.002
individual basis”. McGill contradicts that saying: “this opinion was stated in the face of broad evidence regarding provocative testing of the patient that determines the motions, postures or applied loads that cause pain”. We do not know at which critical level PSB factors have a deterministic influence on the pathogenesis of LBP. The fact that pain can be triggered by provocation tests in patients does not change this. Often bright light exacerbate pain in patients with migraine but does light play a role for etiology of migraine? The important question is rather what has changed structure so that it is sensitized to pain. This can be caused by PSB factors, but also by non-structural factors such as the psychosocial background of the patient, genetic or systemic factors, or a combination of all these aspects. We have no valid doseeresponse relation which would help us to determine approximately where risk factors contribute to individuals back pain. Neither degeneration of the spine nor high scores of fear-avoidance-belief-questionnaires nor low job satisfaction or obesity or depression or strength of the abdominal muscles or the number of smoked cigarettes lead necessarily to back pain. We know that these factors and some more are risk factors (van Tulder et al., 2002) but their magnitude can vary substantially on a individual basis. Since we don’t know the complex mechanism, we can’t exclude a whole model from etiology and therapy of LBP. Stuart McGill writes that “Professor Lederman selected a few studies that suggested no causation of back pain from structural and neuromuscular asymmetry”, but this is not the case. Lederman quotes more than 130 references for his theses. These are considerably more than 300 studies if one takes into account the systematic reviews. Lederman has presented a work which is researched very well regarding the epidemiological studies. I have proofed his references over a period of 2 months and found only a few relevant studies which Lederman has not quoted. It would only be fair to say even if one does not share Lederman’s conclusions (and I don’t share them), that most articles about aspects of PSB factors are not based on such a extensive research. Of course it is reasonable to ask e as McGill has done e why no therapeutic studies were taken into account. At that point Lederman makes the mistake of writing about the therapeutic effects of PSB factors without including the evidence of the therapeutic studies. He infers from the supposed little predictive value of PSB factors to conclude that manual therapy is of little value. At best his conclusions would be
260 plausible; but they may simply be wrong. It is necessary to understand that plausibility is not a substitute for causality. I regard Lederman’s article as a courageous work, however, his conclusions are not necessarily supported by his own references. I recommend making the effort to study his references. We have conflicting evidence about the meaning of PSB factors on the emergence or retention of LBP. Some systematic reviews come to the conclusion it is unlikely that occupational lifting or carrying is independently causative of LBP (Wai et al., 2010; Roffey et al., 2010), but other reviews noted that there is an association between lifting or heavy physical activities and back pain (Hoogendoorn et al., 1999; Kuiper et al., 1999). Some studies argue that structural variables on both MRI and discography testing at baseline had only weak association with back pain episodes (Kalichman et al., 2008, 2009; Carragee et al., 2005) other studies conclude that most degenerative disc “abnormalities” were moderately associated with LBP (Kjaer et al., 2005a) or that disc protrusions, endplate changes, and anterolisthesis in the lumbar spine were strongly associated with seeking care for LBP (Kjaer et al., 2005b). Lederman writes that twin studies have demonstrated “that as much as 47e66% of spinal degeneration is due to hereditary and shared environmental factors, whereas only 2e10% of the degeneration can be explained by physical stresses.” But the authors of the twin studies also write “the consistent finding, that L4-S1 lumbar discs are more degenerated than L1-L4 discs is a strong indicator that lifetime physical exposures have a role in disc pathogenesis” (Battie et al., 2004) (p. 2688). Therefore the challenge is to refine “influential environmental exposures, such as biomechanical forces, which may include hypotheses on interactions with other systems, and the pathways through which they may affect lumbar disc degeneration and associated pathology (Battie et al., 2009) (p. 58). Only strong evidence is given that physical examination, as routinely applied in occupational medicine (e.g. landmarks of pelvis state or movements in 3 planes) is without great predictive value (Van Nieuwenhuyse et al., 2009; Takala and Viikari-Juntura, 2000; Bigos et al., 1991; Battie et al., 1990). But also here a systematic review (Borge et al., 2001) concludes that “this area has not been fully investigated. Therefore, there is no satisfactory answer to the question of whether some physical examination tests have a prognostic value in the conservative treatment of chronic low back pain” (p. 292). Local pathologies alone cannot explain the different forms of LBP (van Tulder et al., 2002). It might be that back pain is frequently a part of a widespread pain problem instead of being isolated, regional pain (Hestbaek et al., 2003; Hestbaek et al., 2006). To recognize this means not that the PSB factors should necessarily be dismissed. The challenges in the area of research are different: Do we have the correct questions in the studies, do we have sufficient data, sufficiently large numbers of subjects, sufficiently large number of subgroups and a sufficient understanding of the pathology of LBP? Have we already understood the biological complexity of LBP to include or exclude potential risk factors? I don’t think so. A conflicting evidence for a connection of PSB factors and LBP does not represent unambiguous evidence against this association. In a critical debate it is easy possible to overlook this. The lack of evidence of an effect is not evidence of the lack of an effect. If we accept that LBP is a multi-factorial syndrome e and we
Letter to the Editor have a strong evidence for this position (Koes et al., 2010; Breen et al., 2006) - every single aspect which is discussed for etiology and therapy is unable to explain the complexity. As soon as we leave the model of simple linear associations, far more questions than answers remain in every way. We know that we don’t know enough. Bart Koes, member of the advisory board of the Cochran Back Group, recently expressed it in this way: Asked about the progress in regard to the etiology of LBP he answered: “Have we made progress? Overall, I would say yes. Even if we have to conclude that we do not yet understand the association between some exposures and low back pain, that in itself is an advance in knowledge. I think we have a clearer insight now that there is not a single risk factor solely responsible for the occurrence of low back pain” (BackLetter, 2009) (p. 70).
References BackLetter, 2009. Spinal loading and back pain. The BackLetter 24, 61. Battie, M.C., Bigos, S.J., Fisher, L.D., Spengler, D.M., Hansson, T.H., Nachemson, A.L., et al., 1990. The role of spinal flexibility in back pain complaints within industry. A prospective study. Spine (Phila Pa 1976) 15, 768e773. Battie, M.C., Videman, T., Kaprio, J., Gibbons, L.E., Gill, K., Manninen, H., et al., 2009. The Twin Spine Study: contributions to a changing view of disc degeneration. Spine J. 9, 47e59. Battie, M.C., Videman, T., Parent, E., 2004. Lumbar disc degeneration: epidemiology and genetic influences. Spine (Phila Pa 1976) 29, 2679e2690. Bigos, S.J., Battie, M.C., Spengler, D.M., Fisher, L.D., Fordyce, W.E., Hansson, T.H., et al., 1991. A prospective study of work perceptions and psychosocial factors affecting the report of back injury. Spine (Phila Pa 1976) 16, 1e6. Borge, J.A., Leboeuf-Yde, C., Lothe, J., 2001. Prognostic values of physical examination findings in patients with chronic low back pain treated conservatively: a systematic literature review. J. Manipulative Physiol. Ther. 24, 292e295. Breen, A.C., van Tulder, M.W., Koes, B.W., Jensen, I., Reardon, R., Bronfort, G., 2006. Mono-disciplinary or multidisciplinary back pain guidelines? How can we achieve a common message in primary care? Eur. Spine J. 15, 641e647. Carragee, E.J., Alamin, T.F., Miller, J.L., Carragee, J.M., 2005. Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. Spine J. 5, 24e35. Fletcher, R., Fletcher, S., 2005. Clinical Epidemiology. The Essentials, fourth ed.. Lippincott, Williams & Wilkins, Philadelphia. Hestbaek, L., Leboeuf-Yde, C., Kyvik, K.O., 2006. Is comorbidity in adolescence a predictor for adult low back pain? A prospective study of a young population. BMC Musculoskelet. Disord. 7, 29. Hestbaek, L., Leboeuf-Yde, C., Manniche, C., 2003. Is low back pain part of a general health pattern or is it a separate and distinctive entity? A critical literature review of comorbidity with low back pain. J. Manipulative Physiol. Ther. 26, 243e252. Hewett, T.E., Lindenfeld, T.N., Riccobene, J.V., Noyes, F.R., 1999. The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study. Am. J. Sports Med. 27, 699e706. Hoogendoorn, W.E., Van Poppel, M.N., Bongers, P.M., Koes, B.W., Bouter, L.M., 1999. Physical load during work and leisure time as risk factors for back pain. Scand. J. Work Environ. Health 25, 387e403. Kalichman, L., Kim, D.H., Li, L., Guermazi, A., Berkin, V., Hunter, D.J., 2009. Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community-based population. Spine (Phila Pa 1976) 34, 199e205.
Letter to the Editor Kalichman, L., Li, L., Kim, D.H., Guermazi, A., Berkin, V., O’Donnell, C.J., et al., 2008. Facet joint osteoarthritis and low back pain in the community-based population. Spine (Phila Pa 1976) 33, 2560e2565. Kjaer, P., Leboeuf-Yde, C., Korsholm, L., Sorensen, J.S., Bendix, T., 2005a. Magnetic resonance imaging and low back pain in adults: a diagnostic imaging study of 40-year-old men and women. Spine (Phila Pa 1976) 30, 1173e1180. Kjaer, P., Leboeuf-Yde, C., Sorensen, J.S., Bendix, T., 2005b. An epidemiologic study of MRI and low back pain in 13-year-old children. Spine (Phila Pa 1976) 30, 798e806. Koes, B.W., van Tulder, M., Lin, C.W., Macedo, L.G., McAuley, J., Maher, C., 2010. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur. Spine J. 19, 2075e2094. Kuiper, J., Burdorf, A., Verbeek, J., 1999. Epidemiologic evidence on manual materials handling as a risk factor for back disorders: a systematic review. Int. J. Ind. Ergon. 24, 389e404. McLean, S.G., Beaulieu, M.L., 2010. Complex integrative morphological and mechanical contributions to ACL injury risk. Exerc. Sport Sci. Rev. 38, 192e200.
261 Roffey, D.M., Wai, E.K., Bishop, P., Kwon, B.K., Dagenais, S., 2010. Causal assessment of workplace manual handling or assisting patients and low back pain: results of a systematic review. Spine J. 10, 639e651. Takala, E.P., Viikari-Juntura, E., 2000. Do functional tests predict low back pain? Spine (Phila Pa 1976) 25, 2126e2132. Van Nieuwenhuyse, A., Crombez, G., Burdorf, A., Verbeke, G., Masschelein, R., Moens, G., et al., 2009. Physical characteristics of the back are not predictive of low back pain in healthy workers: a prospective study. BMC Musculoskelet. Disord. 10, 2. van Tulder, M., Koes, B., Bombardier, C., 2002. Low back pain. Best. Pract. Res. Clin. Rheumatol. 16, 761e775. Wai, E.K., Roffey, D.M., Bishop, P., Kwon, B.K., Dagenais, S., 2010. Causal assessment of occupational carrying and low back pain: results of a systematic review. Spine J. 10, 628e638.
Helge Franke Fu¨rst-Bu¨low-Str. 10, 57074 Siegen, Germany E-mail address:
[email protected]
Journal of Bodywork & Movement Therapies (2011) 15, 262e267
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REVIEW
Consideration of sleep dysfunction in rehabilitation Marie Carmen Valenza, PT, Msc a, Daniel O. Rodenstein, PhD b, ˜as, PT, PhD c,* ´sar Ferna ´ndez-de-las-Pen Ce a
Department of Physical Therapy, Faculty of Health Sciences, Universidad de Granada, Spain Pneumology Department, Cliniques Universitaires St. Luc University of Louvain, Brussels, Belgium c Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, Alcorco´n, Spain b
Received 26 May 2010; received in revised form 4 July 2010; accepted 24 July 2010
KEYWORDS Sleep dysfunction; Physical therapy; Rehabilitation; Pain; Sleep apnea
Summary The physiology of sleep is not completely understood but it is widely accepted that sleep is important to the human body in the recovery of metabolic and neurological processes. This paper summarizes the effects of sleep dysfunction on different systems and considers implications in the context of rehabilitation. When sleep is experimentally completely or partially curtailed important brain functions are impacted leading to psychological and neurological disturbances. Increased cortisol levels, reduction of glucose tolerance, and increased sympathetic nervous system activity have also been identified in healthy subjects under such conditions. Several studies show that 50e80% of patients with chronic pain suffer from sleep dysfunction. It has been suggested that on the one hand pain can cause sleep dysfunction and on the other hand that sleep dysfunction can aggravate pain. The physiologic mechanism behind this interaction is not completely clear; although most authors describe the relationship between pain and sleep dysfunction as aberrant processing of tactile-cutaneous sensory inputs at the meso-encephalic level and in the trigeminal nucleus both when asleep and awake. Decreased duration of sleep also increases heart rate, blood pressure and sympathetic activity magnifying the individual’s response to stressful stimuli. Possible causal mechanisms for the established connection between short sleep cycles and coronary pathology include sympathetic nervous system hyperactivity, increased blood pressure increase or reduced glucose tolerance. Finally, sleep and fatigue have traditionally been linked. Fatigue can have a physical etiology but is also associated with depression. Sleep alterations are also considered an important risk factor for psychological dysfunction and also mental illness. However, despite the noted repercussions of sleep dysfunction, studies investigating interventions to improve sleep have been limited in number. Benefits of exercise programs on sleep habits have been controversial with some have finding positive effects, whereas others did not find any
* Corresponding author. Ce ´sar Ferna ´ndez de las Pen ˜as, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Avenida de Atenas s/n, 28922 Alcorco ´n, Madrid, Spain. Tel.: þ34 91 488 88 84; fax: þ34 91 488 89 57. E-mail address:
[email protected] (C. Ferna ´ndez-de-las-Pen ˜as). 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.07.009
Consideration of sleep dysfunction in rehabilitation
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significant effect. It is possible that the dose or intensity of exercise programs may have an important influence in the outcomes. It is our opinion that based on the multi-system repercussions of different sleep dysfunctions, evaluation of sleep habits should be considered fundamental in the context of rehabilitation and should be included as part of the clinical history of each patient attending physical therapy. ª 2010 Elsevier Ltd. All rights reserved.
Introduction The physiology of sleep is not completely understood but it is widely accepted that sleep is important for recovery of normal metabolic and neurological activity (Shapiro and Flannigan, 1993). For instance, the REM phase of sleep significantly impacts memory and learning. Hence, any pathology or behaviour altering normal sleeping habits may have an important impact on health status. The structure of sleep has been studied for many years and the conclusion is that sleep is not a homogeneous phenomenon. It is distributed in two phases: REM and non-REM phases, which are electro-physiologically differentiated:
Non-REM phase This phase is characterized by a high voltage-low frequency electroencephalogram and a cortical synchronization with both sleep time and visible K complexes. Muscle tone is progressively reduced in the deepest phases of the sleep with the exception of the diaphragm tone, which is maintained independently of the phase of sleep. Authors define the non-REM as a phase of brain inactivity and relative regulation of an active body (Carscadon and Dement, 1994). It is divided into four steps, numbered 1 to 4 depending on depth, going from a shallow sleep in the phase 1 to the deepest sleep in the phase 4. The non-REM phase is controlled by the ascending reticular activating system and by the supraquiasmatic nucleus. This phase represents a decrease of the basal metabolism and is associated with decreased O2 consumption, CO2 production, heart rate, blood pressure, body temperature, and respiratory rate (Rosenberg-Adamsen et al., 1996).
REM phase This phase is characterized by a low voltage-high frequency electroencephalogram, accompanied by rapid and coordinated ocular movements and muscle atony (Shapiro and Flannigan, 1993; Dement and Kleitman, 1957). Carscadon and Dement (1994) identified an inhibition of the spinal motoneurons that may explain the observed reduction in muscle tone. It should be noted that no consensus exists for a definition of normal sleep in terms of duration or length of REM and non-REM phases. What has been shown is that sleep is a cyclic process that repeats each 90 min, where the nonREM phase takes around 80% of the duration and the REM phase usually accounts for the remaining 20% (Carscadon and Dement, 1994). In addition, although duration of normal sleep has been established as around 7.5 h/day (Carscadon and Dement, 1994); some authors have defined
sleep dysfunction as less than 6 h per day (Buysse et al., 1989). The current paper summarizes the effects of sleep dysfunction on different physiological systems and presents considerations in the context of rehabilitation.
Effects of sleep dysfunction on different body systems Pathological modifications of the architecture, quality and quantity of sleep are called “sleep dysfunctions” and these occur in all age-groups. Most of the studies conducted on healthy subjects have focused on curtailed sleep with effects on the duration and composition of sleep architecture. Studies into complete or selective restriction of sleep have found important effects on brain function leading to psychological and neurological dysfunctions (Horne, 1985), changes in behavioural and psychological performance (Horne, 1985; Bonnet, 1986; Gillberg and Akersted, 1994), somnolence (Bonnet, 1986), and concentration difficulties (Horne, 1985). In addition, mood and life attitude are affected with irritability, lack of vitality, anxiety and confusion reported (Agnew et al., 1967; Horne, 1985). Physiological effects including increased cortisol levels, reduced glucose tolerance, and increased sympathetic nervous system activity (Spiegel et al., 1999) have been found in healthy subjects as a result of complete or partial sleep restriction. Tochibuko et al. (1996) reported increased blood pressure and sympathetic activity in individuals sleeping only 3.6 h.
Sleep dysfunction and pain The relationship between sleep and pain is complex (Smith and Haythornthwaite, 2004). Traditionally pain has been considered a state characterized by hyper-vigilance state, whereas sleep is considered a state with reduced vigilance. The interest in the relationship between pain and sleep has been identified in the literature as early as 1934 when Copperman et al. (1934) demonstrated the effect of sleep dysfunction on the nociceptive process. Later studies (Walter et al., 1960; Smith and Haythornthwaite, 2004) have demonstrated an apparent bidirectionality in this relationship with pain causing sleep dysfunction and sleep dysfunction aggravating pain. More recent studies have demonstrated that changes in the nociceptive process result from sleep disturbances appear particularly in subjects with selective REM phase restriction (Older et al., 1998; Lentz et al., 1999; Arima et al., 2001; Onen et al., 2001). The physiologic mechanism related to these processes is not completely clear although most authors describe it as an aberrant processing of tactile-cutaneous sensory inputs at the meso-encephalic level and in the
264 trigeminal nucleus both when asleep and awake (Lavigne et al., 2005, pp.1246e1255). Several studies have shown that 50e80% of patients with chronic pain also experience sleep dysfunctions (Pilowsky et al., 1985; Atkinson et al., 1988; Morin et al., 1998; Smith et al., 2000). The most studied pathologies in the context of sleep cycles have been fibromyalgia syndrome, low back pain and whiplash (Menefee et al., 2000; Schlesinger et al., 2001). Menefee et al. (2000) identified a positive correlation between pain intensity and severity and sleep dysfunction. A number of studies have also investigated serotonin production and its role in sleep and the pain. Kundermann et al. (2004) demonstrated that serotonergic dysfunction was related to increased thermal pain sensitivity, while Wei et al. (2008) found that serotoninergic receptors in the spinal cord have a complex role in the control of sleeprestriction induced cutaneous hypersensitivity. However, at this time understanding of the mechanisms underlying the association between serotonergic dysfunction, pain and sleep remains limited (Ohayon, 2009). Headaches have also been associated with sleep dysfunction (Alberti, 2006) and numerous studies have examined this relationship (Ødega ˚rd et al., 2010). A relationship has been reported between headaches, low sleep efficiency, frequent waking and reduction of the low waves of sleep in the tracing during or at the end of the REM phase (Chervin and Zallek, 2001; Dexter and Weitzman, 1970; Manzoni et al., 1981) Up to 55% of patients with headaches present with primary sleep disorders such as apnea or restless legs syndrome (Spierings et al., 1996). Patients diagnosed with sleep apnea also usually suffer morning migraines (Idiman et al., 2004). However, it is not clear whether pain causes or contributes to these sleep abberations. Nevertheless, it seems clear that when pain and sleep interact, the biological capacity and behaviour of the individual is compromised causing a decrease in quality of life.
Sleep disturbances and hemodynamic alterations Sleep and arterial rigidity The associations between sleep disorders and cardiovascular and neurological control has important clinical implications. Various studies have shown that sleep restriction increases heart rate, blood pressure and sympathetic activity predisposing the individual to an inadequate response to stressful stimuli (Tofler et al., 1990; Krachman et al., 1995; Masahiko et al., 2000). It is postulated that the renin-angiotensin system is activated causing endothelial vasoconstriction (Willich et al., 1987). Coronary pathology The possible connection between sleep duration and its effect on coronary artery disease has been widely investigated and it has been found that sleeping less than 7e8 h per night increases the incidence of cardiac related death (Schwartz et al., 1999; Ayas et al., 2003; Gangwisch et al., 2006; Wingard and Berkman, 1983; Kripke et al., 1979; Sehdev and Hutchins, 2001). Mechanisms for the correlation between short sleep and coronary pathology may include sympathetic hyperactivity, increased blood
M.C. Valenza et al. pressure or reduced glucose tolerance. Indicating the complexity of the associations, Spiegel et al. (1999) and Tochibuko et al. (1996) found an increase in blood pressure with brief sleep restriction but a decrease in blood pressure with long sleep restriction.
Sleep dysfunctions and fatigue In the context of sleep dysfunction, fatigue deserves special attention due to its possible multi-factorial etiology. Fatigue can be defined as a distressing, persistent, subjective sense of tiredness or exhaustion that is not proportional to physical or emotional activity and interferes with daily activities and functioning. Indicating the likely complicated interaction of sleep dysfunction and fatigue, several studies have reported relationships between sleep alterations and depression (Bianchi et al., 2005), sleep alterations and fatigue (Girgrah et al., 2003) and fatigue and depression (Huang and Lin, 2009). When dealing with physical fatigue several studies have found a greater psychological rather than musculoskeletal component (Sehdev and Hutchins, 2001; Bianchi et al., 2005). Schaefer (1995) suggested a possible interaction between sleep, fatigue and fibromyalgia. Fatigue is one of the 5 criteria indicating clinical remission in patients with rheumatoid arthritis (Pincus et al., 2007).
Sleep disturbances and musculoskeletal function The psychological and physiological effects resulting from sleep alteration on musculoskeletal function have been described yet remain controversial. Martin (1981) suggested a cause-and-effect relationship between sleep dysfunction, psychological effects and musculoskeletal function changes. It has been suggested that the greatest effect of sleep disturbances would be a reduction in high-intensity physical exercise tolerance (Martin, 1981). Evidence suggests that athletes are concerned about the effects of inadequate restful sleep on their physical performance (Leger et al., 2005), although the effects of sleep restriction on physical performance (e.g. anaerobic power, muscle strength, stamina, heart rate, ventilation and oxygen consumption) are not clearly understood (Souissi et al., 2003). Rodgers et al. (1995) found that a 48-h sleep restriction period caused a considerable reduction in performance in physical activities that required from 30% to 45% of VO2ma ´x without affecting the anaerobic power. Souissi et al. (2003) proved that the length of restriction of sleep period could be important as the peak-power was not affected after 24 h of sleep restriction; however, 26 h of sleep restriction did significantly affect significantly the peak-power.
Sleep disturbances, cognitive and psychological alterations It seems that prolonged sleep restrictions have a relevant effect on cognitive and emotional function (Pilcher and Huffcutt, 1996). Different studies conducted on healthy subjects found progressive cognitive function deterioration (e.g., lack of concentration or memory) related to sleep dysfunction (Dinges et al., 1997; Van Dongen et al., 2003).
Consideration of sleep dysfunction in rehabilitation Among the different cognitive functions, memory has most often been the subject of study (Bell-McGinty et al., 2004; Mu et al., 2005; Lim et al., 2007). Other cognitive alterations, e.g., verbal learning (Thomas et al., 2000; Drummond et al., 2005), divided attention (Drummond et al., 2001), decision making processes (Venkatraman et al., 2007) or emotional response to images (Michael and Lisa, 2008) have also been studied but to a lesser extent. Sleep alterations are also considered an important risk factor for psychological dysfunction and mental illness (Chang et al., 1997; Koren et al., 2002; Argoff, 2007). For instance, people with schizophrenia usually have long periods of weakness due to decreased duration of sleep whereas people with obsessive symptoms require less sleep (Chang et al., 1997). People suffering from depression have precocious waking with a subsequent difficulty falling sleep again, while subjects with anxiety have problems in getting to sleep. It has been shown that serotoninergic system is involved in the regulation of sleep and wakefulness (Cifariello et al., 2008). In particular, REM-phase sleep depends on the decrease of serotoninergic tone within brain stem structures. Sleep restriction also induces an activation of serotoninergic neurons due to prolonged wakefulness. Further, the common neurobiological mechanisms resulting from sleep restriction suggest that sleep loss in insomniac or depressed patients might be an endogenous compensatory process (Adrien, 2002). In addition, poor sleep has also been associated with emotional stress. This has been shown in the form of depression, hostility, fatigue and confusion (Atkinson et al., 1988). Sleep alterations in patients with chronic pain have also been connected with a modification of sensitivity to pain, which may become a perpetuating factor in the cycle connecting chronic pain with sleep alterations and depression (Moldofsky and Scarisbrick, 1976). Nevertheless, the way in which sleep restriction affects cognitive function is treated differently by different authors, probably due to discrepancies between studies.
Sleep apnea Sleep apnea obstructive syndrome (SAOS) is produced by an intermittent and repetitive occlusion of the superior airway during sleep, causing a complete (apnea) or partial (hypopnea) interruption of the airflow. It is one of the more studied sleep dysfunctions due to its multiple repercussions in different body systems. In fact, sleep apnea is an example of sleep alteration with a great quantity of associated pathologies. The prevalence of SAOS ranges from 4 to 6% in males and is reported as 2% in females (Young et al., 1993; Marı´n et al., 1997). Apneas and hypopneas have a variable duration and affect cardiorespiratory homeostasis in different ways. Its repetition during sleep, sometimes several hundred times in one night, and day after day for years, gives rise to important disturbances in the central nervous system, myocardial and brain perfusion and the systemic and pulmonary blood circulation. Diurnal hyper-somnia, snoring and a spousal report of apnea pauses are the 3 main symptoms. Definitive diagnosis is based on polysomnographic monitorization or on nocturnal cardiorespiratory polygraphy. The lack of sleep has
265 also been associated with behaviour and personality disorders (depressive syndrome, irritability or paranoia), lack of memory, intellectual deterioration and diminished motor ability and perceptive skills. Further, obstructive apneas also cause important alterations in intrapulmonary gas exchange increasing the risk of cardiovascular (Krieger et al., 1989; Hung et al., 1990) and systemic hypertension (Paloma ¨ki, 1991). Similarly, these patients often also present with a greater incidence of cardiac arrhythmia (sinus bradycardia, sinus blockade, auricle-ventricular jamming) and nocturnal sudden death (Shepard, 1994).
Considerations in the context of rehabilitation Despite the repercussion of sleep dysfunctions, studies that have investigated interventions for improving sleep are few and far between (Page et al., 2006). Although no definitive evidence is currently available, non-pharmacological interventions have shown positive findings in promoting high-quality sleep and daytime functioning (Page et al., 2006). For instance, it has been identified that exercise programs improve sleep habits in obese patients with mild to moderate sleep apnea (Barnes et al., 2009) and that they improve central sleep apnea in patients with chronic heart failure (Yamamoto et al., 2007). Further, Tai Chi exercises enhanced sleep stability in patients with chronic heart failure (Yeh et al., 2008). On the contrary, moderateintensity walking or low-intensity yoga were not effective in improving sleep quality (Elavsky and McAuley, 2007). It is possible that dose or intensity of exercise programs have an important influence in the outcomes. Finally, different hands-on techniques may be also used for improving clinical implications of sleep disturbances. In fact, oropharyngeal exercises significantly reduced severity and symptoms in individuals with sleep apnea obstructive syndrome (Guimara ˜es et al., 2009). No further scientific evidence related to hands-on techniques and sleep changes is available. Based on the systemic repercussions of different sleep dysfunctions reviewed in the current paper, evaluation of sleep habits should be considered a fundamental clinical competency in contemporary physical therapy (Coren, 2009). In fact, questions on sleep dysfunction should be included in the clinical history of each patient attending a physical therapy clinic allowing the therapist to tailor management to also this possible aspect of a patient’s presentation. Buysse et al. (1989) developed “The Pittsburgh Sleep Quality Index” to assess the quality of sleep in psychiatric conditions. Clinicians may also use this Index in their patients in relation to sleep. Some key questions can be recommended: 1) For how long do you sleep at night? 2) Do you usually wake up during the night? 3) Do you need much time to get to sleep? 4) Do you feel rested when you wake up in the morning? In our clinical practice these 4 questions help us, as clinicians, to provide an orientation with regard to the quality of sleep in our patients with chronic pain.
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Journal of Bodywork & Movement Therapies (2011) 15, 268e280
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HYPOTHESIS
Pandiculation: Nature’s way of maintaining the functional integrity of the myofascial system? Luiz Fernando Bertolucci, MD* Associac¸a˜o Brasileira de Rolfing, Av. Dr. Arnaldo, 1644, CEP 01255-000, Sa˜o Paulo, Brazil Received 31 October 2009; received in revised form 14 September 2010; accepted 11 December 2010
KEYWORDS Fascia; Connective tissue; Myofascia; Yawning; Sleep-wake rhythm
Summary Pandiculation is the involuntary stretching of the soft tissues, which occurs in most animal species and is associated with transitions between cyclic biological behaviors, especially the sleep-wake rhythm (Walusinski, 2006). Yawning is considered a special case of pandiculation that affects the musculature of the mouth, respiratory system and upper spine (Baenninger, 1997). When, as often happens, yawning occurs simultaneously with pandiculation in other body regions (Bertolini and Gessa, 1981; Lehmann, 1979; Urba-Holmgren et al., 1977) the combined behavior is referred to as the stretch-yawning syndrome (SYS). SYS has been associated with the arousal function, as it seems to reset the central nervous system to the waking state after a period of sleep and prepare the animal to respond to environmental stimuli (Walusinski, 2006). This paper explores the hypothesis that the SYS might also have an auto-regulatory role regarding the locomotor system: to maintain the animal’s ability to express coordinated and integrated movement by regularly restoring and resetting the structural and functional equilibrium of the myofascial system. It is now recognized that the myofascial system is integrative, linking body parts, as the force of a muscle is transmitted via the fascial structures well beyond the tendonous attachments of the muscle itself (Huijing and Jaspers, 2005). It is argued here that pandiculation might preserve the integrative role of the myofascial system by (a) developing and maintaining appropriate physiological fascial interconnections and (b) modulating the pre-stress state of the myofascial system by regularly activating the tonic musculature. The ideas presented here initially arose from clinical observations during the practice of a manual therapy called Muscular Repositioning (MR) (Bertolucci, 2008; Bertolucci and Kozasa, 2010a; Bertolucci, 2010b). These observations were supplemented by a review of the literature on the subject.
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Pandiculation
269 A possible link between MR and SYS is presented: The neural reflexes characteristically evoked through MR are reminiscent of SYS, which both suggests that MR might stimulate parts of the SYS reaction, and also points to one of MR’s possible mechanisms of action. ª 2010 Elsevier Ltd. All rights reserved.
Note on terminology Pandiculation (from the Latin: pandiculare Z stretching) is most often used to denote both the yawning and the involuntary stretching of somatic muscles, which together characterize the stretch-yawning syndrome (SYS). Though the yawn and the stretch are associated phenomena, each can occur independent of the other. Most studies about SYS focus on yawning, although the oft-accompanying stretch is occasionally described. It is less common for studies focus on the stretch component alone. In this text, SYS will be used to denote the combined behavior, while pandiculation will be used to denote the stretch behavior by itself.1 Although such use is not the most common, the author rejected the term stretch to denote the involuntary stretching part of the SYS because it can be confused with voluntary muscle lengthening, which is part of a wide range of sports and bodywork activities, and is an entirely distinguishable phenomenon.
1
Where other authors are quoted directly, the terminology is their own.
Pandiculation: determining and maintaining neural circuitry and peripheral motor effectors Pandiculation is an old and almost ubiquitous behavior that occurs in similar form and circumstances across a wide spectrum of species (Baenninger, 1997). The regularity and vigor of pandiculatory movements suggest that they might be physiologically significant. Walunsinki notes that according to Darwin’s concepts, the cost of a behavior with high metabolic demand is likely to be outweighed by some adaptive benefit (Walusinski, 2006). Indeed, the phylogeny and ontogeny of pandiculation reveal its likely role in the development and maintenance of motor function, in both its structural and neural aspects. Fraser (Fraser, 1989a), in connection with ultrasound fetal studies on sheep, refers to fetal pandiculation as a mechanism that influences functional determination of the moving parts of the musculoskeletal system and contributes to articular development and maintenance. He also identifies a bodily care and self-maintenance function of pandiculation, which restores muscle homeostasis in poultry, dogs, cats and horses, among other animals (Fraser, 1989a). In ostriches, a similar “maintenance” pandiculation has been described by Sauer and Sauer (Sauer and Sauer, 1967). In man, pandiculation is also ontogenetically precocious, starting as early as 12 weeks of gestation (de Vries et al., 1982). It has been associated with the development of motor neural circuitry (Lagercrantz and Ringsted, 2001; Marder and Rehm, 2005; Briscoe and Wilkinson, 2004) and associated musculoskeletal effectors (de Vries et al., 1982; Walusinski et al., 2005). In fact, individual muscles are differentiated from primitive mesodermal condensations only after the establishment of their neural connections (Sadler, 1995), based on their specific motor actions, as discussed below: Muscle development begins with primitive myoblasts, which aggregate and give rise to the primary myotubes. Around the 10th week of gestation, the primary myotubes
are invaded by spinal cord motor neurons, which give the primary myotubes contractile capacity. Within the primary myotubes, additional myoblasts aggregate, eventually giving rise to secondary myotubes, both sharing the same basement membrane at this stage. Later in fetal development, the secondary myotubes connect with tendon structures, at which time they develop their own basement membranes and become independent structures (Jones et al., 2004). The differentiation of primary and secondary myotubes into discrete motor unit populations is implied by the differentiation of separate encasing fascial layers and gliding interfaces, which enclose and allow independent motion of their contents; i.e., discrete fascial linings – and the areolar matrices between them, which allow them to glide against each other – are established upon functional grounds. Such mechanical-structural coupling is not confined to soft tissues; it can be extended to bone (Wolff, 1986), joint surface shapes (Kapandji, 1987) and virtually every tissue under mechanical stress (Moore, 2003; Silver et al., 2003). Besides shape, the molecular compositions of musculoskeletal structures are also functionally determined, involving the phenomenon of mechanotransduction (Ingber, 2006, Stevens-Tuttle et al., 2008; Banes et al., 1999), further discussed below. In summary of the above, repetitive motion gradually determines shapes and compositions of moving structures, as well as their associated neural control pathways. The precociousness and stability of pandiculation suggest its contribution to such development.
Neuropharmacology and neurophysiology of SYS: an arousal function? The SYS has been associated with the maintenance of arousal and attention; i.e., it sets and maintains the central nervous and locomotor systems so that the animal is able to perceive environmental stimuli and respond to them with
270 appropriate motor actions (Baenninger, 1997; Walusinski, 2006; Askenasy, 1989). Although no particular cerebral structure has been definitively associated with yawning (Argiolas and Melis, 1998), because yawning is seen in anencephalic newborns with only the medulla oblongata (Heusner, 1946), the brainstem appears to be involved. In addition, pharmacological and clinical evidence suggests the involvement of the hypothalamus, bulbus and pons. Since the 1960s, injection of various substances (e.g., adrenocorticotropin [ACTH], a-melanocyte stimulating hormone [a-MSH] and related peptides) into the CNS, has been shown to stimulate SYS activity in laboratory animals (Argiolas and Melis, 1998). More recently, it has been shown that rats’ stereotypical yawning, including trunk stretching (SYS), can be triggered by stimulation of the paraventricular nucleus (PVN) of the hypothalamus via electrical or chemical (nitric oxidereleasing compounds) means (Sato-Suzuki et al., 1998). Today, it is commonly believed that, once stimulated, PVN oxytocinergic neurons release oxytocin into extrahypothalamic structures; and that these structures, in turn, mediate SYS and arousal responses (Walusinski, 2006). As SYS involves various behavioral and autonomic events, it is assumed that the PVN integrates the outputs of various origins and creates efferents on at least five different levels: respiratory, cardiovascular, facial motor, spinal motor and arousal systems (Sato-Suzuki et al., 1998), which are responsible, respectively, for the reactions of deep breath, drop in blood pressure, mouth opening, trunk stretching, and arousal response. Other neurotransmitters, including orexins, acetylcholine, dopamine, serotonin, and opioid peptides have also been shown to mediate the expression of SYS behavior (Argiolas and Melis, 1998; Sato-Suzuki et al., 2002).
L.F. Bertolucci
Figure 2 Yawning is commonly accompanied by pandiculation of the upper extremities.
Sato-Suzuki’s model on yawning/arousal responses in rats illustrates the main CNS pathways possibly involved in SYS (Sato-Suzuki et al., 2002) (Fig. 1). Pandiculation can be considered a Modal Action Pattern (MAP) (Rosenbloom, 1994), an orderly sequence of reflexive behaviors, within which category evolutionarily important instinctual activities such as feeding, mating and other social behaviors important to survival are classified. As such, pandiculation seems to be elicited by complex array or sequence of stimuli, which might include both exteroceptive signals (e.g., light-darkness) and interoceptive ones (e.g., circadian endocrine cycles and somatic interoception) (Walusinski, 2006).
Figure 1 Schematic representation of Sato-Suzuki’s model on yawning/arousal responses mediated through the PVN in rats. Orexin neurons from the lateral hypothalamic area (LHA) may directly activate neurons in the paraventricular nucleus (PVN), which in turn project to the locus coeruleus (LC) or the basal forebrain. Oxytocinergic neurons from the PVN project to the lower brainstem, including the facial nucleus and respiratory related neurons which are implicated in the yawning response. OXT, oxytocin; OX, orexin; NA, noradrenaline; Ach, acetylcholine. Reprinted with permission from: Ikuko Sato-Suzuki, Ichiro Kita, Yoshinari Seki, Mitsugu Oguri, Hideho Arita. Behavioural Brain Research 128 (2002) 169e177 Cortical arousal induced by microinjection of orexins into the paraventricular nucleus of the rat.
Pandiculation
SYS phenotype The SYS has a similar and stereotyped phenotype along the evolutionary scale, having remained virtually unchanged. Yawning (Fig. 2) starts with a long and deep inhale, reaches a peak, and concludes with a short exhale. Respiratory, mouth, neck and upper spine muscles engage in co-contraction, simultaneously stiffening the joints and stretching the myofascial tissues (Walusinski, 2006). The few references to pandiculation in the existing literature describe it as a series of coordinated actions that unfold sequentially, building up soft tissue contractile tension to a peak, at which point the joints of the limbs and trunk are maximally extended e or, alternatively, the trunk is arched in flexion (Fraser, 1989b). After the peak, the soft tissue tension level plummets, yielding a sense of pleasure and well-being (See section on Pleasure, below). The actions can be regional or involve the whole body, and are often bilaterally symmetrical (Fraser, 1989b).
SYS: compensatory response to temporary stiffness or immobility? The patterns of full body pandiculation are, in general, similar to the ones used in striding and righting behaviors (Fraser, 1989b) – i.e., they emulate ordinary functional movements – while pandiculation of limited bodily regions seem to be a corrective response to the stiffness induced by temporary positional stress or immobility. During turnover metabolism extracellular matrix (ECM) components are continuously both reabsorbed and synthesized. Molecular interactions between glicoseaminoglicans (GAGs), fibers and other components continuously change structural mechanical properties. The weaving of protocollagen monomers into fibers is spontaneous, driven by hydrophilic interactions of hydrogen bonding between water and amino acid side chains. All that is necessary for this process are the physiologic conditions of temperature, pH, ionic strength and degree of hydration (Leikin et al., 1995; Giraud-Guille et al., 2003). Mechanical stresses are the main determinants of form and relationship in this continuous and spontaneous reweaving; i.e., movement is crucial to the maintenance of the appropriate form and function of the ECM (Kjær et al., 2005, 2006, 2009; Tomiosso et al., 2005). For example, dense tissue is deposited in response to the mechanical need for tensional resistance, while areolar tissue is renewed where gliding is required. Without mechanical input, the ECM would be laid down amorphously and its configuration would not meet physiological requirements. For the configuration of the ECM to be physiologically appropriate, the mechanical input that stimulates it must first be appropriate. For example, a long striding movement will remain possible only to the extent it is sufficiently expressed, because only such expression will stimulate a supportive ECM configuration (Kjær, 2004; Kjær et al., 2009, Heinemeier et al., 2007). But, most of the time, animals are not expressing their optimal qualities of movement, such as running at maximum speeds and attaining maximum range of movement (ROM) in the joints. What’s more, sleep imposes a regular period of
271 immobilization, to which the patterns of collagen weaving and ECM relationships will accommodate. This suggests a continual tendency to “tie up” the animal’s entire structure: cross-linking of collagen fibers directed by sub-optimal movements can limit function by diminishing (a) tissue length and strength and (b) the internal gliding capacity between parts necessary for attaining optimal motor potential. Unless it is counteracted, this process could lead to progressive loss of ROM in the joints and stiffening of tissues, both of which might compromise tissue health by restricting fluid distribution and distorting cell shape – and thus inhibiting appropriate gene expression. The mechanically driven modulation of genetic activity will be further discussed in the section on Mechanotransduction, below. Pandiculation, with its specific and vigorous muscle activity, might be a means to compensate for the mechanical signals delivered by rest periods and sub-optimal movements. Fraser mentions, in connection with his studies of pandiculation among various species, that it might be considered a feedback from stiffness, and possibly be triggered by extended periods of immobility in asymmetrical positions. He concludes that if the body tends to stiffen, pandiculation “can serve to restore the limb (and related musculature) to an original (homeostatic) state (Fraser, 1989a, 1989b)”. In fact, SYS has much in common with other homeostatic functions, as discussed immediately below.
Emotional motor systems and SYS In humans, voluntary motricity involves the concerted activity of all constituents of the motor system. Movement planning is translated into actual motor responses through a chain of neural activity that starts at the prefrontal cortex, and then reaches the premotor area and the primary motor cortex sequentially (Kandel et al., 2000; Hallett, 2007). Neurons in the primary motor cortex project their axons directly to motor neurons via the cortico-spinal tract. As these axons descend, they form the medullary pyramids; thus, the entire projection is also called the pyramidal tract. The motor information the pyramidal tract carries is modulated not only by sensory information, but also by information from lower motor regions (basal ganglia, thalamus, midbrain, cerebellum, spinal cord), which information allows voluntary movements to be smooth, precise and well coordinated (Kandel et al., 2000). The modulation of information in the pyramidal tract is mainly unconscious and automatic; i.e., the subcortical centers provide the unconscious, involuntary and patterned components essential to movement control (Jacobs and Horak, 2007; Guyton and Hall, 2006; Takakusaki et al., 2003), in contrast to the volitional components of motor action governed by the cortical centers. In general, the lower the structure, the simpler the motor information it conveys. For example, the spinal cord is at the lowest level; and the information it conveys serves to mediate simple reflexes related to rhythmic automatisms such as locomotion and scratching. Higher centers mediate more complex motor activity in a hierarchical organization of complexity (Kandel et al., 2000). For example, while lesions of the primary motor cortex can produce contralateral
272 hemiplegia in humans, some postural and stereotyped involuntary movements may be preserved (Kandel et al., 2000). Similarly, components of certain instinctual behaviors can be executed without the intervention or modulation by the cortical centers. Instinctual behaviors evolved to guarantee the continuity of organisms’ lineages, maintain internal homeostasis, and insure successful breeding (Dentona et al., 2009). They are mediated primarily by the limbic system and include those life-supporting activities (e.g., feeding, self-defense, sex) collectively named emotional behaviors (Guyton and Hall, 2006; Kandel et al., 2000). In experimental animal models, stimulation of limbic structures, notably the hypothalamus and the amygdala, has elicited various emotional behaviors (Kandel et al., 2000,Guyton and Hall, 2006). – even in the absence of the cerebral cortex. For example, after decortication, an investigative procedure in which the connections between cortical and subcortical structures are severed, the latter continue to function without inhibitory influence of the former. Decorticated animals can feed themselves, express rage and fight, and have sexual intercourse (Magoun and Ranson, 1938; Smith, 1939; Guyton and Hall, 2006), which shows that the limbic system can produce such behaviors in the absence of cortical participation. In fact, the limbic system sends diffuse and innumerable projections to the medulla. It is a system unto itself, able to produce motor activity independent of the voluntarily driven pyramidal system. Holtstege describes it as the emotional motor system because limbically regulated behaviors depend on the emotional state of the animal. The functions governed by the limbic system include different types of involuntary movements associated with olfaction and eating, such as licking, chewing, and swallowing; clonic and rhythmical movements (e.g., locomotion, shivering); sexual function; vocalization, laughing, and crying; and defense reflexes, among others (Guyton and Hall, 2006; Holstege, 1992). Indeed, in laboratory animals various stereotyped behaviors have been reproduced with electrical or chemical stimulation of mesencephalic nuclei, particularly the PVN (paraventricular nucleus) of the hypothalamus. Chewing, licking, lordosis in females, penile erection, and grooming have been observed (Argiolas et al., 2000; De Wied, 1999; Vergoni et al., 1998). The SYS is among these behaviors produced by the limbic system, and its phylogenic longevity suggests an adaptive function. One function of the PVN is to integrate the central and peripheral autonomic systems. The PVN projects onto all autonomic neurons in the brainstem and spinal cord, given that it is involved in various autonomic and endocrine functions relative to the maintenance of homeostasis (Kandel et al., 2000). These functions include: production of cortisol via secretion of corticotropin-releasing factor (CRF); production of oxytocin and vasopressin (hormones involved in milk production and water balance respectively); and regulation of factors such as food intake, heart rate, and blood pressure (Kandel et al., 2000; Holstege, 1992). That the SYS is mediated by the PVN suggests that the SYS might serve some general homeostatic function, which functions are carried out autonomously by the emotional motor system. In man, the workings of the emotional motor system are illustrated by the involuntary movements of patients with
L.F. Bertolucci voluntary motor pathway lesions. For instance, when hemiplegic patients yawn, they have been observed to raise involuntarily an otherwise plegic arm (Graham, 1982; To ¨pper et al., 2003; Stewart, 1921), with the muscles of the paralyzed limb activated nearly as much as those of a normal limb would be in a voluntary movement (Omam et al., 1989). Also observed in hemiplegic patients are sinkinesias, in which voluntary movement of one part produces involuntary movement of another; e.g., thigh flexion and arm abduction during sneezing, or arm movements during micturation (Walshe, 1923). Similarly, patients with voluntary facial palsy show facial movements while laughing (Hopf et al., 1992; To ¨pper et al., 1995; Chernev et al., 2009), and patients incapable of voluntarily opening their mouths do indeed open them while yawning (Askenasy, 1989). Taken together, the experimental and clinical observations summarized above illustrate that automatic (emotional) motor behaviors can express their patterns independent of the voluntary somato-motor system. Because in normal subjects the former is under the inhibitory influence of the latter (Marder and Rehm, 2005; Pincus and Tucker, 1974), involuntary limbic behaviors tend to appear when volitional motor circuits are damaged e naturally (as in hemiplegia) or artificially (as in decortication). The fact that normal human motor behavior includes the modulation of instinctual drives (Smith, 1992) might explain why SYS behavior tends to decrease as the person ages.
Pandiculation versus ordinary stretching: automatic versus volitional motor actions If we attend to our interoceptive sensations, our experience tells us that pandiculation and SYS exhibit peculiar motor recruitment. If one “yawns” on purpose, one’s internal sensations are quite different from those elicited by a spontaneous yawn. Similarly, the sensations produced by spontaneous pandiculation are different from those that accompany either “volitional pandiculation” or volitional soft tissue stretching. The patterns of volitional stretching are cognitively established and the action purposely performed. They often involve relaxation of the muscles through a diminution of their actions: the subject muscle is elongated passively, as a result of either gravity or the activity of opposing muscles. By contrast, the patterns of pandiculation are automatic. Through intense and involuntary deep muscle cocontractions, the soft tissues actively elongate themselves against the bony structures as the joints are stiffened. Each movement within the pattern emerges in sequence, apparently from the recruitment of a mosaic of reflexes, the sequence of which can neither be anticipated nor purposely performed. Just as a spontaneous yawn feels quite different from a deliberate imitation of one, spontaneous pandiculation feels quite different from a voluntary pandiculation-like stretch. Because the voluntary and emotional motor systems have discrete neural pathways, pandiculation’s distinctive internal sensations might be attributable to the motor unit recruitment sequences dedicated to automatic movement patterns. Indeed, the
Pandiculation contrast between interoceptive experiences during automatic versus volitional motor actions has been documented (Hommel, 2009). What’s more, operation of the hierarchically higher volitional system can inhibit that of the lower automatic system; this inhibition can disrupt the characteristic spontaneity of the SYS in favor of a cognitively directed stretch. Automatic arm abduction during yawning in hemiplegia shows the non-volitional nature of SYS: the patients did not show any arm movement when they imitated a yawn (To ¨pper et al., 2003). In other words, voluntarily imitation of the automatic motor pattern (via the cortico-spinal system) will not reproduce immediately the instinctive patterns originated in the limbic system (via the emotional motor system). Moreover, if the motor patterns are discrete, their physiological effects should be discrete, as well. The importance of stretching to the maintenance of musculoskeletal health is well-known. In humans, each of the myriad of physical fitness regimens that include stretching has its own rationale; and although all muscle groups should be stretched, different regimens address particular problems and are intended to compensate for various patterns of muscle shortness or consequent joint mobility restriction. But how do animals in the wild maintain musculoskeletal health? They perform no voluntary stretching and still maintain their motor capabilities. Might SYS be responsible? If so, and if it were possible to stimulate SYS, might SYS be employed to achieve therapeutic goals? Various somatic practices encourage the SYS because of its apparent homeostatic effects, e.g., Hanna Somatics, Joyflexing, Eutonia (Hanna, 2004; Johnson, 2002; Vishnivetz, 1995). In Eutonia, the SYS is observed to be evoked by certain attentional states and forms of mechanical stimulation. Similarly, the specific mechanical stimulation of Muscle Repositioning might also stimulate the SYS. (see section on responses induced by MR, below).
Pleasure and health Ancient biological behaviors associated with the maintenance of homeostasis are directed through interoception – the sensory experience reflective of the physiological condition (Craig, 2003). Sensory experiences of displeasure and pleasure define the affective qualities of stimuli, which influence an animal’s behavior (Guyton and Hall, 2006; Bozarth, 1994). The positive affects of pleasurable experiences support many life-supporting behaviors: satisfaction of hunger and thirst, sexual intercourse, and vesicle and bowel evacuation are examples of instinctive behaviors that, once accomplished, reward the animal with an experience of pleasure, which biologically reinforces their expression. Preservation of health (salutogenesis) is intimately linked to the perception of positive affects (Esch and Stefano, 2004). Such positive affect states are closely related to ancient subneocortical limbic brain regions common among humans and other mammals, in which various neuropeptides appear to mediate homeostatic satisfactions (Burgdorf and Panksepp, 2006; Vincent, 1994; Cabanac, 1992). The instinctive behaviors, contributing as they do to the maintenance of the internal milieu, can be considered
273 homeostatic drives (Sherwood, 2010), a category within which pandiculation may also be included. Not only has pandiculation been associated with pleasure and well-being (Fraser, 1989a; Sauer and Sauer, 1967; Russel and Fernandez-Doz, 1997; Walusinski, 2006; Steward, 1921), but it also shares with the other homeostatic drives involvement of the PVN nucleus of the hypothalamus. Homeostasis is maintained chiefly by the parasympathetic division of the autonomic nervous system (Recordati and Bellini, 2004), and increased parasympathetic activity has been detected during SYS (Askenasy and Askenasy, 1996). What’s more, the frequency of SYS is correlated with degrees of health or convalescence: Fraser (Fraser, 1989b) notes that pandiculation is absent in animals with some systemic illnesses, but returns as the animal recovers. Similarly, in recovering hemiplegic patients, SYS and synkinesias characteristically re-emerge (To ¨pper et al., 2003; Hwang et al., 2005) in advance of voluntary limb movements. Notably, patterns of involuntary synkinesias have been proposed as a parameter for assessment of poststroke hemiparesis recovery, as the timing of how the patterns emerge seems to be related to the patient’s functional outcomes (Hwang et al., 2005). During coma, yawning foretells the approach of wakefulness (Braunwald et al., 1987). Therapeutic application of transcranial electromagnetic fields in the treatment of Parkinson’s disease and multiple sclerosis has elicited SYS. In a multiple sclerosis investigation, SYS reappeared in those patients whose disease had gone into remission in response to treatment (Sandyk 1999, Sandyk, 1998). However, excessive pandiculation is associated with certain diseases and the use of certain drugs (Askenasy, 1989). This suggests a possible distinction between a complete (and successful) and an incomplete (and unsuccessful) pandiculation. Perhaps the former, having fulfilled its purpose, physiologically recurs; while the latter, seeking completion, pathologically repeats. Consider, for example, the palpable frustration that accompanies the interruption of a yawn or sneeze!
