sportEX Dynamics Journal Issue 40 - April 2014 by Co-Kinetic

ISSUE 4 0 Apr 2014 ISSn 1744-9383

promoting

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highlights

manual therapy

n functionAl fAsciAl tAping n Playing hurt

n interPreting research n fascia and anatomy

CONFERENCE

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SMA MEMBERS - £75.00 (GBP) NON SMA MEMBERS - £100.00 (GBP) STUDENTS - £60.00 (GBP) Non members of the SMA are welcome to attend the annual conference & workshops. Should attendees subsequently join the SMA the normal £25 joining fee will be waived. ACCOMMODATION AVAILABLE AT PREFERENTIAL RATES TO CONFERENCE ATTENDEES Contact the Milennium Madjeski Hotel on 0118 925 3500. Quote “Sports Massage Association Conference” when booking. CONFERENCE DELAGATE RATES: Single £72 (inc VAT) B&B Double/twin £84 (inc VAT) B&B Rooms available for Friday 27th and Saturday 28th. First 40 rooms booked guaranteed at this rate.

contents April 2014 Issue 40

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 Dr Joseph Brence, DPT, COMT, FAAOMPT, DAC Technical advisors Steve Aspinall Bob Bramah Paula Clayton Stuart Hinds Rob Granter Michael Nichol Joan Watt Dr Greg Whyte

Manual therapy is making a big time comeback it would seem. Physios out there, have we timed this badly? I was the last year to go through the old physiotherapy Diploma qualification at Addenbrookes Hospital, Cambridge (pah yes a diploma I know, the BSc was still very new at the time, for those of you reading this and wondering what I’m banging on about!). We spent many happy (?) hours, particularly in our first year, running around in blue gym knickers, practicing our manual therapy techniques (stop it there!). Since then I’ve employed two student physios at sportEX who look at me as if I’ve dropped off another planet when I mention how much hands on work we did while we were training. Despite still thinking I’m 25 while logically knowing I’m the other side of 40+, my training days weren’t really that long ago were they? And yet look at what we’re now discovering about the anatomical structure of the body that we thought we knew everything about, and even more significantly just how interconnected our fascial network is. Did we just give away the goose that lays the golden eggs? For all those of you who have been brave enough to commit to manual therapy as a profession, I suspect you have chosen very wisely. In this case the future looks bright (even if it is more pearly white than orange).. Yes, I know the evidence base for massage (or apparent lack of, for so long) has had a major impact on the development of a profession for which this is a guiding philosophy but if we have learnt anything from the evidence presented in the Horizon programme, The Power of the Placebo, screened in the UK in February, just because the evidence appears to be very hard, almost impossible sometimes, to find, it doesn’t mean it’s not there.

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

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

Tor Davies, physio-turned publisher and sportEX founder

ISSUE 59 Jan 2014 ISSN 1471-8138

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ng exceotille n in

sports ce

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n latest researc h news n research analysis n psycholo of sportsgy injuries n hamstrin in footbalg injuries l n patellofe moral taping nm anageme of patellant dislocat ion

medicin sportEX medicine - ISSN 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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THE ENVIRONMENT

Apr 2014

sportEX is printed in the UK by Cambrian Printers Ltd, award-winning colour printing specialists, independently audited to ISO 14001 and EMAS environmental standards. sportEX is printed on paper from FSC certified forests using vegetable-based inks, chemical free plates and presses running alcohol free. It is also mailed in biodegradable polybags.

4 Journal watch 8 Functional fascial taping This quarter’s latest soft tissue research

Contents

Research into the use of functional fascial taping for non-specific low back pain

hurt 13 Playing

Are your athletes playing while injured or in rehabilition? How much does the role of ethics play in your practice?

21 Reading research 27 Modern anatomy

Are you getting the most our of your reading? Is there really anything left to learn or have we just been scratching the surface?

To find out more about sportEX visit

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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Specific and cro croSS over effectS of maSSage for muScle SoreneSS: randomiSed controlled trial. Jay K, Sundstrup e, et al. the international randomi Journal of Sports physical therapy 2014;9(1):82 This study took 22 healthy untrained men (mean age 34 +/- 7 years), with no prior history of knee, low back or neck injury or other adverse health issues who had delayed onset muscular soreness (DOMS) of the hamstring muscles induced by 10 x 10 repetitions of the stiff-legged dead-lift. On the second visit 48h later they received either 10min of roller massage on one leg, while the contralateral leg served as a cross over control, or rested for 10min with no massage at all. They were tested for a soreness rating (modified visual analogue scale 0–10), pressure pain threshold (PPT) and active range of motion (ROM) of the hamstring muscles at 0, 10, 30 and 60min after treatment. There was a significant group-by-time interaction for soreness and PPT, with the massage group experiencing reduced soreness and increasing PPT compared with the control group. There was no group-by-time interaction for ROM. At 10 min postmassage there was a significant reduction in soreness of the non-massaged limb in the cross over control group compared to controls but this effect was lost 30min after massage.

sportEX comment Roller massage helps with DOMS. A full ‘rub’ from an experienced soft tissue therapist would be even better.

e effect of deep Stripping maSSage alone or witH eccentric reSiStance on HamString lengtH and StrengtH. forman J, geertsen l, rogers, me. Journal of Bodywork and movement therapies 2014;18(1):139–144 Sixty four people (age 18–62) were diagnosed with tight hamstrings as defined by supine, passive terminal knee extension of <75°. Hamstring lengths and strength were tested before and after intervention. Intervention A was longitudinal deep stripping massage strokes (DSMS) to the hamstring. The subject was placed prone on a couch with a green Thera-Band around the ankle providing resistance to knee flexion. Then with the help of a metronome the subject moved from flexion to extension under eccentric loading taking 10s to complete the move. During this time the therapist concurrently performed a series of deep longitudinal stripping massage strokes (7 out of 10 on the verbal pressure scale) up the participants’ hamstring muscles from the insertion points to the ischial 4

tuberosity. This was done 15 times starting lateral and moving to medial using the flats of the knuckles of one hand as the therapist reinforced their wrist by grasping it with their other hand and held a green Hand Exerciser (Hygenic, Akron, OH) ball as a shock absorber in the hand performing the strokes. Intervention B was as above but with the subject passive. Both interventions increased flexibility, the eccentric resistance being greater (10.7% v. 6.3%. There was no change in strength.

sportEX comment In practical terms all the TheraBand stuff can probably be dispensed with. The same thing can be done with the subject just extending the leg during the stripping stroke. Nice proof that it works though.

tH effect of ice SluSHy ingeStion and tHe moutHwaSH on tHermoregulation and endurance performance in tHe Heat. Burdon ca, Hoon mw, et al. international Journal of Sport nutrition and exercise metabolism 2013;23(5):458–469 Ten males performed three trials involving 90min of steady state (SS) cycling in the heat (32.1 ± 0.9°C, and 40 ± 2.4% relative humidity) followed by a 4kJ/kg body mass time trial (TT). During SS, participants consumed an identical volume of sports beverage every 15min as either ice slushy at –1°C (ICE), thermoneutral liquid at 37°C (CON), or thermoneutral liquid consumption with expectorated ice slushy mouthwash (WASH). The results were that rectal temperature, hydration status, heart rate and skin blood flow were not different between trials. ICE tended to lower the rating of perceived exertion and improve thermal comfort v. CON. ICE improved performance compared to CON but not WASH.

sportEX comment It seems that ingestion is best. It would have been interesting to add a perception questionnaire. Did the cyclists have the impression that they were cooler swallowing the cold drinks?

sportEX dynamics 2014;40(April):4-7

JOURNAL WATCH

Journal watch e effect of tHerapeutic infra-red in patientS witH non-Specific low BacK pain: a pilot Study. ansari nn, naghdi S, et al. Journal of Bodywork and movement therapies 2014;18(1):75–81 Ten patients (5 men and 5 women; mean age 36.40 ± 10.11 years, range = 25–55) with non-specific low back pain (NSLBP) and disease duration of 21.7 ± 11.50 months were treated with infra-red (IR) for 10 sessions, each for 15min, 3 days per week, for a period of 4 weeks. Outcome measures were the Numerical Rating Scale (NRS), the Functional Rating Index (FRI), the Modified–Modified Schober Test (MMST), and the Biering-Sorensen test to assess pain severity, disability, lumbar flexion and extension range of motion (ROM), and back extensor endurance, respectively. Data were collected at: baseline, at the end of 5th treatment session (after 2 weeks), and at the end of the treatment (after 4 weeks). There were statistically significant effects of IR on all outcomes of pain, function, lumbar flexion–extension ROM, and back extensor endurance.

sportEX comment What goes around comes around. There was a time when the heat lamp was a ubiquitous piece of physio room equipment. Search the back of your departmental storeroom and they are probably still there.

criterion-related validity of Sit-and-reacH teSt for eStimating HamString and lumBar extenSiBility: a meta-analySiS. mayorgavega d, merino-marban r, viciana J. Journal of Sports Science & medicine 2013;12:1–14 Database searches revealed 34 relevant studies using the sit and reach test from which resources were pooled. This resulted in a moderate mean criterion-related validity for estimating hamstring extensibility but a low mean for estimating lumbar extensibility. Generally, females, adults and participants with high levels of hamstring extensibility tended to have greater mean validity for estimating hamstring extensibility.

sportEX comment If you are interested in statistics this is the paper for you because it contains lots of them. For the rest of us it simply means that if you have limited equipment or lots of people to test, the sit-and-reach test is good for estimating hamstring extensibility but not much good at lumbar extensibility.

r roller maSSage improveS range of motion of plantar flexor muScleS witHout SuBSequent decreaSeS in force parameterS. Halperin i, aboodarda SJ, et al. the international S Journal of Sports physical therapy 2014;9(1):92 Fourteen recreationally trained subjects were given a warm-up then assessed for passive dorsiflexion, ankle range of motion (ROM), maximal voluntary contraction (MVC), and a single-limb balance test with eyes closed. They then either did static stretching (SS) or were given a massage roller for 3 sets of 30s with 10s rest between. This

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was repeated (and measured) at 0 and 10min after intervention. Roller massage increased and SS decreased maximal force output during the post-test measurements, with a significant difference occurring between the two interventions at 10min post-test. Both roller massage and SS increased ROM immediately and 10min after the interventions. No significant

effects were found for balance.

sportEX comment We are on a roll here. Ultimately this roller stuff is working on the myofascia. Rollers are OK for a follow-up programme after a trained therapist has started the process.

