Journal of
Official journal of the: ® Association of Neuromuscular Therapists, Ireland ® Australian Pilates Method Association ® National Association of Myofascial Trigger Point Therapists, USA ® Pilates Foundation, UK
Volume 14 Issue 1 2010
Bodywork and Movement Therapies EDITOR-IN-CHIEF
Leon Chaitow ND, DO c/o School of Integrated Health, University of Westminster, 115 New Cavendish Street, London W1M 8JS, UK Preferred mailing address: P.O.Box 41, Corfu, Greece 49100 (
[email protected])
ASSOCIATE EDITORS John Hannon DC San Luis Obispo, CA, USA (
[email protected])
Dimitrios Kostopoulos PhD, DSc, PT Hands-on Physical Therapy, New York, NY, USA (
[email protected])
Glenn M. Hymel EdD, LMT Department of Psychology, Loyola University, New Orleans, LA, USA (
[email protected])
Craig Liebenson DC Los Angeles, CA, USA (
[email protected])
ASSOCIATE EDITORS: PREVENTION & REHABILITATION Matt Wallden MSc, Ost, Med, DO, ND London, UK (
[email protected])
Warrick McNeill MCSP London, UK (
[email protected]) International Advisory Board D. Beales MD (Cirencester, UK) G. Bove DC, PhD (Kennebunkport, ME, USA) C. Bron PT (Groningen, The Netherlands) I. Burman LMT (Miami, FL, USA) J. Carleton PhD (New York, USA) F. P. Carpes PhD (Uruguaiana, RS, Brazil) Z. Comeaux DO FAAO (Lewisburg, WV, USA) P. Davies PhD (London, UK) J. P. (Walker) DeLany LMT (St Petersburg, FL, USA) M. Diego PhD (Florida, USA) J. Dommerholt PT, MS, DPT, DAAPM (Bethesda, MD, USA) J. Downes DC (Marietta, GA, USA) C. Fernandez de las Peñas PT, DO, PhD (Madrid, Spain) T. M. Field PhD (Miami, FL, USA) P. Finch PhD (Toronto, ON, Canada) T. Findley MD, PhD (New Jersey, USA) D. D. FitzGerald DIP ENG, MISCP, MCSP (Dublin, Ireland)
S. Fritz LMT (Lapeer, MI, USA) G. Fryer PhD. BSc., (Osteopath), ND (Melbourne City, Australia) C. Gilbert PhD (San Francisco, USA) C. H. Goldsmith PhD (Hamilton, ON, Canada) S. Goossen BA LMT CMTPT (Jacksonville, FL, USA) S. Gracovetsky PhD (Ocracoke, NC, USA) M. Hernandez-Reif PhD (Tuscaloosa, AL, USA) P. Hodges BPhty, PhD, MedDr (Brisbane, Australia) B. Ingram-Rice OTRLMT (Sarasota, FL, USA) J. Kahn PhD (Burlington, VT, USA) R. Lardner PT (Chicago, IL, USA) P. J. M. Latey APMA (Sydney, Australia) E. Lederman DO PhD (London, UK) D. Lee BSR, FCAMT, CGIMS (Canada) D. Lewis ND (Seattle, WA, USA) W. W. Lowe LMT (Bend, OR, USA) J. McEvoy PT MSC DPT MISCP MCSP (Limerick, Ireland) L. McLaughlin DSc PT (Ontario, Canada) C. McMakin MA DC (Portland, OR, USA)
J. M. McPartland DO (Middleburg, VT, USA) C. Moyer PhD (Menomonie, WI, USA) D. R. Murphy DC (Providence, RI, USA) T. Myers (Walpole, ME, USA) C. Norris MSc CBA MCSP SRP (Sale, UK) N. Osborne BSc DC FCC (Orth.), FRSH, ILTM (Bournemouth, UK) B. O’Neill MD (North Wales, PA, USA) J. L. Oschman PhD (Dover, NH, USA) D. Peters MB CHB DO (London, UK) M. M. Reinold PT, DPT, ATC, CSCS (Boston, MA, MD, USA) G. Rich PhD (Juneau, AK, USA) C. Rosenholtz MA, NCTMB (Boulder, CO, USA) R. Schleip MA, PT (Munich, Germany) J. Sharkey MSc, NMT (Dublin, Ireland) D. G. Simons MD (Covington, GA, USA) D. Thompson LMP (Seattle, WA, USA) E. Wilson BA MCSP SRP (York, UK) A. Vleeming PhD (Rotterdam, The Netherlands)
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EDITORIAL
Has osteopathy a role to play in treatment of flu? H1N1 influenza (also referred to as swine flu)e for most people who contract it e is no more aggressive or dangerous than regular seasonal influenza. (CDC 2009) And yet for some the infection has proved fatal, with reports suggesting that the majority of fatalities, related to H1N1 infection, have occurred in individuals who are immune compromised, or who have serious secondary pathologies, including diabetes, liver and/or heart disease. Most fatalities occur when the infection moves from the standard influenza-like symptoms, to a severe acute respiratory syndrome (SARS), leading to pneumonia. This is a similar pattern to those who contracted Avian H5N1 influenza, several years ago. (MMWR 2003)
Osteopathic possibilities? The Spanish flu outbreak of 1918 was the first of its kind to have a variety of modern treatment approaches applied. These included osteopathic, naturopathic and chiropractic care, in addition to standard medical care. The U.S. Dept Health & Human Services lists three reasons why, at that time, standard medical care was ineffective. First, physicians mistakenly believed Pfeiffer’s bacillus (rather than a virus) was responsible, despite a lack of supportive scientific evidence. Secondly, masks were relied upon despite their ineffectiveness with viruses (masks CAN prevent bacterial spread). Lastly, although few physicians believed in miasmas and imbalances in the humours, their remedies derived from these theories. (U.S. Dept Health & Human Services 2009) Magoun (2004) has presented a well-documented approach to osteopathic care at that time e with implications for those who have influenza nowadays, whether regular seasonal, Avian H5N1, or the current model, H1N1. Magoun (2004) discusses osteopathic manipulative approaches: In the United States, more than 28% of the population succumbed (Kolata, 2001) In US military hospitals, the mortality rate averaged 36%, while the mortality rate in US medical hospitals fell between 30% and 40%, with the exception of a rate of 68% in medical hospitals in New York City. (Patterson 2000) . the American School of 1360-8592/$36 ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.09.001
Osteopathy, now the Kirksville College of Osteopathic Medicine . contacted all their alumni. This effort culminated in 2445 osteopaths responding in treating 110,122 patients with influenza, with a resulting mortality of 0.25%. One of the few osteopathic medical hospitals, 400- bed Massachusetts Osteopathic Hospital, in Boston, also reported a mortality of 0.25% for that period. (Walter 1992) Building on this historical evidence, Hruby & Hoffman (2007) note that, although there were no controlled studies (and no descriptive comparisons between MD and DO patients), osteopaths achieved a high success rate perhaps due to osteopathic manipulative therapy
What treatment did osteopaths use OMT (osteopathic manipulative treatment) comprised a series of modalities that attempted to enhance thoracic mobility and lymphatic drainage, as well as liver, spleen and abdominal function. Hruby & Hoffman have described the range of approaches used e not as a specific protocol, but, ‘‘as a listing of OMT procedures as a resource for use in an overall treatment plan for a given patient ... These include thoracic, hepatic, splenic, abdominal and pedal lymphatic pump procedures, as well as rib raising procedures. Also included are other OMT procedures that, although not thoroughly researched, have been clinically observed to provide similar effects. These procedures include soft tissue procedures, pectoral traction, mandibular drainage, frontal and maxillary lifts, and diaphragm doming .[as well as]., muscle energy techniques that can help to improve rib cage biomechanics.’’ Most such approaches would be familiar to osteopathic practitioners.
Belief It may be useful to reflect on the effects of the strong and widespread conviction, held by many osteopaths (and chiropractors) e that manipulative methods are capable of encouraging the self-regulating functions of the body e and how such convictions e(possibly more widely held in 1918
2
Editorial
than 2010?) were able to translate to their flu-ridden patients? Paulus (2006) articulates this view when he says that the ‘‘quintessential goal’’ of the osteopath should be to: ‘‘diagnose the lack of motion and to help restore any quality of motion to the disordered region .. restoration of motion, not alignment of the musculoskeletal system, activates the therapeutic process that bring about healing.’’
Current evidence? Interestingly, although PubMed lists 956 H1N1 citations during the past six months, not one includes these keywords: manual therapy, lymphatic or even physical therapy. (PubMed, 2009) However recent research supports the possibility that general OMT is beneficial in enhancing immune function, particularly with respect to upper respiratory infections. For example: Sleszynski and Kelso (1993) demonstrated that prevention of post surgical atelectasis, using osteopathic thoracic manipulation was just as successful as incentive spirometry Jackson et al. (1998) found lymphatic and splenic pump techniques enhanced the antibody response to hepatitis B vaccination Noll et al. (1999, 2000) provided clear evidence of the value of OMT in care of elderly hospitalized pneumonia patients. Manual methods were applied to elderly hospitalized patients with pneumonia, Hospital time was reduced from a mean of 8.6 days without OMT to 6.6 days for those receiving OMT. Additionally OMT patients required less intravenous antibiotics Nicholas & Oleski (2002) Described a four-step protocol, composed of rib raising and treatment of the thoracic inlet, respiratory diaphragm, and pelvic diaphragm e for postoperative pain. ‘‘Patients who receive morphine preoperatively and OMT postoperatively tend to have less postoperative pain and require less intravenously administered morphine. In addition, OMT and relief of pain lead to decreased postoperative morbidity and mortality and increased patient satisfaction. Also, soft tissue manipulative techniques and thoracic pump techniques help to promote early ambulation and body movement.’’ Knott et al. (2005) demonstrated that osteopathic thoracic pump, and abdominal pump techniques, increased the flow of lymph through the thoracic ducts of mongrel dogs.
The potential value of such methods, applied in appropriate situations, alongside standard medical care, by osteopaths, physiotherapists, chiropractors, or other suitable trained therapists/practitioners, deserves further study, and not just in relation to H1N1.
References CDC, 2009. http://www.cdc.gov/h1n1flu/sick.htm (accessed 14. 09.09.). Hruby, R., Hoffman, K., 2007. Avian influenza: an osteopathic component to treatment. Osteopat Med Primary Care 1, 10. Jackson, K., et al., 1998. Effect of lymphatic and splenic pump techniques on the antibody response to hepatitis B vaccine: a pilot study. J. Am. Osteopath. Assoc. 98, 155e160. Knott, M., et al., 2005. Lymphatic pump treatments increase thoracic duct flow. J. Am. Osteopath. Assoc. 105, 447e456. Kolata, G., 2001. Flu e the Story of the Great Influenza Pandemic of 1918 and the Search for the Virus that Caused It. Simon & Schuster, New York. Magoun, H., 2004. More about the use of OMT during influenza epidemics. J Am Osteopathic Assoc 104 (10), 407. Morbidity & Mortality World Report, Mar 28, 2003. Outbreak of Severe Acute Respiratory SyndromedWorldwide. Centers for Disease Control. 52:241e246, 248. Nicholas, A., Oleski, S., 2002. J. Am. Osteopath. Assoc. 102 (Suppl. 3), S5eS8. Noll, D., et al., 1999. Adjunctive osteopathic manipulative treatment in the elderly hospitalized with pneumonia: a pilot study. J. Am. Osteopath. Assoc. 99, 143e152. Noll, D., et al., 2000. Benefits of osteopathic manipulative treatments for hospitalized elderly patients with pneumonia. J Am Osteopath Assoc. 100, 776e782. Patterson, M., 2000. Osteopathic methods and the great flu pandemic of 1917e1918. J. Am. Osteopathic. Assoc. 100, 309e310. Paulus, S., 2006. Concerning osteopathy: vital motions and material forms 2006. http://www.interlinea.org/ (viewed September 18, 2009). PubMed, 2009. http://www.ncbi.nlm.nih.gov/pubmed?termZ %28swineþORþH1N1%29þANDþ%28fluþORþinfluenzaþORþvirus þORþoutbreakþORþpandemic%29þANDþ%22lastþ6þmonths%22 [edat] (viewed September 16, 2009). Sleszynski, S.L., Kelso, A.F., 1993. Comparison of thoracic manipulation with incentive spirometry in preventing postoperative atelectasis. J. Am. Osteopathic. Assoc. 93, 834e838. 843e845. U.S. Dept Health & Human Services, 2009. http://1918.pandemicflu. gov/the_pandemic/03.htm (viewed September 16, 2009). Walter, G., 1992. The First School of Osteopathic Medicine. The Thomas Jefferson University Press at Northeast Missouri State University, Kirksville, Mo, p. 95.
Leon Chaitow New Medicine Group, 144 Harley Street, London W1, United Kingdom E-mail address:
[email protected] Journal of Bodywork & Movement Therapies (2010) 14, 3e12
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CLINICAL HYPOTHESIS
Fascia: A missing link in our understanding of the pathology of fibromyalgia Ginevra L. Liptan a,b,* a
Dept. of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, United States b Legacy Good Samaritan Pain Management Center, 1130 NW 22nd Ave, Suite 345, Portland, OR 97210, United States Received 26 January 2009; received in revised form 7 August 2009; accepted 11 August 2009
KEYWORDS Central sensitization; Myofascial release; Manual therapy; Inflammation; Connective tissue; Growth hormone
Summary Significant evidence exists for central sensitization in fibromyalgia, however the cause of this process in fibromyalgiadand how it relates to other known abnormalities in fibromyalgiadremains unclear. Central sensitization occurs when persistent nociceptive input leads to increased excitability in the dorsal horn neurons of the spinal cord. In this hyperexcited state, spinal cord neurons produce an enhanced responsiveness to noxious stimulation, and even to formerly innocuous stimulation. No definite evidence of muscle pathology in fibromyalgia has been found. However, there is some evidence for dysfunction of the intramuscular connective tissue, or fascia, in fibromyalgia. This paper proposes that inflammation of the fascia is the source of peripheral nociceptive input that leads to central sensitization in fibromyalgia. The fascial dysfunction is proposed to be due to inadequate growth hormone production and HPA axis dysfunction in fibromyalgia. Fascia is richly innervated, and the major cell of the fascia, the fibroblast, has been shown to secrete pro-inflammatory cytokines, particularly IL-6, in response to strain. Recent biopsy studies using immuno-histochemical staining techniques have found increased levels of collagen and inflammatory mediators in the connective tissue surrounding the muscle cells in fibromyalgia patients. The inflammation of the fascia is similar to that described in conditions such as plantar fasciitis and lateral epicondylitis, and may be better described as a dysfunctional healing response. This may explain why NSAIDs and oral steroids have not been found effective in fibromyalgia.
* Legacy Good Samaritan Pain Management Center, 1130, NW 22nd Ave, Suite 345, Portland, OR 97210, United States. Tel.: þ1 503 413 7513; fax: þ1 503 413 7503. E-mail address:
[email protected] 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.08.003
4
G.L. Liptan Inflammation and dysfunction of the fascia may lead to central sensitization in fibromyalgia. If this hypothesis is confirmed, it could significantly expand treatment options to include manual therapies directed at the fascia such as Rolfing and myofascial release, and direct further research on the peripheral pathology in fibromyalgia to the fascia. ª 2009 Elsevier Ltd. All rights reserved.
Introduction The etiology of fibromyalgiada disorder characterized by widespread muscle pain and tenderness at specific soft-tissue tender pointsdremains unclear. However, in the past decade evidence for abnormal pain processing in fibromyalgia has significantly advanced our understanding of this disorder. In 2002, a functional MRI study demonstrated that it took much less thumbnail pressure in fibromyalgia patients to activate the pain sensing areas of the brain compared to controls (Gracely et al., 2002). Another study found that fibromyalgia patients experienced stronger pain and larger areas of referred pain after intramuscular injection of hypertonic saline (Sorensen et al., 1998). Other research has shown abnormal temporal summation and wind-up of pain in fibromyalgia (Staud et al., 2004). These findings demonstrate that in fibromyalgia the central nervous system has an exaggerated response to pain, a phenomenon called central sensitization. Central sensitization is caused by repeated or sustained noxious input to the dorsal horn neurons leading to increased neuronal responsiveness or central sensitization. In fibromyalgia, however, no evidence of muscle pathology has been described, leading to speculation that the central sensitization in fibromyalgia may occur spontaneously though some as yet unknown mechanism (Ji et al., 2003). Others argue that myofascial trigger points cause the central sensitization in fibromyalgia (Staud, 2008). However recent biopsy studies have found increased levels of collagen and inflammatory mediators in the fascia of fibromyalgia patients. This paper proposes that dysfunction and inflammation of the intramuscular connective tissue, or fascia, leads to the central sensitization seen in fibromyalgia.
Central sensitization Central sensitization, a state of heightened sensitivity in the spinal cord, is thought to be a physiologic adaptation of the nervous system to sustained painful input. It is the end result of a complex neuronal response to peripheral nerve injury or tissue inflammation. Recent studies support an important role for dorsal horn glial cells (support cells for neurons) and NMDA receptors in producing abnormal pain sensitivity in the spinal cord (Watkins et al., 2001; Dickenson and Sullivan, 1987). In lab animals, central sensitization can be induced by injecting inflammatory chemicals into muscle, and by damaging peripheral nerves. Central sensitization has also been described in many chronic pain conditions, including endometriosis (Bajaj et al., 2003), peripheral arterial disease (Lang et al., 2006), and chronic low back pain (O’Neill et al., 2007). In these conditions there is a known source of persistent nociceptive input that keeps the CNS in a continued state of sensitization. One group showed that central sensitization associated with painful hip
osteoarthritis normalized following successful hip replacement surgery (Kosek and Ordeberg, 2000).
What causes central sensitization in fibromyalgia? Since patients with fibromyalgia complain of sore, painful muscles, investigators have long been searching for muscle pathology in fibromyalgia. These studies have included muscle biopsies with structural and ultra-structural observation, magnetic resonance imaging and metabolic studies, electromyography, and studies of blood flow and muscle strength. For the most part these studies have not shown consistent differences between healthy and fibromyalgia muscles. In Simm’s rigorous review of 32 studies of muscle in fibromyalgia he states ‘Although controversy persist, the weight of evidence from studies that are methodologically sound suggests that muscles are not abnormal’ (Simms, 1996). Others still argue that peripheral pain mechanisms must play an important role in fibromyalgia pain. ‘Central sensitization has to have an initial genesis and nociceptive stimuli from painful foci in muscle are increasingly recognized as being relevant to the development of fibromyalgia’ (Bennett, 2004). Supporting the idea that there are softtissue abnormalities in fibromyalgia is the distribution of pain, which is not uniform as one would expect if the pain was generated solely from a spontaneous central nervous system hypersensitivity, but is most prevalent in certain areas of the soft-tissue, especially the shoulders, chest, and lower back (Starz et al., 2008). The often observed worsening of fibromyalgia pain after an episode of muscle overuse also argues for a peripheral pathology in FM. Myofascial trigger points have been suggested as the peripheral source of painful input leading to central sensitization in fibromyalgia. Myofascial trigger points are discrete painful spots located in a palpable taut band of skeletal muscle, classified as active if they cause pain at rest, and latent if they are painful only with palpation (Simons et al., 1999). However, attributing the central sensitization seen in fibromyalgia solely to trigger points is problematic. Not all patients with fibromyalgia have trigger points, and not all patients with trigger points have fibromyalgia. One study found 68% of fibromyalgia patients had identifiable trigger points (Granges and Littlejohn, 1993), and another found trigger points in only 38% of fibromyalgia subjects examined (Wolfe et al., 1992). Myofascial trigger points are also quite commond33e54% of completely asymptomatic individuals have latent trigger points (Sola et al., 1955; Schiffman et al., 1990).
Background The symptoms of fibromyalgia have historically been described by many different terms, including ‘Chronic
Fascia: a missing link Rheumatism’ and ‘Muscular Rheumatism’. In a review article in 1904, Stockman described the symptoms of chronic rheumatism as ‘pain, aching, stiffness, a readiness to feel muscular fatigue, interference with free muscular movement, and very often a want of energy and vigour’ (Stockman, 1904). Chronic rheumatism was not thought by Stockman to affect the joints themselves, but rather the fibrous tissues structures of the muscles. He attributed chronic rheumatism primarily to infectious causes, particularly rheumatic fever and influenza, but also noted some cases with no infectious etiology. Stockman notes the work of Balfour and Scudamore, two British physicians who separately in the early 19th century put forward the idea that the pain of muscular rheumatism occurs as a result of thickenings developing in the fibrous connective tissue of muscle. Sir William Gowers attributed symptoms of muscular rheumatism to the ‘inflammation of fibrous tissue’, and proposed that the condition should be called ‘fibrositis’ (Gowers, 1904). Due to lack of evidence of peripheral inflammation, in 1976 the term ‘fibromyalgia’ was proposed, and ultimately adopted by the American College of Rheumatology when they released formal diagnostic criteria for the condition in 1990 (Wolfe et al., 1990). However the current terminology still reflects the concept of connective tissue abnormality in fibromyalgia, as the name is composed of the Latin words for fiber, muscle, and pain. Allopathic medicine has historically regarded fascia as relatively inert. According to a recent article in Science magazine ‘medical books barely mention fascia and anatomical displays remove it’ (Grimm, 2007). However in osteopathic medicine, the fascia has long been recognized as a potential cause of pain and soft-tissue dysfunction. As one osteopath writes ‘The whole of OMT [osteopathic manipulative treatment] has been concerned, purposefully or not, with manipulation of the fascia’ (Danto, 2003).
5
Figure 1
Published with kind permission of Ron Thompson.
to its roles in regulation of inflammation and wound repair. Fibroblast activation is induced by various stimuli that occur with tissue injury. Activated fibroblasts isolated from the site of a healing wound will continue to secrete higher levels of ECM and proliferate more rapidly than fibroblasts obtained from normal tissue. Fibroblasts are also an important source of ECM degrading proteases, and have
Fascia Fascia is the dense connective tissue that envelopes muscles grossly, and also surrounds every bundle of muscle fibers and each individual muscle cell. This connective tissue is inextricably linked with the muscle, and is continuous with the tendons and periosteum (Figures 1 and 2). The fascia is composed of cellsdincluding fibroblasts, macrophages and mast cellsdand extracellular matrix. The extracellular matrix (ECM) is composed of ground substance and collagen and elastin fibers. Fascia is essentially a dense gel (the ground substance) in which cells and fibers are suspended, giving it colloidal properties. Fascia is richly innervatedda histological study found nerve fibers in all specimens of the deep fascia, including a variety of both free and encapsulated nerve endings, especially Ruffini and Pacini corpuscles (Stecco et al., 2006). In fact muscle innervation is primarily located in the fascia: consisting of 25 percent stretch receptors of muscle cells, and 75 percent free nerve endings in intramuscular fascia, and in the walls of blood vessels and tendons (Bonica, 1990). The principal cell of the connective tissue is the fibroblast, which produces the extracellular matrix, in addition
Figure 2 Structure of skeletal muscle, illustrating the layers of surrounding connective tissue known as the fascia, which includes the deep fascia, epimysium, perimysium and endomysium.
6 a crucial role in maintaining homeostasis and repair in the ECM (Kalluri and Zeisberg, 2006). Fascia has been demonstrated in vitro to have some contractile behavior. Some fibroblasts, called myofibroblasts, express alpha-smooth-muscle actin and are able to contract (Schleip et al., 2005, 2006). Increased expression of smooth-muscle actin is thought to be triggered by mechanical stimulation and inflammation in order to promote wound healing and tissue repair. Fibroblasts also respond to mechanical stretch with hyperplasia and secretion of inflammatory cytokines (Skutek et al., 2001). Using in vitro models, Dodd et al. demonstrated that fibroblasts respond to acyclic mechanical strain by altering shape and alignment, undergoing hyperplasia and secreting inflammatory cytokines, including IL-6 (Dodd et al., 2006). Fibroblasts have a vital role in the regulation of inflammation. Dysregulation of fibroblasts has been implicated in the chronic inflammation seen in rheumatoid arthritis. Synovial fibroblasts isolated from rheumatoid arthritis joints were found to secrete increased amounts of NF-kB, a transcription factor that ‘appears to play a critical role in perpetuating both tissue hyperplasia and the inflammatory response at sites of chronic inflammation’ (Miagkov et al., 1998; Buckley et al., 2001).
Fibrosis and adhesions One of the hallmarks of connective tissue, including fascia, is its mutability and remodeling in response to mechanical stress. However, under certain conditionsdexcess mechanical stress, inflammation or immobilitydthis process can result in excessive and disorganized collagen and matrix deposition resulting in fibrosis and adhesions (Langevin, 2008). In plantar fasciitis and tendinitis of the elbow these types of changes have been reported. Two series of surgical biopsies in patients with plantar fasciitis reported fascial thickening, collagen disorganization and increased fibroblasts. Jarde et al. (2003) in a report on 38 cases of plantar fasciitis noted ‘collagen degeneration with fibers losing their longitudinal arrangement and presenting with a haphazard orientation, with an increase in fibroblastic cellular density’. They also noted microcalcifications in the fascia of a few of the surgical specimens. The authors found that these lesions were similar to those found in cases of tendon injury. Tendons are essentially a denser version of intramuscular fascia with the same components of fibroblasts, collagen and extracellular matrix. According to a review of the histopathological changes found in lateral epicondylitis, the most common findings were hypertrophy of fibroblasts and abundant disorganized collagen (Kraushaar and Nirschl, 1999). A biopsy study of the thoracolumbar fascia in chronic mechanical low back pain found evidence suggestive of fascial inflammation, in particular degenerative changes in the collagen fibers and microcalcifications in the fascia (Bednar et al., 1995). In an ultrasound-based comparison, chronic low back pain patients had approximately 25% thicker perimuscular connective tissue in the
G.L. Liptan thoracolumbar fascia than healthy controls (Langevin et al., 2009). Eosinophilic fasciitis, a rare condition resulting in widespread eosinophilic infiltration and inflammation of the fascia results in significant fibrosis of the fascia. ‘Adhesions seen in eosinophilic fasciitis, which develops grossly thickened fascia and fibrosis are indicative of the potential for fascial inflammation to cause adhesions’ (Franklyn-Miller et al., 2009).
Evidence for fascial dysfunction in fibromyalgia When Stockman examined muscle biopsy studies of patients with ‘chronic rheumatism’ in 1904, he found inflammatory hyperplasia of the connective tissue. Specifically he described a section of inflamed perimysium which on light microscopic evaluation consisted of a ‘proliferated and oedematous fibrous tissue with an amorphous matrix’, leading him to conclude that ‘the essential pathological changes in chronic rheumatism are confined to white fibrous tissue’ (Stockman, 1904). However, Collins later examined Stockman’s published illustrations and noted ‘scarcely more variation in fibrous tissue structure than can be encountered normally in different situations in the human body’. Collins also examined 7 ‘typical fibrositic’ nodules under light microscopy and found no evidence of inflammation (Collins, 1940). Both of these early studies suffered from methodological flaws including lack of controls groups and poorly defined diagnostic criteria. More recent studies of FM muscle using standard histopathology techniques under light microscopy have not shown any consistent pathology (Lindh et al., 1995; Drewes et al., 1993). However one group described a ‘network of reticular fibers connecting muscle fibers’ causing a ‘rubberband like’ constriction of muscle fibers seen under light microscopy (Bartels and Danneskold-Samsoe, 1986). Electron microscopic studiesdwhich examine the myofibrils and sarcomeres that make up individual muscle cellsdhave also not shown any differences between fibromyalgia muscles and controls (Yunus et al., 1989a). While no consistent abnormalities have been found at either the ultrastructural or structural level of muscle cells using standard techniques, two recent studies using specialized immuno-histochemical staining techniques focused on the intramuscular connective tissue have discovered some intriguing abnormalities. Spaeth et al. describe an increase in collagen IV surrounding the muscles of fibromyalgia patients. Comparing immuno-stained muscle biopsies from 25 fibromyalgia patients to 26 healthy controls, they described a ‘slight, but significant increase in collagen surrounding the muscle cells of the fibromyalgia patients’ (Spaeth et al., 2005). Ruster et al. also found increased levels of collagen in the endomysium in fibromyalgia muscles, and in addition describe evidence for endomysial inflammation and tissue damage. Specifically, they note elevated levels of N-carboxymethyllsine (CML), an advanced glycation end-product (AGE) that is considered to be a marker of oxidative stress and tissue damage, in the fascia of fibromyalgia patients.
Fascia: a missing link ‘CML staining was stronger in the fibromyalgia patients, and was detected primarily in the interstitial tissue between the muscle fibers’ (emphasis added). They reported increased staining of collagen types I, II, and VI in the interstitial tissue compared to healthy subjects and found ‘the collagens and CML were co-localized, suggesting that the AGE modifications were related to collagen’. In addition, they found increased levels of CD-68 positive macrophages and activated NF-kB in the interstitial tissue of fibromyalgia muscles (Ruster et al., 2005). As described earlier, NF-kB is a transcription factor that plays an important role in the regulation of fibroblast hyperplasia and cytokine release, and high levels of NF-kB have also been reported in synovial fibroblasts from rheumatoid joints (Miagkov et al., 1998). This immuno-histochemical evidence is suggestive of fascial inflammation in fibromyalgia. As described earlier, focal fascial inflammation has been described in other conditions as plantar fasciitis and low back pain. Giesecke et al. found evidence for central sensitization in idiopathic chronic low back pain patients (Giesecke et al. 2004). Since local myofascial inflammation as described in chronic low back pain could be a trigger of central sensitization, it is possible that a more generalized fascial inflammation could lead to central sensitization as well. In fact peripheral afferent nociceptors of muscle, the majority of which reside in the fascia, have been shown to be highly effective at causing central sensitization (Wall and Woolf, 1984).
Growth hormone and sleep abnormalities Moldofsky was able to cause symptoms of fibromyalgiadwidespread muscle pain and fatiguedin healthy patients by depriving them of deep (slow-wave) sleep experimentally (Moldofsky and Scarisbrick, 1976). These symptoms resolved once subject were again allowed deep sleep. Sleep studies have demonstrated that fibromyalgia patients experience reduced deep sleep that is frequently interrupted with alpha-waves which are normally associated with states of wakefulness (Moldofsky et al., 1975). Growth hormone is primarily secreted during deep sleep and after exercise, and is responsible for regulating the healing and maintenance of tissues. Nearly 70% of total GH secretion occurs at night, and GH secretion ‘will not occur if sleep stage III or IV is prevented by awakening the subject’ (Felig et al., 1995). Reduced 24 h secretion of GH in FM has been reported, with the decrease most noticeable during the night when GH secreted in the patients was much lower than in controls (Leal-Cerro et al., 1999). Another group also found reduced GH secretion during sleep compared to controls (Landis et al., 2001). More than 90% of fibromyalgia patients have inadequate growth hormone response to exercise (Paiva et al., 2002) and one third have significantly low circulating IGF-1 levels (Bennett et al., 1992). Human growth hormone replacement in FM patients resulted in significant improvement of symptoms and reduction in tender points in one study (Bennett et al., 1998). Some of the clinical features of FM are similar to those described in adult GH deficiency syndrome including fatigue, muscle weakness, impaired exercise tolerance and
7 depression. Unlike FM, pain is not a major feature described in adult GH deficiency syndrome. However treatment with GH has been reported to improve pain levels in adult GH deficient patients (Cuneo et al., 1998). These conditions may not be directly comparable, however, because true adult GH deficiency is usually acquired due to pituitary damage and is generally accompanied by multiple other pituitary hormone deficiencies. In contrast, fibromyalgia patients have normal pituitary responses but have subtle alterations in hypothalamic control of growth hormone release (Leal-Cerro et al., 1999). Fibroblasts have growth hormone receptors, and in response to growth hormone secrete many important locally acting growth factors, such as IGF-1 (Murphy et al., 1983; Oakes et al., 1992). Fibroblasts play a central role in wound healing, and IGF-1 is a major physiological mediator of normal wound healing (Suh et al., 1992) A study of wound healing in rats revealed increased IGF-1 immunoreactivity in fibroblasts, epidermal cells and macrophages in the incisional area (Todorovic et al., 2008). Improved wound healing and increased staining for IGF-1 in healing tissue have been reported after administration of recombinant human growth hormone (Gilpin et al., 1994; Herndon et al., 1995). Local IGF-1 administration has also been found to improve wound healing (Suh et al., 1992; Beckert et al., 2007). An intriguing study of gamma-hydroxybutyrate, a medication known to increase slow wave sleep, was found to both increase growth hormone levels and improve wound healing in rats (Murphy et al., 2007). This medication has also shown benefit in recent human studies of patients with FM as well, and the improvements in sleep significantly correlated with improvements in pain scores (Russell et al., 2009).
Hypothesis Fascial dysfunction and inflammation may lead to the widespread pain and central sensitization seen in fibromyalgia. This paper proposes that the fascial dysfunction in fibromyalgia could be caused by chronic tension in the fascia and an impaired fascial healing response due to inadequate growth hormone stimulation. In genetically prone individuals, a trauma may trigger prolonged dysfunction of the stress response. This chronic autonomic arousal and hypervigilance may cause excess fascial tension, interfere with deep sleep and impair growth hormone release (Figure 3). There seems to be a genetic component to fibromyalgiadfirst-degree relatives of patients with fibromyalgia are 8.5 times more likely to have fibromyalgia than relatives of patients with rheumatoid arthritis (Arnold et al., 2004). An association between trauma and fibromyalgia has also been reported, with one study finding that ‘physical trauma in the preceding 6 months is significantly associated with the onset of FM’ (Al-Allaf et al., 2002). Hyperactivity of the stress response has also been described in fibromyalgia, with dysfunction of both hypothalamicepituitaryeadrenal axis and of the autonomic nervous system (Adler et al., 1999; Cohen et al., 2000). Hyperactivity of the HPA axis can also cause a blunted growth hormone response (Jones et al., 2007). Chronic sympathetic dominance of the nervous system may also promote chronic tension in the fascial system.
8
G.L. Liptan mechanical stress from daily activities, and thus have higher levels of fascial inflammation. The areas near muscle/tendon junctions are particularly susceptible to microinjuries from mechanical forces. In fact, six of the 18 tender points used to define the condition occur in or near areas of tendinous insertions, namely those at the suboccipital muscle insertions, near the epicondyles and at the medial fat pad of the knee (Figure 4a and b).
Anti-inflammatories in fibromyalgia If fascial inflammation exists in FM, why are non-steroidal anti-inflammatory medications (NSAID) and corticosteroids ineffective? No improvement in fibromyalgia symptoms was reported with prednisone 15 mg per day for two weeks, or with the NSAID medications ibuprofen and naproxen (Clark et al., 1985; Goldenberg et al., 1986; Yunus et al., 1989b). This paper argues that there is indeed fascial inflammation in fibromyalgia, but that it is a type of inflammation that is not responsive to oral NSAIDs or corticosteroids. The fascial inflammation proposed to exist in fibromyalgia is similar to that described in chronic overuse injuries such as lateral epicondylitis and plantar fasciitis. This inflammation is attributed to cumulative microtrauma that overwhelms the tissue’s ability to repair itself, resulting in a chronic inflammatory reaction that may be more appropriately termed a ‘dysfunctional healing response’. The response to injury of connective tissue, including fascia, ligaments and tendons, occurs in three phases (Kumar, 1999).
Figure 3 Proposed etiology of central sensitization in fibromyalgia.
1) Inflammatory phasedinvasion of polymorphonuclear cells and monocytes/macrophages, and release of prostaglandin and cytokines 2) Proliferative phasedfibroblasts activated to produce collagen and extracellular matrix that is laid down in disorganized fashion 3) Remodeling phasedprogressive maturation and alignment of collagen fibers and remodeling of extracellular matrix
Fascia has recently been shown to be able to have significant contractile force in vitro, and this fascial contractility is though to contribute to the incredible feats of strength humans can perform in emergenciesdsituations in which the sympathetic nervous system is also dominant (Schleip et al., 2005; Schleip et al., 2006). In response to chronic excess fascial tension, fibroblasts would likely overproduce collagen and extracellular matrix in a continuous attempt to respond to the increased mechanical stress. However due to inadequate growth hormone stimulation of fibroblast there may be an impaired fascial healing response resulting in chronic fascial inflammation; there is ‘a critical role for fibroblasts in regulating the switch from acute to chronic inflammation in tissues’ (Buckley et al., 2001). This widespread dysfunctional fascial healing response could be considered a ‘bodywide fasciitis’ as compared to the more focal fasciitis seen in other conditions such as plantar fasciitis. The tender points of fibromyalgia may reflect areas that suffer the greatest microtrauma and
The anti-inflammatory effect of NSAIDs is due to their interference with prostaglandin production, thus they are effective in the initial inflammatory phase of injury repair. NSAIDs have been shown to be helpful in decreasing pain and swelling in acute soft-tissue injuries, but not in chronic soft-tissue inflammation (Heere, 1987). A randomized controlled trial of NSAIDs in plantar fasciitis found that both placebo and NSAID group improved over time, and there was no statistical difference between the groups at 1, 2 or 6 months (Donley et al., 2007). Another randomized controlled study found no difference between placebo and NSAID treatment in chronic achilles tendinopathy (Astrom and Westlin, 1992). Local corticosteroid injections have shown effectiveness in overuse injuries but this effect tends to be short-lived. A randomized controlled trial of steroid injections in plantar fasciitis found a statistically significant pain reduction at 1 month in the treatment group that had disappeared by 3 months post treatment (Crawford et al., 1999). In lateral epicondylitis steroid injections also provide
Fascia: a missing link
Figure 4
9
a and b: 18 tender points of fibromyalgia as established by 1990 ACR criteria (Wolfe et al., 1990).
only temporary improvement, and ‘the significant shortterm benefits of corticosteroid injections are paradoxically reversed after six weeks with high recurrence rates’ (Bissett et al., 2006). In an animal model of chronic muscle inflammation created by injecting inflammatory stimulants into the hamstrings of mice, neither NSAIDs nor high-dose oral corticosteroids were effective in reducing inflammation. The inflammation could only be reduced by local corticosteroid injection directly into the muscle (Green and Mangan, 1980). Notably, while NSAIDs and oral steroids have been tested in FM, the effectiveness of local steroid injections in FM has not been assessed. NSAIDs and corticosteroids are not only ineffective in relieving chronic soft-tissue inflammation but may actually hinder the healing process. Two studies reported slowed muscle repair in animals treated with an NSAID (Obremsky et al., 1994; Almekinders and Gilbert, 1986). Indomethacin added to repetitively stretched fibroblasts in vitro reduced the secretion of prostaglandins but also inhibited the synthesis of DNA, an effect that may be detrimental in the remodeling phase of repair (Almekinders et al., 1995). Corticosteroids are also notorious for impairing surgical wound healing (Suh et al., 1992). Thus NSAIDs and corticosteroids may actually worsen an already dysfunctional tissue repair response in fibromyalgia.
Manual therapy in fibromyalgia treatment In 1904 Stockman recognized the potential of manual therapy in treating chronic rheumatism (what is now called fibromyalgia) and noted that ‘indurated fibrous tissue can
however only be removed by local and well-directed manipulations’ (Stockman, 1904). This idea was reiterated recently by a leading fascia researcher, ‘Treatments involving direct mechanical stimulation of connective tissue can potentially reverse connective tissue fibrosis’ (Langevin, 2008). Myofascial fibrotic changes can theoretically be treated by breaking up excessive collagen adhesions through soft-tissue and myofascial release techniques (Ward, 2003). If there is excess tension in the fascial system in fibromyalgia due to chronic sympathetic nervous dominance, manual therapy may also help reduce that tension. A randomized controlled pilot study demonstrated that osteopathic manipulative treatment (OMT), in conjunction with medication, was more effective in relieving symptoms of fibromyalgia than medication alone (Gamber et al., 2002). A total of 24 patients were included in the study, and the treatment group received once weekly OMT sessions for 23 weeks. The control group received either moist heat packs at each visit or no additional treatment beyond their usual medications. The osteopathic manipulative techniques used in this study were individualized for each patient, so it is difficult to assess how much treatment directed specifically at the fascia that each patient received. Each patient received Jones strain/counterstrain techniques and other modalities per provider discretiondincluding myofascial release, muscle energy, softtissue treatment and craniosacral manipulation. A Swedish study on connective tissue massage in fibromyalgia found a pain-relieving benefit of 37% in addition to reduced use of analgesics and positive effects on quality of life. The treatment group consisted of 23 patients who received 15 treatments over 10 weeks, while the control
10 group participated in weekly discussion groups. The connective tissue massage is described as a ‘manual techniques to detach dense connective tissue’, but no further description of the technique is provided. Interestingly, this treatment was chosen for the study because ‘experienced massage therapists who were surveyed prefer connective tissue massage for the treatment of individuals with fibromyalgia’ (Brattberg, 1999). However, for manual therapies to be effective in fibromyalgia, they must take into account the colloidal properties of fascia, and according to Chaitow and DeLany ‘the amount of resistance colloids offer increases proportionally to the velocity of force applied to them. This makes a gentle touch a fundamental requirement . when attempting to produce a change in, or release of restricted fascial structures which are all colloidal in their behavior’ (Chaitow and DeLany, 2000). Therefore, only slow and sustained pressure will effect changes in the fascial tissue. Appropriate manual therapy must allow for the state of reduced growth hormone and thus reduced capacity for tissue repair in fibromyalgia by allowing for sufficient rest between sessions. Utilizing the growing body of knowledge on the properties of fascia can help manual therapists treat fibromyalgia patients with techniques that don’t cause further injury and inflammation, but rather gently break apart existing fascial restrictions and adhesions and promote tissue healing.
Conclusion This paper presents the hypothesis that fascial dysfunction in fibromyalgia leads to widespread pain and central sensitization. Using other known abnormalities in fibromyalgia, a proposed mechanism leading to fascial dysfunction in fibromyalgia is described. The in vivo microdialysis techniques developed by Shah’s group to assess myofascial trigger points could also be used to evaluate the chemical composition of fascial interstitial fluid for evidence of inflammation (Shah et al., 2005). In vitro examination of fibroblasts removed from fascial tissues in fibromyalgia could look for evidence of activation, such as excess secretion of extracellular matrix and inflammatory mediators. Comparing fascial IGF-1 levels in fibromyalgia to controls may also be useful. Finally, clinical studies of manual therapies that target the fascia, like Rolfing and myofascial release, could help define the role of fascia in producing fibromyalgia pain. Directly comparing a therapy aimed at releasing fascial restriction such as myofascial release to a massage therapy that focuses primarily on muscle relaxation would be informative. If there is clinical improvement with manual therapies targeting the fascia, this could significantly improve our ability to treat fibromyalgia, and guide further research on the peripheral pathology of fibromyalgia towards the fascia.
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Journal of Bodywork & Movement Therapies (2010) 14, 13e18
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APPLIED PHYSIOLOGY
Skin distraction at select landmarks on the spine midline in the upright and fully flexed postures Paul J. Moga, D.O., Ph.D Post Office Box 4088, Ann Arbor, Michigan 48106e4088, USA Received 31 January 2008; received in revised form 13 March 2008; accepted 28 April 2008
KEYWORDS Skin distraction; Spinal motion; Spinal angles; Hamstring tightness; Fascia; Manual medicine; Spine
Summary Background: This study was aimed at quantifying superoinferior and mediolateral skin distraction over the spine’s midline for the purpose of designing a unique surface marker for use in a study originally proposed by Wojtys and Ashton-Miller. It was also aimed at testing the null hypotheses H01: There is no difference in the amount of skin distraction between hamstring normal and hamstring tight subjects and H02: There are no age or gender differences of skin distraction. Methods: Nine male and twelve female volunteers served as the convenience subjects for this IRB-approved study. Eight subjects were classified as hamstring ‘‘tight’’ (short) using the Finger-to-Floor Reach Test. Skin distraction was measured at five spine midline landmarks palpated on the subjects’ bared backs: T1, T10, L3, S1, and the posterioresuperior iliac spine (PSIS). A pattern of four dots was placed at each landmark using a rectangular template and non-toxic, water-soluble ink. Measurements were taken between superoinferior and mediolateral pairs of template points with subjects in both upright (‘‘initial’’) and fully flexed (‘‘final’’) postures. Between-measurement differences were then calculated, expressed as percent strain, and pooled for mean percent strain values. Repeated measures produced a maximum strain error of about 1.7%. Results: With the exception of the skin over the T10 landmark, distraction in the superoinferior direction was greater than that in the mediolateral direction. There were no significant differences in skin distraction between age or gender groups. However, hamstring short males had significantly smaller superoinferior skin distraction at L3 than their hamstring normal counterparts [35% (5.2) vs. 46% (4.6), pZ0.049), while hamstring short females had a smaller mean mediolateral distraction at the same level that approached significance [2.5% (2.5) vs. 7.6% (5.4), pZ0.080). At this landmark, there was a moderately strong, inverse correlation (rZ 0.720) between mediolateral percent strain and reach distance in hamstring tight subjects. Conclusion: In general, superoinferior percent strain increased and mediolateral percent strain decreased from thoracic to sacral regions, likely reflecting the relative increase in spine segment motion from thoracic to lumbar region. The larger mean mediolateral
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14
P.J. Moga distraction at the T10 level was probably the result of traction on the skin at that level by the dependence of appendicular structures in forward flexion. Finally, the negative value at the T1 landmark was probably the result of the cervical spine extension that occurred during flexion as the subjects lifted their heads to look up. ª 2008 Elsevier Ltd. All rights reserved.
Introduction The accuracy of the spine angle measurements based on skin surface markers depends on the marker’s ability to withstand skin distraction during subject movement, as this movement may introduce error (e.g., Vanneuville et al., 1994). Quantification of such movement is therefore essential to surface marker design. Because such information is lacking in the literature, a small study was performed to answer two questions: first, how much does the skin distract over the midline of the spine at select landmarks and second, are there significant differences in the amount of distraction between landmarks? The answers to these questions would be incorporated into the design of a unique surface marker for use in an optoelectronic study (Moga, 2002) that compared the spine angles of subjects who were hamstring normal (able to touch the ground in sagittal plane flexion) and hamstring short (unable to touch the ground in sagittal plane flexion). In keeping with the hamstring category comparison, the following null hypotheses were advanced:
Primary null hypothesis
methods measure the angle between two lines that demarcate the spine segment of interest. In the Cobb technique (1948), the most cephalad vertebra of the spine segment of interest is demarcated by a line tangential to its superior endplate. The most caudad vertebra of the same spine segment is similarly marked by a tangent to its inferior endplate. The angle between the two tangents at their intersection represents the spine segment angle (Figure 1). In Ferguson’s method (1949), the intersecting lines of the spine segment are based on three centroids, rather than two vertebral endplates. Centroids are points ‘‘at the geometric center of a polygon’’, which ‘‘.can be used to represent a polygon as a point’’ (Gregory, 2002). In this case, the polygon is the vertebral body or centrum. The vertebrae selected are at the cephalad aspect, the apex, and the caudad aspect of the spine segment of interest (Figure 2). Centroids are determined as the intersection of two lines drawn on each vertebral body from a corner to the opposite corner. Then two lines are drawn, one from the cephalad vertebral centroid to that of the apical vertebra, and the other from the caudad vertebral centroid to that of the apical vertebra. As in the Cobb method, the angle between the intersection of two lines represents the spine segment angle.
H01: There is no difference in the amount of skin distraction between hamstring normal and hamstring short subjects. It was expected that hamstring short subjects would have less skin distraction than hamstring normal subjects, which would reflect a reduced flexion range of motion.
Secondary null hypothesis H02: There are no age or gender differences of skin distraction.
Background There are primarily two approaches used to determine spine segment angles: contact and non-contact. The contact approach requires the application of goniometric measuring devices directly to the skin over palpated landmarks. These devices include Loebl’s pendulum goniometer (1967); Debrunner’s kyphometer (1972), and Willner’s pantograph (1981). The non-contact approach may be subdivided into two basic categories: radiographic and non-radiographic. The radiographic approach utilizes X-ray exposure to identify specific vertebral landmarks. The angles between these landmarks are then determined generally by using either the Cobb or, less commonly, the Ferguson method. Both
Figure 1 Cobb method (after Riseborough and Herndon, 1975) angle q, representing the angle of the spine segment, is measured as the angle between tangents to vertebral endplates (image ª Paul John Moga, 2002).
Skin distraction at select landmarks on the spine midline
15
Figure 3 Balsa template horizontal base: 2.8 cm1.8 cm 0.6 cm; vertical stanchion: 4.4 cm1.2 cm0.6 cm; image ª Paul John Moga, 2002. Figure 2 Ferguson method angle q, representing the angle of the spine segment, is measured as the angle between centroidbased lines (image ª Paul John Moga, 2002).
Non-radiographic, non-contact techniques used to measure spine segment angles include photogrammetric methods that mitigate the need for X-ray exposure. Like contact goniometric methods, non-radiographic techniques generally require both demarcation and labeling of spine segment landmarks. However, rather than relying on radiographic landmarks, surface-mounted markers are placed at manually palpated structures that define spine segment endpoints. Once the spine segment is defined, techniques similar to those of Cobb and Ferguson may be used to determine the spine angle. A modification of the Ferguson method was used in the photogrammetric method as described by Wojtys et al. (2000). In that study, flat, adhesive markers were placed on the skin’s surface at either end of the spine segment of interest. A test platform having cameras with photographic axes perpendicular to the plane of the subjects’ backs was used. A custom software program was developed to measure spine angles from the photographs as the angle of intersection between lines tangential to the skin’s surface landmarks. A modification of the Cobb method was utilized in the optoelectronic method as described by Moga (2002). In that study, specially designed platform markers were positioned on the skin over select spine landmarks at either end of the spine segment of interest. A commercially available, electronic videographic system having camera axes parallel to the skin surface was used to record marker position. Using the system’s software, spine angles were then calculated as the intersection of the angles between lines perpendicular to the skin’s surface, as demarcated by the skin markers’ perpendicular arms. At least one problem exists with the use of surfacemounted markersdDo the markers accurately reflect the position of bony landmarks? Authors such as Thurston and
Harris (1983) or Stokes et al. (1987) have shown that the error between skin mounted targets and true skeletal motion ranges from 8% to 10%. Leroux, et al. (2000) determined correlation coefficients of 0.94 and 0.91 for kyphosis and lordosis, respectively, between radiographic Cobb measurements and ‘‘spatial localization’’ of markers placed superficial to spinous processes. Troup et al. (1968) obtained correlation coefficients of 0.91 between surface marker and X-ray spine angles for erect and fully flexed postures for 14 observations, with no significant differences between the methods (Student’s t-test, p120 dB. All data were processed using specific software for acquisition and analysis (Tool Box BR V1.0 by EMG System do Brasil LTDA) (Figure 1), a converting plate for A/D 16 bits signal to convert analog to digital signals with a sampling frequency of anti-aliasing 2.0 kHz for each channel. The differential double electrodes used consisting of three rectangular parallel bars of Ag/AgCl (1 cm in length, 0.2 cm in width and separated by 1 cm) were used and were coupled to a rectangular acrylic resin capsule 2.2 cm in length, 1.9 cm in width and 0.6 cm high with an internal amplifier in order to reduce the effects of electromagnetic interference and other noise (Amorim et al., 2006). Electrodes were fastened to the skin where it was previously cleaned with alcohol 70%, to reduce the impedance, and guided by bone prominences and the route of the muscle fibers (Dornelas de Andrade et al., 2005). This system obtained data, in root mean square (RMS), of each sample participant. Surface silver electrodes were positioned in the motor point, located in the muscular womb center, indicated by masseter muscle hypertrophy in contraction. In all procedures the capture and analysis of EMG signals were carried out as recommended by the International Society Electrophysiology Kinesiology (ISEK) (Solomonow, 1995). The EMG evaluation occurred in the mandibular resting position, and after a maximal voluntary contraction (MVC), isometric muscle contraction, biting a chewing gum placed bilaterally. Chewing gum was used to eliminate the discomfort of tooth contact. Patients were placed sitting safely on a comfortable chair, staring the computer screen, which was exhibiting the electromyographic signs. A clear and precise verbal command was given to the patients concerned about muscles’ contractions and signs acquired. The utilization of a computer screen, like a biofeedback, was used to control the intensity of maximum voluntary contraction, in order to eliminate subjective muscular effort. The data were collected twice per patient: after a work period without occlusal splint wearing (before occlusal splint wear) and after a night’s wearing the occlusal splint (after occlusal splint wear). The signal treatment was performed by complete wave rectification, linear cover by Butterworth of fourth level, with 5 Hz frequency of cut, normalized in time base and amplitude, where the amplitude was normalized by mean.
236
C.F. Amorim et al.
Figure 1
Software acquisition and signal processing.
The intensity variability of the EMG signs in the different muscular situations was made by ManneWhitney’s Test and Wilcoxon’s Test based on the values of rectified signal of paired samples. The level of significance adopted was 0.05.
Results Figure 2 shows the values concerning to electromyographic signs acquired on left and right masseter muscles in rest position. It could be observed that the comparative values of EMG signs measured respectively on right and left masseter muscle in mandibular rest position. Both masseter muscles show EMG signs verified after a work journey before and after wearing occlusal splint. Figure 3 and Table 2 demonstrate the values concerning to electromyographic signs acquired on left and right masseter muscles in maximal volunteer contraction (MVC), isometric muscle contraction. It shows the comparative values of EMG signs measured respectively on right and left
masseter muscle in maximal volunteer contraction before and after occlusal splint wear.
Discussion Sleep bruxism is a parafunctional oral habit characterized by harmful tooth clenching and grinding movements during sleep, which result in excessive tooth wear, periodontal disease and temporomandibular disturbances (Xhonga, 1977). Recently, the relationships between stress, muscular hyperactivity and painful symptoms have been studied using EMG. The clinical use of EMG in orofacial pain, muscular hyperactivity and specific daily activities shows considerable variations among patients (Rugh and Harlan, 1988). EMG signs evaluated on the right masseter in rest (Figure 2) showed reduction of the electromyographic activity with a significant statistical difference in 15 of the
Figure 2
8 7 6 5 4 3 2 1 0
Left Masseter Muscle Amplitude µV RMS
Amplitude µV RMS
Right Masseter Muscle
1
2
Before occlusal splint
After occlusal splint
8 7 6 5 4 3 2 1 0
1
2
Before occlusal splint
After occlusal splint
Values of EMG signs of the masseter muscle in rest, with statistically significant difference to p < 0.05.
Figure 3
237
Right Masseter Muscle
200 180 160 140 120 100 80 60 40 20 0
Amplitude µV RMS
Amplitude µV RMS
Behavior analysis of electromyographic activity
1
2
Before occlusal splint
After occlusal splint
Left Masseter Muscle
200 180 160 140 120 100 80 60 40 20 0
1
2
Before occlusal splint
After occlusal splint
Values of EMG signs of the masseter muscles in MVC, with statistically significant difference to p < 0.05.
subjects analyzed. The Average of the EMG sign obtained on the left masseter at rest (Figure 2 and Table 1) also showed a significant statistical difference in 15 subjects, with all 15 presenting a reduction in the myoeletric activity. One of the subjects tested presented no significant statistical difference on EMG signs measured on the right masseter but showed significant differences on EMG values on the left. In another patient it could be observed an inverse situation: significant differences on EMG signs on the right masseter and no significant differences on EMG signs on the left masseter. This situation of different results found in masseter muscles of the same individual can be explained by (Baba et al., 2000), which showed that inadequate force distribution of the masticatory muscles and temporomandibular joints, can lead to occlusal asymmetry. EMG signs obtained on the right masseter in maximum voluntary contraction (MVC) showed that 2 subjects presented no significant statistical differences between signs measured before and after occlusal splint use. EMG signs on the left masseter in maximum voluntary contraction (MVC) (Figure 3) showed that 13 subjects presented significant statistical differences, with all 13 showing reduction of the sign values. Two subjects presented no statistical differences. Another study showed a significant difference in the distribution of masticatory forces on muscles and temporomandibular joints. During tooth clenching, small jaw movements occur and it affects the temporomandibular joints loading. In an experimental situation, the maximum level of force could differ depending on jaw movement, which affects the clenching force and the EMG activity. The results from this study indicate that the distribution of clenching forces in sleep bruxism could be influenced by occlusal patterns of the subject (Baba et al., 1996). Our findings related to electric potential produced by right and left masseter during occlusion, without clenching,
Table 1 Average of EMG signs of the masseter muscles in rest, with statistically significant difference to p < 0.05.
are in accordance with scientific literature. Our results showed a significant statistical decrease of electromyographic activity for muscles of both sides. Only one subject presented no significant result. The efficacy of OS and placebo was compared during 6 weeks, and the authors found no statistical difference between the 2 types of devices, but the findings showed that there was statistically significant reduction of the masseter EMG activity immediately after the insertion of splints. However, there were no significant changes in 2, 4 and 6 weeks after the insertion of either splint (Baba et al., 2000). The results of our study also are in agreement with those found by Landulpho et al. (2002), which showed a significant reduction (p < 0.05) in the EMG activity of masseter during isometric muscle contraction in occlusal splint wearers, indicating decrease of electromyographic activity. A randomized cross-over study using 10 patients, compared the masseter EMG effects of two types of occlusal splint: a nociceptive trigeminal inhibitory splint providing occlusion only on the front teeth and a standard occlusal splint. Each patient received both splints and the study lasted 7e8 weeks including the washout period. The authors concluded that the significant decrease of EMG activity is not associated with a reduction in temporomandibular disorders’ signs or symptoms, once 5 of 10 patients perceived pain at baseline (Baad-Hansen et al., 2007). Armijo-Olivo and Magee (2007) evaluated the electromyographic activity of the masticatory (masseter and anterior temporalis) and cervical (upper trapezius and splenis capitis) muscles during resisted jaw opening in awake patients, and found that EMG activity of these 4 muscles significantly increased during resisted jaw opening.
Table 2 Average of EMG signs of the masseter muscles in MVC, with statistically significant difference to p < 0.05. Before splint using
After splint using
Before splint using
After splint using
Right
Left
Right
Left
Right
Left
Right
Left
8.23 2.6 mV
7.40 1.6 mV
6.59 1.5 mV
5.82 1.3 mV
178.90 7.6 mV
170.60 6.6 mV
120.40 6.5 mV
129.37 5.3 mV
238 Therefore, more investigative studies are necessary to verify the relationship among peripheral and central factors, and sleep bruxism etiology. Different investigative methods may also be tested, comparing the control and pathological groups after situations of induced stress or electroencephalographic exams correlating sensitive-motor activities during the sleep.
Conclusion Occlusal splints wearing as a prevention or treatment of sleep bruxism should decrease electric activity of right and left masseter in situation of mandibular rest and maximal isometric muscle contraction in women. Stress factors during a work period can influence the increase of electric activity of masseter muscles in sleep bruxism bearers.
Acknowledgments The authors are grateful to Thiago R. Amorim for his help in developing the software of analysis. The amplifier system and the differential double electrodes, were made available by EMG System do Brasil, Sa ˜o Jose ´ dos Campos e Sa ˜o Paulo, Brazil. This study was supported by FAPESP e Fundac ¸˜ ao de Amparo a Pesquisa do Estado de Sa ˜o Paulo and CNPq e Conselho Nacional de Desenvolvimento Cientl´fico e Tecnolo ´gic.
References Amorim, C.F., Amorim, L.J., et al., 2006. Electromyographic analysis of mouth’s orbicular muscle in individual class II. In: XVI Congress of The International Society of Electrophysiology and Kinesiology, vol. 52. Armijo-Olivo, S., Magee, D.J., 2007. Electromyographic activity of the masticatory and cervical muscles during resisted jaw opening movement. J. Oral Rehabil. 34 (3), 184e194. Baad-Hansen, L., Jadidi, F., Castrillon, E., et al., 2007. Effect of a nociceptive trigeminal inhibitory splint on electromyographic activity in jaw closing muscles during sleep. J. Oral Rehabil. 34 (2), 105e111. Baba, K., Ai, M., Mizutani, H., Enosawa, S., 1996. Influence of experimental occlusal discrepancy on masticatory muscle clenching. J. Oral Rehabil. 23 (1), 55e60. Baba, K., Akishige, S., Yaka, T., Ai, M., 2000. Influence of alteration of occlusal relationship on activity of jaw closing muscles and mandibular movement during submaximal clenching. J. Oral Rehabil. 27 (9), 793e801. De Luca, C.J., 1997. The use of surface electromyography in biomechanics. J. Appl. Biomech. 13 (2), 135e163.
C.F. Amorim et al. Dornelas de Andrade, A., Silva, T.N., Vasconcelo Ket, A.L., 2005. Inspiratory muscular activation during threshold therapy in elderly healthy and patients with COPD. J. Electromyogr. Kinesiol. 15 (6), 631e639. Glaros, A.G., Rao, S.M., 1977. Bruxism: a critical review. Psychol. Bull. 84 (4), 767e781. Hiyama, S., Ono, T., Ishiwata, Y., Kato, Y., Kuroda, T., 2003. First night effect of an interocclusal appliance on nocturnal masticatory muscle activity. J. Oral Rehabil. 30 (2), 139e145. Kato, T., Dal-Fabbro, C., Lavigne, G.J., 2003. Current knowledge on awake and sleep bruxism: overview. Alpha Omegan 96 (2), 24e32. Landulpho, A.B., e Silva, W.A., e Silva, F.A., Vitti, M., 2002. The effect of the occlusal splints on the treatment of temporomandibular disorders e a computerized electromyographic study of masseter and anterior temporalis muscles. Electromyogr. Clin. Neurophysiol. 42 (3), 187e191. Lavigne, G.J., Rompre ´, P.H., Montplaisir, J., 1996. Sleep bruxism: validity of clinical research diagnostic criteria in a controlled polysonographic study. J. Dent. Res. 75 (1), 546e552. Lavigne, G.J., Rompre ´, P.H., Poirier, G., et al., 1998. Rhythmic masticatory muscle activity (RMMA or chewing-automatism) during sleep in normal controls. J. Sleep Res. 7, 229. Lobbezoo, F., Naeije, M., 2001. Bruxism is mainly regulated centrally, not peripherally. J. Oral Rehabil. 28 (12), 1085e1091. Lobbezoo, F., Van Der Zaag, J., Naeije, M., 2006a. Bruxism: its multiple causes and its effects on dental implants e an updated review. J. Oral Rehabil. 33 (4), 293e300. Lobbezoo, F., Brouwers, J.E., Cune, M.S., Naeije, M., 2006b. Dental implants in patients with bruxing habits. J. Oral Rehabil. 32 (2), 152e159. Lobbezoo, F., Soucy, J.P., Hartman, N.G., et al., 1997. Effects of the D2 receptor agonist bromocriptine on sleep bruxism: report of two single-patient clinical trials. J. Dent. Res. 76 (9), 1610e1614. Michelotti, A., Farella, M., Gallo, L.M., et al., 2005. Effect of occlusal interference on habitual activity of human masseter. J. Dent. Res. 84 (7), 644e648. Raadsheer, M.C., Kiliaridis, S., Van Eijden, T.M., et al., 1996. Masseter muscle thickness in growing individuals and its relation to facial morphology. Arch. Oral Biol. 41 (4), 323e332. Rugh, J.D., Harlan, J., 1988. Nocturnal bruxism and temporomandibular disorders. Adv. Neurol. 49, 329e341. Seligman, D.A., Pullinger, A.G., 1995. The degree to which dental attrition in modern society is a function of age and of canine contact. J. Orofac. Pain 9 (3), 266e275. Solomonow, M.A., 1995. Practical Guide to Electromyography. International Society of Biomechanics Congress XV, Jvaskyla, Finland. 1995. Treacy, K., 1999. Awareness/relaxation training and transcutaneous electrical neural stimulation in the treatment of bruxism. J. Oral Rehabil. 26 (4), 280e287. Tosun, T., Karabuda, C., Cuhadaroglu, C., 2003. Evaluation of sleep bruxism by polysomnographic analysis in patients with dental implants. Int. J. Oral Maxillofac. Implants 18 (2), 286e292. Xhonga, F.A., 1977. Bruxism and its effect on the teeth. J. Oral Rehabil. 4 (1), 65e76.
Journal of Bodywork & Movement Therapies (2010) 14, 239e244
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CLINICAL INFLUENCES
Differences in practitioners’ proficiency affect the effectiveness of massage therapy on physical and psychological states Nozomi Donoyama a,*, Masanao Shibasaki b a Course of Acupuncture and Moxibustion, Department of Health, Faculty of Health Sciences, Tsukuba University of Technology, 4-12-7, Kasuga, Tsukuba 305-8521, Ibaraki, Japan b Allergy and Immunology, Department of Health, Faculty of Health Sciences, Tsukuba University of Technology, 4-12-7, Kasuga, Tsukuba 305-8521, Ibaraki, Japan
Received 24 March 2008; received in revised form 16 January 2009; accepted 27 January 2009
KEYWORDS Massage therapy; Proficiency; Practical training; Muscle stiffness in the neck and shoulder; Visual analogue scale (VAS); State anxiety; Salivary cortisol; Secretory immunoglobulin A (s-IgA)
Summary Objective: An examination was made of how differences in the proficiency of massage practitioners had different physical and psychological effects on clients. Method: Eight healthy 50-year-old females, suffering from chronic neck and shoulder stiffness, were recruited and four interventions were conducted: three 40-minute massage therapy interventions, one each by a freshman and a sophomore student studying massage therapy, and one by their instructor, and one rest on the massage table. Visual analogue scale score for muscle stiffness in the neck and shoulder, state anxiety score, and salivary cortisol concentration levels and secretory immunoglobulin A, were measured pre- and post- interventions. Results: Visual analogue scale of neck and shoulder stiffness after massage by the instructor was significantly lower than that after the other interventions, and the score of state anxiety was lower than that after resting. ª 2009 Elsevier Ltd. All rights reserved.
Introduction Recently, the use of complementary and alternative medicine (CAM) therapies has increased around the world, and the prevalence of and expectations for massage
* Corresponding author. Tel.: þ81 29 858 9631; fax: þ81 29 855 1745. E-mail address:
[email protected] kuba-tech.ac.jp (N. Donoyama).
therapy have rapidly increased, particularly because of its emphasis on stress reduction and increased physical and psychological relaxation (Lovas et al., 2002). In Japan, practitioners of massage therapy, including traditional Japanese massage called Anma therapy, foreign-style massage, and shiatsu, should undergo professional training for at least three years after finishing high school, and then they should pass the national examination to obtain a national license for massage practitioner. In Japan, hands-on therapies, including those mentioned above, are often collectively called ‘‘massage’’ and are not properly
1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.01.007
240 distinguished from each other. In this case, traditional Japanese Anma therapy is the most widely used form of ‘‘massage’’. Thus, in this manuscript, the term, ‘‘massage’’ is used to refer to the traditional Japanese Anma therapy. (It is recommended that the previous study (Donoyama et al., 2010) be referred to for more detailed information on the traditional Japanese Anma therapy.) Japanese law stipulates that students who are in schools for professional education for at least three years, have to pass 77 units of coursework (one unit includes 15e30 lecture hours and 30e45 practical training hours), including basic massage studies (e.g. anatomy, physiology, basic kinesiology, pathology, hygiene and public health, general clinical medicine, clinical medicine, rehabilitation medicine, medical systems overview), professional massage studies (e.g. oriental medicine, meridian and treatment points, massage theory, clinical oriental medicine, clinic management), and practical training (e.g. basic practical training, clinical training, clinical clerkship at massage clinics and medical settings). Special emphasis is placed on 10 units that involve about 450 h of practical training and clinical clerkship (Japan Association of Massage and Acupuncture Teachers, 2003). In spite of this hard study and intensive practical training, the public and the government seem to believe that it is easy for anyone to treat physical symptoms, relieve mental stress, and induce relaxation. As evidence of that, it is easy in Japan for persons without a national license for massage therapy to practice illegally and almost none of them have been punished by the government. It is thought to be dangerous for therapists who are not adequately familiar with human body structures and functions, formation of diseases, and principles of massage therapy to treat clients. There is a review that has reported incidents of massage therapy practiced by unlicensed therapists and students that resulted in aggravation of lower back pain, induction of pain in part or even all of the body, infection through massage oil, and even rib fracture, among other adverse effects (Donoyama, 2002). Even given the occurrence of such harmful mistakes, is it true that any practitioner can use massage therapy to treat clients? Massage therapy is composed of tactile, pressure, and mechanical stimuli given from the surface of the body to muscles and other soft tissues. Can massage therapy always have the same effect on clients, regardless of the proficiency or experience of the practitioner? In order to answer this question, the present study examined the results of massage sessions conducted by practitioners with differing levels of experience and the different physical and psychological effects these sessions had on clients, by measuring the visual analogue scale (VAS) of participants’ symptom of the neck and shoulder stiffness, state anxiety, salivary cortisol, and secretory immunoglobulin A (s-IgA).
Materials and methods Participants Ten healthy females were recruited randomly from a volunteer list, in which about 150 persons are registered as volunteers for the massage experiments in the
N. Donoyama, M. Shibasaki laboratory. Requirements for participants’ gender, age, and physical condition were: (i) to be a female in the fifth decade of life; (ii) to feel chronic muscle stiffness around the neck and shoulders;, (iii) to have no disease requiring medical intervention; (iv) to desire massage therapy; and especially to eliminate the influence of sexual hormones, as suggested in the study by Kirschbaum et al. (1999) showing that salivary cortisol levels are affected by the menstrual cycle, (v) to be a few years post-menopause, and (vi) to feel no current symptoms of menopause. Muscle stiffness in the neck and shoulders is defined by symptoms which produce a feeling of irritation, an unpleasant sensation, strain, stiffness, ache and/or pain in the Regio axillaris and/or Regio scapularis muscles (Hirabayashi, 2002; Ishii and Hirasawa, 2002). All participants gave their informed consent, were screened for conditions of chronic muscle stiffness in the neck and shoulders, and the absence of medical disease was confirmed by a doctor. They were asked to avoid strenuous exercise on the days they were participating in the study and to avoid eating and drinking within one hour of participating in the study.
Interventions All participants received four interventions, conducted on different days. Three 40-minute massage therapy sessions, one each conducted by a freshman student (60-h practical training, 6-month educated) and a sophomore student (240h practical training, 15-month educated) who were majoring in acupuncture and massage therapy at a university, one session conducted by an instructor who taught them and had more than 15 years of experience in massage therapy and its education, and one session consisting of a 40-minute rest on the massage table without massage therapy. Student therapists (five freshmen and five sophomores) were recruited to conduct two interventions each. Participants were randomly assigned to the students but in a way that would guarantee that each participant would receive one intervention by a freshman and one by a sophomore. They did not know the academic year of the students. The instructor treated all 10 participants. Interventions were conducted at one-week intervals. The massage procedure essentially consisted of basic and clinical versions of traditional Japanese massage taught at the university, Anma therapy, which is composed primarily of massage techniques that are commonly used in Japan. Anma therapy is usually administered through clothing or using a piece of cloth; here, it was administered through clothing. Practitioners were given leeway with their massage sessions in order to deal adequately with individual participants’ symptoms of neck and shoulder stiffness. However, all practitioners in this experiment were required to use at least the following massage procedure: have the participant lie down on one side and stroke, knead, and press her neck, shoulder, back, lower back, arm, hand, leg and foot. Next, have the participant lie down on the opposite side and repeat the same procedure on the other side of her body. Finally, with the participant in a prone position for several minutes, stroke, knead, and press her whole body except the head. This massage procedure was the same as in our previous study,
Practitioners’ proficiency and effectiveness of massage therapy on physical and psychological states so please refer to our previous article for details (Donoyama et al., 2010).
Procedure of the experiment Upon arrival at the laboratory, participants rinsed their mouths out with water from a disposable paper cup and took a 15-minute rest. Then, a saliva sample was obtained, and participants wrote self-assessments of their neck and shoulder stiffness using the visual analogue scale and feelings of anxiety using the State Trait Anxiety Inventory. A 40-minute intervention was then performed. After the session, assessments were made again. Each time, the experiments began at 3:00 p.m. in consideration of the circadian rhythms of cortisol and s-IgA in saliva (Walker et al., 1984; Dimitriou et al., 2002). This study was approved by the Medical Ethics Committee of Tsukuba University of Technology and was performed according to the ethical standards set forth in the Helsinki Declaration of 1964 and its amendment of 2000.
Measurements (i) The visual analogue scale (VAS) was used to assess the severity of the subjective symptoms, muscle stiffness in the neck and shoulders. A sheet of paper (width 100 mm height 40 mm) was given to each subject and it was explained that the left edge of the paper represented no symptom and the right edge represented the most serious symptom that the subjects could imagine. The subjects were then asked to indicate how serious the degree of their neck and shoulder stiffness was at that time by ticking the corresponding location on the paper. The length from the left edge of the paper to the tick was measured and treated as the VAS score. (ii) The state anxiety score, which was measured by the Japanese version of the State Trait Anxiety Inventory (STAI) by Spielberger et al. (Mizuguchi et al., 1991), was a self-report Likert scale consisting of 20 items to assess the degree of anxiety being felt by participants at that time. The scores obtained ranged from 20 to 80, with higher scores representing stronger states of anxiety. (iii) Saliva was collected pre- and post-interventions. Each time, a swab was removed from a Salivette (Sarstedt, Aktiengesellschatt & Co., Germany), chewed 60 times gently for a minute in synch with a metronome, then returned to the Salivette. It was sealed and frozen immediately in a freezer on the night when the intervention was conducted. The next morning, the Salivettes were delivered to the assay company (SRL Inc, Tsukuba, Japan). Assays were conducted to determine the concentration of salivary cortisol and s-IgA in samples by g-cortisol and enzyme immunoassay (EIA) sIgA test, respectively.
Statistical analysis In the present study, data for eight participants who could take part in all four of the interventions were analyzed; two persons withdrew from one intervention due to family circumstances.
241
To compare the immediate changes by interventions, repeated measures analyses of variance (ANOVA) with Bonferroni correction were performed. Next, values before interventions were converted into scores based on 100, values after interventions were calculated, and each intervention group was compared by repeated measures ANOVA with Bonferroni correction. All statistical analyses were performed by SPSS 15.0. Alpha was set equal to 0.05, thereby implying that any statistical outcome that had a p < 0.05 would indeed be statistically significant.
Results The repeated measures ANOVA with Bonferroni correction were performed to clarify differences among massage therapy sessions by the freshman students, the sophomore students, and the instructor, and the rest (control), and results are shown in Table 1. Post-intervention VAS scores were significantly lower than those obtained pre-intervention (F Z 38.2, p Z 0.0005). There were significant differences among the four interventions (F Z 9.7, p Z 0.017); the VAS scores were significantly lower after massage therapy sessions by the instructor than those by freshman students (p Z 0.041) and after the rest sessions (p Z 0.043). Post-intervention state anxiety scores were significantly lower than those obtained pre-intervention (F Z 16.7, p Z 0.005); however, there were no significant differences among the four interventions (F Z 0.7, p Z 0.448). For concentration levels of salivary cortisol, post-intervention values were significantly lower than those obtained pre-intervention (F Z 16.4, p Z 0.005); however, there were no significant differences among the four interventions (F Z 1.5, p Z 0.264). Concentration levels of s-IgA post-intervention were increased significantly compared with those obtained pre-intervention (F Z 23.1, p Z 0.002); however there were no significant differences among the four interventions (F Z 1.7, p Z 0.237). Second, values before interventions were converted into scores based on 100, values after interventions were calculated, and each intervention group was compared by repeated measures ANOVA with Bonferroni correction (Table 2). The VAS scores of neck and shoulder stiffness were found to be significantly lower after massage therapy sessions by the instructor than after the other interventions (the instructor vs. the freshman students, p Z 0.017; the instructor vs. the sophomore students, p Z 0.049; the instructor vs. the rest, p Z 0.004), and the value of state anxiety was lower after massage therapy sessions by the instructor than after resting on the massage table (p Z 0.002).
Discussion In the post-massage therapy by all three kinds of practitioners, VAS scores were lower than the pre-massage therapy VAS scores, whereas the rest-sessions did not reduce the scores. Despite their relatively brief period of academic learning, the students could fractionally improve the symptoms of muscle stiffness in the neck and shoulders. In previous studies on anesthetized rats (Cao et al., 1992; Sato et al., 1996, 2002) tactile and pressure stimuli, from
242
N. Donoyama, M. Shibasaki
Table 1 Comparison of temporal changes in values among four interventions (repeated measures analyses of variance ANOVA with Bonferroni corrections). Time
Effect Pre
Post
Group
Time
Group time
Mean SE (95% CI)
Mean SE (95% CI)
F
F
F
Visual analogue scale Freshmen 75.8 5.9 (62.6e86.9) 57.4 8.3 (40.5e74.3) Sophomores 70.8 5.9 (58.6e82.9) 54.9 8.3 (38.0e71.8) Instructor 72.5 5.9 (60.3e84.7) 23.3 8.3 (6.3e40.2) Rest (control) 58.4 5.9 (46.2e70.5) 57.1 8.3 (40.2e74.0) State anxiety Freshmen 36.8 2.7 (21.1e42.4) 30.0 2.1 (25.8e34.2) Sophomores 37.5 2.7 (31.9e43.1) 28.4 2.1 (24.1e32.6) Instructor 36.4 2.7 (30.8e42.0) 26.8 2.1 (22.5e31.0) Rest (control) 34.1 2.7 (28.5e39.7) 30.3 2.1 (26.0e34.5) Cortisol (mg/dL) Freshmen 0.239 0.020 (0.198’e0.279) 0.219 0.019 (0.179e0.258) Sophomores 0.276 0.020 (0.236-0.317) 0.240 0.019 (0.209-0.279) Instructor 0.234 0.020 (0.202e0.283) 0.199 0.019 (0.159e0.238) Rest (control) 0.230 0.020 (0.190e0.270) 0.205 0.019 (0.166e0.244) s-IgA (mg/mL) Freshmen 417.8 54.1 (307.0e528.6) 819.6 142.7 (527.3e1111.8) Sophomores 355.7 54.1 (244.9e466.5) 813.5 142.7 (521.2e1105.7) Instructor 389.3 54.1 (278.5e500.1) 571.8 142.7 (279.5e864.1) Rest (control) 434.1 54.1 (323.2e544.9) 719.0 142.7 (426.7e1011.2)
p
p
9.7 0.017* 38.2 0.0005*** 7.8
p 0.027*
p Z 0.041* p Z 0.043* 0.7 0.45
16.7 0.005 ** 0.2
0.69
1.5 0.26
16.4 0.005 ** 1.8
0.23
1.7 0.24
23.1 0.002 ** 3.8
0.09
*p < 0.05; **p < 0.01; ***p < 0.001.
the surface of the body affected the autonomic nervous system and induced reflexive motions, somato-visceral reflexes, which are thought of as a massage therapeutic mechanism. In previous studies (Field, 2002a,b; Mori et al., 2004), it was found that manual mechanical stimuli by massage increase blood flow, remove metabolites and waste products. This suggests that massage stimuli by even unskilled students may be able to induce autonomic nerve reflexes and cause some alleviation of physical symptoms of muscle stiffness in the neck and shoulders. Nevertheless, the massage therapy by the instructor was significantly different from that by freshman students and the resting session (Table 1). The comparison of values after interventions, when values before interventions were converted into scores based on 100 among the four interventions, clearly indicates that VAS scores after the massage therapy by the instructor were significantly lower than those by the other three types of interventions (Table 2). As a result, it was concluded that the massage therapy by the experienced and skilled practitioner was much more effective in improving the physical subjective symptoms than that by the unskilled practitioners. The changes in the post-intervention state anxiety scores indicated that massage therapy by all three kinds of practitioners and the resting session could reduce state anxiety compared with before interventions, although the differences among the four interventions were not clear (Table 1). Next, a comparison of values after interventions, when values before interventions were converted into scores based on 100 among the four interventions, showed that the score of state anxiety after massage therapy by the instructor was significantly lower than after resting on the
massage table (Table 2). The results imply that massage therapy by an experienced and skilled practitioner can greatly improve not only the physical symptoms of the muscle stiffness in the neck and shoulders but also psychological conditions, and state anxiety. Moreover, in the present study, salivary cortisol concentrations in the post-interventions were decreased significantly (Table 1). The significant decreases in salivary cortisol levels after massage sessions were the same as in previous studies (Field, 1998, 2000; Field et al., 1992, 1997, 1998; Hart et al., 2001; Hernandez-Reif et al., 2000). Cortisol is a major steroid hormone secreted by the adrenal cortex via reactions in the hypothalamusepituitarye adrenal axis and autonomic nervous system that is commonly used as an index of stress (Fukuda and Morimoto, 2001). This result suggests that stimulation from the surface of the body can affect the autonomic nervous system and help to release psychological stress through the hypothalamusepituitaryeadrenal axis. In our previous study, in which saliva had been collected directly, rather than with Salivettes, salivary cortisol concentration levels after massage therapy by the same practitioner participating in the present study were not reduced significantly compared with those before the massage sessions (Donoyama et al., 2010). It is thought that the use of Salivettes to obtain saliva without distress could increase the accuracy of measurements taken of cortisol concentration levels before and after massage therapy. However, there were no significant differences among the four interventions (Tables 1 and 2). S-IgA concentration levels were significantly increased after interventions, however, there were no significant
Practitioners’ proficiency and effectiveness of massage therapy on physical and psychological states
243
Table 2 Comparisons of values after interventions when values before interventions were converted into scores based on 100 (repeated measures analyses of variance ANOVA with Bonferroni corrections).
differences among the four interventions (Tables 1 and 2). Previous studies not only on massage therapy (Green and Green, 1987; Groer et al., 1994) but also on relaxation by watching a humorous movie (Dillon et al., 1985) and imagery (Jasnoski and Kugler, 1987) showed the same results, i.e. increase of s-IgA after interventions. These findings in previous studies suggested that increases in wellbeing (Dillon et al., 1985) and holistic benefits (Groer et al., 1994) caused s-IgA to increase. The present study implies that all four kinds of interventions could enhance wellbeing and provide holistic benefits to participants and, in the results, s-IgA concentrations were increased. This in turn may enhance immunological functions and help prevent illness. However, massage therapy is no more effective for increasing s-IgA than resting, watching humorous movies, or viewing images. In conclusion, this study has verified that massage therapy practiced by a competent experienced practitioner can greatly alleviate subjective symptoms of muscle stiffness in the neck and shoulders and state anxiety, and lower salivary cortisol as an index of psychological stress. It is thought that the differences in effectiveness between an experienced practitioner and unskilled student depend on the proficiency of the practitioner, which has been cultivated by experience. Massage instructors have the responsibility to educate students to become professionals who can attend to clients’ needs. The results presented here strongly suggest that practical training and clinical clerkship should be an integral part of massage therapy education. The limitations of this study should be noted. Since it was too difficult to recruit massage professionals with the
same experiences and the same skills, one instructor was used across all eight subjects in the study. This was not the case with the freshman and sophomore interventions. All eight subjects should have been treated by each and every freshmen and sophomore. In the absence of this type of control, it is possible that variances across the five freshmen and across the five sophomores might have been a factor influencing the outcomes of the study. In the present study, repeated measures ANOVA was performed twice to clarify differences among the four interventions, as shown in Tables 1 and 2. The first analyses using ANOVA were expected to reveal differences among the four interventions; however, they could not clearly indicate significant differences among the interventions. Therefore, values before interventions were converted into scores based on 100, values after interventions were calculated, and each intervention group was compared by repeated measures ANOVA with Bonferroni correction. As a result, statistically significant differences among the four interventions finally became clear. This suggests that our sample size was too small to perform statistical analyses. It would thus be advisable to try the study again with a sufficiently large sample size to confirm the results.
Acknowledgement The present study, No. 17653125, was supported by a science study program grant from the Education and Science Ministry of Japan, 2006.
244
References Cao, W.H., Sato, A., Sato, Y., Zhou, W., 1992. Somatosensory regulation of regional hippocampal blood flow in anesthetized rats. Japanese Journal of Physiology 42 (5), 731e740. Dillon, K.M., Minchoff, B., Baker, K.H., 1985. Positive emotional states and enhancement of the immune system. International Journal of Psychiatry in Medicine 15, 13e18. Dimitriou, L., Sharp, N.C.C., Doherty, M., 2002. Circadian effects on the acute responses of salivary cortisol and IgA in well trained swimmers. British Journal of Sports Medicine 36, 260e264. Donoyama, N., 2002. Incident reports review by manual therapies. Journal of Japanese Association of Manual Therapy 13, 21e28 (in Japanese). Donoyama, N., Munakata, T., Shibasaki, M., 2010. Effects of Anma therapy (traditional Japanese massage) on body and mind. Journal of Bodywork and Movement Therapies 14 (1), 55e64. Field, T., 1998. Massage therapy effects. American Psychologist 53, 1270e1281. Field, T., 2000. Touch Therapy. Churchill Livingstone, Edinburgh. Field, T., 2002a. Massage therapy. Medical Clinics of North America 86 (1), 163e171. Field, T., 2002b. Massage therapy research methods. In: Lewith, G., Jones, W. (Eds.), Clinical Research in Complementary Therapies. Harcourt, Edinburgh. Field, T., Hernandez-Reif, M., Seligman, S., Krasnegor, J., Sunshine, W., 1997. Juvenile rheumatoid arthritis: benefits from massage therapy. Journal of Pediatric Psychology 22, 607e617. Field, T., Morrow, C., Valdeon, C., Larson, S., Kuhn, C., Schanberg, S., 1992. Massage reduces depression and anxiety in child and adolescent psychiatric patients. Journal of the American Academy of Child and Adolescent Psychiatry 31, 125e130. Field, T., Schanberg, S., Kuhn, C., Field, T., Fierro, K., Henteleff, T., Mueller, C., Yando, R., Shaw, S., Burman, I., 1998. Bulimic adolescents benefit from massage therapy. Adolescence 33, 555e563. Fukuda, S., Morimoto, K., 2001. Lifestyle, stress and cortisol response: review 1. Environmental Health and Preventive Medicine 6, 9e14. Green, R.G., Green, M.L., 1987. Relaxation increases salivary immunoglobulin A. Psychological Reports 61, 623e629. Groer, M., Mozingo, J., Droppleman, P., Davis, M., Jolly, M.L., Boynton, M., Davis, K., Kay, S., 1994. Measures of salivary
N. Donoyama, M. Shibasaki secretory immunologlobulin A and state anxiety after a nursing back rub. Applied Nursing Research 7, 2e6. Hart, S., Field, T., Hernandez-Reif, M., Nearing, G., Shaw, S., Schanberg, S., Kuhn, C., 2001. Anorexia nervosa symptoms are reduced by massage therapy. Eating Disorders 9, 289e299. Hernandez-Reif, M., Field, T., Krasnegor, J., Theakston, H., 2000. High blood pressure and associated symptoms were reduced by massage therapy. Journal of Bodywork and Movement Therapies 4, 31e38. Hirabayashi, S., 2002. Cervico-omo-brachial syndrome (including muscle stiffness of shoulder). In: Ogata, E. (Ed.), Today’s Therapy. Igakushoin, Tokyo (in Japanese). Ishii, S., Hirasawa, Y. (Eds.), 2002. Standard Textbook Orthopedics and Traumatology: Locomotive Quality of Life. Igakushoin, Tokyo (in Japanese). Japan Association of Massage and Acupuncture Teachers, 2003. Massage & Acupuncture Education for the Visually Impaired in Japan. King Printing Co, Tokyo. Jasnoski, M.L., Kugler, J., 1987. Relaxation, imagery, and neuroimmunomodulation. Annals of the New York Academy of Sciences 496, 722e730. Kirschbaum, C., Kudielka, B.M., Gaab, J., Schommer, N.C., Hellhammer, D.H., 1999. Impact of gender, menstrual cycle phase, and oral contraceptives on the activity of the hypothalamuspituitary-adrenal axis. Psychosomatic Medicine 61 (2), 154e162. Lovas, J.M., Graig, A.R., Raison, R.L., Weston, K.M., Segal, Y.D., Markus, M.R., 2002. The effects of massage therapy on the human immune response in healthy adults. Journal of Bodywork and Movement Therapies 6 (3), 143e150. Mizuguchi, K., Shimonaka, Y., Nakazato, K., 1991. The Japaneselanguage version of STAI. Sankyobo, Kyoto (in Japanese). Mori, H., Ohsawa, H., Tanaka, T.H., Taniwaki, E., Leisman, G., Nishijo, K., 2004. Effect of massage on blood flow and muscle fatigue following isometric lumbar exercise. Medical Science Monitor 10 (5), CR173eCR178. Sato, A., Sato, Y., Suzuki, A., Uchida, S., 1996. Reflex modulation of catecholamine secretion and adrenal sympathetic nerve activity by acupuncture-like stimulation in anesthetized rats. Japanese Journal of Physiology 46 (5), 411e421. Sato, A., Sato, Y., Uchida, S., 2002. Reflex modulation of visceral functions by acupuncture-like stimulation in anesthetized rats. International Congress Series 1238, 111e123. Walker, R.F., Joyce, B.G., Dyas, J., 1984. Salivary cortisol: 1. Monitoring changes in normal adrenal activity. In: Read, G.F., Riad-Fahmy, D., Walker, R.F., Griffiths, K. (Eds.), Immunoassays of Steroids in Saliva. Alpha Omega, Cardiff.
