sportEX Dynamics Journal Issue 41 - July 2014 by Co-Kinetic

ISSUE 41 July 2014 ISSn 1744-9383

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sports sports ■ SOAP NOTES ■ LUMBAR MOBILISATIONS AND NEURODYNAMIC MOBILITY ■ WHIPLASH INJURY IN ATHLETES ■ CAREERS IN SPORTS THERAPY ■ BOOK REVIEWS

■ VOLUNTEERING AT LONDON 2010 ■ MUSCULOSKELETAL ASSESSMENT THE CYRIAX WAY ■ THE EFFECTS OF CORTISOL ON THE BODY ■ A DIFFERENTIAL DIAGNOSIS OF SHOULDER PAIN ■ CREATING CPD PORTFOLIO

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■ ATHLE TES, SYSTEM THE IMMUNE AND THE MASSAGE BENEF

■ VOLUNTEERING AT LONDON LON DON 2010 ■ MUSCULOSKEL ETAL ASSESSMENT THE CYRIAX WAY ■ THE EFFECTS OF CORTISOL ON THE BODY ■ A DIFFERENTIAL DIAGNOSIS OF SHOULDER PAIN

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■ SIMPLE TEST FOR INJURIES CALF ■ ASSESS MENT OF POSTURE ■ BIOMEC HANICS & CYCLING ■ BALANC ING YOUR WORKLOAD ■ BOOK REVIEWS

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■ TIBIAL IS POSTE DYSFUNCTIO RIOR N ■ BODY IMAGE ORNAMENT : INSTRUMEN

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■ THE TROUBLESOME KNEE ■ EVIDENCE-BASED MASSAGE ■ A STEP-BY-STEP GUIDE TO CPD ■ DVD AND BOOK REVIEWS ■ BREATHWORK AND SPORTS n WhAt PERFORMANCE is EViDE NCE-B PRACtiCE? AND WhY AsED n AssEss APPlY it? MENt OF thE hiP n stRENg JOiNt th PRiNCiPlEs tRAiNiNg – AND PRAC tiCE

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■ SIMPLE S INJURIE POSTURE PO MENT OF ■ ASSESS CYCLING HANICS & ■ BIOMEC WORKLOAD WOR ING YOUR ■ BALANC REVIEWS ■ BOOK

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■ LATEST RESEARC H NEWS ■ TAPING: DOES SUPPORT THE THE SCIENCE HYPE? ■ 21ST CENTURY ANATOMY ■ TAPING: CONTROL LING MYOFASCIAL TENSION ■ BIKE FITTING: FOR THERAPISOPPORTUNITIES TS

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sports care ■ USING GOOGLE SCHOLAR FOR CPD PURPOSES ■ THERAPIST INJURY RISKS ■ TREATMENT OF POSTURAL ABNORMALITIES ■ GAIT ASSESSMENT IN SPORT

Finalist in the 2010 Digital Magazine Awards

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■ PRE-SEASON MUSCULOSKELETAL SCREENING ■ EVIDENCE-BASED MASSAGE ■ PATELLA DISPLACEMENT MEASUREMENT ■ DEEP TRANSVERSE FRICTION ■ NEUROMUSCULAR RE-ABILITATION

■ ATHLETES, THE IMMUNE SYSTEM AND THE BENEFITS OF MASSAGE ■ TIBIALIS POSTERIOR DYSFUNCTION ■ BODY IMAGE: INSTRUMENT OR ORNAMENT

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■ BODY COMPOSITION

■ SIMPLE S INJURIE STUREE POSTUR MENT OF ■ ASSESS CYCLING C HANICS & OAD ■ BIOMEC UR WORKL YOUR ING YO ■ BALANC REVIEWS ■ BOOK

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■ MUSCLE PHYSIOLOGY AND MASSAGE ■ INTRODUCTION TO VACUUM CUPPING MYOFASCIAL

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■ CASE STUDY OF AN MSC IN MASSAGE ■ THE MASSAGE PRACTITIONER IN THE ELITE MEDICAL TEAM

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■ TISSUE LE MODIFIC LIFESTY SPORT UCTION TO ANKLE ■ AN INTROD FOOT AND SPECIFIC ITB INJURIES L HIP AND THE LATERA ■ PAIN IN LITERATURE TAPE - A ■ KINESIO REVIEW A INSPIRING ISTS N 2012 ■ LONDO TION OF THERAP GENERA

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■ EFFECTIVE PATIENT COMMUNICATION

■ SIMPLE TEST FOR CALF CALF INJURIES ■ ASSESSM ENT OF POSTURE RE ■ BIOMECHA NICS & CYCLING ■ BALANCIN G YOUR WORKLOA WO D ■ BOOK REVIEWS

■ MTSS CASE STUDY HIGHLIGHTS ■ AN OVERVIEW OF

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■ MUSCLE PHYSIOLOGY AND MASSAGE Finalist in ■ INTRODUCTION TO MYOFASCIAL the 2010 CUPPING Digital MagaziVACUUM ne Awards ■ CASE STUDY OF AN MSC IN MASSAGE ■ THE MASSAGE PRACTITIONER IN THE ELITE MEDICAL TEAM

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■ ALTERNATIVE EXERCISE PRESCRIPTION

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■ INSTRUMENT-ASSISTED SOFT TISSUE MANIPULATION

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■ THE TROUBLESOME KNEE ■ EVIDENCE-BASED MASSAGE ■ A STEP-BY-STEP GUIDE TO CPD ■ DVD AND BOOK REVIEWS ■ BREATHWORK AND SPORTS PERFORMANCE

■ CRANIOSACRAL THERAPY: ITS ROLE IN SPORT ■ SPORTS MEDICINE, REHABILITATION AND THE LAW

■ VOLUNT WA WAY LOSKELETAL ■ MUSCU MENT THE CYRIAX OL ON ASSESS OF CORTIS ■ THE EFFECTS SIS OF THE BODY NTIAL DIAGNO ■ A DIFFERE PAIN SHOULDER LIO G CPD PORTFO ■ CREATIN

■ HYDROTHERAPY IN SPORT ■ PODIATRY AND ITS ROLE IN SPORTS MEDICINE ■ CHIROPRACTIC AND SPORT

■ ATHLETES, THE IMMUNE SYSTEM AND THE BENEFITS OF MASSAGE ■ TIBIALIS POSTERIOR DYSFUNCTION ■ BODY IMAGE: INSTRUMENT OR ORNAMENT

■ TREATMATHLETES ‘ELITE’ PNF ■ MET VERSUS LIO ADVICE CPD PORTFO ■ MORE AL GUIDE GE SURVIV ■ MASSA EERING UPDATE ■ 2012 VOLUNT

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■ MUSCLE FACILITATED PHYSIOLOGY STRETCHING AND MASSAGE ■ INTRODUCTION TO MYOFASCIAL VACUUM CUPPING ■ CASE STUDY OF AN MSC IN MASSAGE ■ THE MASSAGE PRACTITIONER IN THE ELITE MEDICAL TEAM

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■ THE TROUBLESOME KNEE ■ EVIDENCE-BASED MASSAGE ■ A STEP-BY-STEP GUIDE TO CPD ■ THE TROUBLESOME KNEE ■ EVIDENC ■ DVD AND BOOK REVIEWS E-BASED MASSA ■ A STEP-B ■ BREATHWORK AND SPORTS Y-STEP GUIDE GE ■ DVD AND PERFORMANCE TO CPD BOOK REVIEW ■ BREATH S WORK PERFORMANCE AND SPORTS

■ ATHLETES, THE IMMUNE SYSTEM AND THE BENEFITS OF MASSAGE ■ TIBIALIS POSTERIOR DYSFUNCTION ■ BODY IMAGE: INSTRUMENT OR ORNAMENT

■ BODY COMPOSITION

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■ SIMPLE INJURIES ENT OF POSTURE ■ ASSESSM NICS & CYCLING ■ BIOMECHA D G YOUR WORKLOA ■ BALANCIN

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■ USING GOOGLE SCHOLAR FOR CPD PURPOSES ■ THERAPIST INJURY RISKS ■ TREATMENT OF POSTURAL ABNORMALITIES ■ GAIT ASSESSMENT IN SPORT

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■ ATHLETES, THE IMMUNE SYSTEM AND THE BENEFITS OF MASSAGE ■ TIBIALIS POSTERIOR DYSFUNCTION ■ BODY IMAGE: INSTRUMENT OR ORNAMENT

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■ BODY COMPOSITION

■ FUNCTIONAL FASCIAL ■ PLAYING HURT RESEARCH ■ INTERPRETING ■ FASCIA AND ANATOMY

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■ LATEST RESEARCH NEWS ■ TAPING: DOES THE SCIENCE SUPPORT THE HYPE? ■ 21ST CENTURY ANATOMY ■ TAPING: CONTROLLING MYOFASCIAL TENSION ■ BIKE FITTING: OPPORTUNITIE S FOR THERAPISTS

therapy

HIGHLIGHTS NEWS ■ LATEST RESEARCH ■ YOUTH STRENGTH AND CONDITIONING TRAINING

■ SELF-MYOFASCIAL RELEASE ■ ACHILLES TENDINOPATHY MANAGEMENT

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■ AQUATIC THERAPY IN SPORTS INJURY REHABILITATIO N ■ CRITIQUE OF FASCIAL RELEASE

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■ EVIDENCE FOR THE USE OF KINESIO TAPE – AN UPDATE ■ MAXIMISING THE GLUTEUS – PART 2

■ MUSIC, PAIN AND SPORT

■ BODY COMPOSITION

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■ TISSUE HEALING AND LIFESTYLE MODIFICATIONS ■ AN INTRODUC SPECIFIC FOOTTION TO SPORT AND ANKLE INJURIES

■ PAIN IN THE LATERAL HIP AND ITB ■ KINESIO TAPE - A LITERATUR REVIEW E

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■ THE USE OF OILS AND OTHER MEDIUMS IN SPORTS MASSAGE ■ ANKLE INVERSION SPRAIN ■ MASSAGE AND PRE-EVENT RIDERS ■ MYOFASCIAL TRIGGER POINTS IN MUSCULAR PAIN ■ THE LEGAL ASPECTS OF HEALTH AND SAFETY

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■ BODY COMPOSITION

promoting best practice in manual therapy

contents july 2014 issue 41

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

jul 2014

So with this issue we’re entering our 16th year of publishing and I’ve indulged in some reflection of this time on page 33+34. In sportEX medicine I’ve used my editorial to reflect on what this time has meant for our readers. Physical therapy has sadly got caught up in turf wars between professions, manual therapy on the other hand is going from strength to strength. In May we attended the inaugural Fascia Symposium which is to be held again in 2 years time. It was well attended with around 320 delegates from across the world and the speaker quality was superb. Having been involved with the Sports Massage Association from it’s inception and therefore having been very tuned in to the concept of fascia, it’s exciting to see so much happening in this area. Massage and manual therapy is really starting to fly. Not only is the evidence base for the benefits of massage growing steadily, but the almost daily discoveries about the interconnectedness of the body through the myofascial system, is even more exciting and we will be developing this area of content strongly in sportEX dynamics over the coming years. For me the subject of massage and manual therapy is is only going to get hotter and I’m thoroughly looking forward to seeing what comes from the next 15 years of publishing!

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

Tor Davies, physio-turned publisher and sportEX founder is published by Centor publishing ltd 88 nelson road Wimbledon, sW19 1HX Tel: +44 (0)845 652 1906 fax: ax: +44 (0)845 652 1907 www.sportex.net oTHer TiTles in THe sporTeX range

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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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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 Kinesio taping 13 fibromyalgia

ConTenTs

This quarter’s latest soft tissue research Find out why it is used and how to apply it chronic pain is a big problem in the UK. Improve your understanding of the conditions that cause it

17 Treating persistent pain 23 Teaching and learning anatomy 27 fascial stretching 33 sporteX milestones Empathy improves treatment outcomes Multimodal learning improves recall

Follow the 10 principles of Fascial Stretch Therapy for quicker results

A look back over the last 15 years of sportEX

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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online

click on researcH titles to go to abstract

Seven lucky male volunteers exercised on a cycle ergometer until 1.96 ± 0.25% body mass (mean ± SD) was lost. Participants were then randomly allocated a different beer to consume on four separate occasions. Drinks included a lowalcohol beer (2.3% ABV; LightBeer), a low-alcohol beer with 25mmol/L of added sodium (LightBeer+25), a fullstrength beer (4.8% ABV; Beer), or a full-strength beer with 25 mmol/L of added sodium (Beer+25). Volumes consumed were equivalent to 150% of body mass loss during exercise and were consumed over a 1h period. Body mass and urine samples were

Deep tissue massage anD nonsteroiDal antiinflammatory Drugs for low back pain: a prospective ranDomizeD trial. majchrzycki m, kocur p, kotwicki t. the scientific world Journal 2014;doi:10.1155/2014/287597 Fifty-nine patients, aged 51.8 ± 9.0 years old, with chronic low back pain were divided into given a treatment group (TG) who received 2 weeks of deep tissue massage (DTM) or a control group (CG) who received 2 weeks of DTM combined with non-steroidal anti-inflammatory (NSAID). Outcome measures were visual analogue scale, Oswestry disability index (ODI), and Roland-Morris questionnaire (RM). In both the TG and the CG, a significant pain reduction and function improvement were observed. All pre- versus posttreatment differences were significant but there was no significant difference between the TG and the CG.

sportEX comment DTM works for low back pain to reduce pain and increase function. NSAIDs bring no added benefit so save your money (and your stomach lining).

beer as a sports Drink? manipulating beer’s ingreDients to replace lost fluiD. Desbrow b, murray D, et al. international Journal of sport nutrition and exercise metabolism 2013;23(6):593–600 obtained before and hourly for 4h after beverage consumption. The results showed that significantly enhanced net fluid balance was achieved following the LightBeer+25 trial (–1.02 ± 0.35kg) compared with the Beer (–1.59 ± 0.32kg) and Beer+25 (–1.64 ± 0.28kg) treatments. Accumulated urine output was significantly lower in the LightBeer+25 trial (1,477 ± 485ml) compared with the Beer+25 (2,101 ± 482 ml) and Beer (2,175 ± 372ml) trials.

sportEX comment This is the sort of research we like and we are sorry that we didn’t report it earlier but we were doing our own bit of supping research to verify the results! On a serious note anyone familiar with sports where there is a high level of post-match social interaction will know that re-hydration strategies are often hard to follow. Think away games and a couple of crates of larger on the bus home. This study shows that all is not lost as long as you buy the right crate.

