sportEX Dynamics Journal Issue 43 - January 2015

ISSUE 43 Jan 2015 ISSn 1744-9383

promoting

best practice in

highlights

manual therapy

n is massage an industry in crisis? n difficulties with manual therapy research n Kinesio tape evidence base update n yoga in rehabilitation

BOLD HEAD LIGHT HEAD

ANATOMY & SOFT TISSUE INJURY REVIEW

By Dr Simon Kaye, Sports Physician and General Practitioner

ONLINE & MOBILE £24.95 PRINT COPY AVAILABLE AT TIME OF PURCHASE AS A £6.99 UPGRADE WITH ONLINE PURCHASE

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11/07/2013 10:58

CONTENTS ■ Overview of diagnosis and treatment of sports injuries ■ Shoulder Joint and girdle ■ Elbow and Wrist ■ Ankle ■ Knee ■ Spine ■ Hip joint and pelvic girdle

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■ Provides tips for examination, learning exercises and highlights key points ■ Gives links to further reading ■ Useful for practitioners and those in training

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rec cles anx ity. The plus The hip,. With the ro-iliac join the anatom vious arti tion). injured l phal ve Dista s erely tive instabil pulsion, pre rma toe) to achie acutely to the sac cle review (5th at as ment nly sev rela re info anx ng and y, pro move le phal e form for mo commo due to its of the bod in squatti and nubrial injuries s. This arti es Midd ees, o-ma Pictur toe) most the samthe article 180 degr stly at Primal (5th port und as and stern walking t as ©2010 change follows joint ter than cic rotation e is the ulder mo w sup the gro y, as in imal this end of and the AC of abduction and grea thora the foo Prox with rds The kne the sho e is to allo o near sly in joint of some ees n of at the onwa the bod phalanxGP mediate some like tors box ved with 180 degr degrees toe) Inter Previou (issue ving acceleratio ates limb, n of the kne of the Kay, iform 150 (see is achie t in n(5th cles. t st be mo demonstr cune id ing Simo um es n From ction/flexion roer arti , hip join and wri patient Pictur Sacr red join functio g position can either wing rap hume joint

By Dr abdu d the Primal e w ral erview : l refresh ue 44) behin ts well. nly inju ligament Fifth ©2010 t allo radia ion llowin y ov mo tarsofaltwo joints ral joint n of femo is foo T1-3. n from injury the elbo of the spin Pate allo men puls t (iss ular ple ortio meta tom m, the rvatio Pro move ral prop -fib st com n Kay ies of ulder join 46) and ana consists the tibio-femo the tibia abulu ilium Obse providing as title joint ly sim femo of the Simo Medial body the high the acet m of thick sitting. or moving ges in ue s of the mo erior taloa relative inversion of ment gross iform the ser sho joint