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Heavy reSiStance training and Supplementation witH tHe alleged teStoSterone BooSter nmda HaS no effect on Body compoSition, muScle performance, and Serum HormoneS aSSociated witH tHe HypotHalmo-pituitary-gonadal axiS in reSiStance-trained muScle. willoughby dS, Spillane m, Schwarz n. Journal of Sports Science & medicine 2013;12:192–199 Twenty males who were used to lifting heavy things trained four times a week for 4 weeks while orally taking either 1.78g of NMDA or a placebo. Measurements of body composition, muscle strength, serum cortisol, prolactin, and gonadal hormone levels were taken before the programme and on day 29. No changes were noted for total body water and fat mass in either group. For body mass and fat-free mass, each was significantly increased in both groups in response to resistance training, but were not affected by supplementation. In both groups, lower-body muscle strength was significantly increased in response to resistance training; however,

supplementation had no effect. All serum and gonadal hormones were unaffected by resistance training or supplementation nor associated with increases in muscle strength and mass. At the dose provided, NMDA had no effect on HPG axis activity or ergogenic effects in skeletal muscle.

sportEX comment NMDA (N-methyl-Daspartate) is an amino acid derivative similar to glutamate. One of the things it does is to act as an excitotoxin, which means it kills nerve cells by over-exciting them. This study says one of the things it doesn’t do is make the gym bunnies bigger or stronger, so why anyone would take it is beyond us!

tHe relation of experience in oSteopatHic palpation and oBJect identification. Sabini rc, leo cS, moore ae. chiropractic & manual therapies 2013;21:38 A group of 15 objects were fastened to a board and covered with a one-eighth of an inch cotton cloth. Then 89 participants of various experience in the manual therapy trade were asked to palpate the objects through the cloth, say what they were and draw them. Sadly they didn’t do very well and there was no statistically significant difference found among osteopathic medical students, fellows, residents, and practising physicians in the correct identification of the objects. For the record the objects were as follows. The figure following is the percentage of their identification. Button (54), screw (91), Ketchup packet (96) (how did they know it was ketchup and not mustard or brown sauce?), paperclip (63), a quarter coin (92) (it was done at a conference in the USA), syringe (97), nail (96), staple (61), key (100), zipper (12), brush (26), raison (0), pecan (24), a single strand of hair and a piece of paper (35) (that’s an old massage school trick).

sportEX comment To quote the authors conclusion “Correlation with clinical palpation cannot be made as it requires a subset of palpatory skills not tested in this study”. What a waste of time and effort. This is party game not serious research.

muScle-StrengtHening and conditioning activitieS and riSK of type 2 diaBeteS: a proSpective Study in two coHortS of uS women. grøntved a, pan a, et al. ploS med 2014;11(1):doi:10.1371/journal.pmed.1001587 This was an 8 year study (2000–2008) involving 99,316 middle-aged and older women aged 36–81 years who were free of diabetes, cancer and cardiovascular diseases at baseline. Participants reported weekly time spent on resistance exercise, lower intensity muscular conditioning exercises (yoga, stretching, toning), and aerobic moderate and vigorous physical activity (MVPA) at baseline and in 2004/2005. During 705,869 person-years of follow-up, 3,491 incident type 2 diabetes (T2D) cases were documented. Data analysis showed that those that those who engaged in at least 150min/week

of aerobic MVPA and at least 60min/ week of muscle-strengthening activities had substantial risk reduction compared with inactive women.

sportEX comment It is estimated that 370 million people worldwide have diabetes mellitus. Long-term complications of include an increased risk of cardiovascular problems and a reduction in lifespan of around 10 years. It seems that in women at least a little bit of exercise helps. The World Health Organization recommends that adults should do at least 150min/week of moderate-tovigorous aerobic physical activity plus muscle-strengthening and conditioning activities such as weight training and yoga on two or more days a week to reduce the risk of diabetes and other non-communicable diseases. See you down the gym then! sportEX dynamics 2014;40(April):4-7

JOURNAL WATCH

were JameS Bond’S drinKS SHaKen BecauSe of alcoHol induced tremor? Johnson g, guha in, davies p. BmJ 2013;347:doi: http://dx.doi.org/10.1136/bmj The 14 original James Bond books were studied and every alcoholic drink noted with an estimate of units imbibed. The days when he didn’t indulge in a snifter or two were also noted. This was usually because he was incarcerated by foul villains or incapacitated as a result of their devilish schemes. All in all 007’s weekly alcohol consumption was 92 units a week, which is over four times the recommended amount. His maximum daily consumption was 49.8 units. He had only 12.5 alcohol free days out of 87.5 days on which he was able to drink.

sportEX comment We pride ourselves on bringing you news of cutting edge medical and human performance research. It seems Mr Bond was a bit of a lush. According to the authors of this study poor James would ‘in reality’ have suffered from poor levels of physical, mental and sexual functioning as a result of his Martini intake. And, the bounder drove the Aston Martin home after a skin full. ‘In reality’ this is a group of researchers with nothing better to do.

d doeS poSture of tHe cervical Spine influence dorSal necK muScle activity wHen lifting? peolsson a, marstein e, et al. manual therapy 2014;19:32–36 Using ultrasound, 21 healthy subjects had their neck dorsal muscle deformation compared over two time points (at rest and during lift) while they performed a lifting task. This consisted of them sitting without back support with their feet flat on the floor, and their spine positioned in a clinically evaluated neutral position. An inclinometer was attached to their head, and was centred over the tragus

Fifteen healthy women aged between 19 and 23 years had matrix rhythm therapy applied to the left lower extremity for a single 30min session. At least 1 week later, massage was applied to the same place for 30min. The same physiotherapist applied both sessions. Measurements of blood velocity (cm/s), artery diameter (mm), and blood flow (ml/min) of the popliteal and the posterior tibial arteries were measured with colour Doppler ultrasonography. All images were evaluated by the same radiologist. The results were that after both treatments, blood velocity, artery

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of the left ear. Participants held a hand weight (2.5kg for male participants and 1.5kg for females) with the shoulder in 70° flexion, the elbow extended, and the forearm in neutral pronation/ supination. This was all done with the head in a neutral, flexed or forward head posture. The data was analysed using post-process speckle tracking. Results demonstrated significantly greater muscle deformation induced

by flexed and forward head postures, compared to the neutral posture, for all dorsal neck muscles at rest Significant condition-by-time interactions associated with the lift were observed for four out of the five dorsal muscles.

sportEX comment This demonstrates the importance of head and neck posture during lifting activities.

implementation of matrix rHytHm tHerapy and conventional maSSage in young femaleS and compariSon of tHeir acute effectS on circulation. taspinar f, Bas aslan u, et al. the Journal of alternative and complementary medicine 2013;19(10):826–832 diameter, and blood flow in arteries increased. However, matrix rhythm therapy caused a more prominent increase in the amount of blood flow in the popliteal and in the posterior tibial artery than did massage.

sportEX comment So women benefit from the rhythm method. Matrix rhythm is, according to some of the advertising, “an innovative therapeutic approach at the core of modern 21st Century

medicine”. Apparently all endothermic animals (including us) constantly vibrate at between 8 and 12 vibrations per second. Unless you have a fever or pathological muscle tremor you can’t see this without hi-tech equipment. If you oscillate tissue a bit more with a special gadget it has therapeutic effects. You can buy one for around 3 grand. There are courses to go on as well.

Functional Fascial ® taping research Functional fascial taping® (FFT) is a fast and effective way to decrease pain, assist function and allow rehabilitation to commence in a pain-free environment. Clinically, FFT can be used to determine soft tissue dysfunction in musculoskeletal conditions with a high degree of accuracy. This article discusses research on the effects of FFT on non-specific low back pain, which was was the subject of Shu-Mei Chen’s PhD at Deakin University and was supervised by Professors Jill Cook and Sing Ky Lo. Shu-Mei Chen and Ron Alexander were the clinical investigators and the outcome assessor was Shu-Mei. This study was published in 2012 in the Journal of Clinical Rehabilitation (1). By ron alexander, FFT Founder, sTT (MusculoskeleTal)

Background non-specific low back pain (nSLbP) is a common musculoskeletal disorder with a high lifetime prevalence and high rate of recurrence (2). Pain can hinder movement and disturb neuromuscular activity and motor control and thus affect function (3). individuals with chronic pain can experience further disability due to psycho-social problems that result in personal and societal economic burdens (4). Limiting pain in magnitude and time is therefore likely to minimise or reverse the negative consequences of nSLbP. After an acute low back pain episode 90% of people will get better after 6 weeks regardless of treatment,

10% will go on to have pain for 12 months. Patients cannot be given a clear diagnosis and do not present with signs on imaging. eighty-five percent of back pain patients fall within this group.

How is FFT diFFerenT To oTHer Taping TecHniques? Functional fascial taping (FFT) has two components: Assessment and Application (5).

assessment The assessment procedure follows the standard clinical processes of test, intervene and re-test. This procedure is guided by the patient’s symptoms and allows for continual reassessment as symptoms decrease. This test has pain-specific direction variability. The

FUnCTionAL FASCiAL TAPing iS A FAST AnD eFFeCTive wAy To DeCReASe PAin, ASSiST FUnCTion AnD ALLow RehAbiLiTATion in A PAin-FRee enviRonMenT 8

sportEX dynamics 2014;40(April):8-12

research research analysis

ThiS STUDy DeSign wAS A RAnDoMiSeD, PLACeboConTRoLLeD TRiAL CoMPARing The eFFeCT oF FFT wiTh A ConTRoL gRoUP (ShAM TAPing)

Figure 1: Control group with sham taping, session 1. n Sit, pain provocative position. n Measure pain region, sham calculations performed, patients potentially thought the procedure looked technical. n Apply white and rigid tape, by placing tape over the measured area. Rigid tape ½ width wide. n 2nd week flexion exercises. (Photo credit: Ron Alexander, 2007)

Figure 2: FFT group, session 1. Sit, pain provocative position. n Assessed tissue directionally specific. n Apply white and rigid tape ½ width wide; FFT gathering technique. n 2nd week flexion exercises. (Photo credit: Ron Alexander, 2007)

makes the tape tighter. This comes about by decreasing area, which increases force and creates more pressure. in this case the pressure is tension, resulting in greater load on the tissues. This aims to offer a specific vector force away from the pain, in the direction predetermined by the assessment. The application may sound like it may decrease range of motion; however, it does not, and it actually has a facilitatory effect on range in most cases. After these two stages are performed patients/ athletes have pain relief and tension/ load to tissues during daily activities or exercise for an extended and predetermined period of time.

researcH MeTHods

Figure 3: FFT group, session 2. (Photo credit: Ron Alexander, 2007)

Figure 4: Control group with sham taping, session 2. (Photo credit: Ron Alexander, 2007)

assessment intervention is performed in the pain-provocative position and is determined by the optimal direction of ease. it is a systematic process distracting the skin and underlying tissue, with a graded tangential force directly over the pain. This is similar to the approach of Andrew Still (1828–1917), the founder of osteopathy. Then, whilst still in that range and with positive change, we observe if an increase in range is possible. The right

direction takes in a number of factors and multiple vectors can be used.