Mechanotransduction, tensegrity and health Arguably, a cell’s function is fundamentally dependent on its shape. No longer considered mere gelatinous cytoplasm enveloped by a flexible membrane, the cell is now believed to be structured by an internal cytoskeleton consisting of a complex array of microtubules and microfilaments (Ingber, 2008a). Mechanical stimuli govern the synthesis of the cytoskeleton, which determines the cell’s form (Patwari and Lee, 2008; Bischofs et al., 2008). What’s more, mechanical links between the cytoskeleton, on the one hand, and cellular components such as protein synthesis machinery (e.g., ribosomes and mRNA) and membrane receptors, on the other hand, mechanically modulate the components’ functions by a mechanism known as mechanotransduction (Ingber, 2008b; Bischofs et al., 2008; Chiquet et al., 2009). Through mechanotransduction, mechanical stimuli are transduced into chemical responses (Humphrey and Delange, 2004), such as protein synthesis. By modulating gene expression, the activity of membrane surface receptors and ion channels, and related cellular
274 functions, mechanical forces govern the cell’s development, maintenance, functions and fate (e.g., Dahl et al., 2010; Chiquet et al., 2009; Patwari and Lee, 2008; Haudenschild et al., 2009). A cell’s shape, molecular constitution and functions reflect the mechanical stresses put upon it. For example, in response to particular dynamic mechanical load patterns, human mesenchymal stem cells enable distinctive gene expression patterns, which in turn produce changes in cell shape and volume (Haudenschild et al., 2009). It appears that each tissue is developed and maintained to bear the stresses to which it is exposed; e.g., tension stimulates both fibroblastic and osteogenic genes, while compression stimulates genes associated with chondrogenesis (Haudenschild et al., 2009). Evidence suggests that mechanical stimuli alone can even help a genomic-defective cell to attain a normal phenotype (Gieni et Hendzel, 2008). But because cells are not isolated, cell shape is also influenced by the cell’s relationship to the extracellular matrix (ECM) surrounding it. Through interactions at adhesive sites on the cell membrane, components of the ECM affect the net mechanical outcome of the externally acting forces (Streuli, 2009; Bischofs et al., 2008). For example, fibroblasts and other adherent cells sense the physical parameters (e.g., rigidity) of the ECM and modify their protein expression accordingly, and thus alter their own morphology (Do ¨bereiner et al., 2005; Chiquet et al., 2009). In connection with the influence of the ECM, note that it seems to behave as a liquid crystal (Giraud-Guille et al., 2003; Giraud-Guille, 1992; Bouligand, 1972; Kreis and Boesch, 1994). Therefore, the growth, shape and function of living tissue – not unlike those of macromolecular crystals produced in reactors e also seem to be governed by mechanical stimuli independent of biological activity (Lappa, 2003). Thus, mechanical stresses seem to direct the ECM’s composition and form (and therefore the organism’s shape and patterns of mobility) both biologically (via mechanotransduction) and non-biologically (via its liquidcrystalline properties). Macroscopically, the ECM can be conceptualized as a fibrous skeleton (Bienfait, 1987) linked to the bony skeleton. These two skeletons are believed to constitute a tensegrity structure (Ingber, 2008a, 1998): the bones, which resist compression, maintain the distance between joints and counteract the basal tension (pre-stress) imposed by the soft tissues. The soft tissues are the tensional elements, which maintain the relative positions of the bones. Tensegrity exists on smaller scales, as well; i.e., structural hierarchies link the macroscopic assemblage of bones and soft tissue to the mechanosensitive cytoskeleton, which is linked to the cellular components governing gene expression (Ingber, 2006). Movement and posture – acting simultaneously in macroscale and microscale – mechanoregulate cell function and ECM form and relations (Kjær, 2004; Kjær et al., 2009, Heinemeier et al., 2007). The variety of locomotion on display in any crowded street illustrates how individual human movement is. Within the wide variety of motor patterns, one observes qualities of movement: coordinated, fluid, and aligned movement, on the one hand – and encumbered, abrupt and
L.F. Bertolucci misaligned movement, on the other hand. Not all qualities of movement present equally beneficial stimuli for cell shape and function, and positive and negative stresses might play their parts in health and disease. Perhaps optimal movement is that which properly distributes mechanical stress through the various tissues and cells, stimulating them according to their needs. Each cell requires particular mechanical stimuli to its normal function (Ingber, 2006), and the structural and mechanical characteristics of the ECM are the ever-changing products of the various mechanical stresses imposed upon it. In short, the mechanical balance between hard and soft tissues dictates stress distribution, which plays a key role in cell shape and metabolism. In pandiculation, the intense mechanical stimuli produced by forceful co-contraction of antagonist muscle groups might serve as appropriate organizing signals to the cells and tissues by re-optimizing the mechanical conditions of their environment.
Optimal mechanical stimuli might maintain potential for optimal motor function The vigorous mechanical stimulus of SYS produces maximum soft tissue span and joint extension, which, in turn, maximize body dimensions; e.g., yawning enhances pharyngeal diameter fourfold and separates vocal cords to a degree that “cannot be noticed in any other moment of life (Walusinski, 2006)”. SYS might be a biological compensation for periods of immobility and/or vicious body positions, restoring the animal’s mobility by breaking up abnormal ECM cross-links formed by inactivity or suboptimal activity. Abnormal ECM cross-links might shorten soft tissues and reduce internal lubrication, leading to motor rigidity. SYS might restore soft tissue length and normal internal gliding movements, at the same time as mechanotransduction maintains tissue composition by matching ECM constituents to the mechanical demands of the cells, thus protecting the cells from mechanical damage (Banes et al., 1999; Ingber, 2006).
SYS and arousal: restoration of postural tonus and tensegrity Yawning is reportedly more common in carnivores, which exhibit pronounced cycles of rest and activity, than in herbivores, the behavior of which exhibits less frequent cycles of arousal (Baenninger, 1997). This is further evidence of the arousal function of SYS. Upon awakening, the reticular formation relays activating stimuli not only to the thalamo-cortical systems, but also to the postural and locomotor systems. This activation makes the fight-flight response readily available (Walusinski, 2006). The fact that animals most often awaken immediately following REM sleep (which is characterized by muscle atonia), led Walunsinky (Walusinski, 2006) to postulate an opposing relationship between REM sleep and SYS, during which strong muscular contractions elicit an immediate shift of the previous neural patterns controlling the REM sleep, facilitating the appearance of a functional network appropriate for the control of the wakeful motor pattern.
Pandiculation Apparently, SYS restores to the myofascial system the elevated level of tonus required for activity in gravity: because in sleep the myofascia is slack and relaxed, the body segments must be reassembled upon awakening before the organism can move properly in the field of gravity. In a tensegrity structure, the orderly distribution of prestress permits rapid mechanical communication throughout the entire body. Whatever the entry point and direction of an external mechanical stimulus, the reciprocal tensions within the body allow the stimulus to reach and affect mechanoreceptors throughout the entire system. A tensegrity structure thus exhibits much greater mechanosensitivity than a slack system, in which the influence of external stimuli remains local. The absence of slack in a well-balanced tensegrity structure also means that mechanical communication is virtually instantaneous. This facilitates fast and accurate motor responses (Ingber, 2006, Ingber, 2008b; Chen and Ingber, 1999), the adaptive value of which is evident. Such structural coupling among elements in a tensegrity structure, named “morphological communication”, has already been proposed even to assist in controlling movement, alongside the nervous system (Rieffel et al., 2010). For the basal tension of a tensegrity structure to be efficiently distributed, the links among the tension elements must be precisely located. In addition, the compression elements must approximate precisely relative to each other, which requires both free articular ROM and free gliding among associated e and precisely located myofascial structures. A functional combination of linking among tensional elements with gliding among compressional elements is essential to the “assembly” of bony and fibrous skeletons that exhibit full tensegrity properties. Each body form (particular arrangement of intersegmental relative positions) implies a certain combination of precisely located structural linking and gliding configurations to distribute pre-stress evenly. The immense variety of body forms that movement implies, each one affected by gravity, allows us to imagine how innumerable are the linking-gliding configurations.
Figure 3 Dogs often pandiculate in this pattern of extension of the forelimbs and trunk; yawning is also frequently simultaneously present. Pandiculation involves progressive cocontraction and stretching of soft tissues, which may extend to virtually every muscle in the body.
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Figure 4 The downward dog yoga asana is reminiscent of a pandiculating dog.
Perhaps the vigorous co-contractions of pandiculation systematically reshape the structural linkage among segments and simultaneously signal the cells (via mechanotransduction) to synthesize the ECM components required to maintain the appropriate environment (Fig. 3). If so, pandiculation might help restore optimal musculoskeletal arrangements, and thus optimize motor capabilities.
The pandiculation connection: yoga and martial arts The downward dog position (Fig. 4), like many yoga asanas, is reminiscent of an animal pandiculation position (Iyengar, 1979). In fact, some say yoga is derived from automatic and spontaneous actions of sages deep in meditation, and that yoga should be practiced spontaneously (Muni, 1994). Eastern martial arts might also have a connection with pandiculation. Qi Gong, for instance, requires the body to be fortified with automatic (involuntary) tonus in the deep postural muscles at the same time the superficial muscles associated with voluntary activity are relaxed (Fig. 5).
Figure 5 Qi Gong posture. The stretching of the whole myofascial system is reminiscent of pandiculation.
276 Under these conditions, the body is integrated as a whole and all its parts relate with one another in movement (see http://www.caiwenyu.com.br/09_Fotos_p_ing.htm). These conditions cannot be produced by voluntary motor action, but emerge spontaneously with appropriate states of attention in which mechanosensing is enhanced. A person in such state could take advantage of elastic potential energy stored in the body when performing a blow. This characteristic of Qi Gong suggests a tensegrity-based mode of action with a high pre-stress level. In fact, potentiation of performance has already been shown in prestretched muscles, due to their ability to store potential elastic energy (Bosco et al., 2008; Ettema et al., 1990; Ishikawa et al., 2006). Elements of martial arts training forms are often described in terms suggestive of animal pandiculatory patterns (Johnson, 2002). This invites reflection upon the fact that decorticated cats and dogs do exhibit instinctual behaviors, such as eating, copulating and fighting (Argyle, 1988); i.e., that basic life-supporting behaviors can happen without cortical participation. In fact, fighting appears to be a largely reflexive behavior, the expression of which is associated with subcortical structures such as the hypothalamus and midbrain periaqueductal gray (PAG) (Ulrich and Azrin, 1962; Shaikh and Siegel, 1994).
Responses induced by MR might be similar to those of pandiculation Like pandiculation, MR’s manual local loading of the myofascial system integrates body parts, apparently by inducing co-contraction of opposing muscle groups (Bertolucci, 2008; Bertolucci and Kozasa2010a, Bertolucci, 2010b), at the same time as it evokes a measurable rise in tonic muscle activity indicative of an overall increase in load. The client’s subjective experience is similar to that evoked by pandiculation, which suggests a common element among pandiculation, yoga and martial arts and MR. In pandiculation, muscle activation begins locally and spreads to neighboring areas until it reaches a peak of distribution and intensity; i.e., joints progressively stiffen through a chain of reflexes, in which neighboring segments are sequentially engaged to form an ever-larger block that eventually encompasses the entire body. Following the peak, the tissues release. MR induces a similar progressive engagement of body segments. The inclusion of each segment increases the overall tension within the block until, following the peak, the practitioner feels an abrupt soft tissue release. The progressive segmental engagement is paralleled by an increasing involuntary tonic muscle activity observable both by palpation and by electromyography (Bertolucci, 2008; Bertolucci and Kozasa, 2010a; Bertolucci, 2010b). Let us imagine how it might be that MR and pandiculation would evoke similar muscle activity. The author hypothesizes that the manual forces applied during MR maneuvers mimic internal forces, and therefore induce mechanoreceptor afferents, similar to those characteristic of pandiculation. In the clinical setting, recipients of MR treatments have exhibited spontaneous pandiculation-like movements (see
L.F. Bertolucci videos at http://musclerepositioning.blogspot.com/), and have described their subjective experiences during MR as similar to their experiences during pandiculation. Some clients also report having resumed the habit of pandiculating in the morning, to which they attribute a greater sense of bodily well-being along with relief from musculoskeletal symptoms. These observations support the hypothesis of a similarity between MR and pandiculation. Perhaps MR is a blend of myofascial release and “assisted pandiculation”, with the soft tissue release evoked by a combination of the practitioner’s manual input and the internally generated forces of tonic pandiculation-like reactions. This combination of forces might produce a greater effect in the soft tissues than either manual input or pandiculation alone.
Is SYS culturally inhibited? SYS recruits the medullar, genetically determined Central Pattern Generators which, in higher primates, are under neocortical control (Marder and Rehm, 2005). Humans, unlike other primates, have been observed to yawn less frequently as they age (Walusinski et al., 2005); however, in various old world monkeys (Cercocebus albigena, Macaca fuscata and Macaca fascicularis) yawning has been shown to become more frequent as plasma androgen levels increase (Deputte, 1994; Troisi et al., 1990). As yawning has negative social connotations in most cultures and religious traditions (Walusinski et al., 2010), perhaps cultural conditioning inhibits the SYS in humans. Given the likely homeostatic function of SYS, any such inhibition might contribute to the high incidence of human musculoskeletal disorders.
Biological clocks and health Maintenance of homeostasis is closely related to biological rhythms, which are controlled by both environmental and endogenous stimuli (Are ´chiga, 2003). Biological rhythms are generated by intracellular mechanisms called circadian clocks, which are present in both specific CNS centers and most peripheral tissues (Duguay and Cermakian, 2009; Are ´chiga, 2003). In particular, they are present in fibroblasts, the cells responsible for the synthesis of ECM constituents. The intrinsic biological rhythms of fibroblasts have been shown to be involved in various metabolic functions (e.g., cytoskeleton protein synthesis, cell cycle control and enzyme synthesis, among others) (Bursian, 2009). While the fibroblast’s metabolic machinery has a rhythm of its own, it is at the same time influenced by mechanical stimuli e including, presumably, those generated through other biological rhythms. This raises the question of whether various biological rhythms mutually influence each other. It is already known that various biological rhythms are related: e.g., heart rate, respiration, and periodic somatomotor excitation have been shown to interact (De Haro and Panda, 2006 Niizeki et al., 1993). The existence of such complex relationships among biological rhythms led to the concept of multi-oscillatory systems, as well as the hypothesis that synchronization among various co-existing
Pandiculation rhythms is a determinant of gene expression and biological activity in both plants and animals (Lloyd, 2009; BellPedersen et al., 2005). Quite possibly, the circadian clocks intrinsic to the fibroblasts might correlate regularly with other bio-cyclical phenomena such as the sleep-wake transition associated with SYS. Sleep-wake and other biological rhythms have already been shown to be related to the immune response (Shepard and Shek, 1997), which indicates their importance to general health and inspires further study as to the possible role of rhythmic activities (such as SYS) in the maintenance of homeostasis in both particular tissues and in the organism as a whole. Tissue microdialysis, serum metabolic-tracers, neuroimaging, EEG and EMG are all possible resources for further investigation of the physiological role of SYS.
Conclusion The concept of myofascial force transmission (Huijing and Jaspers, 2005) assumes the presence of ECM links among musculoskeletal components, which links unite those components into an integrated system; i.e., the fascia itself is assumed to play an integrative role. Integrated movement both requires and stimulates appropriate matrix connections. However, animals engage in a great deal of nonoptimal movement, of which immobilization (e.g., during sleep), trauma and bad postural habits are among the causes. Should normal activities generate both “good” and “bad” mechanical signals to the ECM, the bad signals would need to be countermanded by good ones for the animal to maintain full movement capabilities throughout life. Pandiculation might provide one source of good signals by (i) breaking bad connections while stimulating better ones, and (ii) resetting postural muscle tonus to produce integrated movement, which movement is a further source of good mechanical signals. In short, pandiculation might be a form of neuro-myofascial hygiene. If this be true, might we encourage pandiculation to enhance general health? This would require a reassessment of the cultural stigma against yawning and pandiculation, as well as further investigation of therapeutic approaches, such as Muscle Repositioning, that seem to stimulate it.
Acknowlegments Thanks to Yeda Bocaletto, Angela Lobo, Soraia Pacchioni and Heidi Massa in the production of the manuscript.
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Journal of Bodywork & Movement Therapies (2011) 15, 281e290
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MANUAL MODALITY
The effects of the Bowen technique on hamstring flexibility over time: A randomised controlled trial Michelle Marr, MSc, PgCertEd, MCSP Chartered Physiotherapist and Lecturer a,*, Julian Baker, Director and Principal Instructor of The European College of Bowen Studies b, Nicky Lambon, MA, DipTP, CertEdFE, MCSP Principal Lecturer, Physiotherapy Programme Manager and Director of Faculty Placement Unit at Coventry University a, Jo Perry, MSc, MCSP, MMACP, Grad Assoc Phys Senior Lecturer, Coventry University a a School of Physiotherapy and Dietetics, Faculty of Health and Life Sciences, Coventry University, Priory Street, Coventry CV1 5FB, UK b European College of Bowen Studies, The Corsley Centre, Old School, Deep Lane, Corsley, Wiltshire, BA12 7QF, UK
Received 11 January 2009; received in revised form 23 June 2010; accepted 24 July 2010
KEYWORDS Hamstring; Flexibility; Bowen technique; Randomised controlled trial/RCT
Summary The hamstring muscles are regularly implicated in recurrent injuries, movement dysfunction and low back pain. Links between limited flexibility and development of neuromusculoskeletal symptoms are frequently reported. The Bowen Technique is used to treat many conditions including lack of flexibility. The study set out to investigate the effect of the Bowen Technique on hamstring flexibility over time. An assessor-blind, prospective, randomised controlled trial was performed on 120 asymptomatic volunteers. Participants were randomly allocated into a control group or Bowen group. Three flexibility measurements occurred over one week, using an active knee extension test. The intervention group received a single Bowen treatment. A repeated measures univariate analysis of variance, across both groups for the three time periods, revealed significant within-subject and between-subject differences for the Bowen group. Continuing increases in flexibility levels were observed over one week. No significant change over time was noted for the control group. ª 2010 Elsevier Ltd. All rights reserved.
* Corresponding author. Therapy Fusion Ltd., Trinity House, Aintree Rd, Stratford-upon-Avon, CV37 9FL, UK. Tel.: þ44 (0) 7875 597342, þ44 (0) 1373 832 340. E-mail addresses:
[email protected] (M. Marr),
[email protected] (J. Baker). 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.07.008
282
Introduction The hamstring muscles are commonly linked with movement dysfunction at the lumbar spine, pelvis and lower limbs, and have been coupled with low back pain and gait abnormality (Mok et al., 2004; Orchard et al., 2004; Vleeming and Stoeckart, 2007). Hamstring strains are regularly cited as a sport-related injury (Dadebo et al., 2005; Hoskins and Pollard, 2005), with high risk of recurrence and lengthy recovery times (Gabbe et al., 2005; Sole et al., 2008). Development of pathology and movement dysfunction have been attributed to many intrinsic and extrinsic factors (Alter, 2004). Such factors include: flexibility, strength, stability, timing, endurance, previous injuries, psychosocial aspects, equipment and environmental conditions. Limited flexibility has often been associated with neuromusculoskeletal symptoms (Spernoga et al., 2001; Witvrouw et al., 2004), providing a continual drive to investigate more effective treatment options.
The Bowen technique The Bowen technique is named after Tom Bowen (1916e1982), who created a form of bodywork in Geelong, Australia. Described as a soft tissue remedial therapy, the therapist uses fingers or thumbs to apply pain-free, gentle rolling moves over muscle, ligament, tendon and other connective tissues in specific parts of the body (Baker, 2009). Each treatment programme is personalised and determined following assessment. Reports following treatment have included improvements in; pain, range of motion (ROM), oedema, heart rate, respiration, injury rates and functional recovery (Whittaker et al., 1997; Kinnear and Baker, 1999; Carter, 2002; Esson and Godfrey, 2002; Rattray, 2002; Rattray and Godfrey, 2002; Baker, 2008; Godfrey, 2008; James, 2008). Despite a growing body of evidence, there is a paucity of quantitative research to support such claims.
Literature review The topic of flexibility is frequently debated in the literature. The need for the human body to alter flexibility variables to optimise muscular performance and prevent injury remains undisputed (Nigg et al., 2000; Witvrouw et al., 2004). The complex nature of these multi-tissue events to allow changes in length-tension relationships also remains unchallenged. Yet, the importance of interactions between the so-called ‘active’ components, (musculotendinous unit and nervous system), and ‘passive’ components (connective tissues) remains unclear, and has prevented consensus over a single definition of flexibility (Shrier, 1999; Alter, 2004; Dadebo et al., 2005). As a result, the many definitions that do exist have tended to focus on the following themes (Alter, 2004): the motion available actively and passively (Halvorson, 1989; Saal, 1987), the fluidity or freedom to move without pain (Kisner and Colby, 2007), the speed and purpose of movement (Galley and Forster, 1987) and, the extensibility of soft tissues rather than joint ROM (Halbertsma et al., 1996). To date, there is no quantification of what ‘normal’ or desirable levels of
M. Marr et al. flexibility are. For the purposes of the present study, Kisner and Colby’s (2007, p. 66) definition was accepted: ‘Flexibility is the ability to move a single joint or series of joints smoothly and easily through an unrestricted, pain-free ROM. Muscle length in conjunction with joint integrity and the extensibility of periarticular soft tissues determine flexibility’.
Flexibility: ‘active’ and ‘passive’ components The components that affect flexibility have tended to fall into two categories: ‘active’ and ‘passive’. In previous years, the focus has been on the ‘active’ musculotendinous unit (MTU) and neural structures, with regard to ROM, performance, timing and injury, rather than on the connective tissues, which have been considered more of a ‘passive’ contributor to changes in ROM (Alter, 2004). The role played by the many types of connective tissue in the control, mechanics and support of movement is the subject of much research and debate (Guimberteau, 2005; Findley and Schleip, 2007, www.fasciacongress.org/2009). Fascia (loose areolar tissue), the most abundant connective tissue, that surrounds and supports all tissues, has been classified into ‘superficial’ and ‘deep’ layers (Hedley, 2005aec). The integral nature of its relationship with the skin begs the question that any form of manual therapy, or penetration beneath the skin, must have an effect upon these layers, even if the intention is to target the deeper structures linked to viscera, muscle and bone. Langevin et al. (2002) examined the involvement of fascia during acupuncture, using high frequency ultrasound on rat abdominal tissue. The study concluded that the winding of fascia around the needle was indeed the mechanism responsible for the needle grasp effect, rather than contraction of muscle. Furthermore, the cellular and molecular effects of the mechanical signals through this interface have been shown to be widespread, varying from cell contraction to signal transduction to gene expression (Langevin et al., 2002). Fascia has been reported to have the following functions: (1) it provides a 3D framework for all tissues promoting alignment and stability (DeRosa and Porterfield, 2007), (2) it can respond to change in tension levels by transmission of signals to other interfaces (Langevin, 2006; Stecco et al., 2009), termed ‘mechanotransduction’, and (3) it provides the necessary lubricant between tissue interfaces to enable movement (Alter, 2004). Research by Hinz and Gabbiani (2007), Schleip et al. (2006, 2007), Petroll (2008) and Thomasek et al. (2002) have reported a fourth function, that fascia is capable of generating its own mechanical tension through the contraction of smooth muscle cells within its matrix. Researchers were able to produce in-vivo fascial contractions, measuring sufficient mechanical tension to potentially influence the dynamics of the human musculoskeletal system (Schleip et al., 2007).
Treatment for limited flexibility For decades, stretching, with or without warm-up, has been the most advocated conventional treatment for improving or maintaining flexibility levels (Murphy, 1991; Shrier,
Effects of the Bowen technique on hamstring flexibility over time 1999). Pre-exercise stretching has been reported to help reduce risk of injury and improve muscle performance (Safran et al., 1989; Best, 1995). Contrasting reports have also stated that static stretching may increase the risk of injury through desensitisation of the stretch reflex (Shyne and Dominguez, 1982; Saal, 1987; Murphy, 1991; Gleim and McHugh, 1997) with subsequent reduction in muscle strength and torque. Dynamic stretching has also been reported to improve muscle efficiency and reduce injury by using specific functional movement sequences as a training tool (Tollison, 2009). Yet studies into dynamic stretching have demonstrated both increase and decrease in post stretch ROM (Alter, 2004; O’Sullivan et al., 2009). Due to a multitude of opposing findings and a lack of recent, homogeneous research or reviews since Weldon & Hill’s study in 2003, it is difficult to draw definitive conclusions on the topic of stretching. The Bowen technique is also implicated where movement range is restricted (Kinnear and Baker, 1999; Carter, 2002; Baker, 2005) reporting post-treatment changes in ROM in the absence of stretching, joint mobilisation, or warm-up procedures (Kinnear and Baker, 1999; Carter, 2002; Baker, 2005). Therefore, the aim of the present study was to investigate the effect of the Bowen Technique on hamstring flexibility over time.
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week and were aged between 18 and 50 years. A deficit of at least 15 degrees from full knee extension was required at baseline, determined after randomisation. Individuals were excluded if current or previous symptoms or pathology were reported in the lower limbs, pelvis or the lumbar spine. Those who performed sport at a professional or semiprofessional level were also excluded.
Ethical considerations The Research Ethics Committee at Coventry University granted ethical approval for the study. Participants received a detailed information sheet, verbal explanation of the study intentions and a consent form. All concerned were aware of the right to withdraw from the study at any time.
Reliability
A prospective, assessor-blind, randomised controlled trial investigated the effects of the Bowen technique on hamstring flexibility. Data were collected over one week using a repeated measures design.
An intra-tester reliability study was performed, due to the removal and replacement of the electrogoniometer on each participant’s leg. Ten subjects lay supine on a plinth. Markers and use of equipment proceeded as per the data collection section. Subject’s placed the dominant leg in a random level of knee flexion, remaining supported and unmoved in this position. With the measured angle concealed, the equipment was removed, recalibrated and replaced. The results were tested for stability using an Intraclass Correlation Coefficient (2,1) (Sim and Wright, 2000, p. 335) revealing that intra-tester equipment replacement was reliable (r Z 0.99). This result has also been confirmed by Rothstein et al. (1983) and Gogia et al. (1987) where r Z 0.91e0.99 during tests. The reliability of the active knee extension test has been confirmed by Gajdosik and Lusin (1983).
Sample
Interventions
One hundred and twenty asymptomatic non-professional athletes, were recruited following advertisements in sports centres in Warwickshire. A sample size calculation was based on previous work by Feland and Marin (2004), who recorded hamstring flexibility changes using an experimental and control group. Based on their between-subject standard deviation of 6.58 degrees (experimental condition), a power analysis for the current study calculated that a total of 100 subjects (50 per group) would enable a difference in hamstring flexibility (as measured by knee ROM) of 6.5 degrees (effect size 0.63) to be detected at a 5% significance level with 80% power (Altman, 1982). Accounting for an attrition rate of 20% (Altman, 1991; Cohen, 1992), the number of subjects required was 63 per group. A third-party randomisation method was selected, where treatment allocation excluded the author, practitioner and assessor, and was entrusted to an independent individual. Microsoft Excel’s Analysis Tool Package was used to randomly allocate 120 subjects into two equal sample sizes (Bowen and Control). In this way, the process of randomisation was unbiased and concealed (Bland and Altman, 1994). Subjects were included provided they partook in a minimum of one 30-min cardiovascular, strengthening or flexibility conditioning programme per
Each subject, wearing loose shorts, had three flexibility measurements taken from the hamstring muscles of the dominant leg over seven days. Dominance was defined as the preferred leg to kick a football. The independent assessor, blind to group allocation and interventions received, performed all measurements, but was not involved in either intervention procedure. Measurements were collected at baseline, post-intervention and at a oneweek follow-up. An active knee extension (AKE) test was chosen following a report that dynamic flexibility measurements are the most valid indicators of functional MTU activity (Hunter and Spriggs, 2000), with movement restricted at the lumbar spine and pelvis. A Bowen treatment lasted a mean of 20 minutes. Retesting of the control group therefore occurred 20 minutes after baseline. Between measurements, the control group rested in supine. The final flexibility measurement was collected one week later, within one hour of the original measurement time, to minimise the effects of diurnal variations. An accredited Bowen practitioner, with 17 years of experience, performed the same treatment routine on all subjects in the Bowen group. Each subject received a single treatment of the following documented Bowen treatment techniques, as shown in Baker (2005), receiving bilateral
Method Design
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Initial screening by phone: Excluded n= 23 (13 females:10 males)
Responses n = 143 (84 females: 59 males)
Injured n=8
Age n=11
Non-consenting n=4
(5 females: 3 males)
(6 females:5 males)
(2 females: 2 males)
Verbal consent after telephone screening n = 120 (71females:49 males)
Randomisation Into 2 groups n = 60 per group
Non-attendance at baseline n=4 (2 females: 2 males)
Written consent, Baseline & Post-Intervention data collection Bowen Group n = 60
Written consent, Baseline & Post-Intervention data collection Control Group n = 56
New Injury Missing final measurement data: n=1
Non-attendance at follow-up. Missing final measurement data: n=4
(1 female)
(2 females: 2 males)
Bowen Group 1 week follow-up n = 59
Control Group 1 week follow-up n = 52
(36 females: 23 males)
(32 females: 20 males)
Fig. 1
Flow chart of participant recruitment and allocation.
rolling moves over; segments of the erector spinae from the lumbar towards the cervical spine, latissimus dorsi, the gluteals, the hamstring muscles proximally and distally, tensor fasciae latae (TFL) and a medial hip adductor move. Techniques correspond to Bowen techniques pages 1e3, hamstring technique and medical adductor move as part of the pelvic technique (Baker, 2005).
Post-intervention Subjects were asked to continue their normal weekly exercise or activity routine. Participants were encouraged to maintain the permanent pen marks on the skin until the final measurement.
Data collection procedures Each subject lay supine, with the head in neutral on a single pillow. Using the dominant leg, a permanent ink pen marked a point 2 cm superior to the lateral femoral condyle in line
with the greater trochanter, and also over the midpoint of the head of the fibula in line with the lateral malleolus. Each edge nearest to the spring on a Biometrics flexible electrogonimeter (model no: SG150, serial no: B16421703, Gwent, UK) was placed directly over the skin marks, using non-allergic, double-sided skin tape. The electrogoniometer was attached to a Biometrics angle display unit (model no. ADU301, serial no. M01048/5198, Gwent, UK). The pelvis was secured across the iliac crests using a non-slip adjustable nylon strap with the pelvis in posterior tilt. The non-dominant limb was also secured across the thigh with an additional strap. The fulcrum of a 30 cm goniometer was placed over the greater trochanter and the arms were lined up along the mid-axillary and the lateral femoral condylar lines respectively, placing the hip in 90 degrees of active flexion. A removable wooden bench acted as a reference point and was secured by a non-slip strap to prevent movement. The foot and ankle rested in neutral, following reports of statistically significant differences in straight-leg-raise measurements with the foot in dorsiflexion (Gajdosik et al., 1985). The participant extended their dominant leg, once, until the
Effects of the Bowen technique on hamstring flexibility over time first feeling of mild tension or pulling was felt in the back of the thigh. Participants were informed that the technique should be free of pain and discomfort and to avoid the induction of a stretch reflex (clonus) (Fig. 3) by over extending. All participants received the same verbal instructions. The knee maintained contact with the bench throughout the procedure. The independent assessor also ensured that any pressure from the extending limb did not move the bench. A single AKE movement was recorded, per measurement, rather than a mean of several measurements to avoid changes due to repeated mobilisations (Atha and Wheatley, 1976). During the final flexibility measurement all marked points were rechecked against the original bony landmarks to optimise accuracy of equipment replacement.
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Data analysis The outcome measure for this study was hamstring flexibility, determined by AKE, and recorded as the angle of knee flexion (i.e. lack of full extension, measured in degrees). Testing of the null hypothesis was performed using descriptive(Fig. 2) and inferential statistical analyses (Tables 1e3). Descriptive analyses included measures of central tendency and variation (mean, standard deviation, minemax and confidence intervals) and were further illustrated using box-plots and profile plots of the two groups over the three time periods. All statistical analyses were conducted using SPSS (2006, version 15). A general linear model repeated measures univariate analysis was utilised, with group (Bowen Technique vs Control) and time (baseline, post-intervention and one week follow-up), as factors for analysis, at a significance level of 5%. Multiple-imputation analyses (nine imputations) were performed on the nine incomplete data sets to evaluate the impact of missing data.
Results Descriptive analysis Table 1 illustrates the anthropometric characteristics of the participants, taken at baseline. Table 2 shows the measurements of hamstring flexibility for both groups across the three time periods and these are also illustrated in Figs. 4 and 5. A repeated measures univariate analysis of variance (using a General Linear Model) was conducted to compare and contrast within and between-subject differences in hamstring flexibility across the two groups, and across the three time periods (see Table 3). Within-subject significant differences were revealed within the Bowen group in the baseline to post-intervention period (p Z 0.0005), and in the baseline to follow-up time period (p Z 0.0005), but not in the post-intervention to follow-up time period (p Z 0.36). Between-subject significant differences were also observed in the Bowen group, across time and across groups in the baseline to postintervention and baseline to follow-up phases (p Z 0.008 and p Z 0.0005 respectively). Results showed a pattern of increasing flexibility levels over one week for the Bowen
Fig. 2 (aec) Photographs of a selection of Bowen treatment techniques.
Fig. 3
Photograph of the AKE test.
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Table 1 Demographic characteristics of participants after randomisation (*4 missing data sets at baseline due to attrition e the gender of these 4 sets has been imputed) Characteristics
Intervention group (n Z 60)
Control group (n Z 56)
Gender
62% Female (m/f Z 23/37)
61% Female (m/f Z 22/34)
Mean & SD Age (years) Height (meters) Weight (kilograms)
35.2 (9.7) 1.7 (10.0) 73 (12.9)
MineMax 18e50 1.5e1.9 50e100
group. There was no significant change across time for the control group either within or between subjects (p Z 0.70, p Z 0.14 and p Z 0.051 respectively, see Table 3). Multiple-imputation analyses (nine imputations) were performed to evaluate the impact on the results of the nine missing or incomplete data sets on the results, due to attrition or injury. The following variables were imputed; baseline and post-intervention ROMs, gender, age, height and weight. Although the imputed values did result in a change in the p value of the Bowen baseline to postintervention results (from p Z 0.008 to p Z 0.0005, after imputation), these changes did not affect the overall results from the initial analyses (Table 3).
Discussion A single treatment of the Bowen technique demonstrated immediate significant increases in the flexibility of the hamstring muscles in asymptomatic subjects, both withinsubjects (p Z 0.0005) and between-subjects (p Z 0.008), maintaining improvements for one week without further treatment (p Z 0.0005, mean increase of 9.73 ). Evidence of previous research showing continual increases in hamstring flexibility over one week, following a single treatment, was not found.
Comparative studies In 1999, Kinnear and Baker investigated the effect of the Bowen Technique on ROM at the shoulder in 100 patients with shoulder dysfunction and pain. Following a course of three Bowen treatments, shoulder ROM demonstrated significant improvements (p < 0.05, mean increase in ROM
Table 2 periods.
Mean & SD 33.2 (10.2) 1.7 (9.0) 69 (11.2)
MineMax 20e50 1.5e2.0 51e98
of 23 ) when compared with a placebo group. Whilst these results present evidence to support changes in participants with pathology, Kinnear and Baker’s (1999) study did not measure changes over time or use statistical tests to evaluate changes in pain. In 2002, Carter also performed a quantitative study of the effect of five Bowen treatments on 20 patients with “Frozen Shoulder”. Reports of improved shoulder mobility and associated function were observed, with 70% of subjects gaining a return in movement equal to their non-affected side. Lack of detail pertaining to methodology, data collection and statistical analysis limits interpretation of this paper. Hopper et al. (2005) examined the effect of two massage techniques on hamstring muscle length in competitive female hockey players reporting increased hamstring flexibility levels (p Z 0.01) in both massage groups. These improvements were not maintained after 24 h and used passive flexibility tests without an independent control group. Spernoga et al. (2001) and de Weijer et al. (2003) also performed single-application stretch programmes on asymptomatic subjects and observed maintained improvements in flexibility for six minutes and twenty-four hours, respectively. Feland and Marin (2004) measured hamstring extensibility in three experimental groups with varying intensity of isometric hamstring contractions against a control group. All contract-relax groups showed significant increases compared with the control. However, there was no significant difference in hamstring flexibility levels between the CR groups, and changes over time were not evaluated. Smith et al (2008) also reported significant increases in hamstring length using two groups of varying length contraction using Muscle Energy Technique (MET). Increases in hamstring flexibility were evident immediately post-test (p < 0.005: mean increase of 8.24 ), with improvements
Hamstring flexibility (as measured by degrees of knee flexion) for Control and Bowen groups across the three time
Group
Time period Baseline (n Z 116)
Post-intervention (n Z 116)
One week follow-up (n Z 111)
Control
Mean Standard deviation Minemax CI’s
28.46 9.44 15, 46 25.8, 31.1
28.50 9.61 13, 47 25.5, 31.1
27.23 10.22 4, 49 24.9, 30.0
Bowen
Mean Standard deviation Minemax CI’s
29.41 9.46 15, 50 26.9, 31.7
21.68 10.84 0, 43 19.0, 24.3
19.39 8.85 2, 39 17.0, 21.8
Effects of the Bowen technique on hamstring flexibility over time
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Table 3 Differences in Hamstring flexibility (in degrees of knee flexion) within and between control and Bowen groups (across three time periods). Group
Time period Baseline to postintervention (n Z 116)
Post-intervention to follow-up (n Z 116)
Baseline to follow-up (n Z 111)
Within Control Group, n Z 56
Mean SD CI P values
0.02 4.18 1.7, 1.82 0.70
1.13 4.33 0.68, 2.94 0.14
1.23 3.92 0.49, 2.95 0.051
Within Bowen Group, n Z 60
Mean SD CI P values
7.73 8.07 6.04, 9.42 0.0005*
2.29 8.06 0.59, 3.99 0.36
9.73 7.73 8.41, 11.63 0.0005*
Between Control & Bowen groups, n Z 116 (In brackets: Imputed data for n Z 120 (1200 imputations)
Mean SE CI
7.47 (7.91) 1.18 (0.49) 9.81, 5.13 (8.88, 6.93) 0.008* (0.0005*)
1.58 (0.90) 1.19 (0.50) 3.93, 0.77 (1.89, 0.08) 0.186 (0.072)
9.73 (8.75) 1.14 (0.48) 11.34, 6.83 (9.69, 7.81) 0.0005* (0.0005*)
P values
*Statistically significant result and bracketed figures indicate the results of multiple-imputation analyses.
being shown one week later (p < 0.04: mean increase of 2.49 from baseline). A control group was not included for comparison, and detail is lacking relating to how a 40% knee flexion isometric contraction was established reliably by each participant. The present Bowen study differs from Smith and Fryer (2008) MET study, because the mean flexibility levels in the Bowen intervention group continued to increase throughout the three recordings over 7 days (mean increase over 1 week Z 9.73 ).
Study limitations The hamstrings were the only muscles to be assessed in the current study, but the technique involved treating the paraspinal muscles, latissimus dorsi, gluteals, TFL, hip adductors as well as the hamstrings. Measurements taken
Fig. 4
can only account for changes in flexibility of the hamstring muscles and did not evaluate movement control characteristics or injury statistics. Therefore, increases in flexibility cannot be correlated with changes in stability, efficiency or strength. The Bowen techniques performed during this RCT also required identical treatment routines with controlled variables, to enable comparison. This differs from usual clinical practice, where a personalised programme of treatment is determined following assessment, and may result in a variety of possible technique combinations or regions treated. It is unknown if the results would have differed if this approach had been adopted. It is also difficult to speculate whether real-life treatment outcomes may have shown further improvements, where individuals often have co-morbid conditions, thereby adding additional variables. The authors accept that tight
Box-plots of Hamstring flexibility and Intervention Group (*represents an extreme case).
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M. Marr et al. may be transmitted from one region to another (Langevin, 2006; DeRosa and Porterfield, 2007). Muscles are linked to each other through fascial and ligamentous connections.the force of muscle contraction is potentially passed via specialized connective tissues to the skeletal structures and lumbopelvic articulations (DeRosa and Porterfield, 2007, p. 48)
Fig. 5 Profile plots illustrating the changes in estimated marginal means of hamstring flexibility against time for each group.
control of variables may not reflect everyday events and outcomes, yet is necessary to perform an RCT. A further weakness of the current study relates to a flawed randomisation process. Subjects were randomised into two groups after the phone-call screening phase (see Fig. 1), yet before the final inclusion criterion had been assessed. Baseline hamstring flexibility measurements were the final inclusion criterion, and required a minimum flexibility deficit of at least 15 degrees from full AKE. Following assessment, it was found that all subjects did meet this criterion, therefore no participants were excluded at baseline. However, because of this randomisation process, 4 subjects did not attend between phone-call screening and baseline measurement, resulting in a 3.2% attrition rate prior to data collection. Incomplete data from these 4 subjects (n Z 4), in addition to the five incomplete data sets due to non-attendance at the follow-up phase (n Z 4), plus 1 new injury (n Z 1), resulted in a need for multi-imputation analyses to assess the impact of the nine incomplete data sets. Following imputation, the results showed that there were no changes from the initial analyses.
Clinical implications Explanations for the changes observed with the Bowen technique have not been well researched. The superficial pressure applied during the technique, yet lack of joint loading, weight bearing, warm-up or stretching, invalidates changes attributable to tissue creep through loading or plastic deformation of tissues. Furthermore, the use of a single repetition AKE test minimised the effect of tissue lengthening due to repetitive tissue mobilisation from the measurement procedure itself. Many of the studies previously discussed have localised interventions specifically to the hamstring muscles. The present Bowen study provided manual stimulation to multiple regions including; the cervical, thoracic and lumbar spine, pelvic attachments; latissimus dorsi, hamstrings, gluteals, hip adductors and TFL. The anatomical linkage through the presence of inter and intramuscular fascial ‘slings’ and compartments has enabled a deeper, more integrated approach to understanding how manual stimulation or mechanical tension
This view is also supported through cadaveric work by Stecco et al. (2009) who confirmed the ‘anatomical continuity’ of integrated attachments between muscles and superficial and deep fascia through specific fascial expansions. Each of 15 cadavers demonstrated a similar pattern of tissue connectivity, being arranged according to directions of movement. These observations, despite being limited through absence of an intact sensorimotor system, also confirm the basis for Myers’ (2001) work, in the demonstration of Myofascial Trains and Hedley’s (2005, vols. 1e3) work on Integral Anatomy. All three authors have inferred that these anatomical trains are directly involved in the organisation of movement and transmission of muscular force (Myers, 2001; Hedley, 2005a, b, c; Stecco et al., 2009). The studies cited above contribute towards a more integrated understanding of the occurrence of pain at some distance from its origin, through Travell and Simons’ (1992) work on Myofascial Trigger Points. In addition, the role played by the nervous system, both locally and centrally, to control changes in soft tissue length and tension has advanced considerably (Comerford and Mottram, 2001a, b; Nigg, 2001; Langevin et al., 2002). Lee et al. (1999, p. 632) state that the motor and sensory system connections allow reflex fine-tuning by ‘facilitating the control of limb stiffness’. This suggests that changes in stability, or stiffness and tone may have occurred, not only within the MTU, but also within the ‘passive’ constituents, (the viscoelastic connective tissues), through alteration of reflex pathways (Solomonow et al., 1998; Schleip et al., 2006). The superficial Bowen moves that were applied to each participant in the Bowen intervention group, occurred along the posterior layer of the thoracolumbar fascia (as described by DeRosa and Porterfield, 2007), and included manual stimulation of the fascial linkage of the latissimus dorsi to the gluteus maximus. This was followed by stimulation of the hamstring and adductor muscles, with proven anatomical continuity through to the gluteus maximus and into the lumbopelvic slings (DeRosa and Porterfield, 2007). In other words, the Bowen treatment received, provided a planned direction of manual stimulation throughout the extensors of the spine, trunk and lower limbs. It is therefore suggested, based on the growing body of literature relating to myofascial continuity (Myers, 2001; Hedley, 2005, vols. 1e3; Langevin, 2006; Schleip et al., 2006, 2007; Stecco et al., 2009; Vleeming and Stoeckart, 2007), combined with literature on neural modulation, that these are the most plausible explanations for the changes observed within the present study.
Summary and conclusion A unanimous view exists that the body needs the ability to alter flexibility variables to optimise task performance, ROM,
Effects of the Bowen technique on hamstring flexibility over time timing, stability and therefore prevention of injury. Flexibility is a phenomenon consisting of complex, multi-tissue interactions that permit length-tension changes. As a result of the findings of the present study, it can be concluded that a single treatment of the Bowen Technique significantly increases the flexibility of the hamstring muscles in asymptomatic individuals and maintains this level of increase for one week, demonstrating continuing improvements. Further research is required into the effects of the Bowen Technique on injury statistics, motor control characteristics and into the mechanisms that detect and respond to manual therapy in healthy and pathological tissues.
Acknowledgments Acknowledgments go to the group of 120 volunteers who kindly donated their time to this study. Grateful appreciation is extended to Louise Atwill and the team at the European College of Bowen Studies and to the staff at Coventry University for their support and assistance. Thanks also go to the Chartered Society of Physiotherapy for grant support.
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Journal of Bodywork & Movement Therapies (2011) 15, 291e297
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FUNCTIONAL PATHOPHYSIOLOGY
Breathing and temporomandibular joint disease Jim Bartley, FRACS, FFPMANZCA* The Auckland Regional Pain Service, Auckland District Health Board, 10 Owens Road, Epsom, Auckland 1023, New Zealand Received 1 December 2009; received in revised form 26 May 2010; accepted 31 May 2010
KEYWORDS Temporomandibular joint; Depression; Anxiety; Hyperventilation; Gender differences; Etiology; Pain; Biomedical; Pathogenesis; Biopsychosocial
Summary Temporomandibular joint disease (TMD) refers to a collection of pain related conditions in the masticatory muscles and temporomandibular joint. Occlusal factors have been implicated in TMD pathogenesis, yet despite decades of research no causal relationship between occlusion and TMD has been found. The significance of psychosocial factors in both the assessment and the long-term management of patients with TMD is receiving increased recognition. The teaching of relaxation skills and coping strategies are effective, proven TMD therapies. The role of breathing re-education in temporomandibular joint (TMJ) disorders is rarely mentioned. A focus on breathing patterns and their disorders potentially explains how biomechanical factors associated with psychosocial influences might lead to pathophysiological changes within the TMJ as well as in the associated muscles. Attention to factors such as breathing and postural rehabilitation provides health professionals valuable, additional tools to help care for patients with TMD. ª 2010 Elsevier Ltd. All rights reserved.
Introduction Temporomandibular joint disease (TMD) refers to a collection of pain related conditions in the masticatory muscles and temporomandibular joint. Occlusal factors have been implicated in TMD pathogenesis, yet despite decades of research no causal relationship between occlusion and TMD has been found (Koh and Robinson, 2004; Mackie and Lyons, 2008). The tendency of TMD to improve with the passage of time, regardless of treatment modality (Sherman and Turk,
* Tel.: þ64 649 631 0475; fax: þ64 649 631 0478. E-mail address:
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2001), has hampered research. The condition appears selflimiting and associated with no significant long-term disability in the majority of patients. Where patients have been followed up for 20 years, the end result of TMD is often not incapacitating (Magnusson et al., 2005). The significance of psychosocial factors in both the assessment and the long-term management of patients with TMD is receiving increased recognition (Suvinen et al., 2005). Physical and/or sexual abuse during childhood (Curran et al., 1995) as well as anxiety and depression are often associated with TMD (Madland et al., 2000; Manfredini et al., 2004; Wright et al., 2004). Significantly, the teaching of relaxation skills and coping strategies are effective, proven TMD therapies (Sherman and Turk, 2001; Suvinen et al., 2005; Orlando et al., 2007; Carlson, 2008).
1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.06.002
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Breathing patterns While the main function of respiration is the homeostatic regulation of arterial pO2 and pCO2 levels, breathing is also influenced by emotions and the limbic system (Homa and Masaoka, 2008). Respiratory symptoms are common in people suffering from anxiety and/or depression (Goodwin et al., 2004) and breathing re-education is an effective treatment for both depression (Tweeddale et al., 1994) and anxiety (Gilbert, 2003). In stressful situations the limbic system activates the “fight-or-flight” response (Von Sche ´ele and von Sche ´ele, 1999) and the breathing pattern can change from a diaphragmatic (or abdominal) breathing pattern to a thoracic (or chest) breathing pattern (Schleifer et al., 2002). The corresponding increase in respiratory rate and in minute volume (the volume of air inhaled and exhaled per minute) leads to a hyperventilation state where by definition the increase in respiratory rate exceeds the metabolic demands for oxygen (Schleifer et al., 2002) and arterial pCO2 is lowered. TMD patients when compared to controls have a similar breathing rate, but a significantly lower end tidal pCO2 (Carlson et al., 1998) indicating that TMD patients hyperventilate creating a respiratory alkalosis (Foster et al., 2001). End tidal pCO2 refers to the peak concentration of CO2 in a single breath of air at the end of expiration; it provides a close estimate of arterial pCO2. (Schleifer et al., 2002). The hyperventilation seen in TMD (Carlson et al., 1998) can be regarded as part of the “fight-or-flight” response (Von Sche ´ele and von Sche ´ele, 1999). In the 1930s, Cannon described the physiological changes associated with the “fight-or-flight” response as being characterized by increased sympathetic nervous system activation, increased central nervous system arousal and increased skeletal muscle activity (Jacobs, 2001). Hyperventilation by lowering arterial pCO2 induces an acute respiratory alkalosis, with a corresponding increase in plasma pH and the movement of CO2 from intracellular to extracellular fluids. The increased pH enhances the likelihood of motor unit neuron depolarisation or excitation (Schleifer et al., 2002) contributing to increased central nervous system arousal. The increased pH also improves muscle function as seen in short duration cycle sprints (Bishop et al., 2004) contributing to the increased skeletal muscle activity again necessary in a “fight-or-flight” response. Ironically this same ‘fight-or-flight” response when prolonged can contribute to musculoskeletal disorders (Jacobs, 2001). The increased neural excitation associated with the central nervous system arousal contributes to increased muscle tension and muscle spasm (Schleifer et al., 2002). A respiratory alkalosis reduces the release of oxygen from haemoglobin (Bohr effect) (Schleifer et al., 2002). Prolonged hyperventilation influences the alkaloid buffering system (Von Sche ´ele and von Sche ´ele, 1999). In chronic respiratory alkalosis renal compensatory mechanisms excrete HCO 3 in order to return the plasma pH back towards the normal range (Foster et al., 2001). The systemic loss of bicarbonate from intracellular and extracellular fluids reduces the body’s ability to buffer any build up of metabolic byproducts such as lactic acid in muscle tissue (Von Sche ´ele and von Sche ´ele, 1999; Schleifer et al., 2002). In this situation skeletal muscle fatigues more readily (Von Sche ´ele and von Sche ´ele,
J. Bartley 1999). In an alkalotic state, muscle lactic acid efflux also increases leading to an increase in blood lactic acid levels (Galloway and Maughan, 1996). Lactic acid contributes to muscle pain (Mense, 2008). In stressful situations the change in breathing pattern from a diaphragmatic (or abdominal) breathing pattern to a thoracic (or chest) breathing pattern (Schleifer et al., 2002) leads to the increased utilization of upper body muscles. When used as accessory muscles of respiration, the sterno (cleido) mastoid muscles not only lift the chest upward but can also pull the head forward (Simons et al., 1999a). In this situation the scalene and parasternal intercostal muscles also flex the neck (Simons et al., 1999b). Because the eyes need to keep looking forward, the head extends at the atlanto-occipital joint and the suboccipital muscles at the base of the skull shorten, to extend the head (Simons et al., 1999c ; Hruska, 1997). These suboccipital muscles, designed for fine eye movement coordination, are frequently tender to palpation in patients who suffer from migraine (Mongini, 2007; Fernandez-de-Las-Penas et al., 2008), tension type headache (Mongini, 2007; Fernandezde-Las-Penas et al., 2006) and TMD (Chaves et al., 2005). In dysfunctional breathing, the pectoralis minor muscle lifts the chest upward, but in so doing pulls the shoulders forward (Hruska, 1997; Simons et al., 1999d). This action is opposed particularly by the upper trapezii and levator scapulae muscles (Simons et al., 1999d). Patient with a dysfunctional breathing pattern typically adopt a posture, with rounded shoulders and a forward head position (FHP) (Hruska, 1997). The FHP has been implicated in TMD (Woda et al., 2001), but the quality of evidence supporting this association has been questioned (Olivo et al., 2006). The distance between the upper and lower teeth with the mandible in rest position is the freeway space (Woda et al., 2001). A FHP leads to a decrease in freeway space (Woda et al., 2001). Dental splints increase the freeway space and reduce the pressures on the TMJ generated by clenching (Nitzan, 1994). Correspondingly a reduction in freeway space through mandibular elevation results in an increased pressure on the temporomandibular joint itself (Hruska, 1997). A FHP is believed to alter occlusion, lead to increased posterior tooth contact and increased temporomandibular joint (TMJ) compression e all anatomical changes emphasized in TMD (Mannheimer and Rosenthal, 1991; Hruska, 1997). Mouth breathing can lead to a FHP with alteration in mandibular position (Neiva et al., 2009). In children, mouth breathing is associated with increased masticatory muscle tenderness (Chaves et al., 2005). Correction of head and cervical posture which increases freeway space (Woda et al., 2001) is considered important in TMD treatment (Olivo et al., 2006). The restoration of diaphragmatic breathing is also an important musculoskeletal and psychological therapy used in correcting the FHP (Simons et al., 1999e), and in helping patients suffering from TMD (Hruska, 1997; Sherman and Turk, 2001).