By Dr by The knee joint ral cle the S of the r limb as well ing. ruent due to move cune ant labru le is the chan joint er two main Late of the facettwo cong e is of ed in abulum last in ered the le joint (issn this arti girdles. covered by a running vement d into 1. the ists iform to furth acet uction flexible of the uppe lifting and carrybility and articles head lised (behind The anker limb, the d ankle) severity the mortic as cov is the cons cune with the ing. stabi femur e mo ps are involvbe divide , ank acting give muscle ioned 1-2). lla) , esher Simon introDlder the mostof motion like throwing, nse of insta my re which This we have GP further tissue, pate les tures in kick m (figs. hip is id r, cush muSclmuscle grout can roughly ue 45) we have articulate anato y refr e mo ted the low sic spraine but as the joint and ch can be le, musc expe ective n Kay, of the Dr Cubo the femu cular struc The shoua wide range ments ent which ilising acetabulu of the conn men at the reviews the entS ved in neck r, and ry series e joint (issAlthough Differ clas and becom cult to anatom and hip, Dr Simo associa /stab ces on two avas r move comes Move -talar upted whi r the ank cular r mino e more s en the ral position r projected the inju st vem By a invol us with actor (the surfa is lder. briefly powe Navi . and sub hav femu le us wri kne ility deep by teres mo diffi e into I lity e radio contr shou femu e 49) mob nto (IS), ps are rating from Talus thejoint articl side previou e, ank disr but 47), - a joint on The neut of the that – the handse going various soft of the : gene uctionto its stabi ly. stabilisedsici dorsi, pinatus tely this ntial. This s laterally l joint (RC) (issue ligame muSclmuscle grou the spin e e areas . eases,ulnar can be s imus on our ulder, kne will con regions other. infras found pragmatic practical, les ie. facet lder befor s to the joints the neck ly and outlin 1) knee introDmostly due at least acute ent tor cuff aneumora Unfortuna injury pote the men r, latiss triceps. Thes joints re about musc with . We apy, ry incr le joint injury. We a video a s Calc owing the shou of injurie 1. Rota spinatus (SS),(see Video I have majo sho patella-fe V-shaped h articulate lla Differ hip, tring t of the roat the anatomical to each posterior in cle. joint, is girdle her inju ying nosu Foll d and e, tly the ralis ch it move mo ow men The es )) Pictures ank s femo the osis arti hams lder and high ments of , ies 2. e whic siot to mbra is Primal pate sligh tibio g h issu n of move flexion y injure from shou diagn m. it ©2011 rap ory, this of supra laris (SSc – pecto of injuri g phy r, bicep fashion, accompan and ) lla een shallthe approa pate ral h. The related d bot semi-me e help h (PM) a rarel recognitio ent and mino with view ssed and movelook at the ng up the the true as any kne foot in this betw coverin ks in this r is ntric acetabulu femo of undin the own various the logy for therapy, ofascial the ple, rior som 1. Knee dinosus, iques subscapu movers pectoralis the ral troug ately two main gem maki whic be asse /ecce surro menisci like an with groupe (supe um the femu Pubis ary Peo femo fulcrum for With r, detailed the back tures nt techn ture can r impin joint and ists of ischi joint ing my ing und it no apo severe ar joint and semi-ten s femoris le, popliteus, st sports cture, my Kay loo We have are so intim 2. Prim teres majo in a concentric entS head of struc the foot with the cons by three in front ges. as a ) dicine. patientn. s of ice acetabula -iliac assessmeeach struc lling es roand surro head again ly tissue chan id, only view Review politan, mix ch. I make involves acts LiGamstanding, the acetabulum allow bone mort ists Pictur sacro and bicepssory musc to flexio muscles x me pun trave joint most hume The ankle rior delto simple the tibia, rus how ntially sub-tal to a stic dial joint, main elbow. er as they t Primal situation hip is to , s joint (ante prior to the to the Femur les act some showing esse muscle, s The ro-ra s ch. It .

Whils ting into efficient. ricep s©2010 ns, acu ulna into the ): : orthodo y holi the hume g shoulder ) - cons (similar the acce the knee close is one cosmo ce’ approa musc les, the ion of the the hip vastu e 1a: hume osed ge, ricep and inser rus. joints work the joint - quad tightly joint, s of in musc the limbs ver ks Figur to hold approa mobilisatio good old that a trul durin (fig.3 foota les like quad togeth the radiuination) held rotating lateralis, lly diagn ankle bone red by unloc in wood the talus n/ ent ally more no part ents the humeRC musc job is g stability knee The funct trunk on otion. Howetibia eral (GH) joints are GP extension vastus t 1. the 2. the rotation of ‘eviden ary care of e 1: The the n joint differentia are cove h contractio pays of the it mechanic e. Their The key ligam oral ligam the two the elbow rview gleno-humgirdle. These ation/sup medialis. also aid N Kay, 2. Knee s femoris, ing ssage, iatry and differen Figur including sleev ort of is to fibula g locom maintainin les are -fem ent s of the and teno ular facet allow twitc GP s with SIMo . s inter supp plete durin les ments ing and so thus y ove ifically the ally (pron and the making that the by on, primlation, ma musc lder artic ulate 1. Ischio moral ligam ent. , pod Pictures and footstrike ie. rectu and vastu e 1: Joint n Kay, musc the incom ularly e of move