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application Tape application aims to create a graded load (tension) to tissues and employs a gathering technique to directly tighten the skin and the tissue below to change the tissue slack and possibly to affect the deeper structures. The rigid tape width is half the standard size of 38mm; halving it

This pilot study design was a randomised, placebo-controlled trial comparing the effect of FFT with a Control group (with sham taping) during a 2-week intervention with 2-, 6- and 12-week follow-up. Forty-three participants with a flexion deficit were recruited from the general population. All baseline characteristics were similar within and between the groups FFT (n = 21) and Control (n = 22). we used what is considered to be the best prognostic measures for investigating low back pain (LbP), which was the result of a systematic review conducted by Shu-Mei and later confirmed from a presentation by LbP expert Professor bogduk at a Melbourne Conference. The study had two people in both groups drop out in the first 2 weeks and a further two in the FFT group within 6 weeks. The treatment procedure was standard between the two groups except for how rigidly the tape was applied. Lumbar flexion exercises were given in the second week and a manual for skin care was provided to all participants. both groups were treated four times over a 2-week period. 9

Retrocalcaneal bursitis and Achilles tendopathy

Patients were to keep the tape on and it was tightened daily. After 2 weeks the tape was removed. in treatment sessions 2, 3 and 4, the patients in both groups went into trunk flexion, in the pain provocative position and the same tape procedures as in session 1 were applied (Figs 1–4). The results from the study are far too detailed for this article, so an overview will be provided.

resulTs we used a statistical analysis called AnovA (Analysis of variance), to observe the results of a number of the prognostic indicators for LbP. The analysis looked at five repeated measures to detect change in pain and function, within and between the treatment groups, over the duration of the study, expressed as an effect size and compared with baseline (start of the project). The measures were used so we can confirm findings/ data a number of times. The results from the study showed the FFT group demonstrated significantly greater reduction in worst pain compared to the Control group after the 2-week intervention. The study was set so that the P-value had to show less than 0.05 for clinical significance (meaning that there is less than 5% probability of getting no effect). At the end of the trial the P-value result was 0.02. This number indicates that 2% of the time change may have occurred through chance with a 98% certainty that it was the intervention (FFT) that had created change. The study was also set to show a greater than 0.5 effect size (a measure of the strength of treatment) for clinical significance. The result was 0.74, which means that the effect from FFT is very large and 10

a powerful treatment. There were an additional two measures to test our findings, both of which confirmed that FFT was clinically significant for reducing worst pain. The same AnovA table was applied to the modified oswestery disability index questionnaire (moDi) to observe change in function. Although the data showed higher numbers in the FFT group, it was not clinically significant. The results from this data may have been underpowered at this stage due to the dropouts. if we had had better adherence to treatment or if we had had higher number of participants, we believe that greater change would have occurred and been detected. There were no significant differences between the two groups in relation to average pain at any time periods. The study also looked at pain intensity and function, and used a calculation called Minimal Clinical important Difference (MCiD). Although the name uses the wording `minimal’, it’s actually an important calculation and used in various research projects. For example, if a patient presents with 7/10 pain and after treatment the symptoms are reduced by more than 2, so less than 5/10, this means that they have attained MCiD, ie. intense pain reduced to comfortable pain. in order to confirm clinical relevance the study had to show less than 0.05 P-value. The data showed that in the FFT group, 17 people attained and 4 did not attain MCiD. within the Control group, 9 attained and 11 did not attain MCiD. Therefore a higher proportion of patients in FFT group attained MCiD in worst pain (0.007 P-value) and function (0.007 P-value) than did those in the Control group after the 2-week intervention. why did the four dropouts occur in the FFT group? one patient had soft tissue pain reduction which revealed an underlying osseous pathology that required surgery. one person thought

they were in the Control/Sham group and dropped out and two patients got better. These two learnt how to apply FFT and dropped out. The principal supervisor, Jill Cook, explained that their data was to be recorded as a nil result and had to stay in the data. This was because the intention to treat analysis had been used, which meant that anyone who enters the study and drops out for any reason must be recorded as nil or no result from either taping group. on the day that the fourth person, dropped out (second pain free patient) i went for a nice long walk. Taking the focus away from patient compliance for a moment and looking at those who remained in the study, we can look at what was truly happening. of the people who stayed in the study, we had in the FFT group 17 people out of 17, or 100% who attained positive MCiD. The result for the Control group was 50%. even with the dropouts, we have still shown an amazing result at 0.007 P-value for both pain intensity and function. This score means that if the project was repeated 1000 times then a similar result would be achieved for 993 times. Clinically for practitioners this indicates that by decreasing pain we increase function. we can confidently state that this was a real effect and not simply a matter of chance. over the following weeks the patients within the FFT group continued to show the same consistent results; however, the Control group started to show improvement. This can be the naturally occurring effect due to patient expectation to treatment. even with the tape being placed on the body we would have proprioceptive input and subtle load, especially when they moved into truck flexion. (For more information about the role of placebos in research, see an article by bianca nogrady ‘Placebos more effective than mere sugar pills’: www.abc.net.au/health/features/ stories/2013/11/11/3888346.htm.)

in The FFT gRoUP, 17 PeoPLe oUT oF 17, oR 100%, ATTAineD PoSiTive MCiD. The ReSULT FoR The ConTRoL gRoUP wAS 50% sportEX dynamics 2014;40(April):8-12

ReseaRch

discussion in clinical practice we know that nSLbP is a complex musculoskeletal condition and that it can be multifactorial in nature. As clinicians we need to know if individual treatments are effective as well as when to use these. in this study, we looked at FFT and trunk flexion, in a normal practice, of course, you would be using other treatments and thus potentially achieve better results. numerous reasons can contribute to nSLbP such as computer set-up, smoking and psycho-social factors, etc. whilst nSLbP evidencebased treatments are lacking (6), massage (7,8) has been shown to be effective; however, this is limited to the hands on session. FFT allows the treatment to work for a longer period of time. i am definitely not saying that we don’t ever need to do massage/ soft tissue work, but clinicians can be more effective by incorporating FFT as it can be left on for hours and reapplied for days or weeks if need be. The data from this study demonstrates that a window of opportunity is created by the use of FFT. The patient experiences a rapid decrease in pain and an increase in function, the patient is encouraged to go back into the previous pain range and this potentially creates decreased apprehension of pain. This elevates the patient’s mood and speeds recovery because you can start rehabilitation earlier than is usually the case. An additional benefit is that the rehabilitation is being performed in a pain free environment. it may also now provide an opportunity to refer patients who have other contributing factors that are out of the scope of manual therapists, as the patient may be more receptive to change.

wHaT could Be Happening To THe Body? There is still not a thorough understanding of the mechanism by which any taping technique creates change (9). our hypothesis for this study was limited to what could be taking place physiologically. The FFT assessment procedure has painspecific direction variability, which may indicate the neuro-fascial interface. This may stimulate large-diameter afferent fibres and then modulate nociceptor www.sportEX.net

PAin CAn hinDeR MoveMenT AnD DiSTURb neURoMUSCULAR ACTiviTy AnD MoToR ConTRoL, AnD ThUS AFFeCT FUnCTion input (gate control mechanism). The load from the tape could potentially change the sliding of fascial tissues relative to tissues next to them. The load from the tape may also potentially affect the skin and/or remodel the internal architecture of connective tissue (9,10), this may include changing mechanoreceptor activation (11). This hypothesis was supported by a paper on motor synchronisation that investigated the knee (12); however, the same principals translate to the back. Further research to investigate the potential mechanisms of how FFT could affect pain perception is required. we conducted an interesting experiment this year at the Australian Association of Massage Therapists’ (AAMT) conference. Let me explain, as some of you may have taken part and not realised it. i presented FFT at the AAMT conference in May 2013, where i also presented twice a 3-hour workshop at the conference and we had 60 people in each. i presented a lecture, followed by a demonstration and then taught everyone the elementary steps of the technique. i then had participants do an unbiased neural tension test in the arm, because not everyone is going to have a positive neural tension test and i wanted them to perform an objective exercise. Most therapists are neurofascially tight in the arms because of the way they work. From experience i know that this test produces some pretty obvious neuro-fascial symptoms in asymptomatic people and we can observe a decrease in pain and an increase in range. if anyone didn’t have discomfort doing this they were to choose an area in their hypermobile body (one or two in every crowd) that either produced pain or was uncomfortable. each person had 20 minutes to perform the assessment and tape application. After the second workshop, 120 people had performed the exercise. of these 120 people, 100% had experienced a decrease in symptoms and an increase range of motion. This exercise was repeated at

the world Congress on Low back and Pelvic Pain (in Dubai, october 2013) on 48 people with 100% result. our data from our randomised controlled trial on FFT for nSLbP supports what we had observed at the two conferences and is confirmed at almost all FFT workshops. These consistent results indicate that the effect from FFT is predictable, in that you can have an effect in a large number of cases. Although there are situations where it doesn’t work, it is evidence based, it is a relatively simple technique and it provides immediate results. References 1. Chen SM, Alexander R, et al. efficacy of functional fascial taping on pain and function in patients with non-specific low back pain: a randomised controlled trial. clinical rehabilitation 2012;26(10):924–933 2. Pengel Lh, herbert RD, et al. Acute low back pain: systematic review of its prognosis. BMJ 2003;327:323 3. Swinkels-Meewisse ie, Roelofs J, et al. Fear-avoidance beliefs, disability, and participation in workers and non-workers with acute low back pain. the clinical Journal of pain 2006;22:45–54 4. Penny Ki, Purves AM, et al. Relationship between the chronic pain grade and measures of physical, social and psychological well-being. pain 1999;79:275–279 5. Alexander R. Functional fascial taping. Presented at the 5th international olympic Committee world Congress on Sport Sciences with the Annual Conference of

Tape applied for downhill skiing

Science and Medicine in Sport 1999, Sydney, Australia. book of abstracts, p.36 (http://spxj.nl/1dii2w2) 6. beurskens AJ, de vet hC, et al. efficacy of traction for non-specific low back pain: a randomised clinical trial. the lancet 1995;346(8990):1596–1600 7. Tsao JCi. effectiveness of massage therapy for chronic, non-malignant pain: a review. evidence-Based complementary and alternative Medicine 2007;04(2):165–179 8. Kumar S, beaton K, hughes T. The effectiveness of massage therapy for the treatment of nonspecific low back pain: a systematic review of systematic reviews. international Journal of general Medicine 2013;6:733–741 9. ingber De. Tensegrity-based mechanosensing from macro to micro. progress in Biophysics and Molecular Biology 2008;97:163–179 10. Langevin hM, Storch Kn, et al. Tissue stretch induces nuclear remodeling in connective tissue fibroblasts. histochemistry and cell Biology 2010;133:405–415 11. grigg P, Del Prete Z. Stretch sensitivity of cutaneous afferent neurons. Behavioural Brain research 2002;135:35–41 12. Macgregor K, gerlach S, et al. Motor synchronisation. Cutaneous stimulation from patella tape causes a differential increase in vasti muscle activity in people with patellofemoral pain. Journal of orthopaedic research 2005;23:351–358.

DISCUSSIONS

Th AuThoR ThE Ron Alexander is the director/founder of the Functional Fascial Taping Institute. FFT was refined over Ron’s eight years’ service as the principal soft tissue therapist (musculoskeletal) for The Australian Ballet. During this time he was awarded the Lady Southey Scholarship for Excellence from the Australian Ballet Foundation. More recently he was a co-investigator of Randomised Double Blind Placebo Controlled Trial of FFT for Non-Specific Low Back Pain (PhD) Deakin university, Melbourne, Australia. Ron has an interest in chronic pathologies and continues to research the effects of FFT.

FurTHer resources n Ron Alexander’s FFT website (www.fft.net.au) n Ron Alexander’s poster ‘Low back pain: a case report’, presented at the Fascia Research Congress, boston, MA, USA, 2007 (http://spxj.nl/1iPSgcy) n Alexander R. Functional fascial taping® for lower back pain: a case report. Journal of Bodywork and Movement Therapies 2008;12(3):263–264 n Chen SM, Alexander R, et al. efficacy of functional fascial taping on pain and function in patients with non-specific low back pain: a randomised controlled trial. clinical rehabilitation 2012;26(10):924–933.

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n what are the clinical implications of this study? n when would you use FFT rather than conventional taping? n what are the benefits of research to the massage industry?

key poinTs

youTube Video: ron alexander on Functional Fascial Taping http://spxj.nl/1esxmLx

n Functional fascial taping effectively decreases pain and improves function. n rehabilitation progresses better in a pain-free environment. n FFT assessment is guided by the patient’s symptoms and follows sound clinical practice of test, intervene and re-test. n The study was a randomised controlled trial comparing the effect of FFT with a sham-taped control group. n Two participants found FFT so effective that they dropped out of the study before it finished. n FFT is thought to work by affecting the neurofascial interface. n a large sample size is necessary to generate robust results.