Journal of Bodywork & Movement Therapies (2010) 14, 245e254
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journal homepage: www.elsevier.com/jbmt
QUALITATIVE STUDY
The experiences of basic body awareness therapy in patients with schizophrenia Lena Hedlund, RPT, MSc*, Amanda Lundvik Gyllensten, RPT, PhD Department of Health Sciences, Division of Physiotherapy, Faculty of Medicine at Lund University, PO Box 157, 221 00 Lund, Sweden Received 13 October 2008; received in revised form 3 March 2009; accepted 31 March 2009
KEYWORDS Physiotherapy; Affect regulation; Self-esteem; Cognitive function; Rehabilitation
Summary Background: Basic Body Awareness Therapy (BBAT) is a physiotherapeutic treatment method that is commonly used in Scandinavian mental health services. However, for patients with schizophrenia, there are few studies that verify the effectiveness of BBAT, or explain which dysfunctions or disabilities BBAT has an effect on in this group of patients. The aim of the present study was thus to describe patients’ experiences of BBAT, focusing on perceived main treatment effects. The areas of perceived effects are to be investigated in future research. Method: In a qualitative study, eight patients with schizophrenia were interviewed. The interview transcriptions were analysed with content analysis methodology. Result: Patients with schizophrenia report positive treatment effects of physiotherapy with BBAT. Four main categories were identified: affect regulation, body awareness and self-esteem, effects described in a social context and effects on the ability to think. These should be targeted in a future randomized and controlled study. ª 2009 Elsevier Ltd. All rights reserved.
Background Schizophrenia is a severe mental disease which causes great suffering for the afflicted individual and renders large costs for society. It involves a variety of symptoms, including both negative symptoms (blunted affects, passivity and isolation) and positive symptoms (hallucination) (McGorry, 2005) as well as cognitive dysfunctions that include a broad variety of impairments concerning attention, memory, verbal fluency, psychomotor speed * Corresponding author. Tel.: þ46 46 222 00 00. E-mail address:
[email protected] (L. Hedlund).
and executive functions (Helldin et al., 2006). These negatively affect the daily life of the individual (McGorry, 2005) and the link between cognitive dysfunction and negative symptoms is well supported (Helldin et al., 2006). Blunted or flattening of affects is a common major symptom in schizophrenia and is associated with difficulties in engaging in social activities (McGorry, 2005; Brune, 2005). Alexithymia is a term reflecting the difficulties in verbalizing and apprehending your own and others’ emotions and mental states and is more common among patients with different kinds of psychoses, especially those with schizophrenia (Maggini and Raballo, 2004a).
1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.03.002
246 Another aspect of the disease concerns insecure identity, a lack of self-esteem, depression and anxiety (Van Dongen, 1998; Pallanti et al., 2004). Furthermore, many patients suffer from symptoms of disembodiment, body image disturbances and deficits in the feeling of being an agent in their own bodies and lives (Priebe and Ro ¨hricht, 2001; Maggini and Raballo, 2004b). One theoretical ‘‘starting point’’ for almost all bodyemind physiotherapeutic treatments is the psychomotor developmental aspects of movement and cognition, mainly based on Piaget’s theory of psychomotor development, focusing on the child’s activity as a central aspect in development (Gebhardt et al., 2008). Lately researchers have focused on unconscious processes and the interplay between different areas in the brain and the connection between the body and thought processes. From this perspective, our cognition is to a large extent dependent on acting and sensory motor experiences, in relation to environmental and social contexts. Roth and Lawless describe this embodied form of cognition as ‘‘basic level schemata’’ and suggest that these are (a) generally selfexplanatory and (b) basic elements of cognitive functioning (Roth and Lawless, 2002). One main physiotherapeutic treatment, in the Scandinavian mental heath services, is Basic Body Awareness Therapy (BBAT) with roots in the eastern tradition of body movement, Tai Chi Chuan (Gyllensten et al., 2003a). In the treatment process, the basic goals include establishing better contact with the living body, increasing the feeling of ‘‘ownership’’ of the body and increasing the tolerance for different sensory motor and affective sensations. The psychomotor interplay is trained through different body functions; the ability to have a stable and relaxed posture, to be grounded, to be able to coordinate movement with breathing, the ability to be well-defined in movements and interpersonal relations and finally the ability to be mentally present or mindful (Gyllensten et al., 2003a). The patients take part in various exercises where they are asked to be mentally present and observe their own activities, reactions and other experiences within or without the body (Gyllensten et al., 2003a). For a further description of BBAT, see Appendix B. BBAT has been shown to be effective and relevant as part of the treatment for several groups of patients with mental illness (Mattsson et al., 1997; Grahn et al., 1998; Eriksson et al., 2007; Gyllensten et al., 2003a), but there are few studies concerning patients with schizophrenia or other severe psychoses. In a controlled prospective study, 17 patients with schizophrenia who were treated with BBAT for 6 months were compared with nine patients with schizophrenia who only received treatment as usual. The results revealed that patients, treated with BBAT, significantly improved their quality of movement, body image, gaze, sexual interest and suffered less from anxiety compared with the control group (Roxendal, 1985). In a qualitative study, focusing on the perceived and most important aspects of treatment, six patients with schizophrenia reported that they experienced better own control and that this feeling was important for them (Gyllensten et al., 2003b). It is thus important to continue to evaluate the effects of BBAT and a relevant first step is to describe the patients’ own experiences of the method. The aim of the present study was thus to describe patient experiences of BBAT, focusing on
L. Hedlund, A.L. Gyllensten perceived main treatment effects. The areas of perceived effects are to be investigated in future research.
Method Participants Two physiotherapists, who were experts in the BBAT method, nominated 10 physiotherapists who had experience of work with patients with schizophrenia or similar diseases for at least 2 years and had an adequate education in BBAT, at level two or higher. All the physiotherapists worked at community psychiatric clinics for patients with schizophrenia and other severe mental illnesses. They all agreed to participate in the study, engaging at least one patient, a person who in writing declared that he or she was willing to participate in an interview with one of the researchers. The inclusion criteria for the patients were that they were diagnosed with schizophrenia or similar diseases and had received BBAT for at least 1 year. Twelve patients agreed to participate in the study, one of whom later declined thus resulting in 11 available informants. One patient did not appear for the interview. After eight interviews, no new information was communicated, with the same information being received. The decision was thus made to end the data collection and consequently two of the 11 patients who had agreed to participate were not called for an interview. The patients lived in three different towns in Sweden and were diagnosed by their psychiatrists, in accordance with ICD-10, as having schizophrenia (three patients), unspecified schizophrenia (two patients), undifferentiated schizophrenia (two patients) and paranoid schizophrenia (one patient). All of the patients received other treatments, pharmacological and various verbal therapy forms, mostly of a supportive nature, over and above the BBAT. Four of the patients were male and four were female, the ages ranged from 29 to 56, with an average of 45.5 years, median 48.5 years. Their duration of illness ranged from 4 to 30 years, averaging 16.3 years, median 16 years and had received BBAT for 2e 7 years, averaging 3.3 years, median 3 years. All patients were single and lived alone except for one who lived with her parents. One patient had only received BBAT individually, while the others had started individually and then continued in small groups.
Interview technique and interview process The study utilized a qualitative method with interviews as the source of information (Burnard, 1991). The first author used an interview guide focusing on the experienced effects of the BBAT treatment. The interview guide consisted of open questions with follow-up questions (see Appendix A). The interviews were characterized as only allowing short periods of silence and not having the ambition of attaining higher levels of abstraction due to the patients’ varying cognitive disabilities and sensitivity to stress. In seven cases, the interview took place at the patients’ ordinary community psychiatric clinic, while one interview was carried out at the patient’s home. The interviews were recorded, transcribed and then sent back to the patients
The experiences of basic body awareness therapy for an approval of the content, together with prepared envelopes. None of the patients commented on the transcribed content of the interview, while three patients wrote a letter about their treatment progress after the interview.
The process of analysing the transcriptions The main interest of the present study was the different experiences of treatment effects. A cross-case analysis was thus performed, based on a manifest content analysis and triangulation in order to increase validity (Burnard, 1991; Farmer et al., 2006). The total number of transcribed pages of text was 160, written with double line spacing. Manifest content analysis is a qualitative method, which can include a quantitative strategy for organizing the transcribed text. The text is systematically reduced into meaning units in distinction to latent analysis, where the underlying meaning of the text is interpreted and used (Graneheim and Lundman, 2003). A meaning unit is an existing word in the text that represents or is central to the meaning of the sentence, e.g. ‘‘I get more strength after training with BBAT’’. The meaningful unit here is ‘‘strength’’. These meaning units are then categorized in several stages and organized quantitatively (Burnard, 1991). In the present study, four persons e one psychiatrist, one psychiatric nurse, the first author and another physiotherapist e read and identified the meaning units separately. In a comparison, the level of agreement between the four persons was good, except for a few cases that eventually resulted in either disqualification or changes of the meaning unit. The first author and the physiotherapist, who is also trained in BBAT, then continued the process of analysis by comparing their own separate categorization of transcriptions from three patient interviews. The analysis revealed that the agreement was very good between the two physiotherapists. Approval was granted by the Regional Ethical Committee in Lund, Sweden, registration number 108/2008.
Result All informants reported some positive treatment effects, both in the short as well as the long term. Their contributions to the result, the number of meaning units, differed greatly, due to their varying capacity to verbalize their experiences in the interviews. For example, one informant contributed 18 meaning units while another informant’s transcribed text consisted of 150 units. Four different main categories were identified; affect regulation, body awareness and self-esteem, effects described in a social context, and effects on the ability to think. Each of the main categories contained a number of subgroups, shown in Table 1.
Affect regulation All the informants described how the treatment resulted in a change of their emotional state towards more subjectively pleasant feelings (see Table 1). The treatment
247 increased the experience of vitality and interest, and also the ability to accept and tolerate more unpleasant experiences, such as discomfort and distress. They mostly felt stronger or more vigorous, alert and relaxed after the BBAT sessions. An informant who had suffered from a painful tiredness for many years explained: Well, yes, often you feel a sense of well-being afterwards, life feels easier and the well-being increases. Mostly I feel more alert afterwards, in fact, I don’t get tired. Often when you feel more relaxed, you may feel tired but that doesn’t happen so often to me. I usually get more alert (8). Another informant described how she found her strength when training her strength to protect her body boundaries and integrity: . and when I say NO! Then I get the strength . I have a living soul, I own my body and can say NO! (6). When unpleasant feelings occurred, the patients were encouraged to deal with them. Five informants had experienced that the difficult moments had become easier and easier when continuing with BBAT and three of them thought that it might be beneficial to specifically train those moments that were difficult to deal with. As one informant said: . and I don’t want to escape the difficult moments because one of these moments may give you the greatest benefits. No, it is rather that I suspect that it can be like that, the fact that it hurts a little bit, or is strenuous shows that you are untrained and really need the training (8). The exercises offered the opportunity to get in contact with oneself, which sometimes can be difficult. It addresses one of the main problems with having a false or low sense of self that is common in this group of patients. Ehm, well, the fact that you are left alone with your own way of dealing with time . and there’s no other way. You didn’t have any tools to use, instead you had to just deal with the time. And the exercises were a little bit . prickly for one’s psyche, quite simply (3). Six informants used the exercises in BBAT in order to be able to feel better in their everyday lives, noted in the subgroup as better coping (see Table 1). Two of them described that they could deal more successfully with anxiety and were able to prevent it from developing into panic. Another informant described how she now deals with her psychotic anxiety: I become aware of my breathing, my body and stretch in situations where I otherwise would have felt that my body was disconnected (5). A further four informants said they suffered from generalized anxiety to a lesser extent, and that stress and fears were reduced in the long run. Three of them felt calmer and in greater control by focusing on being mentally present and in contact with their bodies. One informant said that, by using the exercise and focusing on his centre of coordination in the solar plexus region, he was able to prevent himself from being overwhelmed.
248
Body awareness and self-esteem Seven of eight informants reported improvements in their ability to be mentally present, to be in better contact with their bodies, to have increased awareness of their movement behaviour and changes in body posture, balance and movability (see Table 1). Increased ability to be more mentally present and in better contact with their bodies were reported by six informants. They experienced an increased sensory awareness and were in better contact with the surroundings. One informant who used to be preoccupied by her illness said: I was too focused on my own brain, my head, the voices and my illness, unaware of how I dressed myself, if it was warm or cold . I’ve opened up for a bigger room, with clothes and warmth and everything, And see the nature and trees and birds (6). The exercise made it possible for the informant to experience a greater sense of being grounded in the self, and to meet the stillness inside. Well, I think so, when we do this exercise, lying on the mattress, then I feel my breathing and that I am in my body and I feel this stillness within myself (6).
L. Hedlund, A.L. Gyllensten Six of the informants described an increased activity level, ranging from a minor change to a more thorough change. When talking about BBAT and the standing exercise, one informant said: Well, one change I’ve noticed is that, before, I used to lie down on my sofa, when watching TV. Now I sit instead, in fact. Actually, I don’t know why. It has just become like that (1). After many years of disliking moving her body, one informant described that she nowadays liked to do it: Well, yes it is, and then another positive effect it has had is that I’ve started to be more interested in becoming physically active. Actually, I did like to take a walk even before but now I’ve started to train in a gym and practice Yoga and Tai Chi. I’ve never been interested in that before (8). The importance of good balance and posture is often connected with increased self-esteem and feelings of security. This is described by five informants. One informant tries to explain what it meant to him, to get a better posture and also raise his head: Well, symbolically you think of an emperor, a king in China or something, or an old King from the North,
Table 1 Main categories and subcategories in the order of how many informants reported a certain effect, with the frequency of the meaning units in the transcribed text and, in parentheses, the number of informants contributing to each category or subcategory (range and medians are also reported). Main categories and subcategories, total number of meaning units in main category (number of informants)
Affect regulation, 184 (8) Increased sense of well-being and a better mood Finding it difficult and disliking some parts of the treatment Calmer Better coping Relaxed and positively tired More alert and strengthened Increased interest Decreased anxiety, stress and fear Body awareness and self-esteem, 201 (7) More mentally present and in better contact with the body and body sensations More active Better self-esteem Increased awareness of their own behaviour Better balance and posture Movability Effects described in a social context, 36 (6) More relaxed and natural in social situations, greater ability to have eye contact with others Greater integrity Less shame Effects on the ability to think, 28 (5) Better concentration and ’’calmer or clearer’’ thoughts
Total number of meaning units in each subcategory (number of informants)
Range (median)
46 (8) 28 (8) 20 (6) 23 (6) 21 (6) 26 (5) 13 (5) 7 (4)
1e10 (4) 1e5 (4) 1e9 (3) 1e7 (3) 1e6 (3) 3e9 (3,5) 1e5 (2) 1e3 (1,5)
73(6)
1e18 (4)
17 60 18 18 15
2e4 (2,5) 2e20 (8,5) 1e6 (4) 2e6 (5) 1e6 (2)
(6) (6) (5) (4) (4)
17 (5)
1e6 (3)
12 (3) 7 (3)
2e8 (2) 1e4 (2)
28 (5)
4e9 (5)
The experiences of basic body awareness therapy without political involvement I mean, and to be elevated, to be more satisfied with life, I think, as in ‘‘I’ve got enough, I don’t have to fight for it’’. A King doesn’t have to do that. They know that they will get it if they just ask for it. . It’s a kind of relaxation (3). One informant who thought he had a better postural stability, spontaneously reflected on the mental consequences of this: I think it is that I feel much calmer and more stable. It is as if I’ve got better self-esteem (4).
Effects described in a social context Most of the informants received their treatment in small groups and described several advantages of this. In addition to the effects of the group treatment itself, six informants described effects in a social context that they thought could be attributed to the effects of BBAT. The effects were better ‘‘coping’’, increased feelings of integrity and ability to be in contact with others. Some informants carried out BBAT exercises before socializing with friends. One informant, who had struggled with her feelings of shame, described her benefits from the exercise: I think when you have felt so insecure, and ashamed, it’s very important to get your self-esteem back and if you dare to look people in their eyes, then they look down if you hold your gaze still. Sometimes it’s very hard but I try. And I try to straighten myself up, sometimes I don’t manage, but I try to think about it and not look down, but straight ahead instead (6). The informants reported that they were more relaxed when socializing with other people, due to better awareness and acceptance of their true selves: Today I allow myself to be quiet. Before I forced myself to be more talkative, I couldn’t accept that I was quiet, I felt like a failure. So it was. So I forced myself to talk in situations where I didn’t want to, which hurts you in the long run (8). Another aspect of recovery is the need to be and behave like ‘‘normal’’ people. One informant described the importance of the erect posture in a social context: It’s important to me, to be like other people mentally, psychologically and socially, to be like others. That is one of my main goals as a psychiatric patient, so to speak (3).
Effects on the ability to think Five informants reported an increased ability to concentrate, and an experience of a ‘‘calmer activity level’’ in the brain, clearer thoughts or having the feeling of being mentally awake. When doing sitting BBAT exercises one informant experienced the following: I look down and focus my eyes there and experience a stillness, sometimes there’s a lot of babble, but
249 sometimes it stops and becomes quiet and that feels very good, I feel clear in my head (6). Another informant said: Well, what shall I say . the possibility of hearing voices decreases when I.when I’ve been to physiotherapy. I feel clearer in my head . so it feels very good (5). The informant who suffered from tiredness said that her thoughts did not become calmer: Instead, when I get more alert it affects how I feel in my head. My thoughts become maybe a little bit more alive, it feels like my level of thinking gets ‘‘more vital’’ or how shall I put it (8).
Discussion Discussion of methods This study is a qualitative approach describing the treatment effects of BBAT, as told by patients with schizophrenia. The number of informants was small, only eight patients were interviewed about their experiences. The main purpose was, however, to get patient-based suggestions of variables, that could be examined further in a planned randomized controlled study, and in such studies there are limited possibilities for following up all the effects that were experienced, except for the main ones. The decision to end the data collection after eight interviews was based partly on the fact that the same treatment experiences were reported several times and no new themes were conveyed in the last interviews and partly on the first author’s 20 year experience of working with BBAT and patients with schizophrenia providing a certain preunderstanding of treatment effects. However, there may be some bias regarding this decision. The informants had a positive attitude, showed interest and made efforts to be understood by the interviewer. As a group, patients with schizophrenia are considered to be difficult to motivate to participate in studies, in part due to their negative symptoms. Therefore, patients with less positive experiences of BBAT probably did not participate in this study. Instead, the patients who participated in this study can be considered to be well motivated. This may be due to positive treatment responses or other reasons, for example, a desire to tell their personal story once more. Another possibility could be that a positive therapeutic encounter had been established between them and their physiotherapist. The patients included in the study were offered the opportunity to participate by their own physiotherapist. This also may have influenced the selection of participants, resulting in a positive sample of patients. In order to increase the internal validity, three methods for validity check were used (Farmer et al., 2006). First the transcriptions were returned to the informants, with prestamped envelopes. There were no comments on the transcriptions, but three informants replied with personal comments about their ongoing progress. Another check of validity was the use of ‘‘triangulation by researcher’’ (Farmer et al., 2006). Three other persons were engaged in the sorting of meaning units, and two of
250 them had a different professional background. In this comparison, there was a high level of agreement. Then, when categorizing the meaning units to a higher abstraction, a comparison was made between the first author and another qualified physiotherapist. The level of agreement was very high. Finally, the first author used different theoretical frameworks, such as physiotherapeutic, psychological and neurocognitive, when discussing the results. This broadened the discussion and decreased the use of narrow-minded interpretation (Farmer et al., 2006). Most of the informants also met other caregivers at the same time. Many of the described effects are therefore probably a result of the influence of several therapists. Different kinds of psychotherapy and medication can make it possible for other interventions to work and vice versa. However, some effects are described by the informants themselves as a direct result of BBAT, related in time and connected to different exercises. This is true for most of the experienced treatment effects, categorized under ‘‘affect regulation, effects on the ability to think, body function and self-esteem’’. When it comes to the effects described in a social context and an increased activity level, these effects are not experienced close to the BBAT session and therefore more likely to be influenced by a number of different factors. After a psychotic episode, there are normally different recovery phases that also influence the remission Andersen et al., 2003. On the other hand, there are several studies within different areas concerning the effects of BBAT that have shown similar effects, irrespective of diagnosis (Mattsson et al., 1997; Grahn et al., 1998; Gyllensten et al., 2003a). This increases the possibility of these results being related to the effects of BBAT.
Discussion of results According to the content analysis, certain experienced effects of the BBAT treatment were reported frequently, by most of the informants. This indicates that the experienced treatment effects might be rather general and common experiences, shared by many. Recovery from schizophrenia is a complex and truly individual process (Sells et al., 2004). Today there is a widening interest in the recovery process, what hinders and what initiates/ stimulates recovery (Onken et al., 2002). According to the philosophy of BBAT, little attention is paid to different symptoms and difficulties. Instead the therapist looks at the patients’ own view of their problems, the status of the body functions and individual strengths and resources (Gyllensten et al., 2003a). Therefore, in the long run, it is especially interesting to find out if BBAT offers the patients increased recovery potentials by matching their individual needs.
Affect regulation All of the eight informants reported changes of different affects and emotions from BBAT. They experienced themselves as vitalized, with increased feelings of interest (five of eight). Those changes must be considered as very important for patients with negative symptoms who
L. Hedlund, A.L. Gyllensten struggle with a lack of interest and motivation. Without a basic vitality and feelings of interest, the ability to make changes in life is limited. Patients with schizophrenia are known to have symptoms such as blunted affects, and difficulties in how to discriminate and communicate them (McGorry, 2005; Brune, 2005). In this study the patients could describe different affects/emotions. Whether this was also the case from the beginning of the treatment cannot be answered in the present study, but the informants described that their emotional state changed when using BBAT. Some informants had even learned how to use the exercises to regulate their affects/emotions outside the treatment sessions. They noticed that the more stressful feelings decreased with continued BBAT. It gave them a feeling of control and security and helped them to protect their integrity. Within the research field of affects and emotions, there is an interest in the developmental aspects of affect regulation, as a normal and pathological process. The connection between attachment and affect regulation is described in an article by Mikulincer et al. (2003). The authors present a theory of the child’s normal development of affect regulation, as an intimate process, linked to an emotionally present object. This ‘‘object’’ teaches the child how to regulate its affects, mostly in a subtle, unconscious way. In order for this to be true, certain conditions must prevail; a safe attachment to a successfully affect regulated object, stimulates the child to discover itself, actively deal with displeasure and to make use of the motivating force of pleasure. This leads to an increased ability to solve different emotional problems. The child’s self-image expands and the self-esteem increases due to the incorporation of the parents’ successful strategies to regulate affects and their own experiences of successful regulations. The child eventually develops a feeling of control, of being an agent with the capability to deal with emotions (Mikulincer et al., 2003). In comparison with this description, BBAT offers several similar components in the treatment process. One ambition is to encourage the patients to be curious about their bodily experiences and reactions. The physiotherapist is to be emotionally present and responsible for the intensity in experiences not overwhelming the patient. The regulation techniques, used in BBAT, arise both from theory and from the physiotherapist’s self-experienced knowledge about different ways to physically increase or decrease affective reactions, as well as the importance of verbalizing the experiences and mentally accepting different affects and body reactions. The physiotherapist also involves the patient in the decision-making concerning their own experiences so that the patients themselves learn to deal with their emotions. This is especially important when distressing and painful experiences occur. Low tolerance for stress and stimuli is a common symptom within patients with schizophrenia (McGorry, 2005) and in this study all eight informants reported experiences in BBAT that were unpleasant. However, they mostly understood the benefits of being exposed to the unpleasant feelings. Therapeutically, it is important to emphasize the normality in unpleasant experiences, not to be afraid of it but at the same time encourage the patients own integrity and respect the need for avoidance. When given these opportunities, the
The experiences of basic body awareness therapy tolerance often increases naturally and, if not, the physiotherapist guides the patients to a more acceptable experience.
Body awareness and self-esteem Body function, as described within the BBAT, includes the ability to have a stable and relaxed posture, to be grounded, to be able to coordinate movement with integrated breathing, to be well-defined in movements and interpersonal relations and finally, to be mentally present or mindful (Gyllensten et al., 2003a; Hofman and Asmundson 2008). These body functions are systematically trained for better functioning. Seven of eight informants reported improvements concerning body functions, as experienced in having better balance and posture, more flexibility in movement and more in contact with their bodies and surroundings. Moreover, the reports of better balance and posture are linked to security and better self-esteem. The intimate connection between self-awareness, self-esteem and the ability to feel secure in our bodies is clearly shown by these statements and also described by Dropsy (1999). He postulates that when the person is ‘‘rooted’’ to the ground, with a better balance between the two forces, gravity and the postural reflexes, there is a better ability to relax, feel calm and be mentally present and alert. The increased contact with body functions is often followed by a deeper feeling of existence and a better contact with the true self and agency. Dropsy declares that many people have a threefold contact problem, with the body, with the physical reality (the room, spatial orientation and time) and with other people. If there is a problem with one of the contact domains, it also has an effect on the other domains and vice versa. ‘‘Opening up’’ in one domain leads also to improvement in the other two (Dropsy, 1999; Gyllensten, 2004). Furthermore, five informants described moments in BBAT that had led them to reflect on their own behaviour. They have ‘‘become aware of, observed and noticed’’ different aspects of movement. The ability to reflect is a very fundamental function of the ‘‘observing self’’ that is essential for self-regulation, to take good care of yourself and the ability to change (de Vigemont and Fourneret, 2004). For one informant, his erect posture was important so that he could look like ‘‘normal’’ people do. Patients with schizophrenia often make odd gestures and have restricted body movements and facial expressions, due to both the illness and the side effects of medication, such as tardive dyskinesia (McGorry, 2005). This probably contributes to the process of stigma. By normalizing the posture, movements and gestures, you can to some extent protect your integrity and minimize the risk of being exposed to discrimination. The importance of better body control, in this context, is also presented by another qualitative study, also concerning patients with schizophrenia (Gyllensten et al., 2003b). Six informants had increased their level of activity. Passivity is one of the major negative symptoms of schizophrenia and there is a strong association with cognitive dysfunction (McGorry, 2005; Helldin et al., 2006). However, there are probably several reasons for passivity. It could be
251 explained as a part of a more depressive symptomatology which often includes lack of vitality, anxiety, feelings of hopelessness, worthlessness and loss of meaningfulness. The informants in the present study described increased alertness and strength, increased interest, decreased anxiety, better self-esteem and a better ability to ‘‘think’’. Moreover, BBAT contains soft exercises that allow the informant to adapt to physical activity at their own pace and this contributes finally to a change of behaviour. All these effects may explain the increased activity level which must be considered as an important change within the schizophrenia symptomatology.
Effects described in a social context Patients with schizophrenia are known to have difficulties in social contexts, such as withdrawal and passivity (Brune, 2005; McGorry, 2005) In addition to the cognitive dysfunctions, a concurrent existence of social anxiety, low tolerance of stress and low self-esteem, with easily aroused feelings of shame, contributes to the need for withdrawal. In this study, six informants described experiences that included increased opportunities for participation in social activities. They talked about shame, integrity, acceptance of the self and the need to be like others. One important aspect of social interaction is the ability to separate yourself from others, to filter the impressions of others and be able to defend your integrity when needed. The exercises of the body function ‘‘delimitation of movement’’ leads to the experience of limits with the need to accept and respect limitations, but also to ‘‘be safe’’ within the limits. This is a ‘‘basic level schemata’’, generally self-explanatory, and of great importance to later social functioning (Roth and Lawless, 2002).
Effects on the ability to think Five of the eight informants described experiences of a better ability to ‘‘think’’ after treatment sessions. The ability to concentrate increased, thoughts became calmer and the feeling of clarity of the mind increased. Attention difficulties are common in patients with schizophrenia (Helldin et al., 2006). The treatment process with BBAT constantly appeals to the awareness of surroundings, the body and bodily sensations and emphasizes the efforts to make voluntary movements that emanate from the body functions and this stimulates attention in a very direct, concrete and personal manner. The feeling of having greater clarity of thought might also be a result of greater alertness. A specific cognitive function is ‘‘vigilance’’, important for the ability to sustain the attention over time and is partly regulated by the reticular formation, restraining the ‘‘wakefulness’’ in the central nervous system (Helldin et al., 2006). The exercise with BBAT may have a specific influence on this function, resulting in clearer thoughts as well as increased ability to be mentally present and in better contact with the body etc. As defined in ‘‘embodied cognition’’, this is one of the ‘‘basic elements of cognitive functioning’’ that is intimately linked to the body and its function (Roth and Lawless, 2002). Furthermore, another explanation for ‘‘clearer thoughts’’
252 might be that BBAT regulates muscular tension and anxiety and thereby decreases the disturbance on the cognitive processes. Consequently, there are at least three different mechanisms that may explain the better ‘‘ability to think’’ which might be stimulated or activated with BBAT.
Conclusion This qualitative study focused on possible treatments effects of Basic Body Awareness Therapy, as they were experienced by eight patients with schizophrenia. Four main categories were identified; Affect regulation, body awareness and self-esteem, effects described in a social context and effects on the ability to think. These results should be targeted in future randomized controlled studies.
Conflict of interest statement There are no conflicts of interest in this study.
Acknowledgements This study was funded by the Swedish Council for Working life and Social Research (FAS) and the County Council of Scania, Sweden.
Appendix A. Interview guide (1) Tell me if and how the treatment with BBAT has helped you in any way? - In the short term - In your every day life - In the long term (2) What feels good about doing the BBAT exercise? (3) Are there exercises that feel bad or are difficult to do? (4) Tell me more about your experiences of working with BBAT.
Appendix B. Description of body awareness therapy Therapists’ education Basic Body Awareness Therapy is a physiotherapeutic treatment, developed in Scandinavia. The education to be a certified body awareness therapist requires a five step educational programme. The programme consists of theoretical, practical and clinical training, with considerable emphasis on one’s own treatment experience and process. The students have homework to do between the four 1week training sessions. The first two levels focus on developing body awareness and an understanding of the process from an inside perspective. The theoretical framework and history of body awareness, as well as how to verbalize goals and motivational aspects in patients work, are also focused on. In the third level, students work with and write a report on the individual process with a patient going through BBAT. The fourth level focuses on treatment
L. Hedlund, A.L. Gyllensten with a group where the student also writes a report on the dynamics in the BBAT group processes and the role of the therapist in BBAT. The student also reads about 2000 pages of relevant literature that are processed and critically evaluated from a clinical perspective. This is done in two literature reports. All reports are evaluated by a teacher who approves and gives feedback. The fifth level consists of a written project paper of clinical interest. Education in BBAT is offered both as private education at the Institute for Basic Body Awareness Therapy in Sweden or public education e.g. examination in BBAT methodology at the University College of Bergen, Norway (60 EC credits). After this students become certified BBAT therapists. The full education is available only for registered physiotherapists. Other professionals are accepted for steps one and two. A typical therapist’s training consists of 30 weeks during 4e5 years. Today, there are around 150 certified BBAT therapists in Europe (Sweden, Norway, Denmark, Finland, Island, Switzerland, UK and Spain). In this study, the experts in BBAT were certified BBAT therapists, teachers at the private institute, educating therapists with more than 20 years of clinical practice within psychiatric physiotherapy.
The methodology of BBAT History BBAT is inspired by Western movement practice, like Feldenkrais, Alexander technique and the European movement tradition (Gindler and Selver), the expressive arts, like dance (Graham and Laban) and theatre (Stanislavski). Body-oriented psychotherapy (Reich and Lowen) also influences BBAT. From the East, Zen meditation and Tai-chi Chuan (Tai Chi), are important sources of inspiration. BBAT was developed to be starting exercises for Tai Chi and tends to follow the same principles. A French psychotherapist and actor, J. Dropsy, synthesized the aforementioned traditions and published two books describing the method (Gyllensten, 2004). A Swedish physiotherapist used the method in the treatment of patients with schizophrenia and published the results in a thesis at the medical faculty of Gothenburg University, 1985 (Roxendal, 1985). Since then, the methodology has been used within physiotherapy mainly in psychiatric physiotherapy, but also in the rehabilitation of prolonged pain. Today, there are 12 theses using BBAT or the Body Awareness Scale (BAS). Eleven of them have been written by physiotherapists and one by a medical doctor (http://www.ibk.nu). Methodology In BBAT one uses movement, breathing, massage/hands-on guiding and awareness to try to restore balance, freedom and the unity of body and mind. BBAT is described as resource-oriented which in this case means working with the resources of the body as a whole. Turning attention both to the doing and to what is experienced in the movements is central and stimulates awareness and movement performance. BBAT differs from Tai Chi in the way that movements are quite simple, focused on the experience of stability, ease and intension (Gyllensten,
The experiences of basic body awareness therapy 2004). The therapist encourages the patients to move in ways more optimal for postural control, balance, free breathing and coordination. The relation to the ground, vertical balance in the centre line, centring of movements and coordination from the trunk and the solar plexus area, breathing, flow and awareness are seen as important aspects of the body-ego, trained in BBAT (Gyllensten, 2004). BBAT can be executed both individually and in a group. It is performed lying, sitting, standing, walking and running. BBAT also includes partner work, in structured massage or push-hand exercises from Tai Chi. The treatment takes the starting point in an assessment, the Body Awareness Scale (BAS), where strengths and weakness of functional capacities and activities are assessed. This means that every treatment is individually created and no protocol, common for all patients is used. However, the treatments are alike, using a common number of structured movements, in different starting positions that can be individually applied according to the patients’ need. Compared to other body-oriented or mindfulness-oriented treatments, there is a systematic training of the ‘‘physical level of the self’’, originating from the specific body functions above and the intentional and observing self, on a mental level. The number of BBAT sessions needed depends on both the medical diagnosis and the functional capacities of the individual patient. For example, patients with moderate depression or anxiety demonstrate a significant improvement of symptoms, self-efficacy, attitude to the body and body awareness after about 12 sessions (Gyllensten et al., 2003a). Patients with schizophrenia often need considerably more sessions, about 9 months or more (Roxendal, 1985). The equipment needed in BBAT is a rather spacious room without a lot of furniture. For sitting exercises a stool or meditation cushion are needed. For lying exercises a ground sheet can be used. No music is used since the individual’s own rhythm is central and the connection between movements and breathing is emphasized. Teamwork Physiotherapists working with BBAT for patients with schizophrenia are usually an integrated member of a professional team including psychiatrists, psychologists, social workers, psychiatric nurses and occupational therapists. In order for a patient to receive BBAT there has commonly been a discussion in a team conference, in the presence of the patient’s psychiatrist. Usually, if the patient receives BBAT, it has been initiated by either the patient complaining of bodily symptoms or functional deficits related to the body or by the patient’s casemanager. Each patient usually receives different interventions from different professionals, e.g. case-management, psychotherapy and BBAT. In some rural regions of Sweden, the physiotherapists are not connected to a team but treat the patients at a private clinic after psychiatrist referral. Patients who have active delusions or hallucinations can receive treatment with BBAT and the treatment will then be adjusted to the patient’s ability to be mentally present. The BBAT can often decrease hallucinations and delusions by increasing the contact with the body.
253
References Andersen, R., Oades, L., Caputi, P., 2003. The experience of recovery from schizophrenia: toward an empirically validated stage model. Australian and New Zealand Journal of psychiatry 37, 586e594. Brune, M., 2005. ‘‘Theory of mind’’ in schizophrenia: a review of the literature. Schizophrenia Bulletin 31, 21e42. Burnard, P., 1991. A method of analysing interview transcripts in qualitative research. Nurse Education Today 11, 461e466. de Vigemont, F., Fourneret, P., 2004. The sense of agency: A philosophical and empirical review of the ‘‘who’’ system. Consciousness and Cognition 13, 1e19. Dropsy J, 1999. Human expression: the coordination of mind and body, in: Skjaerven LH (Ed.), Quality of Movement e the Art and Health. Reportno 1/99, Bergen University College Department of Health and Social Sciences, Norway. Eriksson, E.M., Mo ¨ller, I.E., So ¨derberg, R.H., Eriksson, H.T., Kurlberg, G.K., 2007. Body awareness therapy: a new strategy for relief of symptoms in irritable bowel syndrome patients. World Journal of Gastroenterology 13 (23), 3206e3214. Farmer, T., Robinson, K., Elliott, S.J., Eyles, J., 2006. Developing and implementing a triangulation protocol for qualitative health research. Qualitative Health Research 16, 377e394. Gebhardt, S., Grant, P., von Georgi, R., Huber, M.T., 2008. Aspects of Piaget’s cognitive developmental psychology and neurobiology of psychotic disorders e an integrative model. Medical Hypotheses 71, 426e433. Grahn, B., Ekdahl, C., Borgquist, L., 1998. Effect of multidisciplinary rehabilitation programme on health related quality of life in patients with musculoskeletal disorders. Disability and Rehabilitation 20, 285e297. Graneheim, U.H., Lundman, B., 2003. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today 24, 105e112. Helldin, L., Kane, J.M., Karilampi, U., Norlander, T., Archer, T., 2006. Remission and cognitive ability in a cohort of patients with schizophrenia. Journal of Psychiatric Research 40, 738e745. Gyllensten AL, 2004. Basic Body Awareness Therapy. Thesis, Lund. Gyllensten, A.L., Hansson, L., Ekdahl, C., 2003a. Basic outcome of basic body awareness therapy. a randomized controlled study of patients in psychiatric outpatient care. Advances in Physiotherapy 5, 179e190. Gyllensten, A.L., Hansson, L., Ekdahl, 2003b. Patient experiences of basic body awareness therapy and the relationship with the physiotherapist. Journal of Bodywork and Movement Therapies 7, 173e183. Maggini, C., Raballo, A., 2004a. Alexithymia and schizophrenic psychopathology. Acta Bio Medica Ateneo Parmense 75, 40e49. Maggini, C., Raballo, A., 2004b. Self-centrality, basic symptoms model and psychopathology in schizophrenia. Psychopathology 37, 69e75. Mattsson, M., Wikman, M., Dahlgren, L., Mattsson, B., Armelius, K., 1997. Body awareness therapy with sexually abused women. Part 2. Evaluation of body awareness in a group setting. Journal of Bodywork and Movement Therapies 2, 38e45. McGorry, P., 2005. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders. Australian and New Zealand Journal of Psychiatry 39, 1e30. Mikulincer, M., Shaver, P.R., Pereg, D., 2003. Attachment theory and affect regulation: the dynamics, development and cognitive consequences of attachment-related strategies. Motivation and Emotion 27, 77e102. Onken, J.S., Durmont, J.M., Ridgway, P., Dornan, D.H., Ralph, R.O., 2002. Mental health recovery: what helps and what hinders? A National Research Project for the Development of
254 Recovery Facilitating System Performance Indicators. National Technical Assistance Centre. Pallanti, S., Quercioli, L., Hollander, E., 2004. Social anxiety in outpatients with schizophrenia: a relevant cause of disability. The American Journal of Psychiatry 161, 53e58. Priebe, S., Ro ¨hricht, F., 2001. Specific body image pathology in acute schizophrenia. Psychiatry Research 101, 289e301. Roth, W., Lawless, D.V., 2002. How does the body get into the mind? Human Studies 25, 333e358.
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Journal of Bodywork & Movement Therapies (2010) 14, 255e261
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FASCIA RESEARCH: VISCERAL ADHESIONS
Notes on visceral adhesions as fascial pathology Gil Hedley
Received 25 April 2009; received in revised form 13 October 2009; accepted 19 October 2009
Summary Fascia is introduced as an organizing anatomical category for visceral mesothelia. Normal tissue relations are discussed in order to frame the presentation of abnormal visceral adhesions as fascial pathology, 4 types of which are identified. Laboratory dissections of fixed and unembalmed human cadavers provide the basis for insights into these pathologies as regards self-care and therapeutic technique. ª 2010 Elsevier Ltd. All rights reserved.
Intent Many clinicians assess and treat perceived limitations of visceral mobility which are attributed, among other things, to visceral adhesions. This article notes some of the lines between normal and pathological adhesions of various types. The intent is to illuminate this inner world of visceral adhesions considered as fascial pathology, in the hope of providing useful information for those who carefully consider the same in their therapeutic practices.
Anatomical background It is hard to overstate the value of undertaking many gross human dissections for establishing a baseline understanding of normal tissue relations. Such experience enables one to differentiate more readily between a normal presentation, a healthy but anomalous presentation, and a pathological presentation of visceral relationships. Exactly how to
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perceive these same differences when palpating the living is left to the skilled teachers of visceral manipulation. This paper simply reports what has been found in the laboratory by the present author. Conventional anatomical literature and study is founded on a regional approach. Because of this focus on particular regions as distinct subjects of study from other regions of the body, generalizations regarding common tissue textures and analogous functions sometimes escape the regional method. The author has developed and subscribes to a method of study which he calls ‘‘integral anatomy.’’ While these notes do not permit a full explication of the object and methods of integral anatomy, suffice it to say that the approach places particular emphasis on the whole person while emphasizing the textural layers of the body in their continuities and relationships across purported regional boundaries. This having been said, the author synthesizes the disparate information regarding the anatomical structures of the visceral regions by introducing the general and commonly recognized category of ‘‘fascia’’ as an organizing principle referent. The membranes and fibrous layers which surround the organs of the body do in fact represent various specialized types of the more
1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.10.005
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G. Hedley
general category of ‘‘fascia,’’ the general properties and anatomy of which this author gives a more thorough accounting elsewhere (Hedley, 2005a,b, 2006, 2009). In that prior resource is introduced the notion of ‘‘visceral fasciae.’’ According to this account, the notion of ‘‘visceral fasciae’’ is observed to include, in a manner that repeats across regions, a fibrous outermost layer, a parietal serous layer, and a visceral serous layer. Careful and considerate attention to these tissues is given by Barral in his several volumes of work, upon which the present author relies, especially in so far as they provided foci of interest for more direct explorations in the laboratory. (Barral and Mercier, 1988; Barral, 1989,1991,1993) In order simply to convey from an integral perspective the various structures, already known and identified in a disparate manner through the conventional regional approach, the author developed Table 1. (Hedley, Vol. 3, 2006.) In Table 1, a schematization of the various structures by region is offered, including the membranes of the CNS for the sake of analogical completeness, in a manner that organizes them according to analogous tissue textures.
Normal adhesion of the parietal layer to the fibrous layer It is the author’s experience that it is normal for the parietal, or ‘‘wall’’ layer, to be adherent to the outermost fibrous layer. The parietal serous membranes are relatively well fixed to the fibrous layer in normal tissue presentations, though they can be manually ‘‘peeled’’ apart and thus differentiated in gross dissection in a manner which clearly demonstrates the distinctness of the two layers. The degree to which the parietal layer is fixed is somewhat predictable based on region. The parietal peritoneum, for instance, is considerably more firmly fixed with fibers at the anterior midline to the transversalis fascia than it is more lateral to this line. The two layers can be peeled apart manually along most of their shared surface, but at the midline a scalpel is required to differentiate them (Photo 1).
Normal adhesion of the visceral layer to the viscera It is also the author’s experience that it is normal for the visceral layer of serous membrane to be adherent to the underlying parenchymal tissues of the given organ which it covers. Because of their complete adherence to the tissue of the organs they cover, this author refers to the visceral serous membrane as the ‘‘skin’’ of the organ. The pelvic ‘‘space’’ is technically sub-peritoneal and outside of this Table 1
Photo #1 Above, we see the entire parietal peritoneum presenting after the more superficial transversalis fascia has been differentiated and reflected superiorly. The visibly yellowish midline tissues represent the normal locus of higher degrees of normal fibrous fixation to the overlying transversalis fascia. Image Copyright Gil Hedley, 2006. Used with permission.
typology. For the sake of anatomical accuracy then, it should be said that the rectum, uterus and bladder are all invested/covered superiorly by parietal rather than visceral peritoneum (Photo 2). Proceeding from the deep aspect of the visceral layer of the serous membrane, there are fibers that are continuous with the connective tissue matrix of the underlying tissues. Therefore the ‘‘skin’’ of an organ, despite its obvious continuity as a fascial ‘‘wrap,’’ cannot be very readily ‘‘peeled’’ from the enveloped organ itself, with which it exists in perfect continuity. The visceral serous membranes rather shred when an attempt is made to differentiate them, much as the periosteum does, when the deeper connections are severed and the thin fabric of the surfacing layer recoils upon itself. In this manner then, the degree of normal ‘‘adhesion’’ of the visceral serous membrane to the organ exceeds the tenacity of the relationship of the fibrous outermost layer and the parietal serous layer, whether pleural, pericardial or peritoneal. The pia mater of the central nervous system is the least substantial as compared to its visceral membranous fascial analogues. It does not manifest enough depth in itself, or enough fibrous matter, being only a two or three cell-deep covering over the brain, even to ‘‘shred’’ in the fashion of the visceral pleura, for instance. It is soft enough to easily push a finger through, which is not the case for the visceral layer of the serous membranes in general. The pia simply cannot be differentiated as a layer except histologically.
Schematization of cranial and visceral fasciae.
Visceral Spaces
Fibrous outermost layers
Parietal serous layers
Visceral serous layers
Intracranial Thoracic Cardiac Abdominal
Dura mater Endothoracic fascia Fibrous pericardium Transversalis fascia
Arachnoid Parietal pleura Parietal pericardium Parietal peritoneum
Pia Visceral pleura Visceral pericardium Visceral peritoneum
Table 1 is taken from The Integral Anatomy Series, Vol. 3: Cranial and Visceral Fasciae, Copyright Gil Hedley, 2006, on DVD. Used with permission.
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Adhesion distinguished from ligamentous distortion
Photo #2 Above we see the visceral peritoneum covering the hepatic flexure of the colon. Image Copyright Gil Hedley, 2009. Used with permission.
Normal relations of parietal and visceral layers to each other The parietal and visceral layers of the various serous membranes form a continuity of tissue: the fascia is continuous, but it reflects off of the organs and then doubles-back around them to form an enveloping ‘‘balloon’’ around them as well. (Gray, pp. 459, 901, 970, 1901/1977) Within the parietal layer, then, the viscera, themselves covered in their ‘‘skins,’’ ideally slide one against another in perpetual motion in their ranges of normal mobility. They also slide against the parietal layer which surrounds them and with which they have varying degrees of contact throughout their range of motion. Further, in certain areas, the parietal layer is in sliding contact with itself.
Normal sliding surfaces So normal sliding surfaces can be said to include visceral serous membranes against one another, parietal serous membranes against themselves, and finally visceral serous membranes against parietal serous membranes. A few examples of these three categories of sliding surfaces are schematized in Table 2.
Definition of pathological adhesion A pathological adhesion, for the purposes of this conversation, is defined as a fixed connection between tissues which would normally slide relative to each other. Such adhesions are ‘‘pathological’’ to the extent that the normal range of motion of the tissues is inhibited by the abnormal relations of the visceral fascia. The normal motion of the organs in their own right, as well as in their relationships with one another, are an essential aspect of the proper physiological functioning of the organs. Therefore the disruption of normal motion via fascial pathology in the form of adhesions is potentially disruptive of highest organ function (Photo 3).
An adhesion is distinguished by the author for the purposes of these notes from the phenomena of distortions of visceral ligaments. ‘‘Ligaments’’ in anatomical nomenclature most generally indicate literally a form of ‘‘tying’’ of one structure to another. (from Latin, ligare, to bind or tie) Ligaments ‘‘tie’’ bone to bone, but they also ‘‘tie’’ organ to organ, and so on. Visceral ‘‘ties,’’ or ligaments, most often consist of various reflections, folds and spannings of the serous membranes (mesothelia) as they envelop the complex but interrelated forms of the viscera themselves and the convolutions of the spaces wherein the viscera move. In the author’s experience, the serous membranes are found to be highly elastic, which property is demonstrable not only in unfixed but also in fixed tissue samples, evidenced insofar as they recoil in various degrees when incised. The elastic property derives anatomically from the ample presence of both simply elastic as well as actively contractile fibers within the membranes. (Schleip, 2006, p.3) The causes of tissue shortening are various and beyond the scope of the present article. It is sufficient for now to simply distinguish for conversation’s sake between adhesions, where normal sliding surfaces are stuck to one another, and ligamentous distortion, where abnormal shortening or lengthening of the relationships of organs through their various ‘‘tyings’’ represent a different kind of fascial pathology of the viscera.
Types of pathological adhesion by cause Table 2, therefore, can serve equally well to outline potential loci of adhesions, because any normal sliding surface contacts also have the potential to become stuck: that is, to adhere, to one another. It is the author’s observation of clinical evidence in the laboratory that the circumstances which give rise to the adhesion of normally sliding surfaces are multiple. They include, but are not exhausted by, the following causes: 1) inflammation from infections or other types of disease processes 2) inflammation and scarring as the sequelae of surgical intervention 3) the sequelae of prior limitations upon movement cycles 4) intentional therapeutic adhesion
Inflammation from infections or other types of disease processes Serous membranes, like other tissues of the body, being highly vascular and innervated, are subject to inflammation from a variety of causes. Any ‘‘-itis’’ in the region of the viscera could potentially, though not necessarily, result in an adhesion. For instance, a lung infection could result in one or more points of fibrous connection of varying degrees of density between the visceral and parietal pleura. Pericarditis may result in a broad fixation of the visceral and parietal
258 Table 2
G. Hedley Examples of normal sliding surfaces.
Visceral layers against each other
Parietal layers against themselves
Visceral layers against parietal layers
Stomach to liver
Diaphragmatic aspect of parietal pleura to costal aspect of parietal pleura Diaphragmatic aspect of parietal pleura to mediastinal aspect of parietal pleura Uterus to rectum
Visceral pleura to parietal pleura Visceral pericardium to parietal pericardium Visceral peritoneum to parietal peritoneum
Loops of small intestine to themselves Ovaries to loops of small intestines Table 2 Copyright Gil Hedley, 2009. Used with permission.
pericardium. The normally free border of a cystic ovary may become adherent to the adjacent parietal peritoneum of the posterior abdominal wall (Monk et al., 1994). The author regularly dissects these types of ovarian adhesions as they appear commonly in cadaver specimens (Photo 4). This author has directly observed in the laboratory how other disease processes can result in adhesions beyond those deriving from straightforward inflammatory processes. Cysts and tumors can have the effect of binding two organs or two sliding surfaces together with the aberrant growth serving as the focal point of adhesion between the membranes. Ulcers, cancerous metastases and pancreatitis exemplify more extreme types of inflammation where strong adhesions may result from the disruption of the local tissues (Troitskii, 1968).
Inflammation and scarring as the sequelae of surgical intervention Surgery offers so many advantages that we are prone to forgive some of the problems that it can cause, among which can be counted visceral adhesions, and scarring. Where there are surgical scars observed on the outside of a human form, one can almost unerringly predict some manifestation of adhesions and scarring within the form. Scarring is defined by this author, for the sake of this discussion and based on
Photo #3 Arrow identify the adhesion of the visceral peritoneum of the small intestine to the parietal peritoneum of the ascending colon: these normally have a sliding relationship with each other. Image Copyright Gil Hedley, 2009. Used with permission.
direct observation, as aggregations of fibrous matter that result when surgical incisions or other types of wounds heal, leaving tissue layers (skin, superficial fascia, deep fascia, and membranes) pinned to each other with reduced play and elasticity. This author has also observed how the fiber direction of scars so defined is usually plaited in a multidirection manner, distorting the normal vectors of elasticity and tension native to the tissue. Scars can also be evident within the visceral spaces wherever incisions have been made, and in these cases they sometimes have as sequelae the adhesion of local tissues. (Zong et al., 2004) For instance, this author has directly observed how open heart surgeries will often result in major adhesions of the left lung to the chest wall, i.e., the visceral to the parietal pleura, as well as considerable adhesion of the visceral to the parietal pericardium. Because the incisions of surgery necessarily cause inflammation of the local tissues, in combination with scarring this can result in the formation of a seemingly progressive adhesion of visceral fasciae (Liakakos et al., 2001) (Photos 5 and 6).
The sequelae of prior limitations upon movement cycles Visceral ligaments and the spatial relationship of the organs to one another define the normal range of motion of the
Photo #4 Above the arrows indicate the whole inferior margin of the liver adherent to the greater omentum as the likely sequela of inflammatory processes. Image Copyright Gil Hedley, 2009. Used with permission.
Fascia research: Visceral adhesions
259 subsequent irritation of the membranes will initiate the formation of adhesions between the membranes which when fully progressed will have the effect of mitigating further collapse: the adherent membranes serve to sustain the inflation of the lung. (Montes et al., 2006) The loss of the sliding surface between the visceral and parietal pleura is the price willingly paid for the higher good of the lung’s permanent inflation. This author has directly observed how surgeons will suture tissues together in a manner demanding fixed relationships of tissues which might otherwise prolapse or spread apart. Thus sometimes tissues are adherent because it is demanded of them to be so (Wong and King, 2004).
Varying impact of adhesions Photo #5 Adhesions of visceral to parietal pericardium following upon open heart surgery. Image Copyright Gil Hedley, 2006. Used with permission.
viscera as they respond to the breath cycle. A scar or initial adhesion represents an abnormal limit cycle upon the phases of movement characteristic within the visceral spaces. It is this limitation of movement which is at the heart of the type of progressive adhesion noted above. Adhesions beget adhesions, as the initial limitation of normal motion extends like a growing cloud of stillness in the immediate tissues. This type of progressive adhesion will form as a diffused and general fixed relationship of the tissues across a broad surface, rather than as a cluster of single-pointed fibrous linkages. In dissection, one ‘‘peels’’ these adhesions apart, as opposed to cutting or ‘‘popping’’ them at individual points of relationship. The author has dissected many human forms where numerous precedent abdominal surgeries have resulted in virtually the entire visceral contents becoming adhered into a single common mass (Photos 7 and 8).
Intentional therapeutic adhesion
The adhesion of normally sliding surfaces in any of the manners described range on a continuum of impact upon normal organ function from inconsequential to debilitating. Where the abdominal organs are reduced to a virtually solid and immobilized mass as a result of repeated major surgical interventions, the physiology of the organs are necessarily affected by their lack of mobility over time. On the other hand, a minor and singular adhesion of a fatty epiploic apendage of the descending colon to the adjacent parietal peritoneum is unlikely to have any particularly untoward effect, given the normally relatively fixed position of the colon along the posterior wall of the abdomen by the parietal peritoneum (Photo 9).
Palpating for adhesions Part of the process of careful dissection of the viscera involves visually observing and manually palpating the tissues. This inspection process often reveals a variety of adhesions in the mostly elderly forms which donor programs provide. Often it is possible to deduce or infer the causes of the adhesions based on the evidence at hand, and given a lack of explicit medical history, these inferences are all
In the instance of a repeatedly collapsing lung, talc may be introduced between the visceral and parietal pleura. The
Photo #6 After the removal of the adhesions of the visceral and the parietal pericardium shown above. Image Copyright Gil Hedley, 2006 used with permission.
Photo #7 Above is a specific fibrous adhesion of the visceral pleura of the right lung at its most inferior tip, to the parietal pleura in its mediastinal aspect. Image Copyright Gil Hedley, 2009. Used with permission.
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Photo #8 Above a progressive adhesion of the entire visceral surface of the lung to the mediastinal pleura is being manually peeled apart in dissection: the arrows indicate the still undifferentiated adhesions at the margins of the lung. Image Copyright Gil Hedley, 2009. Used with permission.
there is to go by. Many of the adhesions discovered, when not obviously associated with evident disease processes or surgical interventions, would likely have escaped the knowledge of the donors and their doctors. Nonetheless, they may have been subtly affecting optimal visceral motion and health. The question then remains open as to how a therapist trained in visceral manipulation might facilitate the visceral motion in the living in a manner that might relieve some of the adhesions revealed in the dissection process.
Direct vs indirect approaches to releasing adhesions In the process of differentiating the viscera it becomes necessary to release adhesions as they are found. Many
G. Hedley adhesions can simply be directly pulled apart manually in dissection. The author has often imagined that the same could probably have been accomplished manually in vivo as well, given the appropriate leveraging of the tissues in question. However, though this type of direct technique seems possible, it does not, upon careful consideration, appear to be the most advisable approach. Fibrous adhesions when broken abruptly can result in small wounds to the tissues related by them, which wounds themselves would be likely sources of inflammation. So a cycle of adhesion could easily be re-introduced with such a strategy, creating little progress, or even exacerbating the problem. A more indirect technique for releasing adhesions in vivo would appear to be desirable. By manually facilitating movement towards the normal range of motion of the fixed tissues with gentle traction, timed with several fulsome breath cycles on the part of the client, the expanding range of motion may itself induce the dissolution of the adhesions, not necessarily in the moment, but over time. In the same way that restrictions upon movement from adhesions may progress into greater levels of adhesion over time, enhancements of movement may progress into greater levels of movement and the restoration of normal sliding relationships of tissues.
Hypothetical examples of indirect release of adhesions in vivo These examples are hypothetical and are not meant to serve as medical advice. They could serve as sample protocols for researching the impact of interventions with respect to post surgical adhesions.
Self-care example An individual might help themselves to release adhesions from progressing after thoracic surgery with a practice of simple variations on thoracic twists. For instance, with hands grasping on a pull-up bar positioned at a height within easy reach, an individual could introduce gentle torques into their thorax, accompanied by several deep breath cycles at each position explored. Such could be a daily practice for a few minutes a day post-surgery. The external torsion accompanying the internal breath could literally stretch and mobilize fixed but normally sliding tissues of the thorax. The reiteration of larger cycles of motion thus introduced could have the effect over time of gently dissolving adhesions, slowing the progression of further adhesion, or at least increasing the elasticity and range of motion of the individual’s visceral relationships, both normal and pathological.
Practitioner-supported example
Photo #9 Epiploic appendage of descending colon adhering to parietal peritoneum. Image Copyright 2009 Gil Hedley. Used with permission.
In instances where the support of a practitioner is warranted, taking the same example as above, a trained bodywork practitioner could gently introduce torsions into the patients thorax while coaching their position and breath cycles, with an intent on varying the presenting
Fascia research: Visceral adhesions motion patterns which may be reflecting underlying adhesions. By increasing the factors which thus increase demand for the gliding of sliding surfaces which may be fixed, greater movement cycles may reiterate and accrue to the advantage of the client in the manner described above.
References Barral, J.-P., Mercier, P., 1988. Visceral Manipulation. Eastland Press, Seattle. Barral, J.-P., 1989. Visceral Manipulation II. Eastland Press, Seattle. Barral, J.-P., 1991. The Thorax. Eastland Press, Seattle. Barral, J.-P., 1993. Urogenital Manipulation. Eastland Press, Seattle. Gray, Henry, 1901/1977. Anatomy, Descriptive and Surgical. Gramercy Books, New Jersey. Hedley, G., 2005a. The Integral Anatomy Series, on DVD. In: Skin and Superficial Fascia, vol. 1. Hedley, G., 2005b. The Integral Anatomy Series, on DVD. In: Deep Fascia and Muscle, vol. 2. Hedley, G., 2006. The Integral Anatomy Series, on DVD. In: Cranial and Visceral Fasciae, vol. 3.
261 Hedley, G,, 2009. The Integral Anatomy Series, on DVD Viscera and their Fasciae. Liakakos, T., Thomakos, N., Fine, P.M., Dervenis, C., Young, R.L., 2001. Peritoneal adhesions: etiology, pathophysiology, and clinical Significance. Dig. Surg. 18, 260e273. PMID 11528133. Monk, Bradley J, Berman, Michael L, Montz, F.J., 1994 May. Adhesions after extensive gynecologic surgery: clinical significance, etiology, and prevention. Am. J. Obstet. Gynecol. 170 (5), 1396e1403. Montes, J.F., Garcı´a-Valero, J., Ferrer, J., 2006 Sept. Evidence of innervation in talc-induced pleural adhesions. Chest 130 (3), 702e709. PMID: 16963666. Schleip, R., 2006, Active Fascial Contractility. Implications for Musculoskeletal Mechanics, Dissertation, Ulm University, Ulm, Germany. Troitskii, R.A., 1968 April. Abdominal adhesions and tumor growth. Bull. Exp. Biol. Med. 65 (4), 441e443. Wong, S.W., King, D., 2004 Aug. Sutureless intestinal plication. ANZ J. Surg. 74 (8), 681e683. Zong, Xinhua, et al., 2004. Prevention of Postsurgery-induced abdominal adhesions by electrospun bioabsorbable nanofibrous poly(lactide-co-glycolide)-based membranes. Ann. Surg. 240 (5), 910e915. 2004 Nov.PMID: PMC1356499.
Journal of Bodywork & Movement Therapies (2010) 14, 262e271
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CLINICAL INFLUENCES
Extensor coxae brevis: Treatment strategies for the deep lateral rotators in pelvic tilt Thomas Myers 318 Clarks Cove Rd, Walpole, ME 04573, USA Received 5 December 2008; received in revised form 26 November 2009; accepted 8 December 2009
KEYWORDS Myofascial; Pelvic neutral; Hip joint; Postural assessment; Piriformis
Summary The group of myofascial units known as the deep lateral rotators are considered in light of their role as postural hip extensors, resulting functional and palpatory assessments of pelvic neutral are presented, and treatment strategies for anterior and posterior pelvic tilt are discussed. ª 2009 Elsevier Ltd. All rights reserved.
Our Uniquely Human Hip The differing roles of five small but important myofascial units e the gluteus medius, piriformis, obturator internus, obturator externus and quadratus femoris e within the unified fascia of the posterior hip are here examined. This group of muscles, commonly named as ‘deep lateral rotators of the hip’, can be seen alternatively as postural extensors of the coxofemoral (hip) joint. Within this perspective, we propose informal assessments and treatment strategies for these structures in anterior and posterior pelvic tilt (Fig. 1). One of the many unique features of human plantigrade carriage is that our femur in standing posture is in general coronal alignment with the spine. Comparatively, few other quadrupeds or even primates are accustomed to such hip extension; their mid-range positions for the femur are
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[email protected] substantially flexed, usually at 90 or more to the angle of the sacrum (Fig. 2). Bring the leg of any cat or dog into such full extension; and one is likely to get an unmistakable non-verbal response before reaching the angle required for human standing. Even our closest relatives, the chimpanzee and gorilla, who can achieve fuller extension when necessary, seem to drop gratefully (in this author’s observation) back toward hip flexion, whereas humans routinely spend the day standing ‘naturally’ in what would be for most other primates or quadrupeds the more extreme end of the flexioneextension range. One can say ‘extreme’ even in the human, given that there is very little additional extension left for the femur in most of us, due to the twisting of the coxofemoral ligament complex, specifically the pubofemoral ligament under (or blended with, in our limited but repeated dissection observation) the iliopsoas tendon. Even the minor hyperextension required for our gait can be observed at a certain point to incur lumbar hyperextension rather than further extension of the femur relative to the hip (Fig. 3). The
1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.12.003
Extensor coxae brevis
Figure 1 The ‘extensor coxae brevis’ group. Art courtesy of John Hull Grundy, used with permission..
posturally lazy can thus shift the pelvis forward over the feet to ‘lean’ against these ligaments, whereas the yogically or acrobatically trained, or those with a naturally loose ligamentous bed, can achieve greater than normal coxofemoral hyperextension before the movement is transferred from hip to spine. Attaining and maintaining our upright posture in either phylogenetic or ontogenetic terms requires approximating the ischial tuberosity (IT) to the femur. Hip extension can involve either extending the femur away from the front of the pelvis and spine, as we just did with our cat, or bringing the posterior aspect of the pelvis closer to the shaft of the femur. Human standing requires the latter: swinging the pelvis posteriorly around the stationary head of the nearly vertical femur, as in Fig. 3. Coupled with the erector spinae above and the soleus below in keeping the body upright, the author contends that the hip extensors are the muscles that must shorten, over evolutionary time, to extend the
Figure 2 Human standing involves a uniquely extended hip joint where the femur is generally aligned with the axis of the spine, compared to other mammals, even primates, where the coxofemoral relation is 90 or less.
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Figure 3 In human standing the hip bone must make a powerful movement around the femur to approximate the ischial tuberosity to the femur and lift the spine (After Molliere).
hip. A relaxed body out of gravity will assume the ‘dead man’s float’ position, with the hips flexed into a more quadrupedal position. The primary hip extensors are usually considered to be the hamstrings, pulling directly inferior from the posterior surface of the IT, with fascial extensions onto the sacrum. These muscles are also fascially continuous with both the erectors and the triceps surae (fellow travelers in the Superficial Back Line (Myers, 2009) e Fig. 4). While the role of these ischiocrural muscles as hip extensors is unassailable, they have two disadvantages in performing the postural1 part of this uniquely human hip extension: 1) All three hamstrings are two-joint muscles, flexing the knee as well as extending the hip. This author’s clinical finding is that the body’s brain primarily uses the deeper, single-joint muscles to maintain posture whenever possible, leaving the more superficial multijoint muscles to modulate and coordinate movement.1 How do the hamstrings mediate between their pivotal postural and dual movement roles? I.e.: how do the hamstrings maintain hip extension without also flexing the knees? Having this tendency constantly opposed by the quadriceps would be energetically inefficient. 2) All the hamstrings are very long. Because of the linear alignment of myosin and actin elements, maintaining posture via such long muscles (despite the extensive membranes and tendon arrangements within them) is mechanically and physiologically disadvantageous (Fig. 5).
1 We can avoid the controversy concerning whether muscle activity is or should be involved in human standing posture by positing that a) human standing involves constant low-amplitude shifting and resulting tonic muscle activity, and b) muscle activity in hip extensors would be necessary to prevent hip flexion during loading, i.e. when carrying a child on the front of the trunk or it’s postural equivalent such as a pot belly.
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Figure 4 A dissection of the Superficial Back Line laid over a classroom skeleton. The hamstrings e part of this myofascial continuity e pull down on the ischial tuberosity. Photo courtesy of the author and the Laboratories for Anatomical Enlightenment.
Which are single-joint muscles whose tonus might maintain human hip extension against the force of gravity, any myofascial tension in the numerous hip flexors, or any recoil of the pubofemoral ligaments? In answer, we find the long portion of the adductor magnus e a single-joint extensor of the hip just deep to the hamstrings e and the deep lateral rotators. (Fig. 6) In fact, every one of the muscles behind the coronal midline of the femur can help extend the hip: in addition to the posterior fibers of adductor magnus, we can include portions of the gluteus medius and gluteus minimus, piriformis, gemellus
T. Myers superior and inferior, obturator internus, and quadratus femoris (see Fig. 1). This list constitutes the posterior portion of what can be seen as a ‘fan’ of muscles, or a set of myofascial ‘spokes’ around the ‘hub’ of the greater trochanter (Myers, 2004a). The tensor fasciae latae, and anterior portions of gluteus medius and minimus constitute the anterior e and thus hip flexor as well as abductor and medial rotator e part of this fan. The fact that the muscles named above are commonly named the ‘deep lateral rotators’ (of the femur) demonstrates that their role as extensors of the hip has been under-appreciated in our consideration of hip biomechanics. The ‘lateral rotator’ designation implies that the pelvis is the stable origin and the greater trochanter of the femur is the moveable insertion. For the remainder of this article, we will be reversing the emphasis, taking the femur of the standing leg (or both legs) as origin and the posterior aspects of the os coxae and sacrum as the insertion e hence extensor coxae brevis. Any of the hamstrings, save the short head of biceps femoris, would thus be ‘extensor coxae longus’. Both groups, we are hypothesizing, share the workload of extending the hip and preventing unwanted hip/trunk flexion Though the two tasks of lateral femoral rotation and hip extension are related (think of the push-off phase of rollerblading or ice-skating as extensions of similar smaller movements in walking), their role as lateral rotators is subordinate, in this writer’s opinion, to their postural role in keeping the hip extended.2 If we concur with that role, these muscles become crucial to any strategy for dealing with an anterior or posterior pelvic tilt, as these postural positions could be alternatively described as hip flexion and extension respectively. In hip flexion/anterior pelvic tilt, these muscles will tend to be eccentrically loaded (neuromyofascially ‘locked long’); in hip extension/posterior tilt, they will tend to be concentrically loaded (‘locked short’) e though the precise parameters of such designations are yet to be defined. The extremes of both anterior and posterior pelvic tilt may involve a functional weakness in terms of these surrounding muscles’ ability to generate forceful contraction on any attachment or across the hip joint itself. Eccentrically loaded muscles have less overlap between the myosin and actin proteins, and thus cannot generate a strong contraction. Concentrically loaded muscles have plenty of overlap (so it is more difficult to generate relaxation in them), but are so near the end of the ‘ratchets’ that they cannot generate significant further contraction.3 Even though there is a certain amount of adjustability in tonal length within the muscles, neither of these ‘out of
2 This is an assumption not universally shared: No less an authority than Serge Gracovetsky says: ‘‘As a rule of thumb, the muscles must be considered as ‘‘gas guzzlers’’ and, to execute any tasks with minimum energy consumption or minimum stress in all joints, the musculoskeletal system will always attempt to use its ligaments first, and fire a muscle as a last resort.’’ (Gracovetsky, 1986). 3 Again, this is a presumption based on clinical palpation only. Hoyle found most striated muscle to be heterogeneous (Hoyle, 1967).
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Figure 6 The adductor magnus assists the hamstrings and the deep lateral rotators in maintaining hip extension. Art courtesy of John Hull Grundy, used with permission.
Figure 5 Given that they are very long two-joint muscles, the hamstrings are ill-equipped to be postural muscles.
neutral’ positions would seem to provide efficient and strong muscle contraction in functional movement. If so, we speculate that those clients whose characteristic postural position tends toward one or the other of these extremes have neither a strong and adjustable initiator for leg movement, nor a stable but responsive foundation for spinal movement.
Assessing pelvic tilt If the treatment option employed varies with pelvic tilt, how shall we define pelvic neutral? Opinions abound as to what
constitutes a ‘neutral pelvis’. Ida Rolf suggests that when the superior surface of the pubic bone and the tip of the coccyx are in horizontal alignment, the pelvis is in a proper neutral (Rolf, 1977). Hiramoto and Kendall and McCreary posit that pelvic neutral is when the ASIS and the front surface of the pubic bone are in the same coronal plane (Hiramoto, 2000; Kendall and McCreary, 1983). Others suggest an ideal angle between the ASIS and PSIS (Shamberger, 2002). This author finds such markers objectionably geometric and fixed, as they fail to account for individuated dynamic relations between the femur and the lumbar spine through the pelvis. A more complete goniometric method might yield more convincing and less cut-and-dried measures with further research (Sprigle et al., 2003). We have been using a more individually responsive test, which has its own problems, but produces, in our opinion, a truer overall result than these simple geometric visual measures. Again, more research with such measuring devices as a laser or balance beam might be possible to introduce objectivity and
266 eliminate ideomotor bias from the following subjective (but nonetheless interesting and sensitive) assessment method. With the subject in relaxed standing, place your hand ever so gently on their head, with a cranial touch e no more than a nickel’s worth of pressure. Resting in the hair will suffice to feel what you are looking for. From whatever pelvic position is ‘normal’ for this person, have them tilt the pelvis a bit anteriorly. Does the head rise into or shrink away from your hand? If they increase the forward tilting of the pelvis toward their end-range of hip flexion, at some point the body will shorten away form your hand. Have them return to their normal. Now have them tilt the pelvis posteriorly a little. Same question: does the head bloom into your hand or shrink away? Again, if they continue into more extreme posterior tilt toward the end-range of hip extension, the spine will eventually shorten. Have the subject slowly oscillate through the top of the movement until you are sure where the ‘highest’ point in the cycle occurs. In this model, pelvic neutral e the postural ideal e is when the head is at its highest, indicating that the spine is at its longest. The operating presumption for this test is that the pelvis should rest in the position where the spine is ‘living its full length’. Repeat the exercise in each direction a few times to make sure you are reading the results correctly. This test is more accurate the more differentiated the client’s pelvic movement can be, such that they can isolate the movement of the pelvis from compensatory movement in the rib cage, legs and lumbars. In individuals who are challenged with excessive stiffness, injury, or surgery, the test will be less effective, as the spine will shorten due the forward or backward displacement of the head or rib cage. In most cases, however, the anterior or posterior tilt of the pelvis reveals that ‘highest point’, often only a few degrees from where they habitually rest, and that is where you should aim for having the patient rest in normal. This angle of the pelvis where the spine lives its fullest length, for the purposes of this paper, is defined as their particular ‘pelvic neutral’. Periodically retest over time, as the results can shift a little as greater balance is achieved. Please note that we are not suggesting that you should instruct your clients to ‘put’ themselves in this normal; if you do good work, the subject will arrive naturally and without effort at his own ‘personal best’ normal.
T. Myers muscle is a distinct slip running on the oblique line between the posterior superior iliac spine (PSIS) and the superior aspect of the greater trochanter. By strumming across this line, the trailing edge of this muscle and its fascia can usually be distinctly felt as if it were a separate muscle.
Piriformis The only two-joint muscle of this group, as it also crosses the sacroiliac joint, passes from the top of the greater trochanter through the greater sciatic foramen to attach to the anterior aspect of the middle three segments of the sacrum (Fig. 7). The piriformis is thus the sole axialappendicular muscle of this group, with the ability to create ‘force closure’ on the sacroiliac joint during gait (Vleeming et al., 2007). This function combines with its contribution to stabilizing the sacrum at the bottom of the spinal ‘lever’ in lateral tilts, bends, and rotations of the spine, as well as the more familiar one of laterally rotating the femur (or preventing medial rotation), or teaming up with the pectineus to create pelvic rotation e stretching the poor piriformis among multiple roles (Myers, 2004b). This muscle can be most easily palpated (though sometimes it is not easily palpated at all) in the center of a triangle made from the top and bottom of the sacrum along the midline and the posterior aspect of the greater trochanter. Strumming up and down over the center of this triangle will often (but not always) reveal the small but potent piriformis. Whether it can be distinctly felt or not, this is where piriformis is most easily touched manually (given that we are not entering the body cavities). Proximal to this point, it disappears deep to the sacrum, and distal to this point the tendon can be lost in the general ‘glom’ of connective tissue around the trochanter. Of course piriformis can be ‘reached’ using the femur as a lever to
Anatomy A brief review of the anatomy will be helpful before discussing treatment options. Precise palpation directions are offered as all of these muscles lie deep to the large and thick gluteus maximus, which can make easy palpation challenging. All but a small portion of this muscle (deep and parallel to the quadratus femoris, according to Janda) is quiescent in standing, so its role in hip extension is limited to running and stair-climbing, and not, like the rest of this list, in relaxed standing (Janda, 1986). We proceed from superior to inferior.
Gluteus medius, posterior portion The posterior portion of the gluteus medius is a combination of a hip extensor and abductor. The posterior edge of this
Figure 7 The unique piriformis performs multiple roles, and should be considered from both sides, as one myofascial continuity, as suggested in this art from John Hull Grundy. Used with permission.
Extensor coxae brevis induce a general stretch, though this author finds far more specificity for each of the three slips by means of the direct manual approach.
Gemellus superior This small muscle passes from the lateral end of the sacrospinous ligament to the trochanteric fossa, and may thus provide muscular reinforcement to the ligament in its role of stabilizing the side-to-side movement of the sacrum. In this way, this muscle is, in effect, a two-joint muscle as well, helping to reinforce the sacroiliac joint via the sacrospinous ligament. Palpate this muscle, if it can be distinguished, along a line just superior to obturator internus.
Obturator internus This fascinating muscle also inserts into the trochanteric fossa, but it passes behind the ischium to take a 90 turn over a bursa, fanning out to cover the whole inside of the lower flange of the hip bone within the true pelvis, completely covering the medial side of the obturator membrane. This muscle is thus much larger and stronger than it appears from a posterior view of the hip. It also provides an attachment for the iliococcygeus of the pelvic floor. Take these two muscles together on both sides, and one can see a fascial ‘hammock’, strung from trochanter to trochanter (Fig. 8). This author agrees with Grundy’s view in Fig. 8: this complex can provide a resilient ‘spring’ for the forces transferring from the spine to the legs, sparing the full force from the coxofemoral joint itself (Grundy, 1982).
Figure 8 The obturator internus, again considered from both sides, and when coupled with the pelvic floor (not pictured), forms a sling to cushion the shock of the upper body’s weight on the hip joint. Art courtesy of John Hull Grundy, used with permission.
267 To find the obturator internus (OI), locate the ischial tuberosity (IT) from below on your prone client. ‘Walk’ your fingers up the ‘mountain’ of the ischial bone toward the head until you find a soft ‘meadow’ of muscle e this is the OI, which can usually be felt as a distinct muscle if you strum up and down. From here go directly lateral to find the distal tendinous portion of this muscle, which may blend with one or both gemelli to produce a single large tendon, or may remain palpable as two or three distinct tendons. Following Humphry4 we could see the obturator and the gemelli as a single five-stem ‘bouquet’ of muscles arising from the trochanteric fossa, with the two gemelli forming the upper and lower (and shorter) portions over to the upper and lower ischium, while the obturator internus rounds the tuberosity to divide into three portions e one reaching up toward the iliac portion near the anterior sacroiliac joint, one reaching straight across the obturator membrane for the suprapubic ramus, and one reaching downward toward the ischioubic ramus (Humphry, 1872). To find this larger, internal, and more muscular proximal part of OI requires courage and a willing client e and even then you are limited to the lower two of the three parts just described. Place three fingertips just inside the IT, using the sacrotuberous ligament as a guide for the index finger. Slide in the direction of the navel, lateral to the anal verge and parallel to the ischium. Your fingerpads will feel the IT/ischial ramus at first, but as you pass into the ischiorectal fossa, you will encounter a softer area that is
4
Humphry, 1872, p. 34 ‘The three flattened, closely adjusted tendons which the obturator internus presents as it passes over the smooth surface of the ischium, have often attracted attention. They are the result of a division of the muscle within the pelvis into three flat fan-shaped portions. Of these, one, lying internal to the others (in a superficial plane when dissected from the inner side), arises from the inner surface of the angle formed by the horizontal and the descending portions of the os pubis. It is situated internally to the obturator vessels and nerve, and the arch of fascia which covers them, and therefore away from the obturator foramen. The tendon proceeding from this is the middle tendon of the three. The second division of the muscle, from which the lowest tendon proceeds, arises from the ossa pubis and ischii bounding the lower half of the obturator hole, and from the surface of the obturator ligament. The third division arises from the upper half of the obturator ligament, and from the ossa pubis and ilii above the obturator hole and beneath the brim of the pelvis. It extends upon the ilium nearly to the sacroiliac synchondrosis. This tendon is the upper of the three. It occupies a groove commonly seen just below the spine of the ischium; and it sometimes presents a division into two for a short distance, giving the appearance of four tendons upon the internal surface of the muscle. The two last-mentioned divisions, which may be called respectively ‘‘pubischiatic’’ and ‘‘pubiliac’’, approach one another upon the obturator ligament beneath the first-mentioned, which may be called the ‘‘pubic’’ division. Having passed over the ischium, the tendons unite into one, the edges of which are joined above and below by the gemelli. If traced backwards from the trochanter, the tendon of the obturator gives off, first, in a penniform manner, the fibers of the gemelli; then, in like manner, those of the ‘‘pubiliac’’ and ‘‘pubischiatic’’ portions; and lastly, in like manner, the fibers of the pubic portion’.
268
T. Myers
comprised of the lower fibers of OI. You will be stopped in your upward and forward progress by the pelvic floor/iliococcygeus, which crosses over from the midline to attach to the OI fascia at the arcuate line. Have the client contract the pelvic floor and you will be able to assess its relative strength from the contraction against your fingertips.
Gemellus inferior This small muscle reinforces the obturator internus from below, extending from the distal end of the sacrotuberous ligament on the ischial tuberosity to blend in its attachment with the tendon of the obturator internus. Though this muscle shares with all the others in this list the roles of hip extensor and lateral rotator of the femur, any additional role e such as possibly providing an adjustable reinforcement to the sacrotuberous ligament complex e is as yet unclear (Van der Wal, 2009).
Quadratus femoris The last but not least of our group extends from the lateral aspect of the IT laterally to the posterior trochanter. This muscle is a powerful postural extensor of the hip (or, more accurately, a powerful resistor to hip flexion as well as medial femoral rotation), given its ability to approximate the IT to the posterior aspect of the femur, and will be short and bunched in most clients with a pronounced posterior tilt. Because the muscle is quadrate, it rarely presents as a twangy bit of myofascia, but more often as a graduated mound of tissue. Quadratus can be found and assessed above a line running lateral to the lower end of the IT e frequently just above the line of the superficial gluteal fold. Do not confuse this with the similar mound more distally located on the femur, below the gluteal fold, which is the fleshy attachment of the gluteus maximus.
Obturator externus (OE) This muscle is usually included in the deep lateral rotator group, but is not an ‘extensor coxae brevis’ because it acts e alone in this group e as a hip flexor. This rogue muscle is hard to palpate and difficult to treat in its entirety. Originating from the lateral surface of the lower flange of the hip bone, covering the outer surface of the obturator membrane, the OE passes under the neck of the femur from anterior to posterior to attach into the trochanteric fossa deep to the quadratus femoris. Obturator externus counterbalances the OI in hip flexion and extension, though both combine to resist the medial rotation of the femur (Fig. 9). In running closely under the neck of the femur, it also offers a muscular reinforcement to the neck when it is under extra strain (in landing after a jump, for instance). It is probably not a powerful hip flexor, given the competition it finds in the more advantageously positioned iliacus, pectineus, and rectus femoris, etc., but chronic shortness in its myofascia could conceivably prevent the ischial ramus from moving forward and thus the pubic bone from lifting.
Figure 9 Obturator externus is included in the deep lateral rotator group, but not in our extensor coxae brevis group, as it is a weak hip flexor. Hard to reach and difficult to treat, it is nevertheless a major stabilizer of the pelvis on the leg. Art courtesy of John Hull Grundy, used with permission.
The two obturator tendons arise from the same area of the trochanteric fossa, and can, in this author’s limited dissection observation and Humphrey’s more extensive documentation, blend at their distal end (Humphry, 1872). Together, the two muscles could be seen to reach out from the femur like two hands holding the inner and outer aspects of the lower flange of the pelvis in a close but adjustable grip. This is one of the more obscure muscles of the pelvic area to palpate, but it can be felt by the knowledgeable practitioner on a willing client by entering the femoral triangle of the client lying supine with the knees up. Find the small fascial ‘window’ between the medial edge of the pectineus origin and the lateral edge of the adductor longus tendon and press in superiorly and posteriorly with fingertips or your thumb pad. The tough and generally sensitive tissue beyond these two muscles is the OE, running from the lateral surface of the ischium and obturator membrane back and under the neck of the femur to the trochanteric fossa. Only a small portion of this muscle can be directly palpated.
Treatment Having come this far, treatment options abound. The one sentence pre ´cis is that in cases of a chronic postural set of anterior pelvic tilt/hip flexion the fascia of this muscle group needs to be taken inferiorly individually and as a whole, while in cases of posterior pelvic tilt these myofascial units need to be neuro-muscularly and fascially released and allowed to lengthen and hopefully reset at lower standing tension. In anterior tilt, these muscles will be eccentrically loaded, so any or all of them present in our clinic as twangy, tight, and sore with active trigger points. In posterior tilt, they often present as bunched, often seemingly tied together, with primarily passive trigger points.
Extensor coxae brevis
Figure 10 Treatment of these muscles in posterior tilt generally involves lengthening the myofascial units, and usually from pelvic origin to femoral insertion. Art courtesy of John Hull Grundy, used with permission.
Posterior tilt In posterior tilt, a variety of treatment options may be used to ease standing tension, including neuromuscular therapy techniques, active isolated stretching, strain-counterstrain, or proprioceptive neuromuscular facilitation. In terms of more commonly-used fascial release techniques, working slowly along each individual muscle from pelvic origin toward the femoral insertion, using the guidelines for specificity outlined above, will usually result in lengthened fascia and lower standing tone (Fig. 10). The posterior edge of the gluteus medius is easily located between the superior trochanter and the PSIS. Beneath this muscle, the harder-to-feel but equally potent gluteus minimus can be contacted (usually to the client’s initial horror) by passively abducting the side-lying client’s thigh with one hand or forearm, while working deeply into the posterior hip tissue with the other elbow. The piriformis is harder to locate on some clients, but following the direction to the center of the triangle described above will guarantee that you are on the piriformis whether it can be detected or not. Work laterally and inferiorly toward the insertion to lengthen this muscle (at least temporarily e modulating pelvic tilt is only one of piriformis’s many roles, which include antagonizing the lower psoas over the sacroiliac joint (Myers 2004b), reinforcing the sacrospinous ligament, and preventing excess movement in the sacroiliac joint due to forces descending from spinal movements above, not to mention force closure of the SI joint in walking e therefore treatment of the
5
Resetting the standing tonus of muscles is an elusive concept in research. As a clinician, we ‘know what we feel’, but the science is not yet fully in agreement here (Mori et al., 1982; Asanoma et al., 1998; Bouret and Sara, 2005).
269 piriformis often reverts over a short time until the body reaches sufficient balance in all these forces for the piriformis to retain any new tonal ‘set point’.5) Gemellus superior and inferior are usually addressed with the obturator internus rather than individually, again working along the muscles from the lateral side of the upper ischial tuberosity laterally toward the fossa at the back of the greater trochanter. Work deeply and slowly for best results. For the intrepid practitioner and the willing client, the larger portion of OI can be reached by sliding the fingertips up into the ischiorectal fossa in the direction of the navel, using the sacrotuberous ligament as a guide, as detailed above. Once well onto the muscular fibers of the OI proper, hook the myofascia and bring the issue inferiorly and posteriorly (bring your hand back the same way it went in, but with the fingertips hooked into the fascia), as the client medially rotates the femur. This one technique can result in a substantial reorientation of the pelvis in the direction of an anterior tilt (as well as easing the overlytight pelvic floor, in our experience), helping to restore a neutral lumbar lordosis when the client stands after treatment. The quadratus femoris is a tough square of myofascia that can be worked quite strongly and needs to be worked quite thoroughly in these cases, mostly along the posterior side of the trochanter superior to the gluteal fold. If you are working this muscle with the client prone, ask them to arch their lumbar spine slowly into a lordosis as you work, thus adding an active release component into your technique. Release of this muscle e again along the grain of the fibers, deeply and slowly e often results in the ability to more properly fold the hip joint into flexion without binding.