By Dr facilitates the knee femur in a slow rus into Primal . Man spec id fossa rotator cuff of Note of the which artic on the tibia longitudinthe ulna Figur mius the shou ©2011 partic n of ialis which anatom Tibia nipu techniques sports, are ential. ing, jump ter fibula the ankle at heel is fixed les act the hume the head Dr Simo rang to the 2. Ilio-fe femoral ligam tighten with h the ocne lder or make up d n) med of ulatio e d joint runn ma ces – the gleno ts. The By ice) foot grea musc whic stand shou ir gastr ion of (teno aroun ing, to of joints the surfa the mort -ulna RC ess a whol ns his legs that men move The The of force a rigid level e the the artic tibia is linke ligaments ) and r : 3. Pubo e ligaments ing us to r. radio n is pulled each t. joint ruent the hip, move ing, walk on the or The funct pation eve, joints the head rs. The n when upright on and femu les to roles uction these two handons, powe ide the tendo is effected sing The cong 3. the movemen Mulliga es and h form sub-talar (ACL Thes e phas flexio stand all involve le move on pulling nding dissi of five s: ht s of ty, allow muscle , s all tibia g cros (whic to prov propulsiv PM musc en as the different five secti knee is, I beli depe Talus ligament ent (PCL). prime allow ted g spin introD g how vitallopment, i.e. ion, it is facet straig (see of musc joint fashi ndly fibula rotating t of gravi t use of the Rotation for d into to perform extension ing the s of the kickin r degrees the hip bear ple short joint and as follow-humeral iderin two stroncruciate their approach mass inferior t: complica effec running s on pulat divide of this can stand the facet joint in full nt: of d grea (AC) isometricfossa, allow muscles the scapula. and seco a stable Cons n deve rate nsible iater ligam they have oin three for Fibula lesse 2. the ialised e ut a Poi t facet knee time that ht. For exam cruccula or the ing and huma is a large e purpose use RC respo and mani are injure 1. gleno ioclavicular id of the anterior eriorNavi As part nsible the ents Pleas witho of is spec ical een the congruen Key gh three sepa K lity. beca s. based gleno g walk mation). to allow are to rdination joint being at the weig s of are ract mit ss joint prim ligam rus. The acromium stabi stabilise le activity. are not be betw ugh there le respo Video 1). durin joint that they amount of body conttrans id bone 2. acromoclavicular talar oiliac the post nly for pinatus infor ht, to will the arm note and Altho the hip, the otion, not lthouugh are all ly. They covered GP s and the n Cerv altho exce lock to the hume under the of gait musc eye co-o in a way Sacr xeships infras with e 1: The -weig laris musc on (see the mmo tus supp more c joint joints injurie acic , the sub- ground. talus and cubo avoid and ising refle multiples l ing n Kay, se refer s they capsule Figur 3. corac body ising Unco vascular 1 for rotated, lder is tring are. is or on around is for locom of the SI elbow ent cuff with subscapu ntric fashi ezius, serra joint neum n Thor joint the to minim stand mus Simo cle s ulothoraci joint medially Box surpr asne e (plea sportEX the foot, uneven ments of lingreas they the joint s twist the bar lity calca le same thet spinaately the shou or internally main rotator n of the whils / ecce ula (trap shoulder that hamsthis articl may on ligam in tion te half ising, fine 4. scap oclavicular and ioning a good