Video: ron alexander presenting his randomised controlled trial results http://spxj.nl/1lntge9 This article has been adapted from a version published in Terra Rosa e-magazine no 13, December 2013, www.terrarosa.com.au, who kindly gave permission for us to reproduce it. sportEX dynamics 2014;40(April):8-12

Playing hurt

This article analyses the challenges of working ethically in sport where it is commonplace for athletes to train and play while injured and in pain. To achieve this, the literature surrounding ‘playing hurt’ is examined, principally focusing on cultures in professional football, but also including evidence from other sports. Key ethical issues for healthcare are examined, and the professional and ethical guidelines that clinicians working in sport are bound by are considered in relation to playing hurt. Ways to deal with an ethical issue are suggested. Most importantly, this article challenges you to consider your own practice – are you working ethically?

An ethicAl issue in sports medicine? BY Dr LucY HammonD GSr, PHD

IntroDuctIon In recent months there have been several news items regarding professional sports people ‘playing hurt’. The back pages of the newspapers were dominated in November 2013 by the controversy over Tottenham Hotspur’s decision to allow goalkeeper Hugo Lloris to continue to play in a match after colliding with Romeli Lukaku, suffering a blow to the head and appearing to lose consciousness (see interactive decision-making activity in Box 1). Also in 2013, former Leicester City youth player Alex Cisak accused his surgeon of allowing him to return to training before a wrist fracture had fully healed, leaving him with lingering pain five years later (the legal action was subsequently dropped) (1). A 2013 study of playing while injured in English professional football found there to be at least one injured player reported in the match squad in 48% of 143 games surveyed, across three teams in three different leagues (2). Playing hurt, however, is not confined to male, elite football players, but has also been observed in females, at the amateur level and across both team and individual sports (3–7). For healthcare professionals, the decision of when to ‘return-toplay’ after injury is challenging and

ATHLETES HIDE THEIR PAIN FRoM SIgNIFICANT oTHERS SuCH AS TEAM MATES AND CoACHES 14

multifactorial, and has been the subject of much discussion in the sports medicine literature. A three step model has been proposed to aid this decisionmaking process (8): Step 1 – Evaluation of Health Status; Step 2 – Evaluation of Participation Risk; and Step 3 – Decision Modification. At step 3 of this model, the issues around playing hurt become evident. The authors identify pressure from athletes, masking the injury and conflicts of interest (amongst others) as potential factors that influence clinician decision-making. Interestingly, although the published literature has focused on return-to-play, the decision of when to ‘remove-fromplay’ also presents a challenge (9). For the purpose of this article, playing hurt will refer to both situations – where an athlete sustains an acute or overuse injury and continues to play during that match or subsequent training/matches, and when an athlete has had a period of absence from injury and returns to training/match play while still suffering with the injury.

SPortS cuLture: tHree exPLanatIonS of PLaYInG Hurt The traditional sports medicine literature base has largely ignored the practice of playing while injured; however, sociologists, interested in sports culture and the effects of injury, have examined this area in some detail. Through that work, some broad socio-cultural explanations for athletes accepting pain and playing hurt have emerged, three of which are summarised briefly here: n Pain v. injury Athletic culture is characterised by the conceptual separation of pain sportEX dynamics 2014;40(April):14-20

Professional develoPment

Box 1: InteractIve DecISIon-makInG actIvItY (L. Hammond, 2014)

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Watch the following YouTube videos that depict the events surrounding Hugo Lloris’ head injury in November 2013. Then consider the questions below. video 1: the event: http://spxj.nl/McmqLb

video 2: the criticism: http://spxj.nl/1dLFbjT

FooTBALL PLAyERS ARE FEARFuL oF LoSINg CoNTRACT BoNuSES AND THEIR PLACE IN THE TEAM video 3: the defence: http://spxj.nl/McmwTe

Questions n Lloris appears to have used his ethical right to autonomy to continue to play. Should he have been allowed to? n What pressures could be present on each of the stakeholders involved (eg. Lloris, Tottenham Hotspur’s medical team, André Villas-Boas) that might have influenced their decision-making? n After the injury, Lloris went on to make some good saves and was reported to have had a clear CT scan. Do these outcomes justify the risk of allowing him to continue to play? n As a member of the medical team, what would you do in this scenario?

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and injury: that is, athletes do not view pain as being a part of, or a marker for, injury (10). Furthermore, athletes deny the existence of pain, display a flippant attitude towards their pain, and hide their pain from significant others such as team mates and coaches. Sport has a culture of tolerance towards injury and risk, and athletes receive ‘official recognition’ for playing when injured, which enhances their status within a team (11). n The ‘sport ethic’ This term describes over-conformity to the norms and values of sporting cultures, including ignoring pain and continuing to play when injured (12). Such behaviours would be considered deviant in non-sporting contexts, and so are referred to as ‘positive deviance’, a concept that defines what it means to ‘be an athlete’ (12: p.308). overacceptance by athletes to the sport ethic includes making unquestioned sacrifices for the benefit of the team and for the demands of competition; striving for distinction, achievement and perfection; accepting risks and playing through pain; and accepting

no barriers in the realisation of potential. n Sportsnets Athletes work within professional and social networks (eg. between athletes, coaches, managers, medical personnel and others) that have been termed ‘sportsnets’ (13). These sportsnets confront athletes with a ‘culture of risk’, which compels athletes to feel that they must continue to train or participate in matches while in pain in order to retain their position within the sports team. Athletes are more likely to become immersed in the culture of risk if they have greater contact within the sportsnet than outside of it; where the sportnet controls information that is given to the athlete, and where athletes are easily replaceable.

In focuS: PLaYInG Hurt In enGLISH ProfeSSIonaL footBaLL A number of qualitative studies

Box 2: factorS tHat contrIBute to ProfeSSIonaL footBaLLerS PLaYInG Hurt (L. Hammond, 2014) Dimension

contributory factor explanation

Personal factors

Stage in career

Age: athletes holding off retirement, young players proving themselves

Self-concept

Identifying with ‘athletic’ role, avoiding the ‘injured’ role; self-efficacy in decision-making.

Scheduling

High importance matches (eg. league play-off games, games against league rival); timing in competitive season, fixture congestion

Contracts

Time left on contract; contract bonuses (eg. for appearances, scoring, etc.)

Manageability of injury

The option to delay corrective surgery to the off-season and manage an injury through conservative or invasive means

Squad size

Availability of other players to cover workload of players absent through illness, injury or suspension.

Normalisation of pain

Cultural norm where pain is ignored

Workplace injury

Cultural norm where injury and risk are accepted as part of the occupational role of a footballer

Pressured environment

Pressure from managers, team mates and from self.

Situational factors

Socio-cultural factors

have been conducted with current and former professional football players, as well as team doctors and physiotherapists working in a range of levels of football. These studies suggest that the cultural backdrop of sport described in the previous section is also influential for playing hurt in English football. As well as sociocultural factors, these studies have also shown the decision to play with injury to be affected by a variety of personal (belonging to the particular player rather than any other player or individual) and situational (the combination of circumstances surrounding the player at a given moment) factors (see Box 2 for a summary). ‘Playing’ is important in maintaining a footballer’s strong athletic identity, sense of professional pride, and avoiding the ‘injured role’, which is negatively perceived within the sports environment (14). Footballers have a strong desire to play, and a strong sense of self-belief in their own opinion around whether or not they are able to

sportEX dynamics 2014;40(April):14-20

professional development

play, even if it is against medical advice, for example, one injured player stated: “I think I know my own body … I think I’m old enough now to know my own body and I know if it’s going to hurt or not, or if I can play or if I can’t play” (9: p.10). Personal factors are fairly stable; however, situational factors relating to injury are unstable in their nature and vary greatly according to club and playing league. There is a greater pressure on lower league players to continue to play while injured due to a lack of other available players in the squad, compared to higher leagues teams that have a greater depth of available players (9). Players are fearful of losing contract bonuses and their place in the team (14), and the point in the player’s contract is an important factor in determining whether or not a player will schedule surgery or continue to play (9). Play-off games, relegation battles, cup games and games against league rivals are all considered to be of high importance, and key players who are injured are often required to play in these particular games for the benefit of the team (9,14). Like other sports environments, pain is normalised in professional football and receiving frequent medical treatment is also perceived to be normal. Lower league footballers use a decline in performance rather than pain as a marker for determining when they should leave the field (9). Being prepared to play while injured is considered by football managers to be indicative of a footballer that is a ‘good professional’, or an example of having a ‘good attitude’ (15). one study reported a view in professional football that injured players are of little use to the club, contributed to by managers stigmatising, ignoring or deliberately inconveniencing injured players to deter them from feigning injury (14). The particular culture of a club is likely to be set by the manager, and, as employees of the club, medical teams may become involved in the methods used by the manager to stigmatise injured players. An extract from an article describing an interview with a physiotherapist on this subject illustrates:

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Box 3: GLoSSarY of etHIcaL PrIncIPLeS, termS anD vaLueS (L. Hammond, 2014) term

explanation

advocacy

The active support of a client or patient so that they can make their own choices, achieved through ensuring accurate and honest information, and respect for the patient’s integrity, dignity and privacy.

autonomy

To be self-governing, ie. to be able to make decisions for oneself. People have the right to consent to or refuse treatment, without being constrained, coerced or impeded in any way.

Beneficence

A fundamental ethical concept where the intended care is aimed at what is good for the well being of the patient. Beneficence is the deliberate bringing about of positive action/s or interventions.

conflict of interest

A situation that can undermine a person’s impartiality because of the possibility of a clash between their self-interest and their professional interest.

ethics

The study of people’s moral behaviour, ie. what is right or wrong, good or bad. Healthcare professionals have an obligation to provide care that is good, right or correct.

Informed consent

Exists to protect people from (risk of) harm and to protect their autonomy, and has two strands: information and consent. Patients should receive sufficient knowledge of all relevant facts and factors (information) in order for them to agree to, or refuse, a particular course of action (consent).

non-maleficence

‘Do no harm’: a basic moral duty that individuals should do no harm or damage to another person, and includes prevention of actions that could cause actual harm or risk of harm.

“‘I think if a player is injured they have to work harder and longer and be inconvenienced’. He [the physiotherapist] explained that injured players were made to ‘work their nuts off… so they’d rather train than be injured.’ Describing how injured players were ‘inconvenienced’, he said ‘you have to make it naughty’ and added: ‘I will keep him [the injured player] here until the traffic builds up on the motorway.’” (14: p.172) As with the managerial culture, the relationship between physiotherapist and manager varies greatly from club to club, and in some cases can be strained. It has been suggested that some managers restricted the clinical autonomy of the physiotherapists and club doctors in the treatment of players, overruled physiotherapist decisions and had conducted fitness tests to return-to-play without reference to the physiotherapist (15). Interviews with physiotherapists working in professional football have shown there to be other constraints of working in the elite environment, one

ETHICAL PRINCIPLES CAN CoME uNDER STRAIN IN THE ELITE ENVIRoNMENT being the pressure to return players to play quickly: “In private practice, the client isn’t desperate to be fit by Saturday. The client wants to be cured of the injury so it doesn’t come back… In private practice, my modus operandi is to cure the injury. In professional football, my modus operandi is to get the player on the pitch as quickly as possible … you get people who are playing on injuries that need constant care. And you just end up performing maintenance on top of treatments in between games.” (14: p.189) Events such as these, along with the general issues around playing hurt already analysed, have the potential to give rise to ethical issues for healthcare practitioners working in sport and looking after the ‘player-as-patient’. These are discussed in the next section. 17

etHIcaL ISSueS anD ProfeSSIonaL GuIDeLIneS

Figure 1: ethics thics grid, including key points relating to playing hurt [Adapted from Johns (20)] client’s or patient’s perspective n usually expressing a strong desire to play n Are they aware of any risks or consequences? n Have they understood all of the information provided?

