sportEX Dynamics Journal Issue 37 - July 2013 by Co-Kinetic

ISSUE 3 7 july 2013 ISSn 1744-9383

promoting

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manual therapy

n aquatic therapy in sports injury rehabilitation n critique of fascial release n evidence for the use of kinesio tape â&#x20AC;&#x201C; an update n maximising the gluteus â&#x20AC;&#x201C; part 2 n music, pain and sport

contents july 2013 issue 37

Guest editorial

Publisher Tor DAvIES BSc (Hons) tor@sportex.net art editor DEBBIE ASHEr debbie@sportex.net sub editor ALISoN SLEIGH journal watch BoB BrAMAH subscriptions & advertising support@sportex.net +44 (0)845 652 1906 CoMMISSIoNING EDITorS Brad Hiskins - Australia & NZ Whitney Lowe - USA & Canada Humphrey Bacchus - UK & Europe Glenn Withers - Worldwide Dr Marco Cardinale - Worldwide Dr Thien Dang Tan - USA & Canada TECHNICAL ADvISorS

Steve Aspinall Bob Bramah Paula Clayton Stuart Hinds rob Granter Michael Nichol Joan Watt Dr Greg Whyte

july 2013

At our annual conference in June, The Sports Massage Association (SMA) added the strapline “The Association for Soft Tissue Therapists” to its marketing material. This small addition signals a sea change in attitude and ambition, particularly in the UK. For many years it has been clear that some of our members’ skills have not been adequately reflected in the descriptor Sports Massage Practitioner or Therapist and additionally our membership no longer simply comprises those individuals. Members can of course continue to use the title that suits them best, but it seems logical to make a change that reflects the broader ‘church’ that the SMA has become.

BSc (BASraT), MSc MCSP, MSMA MSc, FA Dip, Mast STT Dip SST Dip SST BSc (BASraT) MCSP, MSMA PhD, BSc (Hons)

It also signals an era of cooperation and collaboration between those organisations that represent ‘soft tissue therapists’. If we are to progress as an industry for the benefit of our members, then the parochialism and defensiveness which has so often marred progress, must stop. We must find ways to cooperate and drive the profession forward. Dare I say it, but that there may also be a case for consolidation of some professional associations where it makes sense to do so. The ‘small thinking’ has to stop – every continent has faced and in many cases still does face the same terminology issues – going forwards we need to work much more closely with Europe, North America, Australia and South Africa in terms of mapping education models as well as agreeing common terminology. Big ideas require ‘big thinking’ – are we ready for the challenge? Any thoughts? Let’s discuss...at http://spxj.nl/SMPvSTT

is published by Centor Publishing ltd 88 nelson road Wimbledon, sW19 1HX tel: +44 (0)845 652 1906 fax: +44 (0)845 652 1907 www.sportex.net otHer titles in tHe sPorteX range

Paul Medlicott, Chair of SMA, Chair GCMT, Profession Specific Board Member (Massage) CNHC

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sporteX medicine - ISSN medicin e 1471-8138. Written specifically for professionals working in the field of soft-tissue injury diagnosis, treatment and rehabilitation - personal subscription £54, practice subscription £94, library subscription £175

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Contents

4 7 13

journal watch

This quarter’s latest research

aquatic therapy It’s use in sports rehabilitation

fascial release

An investigation into the evidence for its effectiveness

18 Kinesio tape 20 Maximising the gluteus: part 2 28 Music, pain and sport The latest evidence base

The second part of this focus on how to treat problems associated with the gluteus muscles

The role of music in rehabilitation

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DISCLAIMER While every effort has been made to ensure that all information and data in this magazine is correct and compatible with national standards generally accepted at the time of publication, this magazine and any articles published in it are intended as general guidance and information for use by healthcare professionals only, and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. To the extent permissible by law, the publisher, editors and contributors to this magazine accept no liability to any person for any loss, injury or damage howsoever incurred (including by negligence) as a consequence, whether directly or indirectly, of the use by any person of any of the contents of the magazine. Copyright subsists in all material in the publication. Centor Publishing Limited consents to certain features contained in this magazine marked (*) being copied for personal use or information only (including distribution to appropriate patients) provided a full reference to the source is shown. No other unauthorised reproduction, transmission or storage in any electronic retrieval system is permitted of any material contained in this publication in any form. The publishers give no endorsement for and accept no liability (howsoever arising) in connection with the supply or use of any goods or services purchased as a result of any advertisement appearing in this magazine.

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CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

Mu MuSCuLAR STRENGTH IN MALE AdOLESCENTS ANd AN pREMATuRE dEATH: COHORT STudy Of O ONE MILLION pARTICIpANTS. Ortega fB, Silventoinen K, et al. BMJ 2012;345:e7279

M MASSAGE THERApy ATTENuATES INfLAMMATORy SIGNALLING AfTER ExERCISE-INduCEd MuSCLE dAMAGE. Crane Jd, Ogborn d, et al. Science Translational Medicine 2012;4(119):119ra13 Massage therapy or no treatment was given to separate quadriceps of 11 young male participants after exercise-induced muscle damage. Muscle biopsies were acquired from the vastus lateralis at baseline, immediately after 10 minutes of massage treatment, and after a 2.5-hour period of recovery. Massage activated the mechanotransduction signalling pathway’s focal adhesion kinase (FAK) and extracellular signal-regulated kinase 1/2 (ERK1/2), potentiated mitochondrial biogenesis signalling [nuclear peroxisome proliferator-activated receptor a coactivator 1a (PGC-1a)], and mitigated the rise in nuclear factor aB (NFaB) (p65), nuclear accumulation caused by exercise-induced muscle trauma. Despite having no effect on muscle metabolites (glycogen, lactate), massage attenuated the production of the inflammatory cytokines tumour necrosis factor-a (TNF-a) and interleukin-6 (IL-6) and reduced heat shock protein 27 (HSP27) phosphorylation, thereby mitigating cellular stress resulting from myofibre injury.

sportEX comment This is one from 2012 that we originally missed. Don’t worry if you don’t understand the chemistry speak – neither do we. All you need to know is that 11 young men were exercised until it hurt and muscle biopsies were taken from their quads before, during and after. (Bet that was a fun meeting with the ethics committee!). The outcome is positive evidence that massage appears to be clinically beneficial in reducing inflammation and the process of forming new mitochondria in cells.

This Swedish study tracked 1,142,599 male adolescents aged 16–19 years for 24 years. Baseline examinations included knee extension, handgrip, and elbow flexion strength tests, as well as measures of diastolic and systolic blood pressure and body mass index. During the time 26,145 participants died from, amongst other things, suicide (22.3%), cardiovascular diseases (7.8%) and cancer (14.9%). High muscular strength in adolescence was associated with a 20–35% lower risk of premature mortality due to any cause or cardiovascular disease, independently of body mass index or blood pressure. There was no association observed with mortality due to cancer. Stronger adolescents had a 20–30% lower risk of death from suicide and were 15–65% less likely to have any psychiatric diagnosis (such as schizophrenia and mood disorders). Adolescents in the lowest tenth of muscular strength showed by far the highest risk of mortality for different causes.

sportEX comment This is a study and half. N = one million plus, over 24 years. We will be reading statistical extrapolations of this study for the next 24 years. For now the fact that strength reduced mortality is more than enough to be going on with. Get Kevin and Perry away from the games consoles and into the gym. The suicide rates are a bit disturbing as well.

M MASSAGE THERApy fOR NECK ANd SHOuLdER pAIN: A SySTEMATIC REvIEw RE ANd META-ANALySIS. Kong LJ, Zhan HS, et al. Evidence-Based Complementary and Alternative Medicine 2013;2013:613279 Seven English and Chinese databases were searched until December 2011 for randomised controlled trials (RCTs) of massage therapy (MT) for neck and shoulder pain. The methodological quality of RCTs was assessed based on the PEDro scale. Meta-analyses of MT for neck and shoulder pain were performed. Twelve high-quality studies were included. In immediate effects, the meta-analyses showed significant effects of MT for neck pain and shoulder pain versus inactive

therapies. And MT showed short-term effects for shoulder pain. But MT did not show better effects for neck pain or shoulder pain than active therapies. Functional status of the shoulder was not significantly affected by MT.

sportEX comment Massage is good for shortterm pain compared to doing nothing. It doesn’t appear any better than other therapies overall. So do the massage in the clinic and send them home with an exercise plan.

sportEX dynamics 2013;37(July):4-6

JOURNAL WATCH

Journal watch pHENOT pHENOTypIC ANd MOLECuLAR dIffERENCES BETwEEN RATS SELECTIvELy-BREd TO BET vOLuNTARILy v RuN HIGH vERSuS LOw NIGHTLy dISTANCES. Roberts Md, Brown Jd, et al. American Journal of physiology 2013; doi: 10.1152/ajpregu.00581.2012 A group of 159 adult rats (28 days old) were given the chance to voluntarily run on a running wheel. After 6 days the 26 who had run the greater distance were breed with each other. The same thing was done with the 26 that covered the least distance. After 10 generations they had a group of selectively bred ‘active rats’ and one of ‘lazy rats’ who were then tested. The voluntary running distances were 8.5–11.0 times greater in active rats than lazy rats (9.3km v. 1.1km for males and 15.4km v. 1.4km for females). The active rats also ran faster and for significantly longer for both sexes. The running patterns were not related to differences in body weight, the amount of food eaten, body fat percentage or weight gained between the two groups, nor in hind-limb muscle characteristics. Analysis of gene expression in the brain uncovered eight gene transcripts that were expressed differently between the groups.

sportEX comment

THERA THERApEuTIC EvALuATION Of LuMBAR TENdER pOINT dEEp MASSAGE fOR CHRONIC NON-SpECIfIC LOw BACK pAIN. Zheng Z, wang J, et al. Journal of Traditional Chinese Medicine 2012;32(4):534–537 A group of 64 patients were randomly divided into an equal treatment group or control group. The first group received tender-point deep-tissue massage plus lumbar traction whereas the other group received lumbar traction alone. A tissue-hardness meter/algometer and a visual analogue scale were used to assess the pressure-pain threshold, muscle hardness and pain intensity. Following treatment the results were for the treatment and control groups, respectively: pressure-pain threshold difference was 1.5±0.8 and 1.1±0.7; the muscle hardness difference was 4.2±1.6 and 3.5±1.3; and the VAS score difference was 1.9±0.9 and 1.4±0.8. Massage and traction performed better than traction alone.

sportEX comment

I can’t help being a couch potato it’s in my genes. “Rats”! OK, it’s an animal experiment but it offers a convenient explanation for inactive families. We shouldn’t forget the power of human free will: “I think, therefore I am not a lazy so and so”.

The two treatments combined performed better than traction alone. You don’t see a lot of lumbar traction machines these days and even fewer actually being used so this study is a bit of a lost opportunity. Massage v. nothing would be nice, but hey we will take any evidence that is positive for hands on treatment.

C COffEE INTAKE ANd dEvELOpMENT Of pAIN duRING COMpuTER wORK. Strøm v, Røe C, et al. BMC Research COM Notes 2012;5:480 Forty eight subjects full-time workers, 22 with chronic shoulder and neck pain and 26 healthy pain-free subjects, performed a computer-based officework task for 90 minutes. Nineteen (40%) of the subjects had consumed coffee (1/2 – 1 cup) on average 1 hour 18 minutes before the start. Pain intensity in the shoulders and neck and forearms and wrists was rated on a visual analogue scale every 15 minutes

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throughout the work task. The results revealed that the coffee drinkers recorded significantly lower pain increase than those who didn’t drink coffee.

sportEX comment Wake up and smell the coffee! Us coffee addicts have known this forever. Decaf is like kissing your sister. Same mechanism but without the buzz.

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CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

Mu MuSCLE TRIGGER pOINTS, pRESSuRE pAIN THRESHOLd, ANd CERvICAL RANGE Of THRESHOL MOTION IN pATIENTS wITH HIGH LEvEL Of dISABILITy RELATEd TO ACuTE wHIpLASH INJuRy. fernández-pérez AM, Manuel A, et al. Journal of Orthopaedic & Sports physical Therapy 2012;42(7):634–641 Twenty individuals with a high level of disability related to acute whiplash associated disorder (WAD) were age and sex matched with 20 healthy controls. Trigger points (TrPts) were examined and pressure-pain threshold (PPT) was assessed bilaterally. Active cervical ROM, neck pain, and self-rated disability were also assessed. The mean number of TrPts for the patients with acute WAD was 7.3±2.8 (3.4±2.7 were latent TrPts; 3.9±2.5 were active TrPts). The control group reported 1.7±2.2 latent and no active TrPts. In the WAD group, the most prevalent sites for active TrPts were the levator scapulae and upper trapezius muscles. The more TrPts there were, the greater reported neck pain and the longer the time since the trauma. The WAD group had significantly lower PPTs in all tested locations and less active cervical ROM.