By Dr onli rotate, thehurd within ACL stop musc hiphas Calcaneu inatio move n Lum al ion of in the note opria gThis injec h the shed by the rotation and concentric by relies the posit the stabi as little rol oxim the nt s both rnally anterior rough r joint appr tion is two-fold: ENTS entric stabilise, ssed appr the scap a t. runn throu (in whic 5. stern neutral posit er exte es publi pain from the if aghpatie injury s for containedvium. The s and The PCL The combwrist allow plus powe to cont durin of the Similarly symphysis enclosed facilitate 2). ulae) Duc n Sacr ygeal. joint addre spine les of with external rotation, in allow ht rs vermen bone neith ht. r. e and concare used occu The sition position g than ous articl lly the MovEM aNKLE Femero- ar move ation h can ankle weig musc howe or scap weigafter ent al figur hands, function is femu by syno the two intro ion of the spinal cord roots to rm and ntric and chest, durin icant mical theitis the pubic and oppo abul whic n Cocc to previ topic). Usua ssory 1: Anim weights, ligam intern (see Ecce forea ing,arthr o signif of our acet e of the the anato rotation). of body and levat on the een posterior muscles of the foot oF ThE t of the truetion, plantar o 1). why gth tion and leg ACL ss Vide ing the jump n side tibia betw The functction of the ned to ioningthe GHof a single a wide range l nerv of huge The acce posterior with stren therapy ient % g men isn’t rnal flexio for this injury is moren. . Exce ionticula joint the shin ments of ction n the knee spina defic-500themiss of the along femur (see showposit disar is desig positionin Move in one direc plane) (vide alar ation s. tions: r ntothe ical use in joint bea 400 le the mind mentPerfeactio occurs that this in full exte ior and and limbs glide 1) Prote n of the S twist flexio trans facet t withi toultim ttal ’ direc leg, ately cerv nts rs S the cuff musc knee joint movegrip. of the ’s role, anter the move and supin strain on ents rciSe that in of powe rior, Theuse ical spine and allow knee limbs , the subt and men on the stops llent (sagi ibutio r the and ‘basic n (coronal eme occu beca joint end ent fer and hand on of ents ante with a or elbow of cerv segm eXe t ion good a positioned s six trunk tibia exce also distr move t is the tesy ently joint notrotat on of , uppe r limbs G ive ility skull vem sion The at the effec w mov the true nG uctio the rs in l at the pronation can put is, and promote traum rmos of ligam r and the thesstrans lesr from trunk of the relatjoint nin lbow oses ro’t inher ie. tibial dorsi-flex dimension for inver elbo exce . rni to Look lowe of as of theles (cour and n/extensi ort the uppe and The stabthe array mino s pane er mo lder occuabduction/add nd axis of t glide their isort of the would ear s model musc al functionsand wrist Lea ment supp for purp The two s and ation hip wasn joint pronation of the foot - flexio via the hume can be gh to the arms symphys ntrically, can to and femu g the omic esthetic): omical see e extra muscof ube usersia) ile men (arou ), s).

The three ver allow Move skull leads the ntricrs slow ed if the throu ShoulDt of the shou ing. of ecce Onlin tors 2) Supp on the pelviand use of ribed Pubic plane elbow pulation le, as mob and pronbox and re 3) direction ng ecce ation. This n (kina ) the anat same with that ritis. evolv este of the howe is a due g the tibia surroundin onse to rotation an anat ton, to of YouT inver the iple’ move ‘basic’ for videoview of ptionlder, nsoarth men o 2) (in cal skull anan . g. Mani have joint in one plane) (Figu oste and hear (sagittal external desc s on pron otion disrushou .prime move mea contracti ectin muscles (vide isn’t itions riorral and are the Move article(supeneut r. skele a need as gross line. in the sanjupositionin r verti is a ‘multn of all six in resp ) and facet nsion of the then the body me vision vertebrae conn As and when the rate of to occu ding g /www m/ which the view ing locomthe problemsr function. ated ment knee human lock unde et The eversion (see Defin ription (sagittal straight and ently, OQ . http:/ be.co stable, stron ts ofoften inatio rior and exte internal allow 11 rol elbow points more the as threa tEX.n in a 15 the foot dial joint the true d of of the has becoring of the g a shot. desc gz18e hair ation men cervical ally differ very latte are activ ligaments (ante nth moveis a comb of the r far er .spor s of only ), and nded youtufine GOZj ing our ions MosttEX.net ule cont supin 3-5 for a ulna joint. humero-ra d part of move the faces sure. N.B. the rim (Atlas) occu bral www which to the as puttin bone turne plane the h#v= the hip posit e trigg h not and it’s caps The seve which how s pres anatomic vertebra joint the other nding on with watc as comb t terms) jointS fully exte .sporrelate main s of The ular joint Knee caus to be rus). within ents whic but also Joint tion, first vertend vertebra figure joint, joint The www ward eversion sion considerethe hand ion is ately depe e 2: anD ro-acetab the hip hume ation men the leg below The e 1b: down ther, an ments). ment of ically rCISE the first from the tensions the ligam Figur the GH shoulder s of thers in two move al posit approxim seco circumduc r e 2: 7 – supin Figur t of inver nd rview move techn allow s toge ched, firing ining rily at BoneSi.e. the femothat make up rate Figur y called It is the to the occu lex. From lop entS NG EXE joint, bone anatomic s tilted to back the femu (palm sepa The move movemenrough grou stret y ove of: ments. occurs prima joints in s Try exam : ) elbow from front al. are comp e, they deveeen ss The hip six joints consists ting the two they are has fused tom ow move ple the pelvi vertical and . anatom movemt of the knee LEarNI etic): which can pronation The joints h allow ment plane take vertic of brae d tion and exce of terac hold multi ectiv to esth and ana ). ttal whic the betw elB e joints ng men the Rota o when coun aroun up) riorly : foot of three joint) .