Anterior tilt For anterior tilt, this entire set of myofascial units needs to be pulled caudad. One fascial portion of this treatment can be accomplished most easily behind the greater trochanter, where they all terminate. With your client prone and the hip relaxed as possible, hook the fascia at the top of the trochanter with an elbow and bring it down along the back of the trochanter (Fig. 11). Several passes and significant weight are often required to effect a change, as you are working with the tendons of all these muscles in the fascial fabric behind the trochanter. Similar work can be done nearer the origin of these muscles by hooking tissue slowly along the posterior iliac crest, just lateral to the PSIS, and along the lateral lower sacrum and ischial tuberosity. Cross-fiber work across each of these individual muscles seems to be helpful in unlocking the eccentric loading in the fibers of these muscles, helping to create (but not guaranteeing) a shorter standing tonus.6 Work slowly back
6 This could be a useful area for future ultrasound research: what is the architecture of fascia, particularly the endomysium, in an eccentrically loaded muscle? And what is the effect of cross-fiber work on this ‘locked long’ myofascial architecture? See Van der Wal, 2009; Purslow 2002; Passerieux et al., 2006 and Huijing 2007.
270
Figure 11 Treatment in anterior tilt generally involves pulling the fascial plane caudally while stimulating the muscles to shorten via cross-fiber work. Art courtesy of John Hull Grundy, used with permission.
and forth across the muscle you wish to focus on, slowly enough not to ‘twang’ the muscle, but to soften and differentiate the myofascia without allowing it to jump beneath your applicator (fingers, knuckles, or elbow). Of course, this work needs to be accompanied by the release of the hip flexors and spinal extensors for best results. Including the OE, the renegade of our group, can be helpful in this regard. Again, this requires a willing client and a certain skill by the practitioner. With your client supine and the knees up, sit next to her hip and cup her knee in your axilla. Find the obvious adductor longus tendon in the groin and place your thumb just anterolateral to its junction with the pubic bone. Insinuate your thumb between the adductor longus and the pectineus. OE lies deep to these two, and is usually distinctly harder than the pectineus, and deeper than the adductor longus or brevis. Contacting it will often elicit a surprised reaction from the client, but with sensitive communication, you can get a release from the portion of the muscle you can touch, which is by no means all of it. This is only one access point to a fairly large attachment, but by changing the angle of the thumbprint slightly from directly superior to inferior and medial against the pubic bone, or superior and lateral, and calling for a slow pelvic rock, more of the muscle belly can be contacted. Most clients with a fixed anterior tilt will find more freedom after this release, which can be repeated as often as time (and the client) allow. Continuing our journey caudad from here, we would encounter the adductor minimus, which due to its positioning and innervation is probably, like the OE a hip flexor. The remaining portions of the large adductor magnus running from the more posterior ischial ramus to the linea aspera and medial femoral epicondyle do appear to participate in hip extension, but are often stuck in
T. Myers a dormant ‘sensori-motor amnesia’, and will benefit from the kinds of muscle-activation techniques such as MET and PNF mentioned above. In cases where the two innominates are in a different angle, the two sides will require different degrees of treatment to ease locked nutation or counter-nutation of the sacroiliac joint. In general however, the inclusion of these ‘extensori coxae brevi’ in your treatment plans for excessive anterior or posterior pelvic tilt will be rewarded. In considering the postural balance of the pelvis on the femur, the hip flexors get a lot of attention and for very good reason: 1) they are large and strong muscles, 2) which must lengthen significantly for full maturational development, and 3) which can be subject (in our observation) to increased tension in common fear or post-traumatic situations, as well as in chronic torsion or rotational patterns not addressed by this article. Here we have made the case that the ‘deep lateral rotators’ may act as postural antagonists to these hip flexors, not leaving the entire job to the long, bi-articular, and often over-worked hamstrings. We offered a test for determining the client’s personal ‘pelvic neutral’, and suggested techniques for this ‘extensor coxae brevis’ group to help move the client toward their functional norm.
References Asanoma, et al., March 1998. Augmentation of postural tone induced by the stimulation of the descending fibers in the midline area of the cerebellar white matter in the acute decerebrate cat. Neurosci. Res. 30 (3), 257e269. Bouret, S., Sara, S., 2005. Network reset: a simplified overarching theory of locus coeruleus noradrenaline function. Trends Neurosci. 28 (11), 574e582. 1 November 2005. Gracovetsky, S., 1986. Determination of safe load. Br. J. Indust Med. 43, 120e133. Grundy, J., 1982. Human Structure and Shape. Noble Books, Chilbolton UK. Hiramoto, Y., 2000. Morpho-metrical features of the pelvis in standing posture. Kaibogaku Zasshi 75 (2), 223e230. Hoyle, J., 1967. Diversity of striated muscle. Am. Zool. 7 (3), 435e 449. doi:10.1093/icb/7.3.435. Huijing, P., 2007. Epimuscular myofascial force transmission between antagonistic and synergistic muscles can explain movement limitation in spastic paresis. J. Biomech. 17 (6), 708e724. Humphry, G.M., 1872. Lectures on human myology. Br. Med. J. 2 (602), 33e35. Janda, V.,1986. ‘‘Muscle weakness and inhibition (pseudoparesis) in back pain syndromes’’ in ‘‘Modern Manual Therapy of the Vertebral Column’’ edited by GP Grieve, New York, ChurchillLivingston, p. 197e201. Kendall, F., McCreary, E., 1983. Muscles, Testing and Function, third ed.. Williams & Wilkins, Baltimore, p. 25. Mori, et al., 1982. Setting and resetting of level of postural muscle tone in decerebrate cat. J. Neurophysiol. 48, 737e748. Myers, T., 2009. Anatomy Trains, second ed.. Churchill Livingstone, Edinburgh. Myers, T., 2004a. Fans of the hip joint. originally published in Massage Magazine 1998, self published 2004 as ‘Body3’. Available from: www.anatomytrains.com. Myers, T., 2004b. Psoas-piriformis balance. originally published in Massage Magazine 1999, self published 2004 as ‘Body3’. Available from: www.anatomytrains.com.
Extensor coxae brevis Passerieux, et al., 2006. Structural organization of the perimysium in bovine skeletal muscle: junctional plates and associated intercellular domains. J. Struct. Biol. 154 (2), 206e216. Purslow, P., 2002. The structural and functional significance of variations of connective tissue within muscle. Comp. Biochem. Phys. 133 (4), 947e966. Rolf, I., 1977. Rolfing. Healing Arts Press, Rochester, VT, p. 87. Shamberger, W., 2002. The Malalignment Syndrome. Churchill Livingstone, Edinburgh.
271 Sprigle, S., Flinn, N., et al., June 2003. Development and testing of a pelvic goniometer designed to measure pelvic tilt and hip flexion. Clin. Biomech. 18 (5), 462e465. Van der Wal J 2009 The Architecture of the Connective Tissues in the Musculoskeletal System e based on a doctoral thesis ‘‘The Organization of the Substrate of Proprioception in the Elbow Region of a Rat’’ published in 1988, reprinted in Journal of Bodywork and Movement Therapies, 2009 (2), 4. Vleeming, A., Mooney, V., Stoeckart, R., 2007. Movement, Stability & Lumbopelvic Pain: Integration of research and therapy.
Journal of Bodywork & Movement Therapies (2010) 14, 272e279
available at www.sciencedirect.com
journal homepage: www.elsevier.com/jbmt
MICROCURRENT ELECTROTHERAPY
The efficacy of frequency specific microcurrent therapy on delayed onset muscle soreness Denise Curtis, MSc, NMT a,*, Stephen Fallows, PhD a, Michael Morris, MSc a, Carolyn McMakin, MA DC b a b
Centre for Exercise & Nutrition Science, University of Chester, Parkgate Road, Chester CH1 4BJ, England, UK Fibromyalgia and Myofascial Pain Clinic of Portland, 69 SW Hampton Street, Portland, OR 97223, USA
Received 6 October 2008; received in revised form 11 January 2010; accepted 24 January 2010
KEYWORDS Frequency specific microcurrent therapy; Delayed onset muscle soreness; Eccentric; VAS
Summary This study compared the effects of frequency specific microcurrent (FSM) therapy versus sham therapy in delayed onset muscle soreness (DOMS) in order to determine whether specific frequencies on two channels would produce better results than single channel single frequency microcurrent therapy which has been shown to be ineffective as compared to sham treatment in DOMS. 18 male and 17 female healthy participants (mean age 32 4.2 years) were recruited. Following a 15-min treadmill warm-up and 5 sub-maximal eccentric muscle contractions, participants performed 5 sets of 15 maximal voluntary eccentric muscle contractions, with a 1-min rest between sets, on a seated leg curl machine. Post-exercise, participants had one of their legs assigned to a treatment (T) regime (20 min of frequency specific microcurrent stimulation), while the participant’s other leg acted as control (NT). Soreness was rated for each leg at baseline and at 24, 48 and 72 h post-exercise on a visual analogue scale (VAS), which ranged from 0 (no pain) to 10 (worst pain ever). No significant difference was noted at baseline p Z 1.00. Postexercise there was a significant difference at 24 h (T Z 1.3 1.0, NT Z 5.2 1.3, p Z 0.0005), at 48 h (T Z 1.2 1.1, NT Z 7.0 1.1, p Z 0.0005) and at 72 h (T Z 0.7 0.6, NT Z 4.0 1.6, p Z 0.0005). FSM therapy provided significant protection from DOMS at all time points tested. ª 2010 Elsevier Ltd. All rights reserved.
Introduction Delayed onset of muscle soreness (DOMS) has been described as damaged muscle tissue membranes combined with
a secondary inflammatory condition (Gleeson et al., 1995; Wilmore and Costill, 2004; Connolly et al., 2003) resulting from unaccustomed eccentric contractions (Taleg, 1973; Newman et al., 1983a,b; Armstrong, 1984; Denegar and Perrin, 1992) and maximal isometric contractions (Clarkson
* Corresponding author. Tel.: þ353 46 9059095. E-mail address:
[email protected] (D. Curtis). 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.01.009
The efficacy of FSM therapy on DOMS et al., 1986). Although many variables are reported in the quantification of muscle damage, the typical symptoms associated with DOMS are loss of strength, pain, muscle tenderness, stiffness, swelling and elevated levels of the enzyme creatine kinase (McHugh et al., 1999). Symptoms can vary from mild muscle tenderness to severe debilitating pain (Cheung et al., 2003). DOMS is a well researched phenomenon and the morphological injury to the muscle has been well described, however the mechanism underlying the injury remains poorly understood. For many years, DOMS was attributed to an accumulation of the metabolic end products of exercise resulting in elevated muscle lactate. This assumption is now understood to be unconnected to DOMS. It is now proposed that the soreness may be the result of, amongst others, mechanical (Newman et al., 1983a,b; Armstrong, 1984; Stauber et al., 1990) or biochemical (Armstrong, 1984; McIntyre et al., 1995) factors. Research suggests that the soreness typically appears between 8 and 24 h post-exercise, peaks at 24e48 h and can last for up to 7 days (Cleak and Eston, 1992; Howell et al., 1993). Although the precise details of muscle damage following eccentric exercise remains unknown, it appears that even a single bout of eccentric muscle contractions can offer significant protection against muscle soreness in subsequent performances of the same exercise. This phenomenon, which has been known to last for several months, was termed the ‘‘repeated bout effect’’ by Nosaka and Clarkson (1995). DOMS is a universal symptom familiar to most athletes that usually occurs after an extended layoff from exercise or unfamiliar, predominantly eccentric exercise. Athletic performance is typically impaired when an athlete is sore. Research by Proske et al. (2003) implied that muscle soreness, following a bout of unaccustomed eccentric exercise, may also contribute to muscle weakness, possibly as a result of reduced excitability of the motor cortex. Thus, any practice or therapy that limits soreness and restores the maximal function of the muscles as quickly as possible would be of interest and practical value to the athlete. Numerous treatment strategies, both prophylactic and rehabilitative, have been introduced to help relieve the severity of DOMS. Some of the proposed treatments include pre- and post-exercise static stretching (Herbert and Gabriel, 2002; Cornwell et al., 2002; Yamaguichi and Ishii, 2005), pharmacological treatments using non-steroidal anti-inflammatory drugs (NSAIDs) (Grossman et al., 1995; O’Grady et al., 2000; Sayers et al., 2001; Connolly et al., 2003; Lanier, 2003), nutritional supplements (Kaminski and Boal, 1992; Warren et al., 1992; Jakeman and Maxwell, 1993), massage therapy (Tiidus and Shoemaker, 1995; Lightfoot et al., 1997), continuous compression (Kraemer et al., 2001) and ice-water immersion (Sellwood et al., 2007). However, little scientific evidence exists to support the effectiveness of any of these therapeutic interventions. The following study compared the effects of FSM therapy versus sham therapy on DOMS in order to determine if the use of certain specific frequencies would produce better results than simple single frequency microcurrent therapy which had been shown by Allen et al. (1999) to be ineffective when compared to sham treatment in DOMS. Allen et al. (1999) determined that 20 min of single channel,
273 single frequency microamperage current using 30 Hz at 200 mA for 10 min and 0.3 Hz at 100 mA for 10 min was not effective in reducing pain or increasing range of motion 24, 48 and 72 h after DOMS induction in the biceps muscle in a group of 18 subjects (3 males, 18 females). The sham group in the Allen paper received treatment from a unit that had been disabled by the manufacturer to provide no electrical stimulation and both the subjects and experimenter were blinded. In the present study the sham treatment was provided by a unit that was not turned on and only the subjects were blinded. To the authors’ knowledge, no controlled studies to date have examined the effects of FSM therapy on DOMS.
History of frequency specific microcurrent (FSM) therapy Microcurrent electrical neuromuscular stimulation (MENS) was developed in the 1970s as a battery operated physical therapy modality delivering current in the microampere range. An ampere (amp) is a measure of the strength of electric current and measures the rate of flow of charge in a conducting medium. One micro amp (mA) equals 1/1000th of a milliamp (mA). By comparison, interferential, TENS, and high-volt pulsed galvanic stimulators deliver currents in the milliamp range causing muscle contraction, pulsing and tingling sensations. TENS applies an electrical force that stimulates pain suppressing A-beta afferent fibers which compete against A-delta and C fibers that transmit pain signals. Most TENS units deliver current around the 60 mA range (Kirsch and Lerner, 1998). Although microcurrent devices are approved in the category of TENS for regulatory convenience, in practical use they are in no way similar and cannot be compared to TENS in their effect. With microcurrent the patient cannot feel the current since there is not enough current to stimulate sensory nerve fibers (Mercola and Kirsch, 1995). Traditionally, microcurrent therapy has been used to increase the rate of healing in injured athletes, to treat and manage muscle pain and dysfunction and to increase the rate of fracture repair (Rowley et al., 1974; Bertolucci and Grey, 1995; Kirsch, 1996, 1997; Lambert et al., 2002). Current in the range of 10 up to 500 mA was observed to increase ATP production, amino acid transport, protein synthesis, and waste product removal in rat skin whereas ATP production leveled off between 500 and 1000 mA and decreased when the current was above 1000 mA (Cheng, 1982). TENS devices provide up to 60 times higher current levels than that seen to decrease ATP production which may explain why TENS units have not been found to be effective in treatment of DOMS (Craig et al., 1996). Typical microcurrent applications use only low and simple one channel frequencies such as 0.3 Hz, 3 Hz, 10 Hz, 30 Hz, and 300 Hz (Manley, 1994; Allen et al., 1999). The therapeutic use of frequencies and electrotherapy began in the early 1900s in the United States and England with thousands of medical physicians using a number of devices to treat a wide range of conditions from arthritis and tuberculosis to pneumonia (Kirsch and Lerner, 1998). The Electromedical Society and the journal Electromedical Digest served as a forum for physicians to share their
274 research and clinical findings. Copies of Electromedical Digest were found in the rare book room of the National College of Naturopathic Medicine in Portland containing frequencies and protocols for the above conditions and articles documenting clinical outcomes in every edition available published between 1920 and 1951. In 1934, as part of its effort to standardize medicine and medical education, the American Medical Association (AMA) decreed that pharmaceutical medications and surgery were the legitimate tools of medicine and that electromagnetic therapies, homeopathy, herbs and other treatments were ‘‘unscientific’’ (Berliner, 1975, Barzansky and Gevitz, 1992). The biophysics and medical research that would provide the mechanisms and science explaining electromedicine would not be done until the 1980s (Becker and Seldon, 1985; Oschman, 2000). The use of electromagnetic therapies and frequencies declined, the research being reported in Electromedical Digest ceased and the last edition of the journal available was published in 1951 (Electronic Medical Digest, 1951). The FDA made the original devices illegal around the same time. The frequencies used in this study were obtained in 1995 from a retired British osteopath who bought a practice in Vancouver, BC (Canada) in 1946 that came with a machine (manufacturer unknown) and a list of frequencies that were created in 1922 thought to address specific tissues and neutralize specific conditions. The list acquired from the osteopath included approximately 100 frequencies alleged to neutralize certain pathologies or conditions and over 200 frequencies thought to address certain tissues. The osteopath’s method of treatment included using a frequency on one channel to ‘‘remove a pathology’’ combined with a frequency on the second channel to ‘‘address a specific tissue’’. The device used by the osteopath has long since disappeared and has never been available for inspection. While it is thought to have plugged into the wall current which may have been DC in 1922, it is not known what current level it delivered and there is no reason to suspect that it delivered microamperage current which was not introduced until the early 1980s. Frequencies found on the back page of Electromedical Digest in a wall chart being sold by Albert Abrams were identical to those that came with the osteopath’s machine where the two lists overlapped. The use of microcurrent and frequencies for the treatment of nerve, muscle pain and injury repair was developed clinically using the osteopath’s two channel, condition and tissue treatment paradigm and has been taught as Frequency Specific Microcurrent (FSM) since 1997 (McMakin, 1998; McMakin, 2004; McMakin et al., 2005). The technique requires use of any microcurrent device that can provide a different frequency on each of two channels using a ramped square wave and alternating pulsed direct current. The devices used in this study are calibrated by the manufacturer (Precision Microcurrent, Newberg, Oregon, USA) and the company standards require that the frequencies be accurate to within 0.5 Hz on both channels. Frequencies on one channel are thought to be effective in neutralizing specific conditions such as hemorrhage, fibrosis, scar tissue, mineral deposits, histamine, and acute and chronic inflammation. These frequencies are combined with frequencies on a second channel thought to be specific for muscles, fascia, tendons, nerves and arteries and other tissues (McMakin, 2004).
D. Curtis et al. The frequency specific protocols were developed clinically through trial and error by one of the authors after it was determined through clinical use on volunteers that the use of a frequency combination that did not produce improvement also did no apparent harm. The descriptions of the frequencies from the list were taken at face value and used speculatively for various chronic and acute conditions in clinical practice to determine if they would produce a change in symptoms and clinical improvement (McMakin, 1998; McMakin, 2004; McMakin et al., 2005). For example, the frequencies described on the list as reversing ‘‘hemorrhage’’ in the ‘‘arteries’’ were used speculatively in acute injuries to reduce bruising ‘‘as if’’ it correctly represented the effect of the frequency. It was subsequently observed not only to prevent bruising and reduce pain but also coincidentally noted to stop bleeding for up to 12 h in patients who were menstruating at the time of treatment. No other frequency tried produced this effect. This frequency had no effect on any other condition. No formal research has been done to verify the effect of this frequency but it has been reproduced on numerous occasions by the authors and many of the 1200 clinicians using FSM worldwide including athletic trainers for the USA National Football League (NFA), surgeons and an obstetrician who use this frequency specifically to stop bleeding and bruising in medically appropriate settings. The other frequencies used in FSM therapy were explored in the same way. 40 Hz was described on the osteopath’s list and in Electromedical Digest as being useful to ‘‘reduce inflammation’’. Use of this frequency in a clinical setting suggested that it did only that and was not useful to change any other condition. Use of 40 Hz on channel A and 10 Hz on channel B was found to reduce pain in fibromyalgia patients and to reduce all of the inflammatory cytokines as measured by micro-immunochromatography (McMakin et al., 2005). One control patient treated with a protocol that did not include 40 Hz had no change in cytokines (McMakin et al., 2005). Clinical response to the frequencies over the last 14 years suggests that the conditions being treated and the tissues being addressed are accurately represented by the frequency descriptions although decades of research will be required to confirm and clarify these effects. Until such research is done no claims can be or are made by the authors for the specific effects of frequencies on biological tissues or conditions. Clinical research, such as this paper, may report the observed and reported effects in a research setting of certain frequency combinations without making specific claims for the frequencies used. Fortunately, medicine is pragmatic and it is not uncommon for apparently effective medications, such as aspirin, to be used for many years before the mechanism is understood.
Methods Participants Following the posting of an advertisement on the student notice board at the National Training Centre (NTC) in Dublin, Ireland, forty-four students volunteered to participate in the
The efficacy of FSM therapy on DOMS study. 18 male and 17 female students (mean age 32 4.2 years) were selected from these volunteers to take part in the study. Each of the participants had one of their legs assigned to a treatment group, while the opposite leg was assigned to a control group. The nomination of the participants’ leg (left or right) as treatment or control was randomized by the toss of a coin. Participants were required to meet the following inclusion and exclusion criteria to be eligible for the study. Inclusion Participants were: 1) aged between 20 and 40 years; 2) healthy and recreationally active; 3) required complete a health screening questionnaire prior to the study; 4) required to give written consent. Exclusion Potential participants were excluded if they were: 1) engaged in resistance training or eccentrically biased exercises for the lower body three months prior to the study; 2) suffering from unstable cardiovascular or pulmonary conditions or diseases; 3) suffering from any pain or injury in the legs or other health problems; 4) pregnant. Participants received a participant information sheet two weeks before the study commenced and were given three days to decide if they wanted to be involved in the research. The study was reviewed by the Ethics Committee of the School of Applied and Health Sciences, University of Chester, UK. A health screening questionnaire was completed by each of the participants on the day of the study to rule out any pathology that may have excluded them from taking part in the research. Participants were asked not to massage, stretch or treat the hamstring muscles in any way and to refrain from NSAIDs or supplements until the final set of data was completed. Massage, stretching, NSAIDs and supplements are common practices that exist for the treatment of DOMS and may therefore have affected the final results. Once the students agreed to participate in the study and had given written consent a phone call was made to each participant to confirm times and dates and also reconfirm inclusion criteria. During this phone conversation participants were verbally instructed to drink at least 2 l of water in the 2 h prior to their allocated time for participation in the study. During the warm-up and training session, a 500 ml bottle of water was provided to each participant to prevent dehydration.
275 themselves with the equipment. Participants were then instructed to perform five sets of 15 maximal eccentric contractions, with a 1-min rest between each set. Post-exercise, one of their legs, randomly chosen, underwent a 20-min FSM programme and the other leg was not treated. The frequencies delivered in the programme were chosen from a list provided by Frequency Specific Seminars, Inc. (Vancouver, Washington, USA) and are thought to be specific for tissues and conditions. The channel A frequency values that were used in this study were chosen because they were thought to be specific to some of the main pathologies induced by DOMS, while the channel B frequency values that were used were chosen because they were thought to be specific to some of the main soft tissues that are affected by DOMS. 18 Hz on channel A was combined with 62 Hz on channel B for 4 min. 124 Hz on channel A was combined with 62 Hz, 142 Hz and 191 Hz on channel B for 1 min each. 40 Hz on channel A was combined with 116 Hz on channel B for 4 min. 40 Hz on channel A was combined with 62 Hz, 142 Hz and 191 Hz on channel B for 2 min each. 49 Hz on channel A was combined with 62 Hz, 142 Hz and 191 Hz on channel B for 1 min each. The intensity was set at 200 mA and the waveslope was set at 10 for the entire 20-min programme.
Procedure for seated leg curl Participants were asked to sit into a Pulse Fitness leg curl machine and align the knee joint with the axis of the machine. The seat was then set so that their backs made full contact with the back rest and to ensure that the posterior aspect of the knee joint was positioned at the edge of the leg curl seat. Starting in full leg extension, their ankles were dorsi flexed and placed on the rollers with the feet no wider than hip distance apart. Subjects were asked to hold the side handles for support. The machine was set to allow for full range of movement (Figure 1). Subjects were instructed to curl the rollers downwards and backwards to full leg flexion (Figure 2) and then slowly return the rollers to full leg extension. Male participants began with a starting weight of 25 kg, whereas female participants started with a weight of 20 kg. Participants either performed 15 repetitions with their starting weight or continuous repetitions until they could no longer push or resist the weight. When participants could no longer push or resist the weight, the weight was reduced by 5 kg and the protocol continued either to fatigue or until the fifteen repetitions were completed. Participants were verbally encouraged to exert maximal resistance in the upward (eccentric) phase of the movement. To ensure consistency, participants were instructed to control the lifting velocity of the rollers by counting from one to five from the beginning to the end range of the eccentric action.
Procedure for FSM treatment Design Following a 15-min warm-up on an ascent Pulse Fitness treadmill, at a speed of 6 km/h, participants were instructed to perform five sub-maximal eccentric contractions on a Pulse Fitness seated leg curl machine to familiarize
Post-exercise, participants were instructed to lie in the prone position on a massage table. Each of the participants’ legs were attached to separate FSM machines (Precision Microcurrent, Newberg, Oregon, USA) that were placed on either side of the table in alignment with the hamstring
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Figure 1
Eccentric end range on leg curl machine.
muscles and positioned so that the patient could not see the front panel of the device or determine which machine was turned on (Figure 3). As DOMS was induced in only the hamstring muscle group, the current was directed only through the soft tissues in this muscle group. The positive leads from the device were attached to graphite gloves that were wrapped in wet towels and placed on the upper portion of the participants’ thighs. The negative leads were attached to graphite gloves that were wrapped in wet towels and placed below the participants’ knees. This allowed the current to flow between the two leads through the soft tissues of the treated leg. One of the machines was turned off providing the sham treatment and the volume on the working machine was turned down. Rated soreness and tenderness were evaluated at baseline and 24, 48 and 72 h post-exercise using a visual analogue scale (VAS). The VAS consists of a 10 cm horizontal line with the two end points labeled 0 (no pain) to 10 (worst soreness ever) (Huskinson, 1974; Joyce et al., 1975). Participants were asked to make a vertical slash across the 10 cm line that corresponded to the level of pain intensity between the limits of no pain felt (left end of line) and worst soreness ever (right end of line). A blank scale was used each time to avoid bias from previous measurements.
Figure 3
Subject position for FSM treatment.
The VAS has been shown to be a valid and reliable measurement for determining the intensity of human pain, it is minimally intrusive and is easily and quickly administered (Lee and Kieckhefer, 1989; Mattacola et al., 1997).
Statistical analysis As the VAS falls into the ratio level of measurement (Myles et al., 1999), parametric tests were conducted to investigate significant differences within and between the groups. Changes in the VAS within the groups were analysed via a One Way repeated measures ANOVA and post hoc analysis utilising multiple paired t-tests tests. Differences between the groups were investigated using multiple Independent t-tests, one at each time point (baseline, 24, 48 and 72 h). Normality was assessed and confirmed prior to each test via the Shapiro Wilk statistic and data are presented as mean standard deviation (SD). All data were analysed using SPSS for Windows (Version 14.0) and significance was set at the 0.05 level. A post hoc sample size calculation based on the data from this study revealed an effect size 0.08. Based on a significance level of 0.05, being a two tailed test with 80%, power, this provided a sample size of 26 participants in each group.
Results Perceived muscle soreness
Figure 2
Concentric end range on leg curl machine.
The baseline values for perceived muscle soreness before exercise as assessed by the VAS (Table 1) for each group revealed no significant difference (p Z 1.000). This indicated that the groups had no prior muscle pain and understood how to use the scale correctly. Once each group had undergone the exercise regime to induce the muscle damage the ratings on the VAS significantly increased. This was observed in both groups with the non-treatment group increasing from zero at baseline to 5.2 1.3 at 24 h (p Z 0.0005) and the treatment group increasing from zero to 1.3 1.0 (p Z 0.0005). This significant increase demonstrated that the exercise regime had worked at inducing muscle damage. It can also be seen that
The efficacy of FSM therapy on DOMS
277
Table 1 Perceived muscle soreness at baseline, 24, 48 and 72 h for each treatment. Baseline 24 h Treatment 00 Non-treatment 00 p Value (between 1.000 groups)
48 h
72 h
1.3 1.0a 1.2 1.1a 0.7 0.6 5.2 1.3a 7.0 1.1a 4.0 1.6a 0.0005 0.0005 0.0005
N.B.: Results presented as mean SD. a Significant difference from baseline VAS score within each group (p < 0.05).
the non-treatment group reported a significantly greater (p Z 0.0005) increase in perceived muscle soreness than the treatment group. A similar trend existed between 24 and 48 h with both groups demonstrating significant increases in perceived muscle soreness (non-treatment p Z 0.0005; treatment group p Z 0.001). The perceived muscle soreness in the treatment group (1.2 1.1) was significantly less (p Z 0.0005) than in the non-treatment group (7.0 1.1). At 72 h the perceived muscle soreness in the treatment group had almost retuned to baseline levels (0.7 0.6) indicating an absence of any pain although the scores in the non-treatment group remained elevated (4.0 1.6) and significantly higher than baseline values (p Z 0.0005). A summary of the results is presented in Figure 4.
Discussion The aim of this investigation was to compare the effects of FSM therapy versus sham at 24, 48 and 72 h post-exercise. Allen et al. (1999) found that 20 min of single channel microcurrent therapy that was not frequency specific compared to sham treatment was not effective in reducing pain or increasing range of motion 24, 48 and 72 h after DOMS induction in the biceps muscle. Clinical evidence suggested that dual channel microcurrent using different frequency combinations was very effective in reducing the pain associated with muscle trauma and DOMS providing the motivation for conducting this study. This study was undertaken to provide a controlled trial evaluation of
Visual Analogue Scale (VAS) score
10 9
Treatment Leg Non Treatment Leg
8 7 6 5 4 3 2 1 0 Baseline
24hrs
48hrs
72hrs
Time (hrs)
Figure 4 VAS scores for TL and NTL over a period of 72 h. N.B.: Results expressed as mean SD.
20 min of FSM therapy compared to sham treatment. It was hypothesized that FSM therapy would offer significant protection from post-exercise muscle soreness. The participants were blinded to which leg was being treated because they could not see the machine and because the current is subsensory. This reduced the possibility of a placebo effect while the treatment was been given. However it should be acknowledged that by using the participant’s opposite leg as a control, it is likely that participants could have guessed quite quickly (probably within hours of the treatment been given) which leg had been treated and which leg had not. As initial improvements in one leg may have had them guessing which leg had been treated, this would have meant that they were no longer blinded. The use of graphite gloves wrapped in wet towels as conductors was assumed to prevent the reduction in voltage seen in Petrovsky’s measurements of graphite electrodes in TENS devices (Petrofsky et al., 2006). The use of wet towels also ensures that the current will remain subsensory since graphite electrodes against dry skin may make even microamperage current sensible (Grimnes, 2008). The method selected for inducing DOMS was deemed successful, as the data collected at 24, 48 and 72 h postexercise differed significantly from the data collected at baseline. This pattern was similar to previous literature related to the time course and intensity of DOMS (Cleak and Eston, 1992; Howell et al., 1993; Nosaka and Clarkson, 1996) and suggests that the methodology was appropriate to create DOMS. The VAS was selected as a measurement for perceived pain because it is patient friendly, low cost, easy to administer and not too time consuming. However, although the VAS is a well established, valid and reliable measurement for determining the intensity of pain, the authors acknowledge the possibility that variations may have occurred in participant responses during the data collection period. As participants were required to independently perceive their soreness at four different time points over a 72 h period, it should be noted that how they perceived their pain may have altered over the 72 h, depending on how they were being affected by their pain at that specific moment. Also, individual tolerance for pain can vary greatly from person to person. Acknowledgement is also given to the possibility that reciprocal facilitation may have had an effect on the overall findings. The FSM units were set up so that the treated leg had current flowing between the positive and negative leads while the untreated leg had no current delivered as the machine on this leg was turned off. Although there is no evidence in any electrical theory or practice that suggests that the current will migrate to other areas outside the area between the two leads, because of the interconnectedness of the body there is no way of knowing what effect, if any, the FSM treatment had on the control leg. No attempt was made in the present study to control for the effects of environmental electromagnetic influences (‘‘electronic smog’’) since such influences would have had equivalent effects on both the treated and untreated leg. In future studies in which there is a sham control group being treated at another time and setting than the
278 treatment group consideration may need to be made for the possible effects of extraneous electrical interference. A possible limitation to the study was that only one marker, perceived muscle soreness, was used to assess muscle damage. Other markers such as maximal isometric strength, range of motion, angle of peak torque, leg circumference and plasma creatine kinase levels were not assessed. A suggestion for future research would be to use multiple markers as an assessment for DOMS. Future studies of FSM in DOMS or any condition may include a methodology that includes separate sham and active treatment groups and will also allow for double blinding the subjects and the experimenters. Even though the patients turned in their pain scores without any further contact with the un-blinded experimenter, the possibility of some experimental error due to lack of experimenter blinding cannot be excluded. To ensure double blinding it is suggested that future studies include a sham unit that is disabled by the manufacturer so that no electrical stimulation passes through it.
Conclusion The results of this study show that at the parameters selected for this investigation FSM therapy did provide significant protection from post-exercise muscle soreness.
Acknowledgements The authors would like to thank Bobby Fitzsimons for his help and assistance with this research project and also the students at the NTC who took part in the study. No funding of this study or incentive for publication was provided by any commercial interest.
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The efficacy of FSM therapy on DOMS Lambert, M.I., Marcus, P., Burgess, T., Noakes, T.D., 2002. Electromembrane microcurrent therapy reduces signs and symptoms of muscle damage. Medicine and Science in Sports and Exercise 34, 602e607. Lanier, A.B., 2003. Use of non-steroidal anti-inflammatory drugs following exercise-induced muscle soreness. Sports Medicine 33, 177e186. Lee, K.A., Kieckhefer, G.M., 1989. Measuring human responses using visual analogue scale. Western Journal of Nursing Research 11, 128e132. Lightfoot, J.T., Char, D., McDermott, J., Goya, C., 1997. Immediate post exercise massage does not attenuate delayed onset muscle soreness. Journal of Strength and Conditioning Research 11, 119e124. Manley, T., 1994. Microcurrent Therapy Universal Treatment Techniques and Applications. Manley and Associates, Corona, California. Mattacola, C.M., Perrin, D.H., Gansneder, B.M., Allan, J.D., Mickey, C.A., 1997. A comparison of visual analogue scale and graphic rating scales for pain and intensity following DOMS. Journal of Sport Rehabilitation 6, 38e46. McIntyre, D.L., Reid, W.D., McKenzie, D.C., 1995. Delayed muscle soreness: the inflammatory response to muscle injury and its clinical implications. Sports Medicine 20, 24e40. McHugh, M.P., Connolly, D.A.J., Eston, R.G., Gleim, G.W., 1999. Exercise-induced muscle damage and potential mechanisms for the repeated bout effect. Journal of Sports Medicine 27, 158e170. McMakin, C., Gregory, W., Philips, T., 2005. Cytokine changes with microcurrent treatment of fibromyalgia associated with cervical spine trauma. Journal of Bodywork and Movement Therapies 9, 169e176. McMakin, C., 2004. Microcurrent therapy: a novel treatment method for chronic low back myofascial pain. Journal of Bodywork and Movement Therapies 8, 143e153. McMakin, C., 1998. Microcurrent treatment of myofascial pain in the head, neck and face. Topics in Clinical Chiropractic 5, 29e35. Mercola, J.M., Kirsch, D., 1995. The basis for microcurrent electrical therapy in conventional medical practice. Journal of Advancement in Medicine 8 (2). http://therapyproducts.net Available on-line from:pages not numbered. Myles, P.S., Troedel, S., Boquest, M., Reeves, M., 1999. The pain in visual analogue scale: Is it linear or nonlinear? Anesthesia and Analgesia 89, 1517e1520. Newman, D.J., McPhail, G., Mills, K.R., Edwards, R.H., 1983a. Ultrastructural changes after concentric and eccentric contractions on human muscle. Journal of Neurological Science 61, 109e122. Newman, D.J., Mills, K.R., Quigley, B.M., Edwards, R.H.T., 1983b. Pain and fatigue after concentric and eccentric contractions. Journal of Clinical Science 64, 55e62.
279 Nosaka, K., Clarkson, P.M., 1995. Muscle damage following repeated bouts of high force eccentric exercise. Medicine and Science in Sports and Exercise 27, 1263e1269. Nosaka, K., Clarkson, P.M., 1996. Changes in indicators of inflammation after eccentric exercise of the elbow flexors. Medicine and Science in Sports and Exercise 28, 953e961. O’Grady, M., Hackney, A.C., Schneider, K., Bossen, E., Steinberg, K., Douglas, J.M., Murray, W.J., Watkins, W.D., 2000. Diclofenac sodium (voltaren) reduced exercise-induced injury skeletal muscle. Medicine and Science in Sports and Exercise 32, 1191e1196. Oschman, J., 2000. Energy Medicine, The Scientific Basis. Churchill Livingston, Edinburgh. Petrofsky, J., Schwab, E., Cuneo, M., George, J., Kim, J., Almalty, A., Lawson, D., Johnson, E., Remigo, W., 2006. Current distribution under electrodes in relation to stimulation current and blood flow: are modern electrodes really providing the current distribution during stimulation we believe they are? Journal of Medical Engineering and Technology 30, 368e381. Proske, U., Weerakkody, N.S., Percival, P., Morgan, D.L., Gregory, J.E., Canny, B.J., 2003. Force-matching errors after eccentric exercise attributed to muscle soreness. Clinical and Experimental Pharmacology and Physiology 30, 576e579. Rowley, B.A., McKenna, J.M., Wollcott, L.E., 1974. The use of low level electric current for the enhancement of tissue healing. Biomedical Scientific Instrumentation 10, 111e114. Sayers, S.P., Knight, C.A., Clarkson, P.M., van Wegan, E.H., Kamen, G., 2001. Effects of ketoprofen on muscle function and sEMG after eccentric exercise. Medicine and Science in Sports and Exercise 33, 702e710. Sellwood, K.L., Brukner, P., Williams, D., Nicol, A., Hinman, R., 2007. Ice-water immersion and delayed-onset muscle soreness: a randomized controlled trial. British Journal of Sports Medicine 41, 392e397. Stauber, W.T., Clarkson, P.M., Fritz, V.K., Evans, W.J., 1990. Extracellular matrix disruption and pain after eccentric muscle action. Journal of Applied Physiology 69, 868e874. Taleg, T.S., 1973. Residual muscular soreness as influenced by concentric, eccentric and static contractions. Research Quarterly 44, 458e469. Tiidus, P.M., Shoemaker, J.K., 1995. Effleurage massage, muscle blood flow and long-term post-exercise strength recovery. International Journal of Sports Medicine 16, 478e483. Warren, G.L., Jenkins, R.R., Packer, L., Witt, E.H., Armstrong, 1992. Elevated muscle vitamin E does not attenuate eccentric exercise-induced muscle injury. Journal of Applied Physiology 72, 2168e2175. Wilmore, J.H., Costill, D.C., 2004. Physiology of Sport and Exercise, second ed. Human Kinetics, Leeds. Yamaguichi, T., Ishii, K., 2005. Effects of static stretching for 30 seconds and dynamic stretching on leg extension power. Journal of Strength and Conditioning Research 19, 677e683.
Journal of Bodywork & Movement Therapies (2010) 14, 280e286
available at www.sciencedirect.com
journal homepage: www.elsevier.com/jbmt
INVITED REVIEW
The biomechanics of spinal manipulation Walter Herzog, PhD* Faculty of Kinesiology, University of Calgary, Calgary, AB T2N 1N4, Canada Received 30 November 2009; received in revised form 19 March 2010; accepted 29 March 2010
KEYWORDS Spinal biomechanics; Chiropractic; Manipulative therapy; Vertebral artery; Stroke; Internal forces
Summary Biomechanics is the science that deals with the external and internal forces acting on biological systems and the effects produced by these forces. Here, we describe the forces exerted by chiropractors on patients during high-speed, low-amplitude manipulations of the spine and the physiological responses produced by the treatments. The external forces were found to vary greatly among clinicians and locations of treatment on the spine. Spinal manipulative treatments produced reflex responses far from the treatment site, caused movements of vertebral bodies in the “para-physiological” zone, and were associated with cavitation of facet joints. Stresses and strains on the vertebral artery during chiropractic spinal manipulation of the neck were always much smaller than those produced during passive range of motion testing and diagnostic procedures. ª 2010 Elsevier Ltd. All rights reserved.
Introduction Chiropractic spinal manipulations are mechanical events. Clinicians exert a force of specific magnitude in a controlled direction to a target site, typically on the spine. High-velocity, low-amplitude (HVLA) manipulations are more frequently used by chiropractors than other treatment modalities, and they are of special interest, as force magnitudes and the rates of force application are high. HVLA treatments cause deformations of the spine and surrounding soft tissues and often elicit a cracking sound that has been identified as cavitation of spinal facet joints (Cascioli et al., 2003; Conway et al., 1993; Haas, 1990;
* Tel.: þ1 403 220 8525; fax: þ1 403 220 2070. E-mail address:
[email protected] Herzog et al., 1993c; Meal and Scott, 1986; Miereau et al., 1988; Reggars, 1996). Despite the acknowledged nature of mechanical force application as a treatment modality (Triano, 2000), and the accepted idea that HVLA treatments produce mechanical effects (e.g., Triano and Schultz, 1997) at the treatment site, little is known about the biomechanics of spinal manipulation. Biomechanics is the science that deals with the external and internal forces acting on biological systems and the associated effects produced by these forces. Here, I will attempt to briefly review what is known about the external forces applied by chiropractors during HVLA manipulative treatments on patients, discuss selected effects of these forces, and then focus specifically on an increasingly important topic of internal force transmission: the stresses and strains experienced by the vertebral artery during HVLA neck manipulations.
1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.03.004
The biomechanics of spinal manipulation
External forces applied by chiropractors during HVLA spinal manipulations Wood and Adams (1984) and Adams and Wood (1984) were the first to quantify the forces exerted by chiropractors during spinal manipulation. Their work involved application of a HVLA manipulative thrust to a treatment dummy. Although a classic piece, the limitation of their work was that treatments were not performed on human subjects, thereby bringing into question the validity of the results for a clinical setting. Hessel et al. (1990) were the first to directly measure the forces applied by chiropractors on human subjects for a variety of different treatment modalities. They used a thin, flexible pressure pad that was placed under the thrusting hand of the clinician to measure the forces applied to the target site on patients. This pioneering work was followed by a series of similar studies, all aimed at obtaining information on the force-time histories of HVLA spinal manipulations (Conway et al., 1993; Herzog et al., 1993a,b; Kawchuk et al., 1992; Kawchuk and Herzog, 1993; Triano and Schultz, 1997; Triano, 2000; Triano and Schultz, 1990). When combining the results of selected force parameters during HSLA treatments, the following results emerged: Peak and Preload forces (Figure 1) varied dramatically depending on the location of treatment application (Herzog et al., 1993a). Peak forces for neck manipulations (on average about 100N) were substantially smaller than the peak forces applied during thoracic and lumbar spine and sacroiliac joint treatments ((all about 400N (Table 1)). Furthermore, the treatment forces varied dramatically between clinicians, and in our laboratory we have measured peak forces ranging from 200N to 1600N (Herzog et al., 1993a), which is an eightfold difference. Figure 2 shows a random sample of ten female and ten male chiropractors performing treatments on a small number of subjects (Forand et al., 2004). Interestingly, the average forces between males and females are about the same ((Forand et al., 2004) (Figure 3)), and so are the average forces between novice and experienced chiropractors (results not shown). From these direct measurements of the external forces applied by clinicians on patients, the following conclusions seem warranted: 1. The external forces applied during HVLA treatments vary dramatically depending on the treatment site Peak force Δf Preload force
Preload phase
Thrust phase time, Δt
Resolution phase
Figure 1 Definitions for the preload force, peak force and thrust time.
281 2. The external forces applied during HVLA treatments vary dramatically across clinicians These results suggest that local mechanical conditions might affect the amount of force applied by clinicians. For example, all clinicians apply substantially less force for treatments of the cervical spine compared to the thoracic spine (Herzog et al., 1993a). The reasons for this observation are not clear, although it makes intuitive sense that a relatively mobile part of the spine (cervical spine) would be treated differently than a relatively stiff segment of the spine (thoracic spine). The amount of force applied to patients by a given chiropractor varies dramatically as indicated above (Conway et al., 1993; Herzog, 1991; Herzog et al., 1993a,b; Kawchuk et al., 1992; Triano, 2000). Clinicians, who tend to adjust with great force, do so consistently and clinicians who use little force do so consistently as well. Some “soft” adjusting clinicians will not even reach the preload forces of some of the “hard” adjusting clinicians, thus it is questionable whether force magnitude is an important variable in the application of a HVLA chiropractic treatment. The thrust times (Figure 1) were approximately 100 ms for cervical and 150 ms for thoracic and lumbar spine treatments. Since the peak force magnitudes vary substantially and thrust times are similar across practitioners, it follows that the rate of force application varies substantially too (Table 1), and thus is likely not a relevant factor for the success of a chiropractic treatment. In the absence of consistent force-time histories for chiropractic manipulations, one may conclude that the detailed force magnitude might not be an important characteristic for the success of a treatment, while the thrust direction might be. Unfortunately, thrust force directions have not been studied systematically, thus this proposition must be considered a hypothesis at present.
Selected effects of HVLA spinal manipulative treatments There are many scientific and clinical publications advertising the efficacy of HVLA spinal manipulation. However, the number of publications investigating mechanical, physiological or neurological effects produced by such treatments is small, and a direct link between the treatment forces, the effects produced by these forces, and the beneficial effects created are almost completely missing. Here, I would like to discuss just some selected effects of HSLA treatments that have been debated intensely. Relative movements of the target segment in the paraphysiological zone One of the premises of HVLA spinal manipulative treatments has been that the target joint (typically a spinal facet joint) is brought to its end range of motion by the application of a directed and well described preload force ((Triano, 2000) (Figure 1)). Following application of the preload force, a force thrust is given that represents the actual treatment, and the idea has been that this thrust force takes the (facet) joint beyond its regular end range of motion into the para-physiological movement zone. Of course, when applying a thrust, every clinician can feel the
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W. Herzog
Table 1
Preload forces (N) Peak forces (N) Thrust times (ms) Rate of force application (n/s)
Cervical spine
Thoracic spine
Sacroiliac joint
Activator instrument
27 107 81 1321
139 399 150 2660
88 323
22 41 32 1281
Force [N]
Forces on T4 by men
Forces on T4 by women Force [N]
900 800 700 600 500 400 300 200 100 0
800 700 600 500 400 300 200 100 0
0
50
Time 100 150 200 250 300 350 400 450 [ms]
0
100
200
300
400
500
Time 600 [ms]
Figure 2 Force-time histories of thoracic spinal manipulations performed by 10 male (left) and 10 female (right) chiropractors. Note the vast difference in force between clinicians.
deformation of the spine under the thrusting hand, however, it was not possible to decide if part of this movement arose from the target joint, or if the entire deformation was caused by joints neighbouring the target joint that were not brought to the end range of motion by preload force application. In order to study this question in detail, we inserted bone pins into three adjacent vertebral bodies of the thoracic spine in human cadavers, and then calculated the relative movements of the vertebral bodies during the preload and the thrust phase of HVLA anterior to posterior thrusts to the transverse process of a thoracic vertebra (Ga ´l et al., 1994, 1997a,b). There was substantial relative movement of the target and adjacent vertebrae during the preload phase, and there was further relative movement of target and adjacent vertebrae during the thrust phase of the manipulative treatment (Figure 4). This result illustrates that there is movement of the target (facet) joint during thrust application beyond the movement achieved by the preload force (Ga ´l et al., 1994, 1997a,b).
Reflex responses associated with HVLA spinal manipulative treatments Spinal manipulative treatments, although aimed primarily at restoring joint (including facet joint) mobility and function, had been thought to produce reflex responses in the muscles underlying the treatment area. In order to test this hypothesis, we measured the surface electromyogram (EMG) of back muscles at the treatment site. Typically, EMG activity was measured within 200e400 ms following the onset of the treatment thrust (Herzog et al., 1995). Muscle activity disappeared following the treatment thrust, and was not observed during preload application, suggesting that this was indeed a reflex response, and that the reflex response was associated with the speed of force application (Figure 5).
P-A translation [mm] 3 0 -3
T10
-6
Sag rotation[deg]
Force [N]
2
600
1
500
0
400
-1
300
start of thrust
T11 T10
T11 0
250
500
750
1000
Time [ms]
200 100 0 0
100
200
300
400
500
600
Time [ms]
Figure 3 Mean force-time histories of thoracic spinal manipulations across 10 male (dashed line) and 10 female (solid line) chiropractors.
Figure 4 Posterier-Anterior translation and sagittal rotation of thoracic vertebrae T10 and T11 during the thrust phase of a thoracic spinal manipulation. Note the approximate 2 degree difference in sagittal rotation during the treatment thrust indicating vertebral movement in the “paraphysiological” zone.
The biomechanics of spinal manipulation
Figure 5 Force-time and EMG-time histories measured during a thoracic spinal manipulation. Note the delayed onset of the EMG response suggesting a reflex activation of the muscles caused by the treatment thrust.
When applying a very short and precisely focused treatment force (using an activator instrument), a reflex response was elicited that had the visual shape of a single motor unit action potential. Furthermore, its delay from the onset of force application (50e100 ms) was such that it was suggested to be a muscle spindle reflex pathway (Herzog et al., 1995). Reflex responses produced by activator application were always restricted to the vicinity of treatment application. For HVLA spinal manipulations, the reflex responses were not restricted to the immediate treatment area, but formed characteristic activation patterns that depended on the site of force application ((Herzog et al., 1995, 1999) (Figure 6)). Finally, patients presenting with spastic muscles showed EMG activity in the muscles of the treatment area. When subjected to a HVLA treatment thrust, the muscles relaxed and EMG activity was abolished in some but not all of the patients (Herzog, 2000) (Figure 7). It is not known why treatments produced a relief of muscle spasticity in some patients but not in others. We conclude from these observations that HVLA spinal
283
Figure 7 EMG-time history for patient with spastic activation of the back musculature. The arrow indicates the time of the treatment thrust. Note the release of spasticity and EMG activation following the treatment thrust.
manipulative treatments elicit a reflex response that is not necessarily localized, and affects locations that are remote from the actual treatment site. Role of the audible release The audible release, or cracking sound, is an indicator of a successful treatment for many chiropractors, so much so, that when an audible release does not occur, many clinicians will immediately apply a second or even third treatment thrust. The role of the audible release has been a matter of intense debate (Brodeur, 1995; Sandoz, 1969) and one of the roles associated with the audible release has been the idea that it causes the reflex responses discussed above. However, there are a variety of observations that do not fit that idea. For example, every HVLA treatment thrust we have recorded was associated with an electromyographical response, but not all of these caused cavitation (Conway et al., 1993). That is, reflex responses were observed in the absence of cavitation. However, in order to address this question directly, we asked chiropractors to apply treatment forces at the exact location and exact direction as they would for a normal manipulative thrust,
Figure 6 EMG-time histories of 16 channels collected before and after spinal manipulation (left). The vertical line indicates the time of onset of the treatment thrust. Note the reflex activations elicited by the thrust for various EMG channels. Approximate placements of the EMG electrodes (open circles) and area of reflex response (enclosed areas 100% response, 80% response and 50% response for smallest, middle and largest area, respectively) for treatments of the left (left) and right (right) sacroiliac joint (filled circle).
284
W. Herzog Distance [mm] 15.5 neutral head position
15 14.5 14 13.5 fully flexed head position
13 0
4
8
12
16 Time [s]
Figure 8 Stretch-shortening time history for a vertebral artery segment during neck flexion.
but to do so very slowly. With a slow force application, an audible release can be elicited, but this release is not associated with a corresponding EMG response (Conway et al., 1987), suggesting that the audible release is not responsible for the observed reflex responses during HVLA chiropractic spinal manipulations.
Internal stresses and strains during HSLA manipulative treatments of the cervical spine One major issue with the use of HVLA spinal manipulation is its safety, especially with respect to neck manipulation and the risk of stroke. Estimates of the risk of stroke vary from 1:5000 to 1:10 million (Cote et al., 1996; Frisoni and Anzola, 1991; Haldeman et al., 1999, 2002; Hurwitz et al., 1996; Lee et al., 1995). Although the proposed risk is extremely small, the serious and irreversible nature of vascular accidents makes this an important issue (Terrett and Kleynhans, 1980). The earliest documented reports of fatal vascular accidents following spinal manipulation can be traced back to the 1930s (Foster vs Thornton, 1934), and 1940s (PrattThomas and Beyer, 1947). The majority of these cases
Figure 10 Mean force-time histories of spinal manipulations of the neck averaged across 15 patients (normal) and 15 measurements from cadaveric specimens (cadaver). Note the force-time histories are virtually identical suggesting thrust treatment forces given to patients and in our cadaver work are very similar.
have involved the vertebrobasilar system, specifically the cephalad/distal loop of the vertebral artery, as it exits the foramen transversarium of C1 (Haldeman et al., 1999). Because of the unique configuration of the vertebral artery, it has been suggested that it experiences considerable stretch and associated tissue stress during extension and rotation of the neck which may lead to occlusion and damage to the arterial walls (Terrett and Kleynhans, 1980). Consequently, it has been hypothesized that HVLA spinal manipulation may also lead to stretch-induced vertebral artery damage, although our biomechanical evidence does not support this view (Herzog and Symons, 2002; Symons et al., 2002). Measurements of internal stresses of soft tissues caused by spinal manipulation are rare, and the only documented reports of such measurements on the vertebral artery are those by Herzog and Symons (2002), and
Length [mm] C2/C3 17 16
C3/C4
19.8 19.6 19.4 19.2 0
Figure 9 Stretch-shortening time history for a vertebral artery segment during a neck manipulative treatment. The onset and end of the thrust phase of the treatment is indicated by the arrows.
10
20
30
40
Time 50 [s]
Figure 11 Stretch-shortening-time history for vertebral artery segments C2/C3 (top) and C3/C4 (bottom) for a rotational range of motion test. Note that the two segments show opposite behaviour: C2/C3 is stretched during neck rotation (as one would expect based on the anatomy) while segment C3/C4 shortens.
The biomechanics of spinal manipulation
285
Force [N] 150 100 50 0 Length [mm] 16.5 16.4 16.3 21.4 21.2 21.0 0
1
2
3 Time [s]
Figure 12 Stretch-shortening-time history for vertebral artery segments C2/C3 (top) and C3/C4 (bottom) for a chiropractic neck manipulation. Note that the two segments show opposite behaviour: C2/C3 is stretched during neck rotation (as one would expect based on the anatomy) while segment C3/C4 shortens.
Symons et al. (2002). In these studies, the strains of the vertebral artery were measured from the neutral length (head and neck in the neutral position) for a variety of range of motion and diagnostic testing, as well as for different HVLA cervical spine manipulations across all levels performed ipsi- and contralaterally to the target vertebral artery (Figures 8 and 9). They then excised the vertebral arteries carefully from the cadaveric specimens used for these studies and measured the corresponding forces experienced by the vertebral arteries for the strains (elongations) measured during the diagnostic and clinical procedures. Symons et al. (2002) and Herzog and Symons (2002) found that stretches to the vertebral artery during neck manipulative procedures (6% for the cephalad/distal segment) were much smaller than the stretches produced during range of motion and diagnostic testing (13%). They also found that the elongations produced during HVLA spinal manipulations did not produce any tensile forces in the vertebral artery, suggesting that the vertebral arteries were slack when the head and neck were in the neutral position and that this slack was not fully taken up during spinal manipulative treatments. Therefore, spinal manipulation did not cause any tensile stress in the vertebral arteries during the treatment procedures. However, the studies by Symons et al. (2002) and Herzog and Symons (2002) had several limitations. Most importantly, measurements were only made for two segments (cephalad to C1 and caudad to C6), forces during the spinal manipulations were not measured and the vertebral arteries of the unembalmed cadavers were devoid of fluid, thus possibly affecting their shape. In order to overcome these limitations, we performed a pilot study to measure the strains in the vertebral artery segments C1eC6 with the arteries filled with gel and while measuring the forces applied by two chiropractors during all diagnostic and treatment procedures. The
forces applied by the chiropractors during spinal manipulations were similar to those administered to patients, thus we may assume that the external mechanics were similar (Figure 10). The peak strain (elongation form neutral) that was measured for any of the 176 treatments procedures was 2.1% while strains for diagnostic procedures were in excess of 10% (flexion 10.1%, rotation 13.0% and Houle’s test 9.4%), suggesting, in agreement with our previous studies, that strains during HVLA cervical spinal manipulations were much smaller than those produced during diagnostic procedures. In contrast to our previous work, however, the strains measured in adjacent vertebral artery segments were not always intuitively apparent. For example, we found the repeatable (across multiple measurements and across clinicians) result that for some diagnostic and treatment procedures, one vertebral artery segment shortened while the adjacent segment was stretched. For example, in Figure 11, we show the right vertebral artery segments C2/C3 and C3/C4 for a left rotation of the neck. Textbook anatomical considerations would suggest that the vertebral artery segments should be stretched, which was observed for the C2/C3 segment, but not the C3/C4 segment which shortened consistently for both chiropractors and for all three repeat measurements. Similarly, these same segments behaved opposite during a HVLA neck manipulation (Figure 12). Again, this result was observed for all three repeat measurements of and both clinicians. Combined, the results of this study suggest that spinal manipulative treatments produce stretches of the vertebral artery that are much smaller than those that are produced during normal everyday movements, and thus they appear harmless. However, textbook anatomical considerations do not necessarily allow prediction of the direction of strain in different vertebral artery segments. Some non-intuitive behaviour was observed that cannot be explained at present but might be related to the intricate coupled motions of vertebral bodies and the complex fixation of the vertebral artery to the transverse foramen of C1eC6. In summary, there is little knowledge of the transmission of stresses and strains across hard and soft tissues during spinal manipulation. This is a vast field of investigation that needs careful attention so that the detailed mechanics of HVLA treatments can be understood and possible risks of these procedures may be identified.
Acknowledgements The Canadian Chiropractic Research Foundation, Canadian Chiropractic Protective Association, The Alberta College and Association of Chiropractors.
References Adams, A.H., Wood, J., 1984. Comparison of forces used in selected adjustments of the low back: A preliminary study. Res. Forum 1, 5e9. Brodeur, R., 1995. The audible release associated with joint manipulation. Journal of Manipulative and Physiological Therapeutics 18, 155e164.
286 Cascioli, V., Corr, P., Till Ag, A.G., 2003. An investigation into the production of intra-articular gas bubbles and increase in joint space in the zygapophyseal joints of the cervical spine in asymptomatic subjects after spinal manipulation. Journal of Manipulative and Physiological Therapeutics 26 (6), 356e364. Conway, B.A., Hultborn, H., Kiehn, O., 1987. Proprioceptive input resets central locomotor rhythm in the spinal cat. Exp. Brain Res. 68 (3), 643e656. Conway, P.J.W., Herzog, W., Zhang, Y., Hasler, E.M., Ladly, K., 1993. Forces required to cause cavitation during spinal manipulation of the thoracic spine. Clinical Biomechanics 8, 210e214. Cote, P., Kreitz, B.G., Cassidy, J.D., Thiel, H., 1996. The validity of the extension-rotation test as a clinical screening procedure before neck manipulation: a secondary analysis. J.Manipulative Physiol Ther 19 (3), 159e164. Forand, D., Drover, J., Suleman, Z., Symons, B., Herzog, W., 2004. The forces applied by female and male chiropractors during thoracic spinal manipulation. Journal of Manipulative and Physiological Therapeutics 27, 49e56. Foster vs Thornton, 1934. Medicolegal abstract. Malpractice: death resulting from chiropractic treatment for headache. Journal of American Medical Association 103, 1260. Frisoni, G.B., Anzola, G.P., 1991. Vertebrobasilar ischemia after neck motion. Stroke 22 (11), 1452e1460. Ga ´l, J., Herzog, W., Kawchuk, G., Conway, P.J.W., Zhang, Y., 1997a. Movements of Vertebrae during manipulative thrusts to unembalmed human cadavers. Journal of Manipulative and Physiological Therapeutics 20, 30e40. Ga ´l, J., Herzog, W., Kawchuk, G., Conway, P.J.W., Zhang, Y.T., 1994. Biomechanical studies of spinal manipulative therapy (SMT): Quantifying the movements of vertebral bodies during SMT. The Journal of the CCA 38, 11e24. Ga ´l, J., Herzog, W., Kawchuk, G., Conway, P.J.W., Zhang, Y.T., 1997b. Measurements of vertebral translations using bone pins, surface markers and accelerometers. Clinical Biomechanics 12 (5), 337e340. Haas, M., 1990. The physics of spinal manipulation. Part IV. A theoretical consideration of the physician impact force and energy requirements needed to produce synovial joint cavitation. Journal of Manipulative and Physiological Therapeutics 13, 378e383. Haldeman, S., Kohlbeck, D.C., McGregor, M., 2002. Unpredictability of Cerebrovascular Ischemia Associated With Cervical Spine Manipulation Therapy. Spine 27 (1), 49e55. Haldeman, S., Kohlbeck, F.J., McGregor, M., 1999. Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine 24 (8), 785e794. Herzog, W., 1991. Biomechanical studies of spinal manipulative therapy. The Journal of the CCA 35, 156e164. Herzog, W. 2000, Clinical Biomechanics of Spinal Manipulation Churchill Livingstone, Philadelphia. Herzog, W., Conway, P.J.W., Kawchuk, G.N., Zhang, Y., Hasler, E. M., 1993a. Forces exerted during spinal manipulative therapy. Spine 18, 1206e1212. Herzog, W., Conway, P.J.W., Zhang, Y.T., Ga ´l, J., Guimaraes, A.C. S., 1995. Reflex responses associated with manipulative treatments on the thoracic spine. Journal of Manipulative and Physiological Therapeutics 18, 233e236. Herzog, W., Kawchuk, G.N., Conway, P.J.W., 1993b. Relationship between preload and peak forces during spinal manipulative treatments. Journal of the Neuromusculoskeletal System 1 (2), 52e58.
W. Herzog Herzog, W., Scheele, D., Conway, P.J.W., 1999. Electromyographic responses of back and limb muscles associated with spinal manipulative therapy. Spine 24 (2), 146e152. Herzog, W., Symons, B., 2002. The mechanics of neck manipulation with special consideration of the vertebral artery. Journal of the Canadian Chiropractic Association 46 (3), 134e136. Herzog, W., Zhang, Y.T., Conway, P.J.W., Kawchuk, G.N., 1993c. Cavitation sounds during spinal manipulative treatments. Journal of Manipulative and Physiological Therapeutics 16, 523e526. Hessel, B.W., Herzog, W., Conway, P.J.W., McEwen, M.C., 1990. Experimental measurement of the force exerted during spinal manipulation using the Thompson technique. Journal of Manipulative and Physiological Therapeutics 13, 448e453. Hurwitz, E.L., Aker, P.D., Adams, A.H., Meeker, W.C., Shekelle, P., 1996. Manipulation and mobilization of the cervical spine. A systematic review of the literature. Spine 21, 1746e1759. Kawchuk, G.N., Herzog, W., 1993. Biomechanical characterization (fingerprinting) of five novel methods of cervical spinal manipulation. Journal of Manipulative and Physiological Therapeutics 16 (9), 573e577. Kawchuk, G.N., Herzog, W., Hasler, E.M., 1992. Forces generated during spinal manipulative therapy of the cervical spine: A pilot study. Journal of Manipulative and Physiological Therapeutics 15, 275e278. Lee, K.P., Carlini, W.G., McCormick, G.F., Albers, G.W., 1995. Neurologic complications following chiropractic manipulation: a survey of California neurologists. Neurology 45 (6), 1213e1215. Meal, G.M., Scott, R.A., 1986. Analysis of the joint crack by simultaneous recording of sound and tension. Journal of Manipulative and Physiological Therapeutics 9 (3), 189e195. Miereau, D., Cassidy, J.D., Bowen, V., Dupuis, P., Noftall, F., 1988. Manipulation and mobilization of the third metacarpophalangeal joint. Manual Med. 3, 135e150. Pratt-Thomas, H.R., Beyer, K.E., 1947. Cerebellar and spinal injuries after chiropractic manipulation. Journal of American Medical Association 133, 600e603. Reggars, J.W., 1996. Recording techniques and analysis of the articular crack. Australasian Chiropractic and Osteopathy 5 (3), 86e92. Sandoz, R., 1969. The significance of the manipulative crack and of other articular noises. Ann. Swiss Chiro.Assoc. 4, 47e68. Symons, B., Leonard, T.R., Herzog, W., 2002. Internal forces sustained by the vertebral artery during spinal manipulative therapy. Journal of Manipulative and Physiological Therapeutics 25, 504e510. Terrett, A.G.J., Kleynhans, A.M., 1980. Cerebrovascular complications of manipulation. In: Haldeman, S. (Ed.), in Principles and Practice of Chiropractic, second edn. Appleton & Lange, Connecticut, pp. 579e598. Triano, J., Schultz, A.B., 1997. Loads transmitted during lumbosacral spinal manipulative therapy. Spine 22, 1955e1964. Triano, J.J., 2000. The mechanics of spinal manipulation in Clinical Biomechanics of Spinal Manipulation. In: Herzog, W. (Ed.). Churchill-Livingstone, Philadelphia, PA, pp. 92e190. Triano, J.J., Schultz, A.B., 1990. Cervical spine manipulation: applied loads, motions and myoelectric responses. Proc.14th Mtg.Amer.Soc.Biomech. 14, 187e188. Wood, J., Adams, A.H., 1984. Forces used in selected chiropractic adjustments of the low back: A preliminary study. The Research Forum,. Palmer College of Chiropractic 1, 16e23.
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BOOK REVIEW Frank C, Lardner R, Page P. The assessment and treatment of muscular imbalance e The Janda Approach Hardback $64, Human Kinetics, Champlain, IL USA, ISBN-13:9780736074001
Vladimir Janda, MD, DSc (1923e2002) influenced generations of practitioners spanning many disciplines. This evidence-based book is written by three physical therapists, all of whom worked with Janda. It emphasizes various assessment and treatment procedures based on the existence of muscle imbalance e the combination of abnormal muscle inhibition (‘‘weakness’’) and hypertonic muscles (tightness). This would make a useful addition to every clinician’s library e especially physical therapists, chiropractors, osteopaths and all those using hands-on therapies. The book is divided into four parts: - The Scientific Basis of Muscle Imbalance includes chapters on the structural and functional approaches to muscle imbalance, and the ‘‘pathomechanics’’ of pain. - Functional Evaluation of Muscle Imbalance discusses posture, gait, muscle length testing and soft tissue assessment. - Treatment of Muscle Imbalance Syndromes describes the restoration of muscle balance and sensorimotor training. - Clinical Syndromes presents four common areas of musculoskeletal pain disorders: cervical, upper extremity, lumbar and lower extremity. Like many pioneers, Janda’s terminology and ideas evolved apart from the traditional clinical sciences. The author’s state: ‘‘There are several schools of thought regarding muscle imbalance. Each approach uses a different paradigm as its basis. Vladimir Janda’s paradigm was based on his background as a neurologist and physiotherapist.’’ The Janda Approach provides more than an introduction of his material for practitioners and students. In the preface the author’s state: ‘‘We wanted to write a text that both preserves and supports Janda’s teaching. This book is only a tool for everyday practitioners; it is not meant to address all chronic pain syndromes or even all muscle imbalance syndromes. Instead, we wanted to provide practical, relevant, and evidence-based information
doi:10.1016/j.jbmt.2009.11.003
arranged into a systematic approach that could be implemented immediately and used along with other clinical techniques.’’ An important concept presented well is the interplay between injuries and muscle imbalance. Janda’s ‘‘muscle imbalance continuum’’ describes tissue damage, pain and altered gait as potential causes of imbalance, while emphasizing that the reverse can also exist. The book’s wide range of topics associated with neuromuscular function is as impressive as the therapeutic options offered e from acupuncture and trigger point therapy to the works of Florence and Henry Kendall, and George Goodheart. All the topics are well researched with 40 pages of references. Janda’s view of muscle imbalance is presented well e the combination of tight/short muscles and weak ones, mediated by the central nervous system with important stimuli from the peripheral nervous system (in particular, proprioception from joints). While the book references Sherrington, Janda often deviated in his approach by treating the tightness as the primary muscle problem rather than the weakness. The book’s side-by-side comparison is made between Janda’s clinical approach to muscle imbalance and that of physical therapist Dr. Shirley Sahrmann. However, to help address the common debate among clinicians regarding which side of muscle imbalance is primary, it might have been useful to also present the different perspectives adopted by physical therapist Diane Damiano (Damiano et al., 1995; Wiley and Damiano, 1998) or George Goodheart DC (Walther, 2000; Goodheart, 1964) whose clinical work focused mainly on muscle weakness. The interpretation of Sherrington’s law of reciprocal inhibition appears to be the difference. The Janda Approach does recommend using muscle testing in certain cases, and suggests, at times, treating the weakness side of muscle imbalance. The Janda Approach describes a full spectrum of muscle imbalance e from relatively common problems associated with aches and pains, including chronic low back syndrome, to the more serious mechanical distortions in brain and spinal cord injured patients. An important tenet is worded well by the authors: ‘‘[Janda] based his approach on his observations that patients with chronic low back pain exhibit the same patterns of muscle tightness and weakness that patients with upper motor neuron lesions such as cerebral palsy exhibit, albeit to a much smaller degree.’’
288 Janda believed that 80% of patient’s with low back pain could be shown to have minimal brain dysfunction. In our symptom-oriented healthcare world, it was refreshing to read Janda’s philosophy that the source of pain is rarely the cause. The book dedicates a chapter to this concept of interactions between the skeleton, muscles and nervous system, and the process of cause and effect. While the authors describe Janda’s many clinical models, clinicians are well aware that patients typically deviate from these patterns, creating their own unique neuromuscular patterns. Like many chapters, the one on posture, balance and gait is excellent. However, despite writing his first book on muscle testing, The Janda Approach describes only a few manual muscle tests, instead relying more on posture, gait, muscle length assessment and basic movement patterns to evaluate muscle imbalance. Because Janda felt that manual therapy was not sufficient by itself to successfully treat the neuromuscular system, the authors discuss his sensorimotor training as an important aspect of patient care. Rather than traditional strength training, Janda used sensorimotor training to promote whole-body neuromuscular activity with emphasis on incorporating certain areas of the brain. These include gently increasing proprioception from the sole of the foot, deep cervical musculature and the sacroiliac joint, as well as vestibular balance training. These physical activities
Book Review help activate/retrain the motor system, improve postural control and optimize gait. The last part of the book contains four chapters, each representing a common clinical syndrome by region: cervical, upper extremity, lumbar and lower extremity. Case histories offer good examples, but they don’t replace an effective assessment and the potential for a wide variety of therapeutic options e many of these are offered by The Janda Approach. Despite this reviewer’s many years of study of Janda’s work, this book provided much new information and ideas, largely because the authors present the material so well. Dr. Maffetone can be reached through his website (www. PhilMaffetone.com):
[email protected] References Damiano, D., Kelly, L., Vaughan, C., 1995. Effects of quadriceps femoris muscle strengthening on crouch gait in children with spastic diplegia. Phys Ther 75, 658e671. Goodheart Jr. G, 1964. Applied Kinesiology. Detroit: Privately Published. Walther, D., 2000. Applied Kinesiology Synopsis, second ed. Systems DC, Pueblo, CO. Wiley, M., Damiano, D., 1998. Lower-extremity strength profiles in spastic cerebral palsy. Dev Med Child Neurol 40, 100e107.
Philip Maffetone
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PREVENTION & REHABILITATION: EDITORIAL
Warrick McNeill, MCSP, Associate Editor* United Kingdom
What is prevention? About 4500 years ago, according to Chinese tradition, and Fletcher (1988), the Yellow Emperor, Huang-di, only paid his physician’s retainer when he was well and stopped paying when he was not. ‘The wise people (the sages) did not treat those who were already ill; they instructed those who were not yet ill.’ Preventative measures (nourishment, rest, exercise and sleep) consisted of 4 of the 5 modes of treatment espoused at that time. Serge Gracovetsky, reports in an interview published on YouTube, that he once, while suffering back pain, went to see seven different Orthopaedic or Neuro Surgeons but received seven different diagnoses. Gracovetsky appears to have applied a similar principle and didn’t pay any of them to proceed with their suggested treatments. Four recommended surgery, three did not. He decided that the best course of action was to do nothing, but go to the Library to find out what he could about back pain. Have we then come very far in the intervening four millennia? On the safetylit.org website, an online source of injury prevention literature, they state: ‘Injuries have causes e they don’t simply befall us from fate or bad luck. To prevent injuries it is necessary to have information about the factors that contribute to their occurrence. With this information we may understand the options for prevention. Effective injury prevention requires a multifaceted, multidisciplinary approach.’ It is also a very broad remit. Too broad perhaps? Health and Safety Directives seem to be impinging on society and the workplace. Enough so as to encourage the UK’s Health and Safety Executive to produce ‘Myth of the Month’ posters debunking ‘Great health and safety myths.’ November 2009s
* Tel.: þ44 7973 122996. E-mail address:
[email protected] poster points out that it is a myth that Health and Safety rules stop classroom experiments. The cartoon shows a rather sad teacher and pupils wearing safety goggles watching paint dry on a card propped up in a safety-glass cabinet. As a Physiotherapist I use the UK Health and Safety Regulations on Display Screen Equipment (1992) (based on the relevant EC directives) in the part of my practice which involves ergonomically assessing staff at their computer workstation, but even then, I’m a second tier external consultant e only brought in when the staff member is already reporting pain, and has usually already been seen by the in-house assessors. Is my role ‘preventative’? Prevention, as a concept of health management, appears to be wasted on the young. The hubris and indestructibility of youth becomes more glaring as one ages and becomes more risk adverse. The young appear not to listen to sound advice, they do not appear to learn by others mistakes rather they seem to want to sustain the injury to discover that they need to avoid injuring themselves in the first place. Being an Injury Prevention specialist working with the young might not possibly score highly on a job satisfaction questionnaire, but how much ‘prevention’ work actually occurs prior to first episode injuries? When my Physiotherapy colleagues discuss prevention it is usually about preventing recurrence of the injury, so it is after the fact of the original insult, and becomes part of rehabilitation. Mark Ford, a Pilates/Gyrotonic/Franklin Method instructor in Australia says, ‘To me rehabilitation and prevention can not be separated. Rehab is not complete if the client doesn’t understand causes, actions and consequences.’ (Ford, 2010). Chaitow (2010) says eloquently in a personal communication, ‘I work with a model in which dysfunction emerges from a background of failed adaptation (to overuse, misuse, abuse and disuse). In such a model prevention is seen to involve modifying or eliminating those stressors that can be
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PREVENTION & REHABILITATIONdEDITOR: WARRICK MCNEILL
About prevention
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identified e so reducing adaptation demands bodywide, or locally. In addition, prevention entails enhancing functionality (bodywide and/or locally) so enabling the system or area to better cope with adaptation demands. Rehabilitation of existing dysfunction involves a similar model of care e with specifically focussed interventions and strategies, as well as generalised ones (better posture, breathing, nutrition, habits of use etc). Prevention therefore only differs from rehabilitation by virtue of the context and the objectives’. So it appears, in the context of therapy and therapists, that prevention and rehabilitation treatments or strategies could possibly be the same thing, but just be a question of timing, before or after an incident (or injury provoking behaviour), that may itself be an original insult, second or third.
Chronic low back pain Exciting advances made in motor control and pain research means that there is a diagnosis and management shift from a pathological and anatomical viewpoint to a dynamic systems approach according to Key (2010a). In the opening chapters of her recently published book, ‘Back Pain: A movement problem.’ Key neatly summarises Waddell who states that: only about 15% of patients with back pain show definite structural pathology, the relationship between imaging and symptoms is weak, and in the absence of a diagnosis Health professionals may look to psychological reasons for their pain, therefore, there is no surprise that the ‘biopsychosocial model’ has evolved. While not discounting the biopsychosocial model readers of the Journal of Bodywork and Movement Therapies may too realise that hands-on or therapeutic exercise answers may exist for their clients neuromusculo-skeletal problems. Key goes further and looks at classification systems for Chronic non-specific low back pain (CNLBP) or ‘ordinary’ back pain, quoting Riddle (1998) that current classification systems are confusing, looking at appropriate treatments, or prognoses, or pathology. She also quotes O’Sullivan (2005) who overviews 8 models, including the ‘Motor control model’ in which O’Sullivan bases his own work. Key suggests the ‘Functional movement model’ that combines many features of other CNLBP models including the biopsychosocial (Key’s own bolding) and Motor control. She suggests that ‘altered function of the posturo-movement system is the primary problem largely responsible for the development and perpetuation of most pain syndromes.’ I asked Key (2010b) about how she considers prevention in the therapeutic context, she said, ‘I certainly consider that prevention is an important aspect of comprehensive therapeutic care e yet this aspect seems to have been largely usurped by the ‘fitness’ and related industries who have little ‘real rehabilitation’ training e hence who knows what they base their ‘‘prevention programs’’ on. I consider that if prevention strategies are to be meaningful and functionally useful, they need to be built upon a well informed understanding around a number of related aspects concerning movement control: (a) What is ‘more ideal’ posturo-movement function? Appreciating this also enables better application of the
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(b)
(c)
(d)
(e)
available evidence; to put research outcomes into the clinical context; and even question the clinical utility of some findings The evidence is pointing more towards deficiencies in motor control being associated with spinal pain disorders and so, more beneficial programs should focus upon the quality of our patterns of movement control rather than the ubiquitous ‘strengthening’ and ‘stretching’ The practitioner needs to be cognisant of the fact that seemingly subtle changes in posturo-movement control are usually apparent before the onset of pain. These changes can tell us a lot about the potential or actual problems the patient may be/is experiencing and so this can also serve a certain predictive role e important for prevention programming. The practitioner needs to appreciate ‘‘what are the more likely patterns of dysfunctional response going to be’’? While evidence is giving us more answers in this area, at this point in time we need to rely more on our clinical pattern recognition and therapeutic skills to provide the substance of more meaningful prevention program. In essence, effective programs of care e therapeutic and preventative, depend upon a balance between artful clinical practice informed by the knowledge that science can offer.’
In summary Key said she ‘is trying to get the message out there that clients most probably need to work smarter not harder!’ We know that a marker for measuring the success of rehabilitation is in dropping recurrence rates, it is the underlining and exclamation point a researcher has when they publish their follow up study, see Hides et al. (2001) work on the deep multifidus.
The 3rd movement dysfunction conference 2009 During a dismally wet Edinburgh weekend Sahrmann (2009a) presented her Keynote Lecture on Low back pain: ‘Isolated or degenerative problem e what are the implications?’. She stated that ‘90% of people are expected to experience low back pain during their life’ with a high recurrence rate ‘between 30 and 80%’ These high incidence and recurrence rates, she says, ‘are consistent with low back pain being associated with the degenerative process’ and this process consists of ‘temporary dysfunction and 4 stages of hyper-mobility before the final stage of hypomobility and spinal stenosis. If the ‘‘acute episodes’’ are part of the pattern of temporary dysfunction associated with segmental hyper-mobility then treatment should be directed toward control and prevention of the progressive hyper-mobility that at a minimum should slow the degenerative process.’ She challenges physical therapists to ‘monitor the pattern of movement of the low back, designing and appropriately instructing the patient in corrective exercises and movement strategies rather than just providing episodic short-term treatment.’ Sahrmann reported that clinical examination is reliable, in trained
About prevention
a deep squat a hurdle step an in-line lunge shoulder mobility an active straight leg raise a trunk stability push up, and a rotation stability test.
Comerford (2009, 2004) in his presentation to conference discussed that in sport (where improving performance becomes a major goal of the support staff, as opposed to, in the clinic where the major goal is reducing pain and disablement) the significant ‘Recurrence of injury and pain’ indicates that something is missing in our current screening and prevention strategies. Comerford pointed out that assessments and screening of athletes is standard across the board. Screenings primarily look at testing joint range, muscle strength (power and endurance) and muscle extensibility. Comerford was clear that these are all relatively unsuccessful at predicting risk of re-injury or recurrence of pain. Like Cook, Comerford also identified that history of previous injury is the single most consistent and reliable predictor of high risk of re-injury. He identified that the isolationist testing of joint range of motion or normal muscle strength is not an adequate rehabilitation end point to prevent recurrence. Comerford suggested it is the assessment of the control of ‘real’ function that is the missing piece of the screening puzzle. He defines ‘real’ function as the influence of the multiple muscle interactions acting on multiple joints in functionally orientated tasks. Comerford advocates the Perfomance Matrix screen, that he presented to the conference. I personally teach a version of this to the pilates community. At the centre of the screen is the assessment of the motion segment (or regional) ‘hyper-mobility’ referred to by Sahrmann earlier. This may be directional (i.e. flexion, extension, rotation etc) and, equally importantly, relates to the threshold at
which it occurs (low or high). Comerford terms this ‘uncontrolled movement.’ Sahrmann refers to the same concept as the ‘direction susceptible to movement’, and O’Sullivan as a ‘control impairment.’ Comerford suggests it is the threshold at which the failure occurs which dictates whether the specific exercises required to improve the uncontrolled movement should be slow motor unit dominant (low threshold) thereby showing a Central Nervous System (CNS) led ‘recruitment’ failure of the muscles that should be providing the control, or a fast motor unit dominant (high threshold) ‘weakness’ e meaning the hyper-mobile area needs muscular strength to provide the control. This is the key differentiation between the FMS and Performance Matrix approaches.
In the real world Swart (2010), Physiotherapist for elite athletes in South Africa reports that ‘in the area of symptoms we mostly find uncontrolled movements with the low threshold tests which makes sense due to the fact that pain affects slow motor unit recruitment. With the Performance matrix or FMS we can determine risk factors for injury in other areas of the body before they occur preventing further time out due to injury. It is less time consuming to prevent injuries rather than treat the injuries, and athletes hate not being able to train. Once there is pathology it usually means the athlete has to rest for 6 weeks to allow for healing or at least I change their exercise program to allow them to perform unloaded training in water. Athletes usually start too quickly and try to progress too fast leading to recurrences of injuries or injuries in other areas due to compensation.’ Barr (2010), an Injury Prevention Specialist for the New York Knicks Basketball Team, confirms the requirement for interdisciplinary co-operation. Barr does not regard reactive injury prevention programs as injury prevention e this, he says, ‘is just an extension of injury rehab.’ Like the Yellow Emperor before him Barr believes that, ‘optimal nutrition, hydration and sleep quality are all essential aspects of injury prevention. If these obvious basics are not taken care of fully, then any other injury prevention strategy employed will have a lesser effect.’ Barr suggests the athlete needs to: be specifically conditioned to perform in their specific sport, after previous bouts of exercise be fully recovered to perform, be in a ready state to perform physically (warmed up) and mentally (focused) and, have optimal neuromuscular control, stability, mobility and strength for the demands of their specific sport. To ensure all these considerations are taken care of reliable screening and testing methods need to be frequently performed. ‘My area of expertise,’ says Barr, ‘and what I believe to be an essential part of the screening process, is the ‘‘analysis of the quality of movement.’’ In my experience screening for ‘‘movement control’’ and ‘‘producing injury
PREVENTION & REHABILITATIONdEDITOR: WARRICK MCNEILL
people, in identifying movement faults and that there is validity in identifying (movement) subgroups (Sahrmann, 2009b). Fass (1996), ‘Exercises: which ones are worth trying, for which patients, and when?’ found that more research on ‘different types of exercising’ in patients with chronic back pain was necessary. Sahrmann’s comments at the Movement Dysfunction conference suggests that there may eventually be a plethora of well reasoned, specific exercises for specific movement faults, identified by pattern recognition and clinical testing, that probably make up the 85% of CNLBP sufferers that do not have a structural pathology. ‘Movement screening’ was highlighted at the conference, first by Gray Cook who introduced his Functional Movement Screen (FMS). Cook (2009) identified that the strongest predictor of future injury is previous injury. The FMS, is a reliable (Minick et al., 2010) predictive system for those who do not have a known musculo-skeletal injury. It assesses functional movement patterns looking for asymmetries and movement limitations, and therefore, he suggests, indicates what ‘to do’ with the client. The test movements are relatively simple and include:
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prevention programs to improve the control of movement’’ have great success. Aside from traumatic injuries most other injuries can be related to ‘‘uncontrolled movement.’’ It is relating uncontrolled movement to the pathology that allows you to understand how uncontrolled movement is an injury risk and correcting uncontrolled movement is injury prevention.’
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Crossover between pain and human performance It is interesting to note that Cook and Comerford, system developers, and Swart and Barr, users of a system of assessing movement control, are physical (or physio) therapists who originally trained to treat pain and injury but have moved out from a narrow focus to look at human performance as well. They have the remit, via their professional training, to look at both patients (those in pain) and athletes (concentrating on those with performance deficits). Not all who read the JBMT will be able to move easily between these two camps. Some movement disciplines such as Pilates or Yoga are not widely regarded as ‘treatment’ and therefore their teachers should not work without the co-operation of a suitably qualified health professional or without clearance from a doctor who is knowledgeable (both about the patients condition and the discipline they are referring to). Yet many who present to Pilates or Yoga Teachers do so because they are in pain, perhaps they do not identify themselves as having pain for fear of being excluded from the session or perhaps they do not see that it is important for the teacher to know about their pain. It is often the wording of the practitioners insurance policy that defines who a Teacher can see, however, it is becoming very clear that movement dysfunctions are responsible for the internal environment that leads to pain. Pain is probably just a late sequelae of the same movement faults that Pilates and Yoga teachers see in every class that they teach. The Teachers have the tools to alter these movement faults by their interventions, cueing and handling, thereby ‘preventing’ the ‘pain’ that could have otherwise have been expected to follow. It is the fact that exercise is often undertaken in group classes so that a teacher should ideally:
keep the group size small, know the clients extremely well, have assistants, play to the lowest common physical denominator, or ‘sub-group’ their classes to fit those with similar problems together, to keep the individual in a group as ‘safe’ as possible.
Individual or ‘one to one’ sessions are a luxury that for many clients is imperative if they are to progress with the least risk of recurrence from being given an inappropriate exercise or trying too hard too soon or simply not working hard enough. In an individual session a teacher is able to discover the modifications that that client requires to zone a specific exercise into something that is maximally beneficial in that instance as opposed to performing
a ‘cheat’ in which the cheat becomes perpetuated. Criticism of the disciplines of Pilates and Yoga (Key, 2010a) to name but two disciplines is fair especially when poorly trained teachers, use exercise recipes and dogma instead of individual assessment, critical thought and exercise modification. In my personal opinion the nascent scientific research looking at Pilates or Yoga often lets itself down by not defining within the research question what part of the discipline it is looking at. The disciplines have varied practices of the same activities yet a broad brush stroke description of what is undertaken is often deemed enough. Describing every detail, especially modifications of exercises encouraged and cueing used, may help the disciplines develop a scientific credibility that at present appears to be unfortunately lacking. Careful thought as to what exercises should be excluded from a particular study might be more beneficial than performing all the available repertoire. The history of chronic low back pain research over the last one or two decades, and recent thoughts on motor control and sub-grouping that are now developing, could be applied to help accelerate research in Pilates or Yoga.