immunomoDulatory effects of massage on nonperturbeD skeletal muscle in rats. waters-banker c, butterfield ta, Dupont-versteegden ee. Journal of applied physiology 2014;116:164–175 Twenty-four male Wistar rats were subjected to cyclic compressive loading (CCL) over the right tibialis anterior muscle for 30min, once a day, for 4 consecutive days using four loading conditions: control (0N), low load (1.4N), moderate load (4.5N), and high load (11N). A custom-fabricated massagemimetic device was used to apply a pre-determined load as it moved. Microarray analysis showed that genes involved with the immune response were the most significantly affected by application of CCL. Load-dependent changes in cellular abundance were seen in the CCL limb for CD68+ cells, CD163+ cells, and CD43+ cells. Surprisingly, loadindependent changes were also discovered in the non-CCL contralateral limb, suggesting a systemic response. These results show that massage in the form of CCL exerts an immunomodulatory response to uninjured skeletal muscle, which is dependent upon the applied load.

sportEX comment And talking of evidence that massage works, here is a belter so SHOUT IT LOUD. Load tissue, as you do with massage, and there is a systemic positive immune response. As your mother said, “RUB IT BETTER”. sportEX dynamics 2014;41(July):4-7

JOURNAL WATCH

Journal watch o optimal types of exercise for lower limb osteoartHritis. stevens m, maher cg. british Journal of sports medicine 2014;doi:10.1136/bjsports-2013-093384 Analysis of sixty randomised controlled trials (8,218 patients) showed that a statistically significant benefit of exercise for both pain and function was apparent. Network meta-analysis of exercise interventions versus no treatment control on pain outcomes showed statistically significant improvement for strengthening exercise, strengthening plus flexibility, combined strengthening plus flexibility plus aerobics, aquatic strengthening and aquatic strengthening plus flexibility plus combined strengthening with flexibility and aerobic exercise. Overall the most effective exercise interventions were those consisting of strengthening exercises combined with aerobic and/or flexibility exercises.

sportEX comment An aging population doesn’t mean an inactive one and there are plenty of active individuals who want to continue sport and exercise despite having a bit of degeneration in the joints. This is evidence that it does them good.

five-week outcomes from a Dosing trial of tHerapeutic massage for cHronic neck pain. sherman kJ, cook aJ, et al. annals of family medicine 2014;12(2):112–120 Two hundred and twenty-eight subjects with chronic non-specific neck pain from an integrated healthcare system and the general population, were randomised into five groups receiving various doses of massage (a 4-week course consisting of 30min visits 2 or 3 times weekly or 60min visits 1, 2 or 3 times weekly) or to a single control group who were put on a 4-week wait list (ie. no treatment). Neckrelated dysfunction was assessed with the Neck Disability Index and pain intensity with a numerical rating scale at baseline and 5 weeks. Clinically meaningful improvement in neck-related dysfunction was rated as a change of≥≥5 points on Neck Disability Index or a≥≥30% improvement in pain intensity. The 30min treatments were not significantly better than the wait-list control condition in terms of achieving a clinically meaningful improvement in neck dysfunction or pain, regardless of the frequency of treatments. In contrast, 60min treatments 2 and 3 times weekly significantly increased the likelihood of such improvement compared with the control condition in terms of both neck dysfunction.

sportEX comment Dosage is the missing ingredient in almost all massage research which makes this study gold dust for those of us repelling the ‘there’s no evidence for massage’ lobby. There is, you just have to do enough of it.

a acute Hamstring inJuries in sweDisH elite sprinters anD Jumpers: a prospective ranDomiseD controlleD clinical trial comparing two reHabilitation protocols. askling cm, tengvar m, et al. british Journal of sports medicine 2014;48:532–539 Fifty-six Swedish elite sprinters and jumpers with acute hamstring injury (verified by MRI) were randomly assigned to one of two rehabilitation protocols. Twenty-eight were assigned to a protocol emphasising lengthening exercises (LP) and 28 to conventional exercises (CP). The outcome measure was the number of days to return to full training. Re-injuries were registered during a period of 12 months after return. The exercises of the LP were specifically aimed at loading the hamstrings during extensive lengthening, mainly during eccentric muscle actions. The CP consisted of conventional exercises for the hamstrings with less emphasis on lengthening. Each

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rehabilitation protocol consisted of three different exercises, one aimed at increasing flexibility, a combined exercise for strength and trunk/pelvis stabilisation and a strength exercise. All were performed in the sagittal plane. The intensity and volume of training were made as equal as possible between the two protocols. The training sessions were supervised, at least once every week, during the whole rehabilitation period, and the speed and load were increased over time. The time to return was significantly shorter for the athletes in the LP (mean 49 days, range 18–107 days), compared with the CP (mean 86 days, range 26–140 days). Irrespective of protocol, hamstring injuries where the

proximal free tendon was involved took a significantly longer time to return to full training than injuries that did not involve the free tendon, LP: mean 73 v. 31 days and CP: mean 116 v. 63 days, respectively. Two re-injuries were registered, both in the conventional exercises protocol.

sportEX comment On paper this looks as if the lengthening protocol is best and is worth doing, but despite the authors trying to match the athletes for age and sporting ability the huge difference in the range in healing times calls into question whether or not there is a level playing field.

online

click on researcH titles to go to abstract

prevalence of visits to massage tHerapists by tHe general population: a systematic review. Harris pe, cooper kl, et al. complementary therapies in clinical practice 2014;20(1):16–20 This systematic review looked at surveys (22 in all) reporting estimates of visits to a massage therapist in a 12-month period from six countries (USA, UK, Canada, Australia, Singapore

and South Korea). As there is no agreed set of criteria for assessing the quality of health-related surveys, the authors devised a six-item, literaturebased quality assessment tool which covered: (1) whether the complementary and alternative medicine therapy (CAM) use questions were clearly described and number of therapies/ questions reported; (2) whether the survey was piloted (this was assumed for government surveys); (3) whether the sample size was >1,000 and/or a CAM-specific sample size calculation was reported; (4) whether the reported response rate was >60%; (5) whether data were weighted to population characteristics (where appropriate) to reduce non-response bias; and 6) whether a 95% confidence interval or standard error were reported for the 12-month prevalence of CAM use. Sixteen of the surveys (73%) met at least four of six quality criteria. The results were that visits by adults ranged from 0.4% to 20% of the general population (median was

5.5%). For children 0.3–3.8% (median 0.7%), while estimates for older adults were 1.5–16.2% (median 5.2%) of the population. Some of the data came from government surveys. The five US government surveys estimated that between 2.0% and 8.3% of the adult (or all ages) population had visited a massage therapist in the previous 12 months. Rates were similar over the years surveyed (1995–2007). Rates for other government surveys were similar: 2.1–6.0% for the UK (2001–2005) and 2.0–7.8% for Canada (1994–2005).

sportEX comment What a great piece of work. A small but significant proportion of the populations of these countries are visiting massage therapists. We can’t speak for the other countries but in the UK there is a considerable reluctance on the part of the medical establishment to admit that massage is a viable treatment. Wake up NHS, all these people can’t be wrong.

skin cancer eDucation for massage tHerapists: a novel approacH to tHe early Detection of suspicious lesions. trotter sc, Qiong l-g, et al. Journal of cancer education 2014;29(2):266–269 One hundred and eighteen qualified USA massage therapists completed a 4h seminar on recognising skin cancer. They were surveyed before and after on their ability to spot conditions from a series of photographs. These included basal cell carcinoma, squamous cell carcinoma, cutaneous melanoma and a benign appearing nevus. At the post-seminar test an extra photo was shown. In each instance participants were asked if the image was suspicious for cancer. They were also asked facts about skin cancer and their comfort levels in recognising and discussing the topic with their clients. Stats included 48.3% stated that they regularly examined their clients for skin lesions during treatment and 39% had in the previous year referred three or more clients for medical examination because of suspicious lesions. Prior to the workshop 34.2% correctly identified the five ABC’s of melanoma identification (asymmetry, borders, colour, diameter, evolution). Post-workshop it was 87.7%. Being massage therapists, a number put ‘elevation’ instead of evolution. One final statistic of note was that 38% stated that they received cancer education in their initial massage courses and 73% said they had done some post-graduation.

sportEX comment New students often ask why they have to do anatomy and physiology in their training other than covering the muscles they are working on. The answer is that you never know what is going to come through the door. All massage therapists should be on the lookout for suspicious presentations. You could save someone’s life.

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JOURNAL WATCH

protein-enricHeD Diet, witH tHe use of lean reD meat, combineD witH progressive resistance training enHances lean tissue mass anD muscle strengtH anD reDuces circulating il-6 concentrations in elDerly women: a cluster ranDomizeD controlleD trial. Daly rm, o’connell s, et al. american Journal of clinical nutrition 2014; doi:10.3945/ajcn.113.064154 One hundred women aged 60–90 years old who were residing in 15 retirement villages were allocated to receive either progressive resistance training (PRT) twice a week with a diet that included 160g cooked lean red meat to be consumed 6 days/week (MEAT) or a control who undertook PRT with a diet of pasta or rice served per day (CRT). Measurements were taken for lean tissue mass (LTM), muscle size, strength and function, circulating inflammatory markers, blood pressure and lipids at various times in the study. The mean protein intake was greater in the MEAT group than in

the CRT group throughout the study the MEAT group experienced greater gains in total body LTM, leg LTM, and muscle strength compared with the CRT plus a 10% greater increase in serum insulin-like growth factor I and a 16% greater reduction in the proinflammatory marker interleukin after 4 months. There were no between-group differences for the change in blood lipids or blood pressure.

sportEX comment An increasing number of studies involving elderly populations appear in these pages. It is nothing to

s strain counterstrain tecHniQue to Decrease tenDer point palpation pain compareD to control conDitions: a systematic review witH meta-analysis. wong w ck, abraham t, et al. Journal of bodywork and movement therapies 2014;18(2):165–173 Strain counterstrain (SCS) is an indirect osteopathic manipulative technique that uses passive positioning to relieve tender point (TP) palpation pain and associated dysfunction. A literature search, conducted for publications from January 2002 and April 2012, yielded 29 articles for eligibility screening. Included studies were limited to randomised control trials comparing TP palpation pain after isolated SCS treatment compared to control conditions assessed with a visual analogue scale. Other study designs or manipulative treatments were excluded. Five randomised controlled trials were included for qualitative and quantitative analysis. The pooled effect of SCS was a reduction of TP palpation pain. Although all studies met at least 8 of 12 methodological quality criteria, most were of low quality.

sportEX comment What this means is that the technique appears to work but the evidence-base research quality is officially low. However, to get points on the methodological quality criteria index you have to do things like blinding the therapist and subject. Can you imagine how you could acheive that? Then there is the ethical issue of not treating or alternatively treating, subjects with a treatable condition. It’s a nightmare. www.sportEX.net

do with the editor’s advancing years. It is to do with the fact that we are keeping active for longer. Check out the leisure centres during the daytime if you want proof. This one shows that a bit of red meat is good for you.

tHe carDiometabolic conseQuences of replacing saturate fats witH carboHyDrates or omega-6 saturateD polyunsaturateD fats: Do tHe Dietary guiDelines Have it wrong? polyunsaturate Dinicolantonio JJ. open Heart 2014;1:doi:10.1136/openhrt-2013-000032 This essay challenges the long-held belief that saturated fats are bad for us. It starts with the history of the vilification of saturated fats and throws doubt on the original research. It also doubts the dietary guidance about fats and cholesterol, pointing out that in America the advice to increase carbs and decrease fats seems to have led to an epidemic of obesity and diabetes. It continues with what would appear to be dietary heresy by challenging the belief that low-fat diets are beneficial to health and quotes several randomised trials that indicate that a low-carbohydrate diet reduces weight and improves lipids more than a low-fat diet. One of these, the Women’s Health Initiative, showed that a low-fat diet did not reduce coronary heart disease, stroke or cardiovascular disease, nor was there a reduction in cancer. Another (a metaanalysis consisting of 21 prospective epidemiological studies, derived from 34,7747 participants) indicated that the intake of saturated fat does not increase coronary heart disease or cardiovascular disease. The final nail in the low-fat diet coffin is two randomised trials indicating a reduction in the incidence of major cardiovascular events with a Mediterranean diet compared with a low-fat diet, and the other showing that a Mediterranean diet reduces all-cause and cardiovascular mortality as well as non-fatal myocardial infarction compared with a prudent diet.

sportEX comment Confused? For years industries have been built on a mantra of low fat good, high fat bad. But now it’s being questioned on the reasonable grounds that over the long term figures don’t add up. This is an open access report that is well worth the read and may change your dietary habits.

Kinesiology taping The brighTly coloured Tape ThaT’s making a big sTaTemenT

Kinesiology taping is the current buzzword in the field of manual therapy. This brightly coloured tape is a common sight at all major sporting events from the Olympics to Wimbledon and the Commonwealth Games. With the growth in popularly it’s ever more important for anyone involved in osteopathy, physiotherapy, massage therapy or any other manual therapy, to have an understanding of kinesiology taping: why it is used, how it works and how to apply it. By John giBBons BsC, gosC sporTs & remedial TherapisT

The origins of kinesiology Taping In the 1970s a Japanese chiropractor, Dr Kenzo Kase, brought the technique to the international arena. Kase wanted to develop a taping system that would naturally assist in the healing of damaged tissue by encouraging lymphatic drainage and at the same time provide support to the joints and muscles without causing restriction to the range-of-motion (ROM).