4a+b is one (sagi the move fuse from are involv hip girdle ular (FA) The verte gical persp Move n (kina ulated foot tly, to fully the tions ut putti 30 to tilted ante faces twist s the tighten ch receptors lation of the consists joint (a hinge rity of which vertebrae . The (Figure of from: ments direc of etab allow (palm extension ion or girdle unt witho move ee of angu abduction embryolo centres main an artic d apart sligh aspects ro-ac (SIJ) the majo The slightly lar facet the the floor) off stret of rotat knee to on and The elbow ro-ulna g ees, three into acco faces of age.

2 x femo -iliac joints of GH with the articu the degr ple durin hume the from n Flexi ll amount be prise e the 3-D 0 degr of years the ratio r. lates 1.

15 25-3 sma to allow is 2:1 2 x sacro symphysis ion consists For examneutral to h articu 8 and nA appreciat joint. can occu ion is ment stable play junct which rotat re flexion rus whic on the ulna s into 1 x pubic ar-sacral n from the GH joint, ees the move ment This subtalar ugh very befo the hume surface altho move le come is at 1 x lumb FA joint, 0 degr oracic ‘unlock’ ruent the clavic 30-9 cong ula-th The et n from t to scap of abduction et et tEX.n men .spor tEX.n tEX.n move 90 degrees www 20 .spor .spor www www n after 26

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www.sportex.net Produced by

■ Back to basics revision of anatomy of each joint ■ Includes 53 anatomy animations and video clips to bring the facts to life ■ Covers diagnosis and treatment options with background theory and evidence based medicine

Picture

by Dr Simon Kay

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© Primal

ANATOMY & SOFT TISSUE INJURY REVIEW

This resource is packed with animations and is highly visual coviering all the major joints and surrounding soft tissues. This guide offers valuable advice and tips to identify injuries, make good diagnoses, give sensible treatment advice and make appropriate referrals. It is also a perfect tool for showng patients and clients exactly which anatomical structures they have injured. The resources is regularly updated and expanded with new images and animations.

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SUBSCRIPTION INCLUDES ACCESS ON IPAD, ANDROID AND KINDLE FIRE TABLETS. For more information visit the Manuals + Guides section at www.sportEX.net

35

contents January 2015 issue 43

Editorial

publisher TOr DavIEs Bsc (Hons) tor@sportex.net art editor DEBBIE asHEr debbie@sportex.net sub editor aLIsOn sLEIgH PhD 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

It is a complete coincidence that we’ve published two articles, from authors from two continents at opposite ends of the world, that highlight serious issues that the manual therapy ‘brand’ is currently facing. To me it is an indication of the gravity of the situation. On the one hand (pun intended!) manual therapy/massage/soft tissue manipulation (there in itself is one issue) is having something of a renaissance in no small part thanks to the growing appreciation of the role of fascia and the interconnectedness of the soft tissues of the body. However on the other hand there are the issues of inconsistent terminology (as described on p8), difficulties establishing solid, repeatable, evidence-based research to support the practical application of massage and lastly a continued fragmentation in terms of professional representation with a growing number of professional associations attempting to represent the same people (an issue we’ve highlighted regularly). Leaving politics aside, it all comes down to one issue, our existing and future potential customers. If we can’t deliver unified terminology, standards and a solid evidence for our practice, how on earth can we expect our potential clients to understand what they’re looking for?