S SEdENTARy TIME IN AduLTS ANd THE ASSOCIATION wITH dIABETES, CARdIOvASCuLAR dISEASE ANd dEATH: w SySTEMATIC REvIEw ANd META-ANALySIS. wilmot EGT, Edwardson CL. diabetologia 2012;55(11):2895–2905 This review searched all the usual suspect medical databases using terms relating to sedentary (sitting) behaviours and health outcomes. It came up with 18 studies using a total of 794,577 participants. Time spent in sedentary positions was directly linked to an increase risk of diabetes, cardiovascular disease and all-cause mortality; the strength of the association was largest for diabetes.

sportEX comment Yet more evidence that we need to move. We are not designed to sit around all day. It’s killing us. Get those fitness-at-work programmes going.

sportEX comment There is controversy over what actually happens to the neck during trauma, but one theory is that neck extensors act eccentrically to slow forward head movement. Could the delayed symptoms be delayed onset muscle soreness? Could the formation of large numbers of TrPts be a reaction to this? We don’t know yet, but we do know that hunting and destroying TrPts is bread and butter to a soft tissue therapist.

wALKING vERSuS RuNNING fOR HypERTENSION, CHOLESTEROL, ANd dIABETES MELLITuS RISK REduCTION. williams pT, Thompson pd. Arteriosclerosis, Thrombosis and vascular Biology 2013;doi: 10.1161/ATvBAHA.112.300878 A group of 33,060 runners and 15,045 walkers were surveyed over a six year period. Baseline expenditure [metabolic equivalent hours per day (METh/d)] was compared with self-reported, physiciandiagnosed incident hypertension, hypercholesterolemia, diabetes mellitus, and coronary heart disease (CHD). Running significantly decreased the risks for incident hypertension by 4.2%, hypercholesterolemia by 4.3%, diabetes mellitus by 12.1% and CHD by 4.5% per METh/d. The corresponding reductions

for walking were 7.2%, 7.0%, 12.3%, and 9.3%.

sportEX comment We can’t all run, especially as we get older, but many of us want to stay fit and healthy and hopefully participating in some form of sport for activity. This study shows you don’t need to kill yourself. In fact the risk reduction for these complaints is greater with walking than running. Get those clients out there!

sportEX dynamics 2013;37(July):4-6

EvidEncE informEd practicE

GoinG Goin G with the flow by Jon Meyler MSc; richard MoSS GSr, MSc; brendon Skinner GSr, bSc

introduction Physical activity is used by a large number of people as a means to stay healthy, lose weight and to improve the condition of the body. One of the key principles that underpin this use is the idea of overload, adding resistance to the body in order to challenge it and to encourage it to adapt. While in many cases the addition of resistance is applied through the use of weights, this is not always suitable for all individuals, particularly those who are recovering from injury. Although this traditional form of resistance training is often utilised, the use of aquatic therapy may offer a more suitable alternative through which to achieve the same outcome.

indicationS to aquatic therapy Aquatic therapy is a treatment modality which centres on the use of water in various forms to add resistance to the body during activity while also encouraging a greater range of motion and decreasing the loading of the body through buoyancy. Although this form of treatment is not new, the development and use of technology has driven its potential application forward. This makes it particularly useful as a modality to be used with injured

The use of aquaTic Therapy in sporTs injury rehabiliTaTion This article aims to inform readers of the basic principles and practices which underpin the use of aquatic therapy as part of an injury rehabilitation programme, and will introduce the common indications and contraindications for the use of this therapy within a patientâ&#x20AC;&#x2122;s ongoing management. The main principles on which aquatic therapy has been developed are described, along with some examples of practical applications, which will allow the reader to take ideas straight from page to pool. patients or individuals who would otherwise be unsuitable for resistance training in traditional land-based settings. It is claimed that aquatic therapy has a number of benefits upon the body including: n Improved muscular strength n Improved muscular tone n Improved muscular activation n Improved joint range of motion n Improved posture n Improved mood state n Improved proprioception n Improved respiratory function

WhIle TRADITIOnAl fORms Of ResIsTAnce TRAInIng ARe OfTen uTIlIseD, The use Of AquATIc TheRAPy mAy OffeR A mORe suITAble AlTeRnATIve ThROugh WhIch TO AchIeve The sAme OuTcOme www.sportEX.net

n n n n

Increased metabolism Decreased swelling Decreased pain Decreased muscle wastage.

Research within this field (1) would suggest that the treatment outcomes possible through the use of aquatic therapy are equal to or, in some cases, exceed those produced through the use of traditional land-based equivalents. Although this would suggest that the use of aquatic therapy, therefore, should be preferred over the use of land-based activities, it should be acknowledged that differences are present in the responses of the body to land-based and water-based activities.

contraindicationS to aquatic therapy While the use of aquatic therapy has been suggested to have many 7

advantages during the rehabilitation of injury (2) there are, as with all treatment modalities, some conditions which would contraindicate its use. These would include: n Waterborne, infectious or contagious diseases n Kidney failure n Open wounds n Abnormal haemodynamics n low vital capacity n fever.

aquatic therapy in reSearch The benefits of aquatic therapy can be separated into three distinct categories; physical, physiological, and psychological. These benefits are commonly associated with the combination of the stability and buoyancy created by the water, the warming effect of the pool and the active nature of the exercise conducted as part of the modality.

improved muscular strength The use of aquatic therapy is thought to create the effect upon the body of increasing the capacity of muscles to produce force and therefore increase the muscular strength of a patient (3). by submerging the body or limbs within water and creating movement, a resistance is applied as the water has to be displaced in order to create movement (4). by adding resistance to an action beyond the normal demands elicited by the resistance created within the â&#x20AC;&#x2DC;normalâ&#x20AC;&#x2122; environment outside of the pool, this is thought to create an overload effect upon the body. This proposed benefit of aquatic therapy has, however, been disputed by lund et al. (5) who suggested that the use of aquatic therapy actually negatively impacted the muscular strength

displayed by participants. It is thought that this reduction in muscular strength is created due to the interaction of increased resistance to movement created by the water being outweighed by the decreased muscular force required to produce movement due to buoyancy (6).

improved muscular tone, improved proprioception and decreased muscle wastage The gains observed in muscular tone and proprioception, and reductions in muscular wastage due to the completion of aquatic therapy are suggested to be associated with the supportive and compressive forces created by the submersion of the body in water (7). The increased levels of application of dynamic forces created by turbulence within the water causes an increased level of stimulation of the mechanoreceptors of the peripheral nervous system (8). by increasing the stimulation of the mechanoreceptors the body increases the natural state of tone within muscles to become more efficient in their reaction to oscillations created by turbulence within the water and therefore becoming a more stable state of balance (4). When the nerves are operating at an elevated level of excitation, the mechanoreceptors provide a larger quantity and better quality of sensory feedback to the nervous system. This allows the body to develop a more accurate evaluation of its current state and location within space and thereby initiate corrective movements to maintain balance more efficiently (8).

improved joint range of motion and decreased swelling The improvement observed in the range of motion exhibited by patients

AquATIc TheRAPy Is A TReATmenT mODAlITy WhIch cenTRes On The use Of WATeR In vARIOus fORms TO ADD ResIsTAnce TO The bODy DuRIng AcTIvITy WhIle AlsO encOuRAgIng A gReATeR RAnge Of mOTIOn AnD DecReAsIng The lOADIng Of The bODy ThROugh buOyAncy 8

completing aquatic therapy and submerged in water is thought to be due to the buoyant nature of the body and the reduced demand placed upon the contractile structures, such as muscles (9). This improvement is similar to those produced through the use of passive movements in place of active movements. The findings of silva et al. (2) would suggest that, due to the distraction of the joint space and reduced loading of the articular surfaces, the increased range of motion possible through the use of the aquatic therapy is particularly beneficial for patients suffering from degenerative or inflamed joints compared to the land-based alternatives. by creating a reduction in the loading of the joints through the buoyancy of the body, the patient is able to articulate surfaces which would normally interact and create pain. The ability of a patient to maintain mobility in the joint and activation of the muscles while minimising the onset of pain would be suggested to allow rehabilitation from injury to occur more quickly (8). This reduction in recovery time could be created by the muscular pump action created by the movement of limbs, the loading effect created by the resistance of the water, the stability offered to the body by the water and the vasodilation created by the warmth of the aquatic therapy pool.

improved posture One of the less published advantages to the use of aquatic therapy is the potential benefits to the posture of patients. Although postural assessment is commonplace within a normal client consultation, the treatment and correction of the postural abnormalities highlighted by these assessments of patients are harder to address. The use of a body of water as part of aquatic therapy provides a supporting structure through which the body is able to return to a more optimal position. The buoyancy of the body when submerged in water allows a reduced demand to be placed upon the body in order to maintain stability and therefore allows the recruitment of damaged or partially healed structures earlier than would be possible using land-based exercise sportEX dynamics 2013;37(July):7-12

EvidEncE informEd practicE

rehabilitation (2). combined with the improved range of motion possible at a joint and reductions in the levels of swelling observed around injuries, this reduces the need for compensatory changes to the posture of a patient, consequently reducing the abnormal loading of the body tissues which commonly create pain or secondary conditions.

demand for oxygen and energy, this stimulates the metabolic reactions to become both more efficient and productive to meet this demand. This increase in activity within the body has been suggested by becker (7) to be observed across a range of the systems of the body including significant increases in cardiac output and stroke volume while significant decreases in heart rate.

improved respiratory function This has been highlighted by the findings of becker (7), which suggested that exercise completed in water is three times more demanding upon the body than the comparative land-based exercise. The more demanding nature of the exercise completed when submerged in water due to hydrostatic pressure has been shown to increase the demands within the body for quantities for oxygen thereby increasing the respiratory functions (10). This increased demand for oxygen and therefore respiratory activity it hampered by the compressive forces exerted by the water upon the chest cavity while submerged. Through the sustained completion of aquatic therapy this increased demand creates an overload affect upon the body and causes the respiratory function to be improved. These observed improvements in respiratory functioning could be suggested to indicate a use of aquatic therapy with patients suffering from reduced respiratory capacity when traditional land-based exercise would be deemed unsuitable or contraindicated.

increased metabolism The rate at which the metabolic reactions occur within the body is influenced heavily by the activity levels of the patient. The use of aquatic therapy therefore has a positive impact upon these reactions. The main mechanism through which this occurs is due to increases in the body’s temperature and is commonly observed within the cells of the skin and muscles which are submerged within the aquatic therapy pool. by then combining this interaction with the completion of exercise and thereby increasing the body’s www.sportEX.net

decreased pain and improved mood state The perception of pain and decreased mood state experienced by patients is often attributed to one of two sources; firstly physical pain created by the damage within the tissues of the body or secondly psychological pain experienced as a result of a negative psychological state. Physical pain can be reduced through the use of aquatic therapy due to a mechanical correction in the state of the body reducing, and ultimately removing the stimulus for the pain (7,11). by removing the mechanical stimulus for pain this will reduce the activity of the nociceptors and thereby reduce the induction of afferent sensory pain messages being sent to the nervous system. The psychological pain experienced by patients, particularly those who are of an athletic nature can also be addressed through the early adoption of aquatic therapy. The completion of exercise, whether through land-based or water-based activities allows a patient to benefit from the perceived reduction in their pain levels. As aquatic therapy allows patients to complete physical activity while their body is still in a state of healing and repair, this allows a quicker return to exercise (9). This attribute of exercise is particularly important when dealing with competitive athletes who are conditioned to perform regularly. The state of inactivity created by injury can produce a cyclic state which negatively reinforces the perceived state of injury which they are suffering and can often result in increased levels of pain. by breaking this cycle the psychological stimulus of inactivity is removed thereby encouraging the patient to heal both physically and psychologically.

Due TO The WIDe vARIATIOn Of use Of The equIPmenT, RehAbIlITATIOn sTRATegIes AnD exeRcIses ARe OfTen Only lImITeD by The cReATIvITy Of The TheRAPIsT’s APPlIcATIOn phySical propertieS of water and how they can be uSed to Support rehabilitation The use of water in rehabilitation often allows patients to perform manoeuvres that they could not perform on land, enhancing a patient’s ability to move through increased ranges of motion and work against resistance based upon the speed of movement through or across the water (12). The physical properties of water that can be used in aquatic therapy to aid rehabilitation include: n hydrostatic pressure n buoyancy n Turbulence n Depth of water.

hydrostatic pressure hydrostatic pressure refers to the pressure created by the weight of water pressing down on an immersed body. The pressure is applied equally in all directions to any solid surface in contact with the fluid, following Pascal’s law (10). The deeper a body becomes immersed in water the greater the hydrostatic pressure experienced. Although hydrostatic pressure plays a small part in the practical application of aquatic therapy, it can generate therapeutic physiological responses. How can this help? The application of hydrostatic pressure helps return blood to the heart, helping it to work more efficiently when exposed to lower pressures. The fluid surrounding the body aids to circulate blood from the extremities to the heart that can be attributed to supporting the reduction of swelling in the extremities (most notably the ankles and feet) (12). 9

A practical application simply being immersed (ie. floating) in water can have therapeutic responses to patients and as such basic activities such as breathing with the trunk immersed can become a resistancebased exercise due to the associated pressure applied by the water to the rib cage. caution should, however, always be taken where respiratory conditions exist with patients.

buoyancy and depth of water buoyancy is generated by the ‘up thrust’ effect of water acting on a body. The principle is based upon Archimedes’ principle that when a body is wholly or partially immersed in a fluid at rest, it will experience a weight loss equal to the weight of the fluid displaced. How can it help? When a patient is immersed in water they are exposed to two opposing forces: n gravity acting downwards n buoyancy acting upwards. These forces can be used to assist in a patient’s rehabilitation by altering their level of equilibrium and stability, providing support or generating resistance (13). buoyancy is of great benefit for any patient that is weight compromised (eg. following joint replacement, major surgery or osteoporosis) as it can reduce the gravitational stress imparted on weak limbs and soft tissues. As a patient becomes further immersed the level of weight bearing reduces by the following estimations: n AsIs – 50% weight bearing (posture controlled by gravity) n xiphoid – 25% weight bearing n c7 – 10% weight bearing (posture controlled by buoyancy). As the water depth increases beyond the AsIs stability and balance becomes progressively harder for patients.

Practical applications Buoyancy resisted exercise – shoulder exercises concentric: Immerse the body part below the water surface (floatation devices are typically required for this). for example, to strengthen the right shoulder adductors hold the float in the right hand, keep the right shoulder immersed and attempt to pull the float down from the surface of the water to the patient’s side (fig. 1). eccentric: Patient controls the speed/ rate at which limb or float returns to the surface of the water. This must be slower than the natural speed that the water wants to return it at. for example, to strengthen the right shoulder adductors, hold the float in the right hand by the side of the body keeping the shoulder immersed in the water. The patient then slowly resists the rate at which the water naturally returns the float to the surface (fig. 2). Buoyancy assisted proprioceptive neuromuscular facilitation (PNF) stretching – hamstring stretch The patient places a buoyancy support (eg. floatation ring, armband) around the ankle and stands with feet together. The patient is instructed to allow the floatation support to rise (keeping the leg straight) until the patient reaches the point of bind. At this point the patient holds the leg in the raised position for 10 seconds. The patient then relaxes and allows the floatation support to rise further to the new point of bind, repeating the process three times (fig. 3).

turbulence Turbulence relates to the random changes in water pressure experienced as an object moves through water. This disturbed area of water is at a low pressure and creates a ‘drag’ to movement, with objects always moving from areas of high pressure to low pressure. The drag effect can be increased via faster movement of the

hyDROsTATIc PRessuRe RefeRs TO The PRessuRe cReATeD by The WeIghT Of WATeR PRessIng DOWn On An ImmeRseD bODy 10

Figure 1: Shoulder adductor concentric exercise using buoyancy.