The temporomandibular joint The temporomandibular joint is a combined hinge and sliding joint (Figure 1). A dense fibrous tissue disc called the articular disc, in the middle of the joint, separates the condyle of
Breathing and temporomandibular joint disease
Figure 1
293
As the jaw joint opens, the condyle rotates on the disc and the disc slides forward on the mandibular fossa.
the mandible and the mandibular fossa. On opening and closing, the rotating action of the condyle is largely against the cartilaginous articular disc. While the lower joint has a rotating action, the upper joint has a sliding (or translating) action. The articular cartilage on the condyle slides forward against the articular cartilage of the mandibular fossa. The synovial fluid in the TMJ has important roles both in supplying nutrition to the avascular cartilaginous tissue within the TMJ and in lubrication (Nitzan, 2001). Whenever the pressure within the TMJ exceeds the capillary perfusion pressure a temporary tissue hypoxia ensues. An intra-articular pressure above 40 mm Hg surpasses the peripheral arteriolar pressure and can cause temporary hypoxia within the TMJ (Nitzan, 1994). Nitzan recorded the average intra-articular pressure on clenching as 73.70 61.06 mm Hg in females as opposed to 31.42 11.47 in males (Nitzan, 1994). Repetitive loading and unloading of the joint can lead to hypoxiaperfusion injury. Reactive oxidative molecules are released which can breakdown the molecules that facilitate joint lubrication (Zardeneta et al., 2000). Increased friction is frequently mentioned as a possible cause of TMJ clicking and possible disc displacement during jaw opening (Tanaka et al., 2008). Bruxism, the habitual grinding of the teeth and jaw clenching, has also been linked to TMD (Michelotti et al., 2010). The repetitive loading and unloading of the joint involved with bruxism would also lead to hypoxia-perfusion injury within the TMJ. Awake bruxism, as opposed to sleep bruxism, is associated with stress, anxiety and depression (Manfredini and Lobbezoo, 2009), once again emphasizing the importance of psychosocial factors in the development and treatment of TMD. Lavage (or irrigation) of the upper joint compartment with saline using arthroscopy or arthrocentesis in closed lock
situations or in osteoarthritic joints improves function and alleviates pain, although it does not change disc position (Brennan and Ilankovan, 2006). In this situation, lavage may be effective by removing reactive oxidative molecules that damage TMJ lubrication (Nitzan, 2003). Dental splints elevate the occlusal plane and reduce the pressures on the TMJ generated by clenching (Nitzan, 1994). This supports the concept that the reduction in the distance between the upper and lower teeth with the mandible in rest position (freeway space) brought about through a FHP (Woda et al., 2001) could result in increased pressure through the mandible on the temporomandibular joint leading to hypoxia-perfusion injury. TMJ clicking without pain or disc displacement is common (Gesch et al., 2004). Clicking in this situation might occur as a result of increased friction between the disc and the eminence of the mandibular fossa e the clicking in this situation seems to occur with a jump by the disc and the condyle over the eminence (Tanaka et al., 2008). Prolonged frictional changes could lead to secondary pathology such as disc displacement where the disc is displaced from on the head of the condyle (Nitzan, 2003). If the disc moves off the condylar head the ligaments holding the disc in place stretch. The chemical inflammation from reactive oxidative molecules within the TMJ and the trauma associated with stretching of the ligaments holding the disc in place could sensitize local nocioceptive endings (Mense, 2008). These issues are discussed more fully in the next section.
Pain production Muscle pain is produced by both peripheral and central mechanisms. Peripheral muscle pain is produced by the
294 sensitization of specific pain receptors called nociceptors. Nociceptors are activated by trauma, mechanical overloading and inflammatory mediators such as bradykinin, prostaglandins, adenosine triphosphate (ATP) and protons (Hþ) (Mense, 2008). An acidic tissue pH, which would be aggravated by a loss of systemic bicarbonate and lactic acid production, is probably one of the main activators of peripheral nociceptors (Mense, 2008). Mechanical factors such as poor posture, which leaves some muscles in shortened positions and others under chronic tension in a lengthened position for prolonged periods, as well as muscle spasm can lead to trigger point development in these muscles (Simons et al., 1999f). The resulting drop in tissue pH would sensitize nociceptors (Mense, 2008). Systemic factors that compromise muscle and neural energy metabolism are also thought to be contributory. These include nutritional deficiencies in vitamin D, a number of the water-soluble vitamins including vitamins B1, B6, B12, folic acid, vitamin C and certain elements such as calcium, magnesium, iron and potassium. Borderline hypothyroidism has also been implicated in muscle pain (Simons et al., 1999g; Gerwin, 2005). Sensitization of muscle nocioceptive endings leads to the release of the neuropeptides substance P and calcitonin gene related peptide. These peptides created local oedema by dilating local blood vessels and increasing their permeability. The sensitization of muscle nociceptors is assumed to be the peripheral mechanism leading to muscle tenderness (Mense, 2008). The influx of nervous impulses from muscle nociceptors into the spinal cord can also lead to central processing changes of pain signals at a dorsal horn level. This leads to a long lasting increase in excitability (central sensitization) due to the effect of glutamate on NMDA (N-methyl-Daspartate) receptors. This is a possible mechanism for referred muscle pain, a contributory factor to increased peripheral muscle tenderness as well as an explanation for myofascial trigger points (Mense, 2008). Glial inflammation has also been implicated as an additional important factor in the initiation of acute pain and the perpetuation of chronic pain in a number of pain conditions including migraine (Bartley, 2009; Milligan and Watkins, 2009). In a rat model, the injection of capsaicin into the TMJ capsule has been shown to cause glial inflammatory changes within the trigeminal ganglion. Glial inflammation is thought to be an additional important factor in the development of a number of peripheral pain conditions as well as providing a potential explanation of the link between TMD and migraine (Thalakoti et al., 2007). In an experimental situation, patients with a history of tension headache or age and sex matched controls were made to clench their teeth for 30 min. Sixty-nine percent of the patients and 17% of controls developed a tension type headache. Muscle tenderness after tooth clenching increased only in those people who then went on to develop a tension headache. The headache can be viewed as a central neural sensitization by tender muscles (Jensen and Olesen, 1996). Incoming pain messages from chronically contracted muscles holding the head and neck in a prolonged unnatural position such as a FHP could generate a central neural hypersensitivity. This is also the position adopted by many people when they sit at a computer (Pascarelli and Hsu, 2001) or hyperventilate using their accessory muscles of respiration (Hruska, 1997).
J. Bartley The findings of tender muscles may indicate that not only the muscles are sore, but also that a central neural hypersensitivity is present. Therefore the masticatory muscle pain seen in TMD may be secondary to the interplay of a number of factors. - Postural changes associated with a FHP which place some masticatory muscles in shortened positions and others under chronic tension in a lengthened position for prolonged periods would be a factor in muscle trigger point and pain development (Simons et al., 1999f). - Increased neural excitation associated with respiratory alkalosis contributing to increased muscle tension and muscle spasm (Schleifer et al., 2002). - The systemic loss of bicarbonate compromising the body’s ability to buffer the build up of metabolic byproducts such as lactic acid in muscle tissue leading to muscle fatigue (Von Sche ´ele and von Sche ´ele, 1999; Schleifer et al., 2002) and muscle pain (Mense, 2008). - Chemical inflammation from reactive oxidative molecules sensitizing local nocioceptive endings in the TMJ (Mense, 2008). - Prolonged peripheral pain leading to changes in pain processing at a central level (Mense, 2008). Breathing patterns may also be linked to pain modulation at a central level (Rhudy, 2010). A number of experiments have also shown that anxiety, which is linked to alterations in breathing patterns (Gilbert, 2003), lowers pain thresholds (more sensitivity) (Rhudy and Meagher, 2000). In an experimental situation, slow breathing rate results in reduced pain intensity and unpleasantness ratings to pulses of painful heat (Zaustra et al., 2010).
Genetic polymorphisms Catechol-O-methyl transferase (COMT) is an enzyme that metabolises catecholamines (adrenalin, noradrenalin and dopamine) through the methylation process. A genetic polymorphism means members of the population with reduced COMT activity are less able to degrade adrenalin, noradrenalin and dopamine. People with this genetic polymorphism have reduced pain thresholds and are more likely to develop TMD (Diatchenko et al., 2005). Rodent studies have shown that COMT inhibition increases pain sensitivity through activation of b2 and b3 adrenergic receptors (Nackley-Neeley et al., 2007). Propanolol, a nonselective b-adrenergic agonist, reduces pain more in those people with the COMT polymorphism and the reduced ability to degrade adrenalin and noradrenalin (Tchivilea et al., 2010). This would indicate that treatments that reduce stress levels and the sympathetic response could be beneficial in those people with reduced COMT activity. Diaphragmatic breathing and relaxation skills reduce the stress response (Martarelli et al., 2009).
Male /female TMD differences While gender differences in pain sensitivity have been attributed to social conditioning and psychosocial factors,
Breathing and temporomandibular joint disease increasing evidence suggests that other biological factors play an important role (Craft et al., 2004; WiesenfeldHallin, 2005). Gonadal steroid hormones, in particular estrogen, are known to modulate opioid analgesia. In rats, increased estradiol levels appear to be risk factor for TMJ pain (Tashiro et al., 2009). TMD pain is 1.5e2 times more prevalent in women (Warren and Fried, 2001). If occlusal abnormalities alone were an important factor, TMD should occur equally in men and women. The incidence of TMD appears to peak around 20e40 years (Warren and Fried, 2001). In females, TMD incidence parallels reproductive function decreasing in menopause when ovarian production of estrogens decreases (LeResche et al., 2003). Females are able to generate significantly higher TMJ pressures during clenching than males (Nitzan, 1994). During the second part of the menstrual cycle after ovulation has occurred women have a greater tendency to hyperventilate lowering arterial pCO2 by 6.5 mm Hg (Hadziomerovic et al., 2008). As discussed the respiratory alkalosis as well as potential postural changes associated with hyperventilation could contribute to TMJ pain. In the second part of the menstrual cycle both progesterone and estrodiol are secreted. The administration of either progesterone or estradiol lowers arterial pCO2 (Hadziomerovic et al., 2008). In females, TMD pain rises towards the end of the cycle and peaks in the first three days of menstruation. A secondary peak in pain also occurs around the time of ovulation (LeResche et al., 2003). TMD pain occurs at the time of low or fluctuating estrogen (LeResche et al., 2003). Estrogen and progesterone both influence minute ventilation and arterial pCO2 levels (Slatkovska et al., 2006). The hormonal intricacies relating to pain and the menstrual cycle are still being untangled (Sherman and LeResche, 2010), but alterations in breathing pattern during the menstrual cycle could contribute to TMD.
Migraine, tension headache and TMD TMD is frequently discussed as a risk factor in migraine (Bevilaqua Grossi et al., 2009) and tension headache (Lupoli and Lockey, 2007). Occlusal treatment may be suggested as a therapeutic option (Stapleman and Turp, 2008). TMD is common in the community (Gesch et al., 2004), migraine sufferers and tension headache sufferers (Ballegaard et al., 2008). Anxiety, depression, and muscle tenderness are often common factors in jaw joint pain, tension headache and migraine (Mongini, 2007). Rather than jaw joint problems per se causing tension headache and migraine, it may be that they share a similar underlying central nervous system pathophysiology (Bevilaqua Grossi et al., 2009). The teaching of relaxation skills and coping strategies as well as being effective in TMD (Sherman and Turk, 2001; Suvinen et al., 2005) is also beneficial in migraine (Campbell et al., 2009) and tension headache (Smitherman et al., 2007).
Conclusions The role of breathing re-education in TMJ disorders (Hruska, 1997) is rarely mentioned. A focus on breathing
295 patterns potentially explains how biomechanical factors associated with psychosocial influences might lead to pathophysiological changes both within the TMJ as well as in the associated muscles. While it has been reasonably postulated that the FHP leads to increased pressure in the joint this part of the picture has not yet been scientifically proven. Attention to breathing and postural correction provides health professionals valuable additional tools to help care for patients with TMD.
Acknowledgements The author would like to acknowledge the contributions and influence of Tania Clifton-Smith, Dinah Bradley and Dr Robert Fried to his thoughts.
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Journal of Bodywork & Movement Therapies (2011) 15, 298e303
available at www.sciencedirect.com
journal homepage: www.elsevier.com/jbmt
ORIGINAL RESEARCH
The effect of close proximity holographic wristbands on human balance and limits of stability: A randomised, placebo-controlled trial Simon R. Brice, BAppSc(ClinSc), BCSc, BAppSc(HumBiol) a, Brett S. Jarosz, CertPT, BAppSc(CompMed), MClinChiro, ICSSD a,*, Rick A. Ames, BSc, DC, FACCS, ICSSD a, James Baglin, BAppSc(Psych Hons) b, Cliff Da Costa, BSc, MSc, MS, PhD b a b
Discipline of Chiropractic, School of Health Sciences, RMIT University, Bundoora, Victoria, Australia School of Mathematical and Geospatial Sciences, RMIT University, Bundoora, Victoria, Australia
Received 7 January 2011; received in revised form 12 January 2011; accepted 14 January 2011
KEYWORDS Athletic performance; Postural balance; Ergogenic aids; Hologram technology; Posturography
Summary The purpose of this study was to investigate the effect of holographic technology wristbands on human balance and stability performance. Forty-two individuals volunteered to participate in the study. A performance technology silicone wristband containing two holograms was utilised as the ‘Device’. A ‘placebo’ performance technology silicone wristband was utilised where the two holograms were removed and replaced with two stainless steel discs to the same dimensions and weight as the Device. Each participant was randomly allocated into two different testing protocol groups: Protocol 1 (Deviceebaselineeplacebo) and Protocol 2 (placeboebaselineeDevice). One week following the initial testing, the Protocol 1 group was tested under the conditions of Protocol 2, and vice versa, so that all participants were taken through both protocols. Results indicated that there was no statistically significant mean change in balance performance brought about by either the placebo or the Device. Notably, the sample data indicated an overall decrease in balance and stability. However, these mean changes are still within the bounds of what would be expected assuming the Device had no overall effect. The findings of this study indicate that holographic technology wristbands have no effect on human balance and stability performance. ª 2011 Elsevier Ltd. All rights reserved.
* Corresponding author. 71e73 Hamilton Street, Gisborne, Victoria 3437, Australia. Tel.: þ61 3 5428 2669; fax: þ61 3 5428 1500. E-mail address:
[email protected] (B.S. Jarosz). 1360-8592/$ - see front matter ª 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2011.01.020
Effect of holographic wristbands on balance
Background Athletes consistently look for “the leading edge”, that extra percentage of perfection that allows them to excel in their chosen sport. Ergogenic aids are seen by athletes as providing that leading edge. Usually these aids are new developments in the areas of drugs or nutrition, training routines or competition strategies and equipment or products (Pelham et al., 2001). One of the major concerns with ergogenic aids is the placebo effect and its relationship to “expectancy”. Expectancy directly relates to the athletes beliefs regarding the effectiveness and success or failure of the ergogenic aid. Research has shown that ”expectancy effects alone can generate increases in performance” (McClung and Collins, 2007). Due to this effect, McClung and Collins (2007) suggest that deception be utilised in any research of ergogenic aids i.e. the use of a placebo in the testing. Over the years there have been a number of ergogenic aids purported to enhance athletic performance. A recent and highly publicised ergogenic product is one that incorporates hologram frequency-embedded technology. The original is marketed by Power Balance, developed by two surfing enthusiasts from California, Troy and Josh Romdarmel. The Power Balance website (2010) states the “performance technology is a mylar hologram embedded with a range of frequencies that react positively with your body’s energy field”, resulting in “faster synaptic response, enhanced muscle response, increased stamina, more flexibility and vastly improved gravitational balance”. The most common holographic technology product sold and endorsed by athletes is in the form of a wristband, though pendants, necklaces, shoe inserts, board shorts, surfboards and credit cards are claimed to have the same reaction (EFX Embedded Wearable Holographic Technology, 2010; EKEN Power Bands, 2010; Power Balance, 2010; Samuels, 2010). This technology and its purported ergogenic aid would sit in the field of energy medicine (Rubik, 2002). Other energy medicine products with claims on enhancing aspects of athletic performance include magnetic therapy in the form of bracelets or shoe inserts and semiconductor energy patches. Research into athletic performance and use of these products has been contradictory and inconsistent (Schall et al., 2003; Jacobson et al., 2008). All of the companies marketing a form of the holographic technology promote an enhancement in balance from interaction with the frequency-embedded holograms. Balance is an integral part of athletic performance, with athletes required to know where their body parts are in space in order to perform the complex movements associated with their sport (Carrick et al., 2007). The control and perception of body orientation and motion demand an adaptation of sensory and motor information processing with independent canal and otolith reflexes, degrees of sway change with changes in head position, and visual conditions affecting a control of balance (Asseman and Gahery, 2005; Cathers et al., 2005; Lackner and DiZio, 2005). Computerised dynamic posturography (CDP), also known as stabilometry, is a standard diagnostic test of balance function (Mirka and Black, 1990; Furman, 1994, 1995; Lipp and Longridge, 1994; Di Fabio, 1995; El-Kashlan
299 et al., 1998; Carrick et al., 2007). Several types of tests can be performed using CDP systems in order to research the effects of various conditions on human balance and stability performance (Pagnacco et al., 2008). Holographic technology wristbands and their use as an ergogenic aid have increased amongst athletes and the general population alike. However, to date, there has been no evidence-based research to support the use of holographic technology wristbands to enhance human performance. Consequently, the purpose of this study was to investigate the effect of holographic technology wristbands on human balance and stability performance.
Methods Sample size Statistical power analysis was conducted to determine a suitable sample size required to detect a moderate effect size 80% of the time, assuming a real effect existed across measures of balance. As this study would be assessing the mean change in measures of balance, a moderate Cohen’s effect size, d Z 0.6, was used as the basis of the statistical power analysis. This moderate level was subjectively chosen to correspond with a clinically significant mean change (i.e. a change that would be noticeable to the wearer of the holographic technology wristband e the ‘Device’). The power analysis was run through G*Power version 3 using the 0.01 significance level, adjusted for multiple comparisons (Faul et al., 2007). The estimated sample size was N Z 36. After collection of sample data, the moderate effect sizes were converted to mean change scores using the Device change sample standard deviation as an estimate of the population Device change standard deviation. The mean change across the balance measures corresponding to a moderate effect of d Z 0.6 was 1.7% for normal surface with eyes open (NSEO), 1.6% for normal surface with eyes closed (NSEC), 2.8% for perturbed surface with eyes open (PSEO), 3% for perturbed surface with eyes closed (PSEC) and 1.8% for Limits of Stability (LoS).
Participants Forty-two individuals (age Z 27.86 9.41 years) comprising 19 males (45.2%) and 23 females (54.8%), volunteered to participate in this study approved by the RMIT University Human Research Ethics Committee. The participants were recruited through an article describing the study in a local newspaper and advertisements that were distributed throughout the university. Each participant completed a written informed consent and eligibility questionnaire prior to data collection. Individuals were excluded from the study for the following reasons: (1) balance or dizziness symptomatology within the previous 3 months; (2) an underlying systemic pathology that might affect balance control, e.g. Cancer, Meniere’s disease, vertebrobasilar insufficiency, cardiovascular disease; (3) currently using medication for hypertension or dizziness; (4) pregnancy; (5) musculoskeletal symptomatology that might affect
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balance control, e.g. acute low back pain, low back pain lasting longer than 3 months in the previous 12 months, ankle or foot injury in the last 3 months; and (6) an inability to complete both testing protocols within the 1 week timeframe. Participants who currently utilised a wristband containing holographic technology were required to discontinue use for at least 1 week prior to, and for the duration of the testing protocols.
Procedures The Power Balance performance technology silicone wristband containing two holograms (Power Balance, LLC, Port Melbourne, Victoria, Australia) was utilised as the ‘Device’. A ‘placebo’ Power Balance performance technology silicone wristband was utilised where the two holograms were removed and replaced with two stainless steel discs to the same dimensions and weight as the Device. The wristbands were blinded from the participants by covering both the Device and the placebo with an adhesive label and turning them inside out. Each participant presented to the laboratory (Time 1) and was randomly allocated into two different testing protocol groups: Protocol 1 (Deviceebaselineeplacebo) Protocol 2 (placeboebaselineeDevice). One week later (Time 2), the Protocol 1 group was tested under the conditions of Protocol 2, and vice-versa, so that all participants were taken through both protocols.
Measurements Outcomes were obtained using CDP. Each participant’s balance was tested using a three-component force platform (Bertec BP Series Force Plate) under five conditions of the Bertec BalanceCheck Screener: normal surface with eyes open (NSEO); normal surface with eyes closed (NSEC); perturbed surface with eyes open (PSEO); perturbed surface with eyes closed (PSEC); and maximum movement in sagittal and lateral directions, known as Limits of Stability (LoS). The Bertec three-component force platform outputs vertical force and two moments which are used to compute the Centre of Pressure (CoP). The data from these three channels was then sent via USB connection to
Table 1
a laptop computer where the Bertec BalanceCheck software computes the total vertical force and the two moments acting on the platform. To minimise potential errors in the CDP testing, the following strategies were employed: (1) standardised instructions were given to each participant on the testing procedures; (2) shoes, jewellery and any items in clothing pockets (e.g. keys, loose coins) removed; (3) mobile phones switched off; (4) the wristbands (Device and placebo) to be held in the participants right hand during CDP testing; (5) using the same investigator to operate the CDP software; and (6) the CDP operator blinded to the randomly allocated testing protocol groups. At Time 1 and Time 2 each participant completed the CDP testing under all three conditions of their protocol group.
Statistical analysis Results are summarised showing the mean change standard deviation (SD) from baseline balance scores for both the placebo and Device conditions. A positive change would indicate an overall mean improvement in balance and stability. Statistically significant mean changes were checked using 99% confidence intervals (CI). Error-bar plots displaying the 99% CIs are presented along with overlaid boxplots to graphically display experimental results. A series of mixed methods ANOVAs were also implemented to assess for significant interactions between condition and protocol.
Results Forty-two participants completed testing at Time 1. At Time 2, seven participants dropped out, making a total of 35 participants completing both testing protocols. A complete break down of age and gender for the sample across Time and Protocol is shown in Table 1. Descriptive statistics showing baseline and mean change in balance measures across conditions (placebo and Device) and time (Time 1 and Time 2) are shown in Table 2. Figure 1 contains overlaid boxplots and 99% CI for each balance measure split between condition and across time. The 99% CI was used in place of the standard 95% CI in order to control for inflated Type I Error brought about from multiple comparisons using five balance measures. The boxplots display the variability in the sample data using quartiles and the location of median change (thick black line). The error-bars within the boxplots display the
Sample characteristics. Time 1
Time 2
Protocol 1
Protocol 2
Gender e n (%) Males Females Total
19 (45.2) 23 (54.8) 42
16 (45.8) 19 (54.2) 35
15 (60) 10 (40) 25
4 (23.5) 13 (76.5) 17
Age e Mean SD Males Females Total
27.21 8.34 28.39 10.37 27.86 9.41
26.44 5.62 29.32 11.14 28 9.04
27.93 9.28 28.8 10.19 28.28 9.45
24.5 1.73 28.08 10.91 27.24 9.6
Effect of holographic wristbands on balance Table 2
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Descriptive statistics and 99% CIs of the mean change across conditions and time. Baseline
Placebo Change
Placeboa Change
Device Change
Devicea Change
Balance Measure
Mean SD
Mean SD
99% CI
Mean SD
99% CI
Time 1 NSEO NSEC PSEO PSEC LoS
94.11 93.07 89.11 82.83 93.73
2.41 2.18 2.53 4.34 2.71
0.42 0.53 0.57 0.43 0.25
2.33 3.52 3.18 4.11 3.28
0.55, 1.39 2, 0.94 1.9, 0.76 2.15, 1.27 1.12, 1.62
0.05 0.01 0.28 1.48 0.07
2.85 2.59 4.70 5.00 2.98
1.23, 1.09, 2.23, 3.56, 1.21,
1.14 1.07 1.68 0.61 1.35
42 42 42 42 42b
Time 2 NSEO NSEC PSEO PSEC LoS
94.22 93.26 88.98 82.54 93.46
1.75 2.59 2.93 5.21 3.14
0.52 0.95 0.26 1.13 0.27
2.55 2.98 4.05 5.00 3.20
1.69, 2.32, 1.61, 1.18, 1.21,
0.45 0.91 1.36 0.98 0.22
2.90 3.62 4.18 4.94 3.20
1.78, 0.89 2.59, 0.76 3.29, 0.57 1.3, 3.26 1.64, 1.2
35 35 35 35 35
0.65 0.42 2.13 3.44 1.75
n
LoS Z limits of stability; NSEC Z normal stability eyes closed; NSEO Z normal stability eyes open; PSEC Z perturbed surface eyes closed; PSEO Z perturbed surface eyes open. a Refers to mean change from baseline. b Sample dropped to n Z 40 for Device condition due to participant losing balance and scoring 0.
mean along with the bounds of the 99% CIs. Figure 1 shows all 99% CIs overlapping a mean change of 0. This indicates that the results of this study show no statistically significant evidence of a mean change in balance brought about by either the placebo or the Device. In fact, in most circumstances, the sample results indicated an overall decrease in balance and stability. However, these mean changes are still within the bounds of what would be expected assuming the Device had no overall effect. The potential moderating effect of the two protocols was also checked between Time 1 and 2 using mixed methods ANOVA. The models consisted of a repeated measures factor, condition, with three levels (baseline, placebo, and
Figure 1
Device) and a between subjects factor, protocol, with two levels (Protocol 1: Deviceebaselineeplacebo and Protocol 2: placeboebaselineeDevice). The ANOVAs were repeated for each balance measure and compared to an adjusted significance level of 0.01. As found previously, there were no statistically significant mean effects between conditions across all balance measures. However, a statistically significant interaction between condition and protocol was found for PSEC at Time 1, F(2, 80) Z 6.43, p Z 0.004. The Protocol 1 (Deviceebaselineeplacebo) group scored M Z 80.61 1.22 for the Device, M Z 83.47 0.87 at baseline, and M Z 83.86 1.05 on the placebo. The Protocol 2 (placeboebaselineeDevice) group scored M Z 80.25 1.27
Overlayed boxplots and error bars (99% CI) for measures of balance across time.
302
S.R. Brice et al.
for the placebo, M Z 81.9 1.05 at baseline, and M Z 82.47 1.05 on the Device. These group statistics suggested that both protocols experienced a practice effect following the first condition.
Conflict of interest
Discussion
None Declared
There is no significant difference between measurements across all protocols for baseline (no wristbands), the placebo device or the real Device. While there was a significant interaction observed between condition and protocol for PSEC at Time 1, this is probably an effect of learning, particularly given that the improvement occurred in a time sensitive manner, regardless of the testing order (Van Daele et al., 2007). As the PSEC was the most difficult procedure, a learning effect is not surprising. While there was a trend showing an overall decrease in balance and stability while testing the Device, this was not statistically significant. Of interest is the fact that no improvements were seen with either the placebo or the Device. It might be expected that an improvement with either the Device or the placebo (or both) would be seen given potential expectancy from the participants, who were aware that they were exposed to both of the wristbands (real and placebo). This lack of an effect may be due to the nature of testing being totally objective, i.e. measuring stability using an objective quantitative computerised sample method rather than assessing a participants’ subjective experience of balance changes while using or not using the Device (Hro ´bjartsson and Gøtzsche, 2001). This would add weight to the argument that any anecdotal improvement in balance or athletic performance while using the Device is based on an individual’s perception rather than any real effect on balance performance. There are limitations to this study. As the number of participants determined by the power analysis is based on a moderate effect size, smaller effects could have been undetected. However, given the lack of any trend towards even a small effect being present, increasing the sample size would have been unlikely to make any difference to the study’s conclusion. It must also be noted that only the effect of holographic technology wristbands on human balance and stability performance was investigated. It has been promoted that strength, flexibility and endurance are also enhanced when in close proximity to holographic technology (EFX Embedded Wearable Holographic Technology, 2010; EKEN Power Bands, 2010; Power Balance, 2010). Further research involving randomised controlled and clinical trials, is both required and warranted to evaluate the additional purported benefits of close proximity holographic technology. Given that this study has strongly refuted the primary balance benefit of holographic technology wristbands, the validity of other purported benefits seems highly unlikely.
Funding
Conclusion The results of the current study indicate that holographic technology wristbands have no effect on human balance and stability performance, as demonstrated by CDP. Furthermore, the validity of purported strength, flexibility
and endurance performance enhancement appears highly unlikely.
This study was partially funded by the Discipline of Chiropractic, RMIT University, Bundoora, Victoria, Australia.
Ethical Approval This study was ethically approved by the RMIT University Human Research Ethics Committee.
Acknowledgements The authors would like to thank Mr. Todd Wilson, Bertec Corporation, USA, for his help in exporting data, and Mr. Paul Bongiorno for help in manufacturing the placebo device.
References Asseman, F., Gahery, Y., 2005. Effect of head position and visual condition on balance control in inverted stance. Neuroscience Letters 375 (2), 134e137. Carrick, F.R., Oggero, E., Pagnacco, G., Brock, J.B., Arikan, T., 2007. Posturographic testing and motor learning predictability in gymnasts. Disability and Rehabilitation 29 (24), 1881e1889. Cathers, I., Day, B.L., Fitzpatrick, R.C., 2005. Otolith and canal reflexes in human standing. The Journal of Physiology 563 (Pt 1), 229e234. Di Fabio, R.P., 1995. Sensitivity and specificity of platform posturography for identifying patients with vestibular dysfunction. Physical Therapy 75 (4), 290e305. EFX Embedded Wearable Holographic Technology 2010 Technology. Retrieved November 26, 2010 from http://www.efxusa. com/technology. EKEN Power Bands 2010 Technology. Retrieved November 26, 2010 from http://www.ekenpowerbands.com.au/index.php/specials/? SIDZ0356ba2dd793afa5298105a9b596b572. El-Kashlan, H.K., Shepard, N.T., Asher, A.M., Smith-Wheelock, M., Telian, S.A., 1998. Evaluation of clinical measures of equilibrium. The Laryngoscope 108 (3), 311e319. Faul, F., Erdfelder, E., Lang, A.G., Buchner, A., 2007. G)Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods 39 (2), 175e191. Furman, J.M., 1994. Posturography: uses and limitations. Baillieres Clinical Neurology 3 (3), 501e513. Furman, J.M., 1995. Role of posturography in the management of vestibular patients. Otolaryngology and Head and Neck Surgery 112 (1), 8e15. Hro ´bjartsson, A., Gøtzsche, P.C., 2001. Is the placebo powerless? An analysis of clinical trials comparing placebo with no treatment. The New England Journal of Medicine 344 (21), 1594e1602. Jacobson, B.H., Smith, D.B., Stemm, J.D., Warren, A.J., O’Brien, M.S., Glass, R.G., 2008. Assessment of the effectiveness of nontransdermal energy patches on muscle endurance
Effect of holographic wristbands on balance and power. Journal of Strength and Conditioning Research 22 (3), 869e873. Lackner, J.R., DiZio, P., 2005. Vestibular, proprioceptive, and haptic contributions to spatial orientation. Annual Review of Psychology 56, 115e147. Lipp, M., Longridge, N.S., 1994. Computerised dynamic posturography: its place in the evaluation of patients with dizziness and imbalance. The Journal of Otolaryngology 23 (3), 177e183. McClung, M., Collins, D., 2007. “Because I know it will!”: placebo effects of an ergogenic aid on athletic performance. Journal of Sport & Exercise Psychology 29 (3), 382e394. Mirka, A., Black, F.O., 1990. Clinical application of dynamic posturography for evaluating sensory integration and vestibular dysfunction. Neurologic Clinics 8 (2), 351e359. Pagnacco, G., Oggero, E., Carrick, F.R., 2008. Repeatability of posturographic measures of the mctsib static balance tests a preliminary investigation. Biomedical Sciences Instrumentation 44, 41e46.
303 Pelham, T.W., Holt, L.E., Stalker, R., 2001. Acupuncture in human performance. Journal of Strength and Conditioning Research 12 (2), 266e271. Power Balance 2010 Technology. Retrieved March 13, 2010 from http://www.powerbalance.com.au/technology. Rubik, B., 2002. The biofield hypothesis: its biophysical basis and role in medicine. Journal of Alternative and Complementary Medicine 8 (6), 703e717. Samuels, L., 2010. The Power Balance. Retrieved October 25, 2010 from. http://www.stabmag.com/features/power-balance-lewissamuels/. Schall, D.M., Ishee, J.H., Titlow, L.W., 2003. Effect of magnetic therapy on selected physical performances. Journal of Strength and Conditioning Research 17 (2), 299e302. Van Daele, U., Huyvaert, S., Hagman, F., Duquet, W., Van Gheluwe, B., Vaes, P., 2007. Reproducibility of postural control measurement during unstable sitting in low back pain patients. BMC Musculoskeletal Disorders 8, 44.
Journal of Bodywork & Movement Therapies (2011) 15, 304e308
available at www.sciencedirect.com
journal homepage: www.elsevier.com/jbmt
PILOT STUDY
A pilot study of the prevalence of leg pain among women with endometriosis Stacey A. Missmer, ScD a,b,c, Geoffrey M. Bove, DC, PhD d,* a
Department of Obstetrics, Gynecology and Reproductive Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States b Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States c Department of Epidemiology, Harvard School of Public Health, Boston, MA, United States d University of New England College of Osteopathic Medicine, 11 Hills Beach Rd., Biddeford, ME 04005, United States Received 6 December 2010; received in revised form 28 January 2011; accepted 30 January 2011
KEYWORDS Endometriosis; Epidemiology; Leg pain; Sciatic nerve
Summary Radiating leg pain is a common symptom presenting in manual therapy practices. Although this symptom has been reported as a complication of endometriosis, its prevalence and characteristics have not been studied. We surveyed members of a national endometriosis support group with endometriosis using a self-administered, mailed questionnaire. The main outcome measures were the prevalence and characteristics of leg pain. Of 94 respondents, leg pain was reported by 48 women (51%), and was bilateral in 59% of these symptomatic women. The likelihood of experiencing leg pain was related to weight gain since age 18, age, and height. The most common treatments tried included exercise, over-the-counter medications, and massage therapy, all with variable results. These data support leg pain as a prevalent complication of endometriosis, and that the disease may affect multiple peripheral nerves. Manual therapists should remain aware to this possible etiology for radiating pain. ª 2011 Elsevier Ltd. All rights reserved.
Introduction Endometriosis is the third leading cause of gynecologic hospitalization in the United States (Eskenazi and Warner, 1997). Despite the high health care costs and * Corresponding author. Tel.: þ1 207 602 2921; fax: þ1 207 602 5931. E-mail address:
[email protected] (G.M. Bove).
morbidity associated with endometriosis, the etiology of endometriosis has not been fully delineated. The pathophysiology likely includes hormonal, anatomic, genetic, and immune factors. Risk may be associated with factors that increase the volume, frequency, and duration of retrograde menstruation and promote implantation and growth of endometrial plaque (Oral and Arici, 1997).
1360-8592/$ - see front matter ª 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2011.02.001
Radiating leg pain and endometriosis Women with endometriosis have been hypothesized to have a greater risk of chronic, cyclic leg pain that is independent of any referred dysmenorrheal pain. However, the prevalence of leg pain from all causes among women with endometriosis is unknown. A search of the literature revealed numerous case studies of sciatica due to endometriosis, and outcomes of surgical interventions that confirmed the origin of pain as from endometrioma on the lumbosacral plexus or intrapelvic sciatic nerve (Binkovitz et al., 1991; Bjornsson, 1976; Denton and Sherrill, 1955; Descamps et al., 1995; Dhote et al., 1996; Papapietro et al., 2002; Takata and Takahashi, 1994; Torkelson et al., 1988; Vaisberg, 1964; Yekeler et al., 2004; Zager et al., 1998). Leg pain was incidentally reported by >40% of the 4000 respondents to a survey by the Endometriosis Association (Sinaii et al., 2008), but specifics of the pain (location, timing, duration) were not assessed. These data suggest that endometriosis involving peripheral nerves is a common cause of leg pain in women. While the direct involvement of peripheral nerves has been referred to as “unusual” (Binkovitz et al., 1991) and “rare” (Dhote et al., 1996) (Torkelson et al., 1988; Yekeler et al., 2004), underrecognition of leg pain among women with endometriosis has been cited (Zager et al., 1998). This may be in part because the symptoms are similar to those often attributed to pathologies of the spinal structures, such as lumbar intervertebral discs, paraspinal muscles, and joints. Manual therapists are likely to encounter patients with leg pain due to endometriosis, and need to recognize this etiological possibility. Because there had not been a formal determination of the prevalence and details of leg pain existing with endometriosis, we performed a survey designed to elucidate details about leg pain that may coexist or be caused by endometriosis.
Materials and methods This research was approved by the Institutional Review Board of the Beth Israel Deaconess Medical Center.
305
Study population and data collection The Endometriosis Association is a national support group in the United States that is focused on progress in treatment and research of endometriosis. A total of 306 members with the disease who resided in the geographic vicinity of Boston, Massachusetts were mailed a 4-page questionnaire to be completed and returned in a postage paid envelope. The time allowed from initial mailing to receipt of the final questionnaire was 3 months. No repeat mailings or other methods to increase response rate were employed. Because endometriosis is sufficiently validated by self reporting when a woman reports laparoscopic confirmation (Missmer et al., 2004), the first question asked was whether endometriosis had been confirmed laparoscopically. Women who did not report laparoscopic confirmation were not asked to complete the questionnaire and were not included in the results. The questionnaire then asked details of demographic and anthropometric characteristics, reproductive history, and pain symptoms. Those who reported suffering from leg pain were asked to provide details of their pain including clinical help sought and treatments attempted. In addition, they completed pain drawings. Analysis of the pain diagrams was performed with acknowledgment of the limitations regarding the determination of the involved nerve(s), which is difficult even during clinical evaluation, particularly when deep pain is involved. As previously performed (Bove et al., 2005), we subdivided the leg into 4 regions: proximal anterior (hip to knee), distal anterior (knee to foot), proximal posterior, and distal posterior. Respondent marks within these boundaries were counted as noting presence of pain in this region of the leg.
Statistical analysis Using SAS Statistical Software Version 8.2 (SAS Institute Inc., Cary, NC), we compared the distribution of demographic, anthropometric, dietary intake, and reproductive
Table 1 Characteristics associated with leg pain among responding women with laparoscopically confirmed endometriosis, compared to responding women without leg pain [n Z 48 of 94 (51%)]. Participant characteristic
UV OR (95% CI)
p-valuea
Time since diagnosis of endometriosis (years) Current age (years) Current height (inches) Current weight (pounds) Weight at age 18 (pounds) Weight change since age 18 (pounds) Current body mass index (kg/m2) Currently overweight (BMI 25 kg/m2) Body mass index at age 18 (kg/m2) Age at menarche Ever used oral contraceptives Parous Currently pregnant or lactating Hysterectomy Postmenopausal
0.96 0.96 0.87 1.01 0.99 1.02 1.07 2.07 1.02 1.20 1.80 1.00 0.58 1.02 0.60
0.15 0.09 0.08 0.39 0.49 0.06 0.13
UV OR Z Univariate odds ratio, CI Z Confidence interval. a Two-sided Wald statistic p-value, test for linear trend.
(0.91e1.02) (0.93e1.01) (0.74e1.02) (0.99e1.02) (0.97e1.01) (1.00e1.04) (0.98e1.16) (0.90e4.77) (0.89e1.18) (0.85e1.69) (0.40e8.07) (0.44e2.29) (0.09e3.63) (0.34e3.12) (0.23e1.56)
0.73 0.30
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S.A. Missmer, G.M. Bove
history characteristics between women with laparoscopically confirmed endometriosis who did and did not report experiencing leg pain. Unconditional logistic regression was used to calculate the crude and multivariable odds ratios (OR) and 95% confidence intervals (CI) that are presented as estimates of the relative risk (Rothman and Greenland, 1998). In the final models, we included all variables that were observed to be significantly associated with leg pain as potential confounders. We conducted tests for trend in ordinal categorical exposures by creating an ordinal variable in which the median value or midpoint of each category was assigned to all participants in that group, and then calculated a Wald statistic (Lemeshow and Hosmer, 1989). Statistical significance was placed at the 0.10 level.
Results Of the 306 mailed questionnaires, 19 were returned due to inaccurate address information. Of those who received the pilot mailing, a total of 94 women (33%) returned a completed questionnaire indicating laparoscopically confirmed endometriosis. These women ranged in age from 16 to 58 with a median age of 42. The women were primarily Caucasian (98%) and premenopausal (74%). Five women were pregnant or breast feeding at the time of questionnaire completion. The median time since diagnosis of endometriosis was 10 years (range Z 1e33 years). A total of 48 women (51%) reported leg pain. While neither current weight nor weight at age 18 were significantly associated with risk of leg pain, we observed a significant 2% increase in risk for each pound gained since age 18 (p-value, test for linear trend Z 0.06; Table 1). In addition, as age increased, the risk of having leg pain increased (p-value, test for linear trend Z 0.09). We also observed a linear association with height (p-value, test for linear trend Z 0.08). No other participant characteristics were associated with the likelihood of leg pain. Forty-five of the 48 women with leg pain depicted their pain on profile diagrams (Figure 1). Pain severity encompassed the entire range, from mild to severe, and was more often reported in more than 1 region (1.8 regions 1 SD). Most women (60%) reported proximal anterior leg pain. The distal anterior region was involved in 31% of women. The proximal and distal posterior regions were involved in 40%, and 47% of women, respectively. Women reported bilateral, unilateral left-, and unilateral right- sided leg pain (59%, 24%, and 17%, respectively; Table 2). Pain was most likely to be experienced during menstruation and just prior to the start of menses. This observation is consistent with the catamenial nature of the disease, where the symptoms result from immune mediated inflammation due to the presence of sloughed endometrial cells. Only 10% claimed that there was no relationship with their menses (i.e., they answered no to all queries). The majority of women (68%) who provided details about efforts to diminish their leg pain symptoms reported mentioning their leg pain to a clinician, and one-third of these women were referred to specialists. Nearly half of the patients were not offered any treatment option for this symptom. However, the majority of women attempted various treatments, and more than 2/3 reported some benefit.
Figure 1 Parts of pain drawings from 6 different respondents to the survey. “xx” marks were used for pain, and dots for numbness or other sensory aberrations. The distributions are consistent with involvement of (A) the femoral nerve; (B) the gluteal and lateral femoral cutaneous nerves; (CeE) the lumbosacral plexus, sciatic, and/or posterior femoral cutaneous nerve; (F) lateral femoral cutaneous nerve (Maigne, 1979). There was no distinction assessed between deep versus cutaneous symptoms. It should be noted that nerve distributions vary considerably between individuals.
Discussion In this cross-sectional pilot study among women with endometriosis, we observed that the prevalence of selfreported leg pain was 51%. The prevalence of leg pain among a comparable group of women is not known, but the few studies available estimate the point and lifetime
Radiating leg pain and endometriosis Table 2
307
Pain and coping characteristics of women who reported experiencing leg pain [n Z 48 of 94 (51%)]. N (%) or median (range)
Pain location and severity Pain in both legs Pain in left leg only Pain in right leg only VAS score for all legs
27 (59%) 8 (17%) 11 (24%) 5.0 (1e10)
Menstrual cycle timing of leg pain During menstruation (early follicular phase) Immediately after menstruation (late follicular phase) During ovulation (early luteal phase) Prior to next cycle start (late luteal phase) All of the time Not menstrual cycle-linked (i.e. no for each time)
22 (73%) 10 (34%) 12 (41%) 19 (66%) 7 (24%) 3 (10%)
Medical intervention Ever mentioned leg pain to a health professional Received referral to an Orthopedist Chiropractor Neurologist
30 (68%) 3 (10%) 2 (7%) 5 (16%)
Attempted treatments Clinician did not suggest treatment Exercise Prescription drugs Over-the-counter drugs Herbs Heat or cold therapy Massage therapy Acupuncture
12 (46%) Treatments tried 33 (80%) 15 (35%) 26 (60%) 8 (20%) 20 (48%) 25 (61%) 12 (31%)
prevalence of sciatic pain from all etiologies to be 2e5% and 2.5e21%, respectively (Hofmann et al., 2002; Riihimaki et al., 1994; Videman et al., 2005; Younes et al., 2006). These data support that endometriosis is a prominent cause of radiating leg pain. It is acknowledged that the population observed in this pilot study may not be generalizable. Members of the Endometriosis Association are a self-selected group of women who have chosen to join a support group and pay annual dues, and their diagnosis, medical details, and experience of endometriosis are strictly self-reported. While these support group member women may represent those with more endometriosis-related sequelae (Sinaii et al., 2008), these data were limited to respondents who reported laparoscopic confirmation of endometriosis, and therefore are more reliable than self-reports alone (Missmer et al., 2004). Given the many causes of leg pain, it is unknown what proportion of our subjects had leg pain due to endometriosis directly affecting one or more peripheral nerve, and what proportion had pain due to co-existing pathologies. It was also not possible to identify cases of referred pain. While we plan to perform examinations of such women in the future, such differential diagnosis is often not possible. However, even if the true proportion of women who suffer from leg pain directly related to an endometriotic lesion affecting a peripheral nerve is much lower than 51%, and given that endometriosis among women of reproductive age is estimated to be as great
Reported pain improvement 23 (70%) 11 (79%) 16 (62%) 4 (50%) 18 (90%) 19 (79%) 8 (67%)
as 10% (Eskenazi and Warner, 1997), leg pain with endometriosis represents a significant public health concern. Further studies including control groups and physical examinations are warranted based on these initial observations. The variability of the pain distributions supports the hypothesis that leg pain associated with endometriosis can affect many different and even multiple nerves in the same woman. Most nerves to the lower limbs pass through the abdominal and pelvic cavities, only separated from the intraperitoneal space by the peritoneum. Inflammatory endometrioma that are attached to the peritoneum in close proximity to a nerve are likely to inflame the nerve and the axons it contains, and indeed show a predilection for nerves (Anaf et al., 2004; Anaf et al., 2000). Such a neuritis could cause local or radiating pain; this is supported by data from rat models (Bove and Light, 1997; Bove et al., 2003, 2009; Sauer et al., 1999). It is also possible that nerve inflammation due to endometriosis leads to abdominal and pelvic pain as well as leg pain, by affecting the nerves supplying the viscera. Finally, afferent activity in these nerves could be sufficient to form what has been called the “peripheral generator” (Gracely et al., 1992; Hedo et al., 1999). In this concept, the nociceptive afferent signals from a pathology induce and then maintain a form of spinal cord or higher center sensitization, which then can lead to the perception of pain in areas that are neurologically remote from the location of the pathology, i.e. are innervated by different nerves. Thus, the pain or other
308 sensations could be perceived in a much wider distribution than would seem appropriate to the pathology. While the sample size for this pilot study is relatively small, these data yield the first quantification of the leg pain experience of women with endometriosis. We hypothesize that this symptom, though prevalent, may elude clinical detection, and indeed may be masked by referred dysmenorrheal pain. It is possible that women do not make the connection between their abdominal/pelvic pain and their leg pain, or are not forthcoming in discussing this with their physician (Zager et al., 1998). Moreover, because non-pelvic pain associated with endometriosis is not well described in the literature, it is also possible that physicians and other therapists do not customarily ask details about such symptoms. The etiology of radiating leg pain is often obscure. When a patient presents with radiating leg pain, most clinicians look for pathologies of the musculoskeletal system, such as altered spinal mechanics or focal muscle hypertonicities (“trigger points”), which can lead to similar symptoms. The initial findings reported here support the concept that endometriosis that directly involves nerves should also be considered in women with endometriosis. While there may not be pathognomonic symptoms aside from the radiating pain distribution, neurological and orthopedic examinations should prove consistent with peripheral nerve involvement. Our goal is that the results of this pilot study will lead to improved diagnostic awareness of this prevalent consequence of endometriosis.
Acknowledgments An abstract version of part of this manuscript was presented as a poster at the Society for Neuroscience annual meeting. Financial support was provided by a grant to Dr. Bove from the National Institute for Child Health and Human Development.