Comparison of kinesiology Tape versus ConvenTional aThleTiC Tape Most types of athletic tape have very little or no stretch; however, kinesiology tape is very elastic and can be stretched longitudinally up to 120–180% of its original size. In addition, the thickness of kinesiology tape and its elasticity are similar to that of human skin. When non-elastic athletic tape is applied to an injury, the rigidity of the tape can cause a restriction or it can even prevent movement of the taped area as seen in Figure 1. This is desirable for severe injuries where immobilisation is necessary to prevent further damage. Most injuries, especially racket sport-related injuries do not 8

require full immobilisation and this is where the flexibility of kinesiology tape comes into its own. Specific kinesiology taping methods can therefore provide support to injured muscles and joints (Fig. 2), while still allowing a safe and pain-free ROM, unlike conventional taping. This enables athletes to continue training or competing while they recover from minor to moderate sports-related injuries.

kinesiology Taping meThod The kinesiology taping method (KTM) is another ‘tool’ for the therapist’s toolbox that can be used effectively in any sports or non-sports related setting. It can be applied in the comfort of a clinic, while treating an athlete at the side of the field or in the dressing room. It can even be applied to a hill walker on top of a mountain. Kinesiology taping is not a ‘standalone’ treatment as it is normally combined with other physical therapies, eg. soft tissue treatments such as muscle energy techniques (METs), myofascial techniques and joint mobilisations. Once this taping system has been thoroughly understood and practically applied, then and only then, will it provide an adjunct to any treatment protocol to assist the overall sportEX dynamics 2014;41(July):8-12

EvidEncE informed informEd practice practicE evidence

Figure 1: Non-elastic athletic tape is rigid and can restrict or prevent movement of the injured taped area. (Reproduced with permission from a practical guide to kinesiology Taping by J. Gibbons. Lotus Publishing, 2014. ISBN 978-1905367481)

occurring process, with the increased pressure that is building up within the soft tissues, will start to irritate the nociceptors (pain receptors) and pain will be perceived. As I often quote during my kinesiology taping courses, “swelling causes pressure and pressure causes pain; to reduce the pain we have to reduce the pressure, and this is where specific kinesiology taping procedures can be utilised to assist in the reduction of the pressure that has built up within the soft tissues”. Other treatment methods can also be used at the same time as kinesiology taping, eg. ice packs and non-steroidal anti-inflammatory drugs (NSAIDs). Kinesiology taping has been clinically shown to help with the natural response to inflammation as it targets different receptors within the somatosensory system. Correct application of KTMs helps alleviate pain and encourages the facilitation of lymphatic drainage by microscopically

lifting the skin as seen in Figure 4. This lifting effect helps create distortions in the skin, thus increasing interstitial space and allowing a decrease in the inflammatory process for affected areas.

BenefiTs of kinesiology Taping Kase et al. (1,2) claimed four main benefits for the application of kinesiology tape: 1. Normalisation of muscular function 2. Increased vascular and lymphatic flow by elimination of tissue fluid or bleeding beneath the skin 3. Reduction of pain through neurological suppression 4. Correction of possible joint misalignment by relieving abnormal muscle tension and helping to influence the function of fascia and muscle Murray and Husk (3) suggested a fifth mechanism: 5. Increased proprioception through

skin pain receptors compressed Figure 2: Kinesiology taping provides support to injured muscles and joints while still allowing safe and pain-free movement. (Reproduced with permission from a practical guide to kinesiology Taping by J. Gibbons. Lotus Publishing, 2014. ISBN 978-1905367481)

well-being of patients and sporting athletes.

how does kinesiology Taping work? Any type of injury or trauma to the body will set off the body’s natural protective mechanism known as the inflammatory response. The main identifiable signs of this response are: pain, swelling, heat and redness as well as restriction to the ROM. As shown with Figure 3, the underlying nerve endings, lymphatic vessels and blood vessels are in a state of ‘compression’ due to an injury. Any type of injury will cause an inflammation, as explained earlier, and this natural process will produce some form of swelling, eg. one common type of swelling is a haematoma, and subsequent pressure will build up within the tissue. This naturally www.sportEX.net

Blood and lymph vessels compressed Build up of lymphatic fluid inflamed muscle Figure 3: Pressure builds up in injured tissue. Injury causes inflammation, swelling and a build up of pressure in the tissue, which causes pain. (Reproduced with permission from a practical guide to kinesiology Taping by J. Gibbons. Lotus Publishing, 2014. ISBN 978-1905367481)

k tape pain receptors uncompressed Blood and lymph vessels dilated lymphatic fluid drained inflamed muscle

Figure 4: Kinesiology taping lifts the skin. Lifting of the skin by kinesiology tape encourages lymph drainage, reducing tissue compression and the associated pain. (Reproduced with permission from a practical guide to kinesiology Taping by J. Gibbons. Lotus Publishing, 2014. ISBN 978-1905367481)

increased stimulation to cutaneous mechanoreceptors. In addition, Kase described kinesiology taping applications for both ‘muscle facilitation’ and ‘muscle inhibition’ techniques. If kinesiology tape is applied from the muscle origin to the insertion with stronger tension, ie. 50–75% of its original length, this may enhance muscle contraction. However, applying kinesiology tape may reduce muscle contraction from the muscle insertion to the origin with weaker tension, ie. 15–25% of its original length (2). Lumos Inc, who own KT Tape®, a brand of kinesiology tape, outline the benefits of the tape as such:

“KT Tape is applied along muscles, ligaments, and tendons (soft tissue) to provide a lightweight, strong, external support that helps to prevent injury and speed recovery. KT Tape works differently for different injuries. KT Tape can lift and support the kneecap, holding it in place for runner’s knee. KT Tape can support sagging muscles along the arch of the foot, relieving the connective tissues for plantar fasciitis. Depending on how it is applied, KT Tape supports, enables, or restricts soft tissue and its movement. By stretching and recoiling like a rubber band, KT Tape augments tissue function and distributes loads away from inflamed or damaged muscles and tendons, thereby protecting tissues from further injury. KT Tape also reduces inflammation and increases circulation which prevents muscle cramping and lactic acid buildup.” (4) The physical therapy assessment of athletes/patients will be the key to deciding what the best treatment protocol is, and whether kinesiology taping is recommended. Information gained from this assessment/ consultation is therefore essential for obtaining the desired results from a kinesiology taping application, as well as any other treatment modalities. Kinesiology taping can be a valuable addition to the treatment protocol as it has been shown to have positive physiological effects on the skin, lymphatic vessels and subsequent circulatory system, as well as having a physiological effect on the fascia, muscles, ligaments, tendons and joints. Kinesiology taping can also be used in conjunction with a multitude of other treatments and modalities within the clinical setting and is very effective during the rehabilitative process. It can also be applied to an acute or chronic injury that has been sustained as well as being used for preventative measures. Kinesiology tape can be applied to the body in many ways and has the ability to assist the re-education of the neuromuscular system, reduce pain, control inflammation, enhance performance, stabilise joints, prevent

injury and promote good circulation and healing. It also assists in returning the body to its natural homeostasis.

how To use and apply kinesiology Tape Kinesiology taping products tend to come in a standard size and length that is normally 5cm × 5m, and this particular size is generally the choice of product for the qualified therapist. The therapist then decides on how and when to use this standard taping product as they will need to cut the tape for the individual patient or athlete who visits the clinic. However, some kinesiology taping products come in a pre-cut form, which in theory makes ‘life’ a little bit easier. My preference is to cut the size and shape of the tape myself at the time of the application.

kinesiology Taping appliCaTions There are many different ways of applying kinesiology tape and the preferred style can vary among therapists/coaches/athletes. I think it is best to stick to some simple rules and once one process has been learnt it can then be adapted according to the needs of the athlete/patient.

general rules Before application Do the following things before applying the tape: n Always check for a history of allergies to tape adhesives n Cleanse skin of any oil, cream and massage wax and trim hair if needed n Measure and cut the tape into the size and shape required n Round off the corners at the end of each tape to prevent it from lifting/ peeling n Never stretch the ends of the tape and leave between 2 and 3cm of tape at each end that will remain unstretched. Pre-stretch Before the kinesiology tape is applied to the injured area, guide and place the soft tissue of your athlete/patient, eg. the muscle, into a position that will cause the tissue to be naturally stretched. sportEX dynamics 2014;41(July):8-12

evidence informed practice

Tape application/stabilising technique Before applying the kinesiology tape, expose the adhesive side of the tape so that it can be attached to the specific body area. It is natural to want to ‘peel off’ the backing from the tape; however, this process is not needed as the tape can simply be ‘torn’ across one of the squares on the back of the tape. This tearing will not damage the kinesiology tape, as only the backing will be removed. Apply a prepared ‘I’ or ‘Y’ strip to the pre-stretched tissue of the body, with little to no stretch of the tape on first application. This technique will help stabilise the area. Pain offload application/ decompression strip The kinesiology tape (normally an ‘X’, ‘Y’ or a smaller ‘I’ strip) can be stretched between 25 and 100% of its original length. This type of application is commonly known as the pain relieving strip or decompression strip and is applied directly over the

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presenting area of pain.

summary of The uses for kinesiology Taping This article has provided an introduction to kinesiology taping and how it can be used by the practitioner. Kinesiology tape has many benefits, such as: n Provides support for weak or injured muscles without affecting the normal ROM. This allows full participation in therapeutic exercises and/or sports training and minimises the risk of developing compensatory imbalances or injuries n Stabilises the area without restricting the movement like conventional athletic tape n Allows the athlete and patient can remain active during the sport/ activity n Helps to reduce pain n Reduces oedema by removal of lymphatic fluid n Can enhance athletic performance and endurance

n Helps prevent injury n Provides psychological benefits as well as a placebo effect. Bibliography 1. Kase K, Tatsuyuki H, Tomoko O. Development of kinesio tape, pp.117–118. In: Kinesio Taping Manual. Universal publishing and printing 1996. ASIN B0018P7Q4O 2. Kase K, Wallis J, Kase T. Clinical therapeutic applications of the kinesio taping method, 2nd edn. Kinesio taping association 2003. ISBN 9780976960843 3. Murray H, Husk L. Effect of Kinesio Taping on proprioception in the ankle. Journal of orthopaedic & sports physical therapy 2001;31:a37 4. KT Tape® web site: What is KT Tape? http://kt-tape.ee/eng/kttape.aspx

furTher resourCes 1. A Practical Guide to Kinesiology Taping by J. Gibbons. Lotus Publishing, 2014. ISBN 978-1905367481 (£24.99) Buy from Amazon http://spxj.nl/1wrwuDn 2. YouTube video: How to apply kinesiology tape by John Gibbons (http://spxj.nl/1k3TpRn).

online

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

YouTube video: How to apply kinesiology tape by John Gibbons (http://spxj. nl/1k3TpRn).

YouTube video: How to apply kinesiology tape for an ankle inversion sprain by John Gibbons (http://spxj. nl/1k3TAvS)

John Gibbons 978 1 905367 48 1 120 pages, paperback, £29.99

Th auThor ThE JOHN GIIBBONS BSC, GOSC, SPORTS AND REMIEDIAL THERAPIST John is the author of a Practical Guide to Kinesiology Taping (Lotus Publishing 2014, ISBN 978-1905367481) Buy from amazon http://spxj.nl/1wrwuDn. rrP: £24.99 (includes free DVD). he is a qualified osteopath, registered with the General osteopathic Council (GosC). John specialises in the assessment, treatment and rehabilitation of sport-related injuries. having lectured in the field of sports medicine and physical therapy for over 12 years, John delivers advanced therapy training to qualified professionals within a variety of sports. n Explain the effect that the application of kinesiology tape has to the skin? n Explain some possible precautions DISCUSSIONS during the use of kinesiology tape? n There are currently over 60 different types of kinesiology tape that are available to buy in the market place. What type of information will you look for before purchasing the product? n What do you understand by the method of applying the tape either from the ‘origin’ or from the ‘insertion’? Do you think it makes any difference to the final outcome? Discuss your answer.

Comes with a FREE 90-minute DVD

key poinTs Gibbons guides the reader, step by step, through the entire process of taping by first marking an area of dysfunction, then preparing and cutting tape, followed by application with variants for specific problems. The opening chapter discusses the principles and benefits of the ‘kinesiology taping method’ (KTM), explaining what it is and when and why you would apply it. The following chapters are designed as a practical guide on the application of tape to treat each individual area of pain and dysfunction through the use of pictorial demonstrations; he also gives a few examples of injuries common to each area of pain and the subsequent variations in taping applications. The book, complemented by the DVD, highlights over ‘50’ specific areas of pain that are identified through individual artistic illustrations that have actually been drawn onto the body. John Gibbons is a registered osteopath with the General Osteopathic Council specializing in the assessment, treatment, and rehabilitation of sports injuries. Gibbons delivers advanced therapy training to qualified professionals within the Premiership football and rugby sectors. To purchase, please go to www.amazon.co.uk.

n kinesiology taping is definitely the current buzzword in the field of sports medicine. n kinesiology taping is not a ‘stand-alone’ treatment. n any type of injury or trauma to the body will set off the body’s natural protective mechanism, known as the inflammatory response. n swelling causes pressure and pressure causes pain. n kinesiology taping has been clinically shown to help with the natural response to inflammation. n kinesiology tape augments tissue function and distributes loads away from inflamed or damaged muscles and tendons. n kinesiology taping can be a valuable addition to the treatment protocol. n increased proprioception is gained by increased stimulation to cutaneous mechanoreceptors.

sportEX dynamics 2014;41(July):8-12

evidence informed practice

Fibromyalgia

The myofascial Trigger poinT connecTion As the number of chronic pain patients in the UK increases, especially patients suffering with fibromyalgia and chronic myofascial pain, a need exists to promote a better understanding of what these conditions are and how best to treat them. This article is for the therapist and the patient and for those with previously unexplained symptoms associated with fibromyalgia, myofascial trigger points and chronic myofascial pain. It will help to bring some clarity to the topic of fibromyalgia. Every member of the medical team involved in the treatment of chronic pain needs to be familiar with myofascial trigger points. BY John SharkeY MSc, Baca BaSeS

Background Fibromyalgia is neither musculoskeletal nor rheumatic. Fibromyalgia does not cause aching muscles. It does not cause numbness or tingling. Patients with fibromyalgia can have these and many other symptoms, but those symptom origins have been terribly misunderstood. So have the patients. Fibromyalgia is the term given to a family of illnesses that have in common central nervous system sensitisation and chronic diffuse systemic pain. Fibromyalgia is systemic, not local. A person cannot have fibromyalgia only in the hands or in the back. The central nervous system is the brain and spinal cord becoming the peripheral nervous system touching every cell in the soma. Fibromyalgia affects the whole body, causing a diffuse pain all over. Fibromyalgia does not cause localised pain. If there is localised pain, it is caused by something else, although fibromyalgia may also be present. Often, but not always, localised pain is caused by one or more myofascial trigger points (1). Fibromyalgia is a chronic bodywide muscle (myofascial) soreness syndrome associated with central and peripheral sensitisations. Sleep disturbance, chronic

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fatigue and visceral pain syndromes (including irritable bowel syndrome and interstitial cystitis) regularly accompany fibromyalgia. Fibromyalgia is characterised by hyperalgesia (amplified pain) and allodynia (which occurs when stimuli that are normally non-painful, such as touch, sounds, light and smells, are interpreted as intense pain by the central nervous system) (2). It is a critical point that myofascial pain syndrome is characterised by the presence of myofascial trigger points located in any of the millions of individual muscle fibres body-wide and not just where the â&#x20AC;&#x2DC;X marks the spotâ&#x20AC;&#x2122; (as seen on so many of the myofascial trigger point posters). This is not only misleading but can, I propose, provide the foundation for a false understanding of the location, aetiology and pathophysiology of myofascial trigger points and, therefore, hinder the possibility of positive therapeutic interventions (3). The problem these syndromes pose lies not in making the diagnosis of muscle pain but rather the need to identify the underlying cause(s) of chronic muscle pain in order to develop

a specific treatment plan. chronic myalgia may not improve until the underlying, precipitating or perpetuating factor(s) are managed.