Call to action As this is the Prevention and Rehabilitation section of the Journal of Bodywork and Movement Therapies I would like to put a call out for papers with a focus on injury prevention or the prevention of injury recurrence. If we accept that motor control deficiencies eventually lead to pain and disability we want to know which movement strategies can be used as motor control tests, or whether those motor control tests currently in use are good predictors of injury risk. Gracovetsky’s (2010) paper discussing ‘Range of Normality’ and injury prevention is an excellent example of the type of paper that improves our knowledge of injury prevention.
Feedback: core stability is a subset of motor control Lederman’s (2010) Myth of core stability paper provoked a muted response in reply to my editorial (McNeill 2010), though it is currently, at the time of writing, the most downloaded article from the JBMT, via ScienceDirect. Comments made showed appreciation of a critical look at core stability, and reiterated that clinicians should be careful not to read too much into research that might not be there. In relation to Core Strengthening, Marcus (2009) quoted ´ me chose’. (The more ‘plus a change, plus c’est la mA things change, the more they stay the same). He identified that in his time as a pain medicine MD that several exercise approaches have come and gone, ‘they become jargonized and thus useless. New is not necessarily better.’ Marcus et al. (2010) points out that he currently uses the Kraus exercise program in his chronic pain treatment protocol. This system (of what we might now regard as non-specific exercise) was developed in the
1950s and reduced or eliminated back pain in 80% of those undertaking them. It seems that despite science and fashion appearing perhaps to be opposite fields of endeavour they both appear influenced by seasons!
In this edition In line with this editorials theme on prevention (and in this case ‘prevention of recurrence’), and with its prevalence in sports, Stephanie Panayi discusses the need for lumbarpelvic assessment in chronic hamstring strain. Josephine Key, who has written before for the JBMT, elaborates further on Vladimir Janda’s ‘Pelvic crossed syndromes’ for this issue. Craig Liebenson’s popular self management: patient section wraps up this editions Prevention and Rehabilitation section. As always, please feel free write to me in response to the Editorial, the papers, or the ongoing themes within the journal or affecting your own practice.
References Barr, A., 2010. Personal correspondence. Chaitow, L., 2010. Personal correspondence. Comerford, M.J., 2004. Core stability: priorities in rehab of the athlete. SportEx Medicine 22, 15e22. Comerford, M.J., 2009. Recurrence of injury and pain in sport e what’s missing. Manual Therapy 14 (5), S1eS54. Cook, G., 2009. What is our baseline for movement? The clinical need for movement screening and assessment. Manual Therapy 14 (5), S1eS54. Fass, A., 1996. Exercises: which ones are worth trying, for which patients, and when? Spine 21 (24), 2874e2878. Fletcher, G.F., 1988. Exercise in the Practice of Medicine, second revised ed. Futura Publishing, Mount Kisco, New York. Ford, M., 2010. Personal correspondence. Gracovetsky, S., 2010. Range of normality versus range of motion: a functional measure for the prevention and management of low back injury. Journal of Bodywork & Movement Therapies 14 (1), 40e49.
293 Hides, J.A., Jull, G.A., Richardson, C.A., 2001. Long term effects of specific stabilizing exercises for first episode low back pain. Spine 26 (11), 243e248. HSE Booklet L26 Display screen equipment work: Health and Safety (Display Screen Equipment) Regulations 1992: guidance on regulations. ISBN: 0-7176-2582-6. Key, J., 2010a. Back Pain: A Movement Problem. Churchill Livingstone Elsevier. Key, J., 2010b. Personal correspondence. Lederman, E., 2010. The myth of core stability. Journal of Bodywork and Movement Therapies 14 (1), 84e98. Marcus, N., 2009. Personal correspondence. Marcus, N., Gracely, E., Keefe, K., 2010. A comprehensive protocol to diagnose and treat pain of muscular origin may successfully and reliably decrease or eliminate pain in a chronic pain population. Pain Medicine 11 (1), 25e34. McNeill, W., 2010. Core stability is a subset of motor control. Journal of Bodywork and Movement Therapies 14 (1), 80e83. Minick, K.I., Kiesel, K.B., Burton, L., Taylor, A., Plisky, P., Butler, R.J., 2010. Interrater reliability of the functional movement screen. Journal of Strength Conditioning Research 24 (2), 479e486. O’Sullivan, P., 2005. Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control impairments as an underlying mechanism. Manual Therapy 10, 242e255. Riddle, D.L., 1998. Classification and low back pain: a review of the literature and critical analysis of selected systems. Physical Therapy 78 (7), 708e737. Sahrmann, S., 2009a. Low back pain: isolated or degenerative problem e what are the implications? Manual Therapy 14 (5), S1eS54. Swart, J., 2010. Personal correspondence.
Web sources Science & Humour with Dr. Serge Gracovestsky e Part 1. http:// www.youtube.com/watch?vZqgh2C8M50Iw. http://www.safetylit.org. http://www.hse.gov.uk/myth/nov09.pdf. Sahrmann, S., 2009b. http://www.webducate.net/icmd_blog/? pZ53. www.functionalmovement.com. www.performance-stability.com.
PREVENTION & REHABILITATIONdEDITOR: WARRICK MCNEILL
About prevention
Journal of Bodywork & Movement Therapies (2010) 14, 294e298
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REVIEW
The need for lumbarepelvic assessment in the resolution of chronic hamstring strain Stephanie Panayi* Shop 5/325 Centre Rd, Bentleigh, VIC 3204, Australia Received 24 June 2009; received in revised form 20 August 2009; accepted 23 August 2009
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KEYWORDS Hamstrings; Mobilisation; Sacroiliac joint; Arthrokinetic reflex
Summary A lumbarepelvic assessment and treatment model based on a review of clinical and anatomical research is presented for consideration in the treatment of chronic hamstring strain. The origin of the biceps femoris muscle attaches to the pelvis at the ischial tuberosity and to the sacrum via the sacrotuberous ligament. The biomechanics of the sacroiliac joint and hip, along with lumbarepelvic stability, therefore play a significant role in hamstring function. Pelvic asymmetry and/or excessive anterior tilt can lead to increased tension at the biceps origin and increase functional demands on the hamstring group by inhibiting its synergists. Joint proprioceptive mechanisms may play a significant role in re-establishing balance between agonists and antagonists. An appreciation of neuromuscular connections as well as overall lumbarepelvic structural assessment is recommended in conjunction with lumbare pelvic strengthening exercises to help resolve chronic hamstring strain. ª 2009 Elsevier Ltd. All rights reserved.
Introduction One of Dr. Ida Rolf’s frequent mantras to her students was ‘Where the pain is, it ain’t!’ According to Dr. Rolf, first and foremost in any evaluation of chronic pain is global assessment of structure. Localised evaluation is necessary for acute injury, however a global approach is often appropriate when addressing chronic musculoskeletal pain. While the etiology of hamstring strain is multifactorial and sometimes difficult to define, this article proposes that assessment of lumbarepelvic biomechanics may play * Tel.: þ61 434 919 487. E-mail address:
[email protected] a valuable part in the successful resolution of chronic hamstring strain. Hamstring injuries are the most prevalent muscle injury in sports involving rapid acceleration and sprinting (Hoskins and Pollard, 2005). At its simplest, treatment of hamstring strain might include stretching and soft-tissue work to increase flexibility and address scar tissue formation. Research into the value of stretching for injury prevention (Herbert and Gabriel, 2002), and the value of massage to effect muscle damage (Tiidus, 1997), does not however show significant effects of these interventions. Research suggests that lumbarepelvic alignment may play a significant role in hamstring strain (Cibulka et al., 1986; Hennessey and Watson, 1993; Hoskins and Pollard, 2005).
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In the 1970s Dr Vladimir Janda (1978) developed a multifaceted approach to musculoskeletal pain. His treatment protocol included restoring postural alignment, correcting the biomechanics of joints, increasing the proprioceptive input to the central nervous system, and exercise to increase muscular endurance (Janda, 1978). Using Janda’s conceptual framework, research relating to assessment and treatment of hamstring strain is presented under the following headings: Posture, Joint Influences, and Lumbare pelvic Stabilisation Exercises.
Lumbar hyperlordosis, anterior tilt of the pelvis, and sacroiliac joint (SIJ) dysfunction have all been implicated in chronic hamstring strain (Cibulka et al., 1986; Hennessey and Watson, 1993; Hoskins and Pollard, 2005). Lumbar hyperlordosis often correlates with anterior pelvic tilt, placing strain on the origin of the hamstrings at the ischial tuberosity, resulting in hamstring tissue pathology (Cibulka et al., 1986). When no tissue pathology is present in the hamstrings, it has also been linked to lumbarepelvic myofascial pain referral, mimicking hamstring strain (Hoskins and Pollard, 2005). Van Wingerden et al. (1997) suggest that the high correlation between tight hamstrings and lower back pain might reflect a beneficial compensatory mechanism for people with pelvic instability. They point out that, in low back pain patients, bending forward is often painful because of the increase in spinal load during this movement. Increased hamstring tension prevents the pelvis from tilting forward, which diminishes the forward-bent position of the spine, thereby reducing spinal load Van Wingerden et al. (1997). SIJ dysfunction has been defined as pelvic asymmetry between the left and right innominates (Pool-Goudzwaard et al., 1998). The two innominates join anteriorly at the pubic symphysis, and posteriorly they border the sacrum. Joint play is movement within a synovial joint that is independent of, and cannot be introduced by, voluntary muscle contraction (Greenman, 1996). The amount of joint play at the SIJ is less than 1/8 of an inch in any plane but allows the innominates to rotate anteriorly and posteriorly during ambulation (Figure 1), causing side bending and rotation in the sacrum (Greenman, 1996). These movements are essential for the normal pain-free, nonrestricted movement of the joint and significant somatic dysfunction can occur if any of these movements are impeded (Greenman, 1996). Ideally, when standing or seated, the innominates do not differ in terms of anterior or posterior rotation. However, it is not uncommon for pelvic obliquity to develop, involving an anterior tilt on one side and a posterior tilt on the contralateral side. Rotation of the innominates and torsion of the sacrum can result from forces being transmitted to these bones from the spine, pelvic floor or lower extremities (Schamberger, 2002). In athletes, training error, or overtraining with unilateral loading, as in kicking or throwing, can exaggerate the normal sacroiliac movements (Ross, 2000). Over time, unilateral muscle tightness or contracture can produce a rotational force on the innominates. For example, a tight rectus femoris muscle could
Figure 1 When walking, as the right leg swings forward the right ilium rotates backward in relation to the sacrum. Simultaneously, the sacrotuberous and interosseous ligamentous tension increases to brace the sacroiliac joint (SIJ) in preparation for heel strike. Just before heel strike, the ipsilateral hamstrings are activated, thereby tightening the sacrotuberous ligament (into which they merge) to further stabilize the SI joint. Figure. 1 is figure 5.15 from A Massage Therapist’s Guide to Low Back and Pelvic Pain Chaitow L., Fritz S. 2007 Elsevier/ Churchill Livingstone, Edinburgh Redrawn from Vleeming et al. 1997 Movement, Stability and low back pain. 1st Edition Churchill Livingstone, Edinburgh.
produce anterioreinferior rotation force on the anterior superior iliac spine, while a tight biceps femoris muscle could produce posterioreinferior rotational force at the ischial tuberosity (Schamberger, 2002). Cibulka et al. (1986) investigated the role of SIJ dysfunction in hamstring strain. Results showed a significant increase in hamstring strength immediately following SIJ mobilisation. The researchers had noted a high correlation between hamstring muscle strains and an anterior tilt of the innominate bones, associated with sacroiliac dysfunctions. They concluded that mobilising the SIJ reduced the tilts of the innominates, releasing undue stress on the previously elongated biceps femoris. More recent research has also found SIJ mobilisation to increase hamstring flexibility (Fox, 2006). Hoskins and Pollard, (2005), found that improving lumbarepelvic biomechanics, including SIJ mobilisation, played a role in treatment and prevention of hamstring injury in Australian Rules footballers. Apart from producing a static stretch of the biceps femoris muscle, fixations of the SIJ can exacerbate pain upon ambulation. Ideally, during hip flexion the innominate on the same side rotates in a posterior and inferior
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direction (using the posterior superior iliac spine as the point of reference), moving the ischial tuberosity anteriorly and reducing hamstring strain. If however, the innominate is fixed in an anterior rotation, the ischium will not move anteriorly during hip flexion and this will increase stress at the origin of the hamstrings. This kind of stress is particularly relevant in sports involving rapid acceleration during running or sprinting (Gabbe et al., 2005). SIJ dysfunction has also been associated with piriformis spasm on the side of the posterioreinferior lateral angle, paravertebral spasm, iliopsoas spasm and gluteal and hamstring spasm (Dowling, 2004).
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SIJ dysfunction and muscle pathology e cause/ effect A primary function of the pelvis is to transfer the loads generated during standing, walking, sitting and other functional tasks (Lee, 2005). Effective load transfer requires optimal force and form closure of the SIJ. Form closure refers to the stable situation of the SIJ due to closely fitting joint surfaces where no extra forces are needed to maintain stability (Pool-Goudzwaard et al., 1998). However, since the sacrum does not fit the pelvis with perfect form closure and some mobility is required during ambulation, ligament and muscle-forces are needed to provide compression of the SIJ, especially during unilaterally loading of the legs when shear forces increase (Pool-Goudzwaard et al., 1998). Force closure refers to the stability of the SIJ produced by surrounding myofascia (Figure 2), particularly that with a fibre direction perpendicular to the SIJ, such as gluteus maximus (Pool-Goudzwaard et al., 1998). Weakness or underactivity of gluteus maximus may therefore predispose the SI joints to injury (Elphington, 2008). While contraction of the myofascia assists form closure of the SIJ, the question remains whether muscular contraction is able to influence the positioning of the sacrum and therefore have the potential for creating SIJ dysfunction. Based on research in which joint restrictions did not alter when myorelaxants were given to hypertonic muscles, Lewit (1985) defines the SIJ as one of three joints in the body where joint restrictions are not the result of soft-tissue changes. However recent research suggests that although the muscles crossing the SIJ are not described as prime movers of that joint, motion can occur at the SI joint as a result of their contraction (Schamberger, 2002; Vleeming et al., 1989a; Vleeming et al., 1989b; Wingerden et al., 2004). In a dissection study of 12 cadavers, Vleeming et al. (1989a) found that in all cases, gluteus maximus attached to the sacrotuberous ligament, and in 50% of cases unilateral or bilateral fusion of the sacrotuberous ligament with the tendon of the long head of biceps femoris was evident. In some specimens, fusion was so complete that there was no connection of this muscle to the ischial tuberosity itself. In a subsequent study, Vleeming et al. (1989b) found that load to the sacrotuberous ligament, either directly or via continuation with the long head of biceps femoris, significantly diminished the forward rotation of the base of the sacrum (Figure 3).
Figure 2 Posterior oblique system: latissimus dorsi, gluteus maximus and the lumbodorsal fascia (which links them). When latissimus and contralateral gluteus maximus contract there is a force closure of the posterior aspect of the SIJ. Figure 2 is figure 5.11 from A Massage Therapist’s Guide to Low Back and Pelvic Pain Chaitow L., Fritz S. 2007 Elsevier/Churchill Livingstone, Edinburgh Redrawn from Vleeming et al. 1997 Movement, Stability and low back pain. 1st Edition Churchill Livingstone, Edinburgh.
Joint influences Mobilisation is commonly utilised to ease joint pain and increase range of movement. Recent research also emphasises the role of joint mobilisation in reciprocal inhibition (Liebler et al., 2001; Makofsky et al., 2007; Yerys et al., 2002). Sherrington’s principle of reciprocal innervation states that during contraction of agonist muscles, the antagonists do not behave passively, but are actively inhibited by central nervous mechanisms (Day et al., 1984). This mechanism, long thought to be based in afferents from muscles or tendons, may also be mediated by the articular receptors; these can inhibit or facilitate muscle tone, and failure to recognise the importance of these arthrokinetic (AKR) circuits may explain the difficulty in neuromuscular re-education and strengthening of muscle groups (Makofsky et al., 2007). In relation to chronic hamstring strain, a tightened anterior hip capsule would facilitate the iliopsoas muscle while inhibiting the gluteus maximus through the arthrokinetic reflex (Yerys et al., 2002). Visible muscle wasting of the gluteal muscles is often seen when tightness is present in the iliopsoas. Since gluteus maximus is a prime mover in hip extension, its inhibition places undue loads on its hamstring synergists (Elphington, 2008), making them more prone to injury. Mobilisations performed on the anterior hip capsule have been shown to significantly increase gluteus maximus strength (Yerys et al., 2002). Muscle weakness may therefore be influenced by inhibition related to capsular hypomobility of the underlying joint (the gluteus
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Figure 3 Deep longitudinal system: erector spinae, deep laminae of the thoracodorsal fascia, sacrotuberous ligament and biceps femoris. When contraction occurs, biceps femoris influences compression of the SI joint and sacral nutation can be controlled. Figure. 3 is figure 5.12 from A Massage Therapist’s Guide to Low Back and Pelvic Pain Chaitow L., Fritz S. 2007 Elsevier/Churchill Livingstone, Edinburgh Redrawn from Lee D 1999 The Pelvic Girdle 2nd Edition Churchill Livingstone, Edinburgh.
maximus is inhibited each time the hip extends against its restrictive barrier of motion). During mobilisation, the alteration in mechanoreceptor discharge theoretically removes the neurally driven inhibition of the gluteus maximus muscle whilst simultaneously inhibiting the iliopsoas muscle through reciprocal inhibition (Yerys et al., 2002). Perhaps the therapeutic role of SIJ mobilisation (Cibulka et al., 1986; Fox, 2006) extends beyond normalising an anterior rotation of the innominate, to stimulating joint receptors involved in an AKR with the hamstrings. The timing, pattern and amplitude of the muscular contractions involved in force closure of the SIJ depend on an appropriate response of both the central and peripheral nervous systems which in turn rely on appropriate afferent input from the joints, ligaments, fascia and muscles (Lee, 2005). Unusual positioning of the SI joints can influence afferent output of the joint capsule and there may be a causal relationship between different afferent output of the joint capsule and changes in the motor programme of supporting myofascial tissue such as transversus abdominus and multifidus (Pool-Goudzwaard et al., 1998).
Lumbar/pelvic stabilisation exercises Lumbarepelvic stabilisation exercises are important to promote normal lengthetension relationships across the pelvis, optimal arthrokinematics, dynamic stability, and efficient kinetic chain muscle activation patterns (Elphington, 2008). The main muscles of lumbarepelvic stabilisation are the multifidus, transversus abdominus and internal obliques (Elphington, 2008). The oblique abdominals and transversus abdominus are particularly important in spinal stability due to their connections with the thoracolumbar fascia and their role in enhancing intra-abdominal pressure (Norris, 1995). Gracovetsky (2008) has described the important relationship between the transversus abdominus and the thoracolumbar fascia in extension of the spine, and how internal abdominal pressure, together with lordosis, controls the force transmission efficiency of the lumbodorsal fascia. The gluteal group is also an important contributor to dynamic pelvic stability and must activate effectively to produce the short foot contact times necessary for fast running (Elphington, 2008). In stability training, the client’s attention to the exercise is crucial. This is not only important so that the exercise is performed properly, but attention is likely to aid in the facilitation of muscles which have become relatively inactive. In a study by Day et al. (1984) conscious inhibition of the wrist flexor reflex was demonstrated with the radial nerve anaesthetised by injection of local anaesthetic at the elbow. Subjects were asked to try to contract the paralysed extensor muscles. Under this condition, attempted voluntary wrist extension inhibited the flexor reflex even though
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When there are joint restrictions, mechanoreceptor inputs to the CNS can cause active weakening (or inhibition) of muscles whose action could take the joint beyond its restrictive barrier. Therefore, trying to strengthen a muscle that is being inhibited before mobilising the joint may be counterproductive. Much in line with Janda (1978), Makofsky et al., (2007) proposed a simple clinical rule of thumb: ‘Stretch what’s tight and mobilise what’s stiff prior to strengthening what’s weak.’ Joint mechanoreceptors can also be stimulated during tasks that maximise sensory input to the central nervous system and elicit subconscious and automatic responses in muscles. This is most effectively done by providing balancechallenging exercises which stimulate the sub-cortical systems which regulate movement and balance (Janda et al., 2006). Bullock-Saxton et al., (1993), found that gluteal muscles activated more affectively by stimulating the proprioceptive mechanism during walking. Subjects wore ‘balance shoes’, which acted as a labile surface, to facilitate cerebellovestibular circuits. This study showed significant increases in gluteal activity and faster contractions after one week of facilitation. Specific sensory motor tasks have been shown to be as effective for improving strength as traditional strength training (Risberg et al., 2007; Ihara and Nakayama, 1986), and lead to shorter latency of contraction (Ihara and Nakayama, 1986). Because the sub-cortical regulatory systems do not rely on conscious control, they are faster, and after time the stabilising process can become ‘second nature’ (Norris, 1995).
298 no extension occurred. Similar results were obtained by Duk Yang et al. (2005) showing that imagination of movement facilitated motorneurons of the agonist muscle while having an inhibitory effect on those of the antagonist muscle. This suggests that focussed attention to specific muscular contraction can play a significant role in muscle facilitation and reciprocal inhibition.
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Summary The etiology of hamstring strain is multifactorial and often difficult to define. There is, however, evidence to suggest that hamstring strain may sometimes be reflective of lumbarepelvic imbalances. These imbalances increase the functional load on the hamstrings by defacilitating the gluteus maximus, and/or increasing the tensile stress on the biceps femoris origin. Apart from working to increase hamstring flexibility and address scar tissue formation, successful resolution of hamstring strain may involve the following: lengthening myofascial components that contribute to excessive lumbar lordosis, anterior pelvic tilt, and pelvic obliquity; mobilising the SIJ and/or the anterior hip joint to stimulate joint receptors and facilitate gluteus maximus and the hamstrings; balance-challenging exercises to further stimulate joint proprioceptor activity and enhance gluteal strength; and strengthening exercises for the lumbarepelvic stabiliser muscles to create and maintain a balanced pelvis. While research into structural alignment and hamstring strain is at this stage neither conclusive nor extensive, the information presented suggests that further research into this area is warranted.
References Bullock-Saxton, J.E., Janda, V., Bullock, M.I., 1993. Reflex activation of gluteal muscles in walking. An approach to restoration of muscle function for patients with low-back pain. Spine 18 (6), 704e708. Cibulka, M.T., Rose, S.J., Delitto, A., Sinacore, D.R., 1986. Hamstring muscle strain treated by mobilizing the SIJ. Physical Therapy 66 (8), 1220e1223. Day, B.L., Marsden, C.D., Obeso, J.A., Rothwell, J.C., 1984. Reciprocal inhibition between the muscles of the human forearm. Journal of Physiology 349, 519e534. Dowling, D.J., 2004. Evaluation of the pelvis. In: DiGiovanna, E.L., et al. (Eds.), An Osteopathic Approach to Diagnosis and Treatment. Lippincott Williams & Wilkins, Philadelphia. Duk Yang, H., Ki Minn, Y., Hong Son, I., Han Suk, S., 2005. Facilitation and reciprocal inhibition by imagining thumb abduction. Journal of Clinical Neuroscience 13 (2), 245e248. Elphington, E., 2008. Stability, Sport and Performance Movement: Great Technique Without Injury. North Atlantic Books, California. Fox, M., 2006. Effect on hamstring flexibility of hamstring stretching compared to hamstring stretching and SIJ manipulation. Clinical Chiropractic 9 (1), 21e32. Gabbe, B.J., Finch, C.F., Bennell, K.L., Wajswelner, H., 2005. Risk factors for hamstring injuries in community level Australian football. British Journal of Sports Medicine 39, 106e110. Gracovetsky, S., 2008. Is the lumbodorsal fascia necessary? Journal of Bodywork and Movement Therapy 12 (3), 194e197. Greenman, P., 1996. Principles of Manual Medicine, second ed. Williams and Wilkins, USA.
S. Panayi Hennessey, L., Watson, A.W., 1993. Flexibility and posture assessment in relation to hamstring injury. British Journal of Sports Medicine 27, 243e246. Herbert, R., Gabriel, M., 2002. Effects of stretching before and after exercising on muscle soreness and risk of injury: systematic review. British Medical Journal 325, 468e478. Hoskins, W.T., Pollard, H.P., 2005. Successful management of hamstring injuries in Australian rules footballers: two case reports. Chiropractic & Osteopathy 13 (4). doi:10.1186/1746-1340-13-4. Ihara, H., Nakayama, A., 1986. Dynamic joint control training for knee ligament injuries. American Journal of Sports Medicine 14 (4), 309e331. Janda, V., 1978. Muscles, central nervous motor regulation and back problems. In: Korr, I. (Ed.), The Neurobiological Mechanisms in Manipulative Therapy. Plenum Press, New York. Janda, V., Vavrova, M., Herbenova, A., Veverkova, M., 2006. Sensory motor stimulation. In: Liebenson, C. (Ed.), Rehabilitation of the Spine: a Practitioner’s Manual, second ed. Lippincott Williams & Wilkins, Philadelphia. Lee, D., 2005. Recent advances in the assessment and treatment of the SIJ: stability and the role of motor control. In: Presentation at the American Back Society Meeting, San Francisco. Liebler, E.J., Tufano-Coors, L., Douris, P., Makovsky, H.W., McKenna, R., Michels, C., Rattray, S., 2001. The effect of thoracic spine mobilisation on lower trapezius strength testing. The Journal of Manual & Manipulative Therapy 9 (4), 207e212. Lewit, K., 1985. The muscular and articular factor in movement restriction. Manual Medicine 1, 83e85. Makofsky, H., Panicker, S., Abbruzzese, J., Aridas, C., Camp, M., Drakes, J., Franco, C., Sileo, R., 2007. Immediate effect of grade IV inferior hip joint mobilization on hip abductor torque: a pilot study. The Journal of Manual & Manipulative Therapy 15 (2), 103e111. Norris, C., 1995. Spinal stabilisation: an exercise programme to enhance lumbar stabilisation. Physiotherapy 81 (3), 31e38. Pool-Goudzwaard, A.L., Vleeming, A., Stoeckart, R., Snijders, C.J., Mens, J.M.A., 1998. Insufficient lumbopelvic stability: a clinical, anatomical and biomechanical approach to ‘a-specific’ low back pain. Manual Therapy 3 (1), 12e20. Risberg, M.A., Holm, I., Myklebust, G., Engebretsen, L., 2007. Neuromuscular training versus strength training during first 6 months after anterior cruciate ligament reconstruction: a randomised clinical trial. Physical Therapy 87 (6), 737e750. Ross, J., 2000. Is the SIJ mobile and how should it be treated? British Journal of Sports Medicine 34, 226. Schamberger, W., 2002. The Malalignment Syndrome: Implications for Medicine and Sports. Churchill Livingstone, UK. Tiidus, P., 1997. Manual massage and recovery of muscle function following exercise: a literature review. Journal of Orthopaedic and Sports Physical Therapy 25 (2), 107e112. Van Wingerden, J.P., Vleeming, A., Kleinrensink, G.J., Stoeckart, R., 1997. The role of the hamstrings in pelvic and spinal function. In: Vleeming, A., et al. (Eds.), Movement, Stability and Low Back Pain. Churchill Livingstone, Edinburgh. Vleeming, A., Stoeckart, R., Snijders, D.J., 1989a. The sacrotuberous ligament: a conceptual approach to its dynamic role in stabilising the SIJ. Clinical Biomechanics 4, 204e209. Vleeming, A., Van Wingerden, J.P., Snijders, C.J., Stoeckart, R., Stijnen, T., 1989b. Load application to the sacrotuberous ligament influences SIJ mechanics. Clinical Biomechanics 4, 204e209. Wingerden, J., Vleeming, A., Buyruk, H., Raissadat, K., 2004. Stabilisation of the SIJ in vivo: verification of muscular contribution to force closure of the pelvis. European Spine Journal 13 (3), 199e207. Yerys, S., Makofsky, H., Byrd, C., Pennachio, J., Cinkay, J., 2002. Effect of mobilization of the anterior hip capsule on gluteus maximus strength. The Journal of Manual & Manipulative Therapy 10 (4), 218e224.
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POSTURAL PHYSIOLOGY
Josephine Key, MPAA, Musculoskeletal Physiotherapist* Edgecliff Physiotherapy Sports and Spinal Centre, Suite 505/180 Ocean Street, Edgecliff N.S.W. 2027, Australia Received 25 April 2009; received in revised form 14 January 2010; accepted 20 January 2010
KEYWORDS Back pain; Pelvic pain; Motor control; Posturo-movement dysfunction; Lumbo-pelvic-hip movement control; Therapeutic exercise; Core stability; Clinical sub-group classification
Summary Structurally, the sacrumecoccyx provides the dual roles of serving as the base of the spinal column while also forming part of the pelvic ring. Physiological movement control of the pelvis and the spine are functionally interdependent. In particular, intra-pelvic control, (that between the ilia and sacrum/coccyx in support and control of the forces and small movements within the pelvic ring) is fundamental to controlling its spatial organization as a whole and its control on the femoral heads, all of which directly influence spinal alignment and control mechanisms. This involves coordinated activity in the related neuro-myofascial systems in providing mechanisms of both intrinsic and extrinsic support and control. ª 2010 Elsevier Ltd. All rights reserved.
Janda proposed the concept of the Pelvic Crossed Syndrome as an underlying factor in the genesis and perpetuation of many low back pain syndromes (Janda, 1987; Janda and Schmid, 1987; Janda et al., 2007). Here, imbalanced muscle activity e tightness and overactivity of the hip flexors and low back extensors and a coexistent underactivity in the abdominals and glutei create a ‘crossed pattern’ of disturbed sagittal lumbopelvic posturo-
* Tel.: þ61 02 93261168; fax: þ61 02 93281695. E-mail address:
[email protected] movement alignment and control. While certainly evident in back pain populations, for the observant clinician it is not a universal finding. Like Janda, our group has been interested in the validity of clinical pattern recognition which appears to also delineate another different, yet broad subgroup within the back pain population who share in common similar features of changed postural alignment and control. This sub-group displays a relative hyperactivity in the upper abdominal wall and piriformis/hamstrings with underactivity in the lower abdominals, deep hip flexors and low back extensors. This also creates an altered ‘crossed pattern’ affecting
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The Pelvic Crossed Syndromes: A reflection of imbalanced function in the myofascial envelope; a further exploration of Janda’s work
PREVENTION & REHABILITATIONePOSTURAL PHYSIOLOGY
300 sagittal lumbopelvic alignment and control and has been described by Key et al. (2008b). It is clinically apparent that most patients presenting with low back and pelvic pain syndromes display at least some of the features attributable to either of these two primary pictures of altered pelvic function. In Janda’ s originally proposed Pelvic Crossed Syndrome, the pelvis is more posterior and this is associated with imbalanced coactivation of the trunk muscles with more dominant activity observed in the extensors. Key et al. (2008b) proposed this syndrome be re-termed the Posterior Pelvic Crossed Syndrome (Figure 1C). Conversely, in the other broad group, the pelvis is postured more anteriorly and this is associated with a predominant tendency to more axial flexor activity e described by Key et al. (2008b) as the Anterior Pelvic Crossed Syndrome (Figure 1B). However, it is important for the clinician to also recognise that underpinning both primary pictures of pelvic posturo-movement dysfunction there is usually a related, common and clinically apparent fundamental deficit in the integrated and balanced control provided from the deep, innermost myofascial sleeve which sub-serves the foundations of lumbopelvic support and control. Key et al. (2008a) proposed that the muscles of the body could for practical purposes be conceptually viewed as essentially consisting of two systems e a deep and a superficial systemic muscle system. They termed the deep system the Systemic Local Muscle System and proposed that this plays a critical role in underlying postural support and control. It is hereby further proposed that in respect to healthy lumbopelvic function, an important part of this deep system is a continuous, largely internal three dimensional myofascial web, providing a scaffold of tensile inner
J. Key support and stability and contributing to a structural and functional bridge between the lower torso and legs. It is suggested that these collective myofascial aggregations be termed the ‘Lower Pelvic Unit’ (LPU). This includes the obvious contractile elements for which there is accumulating evidence of deficient function in subjects with low back and/or pelvic pain e the transversus abdominus (Hodges and Richardson, 1996, 1998, 1999) multifidus (Hides et al., 1996) the diaphragm and pelvic floor muscles (O’Sullivan et al., 2002; Hodges, 2006). Impressions from clinical practice suggest inclusion also of the obturators, iliacus, psoas, and all their related and interconnecting fascial sheaths. Sound activity within this myofascial ‘inner stocking’ sustains many functional roles: e providing deep anterior support to the lower half of the spinal column; with the spinal intrinsics it contributes to lumbopelvic control (Hodges, 2004); while also contributing to the generation of IAP (Cresswell et al., 1994), continence and respiration (Hodges and Gandevia 2000) (Figure 2). Importantly, it is further asserted that from a therapeutic perspective, co-operative activity within the LPU allows the modulation of discrete yet clinically apparent, fundamentally important intra-pelvic movements and spatial shifts. In helping to control our posturo-movements, it acts as the ‘collective internal agonist’ to balance the actions and forces created by activity of the ‘outer antagonists’. This balanced coactivation within the LPU and between it and the large more superficial muscles provides control of the myo-mechanics and movement force couples necessary to allow the pelvis to be the initiator and driver of functional posturo-movement control of the torso on the legs. Control initiated from the base of the spine through the pelvis, directed via the ischia and coccyx, is essential in being able to effectively manage the delicate neuromuscular balance involved in being upright against gravity. It also enables one to draw upon on an endless array of options in the fluid control of movement including being able to create kinematically sound patterns of movement which support basic activities of daily living e bending over, lifting, reaching squatting, jumping and so on e all possible when the pelvis can act in its prime role as the centre of weight shift in the body. Balanced coactivation from the LPU provides internal stability to the pelvis as it swings and swivels on the femoral heads which is necessary in weight shift, load transfer and in controlling equilibrium. This is ‘core control’.
Clinical relevance
Figure 1 Altered control of pelvic position changes the alignment and control mechanisms throughout the spine. Reproduced from ‘‘Back pain: A movement problem’’ by Key, publishing early 2010. With permission from Elsevier.
The experienced clinician knows that seemingly subtle changes and differences in pelvic posturo-movement control can mean a lot in the presenting symptom picture of those with spinal pain and related disorders. Appreciation of the Pelvic Crossed Syndromes and the common associated dysfunction in the LPU helps the practitioner ‘to see’ and better understand what is driving the patients underlying problem and the likely needs in terms of retraining appropriate functional motor control. In the author’s clinical experience, this is best addressed in the patient initially relearning specific activation of deficient elements within the LPU, establishing the important fundamental patterns of intra-pelvic control and
301
Figure 2 Much of the LPU involves a prevertebral and intra-pelvic myofascial web of support. Reproduced from ‘‘Back pain: A movement problem’’ by Key, publishing early 2010. With permission from Elsevier.
integrating these into basic functional patterns of movement control initiated from the pelvis. This will better ensure the likelihood of the patient achieving more functionally appropriate and ‘real core control’.
References Cresswell, A.G., Oddsson, L., Thorstensson, A., 1994. The influence of sudden perturbations on trunk muscle activity and intraabdominal pressure while standing. Exp. Brain Res. 98, 336e341. Hides, J.A., Richardson, C.A., Jull, G.A., 1996. Multifidus muscle recovery is not automatic following resolution of acute first episode low back pain. Spine 21, 2763e2769. Hodges, P., 2004. Abdominal mechanism and support of the lumbar spine and pelvis. In: Richardson, C., Hodges, P., Hides, J. (Eds.), Therapeutic Exercise for Lumbopelvic Stabilisation: a Motor Control Approach Foe the Treatment and Prevention of Low Back Pain, second ed. Churchill Livingstone, Edinburgh. Hodges, P.W., 2006. Low back pain and the pelvic floor. In: Carrie `re, B., Markel Feldt, C. (Eds.), The Pelvic Floor. Thieme, Stuttgart. Hodges, P.W., Richardson, C.A., 1996. Inefficient muscular stabilisation of the lumbar spine associated with low back pain: a motor control evaluation of transversus abdominus. Spine 21 (22), 2640e2650. Hodges, P.W., Richardson, C.A., 1998. Delayed postural contraction of transversus abdominus in low back pain associated with movement of the lower limb. J. Spinal Disord. 11 (1), 46e56.
Hodges, P.W., Richardson, C.A., 1999. Altered trunk muscle recruitment in people with low back pain with upper limb movements at different speeds. Arch. Phys. Med. Rehabil. 80 (9), 1005e1012. Hodges, P.W., Gandevia, S., 2000. Changes in intra-abdominal pressure during postural and respiratory activation of the human diaphragm. J. Appl. Physiol. 2000 (89), 967e976. Janda, V., 1987. Muscles and motor control in low back pain: assessment and management. In: Twomey, L. (Ed.), Physical Therapy of the Low Back. Churchill Livingstone, New York. Janda, V., Schmid, H.J.A., 1987. Muscles as a pathogenic factor in back pain. Proc. IFOMPT New Zealand 1980. Janda, V., Frank, C., Liebenson, C., 2007. Evaluation of muscular imbalance. In: Liebenson, C. (Ed.), Rehabilitation of the Spine: a Practitioner’s Manual, second ed. Lippincott Williams & Wilkins, Philadelphia. Key, J., Clift, A., Condie, F., Harley, 2008a. A model of movement dysfunction provides a classification system guiding diagnosis and therapeutic care in spinal pain and related musculoskeletal syndromes: a paradigm shift e part 1. J. Bodyw. Mov. Ther. 12 (1), 7e21. Key, J., Clift, A., Condie, F., Harley, C., 2008b. A model of movement dysfunction provides a classification system guiding diagnosis and therapeutic care in spinal pain and related musculoskeletal syndromes: a paradigm shift e part 2. J. Bodyw. Mov. Ther. 12 (2), 105e120. O’Sullivan, P.B., Beales, D., Beetham, J., Cripps, J., Graf, F., Lin, I., Tucker, B., Avery, A., 2002. Altered motor control strategies in subjects with sacroiliac joint pain during active straight leg raise test. Spine 27 (1), E1eE8.
PREVENTION & REHABILITATIONePOSTURAL PHYSIOLOGY
The pelvic crossed syndromes: A reflection of imbalanced function in the myofascial envelope
Journal of Bodywork & Movement Therapies (2010) 14, 302
available at www.sciencedirect.com
PREVENTION & REHABILITATIONeSELF-MANAGEMENT: PATIENT SECTION
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SELF-MANAGEMENT: PATIENT SECTION
Improving trunk rotation D.C. Craig Liebenson* International Association for the Study of Pain, American Pain Society, Team Chiropractor, N.B.A. Los Angeles Clippers, L.A. Sports and Spine, 10474 Santa Monica Blvd., #304, Los Angeles, CA 90025, USA Received 5 April 2010; accepted 6 April 2010 Sports such as tennis, golf, baseball, and hockey each involve a tremendous amount of trunk rotation. It is not just striking sports, but also throwing, kicking, running, swimming, skiing, etc which all require your body to rotate through your core. In order to transmit forces from your bigger, stronger leg muscles to your arms, trunk rotation is needed. Back injuries, oblique abdominal strains, rotator cuff problems, and even reduced performance can directly result from diminished mobility in trunk rotation. This selfcare article shows a very simple trunk rotation exercise that can be performed as a warm-up or part of a daily stretching routine. Another benefit of trunk rotation training is that it can help improve to posture. A slouched posture with rounded shoulders will quickly straighten up with these simple stretches.
Kneeling trunk rotation (Fig. 1) Start Kneel on the floor Sit back on your heels Place one hand behind your neck
Technique Lift your head & torso up while simultaneously twisting your upper body
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Figure 1 position.
Kneeling trunk rotation (a) start position (b) final
Think about sticking your chest out Hold this position for a few seconds Then return to the start position
Avoid Staying slouched
Troubleshooting Use towel under forehead Use rolled up towel or ½ foam roll behind knees Be sure to stick chest out so that you are arching your back through your shoulder blades instead of from your lower back
Sets/reps/frequency Perform 1 set 8e12 repetitions 1e2x/day
Journal of Bodywork & Movement Therapies (2010) 14, 303 available at www.sciencedirect.com
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Obituary: David Simons (1922e2010) e the next adventure Jan Dommerholt, PT, DPT, MPS* Bethesda Physiocare/Myopain Seminars, 7830 Old Georgetown Road, Suite C-15, Bethesda, MD 20814-2440, USA
On April 5, 2010, Dr. David Simons, co-author of the Trigger Point Manuals and author of many innovative and thoughtprovoking articles and research studies on myofascial trigger points, started what he described as “the next adventure”, when he passed away at the age of 87. Dave Simons was a pioneer not just in musculo-skeletal medicine, but also in aerospace explorations. After receiving his medical degree in 1946 from Jefferson Medical College in Philadelphia, PA, he served in the United States Air Force, initially as a researcher and during the Korean conflict as a flight surgeon. As project officer for balloon flights at the Aeromedical Field Laboratory at Holloman Air Force Base in New Mexico, he was particularly interested in the effects of galactic cosmic radiation on living tissue. On August 19, 1957, his career reached new heights, when he became the first man in outer space traveling 101,516 feet above the Earth in a pressurized gondola as part of the Man High Project. This 36-hour record-breaking high altitude balloon flight earned him a place on the cover of Life magazine and the title of “Father of Radiobiology”. When attending a two-day lecture and demonstration by Dr. Janet Travell in 1963, he was immediately intrigued by the concept of myofascial trigger points (MTrPs) and described her lectures and demonstrations as “a revelation” and “aweinspiring”. Following his 1965 retirement from the US Air Force, Dr. Simons became coordinator of research at the Veterans Administration and had the opportunity to meet with * Tel.: þ1 301 656 5613; fax: þ1 301 654 0333. 1360-8592/$ - see front matter doi:10.1016/j.jbmt.2010.04.007
and learn from Dr. Travell. Inspired by her teachings, he became certified as a physiatrist and started examining and treating patients with MTrPs. He continued to work with Dr. Travell, and in 1981, they published the first MTrP hypothesis. Eventually, Dr. Simons became the driving force behind writing the Trigger Point Manuals, which have been translated into many foreign languages. Perhaps the words of Hugh Elliot offer a good characterization of our mentor, friend, colleague and teacher Dave Simons: “I am not dying, not anymore than any of us are at any moment. We run, hopefully as fast as we can, and then everyone must stop. We can only choose how we handle the race.” Throughout his life, Dave Simons ran as fast as he could, trying to accomplish as much as possible. At age 85, he started writing a book about global warming out of concern for the well-being and future of the world. When asked why he would take on such an endeavor, he replied that since there are now enough clinicians and researchers in the world carrying on MTrP research and clinical practice, he was no longer concerned that MTrPs soon would be forgotten. “I think I can serve the world better by explaining the real threat of global warming,” he explained. In 2009, he decided not to publish the book after all, but the energy and fervor he displayed was truly inspiring. Instead, he returned to work on the next edition of the Trigger Point Manuals, which he continued until just a few days before his death. Dave Simons will be remembered by doctors, physical therapists, chiropractors, osteopaths, massage therapists, body workers and many other healthcare providers worldwide. His work has and will continue to inspire researchers and clinicians. Every day, thousands of clinicians treat even more thousands of patients based on the works by Travell and Simons. It gave David great pleasure realizing that so much unnecessary suffering was relieved as a result of his endeavors. It seems likely that in his next adventure, David Simons will once again reach new heights and continue to amaze us.
Journal of Bodywork & Movement Therapies (2010) 14, 304e308
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INTERVIEW
Research and osteopathy: An interview with Dr Gary Fryer by Helge Franke Helge Franke*
Received 19 August 2009; received in revised form 12 January 2010; accepted 16 January 2010 Dr Gary Fryer is a Senior Lecturer at Victoria University, Melbourne, and Research Associate Professor with the A.T. Still Research Institute, Kirksville, Missouri. He graduated in 1991 and practiced osteopathy in Melbourne, Brisbane and rural Victoria. Dr Fryer has been extensively involved in osteopathic education and research. In 2007, he joined the A.T. Still Research Institute in Kirksville, Missouri, the birthplace of osteopathy, where during a two-year period he conducted research with and taught osteopathic manipulative medicine as Adjunct Assistant Professor at Kirksville College of Osteopathic Medicine. Dr Fryer has authored many articles in peer-reviewed journals, several book chapters, and has been an invited speaker at osteopathic conferences in the United States, United Kingdom and Europe.
Question: The English osteopath Eyal Lederman, said to me in an interview, that osteopathy lacks 50 years of research. Would you agree with that perception? Yes, I agree. I think the profession became complacent following the pioneering research of Denslow, Korr and colleagues in the 1940s and 1950s (Denslow and Clough, 1941; Denslow and Hassett, 1942; Denslow et al., 1947; Korr et al., 1962). The interpretation of these studies suited the profession, and many believed the osteopathic paradigm was proven and further research was not a priority. This early body of work (paraspinal electromyography [EMG] and
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[email protected] electrical skin resistance) was groundbreaking in many ways and appeared to support the osteopathic paradigm, but by today’s standards it falls short in terms of methodology and analysis. These studies are often cited as demonstrating objective evidence of somatic dysfunction and supporting the rationale of osteopathic manipulative treatment (OMT), but most of them did not directly investigate palpatory findings or the effect of manipulation, and their results have not been re-examined or verified by later studies. I think it was unfortunate that there was little follow-up to this work and that a research culture did not develop in the osteopathic profession. We now see considerable research in the wider field of manual medicine, but the osteopathic profession cannot be considered at the cutting edge in many of these research areas. I have been interested in Denslow and Korr’s pioneering work at Kirksville, but the question of abnormal EMG activity associated with tissue texture abnormality is still uncertain. At the A.T. Still Research Institute, we have been examining intramuscular EMG activity associated with palpatory findings, but e unlike a previous study (Fryer et al., 2006) e have so far been unable to verify any abnormal EMG activity that might account for the abnormal texture at rest (Fryer et al., in press). Interestingly, years after the original EMG study, Denslow reported that abnormal spontaneous activity was not consistently detected on further attempts to reproduce his earlier findings (Denslow, 1975). My feeling is that these tissues appear abnormal due to increases in tissue fluid either from tissue inflammation or secretion of proinflammatory compounds. We have also been examining the EMG response of deep paraspinal muscles from various manual interventions and are currently processing and analysing these results.
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Research and osteopathy Although evidence exists that supports the plausibility of muscle dysfunction associated with minor trauma to the spinal segment (whether reflex contraction or inhibition, sensitized stretch reflexes, or more complex motor changes) (Fryer et al., 2004a,b), we still lack convincing research demonstrating that what we palpate is clinically meaningful. In other words, as a result of palpation, do we find things that are related to pain and dysfunction, that occur less frequently in people without pain or dysfunction, and that are reduced or eliminated by treatment? There is also a need to continue to investigate whether OMT produces relevant physiological and clinical outcomes. On the positive side, I think the osteopathic profession understands the importance of research e both politically and for improving patient care e and there are a growing number of small clinical trials examining osteopathic management of a range of patient complaints and conditions, somatic and non-somatic, and a small number of larger multicentre trials.
Question: Between A.T. Still and today are more than 100 years of development in medicine. In view of new knowledge over this time does it make sense to refer to A.T. Still when asking therapeutic questions? A.T. Still saw a connection between disturbed structure and altered function and through practical experience found that he could influence his patients’ health using manual techniques. I think in many ways we have moved on from Still’s original beliefs, particularly in regard to the physiological mechanisms underlying manipulative therapy. I see relevance in recalling Still’s words for historical perspective and to remind us to look at many aspects of the body (fascia, nerves, fluids, etc) and to not become too orthopaedic or pharmaceutically based. However, I don’t count myself among those who believe that scrutiny of Still’s books will reveal hidden meanings or secrets from the past. Although the structure/function interrelation concept has taken a beating from some quarters, I don’t think it should be dismissed entirely, but there are limits to its applicability. On one level, the connection is self-evident, such as the relationship between poor posture and mechanical strain on tissues, where altered structure results in physiological changes like inflammation or nociception. The possibility that mechanical strain on tissues alters cell physiology is also becoming evident from the process known as mechanotransduction, where fibroblasts have been shown to respond to mechanical forces, changing their physiological processes and even gene expression. This process raises potential new support for structure/ function interaction although the clinical implications of this research are still speculative. As a result of the increasing research and resulting knowledge of pain processing and pain pathophysiology, however, we have reason to further limit the general applicability of the structure/function interrelation concept. The process known as central sensitization may occur in response to a bombardment of noxious input, resulting in neuroplastic changes in the dorsal horn and higher centres to produce long term sensitization of
305 nociceptive pathways. The functional and structural changes in the nervous system result in hyperalgesia and allodynia, the later being pain evoked by stimuli that would not normally be painful. The peripheral tissue injury may resolve completely, but the neuroplastic changes e and the symptoms e remain as a source of pain generated entirely by the nervous system, which appears to be the process underlying many cases of chronic pain. There may also be effects on the peripheral tissue site because the activated nociceptors may secrete pro-inflammatory peptides, enhancing tissue inflammation. Additionally, these central processes may involve changes to motor strategies, activating and inhibiting different muscle groups. The osteopath typically works with the understanding that tissue tenderness and abnormal texture to touch or motion indicate tissue pathology or dysfunction, but in some individuals these symptoms and clinical findings may be generated by the central nervous system (allodynia and neurogenic inflammation), rather than the tissues. Add the importance of patient psychology to recovery and disability (biopsychosocial approach), and the violations to the structure/function interrelation paradigm may be substantial. How we determine that the structure/function concept is relevant in certain instances but not in others is an area that needs closer attention and exploration. Perhaps clinical experience is important for recognising patients who may respond better to treatment, but e from a scientific perspective e this is yet to be determined.
Question: You prefer the term ‘‘evidenceinformed therapy’’ in osteopathy instead of ‘‘evidence-based medicine’’. What is the difference? Due to the lack of high-quality research evidence in osteopathy, we cannot ‘base’ practice on evidence, or we would end up doing very little. I suspect there will never be a time when we can base every aspect of treatment on research literature because it is hard to imagine that there would ever be high-quality evidence for every procedure that we use in patient consultation. Instead, we use existing evidence to inform and guide our decisions in practice e hence, evidenceinformed practice e where we assess the relevance of the existing evidence with the needs of a given patient and make decisions by integrating this knowledge with our own experience, with other forms of evidence (expert opinion, physiological rationale, etc), and with the patient’s own expectations and individual needs. In short, evidenceinformed practice is using research evidence to make informed decisions; evidence-based medicine (EBM), in the strictest sense, disregards clinical judgment and is simply not possible in view of the limited relevant evidence available. The original definition of EBM reads much more like evidence-informed medicine (‘the judicious use of current best evidence by integrating individual clinical expertise with the best available external clinical evidence from systematic research’ (Sackett et al., 1996)), but some EBM purists appear to disregard the role of clinical judgment. There is also a justifiable fear that EBM may be applied for economic reasons, rather than for best care. Evidence from randomised controlled trials addresses average results from
306 large groups and may not necessarily inform a practitioner about individual patients. A treatment found to be effective for the majority of individuals with a similar complaint may not always be best for the individual for a variety of reasons, including the aetiology of their condition, and their past experience (negative or positive) and expectations of treatment. Some approaches or techniques are likely to be more effective in the hands of particular practitioners, related to their skill and experience. It is also likely that certain treatments will have much larger non-specific effects (placebo) for some patients, and these effects should not be dismissed lightly. Hence, there remains a need for balance and integration between external clinical evidence and clinical experience, and this applies, not just to osteopaths, but to all health practitioners.
Question: Evidence-based medicine means not only that we need evidence for decisions about treatment, but also transparency in the process of a decision, a trial or a position. In short, it means we have to deal with information and decisions on treatment in a different way. Therapists have to explain what they are doing. Do you agree with that side of view? Absolutely. We have moved away (I hope) from past practices where patients were told to remain silent because they would be incapable or unqualified to ask an intelligent question to practices where we actively engage the patient with the problem, explore the options with them, and empower them to participate in the solution. I think one positive trend from the EBM movement is the availability of information to empower patients in their treatment decision-making process. Therefore, we can discuss treatment management with a patient in an honest and intelligent way (with an encouraging and positive manner while addressing any inappropriate attitudes or pain behaviours), the merits of best evidence, and the most effective treatment in the experience of the practitioner. Although not every patient wants to be empowered or active in their management, I think those who do are more likely to be compliant in their aftercare management and have a better chance of recovery.
Question: At the ‘‘Fifth International Symposium on Advances in Osteopathic Research’’ last year you said, that there is a political imperative for osteopathy to be effective. What do you mean by that? We need to demonstrate that our approach is effective (assuming that it is). In Australia, we are seeing third party payers, such as our state-based Workcover and other health insurance agencies, begin to limit payments to manual therapists, justified on the basis of EBM. Payment for ‘passive’ treatments that are not well supported by evidence is being limited, and payment for treatment without demonstrated improvement in outcomes (using a validated
H. Franke measure) is also being limited. I actually think this is reasonable and appropriate e why should the state (or anyone) pay for treatments that don’t work or have no evidence of being effective? If we do not provide evidence of effectiveness, then third party payers will progressively withdraw funding. Lack of evidence of effectiveness is also a major hindrance for emerging osteopathic professions in some countries, where clear evidence of effectiveness would greatly assist their recognition and quest for state licensing. This is not to say that we have no evidence of effectiveness. We have a moderate level of evidence for the effectiveness of OMT for low back pain (Licciardone et al., 2005) and have a growing number of small trials that support the effectiveness of OMT for a variety of conditions, such as neck pain, pneumonia in the elderly, irritable bowel syndrome, and other conditions (Noll et al., 2000; Fryer et al., 2005; Hundscheid et al., 2007; Schwerla et al., 2008; Lombardini et al., 2009). Many of these studies involve limited participant numbers and may be criticised on various methodological grounds; but it is heartening to see a renewed interest in research within the profession, and as the profession and its researchers mature, we will see larger, more convincing studies. The growth in the number of osteopathic research studies, however, presents a problem with the compilation and accessibility of evidence relevant to osteopathic management. It would be helpful to have this research collated in a form that could be easily accessible to practitioners, but I am not aware of any such repository. I have often received requests from practitioners asking what studies have been done for a particular condition or treatment. The collection of studies (not to mention the interpretation of them) can be a tedious process when no reviews exist on a subject.
Question: You said also, if a therapist knows without any doubt that a treatment will have no success it’s better he does not treat in this way. This sounds good and I think many osteopaths would agree with you. But what in osteopathy do we really know without any doubt? At this stage, there is not much that we can say without any doubt, but this is probably true of most health professions. Rather, we make decisions as to what course of action is reasonable and rational and may be supported by good external evidence. Osteopathy is not alone in its struggle to support practice with high-quality external evidence. Some researchers have estimated that approximately 13% of medical treatments are based on evidence that supports the beneficial effect of the intervention and that 46% of practice has unknown benefit (BMJ Evidence Centre, 2009). I think I also said that we do not have quality evidence that clearly helps us to select the most appropriate technique, but we are beginning to see some effort in this direction. There is moderate evidence that some techniques produce measurable short-term changes (range of motion, pain thresholds) (Clements et al., 2001; Lenehan et al., 2003; Fryer and Ruszkowski, 2004; Cleland et al., 2005; Ferna ´ndezde-las-Pen ˜as et al., 2008; Kanlayanaphotporn et al., 2009)
Research and osteopathy and evidence that osteopathic management produces improved outcomes for low back pain and certain conditions, although some of these studies are not easily generalizable to all practice situations (Noll et al., 2000; Fryer et al., 2005; Licciardone et al., 2005; Hundscheid et al., 2007; Schwerla et al., 2008; Lombardini et al., 2009). Most of this evidence supports the rationale for the use of these techniques and the conditions or situations where the techniques may be beneficial. This is not to say that they produce benefit without any doubt (nothing in the manual therapy armamentarium, or probably in mainstream medicine, could promise that), but there is a rationale based on limited external evidence for the use of these techniques to achieve certain aims. I think this is the case for high velocity, muscle energy, and a few other techniques. There is also a good case for non-manual approaches, such as addressing inappropriate pain-related behaviours, as per the bio-psychosocial model. There are many manual techniques that are currently being used that have little or no supporting evidence or established efficacy, but I think it can be appropriate to continue using them (based on personal experience and anecdotal evidence) provided they are combined with approaches that have some research or guideline support. If a technique does not have a plausible physiological rationale e in addition to a lack of evidence of efficacy e then it is appropriate to question its use. When there is clear evidence of no effectiveness or evidence of harm, then these approaches should be abandoned (of course, debate will ensue over what constitutes clear evidence of ineffectiveness versus lack of evidence of benefit); although, it is hard to cite an example because of the lack of research. The bottom line is that practitioners should use common sense and be willing to change what they do if there is good evidence to do so.
Question: From your point of view: What is the essence of art in osteopathy? This is a hard one. I change my answer every time I think about it. I think the art encompasses a range of skills. It includes the way we interact with the patient (listening ability, empathy, support, encouragement, etc) and our intuitive interpersonal responses. Then there is the art associated with palpation and manual treatment, and this aspect may largely be intuitive (not supernatural, however not resulting from analytic conscious processes, but assimilated from experience and observational cues) and may complement the analytical approach. This is probably no different from the art associated with other manual and bodywork disciplines, except perhaps the philosophical emphasis on the ‘whole body’ approach in osteopathy may help promote intuitive leaps in a whole body context (in the postural, ergonomic, or psychological spheres). But I admit when talking about art I0 m completely out of my depth!
Question: Are the art of the osteopathy and the knowledge of science necessarily contradictory? I would say complementary, rather than contradictory. The ‘art’ is the manner in which the ‘science’ is applied. For example, the science may tell us that there is short-term
307 benefit in using manipulation to the lumbar spine in low back pain; the art may include the identification of lumbar segments that appear restricted, the application of techniques (such as soft tissue used firmly enough to produce a change in compliance of the muscle mass, but not enough to provoke pain and reactive guarding), and the patiente practitioner interaction that fosters trust and confidence in the treatment, dispels irrational fear and counterproductive behaviours, and instils realistic optimism.
Question: Is it more important to be free in the therapeutic decision-making process or do osteopaths need more guidelines? I don’t have any problem with clinical guidelines provided that they are used as guidelines and do not restrict practice options. Relevant evidence is there to inform and guide our choices for the benefit of our patients. By working within the recommendations of guidelines, our treatments are more likely to be consistent with the best current research, but there should always be the flexibility to use treatments according to the judgment of the clinician (which may be based on previous experience, awareness of patient values or preferences, etc). Guidelines can provide recommendations about treatment approaches that have the best supporting evidence. Practitioners may use these guidelines to add approaches and techniques to what they already use to ensure the best patient care, rather than removing treatments that may currently have only anecdotal or theoretical rationale, but this depends on the individual situation. So I think we can benefit from guidelines without the removal of our clinical judgment or freedom to make decisions.
Question: If you compare the development of research in osteopathy in Europe, USA and Australia e what are the common points and what are the differences? Research began in the US, with early researchers, such as Louisa Burns, F.P. Millard, and Wilbur Cole. It gained momentum with the Kirksville research team, which included J.S. Denslow and Irvin Korr, in the 1940s and 1950s. After the 1960s, the momentum appears to have been lost e with the exception of a few researchers e and only in the past decade have we seen renewed interest and allocation of resources towards osteopathic research. I0 m not aware of any substantial osteopathic research efforts in the UK or Australia until relatively recently, and the same is true of Europe and Canada (particularly given the emerging state of the professions there). Lack of access to funding is a common problem for osteopathic researchers outside the US (and probably within the US). In the UK, the profession has a longer history and is more established than in continental Europe, but few researchers have access to Medical Research Council funds (the UK BEAM trial being an exception). Much of the current research consists of small-scale student projects that are limited by the funding and resources of private colleges and are complicated by an ever increasingly complex Ethics
308 approval process. On the positive side, the establishment of the National Council for Osteopathic Research in 2003 shows a commitment to research, with a number of projects on adverse events in progress. There are also a growing number of osteopathic PhDs and doctoral students. The situation in Australia is similar, with smallscale projects conducted with limited funding from osteopathic departments at state universities, but with few PhDs within the profession. The state of research in Europe and Canada shows great potential. There has been extraordinary growth in smaller clinic-based projects e often associated with the requirements of fulfilling a Master’s degree or similar e resulting in innovative and quality research. I have noticed that researchers in countries, such as Germany and Italy, often investigate treatment (with an emphasis on visceral techniques) of non-musculoskeletal conditions, which is a research area that is not as apparent in the UK or Australia. The main barriers to research in Europe are lack of access to Ethics approval committees and limited resources and funding from private colleges, but because of the post-graduate structure of osteopathic training in some countries (such as Germany), research is being performed by osteopaths with established practices in their own clinics, which does not occur in the UK and Australia because students train in undergraduate programs. There is increasing professionalization taking place in Europe, with Master’s and doctoral programs in progress in several countries. It looks very promising for the future.
References BMJ Evidence Centre 2009 How much do we know? Retrieved 14.01.2010, from http://clinicalevidence.bmj.com/ceweb/ about/knowledge.jsp. Cleland, J.A., Childs, M.J.D., McRae, M., Palmer, J.A., Stowell, T., 2005. Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial. Man. Ther. 10 (2), 127e135. Clements, B., Gibbons, P., McLaughlin, P., 2001. The amelioration of atlanto-axial rotation asymmetry using high velocity low amplitude manipulation: is the direction of thrust important? J. Osteopath. Med. 4 (1) 8e4. Denslow, J.S., 1975. Pathophysiological evidence for the osteopathic lesion: the known, unknown and controversial. J. Am. Osteopath. Assoc. 75 (4), 415e421. Denslow, J.S., Clough, G.H., 1941. Reflex activity in the spinal extensors. J. Neurophysiol. 4, 430e437. Denslow, J.S., Hassett, C.C., 1942. The central excitatory state associated with postural abnormalities. J. Neurophysiol. 5, 393e402. Denslow, J.S., Korr, I.M., Krems, A.D., 1947. Quantitative studies of chronic facilitation in human motorneuron pools. Am. J. Physiol. 150 (2), 229e238. Ferna ´ndez-de-las-Pen ˜as, C., Alonso-Blanco, C., Cleland, J.A., Rodrı´guez-Blanco, C., Alburquerque-Sendı´n, F., 2008. Changes
H. Franke in pressure pain thresholds over C5eC6 zygapophyseal joint after a cervicothoracic junction manipulation in healthy subjects. J. Manipulative. Physiol. Ther. 31 (5), 332e337. Fryer, G., Alivizatos, J., Lamaro, J., 2005. The effect of osteopathic treatment on people with chronic and sub-chronic neck pain: a pilot study. Int. J. Osteopath. Med. 8 (2), 41e48. Fryer, G, Bird, M, Robbins, B, Johnson, J. Resting electromyographic activity of deep thoracic transversospinalis muscles identified as abnormal with palpation. J. Am. Osteopath. Assoc., in press. Fryer, G., Morris, T., Gibbons, P., 2004. Paraspinal muscles and intervertebral dysfunction. Part 1. J. Manipulative. Physiol. Ther. 27 (4), 267e274. Fryer, G., Morris, T., Gibbons, P., 2004. Paraspinal muscles and intervertebral dysfunction. Part 2. J. Manipulative. Physiol. Ther. 27 (5), 348e357. Fryer, G., Morris, T., Gibbons, P., Briggs, A., 2006. The electromyographic activity of thoracic paraspinal muscles identified as abnormal with palpation. J. Manipulative. Physiol. Ther. 29 (6), 437e447. Fryer, G., Ruszkowski, W., 2004. The influence of contraction duration in muscle energy technique applied to the atlantoaxial joint. J. Osteopath. Med. 7 (2), 79e84. Hundscheid, H.W., Pepels, M.J., Engels, L.G., Loffeld, R.J., 2007. Treatment of irritable bowel syndrome with osteopathy: results of a randomized controlled pilot study. J. Gastroenterol. Hepatol. 22 (9), 1394e1398. Kanlayanaphotporn, R., Chiradejnant, A., Vachalathiti, R., 2009. The immediate effects of mobilization technique on pain and range of motion in patients presenting with unilateral neck pain: a randomized controlled trial. Arch. Phys. Med. Rehabil. 90 (2), 187e192. Korr, I.M., Wright, H.M., Thomas, P.E., 1962. Effects of experimental myofascial insults on cutaneous patterns of sympathetic activity in man. J. Neural. Transm. 23, 330e355. Lenehan, K.L., Fryer, G., McLaughlin, P., 2003. The effect of muscle energy technique on gross trunk range of motion. J. Osteopath. Med. 6 (1), 13e18. Licciardone, J.C., Brimhall, A.K., King, L.N., 2005. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet. Disord. 6, 43. Lombardini, R., Marchesi, S., Collebrusco, L., et al., 2009. The use of osteopathic manipulative treatment as adjuvant therapy in patients with peripheral arterial disease. Man. Ther. 14 (4), 439e443. Noll, D.R., Shores, J.H., Gamber, R.G., Herron, K.M., Swift Jr., J., 2000. Benefits of osteopathic manipulative treatment for hospitalized elderly patients with pneumonia. J. Am. Osteopath. Assoc. 100 (12), 776e782. Sackett, D.L., Rosenberg, W.M., Gray, J.A., Haynes, R.B., Richardson, W.S., 1996. Evidence based medicine: what it is and what it isn’t. Br. Med. J. 312 (7023), 71e72. Schwerla, F., Bischoff, A., Nurnberger, A., Genter, P., Guillaume, J., Resch, K., 2008. Osteopathic treatment of patients with chronic non-specific neck pain: a randomised controlled trial of efficacy. Forsch Komplementmed 15, 138e145.
Journal of
Official journal of the: ® Association of
Neuromuscular Therapists, Ireland ® Australian Pilates Method Association ® National Association of Myofascial Trigger Point Therapists, USA ® Pilates Foundation, UK
Volume 14 Number 4 2010
Bodywork and Movement Therapies EDITOR-IN-CHIEF
Leon Chaitow ND, DO
c/o School of Integrated Health, University of Westminster, 115 New Cavendish Street, London W1M 8JS, UK Preferred mailing address: P.O.Box 41, Corfu, Greece 49100 (
[email protected])
ASSOCIATE EDITORS John Hannon DC San Luis Obispo, CA, USA (
[email protected])
Dimitrios Kostopoulos PhD, DSc, PT Hands-on Physical Therapy, New York, NY, USA (
[email protected])
Glenn M. Hymel EdD, LMT Department of Psychology, Loyola University, New Orleans, LA, USA (
[email protected])
Craig Liebenson DC Los Angeles, CA, USA (
[email protected])
ASSOCIATE EDITORS: PREVENTION & REHABILITATION Matt Wallden MSc, Ost, Med, DO, ND London, UK (
[email protected])
Warrick McNeill MCSP London, UK (
[email protected]) International Advisory Board D. Beales MD (Cirencester, UK) G. Bove DC, PhD (Kennebunkport, ME, USA) C. Bron PT (Groningen, The Netherlands) I. Burman LMT (Miami, FL, USA) J. Carleton PhD (New York, USA) F. P. Carpes PhD (Uruguaiana, RS, Brazil) Z. Comeaux DO FAAO (Lewisburg, WV, USA) P. Davies PhD (London, UK) J. P. (Walker) DeLany LMT (St Petersburg, FL, USA) M. Diego PhD (Florida, USA) J. Dommerholt PT, MS, DPT, DAAPM (Bethesda, MD, USA) J. Downes DC (Marietta, GA, USA) C. Fernandez de las Peñas PT, DO, PhD (Madrid, Spain) T. M. Field PhD (Miami, FL, USA) P. Finch PhD (Toronto, ON, Canada) T. Findley MD, PhD (New Jersey, USA) D. D. FitzGerald DIP ENG, MISCP, MCSP (Dublin, Ireland) S. Fritz LMT (Lapeer, MI, USA)
G. Fryer PhD. BSc., (Osteopath), ND (Melbourne City, Australia) C. Gilbert PhD (San Francisco, USA) C. H. Goldsmith PhD (Hamilton, ON, Canada) S. Goossen BA LMT CMTPT (Jacksonville, FL, USA) S. Gracovetsky PhD (Ocracoke, NC, USA) M. Hernandez-Reif PhD (Tuscaloosa, AL, USA) P. Hodges BPhty, PhD, MedDr (Brisbane, Australia) B. Ingram-Rice OTRLMT (Sarasota, FL, USA) J. Kahn PhD (Burlington, VT, USA) R. Lardner PT (Chicago, IL, USA) P. J. M. Latey APMA (Sydney, Australia) E. Lederman DO PhD (London, UK) D. Lee BSR, FCAMT, CGIMS (Canada) D. Lewis ND (Seattle, WA, USA) W. W. Lowe LMT (Bend, OR, USA) J. McEvoy PT MSC DPT MISCP MCSP (Limerick, Ireland) L. McLaughlin DSc PT (Ontario, Canada) C. McMakin MA DC (Portland, OR, USA) J. M. McPartland DO (Middleburg, VT, USA) C. Moyer PhD (Menomonie, WI, USA)
D. R. Murphy DC (Providence, RI, USA) T. Myers (Walpole, ME, USA) C. Norris MSc CBA MCSP SRP (Sale, UK) N. Osborne BSc DC FCC (Orth.), FRSH, ILTM (Bournemouth, UK) B. O’Neill MD (North Wales, PA, USA) J. L. Oschman PhD (Dover, NH, USA) D. Peters MB CHB DO (London, UK) M. M. Reinold PT, DPT, ATC, CSCS (Boston, MA, MD, USA) G. Rich PhD (Juneau, AK, USA) C. Rosenholtz MA, RMT (Boulder, CO, USA) R. Schleip MA, PT (Munich, Germany) J. Sharkey MSc, NMT (Dublin, Ireland) D. G. Simons MD (Covington, GA, USA) D. Thompson LMP (Seattle, WA, USA) C. Traole MCSP, SRP, MAACP (London, UK) P. W. Tunnell DC, DACRB (Ridgefield, CT, USA) E. Wilson BA MCSP SRP (York, UK) A. Vleeming PhD (Rotterdam, The Netherlands)
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Journal of Bodywork & Movement Therapies (2010) 14, 309e311
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EDITORIAL
Italian osteopathy e An exciting European example Osteopathy in Europe e particularly in Italyeis evolving its own professional shape e independent of the long-established United Kingdom model (which is itself changing), and different from osteopathy’s roots in the USA. In the UK, since the initiation of state regulation, and the establishment of the profession’s regulating body, the General Osteopathic Council, there appears to have been an emerging trend towards a more biomechanical/musculoskeletal, evidence-based, focus for the profession. Obvious conditions such as low back pain, and neck and shoulder issues (as examples), seem to be what UK’s close to 4000 osteopaths treat, most of the time, encouraged by the GOC, and the BOA (British Osteopathic Association) the profession’s virtual ‘trade-union’. While those UK trained osteopaths who have had, as part of their training, a broader philosophical and practical exposure e for example where naturopathic subjects are part of the training, or where ‘classical osteopathy’ has been taught e still treat patients with general health conditions, this is not the direction either the GOC, BOA, or the colleges, are encouraging. In the USA the majority of DO0 s no longer employ manipulation as part of their patient care; their work being almost indistinguishable from standard medical practice. Those DO0 s who do use manual approaches in patient care are finding an ever more hostile environment in which, in many States, payment for time spent on such treatment is being denied, or drastically reduced, by health insurance providers. Participation in the 2nd Italian Congress of Osteopathic Medicine, in Rome, in June (June 17e20), demonstrated that an energetic and exciting osteopathic profession is alive and thriving in Italy (as it is in many other European countries e including Spain, France, Belgium, Austria, Germany and Russia). The conference, efficiently organised under the direction of Paulo Tozzi DO, brought together many young (mainly) Italian osteopaths, who appear to have found ways of initiating and/or collaborating in a range of research projects, details of which were presented to an enthusiastic conference audience of around 200. Two veteran American osteopaths were also presenting, Professor Michael Patterson e who in his address confirmed many of the trends discussed above e as well as Viola 1360-8592/$36 ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.07.005
Frymann DO, who continues her teaching and clinical work as she approaches 90. Dr Frymann spoke about her work with infants and neonates, some of it collaboratively with Italian osteopaths. Some of the projects reported on by Italian osteopaths (see selection of summaries below), involved only small number of patients e making it impossible to draw definitive conclusions e however what seems at least as important as the results of such studies (and arguably far more important), is the fact that they are taking place at all.
Dr Viola Frymann, Rome, June 2010
310 A dynamic Italian osteopathic profession is emerging, with an enthusiastic desire to explore osteopathic efficacy in many areas of health concern. One result is a cohort of osteopaths, whose research skills are being refined, offering new insights as to the mechanisms and methods that osteopathic treatment can produce. A brief summary of selected research reports from the Congress include:
Osteopathy in neonatology clinical approach, treatment protocol, statistical study Craighero Germano DO presented a report on 5 years of study of approximately 2000 neonates at Villa Salus Hospital in Venice. A summary report was given involving 1000 infants who had been examined and treated e 772 vaginal births and the remainder caesarean. Based on assessments of these infants the following summary of findings emerged: Infants born vaginally most commonly demonstrated lateral cranial strains and occipital and cranial axis compressions. Infants born by caesarean section demonstrated a greater head circumference with more frequent injuries to the occiput. Based on his years of experience with neonates it was suggested that “osteopathic rebalancing” might prevent adverse structural and functional developmental effects of the observed cranial distortions.
Cancer related fatigue syndrome (CRFS) Members of the research team that investigated the effects of osteopathic care given to patients with CRFS, (Gugliemo Donniaquio, Luca Brema, Marino Pietro, Patrizia Boero) reported on a study conducted at San Paolo Day Hospital, Savona, Italy. The study was conducted by 6th (i.e. final) year osteopathic students from the European School of Medical Osteopathy in Genoa, under the supervision of faculty. The aim was to evaluate whether osteopathic treatment could be helpful in producing objective and effective results in patients with CRFS. Each of the 50 cancer patients (male and female), aged between 40 and 60, received 1 h of osteopathic treatment, every 3 months for 15 months. Treatment involved a cranial osteopathic protocol, as well as “‘multidimensional technique’ involving craniosacral, visceral, somatic-structural and neurovegetative rebalancing methods”. The findings of improved CRFS-related symptoms, and life quality improvements, suggested that a larger study would be justified.
Infertility, endometriosis and osteopathy Two small trials, initiated in a collaboration between surgeons and osteopaths, were reported on. The lead osteopath involved in the study, Alexandre Belloni DO, reported that in both trials, osteopathic treatment involved “elongation, manipulation, inhibition, stimulation” following on
Editorial from “assessment for joint dyskinesia, asymmetry of myofascial tonus and posture.” In her presentation the collaborating surgeon, Anastasia Ussia MD, reported on one study, involving 4 patients, aged between 20 and 40, who had demonstrated idiopathic infertility for over 2 years, accompanied by superficial endometriosis. The osteopathically treated patients were compared with those for whom a ‘wait and see’ approach, was adopted. Three one hour, osteopathic treatments were given at fortnightly intervals. At six-month follow-up three members of the infertile group were pregnant. In a separate pilot study, five patients aged 20e45, who had previously had surgery for serious endometriosis, and who subsequently suffered persistent pain, “not attributable to gynaecological problems”, also received three one hour, osteopathic treatments at fortnightly intervals. At 6 months follow-up, two patients were pain free, and two others showed significant reductions in pain. No conclusions could be drawn due to the small numbers involved in these trials, however the researchers suggest that the encouraging results highlight a need for further studies, with the objective of developing a randomized controlled research project.
Osteopathic manipulative treatment as adjuvant therapy in patients with peripheral arterial disease (PAD.) This study (Lombardini et al., 2009), conducted at the University of Perugia, evaluated and compared endothelial function and lifestyle modifications in 15 intermittent claudication patients who received both medical and osteopathic treatment (OMT group) and 15 intermittent claudication patients, matched for age, sex and medical treatment e the control group e who received standard medical attention. Compared to the control group, the OMT group had a significant increase in brachial flow-mediated vasodilation, ankle/brachial pressure index, treadmill testing, and physical health component of life quality (all p < 0.05), assessed at 2 months and 3 months from the start of the study. A report on this research initiative was published in Manual Therapy in August 2009. Many other reports were delivered at the Rome congress, on topics as varied as: Possible correlations between performance and rebalancing of osteopathic pivots in athletes (Feliziani C Moretti M) Clinical and kinematic evaluation of osteopathy-vsspecific exercise in obese non-specific chronic low back pain patients (Vismara L et al) OMT and epicondylitis (Giacomo S et al) The importance of deglutition in athletic performance (Desiro P) Pain in patients with spinal injuries: OMT effects associated with drug therapy (Arienti C et al) Dynamic Ultrasound evaluation of sliding motion of organs related to fascia layers, before and after osteopathic techniques are applied (Bongiorno D Tozzi P) These examples of research initiatives from Italy suggest a bright future for osteopathy in that country.
Editorial
Reference Lombardini, R., et al., 2009. The use of osteopathic manipulative treatment as adjuvant therapy in patients with peripheral arterial. Man. Ther. 14 (4), 439e443.
311 Leon Chaitow, ND DO 144 Harley Street, London W1G7LE, United Kingdom E-mail address:
[email protected] Journal of Bodywork & Movement Therapies (2010) 14, 312e314
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CONFERENCE REPORT
Lessons from the conference: “Highlighting Massage Therapy in Complementary and Integrative Medicine” Geoffrey M. Bove, DC, PhD a,*, Susan L. Chapelle, RMT b,1 a University of New England College of Osteopathic Medicine, 208A Stella Maris Hall, 11 Hills Beach Road, Biddeford, ME 04005, United States b Squamish Therapeutic Massage, #108-41105 Tantalus Road, Squamish, BC V8B-0A8, Canada
Received 4 June 2010; accepted 4 June 2010 A landmark conference, Highlighting Massage Therapy in Complimentary and Integrative Medicine, was held in Seattle, Washington, on May 13the15th, 2010. The conference was designed to address the status of research related to massage therapy, as well as to have an open discussion regarding attitudes towards research and professional issues. Leaders from diverse manual therapy professions presented interesting and important data. The itinerary and summaries of the meeting can be found at http://www. massagetherapyfoundation.org/researchconference2010. html. In this brief report, rather than summarizing the presentations, we will share a combination of our observations and impressions, as well as suggestions for the direction of massage therapy research. Diana Thompson, LMP, opened the conference by stressing the need for mutual respect and collaboration between clinicians and researchers, and pointed out the overarching need to determine possible mechanisms of action of massage therapy. Helene Langevin, MD, re-emphasized the need for mechanistic understanding. Perhaps more importantly, she
* Corresponding author. Tel.: þ1 207 602 2921 (Lab); fax: þ1 207 602 5931. E-mail addresses:
[email protected] (G.M. Bove), slchapelle@me. com (S.L. Chapelle). 1 Tel.: þ604 567 2666.
pointed out that the majority of treatments provided by massage therapists are for conditions where the etiologies are unknown. While this is true for other providers as well, it is a critical point, and is not usually discussed. If we do not know the etiologies of the problems we are treating, how can we design treatments based on anything but experience? And if a treatment works, can we move backwards to the etiology? Moreover, how can we look for mechanisms without etiologies? These are critical questions to think about and discuss. Dr. Langevin also discussed that while the histology of connective tissue is well understood, the physiology of it is not. It is commonly held that connective tissues are passive. She presented evidence that undifferentiated and pluripotent fibroblasts within connective tissue respond to stresses by migration to injured areas, where they transformation into contractile elements. More data presented showed that fascia is innervated with neuronal processes consistent with those that may mediate pain (such innervation is present in virtually all other structures). Such neurons “police” the structures they are in and mediate inflammatory responses. Dr. Langevin concluded by showing that the thoracolumbar fascia in humans with back pain is thicker than in humans without back pain. While preliminary, these data in combination document that fascia is not only responsive to stresses, but is more so in pathological states. These data have the potential to form a foundation for much future research into the mechanisms of back pain and its treatment.
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Lessons from highlighting massage therapy
Helene Langevin, MD
Dan Cherkin, PhD, shared data from his recent studies. In a study of acupuncture compared to massage, it was shown that massage therapy led to better outcomes. In another study, both “relaxation” and “structural” massage therapy improved function for back pain patients better than normal care. These data constitute good evidence that massage therapy has significant effects for low back pain, and needs further research. Dr. Cherkin pointed out that critical issues such as provider type and training, dosage, technique, and patient type need to be addressed. Willem Fourie, PT, discussed the use of manual therapy in recovery from breast cancer, specifically post-surgical scarring due to mastectomy, which very often leads to chronic pain and lymphedema. The current lack of understanding of the response of connective tissues to surgery became clearer, as did the potential role of manual therapists in post-surgical complications. Mr. Fourie included data from Antonio Stecco to stress the importance of inflammation in surgically disrupted connective tissue. Research into the physiology of postsurgical complications and the effects of treatments directed to the scarring are necessary and seem to be of high priority. This is an excellent example of where therapists could be and should be directly involved in all facets of both laboratory and
Willem Fourie, PT
313 clinical efforts. This particular area seems fertile for studying the potential effects of manual therapy at a cellular level. The first panel discussion involved public health and professional issues that are critical to massage therapy research. It was presented that although there are many thousands of massage practitioners, and that more than 8% of the US population uses their services, the educational standards and licensing of massage practitioners are diverse. The discussion also involved questions of whether massage therapy is a profession or a discipline. Should massage therapy work towards integration into mainstream healthcare, or should it remain largely separate? In many provinces in Canada, massage therapy has enjoyed the respect of being a registered health care profession. Massage therapists in three provinces are governed by the same rules and regulations as other health care providers, and this allows for accountability within the system. In the USA, the licensing is inconsistent between states, and there remain a few states without licensing. The discussion supported the efforts of the associations and educators to standardize education. Such efforts would be expected to lead to uniform licensing, and would also increase the possibility of developing more extensive and collaborative research efforts. The second panel discussion emphasized “translational research.” This phrase is now used along with “from bench to bedside” to describe the reciprocal need of sharing information between the clinic and the laboratory. For clinical science to advance most efficiently, clinicians will need to better inform scientists of their pressing questions, and the scientists will need to develop clinically relevant approaches to answer these questions. Such communication is typically initiated during meetings such as this one. In the breakout sessions, science related to massage therapy was presented. Space does not allow coverage of each presentation. The diversity of the backgrounds of the presenters was striking, and consisted of professional researchers as well as practitioners giving their first presentations. We applaud the newcomers, who should inspire others to feel confident to make such an effort. In the first session, challenges in methodological designs were clearly presented, and this seemed to be somewhat of a revelation to the audience. The presentations accentuated that performing meaningful research is very difficult, time consuming, and expensive, and that a supportive, collaborative, and multidisciplinary environment is of utmost importance. A presentation by Laurel Finch, LMT, CNMT was more about the process than the data, and we found this most inspiring. She reminded us that the foremost skills for performing research are tenacity and the belief that one can succeed. This research meeting for massage therapy can be considered a call to arms for the profession. However, many challenges need to be overcome. We see the two major challenges as being funding and formal education. Funding remains a primary problem for massage therapy research, as it is for all research. In the US, the National Institutes of Health has designed grant mechanisms specifically for manual therapy research. The funds go to the best applications as judged by peer review and the program priorities of the institute. We do not know what resources are potentially available worldwide. Organizations like the
314 Massage Therapy Foundation, as well as other smaller massage therapy associations, have made some funds available for research, despite limited resources. A general impediment to being awarded grants is that advanced degrees are required. Until a cadre of therapists attain such degrees, the profession needs to develop more partnerships with universities and laboratories interested in the effects of manual treatments as provided by massage therapists. The profession is urged to identify and sponsor interested therapists to complete advanced training in research methods. It is our belief that the massage therapy profession needs to develop a standardized education system, designed to give a deeper knowledge of anatomy and pathology as well as to promote critical thinking. Schools must seek degree-granting accreditation, necessary for academic advancement. Besides aiding research efforts, such changes will lead to deeper communication with and respect among health care professionals. Of course, all such changes will positively impact patient care, which is the ultimate goal. As for the direction that massage therapy research might take, it is clear that clinical trials based on case studies need to identify treatment effects on larger cohorts. As for
G.M. Bove, S.L. Chapelle all modalities, animal models need to be developed that resemble the conditions that massage therapists treat. The profession needs to identify research priorities through consensus to ensure that the research proceeds in the most efficient manner possible, and with the most benefit to the public health care system. Perhaps with more of an evidence base, massage therapy can enter the public health system and ultimately be supported as a health care modality for both prevention and treatment of soft tissue pathology. Luata Bray, a shaman and massage therapist, gave a beautiful closing prayer. It is fitting to quote her: “May stones be lifted from your path more easily in the upcoming years. Let us continue to lead the way in offering our communities with solid and acceptable evidence that massage therapy is indeed a medical modality for all people.” The road ahead is indeed rocky, but not impassible.
Acknowledgement Partial funding for GMB to attend the meeting was provided by Elsevier.
Journal of Bodywork & Movement Therapies (2010) 14, 315e317
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CONFERENCE REPORT
Highlighting Massage Therapy in CIM Conference: A massage therapist’s perspective Michael Hamm, LMP CCST Cortiva Institute e Seattle, 425 Pontius Ave North, Seattle, WA 98109, USA
Introduction
Major themes
In May of 2010, the second Highlighting Massage Therapy in CIM Research Conference took place in Seattle, WA. The conference attracted 350 attendees, including massage therapists, allied healthcare practitioners, researchers, and public health administrators. 291 attendees traveled from within the United States, 46 came from Canada, and a handful arrived from Australia, New Zealand, Italy, Greece, South Africa, and the United Kingdom (C. Leeders, personal communication, June 14, 2010). This article is a brief synopsis from the perspective of one attendee. Major themes are highlighted and implications discussed, but a comprehensive overview is not intended in this report.