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S.A. Missmer, G.M. Bove Descamps, P., Cottier, J.P., Barre, I., Rosset, P., Laffont, J., Lansac, J., Body, 1995. Endometriosis of the sciatic nerve: case report demonstrating the value of MR imaging. Eur. J. Obstet. Gynecol. Reprod. Biol. 58, 199e202. Dhote, R., Tudoret, L., Bachmeyer, C., Legmann, P., Christoforov, B., 1996. Cyclic sciatica. A manifestation of compression of the sciatic nerve by endometriosis. a case report. Spine 21, 2277e2279. Eskenazi, B., Warner, M.L., 1997. Epidemiology of endometriosis. Obstet. Gynecol. Clin. North Am. 24, 235e258. Gracely, R.H., Lynch, S.A., Bennett, G.J., 1992. Painful neuropathy: altered central processing maintained dynamically by peripheral input. Pain 51, 175e194. Hedo, G., Laird, J.M.A., LopezGarcia, J.A., 1999. Time-course of spinal sensitization following carrageenan-induced inflammation in the young rat: a comparative electrophysiological and behavioural study in vitro and in vivo. Neuroscience 92, 309e318. Hofmann, F., Stossel, U., Michaelis, M., Nubling, M., Siegel, A., 2002. Low back pain and lumbago-sciatica in nurses and a reference group of clerks: results of a comparative prevalence study in Germany. Int. Arch. Occup. Environ. Health 75, 484e490. Lemeshow, S., Hosmer, D.W., 1989. Applied Logistic Regression. Wiley New York, NY. Maigne, R., 1979. Orthopedic Medicine. Charles C. Thomas Publisher, Springfield, MO. Missmer, S.A., Hankinson, S.E., Spiegelman, D., Barbieri, R.L., Marshall, L.M., Hunter, D.J., 2004. Incidence of laparoscopically confirmed endometriosis by demographic, anthropometric, and lifestyle factors. Am. J. Epidemiol. 160, 784e796. Oral, E., Arici, A., 1997. Pathogenesis of endometriosis. Obstet. Gynecol. Clin. North Am. 24, 219e233. Papapietro, N., Gulino, G., Zobel, B.B.B., Di Martino, A., Denaro, V., 2002. Cyclic sciatica related to an extrapelvic endometriosis of the sciatic nerve - new concepts in surgical therapy. J. Spinal Disord. Tech. 15, 436e439. Riihimaki, H., Viikari-Juntura, E., Moneta, G., Kuha, J., Videman, T., Tola, S., 1994. Incidence of sciatic pain among men in machine operating, dynamic physical work, and sedentary work. A three-year follow-up. Spine 19, 138e142. Rothman, K.J., Greenland, S., 1998. Modern Epidemiology. Lippincott-Raven, Philadelphia, PA. Sauer, S.K., Bove, G.M., Averbeck, B., Reeh, P.W., 1999. Rat peripheral nerve components release calcitonin gene-related peptide and prostaglandin E-2 in response to noxious stimuli: evidence that nervi nervorum are nociceptors. Neuroscience 92, 319e325. Sinaii, N., Plumb, K., Cotton, L., Lambert, A., Kennedy, S., Zondervan, K., Stratton, P., 2008. Differences in characteristics among 1,000 women with endometriosis based on extent of disease. Fertil. Steril. 89, 538e545. Takata, K., Takahashi, K., 1994. Cyclic sciatica. A case report. Spine 19, 89e90. Torkelson, S.J., Lee, R.A., Hildahl, D.B., 1988. Endometriosis of the sciatic nerve: a report of two cases and a review of the literature. Obstet. Gynecol. 71, 473e477. Vaisberg, M., 1964. Cyclic sciatica due to endometriosis. N.Y State J. Med. 64, 1983e1987. Videman, T., Ojajarvi, A., Riihimaki, H., Troup, J.D., 2005. Low back pain among nurses: a follow-up beginning at entry to the nursing school. Spine 30, 2334e2341. Yekeler, E., Kumbasar, B., Tunaci, A., Barman, A., Bengisu, E., Yavuz, E., Tunaci, M., 2004. Cyclic sciatica caused by infiltrative endometriosis: MRI findings. Skeletal. Radiol. 33, 165e168. Younes, M., Bejia, I., Aguir, Z., Letaief, M., Hassen-Zrour, S., Touzi, M., Bergaoui, N., 2006. Prevalence and risk factors of disk-related sciatica in an urban population in Tunisia. Jt. Bone Spine 73, 538e542. Zager, E.L., Pfeifer, S.M., Brown, M.J., Torosian, M.H., Hackney, D.B., 1998. Catamenial mononeuropathy and radiculopathy: a treatable neuropathic disorder. J. Neurosurg. 88, 827e830.
Journal of Bodywork & Movement Therapies (2011) 15, 309e318
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PAIN PHYSIOLOGY
Pain relief due to physiotherapy doesn’t change the motor function of the shoulder ¨rl, PhD a,*, Andreas Matkey, PT a, Susanne Bretschneider a, Falk Mo Annette Bernsdorf, MD a, Ingo Bradl, PhD b,c a Forschungsgesellschaft fu¨r angewandte Systemsicherheit und Arbeitsmedizin mbH, Zentrum fu¨r Bewegungstherapie, Dubliner Straße 12, 99091 Erfurt, Germany b Berufsgenossenschaft Nahrungsmittel und Gaststa¨tten, Department of Prevention, Biomechanics, Dubliner Straße 12, 99091 Erfurt, Germany c University Hospital Jena, Clinic for Trauma-, Hand- and Reconstructive Surgery, Division for Motor Research, Pathophysiology and Biomechanics, 07740 Jena, Germany
Received 20 January 2010; received in revised form 17 May 2010; accepted 25 June 2010
KEYWORDS Co-ordination test; Shoulder; Kinematic; Physiotherapy; Biomechanics
Summary Objective: The purpose of this study is to evaluate the effect of different training methods in physiotherapy on pain relief and change in proprioception and kinesthesia of the shoulder. Further, the connections between pain relief and change in motor function of the shoulder will be investigated. Design: Randomised trial. Setting: Ambulatory care. Participants: Two groups of unspecific shoulder pain patients (group1 n Z 12, group2 n Z 10). One group (n Z 8) of non-symptomatic subjects. Intervention: The first shoulder-pain group was trained using flexible foil, whilst flexible bands were used to train the patients in the second group. Training period was 12 weeks. Main outcome measures: Pain of the shoulder was evaluated through functional pain assessment (Constant-Murley score) before, halfway through and after intervention. Proprioceptive and kinaesthetic ability was measured by an activeeactive angle-replication test for the shoulder before and after intervention. The data of the shoulder patients was compared to the group of non-symptomatic subjects. Results: Pain was reduced significantly in both groups (p < .05) whereas no changes were measured for the ability to replicate angles of the shoulder.
* Corresponding author. Tel.: þ49 (0) 361 26244166. E-mail address:
[email protected] (F. Mo ¨rl). 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.06.008
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F. Mo ¨rl et al. Conclusion: This suggests that pain relief in the shoulder is not associated with enhancement of the investigated parameters in motor function. ª 2010 Elsevier Ltd. All rights reserved.
Introduction The coordinative capabilities of the shoulder are important to ensure the precise movement of the humerus. Spatial coordination does not just affect single bones articulating with each other. Without the compensatory motions of adjacent joints, incorrect motions of the shoulder as the root in a segmented body part like the arm will be propagated to the forearms and the hands. So lack of coordination of the shoulder may affect every day-life activities like picking up a pencil or moving a cup to the mouth. In the field of orthopaedics and physiotherapy, shoulder pain is often linked to poor motor function or miss-coordination or biomechanical stress (Keyserling, 2000; Hoozemans et al., 2002; Kleine et al., 1999; Hughes et al., 2003). The relation is unclear and therefore a question arises as to whether shoulder pain is a result or a cause of poor motor function of the glenohumeral joint. In this context, there are indications that severe damage to the structures of the shoulder that are important for motor function does not lead to shoulder pain or impede everyday activities (Schibany et al., 2004). Studies of exercise therapy for the shoulder-neck region claim all kinds of correlations between training, pain relief and a significant enhancement in physical parameters like strength and range of motion (Green et al., 2003, 1998, 2000; Buchbinder et al., 2007; Ainsworth, 2006; Ylinen et al., 2003; Sokk et al., 2007). Therefore training patients to relieve shoulder pain does not seem an unrealistic goal. However, most studies justify their achievement in therapy only in terms of pain relief. Functional parameters have been deduced only partly, using questionnaire methods (disability index etc.). Physical measures, such as strength or range of motion of the shoulder joint, have seldom been examined (McClure et al., 2004). At the moment there is no clear evidence for a main physical measure in correlation to pain relief. Further, there is a lack of information on changes of motor function, e.g. proprioception or kinesthesia, so biomechanical tests to compare motor function before and after intervention are rare. In order to measure proprioceptive abilities of the glenohumeral joint, the passive position sense of the shoulder has been deduced using complex laboratory instruments (Blasier et al., 1994; Carpenter et al., 1998; Lee et al., 2003). In summary, the passive position sense depends on the speed used during the test. Further, sensibility seems to be better at extreme positions of the shoulder (Janwantanakul et al., 2001). Moreover, methods to measure the ability to reproduce a special position of the humerus can be divided into passive and active tests. Passive tests also use elaborate instruments (Ulkar et al., 2004). Deficits in the passive ability to reproduce a particular position of the arm were documented for patients suffering from shoulder instability (Jerosch and Thorwesten, 1998). To our knowledge, only one study so far has investigated the effect of physical training on proprioception and
kinesthesia of the shoulder (Swanik et al., 2002). In the field of active rehabilitation (physiotherapy or sports therapy) of shoulder pain patients, there is a lack of information about changes in coordinative abilities from therapeutic intervention. So further key questions arise: Is physiotherapy able to change proprioceptive abilities such as the capability to reproduce a specific angle of the glenohumeral joint? Is there a connection between pain reduction and change of ability to reproduce an angle? In this context the aim of our study was to analyse training effects in two different groups of non-specific shoulder pain patients. For the training, different devices were utilized. The first group used a flexible foil, whereas the second group was trained using flexible bands. These devices have different approaches to the training of the shoulder. The flexible foil aims mainly at stabilising the shoulder. At this time, there is no evidence for its efficiency. Training using flexible bands mainly affects the force production of muscles surrounding the shoulder, but evidence is rare (Sugimoto and Blanpied, 2006). As both devices are commonly used in physiotherapy, the purpose of this study is to evaluate the effect of both methods on pain relief and change in proprioception and the kinaesthetic aspects of motor function. The pain and functional conditions of the patients were monitored using questionnaires before and after intervention. To obtain a correlation with a functional measure of motor function, the active capability to reproduce angles of the shoulder joint was also measured by a biomechanical test before and after intervention. Thus, we compared the effect of different training devices. Further, we provide information concerning the connection between pain relief and change in motor function based on a physiotherapy protocol. Moreover, this study is an attempt to give information regarding the extent to which motor function influences shoulder pain.
Materials and methods Procedure and intervention Shoulder patients were recruited with the co-operation of the State Ministry of the Environment. All patients were examined medically and orthopaedically by an orthopaedist in order to exclude subjects who did not fulfil the inclusion criteria. Inclusion criteria were: unspecific pain of at least one shoulder in combination with orthopaedically-assessed functional deficits. Exclusion criteria were common contraindications like diseases of the cardiovascular system, high blood pressure, post-surgical conditions, acute prolapse of an intervertebral disc (4 months), neurological symptoms or rotator cuff tear. Rotator cuff was tested by the orthopaedist using common tests, e.g. drop arm test, lift off test (Fuchs et al., 1999; Park et al., 2005; Hughes et al., 2008; Colsant et al., 2010). Before training, all patients were assessed for functional pain capability of the shoulder (see Functional pain assessment) and investigated using an extensive angle-
Pain relief due to physiotherapy doesn’t change the motor function of the shoulder replication test (see The angle-replication-test). Functional pain assessment was repeated halfway through and after the training. Being complex and time-consuming, the anglereplication test was repeated only after the training period. Patients were randomly distributed to train with flexible foil or with flexible band. The training course was subdivided into 24 workouts and extended over at least 12 weeks, with 2 workouts per week. When there was loss of a workout because of holiday or illness the workout was carried out in the following week. Every workout was individual (there were no group-workouts) and coached by a physiotherapist or a sports therapist. Shoulder pain patients usually have higher tonicity in upper trapezius (Delaney et al., 2002; Sjo ¨rs et al., 2009; Masi and Hannon, 2008) which may reduce the benefit of the training (e.g. the patient would not be able to exercise as instructed by the therapist). To reduce muscle tone, the region of the upper trapezius was treated randomly through physiotherapy techniques such as myofascial release or a hot rolled towel (5e10 min) at the beginning of every workout. For the myofascial release of the upper trapezius, the patients were asked to lay on their backs. Then, the fingers of the therapist touched the surface of the muscle on the skin at a 90 angle to the fibre direction of the muscle and around 45 to the surface of the skin. For this, only the gravity of the head/neck was used. The pressure applied by the fingers was minimal so that the fingers did not slip. The tissue was displaced, however (around 5 N). This procedure lasted from 30 to 60 s until a sense of release, or lengthening of the muscular system was noticeable. A “hot rolled towel” here means that up to half a litre of boiling water was poured into the centre of a rolled hand-towel. This creates a high but skin-friendly temperature on the outer surface of the rolled towel. The towel was then repetitively applied to the surface of the muscle for less than a second at a time, for a total period of 3 min or more. After the outside of the towel had cooled, it was unrolled to keep the temperature high. Active therapy lasted 20 min. Therefore, every single workout took 30 min. Training was organised as set training. As far as the declaration of Helsinki is concerned the protocol has been approved by the appropriate ethical committee. All subjects were volunteers and gave written consent. Training with flexible foil The device used for training with flexible foil was Propriomed (Haider Bioswing, Pullenreuth, Germany). The function of this device is comparable to the Bodyblade and explained elsewhere (Puta and Herbsleb, 2005). Training with the Propriomed device was designed according to the manufacturer’s instructions (Puta and Herbsleb, 2005). Different exercises were selected by the therapist to suit the abilities of the patient. All exercises were done in a standing position. The first exercise was to hold the device ambidextrously, keeping the hands above head height and to swing it up and down the sagittal plane of the body (Figure 1, E1). The second exercise was in the same position but to oscillate the flexible foil back and forth (Figure 1, E2). The third exercise was single-arm oscillation on the side of the head (Figure 1, E3). The fourth exercise is comparable to the third exercise but involves moving the
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device during oscillation through arm elevation from a position in front of the body to one on the side of the head (Figure 1, E4aeE4c). Parameters were varied for a progressive workout. Firstly, exercise time was extended. Secondly, the number of exercises was increased. Thirdly, the direction of oscillation was changed (upedown; backeforth), and fourthly, the frequency of the device was increased by changing the positions of the weights. Training with a flexible band The flexible bands used were typical Therabands (TheraBand GmbH, Hamadar, Germany). Bands in different colors were used for different force exertion according to gender, the weight and the strength of the patient. Female patients usually trained with yellow or red bands whereas male patients trained with red or green bands. An exception was made for patients suffering from severe pain or restrictions. These patients used white bands. Four different exercises were used to train the patients. All exercises were done in a standing position. The first exercise called “programming” was done without Theraband. Here the patient had to lift one arm with the elbow flexed at 90 , the wrist straight and the thumb pointed backwards on the side of the head. In this position, the patient had to lift the scapula or to rotate the whole arm using clavicle and scapula (Figure 2, E1aeE1b). The second exercise consisted of an outward rotation of the forearms against tension of the flexible band. For this purpose, the arms hang laterally to the trunk, elbows flexed at 90 , the wrists straight and the thumbs directed cranially. Then, an outward motion and an outward rotation of the forearms was performed (Figure 2, E2aeE2b). The third exercise called “programming by flexible band” was a mixture of exercises one and two. Here, the patient grasped the band as in exercise two but had to lift one arm onto to the side of the head as in exercise one (Figure 2, E3aeE3b). The fourth exercise was an extension of exercise three. Here, the trunk was tilted through low flexion of the hips and knees. Lifting the arm as in exercise three had to be performed alternately with the left and right arm (Figure 2, E4aeE4b). More exercises per workout were performed in the course of training. Training was organised as set training including 3 sets of 5e10 repetitions.
Subjects The patients selected from the State Ministry of the Environment were mostly office workers whose exposure to physical labour is low. All subjects were instructed to do no other sports in their leisure time. Several patients had done demanding activities or sports in leisure time more than a year before. Both training groups showed comparable data in age, height and weight. An exception is gender: the flexible-foil group having more female patients (Table 1). To obtain values of a non-restricted capability to reproduce angles of the shoulder for comparison to the patients’ data, a group of young subjects without a history of shoulder pain or injury was recruited and measured using the angle-replication-test. The patients’ test data shows no correlation to age (r Z 0.18, p Z .28). To the author’s knowledge, no differences in proprioception of the
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Figure 1 Exercises with flexible foil. Up and down oscillation in sagittal plane (E1), Back and forth oscillation in transversal plane (E2), single-arm oscillation on side of the head (E3), single-arm oscillation through arm elevation within different states (E4aeE4d), see Training with flexible foil for details.
shoulder were found in age groups for pain-free subjects. Only one study shows a significant decline in proprioception of the shoulder in senior citizens (50e70 yrs) (Zuckerman et al., 1999).
Functional pain assessment To estimate the pain situation and the raw functional conditions of the shoulder, the Constant-Murley shoulder assessment was used (Constant and Murley, 1987; Constant, 1991; Krepler et al., 2006). The score of the test judges a normal (more than 95 pt) or a deficit pain condition. 25% of the score was assigned by a strength test. Because the test did not discriminate the force levels depending on the subject’s gender, we also show data without strength
information. The pain of the shoulder during testing was deduced using a visual analogue scale.
The angle-replication-test Procedure To get a specific measure of proprioception, every subject had to perform an extensive activeeactive angle-replication-test of the shoulder. Here, in contrast to other motor function tests, the patients had to move their arms to the test position themselves during the test. The angular location of the shoulder was visualised on a display located in front of the subject. In this way, the subject was able to correct the angular location up to the specific angular value based on the test-protocol. After this, the subjects had to close their eyes and keep the arm in the pre-defined
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Figure 2 Start and end positions of exercises with flexible band. “Programming” without flexible band (E1a, b), outward rotation of the forearms against band tension (E2a, b), “programming by flexible band” (E3a, b), “programming by flexible band” in trunk tilt position (E4a, b), see Traing with a flexible band for details.
position for about 10 s. The therapist leading the test advised the subjects to sense the position of the shoulderarm-complex without visual feedback. With eyes closed, the subject had to change the arm position to a neutral position e.g. hanging relaxed at the side of the body. Then, (eyes still closed) the therapist advised the subject to change the position of the arm to the instructed position. A difference between the pre-adjusted position (with visual control) and the newly adjusted position (without visual control) was measurable in the coordinative ability of the subject (Figure 3). The therapist checked that their eyes were still closed. Both shoulders were tested separately. The angle-repetition-test was performed for three different motions in different angles. The motions were anteversion (sagittal plane), abduction (frontal plane) and inward and outward rotation (transversal plane). Inward and outward rotation of the humerus were measurable in the neutral position of the upper arm with the elbow flexed at 90 (see Kinematic measures). Every test was repeated three times for each angle within each motion. Motion and repetition at specific angles were randomised (Table 2,
Table 1
accuracy and reliability are discussed in Kinematic measures). Kinematic measures During the angle-repetition-tests, angular positions of the shoulder and the arm were measured and visualised online using the zebris CMS-HS 3D motion measuring system (Zebris Medical GmbH, Isny, Germany). For this purpose, zebris markers were applied on landmark C7 on the cervical spine and landmark TH12 on the thoracic spine. On the shoulderarm-complex, markers were applied on acromion, epicondylus lateralis at the elbow and caput ulna of the ulna. It was thereby possible to measure the angle between trunk and humerus as a measure for anteversion (sagittal plane) and abduction (frontal plane) and the angle between shoulder (vector C7 e acromion) and forearm as a measure for axial rotation of the humerus (transversal plane). Five seconds of holding the arm in a pre-adjusted position and readjusting the arm to a pre-defined position were measured (both without visual control of the subject) whilst performing the anglerepetition test. Sampling rate for all measurements was
Number of subjects in the different groups, age [years], body height [m] and body weight [kg] as mean (std).
Group
Flexible foil
Flexible band
Nonesymptomatic
Sex(\/_) Age Body height Body weight
10/2 45.7 (10.8) 1.67 (0.08) 68.0 (12.0)
6/4 47.9 (7.4) 1.71 (0.13) 67.8 (16.3)
2/6 28.9 (4.3) 1.77 (0.07) 73.8 (10.9)
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Figure 3 An example of how to select the data. The plot is separated in pre-adjustment (left) and test (right) interval with the selected data intervals.
50 Hz. The accuracy of the setup used here shows a mean standard error of 0.59 . The re-test reliability has a correlation of r Z 0.95 (p < .001) and an inter class correlation of icc Z 0.91. The used angle-replication test is comparable to tests from in the literature (Jerosch et al., 1996).
biomechanical data before and after the intervention, the paired-sample Wilcoxon-signed-rank test was used. Significance level for all tests was p Z .05. A linear correlation analysis was calculated to get a measure of the coherence of pain relief and the change in motor function.
Data-processing and statistical analysis
Results
The difference between pre-adjusted and self adjusted angle without visual control was calculated using Matlabroutines (The MathWorks, Inc., NatickMA, USA). For this purpose, intervals of 3 s length without large variation within the data of pre-adjusting and readjusting the arm were selected manually (Figure 3). The mean of both intervals was calculated to estimate the difference between both postures. In this context, a negative number signifies a bigger angle while testing without visual control; a positive number a smaller one. In the example a clear difference can be seen. Medians and quartiles for every subtest of the anglereplication test and the pain assessment were calculated. To compare the biomechanical data of pre- and post-test with the non-symptomatic group, the Wilcoxon rank sum test (ManneWhitney U-test) for independent samples was used. To compare the data of pain assessment and
Improvement in functional pain assessment
Table 2
Pain was reduced in both intervention groups. In the flexible foil group the median deduced by the visual analogue scale (VAS) decreased high significantly from 3.1 to 0.5 (p < .001). The intervention using flexible bands decreased the VAS value from 2.5 to 1.8 (p < .05). So there seems to be more benefit in pain relief by training using the flexible foil device. Significant improvement in functional pain assessment was found during both interventions. The intervention using flexible foil enhances the ConstantMurley-score (without strength information) within the first 6 weeks high significantly (14.7 pts, p < .01). In this period the intervention by flexible bands shows no statistical significant change (6.7 pts, Figure 4 A). No further significant changes were found for either group between weeks 6e12 of intervention. The difference between the
Planes of motion, motion and the specific angles for the shoulder angle-repetition-test.
Plane of motion
Motion
Angles [ ]
Sagittal Frontal Transversal
Anteversion Abduction Inward rotation outward rotation
60, 90, 120 60, 90, 120 Neutral position neutral position
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Figure 4 Median and quartiles of ConstanteMurley-score without strength test (A) and including strength test (B) for flexible foil (B) and flexible band group (6) before, after 6 weeks and after 12 weeks of intervention. Both intervention methods show significant improvement (*p < .05; **p < .01; ***p < .001).
pre-training and post-training test is bigger in the flexible foil group (22.7 pts, p < .01) than in the flexible band group (6.0 pts, p < .05). This signifies a small advantage in therapy achievement for the flexible foil when rejecting the strength information, i.e. the flexibility of the shoulder may be trained more effectively using this device. A different outcome was found for the Constant-Murleyscore-including-strength-test, (Figure 4B). Both groups showed highly significant achievement after 6 weeks of intervention (flexible foil: 7.0 pts, flexible band: 5.0 pts, both p < .01) but no further significant change between weeks 6 and 12 of therapy. Pre-training and post-training tests show a highly significant difference for the group trained by flexible bands (6.5 pts, p < .001) and a significant change for the flexible foil (6.0 pts, p < .01). Due to this, including all the information of the Constant-Murley score both interventions show clear enhancement. With a Constant-Murley score higher than 95 pts (no important limitation in the function of the shoulder) it was possible to achieve functional pain rates. However, there were further impairments to the medians of patients after 12 weeks of intervention (Figure 4B). A better result was found for the score excluding strength information. Here, the flexible foil group and the flexible band group showed comparable median values with non-impaired subjects, with 93.3 pts and 93.7 pts respectively.
Changes in motor function by physiotherapy Before intervention no group differences between the patients (flexible foil vs. flexible band) in proprioception were detectable with the exception of inward rotation (p < .05). In comparison with the non-symptomatic group, the patients showed significantly lower abilities to reproduce spatial positions of the shoulder. This is true for all tested angles in abduction (p < .01), and in anteversion at 60 (p < .05), but not in inward or outward rotation tests. There is a marginal difference between pre-training and post-training tests in anteversion at 90 (Wilcoxon-test p Z .07, Figure 5). In abduction and anteversion, the measured differences in the patients were two to four times bigger than the differences in the non-symptomatic group. For example, in position abduction 120 , the median error of the non-symptomatic group was 1.2 . In contrast, patients showed a median error of 4.7 . After intervention, the patients, in comparison with the non-symptomatic group, still showed significantly lower abilities to reproduce the test angles in abduction and anteversion at 60 (p < .01), and significantly lower ability to reproduce angles in anteversion at 90 (p < .05). For the flexible foil group, there is an exception in anteversion at 90 where no significant difference to the non-symptomatic group was found (p Z .1). For the flexible band group,
Figure 5 Median and quartiles of angle-replication-capability for non-symptomatic group (B), flexible-foil-group before (,) and after intervention (>), flexible band group before (D) and after intervention (*) in different test positions. Stars indicate significant differences compared to non-symptomatic group (*p < .05; **p < .01).
316 position abduction 120 showed no significant differences in comparison with the non-symptomatic group (p Z .37). From this, it follows that both interventions only randomly affect the patients’ proprioception to achieve the level of the non-symptomatic group (Figure 5). Given these poor outcome rates, inner group changes of the patients were tested: Again, in both groups, the parameters measured in motor function were not affected by intervention. The only exception is the flexible band group in abduction at 120 . Here, the difference is reduced after the training (p < .05). In summary, the effect of both training methods on the investigated capability in motor function is intermittent and random.
About the coherence of pain relief and change in motor function Because of the different results in pain relief and changes in motor function by intervention the changes in ConstantMurley score and angle-replication capability were calculated and plotted against each other (Figure 6). As expected, there is no statistical coherence of pain relief and change in motor function (r Z 0.02; p > .05). This means that the improvement in pain of the shoulder is not associated with good or poor capability in proprioception.
Discussion Intervention using physiotherapy-driven training reduces the pain of the shoulder. This result was expected and is comparable to other studies in efficiency of physical interventions (Green et al., 2003, 1998, 2000; Ylinen et al., 2003; Sokk et al., 2007). The attempt to find differences in pain relief due to different methods failed. Based on the data of shoulder-functional pain assessment, no method shows a clear advantage. In detail, rejecting strength information in the functional pain score used, the intervention by flexible foil shows a high significant improvement after 6 weeks, otherwise the training by flexible bands rather improves the entire score after 12 weeks of
Figure 6 No coherence of change in Constant-Murley-score and change in angle-replication-capability.
F. Mo ¨rl et al. intervention. So, for a short-term functional pain relief, the intervention by flexible foil is to be preferred. But for lasting effects (12 weeks), the intervention by flexible band has advantages. In summary, neither of the used methods shows a clear advantage. A clear deficit in the ability to reproduce angles of the shoulder as a special part of proprioception was detected before and after 12 weeks of intervention for the patients. For instance, the documented values in abduction at 120 show up to 4 times greater values than healthy subjects. This is a very imprecise reproduction of a specific angle (Swanik et al., 2002). The situation before intervention was expected and has been shown in other studies (Jerosch and Thorwesten, 1998; Zuckerman et al., 2003; Po ¨tzl et al., 2004; Cuomo et al., 2005). In contrast to the data presented here, an enhancement in joint position sense of the shoulder after surgery was measurable (Cuomo et al., 2005; Zuckerman et al., 2003; Po ¨tzl et al., 2004). This may be due to the tightening of the articular capsule, ligaments and tendons after surgery. The training methods used mainly affect muscles in common length conditions. For this reason, end positions in the range of motion of the shoulder were not used. As a matter of fact, the importance of the muscles for active joint position sense is high but not as important as the role of the ligaments. One study documents an increase in kinaesthesia of the shoulder by plyometric training in division I swimmers (Swanik et al., 2002). But there is no clear evidence as to which active or passive structures lead to a poor motor function of shoulder-pain patients. In summary, the devices used here mainly affect muscles and so train the measured proprioceptive ability within 12 weeks only randomly. To train the properties of passive joint structures, the full range of motion, as well as fast motions in end positions of the joint have to be used (Swanik et al., 2002). It is questionable whether such training methods are applicable in shoulder pain patients. Furthermore, changing the abilities of the basic passive structures like ligaments may take more time and, where applicable, may increase the outcome rates of physiotherapy of the shoulder in the long term. For the sample presented here, pain relief and change in motor function of the affected shoulder joints were not in coherence. This result is a first sign that shoulder pain is not closely associated with poor motor function of the shoulder. On the one hand, after intervention, many patients of the sample had no observable shoulder pain deduced by the assessment methods but still had a poor angle-replication capability. On the other hand, there may be shoulder-pain patients performing excellent motor function. Poor motor function of the shoulder may lead to shoulder pain sooner or later, but this is not the main reason for pains of the shoulder. Other parameters like muscle-strength, flexibility, intra-and intermuscular coordination, or properties of passive joint structures may also play a role in this context. Within the biomechanical test environment used here, it was impossible to show that the deduced parameters in motor function could be trained either by the use of flexible foil or flexible band. The changes in the data of the functional pain assessment show that training by flexible band affects strength, whereas training by flexible foil affects flexibility. This shows that different training methods for
Pain relief due to physiotherapy doesn’t change the motor function of the shoulder the shoulder joint result in partially different (physical) training results but in comparable pain release rates. The literature only gives information for the effect of the flexible band (Page et al., 1993). Isokinetic strength enhancement after training using elastic bands or elastic foil was not verified (Sugimoto and Blanpied, 2006). One study shows muscular activation patterns and gives stability information during exercise using a flexible foil, but there is no information about what is really trained by flexible foil (Moreside et al., 2007). In the field of kinaesthesia the ability to reproduce a specific angle of the shoulder is only a small area. As mentioned in the introduction, this ability can be divided into active and passive reproduction. It is impossible to test all kinaesthetic abilities using one single test. On the other hand, testing all abilities is laborious and time-consuming. Other kinaesthetic abilities could have been trained using the documented protocol but were not measured by the tests we used. Due to this, the poor coherence in pain reduction and change in proprioception is only valid for the ability measured here. Further studies should examine other abilities in kinaesthesia. In this study, the data of a passive control group, consisting of young subjects without shoulder pain, was used to evaluate the data of the patients. For future studies, the data of a placebo training group of patients should be compared to the data of the active patient group. In conclusion, the attempt to explain the mechanics of shoulder pain in the field of motor function failed for the parameters presented here. Like other studies (Ainsworth, 2006; Buchbinder et al., 2007; Green et al., 1998, 2003) our data shows pain relief by physiotherapy but gives no information about why pain is relieved. Because both devices clearly affect muscles surrounding the glenohumeral joint and the rotator cuff, the pain relief may correlate with change in muscle function. Otherwise systematic exercises and training affect the metabolism of passive structures like articular cartilage and ligaments. The intervention may have an effect on painful processes of such structures.
Acknowledgements Thanks to Jan Ba ¨r for data collection. Special thanks to Gordon Ross and Jens Mittelbach for language assistance.
Conflict of interest statement There is no conflict of interest of any author regarding the results, the training used or the measurement devices. None of the authors has any financial relations with the manufacturers of the devices used.
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Journal of Bodywork & Movement Therapies (2011) 15, 319e325
available at www.sciencedirect.com
journal homepage: www.elsevier.com/jbmt
MYOFASCIAL PAIN
Effect of ischemic pressure using a Backnobber II device on discomfort associated with myofascial trigger points* Dawn T. Gulick, PhD, PT, ATC, CSCS*, Kerstin Palombaro, PhD, PT , Jill Black Lattanzi, EdD, PT Widener University, Institute for Physical Therapy Education, One University Place, 126 Cottee Hall, Chester, PA 19013, USA Received 4 March 2010; received in revised form 16 June 2010; accepted 25 June 2010
KEYWORDS Trigger points; Referred pain; Ischemic compression; Backnobber
Summary Objective: The purpose of this study was to assess the effectiveness of ischemic pressure on myofascial trigger point (MTrP) sensitivity. Design: Randomized, controlled study with the researcher assessing MTrP sensitivity blinded to the intervention. Participants: Twenty-eight people with two MTrPs in the upper back musculature. Intervention: The sensitivity of two MTrPs in the upper back was assessed with a JTECH algometer. One of the two MTrPs was randomly selected for treatment with a Backnobber II, while the other served as a control. Outcome measures: Pre- and post-test pressureepain thresholds of the MTrPs Results: There was a significant difference between the pre- and post-test sensitivities of the treated and non-treated MTrPs (p Z 0.04). Conclusions: The results of this study confirm that the protocol of six repetitions of 30-s ischemic compression with the Backnobber II rendered every other day for a week was effective in reducing MTrP irritability. ª 2010 Elsevier Ltd. All rights reserved.
* Financial disclosure: we certify that no party having a direct interest in the results of the research supporting this article has or will confer a benefit on us or on any organization with which we are associated AND, if applicable, we certify that all financial and material support for this research (e.g., NIH or NHS grants) and work are clearly identified in the title page of the manuscript. * Corresponding author. Tel.: þ1 610 499 1287; fax: þ1 610 499 1231. E-mail address:
[email protected] (D.T. Gulick).
1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.06.007
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Introduction Travell and Simons (1989, p. 5) clinically define a myofascial trigger point (MTrP) as “a hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band.” MTrPs can develop from a number of conditions including: genetics, aging, and performing a strenuous activity (Cheng, 1987). MTrPs can be brought on by macrotrauma or by cumulative microtrauma. Abnormal posture, repetitive motion, or psychological stresses are examples of cumulative microtrauma (Fishbain et al., 1986; Horowitz and Sarkin, 1992; Travell and Simons, 1989). Formation and presence of a MTrP is correlated with muscle pain, weakness, and movement dysfunction (GravenNielsen et al., 1991; Hong and Simons, 1998; Liley, 1956; Mense, 1991, 1993, 1994, 1996; Simons et al., 1995a,b; Simons, 1996; Travell and Simons, 1989). There are a variety of modalities purported to relieve or diminish the symptoms associated with MTrPs, including ischemic compression (Kostopoulos et al., 2008; Travell and Simons, 1989), massage (Cantu and Grodin, 1992; Ebel and Wisham, 1952; Fernandez-de-las-Penas et al., 2006; Pemberton, 1939; Prentice, 1982; Sjolund and Eriksson, 1976; Tappon, 1988; Travell and Simons, 1989), needling (Hammeroff et al., 1981; Hong and Simons, 1998; Jaeger and Skootsky, 1987; Lewit, 1979; Melzack and Wall, 1965; Melzack et al., 1977; Rantanen et al., 1999; Sjolund and Eriksson, 1976; Tappon, 1988; Travell and Simons, 1989), vapocoolant spray and stretch (Kostopoulos and Rizopoulos, 2008; Melzack, 1981; Simons, 1996; Travell and Simons, 1989), electrical stimulation (Castel, 1982; ClementJones, 1980; Hooker, 1998; Hsueh et al., 1997; Malizia, 1979), laser therapy (Castel, 1982; Cheng, 1987; Laakso et al., 1967; Saliba and Foreman, 1998; Snyder-Mackler and Bork, 1988), ultrasound (Aguilera et al., 2009; Draper and Prentice, 1998; Draper, 1996; Gam et al., 1998; Gulick et al., 2001; Mardimen et al., 1995; McDarmid and Burns, 1987; Srbely et al., 2008; Williams et al., 1987), and diathermy (McCray and Patton, 1984). Anecdotal reports have supported the efficiency of the use of ischemic compression tools in the treatment of MTrPs. However, randomized controlled studies are lacking. In addition, there are no standardization protocols regarding the appropriate amount of pressure, the duration of the compression, or the frequency of treatments. This study was intended to be the first in a series to develop a clinical protocol for use of an ischemic compression tool in the treatment of MTrPs. The purpose of this study was to determine the effectiveness of a home program of ischemic compression using the Backnobber II device.
Figure 1
JTECH algometer.
a similar instrument, the “dolorimeter,” which was used in the evaluation of anti-inflammatory therapy. Testeretest correlations of various forms of this instrument have been reported to be r Z 0.91e0.95 (Gulick et al., 1996; McCarty et al., 1965; Meserlian, 1995). Specific use of the JTECH by Kinser et al. (2009), Fischer (1987), Antonaci et al. (1998), Farella et al. (2000), and Sciotti et al. (2001) demonstrated high values of reliability for a variety of muscles. A Backnobber II (Pressure Positive, Gilbertsville, PA) was used to render the ischemic compression treatment (Figure 2). This molded plastic device has two different size
Methods Instrumentation An algometer (JTECH Medical, Salt Lake City, UT) with a 1-cm diameter tip was used to measure pressure sensitivity (in Newtons) of the participants’ myofascial trigger points (Figure 1). Steinbroker was the first to adapt a pushepull gauge called the “palpometer” to quantify articular tenderness. McCarty et al. (1965) developed
Figure 2 II device.
Ischemic pressure technique using the Backnobber
Effect of ischemic pressure using a Backnobber II device knobs on each end that are designed to correspond to the size of a MTrP and to facilitate personal access to the MTrPs.
Pilot All testing occurred at the Institute for Physical Therapy Education, at Widener University, Chester, PA. Testing took place from July 2009 to November 2009. The Widener University Institutional Review Board for the protection of human subjects approved the examination procedures prior to data collection. Because of the challenges in quantifying pain perception, a protocol development phase was conducted. Testing was performed using the JTECH to fine tune the technique and assess the intrarater reliability. After several practice sessions, intra-rater reliability of one investigator (KP) was assessed for pressureepain tolerance on the upper back muscles as 0.82e0.94. Two additional phases were conducted to discern the best way to assess trigger point discomfort. Pressure threshold (P-threshold) was described by Kostopoulos et al. (2008) as the maximum pressure that can be tolerated. Using a maximal amount of pressure on a MTrP resulted in increasing the subject’s level of discomfort. Pressureepain threshold (PPT) was described as the minimum pressure required to cause pain (Kostopoulos et al., 2008). PPT allowed the investigators to evaluate the participant’s pressure tolerance without imparting additional discomfort. Thus, PPT was accepted as the outcome measure of choice for the current study. The protocol development phase yielded data to calculate the sample size needed for a power of 0.80 at an alpha of 0.05. The target number of participants was 25. This study was a cohort design, where each subject served as his/her own control. Data were collected in two sessions, pre-test and post-test.
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Trigger points/procedure For the data collection process, each participant was positioned prone on a plinth with pillows and wedges under the head, chest, and/or abdomen to achieve a comfortable, anatomically neutral position. The detection of MTrPs was accomplished via manually palpating for taut muscle bands in the upper and mid-back in a double-blind process as per the procedure described by Sciotti et al. (2001). A jump sign/local muscle twitch was observed when palpating some participants but this was not a part of the inclusion criteria, as a local muscle twitch is not deemed a reliable sign for trigger point confirmation (Gerwin et al., 1997). All researchers were Pennsylvania licensed physical therapists with decades of experience in muscle palpation. Researcher #1 palpated for MTrPs and marked each one with a marker. When completed, researcher #2 (blinded to the trigger points identified by researcher #1) also palpated for MTrPs and selected those MTrPs with which there was agreement. When possible, two MTrPs were selected in a corresponding muscle on both the right and left sides, e.g., right and left levator scapula muscles. If this is not possible, an adjacent muscle on the contralateral side was used, e.g., right middle trapezius and left rhomboid muscle. Common MTrPs identified by both researcher #1 and #2 were circumscribed with a permanent black marker. Both MTrPs were assessed using a JTECH algometer with a 1-cm diameter tip. The JTECH was used to measure pressure sensitivity to the pressureepain threshold (PPT) of the participants’ myofascial trigger points (Figure 1). The protocol was for the investigator (KP) to place the algometer on each MTrP and slowly apply pressure until the participant reported that the pressure reached the PPT. The technique was performed twice on each MTrP in an alternating fashion with a minimum of 30-s between tests, i.e., right, left, right, left. This was consistent with the research of Kostopoulos et al. (2008). Levels achieved for each MTrP were recorded on the data collection form in Newtons (N).
Participants
Intervention
Healthy participants over the age of 18 years were recruited by a flyer and/or word-of-mouth on a university campus. Potential participants who contacted one of the investigators were asked if s/he had “knots” (i.e., MTrP) in the back and if s/he was receiving any treatment to these areas. Answers to these questions determined eligibility for participation. If MTrP were not present or if the individual was receiving treatment to the neck or back regions, the individual was excluded from the study. In addition, individuals with sensory deficits or skin lesions in the area of the trigger points, or a personal history of cardiovascular problems, cancer, fibromyalgia, diabetes mellitus, tuberculosis, or the possibility of pregnancy were excluded. Individuals who had any shoulder, cervical, or thoracic surgeries or were taking any medication for musculoskeletal pathology were excluded. After providing informed consent, a total of 10 male and 18 female participated in this study. Two potential participants were excluded due to an absence of trigger points on palpation. Data regarding age, sex, height, and weight were collected.
After testing, the participant was instructed in the use of the Backnobber II (Pressure Positive, Gilbertsville, PA) in order to render the ischemic compression treatment (Figure 2). This is a molded plastic device with two different size knobs on each end that are designed to correspond to the size of a MTrP and to facilitate personal access to the MTrPs. A coin was flipped to determine the treatment side (heads Z right; tails Z left) for each subject. A total of 16 subjects treated the right side and 12 treated the left side. The ball of the Backnobber II was placed on the MTrP on the treatment side. The participant delivered a “trigger point pressure release” as defined by Simons et al. (1999) for 30-s. A rest period of 30-s was provided (Kostopoulos et al., 2008) and the pressure reapplied five more times (a total of six repetitions). Participants were provided with standardized instruction (JBL) to repeat the treatment procedure three times (every other day) in the upcoming week; a treatment log was provided. Upon confirmation of compliance, subjects were retested in the same manner as the pre-test. The investigator using the algometer to assess MTrP sensitivity was blinded to the
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treatment protocol. All records of the subjects were locked in a filing cabinet in an investigator’s (DTG) office.
Data analysis Descriptive statistics were performed on all demographic variables. The means of the two trials of PPT measurements taken with the JTECH algometer were used for the data analysis. Although a one-way ANOVA with repeated measures is a more stringent statistical analysis, a paired t-test was performed on the dependent variable, PPT. The paired t-test was chosen as the statistic because the pairing of the data allows for the acknowledgment of smaller differences between groups relative to the variations within groups. Given a unidirectional hypothesis, a onetailed t-test was implemented. The significance was set at an alpha level of p Z 0.05.
Results The demographic data were as follows: age 24.5 4.1 yrs; height 170 8 cm; weight 71.4 15.3 kg. The means and standard deviation pressureepain thresholds for the MTrPs are displayed in Table 1. The one-tailed t-test results were p Z 0.00998 (critical t Z 1.7056). The MTrPs treated with ischemic compression using the Backnobber II yielded an increase in pressureepain threshold as compared to the non-treated MTrPs.
Discussion The implementation of an efficacious treatment for MTrPs is a challenge when the pathophysiology remains in question. Observation of the electrical activity of a MTrP has suggested that the taut band formation is the result of an end plate dysfunction with excessive acetylcholine release (Simons, 1996; Simons et al., 1995a,b). Hence the hypothesis that MTrPs are an “energy crisis” that perpetuate until the vicious cycle is interrupted (Simons, 1996; Simons et al., 1995a,b). Ischemic compression is one of many options that can be used to interrupt the cyclic pathology of a MTrP. The results of this study support that this particular protocol of ischemic compression was effective in reducing MTrP irritability. The participants reported a significantly greater decrease in the sensitivity of the MTrPs after the four treatment sessions with the Backnobber II than on the untreated MTrPs. The current protocol of six repetitions of 30-s ischemic compression treatments performed every other day for one week effectively reduced the MTrP
Table 1 Mean and standard deviation of treated and non-treated MTrP.
Treated MTrP Non-treated MTrP
Pre-test
Post-test
Mean Standard deviation
Mean Standard deviation
31.73 11.28 N 34.10 12.72 N
44.02 13.31 N 31.83 11.65 N
sensitivity. The choice of six repetitions was modeled after the research of Kostopoulos et al. (2008). Whereas, 30-s of compression were consistent with the work of Bandy and Irion (1994) and Bandy et al. (1997) who determined 30-s as the optimal time for tissue elongation. Although the prior work was related to muscle stretching/elongation, the ischemic compression process is a form of tissue elongation. However, it is not known if altering the number of repetitions or the frequency of treatment would result in a better outcome. Furthermore, there is a paucity of data regarding the quantification of ischemic pressure. In the current study, the application of ischemic pressure was managed by the participant with the instructions of pressing to the point of mild discomfort. The rationale is consistent with the intended independent use of the Backnobber II. The current data is consistent with the study by Hanten et al. (2000). The researchers compared the effects of ischemic pressure and stretch to active range of motion in participants with MTrP of the neck and upper back. The 5-day treatment protocol evaluated PPT, visual analogue scale (VAS), and percentage of time the participants experienced pain. The intervention of ischemic pressure was administered via a Thera Cane (Thera Cane Co., Denver, CO). The researchers reported that the participants were instructed to gradually increase the pressure until a “release was felt,” i.e., “letting go” or “melting.” Ischemic pressure applications were repeated until no further release was obtained. In addition, a neck and upper back stretching protocol of 30e60 s durations were completed two times per day. There was a significant reduction in PPT and VAS reported but there was no difference in the percentage of time the participants experienced pain. The research of Nordez et al. (2006) brings into question the factors that may have yielded these results. Nordez et al. (2006) demonstrated significant improvement in knee range of motion and a reduction in hamstring stiffness with five 30-s static stretching. Thus, since Hanten et al. (2000) studied ischemic pressure with stretching, it is not known if the reduction in MTrP discomfort was a result of the compression, the stretching, or a combination of the two interventions. Lake et al. (2009) compared the treatment of ischemic compression and ischemic compression with stretching to a control group. The researchers examined 40 active MTrPs in 13 subjects. Ischemic compression was applied for 90-s and the stretching techniques were performed for 30-s. Both treatments were performed twice per week for three weeks and demonstrated significant improvement in discomfort and referral patterns when compared to control. However, the researchers did not define the magnitude of the compression applied. Fernandez-de-las-Penas et al. (2006) compared the immediate effect of ischemic compression to that of transverse friction massage in 40 subjects. The protocol for ischemic compression involved gradual application of pressure to an MTrP by a physiotherapist. The pressure was maintained until the painepressure sensation decreased by 50% and then the pressure was increased. This procedure was repeated for 90 s. Outcome data were collected 2-min after the completion of the intervention. Although PPT and VAS improved with treatment, there were no between group differences.
Effect of ischemic pressure using a Backnobber II device A study by Kostopoulos et al. (2008) was the first to look at the effect of ischemic compression (IC), passive stretching (PS), and the combination of compression and stretching on pain perception from myofascial trigger points (n Z 30 in each group). The IC group received three 60-s bouts of trigger point compression with 30-s between treatments. The PS group received static stretching for 45-s intervals with 30-s rest periods. Whereas the combination treatment alternated between IC and PS. All treatments were administered three times. The results were that although all treatments demonstrated a decline in pain perception and spontaneous intramuscular electrical activity, the combined treatment of IC and PS was better than either of the treatments performed individually. The authors theorized that IC causes a temporary local ischemia followed by a reactive hyperemia. The enhanced blood supply helps to restore aerobic metabolism and increase the amount of energy (ATP) available to the muscle to meet the metabolic demands. Furthermore, PS applied slowly inhibits the gamma spindle response and permits muscle relaxation. Together, the treatments appear to have a complementary effect. Fryer and Hodgson (2005) explored the use of manual pressure release versus sham intervention to latent trigger points in the upper trapezius muscle in 37 student volunteers. PPT was recorded using a capacitance pressure sensor attached to the palpating thumb. PPT was recorded and then 20 subjects underwent one 60-s treatment of manual pressure release held to produce a pain rating of 7/10, which the researchers deemed greater than PPT, but less than maximum pain tolerance. The control group received light pressure of no greater than 2 N/cm2. The PPT increased significantly in the treatment group as compared to the control. Additionally, the pressure recorded during manual pressure release significantly increased to maintain the 7/10 pain rating. This study is similar to the present study in that it quantified pressure and recruited young, healthy subjects with latent trigger points. However, the present study provided a home program similar to one that would be given to patients with active trigger points versus providing a single treatment session. Likewise, Aguilera et al. (2009) explored the immediate effects of 90 s of ischemic compression, 2 min of 1-w/cm2 1-MHz ultrasound, and 5 min of sham ultrasound in 66 subjects. Outcome measures included active range of motion (ROM), basal electrical activity (BEA) of the trapezius, and PPT. There was an immediate decrease in BEA and MTrP sensitivity after both modalities. In addition, the ischemic compression group also improved in cervical ROM. Thus, several studies have employed different protocols to effectively reduce MTrP sensitivity. Some examined the immediate effects (Aguilera et al., 2009; Fernandezde-las-Penas et al., 2006) and others administered repeated treatments (Hanten et al., 2000; Lake et al., 2009). Only one study reported utilizing a device to administer the ischemic compression (Hanten et al., 2000). The current study demonstrated that the Backnobber II is a device that can be effectively used to administer the ischemic compression treatment. This is particularly helpful when the MTrP cannot be independently palpated. The device is compact, portable, and easily managed for home use.
323 Nevertheless, the current study has two limitations. First, the study was performed on latent MTrPs in healthy subjects. It is not known if the response would be the same on active MTrPs in symptomatic individuals. Second, although the model of allowing the subjects to self-regulate the amount of pressure administered with the Backnobber II is consistent with a home exercise program, it does not allow for generalization about the quantity of pressure needed to reduce the sensitivity of a MTrP.
Conclusion Although there are numerous anecdotal reports of successful pain relief using ischemic compression with the Backnobber II (http://www.pressurepositive.com/index.aspx), there are currently no other research studies assessing this product. The current study is the first step towards establishing a protocol for the use of the Backnobber II in the management of MTrPs. Release of a MTrP can be instrumental in the reduction of pain and the increase in muscle flexibility. The systematic manipulation of each of the treatment parameters including duration of compression, amount of pressure, and number of repetitions is needed to discern the most effective method for the interruption of the cyclic pattern of discomfort associated with MTrPs.
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Journal of Bodywork & Movement Therapies (2011) 15, 326e334
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CHILDHOOD BEHAVIOUR
The effect of rhythmic exercises on cognition and behaviour of maltreated children: A pilot study* Yigal Goldshtrom, MS*, Debra Korman, BA, Iris Goldshtrom, PT, DPT, Joyce Bendavid, OTR 37-03 Berdan Ave, Fair Lawn, NJ 07410, USA Received 16 September 2009; received in revised form 8 April 2010; accepted 20 June 2010
KEYWORDS Cognition; Exercise; Rhythm; Gross motor skills; Children; Maltreatment children; Rhythmex; Moderate exercise; Aggressive behaviour; VMI scores
Summary Objectives: This study assesses the effect of rhythmic exercises using Rhythmex program on the cognitive function and behaviour of maltreated children living in a group residential facility. Method: School age children (ages 6e9) participated in the study, one group of 23 children exercised with Rhythmex rhythmic exercise program for eight weeks, 2e3 times a week, for 5 min, while a second group of 14 children did not exercise. Both groups took the Visual-Motor Integration (VMI) test pre- and post-intervention and social workers evaluated their behaviour on the Achenbach’s Child Behaviour Checklist (CBCL) pre-intervention and then 12 months later. Results: Improvement of 12 months on average in the VMI scores from pre- to post-intervention among the exercise group participants was observed compared with the control group. Aggressive behaviour was significantly lower on the Achenbach’s CBCL aggression subscale among the exercise group participants compared with the control group. Conclusion: Rhythmic exercises for 5 min, 2e3 times a week for 8 weeks appear to be effective in improving VMI scores and lowering aggressive behaviour among maltreated children when compared to children of the same age who did not participate in the rhythmic exercises program. ª 2010 Elsevier Ltd. All rights reserved.
*
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. * Corresponding author. Tel.: þ1 201 797 8028; fax: þ1 201 797 2676. E-mail address:
[email protected] (Y. Goldshtrom).
1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.06.006
Effect of rhythmic exercises on cognition and behaviour of maltreated children
327
Introduction
Rhythm and cognitive development
Exercises and physical activities are related to enhanced cognitive functioning and brain plasticity (Colcombe et al., 2006; Erickson et al., 2007a, b, c, 2009; Kramer et al., 2005, 2006; McAuley et al., 2004). Studies in animals and humans have revealed that after a period of exercise there is an increase in the levels of several neurotrophic factors related to cognitive functioning, neurogenesis, angiogenesis and plasticity (Deslandes et al., 2009). Factors like Brain Derived Neurotrophic Factor (BDNF), and Long-Term Potentiation (LTP) are essentials for hippocampal functioning, synaptic plasticity, and learning (Bliss and Collingridge, 1993; Cotman et al., 2007; Cotman and Engesser-Cesar, 2002; Winter et al., 2007; Ying et al., 2002). Review of studies of the benefits of exercises for mental function and psychological well-being of children suggests that systematic exercise programs are important for children’s development affecting intelligence, cognition, and academic achievement (Davis et al., 2007; Tomporowski et al., 2008). Rhythmic exercises with auditory cues are different from aerobic or strength exercises as they do not increase heart rate or aerobic intake, but rather connect with a natural rhythm of the brain during bilateral movements (Banerjee and Jirsa, 2007). The following study reports on the effect of a rhythmic exercise program of moderate intensity exercises with a metronome, on the visual-motor integration of elementary school age children who have been maltreated and are now living in a group residential facility.