PerPetuating factorS Precipitating or perpetuating causes of chronic myalgia can include structural or mechanical causes like scoliosis, localised joint hypomobility, generalised or local joint laxity, spastic activity and metabolic factors such as depleted tissue iron stores, hypothyroidism or vitamin d deficiency. Sometimes, correction of an underlying cause of myalgia is all that is needed to resolve the condition. Myofascial trigger points are one of the main factors generating and perpetuating fibromyalgia pain and other symptoms, no matter what initiated the fibromyalgia (1). Myofascial trigger points can cause acute or chronic pain, as well as seemingly unrelated symptoms that are often mistakenly linked to fibromyalgia. The myofascial trigger point can mimic many conditions, causing diagnostic confusion (2). Also, myofascial trigger points tend to refer pain in specific

MyOFAScIAl TrIggEr POInTS ArE OnE OF ThE MAIn FAcTOrS gEnErATIng And PErPETUATIng FIbrOMyAlgIA PAIn And OThEr SyMPTOMS 13

referral patterns (Fig. 1) (3). Peripheral stimuli, such as myofascial trigger points, may initiate noxious sensations including pain, nausea or dizziness. Amplified by fibromyalgia, the pain or other sensations can outlast the stimulus. research verifies that the central sensitisation of fibromyalgia can be initiated and/or maintained by peripheral pain (2). The referred pain of myofascial trigger points is itself a manifestation of central sensitisation (4). In fibromyalgia the filters that protect healthy people from central nervous system overstimulation are not working adequately (5). The fibromyalgia patient may not be able to pinpoint sources of pain, because his or her brain is totally preoccupied with attempting to handle a deluge of pain and other stimuli. In uncontrolled fibromyalgia, anything that can shock the central nervous system – including pain, loud noises and any other

startling stimuli – must be moderated or avoided. Any central nervous system assault can lead to fibromyalgia ‘flare’. during flare, old symptoms worsen and new ones may appear as new myofascial trigger points activate. Everything is hypersensitive. Try not to be overwhelmed if you realise that your patient has a whole dragon pack following them, or even riding on their shoulders. Tame those dragons, one at a time if need be. Make a list of things they can change. Work together with the patient to find a way for them to function without causing harm. become function-oriented: medications and therapies are needed to function – not to avoid function – and movement is key. Patients and therapists need to be aware of this (2). Pay attention to diet, sleep habits, excess alcohol consumption, smoking and the quality of the environment at home and at work. consider posture and alignment. To control the fibromyalgia pain amplification, you must control the pain generators. Far too many have insisted that myofascial trigger points are too complex to understand, and they lump everything under the label ‘fibromyalgia’, using it as a garbage-pail diagnosis. Anything that can perpetuate a myofascial trigger point is called a ‘perpetuating factor’. The initiating factor, the factor that causes activation of a specific myofascial trigger point, may be different from the aggravating or the perpetuating factors, but they

are commonly all called perpetuating factors. The key to controlling any symptom is the identification and control of as many perpetuating factors as possible. If myofascial trigger points are the ‘what’, then perpetuating factors are the ‘why’. An appropriate medical history will indicate if pain patterns are stable or evolving (1). chronic myofascial pain (cMP) is not progressive. The development of satellite myofascial trigger points that worsen symptoms, or cause the appearance of new symptoms, are indicators of perpetuating factors that are out of control. To control symptoms, you must identify and control perpetuating factors. If you do not, in spite of the best treatments in the world, the myofascial trigger points will recur (1). Most medical solutions currently centre on ‘fibromyalgia’ pain medications. Meanwhile, many treatable myofascial trigger point symptoms go untreated or mistreated, and many perpetuating factors remain unidentified and out of control, because not enough UK therapists have been appropriately trained to manage myofascial trigger points. Failure to comprehend the combination of myofascial trigger point pain-generation plus the pain amplification of fibromyalgia leads to undertreatment of the pain itself – yet another perpetuating factor. Therapists and patients alike must understand myofascial trigger points as well as fibromyalgia.

Figure 1: Myofascial trigger points in the temporalis muscle can cause myogenic (‘tension’) headache. This aching pain can extend to the upper teeth and include hypersensitivity to cold, heat and pressure. The teeth may not meet correctly, and there may be uncoordinated chewing, opening and closing of the jaw. These myofascial trigger points can contribute to teeth grinding. Temporalis myofascial trigger point proprioceptive dysfunctions include vertigo, nausea and hearing irregularities such as hypersensitive hearing and tinnitus. (Image reproduced with permission from healing through trigger Point therapy: a guide to fibromyalgia, Myofascial Pain and dysfunction by D. Starlanyl and J. Sharkey. Lotus Publishing 2013.)

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evidence informed practice

treatMent of MYofaScial trigger PointS The following list summarises the key points for treating myofascial trigger points: 1. To help differentiate the myofascial trigger point from pain points, cardinal signs must include: nodule and taut band, jump sign, twitch response, painful end-range of movement, referred pain and autonomic responses. 2. Treat myofascial trigger points that are most superior and medial first. 3. The deltoid seldom develops its own myofascial active myofascial trigger points. Instead most are ‘baby’ or ‘satellite’ myofascial trigger points so treat associated muscles within its functional unit. 4. The upper trapezius is the ‘grand central station’ of myofascial trigger points. 5. Active myofascial trigger points, when irritated by a competent therapist, will result in referred pain or changes in sensation that the patient recognises. 6. latent myofascial trigger points generally result in pain or change in sensations that the patient does not recognise. These myofascial trigger points may be contributing to but are not the true source of a patient’s problem. 7. Myofascial trigger points can form in any muscle fibre and not just in the centre of a muscle or where the ‘X marks the spot’ on so many myofascial trigger point charts; this is misleading (3). Identify and remove/change the perpetuating factor/s. 8. Excellent palpation skills are required to locate myofascial trigger points. 9. Upper or lower limb tension tests should be provided to rule out nerve insults including compression and/or inflammation. 10. Any patient suffering with unresolved pain or changes in sensations should have the possibility of myofascial trigger point involvement ruled out as a primary or secondary cause or contributor.

myofascial trigger points I have come to the opinion that the most effective method for the eradication of myofascial trigger points is by means of dry needling. dry needling saves therapist’s joints from stress while getting straight to the point. For the fibromyalgia patient the pain relief experienced from dry needling, warranted by appropriate health history and physical screening, is instant and much appreciated. If a patient complains of undue increased pain following a myofascial trigger point treatment it is imperative that the therapist be aware that this may be due to failure to identify (and therefore treat) all the myofascial trigger points in any one muscle. Failure to do so is akin to taking a stick and shaking up a hornet’s nest. As a clinical anatomist I appreciate the importance of excellent anatomical knowledge, palpation skills,

ThE MOST EFFEcTIvE METhOd FOr ThE ErAdIcATIOn OF MyOFAScIAl TrIggEr POInTS IS by MEAnS OF dry nEEdlIng clinical knowledge and experience all required for safe, appropriate and effective dry needling. Another effective therapeutic intervention for fibromyalgia and myofascial trigger points involves integumentary taping. The integumentary system is rich in sensory organs and free nerve endings. The skin takes information regarding the outside world to the brain providing a rich source of data required for various anatomical

After a long career in treating www.sportEX.net

functions. Free nerve endings are located in both the dermis and the epidermis (3). The brain is where pain is generated. changes in nociceptive signalling can be influenced by the monosynaptic reflex arc. Appropriate taping provides a therapeutic unloading of special nerve endings including bulbous corpuscles, Pacini endings and Meissner corpuscles and free nerve endings associated with Merkel cells. This unloading can reset monosynaptic reflex arc dysfunction providing a solution to chronic or acute pain problems.

SuMMarY Myofascial trigger points are an ignored yet common cause of acute and chronic pain in the aetiology of numerous chronic pain syndromes. As well as being a significant contributing factor in conditions such as medial and later epicondylalgia, headache, low back pain and fibromyalgia, myofascial trigger points can mimic many other conditions. This article is intended to better inform manual medical practitioners as well as general practitioners and other health care providers regarding what fibromyalgia is and what it is not and the importance of controlling or changing perpetuating factors, especially myofascial trigger points. In order to treat myofascial trigger points effectively one must understand the pathophysiology of trigger points and must recognise the cardinal signs that differentiate myofascial trigger points from tender points. More foot soldiers are desperately needed in the United Kingdom to fight the war on chronic pain and fibromyalgia. A need also exists for therapists of every stripe to consider myofascial trigger points as the main source or contributing factor in unresolved pain conditions. references 1. Starlanyl d, Sharkey J. healing through trigger point therapy: a guide to fibromyalgia, myofascial pain and dysfunction. Lotus publishing 2013. iSBn 978-1583946091 2. Staud r. biology and therapy of fibromyalgia: Pain in fibromyalgia syndrome. arthritis research & therapy

2006;8(3):208 3. Sharkey J. concise book of neuromuscular therapy: a trigger point manual. Lotus publishing 2008. iSBn 978-1905367078 4. gerwin r. Myofascial pain syndrome. here we are, where we must go? Journal of musculoskeletal pain 2010;18(4):329–347 5. carrilo-de-la-Pena MT, vallet M, gomezPeretta c. 2006. Intensity dependence of auditory-evoked cortical potentials in fibromyalgia patient’s: a test of the generalised hypervigilance hypothesis. the Journal of pain 2006;7(7):480–487.

online if you have a current subscription, login at www.sportex.net to view this video or download the mobile apps which are free to subscribers with online access. Video: Myofascial trigger Points. Courtesy of John Sharkey http://spxj.nl/1yIzvXd

further reSourceS 1. Healing through Trigger Point Therapy: A Guide to Fibromyalgia, Myofascial Pain and Dysfunction by d. Starlanyl and J. Sharkey. lotus Publishing 2013. iSBn 978-1583946091 2. Improve your practice with a part-time course from the national Training centre in Ireland leading to an Advanced certificate in neuromuscular Therapy (www.ntc.ie/massage-courses-uk). ThE Th AuThor John ShArkEy Sh MSc, BAcA BA BASES John Sharkey holds a medical degree (MSc) in clinical Anatomy (BAcA), he is an accredited exercise physiologist (BASES), and is founder and programme leader of the MSc in European neuromuscular Therapy, accredited by the university of chester. John is an accepted authority on the topic of chronic pain and is a member of the editorial board of the Journal of Bodywork and Movement Therapies. John is available for presentations, workshops or advanced cPD courses. contact John at: john.sharkey@ntc.ie

keY PointS n fibromyalgia is neither musculoskeletal nor rheumatic. n fibromyalgia does not cause aching muscles. n Myofascial trigger points can form anywhere in a muscle. n fibromyalgia is the term given to a family of illnesses that have in common central nervous system sensitisation and chronic diffuse systemic pain. n fibromyalgia is systemic, not local. a person cannot have fibromyalgia only in the hands or in the back. n Myofascial trigger points are a major perpetuating factor in fibromyalgia and chronic myofascial pain.

n Why is the presence of myofascial trigger points critical in characterising myofascial pain syndrome? n Why is dry needling the most effective method for treating myofascial trigger points? n Where is pain generated? DISCUSSIONS

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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trEating pErsistEnt musculoskElEtal pain Reclaiming a holistic fRamewoRk foR massage and manual theRapy BY Rachel FaiRweatheR Ba, cQSw lMt aOS

BackgROund Many manual and complementary therapies have at their heart a belief in holism, which is defined by the Oxford English Dictionary as, “The treating of the whole person, taking into account mental and social factors, rather than just the physical symptoms of a disease”. When I trained in massage in the early nineties, the term ‘holistic massage’ was in vogue, reflecting the need of bodyworkers to take the whole person into account in both assessment and treatment. Yet slowly and surely this term has become watered down and unfashionable for the serious practitioner interested in treating pain. The term ‘holistic massage’ started to signify a light and ineffective massage with lots of oil (often carried out to Enyatype music!). Terms such as ‘sports massage’, ‘remedial massage’ and the term we use at Jing ‘advanced clinical massage’ came into being to reflect the focus of the more serious massage therapist. Gradually the manual therapy profession as a whole came to place more emphasis on a structural model where the sole aim was to heal

This article outlines how the manual therapy profession has come full circle in the treatment of persistent musculoskeletal pain. Ancient wisdom is supported by modern research which shows that patients benefit most when manual therapy treatment is combined with empathy and good listening skills. damaged tissues and correct structural abnormalities. The psychological and emotional concerns of our clients started to take more of a back seat. The big question is that in doing so, in terms of treating pain, have manual therapists thrown the metaphorical baby out with the bathwater? Chronic musculoskeletal pain is a massive healthcare issue in Great Britain. Surveys estimate that a staggering 45% of the UK population suffers from musculoskeletal pain, with a corresponding effect on NHS resources, sickness absence and the economy (1). Yet long after we were able to put a man on the moon and develop the technology to send text messages instantaneously across the world, we seem to have gained precious little progress in how to effectively treat musculoskeletal pain. The A–Z of chronic pain problems is enough to fill any medic’s heart with dread: arthritis, back pain, carpal tunnel

CHrONIC MUSCUlOSKElETAl PAIN IS A MASSIvE HEAlTHCArE ISSUE IN GrEAT BrITAIN www.sportEX.net

syndrome, fibromyalgia, headaches, tennis elbow, temporomandibular joint disorder (TMJ), neck pain, shoulder problems and persistent sporting injuries are plaguing GPs’ surgeries across the UK. Orthodox medicine often has little to offer beyond basic self-care advice or a long waiting list to see a physio. This leaves consumers turning in desperation to the complementary health care sector – and in particular manual therapy. Can manual therapy really get to the bottom of these common but tricky conditions, or is it just a panacea to help manage symptoms? Which techniques are the best to use to get results and is there evidence to back this up? And, most of all, is there a place for the holistic model in the work of the 21st century massage therapist?

PaRadigM ShiFt: whY the PRedOMinant MOdel OF MuSculOSkeletal Pain iS wROng Medics, the general public and many manual therapists have been indoctrinated consciously or unconsciously with a predominantly structural paradigm to explain musculoskeletal pain. In short, tissues get damaged and an ensuing pain sensation is reported to the brain. 17

So muscles and ligaments tear and fray, discs herniate thus pressing on nerves, and joints wear down producing problematic bony spurs and uneven surfaces. Furthermore, improper alignment of our bones and joints leads to nasty painful symptoms. Anteriorlyor posteriorly-tipped pelvises, unequal length legs and bones that are ‘out’ need to be put back in to proper position to relieve pain. right? Wrong. The biggest newsflash in pain biology research over the past decade is this: The amount of pain you experience does not necessarily relate to the amount of tissue damage sustained.