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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ng exceotille n in

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HIGHLIGH

TS

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 professional standards 12 massage research This quarter’s latest soft tissue research

Unitity is needed if we’re going to create a reputable brand research into the effectiveness of massage is flawed, we look at how we can change this going forward

17 Kinesio tape research

ConTenTs 20 yoga as therapy 29 biotensegrity 34 social Watch

Discover how yoga can complement rehabilitation Fascia and body architecture Useful resources on social media sites

an update on the evidence base

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.

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online

click on research TiTles To go To aBsTracT

The role of running mileage on coordina coordinaTion paTTerns in running. Boyer ka, freedman silvernail J, hamill J. Journal of applied Biomechanics 2014;30(5):649–654 The study aim was to apply a principal component analysis (PCA) to test the hypothesis that differences exist in kinematic waveforms and coordination between higher and low mileage groups. Gait data were collected for 50 subjects running at 3.5m/s assigned to either a low mileage group doing less than 15 miles/ week or higher rate of more than 20 miles/week. The latter group had 1 year of running experience. They found that there were variations in transverse plane pelvic rotation, hip internal rotation, and hip and knee abduction and adduction angles which suggest the coordination of lower extremity segment kinematics is different for lower and higher mileage runners.

sportEX comment Principal component analysis is a tool for reducing lots of possibly connected data into less data. If you are not a statistician it is probably best to leave it at that but if you want to know more try ‘Wikipedia’ and if you can make sense of that try writing an article for sportEX explaining it to the rest of us. In the meantime the conclusions of this study suggest that adopted patterns of coordinated motion may explain why there is a lower incidence of overuse knee injuries in the higher running groups. Knowing that is the easy bit. The hard question is how can coaches and medics help prevent injuries in less experienced runners.

The effec effecTs of orThoTic inTervenTion mulTi-segmenT fooT kinemaTics and on mul planTar fascia sTrain in recreaTional runners. sinclair J, isherwood J, Taylor pJ. Journal of applied Biomechanics p 2014;doi:10.1123/jab.2014-0086 (article in press) Fifteen male participants ran at a rate of 4.0m/s with and without orthotics. Multi-segment foot kinematics and plantar fascia strain data were obtained during the stance phase.

Relative coronal plane range-of-motion of the mid-foot relative to the rear-foot was significantly reduced with orthotics (1.0°) compared to without (2.2°). Similarly relative transverse plane range of motion was significantly lower with orthotics (1.1°) compared to without (1.8°). Plantar fascia strain did not differ significantly between orthotic (7.1) and noorthotic (7.1) conditions.

sportEX comment Much more attention should be paid to foot biomechanics not just by the sporting population but by anyone who is active. What happens at the base affects the entire kinematic chain. Sort out the feet and knees, hips and back will follow. In the general population every knee and hip replacement patient should have a post-op foot analysis (and their leg length checked) because it is bound to have changed.

fooT speed, fooT-sTrike and fooTwear: linking gaiT mechanics and running ground reacTion forces. clark kp, ryan lJ, et al. The Journal of experimental Biology 2014;217:2037–2040 This study used four human footfalls with distinctly different vertical force–time waveform patterns to evaluate whether a basic mechanical model might explain all of them. The model partitions the body’s total mass (1.0Mb) into two invariant mass fractions (lower limb = 0.08, remaining body mass = 0.92) and allows the instantaneous collisional velocities of the former to vary. The results indicate that the model is capable of accounting for nearly all of the variability observed in the four waveform types tested: barefoot jog, rear-foot strike run, forefoot strike run and forefoot strike sprint. The conclusion is that different running ground reaction force–time patterns may have the same mechanical basis.

sportEX comment Given that running performance, energy requirements and musculoskeletal stresses are directly related to the action–reaction forces between the limb and the ground then any model that allows analysis of the variables is to be welcomed. Now bring on the big studies.