Recent studies of infants and young children have investigated the role of rhythm in learning and maturation processes affecting motor, speech, and language development. In a study of hand movements in infants, rhythmic pattern and organized movement were associated with normal development. Unstructured spontaneous hand movements of premature infants were more characteristic of infants with brain injuries, while infants without brain injuries exhibited a structured pattern of hand movements (Ohgi et al., 2008). Another study of language acquisition of infants has suggested that rhythmic pattern movements of infant hands are correlated with “first language” acquisition (Petitto et al., 2004). A study of children with Specific Language Impairment (SLI) has revealed co-occurring motor problems and rhythmic processing deficits, such as difficulty in following auditory cues in a rhythmically timed tapping task compared to other children of the same age (Corriveau and Goswami, 2009). Rhythmic exercises are timed activities and a recent study has linked general intelligence with the mean and variability of reaction time in elementary cognitive tasks, such as finger tapping (Ullen et al., 2008). In a recent study with Rhythmex, it has been suggested that Rhythmex can improve cognitive functions and emotional states in addition to improving motor dysfunction (Goldshtrom et al., 2010). The purpose of this study was to assess the effect of Rhythmic Exercises with Auditory Cues (REAC) on cognitive performance and behaviour of maltreated children living together in a group residential facility using rhythmic exercises.
Motor coordination, emotions, and cognitive functions Motor coordination problems in children have been linked to emotional difficulties and poor social skills (Cummins et al., 2005; Piek et al., 2008; Schoemaker et al., 1994; Schoemaker and Kalverboer, 1994; Skinner and Piek, 2001). Motor difficulty may affect the children’s social status and emotional state if they perceive themselves as less physically and socially competent than their peers. Studies of children as young as six years of age have established a link between motor coordination difficulty and socio-emotional problems (Schoemaker et al., 1994). In a recent study by Piek et al. of preschool age children, motor ability was linked to a child’s emotional state of anxiety/depression (Piek et al., 2008). Studies under functional MRI (fMRI) of the cortex have shown that cognition, emotion, perception and motor functions are intertwined within the neural structure (Afifi, 2003; Belmonte et al., 2004; Munakata et al., 2004). Earlier studies with school age children have reported that exercises improve motor and cognitive functions, emotional and social behaviour (Cummins et al., 2005; Serrien et al., 2007); this, in turn, can affect academic performance. The present study had investigated the effect of rhythmic exercises on the cognitive development of children who were maltreated or neglected. Maltreated, abused, or neglected children appear to have greater cognitive and academic deficits, social withdrawal, and limited peer interactions (English et al., 2005; Hildyard and Wolfe, 2002).
Rhythmic Exercise with Auditory Cues (REAC) in rehabilitation Rhythmic exercises e exercises performed to an auditory cue (using a metronome) e have been proposed in multiple studies in the rehabilitation of people after brain injuries or lesions (i.e. stroke) with central or peripheral impairments, as a single modality or in combination with other modalities (Cauraugh et al., 2009; Cauraugh and Summers, 2005; Luft et al., 2004; Mudie and Matyas, 2000; Richards et al., 2008; Stewart et al., 2006; Whitall et al., 2000). While brain injury can cause impairment of one side or one extremity of the body, REAC exercise programs specify bilateral alternating movements of both sides, like the Bilateral Arm Training With Rhythmic Auditory Cueing (BATRAC) method for the upper extremities after stroke (Richards et al., 2008; Waller and Whitall, 2008; Whitall et al., 2000), and the Rhythmic Auditory Stimulation (RAS) method for lower extremities as walking exercises with Parkinson’s patients (Ellis et al., 2008; Katherine et al., 2007; Password, 2007; Thaut et al., 1996, 1997, 2007), or as walking on a treadmill (van Wegen et al., 2006). The RAS protocol was also reported to help children diagnosed with cerebral palsy to improve their gait performance (Kwak, 2007). The study used a rhythmic exercise program called Rhythmex, a REAC exercise program with an auditory cue that is guided by five principles labelled A.B.C.D.R: A. Alternating hands and feet in movements, B. Bilateral
328 activation of the body and extremities, C. Cross-midline movements, D. short Duration of exercise, and R. Rhythmic auditory cues (via metronome).
Method Participant selection The study was conducted at a children’s group residential facility in Netanya Israel, which is a group home for over 200 at-risk children, ages 0e18 years old, all Jewish and mostly of Sephardic descent, who were abused or neglected by their families. The group home is under the supervision of the Ministry of Labour and Welfare. The children live in separate buildings for boys and girls and attend the public schools in the area during the day. When they return from school, they continue with structured activities that include time for homework, structured and free play time, hobbies, and mealtimes. The children are further grouped by age and gender into separate “houses” headed by a group coordinator at each “house.” Within the houses, every 8e10 children are assigned a group counsellor who follows their activities and engages the children in physical and social activities. The group home has social workers who are liaisons with the schools and the children’s parents. This particular group home does not house children with disabilities or children diagnosed with mental illnesses, except for the diagnosis of ADHD. The children that participated in the study were elementary school age children and they were selected for the study by their age group. Initially, there were 41 children ages 6e11 in the home who were divided into 5 sub-groups by gender and age headed by their group counsellors. During the intervention period 4 children left the home and as result 37 children were left in the study. One of the group coordinators responsible for 2 sub-groups had to be away for the duration of the intervention and therefore, he could not supervise the activities and his groups have been become the non-exercising control group. In addition, the exercises had been scheduled for a specific time in the day and some children had other activities scheduled for that time. These children also have been labelled non-exercising and counted within the control group.
Research design The study used a nonequivalent, control group, pre-test, post-test, factorial design. It compared the effect of rhythmic exercises on cognitive development and behaviour using pre- and post-intervention tests with experimental and non-exercising control groups. The level of cognitive development was compared using the Visual-Motor Integration (VMI) test and the effect on behaviour was assessed with the Achenbach’s Child Behaviour Checklist (CBCL).
Instruments The Visual-Motor Integration (VMI) test The BeeryeBuktenica Developmental Test of Visual-Motor Integration 5th Edition (VMI) is a paper and pencil test used
Y. Goldshtrom et al. to evaluate the sensory-motor integration skills of children (Beery and Beery, 2006). It was first published in 1967 for use as a screening tool in a school setting, as a gauge of change over time or as a quick reference for noting difficulties that may contribute to school performance in the classroom. The test may indicate the integration of a child’s sensory-motor performance, perception of written forms, understanding of the concept that “the whole is greater than the sum of its parts”, current developmental levels, or the achievement of developmental milestones. The test taker is asked to copy a series of geometric forms that range from a simple line drawing to a complex figure. The test is non-verbal, culture-free, time efficient and reliable regarding chronological age. In the VMI visual perception section, the child matches figures on the basis of their form, size, and position in space. In the motor coordination scale, the child draws lines within boundaries. Inter-scorer reliability is 0.94 for the VMI, 0.98 for the Visual, and 0.95 for the Motor. The VMI and its supplemental Visual and Motor tests had overall average reliability (inter-scorer, internal consistency, and testeretest) of 0.92, 0.91, and 0.89, respectively (Beery et al., 2004). The raw VMI scores can also be normalized into chronological age for reporting. Achenbach’s Child Behaviour Checklist Achenbach’s Child Behaviour Checklist/4e18 (CBCL/4e18) is a set of assessments of childrens’ behaviour from the perspective of the parent, teacher, and self-reporting (Achenbach, 1991; Achenbach and Rescorla, 2001). The checklist includes 8 assessments of behaviour: Social Withdrawal, Somatic Complaints, Anxiety/Depression, Social Problems, Thought Problems, Attention Problems, Delinquent Behaviour, and Aggressive Behaviour, as well as sexual behaviour in children. Social workers working in the children’s group home compiled reports from the school, the counsellors and therapists into three categories: Aggressive behaviour, Social behaviour, and Anxiety and Depression. Each category is a compilation of observations about the child’s behaviour with Likert scale values: 0 Z no, 1 Z sometimes, and 2 Z very often; the sum of the answer values in each category signifies the severity of the behaviour. Validity of the Achenbach’s CBCL was demonstrated by comparing the instrument with the Parent Questionnaire (Conners, 1973) and with the Revised Behaviour Problem Checklist (Quay and Peterson, 1983), with correlation ranging between 0.59e0.86 with Conners, and 0.59e0.88 with QuayePeterson (Achenbach, 1991).
Procedures The participants in the exercise group were engaged by their counsellors in rhythmic exercises for a period of 8 weeks, 2e3 times a week for 5 min, in the afternoon in their living quarters. Daily logs were kept documenting the activity and the attendance of each participant. The nonexercising control group was formed when one of the counsellors was called for military duty and as a result his sub-group did not engage in these exercises. In addition, some children in the other groups had schedule conflicts and as result could not be present during the exercise
Effect of rhythmic exercises on cognition and behaviour of maltreated children period. All the 37 children took the VMI test before the exercise periods and at the end of the exercise period 8 weeks after. The Achenbach’s CBCL is an assessment questionnaire filled by the social workers yearly every September for the Ministry of Welfare. The study used the assessment results filled a month earlier as pre-intervention behavioural assessment and then compared it to the next assessment done the following September, 10 months after the intervention. The sub-group counsellors performed the rhythmic exercises with the children after they themselves received an on site training session and watched instructional videos. The progress of the exercise program was monitored from a distance using internet video communication every other week with the groups’ coordinators. Exercising with Rhythmex Rhythmex rhythmic exercises with a metronome are introduced in stages as the various principles are introduced. In this study we gradually introduced the children into the activity by modifying the exercises until they incorporated the full A.B.C.D.R principles. Initially we introduced the children to Alternating hands (A) Bilaterally (B) (right, left, right, left) exercises synchronized with the metronome. We then added to the alternating bilateral pattern hand movements Crossing (C) midline components synchronized with the metronome (Figure 1) for duration of 30e45 s with breaks in between. The next level of exercising had been reached when the children began Bilateral (B) Alternating pattern of hands
Figure 1
Alternating pattern of hands plus crossing midline.
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and feet while stepping in place and synchronizing with the metronome (A.B.C.D.R) (Figure 2). We continued with exercises that were variations on the basic pattern using the A.B.C.D.R principles. For example, in order to engage the boys in the exercises, the hand movements were modified to mimic martial arts (Figures 3 and 4).
Data collection The Beery VMI 5th Edition general form test was given in October 2008 at the beginning of the school year, but the exercises started only a month later due to activities connected with the start of the school year and the local holiday season. The test was administered in groups and the children were asked to copy the figures on the top of the page onto a blank spot at the bottom. The Occupational Therapist who scored the results in October 2008 for the pre-test also scored the post-test results three months later, in February 2009. This therapist did not meet the children nor was she informed of their ages prior to scoring the forms. Raw scores were correlated according to the criteria set forth in the Beery VMI 5th edition. The raw scores have been compared pre- and post-intervention without normalization into age appropriate scores. The Achenbach’s CBCL behavioural assessment was filled by the social workers every September and the results of these
Figure 2 midline.
Alternating pattern of hands and feet crossing
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Figure 3 High hand position crossing midline, alternating hands and feet in martial arts style.
Figure 4 Lower hand position crossing midline, alternating pattern of hands and feet in martial arts style.
assessments 12 months apart were used to assess behavioural changes between the groups. During that period 4 children who participated in the study moved away from the facility and no assessment could be made for them.
SD Z 13.7 months). The participating students group (PAR) had 23 children (13 girls and 10 boys) who participated in the rhythmic exercises, while the non-exercising control group (NON-PAR) had 14 children (6 girls and 8 boys).
Data analysis
The VMI test A 2 by 2 between-groups analysis of covariance revealed that after adjusting for pre-intervention scores, there were significant differences between the 2 treatment groups [F(1,32) Z 5.246, p Z 0.029], with a large effect size (partial eta squared Z 0.14). Gender was not a factor as both boys and girls improved at the same rate (see Figure 1). Table 1 summarizes the VMI scores between the two groups pre- and post-intervention. The exercise group (PAR) gained more than 12 months on average in VMI scores in the 3 months between tests, while the non-exercising control group (NON-PAR) gained 3 months on average during the same 3 months period. Qualitative improvements of the PAR group between the first set of drawings and the second set were noted for closure of shapes, more angular corners, straighter and firmer pencil lines along with improved alignment and slant (Figure 5).
A 2 by 2 between-groups analysis of covariance (ANCOVA) was conducted to compare the effectiveness of the rhythmic exercise program and gender on the VMI and the Achenbach’s CBCL scores. The independent variables were the exposure to rhythmic exercises by the exercise group (PAR) versus the nonexercising participants (NOPAR) and gender. The dependent variables were the VMI test scores and the Achenbach’s CBCL aggressive behaviour sub-scales measured after the exercise period with the measurements taken before the intervention as covariates. Preliminary checks were conducted to detect violation of the assumptions of normality, linearity, homogeneity of variances, homogeneity of regression slopes, and reliable measurement of the covariates.
Results Participant demographics The study included 37 children (19 girls and 18 boys, age ranges between 6 and 11 years old, mean age 8.5 years,
The Achenbach’s CBCL A 2 by 2 between-groups analysis of covariates on Achenbach’s CBCL aggressive behaviour subscale revealed that after adjusting for pre-intervention scores, there were
Effect of rhythmic exercises on cognition and behaviour of maltreated children
331
Table 1 Comparison of the VMI means between the groups pre- and post-intervention show 12 months improvement in VMI scores among the rhythmic exercise participants, and 3 months improvement among the non-exercising participants. Mean scores of the VMI tests Group
Gender
Premean
Postmean
Rhythmic exercises
Boys Girls Boys Girls
77.60 75.85 76.13 84.67
89.10 88.69 80.13 87.50
Non-Exercising control Age and means are provided in months.
significant differences between the 2 groups [F(1,28) Z 4.475, p Z 0.043], with a large effect size (partial eta squared Z 0.138). Gender was also a factor [F(1,28) Z 5.462, p Z 0.027], with a large effect size (partial eta squared Z 0.16) (see Figure 2). Table 2 summarizes the changes in aggressive behaviour scores over a 12 months period. Both the boys and the girls in the rhythmic exercise group have reduced their aggressive behaviour, while in the control group the girls’ aggressive behaviour have actually increased. The aggressive behaviour among the boys in the control group have decreased during that period but they are still more than twice as high as the boys in the rhythmic group (Figure 6).
Discussion The current study highlights the effect of rhythmic exercises on improving cognitive functions and behaviour of
Estimated Marginal Means of the post-intervention VMI 92
Estimated Marginal Means
90
88
86
84
82
Gender Boys Girls
80
Control
Rhythm
Group
Figure 5 A 2 by 2 between-groups analysis of covariance of the effect of 8 weeks, 2e3 times a week for 5 min of rhythmic exercises on VMI scores when compared to non-exercising control group. Significant differences were found between the 2 groups.
maltreated children living in a group home. Maltreated children may suffer physical and emotional traumas, which may affect behaviour and cognitive functions and academic performance as well. The study investigated formerly maltreated children now living in a group home where basic requirements of life are provided, such as food, clothing and personal care, who attend regular schools and participate in extracurricular activities under adult supervision. A rhythmic exercise program called Rhythmex, a free form exercise program following the principles of Alternating Bilateral Crossing midline movements in short Duration synchronized with Rhythmic monotonous auditory beat regulator (A.B.C.D.R), was used as the intervention. The exercises were performed by the children in groups for a period of 5 min, 2e3 times a week, after the school day in their living space. At the start of the program the counsellors expressed frustration because the children could not perform simple step-in-place movements while synchronizing with the metronome. However, by the third and fourth week the children began enjoying the exercises as synchronization with the metronome became easier. The pre-intervention VMI test revealed a 23-month average visual and motor integration deficit among the children. The experimental group had 8 weeks of rhythmic exercises and post-intervention VMI scores revealed an increase of 12 months on average of VMI skill levels. At the same time the non-exercising control group did not significantly improve their VMI scores. The second improvement was observed in behavioural outcomes. A 12 months pre- and post-intervention assessment showed that the rhythmic exercise group significantly reduced their aggressive behaviour more than the non-exercising control group participants. The aggressive behaviour was also reduced among the boys in the control group although not as much as the exercise group, but the girls in the control group showed increased aggressive behaviour. Deficits in brain function such as visual and motor integration can affect the social and academic placement of a child when compared to their age-related peers. A 23-month deficit places these children at risk of both cognitive and behavioural failures, as they feel inferior to their peers at school. After exercising for 8 weeks, 2e3 times a week, for 5 min using Rhythmex exercises, the children had improved their VMI deficit by 12 months, placing these children closer to their peer level at school. Improvement seen in the aggressive behaviour among the exercising group may reflect the improvement in social status.
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Table 2 later.
Mean scores of the Achenbach’s CBCL aggressive behaviour subscale between the groups pre exercise and 12 months
Mean scores of the Achenbach’s CBCL aggressive behaviour subscale Group
Gender
Rhythmic exercises
Mean
Boys Girls Boys Girls
Non-exercising control
Limitations of this study The current study is based on a relatively small sample with children ranging between the ages of 6 and 11 years old. Assignment to the exercise or control groups was not randomized. Children were included in the sample based on the convenience of the institution. Moreover, children from the experimental group moved to the control group if they could not participate in the exercises, which made the control group a self-selected group to some extent. The VMI tests were given in a group setting and not individually, which could have affected some of the results. The control group who did not exercise was compared to the rhythmic exercise group. The children, however, did have the opportunity to participate in physical education in their school and with a PhysEd teacher once a week at the home. These limitations should be considered in interpreting and generalizing the present results. In the future, random controlled sample studies should be performed with larger samples of children and with a wider age range, while also comparing multiple exercise modalities in order to confirm these results. Estimated Marginal Means of Aggressive Behaviour 12.00
Estimated Marginal Means
10.00
8.00
6.00
4.00
Gender Boys Girls
2.00
Non Exercising control
Rhythmic Exercises
Group
Figure 6
Pre
12 Months later
12.30 10.77 13.67 8.00
3.50 7.90 7.58 11.20
Despite the limitations, the current study highlights the role of rhythmic exercises in the development of improved cognitive outcomes and reducing aggressive behaviour and shows that even 5 min a day, 2e3 times a week can provide dramatic improvements among children with visual-motor integration deficits.
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Journal of Bodywork & Movement Therapies (2011) 15, 335e342
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TISSUE PHYSIOLOGY
The presence of physiological stress shielding in the degenerative cycle of musculoskeletal disorders M. Driscoll, Eng., Ph.D. a,b,*, L. Blyum a a b
Advanced Bio-Mechanical Rehabilitation (ABR), 11991 Pierre-Baillargeon St, Suite 201, Montreal, H1E 2E5, Canada Biomedical Research Group, 5135 Bessborough St, Montreal, H4V 2S5, Canada
Received 4 April 2009; received in revised form 23 April 2010; accepted 30 April 2010
KEYWORDS Fascia; Musculoskeletal; Cerebral palsy; Remodeling; Stress shielding
Summary The health of physiological tissue is governed by the continuous conversion of mechanical stimulus (stress) to bio-chemical response, a concept known as mechanical homeostasis. If this regulatory imperative becomes flawed, it may be detrimental, and consequently invoke or encourage the progression of various musculoskeletal disorders. This notion is corroborated by the quantification of altered function and irregular mechanical properties found within the articulations of such phenotypes as cerebral palsy. Although the divergence from healthy to irregular tissue behavior is likely multifactorial, the presence of imbalanced mechanical properties may promote the concept of physiological stress shielding. Extrapolating upon the stress shielding phenomenon may allow inferences to be drawn with respect to the pathomechanisms of progressive disorders. Further, recognition of this association may also provide a new platform from which to interpret the impact of conventional treatments aimed at such syndromes and, in turn, perhaps support new therapeutic avenues. ª 2010 Elsevier Ltd. All rights reserved.
Musculoskeletal stability Joint stability is perceived as a balance of forces stemming from a variety of tissues. Specifically, the dynamic equilibrium of joints is achieved through muscular and ligament tension, joint capsule flexion, cartilage rigidity, and bony structure reaction forces driven by gravitational
* Corresponding author. Tel.: þ1 15148892915; fax: þ1 15143289958. E-mail address:
[email protected] (M. Driscoll).
forces. The health of these physiological tissues is essential for the maintenance of proper joint function and integrity. Conventional interpretation of joint dynamics is performed under several assumptions and optimization procedures that may have considerable influence on numerical interpretations (Pierce and Li, 2005). These admitted simplifications filter the redundancy caused by the immense number of unknown variables involved within their static or dynamic interpretations. Nevertheless, equilibrium analyses of joint articulations achieve reasonable agreement with electromyography (EMG) readings for healthy individuals predicted during gait (Rohrle et al., 1984).
1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.05.002
336 Although detecting muscular activity through EMG has advanced our knowledge of the various activation strategies adopted during gait and other activities, it does not provide empirical interpretation of loads passively sustained within implicated connective tissues such as fascia (considered as ligaments, aponeuroses, joint capsules, endo-, peri-, and epi-mysium throughout this manuscript). Additionally, EMG interpretation does not detect resting muscle tone e an important form of intrinsic stress (Masi and Hannon, 2009). Interestingly enough, these commonly undetected and overlooked loads passively sustained in fascia may be important and acknowledging their role in joint dynamics may explain inconsistencies that arise when evaluating joint mechanics utilizing classical methods. This notion was demonstrated when the inclusion of fascial layers in spinal stability models rectified this previously inconsistent and indeterminate system and provided results that corroborated with physiologic measures (Gracovetsky, 2008). Notwithstanding such revelations, the majority of conventional treatments of musculoskeletal disorders focus on muscle and bone biological and morphological adaptations d perhaps resulting from the popular use of these simplified measuring tools and biomechanical interpretations. Further, acknowledgment of such fascial loads may provide a foundation upon which to recognize several advantages put forth by rehabilitative and massage therapies that target these tissues. This recognition may also provide a more in-depth understanding of the influence of current treatments and provide insight into new innovated rehabilitative techniques.
The role of fascia in musculoskeletal stability Although recently receiving greater interest, a tissue previously neglected that accentuates joint stability is fascia: a connective tissue that surrounds and penetrates muscles tissue; and is present throughout our entire body. Perhaps the initial documentation of its functional importance occurred in the 1940’s when fascia was referred to as an ectoskeleton by Wood Jones who hypothesized the greater prominence of fascial tissues present in the lower body, compared to the upper body, results from significant greater dynamic stability demands in the lower regions (i.e. supported locomotion) (Wood Jones, 1944). This observation lends itself to the inference that the demanding environment of our locomotive musculature requires additional stabilizers d more than previously believed. Such theories where followed up and expanded by several authors who notably include works by (Rolf, 1977) who proposed manual therapy treatment avenues aimed at addressing the specifics of this structurally involve connective tissue. With respect to stability, it has been shown that the health or tensional properties of this membrane partially regulates the contractual ability of the encapsulated muscle (Street, 1983; Huijing, 1999). Further, Huijing et al. experimentally showed (Huijing et al., 1998; Huijing, 1999; Huijing et al., 1999), and supported via simplified finite element analysis (Yucesoy et al., 2001), that the fascial membrane may allow for inter and intra muscular force transmission between adjacent or synergistic muscles. This
M. Driscoll, L. Blyum would otherwise not be possible via conventional interpretations, since it isolates muscle behavior. In recent works, it has been speculated that epimuscular myofascial force transmission may occur in antagonistic muscles (Huijing, 2007; Yucesoy et al., 2008). Although experimental limitations of such studies (i.e. ex-vivo and nonphysiological forces) must be noted, these novel findings are believed to hold true in daily activity. Using in-vivo cat models, it was demonstrated that removal of crural-fascias attachment reduces biceps-femoris torque by up to 50% (Carrasco and English, 1999). Also, passive elasticity in the femur tibia joint of locusts, in combination with viscous damping, has been shown to be strong enough to realign flexed articulation without conscious stimulation (Zakotnik et al., 2006). This passive force is likely generated by pre-stresses invoked on involved fascial connective tissues in addition to resting muscle tone. With regards to humans, over several notable communications and recently summarized, Gracovetsky demonstrated the distinct involvement of lumbodorsal fascia in spine biomechanics (Gracovetsky, 2008). In addition, ex-vivo human lumbar fascia behaves in a matter suggesting the presence of smooth muscle cells (Yahia et al., 1993). Moreover, the educated hypothesis of Schleip et al., (2005) suggests that these contractile cells may alter tissue pre-tension, therefore actively modifying the muscle’s performance and biomechanical influence on the musculoskelal system. These findings, amongst many others, support the notion that fascia plays an important role in joint strength and stability. Therefore, if weakened and/or rendered deficient, fascial membranes may distort regular joint dynamics through the impedance of regular and effective tensional implications. Such alterations would alter the stability and structural integrity of our bodies which is maintained by a balance between passive (fascia) and active (muscle contraction) tensional forces with a complementing hydrostatic (cartilage, intervertebral discs, and visceral pressure) and compressive resistance (bone). Translation of this principle to joint dynamics directly implicates fascia, since it is involved in passive or intrinsic tensional force and may partially regulate the contractile performance of muscles. Application of the aforementioned description of musculoskeletal stability, may explain how local instabilities lead to distant responses and/or pain, as recently observed between instable ankles with injured subtalus joint and irregular tensor fascia-lata muscle force duration (Zampagni et al., 2008). It therefore comes as no surprise, based on the above scientific contributions, that various fascial treatment avenues have been elegantly identified and exploited in practice (Chaitow, 1999; Myers, 2008; Paoletti, 2006; Schultz and Rosemary, 1996). In addition to its biomechanical implications, fascia is highly innervated consisting of nerve endings and encapsulated receptors as identified in the deep fascia examined from 20 upper limbs (Stecco et al., 2007). In a recent review, the implication of ligament innervations was linked to motor control and the structural integrity of the joint (Solomonow, 2006). Similar findings also emphasized this importance, as proprioceptive defects are found in, and may be linked to, disruptive limb control within the irregular structures of patients with cerebral palsy (CP) (Wingert et al., 2009). Although the presence of inadequate
The presence of physiological stress neuro-control mechanism undeniably plays a role in the disruptive ambulation of CP patients, the irregular mechanical environment of their distorted musculoskeletal system may impose additional and restrictive directives to their function.
Consequences of instability in musculoskeletal disorders Perhaps the most prominent demonstration of joint instability is observed within the heavily distorted musculoskeletal system of severe CP patients (i.e. gross motor function classification type 4 & 5 e non-ambulatory). Distinctively, articulations within this CP phenotype are often associated with spastic or hypertonic muscles in conjunction with weak or hypotoned muscles. Such muscle tone and associated force imbalance, has a detrimental influence on the developmental function and performance of affected joints often leading to painful contractures and subluxations. The existence of these biomechanical irregularities influences the musculature under consideration while having important implications on the health of involved fascial tissues. Muscle control limitations in patients with CP are conventionally attributed to an inadequate reflex control system that provides continuous exaggerated contractile reflex information. Therefore, targeted muscles are forced into a long term shortened and “immobilized” state. Muscle then becomes rigid and confined, whereby this status invokes several underlying changes to the functional units biomechanics. An example of this force imbalance is shown as spastic wrist flexors demonstrate preferred biomechanical and chemical involvement when compared to wrist extensors (Ponte ´n et al., 2005). Further, other scientists identified a correlation between biochemical and biomechanical measures of joint contractures in connective tissue of immobilized rabbit knees. As speculated by the authors, these findings suggest a lack of adequate stimulus (joint forces) to maintain tissue health (Akeson et al., 1974). Complementarily, several authors have quantified an increase of passive modulus, i.e. resistance to stretch, in spastic muscles. In particular, several distinguished studies clearly demonstrated this phenomenon using impressive montages and numerical analyses to isolate and quantify passive muscle forces in CP patient compared to control values (Kearney and Stein, 1997; Mirbagheri et al., 2001; Sinkjaer and Magnussen, 1994). Upon revision of internal muscular biomechanics, several factors need to be considered: passive muscle resistance arises from a combination of stretching muscle fibers’ cross-links; the extension of non-contractile proteins of sarcomeric cytoskeleton; and the modulus of the involved fascial layers (epi-, peri- and endo-mysium). Isolated muscle fibers from spastic individuals proved twice as strong as regular or healthy cells and had a significantly shorter resting sarcomere length (Lieber et al., 2003). However, repeating tests with spastic muscle bundles, although stronger than an individual cell, proved approximately three and a half times weaker than healthy muscle bundles (Fride ´n and Lieber, 2003). Upon comparison of these two analyses one might speculate that the
337 extracellular matrix in a healthy bundle of muscle cells is stronger or more efficiently organized. However, as stated, under physiologic conditions, passive resistance (due to passive tissues, such as fascia, while discounting initial intrinsic stiffness and reflex-mediated contractions from muscle) of spastic muscles are more resilient to stretch. The difference between these findings occurs because, under in-vivo conditions, the presence of fascia is implicated as a surrounding tissue. Thus, the altered resistance to stretch may arise from the outer fascial tissue (epimysium and perimysium) that has undergone a form of remodeling and has become more resistant to stretch. It is becoming clear that fascia adds an important aspect to joint dynamics, while spasticity invokes remodeling of both the involved muscle and implicated fascial tissues. It appears that fascia has a role in: passively resisting stretch during joint dynamics; providing tensional forces in order to release stored energy in the form of pre-stress; providing musculoskeletal proprioceptive feedback; and offering a feasible platform for force transmission between one or several muscles that may be actively adjusted via pretension. Correlations between muscle and elastic force from fascia have not been effectively established, nor, to date, have there been studies of the remodeling process of the fascial membrane. Also, the passive distribution of load within the muscle and the connective tissue is not well defined. However, with reference to the publications discussed herein, one can reasonably assume that its presence is significant. It is known that spastic muscles have significantly more resistance to elongation. Therefore, one may deduce with respect to CP patients, both the muscle and the fascial layer have higher mechanical properties that define its resistance to stretch, while the hypotoned stabilizer or weakened co-contractor will likely have a reduced modulus, due to disuse. Previous emphasis of biomechanical remodeling has focused attention on musculature and bones. However, although less evident to the naked eye, implicated fascial tissues also undergo remodeling due to irregular stimulus. Such remodeling is of concern as connective tissues provide an important role in governing the capabilities of the musculoskeletal system. Fascia does not possess the capability to effectively alter its tensional properties as witnessed in skeletal muscles. Therefore, alterations of its intrinsic mechanical properties via remodeling may have considerable implications determining internal stress allocation (tissue stimulus) within musculoskeletal disorders under the stress shielding phenomenon. In the authors’ opinion and the key concept to this manuscript, such a mechanical imbalance plays a decisive role in manipulating internal load allocation in any musculoskeletal disorder whose stabilizing structures have yielded and undergone partial or complete remodeling.
Selective load distribution in musculoskeletal disorders Selective load distribution is hereby speculated to occur in all relevant musculoskeletal disorders with altered internal mechanical properties. However for clarification and
338 argument sake, patients with severe CP will continue to be utilized to demonstrate this principle. In congenital CP patients, irregular and distorted load bearing configurations assumed by their limbs are governed by previously mentioned inadequacies of their functional stabilizers. This is clearly evident upon analysis of these patients’ activities, such as disrupted gait patterns triggered by irregular muscle activation strategies d identified via EMG analysis (Dietz and Berger, 1995). Mechanically, this adopted selective-load support means that severe CP patients will attempt to perform load bearing activities while favoring the hypertonic muscle groups since they are “more fit” to sustain loads. In support of such notion, Tynan et al. identified enlarged peroneal compartments relative to anterior portion when forefoot pes cavus were compared with controls via magnetic resonance imaging. In addition, the authors speculate that this muscular imbalance will continue to provide overaction of the peroneus longus and thus play a role in pathogenesis of symptomatic cases of forefoot pes cavus (Tynan et al., 1992). The transition from regular muscle tone to hypertonic and/or spasticity may be part of the regressive musculoskeletal function identified in severe CP patients using temporal analyses of their function (Hanna et al., 2009). This transition does not occur in the short term. It is a progressive disruption of regular joint mechanics caused by irregular loading conditions imposed within the joint. Although common belief has it that neurological lesions play a dominant role in its etiology, and thus initiate this process, the transition or progression of muscles into heavy spastic and hyper-toned phenotypes may not be attributed to a non-progressive inadequate reflex control system. This is because, in order to alter the mechanical performance of both the muscle and fascial tissues involved in a spastic contraction, one must stimulate these tissues via dynamic or cyclic stresses. For example, attempts to improve biceps strength would not achieve by holding a weight in one position. Instead, repeated loading (biceps curls) would induce changes in the ability to perform arm flexion. These requirements apply for CP patients or any other progressive musculoskeletal disorder. The initial onset of hypertoned muscles, as mentioned, involves muscle shortening and/or immobilization. That is, there is an increase in positive reflex muscle stimulus often triggering flexion or pronation, which restricts functional use, leading to disuse. However, initially, articulations may still be forced through what is quantified as a regular range of motion. Referring to Figure 1, this would be defined as Transition 1 (T1), or by passing from healthy muscle and connective tissue rigidities to hyper or hypotoned muscle groups. In regular joint articulations, passive rigidities of co-contractors are similar. Therefore, mediated contractions dictate controlled motion and internal stress stimulus. Further, in a healthy joint, it is known that intentional stimulus of co-contractions occur. Although not mechanically efficient, as it imposes restrictive moments or reduces functional torque on the selected motion, this cocontraction is necessary to both stabilize and assume accurate control over the desired motion. A child who has transitioned to T1 due to inadequate neurological control, and/or disproportion of muscle and bone growth, will undergo disuse atrophy, or weakening of the extensor or
M. Driscoll, L. Blyum
Figure 1 Depiction of the transition from healthy mechanical properties to the irregular or offset relationship between agonistic and antagonist muscle groups in patients with cerebral palsy.
antagonistic. This event may play a role in the reduced ability to perform accurate and controlled motion as frequently observed in CP patients. As a result of these alterations, balanced or healthy mechanical properties previously present in articulations will be offset. This would entail weakened properties of the antagonist, with elevated stiffness in the agonistic group. Currently, the second transition (T2) is poorly understood, as a consequence of the pathomechanism of hypertonic muscles being a difficult phenomenon to study. However, it is recognized that different muscle groups are more susceptible to: a quicker transition to spasticity; a reduced range of motion; and an associated rigid joint. Further, as mentioned, selective load bearing configurations are undertaken in joints having transitioned to T1. This new mechanical environment imposed on joints induces a stress shielding effect on the antagonistic group. In other words, because the hypertonic muscle group is more rigid than its antagonistic hypotonic group, it will assume the majority of the load. This occurs naturally within internal load distribution and is hypothesized to be dominantly involved in the transition to T2, a more degenerated and detrimental state than T1. Under the stress shielding phenomenon, the possible reason for this occurrence is that distribution of loads will occur via the most suitable mechanism in order to achieve stability. Although the concept of stress shielding is conventionally reserved to describe how the introduction of rigid prosthetics shelters the surrounding bone from regular stimulus, this principle may be extended to describe how connective tissues and/or muscle units that are more rigid than its counterpart will undertake the majority of the load. In a healthy individual one may regulate their stabilizers stiffness, through controlled muscle contractions, in order to achieve affective and energy efficient stability. However, the stress shielding phenomenon may, in part, describe how an injury to any lower leg stabilizer leads to limping for example (conscious selective load bearing). Although pain likely governs the act of limping, one may entertain the idea that this irregular gait may be provoked
The presence of physiological stress
Figure 2 Stress shielding phenomenon mechanical properties of musculature.
339
governed
by
by injured tissues not being mechanically fit to sustain regular loading. In a patient with CP, implementation of the stress shielding phenomenon is more apparent since the conscious adjustability of muscle tone is hindered and, therefore, loads are likely distributed to stiffer parties. Figure 2 coupled with mechanical interpretation further rationalize this phenomenon. As previously described, the hypertonic and hypotonic muscle groups have different rigidities (instantaneous slopes of non-linear moduli) and, therefore, different stress-strain relationships. However, they are both present when joint stability is achieved. For argument sake, imagine that the joint attempts to collapse in a manner that elongates the involved muscle groups equally. As a consequence of one muscle being more rigid than the other, the elongation of the weaker group (3w) will be restricted by that of the stronger muscle (3s), as shown in Eq. (1). Further, fundamentals show that strain, or normalized elongation (3), is dependent on the ratio of
Figure 4
Figure 3 Physiological tissue mechanical homeostasis cycle (sustainable cycle).
stress (s) over its rigidity (E ) (Eq. 2). Therefore, the amount of stress experienced in the weaker or hypotoned muscle group (sw) will be proportional to the ratio of rigidities between the weak (Ew) and the strong (Es) tissues. Therefore internal stress shielding will occur (Eq. 3). 3w Z3s
ð1Þ
s 3Z E
ð2Þ
sw Zss
Ew Ew < Es rsw < ss Es
ð3Þ
This creates elevated stress levels (ss) in the stronger group and reduced stress levels (sw) in the weaker ones
Degenerative cycle of physiological tissue in musculoskeletal disorders.
340
M. Driscoll, L. Blyum
(Figure 2), when compared to regular conditions of a healthy individual.
Important implications of physiological stress shielding Physiological stress shielding is of great importance since the integrity or health of all physiological tissues responds to stress input. Stress is the factor that triggers the appropriate mechanotransduction, which in turn regulates the tissue performance and defines its mechanical homeostasis or sustainable cycle as summarized in Figure 3. However, if sheltered from regular stresses due to physiological stress shielding and/or internal force imbalance and/or irregular muscle activation, neglected tissues will resorb or disappear. In contrast, if excessively stimulated, the tissue will become stronger. This has long been quantified in bone, under Wolff’s Law (Wolff, 1892), and integrated into various feedback algorithms that demonstrate the theories feasibility in predicting disuse atrophy caused by the presence of rigid prostheses (Hart et al., 1984). Further, the notion of tissue-health stress dependence has been quantified to regulate cartilage, ligaments, tendons, and joint capsules (Von Reyher, 1874; Weichselbaum, 1878; Parker and Keefer, 1935; Salter and Field, 1960). This well
Figure 5
known tissue health dependence on stimulation allows one to conceive of the flawed or non-sustainable cycle that occurs in subjects with qualitatively evident and quantitatively documented irregular musculoskeletal stimulus. This unsuitable cycle may be envisioned as a temporal transition from mechanically balanced or healthy properties to those “stability inappropriate” properties of CP patients (Figure 1). In parallel, Figure 4, an inversion of the mechanical homeostasis cycle, provides an appropriate depiction of a regressive musculoskeletal system or degenerative cycle under the stress shielding phenomenon. Although the etiology or origin of this degenerative cycle may arise from a number of factors detailed on the extremities of Figure 4, once initiated this iterative control system will likely continue unless otherwise interrupted via the appropriate treatment. However, it is reasonably safe to conclude that a dominant player in the restrictive transition, from healthy functional characteristics to a distorted and non-functional state such as T2 (Figure 1), is the role physiologic stress-shielding plays in irregular mechanical environments. Such stress-shielding phenomenon was previously demonstrated to occur in spinal columns of patients with scoliosis since the presence of local physiological rigidity increases were shown to cause an augmentation in stress levels when compared to regular conditions and, as a result, encouraged the progression of
Specific therapeutic attempts to impede, halt or reverse the degenerative cycle in patients with cerebral palsy.
The presence of physiological stress
341
Conclusions
Figure 6 Degenerative process of untreated musculoskeletal deficiencies.
the scoliotic deformation as predicted via finite element modeling (Driscoll et al., 2009). In a similar fashion, the hypothesis portrayed herein suggests stress shielding plays a significant role in the deterioration of the CP musculoskeletal system. Specifically with regards to CP patients, the onsets of the phenotypic associated deficiencies are conventionally attributed to neurological shortcomings. However, one must not neglect the likelihood of multifactorial causes nor must they discredit the role of altered biomechanics in the deterioration of a CP musculoskeletal system. Having recognized the significance of such factors, many rehabilitative methods have been adopted in attempt to restore mechanical homeostasis (i.e. reverse the degenerative cycle) as portrayed in Figure 5. Moreover, in the authors’ opinion, this degenerative cycle will become a degenerative process and thus the longer left untreated or neglected the further ones mechanical imbalance or musculoskeletal shortcomings may progress as depicted in Figure 6. These illustrations highlight two important concepts. Firstly, they demonstrate the need to combine therapeutic interventions to fully address the available rehabilitative spectrum of musculoskeletal disorders. Secondly, and perhaps most importantly, the degenerative process emphasizes the need to intervene promptly in order to most effectively restore adequate and regular musculoskeletal function. In other words, this process insinuates that there lies an immense rehabilitative challenge for severely affected CP individuals as they may have “spiraled down” several levels within the suggested degenerative process.
Joint mechanics of a CP patient are disrupted and defined by fascial muscle groups that are strong, over used, hypertonic, and/or spastic, which are often coupled with co-contractors that are hypotonic, under stimulated, and weak. The diverging mechanical characteristics of these two groups lead to asymmetrical load distributions governed by the differences in mechanical properties, a phenomenon known as stress shielding. Further, this principle coupled with the lack of adequate neurological control over strong and weak tissues observed in CP, complements the regressive transition of their musculoskeletal system defined by a degenerative cycle, which are expressed through functional limitations observed throughout the degenerative process. With this under consideration, one may now critically analyze current treatments that seek to address the restrictive phenotypes associated with CP. Moreover, the acknowledgment of physiological stress shielding highlights a therapeutic avenue that requires additional recognition d how to actively transfer stress to the otherwise neglected tissues in order to stimulate beneficial remodeling or self healing. In closing, this article proposes the concept of physiologic stress shielding having a role in the pathomechanism of regressive musculoskeletal disorders such as CP. If neglected, physical fundamentals will continue to shield deficient tissues, thus, sheltering them from what may be characterized as a Darwinian competition for stimulus. In contrast, recognition of this aspect may lend insight into undeniable benefits that arise from therapeutic or massage methods that actively induce stimulus to the physiologically shielded tissues, which play a passive but important role in joint integrity.
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Journal of Bodywork & Movement Therapies (2011) 15, 343e347
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YOGA EXERCISE PHYSIOLOGY
Acute effects of Surya Namaskar on the cardiovascular & metabolic system Bhavesh Surendra Mody* San Jose State University, Department of Kinesiology, One Washington Square, San Jose´, CA 95192, USA Received 18 March 2009; received in revised form 25 April 2010; accepted 30 April 2010
KEYWORDS Cardiorespiratory; Exercise; Fitness; Metabolic; Weight Loss; Yoga
Summary With the recent rise in obesity awareness and the increased understanding of the importance of physical activity in promoting overall health, greater emphasis has been placed on improving physical fitness to enhance quality of life. Surya Namaskar, a component of Hatha Yoga, has been practiced by Asian Indians for hundreds of years and is often used in place of a typical fitness program. It consists of a series of postures (asanas) that are repeated 12 times per round. Only one published study has looked specifically at Surya Namaskar, measuring the energy cost of individual asanas (Sinha et al., 2004). However, practitioners typically perform several rounds of the asanas during a session. Purpose: To assess the cardiorespiratory and metabolic responses of four rounds of Surya Namaskar, a typical amount performed by practitioners, to determine its potential as a training and weight loss tool. Methods: Six healthy Asian Indian men and women (18e22 years) who had trained in Surya Namaskar for over two years participated in the study. Testing was completed in a single session lasting about 30 min. To measure heart rate and oxygen consumption while performing the four rounds, participants were connected to a heart rate monitor and the Oxycon Mobile Metabolic System. Results: Participants exercised at 80% of age-predicted maximal heart rate (HRmax) during Round 2, 84% during Round 3, and 90% during Round 4. Average intensity during the four rounds was 80% HRmax, sufficient to elicit a cardiorespiratory training effect. Oxygen consumption averaged 26 ml/kg/min during each round, resulting in an energy expenditure of 230 kcals during a 30 min session for a 60 kg individual. Conclusion: Regular practice of Surya Namaskar may maintain or improve cardiorespiratory fitness, as well as promote weight management. ª 2010 Elsevier Ltd. All rights reserved.
* Touro College of Medicine, Department of Pathology, 230 West 125th Street, New York, NY 10027, USA. Tel.: þ1 646 981 4500/1 408 924 1000. E-mail address:
[email protected] 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.05.001
344 With the recent rise in obesity awareness and the increased understanding of the importance of physical activity in promoting overall health, greater emphasis has been placed on improving physical fitness to enhance quality of life. Associated with physical activity are physiologic, metabolic, and psychologic benefits, as well as a decreased risk of chronic disease and premature mortality (United States Depart., 1996). Cardiorespiratory fitness is a key component of healthrelated fitness (Kesaniemi et al., 2001; United States Depart., 1996). According to the American College of Sports Medicine (ACSM), improvements in cardiorespiratory fitness result in a combination of the following: improvements in maximal oxygen consumption, decreased workload on the heart, decreased heart rate and blood pressure at a given workload, increased capillary density, increased oxygen extraction, increased threshold for lactate accumulation, and increased threshold for the onset of cardiovascular diseases (Kesaniemi et al., 2001; United States Depart., 1996). Intensity and duration are inversely related components of physical fitness. For example, improvements in health-related fitness can be achieved with high duration, low intensity exercise, or with low duration, high intensity exercise. According to ACSM, 40/50e85% heart rate reserve or 64/ 70e94% of maximal heart rate (MHR) are recommended intensity ranges to induce training effects. This range is purposely broad to reflect the fact that trained individuals need higher intensities, and untrained individuals need lower intensities. For weight management, ACSM recommends an exercise caloric expenditure of 150e400 kcal per day. For an individual weighing 70 kg, an intensity of 6 METs for 15 min would suffice to meet these weight management guidelines (American College of Sports Medicine ACSM, 1998). Traditionally, most people improve cardiorespiratory fitness by walking, jogging, biking, or swimming; however, these modes of exercise do not appeal to everyone. Because many health and fitness clubs are increasingly incorporating yoga and other programs into their group fitness classes, information about these activities is needed to provide practitioners with proper guidelines and recommendations. In addition, with such a diverse population, diverse forms of physical activity are needed to satisfy the needs of society as a whole (National Institute of Health, 1996; Pate, et al., 1995; United States Depart., 1996). Hatha Yoga has gained popularity as a form of physical activity in the United States (Chandler, 2001; Garfinkel and Schumacher, 2000; Hewitt, 1978; Schell et al., 1994). It consists of breathing techniques, physical movements, and meditation to develop mental and physical strength on the path toward Moksha, the highest level of consciousness in Vedic culture (Mehta et al., 1990; Satchidananda, 1990). A particular component of Hatha Yoga, Surya Namaskar (Figure 1), is taught to East Indian children at a young age and becomes an important part of their physical activity regime (Saraswati, 1997; Sivanda, 1981; Yogeshwar, 1980). Surya Namaskar consists of a series of 12 asanas (postures). To complete one round, practitioners perform each asana 12 times before moving to the next mantra. A number of studies have looked at the practice of Yoga in general. Malhotra et al. (2005) has looked at the effects
B.S. Mody
Figure 1
Surya Namaskar asanas overview.
of 40 days of Yoga. They find a decreased waist-to-hip ratio and increased insulin sensitivity in participants with diabetes. Cardiorespiratory endurance, measured by duration on a treadmill until fatigue, increases by three min following eight weeks of Yoga training (Tran et al., 2001). Clay et al. (2005) examines the impact of a single bout of Yoga on cardiovascular physiology and finds that in comparison to sitting on a chair at rest, Yoga only increases oxygen consumption (VO2), METs, heart rate (HR), and % MHR by 0.35 L/min, 1.67, 20 beats per minute (bpm), and 11%, respectively. Greater responses are typically seen when walking on a treadmill at 3.5 mph. The only published study that specifically looks at Surya Namaskar was conducted by Sinha et al. (2004). The VO2 and energy cost (measured in kcal) of the individual asanas were measured. Results indicate an increase in energy expenditure from 0.284 kcal/min at baseline to 2.995 kcal/ min during the 8th posture. The authors conclude that as an aerobic exercise, Surya Namaskar is an ideal activity because it utilizes static stretching and slow, dynamic components of exercise that produce an optimal stress on the cardiorespiratory system. Because of the popularity of Surya Namaskar and the need for a variety of exercise programs, additional research must be conducted on the practice. Current research has observed Surya Namaskar in single bouts; however, research looking at Surya Namaskar during continuous rounds is still lacking. Although the caloric expenditure is
Acute effects of Surya Namaskar
345
Table 1 Heart rate, oxygen consumption, and respiratory exchange ratio at baseline and during each round. (HR Z bpm; VO2 Z ml/kg/min). Participant
1 2 3 4 5 Mean SD
Baseline average
Round 1
HR
VO2
RER
HR
VO2
RER
HR
Round 2 VO2
RER
HR
VO2
RER
HR
VO2
RER
94 85 91 100 80 90 7.78
8.1 8.3 6.2 8.4 5.1 7.22 1.49
0.75 0.68 0.7 1.07 0.9 0.82 0.16
122 154 145 135 139 139 11.98
15.8 26.6 22.5 25.2 23.2 22.7 4.15
0.80 0.81 0.76 0.91 0.78 0.81 0.06
126 174 167 164 166 159 19.03
16.1 31.1 25.1 30.6 25.7 25.7 6.03
0.90 1.00 0.96 1.06 0.97 0.98 0.06
131 186 175 169 178 168 21.44
16.3 32.3 27.7 31.3 26.7 26.9 6.35
0.93 1.06 1.00 1.05 1.04 1.02 0.05
137 197 182 183 184 177 22.85
17.1 33.9 28.4 34.5 26.8 28.1 7.04
0.96 1.12 1.04 1.08 1.03 1.04 0.06
measured for individual asanas, the typical Surya Namaskar practitioner rarely does a single asana. Thus, the purpose of this study was to assess the cardiorespiratory and metabolic responses of four rounds of Surya Namaskar, a typical amount performed by practitioners, to determine its potential as a training and weight loss tool.
Methods Because Asian Indians are the population most likely to practice Surya Namaskar as their primary form of physical activity, potential participants were recruited from local mandirs in the San Francisco South Bay Area. Six healthy Asian Indian participants (3 men, 3 women) volunteered to participate; all had been training in Surya Namaskar for over two years and were well acquainted with its practice. An equipment malfunction occurred while testing one female participant; her data were not included in the analyses. All participants completed a health history questionnaire to ensure they met the inclusion criteria of the study. Participants were healthy Asian Indian Surya Namaskar practitioners between the ages of 18 to 50 years. All participants had prior training in Surya Namaskar. In addition, all participants were classified as low risk according to the American College of Sports Medicine (ACSM) risk stratification. None of the participants were smokers (American College of Sports Medicine ACSM, 1998). The study was approved by the San Jose State University Institutional Review Board, and all participants provided written, informed consent. All testing was completed in a single session at the San Jose State University Exercise Physiology/Biomechanics Laboratory. Participants were asked to refrain from
Round 3
Round 4
participating in rigorous physical activity on the day of testing and to rest the night before. In addition, all were asked to wear loose fitting, light clothing. Upon arriving at the laboratory, participants had their height and weight measured with light clothing and no shoes. A Polar heart rate transmitter was then placed around their chests, and they wore a face mask that covered the nose and mouth. A vest carrying two modules was placed over the chest; the modules wirelessly transmitted VO2, ventilation (VE), and carbon dioxide production (VCO2) to the Oxycon Mobile Metabolic System computer. Participants were asked to remain within 10 feet of the computer. Breath-by-breath data were continuously displayed. When the equipment was in place, resting HR, VO2, VCO2, and VE were recorded. Respiratory exchange ratio (RER) was calculated by dividing VO2 into VCO2. Participants were given 5 min to prepare for the exercise in their normal manner (e.g., stretching, meditation). Following this 5 min preparation, participants continuously performed 12 repetitions of each of the 12 asanas (1 round), completing a total of 4 rounds. Average time to complete 4 rounds was 12 min. Mantras were said mentally during the rounds. At the end of each round, participants were asked if they could continue into the next round or if they wished to stop. Participants were instructed to mimic the pace they typically perform the exercise when on their own.