There can be tissue damage without pain and pain without tissue damage. Yes that’s right. You can be riddled with bulging discs, rotator cuff tears and crumbly joints but be in no pain whatsoever. Conversely you can have real, excruciating and debilitating pain without a single iota of damage to any of your muscles, ligaments or joints. Consider these ‘strange but true’ facts from research studies: 1. tissue damage without pain seems to be reasonably common. Studies have shown that: n Fifty-two percent of those with no low back pain (lBP) have bulging discs and 27% a disc protrusion (2). Another study found that 32% of asymptomatic subjects had

THErE CAN BE TISSUE dAMAGE WITHOUT PAIN ANd PAIN WITHOUT TISSUE dAMAGE BOX 1: the authOR at wORk (Photo credit: A. Barratt, 2014)

‘abnormal’ lumbar spines when examined by magnetic resonance imaging (MrI) (3). n Partial or full rotator cuff tears can be found in 34% of people with no pain or other symptoms, with an amazing 15% having full thickness tears with no pain (4). n A study that carried out MrI on 45 asymptomatic participants with no history of hip pain revealed abnormalities in 73% of hips, with 69% of participants having labral tears (usually considered a major cause of pain and ensuing surgery) (5). n In another study, 61% of the subjects who had meniscal tears in their knees had not had any pain, aching, or stiffness during the previous month (6). Another study on MrI of the knee showed 16% of asymptomatic patients to have meniscal tears (7). 2. Findings from MRi and X-radiography are nOt related to the pain experienced in musculoskeletal complaints. For example, a study examining MrI scans of the shoulder in patients with arthritis found that thinning cartilage in the shoulder joint or the amount of bone spurs has no correlation with pain or function. Clients could be riddled with bone spurs or severely diminished joint space and have little evidence of pain or loss of function (8). Similarly, MrI of the spine of sciatic patients showed no relation between symptoms and degree of disc displacement or nerve root entrapment, leading the authors to conclude, “Magnetic resonance imaging is unable to distinguish sciatic patients in terms of the severity of their symptoms” (9). To be fair, there is some association between MrI findings and pain but this is fairly low and, therefore, not particularly clinically useful. A systematic review by Endean (10) concluded that there was a low association between MrI findings of disc protrusion and degeneration and nerve root displacement but individually, none of these abnormalities provides a strong indication that lBP is attributable to underlying pathology. sportEX dynamics 2014;41(July):17-22

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Similarly, van Tulder (11) concluded, “There is no firm evidence for the presence or absence of a causal relationship between radiographic findings and nonspecific low back pain”. 3. the widely accepted view in manual therapy that postural and structural deviations can lead to musculoskeletal pain is based on scanty evidence. lederman convincingly presents evidence that there is no relationship between postural and structural factors such as leg length difference, pelvic asymmetry, spinal curves and lBP (12). He concludes: “The lack of association between postural structural factors and low back pain has also important implications for what we aim to achieve and for our choice of techniques and exercise used to manage the condition. We can no longer justify the use of manual techniques to readjust, correct or balance-out the misaligned structure.” 4. Just as there can be tissue damage without pain, there can also be pain without tissue damage or structural abnormalities. The majority of low back pain (85%) is now classified as ‘non–specific’, ie. there is no identifiable structural cause such as herniated discs, spondylitis or irritated facet joints. The horrible and persistent pain of rSI (repetitive stress injury) in the wrists and hands has no associated tissue damage, neither does the debilitating pain and hypersensitivity of fibromyalgia or chronic headaches. This feature of pain without tissue damage is particularly true in chronic or persistent pain conditions and is known as ‘central sensitisation’.

nO BRain, nO Pain! lorrimer Moseley has said, “The brain decides whether something hurts or not – 100% of the time with no exceptions” (13). So if the pain condition is not always coming from damage to the tissues, what exactly is going on? In his likeable and readable books and talks on pain biology, neurobiologist lorrimer Moseley summarises prevalent research that shows how www.sportEX.net

S SOCIOlOGICAl FACTOrS CAN AlSO PlAY A PArT IN OU OUr ExPErIENCE OF PAIN pain is a perception of the brain rather than always being an accurate representation of what is happening at the tissue level. Thus, the sensation of pain can be heavily mediated by a variety of factors including emotional state, previous experience, expectations, sense of control over the pain condition and other social and contextual factors This reconceptualisation of the root of chronic pain has led towards a new paradigm known as the biopsychosocial model (a bit of a mouthful, hence commonly abbreviated to BPS) as first proposed by the psychiatrist George Engel (14,15). The biopsychosocial model contrasts strongly with the still prevailing biomedical view that sees pain as a result only of biological factors such as disease, abnormalities of structure or tissue damage. So here we are back with a fancy term for holism – the biopsychosocial model sounds suspiciously like the ‘mind–body’ paradigm that is a firm part of the belief system of most complementary practitioners. recent advances in brain imaging studies have now taken the mind–body model into the realm of science and shown that pain is indeed heavily influenced by our brains. Hence psychosocial factors including beliefs, feelings, emotional state, and sense of control over our circumstances have a much larger role than previously believed in whether we experience pain or not. The biopsychosocial model is now becoming widely accepted in medical

and scientific circles as the most relevant model for the treatment of chronic pain (16).

the BiOPSYchOSOcial MOdel: whY FeelingS ReallY dO huRt and whY Pain iS POlitical Broken down to its component parts the biopsychosocial model postulates that pain is due to the following factors.

Biological The biological components of the pain condition include factors such as disease, tissue damage or abnormalities of structure. For example in musculoskeletal conditions, the ‘biological’ components would be nociceptive inputs such as damaged soft tissue (sprains and strains), degenerative joints (osteoarthritis), disease processes (rheumatoid arthritis) and herniated discs. Our prevailing biomedical model of health usually assigns these components primary importance; however, as we shall see they are only one piece of the jigsaw.

Psychological Psychological and cognitive factors also contribute to the pain experience. These include: Emotions There is a complex and often selfperpetuating relationship between pain and emotion; for example, depression can lead to episodes of 19

chronic pain and chronic pain can lead to depression (17). A systematic review showed that stress, distress and anxiety are significant factors in the development of neck and back pain (18) and another study showed a strong correlation between a diagnosis of anxiety and chronic widespread pain (19). recent brain imaging studies have shown that emotions have a powerful effect on modulating pain: when experimental subjects were shown pictures that provoked different emotional states, this caused corresponding changes in relevant structures involved in pain processing in the brain (20). Pain-related beliefs Our belief about the pain condition can also have a huge effect. A common belief is known as ‘fear-avoidance’, where individuals in pain become terrified of movement leading to increased pain and disability (21). As thoughts themselves are nerve impulses they can be powerful enough to maintain pain states. Catastrophising Another common psychological feature of chronic pain is ‘catastrophising’, which consists of unhelpful thought patterns that basically foresee the worst possible outcome. You all know this syndrome: “I’ve hurt my back . . . I won’t be able to work . . . I will lose the house . . . I won’t be able to feed the kids and they will all be taken into care . . . I will end up in a wheelchair like Great Aunt Betty”. A more helpful thought pattern would obviously be: “I’ve hurt my back; it will get better in a few days; I’ll take it easy but it shouldn’t stop me going into work”. research has demonstrated a consistent relationship between the tendency to catastrophise and heightened pain experience. This has been demonstrated in many groups including those with mixed chronic pain, lBP, rheumatoid arthritis and whiplash (22). Furthermore, catastrophising is a better predictor of ensuing disability than disease-related variables or pain. In addition, catastrophising has been linked with increased use of health care services, longer durations of hospital stay and increased use of medication. 20

Unfortunately the medical profession sometimes doesn’t help with a tendency to catastrophise: a friend who went to the GP with a simple back pain was referred to the disabled hydrotherapy group! She was convinced she was going to be in pain for the rest of her life, whereas in actuality the pain was likely to be a simple soft tissue injury.

extremely effective in the treatment of chronic musculoskeletal pain conditions. Several systematic reviews have found that massage has a positive effect for lBP, especially when combined with self-care and exercise. (25,26) Our own clinical experience suggests that the manual therapist has a far greater chance of achieving success in treating chronic pain if the following factors are taken into account:

Social Sociological factors can also play a part in our experience of pain. For example, one study of those suffering from longterm whiplash pain (23,24) discovered that poor recovery was associated with factors such as: n Being female n Older age n Having dependents n Not having full time employment Clearly working with pain conditions is not a straightforward issue. Pain is not just about whether there are injuries or restrictions within the soft tissue and joint structures of the body but is a result of a number of factors including attitudes, beliefs, expectations, context, behaviour, poverty, oppression and social injustice. It is hard to know where we as individuals we can be most effective. Should we be working with the tissues, addressing psychological factors or out campaigning against social injustice? Without a doubt, physiology, psychology and politics all intertwine in the individual experience of pain.

iMPlicatiOnS FOR the Manual theRaPiSt So what does all this mean for the manual therapist wishing to make a difference in musculoskeletal pain? Chronic pain research suggests that some of the sacred cows of the profession may be based on faulty assumptions. In some cases we may be trying to heal tissue damage that doesn’t exist in the first place or has long since repaired. It may well be the fact that successful manual therapy interventions work more through reducing central sensitisation than healing damaged tissues or correcting errant pelvises. Both clinical experience and research suggest that massage can be

1. develop a strong therapeutic relationship with your client Whether you are a medical doctor, massage therapist, talk therapist or acupuncturist, a key component of facilitating wellness in your client is this therapeutic relationship or alliance. This refers to the sense of “collaboration, warmth, and support between the client and therapist” (27). research shows that if you have a good relationship with your doctor, this in itself means that you are likely to have an improved healthcare outcome regardless of what treatment you receive (28,29). As one reviewer put it, “Successful interactions between patients and their practitioners lie at the heart of medicine”. This is just as true for our work with musculoskeletal pain; studies have shown that positive therapeutic alliance ratings between physical therapists and patients are associated with improvements of outcomes in lBP and increased treatment satisfaction for clients with musculoskeletal problems (27,30). really? Can our client’s bad back be improving just because they like us? Is being smiley more important than soft tissue release? research suggests it is certainly a factor and points to the importance of the practitioner–client bond as part of a competent truly holistic healing process.

2. Perform a thorough and holistic assessment process Taking time to take time with your clients in the assessment process will pay off handsomely in terms of results. Kaptchuk et al. found that the quality and length of the initial interaction with a practitioner was strongly correlated with improvement measures (13). Clients receiving placebo acupuncture for irritable bowel syndrome were sportEX dynamics 2014;41(July):17-22

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randomly divided into three groups: ‘waiting list condition’, ‘limited interaction’ or ‘augmented interaction’. In the waiting list group, the patients had no interaction with the practitioner. In the ‘limited interaction’ the acupuncturist introduced himself and said that ‘he knew what to do’, after which the conversation ceased and the treatment began. In the ‘augmented interaction’ the patient and the practitioner had a 45min conversation before the treatment began where the practitioner expressed empathy, asked the patient about the symptoms, and told the patient that he had very positive experiences with treating these symptoms. The results showed how powerful the interaction with the therapist is independent of what happens in the actual treatment. Patients in the ‘augmented interaction’ group had a significantly greater improvement and more pain relief when compared with the group exposed to the ‘limited interaction’ of the confident but somewhat abrupt practitioner. The latter, in turn, had significantly more improvement than the waiting list group with no human interaction other than the sham acupuncture.

3. watch your language Be aware of how you talk to your client and the ideas you are planting as the ‘expert’. labels such as herniated disc, arthritis or scoliosis can sow the seeds of permanent disability and pain into your client’s psyche by exacerbating the tendency to catastrophise. Be realistic but reassuring about the potential route out of pain.

4. emphasise self-care measures Many clients in pain feel totally disempowered. Giving exercises or other recommendations to help them feel back in control is key to recovery.

5. don’t be afraid to cross-refer For some clients, catastrophising and other fear related beliefs can be helped with simple reassurance and education. Others may need a referral to talk therapist – CBT in particular has been found to be helpful in pain related conditions.

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6. educate, educate, educate Help put your client back in the driving seat. Educate them about musculoskeletal pain and reduce their fear of feeling out of control or dependent on the expert.

7. Focus on reducing nociceptive input with massage techniques Manual therapy techniques are probably best directed towards reducing any potential nociceptive input that may be contributing to maintaining central sensitisation (rather than attempting to correct perceived structural abnormalities). In our own clinical practice we use a combined approach with fascial work, precise trigger point therapy, acupressure and stretching. research has shown that trigger points contribute to central sensitisation (32); for example in whiplash, myofascial trigger points serve to perpetuate lowered pain thresholds in uninjured tissues. Additionally, it appears that lowered pain thresholds associated with central sensitisation can be immediately reversed, even when associated with long standing chronic neck pain (33). So manual therapists don’t be afraid to reclaim your inner holistic practitioner – put on the aromatherapy burner, crank up the Enya tunes and start treating your clients like a whole person again! References 1. Carnes d, et al. Chronic musculoskeletal pain rarely presents in a single body site: results from a UK population study. rheumatology 2007;46:1168–1170 2. Jensen MC, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. the new England Journal of medicine 1994;331:69–73 3. Savage rA, Whitehouse GH, roberts N. The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males. European spine Journal 1997;6(2):106–114 4. Sher JS, et al. Abnormal findings on magnetic resonance images of asymptomatic shoulders. the Journal of Bone and Joint surgery (am) 1995;77:10–15 5. register B, et al.. Prevalence of abnormal hip findings in asymptomatic participants: a prospective, blinded study. the american journal of sports medicine 40(12):2720– 2724 6. Englund M, et al. Incidental meniscal

findings on knee MrI in middle-aged and elderly persons. the new England Journal of medicine 2008;359(11):1108–1115 7. Boden Sd, et al. A prospective and blinded investigation of magnetic resonance imaging of the knee. Abnormal findings in asymptomatic subjects. clinical orthopaedics and related research 1992;282:177–185 8. Kircher J, et al. How much are radiological parameters related to clinical symptoms and function in osteoarthritis of the shoulder? international orthopaedics 2010;34(5):677–681 9. Karppinen J, et al.. Severity of symptoms and signs in relation to magnetic resonance imaging findings among sciatic patients. spine 2001;26(7):E149–154 10. Endean A, Palmer KT, Coggon d. Potential of magnetic resonance imaging findings to refine case definition for mechanical low back pain in epidemiological studies: a systematic review. spine 2011;36(2):160–169 11. van Tulder MW, et al. Spinal radiographic findings and nonspecific low back pain. A systematic review of observational studies. spine 1997;22:427–434 12. lederman E. The fall of the structural model. Centre for Professional development of Osteopaths Online Journal 2010: http://spxj.nl/1laSxJM 13. Moseley Gl. A pain neuromatrix approach to patients with chronic pain. Manual Therapy 2003;8(3):130–140 14. Engel G. The need for a new medical model: a challenge for biomedicine. science 1977;196(4286):129–136 15. Engel Gl. The clinical application of the biopsychosocial model. the american Journal of psychiatry 1980;137(5):535– 544 16. Gatchel rJ, et al. The biopsychosocial approach to chronic pain: scientific advances and future directions. psychological Bulletin 2007;133(4):581–624 17. Tunks Er, Crook J, Weir r. Epidemiology of chronic pain with psychological comorbidity: prevalence, risk, course, and prognosis. canadian Journal of psychiatry. 2008;53:224–234 18. linton SJ, et al. The role of depression and catastrophizing in musculoskeletal pain. European Journal of Pain 2011;15(4):416–422 19. Benjamin S, et al. The association between chronic widespread pain and mental disorder: a population-based study. arthritis and rheumatism 2000;43:561– 567 20. roy M, et al.. Cerebral and spinal modulation of pain by emotions. proceedings of the national academy of sciences of the united states of america 2009;106(49):20900–20905 21. rainville J, et al. Fear-avoidance beliefs and pain avoidance in low back pain-translating research into clinical practice. the spine Journal 2011;11(9):895–903 22. Sullivan MJ, et al. Theoretical perspectives on the relation between catastrophizing and pain. the clinical Journal of pain 2001;17:52–64 21