Figure 2: Shoulder adductor eccentric exercise using buoyancy.

Figure 3: Hamstring PNF stretching using buoyancy.

object that is disturbing the water (eg. the therapist’s hands or kickboard), which results in further lowering of the pressure being exerted on the patient. How can this help? Turbulence can be used to aid movement, disturb balance or create resistance. As such turbulence is a widely used mechanism in aquatic therapy and is effective when seeking to restore function, range of motion and strength within tissues. Practical application To assist movement – hip abduction Patient stands with feet shoulder width apart. The therapist then generates turbulence above the limb, reducing the water pressure in the direction of limb movement. The patient is then instructed to abduct the leg (fig. 4). To resist movement – hip adduction The patient stands with the hip in sportEX dynamics 2013;37(July):7-12

EvidEncE informEd practicE

an abducted position. The therapist generates turbulence above the abducted leg lowering the water pressure above the limb and increasing the pressure (resistance) below the limb. The patient is then instructed to pull the limb down towards the other (standing) leg (fig. 5).

aquatic therapy equipMent available to Support rehabilitation Aquatic therapy equipment can be utilised to aid freedom of movement, assist range of motion, create resistance and challenge or support balance. equipment comes in a variety of forms and in many cases does not require costly expense to either the patient or therapist (fig. 6). Due to the wide variation of use of the equipment, rehabilitation strategies and exercises are often only limited by the creativity of the therapistâ&#x20AC;&#x2122;s application. A range of equipment can be used to: 1. Aid floatation and movement in the water: n Water belts n Arm rings n floatation vests n noodles n Kickboards. 2. Resistance and balance can be challenged with: n Aquatic gloves n Aquatic fins/flippers n Kickboards n foam dumb-bells n hand paddles n noodles. 3. support and protection of patients

can be achieved with: n Wet suits for cold tolerance n sun cream and solar protection if working outdoors n Water shoes for protection against cuts, abrasions or fungal infections.

concluSion While the use of water as part of a treatment programme for injury is not a new modality, the development in technology and underpinning scientific support for its use continue to drive forward. The worth of its inclusion in the treatment of a patient is highlighted by the versatility of the techniques available and the breadth of the scope for its progressive use through the healing processes of a variety of injuries. The limiting factor for the possibilities for the use of aquatic therapy is commonly the imagination of the therapist applying simple theories and knowledge such as the principle of overload training or allowing partial weight bearing activities to be completed by the patient. This practical application can then be supported and supplemented by the availability of specialist aquatic therapy equipment such as endless pools, floats, underwater cardiovascular equipment or weights. This modality therefore lends itself well to the treatment and rehabilitation of most injuries when it is available to a therapist to supplement the use of other treatment modalities to meet the individual needs of their patient.

TuRbulence RelATes TO The RAnDOm chAnges In WATeR PRessuRe exPeRIenceD As An ObjecT mOves ThROugh WATeR

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Figure 4: Hip abduction assisted exercise using turbulence.

Figure 5: Hip adduction resisted exercise using turbulence.

(a)

Figure 6: The aquatherapy pool (a), and a patient benefiting from the use of a noodle (b).

(b)

references 1. geytenbeek j. evidence for effective hydrotherapy. physiotherapy 2002;88(9):514–529 2. silva l, valim v, et al. hydrotherapy versus conventional land-based exercise for the management of patients with osteoarthritis of the knee: A randomized clinical trial. physical therapy 2008;88(1):12–21 3. foley A, halber j, et al. Does hydrotherapy improve strength and physical function in patients with osteoarthritis – a randomised controlled trial comparing a gym based and a hydrotherapy based strengthening programme. annals of the rheumatic diseases 2003;62:1162–1167 4. vaile j, halson s, et al. effect of hydrotherapy on recovery from fatigue. international Journal of Sports medicine 2008;2:539–544 5. lund h, Weile u, et al. A randomized controlled trial of aquatic and land-based exercise in patients with knee osteoarthritis. Journal of rehabilitation medicine 2008;40:137–144 6. lefort s, hannah T. Return to work following an aquafitness and muscle strengthening program for the low back injured. archives of physical medicine and rehabilitation 1994;75:1247–1255 7. becker b. Aquatic therapy: scientific foundations and clinical rehabilitation

applications. american academy of physical medicine and rehabilitation 2009;1(9):859–972 8. beneka A, malliou P, benekas g. Water and land based rehabilitation for Achilles tendinopathy in an elite female runner. British Journal of Sports medicine 2003;37:535–537 9. Kuligowski l, lephart s, et al. effect of whirlpool therapy on the signs and symptoms of delayed-onset muscle soreness. Journal of athletic training 1998;33(3):222 10. cole Aj, becker be. comprehensive aquatic rehabilitation, 2nd edn. Butterworth-Heinemann 2004. Isbn 0750673869 11. Waller b, lambeck j, and Daly D. Therapeutic aquatic exercise in the treatment of low back pain: a systematic review. clinical rehabilitation 2009;23:3– 14 12. henly c, Wollam K. benefits and techniques of aquatic therapy. presented at the 10th international conference of post-polio Health international 2009, Warm Springs, Georgia, USa: Living with polio in the 21st century (http://spxj. nl/14nyuqef) 13. maynard m. foundations in aquatic therapy. course handbook Wellbeing cpd Ltd 2011 (http://spxj.nl/14j4fkw).

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T AuTHors THE Jon Meyler is curriculum team leader for Higher Education sport courses at Moulton College (jon.meyler@moulton.ac.uk). richard Moss is a course manager and lecturer r across the range of HE sports programmes offered at Moulton College. He is also an active BAsraT Executive researcher and sits on the BA Committee as accreditation officer (richard. moss@moulton.ac.uk). Brendon skinner is the course manager for Bsc (Hons) sports Therapy and sports the B Performance and Coaching HE programmes at Moulton College and has been lecturing in sports therapy for 7 years (brendon.skinner@ moulton.ac.uk). n What are the contraindications for the use of aquatic therapy? n What is the principle of turbulence and DISCUSSIONS how is it used in injury rehabilitation? n What is the principle of buoyancy and how is it used in injury rehabilitation? n name three impacts that aquatic therapy can have upon the body.

EvidEncE informEd practicE

by Paula Clayton MSC, Fa DiP, MaSt Stt

yofascial release (MFR) is a form of soft tissue therapy used to treat somatic dysfunction and accompanying pain and restriction of motion. This is accomplished by relaxing contracted muscles, increasing circulation, increasing venous and lymphatic drainage, and stimulating the stretch reflex of muscles and overlying fascia (1).“The fascia is loaded with a constant force in a specific direction until a release occurs, aiming to alleviate problems by breaking up constrictions in the fascia” (2). Myofascial procedures vary significantly, ranging from prolonged stretching and soft tissue mobilisation to subtle, indirect techniques. Such ambiguity is obviously frustrating to the uninitiated clinician, as well as the researcher attempting to quantify

critiquE of fascial rElEasE As soft tissue therapists we are constantly required to provide evidence that what we do actually has some impact on the human body. This article attempts to answer some of those questions. suggested benefits. Most experienced manual therapists readily acknowledge that treatment procedures are inseparable from evaluations. Patient response is constantly monitored and used as an indicator to guide further care. Fascia has been described as the most pervasive tissue in the body, representing a three-dimensional network from head to toe. It forms a true continuity throughout our whole body. This dense, irregular connective tissue surrounds and connects every muscle, even the tiniest myofibril, and every single organ of the body (3). The superficial fascia is attached to the under surface of the skin. Vascular structures, adipose cells and afferent receptors can be found in this layer providing constant conscious and unconscious feedback to the CNS. The deep fascia varies in density, compartmentalising the body, separating and surrounding visceral organs. Subserous fascia, the deepest layer, intimately surrounds and lubricates the internal viscera.

PhySiologiCal ClaiMS Many claims are made about what MFR is and the physiological effects that it can achieve, such as: n Restoration of optimal length of tissue in exact location where abnormal structural thickening is present (4). n Ruptures abnormal cross-linkages between collagen fibres that limit the ability of connective tissue to elongate. Cross linkages form as a result of the inflammatory response to acute or overuse injury (4). n Highly interactive stretching technique (5). n Facilitates maximum relaxation of tight or restricted tissues (5) n Alters density, tonus, viscosity (thixotropy) or arrangement of fascia through the application of manual pressure (6–11). MFR is considered a highly interactive stretching technique that requires feedback from the patient’s body to determine direction, force and duration of the stretch to facilitate maximum relaxation of tight or restricted tissues. How the practitioner understands the nature of this particular responsiveness

MyoFASCIAl THeRAPy IS NoT A CuRReNT FAd IT HAS SIMPly beeN ReCeNTly dISCoVeRed by AlloPATHIC MedICINe VIA THe VeHICle oF PHySICAl THeRAPy. oSTeoPATHIC lITeRATuRe deSCRIbINg MyoFASCIAl ModelS APPeARed IN THe '50s ANd wAS PReCeded by THe CoNTRIbuTIoNS oF elISAbeTH dICke ANd IdA RolF www.sportEX.net

oNly TeNSegRITy, FoR exAMPle, CAN exPlAIN How eVeRy TIMe you MoVe youR ARM, youR SkIN STReTCHeS, youR exTRACellulAR MATRIx exTeNdS, youR CellS dISToRT, ANd THe INTeRCoNNeCTed MoleCuleS THAT CoNSTITuTe THe INTeRNAl FRAMewoRk oF THe Cell Feel THe Pull – All wITHouT ANy bReAkAge oR dISCoNTINuITy of fascia will, of course, influence the treatment. The exasperation of modern scientists when contemplating this phenomenon is readily appreciated. How does one investigate cause and effect when neither intervention nor outcome can be finitely anticipated? does a change occur in the patient’s condition, and, if so, can it be measured and maintained? Myofascial therapy is not a current fad: it has simply been recently rediscovered by allopathic medicine via the vehicle of physical therapy. osteopathic literature describing myofascial models appeared in the 1950s and was preceded by the contributions of elisabeth dicke (connective tissue massage) and Ida Rolf (structural integration).

ClaiMeD bioMeChaniCal eFFeCtS “only tensegrity, for example, can explain how every time that you move your arm, your skin stretches, your extracellular matrix extends, your

cells distort, and the interconnected molecules that constitute the internal framework of the cell feel the pull – all without any breakage or discontinuity” (12). The human structure is held holistically in balance by tension and compression. Structural intervention of whatever sort works through this system as a whole, changing the mechanical relations among a countless number of individual tensegrity-linked structures.

PSyChologiCal eFFeCtS Nathan (13) states that non-verbal communication with the patient treats his/her psyche as well as his/her physical being. The measurable physical changes achieved using MFR are minor when compared to the subjective psychological changes reported by the patient. Nathan goes on to say that this is not a placebo effect, but, rather, a sometimes-profound response to the non-verbal communication of touch.

ReSeaRCh in SuPPoRt oF MyoFaSCial ReleaSe Stretching and applying pressure or tension to fascia stimulates fibroblasts. Fibroblast proliferation in response to changes in applied pressure may provide the initial stimulus for the healing cascade (14). Piezoelectricity (15,16) has been used to explain the plasticity changes occurring following treatment. living organisms and tissue, including fascia, usually have some type of

electrical charge. Mechanical pressure from treatment can either increase or decrease the electric charge, stimulating fibroblasts to produce more collagen fibres and matrix macromolecules in these areas. Shleip (3) also states that fascia is densely innervated by mechanoreceptors which are responsive to manual pressure. MFR is a technique in which the therapist’s hands are used to reestablish motion between fascial planes, reducing fibrous adhesions and re-establishing neural and myofascial glide between tissues. This can easily be misinterpreted as permanent lengthening. Plastic deformation does not take place until the forces within the tissues reach a higher level. Stimulation of sensory receptors has been shown to lead to a lowering of sympathetic tonus as well as change in local tissue viscosity (3) and thixotropic properties (17). According to kruger (17) if the fascial interstitial fibres are strongly stimulated, there will be an extrusion of plasma from the blood vessels into the interstitial fluid matrix. Such a change in local fluid dynamics means a change in the viscosity of the extracellular matrix (eCM), unless irreversible fibrotic changes have occurred or other pathologies exist.

ClaiMeD beneFiCial ReSPonSe to the autonoMiC neRvouS SySteM Following tiSSue ManiPulationS deep mechanical pressure to the human abdominal region (18), as well as sustained pressure to the pelvis, (19) produces parasympathetic reflex responses, including increased activity in vagal fibres (causing local vasodilation) and a decreased eMg (electromyography) activity. Further research suggests activation of the anterior lobe of the hypothalamus results in lower muscle tonus, and a more quiet emotional state (20). Mechanoreceptors also influence local fluid dynamics. during myofascial release, interstitial receptors (which make up the majority of sensory input) activate and trigger autonomic nervous system responses, which change the local pressure in fascial arterioles and sportEX dynamics 2013;37(July):12-17

EvidEncE informEd practicE

capillaries (3). This in turn can cause extrusion of plasma from blood vessels, which can change the viscosity of the eCM (gel-to-sol model). Ruffini endings are also stimulated which lowers sympathetic activity (21). Vagedes (22) and colleagues reported the results of a recently completed clinical trial in relation to low back pain (lbP). This study constitutes so far the largest and most comprehensive randomised clinical trial (RCT) using MFR. Patients – 109 in total – were randomly divided into 4 treatment groups. Treatment of group 1 consisted purely of core stability exercises, group 2 had the same exercises with the addition of deep breathing to increase HR variability,

group 3 were treated with MFR and trigger point therapy, and group 4 had the same treatment combination as group 3 with additional breathing. The results showed that MFR in combination with deep breathing training led to greater improvements than traditional conventional care for lbP and was superior for almost all measures (22). kain et al. (23) compared the use of a hot pack and MFR on increasing range of motion (RoM) of the glenohumeral joint. Significant increases in RoM were found when comparing pre-test scores with post-test scores, and MFR was shown to be as effective as hot packs in increasing RoM.