Like any good conference, it was impossible to witness every worthwhile presentation. A brief scan of the daily agenda revealed an array of compelling subjects and thoughtful speakers. The following are four major themes that emerged:
Purpose/Intent of the Conference In organizing the conference, the Massage Therapy Foundation (MTF) had four primary goals. First was the dissemination of new research to attendees, which included clinical trials, basic mechanistic studies, educational research, case reports, and high-level reviews. Second, the MTF hoped to encourage translational research e that is, empowering both scientist and massage practitioner with knowledge from the other’s field. Third (and perhaps most interestingly), the conference was to incorporate live demonstrations of technique and thus foster more creative research design. Fourth was to facilitate productive collaborations between manual therapists and CIM researchers through focused breakout sessions and theme lunches. (Massage Therapy Foundation, 2009)
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Science as a social enterprise To the newly initiated bodyworker, it is easy to conceive of science as a monolithic entity, churning out its judgments without outside input. Conversely, a scientific investigator may imagine manual therapists as uninterested in his/her work and incapable of constructive discourse. Outgoing MTF President Diana Thompson addressed these misconceptions in her conference-opening talk by encouraging both practitioners and researchers to recognize the creative potential in both domains. She cautioned against the use of insular terminology, described the passion that underlies both kinds of work, and set a tone of mutual curiosity that carried through the conference. During a breakout session on the next day, Menard & Weeks (2010) presented qualitative interview findings on what factors give rise to successful collaborations between CIM providers and research institutions. (These include diligent preparation, personal initiative, and the persistent cultivation of funders and institutional allies.) Overall, the impression given was that a healthy massage research community includes active exchange between researchers and practitioners, and that each group must strive to be accessible to the other. Clinical findings The bulk of the content presented was focused on the effects of manual therapy in practice, and did not attempt to establish new physiological models or to redefine the
316 bodywork field. These clinical presentations spanned the range of evidence, including case reports, pilot studies, clinical trials, and high-level reviews. Haraldsson (2010) updated a 2006 Cochrane Review on massage for mechanical neck disorders, finding that positive evidence remains modest at best, and that studies must be strategically crafted to determine risk, placebo effects, optimum dosage, etc. Moyer (2010) presented a comprehensive quantitative review on cortisol reduction in massage therapy, concluding that cortisol reduction is mostly insignificant (with the major exception being children receiving multiple massage treatments), and that other mechanisms should be proposed for effects on anxiety, depression, and pain. On the other end of the evidence spectrum, a survey of recent case reports highlighted some creative approaches to examining massage in practice. This included an innovative body diagram for concisely describing massage techniques (Larson, 2010) and the use of pupil position for the accurate measurement of postural change in photographs (Goral and Burkett, 2010). Better measures lead to clearer mechanisms The basic science of bodywork can be hard to conduct with appropriate rigor. The multivariate nature of human contact e combined with a relative paucity of scientists who are also trained in manual therapy e make for an anemic literature on physiological mechanisms (Langevin 2010a). Large-scale clinical trials of massage therapy are being conducted without knowledge of how effects are produced. The result is studies whose conclusions are not useful to clinicians. Dr. Helene Langevin summarized this state of affairs with her usual clarity, portraying basic research and clinical trials as two interdependent pursuits. She specifically called for developing better biomarkers in clinical trials (Can we devise more measures that are clinically relevant, non-invasive, and predictive of therapeutic response?)(Langevin 2010b). Willem Fourie, a physiotherapist from South Africa, gave an illuminating talk on the use of ultrasound in measuring the success of manual therapy for scar tissue mobilization (Fourie 2010). In a patient recovering from shoulder surgery, Fourie showed a series of ultrasound scans taken at different times in the course of manual therapy treatment. In the early slides, Fourie pointed out a thick adhesion between superficial and deep layers, and then showed the adhesion dissipate in later scans, until it had mostly normalized. The obvious conclusion was that manual therapy was successful. “Do you agree with me?,” Fourie asked his audience, and after receiving approval from the friendly crowd, proceeded to dismantle his own prior argument. Despite the exciting findings, there were major weaknesses in his methods and the ensuing implications. The scans were taken by multiple people with varying styles of application, the scans themselves were not positioned precisely, and the visual plane of each scan varied somewhat between readings. All of these inconsistencies may have accounted for the apparent reduction in scar, and thus they severely limited the conclusions to be drawn from Fourie’s investigation. Such studies are all too common in the manual therapy field, and too often the clinicians reading those studies fail to recognize the methodological limitations. In offering his own work as a cautionary tale, Fourie exposed some of the pitfalls of incomplete outcomes measures.
M. Hamm Translational research and the future of massage science If the 2005 Highlighting conference was organized around promoting research literacy and participation, this second installment sought to make emerging research more effective. How swiftly can a published finding make its way into a typical massage practice? What makes for sound clinical reasoning? How do the various hunches of bodyworkers become testable hypotheses? Several speakers attempted to address these questions. Julie Ann Day (2010) discussed the work of Italian physiotherapist Luigi Stecco, who developed a fascial manipulation technique through the painstaking extrapolation of a central hypothesis. He proposed that the myofasciae have a proprioceptive function, and that this function is divided into discrete segments throughout the body. As more complex movements are assembled, the body uses retinacula and septa between antagonists to coordinate action. Stecco’s assertions are similar to those of later (contemporary) fascial theorists, but the specificity of his concepts allowed for meaningful histological study to be conducted. Day’s presentation was an urgent appeal to innovative clinicians to hone their treatment models into testable hypotheses. Equally urgent was the call for research that is designed with clinical relevance in mind. In a panel discussion on translational research, Leon Chaitow (2010) listed examples
Figure 1
Diane Thompson LMT and Julie Ann Day PT.
Figure 2
Geoff Bove PhD DC.
Highlighting massage therapy in CIM conference of scientific studies that fail to translate into practice. These include studies that e for practical reasons e are conducted on asymptomatic patients and/or normal tissues. In other studies, conclusions are muddled with too many variables or with clumsy research questions. Dr. Chaitow lamented the lost opportunity in such endeavors. Panelists Geoffrey Bove (2010) and Dan Cherkin (2010) both described their experiences in conducting research with a translational goal. Dr. Bove reported on the effects of mechanical stress on nerve tissue, and delineated three types of peripheral pain (nociceptive, ectopic nociceptive, and neuropathic). It became clear during Bove’s talk that our understanding of pain is undergoing rapid revision, and that the treatment models used in manual therapy must be updated accordingly. Dr. Cherkin, a researcher of low back pain, spoke of the importance of collaborative relationships during the design phase of a clinical trial, and offered a fresh perspective on placebo effects: “Placebo is a reflection of healing. We need to learn how to capitalize on it, and not [merely] control for its effects.” Once concrete findings have been published, it is important to incorporate them into practice. Whitney Lowe (2010) gave the last keynote address, summarizing the concepts from several other presentations into an insightful discussion of “knowledge translation”. The bodywork profession has a number of obstacles e educational, institutional, and cultural e to overcome if it will make full use of the evidence available to it. Lowe offered practical advice on how to manage information overload, how to read articles critically, and how to reform the continuing education model that currently prevails. At the core of the conference was an excitement about the possibility that bodyworkers can find a wider audience, build effective research collaborations, and relieve more suffering within integrative healthcare settings. Along with that excitement came a growing maturity about the role of research in clinical practice. Bodywork remains an art form, and manual therapists make frequent use of compassion and improvisation in their work. In years past, there was a suspicion among some therapists that scientific investigation would undermine the intuitive nature of bodywork. The overall impression from the 2010 Highlighting conference was that science and artistry cannot only coexist, but will thrive in each other’s presence.
317
References Day, J.A., 2010. First the hypothesis: How a biomechanical model can influence fascial anatomy research description. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA. Bove, G., 2010. Translational research panel. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA. Chaitow, L., 2010. Translational research panel. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA. Fourie, W., 2010. Translational research panel. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA. Cherkin, D., 2010. Translational research panel. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA. Goral, K., Burkett, M., 2010,). Massage-induced postural change as a mechanism of effect for reduction of anxiety: related procedures and findings from two case studies. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA Haraldsson, B.G., 2010. Massage for mechanical neck disorders: A systematic review e 2009 update. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA. Langevin, H.M., 2010a. Connective tissue physiology and its relevance to manual therapies. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA. Langevin, H.M., 2010b. Translational research panel. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA. Larson, E., 2010. Massage therapy effects in a long-term prosthetic user with fibular hemimelia. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA. Lowe, W., 2010. Knowledge translation: Key skills for highly successful clinicians. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA Massage Therapy Foundation. 2009. R13 Conference grant proposal to NCCAM, section 5: Conference plan. (PHS 398 Research Plan). Evanston, IL. Menard, M. and Weeks, J., 2010. Developing research collaborations: A “how-to” guide for CAM schools. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA. Moyer, C.A., 2010. Cortisol reductions in response to massage therapy: A comprehensive quantitative review. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA.
Journal of Bodywork & Movement Therapies (2010) 14, 318e325
available at www.sciencedirect.com
journal homepage: www.elsevier.com/jbmt
FASCIA RESEARCH
How much time is required to modify a fascial fibrosis? Borgini Ercole, MD a, Stecco Antonio, MD b, Day Julie Ann, PT c, Carla Stecco, MD d,* a
Borgini Medical Center, Cesenatico, Italy Physical Medicine and Rehabilitation Clinic, University of Padova, Italy c Centro Socio Sanitario dei Colli, Physiotherapy, Azienda Ulss 16, Padova, Italy d Department of Human Anatomy and Physiology, University of Padova, Via A Gabelli 65, 35127 Padova, Italy b
Received 9 October 2009; received in revised form 18 January 2010; accepted 10 April 2010
KEYWORDS Connective tissue; Fascia; Manipulation; Plasticity; Low back pain; Manual therapy
Summary The perception of what appears to be connective tissue fibrosis, and its consequent modification during therapy, is a daily experience for most manual therapists. The aim of this study was to evaluate the time required to modify a palpatory sensation of fibrosis of the fascia in correlation with changes in levels of patient discomfort in 40 subjects with low back pain utilizing the Fascial Manipulation technique. This study evidenced, for the first time, that the time required to modify an apparent fascial density differs in accordance with differences in characteristics of the subjects and of the symptoms. In particular, the mean time to halve the pain was 3.24 min; however, in those subjects with symptoms present from less than 3 months (sub-acute) the mean time was lesser (2.58 min) with respect to the chronic patients (3.29 min). Statistically relevant (p < 0.05) differences were also evidenced between the specific points treated. ª 2010 Elsevier Ltd. All rights reserved.
Introduction Many authors (Myers, 2001; Schleip, 2003; Stecco, 2004; Hammer, 2007; Chaitow, 2008; Masi and Hannon, 2008)
* Corresponding author. Tel.: þ39 049 8272327; fax: þ39 049 8272319. E-mail address:
[email protected] (C. Stecco).
suggest that trauma or overuse syndromes can alter the connective tissue and that, in particular, it could become tighter, altering its histological, physiological and biomechanical characteristics. The process that induces pathological modification of myofascial tissue is still not clear. Some authors (De Deyne et al., 2000; Matsumoto et al., 2002) suggest it could be due to an alteration of the collagen fibre composition. Others (Schleip et al., 2005, 2006; Chiquet et al., 2007; Grinnell, 2008) evidence the
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How much time is required to modify a fascial fibrosis? alteration of the fibroblasts with their transformation into myofibroblasts, while others (Whatmore and Kholi, 1974; Staubesand and Fischer, 1980; Scott, 2003; Hammer, 2007; Stecco and Stecco, 2009) suggest an alteration in the ground substance due to neurophysiological influences and changes in biochemical fluid relationships could be involved. There is some agreement that when fascia loses its pliability and becomes restricted, it could be a source of body misalignment and that, over time, this can potentially lead to poor muscular biomechanics (Barker et al., 2006), altered structural alignment, and decreased strength and motor coordination (Stecco, 2004; Fourie, 2008). Subsequently, patients may experience pain and functional deficit. It is also theorized that different manual and physical techniques could restore the normal physiological state of the fascia, but there is very little scientific evidence about the mode of action of manual therapies in general. The Cyriax method (1980) of deep transverse massage and similar manual therapies, such as the Graston Technique (Hammer, 2003, 2004) and Rolf (1963), propose modification of connective tissue mobility using the force of cross fibre friction. According to the Myofascial Release technique (Barnes, 1990), a sustained pressure applied into a restricted tissue barrier will cause this tissue to undergo histological length changes, and after 90e120 s, a sensation of perceivable release is noted and the tissue softens and becomes more pliable. Other authors claim that restoration of length and health to the myofascial tissue could relieve pressure on pain sensitive structures such as nerves (Sucher, 1993) and blood vessels (Quere ´ et al., 2009), as well as restoring alignment and mobility to the joints (Day et al., 2009). The Fascial Manipulation technique (Stecco, 2004; Stecco and Stecco, 2009) proposes to restore impeded gliding of collagen and elastic fibres within the ground substance by exploiting heat generated from the friction of deep manipulation. According to the law of Van t’Hoff (Haynie, 2001), which describes the relationship between temperature and the velocity of chemical reactions, this process could be established only if friction is applied where rigidity of the fascial tissue is perceived. By applying localized friction in an area of palpable rigidity, the therapist creates local heat and this may increase certain chemical reactions such as the attenuation of the secretion of inflammatory cytokines (Standley and Meltzer, 2008). When connective tissue is heated, it stretches more easily (Lehmann et al., 1970). However, no definitive explanation for the biomechanical bases of these transformations exists. While manual therapists often report perceptions of altered segmental tissue texture and its modification during therapy (Evanko, 2009), and correlations between changes in pain thresholds and perceived changes in tissue consistencies are at the basis of different therapies (Cyriax, 1980; Typaldos, 2002; Chaitow, 2003; Hammer, 2007; Stecco and Stecco, 2009) little direct evidence for these correlations exists (Fryer et al., 2004). Furthermore, a calculation of the mean time required for such changes to occur and the correlation between different patient subgroups with different degrees of altered fascial tissue is still lacking. De Bruijn (1984) described the application of deep transverse massage to soft tissue pain in 13 subjects. The time
319 required to produce a pain relief during application of this massage varied from 0.4 to 5.1 min, with a mean time of 2 min. Carreck (1994) evaluated the effect of a light stroking massage, applied for a total of 15 min in 20 healthy subjects, and demonstrated that this manoeuvre increased pain threshold levels, elicited by transcutaneous electrical stimulation. Kelly (1945, 1946) applied deep transverse massage for 5 min in 46 volunteers using a minimal amount of pressure that did not cause any pain and demonstrated that this particular modality did not produce a significant modification in the pain perception. The aim of this study is to evaluate the time required to modify the palpatory sensation of fibrosis of the fascia in correlation with changes in levels of patient discomfort in 40 subjects with low back pain utilizing the Fascial Manipulation technique. We selected low back pain because it is a leading cause of disability with a significant economic impact, not only on lost productivity but also on healthcare expenditures, approximately a fifth of patients will see multiple physicians in their quest for relief of low back pain (Jerymyn, 2001) and most manual therapies present specific treatment of this pathology. Furthermore, the fascial planes of the thoracolumbar fascia have been hypothesised to play a role in the pathogenesis of low back pain (LBP) (Langevin and Sherman, 2007; Schleip et al., 2007) and there is some initial evidence of correlations between altered connective tissue structures and LBP (Langevin et al., 2009), as well as preliminary studies indicating possible differences in motion between fascial layers in the thoracolumbar fascia in subjects with LBP as compared to a no-LBP groups (Fox et al., 2009). Three small areas over the thoracolumbar fascia that, according to Fascial Manipulation theory (Stecco and Stecco, 2009), are primarily involved in LBP mechanisms have been selected for treatment: - The area located at the level of the first lumbar vertebra, approximately 3 cm laterally to the spinous process of L1 for the paravertebral muscles. Note: in Table 1 this point is indicated with the abbreviation relu (retro-lumbi), which is an abbreviation used in the Fascial Manipulation technique to indicate this specific area (Stecco, 2004). - The area located at the level of the third lumbar vertebra at approximately 5 cm laterally to the spinous process of L3 for the quadratus lomborum. Note: this point is indicated with the abbreviation la-lu (laterolumbi). - The area immediately below the twelfth rib is for the latissimus dorsi, posterior inferior serrati and external oblique muscles. Note: this point is indicated with the abbreviation er-lu (extra-lumbi).
Materials and method Three operators (B.E., S.A., D.J.A.), each one with more than five years of experience in this method, analysed the time required to reduce the pain provoked during the application of this technique by half. Prior to this study, the 3 operators evaluated the three points considered for this study in 10 patients with low back pain and compared
320
B. Ercole et al.
Table 1 The main characteristics of the treated subjects and the initial and final pain, evaluated with the Verbal Numeric Scale, are reported.
a
These patients were treated only on one side because in the opposite side no fascial alteration was detected during comparative palpation.
How much time is required to modify a fascial fibrosis? fibrosis evaluation after each patient until 95% level of agreement was reached (Bland and Altman, 1986). Forty subjects suffering from acute or chronic mechanical low back pain were selected for this study. The research was conducted on 17 males and 23 females with ages ranging from 15 to 67 years (mean age 39.1 years old, SD 13.85). All of the subjects were evaluated with radiography and MRI prior to participation in this study in order to satisfy the inclusion/exclusion criteria for the study. Subjects who showed evidence of clinical neurological deficit, disc herniation, lumbar spine canal stenosis, systemic inflammatory disease such as rheumatoid arthritis, or had suffered either direct trauma or surgery to the back were excluded to avoid the possibility that excessive adherence between subcutaneous planes could influence the results of this study. Symptoms of mechanical low back pain were present for a period ranging from several months (m) to several years (y) and, in general, pain was discontinuous with recurrent exacerbating episodes being common (Table 1). In order to quantify the time required to halve the pain perceived during the application of this technique, the fasciae of three muscular groups often implicated in low back pain were chosen for treatment. These three groups include the paravertebral muscles, the quadratus lumborum muscles, and the muscles that insert onto the inferior border of the twelfth rib. Within each of these muscle groups, a small area of the fascia of approximately two square centimetres, known as the Centre of Coordination,1 was identified and evaluated. According to Fascial Manipulation methodology (Stecco, 2004; Stecco and Stecco, 2009), comparative palpation was then applied to examine all these small areas. This process involves operator skills in palpation and detection of altered fascial tissue, while simultaneously questioning the subject about perceived pain or discomfort. By means of continuous verbal feedback, the patient’s perception of pain and the palpatory sensation of fibrosis by the therapist were correlated and the most altered small area among the three evaluated points was selected. Treatment was bilateral in most cases, however, in some subjects, only a unilateral alteration of the fascia was noted. Consequently, in these cases, treatment was applied unilaterally to the altered or fibrotic Centre of Coordination. On each point selected for treatment, the operator exercised the minimal amount of pressure necessary to create friction against the fasciae of the abovementioned muscle groups. According to a previous study (Pedrelli et al., 2009), a mean force of 73.5 N over the CC of re-lu was required to produce a piercing pain sensation; in the CC of la-lu a mean force of 61.9 N and over the CC of erlu a mean force of 35.8 N. The operators all used pressure applied with the olecranon process and upper part of the ulna to perform the treatments, alternating between right and
1 A Centre of Coordination (CC) is a small area on the deep muscular fascia where force exerted by the muscular fibres of a specific region converge. The resultant myofascial forces appear to be transmitted to the surface of the deep fascia via its continuity with the endomysium, perimysium and epimysium. The CC has the role of coordinating the motor units that are located within this region.
321 left elbows according to the side of the body treated. The direction of the therapeutic manoeuvres varies according to the underlying structure: in a longitudinal direction with respect to the muscular fibres of the erector spinae (Fig. 1b); in a transverse direction for the quadratus lumborum (Fig. 1c); and in an oblique direction for the muscles below the 12th rib (Fig. 1a). All subjects were instructed how to report any experienced pain correctly, and were asked to inform the operator about the progression of pain provoked during treatment utilizing a verbal numeric scale (VNS). The verbal numeric scale (VNS) is a simple scale for the evaluation of pain, quite similar to the VAS (Visual Analogical Scale), with which it has a moderate correlation (Fosnocht et al., 2005). Subjects easily understand the VNS, as they are requested to choose a number from 0 to 10 that represents the level of their pain: zero corresponds to the absence of pain and ten corresponds to the most intense pain imaginable. This scale was chosen for this study because immediate and progressive reporting of pain levels was required and the verbal aspect was more functional than the VAS scale. Subjects were also instructed that they could ask for brief rest periods of a maximum of 10 s during manipulation to avoid extended interruptions that may have influenced results. A chronometer, which was activated at the beginning of each manipulation, was used to evaluate the time required to halve the pain according to pain levels reported by the subject. Prior to commencing treatment, the subjects were asked to report the exact moment in when either a minimal decrease or an important reduction in pain occurred. Subjects were also encouraged to report pain levels regularly (approximately every 30 s) and to indicate when the pain became less than 50% of the initial pain. All these variations in the pain/time curve were noted and reported in the Table 1. The time within which the therapist perceived a consistent change in sliding between the tissue layers was also noted. The mean value of the VNS scale measurements at the beginning and at the end of the treatment was calculated. The analysis of the differences in pain resolution among different subgroup of patients and among the three different evaluated points were compared with nonparamentric tests: KruskaleWallis test and Dunn’s multiple comparison test and ManneWhitney test for double comparisons.
Results At the beginning of treatment, the mean measurement of pain as reported by subjects was 7.9 on the most altered side and 6.7 on the contralateral side, while at the end of treatment it was of 3.2 and 3.0 respectively. The mean time necessary to reduce the referred level of pain to 50% was 3.24 min (SD 1.3), but specific differences could be evidenced among the different patients. In the subjects with sub-acute pathologies (5 min), while in 36%, the reduction occurred more quickly ( .05). This study demonstrated that STM and self-stretching of the pectoralis minor can significantly reduce RSP. ª 2009 Elsevier Ltd. All rights reserved.
* This study was completed at: Touro College, 27-33 West 23rd Street, New York, NY 10010, USA. * Corresponding author. Tel.: þ1 212 305 0683; fax: þ1 212 305 4569. E-mail address:
[email protected] (C.K. Wong).
Introduction The habitual slouched postural common in everyday tasks can be brought on by, or lead to, rounded shoulder posture
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The effects of manual treatment on RSP, and associated muscle strength
Possible clinical relevance: Soft tissue mobilization and stretching of the pectoralis minor muscle can reduce rounded shoulder posture. Soft tissue mobilization and stretching of the pectoralis minor muscle is no more effective than passive touch and pectoralis major stretching in increasing lower trapezius muscle strength. The 2.5 cm threshold for the supine measure of rounded shoulder posture may not detect dysfunction.
(RSP) (Magee, 1992; Chansirinukor et al., 2001). Characterized by protracted, downwardly rotated, and anteriorly tipped scapula position with increased cervical lordosis and upper thoracic kyphosis, RSP has been identified as a predisposing factor leading to upper quarter pain (Greenfield, 2001; Greenfield et al., 1995; Sahrman, 2002; Wang et al., 1999; Lukasiewicz et al., 1999). The cause of RSP is multifactorial. One factor that can contribute to RSP is tightness of the pectoralis minor muscle (Wang et al., 1999; Sahrman, 2002; Lukasiewicz et al., 1999; Borstad and Ludewig, 2005), which can occur with decreased scapular posterior tilt, retraction, and upward rotation during arm raising (Lukasiewicz et al., 1999). Treatment for a tight pectoralis minor is an important component in the rehabilitation of those with shoulder pathology and RSP (Sahrman, 2002; Kisner and Colby, 1990). Treatments suggested for RSP include stretching (Lukasiewicz et al., 1999; Wang et al., 1999; Kisner and Colby, 2002) and soft tissue mobilization (STM) to restore pectoralis minor length (Cantu and Grodin, 2001; Andrade and Clifford, 2001). Strengthening of the lower trapezius and serratus anterior muscles have also been used to actively counteract the strength and movement loss associated with RSP (Ekstrom et al., 2003; Ludewig et al., 2004; Hall, 2005; Smith et al., 2002). However, the effect on RSP of stretching, strengthening, or STM directed to the pectoralis minor muscle remains unknown. The scapular position related to RSP has been measured using x-rays (Greenfield et al., 1995) and with two- and three-dimensional video analysis (Plafcan et al., 1997; Johnson et al., 2001). Clinicians, however, need a reliable physical assessment method to utilize in a clinical setting. A supine method has been described using the distance of the acromion to the supporting table as a simple measurement for RSP (Kendall et al., 1993; Magee, 2002; Sahrman, 2002). While questioned as a measure of pectoralis minor muscle length (Borstad, 2005; Lewis and Valentine, 2007), use of the supine measure as an assessment of scapular position related to RSP has been demonstrated to have good reliability (ICC > 0.90) in both symptomatic and non-symptomatic shoulders (Lewis and Valentine, 2007). The supine RSP measure has also been shown to be comparable to a seated method of scapular posture assessment (Wang, 2006), but should be performed in a consistent degree of humeral rotation position for consistency (Borstad, 2006). The purpose of this study was to determine the effects of STM and self-stretch of the pectoralis minor muscle on
327
RSP and lower trapezius strength (LTS) compared to passive placebo touch and self-stretch of the pectoralis major muscle.
Methods Design Individual shoulders of each participant were considered separately and randomly assigned to the control or experimental group, using a random number table. Participants attended three sessions with 1e7 days between the first and second session, and 2 weeks between the second and third or follow-up session. The first session included completion of a questionnaire and an assessment for RSP and LTS of each shoulder. On the second session, the following were applied to each shoulder: (1) RSP and LTS measurements; (2) the experimental or control treatment; and (3) repeated RSP and LTS measurements. The follow-up outcome measures of RSP and LTS were reassessed on the third session 2 weeks later. One investigator provided all manual interventions and additional investigators provided self-stretch instruction and supervision. Investigators providing treatment did not perform assessments; investigators performing assessments were blinded to group assignment. Separate investigators assessed RSP and LTS without knowledge of each other’s findings and all investigators were blinded to past results. In addition, participants were blinded to the assignment of their shoulders to the control or experimental group. A research coordinator kept the confidentiality of all data and maintained the blinded environment by guiding participants to and from separate treatment rooms.
Study sample Volunteer participants of either gender between the ages of 20 and 40 years old were recruited from a college campus by announcement for this study. Participants were included if they exhibited RSP, as indicated by a distance 2.5 cm from the posterior aspect of the acromion to the table in supine (Sahrman, 2002). Participants were excluded if they had shoulder pain, pathology, or history of shoulder surgery; neurologic or cardiac symptoms; or prescriptions for any medication that altered muscle function. All participants gave informed consent before participating in this study, approved by the Institutional Review Board of the Touro College School of Health Sciences in New York, and participated without expectation of compensation or credit. In total, the study sample included 28 healthy participants with 56 shoulders. Individual shoulders were treated as independent entities and randomized to experimental or control groups. As a result, six participants had both shoulders assigned to the experimental condition, three had both shoulders assigned to the control condition, and 19 had one shoulder in each condition. Sagital plane scapular position has been demonstrated to vary between asymptomatic and symptomatic subjects with a difference between mean seated RSP of 7 2.5e3.2 mm respectively (Lewis et al., 2005). Scapular position has been shown to
328 influence isometric shoulder strength in healthy volunteers measured in kilograms with mean differences of 2.6e3.3 kg with standard deviations of 3.3e4.0 kg between the neutral and protracted or retracted positions (Smith et al., 2002). For the purposes of power analysis, expected mean changes and standard deviations based on these studies were used with a two-tailed power analysis with power set at 80%, a Z .05, and common standard deviation of 5 kg/mm, revealing that 25 shoulders were needed for each group to demonstrate a significant difference for a potential treatment effect size of 4 kg LTS strength or 4 mm RSP. The sample size of 56 shoulders was considered sufficient with 25 shoulders assigned to the control and 31 to the experimental groups.
Measures The demographic, anthropometric, and activity related information of each participant was collected by questionnaire. Rounded shoulder posture (RSP) With the participant lying at rest in supine on an unpadded examination table, scapular position related to RSP was measured with the shoulder positioned in neutral to avoid measurement variations due to humeral rotation (Borstad, 2006). The investigator palpated and marked the height from the examining table to the posterior aspect of the lateral acromion process on an unmarked plastic right angle positioned perpendicular to the table surface as described by others (Kendall et al., 1993; Lewis and Valentine, 2007; Magee, 1992; Sahrman, 2002). The distance was then measured using a separate straight ruler and recorded in millimeters. It has been noted that the supine RSP measure does not correlate well with an index of pectoralis minor length (Borstad, 2006) nor is the RSP measure an effective diagnostic predictor of shoulder symptoms (Lewis and Valentine, 2007). The current study, however, used the supine RSP measure as a measure of scapular position not of pectoralis minor length. In a study that assessed the concurrent validity of the supine RSP measure and a seated assessment of scapular posture, no significant difference between the measures of RSP was observed (Wang et al., 2006). Lower trapezius strength (LTS) To assess LTS, the participant was positioned in supine with hips and knees flexed to approximately 45 and 90 degrees respectively, the chest strapped to the table through the lowest anterior ribs, the shoulder positioned in 160 degrees flexion and abduction using a standard goniometer, the elbow extended, and the distal forearm just proximal to the posterior wrist placed in contact with the padded digital muscle tester (Liebler et al., 2001). The MicroFET2 Muscle Tester (Kom Kare Company, Middletown, OH), which is reported to be accurate with a 2% error for up to 150pound loads (http://www.rehaboutlet.com/manual_ muscle_test.htm, accessed 12/21/2008) was securely mounted on an adjustable platform that allowed the described arm position. A practice trial was performed to familiarize the participants to the testing method, followed by a 1 min rest. A different investigator then used the standard verbal directions ‘‘press as hard as you can’’ and
C.K. Wong et al. recorded the LTS measurement after the participant pressed against the digital muscle tester for 3 s for each shoulder with 10 s rest between two repetitions. The highest value was recorded as the peak strength. One study that reported LTS measure intra-rater reliability of ICC2,1 Z .89, also demonstrated significant construct validity with significantly greater lower trapezius muscle activity observed in the LTS test position compared to the upper and middle trapezius muscle testing positions (Michener et al., 2005). Reliability The reliability of pre-treatment RSP and LTS measurements from separate days of this study for all shoulders were analyzed using intraclass correlation coefficients (ICC) for absolute agreement of single measures with 95% confidence intervals using SPSS version 16.0. Portney and Watkins have suggested that ICC values above .75 indicate good reliability (Portney and Watkins, 1993, p. 514). Thus, the inter-day intra-rater reliability of the supine RSP measure in this study (ICC2,1 Z .80, 95% CI Z .68e.88) was considered good, although less than that of two studies (ICC3,1 Z .88e.93) that used the same RSP measure (Wang et al., 2006; Lewis and Valentine, 2007). Inter-day intra-rater reliability of the LTS measure (ICC2,1 Z .87, 95% CI Z .79e.92) was also considered good and comparable to previously reported intra-rater reliability (ICC Z .80e.95) for other shoulder muscle strength measurements using digital muscle testers (Phillips et al., 2000; Magnusson et al., 1990; May et al., 1997; Bohannon, 1990).
Treatments The experimental group received STM and performed stretching to the pectoralis minor muscle. The control group received passive light manual placebo touch and performed stretching to the pectoralis major muscle. All manual procedures were performed by a single licensed physical therapist certified as an orthopedic clinical specialist by the American Board of Physical Therapy Specialties. Self-stretch exercises were instructed and supervised by separate investigators. Experimental treatment For the STM portion of the experimental treatment, the participant was positioned in supine, anterior shoulder and chest exposed, and arm at the side. The STM procedure consisted of strumming perpendicular to the pectoralis minor muscle with the physical therapist’s fingers allowed to rebound across the muscle belly in a constant rhythm (Johnson, 2001, p. 597), producing muscle play or movement from side to side (Godges et al., 2003; Cantu and Grodin, 2001). Pectoralis minor STM was performed for 3 min with a force sufficient to move the muscle from side to side to the tolerance of the participant (see Figure 1). The STM was followed by a variation of supine pectoralis minor self-stretching described by others (Hall, 2005; Borstad and Ludewig, 2006) that incorporated spine extension/ ipsi-rotation/contra-sidebending with related rib motion. In the supine position with knees bent, the legs were rotated to the floor in the opposite direction of the arm to be
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Figure 1 Hand position and depth for strumming soft tissue mobilization of the pectoralis minor.
Figure 3 Hand position for the passive manual placebo touch of the control treatment.
stretched placing a stabilizing distal tension on the ribs (Sahrman, 2002). The subject then slowly brought the arm in a circular motion overhead pausing at points of tightness, maintaining close contact to the mat (see Figure 2). Overhead arm motion facilitated scapular posterior tipping, elevation, and retraction needed to stretch the pectoralis minor (Hall, 2005; Sahrman, 2002). The stretch was held for 30 s and repeated for a total of 3 min.
Statistical analysis
Control treatment The control treatment consisted of passive placement of the therapist’s fingers on the anterior shoulder over the lateral aspect of the pectoralis major muscle. Placebo touch was held for 3 min without applying tension or inducing movement (see Figure 3). After the passive placebo touch, participants performed a modified ‘door stretch’. With elbow extended, participants placed one hand on the door at waist level and leaned gently through the door, in a stretch intended to affect primarily the clavicular head of the pectoralis major (Kisner and Colby, 2002) (see Figure 4).
Figure 2 The pectoralis minor self-stretch of the experimental treatment.
The limited number of shoulders included in the sample and the finding that both initial LTS and RSP were skewed upward and tended to differ from a normal distribution (ShapiroeWilk p < .01 and p Z .06 for LTS and RSP, respectively), led to the use of non-parametric statistics in this studyda conservative choice since non-parametric tests are less sensitive than parametric tests with small samples (Portney and Watkins, 1993, p. 420). Statistical
Figure 4 The pectoralis major self-stretch or modified ‘‘door stretch’’ of the control treatment.
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C.K. Wong et al.
analysis was performed, using SPSS version 16.0 (SPSS-UK Ltd, St. Andrews House, West Street, Woking, Surrey, GU21 6EB, UK). Pre-treatment group comparisons were analyzed using ManneWhitney U-tests. To determine within-group treatment effects on the outcome measures through the post-treatment period, Friedman tests with statistical significance set at p < .05 and minimum significant differences (MSD) calculated with f Z .05 were performed. Comparisons of the between group treatment effects through the post-treatment period were performed using ManneWhitney U-tests (p < .05).
Results Descriptive data Descriptive statistics are presented in Table 1. No significant difference was found between the control and experimental shoulder groups prior to treatment. Pretreatment LTS and RSP measures revealed no significant difference between groups; means, standard deviations, and ranges for both groups were comparable. No significant change in RSP or LTS occurred in either group between the first and second pre-treatment measures (Friedman, p > .05). Overall, the control and experimental group shoulders were considered statistically equivalent prior to treatment (see Table 1). Treatment effects Experimental group RSP decreased significantly compared to the control group immediately after treatment, at the follow-up measure, and when average post-treatment measures were compared (ManneWhitney U-test: p Z .001, Z.015, .05). It is possible that the placebo touch and self-stretch of the pectoralis major had an effect on LTS equivalent to the experimental treatment through the positive influence of human contact (Cheing and Cheung, 2002; Keller and Bzdek, 1986) or increased neuromuscular recruitment similar to that observed in an initial exercise program (Moritani and deVries, 1979). A variety of placebo treatments have been shown to affect 30% of patients (Winemiller et al., 2005; Lappin et al., 2003; Hoffman et al., 2005) with benefits in objective measures, such as blood flow (Martel et al., 2002) or tumor reduction, of less than 7% in a comprehensive metaanalysis of the use of placebos in oncology research (Chvetzoff and Tannock, 2003). This degree of change is comparable to the 6.3 and 6.6% changes in LTS observed in the present study immediately after treatment in both groups: control and experimental, respectively ‘see Table 2’. It is noted, however, that the control treatment, which included passive placebo touch, had no effect on RSP.
Study limitations The results of the present study must be considered in the context of several limitations. First, the practice of using the shoulders of each participant as independent entities raised two potentially problematic possibilities: that the 19 participants who received different treatments could have distinguished between the control and experimental treatments and responded differently based on group assignment; and that outcomes of one shoulder may have affected the other. For the 19 participants who had a shoulder in each group, ManneWhitney U-tests were conducted to determine whether there was a difference in shoulder performance. There was no significant difference between the control and experimental shoulders of these 19 participants (p > .05), suggesting that participants’ performance with different shoulders may not have depended on the group assignment of their shoulders. Analysis with Friedman’s test was conducted to determine whether any difference in outcomes existed among the participants whose shoulders: (1) received different treatments on each shoulder; (2) received the experimental treatment on both shoulders; or (3) received the control treatment on both shoulders. The results revealed that the six participants whose shoulders were both in the experimental group had greater reductions in RSP than the three whose shoulders were both
C.K. Wong et al. in the control group (Friedman p < .05, MSD f < .05). Though the small number of participants prevents firm conclusions, it is possible that one shoulder may have affected the other undermining the assumption that individual shoulders are independent entities. Future studies should assign individual people, not shoulders, to groups. Second, this study used a small healthy sample of convenience derived from a single college campus precluding generalization of the results beyond the sample population. Lastly, the control and experimental treatments both combined a manual touch or technique with a self-stretch procedure, thus results should not be interpreted as resulting from an individual procedure. While limiting the treatments to a single procedure may have demonstrated the outcome of a specific technique, the procedures were combined in this study to replicate a realistic clinical approach to excessive RSP. The use of passive placebo touch in the placebo-controlled design, while complicating the research design and introducing its own potential effect, remains vital to research involving manual therapy to differentiate manual therapy from simple human touch (Cheing and Cheung, 2002).
Conclusion This study has shown that a single session of STM paired with self-stretching to the pectoralis minor muscle reduced RSP for up to 2 weeks compared to passive manual touch and a pectoralis major self-stretch. Overall, the results of this study support the notion that treatment aimed at the pectoralis minor can benefit shoulder posture and muscle function and may be an important component of shoulder rehabilitation (Sahrman, 2002; Lukasiewicz et al., 1999; Borstad and Ludewig, 2005; Wang et al., 1999; Kisner and Colby, 1990).
Acknowledgements The authors wish to acknowledge the contributions of Limone Paljevic who coordinated this research.
Disclosure statement The authors have no conflict of interest to disclose.
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FASCIA CONGRESS ABSTRACT
Neurocognitive enhancement for the treatment of chronic pain Peter Przekop, DO, PhD a,b,*, Allison Przekop, DO b, Mark G. Haviland, PhD a, Matt L. Riggs, PhD c a Department of Psychiatry, Loma Linda University Medical School, 11374 Mountain View Avenue, Loma Linda, California 92354, United States b Department of Pediatrics, Loma Linda University Medical School, Coleman Pavilion, Room A1109 Loma Linda, California 92350, United States c Department of Psychology, California State University, San Bernardino, California 92407, United States
Received 12 July 2009; received in revised form 11 October 2009; accepted 19 October 2009
Abstract Chronic pain remains at epidemic levels in the United States, affecting approximately 20% of the population (Breivik et al., 2006). At present, treatments generally target symptom relief and seldom address improvements in quality of life and overall healing. Recent insights in neurobiology have demonstrated that chronic pain is a degenerative disease of cortical and sub-cortical structures (Tracy, 2008). Thus, treatments can be designed to enhance specific areas of the brain affected by chronic pain and, thereby, improve patients’ cognitive and emotional abilities. For example, specific treatments can be designed that normalize function of frontal lobe areas negatively affected by the effects of chronic pain.
Method 21 patients who had been detoxified from opiate therapy (13 women and 8 men; average age Z 48.5; average time opiate
* Corresponding author. Department of Psychiatry, Loma Linda University Medical Center, 11374 Mountain View Avenue, Loma Linda, California 92354, United States. Tel.: þ1 909 558 4505; fax: þ1 909 558 6090. E-mail address:
[email protected] (P. Przekop).
dependent Z 8 years) with various chronic pain complaints (post laminectomy syndrome, post cancer pain, fibromyalgia, chronic headache, osteoarthritis; average time in pain Z 9 years) were enrolled in a 12-month comprehensive pain management program designed to enhance brain areas affected by pain. Treatments included group process, mindfulness exercises, movement exercises (Tai Chi, Qi Gong, and Yoga), manual treatments (Qi Gong and Neurofascial release), and the establishment of a treatment community. Patients met weekly for group process that addressed emotional and cognitive decision-making strategies, cognitive change, and movement. Patients received monthly manual treatments that consisted of Qi Gong and Neuro-fascial release. All chronic pain patients received the same management program. All were assessed at intake and at months 3, 6, 9, and 12, with a visual analogue pain scale, the Beck Depression Inventory, the McGill Pain Scale (short form), and the Perceived Stress Scale.
Results By month 12, patients’ scores declined dramatically on all tests (growth curve analysis), and these improvements were statistically significant (p < .01); (p < .01, dependent t tests). Mean reductions: visual analogue (7.0 / 2.3), depression (26.4 / 4.6), McGill-somatic (22.7 / 5.4), McGill-affective (7.7 / 1.5), and perceived stress (26.5 / 12.8).
1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.10.003
Neurocognitive enhancement treatment for chronic pain
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Discussion
References
Targeted treatments appear effective in restoring several aspects of chronic pain patients’ lives. Future studies could be designed to address specific pain complaints or test larger populations.
Breivik, H., Collett, B., Ventafridda, V., Cohen, R., Gallacher, D., 2006. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. European Journal of Pain 10, 287e333. Tracy, I., 2008. Imaging pain. British Journal of Anaethesia 101 (1), 32e39.
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CASE REPORT
Rhythmic exercises in rehabilitation of TBI patients: A case report Yigal Goldshtrom, MS*, Gregory Knorr, PT, Iris Goldshtrom, PT, DPT Pillar of Light, Physical Therapy, Address 37-03 Berdan Ave, Fair Lawn, NJ 07410, USA Received 12 January 2009; received in revised form 20 May 2009; accepted 5 June 2009
KEYWORDS Traumatic brain injury; Rehabilitation; Rhythm; Exercise; Cognitive; Motor; Neuroplasticity
Summary Patients who have sustained traumatic brain injury (TBI) often present with a multiplicity of dysfunctions making rehabilitation challenging. Patients who have taken part in studies of rehabilitation exercises that incorporated monotonous timed auditory cues (using a metronome) following cerebrovascular events demonstrated improvement in gait and motor functions. The purpose of this case report is to describe the efficacy of Rhythmic Exercises with Auditory Cues (REAC) to improve functions in a patient, years after their traumatic brain injury. Methods: A single case report of a 24-year-old female patient, nine years post hemispherectomy following TBI that resulted in right hemiparesis. The patient was taught to perform REAC exercises at home. These exercises were designed to activate the body while Alternating hands and feet Bilaterally with Cross-midline movements for a short Duration while synchronizing the movements with a metronome as a Rhythm regulator. Outcome measurements included gait and functional assessment and cognitive and psychological instrument scores that were compared pre and post treatment. Clinical improvement was observed in the patient’s gait pattern with reduced hip hiking motion and increased cadence. There was a decrease in spasticity in the right arm and leg with some isolated volitional movements of the hand and fingers returning. She also regained sensation in her right arm and leg. Cognitive improvement was demonstrated by increased IQ scores from 78 to 94. Published by Elsevier Ltd.
Introduction
* Corresponding author. Tel.: þ1 201 797 8028. E-mail address:
[email protected] (Y. Goldshtrom). 1360-8592/$ - see front matter Published by Elsevier Ltd. doi:10.1016/j.jbmt.2009.06.002
Traumatic Brain Injury (TBI) is a disorder of major personal and public health significance. A study in the United States has reported that among hospitalized TBI survivors in 2003, forty-three percent remained in long-term disability
Rhythmic exercises in rehabilitation (Selassie et al., 2008). Since 2001 there has been sharp increase in the number of TBI as result of the deployment of 1.5 million military personnel to Iraq or Afghanistan. TBI since the start of military operations have become an important source of morbidity in the Iraq and Afghanistan wars (Warden, 2006). A recent study of a U.S Army brigade had found that as many as 4.9% of the U.S. military personnel reported injuries with loss of consciousness (Hoge et al., 2008). Historically, motor recovery is not expected beyond 6e12 months after injury (DeLisa et al., 1999), leaving TBI patients with a wide range of limitations, including cognitive deficits, motor disabilities, emotional and social dysfunctions, personality changes, and changes in appearance (Chesnut et al., 1999). Patients with neuromuscular involvement have difficulty in executing motor actions because of the reduction in movement capabilities and sensations of the paretic limbs, which results in nonrhythmic and asymmetrical sensorimotor control feedback that limits recovery and function (Sibley et al., 2008). Some injuries require craniotomy (removal of part or the entire hemisphere) with result in loss of motor and sensory awareness in the affected limbs. Loss of sensory awareness such as tactile discrimination is an indication of damage to brain area corresponding to the affected body part. Increased tactile discrimination after brain injury corresponds with brain plasticity (brain reorganization) in primary sensory and motor cortices as result of an enlargement of the representations of the trained body parts (Hodzic et al., 2004).
Brain plasticity Brain plasticity refers to adaptations of the neural network or a restructuring of the network both functionally and hemisphericaly (Doidge, 2007). Functional restructuring happens when a cortical area that has a known function assumes additional function, while hemispherical restructure is the adaptation of the function into the opposite hemisphere. The hemispheres exhibit unique and bilateral functions. The right hemisphere, for example, generally process the nonverbal elements of communications like reading facial expressions, while the left hemisphere process the verbal-linguistic elements of communication like speech (Doidge, 2007). Many functions in the brain occur bilaterally like motor, sight, sound and tactile sensations, and some of those functions, like motor functions occur in the contralateral hemisphere (on the opposite side) of the affected limb. TBI can result in loss of motor function contralateral to the injured hemisphere; while many areas of the brain can be involved in TBI we are limiting the discussion here to the cerebral cortex. Regaining motor function depends on neuroplastic processes that can re-establish the function in the opposite hemisphere, ipsilateral of to the paretic limb, which is known as function lateralization. The recent use of brain scanning technologies offer direct evidence of significant neuroplastic restructuring in the cortical motor area of the brain for patients receiving rehabilitation after stroke or cerebral hemispherectomy (Richards et al., 2008). For example, studies of children after cerebral hemispherectomy reported increased cortical activation both contralaterally and ipsilaterally post hemispherectomy in
337 the primary sensorimotor (S1M1) and the secondary motor areas in the remaining hemisphere. These results were noted following intense gait training using Body WeightSupported Treadmill Training (BWSTT) on a treadmill with rhythmic passive/active activation for two weeksd60 h total training (de Bode et al., 2007). Evidence of brain reorganization under functional MRI (fMRI), specifically ipsilateral to the affected limb, have also been reported in several studies with chronic stroke patients (Calautti and Baron, 2003; Gerloff et al., 2006) with patients recovering from motor deficit after stroke using traditional rehabilitation methods (Dong et al., 2007; Green, 2003; Jang et al., 2007). Multiple studies revealed under fMRI and positron emission tomography (PET) scans that hemispheric adaptation occurs naturally when movement is combined with rhythm. When fingers of one hand are tapped, the activity will be detected in the contralateral hemisphere. However, multiple studies have shown that when finger tapping is combined with an external auditory rhythmic beat the activity had been detected in the ipsilateral hemisphere (Del Olmo et al., 2007; Horenstein et al., 2009; Thaut, 2003). Using PET, increased blood flow to the brain was visualized during rhythmic tapping, like tapping one finger, which activates parietothalamic and premotor activity, predominantly ipsilateral to the finger that is tapping (Thaut, 2003). These studies demonstrated that simple rhythmic finger movement has the effect of developing awareness bilaterally (Horenstein et al., 2009), which is precursor to re-learning motor and cognitive function deficits after brain injury.
Rhythmic exercises with auditory cues (REAC) in rehabilitation The effect of rhythmic activation of the extremities during exercises with resultant brain plasticity and recovery have been proposed in multiple studies; some were studying movement patterns while others have used fMRI to study how the brain is activated in response to timed movements. This case report describes a rehabilitation process with rhythmic exercise program called Rhythmex, a REAC program using exercises with a metronome. Each exercise is guided by five principles labled ABCD & R: A. B. C. D. R.
Alternating hands and feet in movements Bilateral activation of the body and extremities Cross-midline movements Duration of exercise Rhythmic auditory cues (via metronome)
The following studies demonstrate these principles: Bilateral alternating hand and feet exercises foster bilateral cortical activation which generates multisensory crossmodal spatial mapping of vision and touch (Gray and Tan, 2002). The expected result is greater awareness unilateral of the affected limb as a precursor for functional lateralization. Bilateral or bimanual movement training as a single modality or in combination with other modalities has
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Y. Goldshtrom et al. been found to be effective in stroke rehabilitation protocols during the sub-acute and chronic phases of recovery (Cauraugh et al., 2009; Cauraugh and Summers, 2005; Stewart et al., 2006). Bilateral training has been found to improve motor coordination in the affected limb in patients with central or peripheral impairments (Cauraugh and Summers, 2005; Luft et al., 2004; Mudie and Matyas, 2000; Whitall et al., 2000). Some studies did not find bilateral movement training alone to be effective with stroke patients (Desrosiers et al., 2005). Bilateral Arm Training With Rhythmic Auditory Cueing (BATRAC), a repetitive bilateral arm movement exercise has been found to be effective for upper extremity rehabilitation after stroke (Waller and Whitall, 2008; Whitall et al., 2000) Walking exercises with Rhythmic Auditory Stimulation (RAS) have been shown to improve gait with Parkinson’s patients (Ellis et al., 2008; Password, 2007; Thaut et al., 2007, 1997, 1996), and another study with Parkinson’s patients used spatial and temporal rhythmic visual cues to change and improve the patients’ walking speed on a treadmill (van Wegen et al., 2006). Another study using RAS protocol with children diagnosed with Cerebral Palsy reportedly improved their gait performance (Kwak, 2007). Active-Passive Bimanual Therapy (APBT) using passive rhythmical flexion-extension repetitions has been proposed for upper extremities among stroke patients (Stinear et al., 2008) Body Weight-Supported Treadmill Training (BWSTT) with rhythmic cues has been proposed for lower extremity rehabilitation among children after hemispherectomy (de Bode et al., 2007). Cross-midline movement activation creates dynamic multisensory crossmodal integration that can restore body-part perception, improve motor action execution, and body-part self-awareness (Maravita et al., 2003). Body-part awareness and motion activation occur contralaterally in each hemisphere, where sensory information (vision, tactile and audio data) integrates into a dynamic baseline spatial map which then develops into sensory, movement, and overall self-awareness. Studies of cross-limb actions have revealed cross-cortical cooperation in remapping of visual space that occurs while tracking the hand’s positions as it crosses midline (Macaluso and Driver, 2005; Spence et al., 2001). Brain exercises are learning activities, as the brain learns a new task from a novice state to improved performance, different areas of the brain become active. As the neural networks switch from controlled activation into automatic activation a reduction in the general neural activities occurs (Grill-Spector et al., 2006). The ‘‘learned’’ movement is distinguished from a novice conscious movement by its being automatic, rapid, and stereotyped (Thach, 1996). Learning (i.e. movement) for more than 15 min switches the activities in the cortex to an automatic process that prohibits new learning (Raichle et al., 1994).
The use of rhythmic auditory cues in rehabilitation was first proposed in a study among stroke patients (Whitall et al., 2000) which facilitated bilateral arm training using
two levers in a push/pull uniform motion regulated by a metronome. This approach has since been replicated elsewhere (Luft et al., 2004; Stinear and Byblow, 2004; Waller and Whitall, 2004). Even a short period of rhythmic walking among patients with incomplete spinal cord injuries has demonstrated improvements in the gait parameters of cadence, velocity, and stride length (de l’Etoile, 2008). However, when a bilateral training exercise was used with stroke patients but without auditory cues, it did not result in better outcomes compared to the regular exercise protocol (Desrosiers et al., 2005). The purpose of this paper is to report the effect of rhythmic exercises, and in particular on Rhythmex REAC protocol with a single patient with TBI who has improved significantly nine years post hemispherectomy (partial removal of her left hemisphere) for 12 months of Rhythmex exercises. Studies that use REAC protocol have been limited by the extremity they activate; upper extremities in BATRAC and APBT, and lower extremities in RAS and BWSTT, and the devices they use for these activities. Rhythmex is a natural all body movement exercise with the goal of restoring functional movement patterns using rhythmic motions, however small in amplitude, and is adaptable to many dysfunctions, their severity, and exercise settings.
Method Profile of the patient Jill (assumed name) is a 24-year-old female who is presented with Traumatic Brain Injury (TBI) as result of a sledding accident at age 15. She suffered an intracranial hemorrhage, brain contusion, and left open depressed skull fracture that required hemispherectomy twice. Post-operatively, she experienced increased intracranial pressure with hydrocephalus and excess Cerebral Spinal Fluid collection that required shunting on two occasions. Her recovery was complicated by seizures. She presented with refractory seizures that were moderate in intensity and was taking anti seizure medications, to reduce the number of episodes. Motor control As in most cases of patients with TBI and stroke with damage to the motor control centers, her gait demonstrated a combination of deviationsdincluding hip hiking and circumduction, and lack of active dorsiflexion that required a correction by Ankle Foot Orthotics. Her right upper extremity had strong flexor spasticity; no volitional motion below the elbow, and her right hand was fisted and therefore she had to wear a splint. During walking the flexor spasticity in the right upper extremity increased with the elbow gradually flexing to 100 degrees. Dorsiflexion of the affected ankle was minus two degrees when passively ranged, and she had strong clonus when the ankle was forcibly dorsiflexed. She was unable to negotiate stairs functionally and she also had poor balance standing and walking, even with the use of a cane. Her hip joint on the affected side was moderately retracted, as was the shoulder.
Rhythmic exercises in rehabilitation Sensory awareness Jill displayed deficit in her tactile awareness of the affected limbs. She had a complete loss of her sensation to touch from the elbow to the fingers in the right arm and from the knee to the toes in the right foot. She also had right hemianopsia (blindness in one half of the visual field), and expressive aphasia, with resultant difficulty reading, and impaired comprehension and speech. Rehabilitation history In the first two years after the accident, Jill received intensive inpatient physical therapy, and thereafter weekly physical therapy in residential programs. According to her physical therapy reports she received passive and active stretching and gait training. She was discharged from physical therapy completely in 2005 two years before she came to our clinic. She also received occupational therapy, and had participated in a cognitive program to improve her reading ability. Currently, Jill lives in a supervised residential community for individuals with chronic TBI. She sought services in our clinic looking for improvement in her gait, spasticity and functioning of her right hand.
The treatment plan The guidelines in choosing an effective treatment modality for Jill were governed by several factors. One, the chronic stage of her dysfunction nine years post trauma, second, the history of her rehabilitation in the past including passive range of motion, muscle strength, and gait training, and third, the significance of the existing limitations of the involved extremities; the high level of spasticity and low level of mobility and functionality. These limitations preclude the use of techniques like Constraint-Induced (CI) movement therapy for her upper extremities (Taub et al., 2006) due to lack of function in her right hand, BATRAC was excluded due to the spasticity in the shoulder, RAS and similar techniques because of spasticity in the right leg. Rhythmex exercises were chosen because they can be utilized and beneficial even with minimal range of motion. Treatment guidelines and procedures Treatment guidelines followed the ABCD&R principles of the Rhythmex method. A. Alternating upper and lower extremities (like in walking; left leg movement is synchronized with right arm movement and vice versa) B. Bilateral activation of both sides of the body in a reciprocal movement C. Cross midline, hands should cross the midline in movement D. Duration, each exercise was executed 30e90 s before a break R. Rhythmic auditory cue with the metronome Each session starts with an assessment of current limitations, matching the limitations with an appropriate exercise. During each exercise movements must be self
339 generated by the patient and actively executed, regardless of the amplitude of the motion. For example, at the beginning of Jill’s rehabilitation the movement of the affected right arm was limited to the shoulder joint at a range of 10e15 degrees flexion with horizontal adduction and strong elbow flexion to 100 degrees, while the left arm had a normal swing. The rhythm’s tempo was determined by the patient. Once the activity started the clinician observes the actual tempo the patient was able to perform and sets the metronome accordingly. There was no goal tempo or course of progression goals for the tempo. The auditory cue serves as an attention grabber and the tempo should be set comfortably for the patient’s ability. Exercise duration was limited to allow the patient to be active but not fatigued, to prevent the brain switching from control activation to automatic activitation. The duration of each exercise for this case varied between exercises in the range of 30e90 s following 30e60 s resting and about 10 repetitions for each set. The Rhythmex exercises When we began with the Rhythmex exercises, we modified the principles of alternating upper and lower extremities to address Jill’s limitations due to her tightness and increased spasticity. Jill was presented with exercises that activated upper extremities only and separately exercises that activate the lower extremities. The goal was to synchronize upper and lower extremities. The following are examples from Jill’s exercise regimen in the last six months of the rehabilitation including 4 exercises targeting her pelvic area and right shoulder spasticity, 2 of them performed lying on an exercise mat to avoid abnormal gait activation and loss of rhythm, one exercise was performed while standing in place, and one while in the quadruped position. Wag-the-tail The exercise was performed in quadruped position offering distal stability while activating the core muscles. Jill was instructed to side bend the pelvis from left to right with the metronomed40 beats/min for 1 min followed by a rest with 10 repetitions. Upside down bicycle The patient was lying on her back with her feet off the mat, and hips and knees flexed 90 degrees. This position allowed stability of the torso and mobility of the legs. She simulated riding a bicycle, with one leg extending while the other was flexing, with the metronome set ond42 beats/min for 90 s, with a brief 30 s rest the sequence repeated 10 times (Fig. 1). Cross-over bicycle The patient was lying on her back with the feet on the floor, alternately bending each knee and touching it with the opposite hand (Figs. 2 and 3). In this position she benefited from the stability of the trunk and the resting foot. The goal was to achieve 2e5 min of continuous activity per day with the metronomed40 beats/min for 90 s, with a brief 30 s rest repeating the sequence 10 times. This exercise
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Figure 1
Upside down bicycle.
accomplished all the ABCD&R principles; Alternating arms and legs, bilateral activation, crossing midline, sustaining the duration and keeping up with the rhythmic beat. When Jill began the exercise, she could not bring the right (paretic) hand to touch the left leg, but over time her arm became more functional to the point where she now stretches her hand to touch the knee.
Figure 3
Right-hand (paretic) touches left knee.
Results This case report documents a year in Jill’s rehabilitation using Rhythmex, a rhythmic exercises program. Over that period, Jill came to the office every 2e3 weeks and most of
Dancing Starting position is standing with hips and knees slightly bent. The instructions were to shift the weight to the right leg maintaining the hip and knee in flexion while rotating the torso to the left and at the same time allowing the arms to cross midline (Fig. 4). The same movement is then repeated to the opposite side, shifting the weight to the left foot and rotating to the right (as in a dancing motion) keeping the beat with the rotation. Metronome was set to 30 beats/min for 90 s, with a brief 30 s rest and the sequence repeated 10 times. Initially, Jill was not able to shift her weight sideways and rotate her upper body. We began with gentle weight shift, rocking the pelvis side to side to the metronome, within the range allowed by her spasticity. Gradually the spasticity in her hips decreased and Jill gained control over the lateral weight shift. As she progressed in the activity, she gained control over the upper body rotation and with it the ability to cross midline with her arms.
Figure 2
Cross-over bicycledleft-hand touches right knee.
Figure 4 Jill shifting her weight to the left rotating her upper body to the right and crossing midline with her left arm e dancing.
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her workout was done as a home program by herself. During the office visit, she performed all of her exercises while the team modified her exercises (i.e., changing target range of motion, or beat rate) based on her progress and the specific functional goals (see Appendix A). She reportedly spends 20e30 min a day (not counting set up time and rests) 4e5 days a week for 12 months practicing Rhythmex exercises. During that time Jill has shown gradual improvements in several key areas including gait and independent mobility, functional use of the right paretic arm, cognition, and psychological factors.
Gait and independent mobility Jill’s primary goals were to improve her gait and independent mobility. Gait was assessed by her walking pattern and cadence (number of steps per minute), while independent mobility was assessed by balance reactions and coordination of the upper and lower extremities and the trunk. Jill has improved her balance and coordination while in motion as result of reduced spasm in the pelvic area and increase of pelvic stability and isolated hip function, resulting in less hip hiking of the right hip during the swing phase of gait. The improved coordination carried through to her gait pattern, with improvement in cadence, from about 4 steps per 10 s with foot brace (0.4 m/s), to 12 steps per 10 s without a brace and 14 steps with a brace (1.4 m/s). According to the Speed-Based Classification System, Jill’s walking speed has improved from the lowest category of ‘‘household’’ speed to the highest category of ‘‘community’’ speed (Bowden et al., 2008). An additional parameter of improvement of the leg was the return of sensation to touch that was impaired from the knee to the toes since the injury.
Figure 5 The spasticity in her fingers decreased and the fist began to open spontaneously at rest.
2003 her Full Scale rose by merely 2 points to 78 (7th percentile) with Verbal IQ of 78 and Performance IQ of 83. In repeated evaluations in 2005 her WAIS-III Full Scale IQ scores did not change. In April 2008, a few months into the rhythmic exercises, Jill requested to be tested again as part of the application for accommodations during GED testing, because of her difficulty in reading due to the hemianopsia. This time, all of her scores rose markedly: Full Scale rose to 94 (34th percentile) with Verbal IQ of 89 and Performance IQ of 100 (VIQ and PIQ difference of 32.4%).
Levels of agitation
Hand function and ADL Jill’s goals for her right hand were to reduce the spasm and need of the splint, and to gain function. When treatment began Jill wore a hand splint stabilizing her right wrist in approximately 10 degrees of extension. With the splint removed the strong flexor spasticity dominated her posture with wrist flexion and tight fisted fingers. At the present time Jill no longer wears a splint, the hand is held in a relaxed posture (see Fig. 5) and there is reduced tone in the finger and wrist flexors. Jill began gaining isolated function of the hand and fingers (see Fig. 6), being able to pick up a small object between the thumb and index fingers of the right hand. Jill has been using her right hand in ADL activities such as washing dishes and fastening her seat belt. In addition, when initially seen, Jill had no sensation in her right hand from the elbow to fingers. Over the year she experienced sporadic returns of sensation to touch with the ability to discriminate the location. At present she has regained full sensation to touch from the elbow to the fingers.
One of the instruments available for measuring the severity of the brain injury is agitation; and the level of engagement in TBI patients is the Agitation Behavioral Scale (Corrigan, 1989; Lequerica et al., 2007). An instrument with
Cognitive skills Jill has been given several neuropsychological evaluations since her accident in 1999. Her WAIS-III Full Scale IQ evaluation in 2000 was measured at 76 (5th percentile) and in
Figure 6
Picking up an object with relaxed fingers.
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three subscales: Disinhibition, Aggression, and Lability (adaptability to change). A comparison between her state of agitation as measured by the Agitation Behavioral Scale, completed by her parent to reflect Jill’s behavior at the beginning of our treatment in 2007 with a second observation after a year in the program have showed improvements in all of its subscales (See Fig. 7).
Discussion This case report describes the use of Rhythmex, a rhythmic exercise program with auditory cues (REAC) protocol in treating a TBI patient nine years post craniotomy. Several studies in the last decade have showed the benefit of REAC in rehabilitation of patients after stroke and Parkinson’s disease, and with children with Cerebral Palsy. Rhythmex promotes five exercise principles labeled: ABCD & R to inspire spontaneous brain reorganization and re-learning of functions that have been impaired or lost due to brain injury. Exercises must activate the body extremities in an Alternating fashion Bilaterally, while the movements should Cross midline, and with each exercise Duration should only last 30e90 s before resting. The individual exercising must synchronize the movement to a constant Rhythm (such as a metronome). Brain training exercises are learning modalities and unlike muscle training, learning occurs in small windows (the ‘‘novice’’ phase) and intends to bring diminishing results with increase in the length of practice, as the brain switches from control to an automatic activation. Rhythmex training adapts to the ‘‘novice’’ windows in two ways. First it limits the practice to 20 min a day while breaking down each exercise to 30e90 s units, and second by adapting the exercises as their novelty wears off. Options for changing the exercise include increasing the tempo or changing one or all of the movement parameters (i.e., direction, distance, position, etc.).
Rehabilitation with rhythmic exercises When Jill arrived in the clinic she complained she had reached a plateau in her progress toward function using traditional rehabilitation programs. She demonstrated no
ABS Subscale Scores 25
Disinhibition Aggression Lability
20
15
10
5
0 2007
Figure 7
2008
Agitation behavioral subscales scores.
functional improvement since she was released from a rehabilitation program at a university hospital two years after the accident and was sent to live in community residency. When she arrived in our clinic in 2007 she was nine years post TBI. Two years earlier she had been released from all out patient physical therapy services, yet she still showed multiple impairments. The specific disabilities Jill presented in 2007 excluded her as a candidate for rehabilitation methods such as Constrained Induces therapy or any of the REAC (rhythmic) based methods such as BATRAC or RAS because walking was labored for her and she had minimal range of motion in the paretic arm. Rhythmex was suggested because of its flexibility and versatility. For example, after analyzing her level of spasticity and her movement restrictions, it was decided that the best beginning posture for her is in supine (lying on the back) which allows her the highest degree of control over her movement, and although her trunk was supported she could freely move her extremities. Rhythmex allows any small movement to inspire brain reorganization if the motion is active and the individual coordinates the movement with a metronome. Jill started her rehabilitation in our clinic in 2007, her goals were to gain independent mobility and improve the function of her right hand. During the year Jill practiced Rhythmex exercises and regained independent mobility and function (see Appendix A). Her progress covered gross motor functions, sensory awareness, cognitive and psychological functions. Motor improvement included decreased spasticity of the right hand with improved spontaneous movement that allowed the use of the hand to assist in ADL. Spasticity decreased at the right pelvis and hip improving Jill’s gate pattern and cadence. Jill’s balance reactions had improved and she is able to perform activities like walking without her cane, climbing stairs independently and walking backwards. Jill regained her sensation to touch on the right arm and leg. Her cognitive function as measured on standardized IQ tests has improved raising from the 7th percentile to an average level of 34th percentile and opening her possibilities in education. She passed the GED exam and is currently in courses to improve her reading ability in preparation to enroll in college. There has been improvement in her stress level as evident by lowering the agitation level as measured by the ABS scores. Jill is now looking to leave the community residency, find an apartment and planning to get a job. She feels confident taking a train or a bus to a major city or to school by herself, and she enjoys going out with friends. We find that some of the physiological and cognitive improvements in the past year can be attributed to the rhythmic exercises. We recognize that rehabilitation through rhythm has the potential to facilitate changes in brain organization even in patients who have plateaued. The use of rhythmic exercises in this case has correlated with improved motor and cognitive functions bilaterally, regaining movement patterns that were lost or impaired due to the severe brain injury, suggesting that brain reorganization was still able to occur, even this long after her injury. Furthermore, this case shows that rhythmic exercises carried out as home program with sporadic follow up sessions every 2e3 weeks, can be effective in bringing about significant improvements in a multitude of functions
Rhythmic exercises in rehabilitation that include: physiological, psychological, and cognitive, even in a patient nine years post injury. More studies of rhythmic exercises are needed to explore and confirm the effect of rhythmic movement under REAC protocol on brain reorganization and function lateralization.
Appendix A Assessment of outcomes summary
Observation/test Gross Motor Upper Extremities Paretic right hand
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References Bowden, M.G., Balasubramanian, C.K., Behrman, A.L., Kautz, S.A., 2008. Validation of a speed-based classification system using quantitative measures of walking performance poststroke. Neurorehabil. Neural. Repair 22 (6), 672e675. Calautti, C., Baron, J.-C., 2003. Functional neuroimaging studies of motor recovery after stroke in adults: a review. Stroke 34 (6), 1553e1566.
Pre intervention evaluation 2007 Goal: Functional ADL Right upper extremity under the influence of a strong flexor spasticity; no volitional motion below the elbow Right hand splinted in 10 degrees extension
Lower Extremities Climbing stairs
Goal: Independent Mobility Unable to climb stairs without holding the rail or using a cane
Ambulation
Difficulty in ambulating and often use of a cane Unable to ambulate backwards
Cadence
4 per 10 s with ankle foot orthotics (0.4 m/s) e ‘‘household’’ speed
Hip hiking
Marked hiking of the right hip during the swing phase of gait
Sensory Awareness/Fine Motors Tactile discrimination
No discrimination to superficial finger touching in right arm from the shoulder to fingers
No discrimination to superficial finger poking touch in the right leg from knee to toes Cognitive WAIS-III Full Scale IQ evaluations
Psychological Agitation Behavioral Scale (ABS) - An instrument with three subscales: Disinhibition, Aggression, and Lability.
Post intervention evaluation 2008
Spasticity of fingers has decreased and the fist has begun to open spontaneously. Right arm used more in ADL functions like washing dishes and strapping the safety belt in the car. Can climb stairs without assistance, holding the rail, or a cane Ambulating freely without any assistance Able to ambulate backwards without assistance at least 60 feet 12 per 10 s without a brace and 14 with a brace (1.4 m/s) e ‘‘community’’ speed Increased pelvic stability and isolated hip flexion resolving hip hiking Consistent awareness to superficial finger touching of right arm between the shoulders and wrist Consistent awareness to superficial finger poking touch in the right leg from knee and ankle Partial awareness to touch in fingers and toes
Jill’s WAIS-III Full Scale IQ evaluation in 2000 was measured at 76 (5th percentile), repeated tests in 2003 and 2005 show that her Full Scale rose by merely 2 points to 78 (7th percentile) with Verbal IQ of 78 and Performance IQ of 83.
In 2008 her Full Scale rose to 94 (34th percentile) with Verbal IQ of 89 and Performance IQ of 100 (VIQ and PIQ difference of 32.4%).
2007 ABS scores e Disinhibition (22.55), Aggression (17.5), and Lability (18.6)
2008 ABS scores e Disinhibition (17.5), Aggression (14), and Lability (14) e lower agitation level.
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Journal of Bodywork & Movement Therapies (2010) 14, 346e351
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PHYSIOLOGY
Maximal clenching effort influence on the electromyographic activity of the trapezius muscle in healthy subjects* Fabiano Politti a,b,*, Cesar Ferreira Amorim d, ´via Dare ´ Guerra a, Luis Henrique Sales Oliveira b,c, Fla Ivan Luis Souza Pieres a, Evanisi T. Palomari a a
Departments of Anatomy, Cell Biology and Physiology and Biophysics, State University of Campinas (Unicamp) Brazil Department of Physical Therapy, Rehabilitation Sciences Biomechanics Lab, University of Vale do Sapucaı´ (Univa´s), Brazil c Department of Plastic Surgery, Federal University of Sa˜o Paulo (UNIFESP), Brazil d Department of Mechanical Engineering, State University of Sa˜o Paulo (Unesp-FEG), Brazil b
Received 28 January 2009; received in revised form 29 May 2009; accepted 5 June 2009
KEYWORDS Electromyography; Masticatory apparatus; Clenching; Trapezius muscle
Summary Alteration of the occlusion and the position of the jaw can affect the muscles of the neck, due to a relationship between the masticatory and cervical systems. Thus, the objective of this study was to verify whether the bite in maximal clenching effort, in centric occlusion, in individuals with clinically normal occlusion, and without a history of dysfunction in the masticatory system, influences the electromyographic activity of the upper trapezius muscle. A total of 19 normal individuals participated in the study, 14 of which were women (average age of 25.4 4.14 years), and 5 were men (average age of 24.11 3.28 years). The root mean square (RMS) amplitude and median frequency (MF) of the upper trapezium muscle with 40% and 60% of maximal voluntary contraction were analyzed under pre- and post-maximal clenching effort conditions in centric occlusion. The electromyographic signal was collected with a sampling frequency of 2 kHz and the value in RMS was obtained by a moving window of 200 ms. The paired Student’s t-test was used to compare RMS amplitude and MF under preand post-maximal clenching effort conditions. The level of significance for each comparison
* ´S, Department of Physical Therapy, Rehabilitation Sciences Work accomplished at the University of Vale do Sapucaı´ e UNIVA Biomechanics Laboratory. * Corresponding author. Universidade Estadual de Campinas, UNICAMP, Depto de Anatomia, Instituto de Biologia, Cx Postal 6109, CEP 13084-971, Campinas e SP, Brazil. E-mail address:
[email protected] (F. Politti).
1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.06.001
Maximal clenching effort
347 was set to p < 0.05. This study concluded that in individuals without a history of dysfunction of the masticatory system, maximum clenching effort in centric occlusion does not alter the electromyographic signal of the upper trapezius. ª 2009 Elsevier Ltd. All rights reserved.
The trigeminal system is composed of neurons with peripheral extensions that connect to the neuromuscular shafts of the masticatory musculature, to receptors in the temporomandibular joint and to the teeth. These peripheral extensions have the function of informing the position of the jaw and the bite force through the synapses with the neurons of the motor nucleus of the trigeminal nerve, thus forming the simple myotactic reflex arches, also called mandibular reflex (Costacurta, 1979). The existing reflex arch in the trigeminal system allows the afferent relationship of the trigeminal nerve with proprioception of the dental occlusion, vision and standard corporal posture (Gangloff and Perrin, 2002). Furthermore, it also has an important functional relationship with the cervical system, through the inhibition and reciprocal coactivation of the mandible, neck and shoulder during the performance of upper limb positioning, as verified in specific tests (Ferrario et al., 2003; Ciuffolo et al., 2005). Dysfunctions in the masticatory system can induce in the trapezius muscle a condition of hyper-contraction in response to the nociceptive signal in the acting area of the trigeminal nerve (Gola et al., 1995). This muscle is recruited systematically to produce stability at the neck and frequently it can be activated by pain reflexes as a protective mechanism. This increased recruitment of the trapezius muscle may change its ability to sustain prolonged contractions in patients with temporomandibular joint disorders (TMD), which may lead to significant changes in body posture. A relationship between increased muscle EMG activity in the neck muscles and myofascial pain has been observed in subjects with TMD (Pallegama et al., 2004; Tecco et al., 2008). This myofascial pain might not be limited just to these neck and masticatory muscles, but might spread out to several body parts, for example to the shoulder region (Pedroni et al., 2006; Munhoz et al., 2004). These findings, associated with the complex anatomical and biomechanical interaction between the stomatognathic system and the head and neck regions, have led many scientists to discuss these relationships (Mannheimer and Rosenthal, 1991; Darling et al., 1994). As demonstrated by many studies, regardless of the known relationships between the masticatory system, the neck muscles and the scapular waist, it is hypothesized that the activity of these muscles is altered only in cases of dysfunction of the masticatory system (Pedroni et al., 2006; Ciuffolo et al., 2005; Munhoz et al., 2004; Ferrario et al., 2003; Gola et al., 1995). Thus, the objective of this study was to verify whether the bite, in maximal clenching effort, in centric occlusion, in individuals with clinically normal occlusion and without a history of dysfunction in the masticatory system, influences the electromyographic activity of the upper trapezius muscle, as happens in individuals with disturbances in the masticatory apparatus mentioned by the literature.
Material and methods Subjects The subjects of this study are 19 volunteers, 14 of whom were women (average age of 25.4 4.14 years), and 5 were men (average age of 24.11 3.28 years), all were undergraduate and graduate students in the University of Vale do ´S, Minas Gerais State, Brazil. Eligible Sapucaı´ e UNIVA subjects were screened for TMD according to Axis I of the Research and Diagnostic Criteria e RDC/TMJ (Dworkin and LeResche, 1992). To be included in the study, the subject had to meet the following criteria: (a) adult age (>18 years); (b) pain-free active mouth opening >40 mm (including overbite), pain-free active protrusion and laterotrusion >7 mm; (c) difference between active and passive opening 62 mm; (d) positive overjet and overbite between 0 and 4 mm; (e) willingness to participate in the study and to sign a written informed consent. Exclusion criteria were: (a) any TMD diagnosis; (b) chronic pain conditions (>3 month duration) in other parts of the body; (c) current orofacial inflammatory conditions; periodontal diseases; (d) removable dental prostheses; (e) absence of any teeth (except third molars); (f) neurological and movement disorders; and (g) habitual intake of drugs influencing the activity of the central nervous system. Shoulder and cervical spine normality of was determined by these specific tests: (a) Neer’s Test (Neer, 1983): the test is performed by placing the arm in forced flexion with the arm fully pronated. The scapula should be stabilized during the maneuver to prevent scapulothoracic motion. Pain with this maneuver is a sign of subacromial impingement; (b) Hawkins’ Test (Hawkins and Kennedy, 1980): it is performed by elevating the patient’s arm forward to 90 while forcibly internally rotating the shoulder. Pain with this maneuver suggests subacromial impingement or rotator cuff tendonitis; (c) Instability Testing (Harryman et al., 1990, 1992): the tests described in this section are useful in evaluating for glenohumeral joint stability. Because the shoulder is normally the most unstable joint in the body, it can demonstrate significant glenohumeral translation (motion). Again, the uninvolved extremity should be examined for comparison with the affected side; (d) Posterior Apprehension and Instability (O’Driscoll, 1991): with the patient supine or sitting, the examiner pushes posteriorly on the humeral head with the patient’s arm in 90 of abduction and the elbow in 90 of flexion; (e) Spurling’s Test (Palmer and Epler, 1998): the patient’s cervical spine is placed in extension and the head rotated toward the affected shoulder. An axial load is then placed on the spine. Reproduction of the patient’s shoulder or arm pain indicates possible cervical nerve root compression and
348
Figure 1 Test position as the individual elevates the shoulder ipsi-lateral to the dominant arm (A) against the resistance of the load cell (B).
warrants further evaluation of the bony and soft tissue structures of the cervical spine. All volunteers signed a Term of Consent as required by resolution 196/96 issued by the National Health Council and previously approved by the Ethical Committee in Research ´S. Each subject from the University of Vale do Sapucaı´e UNIVA was informed of the purpose and potential risks of the study before their written voluntary consent was obtained.
Equipment Myoelectric signals were obtained using an 4-channel module (EMG System do Brazil Ltda), consisting of a band pass filter of 20e500 Hz, an amplifier gain of 1000, and a common rejection mode ratio >100 dB. All data were acquired and processed using a 16-bit Analog to Digital converter (EMG System do Brazil Ltda), with a sampling frequency 2 kHz. The system was composed of active bipolar electrodes displaying a pre-amplification gain of 20. A channel of the acquisition system was enabled for the utilization of the load cell (Alfa Instruments), having an output between 0 and 20 mV and a range up to 1 kN.
Procedure and data collection Muscle activity was recorded from the upper trapezius, selected because it can be affected by a masticatory dysfunction (Gola et al., 1995) and is always related to tension pain of the head and neck. The bipolar surface circular electrodes (Ag/AgCl e Medical Trace) with 10 mm diameter, were used for the surface recording of EMG with a center to center distance of 20 mm. The electrode was positioned with the medial
F. Politti et al. recording area 20 mm lateral to the midpoint of the line between the C7 spinous process and the acromion (Jensen et al., 1993). A reference electrode was fastened in the C7 spinous process of the volunteers. Before beginning the recording of EMG signals, each individual subject was asked to carry out a series of three maximum force elevations of the shoulder of the dominant arm, with duration of 3 s each, against the resistance offered by the load cell (Figure 1). A 2-min rest period was given between efforts. The mean value from the three trials obtained against the resistance offered by the load cell, represented a subject’s 100% maximum force (MaxForce) elevation of the shoulder. The two sub-maximal force (40% and 60% MaxForce) were used in the analysis activity of upper trapezium muscle in the situation pre- and post-maximal clenching effort (MCE). Initially, the data was collected as the subject tractioned a load cell by elevating the shoulder at 0 upper limb adduction, until reaching 40% and 60% of previously determined MaxForce (pre-MCE). After a 10 min rest, data was collected (post-MCE) under the same sub-maximal conditions (40% and 60% of the upper trapezium MaxForce) as the individual bit two cotton rolls (8 mm thick), positioned in the first and second molar as done by Ferrario et al. (2000) in a similar study. The criteria for the recording of the EMG signals were always the same for all stages of the experiment. At each moment (pre- and post-MCE), 40% and 60% MaxForce samples were collected and maintained through visual feedback provided by a line drawn on the computer screen. The duration of each EMG signal sample was 5 s. In order to avoid a learning effect, the order of the sample collection (40% or 60% MaxForce) was determined by blind draw. Possible risks of bodily compensation during the traction of the load cell and of patterning in the whole experiment were prevented through training before all the tests. Of greatest concern during the experiment was that the head and neck should always be maintained in the same position, so as to avoid interference from the upper trapezius muscle in the activity.
Processing and analysis of the signals Amplitude signal analysis The EMG signals was obtained during the 40% and 60% of MaxForce contractions under the conditions pre- and postMCE. Each sample lasted 5 s with a rest interval of 2 min. The root mean square (RMS) was calculated using a 200 ms moving window. Frequency signal analysis A power spectral analysis was performed on the 5 window for upper trapezius muscle. A fast Fourier transform of 512 points (Hanning window processing) was performed on 19 consecutive, 512 ms segments, overlapping each other by half their length (256 ms), for each 5 s contraction. The Median frequency (MF) was determined from each of the 19 overlapping windows. The mean and standard deviation of the FM during each contraction were calculated for upper trapezius muscle. EMG Analysis Software, Version 1.01 (EMG System do Brasil, Ltda) was used. The basic assumption for the use of spectral characteristics of the signal for inferring motor control strategies or changes in fiber membrane
Maximal clenching effort
349
Figure 2 Mean (standard deviations) of RMS of the upper trapezius muscle at pre- and post-MCE conditions during the elevation of the shoulder at 40% and 60% of MaxForce. Not significant difference was found between the pre- and postMCE (Paired Student’s t-test: p > 0.05).
Figure 3 Mean (standard deviations) of Median Frequency (MF) of the upper trapezius muscle during the elevation of the shoulder. No significant difference was found between pre- and post-MCE, with 40% (t Z 1.44, p Z 0.16) and 60% (t Z 0.83, p Z 0.41) of MaxForce (Paired Student’s t-test).
properties is the scaling effect that muscle fiber conduction velocity has on the power spectrum of the signal (Lindstrom and Magnusson, 1977; Stulen and DeLuca, 1981).
between the masticatory and cervical muscles (Zafar, 2000; Milanov et al., 2001). According to the results of this study, this is reflex is absent which means that MCE in centric occlusion, does not cause a widespread excitation of the trapezius muscle in individuals without a history of dysfunction in the masticatory system. Similar results were also found in subjects with normal mandibular divergence and lower and higher mandibular angles (Tecco et al., 2007). However, a significantly higher EMG activity in sternocleidomastoid and upper trapezius muscles has already been verified during maximal voluntary clenching in retrusive occlusal position, as well as no significant differences in EMG activity between intercuspal position, ipsi-lateral, contralateral and protrusive positions (Zuniga et al., 1995). The EMG pattern observed suggests that the position of the mandible can interfere in the functional link between the masticatory and cervical muscles. The performance of the upper member positioning can also be influenced by mandibular positioning (Ferrario et al., 2003; Ciuffolo et al., 2005). The observations about the mandibular positioning, and the fact that the EMG signal readings were carried out only in centric occlusion, demonstrate that the methodology used in this study affected the results. A possible functional link between the masticatory and cervical muscles is more evident in individuals with dysfunction of the masticatory system. In situations of dysfunction of the masticatory system, the trapezius muscle receives afferent nociceptive signal via the trigeminal system, remaining hyperactive while the nociceptive stimulus lasts. Changes in shoulder position could develop because the masticatory muscle hyperactivity leads to cervical muscle hyperactivity, with contraction of the muscles responsible for shoulder elevation and protrusion (Mannheimer and Rosenthal, 1991). This hyperactivity, which can be related to occlusion dysfunction can also affect neck muscles (Ferrario et al., 2003; Ciuffolo et al., 2005). These observations are clear indications that a modulating activity of muscles such as the trapezius can be altered by the nociceptive signal caused in the activity
Statistical analysis Data of EMG activity from the upper trapezius muscle are presented as means and standard deviations (SD). The parametric Student t-test for paired data was used to compare the difference of the RMS amplitude and MF between pre- and post-MCE recording during elevation of the shoulder at 40% and 60% of MaxForce. In this exploratory study, the level of significance of each comparison was set to p < 0.05. The entire analysis was conducted using the software SPSS (Version 12.0).
Results The values obtained in RMS demonstrated that a postmaximal clenching effort, as contrasted with a pre-maximal clenching effort, does not alter the amplitude of EMG signal under conditions with 40% (t Z 1.0, p Z 0.32,) and 60% (t Z 0.1, p Z 0.91) of MaxForce as demonstrated in Figure 2. The median frequency value demonstrates that MCE does not alter motor control strategies. This result was obtained when comparing pre- and post-MCE conditions with 40% (t Z 1.44, p Z 0.16) and 60% (t Z 0.83, p Z 0.41) of MaxForce in elevation of the shoulder (Figure 3).
Discussion Although these investigations confirm the physiological and anatomic relationships between the masticatory system and the cervical spine (Gola et al., 1995; Zafar, 2000; Milanov et al., 2001), the result of this study demonstrates that the MCE in centric occlusion does not influence the activity of the upper trapezius muscle in individuals without a history of dysfunctions in the masticatory system. The existence of a trigemino-cervical reflex is well known and it may bring about the possible functional link
350 area of the trigeminal nerve, generated by a masticatory system dysfunction, as related by Gola et al. (1995). It has been demonstrated that the masseter muscle and the upper trapezius are a frequent source of pain. This leads to an increase in their fatigability and a reduction in their endurance in response to a given load (Clark et al., 1993). It has been shown that the most painful body site is the cervical spine, followed by the scapular region and the temporomandibular joint (Pedroni et al., 2006). These facts support the idea that nociceptive feedback from the jaw muscles may interact with systemic nociceptive mechanisms, and play a role in musculoskeletal disorders involving pain distributed throughout the head, neck, and limbs. However, it is possible that in situations of dysfunctions in the masticatory system, the trapezius muscle receives afferent nociceptive signals from the trigeminal system, staying hyperactive while the nociceptive stimulus lasts. This can be a possible cause of hyperactivity and the presence of a trigger point (Gola et al., 1995; Fryer and Hodgson, 2005) in this muscle, an issue that should be investigated in future studies.
Limitations The first limitation of this study is related to the sample size, which is considered too small to quantify a possible interaction involving the physiological and anatomic relationships between the masticatory system and the cervical spine. A second limitation was caused by the fact that the results pertained only to healthy individuals. If individuals with dysfunctions in the masticatory systems were included, the results could possibly have been different, which would allow for a more extensive discussion. A third limitation might have been the collection of the EMG signal without altering the positioning of the mandible. Future studies should be conducted with variations (intercuspal, ipsi-lateral, contralateral, protrusive and retrusive occlusal contact positions) regarding the positioning of the mandible.
Conclusions It was possible to determine in this study that in individuals without a history of dysfunction of the masticatory system, maximum clenching effort in centric occlusion does not alter the electromyographic signal of the upper trapezius. This result is not sufficient to disregard a link between the masticatory system and the trapezius muscle.
Acknowledgements This study was partly supported by the FAPESP and CAPES/ PROEX, Brazil.
References Ciuffolo, F., Manzoli, L., Ferritto, A.L., et al., 2005. Surface electromyographic response of the neck muscles to maximal voluntary clenching of the teeth. Journal of Oral Rehabilitation 32, 79e84.