23. Harder S, veilleux M, Suissa S. The effect of socio-demographic and crashrelated factors on the prognosis of whiplash. Journal of clinical Epidemiology 51(5):377–384 24. Suissa S. 2003. risk factors of poor prognosis after whiplash injury. pain research & management 1998;8(2):69–75 25. Furlan Ad, et al. Massage for low back pain: an updated systematic review within the framework of the Cochrane Back review Group. spine 2009;34:1669–1684 26. 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 27. Ferreira PH, et al. The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. physical therapy 2013;93(4):470–478 28. Kelley JM, et al. The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and metaanalysis of randomized controlled trials. PloS One 2014;9(4):e94207

29. Kaplan SH., Greenfield S, Ware JE. Assessing the effects of physicianpatient interactions on the outcomes of chronic disease. medical care 1989;27(3 suppl):s110–27 30. Hall AM, et al. The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review. physical therapy 2010;90(8):1099–1110 31. Kaptchuk TJ, et al. Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome. BmJ 2008;336:999–1003 32. Shah JP, Gilliams EA. Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis: an application of muscle pain concepts to myofascial pain syndrome. Journal of Bodywork and movement therapies 2008;12(4):371–84 33. Freeman Md, Nystrom A, Centeno C. Chronic whiplash and central sensitization; an evaluation of the role of a myofascial trigger points in pain modulation. Journal of Brachial plexus and peripheral nerve injury 2009;4:2.

ThE auThoR Th r rACHEl FAIrWEATHEr BA (Hons), CQSW lMT AOS Rachel is a licensed massage therapist (LMT) and the co-director and founder of the Jing Institute of advanced Massage Training. She has been teaching and practising massage for over 20 years. She is also a Psychology graduate and has a certificate of qualification in social work (CQSW) with a keen interest in mind body approaches to health. Rachel has an associate degree in advanced massage from the New York College for holistic health and Education, where she gained awards for both academic and clinical excellence [associate in occupational studies (aoS)]. She has trained extensively in Eastern and Western bodywork including medical massage, craniosacral, myofascial, structural integration (KMI) trigger point therapy, Thai massage, amma therapy, sports massage, visceral manipulation, and neuromuscular techniques. Rachel writes regularly for several massage and complementary health magazines and is author of an upcoming book on advanced massage approaches to be published next year by handspring Publishing. She is a sought after guest lecturer for several institutions including McTimoney College of Chiropractic, CPDo (Centre for Professional Development of osteopaths), and numerous massage schools in the uK and uSa. She has also been the recipient for 2 years running of the CaM expo award for outstanding achievement in her field. abouT ThE JINg INSTITuTE based In brighton, London and Edinburgh, the Jing Institute run a variety of courses in advanced massage techniques to help you build the career you desire including myofascial courses, a 1-year advanced clinical massage certificate and a bTEC level 6 (degree level) in advanced clinical and sports massage – the highest level of massage training in the uK our short CPD courses include excellent hands on learning in a variety of techniques including trigger point therapy, myofascial release, pregnancy, hot stone and stretching. For the first time you are now able to learn these techniques at your own time and pace with our revolutionary new online courses and webinars. Contact the Jing Institute: Tel: 01273 628942; Email: info@jingmassage.com.

FuRtheR ReSOuRceS 1. JING Institute blog. Useful articles and Jing Tv video blog covering items of interest to massage and manual therapists (http://spxj.nl/1pYs0j8) 2. Why things hurt. video of lorrimer Moseley’s presentation at TEdx Adelaide on pain (http://spxj.nl/1j5Y3sU) 3. BodyinMind.org. Website with blogs and articles on the role of the brain and mind in chronic pain (http://spxj.nl/Sfcdan) 4. Neuro Orthopaedic Institute (NOI) Australasia website: sign up for their informative email newsletter (http://spxj.nl/1hdm5Al).

keY POintS n Massage and other manual therapies have moved away from a holistic approach that takes the whole person into account in assessment and treatment. n research shows that there is no straightforward relationship between tissue damage and pain: there can be pain without tissue damage and tissue damage without pain. n Pain is a perception of the brain: the sensation of pain is heavily mediated by a variety of factors including emotions, cognitions and social factors. n The biopsychosocial model is a more relevant model for bodyworkers than a structural model. This model takes into account not just biological causes of pain (tissue damage and structural abnormalities) but psychological and social factors. n The phenomenon of pain without tissue damage is known as central sensitisation. This is a real and common occurrence in many chronic musculoskeletal pain conditions. n The therapeutic alliance with the client is of prime importance when treating chronic pain conditions. n Implications for the manual therapist include: taking time to do a thorough assessment; minimising catastrophising beliefs and language; emphasis on client control and self-care; education; manual therapy techniques that reduce potential nociceptive input such as trigger point and myofascial release.

DISCUSSIONS

n What is the relationship between tissue damage and pain? n What type of factors can mediate the sensation of pain? n What are the implications of the biopsychosocial model for the manual therapist in terms of client assessment and treatment?

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teaching and education

Optimising the teaching and learning Of anatO anatOmY BY Daniel J. amin BSc mSc, GSR

BackGRounD Discrete sport therapy and sport injury programmes are becoming more common within Further Education (FE) and Higher Education (HE) delivery in the form of BTEC, BSc and MSc courses; searching for ‘sport therapy’ within the University and Colleges Admission Services (UCAS) website reveals 41 education providers (1). Despite this still being low in comparison to the 133 ‘sport science’ providers (2), sport therapy and sport injury-related modules are commonly taught within these more broader sport science programmes, and is often where most students encounter this field of practice for the first time.

leaRninG StYleS The aim for all teachers, tutors and lecturers is to develop and maximise learning amongst their students; however, this is often easier said than done. Depending on the learning preference of an individual learner, it is often not suitable to just present information in one particular manner (3). A variety of learning styles exist: for example, students’ learning can be visual, auditory, reading or kinaesthetic in nature (4); it could be dependent one particular hemisphere of the brain (5); or could be optimised by experimentation, experience, observation or analysis (6). The examples and theories of learning are extensive (7,8) and this article is not the

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Musculoskeletal functional anatomy is a key component of sport therapy, and ensuring anatomy learning and consolidation is a vital aspect for a lecturer to consider given that it is required for student recall throughout a course and beyond the confines of being an undergraduate. A common issue with students is that after a year without a discrete anatomy lesson, when it comes to applying their anatomical knowledge, ie. during ROM assessment in massage, they often struggle to recall and apply their anatomical information in order to effectively enhance their clinical practice.

A SOUnD knOwlEDgE OF MUSCUlOSkElETAl FUnCTiOnAl AnATOMy iS A kEy THEORETiCAl ASpECT UnDERpinning pRACTiCAl SpORT THERApy

appropriate place to discuss them; however, some aspects of sports therapy do lend themselves to a particular style of learning and, often, learner preference is directed towards more active, kinaesthetic approaches, ie. more hands-on practical learning (9). But should this approach be applied just to the learning of practical skills? would the theoretical underpinning of sport therapy benefit from more of this active, kinaesthetic focus?

GooD teachinG of muSculoSkeletal functional anatomY iS cRucial Musculoskeletal functional anatomy (MFA) is arguably the most important aspect of theoretical underpinning in sport therapy, and is a vital link for subsequent learning, ie. kinematic analysis of movement, injury assessment, treatment and rehabilitation, strength and conditioning, and functional movement assessment. As such, it should be introduced at the earliest possible stage within a curriculum and ensured that learning of this content is consolidated beyond the formal assessment scenario. This is imperative when considering the aforementioned links to future topics. Understanding the location of skeletal structures and landmarks, and the location of muscles in addition to knowledge of their origin(s), insertion(s) and action(s) is, therefore, vital for the sport therapy student. So, the question arises, “How best to deliver the MFA aspects of sports therapy, so that they remain embedded with students for their entire educational journey?”

1. material introduced during lecture (predominantly visual in nature)

2a. Peer learning (predominantly auditory in nature)

2. Primary practical focus of learning (problembased and kinaesthetic in nature)

2b. assisting material (visual content from original material)

3. consolidatory workbook

Figure 1: Multimodal approach to teaching anatomy in sport therapy. (D. Amin, 2014)

During my earliest years as an education practitioner, i was not responsible for the anatomy module, and so often i would encounter students who didn’t know their gluteus maximus from their olecranon. This was frustrating when trying to teach them range-of-motion assessment or functional rehabilitation or emergency aid. So, in the first instance, it is important that the person in charge of the anatomy module is a specialist. This may seem a given, however, it is not always the case as anatomy is often not seen as a ‘specialist’ subject – unlike sport and exercise massage, injury rehabilitation, applied psychology, drug use in sport, etc.

multimoDal leaRninG Currently, the literature focuses predominantly on students studying on biomedical programmes and has found that anatomy is taught in the following ways: body painting (10); text-based (11); the use of cadaveric specimens (12); near-peer learning (13); and computer-aided learning (14). Although there are merits to these approaches, there are limitations and often they are not best-suited for/available to the sport therapy student looking to enter the clinical environment upon graduation or during their undergraduate experience. My own anecdotal experiences of teaching anatomy on sports programmes over the last 7 years have led me to develop a multimodal approach (Fig. 1), with a primary practical focus. This multimodal approach, normally entails initially presenting the students with a visual overview of the key anatomical structures that they need to know, along with the additional information associated with the structure, ie. what is its action, origin, insertion, what attaches to it, what movement does it prevent, etc. This initial visual overview is either in the form of 2D or 3D images (Fig. 2a, b) (15) or videos. Once the anatomy has been introduced, it is then quickly followed by the primary practical focus of the learning, which emphasises the kinaesthetic nature of learning. it entails the students being in the clinic and consists of practical palpation of the key structure, accompanied with minimal resisted movement (as in the case of clinical, manual muscle testing) when having to identify muscular structures (Fig. 3). This has worked well with students in both visually identifying structures and the actions of muscles. For instance, a student resisting their partner’s knee during flexion, will clearly see the hamstring muscles in more detail from a macroscopic point of view. Adding resisted external rotation, for instance, will then emphasise the biceps femoris to the student. During this practical learning, it is imperative to also have the learner talk their partner through exactly what they are identifying and what the key associated information is. peer-learning becomes vital in this instance to enable consolidation of accurate information (16). By applying the resisted force, students not only are able to learn important anatomical content for their anatomy modules, but are, more importantly, also being prepared to apply it to future modules such as strength and conditioning, assessment of movement, injury rehabilitation, etc., with limited need for recap and revision (which can often be laborious when other concepts need to be prioritised). sportEX dynamics 2014;41(July):23-26

teaching and education

Gastrocnemius Origins: Medial head – medial condyle of femur lateral head – lateral condyle of femur Insertion: Calcaneus Action: knee flexion Ankle plantarflexion

trapezius Origins: Occipital bone C7-T2 Insertion: Clavicle Scapula Action: Head extension and lateral flexion Scapula retraction and elevation

Figure 2: 2D or 3D images, such as those at Primal Pictures (15), or videos provide a good initial visual overview of the anatomical structure. (Primal Pictures)

Figure 3: Hands-on learning. The initial visual learning experience is quickly followed by practical focus, consisting of palpation of the key structure accompanied with minimal resisted movement helps the identification of muscle structures. (D. Amin, 2014)

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MUlTiMODAl lEARning invOlvES THE pRACTiCAl COnSOliDATiOn OF THEORETiCAl COnCEpTS uSe a vaRietY of leaRninG oPPoRtunitieS As mentioned towards the beginning of this article, a variety of learning opportunities should be presented, so the practical learning of theoretical concepts should be supplemented by the content and activities provided in the more traditional lectures. Around the clinic, for instance, consider putting up the visual content from these lectures so that students have easy access to reference material. This content can also be collated to create a reference workbook. Despite the main outcomes for their learning to be consolidation of information that can be applied in future scenarios (17) students still, obviously, also have a high preference for achieving good grades in their assessments and, as such, a crib table for revision purposes is created for those students who wish to use one. This multimodal approach aims to meet a variety of learning styles so that all learners are sufficiently challenged, but it also aims for much of this important content to become second nature to the learner and something that can be recalled when in the clinical setting. Since introducing this approach, there has been a noticeable improvement not only in cohort scores for the anatomy module on our programme at level 4, but also in the strength and conditioning, assessment of injuries and sport massage modules that are studied at level 5.