Results The age, height, and body weight of the five participants who completed testing were (mean standard deviation) 19.8 1.5 years, 172.7 10.4 cm, and 61.0 5.0 kg,
Table 2 Age, calculated maximal heart rate, and percentage of calculated maximal heart rate at baseline and during each round. (Age Z years; HRmax Z bpm). Participant
Age
HRmax
Baseline
Round 1
Round 2
Round 3
Round 4
%HRmax
%HRmax
%HRmax
%HRmax
%HRmax
1 2 3 4 5 Mean SD
22 20 19 21 18 20.0 1.58
198 200 201 199 202 200 1.58
47 43 45 50 40 45 4
62 77 72 68 69 69 6
64 87 83 82 82 80 9
66 93 87 85 88 84 10
69 98 90 92 91 88 11
346 Table 3
B.S. Mody Metabolic equivalent at baseline and during each round.
Participant
Participant Participant Participant Participant Participant Mean SD
Baseline
1 2 3 4 5
Round 1
Round 2
Round 3
Round 4
METs
METs
METs
METs
METs
2.31 2.37 1.77 2.40 1.46 2.06 0.43
4.52 7.60 6.44 7.20 6.62 6.48 1.18
4.61 8.89 7.17 8.74 7.33 7.35 1.72
4.66 9.23 7.91 8.93 7.63 7.67 1.81
4.88 9.70 8.10 9.86 7.66 8.04 2.01
respectively. Mean HR for the group during the 4 rounds was 156 19 bpm. Heart rate at baseline was 90 8 bpm and increased during each round (Table 1). Mean VO2 for the group during the 4 rounds was 23.14 4.88 ml/kg/min. From baseline, VO2 increased to about 28 ml/kg/min during round (Table 1), representing an 8 METs workload (Table 3). In all cases, the exercise became more strenuous as the participants completed each round. Age-predicted MHR was determined using the formula 220 e age in years. Percentage of age-predicted MHR for each participant during each round is presented in Table 2. Participants completed the 4 rounds in approximately 15 min, including a brief recovery period. Although VO2 increased during each round, the mean workload during the 4 rounds was 6.3 METs. This resulted in an energy expenditure of approximately 6.7 kcal/min, or 400 kcal/hr (Table 3).
Discussion Surya Namaskar is a component of Hatha Yoga that consists of 12 postures performed sequentially 12 times per round. For many Asian Indians, Surya Namaskar is a vital method of maintaining fitness. Yoga is recognized to improve flexibility; however, its application as a weight management and fitness tool has been unrealized. According to ACSM, a moderate to high intensity correlates to a HR of about 64e94% MHR. While working below this level has the potential to induce a training effect, the likelihood of training adaption is greatly increased when working within this training zone. As a group, the participants exercised at 69% of age-predicted MHR during round 1, 80% during round 2, 84% during round 3, and 88% during round 4. Mean intensity during the 4 rounds was 80% of agepredicted MHR. Such a high intensity is typically associated with low duration activity, but in this study participants reported that they were not exhausted after exercising for approximately 12 min (4 rounds). Caloric expenditure while performing Surya Namaskar was measured in this study. Because Surya Namaskar is practiced by the target population as an alternative to traditional fitness methods, it is also being used as a substitute for traditional weight management methods. Weight management is a function of energy (food) intake and energy expenditure, including physical activity. An exercise energy expenditure of 150-400 kcal/day (or about 6 METs) is recommended by ACSM to maintain weight. Coupled with resting metabolism, this energy expenditure is typically sufficient to balance energy input with energy
output (Whaley et al., 2006). The participants in this study expended approximately 100 kcal every 15 min (400 kcal/ hr). Because the participants commented that they could continue beyond 4 rounds, additional calories could possibly be burned before fatigue. The participants were exercising at an average intensity of 6.3 METs. During round four, participants were exercising at about 8 METs (Figure 2); based on this exercise intensity and the high caloric expenditure, four rounds of Surya Namaskar meets the ACSM guidelines for weight management (American College of Sports Medicine ACSM, 1998). Results from this study suggested that performing Surya Namaskar at a pace of 3 min per round met the ACSM guidelines for energy expenditure in weight management. It should be noted that weight management is multifactorial and that it is just one aspect of a healthy lifestyle. Proper diet, balanced lifestyle, and energy expenditure all work together to promote healthy living. Exercise is just one aspect of energy expenditure that plays a part in weight management. Surya Namaskar is relatively new to the western world but common to East Asian populations who perform it as an alternative to traditional methods of aerobic exercise. This study is the first step in identifying the effectiveness of Surya Namaskar in comparison to those traditional aerobic exercise regimes. While this study is suggesting there is a possibility that Surya Namaskar can be an effective aerobic tool, more complete investigations need to be conducted before a definite answer can be given. The small sample size and simple methodology made
Figure 2 round.
Metabolic equivalent at baseline and during each
Acute effects of Surya Namaskar it difficult to infer any conclusions regarding Surya Namaskars. Future studies are needed to properly understand its physiologic and psychologic effects.
References American College of Sports Medicine ACSM, 1998. Position stand: the recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Medical Science in Sports and Exercise 30, 975e991. Chandler, K., 2001. The emerging field of Yoga therapy. Hawaii Medical Journal 60, 286e287. Clay, C., Lloyd, L., Walker, J., Sharp, K., Pankey, R., 2005. The metabolic cost of hatha Yoga. Journal of Strength and Conditioning Research 19, 604e610. Garfinkel, M., Schumacher, H., 2000. Yoga. Rheumatic Diseases Clinics of North America 26, 125e132. Hewitt, J., 1978. The Complete Yoga Book. Schocken Books, New York NY. Kesaniemi, Y., Danforth, E., Jensen, M., Kopelman, P., Lefebvre, P., Reeder, B., 2001. Dose-response issues concerning physical activity and health: an evidence-based symposium. Medicine and Science in Sports and Exercise 33, S351eS358. Malhotra, V., Singh, S., Tandon, O., Sharma, S., 2005. The beneficial effects of Yoga in diabetes. Nepal Medical College Journal 7, 145e147. Mehta, S., Mehta, M., Mehta, S., 1990. Yoga the Iyengar Way. Alfred A. Knopf, Inc., New York NY. National Institute of Health, 1996. Physical activity and cardiovascular health. National Institutes of Health (NIH) consensus
347 development panel on physical activity and cardiovascular health. The Journal of the American Medical Association 276, 241e246. Pate, R., Pratt, M., Blair, S., 1995. Physical activity and public health. a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. The Journal of the American Medical Association 273, 402e407. Saraswati, S., 1997. Surya namaskar, salutation to the sun. Asanas Pranayama Mudra Bandha, 159e172. Satchidananda, S., 1990. The Yoga Sutras of Patanjali: Translation and Commentary, fourth ed. Yogaville Integral Yoga Publications. Schell, F., Allolio, B., Schonecke, O., 1994. Physiological and psychological effects of hatha Yoga exercise in healthy women. International Journal of Psychosomatic Research 41, 46e52. Sinha, B., Ray, U., Pathak, A., Selvamurthy, W., 2004. Energy cost and cardiorespiratory changes during the practice of surya namaskar. Indian Journal of Physiology and Pharmacology 48, 184e190. Sivanda, S., 1981. Surya namaskar. Science of Yoga 4, 37e39. Tran, M., Holly, R., Lashbrook, J., Amsterdam, E., 2001. Effects of Hatha Yoga practice on the health-related aspects of physical fitness. Preventative Cardiology 4, 165e170. United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion 1996 Physical Activity and Health: a Report of the Surgeon General Atlanta, GA. Whaley, M., Brubaker, P., Otto, R., Armstrong, L., 2006. ACSM’s Guidelines for Exercise Testing and Prescription. American College of Sports Medicine, Baltimore, MD. Yogeshwar, 1980. Text Book of Yoga, first ed. Madras India Mylapore.
Journal of Bodywork & Movement Therapies (2011) 15, 348e354
available at www.sciencedirect.com
journal homepage: www.elsevier.com/jbmt
MYOFASCIAL PAIN
Immediate effect of electric point stimulation (TENS) in treating latent upper trapezius trigger points: A double blind randomised placebo-controlled trial Hugh Gemmell, DC, BA, MSc, EdD*, Axel Hilland Anglo-European College of Chiropractic, 13e15 Parkwood Road, Bournemouth, BH5 2DF, UK Received 30 October 2009; received in revised form 1 April 2010; accepted 7 April 2010
KEYWORDS Myofascial pain; Trigger point; Manual therapy; Upper trapezius; TENS
Summary Objective: The purpose of this study was to investigate the immediate effect of electric point stimulation in treating latent upper trapezius trigger points compared to placebo. Design: Double blind randomised placebo-controlled trial. Setting: Anglo-European College of Chiropractic. Participants: Sixty participants with latent upper trapezius trigger points. Interventions: Electric point stimulator type of TENS, or detuned (inactive) electric point stimulator type of TENS. Main outcome measures: The three outcome measures were pressure pain threshold at the trigger point, a numerical rating scale for pain elicited over the trigger point, and lateral cervical flexion to the side opposite the trigger point. Results: On the outcome of pressure pain threshold the electric point stimulator group had a mean change of 0.49 (0.99) kg/cm2, while the placebo group had a mean change of 0.45 (0.98) kg/cm2 (t Z 0.16, df Z 58, p Z 0.88). For change in pain over the trigger point, the electric point stimulator group had a mean decrease of 0.93 (0.87) points, while the placebo group had a mean decrease of 0.23 (0.97) points (t Z 0.70, df Z 58, p Z 0.005). On the outcome of change in lateral cervical flexion the electric point stimulator group had a mean increase of 2.87 (4.55) degrees, while the placebo group had a mean increase of 1.99 (2.49) degrees (t Z 0.92, df Z 58, p Z 0.36).
* Corresponding author. Tel.: þ44 1202 436268; fax: þ44 1202 436312. E-mail address:
[email protected] (H. Gemmell). 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.04.003
Immediate effect of electric point stimulation (TENS) in treating latent upper trapezius trigger points
349
Conclusion: Electric point stimulator type of TENS is superior to placebo only in reduction of pain for treating latent upper trapezius trigger points. ª 2010 Elsevier Ltd. All rights reserved.
Background A trigger point (TrP) is defined as a hypersensitive spot in a skeletal muscle associated with a taut band. The spot is painful on compression and refers pain in a characteristic pattern for each muscle. Referred tenderness, motor dysfunction and autonomic symptoms may also occur (Simons et al., 1999; Hong, 1994; Gerwin, 1995; Gerwin et al., 1997). Trigger points occur anywhere in the body; however, some muscle groups more commonly contain TrPs, especially those involved in maintaining posture (Rickards, 2006). Trigger points are activated directly by muscle overload (acute or chronic), trauma, prolonged muscle contraction, and/or nerve compression (Simons et al., 1999; Huguenin, 2004). Furthermore TrPs may be activated indirectly by other existing TrPs, visceral disease, joint dysfunction and emotional distress (Simons et al., 1999; Huguenin, 2004). Two main types of TrPs are described: active and latent (Simons et al., 1999). Active TrPs reproduce the patient’s usual pain. Latent TrPs produce the characteristic effects of an active TrP, including referred pain, increased muscle tension and shortening, but they do not produce spontaneous pain (Simons et al., 1999; Dommerholt et al., 2006). It is claimed that TrPs and the attendant myofascial pain syndrome is the most common pain disorder of muscle origin seen in clinical practice (Audette et al., 2004). The incidence in the general population varies between 30 and 85%, is more common in women, and pain in the majority of cases is localised to the head, neck and shoulder region (Han and Harrison, 1997; Rickards, 2006). The highest incidence appears to be in patients between 30 and 40 years of age (Cooper et al., 1986; Hou et al., 2002). Latent TrPs are more common than active TrPs (Mense and Simons, 2001; Gerwin, 1995; Drewes and Jennum, 1995; Tough et al., 2007). Several theories have been proposed to explain the pathophysiology of TrPs. The integrated hypothesis is now generally accepted as the best explanation for development of TrPs (Simons, 2002). In this theory a local energy crisis develops due to dysfunctional motor endplates with release of acetylcholine (ACh) under resting conditions, and development of contraction knots due to sustained contraction of sarcomeres. Sustained contraction of muscle fibres results in compression of local capillaries reducing nutrient and oxygen supplies leading to a local energy crisis. This, in turn, results in the release of sensitising chemicals that interact with autonomic and sensory nerves in the area contributing to excessive ACh release, leading to a self-sustaining cycle (Rickards, 2006; Hanten et al., 2000; Simons, 2002). Transcutaneous electrical nerve stimulation (TENS) is defined as the application of electrical stimulation to the skin for pain control. It is non-invasive, inexpensive, safe, and easy to use (Sluka and Walsh, 2003; Rushton, 2002).
Electricity has been used for thousands of years for pain relief, with the first written account given by Aristotle (Kane and Taub, 1975; Howe et al., 2008). However, a theoretical foundation for electroanalgesia was only established in 1965 through the publication of the gate control theory (Melzack and Wall, 1965). The theory proposed that opening or closing of the “gate” existing in the substantia gelatinosa of the dorsal horn is dependent on the relative activity in the large diameter fibres (A-beta) and small diameter fibres (A-delta and C), with activity in the large diameter fibres tending to close the “gate”, and activity in the small diameter fibres tending to open it (Baldry, 2005a). This gate could effectively be closed by a variety of other types of stimulation, which activate the large diameter afferent fibres such as cold, heat, and electrical currents (Howe et al., 2008). TENS has been shown to be an effective treatment option in relieving pain caused by a number of different disorders (Baldry, 2005b). However TENS is not described as a specific TrP modality by Simons et al. (1999), and its effectiveness on TrP pain has been questioned (Baldry, 2005b). Various studies have investigated the relative effectiveness of traditional TENS on TrP pain (Graff-Radford et al., 1989; Hou et al., 2002; Hsueh et al., 1997). However, we were unable to find any published studies that have investigated the effect of electric point stimulation type of TENS on TrPs. Therefore the purpose of this study was to investigate the immediate effect of electric point stimulation in treating latent upper trapezius TrPs compared to placebo based on the outcomes of PPT, Numerical Rating Scale (NRS) score and lateral cervical flexion.
Methods Overview The study was a double blind randomised placebocontrolled trial approved by the Anglo-European College of Chiropractic (AECC) Student Projects Panel. All participants signed a consent form before participating in the study. The study was conducted in a seminar room at the AECC over 6 weeks during September and October 2008. Follow up occurred 5 min after treatment.
Participants Volunteers (N Z 78) were recruited from students, faculty and staff at the AECC, Bournemouth. This was done using posters and email announcements. Sixty volunteers met the eligibility requirements and were enrolled in the study. Inclusion criteria for this study were: male or female between 18 and 60 years of age, asymptomatic, a latent TrP in the upper fibres of the trapezius muscle, pain of at least
350
H. Gemmell, A. Hilland
4 on a 0e10 numerical rating scale with firm compression on the latent TrP. For the purpose of this study a latent TrP was defined as a hypersensitive spot in a taut band that referred pain in a pattern typical for the upper trapezius muscle, but was not causing the participant any pain (Simons et al., 1999). Gerwin et al. (1997) suggest that the minimum criteria required to distinguish a TrP from any other tender area in a muscle are a taut band and tender point in that taut band. Participants were excluded if they had any of the following: 1. 2. 3. 4. 5.
head, neck or upper back pain a pacemaker epilepsy possibility of pregnancy diffuse generalised musculoskeletal pain.
Interventions Electric point stimulator We used a handheld electric point stimulator designed to locate and treat TrPs with a pulsating TENS current. The difference between electric point stimulation and standard TENS is the electric current is delivered through a metal probe on the hand held device compared to electrodes attached to the skin. Purportedly the electric skin resistance of the TrP is lower than its surrounding area, and the instrument is able to detect this change (Sola and Williams, 1956; Sola et al., 1955). When the metal probe touches an area of lowered resistance a speaker in the device emits a sound and a small green light flashes. The pitch of the sound rises with lowering of the skin resistance to enable precise location of the point to be treated. When the highest pitch is reached the button on the top of the instrument is pressed to deliver stimulation into the TrP. Hand contact with the indifferent hand has to be made with the participant’s skin for the electric current to flow to the TrP. A pulsating current of 8e10 Hz is emitted through the probe, and the intensity of the current may be adjusted from 0 to 45 mA. A 9-V battery powers the electric point stimulator. Treatment was delivered to the seated participant by placing the tip of the stimulator on the marked TrP. Sensitivity was set low to detect areas of lowered skin resistance over the TrP. After detecting the lowest electric skin resistance point over the TrP, the stimulator was activated and held with a constant pressure for 3 min. The tip of the stimulator is spring-loaded to enable the same pressure to be applied by increasing pressure until the barrier of the spring is reached. Intensity of stimulation was set to participant tolerance, and at a minimum the subject felt a pulsating tingling sensation that was not unpleasant. The stimulation was not strong enough to cause muscle contraction. While there is no published research on the hand held electric point stimulator, numerous websites tout its ability to detect and treat acupuncture points and TrPs, and the principal author’s clinical observation is that the point stimulator may be useful in treating TrPs. However, a recent study suggests that acupuncture points do not show any changes in electrical skin resistance that are consistent or stable over time (Kramer et al., 2009).
Placebo The same device was used for the placebo group, but with sensitivity set high so noise and light would be the same as for the active group. The intensity was set to zero (inactive), and no contact with the indifferent hand was made with the seated participant’s skin. This was to ensure that no current was applied to the TrP. Light pressure with the device (less than spring barrier) was held over the marked TrP for 3 min. This very light pressure was used to control for a possible treatment effect of firmer pressure to the TrP. Therefore, while both active and placebo interventions involved pressure over the TrP, only the active treatment involved application of an electrical current.
Objectives The specific objectives were to determine if there was a statistically significant difference in pressure pain threshold, in pain level on compression of the TrP, and in cervical lateral flexion between electric point stimulation and placebo applied to latent upper trapezius TrPs. The null hypothesis was that there is no difference between electric point stimulation and placebo. The alternate hypothesis was that electric point stimulation is superior to placebo.
Outcomes The outcome measures were pressure pain threshold (PPT) at the TrP, a numerical rating scale (NRS) assessing local pain elicited over the TrP using a pain pressure algometer (PPA) determined at the point sensation of pressure changed to that of pain, and use of the cervical range of motion device (CROM) to determine lateral cervical flexion to the side opposite the TrP. An examiner masked to treatment allocation of the participant assessed the outcomes. A pressure pain algometer (PPA) is a hand held device that can measure deep tenderness and pressure pain thresholds of muscles, bones and ligaments. It consists of a gauge that is attached to a hard rubber tip 1 cm in diameter. The gauge is calibrated in kg/cm2 and ranges from 1 to 10 kg/cm2. The force recorded was the amount of pressure that caused the sensation of pressure to change to that of pain (PPT). Pressure pain threshold as determined by a PPA has been shown to be reliable and valid (Nussbaum and Downes, 1998; Antonaci et al., 1998; Reeves et al., 1986; Delaney and McKee, 1993; Cathcart and Pritchard, 2006; Pontinen, 1998; Takala, 1990). The participant was asked to indicate when the sensation of pressure changed to that of pain. A trial was conducted over the forearm muscles for the participant to understand what was required. The rubber tip of the PPA was placed over the marked TrP and held perpendicular to the muscle belly with the gauge turned away from the participant. Pressure over the TrP was increased steadily at a rate of 1 kg/cm2/s as recommended by Fischer (1987). The examiner released the pressure when pain was elicited as indicated by the participant. This was repeated three times with a rest period of 20 s between recordings. The mean of the three measurements was used in data analysis.
Immediate effect of electric point stimulation (TENS) in treating latent upper trapezius trigger points The NRS is a standard tool used to measure pain and change in pain, and has been shown to be reliable and valid in measuring sensitivity of a TrP (Jensen et al., 1986,1994,1999; Salaffi et al., 2004; Williamson and Hoggart, 2005). During determination of PPT when the participant indicated sensation of pressure changed to pain, the participant was asked to grade the pain by selecting a number from 0 to 10 to represent the severity of pain. This was recorded three times and the mean was used for data analysis. The Cervical Range of Motion (CROM) instrument contains three inclinometers, which measure motion in all three planes. The device is strapped to the head and does not need to be moved when measuring movements in different planes. Research has shown the CROM to be useful in determination of function, to monitor patient progress, and is reliable with good construct validity (Norkin and White, 1985; Jordan, 2000; Youdas et al., 1991; Koning et al., 2008). The participant was asked to sit up straight and laterally flex their head to the side opposite of the located TrP. The degree of lateral flexion was then recorded. This was repeated three times and the mean value was used in data analysis. The clinician (HG) has over 25 years of experience treating myofascial TrPs with electric point stimulation (EPS). To improve quality of all the measurements the examiner (AH) spent 10 h in training sessions with the clinician, and about 2 weeks using the measures with his fellow students so as to be confident and competent in taking the measurements.
Randomisation Randomisation was conducted a priori using the website www.randomization.com. A clinician (HG) generated the allocation sequence and sealed opaque envelopes were prepared by HG prior to the study and numbered consecutively. Participants were enrolled by AH. HG as the treating clinician allocated participants the next available numbered envelope. The examiner and participants were masked to treatment, but the treating clinician was not. Success of examiner blinding was ascertained by asking the examiner if he was able to guess subject allocation to group and he stated he was not able to do so.
Procedure On arrival for the study the volunteer was screened for eligibility by the examiner (AH). The treating clinician (HG) determined if the volunteer had a latent TrP in the upper trapezius muscle and reviewed the volunteer’s medical history. If there was more than one latent TrP, the most tender was chosen and marked with a cross using a skinpencil. After locating and marking the TrP the clinician exited the room. The examiner determined if the volunteer’s pain over the TrP was at least 4 on the NRS with pressure. If so, the volunteer signed the consent form and was enrolled in the study. The examiner took pre-treatment measurements of PPT, pain sensitivity of the TrP, and lateral cervical flexion range as described above. Participants were not informed of their scores throughout the study to prevent participant bias influencing the results. At this point the examiner exited the room and the treating clinician entered.
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The clinician explained to the participant the procedure for the electric point stimulation, and that they would receive one of two types of stimulation. They were not told that one was a placebo treatment. One was explained as normal TENS with which they would feel a mild tingling sensation, the other being microcurrent there would be no tingling sensation felt. Two different types of EPS instruments were shown to the patient to re-enforce the fact that two types of EPS were being tested. The sounds and light of the instrument to be used were then demonstrated on the participant’s forearm. The clinician opened the next consecutively numbered envelope and the marked TrP was treated with active or placebo stimulation for 3 min as described above, and exited the room. The examiner again entered the room and post-treatment values were assessed 5 min after treatment in the same manner as pre-treatment data were collected.
Statistical methods Data were analysed with GraphPad Instat version 3.0 for Windows (GraphPad Software, San Diego California USA, www.graphpad.com). A normal distribution of the data was assessed by the KolmogaroveSmirnov test (p > 0.05). Baseline characteristics were compared between groups using the independent t-test for continuous level data, and the c2test was used for non-continuous level data. The mean change from pre-test to post-test for each of the outcomes was compared between the groups using the independent t-test. Statistical analysis was conducted at a 95% confidence interval, and p < 0.05 was considered statistically significant.
Results Figure 1 shows participant flow through the study. Thirteen baseline demographic and clinical characteristics of each group are shown in Table 1. All participants in each group were included in each analysis. Due to the number of zero cells for the marital status variables we were unable to calculate statistical significance. However, on comparing the numbers in each category for each group it appears the categories were equal across groups. Therefore there was
Screened (n=78) Excluded (n=18) No trigger point (n=11) NRS below 4 (n=6) Psychosocial issues (n=1)
Randomised (n=60)
Allocated to EPS (n=30) Received EPS (n=30) Analysed (n=30)
Figure 1
Allocated to placebo (n=30) Received placebo (n=30) Analysed (n=30)
Participant flow
352 Table 1
H. Gemmell, A. Hilland Baseline demographic and clinical characteristics.
Variable
Placebo
EPS
Statistic
p Value
Age (SD) Gender (%)
25.6 (4.6) Females: 15 (50.0) Males: 15 (50.0) Married: 2 (6.7) Divorced: 0 (0) Separated: 0 (0) Single: 23 (76.7) Partner: 5 (16.7) Yes: 7 (36.7) No: 23 (63.3) 24.2 (3.9) 4.5 (0.8) 4.0 (1.4) 43.8 (6.6)
24.2 (2.5) Females: 13 (43.3) Males: 17 (56.7) Married: 0 (0) Divorced: 0 (0%) Separated: 0 (0) Single: 28 (93.3) Partner: 2 (6.7) Yes: 11 (23.3) No: 19 (76.7) 23.8 (4.7) 4.7 (1.1) 4.0 (1.4) 46.2 (8.5)
t Z 1.45, df Z 44 c2 Z 0.07, df Z 1
0.16 0.79
Marital status (%)
Tobacco use (%) BMI (SD) NRS (SD) PPT (SD) CROM (SD)
Unable to calculatea
c2 Z 0.71, df Z 1 t t t t
Z Z Z Z
0.35, 1.10, 0.02, 1.23,
df df df df
Z Z Z Z
56 52 58 58
0.40 0.73 0.28 0.98 0.22
Age in years, PPT in kg/cm2, CROM e cervical lateral flexion in degrees. a Due to the number of zero cells unable to calculate.
no difference between the groups in any of the baseline variables (p > 0.05). Comparison between the groups for each outcome measure relative to the pre-test to post-test change score is shown in Table 2. The EPS group increased mean PPT by 0.49 (0.99) kg/cm2, while the placebo group increased mean PPT by 0.45 (0.99) kg/cm2. The difference between the groups was not statistically significant (t Z 0.1564, p Z 0.8762, 95% CI Z 0.84 to 0.91). The EPS group had a mean decrease in pain on pressure over the TrP of 0.93 (0.87) points, while the placebo group had a mean decrease in pain of 0.23 (0.97) points. The difference between the groups was significant (t Z 0.7004, p Z 0.005, 95% CI Z 1.176 to 0.2338). Due to the significant difference between the groups on pain, effect size was calculated for both groups. The effect size for the active group was d Z 0.93 and for the placebo group it was d Z 0.23. On cervical lateral flexion away from the side of the involved TrP the EPS group had a mean improvement of 2.87 (4.55) degrees, compared to a mean improvement of 1.99 (2.49) degrees in the placebo group. The difference between the groups was not significant (t Z 0.9185, p Z 0.3621, 95% CI Z 0.31 to 6.88). No adverse effects were reported by any participant in either group.
Discussion To our knowledge this is the first study to compare electric point stimulation type of TENS to placebo for latent TrPs. Table 2
The results show that EPS is superior to placebo for reduction in pain on pressure over the TrP with a large effect size (d Z 0.93). However, the null hypothesis cannot be completely rejected as the results for PPT and cervical ROM indicate there is no difference between EPS and placebo in treating upper trapezius TrPs. A longer follow up with multiple treatments may have produced a different result. However, a recent systematic review (Vernon and Humphreys, 2008) concluded that there is moderate-to-high quality evidence that immediate clinical improvements are achievable with a single session of spinal manipulation. They feel the benefit of single session trials of treatment can be viewed in two ways. The first is that these trials provide a form of proof of concept in that they indicate if a single dose of the treatment achieves an acceptable level of intended outcome. Secondly, these studies provide evidence of the outcome that can be expected with each session of the treatment, at least for the first treatment. Further, Lewit (2008) suggests that musculoskeletal dysfunctions such as manipulable lesions and TrPs are reversible and, therefore, usually react immediately. This suggests that if the treatment effect is large enough one treatment should be adequate to demonstrate a difference between the groups. Beecher (1959) coined the term “placebo effect” during the 2nd World War when he ran out of morphine and gave saline injections instead, but told the soldiers it was morphine. He obtained a 35% response rate based on expectation. It is now known that placebo rates vary. A review (Walach et al., 2005) of 141 long-term randomised controlled trials found non-specific effects accounted for
Baseline to post-test change between the groups on each outcome.
Outcome
EPS mean change
Placebo mean change
95% CI
t-test
p Value
PPT NRS C Lat Flex
0.49 (0.99) 0.93 (0.87) 2.87 (4.55)
0.45 (0.98) 0.23 (0.97) 1.99 (2.49)
0.84 to 0.91 1.18 to 0.22 0.31 to 6.88
0.1564 0.7004 0.9185
0.8762 0.0047* 0.3621
*Significant p < 0.05. PPT in kg/cm2; pain graded on a numerical rating scale from 0 to 10; C Lat Flex in degrees; t-test Z independent t-test.
Immediate effect of electric point stimulation (TENS) in treating latent upper trapezius trigger points nearly 60% of all treatment effects across disease categories and a wide variety of interventions. One of the difficulties in manual therapy is in using a credible placebo. The type of placebo we used in the current study may be challenged as both groups were subjected to pressure with the EPS device and even light pressure may stimulate mechanoreceptors to affect the pain response. However, the placebo group did not receive any electrical stimulation and we feel the placebo was adequate for our purposes. Future studies could include a third arm of no treatment as a control for natural history, but the question remains is it really possible to have a no treatment group as some interaction occurs between the participant and investigators. Based on the effect size obtained with pain over the TrP (d Z 0.93), alpha set at 0.05, two-sided design, and power of 0.8, 33 participants per group were needed for adequate power to detect a statistically significant difference. With 30 subjects per group we feel the study had adequate power. While the clinician had extensive experience in diagnosing and treating myofascial TrPs, the examiner had limited experience in using the outcome measures. However, we feel adequate training was given and adequate practice was obtained with the outcome measures before the study and that this did not act as a limitation to the study.
Conclusion EPS is superior to placebo in reducing pain on compression over upper trapezius TrPs, but is no better than placebo in improving PPT or increasing cervical ROM.
Conflict of interest statement The authors state they have no conflict of interest including any financial, personal or other relationships with other people or organisations within three years of beginning the submitted work that could inappropriately influence, or be perceived to influence, their work.
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Journal of Bodywork & Movement Therapies (2011) 15, 355e362
available at www.sciencedirect.com
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EXERCISE PHYSIOLOGY
Six weeks of aerobic dance exercise improves blood oxidative stress status and increases interleukin-2 in previously sedentary women Donrawee Leelarungrayub, B.Sc. (PT), Ph.D. (Biochem) a,*, Kunteera Saidee, B.Sc. (PT) b, Prapas Pothongsunun, Ph.D. (Biomechanics) a, Sainetee Pratanaphon, M.Sc. (Physiology) a, Araya YanKai, M.Sc. (PT) a, Richard J Bloomer, Ph.D. (Physiology) c a Oxidative Stress and Exercise Biochemistry Laboratory, Department of Physical Therapy, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai 50200, Thailand b Sport Sciences, Graduate School, Chiang Mai University, Chiang Mai 50200, Thailand c Cardiorespiratory/Metabolic Laboratory, Department of Health and Sport Sciences, University of Memphis, USA
Received 23 October 2009; received in revised form 29 March 2010; accepted 30 March 2010
KEYWORDS Aerobic dance; Oxidative stress; Interleukin-2
Summary This study evaluated the change in blood oxidative stress, blood interleukin-2, and physical performance following 6 weeks of moderate intensity and duration aerobic dance exercise in 24 sedentary women. Blood samples were collected at rest twice before (baseline) and after the 6-week intervention for analysis of protein hydroperoxide (PrOOH), malondialdehyde (MDA), total anti-oxidant capacity (TAC), and interleukin-2 (IL-2) levels. Maximal treadmill run time (Timemax) and maximal oxygen consumption (VO2max) were also measured. All variables were statistically analyzed with a repeated measurement ANOVA and Tukey post hoc. No differences were noted in any variable during the baseline period (p > 0.05). After aerobic dance exercise, VO2max, Timemax, TAC and IL-2 were significantly increased, whereas MDA levels were decreased significantly (p < 0.05). PrOOH did not change either between baseline measures or after exercise. It can be concluded that aerobic dance exercise at a moderate intensity and duration can improve physical fitness, decrease MDA, and increase TAC and IL-2 in previously sedentary women. ª 2010 Elsevier Ltd. All rights reserved.
* Corresponding author. E-mail address:
[email protected] (D. Leelarungrayub). 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.03.006
356
Introduction Aerobic dance is one of the most common exercise practices in the world (Williford et al., 1989). Presently, aerobic dance in Thailand is a popular activity and performed by small groups of middle-aged women rather than men. Cardiorespiratory endurance, balance, lower limb strength and endurance, agility and flexibility have all been reported to improve from this style of exercise (Hopkins et al., 1990; Shigematsu et al., 2002). Music with slow or fast rhythm cadences helps to control and pace the movement of selected body segments (Copeland and Franks, 1991), allowing for an overall body workout. As with other forms of aerobic exercise, aerobic dance performed within a target heart rate of between 50 and 80% of the maximal heart rate (MHR) has demonstrated cardiovascular and metabolic benefits such as increased maximal oxygen consumption (VO2max), improved aerobic endurance capacity, and increased energy production via the mitochondria respiration system (Banfi et al., 2006). Although aerobic exercise is viewed as a health enhancing endeavor, the production of either reactive oxygen species (ROS) such as hydroxyl radical and superoxide radical, or reactive nitrogen species (RNS) such as nitric oxide occurs in an intensity (Quindry et al., 2003) and duration dependent manner (Bloomer et al., 2007). While multiple factors contribute to this increase in ROS and RNS as described in detail previously (Bloomer, 2008), this is often thought to be associated with the increase in oxygen consumption and processing via the mitochondria respiratory chain. While increased radical production is viewed by some as potentially harmful, and in certain times may indeed be, it is important to understand that radical production resulting from strenuous exercise serves as a stimulus to upregulate key endogenous anti-oxidant protective mechanisms (Radak et al., 2008). Hence, some degree of radical production should be viewed as beneficial rather than detrimental. In the case of intense exercise, high production of ROS/ RNS coupled with low anti-oxidant protection (i.e., decreased total anti-oxidant capacity [TAC]) has been shown to damage cellular lipids, proteins, and nucleic acid, in turn promoting an increase in protein hydroperoxide (PrOOH), malondialdehyde (MDA), and DNA fragmentation (Fisher-Wellman and Bloomer, 2009). This has the potential to result in cell and tissue dysfunction. In addition to the increased radical production, the immune system may respond to high intensity exercise giving rise to lymphocyte proliferation (Sureda et al., 2005; Nielsen, 2003), with interleukin-2 (IL-2) over-expression acting as the proinflammatory stimulant (Pedersen and Hoffman-Goetz, 2000), possibly aiding in exercise recovery. When the exercise intensity is low to moderate (55% VO2max) during acute exercise bouts, a decrease in IL-2 has been observed in sedentary women (Giraldo et al., 2009). Similar findings for decreased IL-2 have been noted for chronic exercise of low to moderate intensity (i.e., 12week interval exercise at 60% VO2max) (Rhind et al., 1996). Thus it is possible that aerobic dance exercise of too low an intensity, while providing enjoyment to participants and cardiovascular and fitness related health benefits, may not
D. Leelarungrayub et al. result in increased ROS/RNS production needed to stimulate improved endogenous anti-oxidant capacity, or increased IL-2 needed for immune function. Considering the above, coupled with the widespread use of aerobic dance within Thailand and the lack of scientific evidence related to blood oxidative status of this form of aerobic dance exercise, we determined the effects of a 6 week moderate intensity aerobic dance exercise program on the blood oxidative stress status (assessed via PrOOH, MDA, and TAC) and the pro-inflammatory status (assessed via IL-2). Due to the novelty of this work in relation to aerobic dance and oxidative stress, the present study design did not include random assignment to an exercise or no-exercise control condition. Rather, we measured all variables in a short period within all subjects for control evaluated and compared between pre and post intervention values, with all subjects participating in the aerobic dance exercise program.
Methods This study was conducted over a 7-week period (one week of baseline testing and a 6-week intervention) with 24 sedentary women who volunteered and were asked to maintain their usual diet and family behavior during the entire period. The exception was the inclusion of a 6-week aerobic dance exercise program performed by all subjects, in the evening of 3 days per week for 50 min each day (30 min excluding warm up and cool down). The aerobic dance was performed “Thai” style, which is done in an open field while following a dance instructor on a stage. Physical performance (VO2max and maximal running time until exhaustion), oxidative stress status (protein hydroperoxide [PrOOH], malondialdehyde [MDA], total anti-oxidant capacity [TAC]), and interleukin-2 [IL-2] were evaluated twice within the control period (day 1 and day 8) and once within the day after the completion of the 6-week aerobic dance program. All study procedures were approved by the Ethics Committee at the Faculty of Associated Medical Sciences, Chiang Mai University, Thailand and were performed in accordance with the Helsinki Declaration (2001). All subjects provided written consent before enrolling in the study.
Subjects and physical characteristics Twenty-four Thai sedentary women in Chiang Mai province were included in the study. All subjects performed either irregular exercise (<3 times per week) or no formal exercise. Their illness history related to heart, musculoskeletal, lung or nervous dysfunction was completed from medical charts within six weeks from hospital records. Moreover, screening of health status with a complete blood count (CBC) test was obtained on all subjects before enrolling.
Aerobic dance protocol The aerobic dance exercise protocol was composed of 10 min of warm up with 7 patterns (A.1eA.7), 30 min of aerobic dance with 24 patterns (B.1eB.24), and 10 min of 7
Exercise physiology
357
Figure 1 42 Aerobic patterns in the 4 stages composed of 7 warm up (A), 24 aerobic (B), 7 cool down stage (C), and 4 relaxation with breathing stages (D).
cool down patterns liked in the warm up stage and 4 relaxation with breathing patterns (D.1eD.4) (Fig. 1). A professional dancer led the aerobic dance program from a stage in front of the subjects and the protocol was choreographed to music. The optimal music for dance instruction was chosen by a previous pilot experiment that worked in sampling of 5 sedentary women and dancing with various songs until their heart rate was between 65% and 85% of maximal heart rate, detected with a Polar heart rate
monitoring device (Polar Electro Inc. Lake Success, NY, USA). The dancing protocol was composed of 44 patterns and performed within 30 min, including 10 min each of warm up and cool down.
Physical performance test Physical performance was evaluated during the baseline week, as well as at the completion of the aerobic dance
358
D. Leelarungrayub et al.
Figure 1 (continued)
Exercise physiology intervention. Heart rate monitoring was recorded by a Polar F11 Watch. Each subject completed a maximal running time until exhaustion on a motorized treadmill using the modified Bruce protocol (ACSM’s guideline, 2000). As per ACSM guidelines, subjects were first familiarized with the treadmill and protocol. The test was terminated when subjects reached their maximal age predicted heart rate or a rating of perceived exertion (RPE). VO2max was estimated using an indirect method based on exercise time until obtaining maximal heart rate or an RPE of 15/20, as previously described (Pollock et al., 1987).
Blood sampling Ten milliliters of whole blood was collected in EDTA-anticoagulant tubes. Plasma was separated by centrifugation at 3000 rpm for 5 min and used for the measurement of the oxidative stress markers; malondialdehyde (MDA), protein hydroperoxide (PrOOH), total anti-oxidant capacity (TAC), and Interleukin-2.
Malondialdehyde assay The protocol was following Leelarungrayub’s protocol (Leelarungrayub et al., 2004). 250 ml of plasma was mixed with 750 ml of ortho-phosphoric acid (2.5%, v:v) and vortexed. Then, 500 ml of Thiobarbituric acid (TBA) (0.2 mol/L) in Tris solution (0.14 mol/L) was added. After incubation in a water bath (90 C) for 30 min, all samples were cooled and centrifuged at 10 000 rpm for 3 min. A clear pink color of supernatant was read with a spectrophotometer at 532 nm. The yield of MDA in the sample was calculated by comparing with the absorbance of standard Tetramethoxypropane (TMP) (Sigma) (0e50 mmol/L).
Protein hydroperoxide assay The protocol was modified from that of Gay and Gebicki (2003). Plasma protein at 200 ml was precipitated with 0.5 mol/L perchloric acid (PCA) and resolved with 700 ml of guanidine hydrochloride (GuHCL) (6 mol/L). Then, 40 ml of 0.2 mol/L of perchloric acid, 25 ml of xylenol orange (5 mmol/L), and 10 ml of ferrous solution (5 mmol/L) were added. The whole mixture was left in the dark for 30 min before being centrifuged at 10 000 rpm for 3 min. The yellow supernatant was read for absorbance at 560 nm. The level of protein hydroperoxide was calculated by comparing with the standard tert-butyl hydroperoxide (0e10 mmol/L).
359 cuvette (size 1.5 ml), and gently shaken 9 times before adding again in the spectrophotometer. Decreased absorbance was recorded continuously every 1 min for 3 min, and finally calculated to DA/min. Total anti-oxidant capacity (TAC) of plasma was calculated by comparing with the DA/ min of standard Trolox (0e10 mmol/L) at 0.1.
Interleukin-2 assay The method of determination of IL-2 in plasma was done by following the guidelines in a Quantikine, Human IL-2 Immunoassay (Quantikine, R&D systems, Inc, Minneapolis, MN, U.S.A, 2008). 100 ml of plasma and 50 ml of external standard IL-2 (50 pg/ml) were loaded onto the anti-IL-2 polyclonal antibody-immobilized solid phase and incubated for 2 h at room temperature. After being washed 3 times with wash buffer at 400 ml, 200 ml of horseradish peroxidase (HRP) conjugated IL-2 was added in each well then incubated for 2 h at room temperature. All solution in each well was then aspirated and washed with wash buffer for 3 times before adding the 400 ml of substrate (Tetramethyl benzidine; TMB) and incubating for 20 min at room temperature to develop a color product. Finally, 50 ml of stop solution (2 N sulfuric acid) was added, the blue color changed to yellow and the absorbent detected at 450 nm within 30 min. The concentration of IL-2 in plasma was calculated by comparing to the standard curve of standard IL-2 (31.2e2000 pg/ml).
Statistical analysis Each variable was represented in a mean, standard deviation or mean (SD). Statistic analyzed across the three measurement times (day 1, day 8, and after the 6 week intervention) with a repeated measurement design and Post-Hoc (Tukey) test with an SPSS (Version.10) program was used. The level of statistical significance was set at 0.05 for all tests.
Results Characteristics of the subjects are presented in Table 1. All of the subjects, the CBC results showed values within normal levels (7.78, 2.78 103 cc.mm in WBC, 15.6, 3.56 g/ dl in Hb, 46.34, 1.56% in Hct, 242.56, 45.232 105 in Plt, 51.43, 6.23% in Neutrophil, 30.45, 6.34% in lymphocyte, 2.34, 2.34% in monocyte, and 0.56, 0.23% in Basophil respectively).
Total anti-oxidant capacity (TAC) assay Total anti-oxidant capacity of fresh plasma was assayed with ABTs cation radical decolorization (Re et al., 1999). Stock ABTs cation radical was produced by mixing a 2,20 azino-bis(3-ethylbenzthiazoline-6-sulphonic acid) (ABTS) (14 mmol/L) and potassium persulfate (14 mmol/L) together and stored in the dark overnight. Working ABTs cation radical was diluted from stock ABTs with deinoized water until the absorbance at 734 nm was within 0.68e0.72 before adding plasma. The 10 ml of plasma was added to 990 ml of working solution ABTs cation radical in a plastic
Table 1 Characteristic of 24 females before exercise with aerobic dance. Variables
Mean, S.D.(MineMax)
Age (Years) Height (centimeters) Weight (Kilograms) Body mass index (Kg/m2) Resting heart rate (beats per minute)
44.2, 6.5 154.3, 5.3 58.0, 7.8 24.3, 3.3 79.2, 11.7
(30e55) (150e170) (46e71) (20.18e35.11) (56e101)
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Physical performance
program on the physical performance and oxidative stress markers (including IL-2) on a group of middle-aged previously sedentary Thai women. The results clearly showed the benefits of aerobic dance in terms of improved cardiopulmonary endurance, as well as specific oxidative stress markers (MDA and TAC) and IL-2. The moderate intensity exercise of our aerobic dance protocol places demands on both the aerobic and anaerobic glycolytic energy system (Wvon et al., 2004). Thus the results showed that the maximal running time until exhaustion was significantly improved (from 7.59, 1.52 to 9.31, 1.44 min), demonstrating an increase in lower extremity muscular endurance. These findings concur with the results of (Hui et al., 2009) which showed that regular dancing in older persons significantly improved their 6-min timed walking test and lower limb endurance. In addition to running time, based on the maximal heart rate achieved during the modified Bruce protocol, there was a significant increase in the estimated VO2max (from 29.1,6.6 to 36.9, 5.6 ml/kg/ min). While the above data may be of interest from a fitness point of view, by our own admission, our neglect to measure expired gases during the exercise test for purposes of aerobic power measurement is indeed a limitation of this work. However, our main objective of the present study was not to confirm the improvement in aerobic capacity of aerobic dance, but rather to measure blood oxidative stress and IL-2 levels before and following such exercise. In regards to this focal point, there was a significant reduction of MDA (from 2.28, 0.19 to 0.98, 0.22 mmol/L) and an improvement in the TAC (from 1.31, 0.08 to 2.58, 0.07 mmol Trolox/L). Many studies have previously examined the effects of acute or prolonged heavy intensity exercise with resulting high levels of MDA and lower TAC threshold compared to a baseline period (Hoffman et al., 2007). But in the present study, the intensity of exercise was moderate (75% of MHR; mean HR Z 149.4 (5.6) beats per min) and achieved with a moderate aerobic dance cadence of 70 steps per min for 30 min. It is possible that
Data collected during the baseline week, prior to the intervention period (days 1 and 8) demonstrated that there was not statistically significant variation in any of the physical performance variables assessed (p > 0.05). The estimated VO2max based on the maximal heart rate achieved during the modified Bruce protocol significantly increased from pre to post intervention, as did the maximal running time (p < 0.05; Table 2). Specifically, dance exercise resulted in a significant improvement in VO2max for all subjects (36.9, 5.6 ml/kg/min) compared to pre-intervention (27.8, 9.6 or 29.1, 6.6 ml/kg/min), as well as a significant improvement in maximal time of running until exhaustion (9.31, 1.30 min) compared to pre-intervention (7.23, 2.19 or 7.59, 1.52 min) (Table 2).
Oxidative stress, anti-oxidant status, and IL-2 Data collected during the baseline week (Table 2), prior to the intervention period (days 1 and 8) demonstrated that there was not statistically significant variation in any of the assayed variables: MDA (2.32, 0.62 and 2.28, 0.58 mmol/L), PrOOH (2.11, 0.62 and 1.99, 0.53 mmol/L), and TAC (1.23, 0.54 and 1.31, 0.58 mmol Trolox/L). However, following the 6 weeks of aerobic dance exercise, the results showed significantly lower oxidative stress as measured by MDA (0.98, 0.22 mmol/L) (p < 0.05), in addition to higher TAC (2.58, 0.65 mmol Trolox/ L) (p < 0.05). PrOOH did not significantly change (2.05, 0.74 mmol/L) (p > 0.05). The data also demonstrated a significant increase in IL-2 from 1.98 (0.82) pg/mL(day 1) and 2.01 (0.68) pg/mL (day 8) during the baseline week, to 3.95 (1.77) pg/mL after 6 weeks of aerobic dance (p < 0.05).
Discussion The purpose of this study was to determine the effects of a 6-week moderate intensity aerobic dance exercise Table 2
All variables at baseline before exercise and post-exercise for 6 weeks.
Variables
Before-exercise (day) Mean (S.D) (MineMax) 0
Max running time (minute) VO2max (ml/kg/min) MDA (mmol/L) PrOOH (mmol/L) TAC (mmol Trolox/L) IL-2 (pg/mL)
7.23 (2.19) (3.20e11.00) 27.8 (9.6) (10.2e44.3) 2.28 (0.58) (1.23e3.23) 1.99 (0.53) (1.11e3.21) 1.31 (0.58) (0.45e2.23) 1.98 (0.82) (0.56e3.56)
Post-exercise Mean (S.D) (MineMax) 8
(6 wk) a
7.59 (1.52) (0.85) (4.80e11.14) 29.1 (6.6) (0.84)a (15.3e44.9) 2.32 (0.62) (0.99)a (1.01e3.45) 2.11 (0.62) (0.76)a (0.98e3.23) 1.23 (0.54) (0.92)a (0.25e2.12) 2.01(0.68) (0.99)a (0.72e3.13)
9.31 (1.30) (0.001)a (0.005)b (6.38e12.49) 36.9 (5.6) (0.001)a (0.006)b (24.0e50.8) 0.98 (0.22) (<0.001)a (<0.001)b (0.23e1.67) 2.05 (0.74) (0.998)a ((0.805)b (1.88e3.25) 2.58 (0.65) (<0.001)a (<0.001)b (1.11e3.24) 3.95 (1.77) (<0.001)a (<0.001)b (2.12e6.55)
MDA Z Malondialdehyde, PrOOH Z Protein hydroperoxide, TAC Z Total anti-oxidant capacity, and IL-2 Z Interleukin-2 a Compared to at day 0, and b Compared to at day 8 of before exercise by Repeated measurement and a Post hoc (Tukey) analysis.
Exercise physiology our chosen protocol was of high enough intensity to allow for systemic adaptations to the anti-oxidant defense system, while low enough not to grossly upset the delicate balance between anti- and pro-oxidants in favor of increased oxidative stress. Antioxidants in plasma are composed of water- or lipidsoluble vitamins, uric acid, albumin, plasma-soluble enzymes (e.g., glutathione peroxidase [GPX] and superoxide dismutase [SOD]). In addition there are intracellular antioxidants and anti-oxidant enzymes such as SOD, catalase, glutathione reductase and GPX (Cazzola et al., 2003). This study demonstrated a significant increase in TAC, as well as in IL-2 after 6 weeks of moderate intensity aerobic dance. While TAC is generally used to represent the collective or “total” anti-oxidant contribution, IL-2 is classified as a type 1 cytokine and plays an important function in both intra- and extracellular infection (Ibfelt et al., 2002) by the regulation of growth and function of cells that are involved in both cell-mediated and humoral immune systems (Smith, 1984: Balkwill, 1991). Besides increasing in response to an exercise stimulus, increased IL-2 levels are present in patients presenting with high serum LDL, in those who smoke, or in those with infection (Frostegard et al., 1992). The magnitude of increase in IL-2 levels noted in our study is similar to that of prior work with both elderly and young women engaged in long-term moderate physical training (Drela et al., 2004). The 6-weeks of moderate intensity aerobic dance completed in this study was of long enough duration to increase IL-2 production, which appears related to T-cell proliferation and the restoration of native T-cells in the circulation and this T-cell proliferation increases the antiinfection activity and thereby enhances the immune system (Sureda et al., 2005). In addition, increased IL-2 levels have also been reported to be related to the increase in the NKcell count when prolonged interval exercise at moderate intensity is performed (Rhind et al., 1996). Thus inducing the IL-2 expression may be best when exercise is of longer duration (45e60 min) (Giraldo et al., 2009). This study demonstrated the potential benefits of a moderate intensity aerobic exercise dance program that was 6 weeks in length, in a sample of middle-aged previously sedentary Thai women. In addition to the anticipated improvements in physical performance, we noted a significant decrease in lipid peroxidation as measured by MDA, an increase in total anti-oxidant status, and an increase in IL-2 levels. Based on previous evidence, it is possible that all of our findings may be associated with health improvements over time. Thus exercise with aerobic dance should be promoted and enhanced in other groups either female or male without any adverse effects like anti-oxidant and modulated immunity function in the body. However, it must be noted that as a pilot study, this work was performed using a small group of middle-aged Thai women who were very interested and participated in this study and without the inclusion of a control group. Because of our design hypothesis was assumed not to change variables in a short time of study. But, based on our positive findings, larger intervention trials, inclusive of a no-exercise control group and the inclusion of multiple biomarkers of anti-oxidant status, oxidative stress, and cellular immunity are warranted.
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Acknowledgement We thank the Health Promotion Thailand for the support of this research. We also thank the many volunteers that followed the program with success.