ReSeaRCh Challenging the eFFeCtS oF MyoFaSCial ReleaSe latridis et al. (24) found a very low, but linear, viscoelastic biomechanical response to applied stress in subcutaneous tissues. Also, Shleip (3) states that the traditional explanations as to the effects of MFR are insufficient. There is a three-dimensional mathematical model for deformation of human fasciae in manual therapy (25). Many therapeutic techniques are based on the stretching of connective tissues, but whether that stretching is greater than the stretching applied in daily life, or whether it is of a normal range applied to tissues that have themselves been subjected to less-than-normal

box 1: this series of images demonstrates a variety of MFR treatments used to influence sacroiliac joint positioning and the correction of anterior iliac rotation. MFR is not used in isolation, but forms part of a range of techniques used by the soft tissue therapist in order to effect change in the local and global tissues when injury or dysfunction is present.

Figure 1: Myofascial release to treat the superficial fascia over the abdominal external oblique muscles. (a)

(b)

Figure 2: Treating the abdominal aponeurosis. (c)

Figure 3a–c: Treating the thoracolumbar fascia and superficial fascia over the latissimus dorsi muscles.

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stresses is not known. Chaudhry et al. (25) state that the palpable sensations of tissue release that are often reported by osteopathic physicians and other manual therapists cannot be due to deformations produced in the firm tissues of plantar fascia and fascia lata. However, palpable tissue release could result from deformation in softer fascial tissues, such as those present in the superficial nasal fascia. Most often a release feels like a smooth melting away of tightness or restriction under the therapist’s hand (26). ward (11) and Hertling (27) suggest that the myofascial release endfeel has a soft rubbery quality. what happens when a practitioner claims to feel ‘tissue release’ under the working hand? we could be talking about short-term plasticity and the influence of strokes between a few seconds to 1.5 min. Therapists are rarely taught to apply uninterrupted manual pressure for more than 2 min, so according to Schliep (3) it becomes very difficult to explain the thixotropic model.

guiDelineS FoR PRaCtiCal aPPliCation The therapist needs to be following the grain of the connective tissue, maintaining a fairly steady direction without jumping joints or levels or crossing through intervening planes of fascia (box 1). Care must be taken to note the attachments where these myofascial tracks tie down to the underlying tissues, diverge or converge with the line in question. Identify underlying single joint muscles that may affect the working of that particular line (28). A useful list of guidelines for the practical application of MFR is: 1. Pay attention – to the tissue and what it is telling you at all times. 2. layering – go in only as far as the first layer that offers resistance; work within and along this layer. 3. Pacing – slow, below the rate of tissue melting. 4. body mechanics – minimal effort on the practitioner – allow tissues to give, no strength needed. 5. Movement – client movement makes myofascial work more effective (Rolf said, “put it where it 16

belongs and call for movement.”) This allows the practitioner to feel which level of myofascia is engaged – increases proprioception from muscle spindles and stretch receptors. 6. Pain – sensation accompanied by patients ‘motor intention to withdraw’ it is a reason to stop, let up or slow down. 7. Trajectory – each move has an arc, beginning, middle and end. each session has an arc and even each movement has an arc. know where you are in these overlapping arcs.

expense of creating a naïve perception of medical omnipotence. Accompanying this reductionistic perspective is an emphasis on pathology (verses the patient) and the Cartesian concept of mind/body dualism. Successes and failures are evaluated via biological outcomes, such as RoM and strength; little is left to mystery or chance. Another unfortunate side effect of this evolution is the tendency for patients to relinquish the responsibility for their health to medical ‘deities’ rather than taking an active role in their own welfare.

DiSCuSSion

References

An infomedical model embraces the complex interactions that constitute nomanalistic diagnoses and treatment. Traditional scientific inquiry is challenged to develop alternative methods of investigating these phenomena, and patients are encouraged to become partners in their own health care. Accountability is directly related to patient care. Nomanalistic diagnoses tend to be multi-dimensional, less readily labelled, and more complex to treat, ie. back pain, sympathetic dystrophy, thoracic outlet syndrome. It is within the context of the infomedical model (appreciation of the interaction of multiple factors in the ultimate presentation of disease, mind body relationships) that myofascial therapy should be most critically examined.

1. digiovanna e, Schiowitz S, dowling d. Myofascial (soft tissue) techniques. In: An osteopathic approach to diagnosis and treatment, 3rd edn. lippincott Williams & Wilkins 2005. ISbN 0781742935 (£65.12) buy from Amazon http://spxj.nl/13Cquwz. 2. kinakin, k. optimal muscle training. Human Kinetics publishers 2004. ISbN 0736046798 (£15.45). buy from Amazon http://spxj.nl/12Q0xul 3. Schleip, R. Fascial plasticity – a new neurobiological explanation Part 2. Journal of Bodywork and movement therapies 2003;7(2):104-116 4. bruckner P, khan k. Clinical Sports Medicine, 3rd edn. mcGraw-Hill 2009. ISbN 0070278997 (£86.36). bu from Amazon http://spxj.nl/117g9Av. 5. Manheim CJ, lavett dk. (2001). the t myofascial release manual, 3rd edn. slack incorporated 2000. ISbN 1556424523 (£143.99). buy from Amazon http://spxj.nl/10fF4mg 6. barnes JF. Myofascial release (The search for excellence: A comprehensive evaluator and treatment approach). rehabilitation services, inc. 1990. ISbN 1929894007 7. Cantu RI, grodin AJ. Myofascial manipulation – theory and clinical application. aspen publications 1992. ISbN 0834203103 (£104.91). buy from Amazon http://spxj.nl/19wAptZ 8. Chaitow l. Soft tissue manipulations. thorsons 1987. ISbN 0722514611. 9. Paoletti S. les fascias: rôle des tissus dans la mécanique humaine. sully 1998. ISbN 2911074106 10. Rolf IP. Rolfing: The integration of human structures. Harper collins 1987. ISbN 0064650960 (£105.11). buy from Amazon http://spxj.nl/10Jx3t7 11. ward RC. Myofascial release concepts. In: basmajian JV, Nyberg R (eds) Rational manual therapies, pp223–241. lippincott

ConCluSion body workers of various experiential and educational backgrounds, ignored and unencumbered by scientific scrutiny, have utilised myofascial concepts for a long time (29). Those with instincts common to both camps will ideally one day bridge the gap between myofascial consumers and myofascial critics. western allopathic medicine as described by Irby in 2011 (30) is based on a biomedical model influenced largely by Newtonian physics, deductive reasoning, and encourages specialisation by advocating the breakdown of complex systems into smaller more manageable units. Advances made utilising this system have been considerable, perhaps at the

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Williams and Wilkins 1993 1993. ISbN 0683004204 (£123.22). buy from Amazon http://spxj.nl/19wbt0o 12. Ingber de. The architecture of life. scientific american 1998;278(1):48–57 13. Nathan b. Touch and emotion in manual therapy. churchill livingstone 1999. ISbN 0443056579 (£9.43). buy from Amazon http://spxj.nl/12HnISH 14. gehlsen gM, ganion lR, Helfst R. Fibroblast responses to variation in soft tissue mobilisation pressure. medicine & science in sports & Exercise, 1999;31:531–535 15. oschmann Jl. energy medicine: the scientific basis, 8th edn. Churchill livingstone 2000. ISbN 0443062617 (£31.67). buy from Amazon http://spxj.nl/12Hny3y 16. Athenstaedt H. Pyrelectric and piezoelectric properties of vertebrates. annals of the new York academy of science 1974;238:68–94 17. kruger l. Cutaneous sensory system. In: Adelman g (ed.) encyclopedia of Neuroscience, Vol 1, pp293–294. birkhauser Verlag 1987. ISbN 3764333332 (£70.39). buy from Amazon http://spxj.nl/14k8ao0 18. Folkow b. Cardiovascular reactions during abdominal surgery. annals of surgery, 1962;156:905–913 19. koizumi k, brooks C. The integration of

autonomic system reactions: a discussion of autonomic reflexes, their control and their association with somatic reactions. Ergebnisse der physiologie, biologischen chemie und experimentellen pharmakologie 1972;67:1–68 20. gellhorn e. Principles of autonomic-somatic integrations: physiological basis and psychological and clinical implications. minnesota university press 1967. ISbN 0816668639 (£45.00). buy from Amazon http://spxj. nl/10fItlt 21. Cabri J, van den berg F. Angewandte physiologie, bd. 1, das bindegewebe des bewegungsapparates verstehen und beeinflussen. Thieme 1999. ISbN 3131160314 22. Vagedes J, gordon MC, et al. Myofascial release in combination with trigger point therapy and deep breathing training improves low back pain. 2nd international fascia research congress, pp248–249. Elsevier 2009 23. kain J, Martorello l, et al. Comparisson of an indrect tri-planar myofascial release (MFR) technique and a hot pack for increasing range of motion. Journal of Bodywork and movement therapies 2011;15:63–67 24. latridis JC, wu J, et al. Subcutaneous tissue mechanical behaviour is linear and viscoelastic under uniaxial tension. connective tissue research 2003;44(5):208–217

n why do you think that fascia has become so widely discussed in the past few years? n based on numerous research articles it appears that deep manual pressure stimulates interstitial and Ruffini DISCUSSIONS mechanoreceptors, which results in an increase of vagal activity. what effect does this have on the body? n In real bodies, muscles hardly every transmit their full force directly via tendons into the skeleton, as is usually suggested by our textbook drawings. Rather, they distribute a large portion of their contractile or tensional forces onto fascial sheets. These sheets transmit the forces to synergistic as well as antagonistic muscles. Thereby they stiffen not only the respective joint, but may even affect regions several joints further away. How do you think this knowledge could impact on your current practice?

25. Chaudhry H, Schleip R, et al. Threedimensional mathematic model for deformation of human fasciae in manual therapy. Journal of american osteopath association 2008;108:379–390 26. greenman Pe. Principles of manual medicine. williams & wilkins 1989. ISbN 0683035568 (£104.95). buy from Amazon http://spxj.nl/14pi20c 27. Hertling d, kessler RM. Management of musculoskeletal disorders. Physical Therapy Principles and Methods, 3rd edn. lippincott williams & wilkins 1995. ISbN 0397551509 (£90.94). buy from Amazon http://spxj.nl/12Hpwl0 28. Myers Tw. Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists, 2nd edn. Churchill livingstone 2008. ISbN 044310283x. buy from Amazon http://spxj.nl/14piT0k 29. Juhan, d. Job’s body: A handbook for bodywork. barrytown ltd 2002. ISbN 1581770995. buy from Amazon http://spxj.nl/19wI0Zv 30. Irby d. educating physicians for the future: Carnegie’s calls for reform. medical teacher 2011;33(7):547–550.

Th AuThor ThE Paula Clayton has been working as a senior performance therapist for the English Institute of Sport and British Athletics since 2003. She has travelled extensively to olympic Games (including 2012), Commonwealth Games, World and European Championships with GB track and field as part of the medical team during this time. Prior to 2003 Paula worked in Premiership and Championship football for 4 years. Paula has taught on two sports therapy degree programmes, written a number of articles and has an MSc in Sports Injury. Paula also delivers soft tissue masterclasses to senior physiotherapists and soft tissue therapists within premiership and championship football clubs, national governing bodies and to soft tissue therapists nationally and internationally through her company STT4Perfomance & Clayton Therapies (www. stt4performance.com). Paula also runs a very successful sports injury clinic private practice (established in 1994) in Shropshire with her husband rick.

CPD MCq queStionnaiRe the quiz FoR thiS aRtiCle iS CalleD: FaSCial ReleaSe CRitique

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The evidence for The use of kinesio Tape An updAte

Kinesiology taping continues to be a very popular treatment approach and there is a growing body of evidence to suggest that it has some positive effects on musculoskeletal conditions. This article is an extension of the piece published in the October 2012 issue, looking at what new evidence has appeared since publication and what conclusions can be drawn. by rIchard Moore bSc

IntroductIon In the October 2012 edition of sportEX dynamics (1) I reviewed the evidence to date for the use of kinesiology tape (KT) in the treatment of musculoskeletal conditions. Ten randomised controlled trials (RCTs) were identified looking at KT in the treatment of a variety of conditions including shoulder impingement, patellofemoral pain, chronic lower back pain, whiplash affected disorder and plantar fasciitis. Although far from conclusive, each of these studies showed some positive effects of KT on soft tissue flexibility, fascia thickness, pain and/or disability. In particular KT appeared to offer similar results to traditional treatments such as soft tissue massage, ultrasound, TENS or home exercise but achieved results faster and with fewer applications, although ultimately final outcomes were often the same. It is the aim of this update to identify any new trails published since the previous review that my help to clarify the efficacy of KT in

the treatment of musculoskeletal conditions.

Method A search within the PubMed database identified nine additional RCTs. Two of these focused on the effects on healthy individuals whereas three more looked at the effects on nonmusculoskeletal conditions; congenital muscular torticollis (2), laproscopic cholecystectomy (3) and rheumatoid hand (4). The remaining four trials will be discussed here.

Shoulder paIn This study by Djordjevic et al. (5) compared KT with mobilisation against a supervised exercise plan for twenty shoulder impingement (SI) sufferers over a ten day period. Significant improvement in pain-free active range of motion was seen in the KT/ mobilisation group at the end of the trial compared with the exercise group. Combining KT with mobilisation makes it difficult to attribute the

ThERE ARE NO SINgulARly CONCluSIvE TRIAl RESulTS 18

sportEX dynamics 2013;37(July):18-19

LiTeraTure review

positive effects to KT alone but does suggest that it could play an effective role in a multi-factored approach to SI. Three previous trials (6–8) identified some positive effects from the use of KT in treating SI, particularly in the short term, although long-term results were similar when compared to home exercise programmes. This study offers some additional weight to the use of KT in SI but the small experimental group and lack of specificity make these findings less than conclusive.