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sportEX dynamics 2015;43(January):4-7

JOURNAL WATCH

Journal watch e effecTiveness of massage Therapy as co-adJuvanT TreaTmenT To exercise in osTeoarThriTis of The knee: a randomized conTrol Trial. cortés godoy v, gallego izquierdo T, et al. Journal of Back and T musculoskeletal rehabilitation 2014;27(4):521–529 Eighteen women were randomly allocated to two different groups. Group A was treated with massage therapy and an exercise programme, and group B was treated with the exercise programme alone. The intervention lasted for 6 weeks. Outcomes were assessed using a verbal analogue scale (VAS), the WOMAC index, and the Get-Up and Go test. Baseline, post-treatment, and 1- and 3-month follow-up data were collected. In both groups, significant differences were found in the three variables between the baseline measurement and 3 months after treatment, with the exception of the WOMAC variable in group B. No significant differences were found between both groups in the WOMAC index and VAS variables and the Get-Up and Go test. The conclusion is that combining exercise-based therapy with massage therapy may lead to clinical improvement in patients with osteoarthritis. The use of massage therapy combined with exercise as a treatment for gonarthrosis does not seem to have any beneficial effects

sportEX comment This paper is a fine example of the problems faced d deep massage To posTerior calf muscles in comBinaTion wiTh neural moBilizaTion exercises as a TreaTmenT for heel pain: a piloT randomized clinical Trial. saban B, deutscher d, ziv T. manual Therapy 2014;19(2):102–108 Sixty-nine patients with plantar heel pain syndrome (PHPS) completed a single-blind randomised clinical trial in which they were assigned to a programme of 8 treatments over a period of 4–6 weeks. Functional status (FS) at admission and discharge from therapy as measured by the Foot & Ankle Computerised Adaptive Test was the main outcome measure.

The interventions were deep massage therapy (10min of forceful soft tissue massage mobilisation techniques, directed to the incompliant and painful areas of the posterior calf muscle group) plus a neural stretch (passive straight leg raise combined with dorsiflexion using a long belt) or ultrasound.

Both groups were also given a self-stretching programme of calf stretches. The results showed that both treatment protocols resulted in an overall short-term improvement; however, the massage group was significantly more effective in treating PHPS than the ultrasound group.

sportEX comment Another feather in the massage cap. www.sportEX.net

by anyone wanting to use research to enhance knowledge.

The abstract contains more questions than answers. For a start what is a WOMAC variable? A quick ‘Google’ search and you will know that it is the ‘Western Ontario and McMaster Universities Osteoarthritis Index’ It has 24 items divided into 3 subscales and if you want to use it you have to get permission and the cost is ‘determined on the basis of information specific to each research project’. Next there appears to be contradictions in the terms used. It starts talking about ‘osteoarthritis’ and ends up with, ‘gonarthrosis’.

Google those terms and you will find that they are either interchangeable or different dependant on which site you chose to read. If you still have the will to live you will note that the abstract conclusion appears to contradict itself by saying that massage treatment may lead to clinical improvements but it is not beneficial. The answer may lie in the full paper but unfortunately it is not available via the most widely used route of an educational institution portal.

So if you want to know more you have to buy the article at $27.50. That’s £17.48 at the rate on the day of writing.

Thanks but no thanks. c core sTaBiliTy exercises for low Back pain in aThleTes: a a sysTemaTic review of The liTeraTure. stuber kJ, Bruno p, et al. clinical Journal of sport medicine 2014;24(6):448–456 A search of the usual medical databases was made for studies where athletes with non-specific low back pain (LBP) were treated with core stability exercises in at least one study arm, and back pain intensity and/or disability were used as outcome measures. Five studies including 151 participants met the inclusion criteria, including two RCTs. The quality of the literature on this topic was deemed to be low overall, with only one non-RCT having a moderate quality score, and one RCT having a lower risk of bias. Four studies reported statistically significant decreases in back pain intensity in their core stability intervention group.

sportEX comment Its seems that both the quantity and quality of literature on the use of core stability exercises for treating LBP in athletes is low and what there is has used small and heterogeneous study populations using interventions that vary drastically 5

online

click on research TiTles To go To aBsTracT

massage Therapy for osTeoarThriTis of The knee: a randomized dose-finding Trial. perlman ai, ali a, et al. plos one 2012;7(2):e30248

effecTs of massage in prone posiTion, on Blood pressure and hearT raTe, in healThy women. meftahi n, Bervis s, et al.