References ACSM’s Guidelines for Exercise Testing and Prescription, 2000. Lippincott Williams & Wilkins, Philadelphia, pp. 22e32. Balkwill, F.R., 1991. Cytokines: A Practical Approach. Oxford University Press, New York, p. 309, 330. Banfi, G., Malavazos, A., Iorio, E., et al., 2006. Plasma oxidative stress biomarkers, nitric oxide and heat shock protein 70 in trained elite soccer players. Eur. J. Appl. Physiol. 96, 483e486. Bloomer, R.J., Davis, P.G., Consitt, L.A., Wideman, L., 2007. Plasma protein carbonyl response to increasing exercise duration in aerobically trained men and women. Int. J. Sports Med. 28, 21e25. Bloomer, R.J., 2008. Effect of exercise on oxidative stress biomarkers. Adv. Clin. Chem. 46, 1e50. Cazzola, R., Russo-Volpe, S., Cervato, G., Cestaro, B., 2003. Biochemical assessment of oxidative stress, erythrocyte membrane fluidity and antioxidant status in professional soccer player and sedentary controls. Eur. J. Clin. Invest. 33, 924e930. Copeland, B.L., Franks, B.D., 1991. Effects of types and intensities of background music on treadmill endurance. J. Sports Med. Phys. Fitness 31, 100e103. Drela, N., Kozdron, E., Szczypiorski, P., 2004. Moderate exercise may attenuate some aspects of imunosenescence. BMC Geriatr. 4, 8. Declaration of Helsinki, 2001. World medical assoicated declaration of Helsinki. Ethical principles for medical research involving human subjects. Bull. World Health Organ. 79, 373e374. Fisher-Wellman, K., Bloomer, R.J., 2009. Acute exercise and oxidative stress: a 30 year history. Dyn. Med. 8, 1. Frostegard, J., Wu, R., Giscombe, R., Holm, G., Lefvert, A.K., Nilsson, J., 1992. Induction of T-cell activation by oxidized low density lipoprotein. Arterioscler Thromb. 12, 461e467. Gay, C., Gebicki, J.M., 2003. Measurement of protein and lipid hydroperoxides in biological systems by the ferric-xylenol orange method. Anal. Biochem. 315, 29e35. Giraldo, E., Garcia, J.J., Hinchado, M.D., Ortega, E., 2009. Exercise intensity-dependent changes in the inflammatory response in sedentary women: role of neuroendocrine parameters in the neutrophil phagocytic process and the pro-/anti-inflammatory cytokine balance. Neuroimmunomodulation 16, 237e244. Hoffman, J.R., Im, J., Kang, J., Maresh, C.M., Kraemer, W.J., Frence, D., Nioka, S., Kime, R., Rundell, K.W., Tatmess, N.A., Faigenbaum, A.D., Chance, B., 2007. Comparison of low- and high-intensity resistance exercise on lipid peroxidation: role of muscle oxygenation. J. Strength Cond. Res. 1, 118e122. Hopkins, D.R., Murrah, B., Hoeger, W.W., Rhodes, R.C., 1990. Effect of low-impact aerobic dance on the functional fitness of elderly women. Gerontologist 30, 189e192. Hui, E., Chui, T.B., Woo, J., 2009. Effects of dance on physical and psychological well-being in older persons. Arch. Gerontol. Geriatr. 49, e45ee50. Ibfelt, T., Petersen, R.W., Bruunsgaard, H., Sandmand, M., Pedersen, B.K., 2002. Exercise-induced change in type 1 cytokine-producing CD8þ T cells is related to a decrease in memory T cells. J. Appl. Physiol. 93, 645e648. Leelarungrayub, N., Chanarat, N., Rattanapanone, V., 2004. Potential activity of Thai shallot (Allium ascalonicum L.) extract on the prevention of hemolysis and glutathione
362 depletion in human erythrocyte from oxidative stress. CMU J. 3, 225e234. Nielsen, H.B., 2003. Lymphocytes responses to maximal exercise: a physiological perspective. Sports Med. 33, 853e867. Pedersen, B.K., Hoffman-Goetz, L., 2000. Exercise and the immune system: regulation, integration, and adaptation. Physiol. Rev. 80, 1055e1081. Radak, Z., Chung, H.Y., Koltai, E., Taylor, A.W., Goto, S., 2008. Exercise, oxidative stress and hormesis. Ageing Res. Rev. 7, 34e42. Re, R., Pellegrini, N., Proteggente, A., Pannala, A., Yand, M., RiceEvans, C., 1999. Antioxidant activity applying an improved ABTS radical cation decolorization assay. Free Radic. Biol. Med. 26, 1231e1237. Rhind, S.G., Shek, P.N., Shinkai, S., Shephard, R.J., 1996. Effects of moderate endurance exercise and training on in vitro lymphocyte proliferation, interleukin-2 (IL-2) production and IL2 receptor expression. Eur. J. Appl. Physiol. Occup. Physiol. 74, 348e360.
D. Leelarungrayub et al. Quindry, J.C., Stone, W.L., King, J., Broeder, C.E., 2003. The effects of acute exercise on neutrophils and plasma oxidative stress. Med. Sci. Sports Exerc. 35, 1139e1145. Shigematsu, R., Chang, M., Yabushita, N., Sakai, T., Bakagaichi, M., Nho, H., Tanaka, K., 2002. Dance-based aerobic exercise may improve indices of falling risk in older women. Age Ageing 31, 261e266. Smith, K.A., 1984. Interleukin-2. Annu. Rev. Immunol. 2, 319e335. Sureda, A., Tauler, P., Aguilo, A., et al., 2005. Relation between oxidative stress markers and antioxidant endogenous defenses during exhaustive exercise. Free Radic. Res. 39, 1317e1324. Williford, H.N., Scharff-Olson, M., Blessing, D.L., 1989. The physiological effects of aerobic dance. Sports Med. 8, 335e345. Wvon, M.A., Abt, G., Redding, E., Head, A., Sharp, N.C., 2004. Oxygen uptake during modern dance class, rehearsal, and performance. J. Strength Cond. Res. 18, 646e649. Pollock, M.L., Foster, C., Knapp, D., Rod, J.L., Schmidt, D.H., 1987. Effect of age and training on aerobic capacity and body composition of master athletes. J. Appl. Physiol. 62, 725e731.
Journal of Bodywork & Movement Therapies (2011) 15, 363e374
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TOPICAL ANALGESIA
The effect of cetylated fatty esters and physical therapy on myofascial pain syndrome of the neck Deepak Sharan, MS (Ortho.), DNB (Ortho.), M Sc (Ortho. Eng), Dip (Ortho. & Rehab.) a,*, Biju Nirmal Jacob, BPT, MPT (Ortho.) a, PS Ajeesh, BPT, MPT (Ortho.) a, Jack B. Bookout, PhD, SI (ASCP), BCLD b, Raj R. Barathur, PhD, MS (Genetics), FABMG b a RECOUP Neuromusculoskeletal Rehabilitation Centre, 312, 80 Feet Road, Further Extension of Anjanapura Layout, 10th Block, Bangalore 560062, Karnataka, India b Cymbiotics, Inc, 29268 Meadow Glen Way, West, Escondido, CA 92026, USA
Received 16 September 2009; received in revised form 9 December 2009; accepted 7 February 2010
KEYWORDS Myofascial pain syndrome; Topical analgesic; Cetylated fatty ester complex; Myofascial release; Physical therapy
Summary Participants with Myofascial Pain Syndrome (MPS) of the neck were randomly assigned into 2 groups of the double-blinded study: topical cetylated fatty ester complex (CFEC) cream application plus physical therapy (CF-PT; n Z 37), and placebo cream application plus physical therapy (PL-PT; n Z 35). There were 3 visits during 4 weeks of treatment. Physical Therapy (PT), given twice/week, included Ischaemic Compression, Deep Pressure Trigger Point Massage and Myofascial Releases. Topical cream [CFEC cream (5.6%) and 1.5% menthol] or placebo cream [1.5% menthol, in a cream base] was applied twice/day. CF-PT provided the fastest and most effective study treatment modality. The addition of CFEC cream to PT resulted in statistically significant improvements, compared to PL-PT, for reduction of pain, neck disability and life quality indicators. Our results indicate that cetylated derivatives of fatty acids can effectively reduce pain and symptoms associated with neck MPS, when combined with physical therapy. ª 2010 Elsevier Ltd. All rights reserved.
Introduction * Corresponding author. Dept. of Orthopaedics and Rehabilitation, RECOUP Neuromusculoskeletal Rehabilitation Centre, 312, 80 Feet Road, Further Extension of Anjanapura Layout, 10th Block, Bangalore 560062, Karnataka, India. Tel.: þ91 80 64504224; fax: þ91 80 64504334. E-mail address:
[email protected] (D. Sharan).
Myofascial Pain Syndrome (MPS) is one of the most common, non-articular forms of musculoskeletal pain (Fricton, 1989; Shah et al., 2008). In a chronic pain centre 85% of 283 consecutive patients received a primary diagnosis of MPS (Fishbain et al., 1986). MPS is associated with ‘‘hyperirritable spots’’ or ‘‘trigger points’’ (MTrPs) within palpable taut bands
1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.02.004
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of skeletal muscle or fascia that are painful on compression. These can give rise to characteristic referred pain, tenderness, and autonomic nervous system symptoms (Simons 1995; Simons et al., 1999). Muscles with active MTrPs are more tender and mechanically sensitive than normal muscle, which do not contain MTrPs (Shah and Gilliams, 2008; Simons et al., 1999). Furthermore, MTrPs in the trapezius has been proposed as the main cause of temporal headache (Wolfe et al., 1992), cervicogenic headaches, and neck pain (Simons, 1995; Grosshandler et al.,1985; Gerwin et al., 2004). Of numerous treatment approaches, physical therapy (PT), including Ischaemic Compression and Myofascial Release, currently provides the most promise and symptomatic improvement (Simons et al., 1999; Hou et al., 2002). MTrP Injections (with or without local anaesthetics), spray and stretch and TENS have all shown benefit, while less stimulatory interventions, such as laser and ultrasound, have not convincingly been shown to be beneficial (Huguenin, 2004). Other treatments include osteopathy, yoga, acupuncture, EMG biofeedback and cognitive behavioural therapy (Hong, 2002; Maigne, 1996; Frobb, 2003). Many treatments in widespread use are poorly validated and not necessarily more effective than placebo (Huguenin, 2004). Pharmacological treatment includes nonsteroidal antiinflammatory agents (NSAIDs), steroids, analgesics, and antidepressants (Simons et al., 1999) but significant side effects raise concern about long term use. Botulinum Toxin injection to the MTrPs has been used to reduce muscle activity. An early pilot trial showed a modest pain reduction (Cheshire et al., 1994), but a subsequent trial found no significant therapeutic efficacy (Qerama et al., 1996), while another study found that 17% had moderate to severe side effects, which included impaired motor function and muscle atrophy (Yue, 1995). In 2001, a new formulation containing Cetylated fatty ester complex (CFEC; also known as Esterified fatty ester complex or EFAC) began to be used for arthritic and sports injury-related conditions. The underlying mechanisms of action were apparently associated with reduction of inflammation and cytokine activities (Perez-Jimenez et al., 1999; Hesslink et al., 2002; Diehl and May, 1994; Kraemer et al., 2004, 2005a,b). Fatty acids may induce changes in membrane fluidity, antibody and cytokine production (Grimble and Tappia, 1988), adhesion molecule expression (De Caterina et al., 2000) and signal transduction pathways, suppress leukocyte function (Kremer, 1996; James et al., 2000), trigger apoptosis (Heraud et al., 2000) and, like NSAIDs, reduce production of prostaglandins and leukotrienes (De Caterina et al., 2000; Kremer, 2000). Cetylated fatty acids reduce pain and stiffness, while increasing flexibility and range of motion for arthritic patients (Cochran and Dent, 1997; Siemandi, 1997; Hesslink et al., 2002; Kraemer et al., 2004, 2005a,b; Stammers et al., 1992). This study evaluated the effects of CFEC topical treatment with PT on patients with MPS of the neck.
Neuromusculoskeletal Rehabilitation Centre in Bangalore, India. Males and females (age, 18e65 years) were selected having MPS of the neck for at least 2 weeks duration with 2 MTrPs in any one or more of the following: trapezius, sternocleidomastoid, anterior scalene, suboccipital or levator scapulae muscles. The diagnosis of MPS was made by an Orthopaedic/Rehabilitation Specialist (>10 years experience treating MPS) using the Simons Criteria (Simons et al., 1999), that required 5 major and at least 1 of 4 minor criteria to be satisfied.
Methods
Study design
Study population
The participants, given coded designations, were randomly assigned into two groups: a) topical CFEC cream application plus physical therapy (CF-PT; n Z 37), and b) placebo cream application plus physical therapy (PL-PT; n Z 35).
A total of 74 participants were recruited as volunteers into the study, which was conducted at 8 sites of the RECOUP
Major criteria: 1. Localised spontaneous pain. 2. Spontaneous pain or altered sensations in expected referred pain area for given MTrP 3. Taut, palpable band in accessible muscle. 4. Exquisite, localised tenderness in precise point along taut band 5. Some measurable reduced movement range. Minor criteria: 1. Reproduction of spontaneously perceived pain and altered sensations by pressure on MTrP. 2. Elicitation of local twitch response of muscular fibers by transverse ‘‘snapping’’ palpation or by needle insertion into MTrP. 3. Pain relief obtained by muscle stretching or injection of MTrP. 4. Electromyographic demonstration of spontaneous electrical activity characteristic of active loci in the tender nodule of a taut band. Study duration including recruitment was seven months. 61 males and 11 females, ages 19e51, were selected (study retention rate Z 98.2%). About 60% of patients in each group in this study had chronic conditions (lasting more than 3 months). Exclusion criteria a) Pregnancy or possible pregnancy during study, b) fibromyalgia, whiplash injury, degenerative or inflammatory arthritis of cervical areas, cervical radiculopathy or myelopathy, c) those having myofascial therapy or spinal manipulative therapy during past month, d) persons with articular instability or vertebrobasilar insufficiency, e) those allergic to topical cream components, f) individuals using immunosuppressive agents (DMARDs) and g) those taking NSAIDs or muscle relaxants and unwilling to give up for the study period plus 3 day pre-trial washout period. The IECR Board approved both protocol and informed consent. Prior to study, subjects were informed of study and treatments, and then signed a written consent form. This study adhered to principals of the Helsinki Declaration and its amendments in conformity with GCP principles.
Effect of cetylated fatty esters and physical therapy Assignments were made from a randomised list compiled prior to recruitment. Code assignments were not broken until after participants’ results were obtained. Based on assigned code, medications were given to all participants who were asked to apply it liberally to affected areas twice a day. All participants were shown how to apply and were queried at each session as to the success of compliance with applications. Compliance with only occasional miss of an application was estimated at 90%. Dose administration was regulated through amount of cream provided for participant use. Physical therapy was administered to all through a sequenced protocol including, after evaluation: a) ischaemic compression (90e120 s) followed by a deep pressure soft tissue TrP massage to inactivate MTrPs, then b) myofascial release technique, which is a therapeutic treatment that uses gentle pressure and stretching to facilitate the release of fascial restrictions caused by accidents, injury, stress, repetitive use and traumatic or surgical scarring (LeBauer et al., 2008). Muscle energy techniques, articular mobilisations and neural mobilisations were also used subsequently, where required. Self stretching, relaxation and breathing exercises, ergonomics training and postural correction were also performed, followed by strength training and aerobic conditioning. A total of eight sessions of PT (2 sessions per week; 45 min/session) were given.
Topical treatments CFEC cream formulation contained 8 cetylated fatty esters (5.6% w/w; decanoate, laurate, myristate, myristoleate, oleate, palmitate, palmitoleate and stearate) and 1.5% w/ w menthol in a cream base (pH 6.5). Placebo cream had the same composition but without cetylated fatty esters. Tubes were marked similarly.
Study assessments The study period (4 weeks) included 3 visits used to collect group and individual data. Planned visits (v1-3; week 0 or baseline, week 2 and week 4) were scheduled not to conflict with therapy. Information was collected for each visit by the therapist (symptoms, weight, BP, temperature, pulse and respiratory rate). The primary efficacy measures were changes from baseline week through final week of therapy in average Neck Disability Index (NDI; modified version of the Oswestry Low Back Pain Questionnaire; Vernon and Mior, 1991) and in the Neck Pain and Disability Visual Analogue Scale (NPDVAS; Wheeler et al., 1998; Carlsson, 1983). Secondary measures included algometer readings for each TrP, Cervical Range of Motion measurements (CROM), tenderness to palpation and written participant responses to the 36-item short-form health survey (SF36; Ware and Sherbourne, 1992). The Neck Disability Index (NDI) e 60 question functional outcome tool assessing neck related disability and disability due to neck pain with everyday activities. Sections evaluated pain intensity, personal care, lifting, reading, headaches, concentration, work, driving, sleeping and recreation. For each category a 0e4 NDI indicated no disability while 35e50 NDI (50 is maximum) indicated complete disability.
365 The Neck Pain and Disability Visual Analogue Scale (NPDVAS) e measured disability related to pain in everyday life activities and functional limitations of the neck. 20 assessment questions used 10 cm visual analogue scales (VAS) to evaluate pain in 4 underlying dimensions: dysfunctional or disabling neck problems, pain intensity, affective aspects, and life activity interferences. Maximum score of 100 Z most severe. Test reliability with retest reliability coefficient Z 0.93 under controlled conditions (Wheeler et al., 1999). The Algometer Pain Test (from Wagner Instruments, USA) was performed upon prone subjects with TrP areas exposed. Pressure was applied perpendicularly and gradually through an algometer (1.0 cm2 tip) at each palpated point. When subject verbally cued pain onset the pressure level was noted. An unaffected contra-lateral side or midline test served as control. Test sites were marked by pen for future reference. Palpation (0 Z none, 1 Z minimal, 2 Z moderate, 3 Z severe discomfort with minimal pressure) of the major MTrP was assessed prior to algometer testing. The CROM Instrument measured degrees of rotation, flexion, extension, and lateral bending. The 36-item Short-Form Health Questionnaire (SF36) e assessed the health-related quality of life (HRQOL) effects of MPS on 8 QOL domains: bodily pain, physical functioning, role limitations due to physical problems, mental health, vitality, social functioning, role limitations due to emotional problems and general health. Scoring yielded values 0e100, with greater values representing greater QOL. A composite SF36 Index (8 domain total) was used to provide an overview as to the combined effects of all domains on QOL. This was done by summing individual domain scores, adjusted into a 0e100 scale. Laboratory tests (complete blood counts and erythrocyte sedimentation rates) and radiographs of Cervical Spine (AP and Lateral views) were taken initially to rule out degenerative or inflammatory conditions of cervical spine and assess health. Throughout the study, adverse events were monitored and reported, denoting seriousness, severity, action taken and relationship to study drug.
Statistical analysis The questionnaire responses were analysed, assuming continuous data and an ordinal logistic regression, which estimates cumulative probability of being at or below each individual response level. All statistics were 2 tailed and significance was set at p < 0.05. Response differences within a group were evaluated by one way analysis of variance (ANOVA) with repeated visit measures. For comparisons between groups and for differences within groups at different visits, the nonparametric ManneWhitney U Statistic Test for non-matched groups was used. For NPDVAS, palpation and NDI, % ImprovementðRelative Change from baselineÞ Zð1 ðMeanVisit n =Meanweek 0 ÞÞ 100: For Algometer Readings, SF36 Indices and CROM measurements,
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%ImprovementZððMeanVisit n =Meanweek 0 Þ 1Þ 100; where n Z visit number and week 0 Z visit 1. A minimum estimated sample size for desired study results was 19.27 based on: h . i2 NZ Za ðp0 ð1 p0 ÞÞ½ þZb ðp1 ð1 p1 ÞÞ½ ðp1 p0 Þ where: N: Required sample size; Za: Z for two-sided alpha value of 0.05 (1.960); Zb: Z for beta level of 0.20e0.80 power (0.842); p0: Patient Proportion expected to have better response to placebo under null hypothesis (0.50); p1: Expected patient proportion with better response to treatment (0.80).
Results Table 1 depicts demographics for each group. Each group composition in regards to sex, and average age, weight and body mass index was relatively similar [for height (p > 0.82), BMI (p > 0.30), weight (p > 0.33) and age (p > 0.10)]. Scoring results at time of recruitment indicated that there was no significant difference between groups in regards to NPDVAS, and the mean measures would be categorised as moderate to severe neck pain.
Changes in neck disability with treatment NDI The primary efficacy measure showed that both treatment methods resulted in decreases in disability (Figure 1 and Table 2). At Week 0 (V1), mean NDIs of both groups were sufficiently high to be categorised as ‘‘complete disability’’ (CF-PT, 38.37; PL-PT, 36.24). By last visit, only CF-PT efficacy outcome was significant (p < 0.001) from baseline visit, indicating disability reductions due to treatment. While improvements were noted in the PL-PT group compared to baseline (by week 4, the mean index value improved to ‘‘severe’’), the changes were insignificant. By last visit, CFPT treatment values were statistically significant compared to PL-PT group (p < 0.001). Mean NDI decreased two categories for the CF-PT group (18.8 Z moderate disability) and one category for PL-PT (30.5).
Pain responses of test populations NPDVAS analysis The second primary efficacy measure showed that both treatments resulted in significant improvements from baseline for week 2 and week 4. The baseline average scores Table 1
(standard deviation) for PL-PT and CF-PT were high, 47.3 7.2 and 46.3 10.9, respectively, but not significantly different (Table 2). Improvement by both groups was progressive throughout study. NPDVAS results were significantly different from baseline for both groups by 2nd visit. However, most improvements observed were with CF-PT, which were also significantly different from PL-PT treatment by 2nd and 3rd visit. Treatment effects are shown in Figure 2. Algometer and palpation responses Both average algometer pain thresholds at the major MTrPs and palpation tenderness are given in Table 3. TrP readings show a greater sensitivity to pain than that of selected control regions. For both treatments, sensitivity decreased over the 4 week period but still maintained a lower threshold than that of control regions (average control threshold for all groups was 5.37 0.17; no significant difference between groups). Palpations, performed on the major TrP (TrP1; usually in the trapezius muscle), confirmed tenderness in that area. PT provided increasing reductions in tenderness to palpation throughout the study, but with lack of notable additive effects for CF-PT. SF36 body pain index A subcategory of the SF36 Survey also provides participant feedback on effects of treatment on pain experienced. The SF36 body pain index indicated that participant pain was reduced over the treatment period by both the treatments. As shown (Table 4), average response/group suggested that CF-PT provided better and statistically significant pain management.
Changes in cervical spine range of motion with treatment Both treatment groups increased the average range of motion (Table 3) but the greatest increases were in the areas of extension and flexion. For total rotation and total lateral movement, there were no significant differences between treatments; however, for flexion plus extension, CF-PT provided the greatest increases in movement, significant from that of PL-PT. Otherwise, CFEC topical treatment did not appear to have an additive effect on CROM changes beyond that of PT. The results for total CROM are shown graphically in Figure 3.
Disability-related quality of life e SF36 health survey The SF composite index reflects all 8 domain values, but main contributions were pain, physical function and role
Study group demographics.
Parameter
Number (%) Average age (range) Average weight (kg) Average BMI NPDVAS at recruitment screen (mean SD)
CF-PT group
PL-PT group
Male
Female
Male
Female
31 (83.8%) 29.9 (21e51) 67.8 25.5 52.02 10.17 p Z 0.928
6 (16.2%) 32 (24e42) 59 23.4
30 (85.7%) 28.4 (21e36) 70.0 26.4 51.74 12.94
5 (14.3%) 26.8 (19e34) 57.2 22.4
Effect of cetylated fatty esters and physical therapy
367 that seen with the normative data and would suggest differences between these populations even at the end of our study (Canadian scores, however, were higher in most domains than US and European counterparts; Hopman et al., 2000). In general, CF-PT improved responses in 6 of 8 categories, suggesting a positive effect to QOL. Greatest % average improvements seen with CF-PT was for body pain, physical function, limitations in roles due to physical problems and limitations in roles due to emotional problems. Only with vitality responses were changes from baseline minimal with no observed difference between treatments. The physical function index evaluates disability effects on daily functions [i.e., walking, climbing stairs, dressing and vigorous or moderate activities (heavy lifting, sports and moving objects)]. These results indicate physical function improvements were gained back by CF-PT, but there was no change in PL-PT.
Adverse events
Figure 1 Treatment effects on neck disability index. A negative change indicates a more favorable result. Visit 1 is the baseline visit.
limitations due to physical problems (these observed by separate analyses of each domain; Table 4). Results (Figure 4) indicate that CF-PT treatment responses improved during treatment, while, at best, there was no notable change in overall QOL with PL-PT. In addition, CFPT changes were significantly greater by visits 2 and 3 than PL-PT. Normative data from a random sample of the Canadian population (n Z 9423; age 25; male and female) was used for comparison (Hopman et al., 2000) to study responses (Table 4). As higher values represent a better QOL, the results of both groups in all 8 domains did not improve to
Table 2
No clinically significant events were associated with any treatment nor were adverse events noted as a result of PT. One of 72 patients (1.4%) treated with topical CFEC cream developed a hypersensitivity rash, which quickly resolved after treatment was discontinued. Likewise, there were no non-study events or events of clinical interest not related to the study that would have affected either group responses. Two patients did not complete the study: one developed the rash (indicated above) and the other tested positive for inflammatory arthritis just after study enrolment. Otherwise, no abnormal or alert level blood chemistry results were observed.
Discussion The present study suggests that CFEC topical treatment can aid in the treatment of MPS by reducing debilitating symptoms. The inclusion of CFEC topical applications with PT resulted in significant increases in levels of pain reductions, improved neck disability assessments, reductions in TrP sensitivity and improvements in CROM. Specifically, study analyses showed that for improvements in pain (NPDVAS and SF36 pain index), neck disability
Primary outcome measures within groups and between groups.
Evaluation
Measure
Visit (week)
Efficacy assessment*
Significance between groups
CF-PT
Significance from baseline
PL-PT
Significance from baseline
CF-PT vs PL-PT
Neck disability
NDI
0 2 4
38.4 11.7 27.4 6.3 18.8 7.8
N/A <0.001 <0.001
36.2 11.2 35.5 8.9 30.5 10.4
N/A 0.858 0.081
0.475 <0.001 <0.001
Neck pain
NPD-VAS
0 2 4
46.3 10.2 34.8 7.4 25.3 10.4
N/A 0.003 <0.001
47.3 7.3 43.2 5.5 34.0 8.3
N/A <0.001 <0.001
0.386 <0.001 <0.001
ManneWhitney nonparametric two-tailed test; *significance Z p < 0.05. Treatments: CF-PT Z CFEC with physical therapy; PL-PT Z Placebo with physical therapy.
368
Figure 2 Treatment effects on neck pain & disability visual analogue scale indices. A negative change indicates a more favorable result. Visit 1 is the baseline visit.
(NDI), and life quality (6 of 8 SF36 categories), CF-PT was more effective than PL-PT. For indicators evaluated using the SF36 HRQOL Survey, it was evident that CF-PT had important effects on QOL improvement parameters, compared to PL-PT. Certainly, pain reductions associated with topical CFEC applications (as opposed to placebo cream applications) were critical in contributing to QOL and, when used in conjunction to PT, to improvements in response to PT. Compared to normative data, both groups registered at baseline the lowest QOL scores for pain, physical function, role limits due to physical problems, social functioning, role limits due to emotional problems, and, to some extent, general health. In all these areas, moderate to major improvements were found with CF-PT treatment compared to PL-PT. Our results of only small effects on mental health agree with earlier observations that MPS patients may have QOL profiles mostly affected by physical health (Tu ¨zu ¨m et al., 2004). But it has also been noted that anxiety and depression are frequent in long term MPS patients (Dohrenwend et al., 1999; Eden et al., 2000; Keefe and Dolan, 1986). The effects of CF-PT in reducing role limits due to emotional problems (visit 3 vs baseline, p Z 0.077; CF-PT vs PL-PT at visit 3, p Z 0.010) suggests some anxiety and depression factors may have been addressed with this treatment modality. The addition of CFEC topical applications to physical therapy (CF-PT) provided the most effective treatment modality. This suggests that combining PT with CFEC topical application may address biochemical and pathophysiological abnormalities synergistically. But for some areas, however, the addition of CFEC topical application to treatment did not improve responses. These
D. Sharan et al. areas were total CROM response, MTrPs palpation tenderness and MTrPs pain threshold pressure responses. Neck range of motion improved significantly compared to baseline, as did the reduction in pain and tenderness at the MTrPs, but with no significant difference between groups. CF-PT was statistically equivalent to PL-PT in total CROM and total lateral movement. It would appear that for these responses, PT addresses some underlying MPS factors, for which topical CFEC treatment is not additive. Physical manipulation of the affected muscle areas and exercise programs may be necessary to achieve proper responses desired. This contrasts to the pain, disability indicators and QOL, in which topical CFEC treatment did improve response. Our results concur with those of Gam et al. (1998; study treating MPS with ultrasound, massage and exercise) who found massage and exercise to reduce the number and intensity of MTrP. But they noted that MTrP reduction had little impact on the patients’ neck and shoulder complaints (Gam et al., 1998). Further studies are needed to see if long term CFEC treatment only can reduce or eliminate active and/or latent MTrPs. PT in this study was effective in treating participants’ conditions (PL-PT improvements observed for pain reduction, TrP inactivation, disability reduction and improved range of motion). Patient histories at the Centre indicate that PT of several weeks reduces symptoms and improves the quality of life in both acute and chronic MPS cases equally well. Experience also suggests that without treatment, most MPS conditions continue, if not worsen with time. For use in comparison with this study, the available nonanecdotal information on pharmaceutical approaches is limited. Few clinical trials lend support for various treatment usages (Aker et al., 1996). As in our study, most note with treatment decreases in pain with increased functional capacity and QOL. a. Topical analgesics used include lidocaine patches (5%), EMLA cream (2.5% lidocaine and 2.5% prilocaine), bupivacaine MTrP injections, capsaicin cream (0.025% and 0.075%), and doxepin hydrochloride (Argoff, 2002; Affaitati et al., 2009; Dalpiaz and Dodds, 2001). Lidocaine iontophoresis (LIG) and direct current treatment of trigger points were both found to be effective treatment modalities but no difference was found if both were combined (Kaya et al., 2009). Bupivacaine injections may be accompanied by injection discomfort and high cardiotoxicity (Fine et al., 1988). And paresthesia and coldness/burning sensations were common side effects noted with lidocaine treatments. b. Clonazepam has an antinociceptive effect for pain with chronic MPS (Fishbain et al., 2000). Similar analgesic effects have been reported for alprazolam (Russell et al., 1991), diazepam (Verma, 1982), midazolam (Serrao et al., 1992) and buprenorphine injections (particularly with significant neuropathic component present; Likar and Sittl, 2005). Opioids, however, may be addictive, with sedation a common side effect. c. Clonidine and tizanidine (alpha2 adrenergic agonists) have been used to increase nociceptive thresholds and inhibit spinal neuron response (Longmire, 1999). Side effects, however, may be high. In a tizanidine study showing efficacy (Malanga et al., 2002), 66% reported at least one adverse event (84% treatment related and
Secondary outcomes measures within groups and between groups.
Evaluation
Subcategory
Visit (week)
Efficacy assessmenta CF-PT
% Average improvement
Significance between groupsb PL-PT
% Average improvement
CF-PT vs PL-PT
Observed significance in treatment response
Palpation
Average tenderness rating
0 2 4
2.10 0.72 1.81 0.51 1.4 0.60
0.0 13.8 33.3
2.20 0.65 1.92 0.64 1.56 0.77
0.0 12.7 29.1
0.692 0.631 0.643
Insignificant
Algometer TrP 1
Average pain threshold intensity
0 2 4
2.01 0.48 2.41 0.55 2.96 0.44
0.0 19.9 47.3
2.23 0.60 2.56 0.57 2.84 0.56
0.0 14.8 27.4
0.142 0.277 0.785
Insignificant
Algometer TrP 2
Average pain threshold intensity
0 2 4
2.06 0.62 2.40 0.65 2.86 0.55
0.0 16.5 38.8
2.30 0.58 2.59 0.63 2.83 0.63
0.0 12.6 23.0
0.122 0.346 0.977
Insignificant
CROM Measurements
Total rotation (average in degrees)
0 2 4 0 2 4 0 2 4
116.39 14.09 119.11 13.40 124.86 13.99 127.05 30.18 133.55 23.59 138.64 21.94 93.95 11.63 101.64 12.70 106.00 13.58
0.0 2.3 7.3 0.0 5.1 9.1 0.0 8.2 12.8
119.30 17.06 124.13 16.86 127.33 16.91 115.07 25.90 119.21 23.75 126.41 20.76 91.69 15.13 94.72 13.57 98.66 12.40
0.0 4.0 6.7 0.0 3.6 9.9 0.0 3.3 7.6
0.484 0.216 0.548 0.144 0.037 0.050 0.548 0.068 0.054
Insignificant
Average flexion þ extension (in degrees) Average total lateral (in degrees)
Effect of cetylated fatty esters and physical therapy
Table 3
Significant difference Insignificant
Treatments: CF-PT Z CFEC topical with physical therapy; PL-PT Z Placebo topical with physical therapy. % Average Improvement Z % change for that visit in average from baseline average. a Efficacy Assessments are given as Mean SD. b ManneWhitney nonparametric two-tailed test; significance Z p < 0.05.
369
370
Table 4
Quality of life measures from the SF36 HRQOL survey.
Scale
Efficacy assessmentb
Significance between groupsc
Normative population data
Visit (week)
CF-PT
% Average improvement
Body Pain Index
78.0 22.3a
0 2 4
45.0 12.5 56.4 10.8 64.4 13.2
0.0 25.3 42.9
46.8 12.7 45.3 13.0 48.2 13.2
Physical Function Index
88.2 18.4a
0 2 4
54.0 15.3 64.8 19.2 70.5 27.3
0.0 20.1 30.7
Role Limits due to Physical Problems Index
85.7 30.2a
0 2 4
37.5 31.8 57.3 25.5 68.3 28.8
Mental Health Index
79.0 14.7a
0 2 4
Vitality Index
68.9 17.1a
Social Functioning Index
PL-PT
CF-PT vs PL-PT
Observed significance in treatment response
0.0 3.1 3.1
0.794 <0.001 <0.001
Significant difference
63.0 17.7 58.8 15.8 63.8 18.6
0.0 6.7 1.2
0.060 0.014 0.058
Inconclusive as to trend
0.0 52.0 68.3
43.9 30.0 44.19 24.9 47.0 21.4
0.0 0.6 7.1
0.570 0.042 0.003
Significant difference
64.0 15.4 68.0 17.1 66.9 15.9
0.0 6.3 4.6
65.4 14.7 60.2 12.5 58.1 12.4
0.0 7.9 11.3
0.721 0.058 0.024
Significant difference
0 2 4
58.5 13.0 57.9 9.4 61.9 8.5
0.0 1.0 5.9
59.2 11.3 57.7 7.2 56.8 9.4
0.0 2.6 4.1
0.699 0.934 0.110
Insignificant
88.3 18.6a
0 2 4
59.3 16.1 61.7 16.1 68.5 19.2
0.0 4.1 15.5
55.9 17.4 51.0 15.0 47.6 14.6
0.0 8.7 14.9
0.442 0.012 <0.001
Significant difference
Role Limits due to Emotional Problems Index
87.0 29.3a
0 2 4
52.5 31.6 65.3 32.1 69.2 31.3
0.0 24.4 31.8
52.5 30.2 42.4 28.1 47.5 25.2
0.0 19.2 9.6
0.982 0.012 0.010
Significant difference
General Health Index
77.6 17.7a
0 2 4
55.7 12.9 59.4 12.3 61.2 14.5
0.0 6.6 9.9
53.3 11.3 49.4 11.5 52.6 10.2
0.0 7.4 1.4
0.466 0.002 0.014
Significant difference
D. Sharan et al.
Treatments: CF-PT Z CFEC topical with physical therapy; PL-PT Z Placebo topical with physical therapy. % Average Improvement Z % change for that visit in average from baseline average. a Normative data from a random sampling of the Canadian population (Hopman et al., 2000). b Efficacy Assessments are given as Mean SD. c ManneWhitney nonparametric two-tailed test; significance Z p < 0.05.
% Average improvement
Effect of cetylated fatty esters and physical therapy
371 47% severe). Common tizanidine side effects were dry mouth, somnolence/sedation, asthenia and dizziness (Malanga et al., 2002). d. Thiocolchicoside, a semi-synthetic derivative of colchicoside with muscle relaxant properties, was studied in a randomised trial (ointment, injection, both ointment and injection). Pain severity measured with VAS significantly improved after the third day in all groups. Side effects, including mild nausea and dizziness, were observed in 31% of the patients (Ketenci et al., 2009).
Figure 3 Treatment effects on total cervical range of motion. A positive change indicates a more favorable result. V1 Z baseline visit; V2 Z week 2 Visit; V3 Z week 4 visit.
Figure 4 Changes in the composite SF36 QOL index with treatment. A positive change indicates a more favorable result. V1 Z baseline visit; V2 Z week 2 Visit; V3 Z week 4 visit.
It is probable that the most effective treatment for MPS requires MTrP inactivation, restoring normal muscle length, and eliminating or correcting the factors that created/ perpetuated the MTrPs in the first place (Gerwin, 2005). These factors are coupled with multifaceted physical and chemical neuromuscular alterations (Mense, 2003; Kuan et al., 2007; Shah and Gilliams, 2008; Cook and McCleskey, 2002; Sachs et al., 2002; Shah et al., 2005, 2008). Cytokine and chemokine levels play a crucial role, as they are elevated in muscle regions with active MTrPs but not in normal, uninvolved muscle regions or those in which MTrPs are present but latent (Shah et al., 2005, 2008; Shah and Gilliams, 2008). A well defined sequential cascade of cytokines/chemokines precedes hypernociception (sensitisation), associated with neuropathic pain (Ferreira et al., 1988; Cunha et al., 1991, 1992, 2005; Poole et al., 1999; Lorenzetti et al., 2002; Verri et al., 2006). Ischaemic compression relaxes an MTrP presumably by depriving the muscle of oxygen and glucose through compression of capillary vessels and other manual myofascial therapies possibly stimulate endorphin production or activate the offcells that suppress nociceptive transmission centrally (Gerwin, 1993). The basis for efficacy of CFEC topical applications in this study may be related to that postulated in studies of treatment for osteoarthritis (OA). Kraemer et al. (2004) showed significant improvements in reducing knee joint pain and inflammation with improved QOL using CFEC in a topical formulation (Kraemer et al., 2004) and comparable results also obtained for OA of elbow and wrist (Kraemer et al., 2005a). Similar to some CROM improvements noted in this study, Kraemer et al. (2005b) found that topical CFEC applications improved joint utilisation through more normalisation of postural stability and plantar pressure distribution in knee OA. These reports proposed that cetylated fatty esters may reduce chronic inflammation through suppression of proinflammatory cytokines. Reductions in leukotriene B4 release from neutrophils and monocytes, which modulate inflammation and cytokine release, have also been postulated (Curtis et al., 2000; Kremer, 1996, 2000). Myristoleic acid, cetylated in CFEC, has been implicated as an inhibitor of 5-lipoxygenase, a central enzyme in leukotriene synthesis (Iguchi et al., 2001). CFEC treatment may address alterations in MPS at cellular and chemical levels, while acting in conjunction with PT to improve overall treatment response. Equally important may be the absence (or at most rare/minimal) of side effects associated with this application, which contrasts with other applications, such as with prolonged NSAIDs usage, opioids and other injectibles noted above. Other studies of cetylated fatty ester treatment of
372 fibromyalgia have also given encouraging results (Dunstan et al., 1999; Edwards, 2007), and it is probable that conditions similar to MPS may also benefit [i.e., other repetitive strain injuries including tendonitis, carpal tunnel syndrome and epicondilitis lateralis (Visser and van Dieen, 2006)]. In summary, this may be the first double-blinded study to report that cetylated fatty esters can aid in treating and reducing pain and symptoms of MPS when combined with PT. Improvements of patient conditions were better in most measurements than PT with a placebo cream.
Acknowledgements The authors wish to thank all physiotherapists at RECOUP Neuromusculoskeletal Rehabilitation Centre, Bangalore, involved in treating the patients and collecting the study data.
Disclosure Deepak Sharan has disclosed that he received a research grant and consulting fees from Cymbiotics, Inc. Biju Nirmal Jacob received fees for his work in performing the study. Jack Bookout is employed as Vice President of Cymbiotics, Inc. Raj Barathur is President of Cymbiotics, Inc. The study protocol at RECOUP was conducted entirely by Dr. Deepak Sharan and other Physicians and Physical Therapists. All diagnosis, treatment and interaction with the patients, clinical interventions, data collection and recording were performed by Dr Sharan and the RECOUP staff. Drs Barathur’s and Bookout’s contributions to the study were in pre-launch, monitoring study progress that was based on data collection by RECOUP’s Physicians and Therapists and in post-study analysis with the RECOUP staff after unblinding of the data. This approach was taken in order to avoid any bias.
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PREVENTION & REHABILITATION: EDITORIAL
Warrick McNeill, Dip. Phyty. (NZ) MCSP, Associate Editor* Physioworks 4 Mandeville Place, London W1U 2BG, UK How did you learn your anatomy? Have you have ever spent any time in a ‘university anatomy laboratory’ actively dissecting a cadaver or viewing prosections e a section of a cadaver pre-prepared by a skilled anatomist? Perhaps only a relatively small and relatively lucky section of the readership of the JBMT have learned the fundamental subject of our combined disciplines in this way e the rest have had to learn their anatomy using other, perhaps less illustrious methods, though, in recent years, the advent of multimedia teaching tools, ‘plastination’ and modeling may prove their worth in how we learn anatomy.
Anatomy for doctors With the breadth of disciplines this Journal provides information to, only a few will have been trained at a medical school as a doctor. The traditional focus for teaching anatomy to undergraduate Doctors is by dissection. Interestingly, the words anatomy and dissection have virtually identical meanings in Greek and Latin (Lyons, web source). The Greek, ‘tome-’ meaning ‘a cutting’ and ‘ana-’ meaning ‘up’ tells us how the study of the morphology and structure of the human body was originally undertaken. This method of discovery and learning has clearly stood the test of time as it was first described, in Ancient Greece, in the first half of the third century BC, by Herophilus of Chalcedon and Erasistratus of Ceos (von Staden, 1992). Due to religious and cultural beliefs it wasn’t till around 1315 that the first recorded public dissection by Mondino de Liuzzi was recorded in Bologna (Wilson, 1987), and it wasn’t till the 16th Century that Scotland, then England allowed any cadaveric dissection, and even then, it was heavily controlled. Dissection was later reserved for executed * Tel.: þ44 7973 122996. E-mail address:
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murderers as a recognized punishment, ‘The dissections performed on hanged felons were public: indeed part of the punishment was the delivery from hangman to surgeons at the gallows following public execution,’ says Johnson, (web source). He discusses further the role of ‘body snatchers’ in providing the growing demand for anatomical specimens with the bodies of the poor. It was only after World War One that the donation of bodies for anatomical study increased and after World War Two for all the bodies to be philanthropically provided. Johnson is of the opinion that this probably marks the rise of our changing attitudes: to our own bodies, to socialism and to atheism. The ethical treatment of human cadavers was very heavily underlined in my undergraduate training as a Physiotherapist when we spent two afternoons a week with our Anatomy Tutor, Mrs. Grace Wilson, observing prosections, and the progress of the Medical Students own dissections at the University of Otago Medical School in New Zealand in the 1980’s. The single most important difference, for me, between the colour diagrams of our anatomy text books of the time, and the cadaver, aided perhaps, by the homogenous coloration of the cadaver by its preservation in formalin, was how much the anatomical parts blended with the structures that surrounded or laid next to it e when in the text books or models the distinction was extremely obvious and usually in contrasting bright colors. So it came as no surprise to me that the ‘blending’ of structures was later shown by Tom Myers, author of Anatomy Trains (2009), to show a contiguous myofascial structure from the tongue to the big toe (the deep front line), as well as other myofascial lines, which has helped change our view of the workings of the integrated whole of the musculo-skeletal system. Thomas Myers in his ‘Re-visioning the Fascia as a BodyWide Regulatory System: Dynamic Ligaments,’ (2011) which is based on Jaap van der Wal’s (2009) work he first published, (far ahead of the world’s readiness for it) in
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PREVENTION & REHABILITATION e EDITOR: WARRICK MCNEILL
Anatomy in 3D
PREVENTION & REHABILITATION e EDITOR: WARRICK MCNEILL
376 a doctoral thesis (1988), gives us a clear insight into the ground breaking view of how linked in the ligaments are as part of the myofascial system. Myers says, ‘Van der Wal did a careful dissection of the elbow area in which he did not cut out each muscle with its fascial envelope, but instead extracted only the muscle tissue, leaving the fascial envelopes and their local connections intact. By carefully following the fascial connections, he was able to determine that in most cases, what we call ligaments were mostly linked with the muscles in series, not in parallel. In other words, muscle contractions, which tense the muscle and its myofasciae (epimysium, perimysium, endomysium and tendon), also tense associated ligaments because they are part of this same series of fascia in which the muscle was contracting, not a separate underlying layer, as we have been taught to believe. This means that the ligaments, far from being active only at the moment of the greatest elbow extension.are dynamically active in stabilizing the joint all through the movement, during both concentric and eccentric contraction. This muscleeligament combination van der Wal termed a dynament e a contraction of dynamic and ligament e and the implications of his findings are profound.’ Important current thinking. Within the Medical world there has been an increasing requirement, due to the worlds increasing population, to train more and more Doctors. Medical Schools have had to cope with the pressures of the doubling numbers of students and the costs associated with running expensive Anatomy Laboratories and conforming to the exacting requirements that ethics dictates in the running of such an establishment, while, at the same time concepts are changing about the way that Anatomy should be taught. There have been arguments, reported by Turney (2007), from the surgical community that undergraduate anatomy is in decline, with reductions in allocated time, teaching staff and dissection in most anatomy courses, with the suggestion that the knowledge of the qualifying doctor being below an acceptable level at the time his paper was written. Sugand et al. (2010) reports that ‘the challenge is to reinstate more effective teaching and learning tools while maintaining the beneficial values of orthodox dissection.’ Suggesting things have not yet changed. Turney in 2007 said that, ‘much debate has arisen about how to teach anatomy. This polarizes into those that favor dissection of human cadavers and those that support newer teaching modalities (e.g. self-directed learning, problem-based learning [PBL], and computer-assisted learning [CAL]). These standpoints tend to be supported by either the traditionalists (predominantly surgeons and anatomists) or the modernists (predominantly educationalists), respectively’. Dissection has been traditionally a significant component of undergraduate medical training, with it’s burden of content, calling for rote learning without perhaps a clear contextual understanding of the subject matter. Jon Zahourek, an artist and the founder of ‘Anatomy in Clay’, when I interviewed him (2007), reported that he had spoken with Anatomy Professors who appeared gleeful when they spoke of the high failure rates on their courses. Zahourek called ‘Anatomy e a failed subject.’ Turney wrote that, ‘Learning anatomy became a rite of passage rather than an educationally valid process, clearly requiring
W. McNeill reform . A solution that has been suggested is to integrate anatomy vertically into medical education so that students are exposed to anatomy teaching throughout undergraduate (preclinical and clinical), postgraduate and later professional training. This would provide relevant anatomy at an appropriate level of detail to the stage in training or career development. Tailoring theoretical learning to a particular specialty would reduce the amount of unnecessary theory learned.’ Zahourek points out that there is little more to discover in gross anatomy, as all the bodies organs and muscles have been described, he describes, ‘the great American bulwark of Anatomy “the AAA e American Anatomical Association,” formed in 1888, as now only really being a subset of the world of physiology.’ The focus has now left anatomy as a major area of study and micro-anatomy and histology have taken over as the real subject of study. There is another growth area in anatomy, but it is in “anatomy education” not gross anatomy itself. ‘Problem-based learning,’ a popular teaching method developed over the last 30 years was initially described by Barrows and Tamblyn (1980), they are referenced by Turney, ‘using the rationale that problem-based rather than memory-based learning created a more usable body of knowledge and the medical skills that were most important for treating patients were problem-solving skills rather than memorization.’ Traditionalists argue that it is a way of making the student, not the medical school responsible for learning, and allows the teaching of larger groups of students using less resources. Winkelmann (2007), possibly a traditionalist(?), wraps up his papers conclusion with, ‘Anatomical knowledge is too important to future doctors to leave its teaching to the educational fashion of the day.’ Fashion it might be, but Sugand et al. (2010) sensibly stresses the importance of multi-modal teaching: with modalities being: dissection/prosection, interactive multimedia, procedural anatomy, surface and clinical anatomy, and imaging. It is not the fault of dissection that the modernist is replacing it with the possibly cheaper prosection, I assume, it is more its link with the tradition of anatomy teaching that is the perceived problem. As stated earlier, dissection has stood the test of time (Older, 2004). In fact, dissection consistently scored highest over all the methods of teaching anatomy in the perceptions of first and second year medical students in an Australian study by Azer and Eizenberg (2007). Turney (2007) refers to ‘haptic learning’, that hands on learning, that the sense of touch offers, that is a peculiar strength of dissection, that no other teaching method, even prosection, provides. He points out that surgeons, unsurprisingly, like their students to dissect, as it teaches the very common variation in human anatomy present in the general population. The small window a surgical opening on a living patient makes, does not show all the potential structures that could be damaged inadvertently, so prior knowledge gleaned through dissection is extremely valuable. So it appears that, within the medical world, the arguments about anatomy education have not concluded, there is validity on all sides and there is no doubt that access to cadaveric specimens will remain for long into the
foreseeable future, but what does this mean for those who have not traditionally had access to an anatomy laboratory?.
Anatomy for everyone else If you had answered that you had never been into a university anatomy lab, I would hazard that you have planned to, or have already visited the populist Anatomist, Gunther von Hagen’s ‘Body Worlds’ (web source) exhibitions around the globe. Von Hagen invented a technique he called ‘plastination’ in the 1970’s that used the impregnation of polymer resins into a prosection (or entire cadaver), first to halt decomposition, by depriving the bacteria of decay of what they need to survive e using acetone e and then replacing the acetone with polymer solutions, often silicon, by a vacuum forced impregnation process. The prosections could be arranged in whatever attitude the anatomist chose, limited only by their imagination, and the prosection is fixed in place. You would have joined the more than 32 million people that his website reports have visited one of the exhibitions since they started in 1995. Part sensationalist, part freak show, part circus, part pure science and wholly absorbing e this is anatomy, shown as never before. In a modern world in which over-stimulation may hide an anatomical display vying for visitors amongst other attractions, and, a possibly dull, health based show marketing to the jaded perhaps means that a sensationalist approach is necessary to bring many people to an anatomy exhibition who might never have come otherwise. I just know my own reaction, in 2002, when I visited a Body Worlds exhibition in London, was both visceral and intellectual, but I was unperturbed by the fact that the cadavers had once been living people. I’m sure that many of the non-health professional visitors to Body Worlds will have had to deal with that fact on their entrance to the exhibit. Perhaps the real life or sensationalist postures of the specimens made this easier for the uninitiated to accept. One particular ‘walking Plastinate’, split into 3 freeze frames of body systems: skin, muscle and skeleton still joined at the soles of the feet, I remember, made me marvel at how compact and how efficient the body is. Structure really equals function. I also remember the labeling of the body parts was not as detailed as I wanted it to be and I later suggested to friends learning anatomy at the time that they should take in a small anatomical text book on their visit. This was Anatomy in full, high definition, 3D. I learned much more than I expected to. When I lecture I regularly discuss the exhibition, and many of those attending have seen Body Worlds too. They too, still get animated when they describe what they learned. The ‘Visible Human Project’ is another valuable resource consisting of a fly-through from top to bottom of 1 mm slices of a cross sectionally sliced cadaver. This is an early digital product that helps me mentally construct a 3D model. In the fly-through it is easy to see the fascia surrounding the muscles which when viewed really supports Myers (2007) ‘anatomy of connection’ ideas. He says, ‘almost all the anatomy that one learns is single muscle ‘isolated’ muscle
377 anatomy. You learn anatomy by taking every muscle off the skeleton save one and then you approximate the two ends of that muscle together, so we define muscles by bringing origin and insertion together. That isolates the muscle from its nearby neighbors e for instance, the fascia lata in the lateral part of the leg doesn’t act like a fascia lata without the vastus lateralis contracting underneath it, to push out against it e so there is an interaction between a muscle and a nearby fascial structure that is not predicted and not usually in the books, but its an interaction we have to pay attention to because the ilioetibial band does not work without it. There may be lots of these interactions we are not looking at yet. What anatomy trains are looking at are not the regional things left and right of the muscle but the things north and south of the muscle that connect fascially. In pilates, for example, you are not just working with isolated muscles but with sequences of muscles that work right through the body. Pilates really behooves the teacher to watch how these lines are being worked. If someone is doing their ‘hundreds’ and they have the head incorrectly hyper-extended, then they are not just going to affect the neck badly, they will also be affecting their breathing, and, their pelvic position. These kind of distal effects can be mapped out.’ It is in three dimensions that this really starts to make sense. Since Primal Pictures (web source) completed their mission, taking from 1991 to 2003, to compose a medically accurate 3D model of human anatomy, their models have become indispensable tools to educators and practitioners alike. Primal Pictures haven’t just stood still but continue to customize products for specific groups responding to their needs. Products have been built for Surgeons, Pilates Teachers, Dentists, Yoga Teachers, Fitness professionals, and Chiropracters to name a few. It is in the accuracy of converting scans of living tissues to digitized images which gives the models their life like substance, then the software allows the models to be rotated to improve a viewing angle, or drill down to see the models skeleton on its own, or zoom out layer of muscle by layer of muscle. For me their greatest success is with the 3D Real-time Viewer Regional Anatomy series - accessible at anatomy.tv e looking at the foot, hip, or spine from any angle, making a structure transparent to see it in x-ray view, and flip it around, gives you an understanding a two dimensional drawing can never provide. Animations are also provided showing muscle actions with a change of colour signifying active muscular work. Showing clients these animations does save a thousand words. I don’t just use models on screen or pictures from books to get anatomical ideas across to my clients. For clients with impingement problems at the gleno-humeral joint caused by a faulty posture I do what any somatic therapist would do, describe to them where a more ideal placement of the scapula would be, use handling to lightly correct the bony position, cue the recruitment of the force couple of the lower (and upper) trapezius and the serratus anterior (Sahrmann, 2002), give them physical markers that show a correct change in a mirror, add a little load to increase the proprioceptive feedback and set regular home work. For the right person, I might hold the back of my flat hand out in front of them, telling them it is
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a representation of their shoulder blade in the poor position that promotes impingement. I indicate that the tip of my little finger is their glenoid and the base of my thumb their inferior angle, and show them the three dimensional movement that their scapula makes on their chest wall that upwardly rotates the glenoid while, ‘flattening’ and ‘broadening’ the scapula on their chest wall. The movement of the scapula that only the lower trapezius and serratus anterior can make recruiting together. I might get them to practice that using their own hands, before asking them to attempt it with their own shoulder blades. I aim to improve their self-awareness of the correct placement of the scapula. I might attempt to release a shortened pec minor to make the correct recruitment of the lower trapezius and serratus anterior less of a fight with that shortened pectoralis minor.