F. Politti et al. Clark, G.T., Browne, P.A., Nakano, M., et al., 1993. Co-activation of sternocleidomastoid muscles during maximum clenching. Journal of Dental Research 72, 1499e1502. Costacurta, L., 1979. Anatomia microsco ´pica buco-dental humana. Atheneu/Universidade de Sa ˜o Paulo, Sa ˜o Paulo. Darling, D.W., Krauss, S., Clasheen-Wray, M.B., 1994. Relationship of head posture and the rest position of the mandible. Journal of Prosthetic Dentistry 52 (1), 111e115. Dworkin, S.F., LeResche, L., 1992. Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and specifications, critique. Journal of Craniomandibular Disorders: Facial and Oral Pain 6, 301e355. Ferrario, V.F., Sforza, C., Colombro, A., et al., 2000. A electromyographic investigation of mastigatory muscles symmetry in normoocclusion subjects. Journal of Oral Rehabilitation 27, 33e40. Ferrario, V.F., Sforza, C., Dellavia, C., et al., 2003. Evidence of an influence of asymmetrical occlusal interferences on the activity of the sternocleidomastoid muscle. Journal of Oral Rehabilitation 30, 34e40. Fryer, G., Hodgson, L., 2005. The effect of manual pressure release on myofascial trigger points in the upper trapezius muscle. Journal of Bodywork and Movement Therapies 9 (4), 248e255. Gangloff, P., Perrin, P.P., 2002. Unilateral trigeminal anaesthesia modifies postural control in human subjects. Neuroscience Letters 330, 179e182. Gola, R., Chossegros, C., Orthlieb, J.D., 1995. Syndrome algodysfonctionnel de l’appareil manducateur. Masson, Paris. Harryman, D.T., Sidles, J.A., Clark, J.M., et al., 1990. Translation of the humeral head on the glenoid with passive glenohumeral motion. The Journal of Bone and Joint Surgery 72, 1334e1343. Harryman, D.T., Sidles, J.A., Harris, S.L., et al., 1992. Laxity at the normal glenohumeral joint: a quantitative in-vivo assessment. Journal of Shoulder and Elbow Surgery 1, 66e76. Hawkins, R.J., Kennedy, J.C., 1980. Impingement syndrome in athletes. The American Journal of Sports Medicine 8, 151e157. Jensen, C., Vasseljen, O., Westgaard, R.H., 1993. The influence of electrode position on bipolar surface electromyogram recordings of the upper trapezius muscle. European Journal of Applied Physiology 67, 266e273. Lindstrom, L., Magnusson, R., 1977. Interpretation of myoelectric power spectra: a model and its applications. Proc IEEE 65, 653e662. Mannheimer, J.S., Rosenthal, R.M., 1991. Acute and chronic postural abnormalities as related to craniofacial pain and temporomandibular disorders. Dental Clinics of North America 35 (1), 185e209. Milanov, I., Bogdanova, D., Ishpekova, B., 2001. The trigeminocervical reflex in normal subjects. Functional Neurology 16, 129e134. Munhoz, W.C., Marques, A.P., Siqueira, J.T.T., 2004. Radiographic evaluation of cervical spine of subjects with temporomandibular joint internal disorder. Brazilian Oral Research 18 (4), 283e289. Neer, C.S., 1983. Impingement lesions. Clinical Orthopedics 173, 70e77. O’Driscoll, S.W., 1991. A reliable and simple test for posterior instability of the shoulder. The Journal of Bone and Joint Surgery 73B (Suppl. 1), 50. Pallegama, R.W., Ranasinghe, A.W., Weerasinghe, V.S., et al., 2004. Influence of masticatory muscle pain on electromyographic activities of cervical muscles in patients with myogenous temporomandibular disorders. Journal of Oral Rehabilitation 31 (5), 423e429. Palmer, M.L., Epler, M.E., 1998. Fundamentals of Musculoskeletal Assessment Techniques. Lippincott Williams & Wilkins, Philadelphia. Pedroni, C.R., Oliveira, A.S., Berzin, F., 2006. Pain characteristics of temporomandibular disorder e a pilot study in patients with cervical spine dysfunction. Journal of Applied Oral Science 14 (5), 388e392.
Maximal clenching effort Stulen, F.B., DeLuca, C.J., 1981. Frequency parameters of the myoelectric signal as a measure of muscle conduction velocity. IEEE Transactions on Biomedical Engineering Letters 28, 515e523. Tecco, S., Caputi, S., Tete, S., et al., 2007. Electromyographic activity of masticatory, neck and trunk muscles of subjects with different mandibular divergence. The Angle Orthodontistic 77 (2), 260e265. Tecco, S., Tete, S., D’Attilio, M., et al., 2008. Surface electromyographic patterns of masticatory, neck, and trunk muscles in
351 temporomandibular joint dysfunctions patients undergoing anterior repositioning splint therapy. The Eruropean Journal of Orthodontics 30 (6), 592e597. Zafar, H., 2000. Integrated jaw and neck function in man. Studies of mandibular and headeneck movements during jaw opening e closing tasks. Swedish Dental Journal Supplement 143, 1e41. Zuniga, C., Miralles, R., Mena, B., et al., 1995. Influence of variation in jaw posture on sternocleidomastoid and trapezius electromyographic activity. Cranio 13 (3), 157e162.
Journal of Bodywork & Movement Therapies (2010) 14, 352e360
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CASE SERIES
Clinical and MRI findings after high dosage medical exercise therapy in patients with long lasting subacromial pain syndrome: A case series on six patients ˚vard Østera ˚s a,b,*, Gunnar Myhr c, Lasse Haugerud d, Ha Tom Arild Torstensen e a Sør-Trøndelag University College, Faculty of Health Education and Social Work, Department of Physical Therapy, Ranheimsv 10, N-7004 Trondheim, Norway b Rosenborg Sport Clinic, Lerkendal, N-7492 Trondheim, Norway c Unilabs Røntgen Trondheim, 7030 Trondheim, Norway d Moholt Physical Therapy Institute, Trondheim, Norway e Holten Institute, Lidingo¨, Sweden
Received 8 January 2009; received in revised form 14 May 2009; accepted 16 June 2009
KEYWORDS Medical exercise therapy; Pain; Shoulder; Subacromial pain syndrome; MRI
Summary Background and purpose: The primary aim of this case series was to investigate the effect of a high dosage medical exercise therapy program on shoulder pain in patients with subacromial pain syndrome. Subjects: Six subjects were assigned to a medical exercise therapy group. Methods: They received three treatments a week over three months. Outcome measures were descriptions of the subacromial space including supraspinatus tendon diameter, function, pain, and active range of motion in the shoulder girdle. Results: The subjects showed improvement posttest compared to pretest with respect to pain, function, range of motion, and isometric strength. An MRI demonstrated no change in tendon thickness after the treatment. Inflammatory signs such as fluid in the subacromial bursa decreased in some patients.
* Corresponding author. Sør-Trøndelag University College, Faculty of Health Education and Social Work, Department of Physical Therapy, Ranheimsv 10, N-7004 Trondheim, Norway. Tel.: þ47 73 55 93 05; fax: þ47 73 55 93 51. E-mail address:
[email protected] (H. Østera ˚s). 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.06.004
Effects of exercise therapy in impingement patients
353
Discussion and conclusion: In patients with uncomplicated subacromial pain syndrome, high dosage medical exercise therapy might be an efficient treatment approach. The clinical effects might be explained by morphological changes in the subacromial space. ª 2009 Elsevier Ltd. All rights reserved.
Introduction Shoulder pain is relatively common in the general population (Pope et al., 1997), and the longstanding painful shoulder is well known to be hard to treat (Desmeules et al., 2003). Subacromial impingement syndrome is commonly associated with chronic pain symptoms, but the source of this pain has not been scientifically clarified (Cohen and William, 1998). Theories vary on the origin of the pain in this condition. Khan et al. (1999) suggest that it may come from the subacromial bursa, the rotator cuff tendons, the acromion, or from a combination of pathologies in these various tissues. In the chronic stadium, surgical treatment, such as acromionplasty, is often instituted (Hyvonen et al., 1999). To gain a better understanding of the etiology of the pain in a patient with shoulder impingement, it may be necessary to consider some subacromial anatomical issues. The main blood supply to the rotator cuff comes from the anterior humeral circumflex, the posterior humeral circumflex, the suprascapular and the subscapular arteries (Rothman and Parke, 1965). At a point approximately 1 cm from its insertion on the greater tubercle, the supraspinatus tendon is hypovascular, as demonstrated by various vascular injection studies (Fu et al., 1991). This area is known as the ‘‘critical zone’’. Adduction compounds this hypovascularity by winding the insertional end further around the humeral head. Scheib (1990) suggests that this ‘‘wringing-out’’ further diminishes the blood to the tendon. It is difficult to understand why the supraspinatus tendon has an area of diminished blood supply. Rathburn and MacNab (1970) suggest that since these are flat tendons and the blood vessels run the length of the tendons they are susceptible to traction and direct pressure. The avascular zone therefore might result, and is not a result of degenerative changes. The scientific effect of exercise treatment in patients with impingement is unclear, but exercise as treatment is widely used among physiotherapists. Clinically, medical exercise therapy is believed to increase local circulation in this condition, though this has never been investigated. Inconsistent findings in the literature as to the treatment effects of exercise therapy in subacromial pain syndrome might be explained by the overall low intervention dosages used. The hypothesis is that there are benefits to be gained by increasing the dosages of exercise training for patients with subacromial pain The primary aim of this case series was to investigate the effect of a high dosage of a medical exercise therapy program on subacromial structures and shoulder pain in patients with subacromial pain syndrome.
Materials and methods Subjects. Five men and two women participated in the study. One man was excluded from the study during the intervention period due to surgery. The participants were
recruited by orthopedic surgeons in a regional hospital and by general practitioners. Ethical approval was acquired from the Human Review Committee and all participants provided written consent. Individuals between the ages of 18 and 60 with a unilateral primary shoulder impingement syndrome were assigned if they had: signs of positive impingement, a minimum of three months since the onset of shoulder symptoms, not undergone previous shoulder surgery, normal neck, elbow and thoracic spine function (no positive neurology tests), no neurological diseases, no history of shoulder dislocation, subluxation or fracture, no vestibular or visual disturbances (which would make it impossible to perform the intervention), and no chiropractic, osteopathic or physiotherapy sessions within the last six months prior to entering the study. Individuals were also excluded if they had any cardiovascular, respiratory, systemic, or metabolic conditions limiting exercise tolerance. No subjects refused to participate in the study. The subjects went through a one-day testing procedure before and after the experiment period. They were preliminarily informed about the length of the study and the test parameters that were going to be used. They were asked not to perform strength training the two days before the experiments to avoid the influence of non-restituted musculature. The averages of the subjects’ physical and physiological characteristics before the training period are presented in Tables 1 and 2.
Instrumentation Magnetic resonance imaging (MRI) was performed in a private radiology institute. Coronal T1dweighted turbo spin echo (TSE) and T2dweighted fat saturated TSE, transversal T2dweighted gradientecho and oblique sagittal T2dweighted fat saturated imaging sequences were performed on a Siemens 1.5 Tesla magnet (Symphony) before starting treatment. The coronal images were angulated along the main direction of the superior rotator cuff tendons. This protocol was repeated in a control MR examination three months later. The control MRI was performed one week after the end of treatment. The images were evaluated in a routine clinical setting by two experienced MR radiologists with consensus on configuration of the acromion, subacromial space reduction, degeneration in the acromioclavicular joint, lesions in the rotator cuff, and other soft tissue abnormalities. They agreed on each finding. The subacromial space was measured in the oblique sagittal plane at the lateral edge of the acromion, from the under surface cortical line to the cranial cortical line of the humeral head. The thickness of the supraspinatus tendon was measured in a coronal image located along the central part of the tendon at a point one centimeter lateral to the edge of the acromion. The measurement result was compared in the two MR examinations.
354 Table 1
H. Østera ˚s et al. Baseline values at inclusion of background data.
Case
Age/sex (M Z male, F Z female)
Height (cm)
Mass (kg)
Number of treatments
Durations of symptoms (years)
Subacromial diameter (mm)
1 2 3 4 5 6
49/M 50/M 67/M 44/F 49/F 37/M
181 183 170 170 174 193
75 94 80 70 69 80
35 31 36 28 36 25
0,4 5 0,3 5 15 3
8 10 9 7 7 8
Pain scores The subjective pain score was a composite score of the visual analog scale (VAS). The pain responses were recorded on a 0e100 mm line used for each test. The extreme limits were marked with perpendicular lines using the verbal descriptors of ‘‘no pain’’ or ‘‘worst pain I can imagine’’. The subjects were blinded to their previous markings when follow-up measurements were taken. Measurements were expressed in millimeters. The same rater for all subjects tested the active range of motion (ROM), performed in a standing position with extended elbows. The subjects were asked to flex their shoulder as far as possible. Range of motion was noted with a digital inclinometer (Dualer, JTech Medical Industries, Salt Lake City, Utah, USA). The same procedure was performed measuring active abduction. Function was measured using a functional assessment questionnaire. The functional outcome measures included the self-completed Shoulder Rating Questionnaire (SRQ) for which uniform instructions were given. The five main components are pain (VAS), pain in specific components, activity in daily living, activity level in sports and leisure, and work ability. Psychometric properties (reliability, validity and responsiveness to change) of the SRQ have been previously reported for patients with shoulder pathology (L’Insalata et al., 1997; Williams et al., 1995). The SRQ was scored using the method described by L’Insalata et al. (1997), resulting in a scores rating from 17 to 90, with higher scores indicating better shoulder function with less shoulder symptoms.
Experimental procedures Patient history, symptoms, and clinical findings were the basis for choosing starting positions, range of motion, and Table 2 Case
1 2 3 4 5 6
weight resistance for the patient being able to do three sets of 30 repetitions. Each exercise was tested using a specific clinical test procedure developed in medical exercise therapy (Torstensen, 2004). Note: An example of the exercise protocol will be found in Box 1. Thus, each patient had an individual tailored exercise program. The patient exercised within the comfortable range of motion with normal humeroscapular rhythm, and in the early phase the weight from the pulley apparatus was used to unload some of the weight off the arm, making it possible to perform the high number of repetitions in sets (three sets of 30 repetitions) with good kinetic control. As the patient improved, experiencing less pain, the range of motion and weight resistance were increased and the starting position was changed according to the progression ladder developed in medical exercise therapy (Torstensen, 2004). The number of repetitions and sets was kept constant during the treatment period, which involved three treatments a week for 12 weeks. The intervention program was a combination of 20 min of global aerobic exercises using a stationary bike, treadmill, or step machine, and eight semiglobal and local shoulder exercises using medical exercise therapy equipment. All subjects used the same eight exercises, working with all shoulder muscles.
Remedial exercise program The patients’ history and clinical tests, including muscle tests, specific joint tests and functional tests, are the basis for choosing the correct grading of the exercises focusing on the appropriate weight resistance and range of motion. As an example of the test methodology a patient with 80 degrees of active flexion, 45 degrees of active abduction,
Pain (VAS), range of motion (ROM), shoulder function (SRQ) and supraspinatus tendon diameter with treatment. VAS
ROMdflexion
ROMdabduction
SRQ
Supraspinatus tendon diameter (mm)
Pretest
Posttest
Pretest
Posttest
Pretest
Posttest
Pretest
Posttest
Pretest
Posttest
7,2 7,0 7,5 4,0 6,0 4,0
5,0 2,5 2,0 0,5 4,5 1,0
70 120 90 120 170 180
170 180 170 180 180 180
60 100 90 80 90 180
170 130 160 100 90 180
56 47 45 67 38 45
80 61 79 80 58 69
5 4 6 6 6 4
5 4 6 6 6 4
Effects of exercise therapy in impingement patients
355
Box 1. Exercise protocol. For treatment purposes the patient is performs 3 sets of 30 repetitions with a 30 s break between each set, making it a total of 90 repetitions for each exercise. The test methodology is as follows: From the chosen starting position, range of motion and weight resistance the patient is asked to perform as many repetitions as possible. The patient then starts the exercise, at a speed of approximately 1 repetition every 2 s. When the patient reaches 8e9 repetitions the test is stopped and the patient is asked whether he/she feels it will be possible to complete at least 40 repetitions. Depending on the response the regime is modifieddThe response is either ‘‘yes I think I can reach 40 repetitions’’, in which case the patient continues to at least 40 repetitions. If the report is that it is too easy, the weight resistance is increased or the starting position can be changed. If however the answer is that the effort is too great or that pain in the shoulder is being provoked the weight resistance is lowered and/or the starting position and range of motion modified. When the patient reaches 40 repetitions, and starts to tire, or becomes uncoordinated, or starts to feel some pain or discomfort, the exercise is stopped, 20% is deducted from the 40, ending up with 3 sets of 30 repetitions. The goal is to involve the patient in the test making the patient understand that the goal is to find a baseline regarding range of motion and weight resistance, doing 3 sets of 30 repetitions. The exercise is then continuously monitored, increasing range of motion and weight resistance, but keeping the 3 sets of 30 repetitions constant. The grading of the exercises is a mirror image of the functional ability the patient. internal rotation to the gluteal fold, and external rotation to 35 degrees, the exercises are tested out within these active ranges of motion. Hence the initial starting positions of the exercise program is a mirror image of the available functional level the patient has. When testing out one exercise, the goal is 40 repetitions and then 20% is deducted from the 40 repetitions ending up with 32 being rounded down to 30 repetitions. To be able to do 3 sets of 30 repetitions, 30e60 s breaks are taken between each set, ending up with a total of 90 repetitions. To be able to accomplish at least 40 repetitions, the physiotherapist (based on the clinical assessment) chooses a range of motion, and weight resistance that is likely to achieve this objective. However this is trial end error and each exercise is tested out the following way; The patient is told to complete as many repetitions as he/she can manage. When the patient reaches 8e9 repetitions he/she is told to stop, and the following three questions are asked. 1. Do you think you will be able to reach 40 repetitions, based on the starting position, range of motion, and the degree of effort you have been repeating so far?, 2. Or, is this too easy for you to do? 3. Or, Is this too difficult, causing an increase in symptoms? If the patient says that the loading feels acceptable to reach 40 repetitions, no changes are made and the patient continues the test counting 10, 11 and so forth, up to 40 repetitions. However if the patient says that the exercise is too easy, or too heavy, the exercise is modified, involving either the starting position, the range of motion, or the weight resistance. Thus this is a test, within in the exercise series, that involves the patient in the grading of the degree of effort, so ensuring, as best possible, a positive experience. As the treatment proceeds, and the patient is
improving, the exercises are modified accordingly, changing first the range of motion and then the weight resistance, so that the weight is optimal for doing the sets of 30 repetitions. A change in the exercise program is made at least every 4th to 5th treatment. This system ensures that the patients’ exercise is as pain free as possible. Subjects were informed that, while the exercises might result in muscle fatigue, there should not be an increase in the shoulder pain. It was possible to get the patient to exercise in the pain free range of motion with good coordination, and with the humeroscapular rhythm as close to normal as possible. The subjects performed eight exercises, each of three sets of 30 repetitions, three times a week for three months, making a total of 36 treatments. It is possible that this high exercise dosage results in pain modulation, stimulating the gate control mechanism in the posterior horn, as well as the release of neuropeptides such as endorphins and encephalin from the pituitary gland, into the central nervous system. There was no attrition. Prior to the semiglobal and local exercises the experimental group warmed up for 15e20 min on an ergometer cycle. Half way through the exercise program (four exercises each of three sets of 30 repetitions) the patients cycled for 10 min. After the last four exercises, the patients spent another 10 min on stationary ergometer cycling. The intensity during cycle exercises was moderate to high, i.e. a heart rate frequency of 70e80% of the maximal heart rate, determined as 220 beats per minute, minus age. All patients were treated over a three-month period with three treatments a week. For all patients a physiotherapist was present in the exercise room motivating, supporting and re-grading the exercises according to the patients’ clinical presentation and change in function and symptoms over the three-month treatment period. Thus, all patients received the same amount of attention while they were in the exercise room. The patients were treated in medical exercise therapy groups, where the therapist is in the exercise room, for one hour. Thus the patients were under continuous supervision while exercising. The variables that were continuously
356 regraded were range of motion and weight resistance, while the number of exercises, repetitions, sets, and time performing aerobic work, using a stationary bike, were kept constant. After each treatment the physiotherapist filled in a compliance log for each patient.
Case reports These several case reports constitute a case series type of research methodology.
Case 1 A 49-year-old male visited our clinic five months after he developed shoulder pain. He had problems performing his job as a postman, due to increasing pain during the day, but he was not on sick leave. While he did not perform very much work above shoulder height with the affected arm, he still did much carrying and lifting during an ordinary working day. The subacromial diameter on the affected arm was eight mm. The MRI showed an acromion type 1 and a light degree of calcification in the area 5 mm cranial to the supraspinatus insertion on tuberculum major. After 35 treatments the MRI did not show any changes. He had improved both function and range of motion, and the pain level was decreased.
Case 2 This case is a 50-year-old male working with a moderate degree of physical strain on the upper body, but not with work over shoulder height. As in case 1, this man did not perform any specific kind of physical activity in addition to his work. His shoulder pain had developed gradually, starting approximately five years ago. There was no obvious reason for the initial pain. The MRI at pretest showed a type 1 acromion, no calcification, 10 mm subacromial diameter, but a light degree of liquid between lateral parts of the supraspinatus tendon and the deltoid muscle. A small benign subcortical cyst in ventral parts of the tuberculum major was also found at pretest. After 31 treatments over 12 weeks the radiologist found a normalization of the supraspinatus tendon and no cyst. The patient had marked pain relief; from 7.0 to 2.5 on the VAS, along with increased function and range of motion.
Case 3 A 67-year-old male was seen four months after the initial shoulder symptoms. He had worked as a bureaucrat his entire career, and had never done strenuous overhead physical activities, and had no known shoulder or arm injury. His acromion configuration was type 2, with a subacromial diameter of 9 mm. The MRI showed a light degree of tendinosis in both the supraspinatus and the subscapularis tendons. Despite failing standardized protocols describing quantification tendinosis in these areas, the MRI at posttest, with the same radiologist and corresponding MRI procedure, showed less tendinosis after 36 treatments. He was the patient in the present study that improved most with respect to pain, from 7.5 to 2.0 on the VAS. However, he had only had
H. Østera ˚s et al. shoulder pain for four months. The active range of motion and function also had a marked increase.
Case 4 A 44-year-old female with five years of symptoms did not use her arms much at work, and was not on sick leave. She had previously been a handball player, but with no known shoulder injuries, and she fulfilled the inclusion criteria. At pretest she complained of shoulder pain during light upper body strength training, and she also had a certain degree of pain at rest and in the night. The pretest MRI showed type 2 subacromial configuration, with a subacromial diameter of 7 mm. After 28 treatments her pain level decreased from 4.0 to only 0.5, along with an increase in overall shoulder function. At posttest her active shoulder range of motion was completely normal.
Case 5 The 49-year-old woman had pain in different levels for 15 years, with no pinpointed onset, and no injury. The MRI at pretest showed a type 2 acromion, with an 8 mm subacromial diameter. Structural changes in the transition between muscle and tendon tissue in the supraspinatus were also found. At her office workplace she had a moderate degree of shoulder strain, but no specific physical activity in her leisure time. She needed almost a month to be able to complete the recommended intervention level due to pain, but she was able to train the last two thirds of the medical exercise treatment period as prescribed. After 36 treatments the MRI found normalization in the tissue changes found in the supraspinatus at pretest, and no extra-tendinous oedema in the same area. Her range of motion did not change, but she had less pain and increased function.
Case 6 This 37-year-old male with three years of shoulder pain also had some pain in the other shoulder, but he fulfilled the inclusion criteria. He worked as a physiotherapist, but did not do heavy work due to shoulder strain. However, he had been an active cross-country skier, and he was still performing upper body physical activities on a daily basis. The initial MRI showed acromion type 2, with an 8 mm subacromial diameter. After 25 treatments 12 weeks later, a thin layer between the supraspinatus tendon and the deltoid muscle disappeared, corresponding to a pain relief from 4.0 to 1.0 on the VAS. His function also improved. The range of motion was not affected in the beginning. He was able to increase the frequency of his cross-country skiing, but at posttest he still had increased shoulder pain through strength training in a more than 90-degree flexion or abduction. Each participant’s compliance categorization was determined by averaging the compliance reported on four compliance logs. The compliance level was 83%%, with the number of sessions expected at the outset. The results from the testing of active range of motion in the shoulder girdle are presented in Table 2, which showed an increase in both active abduction and flexion in all subjects from pretest to posttest. The results from the MRI are illustrated in Figures 1e3.
Effects of exercise therapy in impingement patients
357
Figure 1 Longitudinal rupture of the supraspinatus tendon at the musculotendinous junction. 1A and 1B: Pretreatment coronal and sagittal T2 weighted fat saturated images shows irregular signal and high-signal intensity oedema in the superficial part of the tendon (arrow). 1C and 1D: The same images after treatment. The tendon is normal.
Four subjects had type 2 acromial configuration and three had type 1 according to the Bigliani classification (1986). The subacromial diameter was unchanged from pretest to posttest images for all subjects. The thickness of the supraspinatus tendon pretest and posttest is given in Table 1. The thickness changed in three patients, two increased by 1 mm and one decreased by 1 mm. In addition to the measurement values that were found during the MRI, some qualitative soft tissue findings changed during the study period. They included reduced fluid in the subdeltoid bursa in four cases and increased fluid in one case. A partial intratendinous longitudinal rupture normalized during the study, see Figure 1a and b. A small intrasubstance rupture in the supraspinatus tendon was not visible on the follow up in one patient. A calcified tendinosis remained unchanged in one case. One patient with extensive osteoarthritis of the acromioclavicular joint, bursitis of the subdeltoid bursa and penetrating rupture of the supraspinatus tendon was
referred to surgical treatment and was therefore excluded from the study group.
Discussion In this case series, we found reduced pain, improved active range of motion and function, in a group of patients with shoulder impingement syndrome treated with high dosage exercise therapy. In five of the six patients, the subjective qualitative evaluation of the MRI findings suggests a normalization of the subacromial soft tissue structures. Due to the low number of subjects, we do not know whether the high dosage medical exercise therapy correlates with the specific soft tissue findings on the MRI. The shape of the acromion has been classified into three anatomical types by Bigliani et al. (1986). 1. In type 1, the acromial under the surface has a flat shape.
358
Figure 2
H. Østera ˚s et al.
The standard measurement of tendon thickness. 2A: Distance from the tip of acromion. 2B: The measurement.
2. In type 2 the acromial shape is gently curved with the majority of the inferior cortex parallel to the curvature of the humerus head in the oblique sagittal plane. 3. The type 3 acromial shape has an anterior hook that abruptly narrows the anterior acromiohumeral distance (Crues and Fareed, 1991). Type 3 acromion has been found to predispose for impingement syndrome and might be associated with rotator cuff tears in the ‘‘critical zone’’ (Wolin and Tarbet, 1997). In the present study, the number of subjects is too small to suggest a correlation between acromial shape and symptoms, which might be of interest in subjects who are candidates for surgery. Shoulder pain and the shoulder impingement syndrome are third in frequency of visits to general practitioners, only less frequent than headaches and backaches (Bland et al., 1977). The shoulder impingement syndrome is the most common shoulder problem seen in sports medicine. This syndrome may be caused by repetitive overhead use of the arm causing microtrauma to the subacromial tissues. These microtraumas provoke a local inflammatory response, partial tearing, and thickening of the rotator cuff. The subacromial bursa may also become irritated with resultant thickening of its wall, accumulation of fluid, and adhesion formation (Jackson and Graf, 1985). Correct rehabilitation is the key to successful conservative treatment. Nirschl (1989) suggests that intrinsic muscle contractile tension overload is the major factor in rotator cuff tendinosis rather than primary impingement. This, according to him, is why stage 1 and 2 lesions respond positively to exercise therapy. The qualitative MRI evaluation of soft tissue changes in patients with shoulder pain is subjective. Subtle differences in tendon signal intensity and small intrinsic or surface ruptures may be difficult to detect in the first place. Changes between two consecutive studies may be more difficult to objectify. The same problem is apparent when measuring thickness of tendon plates that normally is
in the 4e7 mm range. Intraobserver variability may have been a source of error. The small change in diameter cannot be related to treatment. We would expect a treatment effect on tendon inflammation to lead to a decrease in thickness. Some of the qualitative differences seen in the soft tissue structures may be related to a decrease in local inflammation, e g. decrease in bursal fluid. It is difficult to decide if this is a real treatment response or just a reparative response over time, because of a change in physical activity patterns, regardless of the treatment. The present study used a high number of repetitions in the treatment program. In vitro studies of shoulders have demonstrated an avascular zone in the supraspinatus tendon, located approximately one cm proximal to the insertion of the tuberculum majus (Wolin and Tarbet, 1997;
Figure 3 The acromion shape extrapolated from Bigliani et al. (1986). Sagittal fat saturated T2 weighted image shows the Type 2 acromion with the surface parallel to the head of the humerus.
Effects of exercise therapy in impingement patients
Figure 4
359
Standing unloaded shoulder flexion 3 30 repetitions, 3 kg.
Hawkins and Abrams, 1987). This avascular zone may be a predisposing factor in tendon degeneration and tendonitis with pain and reduced function (Lyons and Orwin, 1998). A positive effect from the medical exercise therapy might be an increase in revascularization and regeneration of the rotator cuff tendons through a biomechanical stimulus from performing dynamic exercises with a concentric and eccentric phase (Torstensen, 2004; Torstensen et al., 1994). This fits well with the move from tendinitis to tendinosis (Khan et al., 2002). In patients with tendinosis of the Achilles tendon, a vasculo-neural growth in the tendon has been registered and may be a possible explanation for pain in patients with longstanding Achilles tendinosis ¨ hberg, 2003). O ¨ hberg (2003) has (Alfredson et al., 2003; O also documented that eccentric training resulted in a decrease in the neovascularization of the tendon and that the tendon infrastructure changed from having ultrasonographically hypoechoic areas and irregular fiber structure in a normal tendon. Even though the function of the shoulder is different compared to the lower leg, there are relevant clinical and functional similarities. A case study by Torstensen et al. (1994) showed that a supraspinatus tendon (tendinosis) regenerated after HD medical exercise therapy. More research is needed into any positive effects on tissue structures that are causing shoulder pain. Pain source? Even after eliminating shoulder pain caused by structures in the neck and thoracic area, it is still difficult to pinpoint exactly which structure in the shoulder is causing the subacromial pain. When the pain is caused by structures within the shoulder joint, there is a very low correlation between structural changes in soft tissues in the shoulder and the pain experience (Needell et al., 1996;
Khan et al., 1998). Adding to the problem of making a true and correct tissue-at-fault diagnosis, health professionals generally find it difficult to agree on a common diagnosis and treatment for patients who have a painful shoulder (Bamji et al., 1996). To avoid these problems the basis for choosing exercises and their grading in medical exercise therapy is strictly based on the patient presentation. This includes the patient history, the patient’s pain reaction, and such clinical findings as active and passive range of motion, palpation, isometric tests, provocation tests, impingement tests, and so on, and not on structural changes of tissues. Another factor that clinicians must take into account is the fact that the more complex and chronic a shoulder problem is, the more complex and diverse the pain mechanisms, the more futile the effort is to direct treatment at a ‘‘specific’’ target tissue. The exercise therapy in this trial did not have the ‘‘single-bullet-therapy’’ effect, as, for example, a cortisone injection; rather the total exercise dosage has the effect of a shotgun hitting all structures in the shoulder, shoulder girdle and the arm. In a systematic review by Michener et al. (2004) on the effectiveness of rehabilitation for patients with subacromial impingement syndrome they concluded that therapeutic exercise was the most thoroughly investigated form of rehabilitation. Controlled trials indicate that therapeutic exercise is more effective in reducing pain and improving functional loss than a placebo in both short- and long-term follow up (Brox et al., 1993; Brox et al., 1999), and more effective than no intervention in short-term follow up (Ludewig and Borstad, 2003). Given the evidence from the last systematic review by Michener et al. (2004),
360 therapeutic exercise is indicated as an effective intervention for patients with subacromial impingement syndrome as opposed to no treatment or placebo treatment. However, the interventions were vaguely described, making the exercise techniques difficult to replicate. It is also unclear what the optimal exercise regimen is or the frequency and intensity of an exercise program. One shortcoming in the present case series is the differences in the number of sessions attended (Table 1). Further research with a time-series analysis could shed some light on this discussion of dosage. It would be interesting and useful to compare symptomatic with asymptomatic subjects in a future study. Further research in this area should address a larger group of patients in randomized clinical trials. Imaging methods such as diagnostic ultrasound should also be included. Randomized clinical trials should also be used to further investigate the therapeutic effects of different exercise therapy regimens in patients with longstanding subacromial pain.
Conclusion The primary purpose of this clinical trial was to investigate whether there might be pain, active ROM or morphological changes after medical exercise regimens in non-operated patients with subacromial pain syndrome. The subjects showed clinically improved results after twelve weeks of medical exercise training for overall pain and function, though further research is needed for this to be more conclusive. In patients with uncomplicated subacromial pain syndrome, medical exercise therapy might be an efficient treatment approach Figure 4a and 4b.
Acknowledgement The authors received no funding in the writing or preparation of this manuscript and have no conflicts of interest.
References ¨ hberg, L., Forsgren, S., 2003. Is vasculo-neural Alfredson, H., O ingrowth the cause of pain in chronic Achilles tendinosis? An investigation using ultrasonography and colour doppler, immunohistochemistry, and diagnostic injections. Knee Surg. Sports Traumatol. Arthrosc. 11, 334e338. Bamji, A.N., Erhardt, C.C., Price, T.R., Williams, P.L., 1996. Clinical audit. The painful shoulder: can consultants agree? Br. J. Rheum. 35, 1172e1174. Bland, J.H., Merrit, J.A., Boushey, D.R., 1977. The painful shoulder. Semin. Artrithis Rheum. 7, 21e47. Bigliani, L.U., et al., 1986. The morphology of the acromion and its relationship to rotator cuff tears. Orthop. Trans. 10, 216. Brox, J.I., Staff, P.H., Ljunggren, A.E., Brevik, J.I., 1993. Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome). BMJ 307, 899e903. Brox, J.I., Gjengedal, E., Uppheim, G., et al., 1999. Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease (stage II impingement syndrome): a prospective, randomized, controlled study in 125 patients with a 2 1/2-year follow-up. J Shoulder Elbow Surg. 8 (2), 102e111. Cohen, R., William, G., 1998. Impingement syndrome and rotator cuff disease as repetitive motion disorder. Clin. Orthop. 351, 95e100.
H. Østera ˚s et al. Crues III, J.V., Fareed, D.O., 1991. Magnetic resonance imaging of shoulder impingement. Top Magn. Imaging. 3, 39e49. Desmeules, F., Cote, C.H., Fremont, P., 2003. Therapeutic exercise and orthopedic therapy for impingement syndrome: a systematic review. Clin. J. Sport Med. 13, 176e182. Dualer IQ. J Tech Medical Industries, Salt Lake City, Utah, USA. Fu, F.H., Harner, C.D., Klein, A.H., 1991. Shoulder impingement syndrome. Clin. Orthop. 269, 162e173. Hawkins, R.J., Abrams, J.S., 1987. Impingement syndrome in the absence of rotator cuff tear (stages 1 and 2). Orthop. Clin. North Am. 18, 373e382. Hyvonen, P., Lohi, S., Jalovaara, P., 1999. Open acromionplasty does not prevent the progression of an impingement syndrome to a tear. J. Bone Joint Surg. Br. 8, 813e816. Jackson, D., Graf, B., 1985. Decompression of the coracohumeral arch. In: Jackson, D. (Ed.), Shoulder Surgery in the Athlete. Aspen Publications, Rockville, MD, pp. 51e63. Khan, K.M., Tress, B.W., Hare, W.S.C., Wark, J.D., 1998. Treat the patient, not the x-ray: advances in diagnostic imaging do not replace the need for clinical interpretation. Clin. J. Sports Med. 8, 1e4. ˚strøm, M., 1999. Khan, K.M., Cook, J.L., Bonar, F., Hardcourt, P., A Histopathology of common tendinopathies. Sports Med. 27, 188e201. Khan, K.M., Cook, J.L., Kannus, P., et al., 2002. Time to abandon the ‘‘tendinitis’’ myth. Painful, overuse tendon conditions have a non-inflammatory pathology. BMJ 324, 627e628. L’Insalata, J.C., Warren, R.F., Cohen, S.B., et al., 1997. A selfadministered questionnaire for shoulder assessment of symptoms and function of the shoulder. J. B. Joint Surg. Am. 79, 738e748. Lyons, P.M., Orwin, J.F., 1998. Rotator cuff tendinopathy and subacromial impingement syndrome. Med. Sci. Sports Exerc. 30 (4), 12e17. Ludewig, P.M., Borstad, J.D., 2003. Effects of a home exercise programme on shoulder pain and functional status in construction workers. Occup. Environ. Med. 60 (11), 841e849. Michener, L.A., Walsworth, M.K., Burnet, E.N., 2004. Effectiveness of rehabilitation for patients with subacromial impingement syndrome: a systematic review. J. Hand. Ther. 17 (2), 152e164. Nirschl, R.P., 1989. Rotator cuff tendinosis: basic concepts of pathoetiology. Am. Acad. Orthop. Surgeons, Instructional Course Lectures 38, 439e445. Needell, S.D., Zlatkin, M.B., Sher, J.S., et al., 1996. MR imaging of the rotator cuff: peritendinous and bony abnormalities in an asymptomatic population. AJR 166, 863e867. ¨ hberg L., 2003. The chronic painful achilles and new methods for O treatment. PhD thesis, Umea ˚ University, Umea ˚, Sweden. Pope, D.P., Craft, P.R., Pritchard, C.M., Silman, A.J., 1997. Prevalence of shoulder pain in the community: the influence of case definition. Ann. Rheum. Dis. 56, 308e312. Rothman, R.H., Parke, W.W., 1965. The vascular anatomy of the rotator cuff. Clin. Orthop. 41, 176e186. Rathburn, J.B., MacNab, I., 1970. The microvascular pattern of the rotator cuff. J. Bone. Joint. Surg. 52-B, 540e553. Scheib, J.S., 1990. Diagnosis and rehabilitation of the shoulder impingement syndrome in the overhead and throwing athlete. Rheum. Dis. Clin. North Am. 16, 971e988. Torstensen, T.A., 2004. A software programmer and sportsman with low back pain and sciatica. In: Jones, M.A., Rivett, D.A. (Eds.), Clinical Reasoning for Manual Therapists. Elsevier Ltd, London, pp. 275e311. Torstensen, T.A., Meen, H.D., Stiris, M., 1994. The effect of medical exercise therapy on a patient with chronic supraspinatus tendinitis. Diagnostic ultrasound e tissue regeneration: a case study. JOSPT 20 (6), 319e327. Wolin, P.M., Tarbet, J.A., 1997. Rotator cuff injury: addressing overhead use. Phys. Sports. Med. 25 (6). Williams, J.W., Holleman, D.R.J., Simel, D.L., 1995. Measuring shoulder function with the shoulder pain and disability index. J. Rheumatol. 22, 727e732.
Journal of Bodywork & Movement Therapies (2010) 14, 361e366
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PHYSIOLOGY
Effect of low back pain on postural stability in younger women: Influence of visual deprivation ˆnio Renato Pereira Moro a, Luana Mann a, Julio F. Kleinpaul a, Anto Carlos Bolli Mota b, Felipe P. Carpes c,* a
Laboratory of Biomechanics, Federal University of Santa Catarina e Floriano´polis, SC, Brazil Laboratory of Biomechanics, Federal University of Santa Maria e Santa Maria, RS, Brazil c Exercise Research Laboratory, Federal University of Rio Grande do Sul e Porto Alegre, RS, Brazil b
Received 24 October 2008; received in revised form 19 June 2009; accepted 26 June 2009
KEYWORDS Body balance; Pain; Sensory feedback; Visual information; Motor control; Lumbar spine; Postural balance
Summary This study investigated the effect of low back pain (LBP) on body balance during normal and visual deprivation during standing in a LBP group (10 women) and a control group (10 women). A 3-D force plate was used to measure the center of pressure (COP) anteroposterior and mediolateral displacements, and resultant velocity. ANOVA was used to compare situations. LPB group presented higher amplitudes of COP for anterioposterior direction (p < 0.01) in conditions of open (3.07 0.53 cm) and closed eyes (3.70 0.71 cm) than healthy women (1.39 0.17 cm and 1.75 0.36 cm, for open and closed eyes, respectively). Similar results were found for COP involving mediolateralsway. The resultant COP velocity was larger for LBP group (p < 0.05) when visual information was removed (3.03 0.68 m/s and 3.63 1.33 m/s for LBP and healthy women, respectively). LBP influenced the stability of young women during quiet standing, and the visual deprivation appears to reinforce LBP effects. ª 2009 Elsevier Ltd. All rights reserved.
Introduction The ability to control of body balance during standing is dependent on the activity of central nervous system (CNS). The CNS plays a fundamental role for generation and regulation of proper muscle activity to control the * Corresponding author. Tel.: þ55 51 3308 5859; fax: þ55 51 3308 5842. E-mail address:
[email protected] (F.P. Carpes).
relationship between the center of mass projection and the area of support (Winter et al., 1998). The postural stability usually is described by changes in the center of pressure e COP e excursion (Winter et al., 1998). The CNS regulates the body stability while standing or during locomotion mainly by means of afferent information from the visual system (Mergner et al., 2005), proprioceptors organs (Bove et al., 2003; Tresch, 2007), cutaneous inflow (Kavounoudias et al., 1998), and changes in vestibular input (Bacsi and Colebatch, 2005).
1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.06.007
362 When some restriction occurs, such as absence of visual feedback while standing with the eyes closed, the stability is expected to decrease (Schieppati et al., 1999). Elite gymnast athletes evaluated during bipedal, unipedal and handstand postures in different levels of complexity presented not only direct effect of visual deprivation on the stability evaluated by COP surface and COP mean velocity, but also, for example, the influence of the segment’s orientation (Asseman et al., 2005). Visual deprivation can also increase instability in dancers (Hugel et al., 1999). This supports the concept that visual information can influence postural stability mainly by changing the interaction with the environment. Fear or apprehension, for instance, while standing on platforms of various heights (0.8, 1.6, and 3.2 m) resulted in increased COP variation depending on the degree of fear of falling and anxiety detected (Davis et al., 2008). Additionally, subjects evaluated under a similar protocol also presented changes in H-reflex that could not be explained by the background muscle activation, but were dependent on presynaptic inhibitory mechanisms anxiety-related (Sibley et al., 2007). The authors suggested this theoretical mechanism is also possible due to pain. Indeed, young-trained gymnasts of normal weight and anxiety-free but with low back pain (LBP) presented increased variability of center of pressure (Harringe et al., 2008). The authors investigated whether athletes training and competing with LBP would change their strategies for postural control. The anteroposterior COP excursion while standing with eyes closed on a foam surface was greater in LBP subjects compared to subjects with lower extremity injury (Harringe et al., 2008). LBP affects the ability to control standing posture (Brumagne et al., 2008a, b). Studies suggest LBP as a public health problem with prevalence up to 20% in USA and up to 40% in European countries (Van Tulder, 1996). Nonspecific LBP has been considered resultant of articular and/or muscular imbalances of the lumbo-pelvic complex (Vogt, 2003) and is more frequent for women (Clarke and Buckley, 1980; Andersen et al., 2006). Among the factors underlying LBP are decrease of agility, coordination and postural control (Alaranta et al., 1994). The low muscular conditioning of muscles of the trunk and lumbo-pelvic complex has also been suggested as influencing the hip strategy for control of body balance in LBP subjects (Carpes et al., 2008). As a corollary, LBP is known to negatively influence the proprioceptive capacity (Mientjes and Frank, 1999; Brumagne et al., 2008a), which probably leads to increased dependence on the visual system (Brumagne et al., 2000, 2008a). This would be related to similar pre-synaptic inhibitory mechanisms similar those observed in fear/ anxiety situations (Sibley et al., 2007; Davis et al., 2008). In this regard, under both quiet stance and dynamic conditions, vision cannot be readily replaced by other sensory inputs in normal subjects (Schmid et al., 2007). If so, the ability to control the body balance in nonspecific LBP subjects, deprived of vision, should result only from nonvisual sensory feedback. Thus, visual deprivation in LBP patients may result in more remarkable effects on body balance than would be the case for healthy subjects. The purpose of this study was to investigate the effects of vision deprivation on the body balance of younger women reporting nonspecific LBP.
L. Mann et al.
Methods Subjects Institutional approval for all phases of this study was obtained from the Committee of Ethics in Research with Humans of the Institution where this study was developed (IRB number 23081.001276/2007-32). Subjects signed a consent form affirming voluntary participation in the study. The subjects were divided into two groups. The experimental group (LBP) comprised 10 women reporting chronic nonspecific LBP for more than three months (mean standard-deviation age of 20.7 2.1 years old, body weight of 57.6 0.6 kg, and height of 1.65 0.04 m). The LBP group was paired to a control group (healthy) without any LBP episode and without history of lumbar surgery, spine abnormalities, neuromuscular, joint and reflex deficits, cauda equina, carcinoma, pregnancy, or radicular symptoms observed during functional evaluation. These 10 healthy women presented mean standarddeviation age of 20.2 1.7 years old, body weight of 56.7 0.2 kg, and height of 1.66 0.03 m. The inclusion in the LBP group was based on LBP uni- or bilaterally with nonspecific origin for more than three months, which was confirmed by use of functional tests previously described in the literature for the low back (Gross et al., 1996). The subjects of both the groups had not been involved with regular physical activity during the six months prior to evaluation.
Pain evaluation LBP was rated by each subjects by means of a visual analog scale from 0 to 10, where 0 represented ‘no pain’, and 10 represented ‘unbearable pain’. The pain grade also suggested 0e2 as ‘light pain’, from 3 to 5 ‘light to moderate pain’, from 6 to 7 ‘moderate to intense pain’, and from 8 to 10 ‘unbearable pain’ (Bird and Dickson, 2001).
Body balance biomechanical assessment The biomechanical assessment of body balance followed the protocol described in a recent publication (Carpes et al., 2008). The changes in center of pressure (COP) displacement were measured using a biomechanical 3-D force plate (Advanced Mechanical Technology, Inc., Watertown, MA, USA) placed in the center of a quiet environment and calibrated as described by the manufacturer recommendations. The force plate was embedded at the level of the laboratory floor, and the room presented no visual or auditory distractions. The subjects had their feet positioning marked on the force plate surface in the first trial, and each individual used this template for all the subsequent trials. Subjects were oriented to stand quietly barefoot separated at a comfortable width (about shoulder-width apart) with their arms resting at their sides. The trials had a duration of 30 s with the subjects maintaining a static posture, and were repeated three times randomly with closed eyes (CE) or opened eyes (OE) in an attempt to minimize variability. The eyes closed characterized the visual deprivation, which was observed by the researcher to make sure that subjects
Effect of low back pain on postural stability
363
Statistical procedures Data were organized for mean and standard-deviation for each situation and group. The data normality was confirmed by means of Shapiro-Wilk’s test. The homogeneity of variances was verified using Hartley’s test. The comparison between situations within and between groups was accomplished by means of a two-way mixed model (between-within) ANOVA. Post-hoc Tukey’s test was applied where main interactions were found. All statistical procedures were conducted using the SPSS 11.5 for Windows (Statistical Package for Social Sciences, Chicago, IL, USA). The significance level was set at 0.05.
Results The LBP group presented scores of 6 2 concerning the pain ratio grade, which denotes moderate to intense pain. The Figures 1e3 depict the findings of the present investigation. The overall results were consistent with significant effects of LBP and visual deprivation on body balance. The visual deprivation was related to increase COPap magnitudes for both groups. LBP subjects presented higher COPap
¢
8
*
CE
8 CE OE 6
COPml (cm)
remained with the eyes closed during the trials. The COP was used to express the neuromuscular responses to postural stability due to changes of the position of center of gravity (Winter, 1990). Data regarding body balance were acquired in the same way for the two groups. The testing protocol was conducted in a quiet room with data being collected at sampling rate of 100 Hz via personal computer using specific software (data acquisition and off-line analysis) of the biomechanical force plate (NetForce, Advanced Mechanical Technology, Inc., Watertown, MA, USA). From COP data, the anterioposterior displacement (COPap), mediolateral displacement (COPml) and resultant velocity (COPvel) were considered for discussion.
¢ *
4 * 2
0 Healthy
LBP
Figure 2 Center of pressure displacement in mediolateral direction (COPml, in cm) for the two groups (healthy and low back pain e LBP) in the situations of closed (CE) and opened eyes (OE). For LBP subjects, the COPml was higher in the closed eyes situation (¢, F Z 9.33; p Z 0.007), and COPml was higher than found for healthy subjects for both closed and opened eyes situation (*, F Z 23.9 and F Z 97.6, respectively, for p < 0.001).
displacement in both situations (see Figure 1). COPap was statistically higher for the subjects, for CE (F Z 59.6; p < 0.001) and OE (F Z 91.35; p < 0.001). COPap was higher in the situation of closed eyes for healthy (F Z 7.85; p < 0.05) and LBP subjects (F Z 5.04; p < 0.05). COPml (Figure 2) did not differ between situation of closed and opened eyes for the healthy subjects (F Z 0.92; p Z 0.350). For low back subjects, the COPml was higher than found for healthy subjects for both closed and opened eyes situation (F Z 23.9 and F Z 97.6, respectively, for p < 0.001). Closed eyes situation elicited higher COPml than while standing with eyes open (F Z 9.33; p Z 0.007). The COPvel (see Figure 3) depicts the velocity of changes in resultant COP position for the different groups and situations. COPvel was not influenced by the visual condition in healthy subjects (F Z 0.01; p Z 0.91 for closed eyes, and F Z 1.28; p Z 0.27 for opened eyes). For opened eyes
OE 8 *
CE 4
¢
OE
*
6
COP vel (m/s)
COPap (cm)
6
2
0
4
2 Healthy
LBP
Figure 1 Center of pressure displacement in anteroposterior direction (COPap, in cm) for the two groups (healthy and low back pain e LBP) in the situations of closed (CE) and opened eyes (OE). COPap was statistically higher for the LBP subjects, for CE (¢, F Z 59.6; p < 0.001) and OE (¢, F Z 91.35; p < 0.001). COPap was higher in the situation of closed eyes for healthy (*, F Z 7.85; p < 0.05) and LBP subjects (*, F Z 5.04; p < 0.05).
0 Healthy
LBP
Figure 3 Center of pressure resultant displacement velocity (COPvel) for the two groups (healthy and low back pain e LBP) in the situations of closed (CE) and opened eyes (OE). Closed eyes situation present statistically significant difference between the groups (*, F Z 7.24; p Z 0.015).
364 condition, no difference was found between healthy and low back pain subjects (F Z 4.26; p Z 0.054). Closed eyes situation present statistically significant difference between the groups (F Z 7.24; p Z 0.015).
Discussion Vision is the sensory input of highest confidence for the CNS in postural stabilization (Latash, 1997). Postural control involves information processing from sensory stimuli deriving from the visual, vestibular and somatosensorial systems in an integrated way to accurately regulate body positioning and center of mass movements (Oie et al., 2002; Della Volpe et al., 2006). If one or more of these systems fail, or the sensoy information is not correctly processed, the risk of a fall or instability increases (Horak and Macpherson, 1996). LBP can alter the sensory input to postural control (Graven-Nielsen et al., 1997; Gill and Callaghan, 1998). It may be related to increased pre-synaptic inhibition of afferent muscles (Sibley et al., 2007) in this case due to pain, or for chronic LBP subjects could suggest an adaptation of cortical processing of proprioceptive information (Rossi et al., 2003). Additionally, the deficit in recovery from perturbations is suggested to be dependent on reduced proprioceptive information, which would elicit increased visual dependence (Nies and Sinnott, 1991; Mientjes and Frank, 1999; Brumagne et al., 2008a). In this regard, for normal subjects under both quiet stance and dynamic conditions, vision cannot be readily replaced by other sensory inputs (Schmid et al., 2007). Gymnasts performing specific movements in bipedal, unipedal and handstand postures were not only affected by visual deprivation, but also by visual deprivation combined with orientation (Asseman et al., 2005). Visual deprivation was suggested as affecting postural control in dancers (Hugel et al., 1999). LBP is known to decrease proprioceptive capacity (Mientjes and Frank, 1999; Brumagne et al., 2008a), which may lead to increased dependence on the visual system in an attempt to improve the interaction with the environment, providing stability (Gautier et al., 2007; Brumagne et al., 2000, 2008a). Therefore, the main purpose of this study was to assess body balance in young women, both healthy and with LBP, with and without visual information. Our results are consistent with increased dependence on visual information in LBP subjects (Mientjes and Frank, 1999; Radebold et al., 2001; Brumagne et al., 2008a; Mok et al., 2004; Nies and Sinnott, 1991; Speers et al., 2002). Subjects presented LBP ratio classified as moderate to intense. Visual deprivation was induced by standing posture while keeping the eyes closed. The results support the influence of LBP in general variables of body balance (Della Volpe et al., 2006; Brumagne et al., 2008a; Harringe et al., 2008). Additionally, we found visual deprivation increasing postural instability more significantly (higher magnitudes of COP displacements) for those with LBP. Among the factors for reduced postural control in LBP subjects is the limited ability for use of a hip strategy due to reduced force and flexibility of the lumbo-pelvic region (Carpes et al., 2008; Brumagne et al., 2008b). Our results eliciting higher variability in mediolateral direction,
L. Mann et al. support the deficit in hip strategy in LPB subjects. This relates to the number of degrees of freedom considering the anteroposterior oscillation when compared to the mediolateral direction that is mainly controlled by the hip strategy (Mochizuki et al., 2006). A hip strategy for postural control involves action of muscles across the trunk and hip with horizontal shear forces as results of torque produced at the hip joint, rather than ankle joint to maintain the body stability. On the other hand, an ankle strategy concerns action of muscles across the ankle joint producing torques that shift the center of vertical foot pressure to maintain the center of mass over the base of support provided by the contact of feet with the ground (Henry et al., 2006). Indeed, LBP subjects present deficits in the sense of position for the region of the hip (Gill and Callaghan, 1998; Brumagne et al., 2000, 2008a), and which evokes an ankle strategy to maintain the standing posture (Brumagne et al., 2004). The influence of muscle fatigue due to change in trunk position combined with pain may lead to increased instability in low back subjects, including subjects with chronic pain. Our results are also consistent with a posture of trunk shift forward in LBP subjects, as elicited by the greater COPap displacement (Brumagne et al., 2008a; Popa et al., 2007). According to Brumagne et al. (2008a) increased forward trunk inclination resultant from anticipation of postural instability may play a key role in the recurrence of LBP. This effect could be similar those resulting from fear and/or anxiety involving postural control while standing on platforms of different heights (Davis et al., 2008) when changes in H-reflex not explained by the muscle activity may also arise (Sibley et al., 2007). The present results and the results from previous studies have implications for the postural control in older subjects with LBP or hemiplegic subjects, as previous suggested (Sibley et al., 2007). Considering LBP as the only factor contributing to changes in postural control, changes in normal standing posture leads to increased activation of back muscles (Brumagne et al., 2008a), and therefore an increased the fatigue rate (Vogt, 2003). These changes in the pattern of back muscle activation have been suggested as a strategy to limit spine movements regardless of the pain intensity (Nies and Sinnott, 1991; Mientjes and Frank, 1999; Brumagne et al., 2008a). Our results for COPvel are consistent with LBP leading to decrease of spine mobility (Thomas et al., 1998) and increased reaction time for a stimulus in the spine (Jayaraman et al., 1994). It negatively affected postural control likely due to alterations in muscle recruitment (Wegener et al., 1997; Bouisset et al., 2002). In the situation of visual deprivation, the subjects with LBP present greater instability; with sensory-motor information insufficient to correct and avoid postural imbalances (i.e. spinal and cerebral reflexes, motor cortex processing and sensorimotor pathways) (for a review see Ebenbichler et al., 2001). Our results demonstrated that LBP subjects deprived of visual information present increased postural instability compared to healthy subjects while standing in the erect posture (Figure 3). This suggests that even the COP is not significantly dependent on visual information during dynamic
Effect of low back pain on postural stability challenging situations (Della Volpe et al., 2006), strong dependence on visual information arises during quiet standing situations. The present results when compared to previous reports reinforces the question as to the question: ‘how much pain’ is being experienced?. The different pain grades (different pain intensities) may affect results. A previous study has suggested the differentiation between intensities of pain as a topic of concern (Mientjes and Frank, 1999), as well as suggesting that conclusions using typical population (elderly people and acute LBP) should be avoided (Brumagne et al., 2008a). Our results suggest that even a moderate LBP can influence postural stability and that visual deprivation reinforce its effects.
Conclusion LBP degrades postural stability. When vision is supressed, our study of young women with moderate to intense pain was remarkable for significant findings. Subjects with LBP were more dependent on visual information for control of center of pressure oscillation during standing than healthy subjects. The LBP also influenced the ability to quickly react to changes in body position (i.e., center of pressure velocity) when the visual input was removed. Similar effects for men and for elderly people should be addressed in further investigations.
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Journal of Bodywork & Movement Therapies (2010) 14, 367e374
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HEAD POSTURE
Influence of forward head posture on scapular upward rotators during isometric shoulder flexion Jong-Hyuck Weon a, Jae-Seop Oh b, Heon-Seock Cynn c, Yong-Wook Kim d, Oh-Yun Kwon e,*, Chung-Hwi Yi e a Department of Rehabilitation Therapy, Wonju Christian Hospital, Wonju College of Medicine, Yonsei University, Wonju, Republic of Korea b Department of Physical Therapy, College of Biomedical and Engineering, Inje University, Gimhae, Republic of Korea c Department of Physical Therapy, Hanseo University, Seosan, Republic of Korea d Department of Physical Therapy, College of Alternative Medicine, Jeonju University, Jeonju, Republic of Korea e Department of Physical Therapy, College of Health Science, Yonsei University, Republic of Korea
Received 30 December 2008; received in revised form 25 June 2009; accepted 26 June 2009
KEYWORDS Electromyography; Forward head posture; Scapular upward rotator
Summary We assessed the effects of forward head posture in the sitting position on the activity of the scapular upward rotators during loaded isometric shoulder flexion in the sagittal plane. Healthy volunteers (n Z 21; 11 men, 10 women) with no history of pathology participated in the study. Subjects were instructed to perform isometric shoulder flexion with the right upper extremity in both the forward head posture (FHP) and neutral head posture (NHP) while sitting. Surface electromyography (EMG) was recorded from the upper trapezius, lower trapezius, and serratus anterior muscles. Dependent variables were examined by 2 (posture) 3 (muscle) repeated measures analysis of variance. Significantly increased EMG activity in the upper trapezius and lower trapezius and significantly decreased EMG activity in the serratus anterior were found during loaded isometric shoulder flexion with FHP. Thus, FHP may contribute to workrelated neck and shoulder pain during loaded shoulder flexion while sitting. These results suggest that maintaining NHP is advantageous in reducing sustained upper and lower trapezius activity and enhancing serratus anterior activity as compared with FHP during loaded shoulder flexion. ª 2009 Elsevier Ltd. All rights reserved.
* Corresponding author. Department of Rehabilitation Therapy, The Graduate School, Yonsei University, 234 Maji-li, Hungob-myon, Wonju, Kangwon-do 220-710, Republic of Korea. Tel.: þ82 33 760 2429; fax: þ82 33 763 2496. E-mail address:
[email protected] (O.-Y. Kwon).
Introduction Work-related neck and shoulder pain are frequently reported in the workplace. Haughiee et al. (1995) found that forward head posture (FHP) is associated with neck and
1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.06.006
368 shoulder pain. In addition, Chiu et al. (2002) found that approximately 60% of individuals with neck pain had FHP. Several variables have been identified as risk factors for the development of shoulder pain, including highly abnormal sustained posture of the cervical spine, repetitive use of the arm, and work with the arm in an elevated position. Lifting and overhead work in the sagittal plane are often performed in construction and assembly line workplaces for loading and unloading, and FHP is the typically assumed posture during much work in construction and on assembly lines. Greenfield et al. (1995) reported that patients diagnosed with shoulder overuse demonstrated increased FHP in comparison with healthy subjects. Musculoskeletal pain occurs due to changes in muscle length when assuming a poor posture for a prolonged period and performing repetitive movements (Bergqvist et al., 1995). Spinal alignment is thought to affect scapular position and shoulder girdle function. Faulty cervical spinal alignment, such as FHP, is usually associated with shortening of the posterior neck extensor muscles and tightening of the anterior neck muscles, as well as the shoulder muscles, affecting scapular position and kinematics (Kebaetse et al., 1999). FHP is also considered to be an etiological factor in the pathogenesis of subacromial impingement syndrome. Postural deviations observed in FHP involve a downwardly rotated, anteriorly tilted, and protracted scapula leading to increased compression in the subacromial space during arm elevation (Lewis et al., 2005). Although there is evidence for an association between abnormal sustained forward posture of the cervical spine and the development of shoulder pain, there is a lack of evidence addressing the issue of how posture of the cervical spine contributes to shoulder pain. A biomechanical mechanism that may explain this association involves altered scapular and humeral kinematics, secondary to scapular upward rotator muscle imbalance. To prevent shoulder pain associated with abnormal neck posture, many researchers have stressed maintenance of a neutral head posture (NHP) during arm movement and functional activity (Edmondston et al., 2007; McLean, 2005). Many studies have been performed to determine the effects of head, thorax, and shoulder position on shoulder and scapular kinematics and the strength of the shoulders and hands. Ludewig and Cook (1996) investigated the effects of head position on scapular orientation and muscle activity during shoulder elevation in the scapular plane without an applied load. However, to our knowledge there have been no previous studies of the effects of head position on muscle activity of the scapular upward rotators during loaded shoulder flexion in the sagittal plane. It is generally believed that FHP is a contributor to the development of chronic neck, shoulder, and even jaw pain (Haughie et al., 1995). However, there is confusion in the literature regarding the impact of head posture on upper quadrant pain. We hypothesized that FHP during loaded isometric shoulder flexion would alter the muscular activation pattern of scapular upward rotator muscles. We assessed the effects of FHP on electromyographic activity of the upper trapezius, lower trapezius, and serratus anterior muscles during loaded isometric shoulder flexion (30 , 60 , 90 , 120 ) in the sagittal plane.
J.-H. Weon et al.
Methods Subjects Healthy subjects (n Z 21; 11 men, 10 women) were recruited from the Department of Physical Therapy, Yonsei University. The subjects had a mean age of 21.3 (3.1) years, a mean weight of 72.4 (2.2) kg, and a mean height of 174.6 (5.3) cm. Exclusion criteria were past or present neurological, musculoskeletal, or cardiopulmonary diseases that could interfere with shoulder flexion in the sitting position. Before the study, the principal investigator explained all procedures to the subjects in detail. All subjects signed an informed consent form, which was approved by the Yonsei University College of Health Science Human Studies Committee. A power analysis determined that 12 subjects were required to obtain a power of 0.8 at a < 0.05. This analysis was based on an estimated effect size (5% MVIC difference) derived from previous literatures (Perry, 1992; McLean and Urquhart, 2002). Perry (1992) has stated that 5% MVIC was an appropriate threshold for determining the onset and termination of muscle activity during gait cycle. And 5% MVIC was used as threshold to measure the level of upper trapezius muscle load in computer and production workers (McLean and Urquhart, 2002). Thus, we estimated the effect size by 5% MVIC. The proposed effect size may have been inflated because it was not derived from pilot data; therefore, 21 subjects were tested.
Equipments Electromyographic (EMG) data were collected using a Biopac MP100WSW and a Bagnoli EMG System. Skin preparation of electrode sites involved shaving and cleaning with rubbing alcohol, as described by Cram et al. (1998). Disposable AgeAgCl surface electrodes were positioned at an interelectrode distance of 2 cm. The reference electrode was attached to the styloid process of the right ulna. EMG data were collected for the following muscles on the right side: upper trapezius (2 cm lateral to the midpoint of a line drawn between the C7 spinous process and the posterolateral acromion), lower trapezius (placed on an oblique vertical angle with one electrode superior and one inferior to a point 5 cm inferomedial from the root of the spine of the scapula), and serratus anterior (placed vertically along the mid-axillary line at rib levels 6e8) (Cram et al., 1998; Nieminen et al., 1993). Each pair of electrodes was aligned along the line of underlying muscle fibers. EMG data were sampled at 1000 Hz. The EMG signals were amplified and digitized using AcqKnowledge 3.7.2 software. Band-pass (20e450 Hz) and band-stop filters (60 Hz) were used. The raw data were processed into root mean square (RMS) data using a moving window of 250 ms and converted to ASCII files for analysis. For normalization, 5-s reference contraction data were recorded while subjects performed three trials of maximal voluntary isometric contraction (MVIC) in the manual muscle testing position, as recommended by Kendall et al. (2005). A 1-min rest period was provided between trials. The mean RMS was calculated for each muscle. The EMG signals collected
Influence of forward head posture during each degree of shoulder flexion are expressed as percentages of the calculated mean RMS of MVIC (%MVIC).
Procedure Each subject was required to assume an upright position, sitting comfortably in a low-backed wooden chair. The height of the chair backrest was low enough (lower thoracic level) to allow movement of the scapula in all subjects. We performed this test on the right side to minimize artifacts from the electrocardiographic signal. While sitting in a chair, the subject was asked to raise the right upper extremity in the sagittal plane (30 , 60 , 90 , 120 ) in both the NHP and FHP in random order. Surface EMG was recorded from the upper trapezius, lower trapezius, and serratus anterior muscles (Figure. 1). A plumb line hanging from the ceiling was used to determine the subjects’ posture. In NHP, each subject’s external auditory meatus, acromion, and greater trochanter were aligned with a base plumb line that was perpendicular to ground level. In FHP, the subject was instructed to position his or her head anteriorly in a horizontal plane allowing the tragus to be aligned to a target plumb line, which was placed 5 cm anterior to the base plumb line. An inclinometer was used to determine when the shoulder was at 30 , 60 , 90 , or 120 flexion. A horizontal bar was placed at this level and provided feedback to the subject when instructed to flex his/her right shoulder with a 2-kg dumbbell in the hand until the upper aspect of the right wrist touched the bar and to hold the position without elbow flexion for 5 s. The EMG signal was recorded during this 5-s isometric contraction period. A 2-min rest period was provided between measurements to minimize muscle fatigue and the mean RMS of three trials was determined for comparison. Prior to
Figure 1
369 testing all subjects were familiarized with shoulder flexion in the sagittal plane with a 2-kg dumbbell. All subjects were comfortable, with standardized position and movement at the time of data collection.
Statistical analysis The data are expressed as the means standard deviation. A 2 3 repeated measures ANOVA with one within-subject factor (posture) and one within-subject factor (muscle) was used to determine the main effects and interaction effects at each degree of flexion, with the significance level set at a Z 0.05. If statistical significance were found for a main effect of muscle, multiple comparisons were performed using paired t-tests with the appropriate Bonferroni adjustment.
Results There were significant posture-by-muscle interactions for EMG activity at 30 , 60 , 90 , and 120 loaded isometric shoulder flexion. There was a significant main effect of posture for the EMG activity in 30 , 60 , 90 , and 120 loaded isometric shoulder flexion. There was also a significant main effect of muscle on EMG activity in 30 , 60 , 90 , and 120 loaded isometric shoulder flexion (Table 1). Multiple comparisons among the three muscles are presented in Table 2. A significant posture-by-muscle interactions were further analyzed conducting separate repeated measures ANOVA for three 2 2 subtables in each shoulder flexion angle. There were significant interaction effects except for the interaction effects between upper trapezius and lower trapezius in 90 and 120 (Table 3).
Loaded isometric shoulder flexion at 90 shoulder flexion. (A) Neutral head position. (B) Forward head position.
370 Table 1
J.-H. Weon et al. Summary of analyses of the EMG data.
Degree of flexion
Effect
F value
p-Value
30
Posture Muscle Posture muscle
F1,20 Z 29.702 F2,40 Z 16.815 F2,40 Z 35.685
.000 .000 .000
60
Posture Muscle Posture muscle
F1,20 Z 39.502 F2,40 Z 21.982 F2,40 Z 26.309
.000 .000 .000
90
Posture Muscle Posture muscle
F1,20 Z 37.885 F2,40 Z 7.567 F2,40 Z 30.383
.000 .002 .000
120
Posture Muscle Posture muscle
F1,20 Z 20.744 F2,40 Z 8.452 F2,40 Z 31.629
.000 .001 .000
Discussion
Results of post hoc paired t-tests revealed that EMG activity in the upper trapezius and lower trapezius was significantly increased and EMG activity in the serratus anterior was significantly decreased during loaded isometric shoulder flexion with FHP in 30 , 60 , 90 , and 120 (P < 0.05) (Figure 2). Results of post hoc paired t-test for multiple comparisons between muscles are presented in Figure 3. In NHP, there were significant differences in EMG activity between serratus anterior and upper trapezius all shoulder flexion positions, and significant differences in EMG activity between upper trapezius and lower trapezius were found at 30 , 60 , and 90 shoulder flexion (Padj < 0.017). A significant difference in EMG activity between serratus anterior and lower trapezius was revealed at 90 and 120 shoulder flexion in NHP (Padj < 0.017). In FHP, the EMG activity between serratus anterior and upper trapezius was significantly different at 60 shoulder flexion, the EMG activity between upper trapezius and lower trapezius was significantly different at 30 , 60 and 90 shoulder flexion, and the EMG activity between serratus anterior and lower
Table 2
trapezius was significantly different at 30 and 60 shoulder flexion (Padj < 0.017).
Multiple comparisons between muscles.
Pain and stiffness in the shoulder and posterior neck lead to an inability to work or carry out household and leisure activities, burdening both patients and society (Nie et al., 2005). Postural neck pain is usually associated with sustained static loading of the cervical spine and shoulder girdle, induced by faulty posture and incorrect movement patterns. Although many previous studies have examined the relationship between FHP and pain, our study is the first to determine the effects of FHP on the upper trapezius, lower trapezius, and serratus anterior muscle EMG activity related to scapular upward rotation during loaded isometric shoulder flexion in the sagittal plane. In the present study, the activities of the upper trapezius and lower trapezius were increased significantly, while that of the serratus anterior was decreased significantly in FHP in comparison with those in NHP during all degrees of loaded isometric shoulder flexion. There are several potential mechanisms that may explain our results. First, FHP may alter the length and tension of the levator scapula muscle during scapular upward rotation. Significantly increased levator scapulae activity was reported previously in FHP vs. NHP (McLean, 2005). The upper trapezius is an agonist muscle for upward rotation of the scapulae, and the levator scapula is an antagonist for scapular upward rotation. Thus, increased tension of the levator scapula will prevent scapular upward rotation. To overcome this increased levator scapula tension, it is believed that the upper and lower trapezius should be activated to a greater extent in FHP than in NHP. Second, scapular or thoracoscapular position could be changed during the FHP condition. Clinicians have postulated that abnormal cervical spine alignment alters the
Table 3
Summary of interaction comparisons.
Degree Interaction of flexion
F value
pValue
30
Posture muscle (UT vs LT) Posture muscle (UT vs SA) Posture muscle (LT vs SA)
F1,20 Z 16.656 .001 F1,20 Z 32.240 .000 F1,20 Z 52.740 .000
Degree of flexion
Muscle comparison
p-Value
30
Upper trapezius vs lower trapezius Upper trapezius vs serratus anterior Lower trapezius vs serratus anterior
.000 .002 .016
60
60
Posture muscle (UT vs LT) Posture muscle (UT vs SA) Posture muscle (LT vs SA)
Upper trapezius vs lower trapezius Upper trapezius vs serratus anterior Lower trapezius vs serratus anterior
.000 .000 .010
F1,20 Z 39.502 .016 F2,40 Z 21.982 .000 F2,40 Z 26.309 .000
90
90
Posture muscle (UT vs LT) Posture muscle (UT vs SA) Posture muscle (LT vs SA)
Upper trapezius vs lower trapezius Upper trapezius vs serratus anterior Lower trapezius vs serratus anterior
.008 .003 .929
F1,20 Z 37.885 .400 F2,40 Z 7.567 .000 F2,40 Z 30.383 .000
120
120
Upper trapezius vs lower trapezius Upper trapezius vs serratus anterior Lower trapezius vs serratus anterior
.548 .002 .001
Posture muscle (UT vs LT) F1,20 Z 20.744 .155 Posture muscle (UT vs SA) F2,40 Z 8.452 .001 Posture muscle (LT vs SA) F2,40 Z 31.629 .000
NHP, neural head posture; FHP, forward head posture; SA, serratus anterior; UT, upper trapezius; LT, lower trapezius.
Influence of forward head posture
371 60 degrees
30 degrees 40
*
*
* %MVIC
20
UT
LT
20
0
0 SA
UT
LT
SA
Muscle
Muscle 90 degrees
*
*
120 degrees
*
70
*
*
*
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LT
60
50
50
40
%MVIC
%MVIC
*
10
10
60
*
30
30
%MVIC
*
40
30 20
40 30 20
10
10
0
0 SA
UT
SA
LT
Muscle
Muscle NHP
FHP
Figure 2 Comparison of the EMG activity between NHP and FHP in 30 , 60 , 90 , and 120 loaded isometric shoulder flexion. Abbreviation: NHP, neural head posture; FHP, forward head posture; SA, serratus anterior; UT, upper trapezius; LT, lower trapezius. *P < 0.05.
resting position of the scapula (Greenfield et al., 1995). Previous studies have shown that sitting posture and thoracic spine position affect scapular kinematics (Finley and Lee, 2003; Kebaetse et al., 1999). Ludewig and Cook (1996) reported that the scapular upward rotation and posterior tilting were significantly decreased in the 20 flexed head position during humeral elevation without load. Although we did not measure scapular kinematics directly in this study, the FHP-related altered scapular position may have affected the movement pattern of the scapular upward rotation during loaded isometric shoulder flexion. Previous studies have also shown that shoulder positions affect shoulder muscle strength (Smith et al., 2002). Thus, these previous findings of position-induced changes in kinematics, muscle activation patterns, and length-tension relationship appear to be consistent with our findings. Third, it is possible that the changes in biomechanics of FHP influenced muscle activation. When the flexion moment of the cervical spine is increased in FHP, the level of neck extensor muscle activation is increased to counterbalance the increased flexion moment. This is consistent with our observation that upper trapezius muscle activity was increased in FHP. A previous study (Ludewig and Cook, 1996) indicated that scapular upward rotation and posterior tilting were significantly decreased in flexed head positions and there were no significant differences in the EMG activities of the upper and lower trapezius, levator scapula, or serratus
anterior according to head position (0 , 25 , 50 ) during humeral elevation in the scapular plane, without an applied load. In our study, however, EMG activities of the upper and lower trapezius and serratus anterior were significantly different between NHP and FHP. The different findings of the present study may have been due to the pattern of arm elevation (i.e., the plane of arm elevation or external load application) affecting the scapular movement pattern. In our study, subjects were asked to elevate their arm in the sagittal plane with a 2-kg weight to simulate a real work position, in contrast to the unloaded arm elevation in the scapular plane in the study of Ludewig and Cook (2000). Other groups have shown that differences in the pattern of arm elevation resulted in changes in scapular movement patterns. McQuade and Smidt (1998) reported that the scapulohumeral rhythm was significantly altered according to the external weight on the arm during dynamic humeral elevation in the scapular plane. Up to about 40% of maximum arm elevation, the lighter the load, the higher the scapulohumeral rhythm. Doody et al. (1970) also reported that the scapulohumeral rhythm decreased in the initial phase of motion with additional load during abduction in the scapular plane. In the present study, significant increases were observed in upper trapezius and lower trapezius muscle activity in FHP vs. NHP. Kinematic changes in scapular motion have been linked to muscle force imbalances between the upper and lower or between medial and lateral forces (Sahrmann,
372
J.-H. Weon et al. NHP
%MVIC
40
*
FHP
*
*
50
*
*
30 20 10
*
*
30 20
0
60 degree
30 degree NHP
*
*
NHP
FHP 100
*
*
80
%MVIC
80
%MVIC
*
*
10
0
60
FHP
40
%MVIC
50
NHP
40 20
*
FHP
*
60 40 20
0
0
90 degree
120 degree SA
UT
LT
Figure 3 Comparison of the EMG activity between muscles in 30 , 60 , 90 , and 120 loaded isometric shoulder flexion. Abbreviation: NHP, neural head posture; FHP, forward head posture; SA, serratus anterior; UT, upper trapezius; LT, lower trapezius. *Padj < 0.017.
2002). Kinematic changes have been reported to occur in patients with shoulder impingement syndrome. Ludewig and Cook (2000) reported that construction workers with shoulder impingement syndrome showed increased upper and lower trapezius muscle activity and decreased serratus anterior muscle activity during humeral elevation in the scapular plane in comparison with subjects without shoulder impingement. Overactivity of the upper and lower trapezius and changes in scapular kinematics may contribute to neck and shoulder pain. Increased muscle activation to maintain a certain posture can result in localized muscle fatigue and may worsen signs and symptoms of repetitive injury in the cervical and shoulder regions (McLean, 2005). Continued muscle contraction has been shown to be reported to chronic cervical and shoulder pain syndrome (Larsson et al., 1988; Sluiter et al., 2001), and the progressive deterioration in posture of computer workers has also been shown to be associated with increased muscle activity in the trapezius during data entry task performance (Kleine et al., 1999). Previous studies have demonstrated that there is a trend toward higher muscle activation while performing similar tasks in individuals with musculoskeletal disorders, especially trapezius myalgia, in comparison with healthy subjects (Veiersted et al., 1990, 1993; Waersted et al., 1991). In the present study, maintenance of FHP induced stress in the intervertebral foramen and posterior structures at several cervical levels and possible injury to joint structures that may result in nociceptor stimulation, and consequently reflexive contraction of cervicobrachial muscles to protect tissues from further injury. Such increased muscle activity may then facilitate further tissue damage (Ha ¨gg and Astro ¨m, 1997; Ha ¨gg and Suurku ¨la, 1991; Hermens and Hutten, 2002).
Activation of scapular upward rotators during arm elevation is important for movement of glenohumeral joint as decreased scapular upward rotation has been suggested to be a mechanical risk factor contributing to the development of subacromial impingement syndrome by reducing the subacromial space and increased subacromial pressure (Flatow et al., 1994; Kibler and McMullen, 2003; Michener et al., 2003; Sahrmann, 2002). During glenohumeral elevation, the serratus anterior is required to work with the trapezius to rotate the scapula upward to allow free movement of the humeral head under the coracoacromial arch (McQuade et al., 1998). Ludewig and Cook (2000) reported decreased activity level of the serratus anterior and reduced upward rotation of the scapula in patients with subacromial impingement syndrome. In addition, decreased scapular upward rotation is thought to be associated with glenohumeral instability by altering glenohumeral joint alignment. Decreased muscle activity of the serratus anterior may reduce control or stabilization of scapular motion statically or dynamically. We found that serratus anterior muscle activity was significantly decreased during loaded isometric shoulder flexion with FHP in comparison with NHP, and this change in activity of the serratus anterior muscle may lead to alterations in scapular and glenohumeral kinematics. The serratus anterior muscle is an important scapular stabilizing muscle during arm movement. The serratus anterior is a scapular abductor and antagonist of the upper and lower trapezius, which are adductors of the scapula. Decreased activity of the serratus anterior muscle may cause scapular adduction during arm elevation in FHP. The serratus anterior may provide proximal stabilization of the scapula on the thorax
Influence of forward head posture during arm movement. Decreased activity of the serratus anterior muscle may cause winging of the scapula during arm elevation in FHP. Ludewig and Cook (2000) reported that the serratus anterior showed decreased activity in construction workers with impingement across all loads (2.3 kg, 4.6 kg loads) and all phases (31e60 , 61e90 , 91e120 ) during humeral elevation in the scapular plane in comparison with subjects without shoulder impingement. Prolonged FHP may cause shoulder impingement syndrome related to occupational or recreational exposure to lifting and overhead work, because of decreased serratus anterior muscle activity during lifting. The lower digitations of the serratus anterior that insert on a triangular area on the inferior scapular angle draw the lower angle of the scapula forward to couple with the upper trapezius and levator scapulae in forward rotation (Kent, 1971). Ludewig and Cook (1996) reported that scapular posterior tilting was significantly decreased in the 20 flexed head position during unloaded arm elevation in the scapular plane humeral elevation. The decreased serratus anterior muscle activity observed in the present study may have contributed to the reduction of scapular posterior tilting during arm elevation in the sagittal plane in FHP. Subjects with impingement syndrome showed less posterior tipping of the scapula in comparison to subjects without impingement (Sahrmann, 2002; Lukasiewicz et al., 1999). FHP may cause the anterior tilting of the scapula due to decreased serratus anterior muscle activity during working overhead or lifting a tool or loaded components in construction or assembly line work. Thus, FHP may contribute to the development of shoulder impingement syndrome or neck and shoulder pain. In a preliminary study, subjects were asked to flex their right shoulder while holding a 2-kg or 3-kg dumbbell until the upper aspect of the right wrist touched the bar and to hold the position for 5 s. Using the 3-kg weight, subjects complained of discomfort and fatigue in the right shoulder joint and muscles secondary to the increased load. Thus, we used the 2-kg dumbbell for the load in the present study. Our study has several limitations. First, to measure upward rotator muscle activity, we used surface EMG and assumed that the recorded EMG signal indicated the activity of each muscle. However, signal alterations could potentially be caused by muscle movements below the surface electrode or cross-talk from adjacent muscles. Second, it is difficult to conclude that increased upper trapezius and lower trapezius and decreased serratus anterior activity caused reduced scapular upward rotation during shoulder flexion in FHP without kinematic data for scapular upward rotation during isometric shoulder flexion. Further studies involving the collection of kinematic data are warranted to verify that scapular upward rotation occurs during shoulder flexion in FHP. Our results should not be generalized to other populations, because all the subjects in the study were young and healthy, with no cervicobrachial pathology. Thus, the benefits of NHP in this study should be confirmed in other patient populations. The results of the present study indicated significant increases in upper and lower trapezius activity and a significant decrease in serratus anterior activity with FHP during loaded isometric shoulder flexion in the sagittal plane. Thus, assuming NHP during loaded isometric shoulder flexion at different degrees can be advocated as
373 a biomechanically favorable posture to reduce excessive activity of the upper and lower trapezius and to increase the activity of the serratus anterior.
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Journal of Bodywork & Movement Therapies (2010) 14, 375e381
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BIOMECHANICS
The effect of patellar taping on joint reaction forces during squatting in subjects with Patellofemoral Pain Syndrome (PFPS) ¨ Hudson c Javid Mostamand a,*, Dan L. Bader b, Zoe a Department of Physiotherapy, Faculty of Rehabilitation Sciences, Isfahan University of Medical Sciences, Isfahan, 8174673461, Islamic Republic of Iran b Department of Engineering, Queen Mary University of London, Mile End Road, London, E1 4NS, UK c Centre for Sports and Exercise Medicine, Barts and the London Queen Mary’s School of Medicine and Dentistry, Mann Ward, Mile End Hospital, Bancroft Road, London, E1 4DG, UK
Received 24 March 2009; received in revised form 25 June 2009; accepted 1 July 2009
KEYWORDS Patellar dysfunction; PFJ biomechanics
Summary Introduction: The mechanisms of pain reduction have not completely been established following patellar taping in subjects with patellofemoral pain syndrome (PFPS); although it might be related to alteration in the kinetics of the patellofemoral joint. Methods: Patellofemoral Joint Reaction Force (PFJRF) of eighteen subjects with PFPS and eighteen healthy subjects as controls were assessed by a motion-analysis system and one force plate. This procedure was performed on the affected knee of subjects with PFPS, before, during and finally after patellar taping during unilateral squatting. A similar procedure was also performed on the unaffected knees of both groups. Results: The mean values of PFJRF prior to taping (2025 N, SD 347 N) were decreased significantly following a period of taping (1720 N, SD 303 N) (P < 0.05). There were no significant differences between the mean values of PFJRF among controls (1922 N, SD 398 N) and subjects with PFPS prior to taping (P > 0.05) which might be due to small sample size in both groups and large variability observed in the study. Interpretation: Decreased values of PFJRF may explain the mechanism of pain reduction following patellar taping in subjects with PFPS. ª 2009 Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ98 (0) 311 792 2024; fax: þ98 (0) 311 6687270. E-mail addresses:
[email protected] (J. Mostamand),
[email protected] (D.L. Bader),
[email protected] (Z. Hudson).
Introduction Although the aetiology of patellofemoral pain syndrome (PFPS) is not clearly understood, it has been suggested that the pain and discomfort is likely to be the result of
1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.07.003
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abnormal biomechanical factors that alter the distribution of shearing and compressive forces on the patellofemoral joint (PFJ) during normal activities (Sikorski et al., 1979). Patellofemoral pain is usually aggravated during activities associated with the flexed knee; such as stair stepping, (Crossley et al., 2002) or with prolonged sitting (McConnell, 1986). It is believed that these activities result in higher patellofemoral joint reaction force (PFJRF) and hence higher patellofemoral joint stress (PFJS) (Reilly and Martens, 1972; Wallace et al., 2002). It seems that increased level of PFJRF and consequently higher PFJS is related to the improper tracking of the patella through the trochlear groove during these activities (Hvid et al., 1981). It is therefore proposed that these forces and stresses may be increased in subjects with PFPS during these knee bent activities, which may cause the perception of pain. Patellar taping is known as an effective treatment method for improving the symptoms of PFPS (Crossley et al., 2002; Ng and Cheng, 2002). It is believed that this method affects the tracking of the patella and centralizing it within the trochlear groove (Powers et al., 1998; McConnell, 2002). The mechanism by which taping affects the PFJ is not completely clear; so, it has been proposed that the application of the tape alters the knee extensor moment and PFJRF of the various articulations associated with the knee joint during knee bent activities (Larsen et al., 1995; Somes et al., 1997). The effect of patellar taping on the knee moments of healthy subjects has previously been investigated during stair-stepping task (Selfe et al., 2008). Authors found that patellar taping reduced the range of coronal and transverse plane knee moments. Decreased level of knee extensor moment and consequently PFJRF and PFJS may therefore explain decreased level of pain following application of tape in subjects with PFPS. In addition, two previous studies assessed the effect of patellar taping on sagittal plane knee moments during a leg vertical jump, lateral step-up and stair-stepping task in subjects with PFPS (Ernest et al., 1999; Salsich et al., 2002). The results showed that the taping increased the range of sagittal plane knee moments in these subjects.
Table 1
Different values of moment in various planes in both healthy and PFPS subjects require more investigations to explain any kinetic changes following patellar taping in subjects with PFPS. As far as the authors know there have been no studies considering the effect of patellar taping on both sagittal plane knee moments and PFJRF of subjects with PFPS during squatting. Therefore, this study was aimed to measure these moments and consequently PFJRF, after application of the patellar tape in subjects with PFPS. This study was developed to establish methods that could indirectly explain the pain reduction mechanism of patellar taping.
Methods Subjects To determine the sample size for testing the hypotheses on subjects, it was important to establish the variability of the PFJRF. As this variable has not previously been reported, the sample size for this study was based on the quantitative data that were collected for PFJRF from subjects. Post hoc sample size analysis was therefore conducted after data collection on subjects recruited to this study. Based on the sample size analysis with a power of 80% and a two-sided significance level of 0.05, twelve samples were required to statistically compare the mean PFJRF differences of 302 N (SD 274 N) on the painful knee of subjects with PFPS before patellar taping (2052 N, SD 336 N) and after application of the tape (1750 N, SD 252 N). These values were derived from thirteen subjects with PFPS. Considering probable drop-outs, eighteen subjects with PFPS were recruited in the study from the physiotherapy department of Mile End Hospital of London (Tower Hamlet Primary Care Trust). These subjects were diagnosed by experienced physiotherapists, using the clinical examinations; although the final decision about entrance of participants into the study was made by the researcher on the basis of meeting all inclusion criteria (Table 1). Eighteen healthy subjects with no history of the knee pain were also selected from the
Inclusion and exclusion criteria for both groups of study. Inclusion criteria
PFPS group
1. Anterior or retropatellar pain, insidious in nature, which was aggravated by at least two of the following common functional activities of daily life: -
prolonged sitting stair climbing squatting running kneeling hopping/jumping
Exclusion criteria 1. Any traumatic, inflammatory or infectious pathology in the lower extremity 2. Dislocation or subluxation in the PFJ 3. History of surgery in the knee joint 4. Any signs of secondary osteoarthritis in the knee joint
2. Pain during an objective single leg squatting of 10-seconds 3. Aged less than 40 years (both genders) 4. Completed consent form Control group 1. Age, gender, weight and height matched to PFPS group 2. Completed consent form
As above
The effect of patellar taping on joint reaction forces students and staff of Queen Mary University of London as a control group. The age, sex, height and weight of control group was matched to those subjects in the PFPS group. For each PFPS subject a relevant control with maximum age difference of 2 years were selected. The difference of weight and height between each PFPS subject and his/her healthy control was supposed to be less than 2 kilograms and 3 centimeters, respectively. The study was approved by the East London and City Research Ethics Committee before recruiting both groups’ subjects. A written informed consent was taken from each subject.