DifficultieS of teachinG muSculoSkeletal functional anatomY However, some difficulties can be encountered when trying to best teach MFA, such as an instant reluctance for new undergraduates to be dressed down to their underwear in front of relative strangers. Similar observations have been found elsewhere (18), although emphasising the industry nature of such an occurrence encourages them to take a professional attitude from the onset. Often the volume of knowledge that the student encounters is difficult for them to carry forward beyond the actual assessment (19) – a minimum of 250 discrete pieces of information are often required to encapsulate key anatomical knowledge with relation to sport therapy. Hence, the importance of providing a multimodal method of delivery to enable the students to learn and consolidate as much of this as possible so that when it is required for recall, possibly over a year later and beyond, there is minimal need for the lecturer to spend time recapping all this important information. 25

MUlTiMODAl lEARning wORkS wEll wiTH STUDEnTS in BOTH viSUAlly iDEnTiFying STRUCTURES AnD THE ACTiOnS OF MUSClES SummaRY The benefits of optimising the learning of MFA in sports therapy are hopefully clear – it is a foundation for many aspects of future learning on a student’s higher education programme, in addition to future possible employment. The multimodal model of learning described here is one that aims to be as close to the clinical scenario as possible, and hopefully, overcomes the pitfalls that students face when requiring to learn this content. References 1. University and Colleges Admission Services (UCAS) website. ucaS Search tool: helping you into university & college in the uK http://spxj.nl/1kgSeq6 (Accessed 15 May 2014) 2. UCAS website. ucaS Search tool: helping you into university & college in the uK http://spxj.nl/1xhrRMM (Accessed 13 May 2014) 3. pask g. Styles and strategies of learning. educational Psychology 1976;46:128–148 4. Fleming nD, Bonwell CC. vARk: A guide to learning styles. VaRKLearn 1998: http://spxj.nl/1i8A5wT (Accessed 14 May 2014) 5. Dunn R. Hemispheric preference: the newest element of learning style. american Biology teacher 1982;44:291–294 6. kolb DA. The learning style inventory: technical manual. McBer & company 1976. aSin B0006X5KMo 7. Cassidy S. learning styles: an overview of theories, models, and measures. educational Psychology 2004;24:419–444 8. Coffield F, Moseley D, et al. Should we be using learning styles? what research has to say to practice. Learning and Skills Research centre 2004. iSBn 1853389145 http://spxj.nl/1mMkpAk 9. peters D, Jones g, peters J. preferred ‘learning styles’ in students studying sports-related programmes in higher education in the United kingdom. Studies in higher education 2008;33:155–166

ThE AuThOR Th DAnIEl J. AmIn BSc mSc, GSR D Daniel Amin has been a lecturer in sport injury and rehabilitation for the past 7 years, in addition to being a practitioner in the field of injury rehabilitation within semi-professional football. he achieved a distinction at masters level in Sport Injury Rehabilitation from the university of Salford and has used much of this work to not only inform his practice whilst delivering the undergraduate programmes at his institution, but also to present at many international conferences and achieve publication in several peerreviewed journals. his current research interests lie with how functional movement correlates with athletic performance outcomes, and how to use digital technology to optimise the feedback process for undergraduate students.

10. nanjundaiah k, Chowdapurkar S. Body painting: a tool which can be used to teach surface anatomy. Journal of clinical and diagnostic Research 2012;6:1405–1408 11. Azer SA. learning surface anatomy: which learning approach is effective in an integrated pBl curriculum? Medical teacher 2011;33:78–80 12. Mclaghlan JC, patten D. Anatomy teaching: ghosts of the past, present and future. Medical education 2006;40:243–253 13. Evans DJ, Cuffe T. near-peer teaching in anatomy: an approach for deeper learning. anatomical Sciences education 2009;2:227–233 14. veneri D. The role and effectiveness of computer-assisted learning in physical therapy education: a systematic review. Physiotherapy Review and Practice 2011;27:287–298 15. primal pictures. Functional anatomy. 3d Human Anatomy Medical Software, 2010: http://spxj.nl/1mynDCg (Accessed 14 May 2014) 16. youdas Jw, Hoffarth Bl, et al. peer teaching among physical therapy students during human gross anatomy: perceptions of peer teachers and students. anatomical Science education 2008;1:199–206 17. McCrory p. How should we teach sports medicine? British Journal of Sports Medicine 2006;40:377 18. Finn gM, Mclachlan JC. A qualitative study of student responses to body painting. anatomical Sciences education 2010;3:33–38 19. prince kJ, Scherpbier AJ, et al. Do students have sufficient knowledge of clinical anatomy. Medical education 2005;39:326– 332.

fuRtheR ReSouRceS 1. getBodySmart – An online human anatomy and physiology textbook (http://www.getbodysmart.com/)

keY PointS n knowledge of musculoskeletal anatomy is an essential foundation for sport therapy. n Optimising teaching styles to suit students is vital to enhance learning. n Developing a multimodal approach to learning anatomical concepts helps for consolidation of information. n Emphasising a practical, kinaesthetic approach to learning anatomy transfers well to future clinical learning and practice. n There is limited literature focusing specifically on how sport therapy and sport rehabilitation students learn best.

DISCUSSIONS

n Consider how a multi-modal approach to teaching can enhance the delivery of other foundations of sport therapy learning. n How do you enhance the teaching of theoretical concepts of anatomy? n what aspects of sport therapy do you believe to be ‘threshold concepts’?

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EvidEncE informEd practicE

Improve squat patternI patternIng wIth FascI FascIal stretch therapy™ Stretch to Win – Fascial Stretch Therapy® (STW-FST) offers sport manual and movement therapists and trainers a quick, effective and logical system to improve function. STW-FST combines innovative passive, active and assisted mobility and stretching movement patterns that can be used to remove the restrictions that are the barriers to good mobility. The squat is used as an example and we will focus on the hip, knee and ankle. This article, Part 1, introduces and describes the STW-FST system, with a focus on the hip. The next article, Part 2 which will be published in October, will focus on the knee, foot and ankle for a comprehensive discussion of correcting faulty patterns in the squat movement.

By chrIs FrederIck pt, kMI

IntroductIon The focus in this article is to introduce you to how to use Fascial Stretch Therapy (FST) techniques to correct faulty movement patterns in the squat. Then functional training can progress safely and not get interrupted or slowed down by pain, weakness or imbalances caused by movement restrictions. A consequence of this is better, faster, more complete results with greater confidence gained from both therapist/trainer and client.

What Is FascIal stretch therapy? FST is a modified proprioceptive neuromuscular facilitation (PNF)-based, client-assisted flexibility system. The therapist/trainer uses hands-on, direct techniques on a table with stabilisation straps to assess and remove restrictions to movement in joints, muscles, fascia and the nervous system (Fig. 1). Results are quicker and more thorough than traditional, isolated stretching because of the following 10 Principles that make up the system.

Figure 1: Stretch to Win. Fascial Stretch Therapy (FST) follows a set of 10 Priniciples. (Photo credit: C. Coons, 2013)

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Figure 2: Traditional finger stretching. [Photo credit: A. Frederick, 2013 (6)]

Figure 3: FST finger stretch start position. [Photo credit: A. Frederick, 2013 (6)]

Figure 4: FST finger stretch end position. [Photo credit: A. Frederick, 2013 (6)]

stretch to WIn prIncIples

n About 50% of a healthy person’s lack of ROM at the joint has been suggested in research to be due to tightness in the joint capsule (1). n Stretching the joint capsule before the deeper muscles that are close to that joint results in better functional flexibility. n When ROM in a joint is restricted, ROM in the muscle is also restricted. Because muscles attach to bones and bones connect to other bones by way of joints, restriction in one joint capsule can lead to restrictions and compensations in other parts of the body. For these reasons we always start with traction at the hip joint in lower body protocols.

FST uses multi-plane stretching not found in traditional isolated stretching.

To demonstrate the Stretch to Win techniques, compare the traditional and FST versions of an exercise called the ‘Frederick Finger of Fascia’ in examples 1 and 2 below. Example 1: Traditional finger stretch (Fig. 2) 1. Point the finger of the non-dominant hand up. 2. Place the other finger onto the pad and push back until you feel first slight resistance or pressure. 3. Note the range-of-motion (ROM) and how it feels. Example 2: Fascial Stretch Therapy finger stretch (Figs 3 and 4) 1. Grasp the finger firmly then gently traction to ceiling. 2. While maintaining traction, guide the finger back. 3. Note an average ROM gain of about 3-fold more without pain or force. conclusion: FST yields more gains in ROM of joint, muscle and fascia. The complete protocol that we perform to assess and correct imbalances always follows our 10 Principles, which are described below. They are grouped under the tissue that they focus on most: joint, muscle and nervous system.

In general, always traction the joint and muscle before using client assisted mobilisation or stretching. Contraindications and precautions to traction of joints and other soft tissues include but are not limited to: instability, hypermobility, local acute or sub-acute injury.

Muscle Principle 4. Follow a logical order Start with the joint, then shorter muscles and fascia before longer ones. Begin mobilising and stretching from the core of the body and progress out

Figure 5: Traditional hamstring stretch. A sagittal-plane single leg raise targets one plane of movement. [Photo credit: M. McNutt, 2011 (6)]

Principle 3. Use multiple planes of movement Simply put, we move in multiple planes, therefore we should stretch in multiple planes. Here are some examples:

Joint

Example 1: traditional sagittal-plane stretch Figure 5 shows a traditional sagittalplane single leg raise, targeting one plane of movement.

Principle 1. Target the entire joint Principle 2. Get maximal lengthening with traction Joints get compressed so start by decompressing joints before mobilising and stretching:

Example 2: Fascial Stretch Therapy multi-plane stretch Figure 6 shows FST multi-plane stretch with a specific traction, diagonal, rotation and spiral pattern.

Figure 6: Multi-plane FST hamstring stretch. [Photo credit: M. McNutt, 2011 (6)]

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EvidEncE informEd practicE

Figure 7: Fascial stretching starts from hip joint in lower body protocols. [Photo credit: M. McNutt, 2011 (6)]

to the extremities. For example, in the lower body all protocols start with hip. Unlike other techniques that start at the foot or the head, this system works from the core and deepest layers of fascia out (Fig. 7). Low back researcher, Dr Stu McGill points out that all movement is generated from the ‘punctum fixum’ or fixed point of the core. Restrictions in fascia and the muscles of the pelvis, hip, and lumbar complex can negatively impact all primary movement patterns. If you are not starting at the centre of the body, that is a missed opportunity. Principle 5. Achieve range-of-motion gain without pain Many people believe that stretching hurts or, at the least, is associated with discomfort. Therefore clients are often protective and guard their body even when they agree to be stretched. The result is ineffective stretching. In our experience, the best and fastest results are achieved without pain. Traction, oscillation and circumduction (TOC) mobilisation before stretching is how we begin all FST sessions. These are the benefits to TOC: n Assesses joint and muscle response to specific movements n Client immediately relaxes to allow more effective stretching n Pain can be relieved in seconds. This process allows you to make gains without pain. Principle 6. Stretch fascia, not just muscles Most stretching techniques focus on stretching isolated, individual muscles. While this approach may have some success, in our experience it often fails. www.sportEX.net

This is because the isolated muscle-bymuscle approach to stretching fails to address research that has shown that: n The brain is organised according to movement patterns and sequences, not isolated muscles. n Active muscle contraction as well as passive stretching of one muscle generates forces by adjacent muscles, nerves and fascia. n Mechanoreceptors in muscle (spindles and Golgi tendon organs or GTOs) constitute only about 20% of the body. The rest is distributed in the fascia in the form of free nerve endings and other receptors. Although stretching one muscle may stretch some of the fascia within and around the muscle and near its attachments, it does not extend into other fascial planes. As explained in the previous 5 Principles, there are many other protocols that must be in place in order to correct restrictions and imbalances in the fascia. Start thinking of stretching fascial connections of the musculoskeletal system not just isolated muscles. [Note: terms found in Thomas Myers’ book Anatomy Trains (2) will be used including individual muscles found in those fascial lines that we are targeting; see Fig. 8.] Principle 7. Facilitate body reflexes for optimal results (PNF) Michael Alter, author of The Science of Flexibility (3), states that most research on PNF stretching shows better outcomes when compared to traditional static stretching. FST uses one technique from PNF called contract-relax (C-R), with which most therapists and trainers are very familiar. However, we have discovered that best results are obtained when using anywhere from a low of 5% to a high of 20% of maximal active contraction. Using multi-planar patterns of C-R combined with multi-planar patterns of FST results in better outcomes to remove restrictions and improve muscle activation in the squat and other patterns.

nervous system Principle 8. Synchronise breathing

Figure 8: Superficial back line. [Primal Pictures, adapted from Myers (2)]

with movement Principle 9. Tune nervous system to current conditions Principle 10. Adjust stretching to current goals These 3 Principles are grouped together as they greatly influence each other. We all know how important coaching proper breathing technique is for successful therapy and training outcomes. Since stretching has always been associated with pain in many clients, they tend to hold their breath during the stretch phase. Just getting them to exhale on the assisted stretch starts the process of changing muscle tone and tension through the nervous system: n Breathing slowly stimulates the parasympathetic system which decreases muscle tone and tension. n Breathing fast stimulates the sympathetic system, which increases muscle tone and tension. Instead of ‘one-size-fits-all’ traditional, isolated stretching, coaching slower breathing with slow assisted stretches can stimulate the parasympathetic system of athletes for post training cool down and recovery. Muscle tension quickly releases with slow breathing-slow stretching for an excellent regeneration session starting right after training or on an off day. Coaching quicker breathing, as 29

you perform faster, flowing dynamic assisted stretches on your client for 5–10 min before athletic training, can often work better than the client’s dynamic warm-up. Under your hands, you can immediately feel and correct restrictions and imbalances that would negatively impact the training session. Breathing right and stretching right helps to properly stimulate the nervous system for better function and better results.

n Stop the stretch if a pop or extreme give in joint ROM occurs on each repetition of stretching. n Follow contraindications and precautions as for all other training.

squat problem 1: feet turned out (Fig. 9)

summary Movement patterns like the squat require full body assessments and strategies for optimal training and coaching. The 10 Principles of FST constitutes an entire system that meets the need to quickly and thoroughly find solutions to problems with faulty movement patterns from mobility restrictions and flexibility imbalances.

the hIp: three proBleMs and three solutIons For Faulty squat technIque Faulty squat patterns are often wholebody issues. Therefore the FST solution to many of these problems is to use a series of short or long connected myofascial lines to simultaneously correct it, often all at once. Here are some tips to help you learn the techniques: (a)

Figure 9: Squat problem 1. Feet turned out. (Photo credit: J. Luke, 2014)

n Practise all three solutions on colleagues first to get feedback before working with clients. n Perform all stretches on the exhalation, release for inhalation for 1 rep. n Repeat all stretches: 3 reps or as needed. n Re-test the squat after each stretch to monitor improvement. General contraindications related to performing FST technique: n Stop the stretch if pain occurs; gently oscillate to eliminate pain in seconds. (b)

This problem is frequently blamed on the tight, short peroneals (aka fibularis) in the lower crossed syndrome or just pronated feet. In our experience, most of the time, this is not the case. More commonly, it can be all or some of the following myofascial connections: n Compressed, tight lumbar spine and paraspinals n Short, tight hip external rotators n Laterally shifted fascial compartments of the quadriceps–iliotibial band n Adhesions in lateral quadriceps– anterior iliotibial band fascial interface n Tibial external rotation n Fibula shifted superiorly, rotated externally n Short lateral band of plantar fascia.