MedIal epIcondylItIS To assess the validity of KT in the treatment of baseball players with medial epicondylitis (ME), this study by Chang et al. (9) took ten symptomatic and seventeen healthy individuals and tested under three conditions: no tape, placebo tape and KT. Outcomes measured were wrist flexor strength, related/absolute force sense errors and pain tolerance. No significant improvements were seen in wrist flexor strength or related force sense errors in either group under any conditions. Absolute force sense error and tolerance of pressure pain did show positive effects but under both KT and placebo taping conditions. Therefore the positive effects cannot be assigned to KT specifically but the therapeutic value of tape in the treatment of ME does warrant further investigation.

MechanIcal neck paIn In this study by Saavedra-hernández et al. (10), eighty patients with mechanical neck pain were assigned to receive either cervical manipulation or application of KT with pain, disability and cervical range of motion (ROM) recorded at baseline and after one week by an assessor blinded to allocation. Both groups demonstrated improvements in pain and disability, beyond minimum clinically relevant levels, and ROM was improved in both groups, with rotation most improved in the manipulation group. The lack of a control group makes it difficult to identify any results beyond those expected naturally over time but the trial does suggest that KT could be a safer, less controversial treatment protocol than cervical spine manipulation, when looking at pain and disability. www.sportEX.net

neck and lower back paIn Rather than focusing on a single complaint, this study by Karatas et al. (11) used KT to treat both lower back pain and neck pain on a cohort of 32 surgeons. The visual Analogue Scale (vAS) alongside Oswestry low Back and Neck Disability Indexes were used both before and after KT application on days 1 and 4 to assess the effects on daily activities. Positive effects were seen on both lower back and neck pain and range of motion after KT application. A lack of control or comparison group is a fundamental flaw in this study design.

concluSIon Although four additional trials have been identified, none offer particularly strong evidence for the efficacy of KT in treating shoulder impingement, medial epicondylitis, mechanical neck or lower back pain. Study design is often poor with either a lack of a control group or combined treatment protocols, making any positive results difficult to accurately attribute to KT. That said, this brings the total to fourteen trials investigating the use of KT for a variety of musculoskeletal conditions and although none alone offers particularly conclusive outcomes, when taken together there is a growing body of evidence to suggest that KT does have a place in the treatment room, alongside more established treatment approaches, although larger studies with a stronger design are clearly required.

BuT ThERE IS A gROWINg BODy Of EvIDENCE SuggESTINg POSITIvE EffECTS (2012) Mobilization with movement and kinesiotaping compared with a supervised exercise program for painful shoulder: results of a clinical trial. Journal of Manipulative and physiological Therapeutics 2012;35(6):454–463 6. hsu y, Chen W, et al. The effects of taping on scapular kinematics and muscle performance in baseball players with shoulder impingement syndrome. Journal of electromyography and kinesiology 2009;19:1092–1099 7. Thelen M, Dauber J, Stoneman P. The clinical efficacy of kinesio tape for shoulder pain: A randomized double-blinded, clinical trial. Journal of orthopaedic & sports physical Therapy 2008;38(7):389–395 8. Kaya E, Zinnuroglu M, Tugcu I. (2010). Kinesio taping compared to physical therapy modalities for the treatment of shoulder impingement syndrome. clinical rheumatology 2010;30(2):201–207 9. Chang hy, Wang Ch, et al. Could forearm Kinesio Taping improve strength, force sense, and pain in baseball pitchers with medial epicondylitis? clinical Journal of sports Medicine 2012;22(4):327–33 10. Saavedra-hernández M, CastroSánchez AM, et al. Short-term effects of kinesio taping versus cervical thrust manipulation in patients with mechanical neck pain: a randomized clinical trial. Journal of orthopaedic & sports physical Therapy 2012;42(8):724–730 11. Karatas N, Bicici S, et al. The effect of Kinesiotape application on functional performance in surgeons who have musculo-skeletal pain after performing surgery. Turkish neurosurgery 2012;22(1):83–89.

references 1. Moore R. What is the current evidence for the use of kinesio tape? sporteX dynamics 2012;34:24–30 2. Öhman AM.The immediate effect of kinesiology taping on muscular imbalance for infants with congenital muscular torticollis. physical Medicine & rehabilitation 2012;4(7):504–508 3. Krajczy M, Bogacz K, et al. The influence of kinesio taping on the effects of physiotherapy in patients after laparoscopic cholecystectomy. The scientific world Journal 2012;2012:article id 948282 4. Łuniewski J, Bogacz K, et al. The use of kinesiology taping method in patients with rheumatoid hand--pilot study. ortopedia, traumatologia, rehabilitacja 2012;14(1):23–30 5. Djordjevic OC, vukicevic D, et al.

ThE AuThors Th richard Moore, Bsc (hons) osteopathy, is a r registered osteopath based in Nottingham. h he has worked with athletes and non-athletes alike and has been using kinesio tape since 2011, having trained under sportTape, Kinesio uK and rockTape. www. mooreosteopathy.co.uk

DISCUSSIONS

n When is it appropriate to consider KT? n What outcome measures should be used? n how does KT interact with other treatment approaches?

MaxiMising your gluteus – Part 2 Many athletes and patients attend the clinic every day with pain somewhere in their body. The question the therapist needs to ask is, ‘Can the gluteal muscles be partly or wholly responsible for the pain that the patient is presenting with?’ If the answer is yes, then we need to know why this muscle group, out of all the other muscles we have in the body, might be the key to the problem. This article is split into two parts. Part 1, presented in January’s issue, discussed the functional anatomy of the gluteus maximus and described how to identify if weakness or misfiring of the muscles is responsible for the athletes problems. Part 2, presented here, discusses how to correct the misfiring and to re-educate the firing of the Gmax by looking specifically at the antagonistic muscles that become adaptively shortened. Once this process is understood I will then explain and demonstrate using advanced soft-tissue techniques that I use to help correct the malalignment of the pelvis and lumbar spine through the treatment of the soft tissues.

by John Gibbons bsc (osT), Adv dip Rem mAssAGe

et’s recap for a moment and think back to Part 1 of this article, where I suggested that the physical therapist should ask themselves if the patient’s pain is purely a ‘symptom’ or whether it is the actual ‘cause’, before rushing in to treat the area of pain. Remember Dr Ida Rolf (founder of the technique ‘Rolfing’) who stated ‘where the pain is the problem is not’, in my experience this is more often or not true. Think back to Part 1: an athlete can present with any of the following symptoms: n Tight/painful hamstrings or lumbar erector muscles n Insufficient forward or upward power production from the legs n Pelvic position dropped when running n Tight/painful adductor magnus (inner thigh)

n Asymmetrical body orientation n Better balance one side than the other n Excessively tight latissimus dorsi on the contra-lateral side to the weak, misfiring Gmax. A likely cause for the athlete’s symptoms, as previously discussed, could well be gluteus maximus (Gmax) weakness or delayed timing due to the misfiring sequence. This article will focus on ‘maximising’ the ‘gluteus’ through a treatment perspective using muscle energy techniques (METs) to lengthen the shortened and tight antagonistic muscles that are potentially causing the weakness inhibition to the gluteus. Hopefully after reading Part 1 you will have a better understanding of the role of the Gmax in terms of its function and the effect it potentially has on all areas of the body if the Gmax is found to be weak or misfiring. In Part

1, I looked specifically at a case study of a 24-year-old elite rower, focusing on his weak and misfiring Gmax. Now, we will look at how to correct the misfiring and to re-educate the firing of the Gmax by looking specifically at the antagonistic muscles that become adaptively shortened. Once this process is understood, the advanced soft-tissue techniques that were used to correct the mal-alignment of the pelvis and lumbar spine will be explained and demonstrated.

WhAT ARe muscLe eneRGy Techniques? METs are an additional tool for the physical therapist’s manual-therapy toolbox: this advanced soft-tissue technique can help to release and relax muscles, and also stimulate the body’s own healing mechanisms. METs are unique in their application, as the patient provides the initial effort while the physical therapist facilitates the

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A TIGHT MuSClE WIll Pull THE JOINT INTO A DySFuNCTIONAl POSITION AND THE WEAk MuSClE WIll AllOW THIS TO HAPPEN

process. The primary force originates from the contraction of soft tissue; this force is then used to assist and correct the presenting musculoskeletal dysfunction. One of the main uses of these methods is to normalise joint range of motion (ROM), rather than increase flexibility, and METs can be used on any joints with restricted ROM that are identified during the subjective passive assessment.

benefiTs of meTs Restoring normal tone in hypertonic (short/tight) muscles cell body of sensory neuron Afferent impulses from stretch receptor to spinal cord muscle spindle

interneuror efferent impulses cause contraction of the stretched muscle that resists/reverses the stretch efferent impulses inhibit contraction of agnostic muscles (reciprocal inhibition)

Figure 1: Reflex arc and reciprocal inhibition.

prolonged stretch will cause impulses from the afferent fibre from the golgi tendon organ

Physical therapists regularly use METs to try to help relax the hypertonic shortened muscles. If a joint has limited ROM, then, through the initial identification of the hypertonic structures, appropriate techniques can assist in reaching normality in the tissues. METs applied in conjunction with massage therapy can be very beneficial in helping to achieve this relaxation effect.

strengthening weak muscles METs can be used to help strengthen weak, or even flaccid, muscles: the client is advised to contract the muscle classified as weak against a resistance applied by the therapist (isometric contraction). Timing of techniques can be varied: for example, the patient resists the movement to approximately 20–30% of their capability for 5 to 10 seconds, rests for 10 to 15 seconds, and then repeats the process five to eight times. This can be improved over time.

preparing muscle for subsequent stretching interneuror impulses from the efferent fibre will cause a relaxation effect into the muscle (piR) efferent fibre to antagonistic muscle causing inhibition (Ri) quadriceps (extensors) hamstrings (flexors)

Figure 2: post-isometric relaxation.

In some circumstances, the sport in which a client participates may affect joint ROM. Most people can benefit from improved flexibility, and, although the focus of METs is to reach normal ROM, a more intensive MET approach can be employed to improve flexibility beyond this. The procedure might involve the client contracting beyond the standard 10–20% of the muscle’s capability. Once METs have been incorporated into the treatment plan, a flexibility programme could follow.

improved joint mobility One of my favourite sayings when I

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teach muscle testing courses is: ‘A stiff joint can cause a tight muscle and a tight muscle can cause a stiff joint’. Does this not make perfect sense? When used correctly, METs can improve joint mobility even when the muscles are relaxing initially. A relaxation period follows the muscle contraction, which then helps to achieve the new ROM.

physioLoGicAL expLAnATions foR The effecTs of meTs Two distinct physiological processes can explain the main effects of METs; these are post-isometric relaxation (PIR) and reciprocal inhibition (RI). Certain neurological influences occur during METs, but before considering PIR/RI, it is useful to take into account the two types of receptors involved in the ‘stretch reflex’ (Fig. 1), which are: n Muscle spindles sensitive to change in length and speed of change in muscle fibres n Golgi tendon organs that detect prolonged change in tension. Stretching a muscle causes an increase in the impulses transmitted from the muscle spindles to the posterior horn cell (PHC) of the spinal cord. In turn, the anterior horn cell (AHC) transmits a greater number of motor impulses to the muscle fibres, which creates a protective tension to resist the stretch. However, increased tension maintained for a few seconds is sensed within the Golgi tendon organs, which transmit impulses to the PHC and have an inhibitory effect on the increased motor stimulus at the AHC. This inhibitory effect causes a reduction in motor impulses and consequent relaxation (Fig. 2). The net effect is that the prolonged muscle stretch will increase overall stretching capability due to the protective relaxation of the Golgi tendon organs overriding the protective contraction. However, a fast stretch of the muscle spindles will cause immediate muscle contraction and – if not sustained – there will be no inhibitory action. When an isometric-contraction prolonged stretch is sustained, neurological feedback through the 21

spinal cord to the muscle itself results in PIR, causing a reduction in tone of the contracted muscle. This lasts for approximately 20 to 25 seconds, during which the tissues can be more easily manipulated to a new resting length (Fig. 2). During RI (Fig. 1), the reduction in tone relies on the physiological inhibiting effect on antagonists during the contraction of a muscle. When the motor neurons of the contracting agonist muscle receive excitatory impulses from the afferent pathway, the motor neurons of the opposing antagonist muscle receive inhibitory impulses from their afferent pathway. It follows that contraction or an extended stretch of the agonist muscle must elicit relaxation or inhibit the antagonist, and that a fast stretch of the agonist will facilitate a contraction of the antagonist. The refractory period also lasts for approximately 20 seconds but, with RI, it is thought to be less powerful than PIR. In certain circumstances, use of the agonist may be inappropriate due to pain or injury.

meThod of TReATmenT The following list defines the method of treatment: n The therapist guides the muscle to the point of resistance (point of bind), before releasing slightly from that position (especially if the tissue is tender). n Against a resistance, the patient isometrically contracts the affected muscle (PIR) or the antagonist (RI) to approximately 10â&#x20AC;&#x201C;20% of its strength capabilities. n The patient holds the contraction for 10 to 12 seconds. n By taking a deep breath in, the patient relaxes fully and, as they breathe out, the therapist passively guides the specific joint that lengthens the hypertonic muscle into a new position, effectively normalising joint ROM. n The process is repeated until no further progress is made (normally three to four times), and the final stretch is held for approximately 20 to 30 seconds. METs are quite a mild form of stretching when compared to other 22

Origin Psoas major: transverse processes of all lumbar vertebrae (l1-l5). Bodies of twelfth thoracic and all lumbar vertebrae (T12-l5). Intervertebral discs above each lumbar vertebra. Iliacus: superior two-thirds of iliac fossa. Anterior ligaments of the lumbosacral and sacroiliac joints.

psoas major origin

iliacus

Insertion lesser trochanter of femur. Action Main flexor of hip joint and assists in lateral rotation of hip. Acting from its insertion, flexes the trunk, as in sitting up from the supine position. Lesser trochanter insertion

Nerve Psoas major: ventral rami of lumbar nerves (l1, l2, l3, l4). Iliacus: femoral nerve (l1, l2, l3, l4).