Who has authority to act? n Are you the sole practitioner in the team? n Are there other health professionals, eg. club doctor? n Do you have clinical/ professional autonomy?

other health professionals’ perspective n Eg. orthopaedic surgeon, sports physician, psychologist.

Is there a conflict of values? n Duty towards injured player n Duty towards employer, ie. club.

Situation n Team position in league n Point in competitive season n Point in players contract n Availability of other players.

ethical principles n Autonomy n Non-maleficence n Informed consent n Beneficence.

Your perspective n Personal and cultural values n Professional values n Previous experience.

Your perspective n Hierarchy between manager/coach/health professionals/players.

organisation’s perspective n Financial position of club n The laws of the game n Manager’s job security.

Modern healthcare ethics places central importance on a number of ethical principles, which include informed consent, autonomy, beneficence and non-maleficence (see Box 3). Depending on the circumstances, enabling athletes to play hurt has the potential to violate ethical principles: for example, if players are pressurised or coerced into playing while injured, or if they are not aware of the associated risks. That said, if players are fully informed of the risks and potential consequences of playing hurt and wish to do so without any pressure from others, no ethical issues are raised. There is a potential for conflicts of interest to arise for health professionals working in professional sport, as they have an ethical obligation to advocate for the athlete but also an obligation towards the team if they are

Box 4: anaLYSIS of keY etHIcaL PrIncIPLeS SurrounDInG PLaYInG Hurt, maPPeD aGaInSt keY ProfeSSIonaL/etHIcaL coDeS (L. Hammond, 2014) NB: Number in parentheses indicates that part of the section of the professional code maps to the ethical principle ethical principle

relationship with ‘playing hurt’

autonomy If an athlete has autonomy, they have the right to continue to play whilst injured if they choose to do so. However it is important they are informed of the risks of doing so (see informed consent).

Section/sub-section of code cSP (16) 3.1.1 Seek to understand, and take full account of, individuals’ needs, preferences, expectations and goals in delivering a service to them. 3.2.1 Promote and uphold individuals’ rights and choices, including their right not to consent to decisions or actions affecting them. 3.2.5 Promote, support and empower individuals to participate in decision-making, to self-manage and be independent.

Informed consent

Athletes should be fully aware of the risks and benefits of playing in matches whilst injured. Explanation of risks should include both short- and long-term risks, including any sequaelae that will affect them after their athletic career is over. Practitioners have a duty to inform the athlete, and also to ensure that the information given is comprehended. The consent to play hurt should be given freely, without pressure from others.

3.2.2 Ensure individuals have given valid consent to any decision or action affecting them. 3.2.3 Share all relevant information to support individuals in making their own decisions, including that relates to issues of risk and consent.

BaSrat (17) 3.6 Members shall discuss with their client relevant options regarding their care and ensure that the client has the option to ask questions or discontinue care, without penalty, at any time.

SSt (18) (8) n A person who is capable of giving their consent has the right to refuse treatment. you must respect this right. you must also ensure that he or she is fully aware of the risks and consequences of refusing treatment.

(3.5) Members shall understand the importance of and demonstrate the ability to obtain, maintain and document informed consent.

(8) n you must explain to the patient/client the treatment that you are carrying out, the risks involved (if any), and other treatments possible. n you must make sure that you get the patient’s/client’s informed consent for any treatment that you carry out.

sportEX dynamics 2014;40(April):14-20

Professional rofessional develoPment

paid employees (8). Healthcare professionals working in elite sport are required to make complex decisions with their patients, and it is possible that at times, ethical principles can come under strain in the elite environment. Professional or regulatory bodies for healthcare professionals have their own codes relating to conduct and ethics to which their members are bound, and have a duty to be familiar with (16–18). These codes provide a guideline for practitioners in setting out professional behaviours and values, but do not explicitly address how to deal with potential ethical dilemmas. The issues around playing hurt are mapped with relevant professional guidelines from the Chartered Society of Physiotherapy (CSP), British Association of Sport Rehabilitators and Trainers (BASRaT) and the Society of Sports Therapists (SST) in Box 4. A further consideration for decision-making in sport is the rules of the game, which vary somewhat when it comes to medical management

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of athletes. For example, analgesic injections are banned in rugby union on match days except in exceptional circumstances whereas there is no legislation around the use of injected analgaesics in professional football, and decisions are at the discretion of the treating medical team (19). If a practitioner is concerned over an ethical situation or dilemma, first, it is important to determine whether it is in fact an ethical issue or not. To do this, an ethics grid can be used [see Fig. 1, adapted from Johns (20)]. This grid encourages consideration and understanding of the situation from one’s own perspective, the perspective of the patient, and that of the organisation and/ or other stakeholders. This approach aids reflection on the information in order to decide if there is an ethical issue present or not. If there is an ethical issue present, the practitioner should follow the organisational or professional guidelines. Alternatively if guidelines are not available, they can consider all of the possible options for dealing with

the situation. Each option should then be evaluated to see whether it meets the key ethical principles of autonomy, informed consent, beneficence and nonmaleficence. you might choose to take the action that performs the best when considered against the ethical principles.

SummarY In summary, athletes at all levels ‘play hurt’, and these practices have the potential to give rise to ethical dilemmas for healthcare practitioners working in elite sport with athletes as patients. Practitioners can ensure that they are upholding ethical standards by being aware of the constraints of different working environments, along with having a good working knowledge of their professional bodies’ code of ethics. If in doubt: n use an ethics grid to enhance your understanding of the situation from different perspectives and to decide if there is an ethical issue n Discuss your concerns with the parties involved where possible/

appropriate n Contact your professional organisation for advice if needed. References 1. BBC. Burnley goalkeeper Alex Cisak drops wrist operation lawsuit, 2013. http://spxj.nl/1fyhJ6a. Last accessed 07.02.2014 2. Hammond L, Pope g, et al. The impact of playing while injured on injury surveillance findings in professional football. scandinavian Journal of medicine and science in sports, 2013;doi:10.1111/sms.12134 3. Howe D. An ethnography of pain and injury in professional rugby union: the case of Pontypridd RFC. international review for the sociology of sport 2001;36:289-303 4. Liston K, Reacher D, et al. Managing pain and injury in non-elite rugby union and rugby league: a case study of players at a British university. sport in society 2006;9:388-402 5. Nippert A. “I have four months to compete, eight months to heal”: playing through pain and injuries in girls’ interscholastic gymnastics. lambert academic cademic Publishing 2010. isBn 978-3838324159 (£58.01). Buy from Amazon http://spxj.nl/1ggS83x 6. Pike E, Maguire J. Injury in women’s sport: classifying key elements of “risk encounters”. sociology of sport Journal 2003;20:232251 7. Malcolm, NL. “Shaking it off” and “Toughing it out”: socialization to pain and injury in girls’ softball. Journal of Contemporary ethnography 2006;35:495-525 8. Creighton DW, Shrier I, et al. Return-to-play in sport: a decision-based model. Clinical Journal of sport medicine 2010;20:379-385 9. Hammond L, Lilley J, et al. “We’ve just learnt to put up with it”: an exploration of attitudes and decision-making surrounding playing with injury in English professional football. Qualitative research in sport, exercise and health 2013;doi:10.1080/215967 6x.2013.796488 10. young K, McTeer W, White P. Body talk: male athletes reflect on sport, injury and pain. sociology of sport Journal 1994;11:175-194 11. young K. Violence, risk, and liability in a male sports culture. sociology of sport Journal 1993;10:373-396 12. Hughes R, Coakley J. Positive deviance among athletes: the implications of overconformity to the sport ethic. sociology of sport Journal 1991;8:307-325 13. Nixon H. A social network analysys of influences on athletes to play with pain and injuries. Journal of sport & social issues 1992;16:127-135 14. Roderick M, Waddington I, Parker g. Playing hurt: managing injuries in English professional football. international review for the sociology of sport 2000;35:165-180 15. Waddington I. Ethical problems in the medical management of sports injuries: a case 20

study of English professional football. In: Loland S, Skirstad B, Waddington I (eds) Pain and injury in sport: a social and ethical analysis. routledge 2006. isBn 0415357047 (£31.20). Buy from Amazon http://spxj.nl/1kWhKs7 16. Chartered Society of Physiotherapy. Code of Members’ Professional Values and Behaviour, 2011. http://spxj.nl/1jbjuB4. Last accessed 07.02.2014 17. BASRaT. Standards of Ethical Conduct and Behaviour, 2013. http://spxj.nl/1huMpMM. Last accessed 07/02/2014 18. Society of Sports Therapists. Standards of conduct, performance and ethics, 2012. http://spxj.nl/1fyjpNc. Last accessed 03.01.14 19. orchard J. The use of local anaesthetic injections in professional football. British Journal of sports medicine 2001;35:212213 20. Johns C. Becoming a reflective practitioner. Wiley-Blackwell 2000. isBn 0470674261. (£27.30, Kindle Edition £20.48). Buy from Amazon http://spxj.nl/MclgQ2.

furtHer reSourceS 1. Pain and injury in sport: a social and ethical analysis by S. Loland, B. Skirstad, I. Waddington. routledge 2006. isBn 0415357047 (£31.20). Buy from Amazon http://spxj.nl/1kWhKs7 2. Ethics in clinical practice: an interprofessional approach by g. Hawley.

Routledge 2007. ISBN 9780132018272 (£28.49). Buy from Amazon http://spxj.nl/1fdteFh

n In your experience, are athletes provided with sufficient information to make valid informed consent when they become injured? DISCUSSIONS n Who receives better care – a professional/elite athlete or a private-practice patient? n Whose responsibility is the decision to removefrom-play or to allow return-to-play? n Are elite athletes are exploited?

THE AuTHoR T Dr Lucy Hammond is a graduate sport rehabilitator, and completed a PhD in the School of Health Sciences at the university of Nottingham in 2013. Her doctoral research considered injury epidemiology in professional sports (primarily professional football), and evaluated the effects of playing hurt on injury surveillance findings. She has several peer-reviewed publications in international journals in this area and has presented her work at international conferences. Lucy is a senior lecturer at the university of Bedfordshire where she coordinates the professional practice and research units, and she can be contacted there: lucy.hammond@beds.ac.uk

keY PoIntS n Playing hurt is the practice of continuing to play while injured. n It has been observed in all domains of sport. n Sociologists have explored playing hurt, but it has been largely ignored within the sports medicine literature. n Pain is normalised by athletes. n a variety of personal, situational and socio-cultural factors influence professional footballers to play hurt. n Playing hurt can resonate with aspects of

modern healthcare ethics. n Practitioners working in professional sport should be aware of the potential for conflicts of interest. n Professional guidelines identify professional behaviours and values but do not advise how to overcome ethical issues. n reflection on potential ethical issues or dilemmas is important for practitioners. n If in doubt about an ethical dilemma, discuss your concerns with all parties involved.

continuing education Multiple choice questions This article also has a certificated eLearning test which can be found under the eLearning section of our website. For more information on how to access the test click this link http://spxj.nl/cpdquizzes

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sportEX dynamics 2014;40(April):14-20

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How to read a researcH paper BY Dr AllAn Munro PhD, GSr

his article is a follow-up on a previous article called “A short guide to literature searching to maintain currency in your field” (1). In that article I presented a quick guide to finding research using the Google Scholar search engine, including a brief description of how to select papers that were relevant to you. Having found these articles the next, and arguably most important step, is determining whether the paper and its results are trustworthy and should influence your practice. We often accept facts that are given to us without considering where the evidence came from, or indeed how reliable or valid the source may be. Yet it is important that we consider the research processes that brought about the findings to determine whether the ‘fact’ really is accurate. This is an extremely important factor for health professionals when you consider the drive for research-based or evidencebased practice. Let us take an example. A casewww.sportEX.net

The aim of this article is to help the reader to understand and critically analyse research papers in order to make greater use of research literature in relation to practice and learning. If you feel that you don’t always understand the significance of research papers or need a brush up on relevance, this article is for you! study conducted on one individual found that rubbing olive oil onto the athlete’s bruised thigh appeared to help reduce the bruising and the athlete return to competition quicker than expected. Would this be an example of robust evidence indicating that we should start using this as a treatment for dead legs? No! However, if a randomised controlled trial on 300 people with dead legs compared the use of olive oil versus a placebo versus a control group, and found that those who were rubbed with olive oil did in fact return to sport sooner, then that would be considered to be pretty sound evidence of the beneficial effect of olive oil for treating dead leg. What’s more, the media would be hailing the power of the humble olive as a

superfood with magic healing properties! Considering this, the aim of this article is to help readers of sportEX determine what they should be looking for in a research paper in order to Evidence quality RCT Cohort study Case-control study Cross-sectional study Case report

Figure 1: The hierarchy of research study designs (A. Munro, produced by sportEX, 2014).