Fst solution to problem 1: stretch the lateral line (Figs 10–12) The FST lateral line stretch is performed as follows: n Lean back and traction both legs (Fig. 10a). n Walk to one side with both legs (Fig. 10a). n Drop leg closest to table below level (c)

Figure 10: Solution to squat problem 1. (a) Lean back and traction both legs, walk to one side. (b) Drop leg closest to the table below the level of the other leg and (c) drive the dropped leg under the other leg. [Photo credit: M. McNutt, 2011 (6)]

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reveal the dominant problem causing faulty movement patterns, along with secondary ones. You have also learned that STWFST is different from traditional, isolated stretching. This was defined with the 10 Principles that address all systems of the body to make it a complete approach. The next article, Part 2, will focus on the knee, ankle and foot and how the myofascial lines connecting above and below influence how the lower leg functions, tracks and contributes to faulty squat movement patterns.

Figure 11: Squat problem 2. Excessive forward lean. (Photo credit: J. Luke, 2014)

Figure 12: FST solution to squat problem 2. Deep front-line (hip flexors) stretch. [Photo credit: M. McNutt, 2011 (6)]

of other leg (Fig. 10b). n Drive dropped leg under other leg (Fig. 10c). n Add arm reach overhead to increase lateral line stretch. n Repeat until no further gains in ROM or tension limits.

squat problem 3: asymmetrical weight shift (Fig. 13)

The results seen when this solution is applied are: n Feet turn in along with the whole leg up to the hip n Positive changes in the squat and gait n Bonus: leg-length discrepancies are corrected; shoulder–overhead ROM is increased.

squat problem 2: excessive forward lean (Fig. 11) The common causes of this problem are: n Restricted ankle dorsiflexion n Tight hip flexors n Weak posterior chain.

Fst solution to problem 2: deep front-line (hip flexors) stretch (Fig. 12) The FST deep front-line stretch is performed as follows: n Place the bottom leg position in hip/ knee flexion. n Support the top leg at the knee joint and ankle. n Face the client and walk the leg behind them until the stretch felt in the hip flexors. www.sportEX.net

Acknowledgment Figures 2–7, 10, 12 and 14 have been reproduced with permission from Handspring Publishing, UK.

Asymmetrical weight shift (AWS) can occur for many reasons, three of which are: n Leg-length discrepancy n One pelvis in anterior rotation n Unilateral leg asymmetry (eg. only one foot pronates or pronates more).

Fst solution to problem 3: hip joint capsule stretch (Fig. 14) The FST hip joint capsule stretch is performed as follows: n Maintain a hold on one ankle (as shown in Fig. 14) and lean back to assess hip joint capsule space and length. n If the joint is hypermobile and pops or shifts then stop, this is contraindicated. n If there is no or little movement, then repeat the action until movement occurs.

Figure 13: Squat problem 3. Asymmetrical weight shift. (Photo credit: J. Luke, 2014)

suMMary This article is the first of two to introduce you to the Stretch to Win – Fascial Stretch Therapy (STW-FST) System. The focus was on learning how to assess and remove restrictions in the joint and muscles around the back, pelvis and hip extending down the leg and up into the spine by way of myofascial lines. Re-testing the squat after each problem and solution example that was given will

Figure 14: FST solution to squat problem 3. Hip joint capsule stretch. [Photo credit: M. McNutt, 2011 (6)]

References 1. Johns RJ, Wright V. Relative importance of various tissues in joint stiffness. Journal of applied physiology 1962;17(5):824–828. 2. Myers T. Anatomy trains. churchill Livingstone 2013. iiSBn 978-0702046544. (£35.54). Buy from amazon http://spxj.nl/1nwWoB0. 3. Alter MJ. Science of Flexibility, 3rd edn. Human Kinetics 2004. iSBn 978-0736048989. (£44.99). Buy from a amazon http://spxj.nl/1pGmK4n 4. Schleip R, Findley TW, Chaitow L, Huijin, PA. Fascia: The tensional network of the human body. churchill Livingstone 2012. iSBn 978-0702034251. Buy from a amazon http://spxj.nl/1kOD2HR 5. Frederick A, Frederick C. Stretch to Win. Human Kinetics 2006. iSBn 978-0736055291. Buy from amazon http://spxj.nl/1pjqU4o 6. Frederick A, Frederick C. Fascial Stretch Therapy™. Handspring 2014. iSBn 978-1909141087. (£33.00) Buy from amazon http://spxj.nl/1oTNmNW.

Further resources 1. Fascial Stretch Therapy by C. Frederick and A. Frederick. Handspring publishing 2014. iSBn 978-1909141087. (http://spxj.nl/fascialstretch) 2. Stretch to Win by A. Frederick and C. Frederick. Human Kinetics 2006. iSBn 978-0736055291. (http://budurl.com/StretchToWinBook) 3. Fascial Stretch therapy workshops by Stretch to Win (www.StretchToWin.com) 4. Website: Stretch to Win (https://www.stretchtowin.com)

Fascial Stretch Therapy by Chris and Ann Frederick

Written by the pioneers of Fascial Stretch Therapy™, this highly illustrated manual provides an in-depth and very practical description of FST™ - a system of manual therapy and movement training that can be used by a variety of bodywork and movement therapy specialists to reorganise and realign body structure.

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+ FREE RY DELIVE 9.70 just £2end of

e until th -24 2014-06 August o ER go t To oRD scialstretch http://sp

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Published by Handspring Publishing

Th AUThoR ThE ChRIS FREDERICK PT, KMI C Chris has been a physical therapist (PT) since 1989, focusing on orthopaedic and sports manual therapy – particularly with integration of Fascial Stretch Therapy and Kinesis Myofascial Integration (KMI) – along with personalised movement prescription to restore function. he has an extensive background in dance, both as a professional dancer of classical ballet, as well as being a practitioner in the specialty of dance physical therapy/physiotherapy. Chris is also well versed in the ancient movement and healing arts of tai chi and qigong. he is a co-author with Thomas Myers of the chapter on stretching in the seminal book Fascia: The tensional network of the human body edited by Robert Schleip et al. (4). Chris is certified by Thomas Myers in Kinesis Myofascial Integration and is co-author with his wife, Ann, of the books Stretch to Win and Fascial Stretch Therapy (5,6). With Ann, Chris directed his own highly successful clinic for Fascial Stretch Therapy, physical therapy/physiotherapy, Structural Integration, chiropractic, acupuncture, sports massage and Pilates for nearly 20 years. he is now co-director of the Stretch to Win Institute at www.stretchtowin.com, where he is lead instructor in certification training workshops in Fascial Stretch Therapy.

key poInts n Fascial stretch therapy (Fst) removes restrictions to movement in joints, muscles, fascia and the nervous system. n results are quicker and more thorough than traditional isolated stretching. n Fst follows 10 principles. n Fst works in multiple planes of movement. n Fst begins mobilising and stretching from the core of the body and progresses out to the extremities. n the squat problem of turned-out feet can be solved by stretching the lateral line. n the squat problem of excessive forward lean can be solved by stretching the deep front line. n the squat problem of asymmetrical weight shift can be solved by stretching the hip joint capsule.

n Stretching in general is still controversial in the fields of fitness, sport therapies, and rehabilitation as evidenced by many articles in the media of the last year. These articles, for the most part, reference evidenced based studies on DISCUSSIONS the negative effects of static stretching. Does this article in any way help or contribute toward clarifying any aspect of this controversy? n Do you agree or disagree with one of the ten principles for the Stretch to Win system that puts forth the premise that stretching the joint capsule before the deeper muscles that are close to that joint results in better functional flexibility? n Do you agree or disagree with one of the ten principles for the Stretch to Win system that puts forth the premise that stretching should follow a logical anatomical order? n Do the solutions for common fault patterns of the squat movement presented in this article make sense? Please explain.

sportEX dynamics 2014;41(July):27-32

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often say that if I knew at age 27, when I set up sportEX, what I know now, I’d never have started! Getting this business off the ground has demanded EVERYTHING of me and there has been more than one occasion where it was nothing but luck that kept me in business. It’s without doubt the hardest thing I’ve ever done to date but 15 years on thanks to everyone who’s been involved, and particularly my right hand woman, Debbie Asher, who’s been with me from the start, we have managed to build both an incredibly robust brand and product as well as a solid and stable business base. I think back to the stress of those early years and I can’t believe how much things have changed. It seemed so simple then! We got some articles in, had them reviewed, designed some pages, sent them to the printer and then off to the mailing house and that was it, job done. In between we’d print some leaflets up to send out in other magazines and go to some conferences and somehow the subscriptions came rolling in. These days we do all that but we also put it online, create two additional new versions for our apps, produce elearning quizzes, and engage in pre- and post-publication social media campaigns – not to mention manage the increasingly sophisticated back-end technology and commerce platforms catering for multiple payment types and purchase scenarios. There’s so much that has to happen both behind the scenes as well as on the sportEX stage. I used to say I was a phyio-turned publisher, now I feel more like I work in IT, fortunately for sportEX I love doing both. The best thing is having been around in this industry now for 15 years, so many of you have become my friends. As a professional group, you are amazing to work with. I’ve never met so many incredibly kind, giving, caring people and every time I attend a conference, I’m reminded of how lucky I am to run my own business, in a subject matter that fascinates me, with a group of customers that literally couldn’t be nicer. Yes it’s hard work, I have to be a jack-of-all-trades and a master of none, I feel sometimes like I can do everything and sometimes nothing, and it’s impossible to take a holiday without keeping an eye on issues that can’t wait, but I wouldn’t swop it for the world and I can’t thank you enough for giving me the privilege of being able to do it for these last 15 years. I can’t wait to see what the next 15 years bring! 33

milestones Jan 2001 Division of sportEX medicine into two titles – sportEX medicine which continued to focus on MSK diagnosis, treatment and rehabilitation and the launch of a new title, sportEX health, focusing exercise prescription, GP referral and some manual therapy. Due to the fact that many non-prescribing individuals were subscribing, at this point we also made the transition away from pharmaceutical sponsorship, towards a subscriptionbased funding model.

sept 2007 Saw our biggest, July 2004 although sadly our With the membership last, joint sportEX/ of the SMA growing SMA conference at the healthily we launched University of Bedfordshire, our sportEX dynamics featuring 6 international journal with the aim of speakers (3 from Canada, focusing on the dynamics 2 from the US and 1 from of sports performance Australia). At this time our and particularly sports spectacular conference massage/manual therapy. organizer who many of you will remember, Katie James, retired 2007 to motherhood, conference bringing to a close september 14-16 2007 our conference legacy (at least for the time being)! 5th

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June 2009 – We successfully tendered to become the publisher for the Register of Exercise Professionals (REPs) (30,000 members). This included a quarterly printed journal and a monthly email newsletter (circulation now 55,000). The first journal was published in Sept 2009 and we have just gone to press with the Summer 2014 issue.

July 1999 MYOFASCIAL THE

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SATURDAY SPEAKERS

DELEGATE FEES

July 1999 Launch issue of sportEX medicine – originally a controlled circulation magazine sent to general practitioners and sports medicine doctors, supported by pharmaceutical advertising and focusing on MSK and exercise medicine.

Feb 2003 sportEX took over the management of the Sports Massage Association, which had been launched one year previously by the National Sports Medicine Institute, and was facing budget cuts. At the time the SMA had just 130 members. When the SMA board was ready to take on the administration themselves in 2006, we had built the membership base to over 900. sept 2003 We ran the first ever sports massage conference as a joint initiative between sportEX and the SMA. This came about thanks to the kindness and generosity of the organisers of the well-established Bodylife Conference, Kris Tynan and Tim Webster, who donated free space at Leisure Industry Week 2003.

TO BOOK

sept 2006 In 2006 we managed to convince none other than Tom Myers, founder of Anatomy Trains and someone who will go down as a fascia revolutionary, as well as the prolific author and highly regarded soft tissue specialist, Leon Chaitow, to speak at the by-then annual sportEX/SMA conference, which we aptly named The Myofascial Matrix.

sept 2008-2009 We got nerdy and coordinated the development of the elearning platform and strategy, as well as developed much of the content for Central YMCA to deliver fitness and health blended learning through both their training provider, YMCAFit, and their awarding body, Central YMCA Qualifications. Wow, that was a project and a half!

sportEX dynamics 2014;41(July):33-35

milestones

summer 14 l issue 30 £3.50

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Jan 2012 We launched our iPad sept 2010 app, followed a few More nerding with months later by the the transition to a Android app and the new ecommerce Kindle Fire Android and content delivery variation. platform, which has freed us from a lot of the day-to-day administration of earlier days.

apr 2014 With the popularity of our elearning quizzes, we decided to bite the bullet and converted all our elearning quizzes so that they would work on whatever technology platform you accessed them from regardless of whether it was a desktop/laptop or any kind of mobile device.

July 2014

april 2011 When we couldn’t find an elearning delivery platform that didn’t force us to buy annual licenses for users to access the platform, we decided to build our own SCORM-compliant mini elearning platform through which to deliver ad hoc continuing education quizzes linked to our articles. www.sportEX.net

sept 2013 –Jun 2014 I confess has been a period of even more nerding (I don’t get out much as you can probably tell!) while we integrated the data from all our previous web shops into one central CRM (customer-relationship management) system. For the first time in about 8 years we have a record of every purchase, every subscription, every quiz result, every conference attendance and every support case request each of you has made, along with many of the email discussions we’ve had with you over the course of the last 15 years. Phew!

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today n We produce 11 journals a year (4 sportEX medicine, 4 sportEX dynamics and 3 REPs Journals). n We send out between 80,000-160,000 emails every month to 82,000 individuals. n We have just over 5,000 subscribers to our journals n We physically mail our journals to 23 different countries n We cover one of, if not the broadest spectrum of allied health professions, of any specialist publisher in the UK and possibly the world, ranging from every type of exercise professional through to all physical and manual therapists and finally elite sports medics and physicians.

what’s next? n We still hide our light too much under a bushel, so it’s time to get out there and be seen! n Greater exposure overseas, particularly Australia, New Zealand and North America. n A new way of running sportEX as well a new way of delivering content both collaboratively and cooperatively, the two go hand in hand. It’s all planned out, now it’s just a case of the implementation!

Watch this space... 35

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