Figure 3: The psoas and iliacus.

techniques, such as proprioceptive neuromuscular facilitation (PNF); METs are, therefore, more appropriate for rehabilitation. Most conditions involving muscle shortening will occur in postural muscles, since they are composed predominantly of slow-twitch fibres, so a milder form of stretching is perhaps more suitable. The focus of this article is to identify relative shortness and subsequent tightness patterns within soft-tissue structures, ie. specific muscles that are prone to shortening and becoming tight that can cause a weakness inhibition to the Gmax. Part 1 discussed why the Gmax muscles can become lengthened and weakened, and the answer is not to strengthen the so-called weak Gmax muscle, since encouraging strength-based exercise will not assist these specific muscles in regaining their muscular strength as they are held in a weakened position by the short and tight antagonists. The treatment is to lengthen these tight structures by using specific METs. As the Gmax is a powerful hip extensor, the antagonistic muscles are the hip flexors â&#x20AC;&#x201C; the main muscles

Figure 4: The knee is below the level of the hip, indicating a normal length of the psoas.

Figure 5: A tight right iliopsoas.

A STIFF JOINT CAN CAuSE A TIGHT MuSClE AND A TIGHT MuSClE CAN CAuSE A STIFF JOINT sportEX dynamics 2013;37(July):20-27

evidence bold based head light practice head

The following muscles are antagonists to the Gmax and will be discussed in this article (there are other associated muscles, however, they will not be covered here): n Psoas and Iliacus n Rectus femoris n Adductors.

psoAs And iLiAcus The anatomy The anatomy of the psoas and iliacus is shown in Figure 3.

Assessment of iliopsoas – modified Thomas test

Figure 6: Abduction to indicate tight adductors.

Figure 7: Adduction to indicate tight tensor faciate ligament/iliotibial band.

responsible for hip flexion being the psoas, rectus femoris and adductors. One way of encouraging a correct firing pattern is to identify the length of the hip flexors: if they are tested as short, an MET can be used to assist in normalising the resting length of these shortened structures. This theory of lengthening the shortened structures can be applied for a period of approximately two weeks. If the firing pattern has not improved in this twoweek period, strengthening protocols for the Gmax can then be incorporated into the treatment plan. www.sportEX.net

From this modified Thomas position, the therapist looks at where the patient’s right knee lies, relative to the right hip. The position of the knee should be just below the level of the hip, which will indicate a normal length of the iliopsoas. In Figure 5 the therapist is demonstrating with their arms the position of the right hip compared to the right knee. you can see that the hip is held in a flexed position, which confirms the tightness of the right iliopsoas in this case. A tight rectus femoris is also demonstrated here as the lower leg is seen to be held in an extended position. I will cover this muscle later in the article. Also from the position of the modified Thomas test, the therapist can apply an abduction of the hip, as demonstrated in Figure 6, and an adduction of the hip, as demonstrated in Figure 7. A ROM of 10–15° in both planes is commonly accepted to be normal from the modified Thomas position. If the hip is restricted in abduction, ie. a bind occurs at an angle less than 10–15°, the muscles of the adductor group are held in a shortened position; if the adduction movement is restricted, the iliotibial band (ITB) and the tensor facia ligament (TFl) are held in a shortened position.

meT treatment of iliopsoas The patient adopts the same position for the test as described earlier. After placing the patient’s foot into their side, the therapist applies a pressure that induces full flexion of

Figure 8: The patient flexes their right hip against the therapist’s resistance. The therapist is stabilising the right hip with their right hand.

Figure 9: The therapist passively extends the hip to lengthen the iliopsoas, assisted by gravity.

Figure 10: From the flexed position, the patient is asked to resist hip flexion.

Tip The psoas major is also known as filet mignon, which is a piece of beef taken from the tenderloin. A bilateral shortness of the psoas can cause the pelvis to anteriorly tilt and cause the lumbar spine to adopt a position of hyperlordosis. This can cause compression of the facet joints and the patient will present with lower back pain.

the patient’s left hip. Stabilising the patient’s right hip with their right hand, the therapist puts their left hand just above the patient’s right knee. The patient is asked to flex their hip against a resistance for 10 seconds, as shown in Figure 8. After the isometric contraction and on the relaxation phase, the therapist slowly applies a downward pressure. This will cause the hip to passively go into extension and will cause a lengthening of the right psoas, as shown in Figure 9. Gravity will also play a part in this technique, as it will assist the lengthening of the iliopsoas. An alternative way of contracting the iliopsoas is possible from the flexed position shown in Figure 10. This is normally used if the original way of activating the iliopsoas causes discomfort to the patient. Allowing the hip to be in a more flexed position will slacken the iliopsoas – this will assist in its contraction and help reduce the discomfort. The patient is asked to flex their hip against a resistance applied by the therapist’s left hand, as shown in Figure 10. After a 10-second contraction, on the relaxation phase the therapist lengthens the iliopsoas by taking the hip into an extended position, as demonstrated in Figure 9. Note If full sit-ups are performed on a regular basis, the psoas muscle is predominantly used. Repeated situps will make the psoas stronger and tighter, and result in weakness of the abdominals; this can maintain a patient’s lower back pain as discussed in Part 1. To prove the involvement of the psoas, have your patient lie on their back with their knees bent. Hold the patient’s ankles and ask them to dorsiflex their ankles while you resist the movement. This will stimulate the anterior chain musculature, including the psoas, which is part of this chain. The patient then performs the sit-up movement (most fit individuals will be

Origin Straight head (anterior head): Anterior inferior iliac spine. Reflected head (posterior head): Groove above acetabulum (on ilium). Insertion Patella, then via patellar ligament to tuberosity of tibia. Action Extends the knee joint and flexes the hip joint (particularly in combination movements, such as in kicking a ball). Assists iliopsoas in flexing the trunk on the thigh. Prevents flexion at knee joint as heel strikes the ground during walking. Nerve Femoral nerve (l2, l3, l4). Figure 11: Rectus femoris.

able to do many sit-ups). To deactivate or switch off the psoas, we ask the patient to plantar flex their ankles (instead of dorsiflexing them), or to squeeze their gluteals. Either of these actions stimulates the posterior chain musculature, causing the psoas to switch off, as activation of the gluteal muscles results in a relaxation of the psoas through reciprocal inhibition. When the patient is now asked to perform the sit-up, the movement will prove to be impossible, confirming that the psoas is generally the prime mover in a full sit-up.

RecTus femoRis The anatomy The anatomy of the rectus femoris is shown in Figure 11.

Assessment of rectus femoris – modified Thomas test

Figure 12: The knee is held in extension, indicating a tight rectus femoris.

This test is an excellent way of identifying shortness not only in the rectus femoris but also in the iliopsoas as described earlier. The patient adopts the position demonstrated in Figure 12, where they are holding onto their left leg initially, as the right rectus femoris will be tested first. In Figure 12, the therapist demonstrates the position of the right knee compared to the right ankle. Here, the lower leg is seen to be held in an extended position, which confirms the tightness of the right rectus femoris. In Figure 12, you will also notice that the hip is held in a flexed position. This indicates a tightness of the iliopsoas and has already been discussed.

meT treatment of rectus femoris The patient is asked to adopt a prone position, and the therapist passively flexes the patient’s right knee until a bind is felt. At the same time, the therapist stabilises the sacrum with their right hand, which will prevent the pelvis from rotating anteriorly and stressing the lower lumbar spine facet joints (Fig. 13). Note If you consider the patient to have an increased lumbar lordosis, a pillow can be placed under their stomach (Fig. 13). This will help flatten the lordosis and can help reduce any potential

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discomfort that they might experience. From the position of bind, the patient is asked to extend their knee against a resistance applied by the therapist as seen in Figure 13. After a 10 second-contraction, on the relaxation phase the therapist encourages the knee into further flexion, which will lengthen the rectus femoris (Fig. 14).

Figure 13: The patient extends their knee while the therapist stabilises the lumbar spine.

Figure 14: Lengthening of the right rectus femoris.

Alternative meT treatment of rectus femoris based on the modified Thomas test Some patients may find that the previous MET for the rectus femoris puts a strain on their lower back. An alternative and possibly a more effective MET for the rectus femoris is based on the modified Thomas test position. The patient adopts the position of the modified Thomas test as described earlier. The therapist controls the position of the patient’s right thigh and passively flexes their right knee, slowly, towards their bottom (Fig. 15). There will be a bind very soon from this position, so take extra care when you are performing this technique for the first time. From the position of bind, the patient is asked to extend the knee against a resistance applied by the therapist as seen in Figure 15. After the 10-second contraction, on the relaxation phase the therapist passively takes the knee into further flexion (Fig. 16). This is a very effective way of lengthening a tight rectus femoris.

Tip Figure 15: The therapist palpates the rectus femoris, and the patient is asked to extend their knee.

bilateral hypertonicity of the rectus femoris will cause the pelvis to adopt an anterior tilt, resulting in lower back pain due to the fifth lumbar vertebra facet joints being forced into a lordotic position.

AdducToRs The anatomy The anatomy of the adductors is shown in Figure 17.

Figure 16: The therapist passively flexes the knee to lengthen the rectus femoris.

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adductors with their right hand (Fig. 18). When they feel a bind, the position is noted; the normal ROM for passive abduction is 45°. If the range is less than this, a tight adductor group is indicated. However, there is an exception to the rule. If the ROM is less than 45°, it could be that the medial hamstrings are restricting the movement of passive abduction. To differentiate between the short adductors and the medial hamstrings, the knee is flexed to 90° (Fig. 19); if the range now increases, this indicates shortness in the medial hamstrings. So to recap, to identify if the hamstrings are the restrictive factor, the therapist passively flexes the knee and then continues with the passive abduction, as shown in Figure 20. If the range of motion improves, the hamstrings are the restrictive tissues and not the short adductors. Note The term short adductors refer to all of the adductor muscles that attach to the femur, the exception being the gracilis. This muscle attaches to a point below the knee, on the pes anserinus area of the medial knee, and acts on the knee as well as the hip.

meT treatment of adductors One of the most effective ways of lengthening the adductors (short) is to use an MET from the position that is demonstrated in Figure 20. The patient adopts a supine position with knees bent and heels together; slowly, the hips are passively taken into abduction by the therapist until a bind is felt in the adductors. From the position of bind, the patient is asked to adduct their hips against resistance applied by the therapist, to contract the short adductors as seen in Figure 20. After a 10-second contraction, on the relaxation phase the hips are then passively taken into further abduction by the control of the therapist.

Assessment of adductors – hip abduction test

cAse sTudy concLusion

The patient adopts a supine position on the couch. The therapist takes hold of the patient’s left leg and passively abducts the hip while palpating the

If you remember from the case study in part 1, the athlete demonstrated some of the exercises he was doing in his strength training programme. His 25

Origin Anterior part of pubic bone (ramus). Adductor magnus also has its origin on the ischial tuberosity. Insertion Whole length of medial side of femur, from hip to knee. Action Adduct and medially rotate hip joint. Nerve Magnus: Obturator nerve (l2, l3, l4). Sciatic nerve (l4, l5, S1). Brevis: Obturator nerve (l2, l3, l4). Longus: Obturator nerve (l2, l3, l4). Figure 17: Adductors.

Tip overactivity of the adductors will result in a weakness inhibition of the abductors, in particular the gluteus medius (Gmed). This weakness can result in what is known as a ‘Trendelenburg’ pattern of gait.

Figure 19: The knee is bent to isolate the short adductors.

Figure 20: The patient adducts their legs against the therapist’s resistance.

Figure 18: The therapist abducts and palpates the adductors for bind.

knees medially deviated on a squat and a lunge and he looked generally unstable throughout the movement pattern. His Gmax when tested was also found to be misfiring with over activity compensation in his hamstrings and ipsilateral lumbar erectors. This increased compensatory pattern was more than likely to be the culprit of his presenting symptoms. I treated the patient with two sessions a week of physical therapy focusing on lengthening the shortened tight muscles of the psoas, rectus femoris, adductors with METs, and I also focused on treating the lumbar spine erector muscles with specific soft-tissue techniques (massage) work to help release and relax these shortened tissues. I also advised the practice of some basic stretching of the shortened muscles on a daily basis. After two weeks I decided to reassess the hip extension firing pattern and the length of the shortened

muscles. I was very happy to find that the Gmax was showing signs of switching back on in the correct order as explained in Part 1. It was not yet a perfect firing system but I was pleased that there was an initial improvement in his firing sequence and that the hamstrings were not as active as previously tested. The psoas, adductors and rectus femoris also showed improvement in their overall resting length. The athlete was advised to supplement full abdominal curls with anterior and posterior oblique sling exercises using a pulley system, as these are more functional towards abdominal and outer core stability training. After 4 weeks the patient, when reassessed, had a normal hip extension firing pattern and improved length of the muscles, but as there was still room for improvement he was advised to maintain the lengthening exercises

AFTER TWO WEEkS I REASSESSED THE HIP ExTENSION FIRING PATTERN AND THE lENGTH OF THE MuSlCES. I WAS vERy HAPPy TO FIND THAT THE GMAx WAS SHOWING SIGNS OF SWITCHING BACk ON, IN THE CORRECT ORDER sportEX dynamics 2013;37(July):20-27

evidence based practice

as shown. His squat and lunge had better control with no knee deviation. Once these musculoskeletal mechanisms have been implemented he was then recommended to add Gmax exercises into his weekly training programme, as the Gmax and Gmed

work synergistically together as a team. I still see Mr Fit on a regular basis but this time when we do meet up, it is for a social event rather than him popping in to my clinic for a treatment…

John Gibbons, BSc (OST), is a qualified and registered osteopath and specialises in the assessment, treatment and rehabilitation of sport-related injuries. Having lectured in the field of sports medicine and physical therapy for over 12 years, John delivers advanced therapy training to qualified professionals within a variety of sports via his company www.johngibbonsbodymaster.co.uk. He has written many articles on various aspects of physical therapy, which have been published through many international publications. John has also written the highly successful book called ‘Muscle Energy Techniques, a practical guide for physical therapists’. He is in the process of writing his second book, which is due for publication in early 2013; the book is called ‘Maximizing your Gluteus, a practical guide for physical therapists’.