IT IS NECESSARY TO CONSIdER THE RESEARCH PROCESSES THAT BROuGHT ABOuT THE FINdINGS TO dETERMINE WHETHER THE ‘FACT’ REALLY IS ACCuRATE determine whether the results are genuinely useful.

hierArchY of eviDence Firstly, we will consider the hierarchy of research study designs. There are a number of different types of study design, each with their own advantages and disadvantages. The hierarchy of their evidence quality is presented in Figure 1.

randomised controlled trial Randomised controlled trials (RCTs) are considered to present the highest quality evidence available in clinical research due to the robust methodology employed. RCTs are often used in clinical trials to test the

effectiveness of an intervention. In an RCT the participants are screened for eligibility to participate the study and then randomly allocated to a study group. The most simple RCT will include an intervention group (the group receiving the treatment/intervention) and a control group (who receive an alternative treatment, a dummy/ placebo treatment or no treatment/ intervention) (see Box 1 for an explanation of commonly used terms). Both of these groups are then followed in exactly the same way to ensure that no bias is introduced to the study.

cohort study In a cohort study, a group of people are identified and followed over a period of time. The aim is to assess how their exposure characteristics (risk factors) affect their outcomes. Often this is used to assess the effect of suspected risk factors on specific injury occurrence. An example of this might be a prospective study assessing the risk factors for anterior cruciate ligament (ACL) injury, in which participants are

Box 1: coMMon TerMinoloGY exPlAineD (A. Munro, produced by sportEX, 2014)

screened during the pre-season period and followed during the season to see whether they suffer an ACL injury. This type of research is important in developing an understanding of how we can reduce risk of injury.

case-control study A case-control study retrospectively compares a group of participants with certain characteristics (for example a medical condition) against another group who do not have those characteristics. These studies are purely observational and no intervention is attempted. The key difference to a cohort study is the retrospective nature of the observation, ie. the study looks back to determine/study the factors affecting the participants. This is often seen in sports medicine research when patients with a particular injury are compared to a group without it. For example, patients with patellofemoral pain syndrome (PFPS) displaying decreased hip strength compared to healthy participants. The main problem with this study design is the lack of knowledge of cause or effect; whether the injury led to the observed changes (decrease in hip strength) or whether the changes caused the injury.

Term

explanation

cross-sectional study

Bias

An action that prevents unprejudiced consideration of a question. In research this occurs when some action (intentional or unintentional) within the research process may lead to an outcome being more likely to be chosen than another outcome.

hypothesis

An idea to be tested through research.

null hypothesis

A null hypothesis will state that there is no relationship between two variables, or that a treatment will have no effect. Eg. 6 weeks of leg extension exercises will not affect quadriceps strength.

A cross-sectional study is almost identical to a case-control study; however, it lacks a control group to which the results are compared. Therefore, it simply provides a snapshot of the participants at that time and does not give an indication of how this might have changed or will change over time.

Alternative/ experimental hypothesis

What we expect to see if the null hypothesis is false. Eg. 6 weeks of leg extension exercises will increase quadriceps strength.

case report

Placebo

A treatment given which has no beneficial effects. This may be a simulated treatment or a sham treatment which is given to deceive the recipient.

control group

A group of participants who receive no treatment or input and are just observed. They are separate from the treatment/intervention or placebo group.

P value

The P value helps us to determine whether to reject the null hypothesis. The aim of research is to prove that the null hypothesis is wrong and the alternative/experimental hypothesis is true. A P value of 0.05–0.01 indicates there is moderate evidence that the null hypothesis is false. A P value of <0.01 indicates strong evidence the null hypothesis is false.

A case report is an article that describes a particular case. Essentially this is how we work in practice and helps shape our own thoughts and ideas. We use each patient or client as a case study for our own learning. However, in research this is the lowest form of evidence. If several case reports show similar findings, this may form the basis for a case-control study.

SelecTinG The PAPer As discussed in the previous article, sportEX dynamics 2014;40(April):21-25

refresHer review

there are three steps to determining whether a paper is of interest: n Assess the title n Read the abstract n Read the paper.

The title Having read the title of the paper you might immediately decide it is not relevant to you. Say you are looking

RANdOMISEd CONTROLLEd TRIALS (RCTS) ARE CONSIdEREd TO PRESENT THE HIGHEST quALITY EvIdENCE AvAILABLE IN CLINICAL RESEARCH

Box 2: QueSTionS To BeAr in MinD To AiD The evAluATion of reSeArch PAPerS (A. Munro, produced by sportEX, 2014) 1. is the study aim and/or hypothesis clearly stated? 2. Are there any sources of potential bias? n Is the sample representative of the population of interest? Eg. is research on five professional footballers representative of the whole population of professional footballers? n If applicable, were the subjects and/or the examiner blinded to the exposure or intervention group? Being blind is important to ensure there is no bias. If an examiner knows that a participant undertook an intervention, they might expect their results to change and would therefore be biased towards measuring in this way. n Have all confounding variables been accounted for? This may be done with specific inclusion or exclusion criteria, or via more complex statistical analysis. n Should practice trials be included for the outcome measure? If a participant is familiar with a test they are likely to do better – see Munro and Herrington (2) for an example. n Are there any environmental factors to consider? 3. has the outcome measure been clearly defined? is it a standardised measure? n does the outcome measure actually measure what is intended? Is it valid and has this been proven? This has usually been done in a prior research study, for example the visual analogue scale (VAS) has been shown to accurately determine pain scores. n Is the outcome measure reliable? Has this been established previously, or is defined within the research paper? 4. is the sample size appropriate? (has a sample size estimation been carried out?) n Journals are asking with greater frequency for an estimation of the required sample size to be undertaken to ensure that there are enough participants to adequately answer the question posed. Sample size estimation is a statistical technique used to estimate how many participants are needed to have sufficient statistical power. n To give you an idea of what this means, any study looking to prospectively assess risk factors for non-contact ACL injury would require 1000 participants to gain a sample of 20 ACL injuries for analysis. n This may not stop you looking at the study, but you should interpret the results with the appropriate caution. 5. n n n

if the study includes an intervention, was there a control group or placebo group? If so, were the subjects randomly allocated to the groups? Were these groups similar at the outset of the study? If there is no control group, how do we know for certain that the intervention caused the change? If there was a significant change following an intervention, how can we be sure that the intervention caused it, and it was not due to the placebo effect?

6. is the sample relevant to your population of interest? For example, does research on a sample of untrained elderly men apply to younger professional athletes that you may be interested in?

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for articles to help you design a rehabilitation programme for an Achilles tendinopathy patient and an article titled “Rehabilitation of rotator cuff tendinopathy” appears in the results list. You could safely argue that this is unlikely to help in your current search and discard that result. Alternatively, a paper titled “Risk factors for Achilles tendinopathy” may also appear. Although this is not directly relevant to your search, the paper may contain some pertinent information that would help in your programme design. In this case you would move on to look at the abstract.

The abstract Abstracts usually present enough information to gauge the quality of an article. For example, it will include a brief summary of the methods, which should allow you to determine whether the method used can actually answer the research question, but may not include whether the method was actually reliable. Additionally, in relation to the search for an Achilles tendinopathy programme, you would need to access the whole article to fully understand the potential factors involved to help design the programme effectively. The abstract should also include the sample size used in the study; if only 10 participants (n = 10) were included then the results are not likely to be generalisable to the wider population and you would decide to interpret the results with the appropriate caution. There is no commonly accepted minimum number of participants, but a minimum of n = 30 provides a rough guide, any fewer and you should question whether a conclusion can be drawn from this number of cases. Often, abstracts will include P values or similar to demonstrate significant findings. However, P values only tell part of the story (see description box and later discussion). It is always important to access the descriptive summary statistics to see the ‘average’ and the ‘spread’ of the data (eg. mean and standard deviation) to help see the full picture.

Appraising a full paper When reading a research article there are several simple questions to answer 23

Figure 2: A graph showing standard deviation. Each band has a width of 1 standard deviation (sportEX, 2014).

2.5% -3

13.5% -2

34 -1

34 0

13.5% 1

13.5% 2

Standard deviations

Box 3: STATiSTicS – An overview (A. Munro, produced by sportEX, 2014). 1. The mean value is the average for the sample that has been tested only. This is not the average score for the whole population, just the sample in the study. The confidence interval (described later) helps us determine the likely population mean. 2. Standard deviation (SD) is often presented with the mean. The Sd is not the range of scores found within the sample; it is the value within which we would expect around 68% of the samples’ scores to fall. We would normally expect 68% of the sample’s scores to fall within one Sd of the mean, 95% to fall within two Sd of the mean and 99.7% to fall within three Sd of the mean (Fig. 2). n For example, a study presents the age of the sample within a study as 26.1 years ± 1.2 years. This suggests that 68% of the study participants were within 1.2 years of 26.1 years of age and 95% were within 2.4 years. n The greater the standard deviation, the greater the spread of scores. The smaller the standard deviation, the closer scores will be to the mean (average). 3. The confidence interval (ci), often presented as 95% ci, is a range in which the ‘true’ value of a measure is thought to lie. This helps us to estimate the range in which the population mean would lie from a sample mean. When 95% CI is reported in a paper, the population mean is expected to fall within this range around the sample mean. n The smaller the range the greater the certainty in the measure, meaning if the same test were carried out again we could be confident that the result would be similar (showing that a populations mean lies in this range). We can also determine whether a test is significant from the confidence interval; however, this is beyond the scope of this article. 4. Significant difference. if a significant difference was identified (ie. the P value was <0.05) between two sets of data, can this difference be interpreted as clinically relevant? n Are we sure that the difference was greater than the error of the test that measured it? n For example, a study is carried out to determine whether increasing quadriceps strength leads to an increase in anterior reach distance on the Star Excursion Balance Test. The outcome measures are leg extension strength (kg) and reach distance (% of leg length) both of which have been shown to be valid previously. After the intervention mean leg extension strength has increased by 20kg in the intervention group, whilst anterior reach distance scores have increased by 5%, both of which are significant changes according to the P values. However, according to previous research (2) the change in anterior reach distance is not clinically significant as it still lies within the smallest detectable difference value. This value indicates how big of a change is required to be deemed clinically meaningful and not due to error of the measurement being taken. n In contrast, a small ‘underpowered’ (too few participants to detect a difference – see sample size estimation earlier) may not report significant findings, even though there are important, real effects found in the study. This is important when considering the findings of small studies where nonsignificant results are reported.

to help determine its quality. Is the study valid? What are the results? Are the results applicable to your needs? To determine the answers, the following list of questions should be considered when reading a research paper (Box 2). By no means will any given research paper be able to boast a yes to all the questions; however, they help provide you with a guide to the study’s quality and therefore the likely impact of its results. When considering the results, statistics play a big role which cannot be ignored. However, before looking at this, you can determine whether the results are likely to be due to the bias assessed earlier in this section. It is beyond the scope of this article (and author!) to present a masterclass on statistics. However, there are some important concepts to be aware of, particularly regarding the all-conquering P value (Box 3). The authors’ discussion should highlight the study’s key findings and limitations. They should put their findings into perspective with reference to other sources and studies to help explain what they have observed. This section will help you to make sense of the study and how it fits into the literature. The limitations highlighted should also help you to understand how you may, or may not, be able to apply the findings to your own practice. Finally, does the conclusion reached seem to match with the results you have just read? You should also ask yourself whether you have read around all the evidence, not just one article. Just because one article says it works doesn’t mean it’s true. There may be other articles that contradict the findings and this is where your new found appraisal skills come in to action to determine which findings have the strongest evidence. You should also ensure that you do not just read the studies aims and conclusion, as you are likely to miss some key information that might be applicable to your practice, or which might help your appraisal of the article for your own work.