Instrumentation A two camera (DCR-VX2000E, Sony, Japan) motion-analysis system (SIMI Motion e 2D & 3D Motion Analysis, version 7.0, Reality Motion Systems, GmbH, Germany), was used to record three dimensional coordinates of superficial reflective markers of thigh, shank and foot (Figure 1), at a rate of 60 Hz. Unilateral ground reaction force data were also collected from one force plate (Figure 1) (Kistler, 2812A1-3, version 3.20, Switzerland) at a rate of 600 Hz.
Preparation of subjects Anthropometric data of subjects in both PFPS and healthy control groups were measured (Winter, 1990) after they met all inclusion criteria. To collect the kinematic data of subjects using double-sided tape, superficial reflective markers (2.5-cm spheres) were placed on specific bony landmarks, namely, the second metatarsal head, lateral malleolus, lateral shank, lateral femoral epicondyle and lateral thigh of both legs (Wallace et al., 2002). After preparing the subjects, they were instructed to perform several practices for single leg squats, although the subjects with PFPS were warned to practice to a minimum level with the affected knees to avoid exacerbating the pain before the main study. To control any trunk forward flexion or deviation, all subjects were asked to keep their foot in full contact with
Figure 1 Setup used to measure kinematics and kinetics during single leg squatting.
377 the floor during single leg squatting, while verbal feedback was used to encourage subjects to hold their trunks in a vertical position. The first leg to be tested for each subject in both groups of study was selected in a randomized order, even and odd, selected from a container. To implement randomization, forty numbered tags (twenty evens and twenty odds) were put inside a container and each subject drew a tag from the container. Note that labeling was blind to the subjects drawing the tags.
Test procedures Biomechanical assessment of subjects with PFPS in the untaped condition Subjects with PFPS were asked to perform a shallow single leg squat of approximately 45 of knee flexion on the affected leg (to ensure that the knee flexion angle is 30 ) and hold it for approximately 10 s to record any resulting pain on the standard 100 mm visual analogue scale (VAS). Then they were instructed to stand on one leg on the force plate and to keep the contralateral leg off the floor. Each subject was then asked to execute a single leg squat from a neutral position (0 degree of knee flexion) to a depth of approximately 45 of knee flexion (to ensure that the knee flexion angle is 30 ), while maintaining heel in contact with the floor (Figure 1). The duration of squatting functions were constrained to about 3 seconds measured by a stop watch; the measurement was from the initiation of knee flexion to return to full knee extension. Thus a maximum period of 12 seconds was assigned to three repetitions, including the first 3 seconds of test period for concordance of subjects with the activity. Verbal feedback regarding both depth and duration of the function were provided after several practice squats. When the subjects had familiarized themselves with the timing and depth of this single leg squat, testing would commence. Data were simultaneously recorded with the camera system and force plate. Data collection was stopped when the subjects completed the three single leg squats. On completion of this procedure, an identical test procedure was repeated on the contralateral leg.
Figure 2
Medial glide taping technique.
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Biomechanical assessment of subjects with PFPS in the taped condition After recording data, the patellar tape was immediately attached over the affected patellar region in subjects with PFPS in the order of medial glide (Figure 2), according to patellar orientation tests (McConnell, 1986). The choice of taping methods was partly based on assessment of the patella position and partly on the attainment of pain reduction. After application of tape over the patella, each subject was asked to perform a single leg squat and hold it for about 10 s for evaluating the pain level on a separate VAS sheet. The taping method was acceptable if the level of pain was decreased by approximately 50% compared to the untaped condition (Crossley et al., 2002). Then the same test procedures for collecting both kinematic and kinetic data were conducted in taped condition in the same session. Biomechanical assessment of subjects with PFPS after removal of the tape After finishing the measurements in the taped condition, the subjects in PFPS group were instructed verbally and also with illustrated diagrams to be able to independently apply the taping corrections on a daily basis during the follow-up period (Crossley et al., 2002) (see Appendix). At each evaluation session, subjects were asked to apply the patellar tape to check if they can perform it correctly. The subjects were evaluated during 7 days of follow-up period, using the VAS, until they became symptom-free; a period that based on previous studies predicted to last a maximum of 6 weeks (McConnell, 1986; Crossley et al., 2002; Clark et al., 2000; (Eburne and Bannister, 1996); Harrison et al., 1999; Kowall et al., 1996). Once the subjects became symptom-free, they were instructed to remove the tape before coming to the human performance laboratory. At that time, each subject was asked to repeat the testing procedure, in an identical method described in two previous tests, for the third time on the affected knee. Biomechanical assessment of healthy control subjects Subjects in the control group underwent a similar testing procedure as subjects in the PFPS group. One testing session was allocated to these subjects to measure the kinematic and kinetic data of both legs without applying any additional intervention during single leg squatting.
(Winter, 1990). Sagittal- plane knee joint angles and net knee moments (Mk) were calculated from the inertial properties, segmental kinematics, and force platform data using inverse dynamics equations (Winter, 1990). The PFJRF was calculated using a biomechanical model of the PFJ (Salem and Powers, 2001). Based on the model, quadriceps muscle force (Fq) was calculated as the net knee moment (Mk) divided by the moment arm for the quadriceps (Lq). Fq ZMk =Lq The moment arm was estimated using the following nonlinear equation, based on the curve fitting to the data of van Eijden et al. (1987): Lq Z8:0e5 X 3 0:013X 2 þ 0:28X þ 0:046 where, X is the tibiofemoral joint angle. PFJRF was calculated as the product of the quadriceps force (Fq) and a constant (k) as follow: PFJRFZFq $k The constant k was estimated for knee joint angle (X ) using the following non-linear equation, based on the curve fitting to the data of van Eijden et al. (1986): 3:8e5 X 2 þ 1:5e3 X þ 0:462 kZ 7:0e7 X 3 þ 1:6e4 X 2 0:016X þ 1 For each test, kinetic data (Mk, PFJRF) were averaged through the 3 repetitions of single leg squatting. Data were analyzed in the eccentric phase of this activity at 30 of knee flexion.
Data analysis A parametric test (Two-way analysis of variance Z ANOVA) was then chosen to compare data between subjects with PFPS and healthy control in different tape conditions. Though bilateral kinetic data of healthy control subjects were collected, paired sample t-tests revealed that the differences between the mean values of Mk and PFJRF of right and left knees were not statistically significant (P > 0.05). Data sets were therefore combined to compare the results between the affected and unaffected knee of subjects with PFPS. For all tests, a 0.05 level was used to determine statistical significance. SPSS statistical software, version 13.0 was used to perform all statistical analysis.
Data reduction
Results Marker-coordinate and force data were processed by the SIMI motion-analysis system. Using this system, the segmental kinematics for the foot, shank and thigh were computed. The inertial properties for the foot, shank and thigh were determined from the subject’s total body weight, segment geometry and anthropometric data Table 2
Table 2 demonstrates the demographic and anthropometric data obtained from both groups of PFPS and control subjects. As Mk and PFJRF were inter-related by constant values and therefore followed the same patterns during
Anthropometric and demographic data of the PFPS and control groups (mean (SD)).
PFPS group Control group
Number
Gender
Age (years)
Weight (kg)
Height (cm)
18 18
11 men, 7 women 11 men, 7 women
27.9 (6.3) 26.4 (4.9)
71.5 (9.5) 71.6 (11.1)
171.3 (5.9) 171.9 (7.5)
The effect of patellar taping on joint reaction forces
379
Table 3 The mean values (SD) of knee extensor moment (Mk) and patellofemoral joint reaction forces (PFJRF) in subjects with PFPS and healthy control in five different conditions of taping. Significant differences of PFJRF values have been shown between three paired comparisons. Condition of patellar taping
Mk (Nm/kg)
PFJRF (N)
Significant difference between PFJRF values (N)
UnNTa BTb WTc ATd NTHSe
1.51 1.61 1.43 1.37 1.53
1895 2025 1796 1720 1922
UnNTa- BTb Z 130 BTb e WTc Z 229 BTb e ATd Z 305
a b c d e
(0.17) (0.19) (0.18) (0.19) (0.22)
(286) (347) (297) (303) (398)
UnNT, no-tape unaffected knees. BT, affected knees before applying the tape. WT, affected knees with tape. AT, affected knees after application of the tape. NTHS, no-tape knee of healthy control subjects.
eccentric phase of single leg squatting in 30 degrees of knee flexion, the results of PFJRF measurements were reported as final products of the Mk. The Mk values are summarized in Table 3. The mean value of PFJRF of the affected knee in subjects with PFPS before applying the tape (2025 N, SD 347 N) was greater than the mean PFJRF for the corresponding values of the unaffected knees (1895 N, SD 286 N) (P < 0.05). The mean value of PFJRF in the before-taped condition was also greater than the taped condition (1796 N, SD 297 N) and after applying the tape (1720 N, SD 303 N) in the affected knees. However, there was no significant difference between the mean values of PFJRF in the before-taped condition and no-tape condition, in both knees of healthy control subjects (1922 N, SD 398 N) (P > 0.05) (Table 3). Two-way ANOVA revealed that there were significant differences between the mean values of PFJRF in five different conditions of taping in subjects with PFPS and healthy controls (F4, 85 Z 2.65, P < 0.05). The multiple comparison tests using the least significant difference (LSD) demonstrated that these values between the conditions of before taping and taped, before and after taping and also before taping and no-tape of unaffected knees were significantly different (P < 0.05), while there were no significant differences comparing these values for taped and after taping condition and also for before taping and no-tape condition of healthy control subjects (P > 0.05). The magnitude of PFJRF differences between before taping and taped condition and also between taped and after taping, in affected knees was 11.3% and 4.2%, respectively. The mean levels of pain with tape (31 mm, SD 9 mm) and after application of the tape in the last test session (16 mm, SD 9 mm) were lower than the level of pain before application of the tape (60 mm, SD 10 mm) in subjects with PFPS. The differences between these mean values were significant (F2, 51 Z 101, P < 0.001). An immediate pain reduction of approximately 50% occurred among the subjects with PFPS, after using a patellar tape in the first session of test. The similar percentage of pain reduction also occurred in the last test session, compared with the taped condition. Pain reduction
of approximately 50% during each test session, revealed that the magnitudes of these differences were similar.
Discussion Several null hypotheses related to the kinetic data were tested in the current study. The first hypothesis was that Mk and PFJRF will not change immediately after application of patellar tape in PFPS subjects, during single leg squatting. Additionally, that Mk and PFJRF would not change with daily application of patellar tape for at least 6 weeks. The results indicate that after immediate application of the patellar tape and also during less than 6 weeks of follow-up, the knee extensor moment and PFJRF decreased in the affected knee of PFPS subjects. The secondary null hypothesis on similarity of kinetic values in both knees was also rejected by the results; indicated that values were statistically greater in the affected knees of PFPS subjects before application of the tape than unaffected knees. In the present study the reduction of pain following application of patellar tape in subjects with PFPS was associated with a decrease in Mk (from 1.61, SD 0.19 Nm/kg to 1.37, SD 0.19 Nm/kg) and consequently reduction in PFJRF. Conversely, two previous studies reported an increase in these variables following immediate application of patellar tape during different functional activities. Ernest et al. (1999) showed that the taped condition resulted in a greater Mk (1.73, SD 0.36 Nm/kg and 1.40, SD 0.27 Nm/ kg) than the no-tape (1.40, SD 0.46 Nm/kg and 1.21, SD 0.33 Nm/kg) and placebo tape conditions (1.38, SD 0.32 Nm/kg and 1.28, SD 0.28 Nm/kg) during a single leg vertical jump and lateral step-up. In another study, Salsich et al. (2002) also reported the similar increase in Mk, following application of patellar tape during trials of stair ascent and descent. In the no-tape condition, during stair ascent and descent the Mk was 0.12 (SD 0.17) Nm/kg and 0.37 (SD 0.13) Nm/kg, respectively. This variable after applying the tape during stair ascent and descent was 0.30 (SD 0.17) Nm/kg and 0.55 (SD 0.14) Nm/kg, respectively. There is a possible explanation for the decreased kinetic values with patellar taping in the current study. This is related to the quadriceps moment arm which may change during patellar taping. As the PFJRF are the final product of
380 Mk, any potential change in the quadriceps moment arm may result in changes in the Mk and therefore the PFJRF. Smidt (1973) found that the maximum length of quadriceps moment arm is at 30e45 of knee flexion and this length reaches a minimum when the knee is in the full flexion where the patella is located distally in the intercondylar groove. The quadriceps moment arm and Mk may be altered by any potential movement or position of the patella. A radiographic study showed that application of an infrapatellar strap could displace the patella proximally and anteriorly compared to the case without the strap in the extended knee (Levine, 1978). The proximal displacement of the patella may prevent the patella sinking distally into the intercondylar groove and thus maintain a longer quadriceps moment arm. In an optimal condition, the patella is situated parallel to the femur in both frontal and the sagittal planes, so that it is equidistant between the two condyles in a slightly flexed knee (McConnell, 1986). In the current study however, the patellar tape was used across the middle of patella to correct the lateral glide or tilt of the patella, holding it in the centre of intercondylar groove. This corrective taping might have therefore improved patellar position and limited any proximal displacement of the patella, facilitating its distal displacement into this groove during knee flexion. This condition would decrease the quadriceps moment arm and produce a smaller Mk and thus decreased PFJRF. Although the knee extensor moment in sagittal plane in subjects with PFPS was measured in the present and previous studies, the reason of differences in the results may be sought in different functional activities recruited in these studies. This difference may be explained in two ways. Firstly, the muscle recruitment strategies for various activities may be changed, leading to altered muscle activities. For example, the isokinetic leg press exercise has been shown to place a greater demand on the knee extensors than other kinds of closed kinetic chain exercises, including stair-stepping task (Wilk et al., 1996). Therefore in the present study it is possible that squatting placed less demand on the knee extensor moment than stair stepping or vertical jump exercises recruited by the Ernest et al. (1999) and Salsich et al. (2002). Indeed, the taping might have contributed to the recruitment of the quadriceps muscle based on the less muscle demand during squatting, thus produced enhanced muscle efficiency. Secondly, generating the necessary muscle forces to propel the body and control the centre of body mass may be different during various functional activities. It is evidential that during stair-stepping task, the individual must be able to activate the muscles properly and generate the necessary forces to propel the body upstairs and downstairs and control the constantly changing centre of body mass (Shumway-Cook and Woollacott, 1995). It seems that displacement of centre of body mass is very smaller during squatting than the stair-stepping task, because during squatting, the body is not required to be lifted to overcome a height and control the constantly changing centre of body mass. Considering the lesser muscle force required for squatting than stair-stepping task, patellar tape might have decreased the quadriceps muscle force more, hence decreased knee extensor moment during this activity.
J. Mostamand et al.
Conclusion Taping technique aims to align the PFJ and consequently to reduce the pain level in subjects with PFJS. This study showed that PFJRF values in the affected knee of subjects with PFPS were greater than those related to the unaffected knee, although these values were not different from healthy control subjects. This may be related to the small sample size recruited in both groups to compare their kinetic values. It is possible that a true difference in PFJRF existed between the affected knee of subjects with PFPS before using the tape and the knees of healthy control subjects but was not detected, given the large variability associated with the eighteen subjects. It was also revealed that patellofemoral taping reduced the PFJRF values and corresponding pain level during single leg squatting. Reduction of pain in subjects with PFPS may be therefore attributed to the effect of tape in decreasing the value of PFJRF, although this claim would have been verified using only a randomized controlled trial. The reduction of kinetic values may be as a result of alteration in the quadriceps moment arm following patellar taping.
Acknowledgements This article was provided as a part of the study leading to the degree of PhD, which was financially supported by Isfahan University of Medical Sciences and Ministry of Health and Medical Education of Islamic Republic of Iran.
Conflict of interest statement The authors confirm that there are no conflicts of interests regarding this paper.
Appendix Patellar taping techniques
Medial glide technique: To control lateral glide, one end of the tape is secured to the lateral patellar (kneecap) border and the therapist (patient) glides the patella medially with his thumb while maintaining tension in the tape. Then, he lifts the medial soft tissue (skin) toward the patella so that several skin folds appears, and secures the tape medially and across the knee (Crossley et al., 2002).
The effect of patellar taping on joint reaction forces
Medial tilt technique: In order to correct lateral tilt of the patella, the tape is secured at the upper middle portion of the patella (kneecap) and the therapist (patient) pulls the tape medially to lift the lateral border of the patella, correcting the tilt, then he lifts the medial soft tissues (as indicated before) and secures tape (Crossley et al., 2002).
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381 McConnell, J., 1986. The management of chondromalacia patellae: a long-term solution. Australian Journal of Physiotherapy 32, 215e223. McConnell, J., 2002. The physical therapist’s approach to patellofemoral disorders. Clinics in Sports Medicine 21, 363e387. Ng, G.Y.F., Cheng, J.M.F., 2002. The effects of patellar taping on pain and neuromuscular performance in subjects with patellofemoral pain syndrome. Clinical Rehabilitation 16, 821e827. Powers, C.M., Lilley, J.C., Lee, T.Q., 1998. The effects of axial and multi-plane loading of the extensor mechanism on the patellofemoral joint. Clinical Biomechanics 13, 616e624. Reilly, D.T., Martens, M., 1972. Experimental analysis of the quadriceps muscle force and patellofemoral joint reaction forces for various activities. Acta Orthopedia Scandinavia 43, 126e137. Salem, G.J., Powers, C.M., 2001. Patellofemoral joint kinetics during squatting in collegiate women athletes. Clinical Biomechanics 16, 424e430. Salsich, G.B., Brechter, J.H., Farwell, D., Powers, C.M., 2002. The effects of patellar taping on knee kinetics, kinematics, and vastus lateralis muscle activity during stair ambulation in individuals with patellofemoral pain. The Journal of Orthopaedic and Sports Physical Therapy 32, 3e10. Selfe, J., Richards, J., Thewlis, D., Kilmurray, S., 2008. The biomechanics of step descent under different treatment modalities used in patellofemoral pain. Gait and Posture 27, 258e263. Shumway-Cook, A., Woollacott, M., 1995. Motor Control Theory and Practical Applications. Williams & Wilkins, Baltimore, MD, U.S.A. Sikorski, J.M., Peters, J., Watt, I., 1979. The importance of femoral rotation in chondromalacia patellae as shown by serial radiology. The Journal of Bone and Joint Surgery-British 61, 435e 442. Smidt, G.L., 1973. Biomechanical analysis of knee flexion and extension. Journal of Biomechanics 6, 79e92. Somes, S., Worrell, T.W., Corey, B., Ingersol, C.D., 1997. Effects of patellar taping on patellar position in the open and closed kinetic chain: a preliminary study. Journal of Sports Rehabilitation 6, 299e308. van Eijden, T.M.G.J., Kouwenhoven, E., Verburg, J., Weijs, W.A., 1986. A mathematical model of the patellofemoral joint. Journal of Biomechanics 19, 219e229. van Eijden, T.M.G.J., Weijs, W.A., Kouwenhoven, E., Verburg, J., 1987. Forces acting on the patella during maximal voluntary contraction of the quadriceps femoris muscle at different knee flexion/extension angles. Acta Anatomica 129, 310e314. Wallace, D.A., Salem, G.J., Salinas, R., Powers, C.M., 2002. Patellofemoral joint kinetics while squatting with and without an external load. Journal of Orthopaedic and Sports Physical Therapy 32, 141e148. Wilk, K.E., Escamilla, R.F., Fleisig, G.S., Barrentine, S.W., Andrews, J.R., Boyd, M.L., 1996. A comparison of tibiofemoral joint forces and electromyography during open and closed kinetic chain exercises. American Journal of Sports and Exercise Medicine 24, 518e527. Winter, D.A., 1990. Biomechanics and Motor Control of Human Movement, second ed. A Wiley-Interscience Publication, New York NY.
Journal of Bodywork & Movement Therapies (2010) 14, 382e390
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PAIN PHYSIOLOGY
The influence of age and physical activity on the pressure sensitivity of soft tissues of the musculoskeletal system Waldemar Andrzejewski, Krzysztof Kassolik, Marcin Brzozowski*, Katarzyna Cymer Department of Physiotherapy, University School of Physical Education, Faculty of Physiotherapy, 51-612 Wroclaw, al. Paderewskiego 35/p-4, Poland Received 30 January 2009; received in revised form 2 July 2009; accepted 6 July 2009
KEYWORDS Pressure sensitivity; Physical activity; Age
Summary Background: The pressure sensitivity of soft tissues is defined as the slightest pressure causing pain. Sex, movement system illnesses, pain ailments may influence the pressure sensitivity. However, there have been few studies on factors determining the level of pressure sensitivity of skeletal muscles. Objective: The authors have determined to study the influence of age and physical activity on the pressure sensitivity of skeletal muscles. Methods: The examination of pressure sensitivity of trigger points and muscle insertions was carried out using algometry. Results: 76 volunteers (38 students and 38 individuals aged 50e75) participated in the study. The differences in pressure sensitivity between students and people aged 50e75 were not statistically significant. Pressure sensitivity of students differed depending on their level of physical activity. Conclusions: The level of physical activity influenced the pressure sensitivity of skeletal muscles. Age did not significantly influence pressure sensitivity. ª 2009 Elsevier Ltd. All rights reserved.
Introduction
* Corresponding author. Tel.: þ48 071 3473091; fax: þ48 071 3473016. E-mail address:
[email protected](M.Brzozowski).
The pressure sensitivity of soft tissues is defined as the smallest degree of pressure that causes pain (Fischer, 1988). Among the factors influencing the pressure sensitivity are gender, musculoskeletal conditions, painful ailments, and mental health disorders. So far there have
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The influence of age and physical activity been few studies which demonstrate the influence of these factors on the level of pressure sensitivity of skeletal muscles. Some studies measured pressure sensitivity in relation to fibromyalgia, myofascial pain syndrome, or nonspecific spinal pain (Mikkelsson et al., 1992; Offenbacher and Stucki, 2000).
Clinical relevance Therapists who use palpation as a diagnostic tool should take into account factors determining pressure sensitivity. The results of the research described in this paper suggest that physical activity can influence the level of pressure sensitivity of muscles, potentially modifying pain threshold. An additional finding is that there appears to be little influence of age on pressure sensitivity. Fischer researched both pressure sensitivity, and maximum pressure tolerance, of skeletal muscles with an algometer. He demonstrated higher pain sensitivity (lower pain threshold) of muscles in a group of men in comparison with a group of women, as well as different sensitivities of different muscles (Fischer, 1987a). Fischer found that pain caused by a pressure of up to 3 kg/cm2 is characteristic of unhealthy tissue. Additionally, he concluded that a difference in sensitivity of tissues on both sides of the body greater than 2 kg/cm2 is proof of a disease state within the tissue limits (Fischer, 1986). This comparison of the pressure sensitivity of tissues, on both sides of the body, seems to be more reliable for diagnostic purposes than comparing results with population standards, which are individually variable. In the case of double-sided pathological sensitivity, Fischer suggested comparing the results with those taken from neighboring tissues, or the upper limits of norms established for healthy tissues. Mikkelsson carried out a study on pressure sensitivity in women with fibromyalgia. The measurements were performed on the tibial and deltoid muscles. The pain threshold in women with fibromyalgia was lower than in healthy matched controls (Mikkelsson et al., 1992). Measurements are commonly performed on muscles, including myofascial trigger points, and on fascias, tendons, ligaments, and bone tissues. There are two ways to examine pressure sensitivity: manual palpation (Andrzejewski et al., 2007b, 2006; Kassolik et al., 2005) and examination with an algometer, which was designed specifically for this purpose1 (Andrzejewski et al., 2007a, 2005; Fischer, 1987a,b, 1984, 1986; Offenbacher and Stucki, 2000; Reeves et al., 1986; Ronat et al., 2003). The evaluation of pressure sensitivity is a relatively easy and quick diagnostic method. It can be used by various healthcare providers, including physicians, occupational therapists, physical therapists, bodyworkers, etc. Examining sensitivity with an algometer makes the assessment of a patient’s condition more objective, as it limits the patients’ subjectivism and their indecision regarding pain 1 ZAKqAD USqUG ELEKTRONICZNYCH, Niedziałkowskiego Street 22, 51-507 Wrocław, Poland.
383 levels. On the other hand, manual palpation is less objective but, due to its ease, quickness, and availability, it is used more frequently than employment of an algometer. Both methods can be used clinically, with no need to create a special measurement site. Assessing sensitivity assists not only in determining which muscles are extra sensitive, but also in planning a treatment regimen, and monitoring the effectiveness of therapy. The influence of such factors as gender, musculoskeletal system conditions, and mental health disorders, on the pain threshold level has been noted in few studies examining sensitivity (Fischer, 1987a; Mikkelsson et al., 1992). There are however no reports of the influence of age and the level of physical activity on the pressure sensitivity of muscles, knowledge of which can be helpful in treating patients of different ages, or different levels of physical activity. Therefore the aim of this study was to evaluate the influence of age and physical activity on the pressure sensitivity of skeletal muscles using algometry.
Material Seventy-six volunteers participated in the study. They were divided into four groups on the basis of answers in a questionnaire. The first criterion of the division into groups was the age of the participants and the other was the level of physical activity stated in the questionnaire. In group I were 38 individuals aged 50e75 (mean age: 65 years). All subjects in group I were students of The Sudetes University of Third Age, in Wałbrzych, Poland. In the questionnaire, 34 members of the group (90%) declared they engaged in moderate physical activity, 2 (5%) in light physical activity, and the remaining 2 (5%) in vigorous physical activity. The people in this group were relatively healthy and fit for their age, as they were students of the University of the Third Age, which demands quite a lot of activity within the course of the study. All students attended sport classes at least once a week, e.g. group gymnastics in a gym, strolling, Nordic walking or swimming at an indoor swimming pool. In Poland, such an intensity of physical activity is above average for the age group of 50e75. In group II were 38 individuals aged 20e26 (mean age: 22 years). All subjects in group II were students of The University School of Physical Education in Wroclaw, Poland. The members of this group were healthy and fit as they were students of the University School of Physical Education and both before being admitted to the university and during the course of study they had undergone several medical examinations, which were essential to pass an exam on motor fitness in order to continue their studies. In the questionnaire, 16 members of this group (42% of group II) declared they engaged in vigorous physical activity, 16 individuals (42% of group II) moderate physical activity, and the remaining 6 (16% of group II) light physical activity. Out of group II, two further study groups were created: group III, which consisted of 16 students from group II declaring vigorous physical activity, and group IV, consisting of 16 students from group II who declared moderate physical activity. Groups I (University of the Third Age students) and II (University School of Physical Education students) were
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created to see if age influenced pressure sensitivity. Groups III (University School of Physical Education students with vigorous physical activity) and IV (University School of Physical Education students with moderate physical activity) were created to check if a different level of physical activity influenced the pressure sensitivity of soft tissues. Because of the small differences between the levels of physical activity in the group of University of the Third Age students, group I was not taken into account when evaluating the influence of physical activity on pressure sensitivity.
Methods The study consisted of two parts: a questionnaire (Figure 1) and an examination of the pressure sensitivity of muscles. First the study participants completed the questionnaire, than they underwent an examination of pressure sensitivity with an algometer. The algometer used in this study was developed through a joint venture between Wroclaw University of Technology and the Department of Physical Therapy and Massage at the University School of Physical Education in Wroclaw under the supervision of Waldemar Andrzejewski Ph.D. The algometer features a 1 cm2 application head, a shut-off button for subjects, and a reset button (Figure 2). Measurements are displayed in units of pressure (kg/cm2) with a sensitivity of 1 g. Prior to the measurement, all the participants were informed about procedures and were given instructions on how to behave during the measurement. Before the actual measurements three trials were performed so that subjects could easily distinguish the sensations of pressure and pain and were able to stop the measurement at the proper moment. Each subject heard the same instruction: ‘During the measurement, certain points on your body will be pressed. The moment you feel the first pain sensation in the measured area, and not only the sensation of pressure without any pain, please simultaneously say ‘stop’ and press the button you are holding in your hand.’ First the therapist palpated the point in the tissue to be examined and then put the head of the algometer at a right angle and pressed it gradually into the tissue at a rate of 100 g/s. Only the therapist could see the display unit of the algometer. Subjects stopped the measurement by pressing the button at the exact moment when they feel a sharp pain in the area where the head of the algometer had been placed. First and last name : ................................................................................. Age (years) : ................................................................................. Physical activity : 1. light (up to 2 times per week) 2. moderate (at least 3 times per week for 30 minutes) 3. vigorous (at least 5 times per week for 30 minutes or professional sport) Taking painkillers within the recent three months 1. yes 2. no Painful ailments – if present, where exactly
Figure 1
The research questionnaire.
Figure 2
Algometer.
The value of the measurement was then recorded and the device reset, by pressing the button on the upper surface of the main part of the instrument. The therapist successively pressed attachment sites and trigger points of fifteen chosen muscles which, from the authors’ experience, frequently present overstrain changes and, therefore, are most often subject to therapeutic activities. Table 1 includes all the points of the attachments of the tested muscles. Localization of latent trigger points was performed according to Travell and Simons (Travell and Simons, 1992; Simons et al., 1999). Muscles on both body sides were evaluated. During the measurement the subjects were lying relaxed, on one side, with the legs supported, while the other side was being examined. Right limbs of patients were placed on massage cushions. Subjects held the shut-off button of the algometer. Each point was measured bilaterally. The maximum applied pressure was 10 kg/cm2 to minimize the risk of damaging the tissue at higher pressures. The subjects had refrained from any kind of physiotherapeutic treatment, or the use of painkillers, for a period of at least three months before the study. All the subjects were examined by the same therapist, and the measurement was taken using the same instrument. All the individuals had agreed to participate in the study. The study was approved by the local University Ethics Committee. The researchers adopted the hypothesis that age and physical activity influenced pressure sensitivity of skeletal muscles. In order for the hypothesis to be accepted, at least 60% (clear majority) of muscles tested needed to
The influence of age and physical activity Table 1 The points of pressure sensitivity measurement on chosen muscles. Name of muscle
Place of insertion
Superior fibular retinaculum Peroneus longus Biceps femoris Gluteus maximus Gluteus medius
Lateral surface of calcaneum Base of first metatarsal Linea aspera of femur Gluteal tuberosity Superior surface of greater trochanter Lateral surface of anterior superior iliac spine Labium externum of crest of iliac bone Posterior superior iliac spine Greater tubercle of humeral bone Superior angle of scapula Crest of greater tubercle of humerus Coracoid process Pisiform Base of second metacarpal Medial femoral epicondyle
Tensor fasciae latae Latissimus dorsi Erector spinae Infraspinatus Levator scapulae Pectoralis major Pectoralis minor Flexor carpi ulnaris Flexor carpi radialis Adductor magnus
demonstrate a significant difference between values of pressure sensitivity in the compared groups.
Results The mean of the pressure sensitivities for a given body side for each muscle in all groups was calculated. The results were analyzed using Student’s t test for independent samples with a probability of 0.05. For groups I and II a t test for large samples was used and for groups III and IV a t test for small samples. The aim was to check if there were statistically significant differences in sensitivity between groups I (University of the Third Age students) and II (University School of Physical Education students) and groups III (University School of Physical Education students, vigorous physical activity) and IV (University School of Physical Education students, moderate physical activity). The results are presented in Tables 2e9. Tables 2e5 present the comparison of pressure sensitivity between groups I and II. Of a total 60 point to point comparisons, 44 (73.3%) did not reach statistical significance. Table 2 presents the mean values of the pressure sensitivity and the statistical significance of the differences between groups I and II at muscle insertions on the left side of the body. In the majority of muscles (60% of all the researched muscles) there were no statistically significant differences between the two groups. In six of the muscles (peroneus longus muscle, biceps femoris muscle, gluteus maximus muscle, flexor carpi ulnaris muscle, flexor carpi radialis muscle, adductor magnus muscle) there was a statistically significant increased pressure sensitivity in group I. Table 3 presents the mean values of the pressure sensitivity of the muscles and the level of statistical significance of differences between groups I and II at trigger
385 points of the muscles on the left body side. Statistically significant differences (p < 0.05) were found in only two muscles, namely the flexor carpi radialis and the adductor magnus (13.3% of all the researched muscles). Table 4 presents the mean values of the pressure sensitivity and the level of statistical significance of the differences between groups I and II at muscle insertions on the right side of the body. Statistically significant differences in pressure sensitivity were found in only four muscles, namely peroneus longus muscle, biceps femoris muscle, gluteus maximus muscle, and adductor magnus muscle (26.7% of all the researched muscles). Table 5 presents the mean values of pressure sensitivity and the statistical significance between groups I and II at trigger points of the muscles on the right body side. Statistically significant differences (p < 0.05) were found in the following muscles: the peroneus longus, infraspinatus, flexor carpi radialis, and adductor magnus (26.7% of all the researched muscles). Tables 6e9 present the comparison of pressure sensitivity between groups III and IV. Of a total 60 point to point comparisons, 55 (91.7%) reached statistical significance. Table 6 presents the mean values of the pressure sensitivity of the muscles and the statistical differences between groups III (University School of Physical Education students with vigorous physical activity) and IV (University School of Physical Education students with moderate physical activity), at muscle insertions of the left side of the body. In the majority of the muscles (80% of all the researched muscles), the difference was statistically significant (p < 0.05). An increased pain threshold was observed in all the muscles of those in group III. Table 7 presents the mean values of the pressure sensitivity of the muscles and the statistical differences between groups III and IV at trigger points of the left side of the body. In all the muscles the difference was statistically significant (p < 0.05). An increased pain threshold was characteristic of those in group III. Table 8 presents the mean values of the pressure sensitivity of the muscles and the statistical difference between the groups III and IV at muscle insertions of the right side of the body. In fourteen muscles (93.3% of all the researched muscles) the difference was statistically significant (p < 0.05). The difference observed in the erector spinae was not statistically significant. An increased pain threshold was characteristic of those of group III. Table 9 presents the mean values of the pressure sensitivity of the muscles and the statistical differences between groups III and IV at trigger points of the right side of the body. In fourteen muscles (93.3% of all the researched muscles) the difference was statistically significant (p < 0.05). The difference observed in the tensor fasciae latae muscle was not statistically significant. Similar to the above measurements, an increased pain threshold was characteristic of the muscles of those in group III.
Discussion So far, there have been no reports in the literature of the influence of age and physical activity on the pressure sensitivity of muscles.
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Table 2 Mean values of the pressure sensitivity (kg/cm2) at muscle insertions on the left side of the body for groups I (University of the Third Age students) and II (University School of Physical Education students). No
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Researched site e insertion left side
Group I
Superior fibular retinaculum Peroneus longus muscle Biceps femoris muscle Gluteus maximus muscle Gluteus medius muscle Tensor fasciae latae muscle Latissimus dorsi muscle Erector spinae muscle Infraspinatus muscle Levator scapulae muscle Pectoralis major muscle Pectoralis minor muscle Flexor carpi ulnaris muscle Flexor carpi radialis muscle Adductor magnus muscle
5.015 5.012 4.706 5.182 5.296 4.583 4.691 5.129 3.660 3.970 4.007 3.086 4.430 4.447 3.347
kg/cm
2
Group II kg/cm
2
5.212 6.479 5.967 6.611 5.986 4.271 4.557 4.897 4.100 4.138 4.364 3.600 5.177 5.760 4.599
Statistically significant NS * * * NS NS NS NS NS NS NS NS * * *
NS e no statistically significant differences. * e statistically significant difference (p < 0.05).
This study demonstrates that the differences in pressure sensitivity between students and people aged 50e75 were not statistically significant in 73.3% of all the researched muscles. In the majority of cases, age does not significantly influence pressure sensitivity, which is surprising considering the distinct difference in fitness and physical efficiency between the young and participants aged 50e75. The observed increased values of pressure sensitivity in some muscles of the younger people may be the result of static
and dynamic overloading which could be a result of overtraining. The relatively low pressure sensitivity in the group of the people aged 50e75 may be the result of their quite high, for this group age, levels of fitness and physical activity. Generally, in Poland only a few percent of people over the age of 50 regularly attend organized recreation and sports activities. It is commonly known that physical activity influences all human body systems in a positive way. Also the musculoskeletal system and, more precisely, skeletal muscles are influenced very positively. It has been
Table 3 Mean values of the pressure sensitivity (kg/cm2) at the trigger points of the muscles on the left body side for groups I (University of the Third Age students) and II (University School of Physical Education students). No
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Researched site e trigger point left side
Group I
Superior fibular retinaculum Peroneus longus muscle Biceps femoris muscle Gluteus maximus muscle Gluteus medius muscle Tensor fasciae latae muscle Latissimus dorsi muscle Erector spinae muscle Infraspinatus muscle Levator scapulae muscle Pectoralis major muscle Pectoralis minor muscle Flexor carpi ulnaris muscle Flexor carpi radialis muscle Adductor magnus muscle
4.225 4.740 5.421 5.119 5.668 4.566 4.129 5.115 4.406 2.102 2.578 2.934 4.185 3.516 2.624
NS e no statistically significant differences. * e statistically significant difference (p < 0.05).
kg/cm
2
Group II kg/cm 4.867 5.244 6.204 5.211 5.280 3.946 4.696 4.990 5.119 2.499 2.574 3.339 4.245 4.321 4.407
2
Statistically significant NS NS NS NS NS NS NS NS NS NS NS NS NS * *
The influence of age and physical activity
387
Table 4 Mean values of the pressure sensitivity (kg/cm2) at muscle insertions on the right side of the body for groups I (University of the Third Age students) and II (University School of Physical Education students). No
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Researched site e insertion right side
Group I kg/cm
Superior fibular retinaculum Peroneus longus muscle Biceps femoris muscle Gluteus maximus muscle Gluteus medius muscle Tensor fasciae latae muscle Latissimus dorsi muscle Erector spinae muscle Infraspinatus muscle Levator scapulae muscle Pectoralis major muscle Pectoralis minor muscle Flexor carpi ulnaris muscle Flexor carpi radialis muscle Adductor magnus muscle
5.073 4.946 4.458 5.042 5.369 4.942 5.002 5.364 3.967 4.028 3.779 3.248 4.660 4.809 3.127
2
Group II kg/cm
2
5.275 6.136 6.392 6.626 6.198 4.986 4.372 4.642 4.690 3.795 4.455 3.848 5.274 5.239 5.359
Statistically significant NS * * * NS NS NS NS NS NS NS NS NS NS *
NS e no statistically significant differences. * e statistically significant difference (p < 0.05).
shown that, under the influence of physical activity, the number of capillary vessels in skeletal muscles is increased and thus tissue metabolism and tissue efficiency is improved (Jasko ´lski et al., 2002). However, from the authors’ own observations, there are some muscles which, during a lifetime, are subject to greater wear than other muscles. Among basic factors influencing ‘‘greater wear’’ are recurrent minor injuries and lesions occurring while performing everyday activities. This situation is mostly characteristic of muscles stabilizing ankle joints: long peroneal muscle and short peroneal muscle, and muscles stabilizing the brachiocarpal joint: the
ulnar flexor muscle of the wrist, and radial flexor muscle of the wrist. Due to recurrent ankle or wrist sprains, microinjuries in the above mentioned muscles may be triggered and, consequently, sensitivity of the muscles in middle-aged and elderly people may be increased. This possibility is reflected in the research, as the differences in the pressure sensitivity between young participants and University of the Third Age students, were evident only in the case of the above-mentioned muscles. Greater muscle sensitivity may also be increased by degenerative changes in venous and arterial vessels e.g.
Table 5 Mean values of the pressure sensitivity (kg/cm2) at trigger points of the muscles of the right body side for groups I (University of the Third Age students) and II (University School of Physical Education students). No
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Researched site e trigger point right side
kg/cm
Superior fibular retinaculum Peroneus longus muscle Biceps femoris muscle Gluteus maximus muscle Gluteus medius muscle Tensor fasciae latae muscle Latissimus dorsi muscle Erector spinae muscle Infraspinatus muscle Levator scapulae muscle Pectoralis major muscle Pectoralis minor muscle Flexor carpi ulnaris muscle Flexor carpi radialis muscle Adductor magnus muscle
4.244 4.282 5.264 5.250 5.692 4.959 4.322 5.050 4.439 2.336 2.535 2.923 4.078 3.803 2.368
NS e no statistically significant differences. * e statistically significant difference (p < 0.05).
Group I 2
Group II kg/cm 4.564 5.983 6.204 5.585 5.698 4.415 4.442 4.844 5.300 2.690 2.801 3.065 4.717 4.970 3.921
2
Statistically significant NS * NS NS NS NS NS NS * NS NS NS NS * *
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Table 6 Mean values of the pressure sensitivity (kg/cm2) at muscle insertions on the left side of the body for groups III (University School of Physical Education students, vigorous physical activity) and IV (University School of Physical Education students, moderate physical activity). No
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Researched site e insertion left side Superior fibular retinaculum Peroneus longus muscle Biceps femoris muscle Gluteus maximus muscle Gluteus medius muscle Tensor fasciae latae muscle Latissimus dorsi muscle Erector spinae muscle Infraspinatus muscle Levator scapulae muscle Pectoralis major muscle Pectoralis minor muscle Flexor carpi ulnaris muscle Flexor carpi radialis muscle Adductor magnus muscle
Group III
Group IV
kg/cm2
kg/cm2
Statistically significant
6.109 7.765 7.172 8.129 7.249 5.310 5.069 5.557 4.793 4.992 5.263 4.614 6.339 6.723
4.441 5.605 5.008 5.560 5.242 3.452 4.413 4.337 3.468 3.630 3.676 2.980 4.469 5.338
* * * * * * NS * * NS * * * NS
5.428
4.219
*
NS e no statistically significant differences. * e statistically significant difference (p < 0.05).
the deep femoral artery and deep veins of the thigh. The vessels are located in the adductor canal (Hunter’s canal) and, therefore, their degenerative changes lead to an increase in a rest tonus of muscles of the adductor canal and, therefore, also of the adductor magnus muscle. This is also reflected in the research as the adductor magnus muscle of University of the Third Age students, despite its physical activity, presents greater pressure sensitivity in
comparison with the same muscle of younger participants in the study. Moreover, there is also an increased sensitivity of the gluteus maximus muscle which, through the sacrotuberous ligament, remains in structural contact with the adductor magnus muscle, attaching to the ischial tuberosity. Any increase in the rest tonus of the adductor magnus muscle is balanced by an increase in the resting tonus of the
Table 7 Mean values of the pressure sensitivity (kg/cm2) at the trigger points of the left side of the body for groups III (University School of Physical Education students, vigorous physical activity) and IV (University School of Physical Education students, moderate physical activity). No
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Researched site e trigger point left side
kg/cm
Superior fibular retinaculum Peroneus longus muscle Biceps femoris muscle Gluteus maximus muscle Gluteus medius muscle Tensor fasciae latae muscle Latissimus dorsi muscle Erector spinae muscle Infraspinatus muscle Levator scapulae muscle Pectoralis major muscle Pectoralis minor muscle Flexor carpi ulnaris muscle Flexor carpi radialis muscle Adductor magnus muscle
5.668 6.415 7.531 6.549 6.407 4.521 5.839 6.011 6.162 2.944 3.228 3.969 5.342 5.361 5.075
NS e no statistically significant differences. * e statistically significant difference (p < 0.05.
Group III 2
Group IV kg/cm 4.381 4.216 5.255 4.188 4.332 3.325 3.644 4.103 4.357 2.043 1.997 2.878 3.533 3.752 3.911
2
Statistically significant * * * * * * * * * * * * * * *
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Table 8 Mean values of the pressure sensitivity (kg/cm2) at muscle insertions of the right side of the body for groups III (University School of Physical Education students, vigorous physical activity) and IV (University School of Physical Education students, moderate physical activity). No
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Researched site e insertion right side
Group III
Group IV
kg/cm2
kg/cm2
Statistically significant
Superior fibular retinaculum Peroneus longus muscle Biceps femoris muscle Gluteus maximus muscle Gluteus medius muscle Tensor fasciae latae muscle Latissimus dorsi muscle Erector spinae muscle Infraspinatus muscle Levator scapulae muscle Pectoralis major muscle Pectoralis minor muscle Flexor carpi ulnaris muscle Flexor carpi radialis muscle Adductor magnus muscle
6.548 7.212 7.515 8.157 7.519 5.837 5.575 5.299 5.514 4.868 5.645 4.760 6.550 6.146 5.135
4.282 5.207 5.267 5.457 5.082 4.179 3.404 4.189 3.996 3.104 3.812 3.333 4.367 4.729 3.945
* * * * * * * NS * * * * * * *
NS e no statistically significant differences. * e statistically significant difference (p < 0.05).
sacrotuberous ligament, and of gluteus maximus (Myers, 2001). Physical activity is commonly regarded as a factor prolonging youth, simultaneously retarding the aging process. In the questionnaire, 90% of the group of University of the Third Age students declared a moderate level of physical activity. In the group of University School of Physical Education students, 42%
declared a moderate level of physical activity, while a further 42% of the group declared a high level. It is considered that the lack of statistically significant differences in pressure sensitivity of most tissues between the age groups may be caused by the relatively high level of physical activity reported by the University of the Third Age students and the University School of Physical Education students.
Table 9 Mean values of the pressure sensitivity (kg/cm2) at trigger points of muscles of the right body side for groups III (University School of Physical Education students, vigorous physical activity) and IV (University School of Physical Education students, moderate physical activity). No
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Researched site e trigger point right side
Group III
Superior fibular retinaculum Peroneus longus muscle Biceps femoris muscle Gluteus maximus muscle Gluteus medius muscle Tensor fasciae latae muscle Latissimus dorsi muscle Erector spinae muscle Infraspinatus muscle Levator scapulae muscle Pectoralis major muscle Pectoralis minor muscle Flexor carpi ulnaris muscle Flexor carpi radialis muscle Adductor magnus muscle
5.569 7.319 8.022 7.185 7.040 5.318 5.339 5.896 6.584 3.096 3.570 3.883 5.891 6.257 4.878
NS e no statistically significant differences. * e statistically significant difference (p < 0.05).
kg/cm
2
Group IV kg/cm 3.882 4.912 4.774 4.253 4.458 3.771 3.661 3.868 4.245 2.257 2.172 2.454 3.755 4.218 3.251
2
Statistically significant * * * * * NS * * * * * * * * *
390 In group III (University School of Physical Education students with vigorous physical activity) there was statistically significantly lower pressure sensitivity in most of the studied muscles (91.7%) compared to group IV (University School of Physical Education students with moderate physical activity). This may have been caused by the difference in the level of physical activity between the two groups. No muscle, apart from one, had a sensitivity threshold under 3 kg/cm2. Only the levator scapulae muscles on the left side of the body, at a trigger point, had a sensitivity level of 2.944 kg/cm2, which only slightly diverges from the accepted level of 3 kg/cm2. According to Fischer’s criteria, this level may be described as the norm under which tissues present increased pressure sensitivity. It can therefore be concluded that physical activity influences the pressure sensitivity of muscles in a very positive way. In group IV there were muscles whose sensitivities were below this level. These muscles were the levator scapulae, pectoralis major, and pectoralis minor. The muscles are very frequently characterized by some pain relating to trigger points, which may be observed in the findings of the study on both body sides. The presented findings cannot serve as precise norms for the populations of young and elderly people, or of populations of people performing moderate or vigorous physical activity, but they can help in an approximate determination of pressure sensitivity in similar research groups. Despite attempts to determine norms for the sensitivity of given muscles, it is difficult, or even impossible to determine these very precisely, as several factors may influence them, such as posture, gender, and the emotional state of the subject (Merskey and Spear, 1964). However, it seems important to determine more precisely what factors may influence the pressure sensitivity of muscles and up to what level. This would allow using this knowledge in the clinical practice, where the evaluation of pressure sensitivity of muscles plays an important role in determining the general condition of a patient, as a measure of the effectiveness of therapy. This study may act as a stimulus to do more research in a larger group, taking into consideration the influence of diverse factors on the pressure sensitivity of muscles. The results of studies on pressure sensitivity in different age or professional groups with an additional division into the gender of the subjects could be of great interest.
Conclusions 1. The level of physical activity influences the pressure sensitivity of skeletal muscles. The higher the level of activity, the higher the pain threshold (less sensitivity). 2. Age does not appear to influence the pressure sensitivity of skeletal muscles in spite of the fact that there is a tendency for the pain threshold to be lower in older age.
W. Andrzejewski et al.
References Andrzejewski, W., Kassolik, K., Czaplicka, A., Czaplicki, P., Pia˛tkowski, P., 2007a. Algometryczna ocena efektywnos´ci fizjoterapii w zespołach bo ´lowych kre˛gosłupa le˛dz´wiowo-krzy_ zowego. Kwartalnik Ortopedyczny 2, 152e161. Andrzejewski, W., Kassolik, K., Steciwko, A., Rakus, J., 2007b. Skutecznos´´ c masaz_ u medycznego w bo ´lach kre˛gosłupa u oso ´b w wieku starszym. Family Medicine & Primary Care Review 9 (2), 195e203. Andrzejewski, W., Kassolik, K., Karas´, A., Karas´, G., Trze˛sicka, E., 2006. Ocena efektywnos´ci masaz_ u medycznego u oso ´b z bo ´lami dolnego odcinka kre˛gosłupa. Fizjoterapia Polska 6 (4), 150e156. Andrzejewski, W., Kassolik, K., Stodo ´łka, J., Marcinkowski, q, Mucha, A., Migasiewicz, J., Błach, W., 2005. Ocena dolegliwos´ci bo ´lowych narza˛du ruchu wyste˛puja˛cych u studento ´w Akademii Wychowania Fizycznego. Medycyna Sportowa 21 (5), 358e365. Fischer, A.A., 1987a. Pressure algometry over normal muscles. Standard values, validity and reproducibility of pressure threshold. Pain 30, 115e126. Fischer, A.A., 1988. Documentation of myofascial trigger points. Archives of Physical Medicine and Rehabilitation 69, 286e291. Fischer, A.A., 1984. Diagnosis and management of chronic pain in physical medicine and rehabilitation. In: Ruskin, A.P. (Ed.), Current Therapy in Psychiatry. Saunders, Philadelphia. Fischer, A.A., 1986. Pressure threshold meter: its use for quantification of tender spots. Archives of Physical Medicine and Rehabilitation 67, 836e838. Fischer, A.A., 1987b. Tissue compliance meter for objective, quantitative documentation of soft tissue consistency and pathology. Archives of Physical Medicine and Rehabilitation 68, 122e125. Jasko ´lski, A., Jasko ´lska, A., Adach, Z., 2002. Podstawy fizjologii wysiłku fizycznego. AWF, Wrocław. Kassolik, K., Andrzejewski, W., Trze˛sicka, E., Ostrowska, B., 2005. _ medycznego w zespole bolesnego Ocena skutecznos´ci masazu barku. Fizjoterapia Polska 5 (2), 201e206. Merskey, H., Spear, F.G., 1964. The reliability of the pressure algometer. British Journal of Social and Clinical Psychology 3, 130e136. Mikkelsson, M., Latikka, P., Kautiainen, H., Isomeri, R., Isomaki, H., 1992. Muscle and bone pressure pain threshold and pain tolerance in fibromyalgia patients and controls. Archives of Physical Medicine and Rehabilitation 73, 814e818. Myers, T.W., 2001. The Anatomy Trains: Myofascial Meridians for Manual and Movement Therapies. Churchill Livingstone, Edinburg. Offenbacher, M., Stucki, G., 2000. Physical therapy in the treatment of fibromyalgia. Scandinavian Journal of Rheumatology 29 (Suppl. 113), 78e85. Reeves, J.L., Jaeger, B., Graff-Radford, S., 1986. Reliability of the pressure algometer as measure of myofascial trigger points sensitivity. Pain 24, 313e320. Ronat, A., Defrin, R., Ravid, A., Peretz, C., 2003. Spatial summation of pressure pain: effect of body region. Pain 106, 471e480. Simons, D.G., Travell, J.G., Simons, L.S., 1999. Travell and Simons’ Myofascial Pain and Dysfunction; the Trigger Point Manual, second ed., vol. 1. Williams & Wilkins, Baltimore. Travell, J.G., Simons, D.G., 1992. Myofascial Pain and Dysfunction: the Trigger Point Manual. Williams & Wilkins, Baltimore.
Journal of Bodywork & Movement Therapies (2010) 14, 391e396
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Referred pain areas of active myofascial trigger points in head, neck, and shoulder muscles, in chronic tension type headache ˜as, PT, PhD a,b,c,*, Hong-You Ge, MD, PhD b, ´sar Ferna ´ndez-de-las-Pen Ce ´lez-Iglesias, PT e, Cristina Alonso-Blanco, PT, MSc d, Javier Gonza Lars Arendt-Nielsen, DMSc, PhD b a Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation of Universidad Rey Juan Carlos, Alcorco´n, Madrid, Spain b Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Aalborg University, Aalborg, Denmark c Esthesiology Laboratory of Universidad Rey Juan Carlos, Alcorco´n, Madrid, Spain d Department of Health Sciences II, Universidad Rey Juan Carlos, Madrid, Spain e Centro de Fisioterapia Integral, Candas, Asturias, Spain
Received 2 April 2009; received in revised form 27 June 2009; accepted 28 June 2009
KEYWORDS Tension type headache; Muscle trigger points; Referred pain areas
Summary Our aim was to analyze the differences in the referred pain patterns and size of the areas of those myofascial trigger points (TrPs) involved in chronic tension type headache (CTTH) including a number of muscles not investigated in previous studies. Thirteen right handed women with CTTH (mean age: 38 6 years) were included. TrPs were bilaterally searched in upper trapezius, sternocleidomastoid, splenius capitis, masseter, levator scapulae, superior oblique (extra-ocular), and suboccipital muscles. TrPs were considered active when both local and referred pain evoked by manual palpation reproduced total or partial pattern similar to a headache attack. The size of the referred pain area of TrPs of each muscle was calculated. The mean number of active TrPs within each CTTH patient was 7 (95% CI 6.2e8.0). A greater number (T Z 2.79; p Z 0.016) of active TrPs was found at the right side (4.2 1.5) when compared to the left side (2.9 1.0). TrPs in the suboccipital muscles were most prevalent (n Z 12; 92%), followed by the superior oblique muscle (n Z 11/n Z 9 right/left side), the upper trapezius muscle (n Z 11/n Z 6) and the masseter muscle (n Z 9/n Z 7). The ANOVA showed significant differences in the size of the referred pain area between muscles (F Z 4.7, p Z 0.001), but not between sides (F Z 1.1; p Z 0.3): as
* Corresponding author: Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Avenida de Atenas s/n, 28922 Alcorco ´n, Madrid, Spain. Tel.: þ34 91 488 8884; fax: þ34 91 488 8957. E-mail address:
[email protected] (C. Ferna ´ndez-de-las-Pen ˜as). 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.06.008
392
C. Ferna ´ndez-de-las-Pen ˜as et al. determined by a Bonferroni post hoc analysis the referred pain area elicited by levator scapulae TrPs was significantly greater than the area from the sternocleidomastoid (p Z 0.02), masseter (p Z 0.003) and superior oblique (p Z 0.001) muscles. Multiple active TrPs exist in head, neck and shoulder muscles in women with CTTH. The referred pain areas of TrPs located in neck muscles were larger than the referred pain areas of head muscles. Spatial summation of nociceptive inputs from multiple active TrPs may contribute to clinical manifestations of CTTH. ª 2009 Elsevier Ltd. All rights reserved.
Introduction Headache is one of the most prevalent neurological disorders (Bendtsen and Jensen, 2009). Tension-type headache is the most common form of headache and its chronic form (chronic tension-type headache: CTTH) is one of the most neglected (Bendtsen and Jensen, 2006) and is difficult to treat. It has been reported a prevalence rate of 38.3% for episodic tension type headache and 2.2% for CTTH (Schwartz et al., 1998). The prevalence of this headache has increased over the years (Lyngberg et al., 2005). CTTH may cause substantial levels of disability, not only to patients and their relative families, but also to the global society due to very high prevalence (Stovner et al., 2007). Although there has been an increasing interest in the pathogenic mechanisms of CTTH, the real patho-anatomical mechanisms remain to be fully elucidated (Fumal and Schoenen, 2008). It seems clear that hyper-excitability of nociceptive pathway plays an important role in CTTH (Bendtsen and Schoenen, 2006). It has been recently postulated that CTTH pain, at least in part, may be associated with referred pain elicited by trigger points (TrPs) in head, neck and shoulder muscles (Ferna ´ndez-de-las-Pen ˜as et al., 2007a). A myofascial TrPs is defined as a hypersensitive spot within a taut band of a skeletal muscle that elicits a referred distant pain (Simons et al., 1999). From a clinical point of view, TrPs may be active or latent. Active TrPs cause symptoms and both their local and referred pain evoke a familiar pain for the patient. In CTTH, active TrPs evoke symptoms similar to those patients perceive during their headache attacks. We have demonstrated that CTTH is associated with active TrPs in the suboccipital (Ferna ´ndez-de-las-Pen ˜as et al., 2006a), upper trapezius (Ferna ´ndez-de-las-Pen ˜as et al., 2007b), superior oblique (Ferna ´ndez-de-las-Pen ˜as et al., 2005), sternocleidomastoid (Ferna ´ndez-de-las-Pen ˜as et al., 2006b), temporalis (Ferna ´ndez-de-las-Pen ˜as et al., 2007c), and lateral rectus of the eye (Ferna ´ndez-delas-Pen ˜as et al., 2009) muscles. Additionally, we also formulated an updated pain model for CTTH involving both peripheral sensitization from active muscle TrPs and central sensitization in which active TrPs located in those muscles innervated by C1eC3 segments or the trigeminal nerve may be responsible for peripheral nociception producing a continuous afferent barrage into the nucleus caudalis of the trigeminal nerve sensitizing the central nervous system in CTTH (Ferna ´ndez-de-las-Pen ˜as et al., 2007d). Previous studies in patients with CTTH have shown larger referred pain areas elicited from TrPs in the upper trapezius (Ferna ´ndez-de-las-Pen ˜as et al., 2007b) and the temporalis (Ferna ´ndez-de-las-Pen ˜as et al., 2007c) muscles as compared to controls. In addition, there are a number of
muscles in which TrPs can refer pain to the head and hence contribute to CTTH (Figure 1), e.g. masseter, splenius capitis, levator scapulae (Simons et al., 1999), which have not been included in recent published studies. Therefore, the aim of this study was to analyze the differences in the referred pain patterns and size of the areas of those muscle TrPs involved in CTTH including a number of muscles not investigated in previous studies.
Material and methods Patients Thirteen women diagnosed with CTTH, aged from 30 to 50 (mean age: 38 6 years) years of age participated in this study. Patients were recruited from an advertisement in a local newspaper. All subjects were right-handed. Patients were interviewed by an experienced clinician to be certain that they fit the inclusion criteria of the International Headache Society (IHS) criteria for CTTH (IHS, 2004). Headache pain features, temporal profile, family history, and past and current medications were ascertained from the history. To be included, patients had to describe all the characteristics typical of this headache: bilateral location, pressing and tightening pain, mild or moderate intensity (6 on a 11-point numerical pain rate scale from 0 to 10) and no aggravation of headache during physical activity. No patient reported photophobia, phonophobia, vomiting or evident nausea during headaches. In addition, patients had to have headaches for at least 15 days/month. Other primary headaches were excluded. Each patient fulfilled the criteria for CTTH, and there was no apparent evidence of secondary headaches. Medication-overuse headache as defined by the IHS was also ruled out. Furthermore, patients completed a headache diary for 4 weeks in order to substantiate the diagnosis (Phillip et al., 2007). All patients had received several prophylactic drugs several years ago, but none of them were taking any prophylactic drug at the time the study was conducted. Furthermore, patients who received any non-pharmacological treatment (physical therapy, relaxation) within 6 months prior to the study were not considered for the study. Ethical approval of the study was granted by the Local Ethics Committee (VN 2005-0041). Informed consent was obtained from all subjects, and all procedures were conducted according to the Declaration of Helsinki.
Headache characteristics An 11-point numerical pain rating scale (Jensen et al., 1999) (NPRS; range: 0 Z no pain, to 10 Z maximum pain)
Referred pain areas of active TrPs in head, neck, and shoulder muscles, in CTTH
393
Figure 1 Referred pains from upper trapezius, sternocleidomastoid, suboccipital, splenius capitis, splenius cervicis, semispinalis capitis and temporalis muscle TrPs as described by Simons et al. Reprinted with permission from Simons, D., Travell, J., Simons, L., 1999. Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol. 1, second ed. Williams & Wilkins, Baltimore.
was used to assess headache intensity. The headache diary was used to calculate the following variables: (1) headache intensity, calculated from the mean of the NPRS of the days with headache; (2) headache frequency, calculated by dividing the number of days with headache by the number of analyzed weeks (days/week); and (3) headache duration, calculated by dividing the sum of the total hours of headache by the number of days with headache (hours/ day). Patients also drew their headache pattern on an anatomical map.
Muscle trigger point examination Patients were asked to avoid any analgesic or muscle relaxant 48 h prior to the examination, and they were examined when their headache intensity was less than 4 on the NPRS. Myofascial TrPs were bilaterally explored in upper trapezius, splenius capitis, sternocleidomastoid, masseter, superior oblique, levator scapulae and suboccipital muscles by an observer assessor who had more than 8 years of experience in TrP diagnosis. For the upper trapezius, sternocleidomastoid, splenius capitis, masseter and levator scapulae muscles, TrP diagnosis was conducted following the diagnostic criteria described by Simons et al.
(1999): (1) presence of a palpable taut band within a skeletal muscle; (2) presence of a hypersensitive tender spot in the taut band; (3) local twitch response elicited by snapping palpation of the taut band; and (4) reproduction of the typical referred pain pattern of the TrP in response to compression. For suboccipital and superior oblique muscles we adopted the previous published guidelines (Ferna ´ndezde-las-Pen ˜as et al., 2005, 2006a). Briefly, the diagnosis of suboccipital TrPs was made when there was tenderness in the suboccipital region, referred pain evoked by maintained pressure for 10 s, and increased referred pain with muscle contraction [extension of the headeneck] (Ferna ´ndez-de-las-Pen ˜as et al., 2006a). For the diagnosis of superior oblique muscle TrPs, we searched for both local and referred pain elicited by palpation of the superiorinternal corner of the orbit and increased referred pain with both contraction [infra-adduction of the eye] and stretching [supra-abduction of the eye] of the muscle (Ferna ´ndez-de-las-Pen ˜as et al., 2005). TrPs were considered active if both the local and the referred pain evoked by manual palpation reproduced total or partial pattern of the headache (Simons et al., 1999). Muscle TrPs were searched in each muscle with a 1-min interval between two consecutive points. After TrP
394
C. Ferna ´ndez-de-las-Pen ˜as et al.
examination on each point, patients were asked to draw the distribution of referred pain (if it was elicited during examination) on an anatomical map. The referred pain area of muscle TrPs was calculated with a digitizer (ACECAD D9000, Taiwan).
between head pain areas and pain clinical parameters (intensity, duration or frequency) were found.
Statistical analysis
The mean number of active TrPs within each CTTH patient was 7 (95% CI 6.2e8.0). A greater number (T Z 2.79; p Z 0.016) of active TrPs was found on the right side (4.2 1.5) when compared to the left side (2.9 1.0). TrPs in the suboccipital muscles were most prevalent (n Z 12; 92%), followed by the superior oblique muscle (n Z 11 [85%]/n Z 9 [69%] right/left side), the upper trapezius muscle (n Z 11 [85%]/n Z 6 [46%]) and the masseter muscle (n Z 9 [69%]/n Z 7 [54%]). The distribution of active muscle TrPs was significantly different between sides for the upper trapezius (c2 Z 4.792; p Z 0.045), the sternocleidomastoid (c2 Z 4.524; p Z 0.045) and the levator scapulae muscles (c2 Z 5.406; p Z 0.0354). In such a way, active TrPs were mostly located in the right side in both upper trapezius and sternocleidomastoid muscles, whereas levator scapulae TrPs were mostly located in the left side. The distribution of active TrPs in the analyzed muscles is shown in Table 1, and referred pain areas of particular muscles in Table 2. The ANOVA showed significant differences in referred pain areas between muscles (F Z 4.7, p Z 0.001), but not between sides (F Z 1.1; p Z 0.3). Based on a Bonferroni post hoc analysis, the referred pain area elicited from levator scapulae TrPs was significantly greater than the referred pain from the sternocleidomastoid (p Z 0.02), the masseter (p Z 0.003) and the superior oblique (p Z 0.001) muscles. Referred pain areas of upper trapezius, splenius capitis, suboccipital, and levator scapulae were not significantly different (p > 0.3).
Data was analyzed with SPSS version 14.0 (SPSS Inc, Chicago, IL) Results are expressed as mean and 95% confidence interval in the text. The KolmogoroveSmirnov test showed a normal distribution of quantitative data (p > 0.05). The differences in the number of active TrPs between both sides were assessed with the non-parametric Wilcoxon Signed-Rank test. The chi square (c2) test was used to assess the differences in the size of the distribution of active TrPs within each muscle on each side. A two-way ANOVA was used to detect the differences in referred pain area (cm2) between muscles and sides. The Bonferroni test was conducted as post hoc analysis. The Pearson (r) test was used for the correlation analysis between referred pain areas and clinical variables relating to headache (intensity, frequency, duration, history). The statistical analysis was conducted at a 95% confidence level. A p value-less than 0.05 was considered statistically significant.
Results Clinical features of the sample In this CTTH sample, mean duration of the headache history was 11.5 years (95% CI 7.2e15.8 years). The mean headache period per day was 7.2 h (95% CI 5.8e8.5 h), the mean intensity per episode was 4.8 (95% CI 4.4e5.2), and the number of days per week with headache was 4.5 (95% CI 4.1e5.0 days/week). The day of the examination mean headache intensity was 2.3 (95% CI 2.0e2.6). Headache intensity was positively associated with the headache duration of individual attacks (r Z 0.65; p Z 0.02): the greater the intensity, the longer the duration of the headache. The mean head pain area reported by the patients during their attacks was 4.1 cm2 (95% CI 2.6e5.6) in the frontal region, 5.9 (95% CI 4.7e7.2) in the occipital region (including the posterior part of the neck region), 3.3 (95% CI 2.5e4.1) in the left side of the head, and 2.8 (95% CI 1.9e 3.8) in the right side of the head (Figure 2). No correlation
Figure 2
Muscle TrPs in CTTH: number, location and referred pain areas
Discussion This study showed the existence of multiple active TrPs in different head, neck and shoulder muscles in patients with CTTH. Both the local and referred pain elicited by active TrPs reproduced the headache pattern in all the patients. The presence of bilateral active TrPs in trigemino-cervical muscles provides a plausible explanation for the symmetrical bilateral distribution of pain observed in patients with CTTH.
Symptom area of the patients with chronic tension type headache included in the current study.
Referred pain areas of active TrPs in head, neck, and shoulder muscles, in CTTH Table 1
Number of patients with chronic tension type headache (n) with active trigger points (TrPs) located in each muscle.
Active TrPs (n) No TrPs (n)
Active TrPs (n) No TrPs (n)
Upper trapezius muscle
Sternocleidomastoid muscle
Masseter muscle
Left side
Right side
Left side
Right side
Left side
6 7
11 2
2 11
6 7
Right side
7 6
9 4
Splenius capitis muscle
Levator scapulae muscle
Superior oblique muscle
Left side
Left side
Left side
4 9
Right side 4 9
8 5
We found up to seven active muscle TrPs within each headache patient, supporting the assumption of spatial summation of TrP activity in CTTH, as we have previously suggested (Ferna ´ndez-de-las-Pen ˜as et al., 2007a,b,d). Our results underscore the importance of searching for multiple active TrPs in different muscles in patients with CTTH. This finding increases the relevance of multiple TrPs because active TrPs constitute an important source of peripheral nociception since higher concentrations of chemical mediators (bradykinin, calcitonin gene-related peptide, substance P, and serotonin) may be present in active muscle TrPs (Shah et al., 2005). This hypothesis would be related to previous assumptions that peripheral nociception and sensitization mechanisms would play a crucial role in the evolution from episodic to chronic tension type headache (Bendtsen and Schoenen, 2006). Therefore, clinicians should search and treat active muscle TrPs in the musculature which receives a trigemino-cervical innervation in patients with CTTH and try to treat those which referred pain TrP reproduced the headache attack. We also calculated the referred pain areas elicited by active TrPs and found that referred pain areas of suboccipital and levator scapulae muscle TrPs were the commonest ones. It is interesting to note that neck (suboccipital, levator scapulae or splenius capitis), instead of head muscles (masseter or superior oblique), showed the greatest referred pain areas. These findings claim for the relevance of neck muscles in pain perception in CTTH.
Table 2
395
Right side 4 9
9 4
Right side 11 2
Previously we assessed referred pain areas from the upper trapezius (Ferna ´ndez-de-las-Pen ˜as et al., 2007b) and temporalis (Ferna ´ndez-de-las-Pen ˜as et al., 2007c) muscles, but not from the remaining muscles included in the current study. The current study increases the number of muscle TrPs which referred pain is contributing to headache pain pattern in CTTH. Additionally, we also showed that the referred pain areas of the analyzed muscles covered the extension of the entire headache pain pattern of the patients, although we should consider that the referred pain areas of some muscle TrPs, e.g. suboccipital, splenius capitis, and upper trapezius, are located in the same region of the head (frontal or lateral side of the head or neck). In addition, we should take into account that the referred pain pattern of the levator scapulae muscle did not reach the head. Nevertheless, since all CTTH patients reported neck pain symptoms, active TrPs in this muscle are related to the neck pain pattern present in CTTH. Finally, the referred pain patterns elicited by active TrPs in the current study were very similar to those previously reported by Simons et al. (1999) and by Beat de Jung (2006). Nevertheless, some slight differences may be observed, probably due to the pathology of the patients included, or due to the sensitization state in which the patients were explored. An interesting finding was that active TrPs in the upper trapezius and sternocleidomastoid muscles were mostly located in the right side, whereas levator scapulae TrPs were mostly located in the left side. These results are
Referred pain areas of active trigger points on each muscles in patients with chronic tension type headache.
Patients with chronic tension type headache Upper trapezius Sternocleidomastoid Masseter Splenius capitis Levator scapulae Superior oblique Suboccipital
Right side (n Z 11) Left side (n Z 6) Right side (n Z 6) Left side (n Z 2) Right side (n Z 9) Left side (n Z 7) Right side (n Z 4) Left side (n Z 4) Right side (n Z 4) Left side (n Z 8) Right side (n Z 11) Left side (n Z 9) n Z 12
Referred pain areas (cm2) are expressed as means standard deviation (95% confidence interval).
3.4 1.2 2.9 1.2 2.5 0.7 1.8 0.4 2.2 0.5 2.8 1.0 3.8 0.5 3.1 1.5 4.9 1.1 4.1 2.0 2.5 1.1 2.7 1.6 4.5 1.3
(2.5e4.2) (1.7e4.2) (1.8e3.2) (1.4e2.6) (1.8e2.6) (1.9e3.8) (3.1e4.6) (1.0e4.4) (3.1e6.6) (2.4e5.8) (1.7e3.2) (1.5e4.0) (3.7e5.4)
396 similar to those found in a previous study (Ferna ´ndez-delas-Pen ˜as et al., 2007b) in which TrPs in the upper trapezius muscle were also located in the dominant side. A greater prevalence of TrPs in the right side may be related to the fact that all patients were right-hand dominant. Bernard (1997) found that highly repetitive work and forceful arm or hand movements cause neck and shoulder pain. Repetitive use of the muscle in the dominant side may be a factor to the development of TrPs (Simons, 2004). Nevertheless, this hypothesis does not explain why active TrPs in the levator scapulae were more prevalent on the non-dominant side. Future studies should investigate this topic. We should recognize some limitations of the study. Firstly, we only included women with CTTH; therefore our results cannot be extrapolated to men with CTTH. Future studies should include men with CTTH for a more generalization of the results of the current study. Secondly, we included a small sample size, so future studies with a greater number of patients is recommended. Thirdly, since active TrPs are not found often in healthy controls we only included patients, in the current study. The reason was that we wanted to investigate referred pain areas in active TrPs in a patient population.
Conclusions The present study showed the existence of multiple active TrPs in different head, neck and shoulder muscles in women CTTH. Both the local and referred pain elicited by active TrPs reproduced the headache pattern in patients. The referred pain areas of TrPs located in neck muscles were greater than the referred pain areas of head muscles. Spatial summation of nociceptive inputs from multiple active TrPs may contribute to both peripheral and central sensitization in CTTH.
References De Jung, B., 2006. Triggerpunkt-therapie, second ed. Verlag Hans Huber, Bern. Bendtsen, L., Jensen, R., 2006. Tension type headache: the most common, but also the most neglected headache disorder. Curr. Opin. Neurol 19, 305e309. Bendtsen, L., Jensen, R., 2009. Epidemiology of tension-type headache, migraine and cervicogenic headache. In: Ferna ´ndez-de-lasPen ˜as, C., Arendt-Nielsen, L., Gerwin, R. (Eds.), Tension Type and Cervicogenic Headache: Patho-physiology, Diagnosis and Treatment. Jones & Bartlett Publishers, Baltimore, pp. 7e13. Bendtsen, L., Schoenen, J., 2006. Synthesis of tension type headache mechanisms. In: Olesen, J., Goasdby, P., Ramdan, N.M., Tfelt-Hansen, P., Welch, K.M.A., 2006. The Headaches, third ed. Lippincott Williams & Wilkins, Philadelphia, 2006. Bernard, B., 1997. Musculoskeletal Disorders and Workplace Factors: a Critical Review of Epidemiologic Evidence for Workrelated Musculoskeletal Disorders of the Neck, Upper Extremity, and Low Back, second ed. US Department of Health and Human Services, NIOSH, Cincinnati, OH, pp. I-C-59.
C. Ferna ´ndez-de-las-Pen ˜as et al. Ferna ´ndez-de-las-Pen ˜as, C., Cuadrado, M.L., Gerwin, R.D., Pareja, J.A., 2005. Referred pain from the trochlear region in tension-type headache: a myofascial trigger point from the superior oblique muscle. Headache 45, 731e737. Ferna ´ndez-de-las-Pen ˜as, C., Alonso-Blanco, C., Cuadrado, M.L., Gerwin, R.D., Pareja, J.A., 2006a. Trigger points in the suboccipital muscles and forward head posture in tension type headache. Headache 46, 454e460. Ferna ´ndez-de-las-Pen ˜as, C., Alonso-Blanco, C., Cuadrado, M.L., Gerwin, R.D., Pareja, J.A., 2006b. Myofascial trigger points and their relationship with headache clinical parameters in chronic tension type headache. Headache 46, 1264e1272. Ferna ´ndez-de-las-Pen ˜as, C., Ge, H.Y., Arendt-Nielsen, L., Cuadrado, M.L., Pareja, J.A., 2007a. Referred pain from trapezius muscle trigger point shares similar characteristics with chronic tension type headache. Eur. J. Pain 11, 475e482. Ferna ´ndez-de-las-Pen ˜as, C., Ge, H.Y., Arendt-Nielsen, L., Cuadrado, M.L., Pareja, J.A., 2007b. The local and referred pain from myofascial trigger points in the temporalis muscle contributes to pain profile in chronic tension-type headache. Clin. J. Pain 23, 786e792. Ferna ´ndez-de-las-Pen ˜as, C., Simons, D.G., Cuadrado, M.L., Pareja, J.A., 2007c. The role of myofascial trigger points in musculoskeletal pain syndromes of the head and neck. Curr. Pain Headache Rep 11, 365e372. Ferna ´ndez-de-las-Pen ˜as, C., Cuadrado, M.L., Arendt-Nielsen, L., Simons, D.G., Pareja, J.A., 2007d. Myofascial trigger points and sensitisation: an updated pain model for tension type headache. Cephalalgia 27, 383e393. Ferna ´ndez-de-las-Pen ˜as, C., Cuadrado, M.L., Gerwin, R.D., Pareja, J.A., 2009. Referred pain from the lateral rectus muscle in subjects with chronic tension type headache. Pain Med 10, 43e48. Fumal, A., Schoenen, J., 2008. Tension-type headache: current research and clinical management. Lancet Neurol 7, 70e83. IHS. 2004. Headache Classification Subcommittee of the International Headache Society: The International Classification of Headache Disorders, second ed. Cephalalgia 24(Suppl. 1), 9-160 Jensen, M.P., Turner, J.A., Romano, J.M., Fisher, L., 1999. Comparative reliability and validity of chronic pain intensity measures. Pain 83, 157e162. Lyngberg, A.C., Rasmussen, B.K., Jorgensen, T., Jensen, R., 2005. Has the prevalence of migraine and tension-type headache changed over a 12-year period? A Danish population survey. Eur. J. Neurol 20, 243e249. Phillip, D., Lyngberg, A.C., Jensen, R., 2007. Assessment of headache diagnosis: a comparative population study of a clinical interview with a diagnostic headache diary. Cephalalgia 27, 1e8. Schwartz, B.S., Stewart, W.F., Simon, D., Lipton, R.B., 1998. Epidemiology of tension type headache. JAMA 279, 381e383. Shah, J.P., Phillips, T.M., Danoff, J.V., Gerber, L.H., 2005. An in vitro microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J. Appl. Physiol 99, 1977e1984. Simons, D.G., 2004. Review of enigmatic MTrPs as a common cause of enigmatic musculoskeletal pain and dysfunction. J. Electromyogr. Kinesiol 14, 95e107. Simons, D.G., Travell, J., Simons, L.S., 1999. Travell and Simons’ Myofascial Pain and Dysfunction: the Trigger Point Manual, second ed., Vol. 1. Williams & Wilkins, Baltimore. Stovner, L., Hagen, K., Jensen, R., et al., 2007. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia 27, 193e210.
Journal of Bodywork & Movement Therapies (2010) 14, 397e402
available at www.sciencedirect.com
journal homepage: www.elsevier.com/jbmt
CASE STUDY
Diagnosis and treatment of posterior interosseous nerve syndrome using soft tissue manipulation therapy: A case study John Saratsiotis, BSc, BA, DC a,*, Emmanouil Myriokefalitakis, MD b a b
Doctor of Chiropractic, Private Practice, Roupel 9, Peristeri, Athens, Attiki 121-34, Greece Orthopaedic Resident, A’ Orthopaedic Department, General Hospital ‘‘G. Gennimatas’’, Athens, Greece
Received 29 September 2009; received in revised form 22 October 2009; accepted 11 November 2009
KEYWORDS Peripheral nerve entrapment; Posterior interroseous nerve; Posterior interroseous nerve syndrome; Active release technique; Peripheral nerve release
Summary Peripheral nerve entrapments of the upper and lower extremity are commonly seen in practice. Chronically repetitive movement patterns lead to constriction of the nerve due to the development of local fibrosis within the soft tissues surrounding the nerve which also affects nerve traction, mobility, and function. A case is presented of a patient with motor weakness in the wrist and hand in order to illustrate the diagnosis and treatment of posterior interosseous nerve (PIN) syndrome. Using Active Release Techniques Soft Tissue Management and Peripheral Nerve Release Systems the patient’s symptomatology was resolved. Soft tissue-based management in conjunction with neural gliding may be beneficial in the conservative management of PIN syndrome. Further research into the pathophysiology of nerve entrapments will have immediate impact on the management of neuropathies and likely result in emphasizing conservative management and rehabilitation rather than surgical intervention particularly in cases not involving denervation or paralysis. ª 2009 Elsevier Ltd. All rights reserved.
Introduction Peripheral nerve entrapments of the upper and lower extremity are commonly seen in practice. An entrapment can occur anywhere along the course of a peripheral nerve (even though usually entrapment occurs at specific sites). The etiology of these syndromes is typically traumatic
(crush) injury or chronic injury. In both cases, the pathophysiology is similar (local ischaemia due to mechanical pressure), however the pathogenesis differs according to current research (Pham and Gupta, 2009; McKinnon, 2002). Acute injuries (crush injuries) are characterized by axonal injury (triggering Schwann cell dedifferentiation) and subsequent Wallerian degeneration (Pham and Gupta, 2009). In chronic nerve compression injuries simultaneous
* Corresponding author. Tel.: þ30 695 506 9285. E-mail address:
[email protected] (J. Saratsiotis). 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.11.002
398 Schwann cell proliferation and apoptosis are induced leading to localised demyelination and remyelination at the injury site as well as axonal sprouting (Pham and Gupta, 2009). Interestingly, these changes occur in the absence of both morphological and electrophysiological evidence of axonal damage (Pham and Gupta, 2009; McKinnon, 2002). Depending on the nerve involved, the symptoms of nerve entrapment syndromes generally involve pain, sensory and motor changes. Most entrapment syndromes involve mixed sensory and motor nerves and consequently present with all the aforementioned symptoms. However, there are some exceptions such as the posterior interosseous nerve (PIN) which is a pure motor branch of the radial nerve. The PIN is an exception for another reason as well. While most entrapments occur usually due to an osseoligamentous tunnel narrowing, in the case of a PIN entrapment, the compression occurs within the musculo-tendinous radial tunnel. Specifically, in up to 69.4% of the cases, the nerve is compressed by the fibrous arcade of Frohse (Ritts et al., 1987; Ferdinand et al., 2006). The arcade is absent in fetuses and is thought to develop from repetitive rotational (supinationepronation) movements of the forearm (overuse) (Links et al., 2009). Anatomic studies have revealed a variable rate of occurrence which ranges between 30% and 80% of the population (Spinner, 1968; Clavert et al., 2009). Compression of the posterior interosseous nerve within the radial tunnel yields two different clinical pictures that are believed to reflect two distinct clinical entities: posterior interosseous nerve syndrome and radial tunnel syndrome (Ferdinand et al., 2006). Posterior interosseous nerve syndrome is characterized by motor deficits in the distribution of the posterior interosseous nerve. Consequently, it is important for the practitioner to understand the etiology and symptomatology in order to create an effective treatment protocol. Treatment of a PIN syndrome consists of either conservative or surgical management. Initially, wrist and/or elbow splints may be used, physical therapy, use of NSAIDs, or a corticosteroid injection in order to reduce local inflammation and swelling around the nerve (Hyde and Gengenbach, 2007). Therapy should continue for approximately 3e6 months with regular re-assessment of signs and symptoms. If there is no response to therapy, evidence of denervation, or persistent paralysis, surgical decompression should be considered (Stanley, 2006). Physical therapy involves the use of cryotherapy, ultrasound, TENS, and strengthening exercises for weakened musculature. However, recent literature has advocated the effectiveness of deep soft tissue mobilization techniques (myofascial release, Active Release Technique, Graston Technique) in conjunction with neural gliding (‘‘flossing’’) in order to achieve optimal results (Hyde and Gengenbach, 2007; Agrios and Crawford, 1999; Buchberger et al., 1996; Coppieters et al., 2004). A case is presented to illustrate the treatment of posterior interosseous nerve syndrome using Active Release Techniques Soft Tissue Management and Peripheral Nerve Release Systems.
J. Saratsiotis, E. Myriokefalitakis the course of time to right wrist and finger extension weakness. The complaint originally started insidiously 4 months previously with pain in the lateral aspect of the upper forearm (closer to the elbow). During that period the patient was otherwise in good health. The pain was rated as 5 out of 10 on an 11-point Numeric Rating Scale-Pain Intensity (NRS-PI) where 0 represents ‘‘no pain’’ and 10 represents ‘‘worst possible pain.’’ The pain did not radiate into the forearm but was localised approximately 6e7 cm distal to the elbow crease (lateral aspect). The patient did not report any hypesthesia, but did indicate an inability to extend digits 2 through 5, as well as noticing a weakness in wrist extension. No other symptoms were reported. The patient had been diagnosed with right lateral epicondylopathy early-on in his symptomatology (prior to motor weakness presentation). Electromyography and nerve conduction velocity (NCV) testing revealed no particular findings (Figures 1 and 2), except for a mild sensory loss and possible C8 radiculopathy on the right. MRI imaging indicated mild degenerative changes and a disc bulge at the C6/C7 vertebral level. X-ray imaging of the right elbow was unremarkable. Previous treatment included physiotherapy (TENS, ultrasound, massage to lateral forearm, stretching exercises to extensor muscle group) which according to the patient had produced very little benefit. Upon observation no swelling was evident in the forearm, however, a finger drop was observed in the right hand. Active and passive ranges of motion of the cervical spine, elbow, wrist, and fingers were performed and were painfree and symmetrical except for a notable weakness of the metacarpalphalangeal joints (MCP) on the right side. Specifically, active and resisted extension of the right wrist was graded as 4/5 with a slight radial deviation of the wrist. Resisted finger extension was graded as 3/5 for fingers 3e5, while the index finger was graded 2/5 (all at the metacarpalphalangeal e MCP-joints). Elbow flexion was within normal limits and tested 5/5 in both flexion and extension. Resisted supinationepronation caused discomfort in the latter. Orthopaedic testing of the cervical spine (compression, distraction, Jackson’s test) were unremarkable except for mild pain during Jackson’s compression test on the right. Bilateral sensation was tested and the result was bilateral and symmetrical, while reflexes were graded 2þ bilaterally for the upper extremity. Palpation revealed
Muscle
Duration
Height
Phase
Comment_
Deltoid (R)
WNL
WNL
WNL
Small involvement
WNL
WNL
WNL
Small involvement
WNL
WNL
WNL
Involvement
WNL
WNL
WNL
Small involvement
WNL
WNL
WNL
Small involvement
WNL
WNL
WNL
Small involvement
_
Biceps Brachii (R) Extensor Digitorum (R) Abductor Pollicis Brevis (R) 1st dorsal Interosseus (R) Abductor
Case study A 62 year old office worker presented with right lateral forearm pain (4 month duration) that had progressed over
Digiti min. (R)
Figure 1 EMG results of patient indicating weakness in extensor digitorum on the right.