DISCUSSIONS

Figures reproduced with permission from lotus Publishing, and taken from Muscle Energy Techniques: a Practical Handbook for Physical Therapists, ISBN 978 1 905367 23 8. (£12.79) Buy from Amazon http://spxj.nl/vi4JHP

n Discuss how an athlete can present with any of the following symptoms through weakness or misfiring of their glutei: – Tight/painful hamstrings or lumbar erector muscles – Insufficient forward or upward power production from the legs – Pelvic position dropped when running – Tight/painful adductor magnus. n Discuss the benefits of Muscle Energy Techniques (METs) and explain the difference between PIR and RI. n Discuss the origin, insertion, action and nerve innervations of the following muscles: – Psoas – Rectus femoris – Tensor fascia latae – Adductor magus – Gluteus maximus – Gluteus medius.

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The ent ogn is speci into five - ition ility, change to the sac rec distri ction of the spine is two-f is sectio alised butio ro-iliac spina s. This of fem a rarely n Cerv n of old: to perfo ns, each their join the spina l cord of twhich injury relati ero rm differe join and follo article n Thoraical l nerve with 2) Supp ve segm nt roles reviews t and surr -acetabular joint, at (see ents By roots ws n Lumb cic : and skull ort of the and limbs box Dr Simoto least ounding imp the ar trunk at the the same on n Kay,n Sacra , uppe allow musclesingemen r limbs ing locomthe pelvis form anatom end of l nGP t and ntr andintr Cocc otion , the lower oDu o the artic at as pre y and func Most ygea and use The hip, limbs, ctio l. of the situatio below tion viou le for of the most n probl due to relate cerv armsly rarely more s articles of the hip n the high to the emsa desc to its ical injure . dueThe head latter With ribed in this informa d joint, stabi covered proportion anatom cervi functthe furthe at least callityspine series is tion). aceta ion. recognition supp r stabi by the aceta of femo The verte y ort acute bular ral is lised conn desig ly. impin bulum femo the skull ofofthe to the brae by a nedective embr geme ro, is are and allow labru sacro yolog deep to tissue nt andskull for musc -iliac vision Sacr ical perspcomplex. en the , acting m of thick from purpo posit um les, joint andofheari injurie three aceta ses of The ioning and surro ective From anthe situat cervi centr bulum to further 8 and , theyThe funct good neutr cal verteundinng.s The with ion es 15 years which supp devel ion chan anato spo the neck al position (figs.1-2). ges. braeg have two uppe ilium fuse ort of op of the mica of age. rTs slight of the betw the rmos of the lly the hip evolv inju Thepartic ly poste t hip femu to differently, acetaed verteularlyeen trunk on firstisverte ries r proje is sepathe limbs allow a wholebrae durin bra (Atlas the body diag bulum riorly and are g locom acet cted rate latera nos . range , abulu from of ) has and otion stand lly from is & m . Howethe first LiGa beco ing, walki of move has fused trea the me kickin tme nt ng, runni ments includtoverthe vertebralmen g neck Whils ring tS seco ng, ing or lesse all involve nd t stand femu of the the hip, jumping held vertebra ing, the r amou r degrees tightly to great and nt depe key ligam into the head of the er nding multip of time that on the les of the 1. Ischio ents (fig.3) acetabulum femur is body whils -femoral : by three t stand weigh hip bears 2. Ilio-fe all or t. For ing the appro ligam exam xima hips 3. Pubo moral ligam ent tely will trans ple howe ent femo ischi ver durin half theBy ral ligam um Dr Simomit jump Thes g runni body -weig n ing, ent. e ligam effec ht, Kay be 400- the weigh ng, hurdl t of gravi ents tighte Femu ing or intr t throu ntr r 500% witho ty, allow n with oDu gh o ut a of body The the ctio the ing us The shoul great weigh derhip may n Although and the transmissi use of to there on us musc stand the most aroun trans with t. of huge Pubis is throu le fer a d a powe wide of powe gh weigh gene r. muscle the hip, the large mass range flexib rating ts, mean muscles of motio lejoint of musc with is forof the prime fromUnforr to the powe s the trunktunat leg r move Simila body purpose n the locom le stable that if the 180 degreAC joint ely this ment rlyofthe hip wasn , then and highto leg, uppe otionprovid and stern , not ing of this n stabi s like mobi the pubic occu disru es of stabi injury From throw lityr limb r far ptionand ’t inher as well lity. come symp stren poten lity ing, of the 150 degre abduction o-manubria more of move ently SI joints as tial. This gthsand at the hysislifting often detailthe joint abdu ment l move spo es onwa ction/ and . s of the facet expe reliesand would article oppo rTs ment ed BoneS flexio nse of on carry ligaming. T1-3. to inJu shoul s. briefly sition tissue look at the n is achie rds and great achie ries instab ent der befor anD review of the The hip ve struc diagn jointility ved with er than Obse tures s join some diag Sacr rvatio makin osis of injurie e going into the anato is one i.e. the femo 180 degre nos oiliac t tSsimple some thejoint n from g upLearni chang is & foota of six thora a more my s the asses ro-ac behin es in ge, trea girdle cic rotati es, joints smen n the etabu shoul nGto eXe d the joint (kinae . The tme nt differe show t techn der girdle variou lar ing how that on at move s soft sthet make 2 x femo hip girdle ntially joint muS ment patient demo . rciSe eachfacetsiques withic): Look up the diagn s well. cle mov struc on an accomWe nstra Feme 2 x sacro ro-acetabu consists hiposed. Differ at outlin e of the ture can tes some anato pany the joint ent roana of: ementS huma be mica acet musc ing video 1 x pubic -iliac joints lar (FA) tom shoul of asses l mode how n le der.abula The joints y joint the faces skeleton, sed Mover groups are 1 x lumb symphysis (SIJ) shoulder overvi down andl areas to see ment lock of : ew ward press unde ar-sa five joints or speci can roughinvolved in 1. Rotat move The FA cral junctas that makefically anato ly be ure. N.B. r vertical or ment the mical ionfollow joint, divide of supra cuff (RC) posit of thegleno-hum of the the altho1. gleno s: up the d into ion is – pelvis eral ugh very two gross shoul subsc spinatus (SS), the contr -hum By Dr tilted (GH)with the actor 2. acrom apula eral joint Simo30 to theder girdle stable joint, appro infras /stab n Kay, vertic . Thes 2. Prima ris (SSc) is rim slight 3. corac ioclavana al and e xima ly tilted telyone ) (see pinatus (IS), ilising musc icular GP ry move nat delto (AC) thejoints les anter teres rs (PM) Video 1) tom id, femuare 4. scapu oclavicular joint iorly. mino The jointom r y – musc teres majo r, and 5. stern lothor1.acic knee cons overvi les act r, pecto pectoralis majo the hume most oclav thejoint ew ists main r, latiss ly in a ralis mino rus. The neutricular whichjoint joint - of two joints The kneThe imus r, conc the tibiodorsi, entric biceps and side : al RC musc positi consists which of the /ecce e is tricep femo of the on limb, incomplete ntric Pubic chest articu the les like that this s. Thes ral joint the shoul facet fashio , neithe oflate surfa like symp sleev mo the close isn’t the n, hysis ces on gleno the to move e der is s of the r exter with the positi to the Theirst com function id fossa shoe.ulde stabi tibia anato oned joint twowith job move mojoint femuor intern lisedmicalthe nally the arm in full cong thus r is to hold ment nly and surro of the by two spo positi r, cush theexter maintmo s. The prime ally ruent at the allowin the sev mens on ioned rTs nal aining avasc stly ereund kne rotato Shoul move g pos which rotate and d, note inju like an ly itinju stabilduehumerus head er cuff ulDer2. the patelicirotation). (inular rs. The isome is to struc the ity to sitting. musc Move tric ition shoul RC tures allo its relaagainstred join ries diag la-fem les are during shoul mov betw ment glenoPro fashion ing musc , der is een eme nos oral joint les act w t are der tive sup id fossa and exten of the pulsionpulling of runnthe the shoul shallontS pored in a slow cover the the , allow instabil in the low is & trea inghume w back sion t by the head tors plane or rus. of occur V-shaped a joint (sagit der twitch of of the o nea the tme nt only the PM ), and mov ingcan in kick ity. The er eith medi tal planethe patel s in facet contr hume r the intern with ally unde Theing erlesbe hume RC musc musc action body, pro ing. ‘basic s on rus into gro ), abdu lasix which al and the femo esse the foot rus). by the r / ’ direct to mov The sevenntially articu exter und ralction/ move ing the called short rotato the acrom les troug ions: addu actsnal rotati allo en as as in pulsion, plus the the circum quad exter h. The th move ction late flexio as ricep win nal rotatir cuff with ium of the thegtendo head move on (arou ductio muS n (coro squattin s musc patel of body, ment a fulcru of then, which ment infras scapu rap nal intern m cle la on nd axis nid is a ‘multi for s. pinatu is pulled knee is le, trave and the la. al rotati Differ g and the of mov acceler as in wal Rotat s being Rotation andainser comb lling ple’ on, in subsc eme ion making it The acces move themove ent musc is king move respo inatio in front ation apula a conc ntS ment ment occurNote n of all nsible effected s primamechanica ting into ris ment and anter le group entric of the ssory the degre s involv of ior six ‘basic 1. Knee / ecce muscle respo for rily at lly more the are musc that theand tibia, the earticu involv the knee foot poste les the ntric multip flexio e ’semi nsible fibula GH joint, efficie . For exam of angu fashio rior and ed of le as in the femu nt. -tend n - hams lation lationjoints the other The levato scapula (trape r n (see Videofor in thepays no tring n from ple during from of the and bicep inosus, tibia part r scapu knee shoul musc the vertic abdu is linked . der depein neutr two stron les lae) stabil zius, serra 1). s femo semi-mem alanter is at to al. to 25-3 gction cross tus nding the accessory brano ie. from: ris with the femu ise, the ior ing rotate 0 sus on GH joint, cruci n from unloc some ligam r by , musc the poste degre ate es, ks ents le, poplit help from ligam the majo move 30-90Unco – the 2. Knee the knee degre rior cruciThe ent eus, ment ank(ACL es the to scapummo ate ligam n after lerity)isofandthe move ie. rectu extension prior to flexio which Pate move a goodla-thonly for the llo90 degre n. - quad the moment ent (PCL s femo ment tibio ligam low medi femo ricep is 2:1 ents ris, erratio conta es of vascracic ). ular move online st alis s musc ral limb femo supp ment they and vastu vastus inedabdu (the com of ,GH have ly.clas latera les ral ction the ante by syno within monly The gastrm They joint s interm lis, joint thethejoint are vium clavic sic knee rior liga ocne (behi injured ediali vastus betw le comesprained flexio talo and nd s. een the . The ACLmen cove s into n when mius musc canank joint pate red glide standle) inju stopstous les also lla) the foot ular liga in l straig -fib of the two bonery incrtwist injuryplay beca aid also tibia the s and eas but use the is htauprigh men relat onis fixed. stops on the Man t facet true anteriores, thelock toas the twist glide hisly s of the tive sev along femur.ank of the simple Thele substabil minim eritytibia andlegs with Onlin tibia severe -talise ising joint note joint poste PCL e extra on the ar the Inter femu in full of inve can musc rior medi r articl femuas any lejoin sub exten activit and rsio cune ate e for s pane r (see kneeaddre thatbehams l at-tal sion, n fibula disr iform video Dista the ar tring u injuriedty. Pleasthe upte injussed end join e The neutr s). l phala mo by of t ry. to (5th rtice s and this the previo are not nx posit We article whi al and toe) chbecan foot ions us article will meni of for (pleas sciMidd this in this the leg of the knee the anato s publisconside e refer be as By Dr mica le phala fully exten Medi musc topic). Usua hed artic art are l (5th SIMo al le nx lly le. in sportr the ank toe) cune ded in the same N Kay, effect injury is more the pain EX iform mov le, with from on knee The funct a straight GP signif ement the icant flexio Prox line. Move The ntS than n. allow of ion of the ment tibia phala imal is a due stability the of the dissip main ankle the ofThe the knee ation Kne and knee to direc and conn (5th nx seco occu of foot ectin thejoints n Flexio tions array ankle toe) force e joint ndly rs : Navic to provi in two at heel very is to g the tibia : of ligamconsists of n and to allow ular Fifth nA 1. the and stron strike ents de a two main ofexten a stable smal g ankle femu meta l amou gait sion durin(sagi and propu rigidjoint This levelwhich musc joint r and and les tarsa the spina Boxnt of g ttal rotat (simil the surro are activtenon tensi lsive l 1 forrotat walki ion is plane ar undin ng ‘unloc joint l of ons phas to reflex more and) ion or appro the ated to allow a mort in gwood k’ befor posit the es to priate ioningthe inform Late twist running It e within(teno ice the articuinlarrespo eallow contr is . ation flexio move musc theknee facetnse work) act the cune ral ). Ashold (seethe ligam n)ligam foot, to ment which le to cons s nforcan ents. of the to cong ents . This ists avoid iform rough occu the sub-t partthe why Ecce talus which articulates r. is the arthr tighte of two bone ruent exce ntric and alar surfa itis fibula ss not n unev Cubo and main with s joint a the shin occu toget cesonly defic en groun conc the id reaso off stret when they (whic on ient ACL rs if a entric 2. theare hher, n form but also the tibia two beca d. ch recep patie the move muscles stret ligam comp use the nt has Talus are usedmovement ched the mortice) and ent betw tors licate ment exce prona , firing eenwhich to contr s of ss move disarticula after injury Calca tion and s of the the allowd sub-t talus alar joint tion leads foot neus prona and the three sinferi durin ol to mino ment within and tion can supination calca or facet cong osteo inver r traum . Exce g the knee neum put a arthr tors ss a and and cuboruent facet s of the strain itis. of the when ultim As on the foot id bone s on the contr ately Mov ie. move in the shou actin contr s. EMENTS ment g ecce tibialis anter ol the oF ThE s of the lder, ecce ntrica rate ior, caus ntric of prona e trigge lly, to prime aNK Move move r point tion. ment LE rs slow Fibul This s to of the occu a can occu rs true r. ankle dorsi in one direc LEarNI -flexi joint The three on (sagi tion, plant n (kinae NG EXE ttal plane ar and dime joint rCISE Calca ) (vide nsion an articu sthetic): Tibia howe neus s of o 1). Try ver evers be prise lated foot examining ion (vide allows for the subta lar which supin inver o 2) appre d apart slight ation sion can and Talus ciate and (see figure ly, to the Defin pronation subta s itions and lar joint. 3-D aspe fully move 3-5 for a box cts of ment desc and Navic riptio s). the ular n of The move the coun ment terac ting move of evers allow ion and s the into acco foot to ment of it’s unt witho take rough inversion groun ut puttin g exce d ss

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Exercises for early

ACL rehabilitation

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strengthening, bAlAnce AnD stAbilitY exercises QuADricePs flexion

Sit on the floor with your legs straight out in front of you and your arms behind you on the floor supporting you. Pull your toes towards you, pushing your knee into the ground. The muscles at the front of your thigh should contract. Hold for 5 seconds and then relax and repeat.