SuMMArY Hopefully this article will have provided the reader with clear definitions of sportEX dynamics 2014;40(April):21-25

refresHer review

common terms and a concise guide to reading, understanding and appraising research papers. Readers should now have greater confidence that they can critique a research study and be able to better understand the outcomes of these papers. References 1. Munro A. A short guide to literature searching to maintain currency in your field. sporteX dynamics 2011;29:7–10 2. Munro A, Herrington L. (2010). Betweensession reliability of the star excursion balance test. physical therapy in sport 2010;11(4):128–132.

furTher reSourceS 1. Research Methods in Physical Activity (6th edn) by J. Thomas, J. Nelson and S. Silverman. Human Kinetics 2011. isBN: 9781450400374 2. Statistics for Terrified Biologists by H. van Emden. wileyBlackwell 2008. ISBN 1405149566 (£16.00). Buy from Amazon http://spxj.nl/N3ztj2

ThE AuThoR Th Allan is a lecturer in Sport Rehabilitation at the university of Bradford, having previously worked at the university of Derby and university of Salford. having originally completed his undergraduate degree in Sport Rehabilitation at Salford, he recently completed his PhD investigating the use of two-dimensional motion analysis and functional performance tests for identifying individuals at greater risk of ACL injury and PFPS. he also has several peer-reviewed journal articles to his name in this area. Alongside his academic work, Allan works clinically as the head sport rehabilitator for Sedgley Tigers in rugby union, specialising in exercise rehabilitation.

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DISCUSSIONS

n What constitutes a significant P value? n What factors should you consider along with the P value? n How do you decide if the findings of a study are meaningful to you clinically?

KeY PoinTS n Don’t believe everything you read in the abstract, analyse the results. n Don’t be blinded by significant P values, check whether the results are really clinically meaningful. n consider how the findings of research papers might impact on and enhance your practice. n consider the hierarchy of study designs to help determine the strength of the evidence being presented. n Do not take one paper’s word as final, read around the subject. n consider the limitations of each paper and what they mean to you.

studEnt rEsourcEs sportEX publish journals and e-learning resources for people studying manual therapy and injury rehabilitation. If you run a training course and would be interested in providing access to these resources see the bottom of the page for more details. All resources are available online and via our mobile app. BEST of MANUAL THErAPy oNLINE BEST OF

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significant discounts available to both small and large training courses and colleges. Student subscriptions to sportEX medicine and sportEX dynamics also available. For more details about the content of the resources please visit the Manuals & Guides section at www.sportex.net and for pricing enquiries send me an email with approximate student numbers to tor@sportex.net

evidence informed practice

function, form and fascia: What lies beneath? BY Julian Baker

What do We knoW? Most readers of this journal will have at some stage pored over the pages of an anatomy book for any number of reasons: studying for exams, learning new techniques, working out methods of treatment or function. Whatever the reason, understanding how the body, or at least how the musculoskeletal system, works is fairly essential to the working therapist or trainer. But how much of what we see or read really tells us about body-wide movement and function? We tend to accept the truth of what we see and fit it around our understanding of the tools we use and the athletes we work with. But what if something fundamental is missing? What if the truth has been doctored and essential elements of the human form have been tidied away to such an extent that we no longer see what really lies beneath. After 20 years experience of soft tissue work, I attended my first dissection with Gil Hedley in San Francisco in 2007, confident that the structures and tissues around the body held no mystery for me. How wrong can one be? Everything I thought I knew

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Is what we have learned, really what Is there? The study of anatomy is what unites all therapists and coaches. Books line our shelves, and discussions abound about function, pain and injury – all of which stem from the study of these books. But what if the books weren’t revealing the whole truth? This article seeks to examine what we think we know about certain structures of the body, and balance this against what we really see when we go into a dissecting room with an open mind. turned out to be shrouded and hidden. The clarity of definition that I had expected was not there. I had moulded the fiction to fit my own reality and when nothing really resembled anything I had studied, the time had come to restructure my own truth. This is the experience that the dissection process tends to bring to those brave enough to step into the world of the dissecting room. Dissection can be approached in two ways. Firstly we decide to dissect in

a way that conforms to a ‘norm’ and directs our existing understanding or ideas. This then becomes a ‘prosection’, a process of preparing a cadaver so that the various structures and tissues are identifiable.

THE SuGGESTIon THAT Any MuSclE STopS WHEn IT GETS To BonE nEEDS To BE rEconSIDErED

FAScIA, BEInG MADE up oF A TrIplE HElIx oF collAGEn FIBrES, IS proDucED EVEry DAy AnD lAID DoWn In DIFFErEnT ArEAS AccorDInG To THE loAD plAcED In THoSE ArEAS The image shown in Figure 1 is a classic prosection that will have taken days, if not weeks to create. It gives a clear muscular picture of the muscles of the pelvis and upper thigh, yet is a created and brilliantly sculpted piece of artwork that bears no resemblance to the reality of the human form. It could be concluded that the distinction is not important, that we know how muscles move and connect in theory, so wider exploration of the

Figure 1: A prosection showing the muscles of the pelvis and upper thigh. (Image reproduced with the kind permission of Primal Pictures.)

form is unnecessary. The trouble with this approach is that it perpetuates the limiting view of muscle and function and thereby the way that injuries are viewed and treated. In addition, there are countless variations in the human form and many examples whereby what we see in a dissecting room is wildly different from what is depicted in the books. Any anatomical drawing will seek to create an average and will tend to over exaggerate the case in terms of the muscle or structure being depicted.

a historY of dissection Anatomy as a word derives from the Greek words ana (up) and tomia (cutting). So in a literal sense anatomy means to cut up. The implication from this is that the objects we cut up to study are generally dead. Hence anatomy, in its true sense, doesn’t really relate to the living, functional human being, but rather to cold inanimate structures, devoid of life. Anatomy study has had a chequered past, with the 2nd century physician Galen being prevented from performing human dissections by the laws of the day. This, however, did not stop him from writing thousands of pages of material and influencing medical practice for over 1400 years. Much of it was based in truth, but the lack of indepth study of the human form, meant that much was missed. When, in the 16th century, a Belgian called Andreas Vesalius started to challenge many of Galen’s principles, there was outrage amongst the academics of the time who clung tenaciously to Galenic teachings. Such was the concerted campaign against Vesalius, that with the flimsiest of evidence, he was reported to the Inquisition, tried and sentenced to death. Although this sentence was commuted to pilgrimage, he was shipwrecked while returning from Jerusalem, which led to his death, in penury, on the island of Zante in 1564 (1).

It was Vesalius who started the move away from the myths and speculations that had plagued medicine for over a thousand years and this was done predominantly through the process of human dissection. The anatomists of the 17th and th 18 centuries continued in their quest for greater knowledge of the body, but were often hampered by lack of materials. Grave robbing became the scourge of the times, with night watchmen often paid to watch over graves to prevent their occupiers falling in the hands of the ‘resurrectionists,’ as they became known (2). With the popularity of dissection and the shortage of donated material, dead bodies were exchanged for ready cash; it was no surprise that people were killed to be sold on for dissection. The most famous case was that of Burke and Hare in 1829, but one would hazard a guess that this was not an isolated case. The anatomy act of 1832 allowed for the use of unclaimed bodies from workhouses, and although highly unpopular and protested against, the act provided for a steadier stream of material for dissection, and dissection became a mainstay of medical and surgical training for the next 100 years.

the limits of classic dissection The dissector’s art, however, still followed the standard principle of reducing the body to a collection of parts, and little has changed to this day. The dissection of a shoulder will show us the muscles nerves and blood supply, but will not explain the relationships of this area to anywhere else in the body. In short, and in an attempt to maintain a degree of pragmatism, the study of anatomy is useful, but by itself just isn’t enough for those plying their trade in the sporting arena. A useful example is that of the group of muscles we refer to as

sportEX dynamics 2014;40(April):27-32

evidence informed practice

the hamstrings – biceps femoris, semitendinosus and semimembranosus. The universally accepted concept of the origin of this group is the ischial tuberosity. In sport, hamstring injury is one of the most common injuries and one to which most time is lost (3). It’s also an area where recurrence of injury is high and preventive programmes are difficult to establish (4). As a result the top of the leg is worked, stretched, pulled and pushed, but the injury levels continue unabated. So are we missing something?

the BodY as a continuum It seems nonsensical to insist on believing in the classic dissectionderived viewpoint that the hamstring group stops at the ischial tuberosity. For that matter, the suggestion that any muscle stops when it gets to bone needs to be reconsidered. We now know that fascia, the covering of all the organs, muscles, bones and tissues of our body, is the connective tissue that not only binds the muscle but also creates the continuity that will one day form our reconstructed view of the body (5,6). If, instead of looking at the origin or insertion of muscle to bone, we consider these bony attachments as references from which the tension of the structure can continue, then we can begin to look beyond the localised area of pain and injury and start to examine what relevant compensations might be in play in common injuries. Myofascial lines of strain are not a new concept and Tom Myers covers the theory extensively in his Anatomy Trains model (7). Antonio Stecco also demonstrates clearly the degree of fascial continuity that exists in the upper limb (8). As a model for considering the whole structure and human function, Anatomy Trains takes a huge leap forward and promotes the adoption of

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a top-to-toe model for assessment. But as with all models, the relationships suggested are theoretical in their existence and should not be taken literally. The sacrotuberous (ST) ligament does, in every case I have seen, join seamlessly in to the conjoined tendon of the biceps femoris, but this then moves obliquely to the sacrum and then on to the opposite side of the ilium. From here there are numerous possibilities as to where the line of strain could go, and every body will have a different accentuation (Fig. 2). Fascia, being made up of a triple helix of collagen fibres, is produced every day and laid down in different areas according to the load placed in those areas (9). ¬If a certain pattern of movement is adopted, whether through injury in the form of compensation, a limp for instance, or through a certain repetitive movement or even lack of movement, collagen fibres come together to form a supporting fibrous web that allows communication along through and along the structures it wraps. Hence, the hamstring ultimately not only connects to the sacrum, but more interestingly through the sacrum on to the opposite lower back. From this, I might reconsider the way that I view the connections. An elevated hip could potentially load a hamstring on the opposite side. conversely a shortened hamstring could pull through a hip on the opposite side. The possibilities of direction of strain are virtually endless and even small variations will potentially have impact and implications away from the area of initial assessment.

an open mind: neW thinking In dissection, it’s important to be as faithful to an open mind as possible. The tendency will be to discover what you intend to discover or prove. Instead

a B c

Figure 2: The piriformis (A), sciatic nerve (B) and biceps femoris (C) running in to the sacrotuberous ligament. (Photo credit: J. Baker. Image reproduced with the kind permission of Imperial College, Faculty of Medicine, Human Anatomy Unit, London, UK.)

the true explorer will look to challenge their own preconceptions: “Is what I think about A, B or c really true?” Gil Hedley says, “Hold on to your practice dearly and your theory lightly”. In this way we can follow where each body leads us. In the lab there will be constant calls to a table to see something that has been ‘discovered’. A muscle or bone presented in a different way, evidence of injury or repair, deviations of muscle, absences of what is expected and additions to the norm. In the same way that no two personalities are the same, no two bodies are the same, and this follows true in the dissective process; there is no ‘one size fits all’.

galea aponeurotica (scalp fascia)

splenius capitus scm scm Figure 3: The fascia over the sternocleidomastoid (SCM) muscle broadens out into the fascia of the scalp. (Photo credit: J. Baker. Image reproduced with the kind permission of Imperial College, Faculty of Medicine, Human Anatomy Unit, London, UK.)