A simple use of joined up, three dimensional anatomy Liebensen, later in this Prevention and Rehabilitation section discusses scapulo-humeral rhythm that is so often helped by a correct scapular position to start with. It is often easier to describe the action of superficial muscles to a client, ones they can see in the mirror. Jon Zahourek (2007) an Artist who at the age of 40 changed the way he was teaching anatomy to his peers. Zahourek was teaching using the modality of drawing, but as a sculptor he wondered if a sculptural approach would work. He started with a skeletal model and found that he could fashion muscles with plastacine clay (water based that never hardens). He says, ‘The student decides what a muscle would need to be like to move this bone to that position, and they fashion and attach a little clay muscle. We start from the inside and make all the deepest muscles first. We move from the inside out. The deepest muscles are so poorly understood e they are difficult to dissect so the literature is “oh well, there they are.move on” e but the deepest muscles are the ones that really regulate movement. They are the most predictable because they only cross one joint, they are what is positionally interpretable by the Central Nervous System.’ Zahourek quotes what Doug Kramer, the head of Anatomy Labs at New York University, said he liked about Anatomy in Clay e ‘its so intellectually active e you are making the muscles not just observing them e the fact that you are making them means you make the choices.’ ‘Anatomy in Clay courses quickly became popular amongst body workers once a Rolfer discovered a workshop advert in an art magazine at an airport bookshop and tracked Zahourek down in New York. Then,’ Zahourek reports, ‘body workers became our test market before we were discovered by high school teachers, they were excited, we were thrilled, so we re-directed and developed the teaching for use in schools. Anatomy in clay is now taught in over 4000 schools in the United States.’ Anatomy in Clay’s goal has been to teach everyone about anatomy, from as early as possible and to build on the learning like a child learns a language. This goal is related to the fact that Zahourek had a chronic low back pain from a wrestling injury, and one day, early on, when he was
W. McNeill building the connection of the latissimus dorsi, the thoracolumbar fascia diagonally to the opposite sides gluteus maximus. He says his ‘body learned something in a flash’ his kinesthetic sense had been woken by the modeling of the structure and the pain resolved, with no other intervention, treatment or exercise! Perhaps this is the haptic learning choice for those of us who can’t get to dissect to learn anatomy? May be it is not to dissect, anatomize, cut up a body, from the outside in, but it is better to build one up, with our own hands, from the inside out that will be our greatest teacher in this fundamental field of learning. In this edition’s Prevention and Rehabilitation section we have two papers, as well as our usual and popular Craig Leibenson submission. The paper by Jason Brumitt will be of interest for those actively involved in rehabilitation as it is describing a successful case study, giving an initial validation to the Bunkie Test as an assessment tool. Please refer back to the original description of the test by de Witt and Venter (2009). The second paper, by Marcel Bello, comparing rhythmic stabilization versus conventional passive stretching for injury prevention in indoor soccer, doesn’t show a significant difference but suggests that rhythmic stabilization is a useful tool, as it appears to be in the clinic.
Web sources Lyons, Jack, http://www.dartmouth.edu/whumananatomy/resou rces/etymology.htm Johnson D.R, www.leeds.ac.uk/chb/lectures/anatomy1.html www.anatomytrains.com/ligaments www.bodyworlds.com The Visible Human Project www.nlm.nih.gov/research/visible/ getting_data.html www.primalpictures.com www.anatomy.tv www.anatomyinclay.com
References Azer, S.A., Eizenberg, N., 2007. Do we need dissection in an integrated problem-based learning medical course? Perceptions of first- and second-year students. Surgical and Radiologic Anatomy 29 (2), 173e180. mar. Barrows, H.S., Tamblyn, R.M., 1980. Problem-Based Learning: An Approach to Medical Education. Springer, New York. de Witt, B., Venter, R., 2009. The ‘Bunkie’ test: assessing functional strength to restore function through fascia manipulation. Journal of Bodywork and Movement Therapies 13, 81e88. Myers, T., 2007. Unpublished recorded audio interview with author. Myers, T., 2009. Anatomy Trains, second ed. Churchill Livingston Elsevier. Myers, T., 2011. Dynamic ligaments. Massage Magazine, 58e63. March. Older, J., 2004. Anatomy: a must for teaching the next generation. Surgeon 2 (2), 79e90. Apr. Sahrmann, S., 2002. Diagnosis and Treatment of Movement Impairment Syndromes. Mosby. Sugand, K., Abrahams, P., Khurana, A., 2010. The anatomy of anatomy: a review for its modernization. Anatomical Sciences Education 3 (2), 83e93. MareApr.
Turney, B.W., 2007. Anatomy in a modern medical curriculum. Annals Royal College Surgeons England 89 (2), 104e107. March. van der Wal, J., 1988. The Organization of the Substrate of Proprioception in the Elbow Region of the Rat e Thesis. Maastricht NL: University Maastricht. van der Wal, J., 2009. The Architecture of the Connective Tissue in the Musculoskeletal System in Fascia Research II: Basic science and Implications for Conventional and Complementary Health Care. Elsevier, Munich. GmbH.
379 Staden, V., 1992. The discovery of the body: human dissection and its cultural contexts in ancient Greece. Yale Journal Biology and Medicine 65 (3), 223e241. MayeJun. Wilson, L., 1987. William Harvey’s prelectiones: the performance of the body in the renaissance theater of anatomy. Representations 17, 62e95. Winkelmann, A., 2007. Anatomical dissection as a teaching method in medical school: a review of the evidence. Medical Education 41 (1), 15e22. Jan. Zahourek, J., 2007. Unpublished recorded audio interview with author.
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Journal of Bodywork & Movement Therapies (2011) 15, 380e383
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COMPARATIVE STUDY
PREVENTION & REHABILITATION e COMPARATIVE STUDY
Rhythmic stabilization versus conventional passive stretching to prevent injuries in indoor soccer athletes: A controlled clinical trial Marcel Bello a, Laura Beatriz Mesiano Maifrino b,c,*, Eliane F Gama b, Romeu Rodrigues de Souza b a
Post-Graduate Program in Human Movement Science, Brazil Human Movement Laboratory, Sa˜o Judas Tadeu University, Rua Afonso de Freitas, 451, ap 122, CEP 04006-052 Paraiso, Sao Paulo, Brazil c Dante Pazzanese Institute of Cardiology, Sa˜o Paulo, Brazil b
Received 25 May 2010; received in revised form 11 November 2010; accepted 19 November 2010
KEYWORDS Indoor soccer; Rhythmic stabilization; Passive stretching; Prevention of muscle and joint lesions; Indoor football
Summary Objective: Indoor soccer is a sport that exposes the athletes to muscle and joint lesions. The effect of rhythmic stabilization (RS) technique to prevent these kinds of lesions in indoor soccer athletes is largely unknown and its use in athletes is controversial. Nevertheless, empiric evidence suggests that RS might be effective to prevent lesions in indoor soccer athletes. A controlled clinical trial of efficacy was performed to test this hypothesis. Methods: Athletes were randomly divided into two groups: a RS group (7 athletes) and passive stretching (PS) group (7 athletes). At the beginning and at the end of the experiment (after four months) all athletes were subjected to clinical evaluation. Assessments were performed by subjective pain intensity, clinical evaluation and measurements of the range of maximal lower limb flexion movement. Results: Athletes of both groups had lower limb injuries during the four months. The athletes submitted to RS technique had fewer injuries than those subjected to the PS technique although the difference was not significant. Conclusions: Although no significant difference was found between RS and PS, a trend suggests RS may be more effective than PS to prevent muscular and ankle joint lesions in indoor soccer athletes, but more research is needed. ª 2010 Elsevier Ltd. All rights reserved.
* Corresponding author. Human Movement Laboratory, Sa ˜o Judas Tadeu University, Rua Afonso de Freitas, 451, ap 122, CEP 04006-052 Paraiso, Sao Paulo, Brazil E-mail address:
[email protected] (L.B. Mesiano Maifrino). 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.11.002
Introduction
381
Methods
pain and clinical evaluation. In addition, assessment of the range of maximal amplitude of flexion movement of the hip joint (ROM) was measured at the beginning (T0) and at the end of the experiment (T1). ROM was measured using a manual goniometer. The measurements were made on both the dominant and non dominant lower limbs. Athletes were asked to abduct their hip joints as widely as possible and were measured while lying supine, flat on the bed. The validity and reliability of this technique has been amply demonstrated (Sabari et al., 1998; Venturini et al., 2006). The contralateral lower limb was estabilised using an elastic stretching strap while keeping the hip and knee extended. The exclusion criterion was: presence of muscle and/or joint pain at the beginning of the experiment. The RS group received treatment by a physiotherapist specialist. The technique was applied 3 times a week after the training for four months. The procedure was applied to the lower limb of the athlete in the supine position, and the range of motion was reached for each diagonal, with no pain, at which time the athlete was asked to perform a maximum isometric contraction against a resistance provided by the coach at the end of the movement with alternating contractions of the agonist and antagonist muscles (Kofotolis, 2008). Each contraction was held for 6 s alternating the frequency of 5 contractions between the agonist and antagonist muscles in the direction according to the patterns of the Kabat’s method. The initial maximum stretch reflex was activated to improve the function of the neuromuscular spindle and obtain more motor unit recruitment (Adler et al., 1999; Chalmers, 2004). The objective was the active stabilization of the lower limb muscles, and the ankle, knee, and hip joints were then also stabilized through alternating contractions of the agonist and antagonist muscles. Two diagonal movements were applied to the athlete in each lower limb at two series of 10 rhythmic stabilizations for each diagonal (Figures 1 and 2). The PS technique was also provided by a physiotherapist specialist. The stretching sessions of this group were also guided by the therapist. The athletes were asked to perform passive or static stretching of the lower limbs. Thigh and the leg muscles were stretched for 10 s. The technique was applied 3 times a week, after training forfour months.
We performed a randomized, controlled trial that involved 14 indoor soccer athletes of a major team aged 18e27 all of whom had at least 7 years experience. They practiced at least five times a week, varying from physical and technique to tactics training totalling a weekly load of 15 h minimum. Daily training sessions lasted 3 h on average. The athletes were randomly divided into two groups. The first group consisted of 7 athletes (age 24 3) subjected to the RS technique, and the second group, with 7 athletes (age 23 5) was subjected to the PS technique after oriented physical training. The athletes’ diet was verified every fifteen days by a nutritionist, and the athletes were advised to get at least 8 h sleep per night. The muscle and joint injuries detected in both the RS and PS groups were registered during the whole period of treatment. The injuries were diagnosed by the indoor soccer club physician. Assessments were performed by subjective
Figure 1 Diagonal at which the athlete performs flexion of the knee, dorsiflexion and inversion of the ankle, and extension of the toes with adduction and external rotation of the hips. The therapist provides resistance to these movements.
Indoor soccer is an acyclic and intermittent sport, that demands frequent accelerations and decelerations (eccentric deceleration/concentric acceleration/isometric stability for example), and direction changes exposing the athletes to a number of injuries, especially lower limb injuries. The lower limb muscle lesions account for 25% and ankle sprains account for 13% of the indoor soccer injuries, which are in general the main cause of pulling out athletes from tournaments (Ribeiro et al., 2003). In order to avoid muscle and joint lesions, indoor soccer athletes are recommended to perform stretching exercises, generally passive stretching (PS). Nevertheless, the effectiveness of this technique has been cast into doubt by a number of authors (Weldon and Hill, 2003; Witvrouw et al., 2004; Andersen, 2005; Trehearn and Buresh, 2009). Furthermore, stretch tolerance must be considered: overstretching or stretching to a point where pain is felt may be inappropriate and detrimental (Yessis, 2006). Another stretching technique, the rhythmic stabilization (RS) technique based on proprioceptive neuromuscular facilitation(PNF), has been considered more adequate in the sports world (Shimura and Kasai, 2002). The RS technique is based on Kabat’s method, established between 1948 and 1960 by Herman Kabat and his collaborators, which allows muscle reinforcement and amplitude joint gain (Kabat et al., 1959). The RS technique includes the participation of the muscle spindle. One of its functions is to control the integrity of the muscle (Kandel, 2000; Chen et al., 2003). It is based on diagonal exercises, in which through rhythmic stabilization it is possible to alternate contractions of the agonist and antagonist muscles reducing the activity of the muscle spindle to a minimum level (Schuback et al., 2004; Rees et al., 2007; Mahieu et al., 2008; Yuktasira and Kaya, 2009). There are no studies evaluating the effect of RS to prevent muscle and joint lesions in athletes. The purpose of the current case-control study was to evaluate the efficacy of RS to avoid muscle and joint lesions in indoor soccer athletes. The results showed that the RS is as effective as the PS in prevention of lesions in indoor soccer athletes.
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Figure 2 Diagonal at which the athlete performs flexion of the knee, dorsiflexion and eversion of the ankle, and extension of the toes with abduction and internal rotation of the hips. The therapist provides resistance to these movements.
The experimental protocol was approved by the Ethics Committee of the Sa ˜o Judas Tadeu University and conformed to the international norms for human experimentation. Written informed consent was obtained from each athlete after a full explanation of the experiment.
Statistical method To carry out the statistical analysis of the data, SPSS software, version 12.0, was used with significance values set at p 0.05. Scores of range of movement were presented as the means standard deviation (sd). The Fisher’s test was applied to verify spatial dependence between the RS and PS groups’ muscular and ankle injuries and range of motion of the hip joint.
Results In the group subjected to the RS technique athletes suffered 5 muscle and joint lesions. In the PS group, athletes suffered 9 muscle and joint lesions (Figure 3). Only the hamstring muscles and the ankle joint were affected. No lesions were verified in the other muscles and joints of the lower limb. Using Fisher’s test to verify the spatial dependence between lesions in the two groups, no significant difference was found (F Z 0.192, p value Z 0.096). There were no differences in the mean pre-test values of ROM between RS and PS groups, neither for the dominant nor for the non dominant lower limbs. When the two groups (RS and PS) were compared at T1, the same results were obtained. Significant improvement in values of ROM in the RS group was observed at T1 than at T0 for the dominant lower limb (83.1 3.9 vs 84.8 3.8, t Z 2.52, pZ0.045). The PS values observed at T1 were not statistically significantly different to that observed at T0 (85.7 4.6 vs 86.0 5.4, t Z 0.54, pZ0.60) (Figure 4). For the non dominant member, the correspondent results were very similar: 82.7 3.7 vs 84.2 3.1, t Z 3.2, p Z 0.01 (RS values) and 85.1 5.4 vs 85.1 5.2, t Z 0, p Z 1.0 (PS values).
Figure 3 Incidence of muscular and/or joint lesions in indoor soccer athletes from the two groups studied.
Dragon, 2001; Witvrouw et al., 2001; Volpi et al., 2003). Thus, it is crucial to develop special techniques to prevent injuries in athletes, especially muscle skeletal ones, which are the most frequent lesions. The PS technique is the one that has been more frequently used by indoor soccer athletes. However, according to several authors (Cramer et al., 2004; Thacker et al., 2004; Faigenbaum et al., 2006; LaRoche and Connolly, 2006), there is not sufficient evidence to endorse or discontinue routine stretching before or after exercise to prevent injury among competitive or recreational athletes. Furthermore, recent studies have demonstrated that this type of stretching has other disadvantages such as loss of athletes’ maximum strength (Tricoli and Paulo, 2002). In the present work, we evaluated the RS technique to verify whether it is able to prevent muscle and joint injuries in indoor soccer athletes instead of using the conventional PS technique. The present results show that although the athletes of the RS group had fewer lesions (5) in relation to those of the control group (9), when compared statistically, there were no differences between
Discussion The physical demands of competitive sports such as indoor soccer have increased the number of lesions (Rossi and
Figure 4 Range of motion of the hip joint in the dominant and non dominant lower limb. Data are means SD. )p < 0.05 vs RS, T0, dominant.
the two groups. Probably, statistical power was low (due to participant numbers). All the muscle and joint lesions found in this work involved the hamstring muscles (biceps femoris, semitendinosus, and semimembranosus) and ankle joint lesions corroborating previous reports of other authors that this group of muscles and this joint are the most vulnerable to lesions caused by fast-paced action (Bienfait, 2000). Results of this study suggest that improved range of motion was reported at the end of the experiment, suggesting that RS technique provide some protection to the muscle and joints. Statistically significant difference was observed in the RS group between the T0 values and the T1 values for the range of motion in the dominant lower limb.
Conclusion No significant difference was found between the two techniques, but a trend suggests RS may be more effective than PS and more research is needed.
References Adler, S.S., Beckers, D., Buck, M., 1999. FNP: Proprioceptive Neuromuscular Facilitation. Manole Editorial, Sa ˜o Paulo. Andersen, J.C., 2005. Stretching before and after exercise: effect on muscle soreness and injury risk. Journal of Athletic Training 40, 218e220. Bienfait, M., 2000. Bases of the Physiology of the Manual Therapy. Summus Editorial, Sa ˜o Paulo. Chalmers, G., 2004. Re-examination of the possible role of golgi tendon organ and muscle spindle reflexes in proprioceptive neuromuscular facilitation muscle stretching. Sports Biomechanical 3 (1), 159e183. Chen, H.H., Hippenmeyer, S., Arber, S., Frank, E., 2003. Development of the monosynaptic stretch reflex circuit. Current Opinion in Neurobiology 13 (1), 96e102. Cramer, J.T., Housh, T.J., Johnson, G.O., Miller, J.M., Coburn, J.W., Beck, T.W., 2004. Acute effects of static stretching on peak torque in women. Journal of Strength and Conditioning Research 18 (2), 236e241. Faigenbaum, A., Kang, J., McFarland, J., Bloom, J.M., Magnatta, J., Ratamess, J., Hoffman, N.A., 2006. Acute effects of different warm-up protocols on anaerobic performance in teenage atletas. Pediatric Exercise Science 18 (1), 64e75. Kabat, H., McLeod, M., Holt, C., 1959. The practical application of proprioceptive neuromuscular facilitation. Physiotherapy 45, 87e92. Kandel, E. Foundations of Neuroscience and behavior. 2000, Ed. Guanabara, RJ Kofotolis, N.D., 2008. Sequentially allocated clinical trial of rhythmic stabilization exercises and TENS in women with chronic low back pain. Clinical Rehabilitation 22 (2), 99e111. LaRoche, D.P., Connolly, D.A., 2006. Effects of stretching on passive muscle tension and response to eccentric exercise. American Journal Sports Medicine 34 (6), 1000e1007. Mahieu, N.N., Cools, A., De Wilde, B., Boon, M., Witvrouw, E., 2008. Effect of proprioceptive neuromuscular facilitation
383 stretching on the plantar flexor muscle-tendon tissue properties. Medicine Science Sports Exercise 40 (1), 117e123. Rees, S.S., Murphy, A.J., Watsford, M.L., Mclachlan, K.A., Coutts, A.J., 2007. Effects of proprioceptive neuromuscular facilitation stretching on stiffness and force-producing characteristics of the ankle in active women. Journal of Strength and Conditioning Research 21 (2), 572e577. Ribeiro, C.Z.P., Akashi, P.M.H., Sacco, I.C.N., Pedrinelli, A., 2003. Relationship between postural changes and injuries of the locomotor system in indoor soccer athletes. Brazilian Journal of Medicine and Sport 9 (2), 98e103. Rossi, F., Dragon, S., 2001. Acute avulsion fractures of the pelvis in adolescent competitive athletes: prevalence, location and sports distribution of 203 cases collected. Skeletal Radiology 30 (3), 1432e2161. Sabari, J.S., Maltzev, I., Lubarsky, D., Liszkay, E., Homel, R., 1998. Goniometric assessment of shoulder range of motion: comparison testing in supine and sitting positions. Archives of Physical Medicine and Rehabiitation 79, 647e651. Schuback, B., Hooper, J., Salisbury, L., 2004. A comparison of a self-stretch incorporating proprioceptive neuromuscular facilitation components and a therapist-applied PNF-technique on hamstring flexibility. Physiotherapy 90, 151e157. Shimura, K., Kasai, T., 2002. Effects of FNP on the initiation of voluntary movement and motor evoked potentials in upper limb muscles. Human Movement Science 21, 101e113. Thacker, S.B., Gilchrist, J., Stroup, D.F., 2004. The impact of stretching on sports injury risk: a systematic review of the literature. Medicine Science Sports Exercise 36 (3), 371e378. Trehearn, T.L., Buresh, R.J., 2009. Sit-and-reach flexibility and running economy of men and women collegiate distance runners. Journal of Strength Conditioning Research 23 (1), 158e162. Tricoli, V., Paulo, A.C., 2002. Effect of stretching exercises on the maximal power performance. Brazilian Journal of Physical Activity and Health 7, 6e13. ´, A., Aguilar, B.P., Giacomelli, B., 2006. ReliVenturini, C., Andre ability of two methods to evaluation of the range of motion of ankle dorsiflexion in healthy subjects. Acta Fisiatrica 13 (1), 41e45. Volpi, P., Pozzoni, L., Galli, M., 2003. The major traumas in youth football. Knee Surgery, Sports Traumatology, Arthroscopy 11 (6), 399e402. Weldon, S.M., Hill, R.H., 2003. The efficacy of stretching for prevention of exercise-related injury: a systematic review of the literature. Journal of Manipulative and Physiological Therapeutics 8 (3), 141e150. Witvrouw, E., Bellemans, J., Lysens, R., Danneels, L., Cambier, D., 2001. Intrinsic risk factors for the development of patellar tendinitis in an athletic population. A two-year prospective study. American Journal Sports Medicine 29 (2), 190e195. Witvrouw, E., Mahieu, N., Danneels, L., McNair, P., 2004. Stretching and injury prevention: an obscure relationship. Sports Medicine 34 (7), 443e449. Yessis, M., Winter 2006. Runners need active stretching. AMAA Journal 18 (2), 8e18. Yuktasira, B., Kaya, F., 2009. Investigation in to the long-term effects of static and PNF stretching exercises on range of motion and jump performance. Journal Bodywork and Movement Therapies 13, 11e21.
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Rhythmic stabilization versus conventional passive stretching
Journal of Bodywork & Movement Therapies (2011) 15, 384e390
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CASE REPORT
Successful rehabilitation of a recreational endurance runner: Initial validation for the Bunkie test
PREVENTION & REHABILITATION e CASE REPORT
Jason Brumitt, MSPT, SCS, ATC, CSCS, Assistant Professor of Physical Therapy* Pacific University Oregon, 222 SE 8th Avenue, Hillsboro 97123, OR, USA Received 27 February 2010; received in revised form 22 May 2010; accepted 31 May 2010
KEYWORDS Bunkie test; Running; Core stabilization; Therapeutic exercises; Hip weakness
Summary This case report details the musculoskeletal evaluation and the successful rehabilitation of a 24-year-old female recreational distance runner who self-referred to physical therapy with an acute bout of low back pain (LBP). Her LBP was provoked during each distance run. The patient’s musculoskeletal evaluation revealed core weakness, especially on the left. A recently reported functional test, the Bunkie test, was administered as part of the physical evaluation. The scores from the Bunkie test correlated with other quantitative and qualitative findings. A therapeutic exercise program emphasizing core stabilization was prescribed. The patient was able to shortly return to running pain-free. ª 2010 Elsevier Ltd. All rights reserved.
Millions of individuals run for exercise and/or sport each year. Some of the health benefits potentially associated with regular aerobic exercise (e.g. running) include improvements in cardiopulmonary function, muscular strength, and body composition. In addition, regular aerobic exercise may aid in the prevention or management of chronic diseases. However, despite the reported health benefits associated with aerobic exercise, distance runners risk injury to the lumbar spine and the lower extremities (Duffey et al., 2000; Fredericson et al., 2000; Klossner,
* Tel.: þ1 503 352 7265; fax: þ1 503 352 7340. E-mail address:
[email protected]
2000; Taunton et al., 2002, 2003; Gunter and Schwellnus, 2004; Barr and Harrast, 2005; Kennedy et al., 2005; Paluska, 2005; Cosca and Navazio, 2007). Risk factors associated with sports-related running injuries are frequently categorized by anatomical variants, running biomechanics, and training patterns (Bennett et al., 2001; Hreljac, 2005; Reinking and Hayes, 2006; Rauh et al., 2007). Appreciating these risk factors will help the practitioner to prescribe interventions to an at risk distance runner and improve the rehabilitation professional’s ability to evaluate and treat the injured runner. While strides have been made to identify injury risk factors, there are some risk factors (e.g. the runner’s anatomy) that are not amenable to conservative treatments. There is also
1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.06.003
Initial validation for the Bunkie test
Posterior power line.
disagreement in the literature as to the significance of each individual risk factor (Lun et al., 2004; Schache et al., 2005; Reinking and Hayes, 2006). Recent reports suggest “core” weakness may contribute to the onset of a sport related injury (Fredericson et al., 2000; Niemuth et al., 2005). The core may be defined as the anatomical region of the body consisting of the joints and muscles of the trunk (abdominals, spine, and pelvis), the hips, and the proximal lower extremities (Kibler et al., 2006). Trunk and hip musculature play a significant role in maintaining optimal lower extremity biomechanics (Powers, 2003, 2010; Fredericson and Moore, 2005; Hollman et al., 2006). Failure of the trunk and/or hip musculature to stabilize proximal segments while running may affect optimal lower extremity biomechanics during the stance phase contributing to a low back or lower extremity injury (Powers, 2003, 2010; Fredericson and Moore, 2005; Hollman et al., 2006). Several tests have been reported to quantitatively or qualitatively measure core function (McGill, 2002; Plastaras et al., 2005). These “functional tests” are reported to reveal dysfunctional movement patterns, range of motion asymmetries, and/or muscular imbalances. de Witt and Venter (2009) have recently introduced the Bunkie test as
Figure 2
Anterior power line.
Figure 3
Posterior stabilizing line.
a tool to assess the function of the core muscles along fascial lines. The Bunkie test consists of 5 testing positions (Figures 1e5) performed bilaterally (de Witt and Venter, 2009). de Witt and Venter (2009) suggest that either asymmetrical or deficient test scores will help the rehabilitation specialist identify dysfunction and guide treatment. Using their clinical experience, de Witt and Venter suggest that endurance athletes should maintain each test position for at least 40 s (de Witt and Venter, 2009). The purpose of this case report is to highlight the successful rehabilitation of a recreational endurance athlete who experienced an acute bout of low back pain. This report will detail the clinical findings from the patient’s musculoskeletal evaluation and provide initial validation for the Bunkie test.
Case description A 24-year-old female graduate school student self-referred to the university’s physical therapy clinic with a month long episode of low back pain associated with distance running. She reported that she experienced left-sided low back pain (visual analog scale 5e6 out of 10) during each distance run. Each time she attempted a run, her pain would limit
Figure 4
Lateral stabilizing line.
PREVENTION & REHABILITATION e CASE REPORT
Figure 1
385
386
J. Brumitt Table 3 Bunkie test scores measured during the initial evaluation. Test position
Right side (s)
Left side (s)
Posterior power line
12 (patient 30 experienced symptom reproduction during testing) Anterior power line 22 44 Posterior stabilizing line 18 10 Lateral stabilizing line 53 18 Medial stabilizing line 16 13
Physical examination Standing examination Figure 5
Medial stabilizing line.
Table 1 Manual muscle test scores (0e5 scale) measured during the initial evaluation. Muscle group
Right side
PREVENTION & REHABILITATION e CASE REPORT
Gluteus maximus
5
Gluteus medius Hip external rotators Hip internal rotators Hip flexors Hip adductors
5 4 5 5 5
Left side 3þ with symptom provocation 3þ 3þ 4þ 5 5
her ability to complete her typical training distance of 2e4 miles. After each run, her pain would continue for “the next couple of days”. Once her pain subsided, she would attempt a distance run again, which was accompanied by symptom provocation. She reported that no other activity reproduced her pain. Except for low back pain, her medical history was otherwise unremarkable.
Table 2
Posture, active lumbar range of motion (AROM), and lower extremity movement patterns were assessed in standing. The patient demonstrated full, pain-free lumbar active range of motion in all planes. Her static posture appeared unremarkable when viewed from all sides. Two functional tests were conducted to assess the patient’s dynamic lower extremity movement patterns (Manske et al., 2003). Functional tests, such as the squat and the lunge, may reveal dysfunctional movement patterns or functional weakness (Manske et al., 2003). No significant dysfunctional movement patterns were noted when she performed the squat. She did however demonstrate dysfunction when performing the lunge. When lunging, each lower extremity demonstrated a medial collapse (e.g. hip internal rotation and adduction, knee valgum, and tibial internal rotation). This medial collapse was observed bilaterally; however, to a greater degree when the left lower extremity lunged forward.
Seated examination In sitting, a neurologic screening exam and selected manual muscle tests were administered. Lumbar myotomes
Findings associated with table examination.
Patient position
Manual muscle test
Special test
Palpation
Supine
n/a
No pain experienced with palpation.
Side-lying
Gluteus medius (abduction): (R) 5/5; (L) 3þ/5 Gluteus maximus (extension): (R) 5/5; (L) 3þ/5 with symptom provocation
1. Thomas test: symmetrical 2. Leg length: symmetrical in supine and long-sitting 3. Knee to Chest: (-) bilaterally 4. Straight Leg Raise: (-) and symmetrical bilaterally to 90 5. FABERE: (-) bilaterally Obers test: (-) bilaterally
Prone
Ely’s test: (-) bilaterally
No pain experienced with palpation. Tender to palpation: 1. Left PSIS 2. Left lumbar facets L4eL5
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Table 4 Bunkie test positions and the associated regions of the body reported to be tested in each position (de Witt and Venter, 2009). When the right leg is on the bench.
Posterior power line
The low back and the posterior and lateral muscles/fascia of the left lower extremity is reported to be assessed The abdominals and the anterior and lateral muscles/ fascia of the left lower extremity is reported to be assessed The posterior and medial muscles/fascia of the right lower extremity is reported to be assessed The lateral muscles/fascia of the right lower extremity is reported to be assessed The medial muscles/fascia of the right lower extremity is reported to be assessed
Anterior power line
Posterior stabilizing line
Lateral stabilizing line Medial stabilizing line
Figure 7
Hip internal rotation and adduction on the left.
the MMT) in her left gluteus maximus. During the initial MMT for the left gluteus maximus, she utilized a compensatory strategy by activating her hip adductors. Table 2 presents the findings from each test performed on the table.
Bunkie test (L2eS1), lumbar dermatomes (L2eS1), and lumbar reflexes (L3 and S1) were intact bilaterally. Traditional manual muscle tests (MMT) were performed for hip internal and external rotation, hip flexion, and knee extension. Table 1 presents selected manual muscle test scores.
Table examination AROM, MMT for the gluteus maximus and gluteus medius, and special tests were performed on a treatment table with the patient positioned in supine, prone, and side-lying. In supine, AROM for the hips were symmetrical and within normal limits. In prone, the patient presented with 3þ/5 strength (and experienced symptom reproduction during
Figure 6
Positive trendelenburg on the left.
The Bunkie test was administered as previously described by de Witt and Venter (2009). Figures 1e5 depict the 5 testing positions. The bench was adjusted to a height of approximately 25 cm for the patient in this case (de Witt and Venter, 2009). Table 3 presents the patient’s scores (recorded in s) for each test. Table 4 provides a summary of which region of the body a particular test is reported to assess (de Witt and Venter, 2009). For example, when testing the posterior power line, de Witt and Venter (2009) contend that when the right leg is on the bench the low back and the posterior and lateral muscles and fascia of the left lower extremity are assessed (Table 4). The patient’s scores from the Bunkie test (right side posterior power line, right side anterior power line, left side posterior stabilizing line, left side lateral stabilizing line, left side medial
Figure 8
Left thigh adduction.
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Bunkie test position
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Table 5
Therapeutic exercise program.
Exercise
Purpose
Sets/Reps
Clamshell
Performed by the patient for 2 days to facilitate gluteus medius activation To initiate strengthening for the gluteus maximus To strengthen the gluteus medius To improve core endurance To improve core endurance
2 sets 15 reps performed bilaterally
Prone hip extension (with knee flexed to 90 ) Side-lying straight leg raise (hip abduction) Front planks Side planks
stabilizing line) correlated with the aforementioned muscular weakness identified during MMT.
PREVENTION & REHABILITATION e CASE REPORT
Running assessment on treadmill A posterior view of the client running on a treadmill was recorded using a digital camera. A review of the video revealed two biomechanical errors that were frequently repeated throughout the assessment period. Figure 6 illustrates a positive Trendelenburg sign on the left. Figures 7 and 8 illustrate the left lower extremity adducting toward or crossing midline during the swing phase.
Summary of findings The low back pain that the patient experienced during a distance run was assessed to be the result of muscular weakness of her core, especially the muscles of the left hip. The inability to proximally stabilize impaired her lower extremity alignment and function when running. As a result, she experienced abnormal tissue loads in the left lumbar region above that of her tissue’s tolerance (McGill, 2002). The physical therapy evaluation identified weakness in the gluteus maximus and gluteus medius on the left side. This core weakness was noticeable during a functional movement such as the lunge (medial collapse left side greater than the right side). Her scores on the Bunkie test
Figure 9
Prone hip extension exercise.
1 set 15 reps performed bilaterally 2 sets 15 reps performed bilaterally 2 sets 10 s holds 2 sets 10 s holds performed bilaterally
were below the recommended scores for an endurance athlete (de Witt and Venter, 2009). In addition, the patient demonstrated asymmetrical scores with lower scores recorded during the Bunkie testing positions that assessed the left lower quadrant. The objective findings from the physical examination correlated with the qualitative assessment of her running mechanics. She demonstrated a positive Trendelenburg sign (indicative of a weak or inhibited gluteus medius) and faulty running mechanics during the toe off and swing phase on the left. Due to her weak or inhibited left gluteus maximus, she was unable to maintain her left hip and thigh in relative abduction and external rotation (Fredericson et al., 2000; Niemuth, 2007). In addition, it appears that the patient activated her left hip adductors to assist with propulsion on the left in response to her functionally weak gluteus maximus. Neumann (2010) explains that with the thigh internally rotated and adducted (poor proximal stabilization with the gluteus medius), the hip adductors are positioned to provide hip extension. As a result, it may be that the lower extremity was adducted from toe off and was maintained in some degree of adduction through the swing phase on the left.
Treatment Treatment consisted of therapeutic exercises to address core weakness (Table 5). Specific exercises were directed
Figure 10
Side plank exercise.
Figure 11
389
Front plank exercise.
toward improving activation and strength of the gluteus medius (clamshells and side-lying straight leg raise) and the gluteus maximus (prone leg extension (Figure 9)). Side and front planks (Figures 10 and 11) were prescribed to improve endurance capacity of the core. Upon follow-up, the patient was prescribed side planks with hip abduction, front planks with hip extension, and lunges to her home exercise program.
Follow-up The patient returned to physical therapy 8 days later. At this point she reported that she had resumed her typical running distance pain-free. The Bunkie test was administered again with the patient demonstrating improvements in all of testing positions (Table 6). Due to her functional improvements and her improved pain score with running (VAS 0/10) the patient was discharged from physical therapy. During an informal follow-up 4 months later, the patient reported that she had been able to run pain-free for all of her training distances.
Discussion This case highlights musculoskeletal testing considerations for a recreational distance runner with a low back injury and the successful rehabilitation program that addressed the pertinent findings from the examination. Functional tests were administered as part of the musculoskeletal
Table 6
evaluation. It has been suggested that a functional test (or series of tests) may be useful as an assessment tool to identify weakness or dysfunctional activation of the core muscles (Nadler et al., 2001; McGill, 2002). The recently described Bunkie test was utilized to highlight weakness in the patient’s core. To the best of the author’s knowledge the only other report in the literature discussing the Bunkie is the original report by de Witt and Venter (2009). This case report provides an initial validation for the Bunkie test. de Witt and Venter (2009) contend that these 5 tests performed bilaterally assess the function of the core along fascial lines. Future studies are necessary to support the author’s aforementioned claims (the testing of fascial lines). However, the findings from this case report suggest that the Bunkie test may help identify muscular imbalances between core muscle groups. In addition, the patient’s initial Bunkie test scores correlated with the findings from the traditional manual muscle tests. Future research is necessary to identify normative data, to identify which muscle(s) are being assessed during each test position (electromyography), and prospective epidemiological designs to determine the ability of the Bunkie test to identify individuals at risk for injury. Currently, despite the number of functional tests reported to assess core function, there is paucity in the literature to support potential clinical value. Future testing is necessary to identify either the best test or tests to assess core function and to predict injury risk. This case report also adds to the growing body of literature supporting the role of therapeutic exercises addressing core dysfunction in runners. Brumitt et al. (2009) included exercises for the core as part of a comprehensive rehabilitation program for an injured and irondeficient division-III female collegiate cross-country athlete. During the course of her cross-country season she set school records and earned All-American status (Brumitt et al., 2009). Wagner et al. (2010) successfully treated a 42year-old male triathlete whose performance had been affected by recurrent right hamstring cramping. The patient was able to return to sport, completing triathlons without symptom provocation (Wagner et al., 2010). The inclusion of core exercises in a healthy client’s training program may aid performance and reduce injury risk. Core exercises were included in a successful return to running training program for a postpartum client (Brumitt, 2009). After an 8-week course of training, the client had returned to running and realized improvements in core strength (Brumitt, 2009).
Comparison of Bunkie test scores (s) at baseline and 8 days later.
Test position
Right side scores at baseline
Left side scores at baseline
Right side scores at follow-up (8 days later)
Left side scores at follow-up (8 days later)
Posterior power line Anterior power line Posterior stabilizing line Lateral stabilizing line Medial stabilizing line
12 22 18 53 16
30 44 10 18 13
59 37 24 56 23
52 52 23 38 16
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Conclusion Core weakness may be a contributing factor in the onset of a runner’s low back pain. For some clients, assessing the muscular strength and endurance capacity of their core with functional tests may reveal significant dysfunction. The scores from the Bunkie test in this case correlated with other quantitative tests and qualitative findings. Future research investigations of the Bunkie test are warranted to establish demographic data and to determine test reliability.
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References Barr, K.P., Harrast, M.A., 2005. Evidence-based treatment of foot and ankle injuries in runners. Physical Medicine and Rehabilitation Clinics of North America 16, 779e799. Bennett, J.E., Reinking, M.F., Pluemer, B., Pentel, A., Seaton, M., Killian, C., 2001. Factors contributing to the development of medial tibial stress syndrome in high school runners. Journal of Orthopaedic and Sports Physical Therapy 31, 504e510. Brumitt, J., 2009. A return to running program for the postpartum client: a case report. Physiotherapy Theory and Practice 25, 310e325. Brumitt, J., McIntosh, L., Rutt, R.A., 2009. Comprehensive sports medicine treatment of an athlete who runs cross-country and is iron deficient. North American Journal of Sports Physical Therapy 4, 13e20. Cosca, D.D., Navazio, F., 2007. Common problems in endurance athletes. American Family Physician 76, 237e244. de Witt, B., Venter, R., 2009. The ‘Bunkie’ test: assessing functional strength to restore function through fascia manipulation. Journal of Bodywork and Movement Therapies 13, 81e88. Duffey, M.J., Martin, D.F., Cannon, W., Craven, T., Messier, S.P., 2000. Etiologic factors associated with anterior knee pain in distance runners. Medicine and Science in Sports and Exercise 32, 1825e1832. Fredericson, M., Moore, T., 2005. Muscular balance, core stability, and injury prevention for middle- and long-distance runners. Physical Medicine and Rehabilitation Clinics of North America 16, 669e689. Fredericson, M., Cookingham, C.L., Chaudhari, A.M., Dowdell, B.C., Oestreicher, N., Sahrmann, S.A., 2000. Hip abductor weakness in distance runners with iliotibial band syndrome. Clinical Journal of Sports Medicine 10, 169e175. Gunter, P., Schwellnus, M.P., 2004. Local corticosteroid injection in iliotibial band friction syndrome in runners: a randomised controlled trial. British Journal of Sports Medicine 38, 269e272. Hollman, J.H., Kolbeck, K.E., Hitchcock, J.L., Koverman, J.W., Krause, D.A., 2006. Correlations between hip strength and static foot and knee posture. Journal of Sport Rehabilitation 15, 12e23. Hreljac, A., 2005. Etiology, prevention, and early intervention of overuse injuries in runners: a biomechanical perspective. Physical Medicine and Rehabilitation Clinics of North America 16, 651e667. Kennedy, J.G., Knowles, B., Dolan, M., Bohne, W., 2005. Foot and ankle injuries in the adolescent runner. Current Opinion in Pediatrics 17, 34e42. Kibler, W.B., Press, J., Sciascia, A., 2006. The role of core stability in athletic function. Sports Medicine 36, 189e198.
J. Brumitt Klossner, D., 2000. Sacral stress fracture in a female collegiate distance runner: a case report. Journal of Athletic Training 35, 453e457. Lun, V., Meeuwisse, W.H., Stergiou, P., Stefanyshyn, D., 2004. Relation between running injury and static lower limb alignment in recreational runners. British Journal of Sports Medicine 38, 576e580. Manske, R.C., Smith, B., Wyatt, F., 2003. Testeretest reliability of lower extremity functional tests after a closed kinetic chain isokinetic testing bout. Journal of Sport Rehabilitation 12, 119e132. McGill, S., 2002. Low Back Disorders: Evidence-based Prevention and Rehabilitation. Human Kinetics, Champaign, IL. Nadler, S.F., Malanga, G.A., Feinberg, J.H., Prybicien, M., Stitik, T.P., DePrince, M., 2001. Relationship between hip muscle imbalance and occurrence of low back pain in collegiate athletes: a prospective study. American Journal of Physical Medicine and Rehabilitation 80, 572e577. Neumann, D.A., 2010. Kinesiology of the hip: a focus on muscular actions. Journal of Orthopaedic and Sports Physical Therapy 40, 82e94. Niemuth, P.E., 2007. Hip muscle weakness in lower extremity athletic injuries. International SportMed Journal 8, 179e192. Niemuth, P.E., Johnson, R.J., Myers, M.J., Thieman, T.J., 2005. Hip muscle weakness and overuse injuries in recreational runners. Clinical Journal of Sports Medicine 15, 14e21. Paluska, S.A., 2005. An overview of hip injuries in running. Sports Medicine 35, 991e1014. Plastaras, C.T., Rittenberg, J.D., Rittenberg, K.E., Press, J., Akuthota, V., 2005. Comprehensive functional evaluation of the injured runner. Physical Medicine and Rehabilitation Clinics of North America 16, 623e649. Powers, C.M., 2003. The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. Journal of Orthopaedic and Sports Physical Therapy 33, 639e646. Powers, C.M., 2010. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. Journal of Orthopaedic and Sports Physical Therapy 40, 42e51. Rauh, M.J., Koepsell, T.D., Rivara, F.P., Rice, S.G., Margherita, A.J., 2007. Quadriceps angle and risk of injury among high school cross-country runners. Journal of Orthopaedic and Sports Physical Therapy 37, 725e733. Reinking, M.F., Hayes, A.M., 2006. Intrinsic factors associated with exercise-related leg pain in collegiate cross-country runners. Clinical Journal of Sports Medicine 16, 10e14. Schache, A.G., Blanch, P.D., Rath, D.A., Wrigley, T.V., Bennell, K.L., 2005. Are anthropometric and kinematic parameters of the lumbo-pelvicehip complex related to running injuries? Research in Sports Medicine 13, 127e147. Taunton, J.E., Ryan, M.B., Clement, D.B., McKenzie, D.C., LloydSmith, D.R., Zumbo, B.D., 2002. A retrospective caseecontrol analysis of 2002 running injuries. British Journal of Sports Medicine 36, 95e101. Taunton, J.E., Ryan, M.B., Clement, D.B., McKenzie, D.C., LloydSmith, D.R., Zumbo, B.D., 2003. A prospective study of running injuries: the Vancouver sun run “in training” clinics. British Journal of Sports Medicine 37, 239e244. Wagner, T., Behnia, N., Ancheta, W.-K.L., Shen, R., Farrokhi, S., Powers, C.M., 2010. Strengthening and neuromuscular reeducation of the gluteus maximus in a triathlete with exerciseassociated cramping of the hamstrings. Journal of Orthopaedic and Sports Physical Therapy 40, 112e119.
Journal of Bodywork & Movement Therapies (2011) 15, 391e394
available at www.sciencedirect.com
SELF-MANAGEMENT: PATIENT SECTION
Y exercises for correcting the most common faulty movement pattern of the shoulder/neck region* D.C. Craig Liebenson* L.A. Sports & Spine, 10474 Santa Monica Blvd., #304, Los Angeles 90025, USA Received 3 May 2011; accepted 3 May 2011
Shoulder and neck problems frequently persist even after rest, physical therapy, medication, injections and even surgery. One of the great misunderstandings about musculoskeletal pain (MSP) is that it is due to some injury or structural pathology seen on an MRI or X-Ray. In spite of more and more structural imaging pain problems are becoming more persistent and chronic! Over the past few years a new more functional approach has come into focus. Modern assessment of MSP has shifted from diagnosis of structural pathology to functional pathology. Dysfunction is now realized to be the “missing link” in the management of persistent MSP (Wainner et al., 2007). In particular, the assessment and correction of faulty movement patterns which are the real source of biomechanical overload in the kinetic chain (Dome and Kibler, 2006). It is typical to have shoulder or neck pain without any relevant structural pathology on an MRI or X-Ray. Many people have also been shown to have arthritis, or other structural problems such as a rotator cuff tear without having any symptoms whatsoever (Fredericson et al., 2009). What then is it that predisposes one person to have pain or loss of physical capacity in one’s sport or activity? A recent Stanford University study found that over 20% of their NCAA collegiate volleyball players WITHOUT shoulder problems had either tears or arthritic *
This paper may be photocopied for educational use. * Tel.: þ1 31047 02909; fax: þ1 31047 03286 E-mail address:
[email protected]. URL: http://craigliebenson.com/.
1360-8592/$ - see front matter ª 2011 Published by Elsevier Ltd. doi:10.1016/j.jbmt.2011.05.001
degeneration in their shoulders (Fredericson et al., 2009). The authors concluded that IF someone with pain has such structural abnormalities it should not be automatically assumed that they need surgery or need to live with the pain. Instead the real source of pain usually lies elsewhere. The answer lies in what is called functional pathology of the motor system or dysfunctional movement. The most important type of dysfunction is a faulty movement pattern. In the upper back, shoulder girdle or neck area the key faulty movement pattern is an abnormal scapulohumeral rhythm (see Figure 1). This causes the shoulder girdle to shrug up towards the ear(s) and results in increased neck/shoulder muscle tension, rounded shoulders, and forward head posture (see Figure 2). These are the hallmarks of dysfunction which predispose to either pain or loss of athletic performance. Once identified this faulty scapulo-humeral movement pattern or shrugged shoulder(s) should be the first goal of treatment for musculoskeletal pain or training to build physical capacity for athletic development. This hand-out will show a simple training method called the Y exercise which can be used to both identify and correct such a dysfunctional movement pattern. The Y exercise involves testing and training with the arms in an overhead position making a letter Y shape. Some clinicians or trainers will also use the T or W position.
PREVENTION & REHABILITATION e SELF-MANAGEMENT: PATIENT SECTION
journal homepage: www.elsevier.com/jbmt
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Figure 1 Normal Scaplulo-Humeral Rhythm (excessive activity in the upper trapezius & deltoid combined with under-activity of middle trapezius, lower trapezius, & serratus anterior results in a dysfunctional shrugged shoulder movement pattern).
The Y exercise utilizes an important method called shoulder packing or scapular setting. The key to the exercise is to “pack” the shoulder down and back. Imagine standing with one arm extended in front of you with your palm facing down. Now, push down as if pushing down on the top of a stick that is at chest height (see Figure 3). Feel how your shoulder & shoulder blade muscles - in particular your latissimus dorsi - tighten as you push down on the stick. This feeling is the key to stabilizing or setting the scapulae (shoulder blade).
The Y Exercise e Shoulder Packing (“scapular setting”) To start: Stand facing a wall (about 1e2 inches away)
Place palms on the wall Raise arms up in a Y position (see Figure 4a) a) REACH up & shrug” e Pack up (see Figure 4b) Shrug shoulders upwards ears until neck shortens b) “ROLL back & down” - Pack down (set scapulae) (see Figure 4c) Roll (turn) hands out Bring shoulders back & down until neck lengthens c) RAISE Arms Off Wall e (see Figure 4e) Tighten “core” Lift arms off the wall Feel mid-back e just below the shoulder blades working Note: Avoid lifting arms off wall by arching lower back into sway back Perform 10e12 slow repetitions
Overhead Pull Down (a) normal (b) abnormal (shrugged).
Figure 3
Packing the Shoulder Down & Back.
PREVENTION & REHABILITATION e SELF-MANAGEMENT: PATIENT SECTION
Figure 2
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Figure 4 The Y Exercise e Shoulder Packing (a) start position; (b) Pack up (reach up); (c) Pack down (roll back & down); (d) Lift off (raise off wall); (e) Incorrect lift off with sway back.
References Dome, D.C., Kibler, W.B., 2006. Evaluation and management of Scapulothoracic disorders. Current Opinion in Orthopaedics 17 (4), 321e324.
Fredericson, M., Ho, C., Waite, B., et al., 2009. Magnetic resonance imaging abnormalities in the shoulder and wrist joints of asymptomatic elite athletes. PM & R 1, 107e116. Wainner, R.S., Whitman, J.M., Cleland, J.A., Flynn, T.W., 2007. Regional interdependence: a musculoskeletal examination model whose time has come. J. Orthop. Sports Phys. Ther. 37 (11), 658e660.