AssisteD knee flexion Sit on the floor with your knees extended out in front of you. Wrap a resistance band around the foot of your affected leg and then drag your heel along the floor towards you using the resistance band to assist you if needed.

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QuADricePs flexion with heel lift Repeat the exercise above but this time contract enough so that your heel raises off the floor (you could put a rolled up towel under your knee to help). Hold for 5 seconds, relax and then repeat.

seAteD knee benDs Sit on a chair and bring your heel back as far as possible. Hold there for 5 seconds and then return your foot back to the original position.

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Prone knee flexion Lie on your front and bend your knee, bringing your heel towards your back as far as itâ&#x20AC;&#x2122;s comfortable for you. Then lower your leg and foot back to the floor. Both movements should be slow and controlled.

AssisteD knee extension Sit on a chair and position your unaffected leg behind your affected knee. It is important that your unaffected leg is supporting your affected knee at all times. Extend the knee of your affected leg as far as youâ&#x20AC;&#x2122;re able, using the other leg to help it at a slow and controlled pace.

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seAteD stAtic contrActions Sit on a chair and place the ankle of your affected knee against the front chair leg on the same side. Press your ankle against the chair leg so the muscles at the front of your thigh contract.

Hold for 10 seconds and then relax for 3 seconds before repeating.

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suPPorteD mini sQuAts Stand behind a chair, using the back of the chair as support. Bend slightly at both knees and then rise up onto both sets of toes. Squat down again as far as you can without feeling pain and then rise once more, repeating for the recommended sets and reps. SetS

The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. To the extent permissible by law, the publisher, editors and contributors accept no liability for any loss, injury or damage howsoever incurred (including negligence) as a consequence, whether directly or indirectly, of the use by any person of the contents of this article.

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Music: harMony with sport? Pain is a complex phenomenon and cannot be attributed to the physical damage of tissues alone. Other factors such as the psychological and social aspects can all contribute to a person’s experience of pain. Everyone who participates in sport will experience pain from injury at some time and will search for effective pain relief with minimal side-effects. Music is all around us and has many benefits, including relieving pain. However, most people do not associate music with lessening pain and have probably been neglecting its great potential to benefit them. In this article, we explain the research evidence for the influence of music on pain and how it might work as a pain killer. We compare it to medication and discuss the advantages that music possesses since it is acceptable across cultures and increasingly accessible to us. Then, practical ways in which we might use music, both as patients and therapists, are discussed. BY Rosie Holden Bsc, HPc, McsP, and JoHn Holden Md

intRoduction Participating in sport often results in pain from training or competing in matches and competitions. This may be due to direct trauma or as a result of repetitive, overuse injuries. As a physiotherapist and GP we often encounter people with painful injuries from sport such as muscle tears, ligament sprains and fractures. If these pain-provoking injuries are not initially addressed, the patient risks their pain becoming chronic, ie. by definition lasting longer than three months. They would join the 7 million people in the

MUsIc Is A sAfEr AlTErnATIvE bUT MOsT lIKEly TO bE UsEd TO EnHAncE MEdIcATIOn rATHEr THAn rEPlAcE IT EnTIrEly 30

UK suffering from chronic pain. Music, as well as being known to have emotional, mental and spiritual benefits since biblical times, has been investigated for its possible painkilling analgesic properties. A large number of studies have provided considerable evidence that music can decrease pain levels. Music therapy can be delivered individually or in group settings, in hospitals, in community clinics or at home and may involve the patient passively listening to music or actively creating their own music (1). Music therapists specifically use music as a sensory intervention to improve a patient’s perception of their pain.

How MigHt Music woRk as a PainkilleR? Everyone who participates in sport will experience pain from injury at some time and will search for effective pain relief with minimal side-effects. Pain relief may occur by the release of endorphins (the body’s own sportEX dynamics 2012;37(July):30-34

opinions

painkilling chemicals) or changes in catecholamine levels (catecholamines include adrenaline which enable us to perform best) (2). listening to a bach cantata was found to produce a general relaxation response including lower blood pressure (3). Music may also work as patients are distracted by thoughts such as previous meanings and memories, and thus ignore their pain (4). It may be crucial that a patient believes that music will give them some control over their pain (5). This could be fundamental for chronic pain sufferers who need to regain a lost sense of control over their pain (6) (video 1).

online

if you have a current subscription which includes online access, login at www.sportex.net to view this video or download the mobile apps which are free to subscribers.

video 1: understanding chronic pain http://spxj.nl/185kPAb

wHat studies Have sHown A comprehensive, systematic review in the cochrane database (7) recognised that there is great diversity in music and pain studies such as: whether participants were healthy or ill; the rhythm and melody of the music; whether participants chose their preferred type of music; and the duration of listening. Unfortunately experimentally-induced pain cannot fully mimic the painful response in injury-related pain because of the complex psychological and social factors that influence a personâ&#x20AC;&#x2122;s pain experience. for example, the desire to compete in a crucial game could overcome considerable discomfort. It is likely that participants will already be taking painkillers so the effect of music is additional to that. furthermore,

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studies are inevitably short term and highly structured whereas injury-pain may be recurrent and a longer term phenomenon. Interestingly the cochrane review concluded that patients who listened to their preferred choice of music had a non-significant 2% decrease in pain intensity, but pre-selected music produced a significant 5% decrease in

pain strength. This suggests that music selected by others has a greater effect of reducing pain intensity levels than the subjectâ&#x20AC;&#x2122;s preferred music, which is probably not what we would expect. A questionnaire about the music listening behaviour and beliefs of 318 chronic pain sufferers (8) found that the main longer term benefits of music for pain sufferers were enjoyment, relaxation and distraction. respondents who considered music to be personally important to them listened to music more frequently and in turn had a higher quality of life, which suggests that music can lessen pain.

Risks of PainkilleRs Painkillers have significant side effects such as constipation, worsening of asthma and stomach bleeds. Although the anti-inflammatory effects of ibuprofen and other non-steroidal anti-inflammatory drugs (nsAIds) are important in overcoming injury, these are different to their pain-relieving properties. Music is a safer alternative but most likely to be used to enhance medication rather than replace it entirely.

do doctoRs RecoMMend Music foR Pain Relief? Although systematic reviews have not given definitive answers yet upon the effectiveness of music as pain relief, we asked GPs in Merseyside whether they ever recommend that patients with chronic pain listen to music to lessen their pain. About a fifth replied that they do so, suggesting that some GPs already aim to lessen pain in this way, partly by distraction, but generally as part of wider attempts to reduce anxiety, help sleep, and take control in adversity.

advantages of Music

sIncE MOsT PEOPlE dO nOT AssOcIATE MUsIc WITH lEssEnInG PAIn THEy HAvE PrObAbly bEEn nEGlEcTInG ITs GrEAT POTEnTIAl TO bEnEfIT THEM

Music is all around us as we listen to it on MP3 players, hear it on the radio, television and from background music. It can be controlled by the listener and can capture attention strongly, shifting attention from unpleasant sensations. There is evidence that control may be a key aspect of lessening disability and improved quality of life through independence and ability to cope. It is notable that â&#x20AC;&#x2DC;help with painâ&#x20AC;&#x2122; was one of the least important reasons chronic pain sufferers gave for why they listened to music. relaxation, distraction, relieving tension, anxiety and boredom were much more

online

important to them. furthermore it can engender thankfulness, lessen loneliness and prompt pleasant memories.

otHeR non-dRug inteRventions Music is one of a number of alternative methods of relieving chronic pain, such as exercise and cognitive behaviour therapy, that have been found may be effective in randomised controlled trials (9). Perhaps the belief that music can control pain levels may be influential enough alone to have a pain-relieving effect, rather than the actual choice of the music. Placebo effects in pain studies have been found to be powerful enough alone to be clinically useful (10). since most people do not associate music with lessening pain they have probably been neglecting its great potential to benefit them.

conclusions There is now strong evidence that music can help relieve pain, and since it has universal appeal across cultures, is easily accessible and conveniently selfadministered we suggest those with significant pain should be encouraged to try it. The safety, freedom from sideeffects and acceptability of music leads

if you have a current subscription which includes online access, login at www.sportex.net to view this video or download the mobile apps which are free to subscribers.

video 2: understanding Pain: what to do about it in less than five minutes http://spxj.nl/13n0dvK

sportEX dynamics 2012;37(July):30-34

us to recommend the following: n deliberately choose to listen to music to lessen pain n decide when you will listen, whether exercising or relaxing, or both n be confident that music is helping n consider sometimes trying music you would not normally choose n Think what memories you would like to evoke, or associations with people you admire that you wish to remember n develop your own scheme of listening so that you gain more control over your pain. We expect further evidence will emerge about music as a painkiller (video 2). Experimental trials, especially upon actual patients including those with sporting injuries, would be very helpful. Individual reports can inspire and guide others. Publicity will enable more of us to use it to restore exercise to its important place in our lives when pain has disrupted it. And if you are in pain why not give it a try? References 1. finnerty r. Music therapy: A viable intervention for pain control. canadian nursing home 2011;22(1):5–6, 9–11 2. Mccaffrey r, freeman E. Effect of music on chronic osteoarthritis pain in older people. Journal of advanced nursing 2003;44(5):517–524 3. bernardi l, Porta c, et al. dynamic

DISCUSSIONS

interactions between musical, cardiovascular, and cerebral rhythms in humans. circulation 2009;119(25):3171–3180 4. Mitchell lA, Macdonald rAr, Knussen c. An investigation of the effects of music and art on pain perception. psychology of aesthetics, creativity, and the arts 2008;2(3):162–170 5. Mitchell lA, Macdonald rAr. An experimental investigation of the effects of preferred and relaxing music listening on pain perception. Journal of Music therapy 2006;43(4):295–316 6. selby M. Managing chronic pain. practice nurse 2011;41(2):14–19 7. cepeda Ms, carr db, et al. Music for pain relief. cochrane Database of systematic reviews 2006;2:cD004843. Doi: 10.1002/14651858.cD004843.pub2 8. Mitchell lA, Macdonald rAr, et al. A survey investigation of the effects of music listening on chronic pain. psychology of Music 2007;35(1):37–57 9. Park J, Hughes AK. (2012) nonpharmacological approaches to the management of chronic pain in communitydwelling older adults: a review of empirical evidence. Journal of the american Geriatrics society 2012;60:555–568 10. Hróbjartsson A, Gøtzsche Pc. Placebo interventions for all clinical conditions. cochrane Database of systematic reviews 2010;1:cD003974. Doi: 10.1002/14651858.cD003974.pub3.

fuRtHeR ResouRces 1. Music for Pain reduction. Music Psychology with dr victoria Williamson (http://spxj.nl/14z8htO) 2. Musical Meds. blog by Tom Jacobs (http://spxj.nl/12u3X4z)

n Have you found that patients prefer to listen to their own choice of music for their pain? n How often do you find patients listen to music to help their pain? n To what extent do you believe pain has a psychological element?

Th AuThors ThE rosie holden is a physiotherapist r working at the univeristy hospital south Manchester Foundation Trust. she received a First Class honours Bsc Physiotherapy degree from Cardiff university. she has played badminton at club and university level and enjoys football, running, swimming and fell-walking. her love for music started at an early age and she plays the violin and piano regularly in her church worship band. her enjoyment for research started during her university dissertation of the topic ‘The effect of music on a person’s pain pressure threshold.’ This research has developed an interest into the subject of pain and its complexity. Currently working in a busy Nhs outpatient environment, rosie regularly assesses and treats patients experiencing pain. As a member of the CsP and Physiotherapy Pain Association, she continues to further her understanding in this topic. John holden is a general practitioner in Lancashire. he runs regularly and has completed four of the five ‘World Marathon Majors’. he is also a keen fell-walker. In a busy practice he sees many patients with sport’s injuries but his interest in music as a painkiller only started from reading rosie’s dissertation. John has written widely for medical journals and is keen to show how our health can improve with things we take for granted such as music, as well as helping people to use exercise to maintain, improve and restore their health. John holden is a general practitioner in Lancashire. he runs regularly and has completed four of the five ‘World Marathon Majors’. he is also a keen fellwalker. In a busy practice he sees many patients with sport’s injuries but his interest in music as a painkiller only started from reading rosie’s dissertation. John has written widely for medical journals and is keen to show how our health can improve with things we take for granted such as music, as well as helping people to use exercise to maintain, improve and restore their health.

cPd Mcq questionnaiRe tHe quiz foR tHis aRticle is called: Pain and Music

QUIZ

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sportEX dynamics 2012;37(July):30-34