I am constantly looking for opportunities to extend the way that we see the body and thereby human movement. The sternocleidomastoid (ScM) muscle is a beautiful shape and one that is often over looked when considering its role in flexion and the subsequent impact on breath, attitude, lower back and even knees. I had been ‘informed’ by a therapist and lecturer colleague, that the ScM was a sling that went across the back of the head, over the lamboidal suture and joined the other side. It seemed logical, but in the absence of a definitive reference, I wanted to see it for myself. The reality is a lot more

B a

Figure 4: Fascia over the adductor longus (A) and sartorius (B). (Photo credit: J. Baker. Image reproduced with the kind permission of Imperial College, Faculty of Medicine, Human Anatomy Unit, London, UK.)

spectacular (Fig.3) The ScM can very easily be removed from the mastoid process with its fascial continuity intact. However, far from being a sling, the ScM fascia broadens out into the fascia of the scalp, the galea aponeurotica, creating a bonnet or skullcap that spreads over the entire surface of the head. In addition, at the distal end, the fascia blends downwards into the sternum and in some instances all the way down to the rectus abdominus. The implications for this are far reaching. The head is a large weight on top of a relatively small pole. Think bowling ball balanced on a broom handle: 6–7kg of weight needing to be held in place and at the same time be highly mobile. As we walk and run, it is our head that tops off the weight of the body. Type in ‘Drunk Man’ on youTube and have a look at how the head decides where the rest of the body will follow in certain instances. A third example concerns the pubis. Any anatomy text will tell us that adductor longus inserts on to the pubic bone and adducts the thigh at the hip. A separate attachment posterior to this is the gracilis. There is little to argue with here, except for what we see before we start tidying up and trimming the white connective tissue away. In the pre-trimmed photo, we see that the overlaying fascia of the adductor is continuous over the pubic bone and into the fascia of the external oblique and rectus abdominus (Fig.4). What we can’t see here is that the whole of this layer has been detached from the pubis, creating a continuous fibrous sheet through from the abdominals into the adductors, which here also include the gracilis. As with the hamstrings, the strong suggestion is of tissues crossing over a central line and forming a wrapping or sling effect. In this instance one could follow these lines of strain around and into the serratus anterior. The

trouble with these observations is that they are always speculative in terms of function. We can never know the movement patterns of the deceased person we are working on. The lines and patterns that we see may or may not have been laid down as a result of their pattern of movement and until our imaging technology greatly improves, we will not know for sure. The dissection process does, however, give us the chance to try to see these patterns in the living form and visualise what it is we are touching and trying to affect. It’s worth noting that although I have talked about variations that can easily be observed in the human form, none of the pictures here represent uncommon variety. Each form presents the thickness and direction of tissue very differently, but in the matter of continuity these structures and connections are there in pretty much everyone. In some forms, the tissues will be thicker or more present and vary in size from area to area. What everyone has in common is that we see the connective tissues in greater prevalence than traditional anatomical volumes lead us to expect.

discussion If we are going to fully understand the true nature of our form and function, the traditional role is going to leave big gaps in our understanding. newton’s third law of motion tells us that for every action there is an equal and opposite reaction but this is easily neglected in assessing movement and function. Standing from a chair without lining up all our levers and pulleys is quite impossible and even when we are lined up, if we move our heads backwards just a couple of inches while engaged in the act of standing up, we will fall backwards. The tensions of our human form are subtle and balanced and it is our connective tissues in general and our

sportEX dynamics 2014;40(April):27-32

evidence informed practice

fascia in particular that give us this body-wide sensitivity. Through the dissective process we start to fully realise what it is that we are feeling beneath our hands when we treat or move someone. Everything we thought we knew has to be re-thought. Gandhi was once asked a question, to which he gave an insightful answer. The next day he was asked the same question and gave a different answer. challenged that the day before he had said something different, he simply responded, “yes but today I am better informed.”

BEcAuSE oF THE InTErconnEcTInG nATurE oF FAScIA, THE poSSIBIlITIES oF DIrEcTIon oF STrAIn ArE VIrTuAlly EnDlESS AnD EVEn SMAll VArIATIonS WIll poTEnTIAlly HAVE IMpAcT AnD IMplIcATIonS AWAy FroM THE ArEA oF InITIAl ASSESSMEnT

References 1. Benini A, Bonar SK. Andreas Vesalius 15141564. spine 1996;21:1388–1397 2. Moore W. The knife man: blood, body-snatching and the birth of modern surgery. bantam 2006. ISBn 978-0-553-81618-1 (£7.69). Buy from Amazon http://spxj.nl/1ftETdx 3. Dadebo B, White J, George Kp. A survey of flexibility training protocols and hamstring strains in professional football clubs in England. british Journal of sports medicine 2004;38(6):388–394 4. Woods c., Hawkins rD, et al. The Football Association Medical research programme: an audit of injuries in professional football-analysis of hamstring injuries. british Journal of sports medicine 2004;38:36– 41 5. langevin HM. connective tissue: a body-wide signaling network? medical hypotheses 2006;66:1074–1077 6. Hedley G. DVD Vol. 2: Deep fascia and muscle. In: The Integral Anatomy Series. Integral Anatomy productions 2005 (http://spxj.nl/1hWbWhV) 7. Myers TW. Anatomy trains: myofascial meridians for manual and movement therapists, 3rd edn. churchill livingstone elsevier 2013. ISBn 978-0702046544 (£34.67 Kindle edition £26.00). Buy from Amazon http://spxj.nl/1cpcfFI 8. Stecco A, Macchi V, et al. Anatomical study of myofascial continuity in the anterior region of the upper limb. Journal of bodywork and movement therapies 2009;13(1):53–62 9. Juhan D. Job’s body, 3rd edn. station hill press 2003. ISBn 978-1581770995 (£20.78). Buy from Amazon http://spxj.nl/1gEvmTd

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further resources 1. Julian Baker’s website: Functional Fascia. What fascia is and how we go about understanding it simply (www.functionalfascia.com). 2. Bowen Unravelled: A Journey into the Fascial Understanding of the Bowen Technique by J. Baker. lotus, 2013. ISBn 9781905367405 (Kindle £10.40). Buy from Amazon http://spxj.nl/1knAf5n 3. Fascia research Group, ulm university (http://fasciaresearch.de). 4. Gil Hedley’s website: gilhedley.com: Dedicated to exploring inner space by Gil Hedley (http://gilhedley.com). 5. Gil Hedley’s Integral Anatomy videos (http://spxj.nl/1cVbpZn) ThE AuThoR Th Julian Baker has been a Bowen Therapist for 25 years and a teacher of Bowen since 1994. The author of two books on Bowen, The Bowen Technique and Bowen unravelled; A fascial explanation of The Bowen Technique, he is one of the world’s leading experts on Bowen. After studying with Gil hedley, he has been studying fascial anatomy to better explain Bowen and as from this has led fascial dissection courses at Medical Schools throughout the uK and coordinates and co-teaches the Gil hedley six day integral anatomy class. his writing and presentations attempt to present complex subjects simply and in language that is easy to understand and follow and as a result he is regularly asked to speak and lecture around the world. his Functional Fascia company teaches fascial theory and dissection.

DISCUSSIONS

n What images arise in our minds when we palpate? n Do we understand the layers of tissue beneath our hands and how do we know what these consist of? n How much assessment/roM tests involve whole-body movement or understanding and are we tending to localise pain, injury and function?

keY points 1. classical anatomy does not explain function or variation. 2. dissection allows a more connected understanding. 3. dissection shows the true relationships. 4. images in books do not show the tissues as they really are. 5. dissection can be distorted to prove what you want to prove. 6. all the images in books are sanitised, cleaned up edited images. 7. as clinicians we miss much of the relationships in the body because our anatomical understanding is incomplete.

sportEX dynamics 2014;40(April):27-32

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web watch FacebOOk page yOu may wanT TO like

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The sports massage association www.facebook.com/The-Sports-Massage-Association - excellent resource particularly for members, where you can post and receive answers to questions about any activities relating to the SMA.

yOuTube n german documentary on fascia (now with English Translation) http://spxj.nl/1mcsRxI

linkedin grOups n sports massage Therapy corner (4k+ members) – discussions relating to all aspects of massage therapy with some good input from high profile sportEX authors like Bob McAtee n Therapeutic massage for pain control (4.5k+ members) – does what it says on the tin although occasionally veers off the stated forum topic. n sports massage uk (2.5k members) – good spread of topics both clinical as well as a business related. Useful resource if you’re a self-employed massage therapist.

acrOss n Fascia: architecture of connective tissue http://spxj.nl/1nxm03w n Fascia magnified x 25 http://spxj.nl/1cPRnBJ

crOsswOrd links n You can do an online version of this crossword puzzle at http://spxj.nl/Crossword02 n Solutions can be found here: http://spxj.nl/CrosswordSolutions n All sportEX crosswords can be found here: http://spxj.nl/CrosswordPuz

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crOsswOrd

separating or binding 1 Tendons, ligaments, etc. (2 together muscles and organs words) 3 Slant 6 Exists 4 Affecting the entire body 9 Bands of fibrous material 5 Of an arm bone that produce body 7 Rest period vital to recovery movement from injuries 11 Try to cure by special care 8 Relating to the parasympathetic or treatment nervous system 12 ____ scan 10 ___ corder 13 Thin and fit 14 Experiences fatigue 14 Separate forcefully, as of a 16 Roadside refuge muscle 17 Continent, for short 15 Pinch 17 Purpose 18 Wrestling hold 19 Song holder 21 Deepest of Swedish massage strokes 23 Under the weather 26 Economics, (abbr.) 28 Massages strongly 30 Muscle contraction 31 Word showing location 32 ______ points 34 Move slowly, with great effort 36 Prefix with pressure 38 “You __ my sunshine” 39 Motion related 40 Parts of the hand used by masseurs

18 Transcendental number 20 Loud noise 22 Medical trial 24 Wound 25 Musical scale note 27 Pictures, as from x-rays 28 First-aid, for one 29 Finger or toe 33 Auto club, abbr. 35 The radius is part of it 37 Higher

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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 arthr tighte of two bone ruent ntric and alar itis occu the main excess Cubo n when fibulas togetsurfanot with a defic the shin and conc uneven off joint (whic her, cesonly the id reaso rs on groun ient they stret entric if a patie 2. theare h form n but also the tibia two ACL beca d. ch recep 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 . 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