Diagnosis and treatment of PIN syndrome
399
Motor Nerve Conduction Study Distance
NCV
Median (R)
Site
Latency (ms) 4.44
Amplitude 7.42mV
19.4mVms
Area
205mm
51m/s
-
8.46
7.92mV
20.0mVms
147mm
0m/s
Ulnar (R)
3.26
5.88mV
18.9mVms
125mm
60m/s
-
5.34
7.67mV
24.5mVms
180mm
49m/s
_
Sensory Nerve Conduction Study Area
Distance
NCV__
Ulnar (R)
Site
Latency (ms) 2.90
Amplitude 8.90uV
5.34uVms
152mm
52m/s
Median (R)
3.26
10.7uV
2.80uVms
168mm
51m/s
Radial (R)
1.34
27.6uV
11.8uVms
80mm
59m/s
Figure 2 Nerve conduction velocity (sensry and motor) of the upper extremity indicating neuropathy (hypoaesthesic) and possible C8 radiculopathy.
tender areas of nodular consistency within the supinator, while tissue tension was identified in both the extensor carpi radialis longus and supinator on the right, as within the extensor carpi ulnaris. Palpation over the anterior radiohumeral joint and lateral epicondyle did not cause any pain or tenderness. The Rule of Nine test was then performed where a large squared box was drawn over the anterior aspect of the right proximal forearm. The sides of the square were determined by the width of the elbow crease with a fully extended elbow and a fully supinated forearm and the square was further divided into nine smaller equal squares giving three columns and three rows (Loh et al., 2004). It has been suggested that the PIN travels through the lateral column, the median nerve travels through the middle column, while the medial column is traversed by neither (Loh et al., 2004). The areas of pain have been identified in Figure 3. According to Loh et al., the presence of the fibrous bands connecting brachialis and brachioradialis overlying the PIN at the level of the radial head is most likely to
Figure 3 Rule of Nine test and areas of pain upon palpation of patient’s right upper lateral forearm.
involve the lateral 1 square (Loh et al., 2004; Tubbs et al., 2006). The leash of Henry, the tendinous medial edge of the extensor carpi radialis brevis, the arcade of Frohse, and the distal tendinous edge of the supinator or bands within the two heads of supinator make the involvement of lateral 2 and 3 squares most likely (Loh et al., 2004; Tubbs et al., 2006). As seen from Figure 3, the patient’s symptoms localised in the lateral squares 2 and 3. This area, which measured 6e7 cm from the elbow crease, is below the proposed superficial landmark for the leash of Henry (approximately 5 cm from lateral epicondyle), which would indicate an entrapment by most likely the ECRB, the supinator, or the arcade of Frohse. At this point, a diagnosis of posterior interosseous nerve syndrome was made, ruling out the possibility of lateral epicondylopathy, radiculopathy, or radial tunnel syndrome.
Methodology and results The patient was treated using Active Release Techniques applied to the extensor carpi radialis brevis, supinator, and Arcade of Frohse. The treatment of these structures corresponds to protocols 30, 32, 33 from the manual of the Active Release Techniques Soft Tissue Management System of the Upper Extremity. The intended purpose of this treatment was to decrease tissue tension as well as to normalize tissue function. Following soft tissue therapy, nerve traction techniques were performed to the posterior interosseous nerve, once again according to protocol 8 from the Active Release Techniques Soft Tissue Management System for Nerve Entrapments (Figure 4). The purpose of nerve gliding/traction is to maximize the movement of the nerve in relation to the anatomic structures adjacent to it, in this case the supinator muscle and the Arcade of Frohse. After nine visits (with 1 day between visits) the patient reported lateral upper forearm pain rated as 1 out 10 on the 11-point NRS-PI scale. Motor deficits observed with wrist and finger extension resolved and resisted muscle testing was graded 5/5 bilaterally for wrist
Figure 4 Neural gliding using the Active Release Techniques Soft Tissue Management System for Nerve Entrapments of the posterior interosseous nerve: at this point in the technique, the nerve is lengthened proximal to the contact site and shortened distal to the contact site.
400 extension and finger extension of digits 2e5. The patient was given strengthening exercises for wrist and finger extension and asked to return in 1 months time for reassessment. During re-assessment the patient reported no pain in his forearm and noted full strength in his right wrist and hand. At 6 months following treatment the same results were observed.
Discussion The posterior interosseous nerve is a branch of the radial nerve. The radial nerve is the main continuation of the posterior chord (C6eC8, and occasionally T1) of the brachial plexus (Moore and Dalley, 1999; Sellards and Kuebrich, 2005). The radial nerve enters the arm posterior to the brachial artery, medial to the humerus, and anterior to the long head of the triceps (Moore and Dalley, 1999). At mid arm, the radial nerve descends behind the humerus, deep to the long head of the triceps, and then spirals around the humerus in between the medial and lateral heads of the triceps in the spiral groove. Approximately 10 cm above the lateral humeral epicondyle, the nerve pierces the lateral intermuscular septum and enters the anterior compartment of the arm (Moore and Dalley, 1999; Sellards and Kuebrich, 2005). Here, it immediately enters the deep, muscular groove bordered medially by the biceps and laterally by the brachioradialis, the extensor carpi radialis longus (ECRL), and the extensor carpi radialis brevis (ECRB). The nerve then courses immediately in front of the radiocapitellar joint capsule, where it divides into the motor PIN and the sensory superficial radial nerve (see Figure 5). Branches innervating the brachioradialis and ECRL come off before the bifurcation while the ECRB is innervated by either the radial nerve or the PIN (Moore and Dalley, 1999). The PIN enters the radial tunnel underneath a musculo-
Figure 5 The radial nerve courses immediately in front of the radiocapitellar joint capsule, where it divides into the deep motor (PIN) and the sensory superficial radial nerve. [Reproduced with kind permission by Elsevier from Spinner, M., 1968. J. Bone Joint Surg. Br. 50, 809e812].
J. Saratsiotis, E. Myriokefalitakis tendinous arch, the arcade of Frohse. Formed by the upper free border of the superficial head of the supinator, the arcade of Frohse is a semicircular fibrous arch that remains fibrous medially and is found in 30e80% of anatomical specimens (Spinner, 1968; Clavert et al., 2009). Just before the arcade of Frohse, a number of arterial branches (leash of Henry) that arise from the recurrent radial artery cross over the PIN (Moore and Dalley, 1999; Sellards and Kuebrich, 2005). Within the radial tunnel, the PIN rests on the deep head of the supinator. After emerging from the tunnel beneath the supinator, the PIN lies posteriorly to the interosseous membrane of the forearm and innervates the extensor digiti minimi, extensor carpi ulnaris, medially the extensor digitorum communis, and laterally the extensor indicis proprius, extensor pollicis longus and brevis, and abductor pollicis longus (Ferdinand et al., 2006; Moore and Dalley, 1999; Sellards and Kuebrich, 2005). Entrapment of the PIN can occur right at the division of the radial nerve into motor and sensory branches, within the radial tunnel, or after the nerve bifurcates into medial and lateral branches (Ferdinand et al., 2006; Moore and Dalley, 1999). Consequently, depending on where the entrapment is, the presenting signs and symptoms will slightly vary (depending on which muscles have lost innervation). With respect to the radial tunnel, entrapment can occur due to compression from fibrous bands attached to the radiocapitellar joint, the radial recurrent vessels (branches of Henry), the tendinous origin of the extensor carpi radialis brevis, the tendinous origin of the supinator (arcade of Frohse), and fibrous thickenings within and at the distal margin of the supinator (Clavert et al., 2009; Moore and Dalley, 1999; Sellards and Kuebrich, 2005; Konjengbam and Elangbam, 2004). Compression of the posterior interosseous nerve (PIN) within the radial tunnel yields two different clinical pictures that are believed to reflect two distinct clinical entities: PIN syndrome and radial tunnel syndrome (Ferdinand et al., 2006). Both are considered entrapments of the PIN, however, the latter involves pain along the radial aspect of the proximal forearm (mimics lateral epicondylitis) and is characterized by the absence of neurological findings (motor deficit) (Ferdinand et al., 2006; Lister et al., 1979). Electrodiagnostic examination findings fail to demonstrate any abnormality of the PIN, and are not useful in confirming the diagnosis for radial tunnel syndrome, which is generally made on the basis of a physical examination (Ferdinand et al., 2006). One theory suggests that the PIN, while mainly a motor nerve, carries sensory afferent fibres from the wrist as well as group IIA afferent fibres from the muscles along its distribution (Ritts et al., 1987; Lister et al., 1979). It is possible that only afferent fibres are affected with radial tunnel syndrome, whereas only the motor fibres are affected with PIN syndrome (Ritts et al., 1987). Some authors believe radial tunnel syndrome may represent an early posterior interosseous nerve syndrome (Ritts et al., 1987). In the case presented, this might potentially explain the unremarkable results from the electrodiagnostic testing which was performed on the patient early-on in his symptomatology. Most likely, the condition had started as a radial tunnel syndrome that
Diagnosis and treatment of PIN syndrome progressed to a PIN syndrome due to repetitive compression of the nerve. The repetitive overuse (supinationepronation) of the patient’s right forearm potentially promoted histological changes to the radial tunnel structures, particularly the supinator and arcade of Frohse, with progressive development of a local fibrous zone (Clavert et al., 2009). The Active Release Technique Soft Tissue Management System (ART) has proven to be clinically promising in treating conditions related to overuse (Spina, 2007; Leahy, 1995). Within the rehabilitation arena, cumulative trauma disorders are often treated with ART. These types of disorders follow the law of repetitive motion developed by P. Michael Leahy, D.C.:
401 neuropathies (neural tension test). Similarly, rehabilitation techniques used to stretch the nerves and restore neural gliding are frequently successful in relieving patient symptoms (Hyde and Gengenbach, 2007; Coppieters et al., 2004). Consequently, Active Release Techniques Peripheral Nerve Release Systems was used on the posterior interosseous nerve in order to increase gliding motion of the nerve. Overall improvement in symptomatology was observed in this patient with restoration of motor deficits and decrease in pain. The patient was also given strengthening exercises in order to re-educate and strengthen soft tissue structures affected by compression of the PIN.
Conclusion
IZNF=AR where, I Z insult to tissues, N Z number of repetitions, F Z tension of each repetition as percentage of maximum muscle strength, A Z amplitude of each repetition, and R Z relaxation time between repetitions (Leahy, 1995). It is obvious from the above equation, that if the number of repetitions ‘‘N’’ is increased, such as in a case of cumulative trauma, the insult to the tissues also increases. According to Leahy, this soft tissue insult will reduce circulation in the area of concern ultimately leading to tissue hypoxia (Leahy, 1995). Related research has indicated that as the partial pressure of oxygen (PO2) begins to decrease, due to hypoxic conditions, fibroblasts are stimulated by such conditions and start to proliferate at the site of injury (Falanga et al., 2002). This results in abnormally high amounts of collagen deposition causing excessive fibrosis (scar tissue formation). Studies have suggested that deep tissue mobilization techniques induce a controlled amount of microtrauma in an area composed of excessive scar tissue, which in turn appears to stimulate connective tissue remodelling through resorption of excessive fibrosis, along with inducing repair and regeneration of collagen secondary to fibroblast recruitment (Melham et al., 1998; Gehlsen et al., 1999). A preliminary report on the use of ART for a variety of upper extremity overuse syndromes found a 71% efficacy rate (Schiottz-Christensen et al., 1999). Furthermore, localised fibrosis around a nerve leads to compression of the nerve and consequent compressioninduced neuronal swelling, even 1 week after compression is applied (Chien et al., 2003). The swelling occurs proximal to the constriction site and studies show it might be the result of either abnormal cytoplasmic axonal transport or ischemic conditions (McKinnon, 2002; Chien et al., 2003). Histopathologic studies have indicated the swelling is associated with perineural and epineural fibrosis rather than nerve fibre pathology (McKinnon, 2002; Chien et al., 2003). Once the nerve is released in these situations, axonal diameter equalizes a few days later (Chien et al., 2003). The rapid recovery of motor deficiency following treatment in the case presented would indicate chronic nerve compression due to fibrosis rather than axonal nerve injury. Furthermore, this fibrosis would prevent the nerve fibres themselves from going through a full range of movement, without traction, and decreased gliding. Clinical tests that put a stretch on the nerve will provoke patient symptoms and have been used to diagnose specific compression
Posterior interosseous nerve syndrome is an entrapment neuropathy that is not common in the upper extremity, however it can be debilitating due to symptoms of pain and motor deficiency in the wrist and hand. This condition should not be confused with radial tunnel syndrome which involves compression of the same nerve. Chronically repetitive movement patterns lead to constriction of the nerve due to the development of local fibrosis within the soft tissues surrounding the nerve which also affects nerve traction and mobility. Frequently, according to literature, conservative treatment of such conditions involves very little manual therapy. In the case presented, a conservative treatment protocol that included deep soft tissue mobilization techniques (ART) as well as neural gliding (‘‘flossing’’) techniques was introduced with positive results even 1 and 6 months following treatment. Histological studies support the decision to use such treatment methods while the results of this study confirm the need to introduce new effective conservative techniques prior to considering nerve decompression surgery. Further research into the pathophysiology of nerve entrapments will have immediate impact on the management of neuropathies and likely result in emphasizing conservative management and rehabilitation rather than surgical intervention particularly in cases not involving denervation or paralysis.
References Agrios, P., Crawford, J.W., 1999. Double crush syndrome of the upper extremity. J. Sports Chiropr. Rehab. 13 (3), 111e114. Buchberger, D.J., Rizzoto, H., McAdam, B.J., 1996. Median nerve entrapment resulting in unilateral action tremor of the hand. J. Sports Chiropr. Rehab. 10 (4), 176e180. Chien, A.J., Jamadar, D.A., Jacobson, J.A., Hayes, C.W., Louis, D.S., 2003. Sonography and MR imaging of posterior interosseous nerve syndrome with surgical correlation. AJR 181, 219e221. Clavert, P., Lutz, J.C., Adam, P., Wolfram-Gabel, R., Apr 2009. Frohse’s arcade is not the exclusive compression site of the radial nerve in its tunnel. Orthop. Traumatol. Surg. Res. 95 (2), 114e118. Coppieters, M., Bartholomeeusen, K., Stappaerts, K., Nov 2004. Incorporating nerve-gliding techniques in the conservative treatment of cubital tunnel syndrome. J. Manip. Physiol. Ther. 27 (9), 560e568. Falanga, V., Zhou, L., Yufit, T., Apr 2002. Low oxygen tension stimulates collagen synthesis and COL1A1 transcription through the action of TGF-beta1. J. Cell. Physiol. 191 (1), 42e50. Ferdinand, B.D., Rosenberg, Z.S., Schweitzer, M.E., Stuchin, S.A., Jazrawi, L.M., Lenzo, S.R., Jul 2006. MR imaging features of
402 radial tunnel syndrome: initial experience. Radiology 240 (1), 161e168. Gehlsen, G.M., Ganion, L.R., Helfst, R., April 1999. Fibroblast responses to variation in soft tissue mobilization pressure. Med. Sci. Sports Exerc. 31 (4), 531e535. Hyde, T.E., Gengenbach, M.S., 2007. Conservative Management of Sports Injuries. Jones and Bartlett Publishing, Sudbury, MA. Konjengbam, M., Elangbam, J., Jan 2004. Radial nerve in the radial tunnel: anatomic sites of entrapment neuropathy. Clin. Anat. 17 (1), 21e25. Leahy, P.M., 1995. Improved treatments for carpal tunnel and related syndromes. Chiropr. Sports Med. 9, 6e9. Links, A.C., Graunke, K.S., Wahl, C., Green, J.R., Matsen, F.A., JaneFeb 2009. Pronation can increase the pressure on the posterior interosseous nerve under the arcade of Frohse: a possible mechanism of palsy after two-incision repair for distal biceps rupturedclinical experience and a cadaveric investigation. J. Shoulder Elbow Surg. 18 (1), 64e68. Lister, G.D., Belsole, R.B., Kleinert, H.E., Jan 1979. The radial tunnel syndrome. J. Hand Surg. Am. 4 (1), 52e59. Loh, Y.C., Lam, W.L., Stanley, J.K., Soames, R.W., June 2004. A new clinical test for radial tunnel syndrome e the-rule-ofNine test: a cadaveric study. J. Orhtop. Surg. 12 (1), 83e86. McKinnon, S.E., May 2002. Pathophysiology of nerve compression. Hand Clin. 18 (2), 231e241. Melham, T.J., Sevier, T.L., Malnofski, M.J., Wilson, J.K., Helfst Jr., R.H., June 1998. Chronic ankle pain and fibrosis
J. Saratsiotis, E. Myriokefalitakis successfully treated with a new non-invasive augmented soft tissue mobilization technique (ASTM): a case report. Med. Sci. Sports Exerc. 30 (6), 801e804. Moore, K.L., Dalley, A.F. (Eds.), 1999. Clinical Oriented Anatomy, fourth ed. Lippincott Williams and Wilkins, Baltimore. Pham, K., Gupta, R., Feb 2009. Understanding the mechanisms of entrapment neuropathies. Review article. Neurosurg. Focus 26 (2), E7. Ritts, G.D., Wood, M.B., Lindscheid, R.L., 1987. Radial tunnel syndrome. A ten-year surgical experience. Clin. Orthop. 219, 201e205. Schiottz-Christensen, B., Mooney, V., Azxad, S., Selstad, D., Gulick, J., Bracker, M., 1999. The role of Active Release Manual Therapy for Upper Extremity Overuse Syndromes e a preliminary report. J. Occup. Rehab. 9 (3), 201e211. Sellards, R., Kuebrich, C., 2005 Mar. The elbow: diagnosis and treatment of common injuries. Prim. Care 32 (1), 1e16. Spina, A.A., 2007 Mar. External coxa saltans (snapping hip) treated with active release techniques(R): a case report. J. Can. Chiropr. Assoc. 51 (1), 23e29. Spinner, M., 1968. The arcade of Frohse and its relationship to posterior interosseous nerve paralysis. J. Bone Joint Surg. Br. 50, 809e812. Stanley, J., ApreJun 2006. Radial tunnel syndrome: a surgeon’s perspective. J. Hand Ther. 19 (2), 180e184. Tubbs, R.S., Salter, E.G., Wellons, J.C., Blount, J.P., Oakes, W.J., May 2006. Superficial surgical landmarks for identifying the posterior interosseous nerve. J. Neurosurg. 104 (5), 796e799.
Journal of Bodywork & Movement Therapies (2010) 14, 403e410
available at www.sciencedirect.com
PREVENTION & REHABILITATION: EDITORIAL
Chains, trains and contractile fields Matt Wallden, MSc Ost Med, DO, ND, Associate Editor In the film, Planes, Trains and Automobiles, the underlying theme is that two men are trying to get home in time for a major social celebration. The story is focused around the challenges these men face as the route from a to b became increasingly convoluted and indirect. In animal locomotion, this same theme of getting from a to b in the most efficient way is often a key aspect of organismal evolutionary fitness. However, there may be some cases in which a more convoluted, indirect route may be of survival benefit; for example, if you were to track a course of musculature around the body in a spiral fashion (Beach, 2007; Wallden, 2008; Myers, 2001), the longer your route from a to b, the more muscle fibres can be utilised, and therefore the more power can be generated. This is why when power generation occurs in sports, such as when hitting, throwing, kicking or punching, it typically involves a rotary twist of the body; to access this fast twitch spiral musculature coursing from the lower limb through and around the trunk, and back out via a different limb to its extremity. Of course, the more powerful a movement, the less efficient it generally is; this applies as much to the human body as it does to planes trains and automobiles. If a Ferrari competes with smart car, the Ferrari may win, but in the long run, the Smart car will go further on the same amount of fuel. Equally, there is little sense in a creature retaining fuel if it is to be some other creatures dinner as a result. Organismal biological design still seems to have the edge on synthetic counterparts; especially in terms of versatility. Going even further back, prior to human evolution, may provide even deeper insight; for this, it is necessary to look back into deep time.
Deep time Early life on Earth exhibited poor or limited motility; nevertheless, such motility was sufficient to satisfy survival
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[email protected] within the presenting ecological niche that single-celled, photosynthesising organisms found themselves in. Early animal forms, such as sponges, anemones and jellyfish all showed very primitive circumferential movement patterns. These movement patterns have been described as the “radial chain” musculature (Beach, 1989, Personal Communication) or “radial contractile field” (Beach, 2008; Wallden, 2008). Later animal forms, such as flat worms and round worms also exhibit this circumferential movement pattern, but do so sequentially across body segments. It was not until the evolution of vertebrates in the form of fish that effective longitudinal contraction down the body wall could take place (Kardong, 2002; Wallden, 2008). Subsequent development merely elaborated on the established fish-based body plan (Erwin et al., 1997); this was the premise of Gracovetsky’s (1988) Spinal Engine theory, the concept that the spine is what drives the legs forward; the limbs simply amplifying spinal motion in steady-state gait.
Recent times Various thinkers from the exercise and rehabilitation fields have made attempts to understand these developments in the musculoskeletal function of organisms; among them early pioneers including Raymond A. Dart’s Double Helix Mechanism of the Spine, Phillip Beach’s Muscle Chains (1989), which evolved into a concept now called Contractile Fields (2007/2008), Andry Vleeming’s and Diane Lee’s Slings (Vleeming et al., 1997) and Thomas Myer’s Anatomy Trains (2001). In short, these people e and many others alongside e were all doing “joined-up-thinking” in the field of human locomotor anatomy. In the last issue of this Journal, the co-editor of this section of JBMT, Warrick McNeill PT, included a paper on the importance of the deep longitudinal sling in hamstring strain (Panayi, 2010). This sling, described by van Wingerden et al. (1996), Vleeming et al. (1997) and Gracovetsky
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404 (1997) is key in both stabilization of the lumbopelvic complex and, Gracovetsky argues, in utilising ground reaction force to de-rotate the spine in gait. Further research, such as Hungerford et al.’s (2003) paper suggest that this sling may also become facilitated as a result of sacroiliac joint (SIJ) pain; the deeper, intrinsic or “inner unit” musculature being somewhat inhibited or delayed in response in SIJ pain patients e when compared with controls e and the biceps femoris firing ahead of these muscles in a feed-forward mechanism. This may have a logical cross-over to the issues discussed in the paper in this section, by Hashemirad et al. (2010), on the flexor-relaxation phenomenon. They describe how a lumbar spine which has undergone creep due to prolonged flexion (for just 7 min or more) will create a statistically significant delayed flexor-relaxation phenomenon. For those unfamiliar with this response, the typical clinical response being observed is a switch from a “muscular” trunk strategy (erector spinae) to a “ligamentous” trunk strategy (transversus abdominis pulls on the thoracolumbar fascia and whole posterior ligamentous system of the spine tightens) at around 45 degrees of trunk flexion or around 90% of lumbar flexion. This reflex is stimulated by mechanoreceptors in the posterior ligamentous system of the spine inhibiting the lumbar erectors. An implication of Hashemirad et al.’s findings, is that the normal stretch does not activate the flexor-relaxation of the lumbar erectors at the usual time; this means that the hamstrings, the transversus abdominis (and it’s tensioning of the deep layer of the thoracolumbar fascia) which normally become dominant at this point in the movement, are delayed in their action. The upshot is decreased intra-abdominal pressure (due to delayed TrA contraction), decreased force closure at the sacroiliac joints (due to TrA not activating the nut-cracker phenomenon of force closure at the SIJ), decreased extensor moment action of the diamond-shaped middle layer of the thoracolumbar fascia, extended lumbar erector contraction in a position of increased flexion and therefore greater risk of posterior annular loading and potential injury. In short, from one simple act of flexing the lumbar spine for a little too long, the ability of the body to effectively transfer loads during lifting or squatting, via a posterior myofascial chain incorporating the hamstrings, sacrotuberous ligaments, thoracolumbar fascia, posterior ligamentous system, lumbar erectors and transversus abdominis, is compromised. This means that the SIJ’s and the discs become more vulnerable to injury; and the ramifications may be greater than that. The later that the hamstrings become dominant in this movement pattern, for example, the greater the leverage on their proximal insertion due to the angle of trunk inclination. Might this influence their risk for becoming strained? If the loading on the hamstring changes its realtime orientation based on the body’s long-established reflex mechanisms, could this have ramifications further down the deep longitudinal sling e as far as the arch of the foot and its role in absorption, storage and recoil of ground reaction forces? At this point the answers are unclear, but what is known is that a change in the spatiotemporal relationships of the
M. Wallden body; especially if this occurs under load or velocity, such as in a sporting event, creates significant computational stress onto the nervous system, to adapt to a situation that it isn’t reflexively equipped for. Perhaps a clinical realisation arising from this is that not only are ergonomics key, but also paying attention to other causes of creep on the ligamentous system, such as the hypnotic effect of computer and TV screens, the sedative effects of alcohol consumption or of chronic sleep deprivation; potentially switching the body off from its own mechanoreceptive feedback, may offer greater understanding in preventing low back injury.
Muscle, fascia and force transmission A second paper appearing in this edition’s Rehabilitation and Prevention section is titled “Muscle fascia and force transmission” by Peter Purslow, (2010a) PhD. This paper explains in great detail how the inner fascial components of the muscle; the endomysium, which surrounds the myofibril, and the perimysium, which surrounds the muscle fibre bundles, form a network to create fascial continuity between different contractile units; even if one unit is fatigued, damaged, being repaired or, indeed, is simply growing. A muscle can be imagined to behave a little like a bridge, connecting one piece of land (bone) to another piece of land (bone) while traversing some kind of ditch or gap (joint). In this way the bridge (muscle) would be built of hundreds of units e perhaps bricks e (sarcomeres) placed both end to end (in series) and alongside each other (in parallel). These bricks (sarcomeres) are designed to both withhold and to generate great forces. In the structure of the bridge, this is a relatively static role, but in the structure of the muscle, this is a far more complex dynamic interplay between resting tone, and various contractile states (concentric, eccentric, isometric and so on). If one or more bricks were to become damaged, or be knocked out of the structure of the bridge, its integrity and ability to both withstand and to generate force would be significantly impaired. However, in both muscles and in bridges this happens regularly, and reconstruction and maintenance is an ongoing feature of such a functional load-bearing structure. In order to be able to safely repair the bridge while it can still allow loads to be taken, some kind of extrinsic scaffolding needs to be in place; probably across the whole bridge (the epimysium), and it is likely that a more focused brace (perimysium) will need to be placed under the section of bridge that is to be repaired; while, specifically, the bricks (sarcomeres) in contact with the actual brick to be repaired (damaged sarcomere) may need a very specific, localised brace to hold them, while the stone mason is doing his work. This allows replacement of the damaged brick (sarcomere) and effective force transmission between the adjacent bricks (sarcomeres) so that the bridge (muscle) doesn’t lose much, if any functional capacity. This is critical to maintain motility of the system of which the muscle (bridge) is a part (Fig. 1). As Purslow goes on to discuss, there is more to these systems than just biomechanics. He illustrates, for example
405
Figure 1 Muscle, fascia and force transmission. The 3 key components of the fascia which envelops a muscle; the endomysium, perimysium and epimysium, can be seen a little like the struts that may support a brick bridge that is under repair. Since muscle tissue is constantly under conditions of growth, damage and repair, there must be mechanisms in place to allow continued function of the muscle when required. The endomysium and perimysium appear to allow for this, and for intra-muscular force transmission, while the epimysium may be more involved in intermuscular force transmission.
that additional crosslinks may form through advanced glycation end products (AGEs); typical of the changes in connective tissues in those with blood sugar dysregulation, from smoking and from aging. Connective tissue function is not just, then, about how the body is used biomechanically, but what it is exposed to biochemically. Purslow’s work is also relevant to the concept of slings discussed by Panayi (2010) in JBMT issue 14(1), by Myers (1997a, b) many times in this Journal and in his book Anatomy Trains, as well as by Beach (2007, 2008). These slings are, important in providing a whole-body appreciation of dysfunctional states, helping us to track back to where a problem may have arisen from and, indeed, as McNeill (2010) and Chaitow (2010) have discussed, to predict where a future problem may arise. What Purslow’s work seems to indicate is that contractile forces passing through the sarcomeres and direct into the myotendinous junction are route-1 for force generation, but that if a given line of sarcomeres has a damaged unit in series (or “brick” in the line), then this doesn’t stop every other sarcomere in that series from working; but simply allows contractile forces to be transmitted laterally across to a parallel series of sarcomeres (line of bricks) allowing continued function of the muscle,
without significant compromise to performance or to repair. Interestingly, Hunter (2005) presented prospective research on English Premiership soccer players which demonstrated that those players with greater measurable stiffness in their hamstrings at the beginning of the season were the least likely to suffer a hamstring strain during that season. Muscle stiffness is known to be generated by the series elastic components, which act like springs in between each sarcomere (Sarhmann, 2002). Therefore, the more sarcomeres (bricks) in parallel, the more series elastic components, the greater the stiffness, and the more possible pathways for force transmission e as well as for running repairs during play and across the season in general. As to whether these forces can pass out of the contracting muscle and into the surrounding fascia (epimysium), Purslow is uncertain, but explains that it would seem entirely feasible and that there is certainly evidence of a hydraulic amplifier mechanism occurring between agonist muscles within a compartment. Purslow (2010b, Personal Communication) states: “Whether epimysium in some muscles at least can also act in the same way to hydraulically stiffen the muscle so that
Text box 1. Evidence for hydraulic amplification between agonists in muscle compartments “.compartmentalisation increases the efficiency of muscle contraction. The contraction of one muscle within the group pressurises the compartment (from 15 mmHg in normal contractions up to approx. 80 mmHg in tetanic conditions), and even a small elevation in pressure raises the contractile efficiency of all members in the muscle group. Cutting the fascia releases 50% of this normal pressure generation and decreases contractile force for a given extension by 16% (Garfin et al., 1981). The interactions of the contractile proteins actin and myosin in muscle are known to be sensitive to high pressures, but very large pressures (10 MPa, or 100 atm) are required, and the effect of these are to reduce the active tension generated (Knight et al., 1993). Perhaps the more useful explanation of the effect observed at such low pressures is the lateral constraint effect proposed by Aspden (1990), which argues that the reduction in lateral expansion that pressurisation of neighbouring muscles may cause increases the effective muscle stiffness in active contraction, thus leading to increased force production for a given length of contraction.”
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Chains, trains and contractile fields
406 it produces more force for a given length change is, as far as I know, not known, but in some muscles with heavy sheets of tendon-like epimysium it certainly looks a possibility.”
M. Wallden Adolescents from two schools in the Rift Valley Province were also compared: one group (4) who have never worn shoes; and another group (5) who have been habitually shod most of their lives.
PREVENTION & REHABILITATIONdEDITOR: MATT WALLDEN
Load transfer Research conducted by Vleeming et al. (1997) supports this notion of the capacity of the epimysium to transfer load across compartments into adjoining muscle groups. Research conducted both on the transfer of load between the gluteus maximus and the contralateral latissimus dorsi via the thoracolumbar fascia, and on the peroneus longus through to the tendon of biceps femoris, showed that a percentage (approximately 18%) of forces applied to the cadaveric myofascial system were, indeed, transferred across muscle groups. The most likely explanation for this (as had been hypothesized by authors such as Myers, Beach and others) is the direct fascial attachments; but specifically of the epimysium (as opposed to contributions from the endomysium or perimysium). The limitations of these studies are clear, inasmuch as the subjects were not living, had been prepared as cadavers (factors which will both significantly alter tissue properties) and were assessed on a dissection table (ie not in a functional load-bearing or sports-specific position), and using extrinsic application of force rather than intrinsic myogenic contractile forces. Nevertheless, such research allows the bodyworker and movement therapist the possibility of making associations between the apparent “functional anatomy” and what they see clinically.
Time to rewrite the biomechanics books? One such example is the biomechanics of gait. For the last 10 years or so, the running community has been in debate about whether running with a heel strike is functional or not. Many running coaches have suspected that the natural state is to strike the ground with the forefoot since a higher proportion of elite distance runners forefoot strike, than those in the lower echelons of the sport. Yet, despite this, heel striking runners still outnumber the forefoot strikers by some significant margin (Downey, 2009). This is why the research from Lieberman et al. (2010) published earlier this year met with so much interest from the world’s media and, in particular with the biomechanics and podiatry communities. What Lieberman et al. (2010) did, for the first time, was to assess groups of habitually unshod runners, versus habitually shod runners, from different cultures, comparing their running style both barefoot and in running shoes. Adults were sampled from three groups of individuals who run a minimum of 20 km per week: (1) habitually shod athletes from the USA; (2) athletes from the Rift Valley Province of Kenya (famed for endurance running), most of whom grew up barefoot but now wear cushioned shoes when running; and (3) US runners who grew up shod but now habitually run barefoot or in minimal footwear.
Subject
Condition
RFS
MFS
FFS
Habitually shod adults, USA
Barefoot Shod
83 100
17 0
0 0
Recently shod adults, Kenya
Barefoot Shod
9 29
0 18
91 54
Habitually barefoot adults, USA
Barefoot Shod
25 50
0 13
75 37
Barefoot adolescents, Kenya (never)
Barefoot Shod
12 e
22 e
66 e
Shod adolescents, Kenya
Barefoot Shod
62 97
19 3
19 0
RFS Z Rearfoot strike. MFS Z Midfoot strike. FFS Z Forefoot strike. What these results seem to clearly demonstrate is that, while humans are able to rearfoot, midfoot or forefoot strike, it would appear that the primary discriminating factor in this behaviour, is more to do with whether they are shod, rather than their genetic or biomechanical heritage (Figure 2). At this early stage in the research, it would seem that the working conclusion is that the natural state for running appears to be a forefoot strike, while adorning the foot with a running shoe seems to be the primary causative factor in rearfoot strike behaviour.
Clinical implications Assuming further ongoing research seems to support this notion, what may be the clinical implications for such an understanding? Firstly, of course, the biomechanics books may have to be re-written with respect to running gait. Interestingly, of course, most such texts have been written since people started wearing running shoes in 1970s and beyond; and therefore have used data from shod groups. Secondly, other findings, both within this research from Lieberman and from other groups suggest that barefoot running and shod running differ with respect to lower limb joint angles, muscle activation firing patterns, leg stiffness, joint torques, and so on (DeWit et al., 2000; Divert et al., 2005; Kerrigan et al., 2010). Weaker epidemiological studies suggest the possibility that these factors may reduce injury profiles (Warburton, 2001). While research from the strength and conditioning field suggests that increasing leg stiffness; something that happens naturally when running barefoot, is a key way to increase top flight running speed (Peak Performance, 2009).
Figure 2 Rearfoot Strike and Forefoot Strike (adapted from Lieberman et al., 2010). When running in supportive trainers, the majority of runners will strike the ground with their heel. This changes the gait cycle, the cadence, the biomechanics and the loading profile. When running barefoot, the majority of runners will strike the ground with their forefoot. Since cushioned shoes are a recent phenomenon, it is likely that the barefoot condition is more akin to the “natural condition” and to the way human biomechanics have evolved to function.
Back to the fusion If we are to place this research regarding the natural biomechanical state into the context of “joined-upanatomy”, or the fusion of musculature hitherto regarded as “separate” entities, it may be possible to identify a dual speed system: one for low-speed gait (walking) and one for supra-walking pace gait (running, to include jogging, and sprinting). The reason for this is that there is a potential problem with the deep longitudinal system, as described by van Wingerden (2006), Vleeming (1997), Panayi (2010), in the context of this new research on the forefoot strike; it can only really work if you heel strike. Though it wasn’t explicitly discussed by Panayi (2010), the lower portion of the deep longitudinal sling, namely the tibialis anterior and the peroneus longus, which form a connective tissue stirrup around the arch of the foot, to control pronation of the medial longitudinal arch, will work very well if the foot is dorsiflexed before heel strike, as it means that the leverage of the ground
407 reaction force against the heel, in tandem with the descending load of the bodyweight through the talocrural joint, will result in a very strong eccentric load through this lower portion of the sling (which is when a muscle is strongest); effectively controlling both plantar flexion of the ankle and pronation of the medial longitudinal arch. But, if the natural state of running is to plantarflex the foot and to forefoot strike, then this system suddenly becomes very inefficient; not serving to control pronation, nor to translate forces up the sling to provide force closure to the load-bearing sacroiliac joint. In forefoot strike, the deep longitudinal sling’s appears to be practically nullified. Since this forefoot strike appears to be the natural state; and this in tandem with the prevailing theory of human evolutionary nutrition, for the last 2 million years, it seems relied heavily on the persistence hunt where the prey is literally run to exhaustion (Lieberman et al., 2010; Liebenberg, 2006), it would seem that effective load transfer through the myofascial net would be key in allowing our ancestors to optimally exploit their ecological niche. So what is the answer? Perhaps there is another means of explaining the efficiency of natural state human running gait. The stability of a moving object increases as its velocity increases. Similar to a cyclist moving at a very slow speed, versus at high speeds, gait may also be recognized for the fact that there is greater transverse plane motion; translated into greater pronation stresses during walking, than there is during sprinting. Indeed, the efficacy with which the human body can create sagittal plane or forward momentum is key in its ability to get from a to b quickly and without energy “leakage” into the frontal or transverse planes. Hence it would be reasonable to assume that the laterally placed (and therefore counter-pronation) musculature of the deep longitudinal system (peroneus longus, tibialis anterior and biceps femoris into sacrotuberous ligament), may be more important at slower, walking velocities, but that it may become usurped in a higher velocity activities such as running, but another sling mechanism. Myers’ superficial back line or “train” has been described in earlier editions of JBMT (Myers, 1997a, b) and in his book “The Anatomy Trains”, Myers depicts this myofascial sling as running from the deep toe flexors (active eccentrically in forefoot strike) and plantar fascia and, direct through the connective tissues into the Achilles tendon and into the triceps surae. The ankle being plantarflexed before heel strike means that as the forefoot strikes the ground, the triceps surae will be eccentrically loaded (where they are at their strongest) and, interestingly, it is eccentric loading that is missing from the gait cycle if someone rearfoot strikes. Could there be a correlation between a lack of forefoot striking and Achilles tendinopathy, after all, since the work of Alfredson (1998), one of the primary methodologies for treating tendinopathic injury has been to prescribe an eccentric loading protocol. Following the anatomy up, the two heads of the gastrocnemius run medially to their super-incumbent hamstrings, the semimembranosus/tendinosus and the two heads of biceps femoris; sweeping around laterally to insert on the condyles of the femur.
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11
11
13 10
10
11 9 10
9 8
8 7
7 6
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4
3 2 1 Myers Superficial Back Line. Myer’s description of the superficial back line runs from 1) the deep toe flexors into, 2) theplantar fascia to, 3) the junctional fascia between the plantar fascia and Achilles tendon. 4) is the triceps surae and 5) is where the two head of the gastrocnemius wrap around the tendons of 6) the medial and lateral hamstring groups. The hamstrings course up and are continuous and are continuousboth with each other and with 7) the sacrotuberous ligament, which spans from 8) the ischial tuberosity up to 9) the sacroiliac joint, where it blends with 10) the deep fibres of the multifidus and the erector group _ finally running all the way up to 11) epicraneus and 12) the frontalis muscle.
The functional relevance of this is that if there is a strong contraction of the triceps surae complex, as would be expected during landing with a forefoot strike, this will create a sudden sharp pull on the hamstring tendons; akin to a tendon-jerk reflex. This will stimulate a strong and bilateral contraction of both hamstring groups (in contrast to just the laterally placed biceps femoris of the deep longitudinal sling), which will transfer loads into the sacrotuberous ligament and across the load-bearing sacroiliac joint. It has been reported by Vleeming et al. (1997), as though it is only the tendon of the biceps femoris which blends with (and therefore transfers load into) the sacrotuberous ligament, yet to quote Gray’s Anatomy 37th edition (1989), the biceps femoris has two proximal attachments: a long head, attached to . the ischial tuberosity by a tendon common to it and the semitendonosis, which blends with the lower part of the sacrotuberous ligament. This edition of Gray’s goes on to say of the proximal semimembarnosus that its fibres are partly interwoven with the biceps femoris and semitendinosus, so it would seem quite logical to deduce that all three muscles may contribute something to the force closure described by
Vleeming et al. (1997) in their description of the deep longitudinal sling.
A possible parallel field of investigation In the field of podiatry, there is an emerging concept around a similar dual mechanism focused around the foot mechanics; termed biaxial propulsion- see Textbox 2 below (Curran, 2010a). In summary, the high and low gear axis really only works during the propulsive phase, so it may be that during a forefoot strike, the autosupport of the foot may gain high gear (a functionally pronated forefoot) and appropriate calcaneocuboid stability as a result. If this were correct, then with the toe-heel-toe loading of forefoot stike runners, it would seem to imply that the high gear mechanism may be engaged to provide stability “in both directions” both receiving load and expressing load. The same may be said of the windlass mechanism; that it may both store up energy on toe strike and recoil energy on toe-off. It
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During the late 1970s, the Danish anatomist Finn Bojsen-Møller described the interrelationship of the loading mechanism of the calcaneocuboid joint that is secondary to the timely tightening of the plantar fascia. Reliant on weight flow through to the first web space, the overall effect of this complex, yet essential mechanism produced stability of the rearfoot and midfoot via compression of the calcaneocuboid joint prior to heel lift. During his investigations, Bojsen-Møller also examined the metatarsal parabola (2 > 1 > 3 > 4 > 5 or 2 > 1 Z 3 > 4 > 5), which revealed an anterior protrusion of the 2nd metatarsal; a seemingly consistent feature associated with the normal foot. In effect, two different axes of propulsion at the MTP joints were observed to exist. One passing transversely through the heads of the first and second metatarsal (transverse or high gear axis) and the other passing obliquely through the second through to the fifth metatarsal heads as the (oblique or low gear axis). Further investigation of these propulsive axes revealed a number of functional advantages, and in particular the transverse axis. By evaluating the distance between each axis from a central point of the ankle joint, the distance to the perpendicular bisection of the transverse axis was documented as being greater (approximately 15e20%) when compared to the same distance to the perpendicular bisection of the oblique axis. Therefore, during high gear (transverse axis) propulsion in which weight flow is directed medially, the forefoot was observed to be functionally pronated (partly through the action of the peroneus longus). It is hypothesized that the position of the forefoot brings the dorsal border of the calcaneus and calcaneal process of the cuboid together. This in turn, provides an osseous block to further motion creating stability and is referred to as the “closed-packed position.” The greater distance from Bojsen-Møller’s central point of the ankle joint to the perpendicular bisection of the transverse axis was assumed to produce a taut attitude of the plantar fascia. This provides further compression of the cuboid on the calcaneus that results in the crucial stability required for propulsion. Conversely, during lateral weight flow (oblique axis or low gear propulsion), it was hypothesized that because of the inverted position of the foot, the calcaneocuboid joint failed to obtain the closed-packed position as previously described. This is thought to be coupled with an insufficient tightening of the plantar fascia due to the shortened distance associated with oblique axis propulsion. As a result, it can be assumed that the lateral aspect of the forefoot would absorb the majority of the forces. is worth noting that biaxial propulsion is just one of the many autosupport mechanisms of the foot, and is dependant on timely motions and activation of other mechanisms. For example, if someone had a limited first MTP joint then it is likely to disrupt weight flow and failure of appropriate support - and of course this will happen whether barefoot or shod if the biomechanical dysfunction is already present (Curran 2010b). Nevertheless, barefoot gait poses no restriction on MTP range of motion; so decreases likelihood of compromise to this mechanism. Perhaps some of these mechanisms go some way to explain why unshod gait is typically more biomechanically efficient.
Conclusion The body is majestically complex e even in its biomechanical make-up alone. If I were a mechanic working, as fascinating as it may be, with planes, trains and automobiles, I think I would look over my shoulder with some envy at the biomechanics who worked with chains, trains and contractile fields.
References Alfredson, H., Pietila ¨, T., Jonsson, P., Lorentzon, R, 1998. Heavy load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. The American Journal of Sports Medicine 26 (3), 360e366. Aspden, R.M., 1990. Constraining the lateral dimensions of uniaxially loaded materials increases the calculated strength and stiffness-application to muscle and bone. J. Mater. Sci. Mater. Med 1, 100e104. Beach, P., 1989. Development of muscle chains theory. Personal communication.
Beach, P., 2008. The contractile field e a new model of human movement e part 3. Journal of Bodywork and Movement Therapies 12, 158e165. Beach, P., 2007. The contractile field e a new model of human movement. Journal of Bodywork and Movement Therapies 11, 308e317. Chaitow, L., 2010. Clinical prediction rules. Journal of Bodywork and Movement Therapies 14 (3), 7e8. Curran, S., 2010a. Sagittal plane facilitation of motion theory and associated pathologies. In: Albert, S.F., Curran, S.A. (Eds.), Lower Extremity Biomechanics: Theory and Practice. Volume 1. BiPedMed Press, Denver, USA. Curran, S., 2010b. Biaxial propulsion and calcaneo-cuboid locking mechanism. Personal communication. Divert, C., et al., 2005. Stiffness adaptations in shod running. Journal of Applied Biomechanics 21 (4), 311e321. DeWit, B., et al., 2000. Biomechanical anlaysis of the stance phase during barefoot and shod running. Journal of Biomechanics 33 (3), 269e278. Downey, G., 2009. Lose your shoes. Is barefoot better? http:// neuroanthropology.net/2009/07/26/lose-your-shoes-isbarefoot-better/ (accessed 30.06.10). Erwin, D., Valentine, J., Jablonski, D., 1997. The origin of animal body plans. American Scientist 85, 126e137. Garfin, S.R., Tipton, C.M., Mubarak, S.J., Woo, S.L.Y., Hargens, A.R., Akeson, W.H., 1981. Role of fascia in maintenance of muscle tension and pressure. Journal of Applied Physiology 51, 317e320. Gracovetsky, S., 1988. The Spinal Engine. Springer, Vienna. Gracovetsky, S., 1997. Linking the spinal engine with the legs: a theory of human gait. In: Vleeming, A., Mooney, V., Dorman, T., Snijders, C., Stoeckart, R. (Eds.), Movement, Stability and Low Back Pain e The Essential Role of the Pelvis. Churchill Livingstone, New York, pp. 243e252. Hashemirad, F., Talebian, S., Olyaei, G., Hatef, B., 2010. Compensatory behaviour of the postural control system to
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410 flexion-relaxation phenomena. Journal of Bodywork and Movement Therapies 14 (2). Hungerford, B., Gilleard, W., Hodges, P., 2003. Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain. Spine 28 (14), 1593e1600. Hunter, G., 2005. Hamstring strain in professional football. Football Association Medical Society Non- League Conference, Lilleshall, UK, October 2005. Kardong, K., 2002. Vertebrates. McGraw-Hill, New York. Kerrigan, D., Casey, M.D., Jason, F., Geoffrey, S., Keenan, M., Dicharry, J., Della, U., CroceWilder, R., 2010. The effect of running shoes on lower extremity joint torques. PM&R 1 (12), 1058e1063. Knight, P.J., Fortune, N.S., Geeves, M.A., 1993. Effects of pressure on equatorial X-ray fiber diffraction from skeletal muscle fibers. Biophysical Journal 65, 814e822. Liebenberg, L., 2006. Persistence hunting by modern huntergatherers. Current Anthropology 47 (6), 1017e1025. Lieberman, D., Venkadesan, M., Werbel, William A.W., Daoud, A., D’Andrea, S., Davis, I., Ojiambo Mang’Eni, R., Pitsiladis, Y., 2010. Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature 463, 531ee536. McNeill, W., 2010. Journal of Bodywork and Movement Therapies 13 (3), 272e275.
M. Wallden Myers, T., 1997a. The ‘anatomy trains’. Journal of Bodywork and Movement Therapies 1 (2), 91e101. Myers, T., 1997b. The ‘anatomy trains’: part 2. Journal of Bodywork and Movement Therapies 1 (3), 135e145. Myers, T., 2001. The Anatomy Trains. Churchill Livingstone. Panayi, S., 2010. The need for lumbar-pelvic assessment in resolution of chronic hamstring strain. Journal of Bodywork and Movement Therapies 14 (1), 294e298. Peak Performance, 2009. Training for Sprinting, Speed & Acceleration. Purslow, P., 2010a. Muscle, fascia and force transmission. Journal of Bodywork and Movement Therapies 14 (2). Purslow, P., 2010b. Personal communication. Sarhmann, S., 2002. Diagnosis and Treatment of Movement Impairment Syndromes. Mosby. Vleeming, A., Snijders, C., Stoeckart, R., Mens, J., 1997. The role of the sacroiliac joins in coupling between spine, pelvis, legs and arms. In: Vleeming et al. (Eds.), Movemen, Stability & Low Back Pain. Churchill Livingstone, 53–71. Wallden, M., 2008. Rehabilitation and Movement Re-education Approaches. Naturopathic Physical Medicine. Elsevier. Warburton, M., 2001. Barefoot running. Sportscience 5 (3). sportsci.org. van Wingerden, J.P., Vleeming, A., Stoeckart, R., Raissadad, K., Snijders, C.J., 1996. Force transfer between biceps femoris and peroneus muscle; a proposal for a longitudinal spring mechanism in the leg.
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FASCIA PHYSIOLOGY
Muscle fascia and force transmission Peter P. Purslow, PhD Department of Food Science, University of Guelph, Guelph, Ontario N1G 2W1, Canada Received 13 October 2009; received in revised form 3 January 2010; accepted 7 January 2010
KEYWORDS Muscle; Connective tissue; Extracellular matrix; Mechanical function; Myofascial force transmission; Endomysium; Perimysium; MMPs; ECM turnover
Summary This paper reviews the major intramuscular extracellular matrix (IM-ECM) structures (endomysium, perimysium and epimysium) and their possible mechanical contributions to muscle functions. The endomysium appears to provide an efficient mechanism for transmission of contractile forces from adjacent muscle fibres within fascicles. This coordinates forces and deformations within the fascicle, protects damaged areas of fibres against over-extension, and provides a mechanism whereby myofibrils can be interrupted to add new sarcomeres during muscle growth without loss of contractile functionality of the whole column. Good experimental evidence shows that perimysium and epimysium are capable in some circumstances to act as pathways for myofascial force transmission. However, an alternative role for perimysium is reviewed, which involves the definition of slip planes between muscle fascicles which can slide past each other to allow large shear displacements due to shape changes in the whole muscle during contraction. As IM-ECM is continually remodelled so as to be mechanically adapted for its roles in developing and growing muscles, control of the processes governing IM-ECM turnover and repair may be an important avenue to explore in the reduction of fibrosis following muscle injury. ª 2010 Elsevier Ltd. All rights reserved.
Introduction The soft connective tissues associated with muscle tissue have been referred to as the intramuscular extracellular matrix (IM-ECM), intramuscular connective tissue (IMCT) and muscle fasciae (MF). Although these general names can be used interchangeably, the term IM-ECM will be used here. Substantial reviews of the structure, development, composition and function of IM-ECM exist (Purslow and Duance, 1990; Purslow 2002, 2008). The mechanisms and
pathways by which IM-ECM is remodelled and adapted due to changing functional demands during muscle growth and repair, and in response to exercise training or disuse, are addressed by Kjær and Magnusson (2008). Like most other soft connective tissue structures, the amount and composition of IM-ECM structures are not simply programmed during embryogenesis and subsequent post-natal maturation processes. The amounts and composition of the various IM-ECM structures in living tissue represent a dynamic balance between deposition, growth, remodelling and degradation, which is affected by the interplay between
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functional demands on the tissue and the mechanical environment. The cellular mechanisms of mechanotransduction in fibroblasts are reviewed by Chiquet et al. (2009). The purpose of the current review is to highlight information pointing to the crucial roles of IM-ECM in force transmission and accommodation of shape changes in functioning muscle.
General structure and biochemical composition of IM-ECM As schematically shown in Fig. 1, each muscle is surrounded by epimysium, a connective tissue layer that is continuous with the tendons that attach the muscles to the bones. In some long strap-like muscles the epimysium is composed of two parallel sets of wavy collagen fibres in a crossed-ply arrangement, embedded in a proteoglycan matrix (see Fig. 2). When the muscle is at its resting length, the two sets of collagen fibres are arranged at angles of approximately 55 to the long axis of the muscle fibres. In other muscles, and especially in pennate muscles, the arrangement of collagen fibres in the epimysium is parallel to the long axis of the muscle and forms a dense surface layer that functions as a surface tendon. The perimysium is a continuous network of connective tissue which divides the muscle up into fascicles or muscle fibre bundles. Fascicles run along the length of the muscle from tendon to tendon, and the ends of muscle fibres form highly folded interdigitating joints (the myotendinous junction) with the tendon at this point (Trotter, 1993). The perimysial network merges into the epimysium at the surface of the muscle and is mechanically connected to it. Within each fascicle or muscle fibre bundle, the endomysium is a continuous network of connective tissue that separates individual muscle fibres. Each of the epimysium, perimysium, and endomysium layers has its own structure and composition, but generally these connective tissue layers are composed of collagen fibres in an amorphous matrix of hydrated proteoglycans (PGs) which plays a crucial role in mechanically linking
Fig. 1 Schematic diagram of IM-ECM structures in a skeletal muscle. Epimysium delineates the surface of the muscle, perimysium separates muscle fascicles and endomysium separates individual muscle fibres. Also depicted are the contractile myofibrils within each muscle fibre. (Artwork: Dr. L.-T. Lim).
Fig. 2 Light micrograph of epimysium from bovine sternomandibularis muscle, showing arrangement of collagen fibres in crossed-plies. The fibres are in two parallel layers lying at þ55 and 55 to the muscle fibre axis. From Purslow (1999), with permission. In epimysium from other muscles the collagen is more aligned with the muscle fibre direction and acts as an exo-tendon or aponeurosis.
together the collagen fibre networks in these structures (Scott, 1990). Listrat et al. (1999, 2000) show that collagen types I, III, IV, V, VI, XII and XIV are all expressed in muscle development. Collagen typically represents 1e10% of the dry weight of adult skeletal muscle (Bendall, 1967). Fibres of elastin can be found in the IM-ECM of some muscles, principally in the perimysium. However, the amount of elastin is small in most muscles and is typically less than 1% of muscle dry weight (Bendall, 1967). Collagen fibres are stabilised by the formation of covalent crosslinks directed by a clear set of post-translational modifications which act on the collagen molecules extracellularly after assembly of the collagen molecules into the quarter-stagger overlapped arrangement characteristic of fibrils (Bruns and Gross, 1973). The formation of crosslinks is essential for the mechanical strength and stiffness of collagen fibres (Bailey et al., 1998). During gestation and post-natal maturation there are changes in the types and amounts of covalent crosslinks that stabilise the collagen molecules within all connective tissues in the body, including IM-ECM. There are also non-enzymatic reactions of collagen with glucose and other aldehydes. Formation of additional crosslinks through advanced glycation end products (AGEs) is typical of the changes in connective tissues in diabetes and during ageing and glycation, and is thought to be a significant contributor to changes in the mechanical properties of connective tissues with age (Paul and Bailey, 1996). Advanced glycation end products can be incorporated into the body from dietary sources (e.g. heat processing of some foods creates AGEs) and from tobacco smoke (Avery and Bailey, 2008). In this way, diet and lifestyle may affect the mechanical properties of IM-ECM via AGE-cross-linking of collagens.
IM-ECM changes during muscle development During embryonic development of intramuscular connective tissue, the amounts of the various collagens and PGs
changes (Velleman et al., 1999; Listrat et al., 1999; Lawson and Purslow, 2001). Spatial variations between the endomysium and perimysium within one muscle (Nishimura et al., 1997) and differences in expression of both collagen type I and PG components such as laminin between muscles (Lawson and Purslow, 2001) are both determined early in prenatal development. In bovine muscles, type I collagen expression is always higher than type III expression at all stages of gestation and post-natally (Listrat et al., 1999). Thus some differences in the composition of intramuscular connective tissue appear to be pre-programmed in embryogenesis. However, there are some variations in the amounts of collagens as muscle development progresses. In bovine psoas and triceps muscles the total collagen concentration and amounts of collagen type I is maximum at the point in gestation when the expression of myosin within muscle fibres changes from the embryonic to the adult form (Listrat et al., 1999). After this, the growing diameter of the muscle fibres dilutes out the connective tissue content of the muscle. In contrast, the pectoralis and quadriceps muscles of the chick show steady increases in collagen type I content and laminin content through gestation and post-natally (Lawson and Purslow, 2001). Whether these differences between bovine and chick muscle growth are due to avian versus mammalian phyla differences or due to functional differences in the muscles studied remains unclear.
The amounts and composition of endomysium and perimysium vary between functionally different muscles In fully developed adult animals, there are large differences in the amounts and composition of IM-ECM between different muscles in the body. Histological comparison (see Fig. 4 in Purslow, 2005) illustrates that the continuous perimysial network surrounds or separates fascicles of radically different sizes and shapes in different muscles from the same animal. This difference also results in different thicknesses of perimysial connective tissue. A comparison of the connective tissue content of 14 bovine muscles shows that the endomysial collagen content is between 0.47% and 1.2% of dry weight, but the perimysial collagen content in the same muscles ranges from 0.43% up to 4.6% of dry weight (Purslow, 1999). The amount of perimysium in muscles varies far more than the amount of endomysium. These variations, especially in the amount and spatial organisation of the perimysium have long been taken to show that IM-ECM must play strong roles in the normal physiological functioning of each muscle. As reviewed in the following two sections, some possible explanations of these roles are emerging but are far from complete.
Structure and functional roles of the endomysium As reviewed by Purslow and Duance (1990), each muscle cell is surrounded by its own plasmalemma and basement membrane. Filling the intervening region between the basement membranes of two adjacent muscle cells is the much more substantial reticular layer, which is comprised
413 of a network of collagen fibrils and fibres in a proteoglycan matrix. The thickness of the endomysium as a whole varies with muscle length, becoming thicker at short muscle lengths and thinner as the muscle is extended (see Trotter and Purslow, 1992). Transmission electron micrography of intact endomysium in situ confirms that all of the collagen fibres in the network layer lie in the plane of the layer (Trotter and Purslow, 1992). The only location where this does not hold true is in the junction zones between the perimysium and the endomysium of muscle cells that lie in the surface of the fascicle. Swatland (1975) concluded that the reticular layer was a single structure shared between adjacent muscle cells, and that this endomysial structure forms a continuous network that runs across the whole muscle fascicle. This interpretation is very strongly borne out by scanning electron microscopy of endomysial collagen networks prepared by NaOH-extraction of muscle to remove all cell components, PGs, plasmalemma, and basement membrane structures (Trotter and Purslow, 1992; Purslow and Trotter, 1994; Nishimura et al., 1994, 1995; Liu et al., 1995). This preparation technique was first demonstrated on connective tissues generally by Ohtani et al. (1988). Fig. 3 (from Purslow and Trotter, 1994) shows such a preparation. The structure of the endomysium appears broadly identical in all SEM preparations from skeletal muscle from different muscles and species, and also in cardiac muscle (Purslow, 2008). The planar network of collagen fibres in the thick reticular region of the endomysium is often described as a random or quasi-random network of irregularly wavy fibres. These collagen fibres run at almost every angle to the muscle fibre long axis, but the network is not truly random. Detailed image analysis of the distribution of fibre directions with respect to the long axis of adjacent muscle cells reveals that there is a preferred direction in the wide distribution of collagen fibre orientations, and that this preferred orientation changes with muscle length (Purslow and Trotter, 1994). At short muscle lengths, more of the collagen fibres in the endomysial network are aligned circumferentially, and at long muscle lengths there is a higher preference for fibres to be aligned longitudinally. The reorientation of collagen fibres in this network at short and long muscle lengths also involves some stretching out of the wavy fibres, but at all sarcomere lengths a very large proportion of the collagen fibres are still wavy. The mechanical consequence of this is that the planar network will be very compliant in tension at all physiologically relevant muscle lengths, and can easily deform to follow changing muscle lengths in vivo. Although this behaviour potentially provides overload protection at high deformations, such protection will only occur at muscle lengths well above those experienced in normal function. These implications are confirmed by detailed modelling of the in-plane tensile properties of the endomysium (Purslow and Trotter, 1994). Their models of the tensile properties of the endomysial network are in agreement with experimental forcelength measurements by Podolsky (1964) and Magid and Law (1985) who compared the tensile properties of relaxed single muscle fibres with and without endomysium. The difference that the removal of the endomysium makes to
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Fig. 3 Scanning electron micrographs of the collagen fibre scaffolding in IM-ECM structures in bovine sternomandibularis muscle as revealed by NaOH-digestion of myofibrils, cytoskeletal proteins, cell membranes, and proteoglycans. Upper panel; low-magnification view, showing thicker perimysial sheets surrounding fascicles. Lower panel; high-magnification oblique view, showing endomysial networks. From Purslow and Trotter (1994) with permission.
the passive elasticity of single fibres is very small at physiologically relevant sarcomere lengths, showing that the endomysium is extremely compliant in tension along the muscle fibre direction over normal working muscle lengths in vivo. Many muscles in species from many phyla contain muscle fibres that do not run along the entire length of fascicles, but terminate before reaching the myotendinous junction (Gans and Gaunt, 1991; Trotter, 1993; Trotter et al., 1995). Muscle fibres in series-fibred muscles are relatively short compared to the length of the fascicle except in humans, which appear to have relatively longer fibres in their seriesfibred muscles. Although some intrafascicularly terminating muscle fibres do seem to have attachments to connective tissue
P.P. Purslow bands internal to the muscle and occasionally have myomuscular junctions where two muscle fibres have interdigitating folded joints between them, the most common termination is a gentle tapering down to an end. These tapering fibres have no terminating structure that would link them directly to another muscle fibre or to the tendon (Trotter, 1993). The fibres are staggered by about one quarter of their length with respect to the adjacent muscle fibres, so that the tapering end of one fibre terminates with the endomysial network surrounding it forming a seamless connection to the endomysium of its neighbours (Purslow and Trotter, 1994). The endomysium is the only structure that links muscle fibres together within fascicles. In seriesfibred muscles, transmission of tension generated in intrafascicularly terminating fibres to the ends of the fascicles absolutely necessitates transmission of force through the endomysial network, as this is the only structure continuously linking the fibres (Trotter et al., 1995). Trotter and Purslow (1992) show that the endomysium is compliant in tension, so that force transmission is unlikely by this means, but they also suggest that force transmission is by shear through its thickness. The key idea is that the endomysium, while very compliant to tensile forces acting within the plane of the network, is much more efficient in providing a non-compliant linkage by shear through its thickness. A formal derivation from fibre composites theory shows that, for practical purposes, the stiffness of the endomysium in shear through its thickness varies only slightly with the orientation of the collagen fibrils in the plane of the endomysium (Purslow, 2002). Any linkage that transmits forces from intrafascicularly terminating muscle fibres to tendinous attachments must be non-compliant (i.e. high stiffness) in order to be efficient. Especially in isometric muscle contractions, any significant stretching in the length of the fascicle due to stretchy connections would result in a very poor transmission of contractile force. The serieselastic nature of this shear linkage can be represented as an apparent longitudinal stiffness Eapp (Purslow, 2002) given by . 2 Eapp ZG L T
ð1Þ
where G is the translaminar shear modulus of the endomysium, T is its thickness and L the muscle fibre length. Even if we take a fibre as short as 1 cm in length, L/T is in the order of 2000, so that Eapp is going to be in the order of 4 106 greater than the true translaminar shear modulus of the endomysium. In a ‘‘composite’’ consisting of two parallel muscle cells with the endomysium sandwiched between them, the apparent longitudinal stiffness of endomysium as it deforms in shear will still be orders of magnitude higher than the tensile stiffness of the muscle fibres themselves. Due to this high value of Eapp the longitudinal stiffness of the entire assembly is going to be dominated by stretching in the muscle fibres themselves rather than in the linking endomysium. This shear linkage through the thickness of the endomysium provides a force transduction pathway from one muscle cell to its neighbours which is highly efficient. However, the endomysium can deform easily in the plane of the network, due to its low tensile stiffness, and so does not restrict changes in muscle fibre length and diameter as muscles contract and relax.
Lateral load sharing through the endomysium is an important concept that also explains how it is possible for muscles to grow and to repair damaged sarcomeres. Lateral load sharing and coordination of deformations means that a fibre can be interrupted for the addition of new sarcomeres necessary for muscle lengthening during growth, without loss of function of an entire contractile column. By the same mechanism, the contractile capacity of the weakness of a sarcomere in which damaged myofibrils are being broken down and remodelled during muscle repair does not lead to tearing of the fibre at this point, as the endomysial connections between adjacent fibres serve to keep the strains uniform throughout the tissue. In submaximal contractions not all the motor units in the muscle are recruited, so that many non-contracting fibres are usually adjacent to contracting fibres. Coordination by shear linkages through the endomysium explains how sarcomere lengths in non-contacting fibres keep in register with those in adjacent, contracting fibres. This maintains uniform sarcomere lengths in the muscle. The continuous meshwork of endomysium that connects adjacent muscle fibres together, therefore, forms a connecting matrix that coordinates force transmission between fibres in a fascicle and keeps fibres in uniform register (Purslow, 2008).
Functional anatomy of the perimysium Two sizes of fascicles and, therefore, two levels of perimysial structure can be distinguished in cross-sections of muscle. Small (primary) fascicles or muscle fibre bundles are delineated by primary perimysium. Groups of primary fascicles are then organised into larger, secondary fascicles by secondary perimysium, which tends to be thicker than primary perimysium. In porcine semitendinosus muscle, the thicker secondary perimysium is in the order of 10 mm thick at birth and increases to approach 50 mm in 55 month old pigs (Fang et al., 1999). The thickness of primary perimysium in cattle muscles ranges from 54.6 m to 133 mm (Brooks and Savell, 2004). Both of these perimysial layers form a fenestrated network that extends across the entire cross-section of the whole muscle. The perimysium does not form a distinct sheath that surrounds one fascicle, but rather is a shared structure lying between two fascicles (Purslow and Trotter, 1994). Nodes form at the junction between perimysial sheets and the fascicles occupy polygonal ‘‘holes’’ in this network, in a manner similar to muscle fibres occupying polygonal ‘‘holes’’ in the endomysial network (but at a larger scale). At the surface of the muscle the perimysium merges and seamlessly joins with the epimysium (Nishimura et al., 1994). The perimysial layer separating two fascicles is primarily comprised of crossed-plies of wavy collagen fibres in a proteoglycan matrix. In a few muscles (e.g. bovine semitendinosus) there are substantial amounts of elastin fibres associated with the collagenous network (Rowe, 1981). The collagen fibre bundles are far larger in diameter than the fine fibres and fibrils in the endomysium and have a regular sinusoidal waviness, with all collagen fibre bundles lying parallel to each other in each ply, and having the same wave periodicity. In porcine semitendinosus muscle the degree of waviness has been observed to increase with animal age
415 (Fang et al., 1999). The collagen fibres lie in the plane of the perimysium, do not run through its thickness, and all the collagen fibres in each ‘‘ply’’ are parallel to each other and lie at 55 to the muscle fibre axis at the resting length of the muscle. This angle changes with muscle length, varying from around 80 at an extremely short sarcomere length of 1.1 mm to approximately 20 at a long sarcomere length of 3.9 mm (Purslow, 1989). Mathematical modelling of the tensile properties in the plane of this network using fibrous composites theory (Purslow, 1989), and direct measurements of the tensile strength and stiffness of perimysial sheets dissected from muscle (Lewis and Purslow, 1989; Purslow, 1999), show that the perimysium is easily deformed in tension until the collagen fibres have become aligned along the stretching direction and the waviness in the fibres pulled out straight. This shows that the perimysium can build up a high tensile stiffness and carry large loads in tension, but only at very large extensions well beyond the range of working lengths in living muscle. The tensile properties of the perimysium are, therefore, similar is nature to the endomysium. Both are initially easily deformed networks that can follow length and diameter changes imposed by the muscle fibres and fascicles contracting and being lengthened by the action of antagonistic muscles. It is tempting to extend the analogy between endomysium and perimysium by proposing that the perimysium could also act to transmit the forces generated in fascicles to their adjacent neighbours by translaminar shear. Although it can be shown that force transmission by such a mechanism can be invoked in circumstances of extreme muscle damage or by cutting the tendinous attachments to some fascicles (Huijing, 2009), there are two considerations that we can raise that diminish the likelihood of this mechanism being involved in living muscle, at least under normal working conditions. Firstly, considering again that the series-elastic nature of a shear linkage can be represented as an apparent longitudinal stiffness Eapp and that Eapp given by Eq. (1) above then even if the perimysium can be up to 50 times thicker than endomysium, the (L/T )2 term in this equation could be up to 2500 times smaller for the same length of perimysium than for the endomysium. If the translaminar shear modulus of the perimysium and endomysium would even be within an order of magnitude of each other, this means that thicker perimysium would have a far smaller Eapp, i.e., it would be far more compliant in shear than the endomysium. This would represent a rather sloppy and inefficient force transmission pathway. The second consideration revolves around the observation that the amounts and structure of endomysium are relatively constant and only slightly vary between different muscles, whereas the amounts of perimysium, its thickness, and the size and shape of primary and secondary muscle fascicles vary tremendously. The endomysial structures providing tight shear linkages between adjacent muscle fibres are reasonably conservative and do not vary so much from muscle to muscle. So, if the perimysial network functions similarly, why should its amounts and spatial arrangement vary so much more? Schmalbruch (1985) cites a model originally proposed by Feneis which proposes that the perimysium provides ‘neutral’ connections between adjacent fascicles. These
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416 connections permit fascicles to slide past each other, and also facilitate shape changes in the muscle during contraction. All fan-shaped, fusiform, and especially pennate muscles change shape when contracting, and in order to accommodate this there must be slippage, or sliding, of some elements within the muscle (i.e. shear deformations). For pennate muscles it is easy to formally calculate the shear strains within the muscles as they contract and the pennation angles change. In ultrasonic images of human muscles, ‘‘boundaries’’ between fascicles can be seen, and measurement of changes in the angle of these during contraction allows shear strains to be predicted. Shear strains within working human muscles are substantial and vary considerably between human muscles such as quadriceps, vastus lateralis and gastrocnemius (Purslow, 2002). If the endomysium maintains adjacent muscle fibres in tight shear register, then where can these large and variable shear strains be accommodated? Simple observations on rigor muscle that is manipulated to produce internal shear show that deformations preferentially occur at the boundaries between fascicles, and that very little shear displacements occur within a fascicle (Purslow, 1999). If the theory that the division of muscle into fascicles is to facilitate shear deformations that are necessary for contracting muscle to change shape is correct, then it seems to offer an explanation of why the amount and distribution of perimysium changes so very markedly from muscle to muscle. Thin perimysia surrounding small fascicles in long strap-like muscles may be associated with relatively small shear displacements, whereas thicker perimysial sheets and larger primary fascicles may relate to larger shear displacements. However, comprehensive data on the relationship between perimysial thickness, fascicle size, and the actual distributions of shear strains in working muscles need to be collected to test this theory.
Control of turnover of IM-ECM as a possible treatment in muscle injury and repair of fibrosis Muscle growth, turnover, and repair necessitate remodelling of IM-ECM, principally under the control of matrix metalloproteinases (MMPs) and tissue inhibitors of MMPs (TIMPs). MMPs are expressed by muscle cells as well as by fibroblasts in the IM-ECM (Balcerzak et al., 2001). Adaptation of muscle, including muscle hypertrophy following exercise training is known to involve increased expression of a range of MMPs (Kjaer, 2004). Expression of MMPs is stimulated by mechanical forces, hormones, and growth factors as well as nutritional components. Myoblasts express almost as much MMP and total collagenase activity as fibroblasts in cell culture and tend to increase this expression more strongly than fibroblasts when mechanically stimulated by biaxial stretching (Cha and Purslow, unpublished data). Numerically, muscle cells vastly outnumber fibroblasts within normal muscle tissue. Epinephrine (adrenaline) is a general agonist of all types of adrenergic receptors, and in muscle principally acts to increase glycolysis via a signalling pathway involving AMP-activated protein kinase (Shen and Du, 2005). There is also adrenergic control of protein metabolism in skeletal muscle. Epinephrine acts to increase calpastatin levels, so reducing protein turnover by calpains and resulting in net muscle accretion (Navegantes
P.P. Purslow et al., 2009). Beta-adrenergic agonists (e.g. clenbuterol, ractopamine, cimaterol, salbutamol) mimic this effect and chronic administration of these growth promoters leads to muscle hypertrophy or amelioration of muscle wasting (Navegantes et al., 2002). Although some reports associate the effect of catecholamines on protein metabolism with c-AMP dependent kinase, Yamaguchi et al. (1997) showed that the p38 MAPK pathway can be activated by beta-adrenergic receptors in kidney cells. Expression of MMPs 1 and 13 is activated by the p38 MAPK pathway in keratinocytes (Johansson et al., 2000). Recent work in our laboratory (Cha and Purslow, unpublished data) shows that both skeletal muscle fibroblasts and myoblasts increase MMP expression in the presence of epinephrine, but with different time-courses and degrees of correlation with expression of AMP-activated protein kinase. Cardiac muscle is obviously different from striated muscle functionally and structurally, yet there are striking similarities about the organisation and function of ECM structures between the two muscle types (Purslow, 2008). A change in the balance between synthesis and degradation of ECM in the myocardium is a characteristic of many types of heart failure, including hypertensive heart failure and infarction/ ischemia (Berk et al., 2007; Graham et al., 2008). Banfi et al. (2005) reported increased plasma levels of MMPs 2&9 in patients with chronic heart failure and also a significant correlation between norepinephrine and MMP2 levels. Cardiac fibroblasts are known to react to both mechanical stimuli and catecholamines in terms of both proliferation and expression (Villareal and Kim, 1997), and cardiomyocytes from chick embryos are known to react to stimulation of the alpha-adrenergic receptor via noradrenaline by activation of p38 MAPK (Tsang and Rabkin, 2009). Ongoing studies to provide fundamental information about the control of expression of IM-ECM forming cells may have far-reaching impact on muscle ageing, injury, and repair.
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417 cell-maceration scanning electron-microscope method. Archives Of Histology and Cytology 51, 249e261. Paul, R.G., Bailey, A.J., 1996. Glycation of collagen: the basis of its central role in the late complications of ageing and diabetes. International Journal of Biochemistry and Cell Biology 28, 1297e1310. Podolsky, R.J., 1964. The maximum sarcomere length for contraction of isolated myofibrils. Journal of Physiology 170, 110e123. Purslow, P.P., 1989. Strain-induced reorientation of an intramuscular connective tissue network: implications for passive muscle elasticity. Journal of Biomechanics 22, 21e23. Purslow P.P., 1999. The intramuscular connective tissue matrix and cell-matrix interactions in relation to meat toughness. Proceedings of the 45th Interantional Congress of Meat Science and Technology, Yokohama, Japan, pp. 210e219. Purslow, P.P., 2002. The structure and functional significance of variations in the connective tissue within muscle. Comparative Biochemistry and Physiology. A Molecular And Integrative Physiology 133, 947e966. Purslow, P.P., 2005. Intramuscular connective tissue and its role in meat quality. Meat Science 70, 435e447. Purslow, P.P., 2008. The extracellular matrix of skeletal and cardiac muscle. In: Fratzl, P. (Ed.), Collagen: Structure and Mechanics. Springer, NY, pp. 325e358 (Chapter 12). Purslow, P.P., Duance, V.C., 1990. The structure and function of intramuscular connective tissue. In: Hukins, D.W.L. (Ed.), Connective Tissue Matrix, vol. 2. MacMillan, pp. 127e166. Purslow, P.P., Trotter, J.A., 1994. The morphology and mechanical properties of endomysium in series-fibred muscles; variations with muscle length. Journal of Muscle Research and Cell Motility 15, 299e304. Rowe, R.W.D., 1981. Morphology of perimysial and endomysial connective tissue in skeletal muscle. Tissue and Cell 13, 681e690. Schmalbruch, H., 1985. Skeletal Muscle. Springer, Berlin. Scott, J.E., 1990. Proteoglycan: collagen interactions and subfibrillar structure in collagen fibrils. Implications in the development and ageing of connective tissues. Journal of Anatomy 169, 23e35. Shen, Q.W., Du, M., 2005. Role of AMP-activated protein kinase in the glycolysis of postmortem muscle. Journal of the Science of Food and Agriculture 85, 2401e2406. Swatland, H.J., 1975. Morphology and development of connective tissue in porcine and bovine muscle. Journal of Animal Science 41, 78e86. Trotter, J.A., 1993. Functional morphology of force transmission in skeletal muscle. Acta Anatomica 146, 205e222. Trotter, J.A., Purslow, P.P., 1992. Functional morphology of the endomysium in series fibered muscles. Journal of Morphology 212, 109e122. Trotter, J.A., Richmond, F.J.R., Purslow, P.P., 1995. Functional morphology and motor control of series fibred muscles. In: Holloszy, J.O. (Ed.), Exercise and Sports Sciences Reviews, vol. 23. Williams and Watkins, Baltimore, pp. 167e213. Tsang, M.Y.C., Rabkin, E.W., 2009. p38 Mitogen-activated protein kinase (MAPK) is activated by noradrenaline and serves a cardioprotective role, whereas adrenaline induces p38 MAPK dephosphorylation. Clinical and Experimental Pharmacology and Physiology 36, e12ee19. Velleman, S.G., Liu, X.S., Eggen, K.H., Nestor, K.E., 1999. Developmental downregulation of proteoglycan synthesis and decorin expression during turkey embryonic skeletal muscle formation. Poultry Science 78, 1619e1626. Villareal, F.J., Kim, N.N., 1997. Regulation of myocardial extracellular matrix components by mechanical and chemical growth factors. Cardiovascular Pathology 7, 145e151. Yamaguchi, J., Nagao, M., Kasziro, Y., Itoh, H., 1997. Activation of p38 mitogen-activated protein kinase by signalling through G protein-coupled receptors. Journal of Biological Chemistry 272, 27771e27777.
PREVENTION & REHABILITATIONdFASCIA PHYSIOLOGY
Muscle fascia and force transmission
Journal of Bodywork & Movement Therapies (2010) 14, 418e423
available at www.sciencedirect.com
PREVENTION & REHABILITATIONdSPINAL PHYSIOLOGY
journal homepage: www.elsevier.com/jbmt
SPINAL PHYSIOLOGY
Compensatory behavior of the postural control system to flexionerelaxation phenomena Fahime Hashemirad a,b,c,*, Saeed Talebian a, Gholam R. Olyaei a, Boshra Hatef c a Physical Therapy Department, Rehabilitation Faculty, Tehran University of Medical Sciences and Health Services, Tehran, Iran b Akhavan Spine Physical Therapy Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran c Sports Medicine Research Center, Tehran University, Tehran, Iran
Received 4 September 2009; received in revised form 16 February 2010; accepted 15 April 2010
KEYWORDS Creep; Erector spinae muscles; Flexionerelaxation; Lumbar spine
Summary Laxity of the passive tissues of the spine during prolonged spinal flexion has been shown to disturb spinal stability. This study investigated the effects of short periods of static lumbar flexion and short rest periods on the flexionerelaxation angle for the erector spinae muscles in 36 healthy female college students. The surface electromyographic activity of the erector spinae muscles was measured in three states before the onset of creep, immediately after 7 min of static lumbar flexion, and after a 10 min rest. The results showed that 7 min of static lumbar flexion will produce relaxation of the erector spinae muscles that occurs at greater absolute lumbar and trunk angles, during the forward bending activity (P < 0.05), while the corresponding relative angles did not change before and after creep. The results also indicate that postural compensations are dominant over the muscular compensations for load sharing in flexionerelaxation phenomena of asymptomatic healthy participants. This further highlights the importance of postural modulation in the control of movement and preservation of skeletal stability. Clinical relevance: Considering spinal posture in the upright condition, and its changes by phenomena such as creep, can reduce postural injuries by instructing subjects to approach a more vertical posture, after periods of bending, to compensate the stretching effects of the tissues and thus regaining the normal muscular activity pattern. ª 2010 Elsevier Ltd. All rights reserved.
* Corresponding author. Akhavan Spine Physical Therapy Center, University of Social Welfare and Rehabilitation Sciences, Shahid Jaafar Asadi Manesh Alley, After Monirie Square, Valie Asr Avenue, Tehran, Iran. Tel.: þ98 21 66467000. E-mail address:
[email protected] (F. Hashemirad). 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.04.008
Introduction Creep deformation in the various passive tissues of the spine including ligaments, intervertebral discs, and joint capsule is thought to increase the laxity of the intervertebral joints, allowing increased relative motion, which destabilizes their natural alignment, with the potential for consequent injury and associated pain (Jackson et al., 2001; Solomonow et al., 1999; Wiliams et al., 2000). High incidence of low back pain (LBP) disorders is associated with occupations requiring sustained and repetitive lumbar flexion (Little and Khalsa, 2005). As the trunk is flexed from a standing position toward full lumbar flexion, lumbar extensor muscles exhibit myoelectric silence and this phenomenon is called flexionerelaxation (FRP) (Floyd and Silver, 1955; Kippers and Parker, 1984; Olson et al., 2004). In the fully flexed posture, the body weight is supported mainly by a passively generated extension moment from spinal ligaments, intervertebral discs and the passive components of the extensor muscle-tendon units (McGill and Kippers, 1994). If the flexed posture is maintained, the passive tissues will deform at a slow rate due to their viscoelastic material properties, and this creep deformation of the spinal tissues provides more laxity in the passive tissues and reduced resistance to forward flexion moment (Shin and Mirka, 2007). The change in the passive tissue stiffness is expected to affect the activation level of back extensor muscles because flexion moment generated by upper body weight is supported by cocontribution of both active and passive components. The creep response and recovery behavior of erector spinae is an interesting model to study the modulation of lumbar stability. Solomonow et al. (2003a) showed creep, developed during a short static lumbar flexion, elicited significant changes in the muscular activity pattern of the flexionerelaxation phenomenon. The effects of creep on the upright posture and considering this in EMG activity of erector spinae have not yet been fully identified. Understanding how the trunk and lumbar angles are affected by the creep phenomenon and how the erector spinae muscles activation pattern is influenced by these changes, can be helpful in the assessment of the creep phenomenon and choosing a preventive strategy for low back pain. The aims of this study were to investigate how a short static posture of 7 min affects the absolute and relative angles of flexionerelaxation response and how a short rest period of 10 min would moderate those effects. Since considering the starting posture while measuring range of motion is of great importance (Vachalathiti et al., 1995), it was presumed that using the two measures of “absolute” and “relative” angles would lead to different results, therefore in this study, we have chosen the latter to get a better estimate of the effect of creep phenomenon on spinal motion characteristics, while keeping the absolute value for comparative purposes.
Methods Subjects Thirty-six healthy female students without a history of back pain during the last 2 years were recruited from Tehran
419 university of Medical Science and Health Services to participate. All participants were free from chronic and current back problems and after being introduced to the nature of the study, signed consent forms that they were willing to take part. Previous studies have shown the creeprelated changes to be different in males and females (Solomonow et al., 2003a). Thus to neutralize the effect of gender and its consequent confounding factors, and also since they were more accessible, only females were studied. The mean (standard deviation) age, height and weight of the thirty-six participants were 22.3(3.4) years, 1.6(0.1) m and 56.7(6.3) kg, respectively.
Instrumentation Surface EMG data were collected using a 4-channel electromyography device (Medelec, Promiere model). The EMG signals were detected by pregelled AgeAgCl electrode pairs applied at the L3-4 level over the left erector spinae musculature (about 4 cm lateral from midline). Center to center electrode distance was 2.5 cm; electrodes were longitudinally oriented along the fibers of the erector spinae muscles. A reference electrode was taped on the left wrist. To identify the L3 level we first found the sacrum and followed the spinous processes of the lumbar vertebrae up to L3. L3 is located at the center of the lumbar curvature and due to its long transverse processes, provides mechanical advantage for the muscles so the investigation of muscular activity at this level is preferred (Bogduk, 1997) and it is more comparable to other research reports (Solomonow et al., 2003a). The EMG signals were amplified by 1000 with a frequency band pass of 20e500 Hz, Gain 100 mV/Div., 80 dB signals to noise ratio and CMRR of 90 dB. Maximum acceptable skin impedance level was set at 5 kU. Sampling rate of recording was 1000 Hz and the data were digitized and stored by a 12-bit A/D board. Angular variables were estimated by a digital camera (JVC-GZ-MG50AS) placed 1 m away from the subject at waist level with a direct view of the subject’s right side in the sagittal plane. The camera collected kinematics data at the rate of 25 frames per second. The markers used to measure the segment angles were attached to the subjects as follows: three circular markers were attached to the right greater trochanter, lateral midline along the iliac crest and the lower palpable edge of the rib cage (Solomonow et al., 2003a). Video and EMG data were synchronized by an electrical circuit which triggered them at the same time.
Protocol The skin was cleaned with alcohol preparation pads before attachment of the EMG electrodes. The electrodes and skin markers were placed as described above, and the signal was checked prior to test trials to make sure of proper marker detection and lack of EMG signal noises. The subjects stood just behind a horizontally drawn line on the ground barefoot with their feet pelvis-width apart, their wrists hooked together in the front of their body, and their
PREVENTION & REHABILITATIONdSPINAL PHYSIOLOGY
Compensatory behavior of the postural control system
PREVENTION & REHABILITATIONdSPINAL PHYSIOLOGY
420 knees kept straight and bent forward from the waist level as far as possible. After introducing the task to the subjects and making sure of the accuracy of the maneuver, subjects performed two trials separated by 30e50 s between them. Each trial consisted of an approximately 3 s of quiet standing followed by 3e5 s full forward flexion. The deep flexion was held for 4 s followed by 3e5 s extension to upright posture, and then static standing through the end of recording. Finally one of the trials was chosen depending on signal quality for data analysis (Hashemirad et al., 2009). After recording EMG and kinematics data, the subjects sat on the floor with their trunk in full lumbar flexion. A hemicylindrical foam bolster was placed under the thighs to tilt the pelvis posteriorly, and reduce hamstring stretch (Solomonow et al., 2003a) (Figure 1). The subjects stayed in this static flexion position for 7 consecutive minutes, immediately after which they stood up and performed another set of flexioneextension tasks similar to the one performed prior to the static flexion period. Following that the subjects sat on a chair to recover for 10 min and then the trial, and recordings of EMG and kinematics were all repeated.
Data analysis The recorded EMG signals were full-wave rectified and smoothed with the time constant of 50 ms to yield linear envelops. The EMG values were normalized using the peak EMG magnitude during the task. A threshold level of 5% of this magnitude was used to determine the onset and the end of the flexionerelaxation period. The onset of the flexionerelaxation phenomenon (EMG-Off) was defined as the point at which the magnitude of EMG signal got less than the threshold level and the end point of the phenomenon (EMG-On) during the extension phase was defined as the point at which EMG signals amplitude exceeded the threshold level (Olson et al., 2004) (Figure 2). The video data were analyzed using Ulead video studio software (version 7) to match the frame of the video with the corresponding EMG signals (frames of EMG-Off and EMGOn). Measurement of the angles of interest in each specific frame was done with Auto CAD software (2006). The trunk, hip and lumbar angles were measured by lateral markers. Trunk angle was defined as the angle between the vertical line crossing the ilium marker and the line connecting the rib and ilium markers. The hip angle
Figure 1 Schematic representation of a subject during the 7 min of static lumbar flexion.
F. Hashemirad et al.
Figure 2 Typical recording of EMG activity during the flexioneextension task. Raw EMG and the linear envelope data were used to estimate EMG-Off and EMG-On points. The extension phase used for normalization of the EMG linear envelope is also provided.
was defined as the angle between the vertical line crossing the ilium marker and the line connecting the greater trochanter and ilium markers while the angle of lumbar flexion was defined as the difference between the two previous ones (trunk angle hip angle) (Solomonow et al., 2003a) (Figure 3). The angle measurements were done as absolute and relative. The relative angles were calculated with respect to the corresponding angles in the erect posture. The dependent variables included absolute and relative angles of the trunk and lumbar in full flexion, EMG-On and EMG-Off, in three conditions of before, immediately after and 10 min after the creep.
Figure 3 Schematic representation of a subject performing the forward bending task and the measured angles where a, b and g are the trunk, hip and lumbar angles, respectively.
Compensatory behavior of the postural control system
421
Parameters (absolute angles)
Before creep (condition I) X(SD)
After creep (condition II) X(SD)
After 10 min rest (condition III) X(SD)
P value Conditions I,II
Conditions I,III
Conditions I,III
Trunk angle Full flexion EMG-off EMG-on
103.3(17.1) 102.7(16.8) 83.9(14.8)
106.4(17.7) 106.1(17.9) 84.7(20.4)
106.1(17.7) 105.5(18.1) 87.1(22.2)