Journal of rehabilitation sciences and research 2014;1(2) Sixty-one healthy women were divided into two groups. One lay prone and was given a 15min massage while group two just lay prone for 15min. Immediately before and after interventions, systolic and diastolic blood pressure and heart rate were measured in both groups. Systolic blood pressure decreased significantly in both groups. There was no significant difference between groups. Changes of diastolic blood pressure and heart rate were not significant in either group.

This is a follow-up to a previous trial of massage for osteoarthritis (OA) of the knee which demonstrated that the feasibility, safety and possible efficacy of massage for OA that persisted at least 8 weeks beyond treatment termination.

This study is a randomised controlled trial (RCT) to identify the optimal dose of massage within an 8-week treatment regimen. One hundred and twenty-five adults with OA of the knee were randomised to one of four 8-week regimens of a standardised Swedish massage regimen (30 or 60min weekly or biweekly) or to a Usual Care control (treatment without massage). Outcomes included the Western Ontario and McMaster Universities Arthritis Index (WOMAC), visual analogue pain scale, range of motion, and time to walk 50 feet, assessed at baseline, 8-, 16-, and 24-weeks. The bottom line result was that given the superior convenience of a onceweekly protocol, cost savings, and consistency with a typical real-world massage protocol, the 60min once-weekly dose was determined to be optimal, establishing a standard for future trials.

sportEX comment

sportEX comment This is not a great study on a number of levels. Although the direction of strokes and the area of massage are described there is no mention of the depth of treatment making the actual dose undetermined. The subjects are healthy so their blood pressure is normal. It needs to be repeated on people with hypertension.

Compare and contrast to the similar study reported in the Journal of Back and Musculoskeletal Rehabilitation on p5. This one reaches a proper conclusion and it is available in full in an open access journal. If we are going to be picky, the dose given only considers time not depth of treatment but at least we could read the paper to discover this.

effecT of massage on doms in ulTramaraThon runners: a piloT sTudy. visconti l, capra g, et al. Journal of Bodywork and movement Therapies. 2014;doi: http://dx.doi.org/10.1016/j.jbmt.2014.11.008 (article in press) Epidemiological data was collected during the Tor des Geants, an international ultramarathon race of 330km in length and 24,000m in elevation. Two hundred and twentyone treatments were performed on 220 ultramarathon runners, of which 207 were males and 34 were females; the age group most represented ranged from 40 to 50 years. The most common symptom was pain, which occurred in more than 95% of cases, and the most affected area was the lower extremities (90% of subjects).

Twenty-five athletes complained of DOMS. In the patients analysed, treatment with massage generated a

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significant improvement. The numeric pain rating scale (NPRS) value was 3.6 points on average (SD 2.1) after massage, and there were no cases of worsening DOMS after massage as determined using the patient global impression of change (PGIC). The values of minimal clinically important difference (MCID) in DOMS management were calculated on the basis of the receiver operating characteristic (ROC) curves and two other anchor-based methods in the PGIC and were 2.8 to 3.9 points on the NPRS.

sportEX comment Ultramarathons are a huge

amount of physical effort so it is hardly surprising that the competitors need a massage. The banner headline result was that massage was an effective treatment to reduce DOMS during the onset of symptoms. You will notice that we have not produced a full reference for this article. That is because there is a growing tendency for journals to publish articles in press on their web sites. Sometimes it can be months before these actually get into a specific edition of the journal. We tell you about them as soon as we can because we want to share the information.

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JOURNAL WATCH

The effecT of Back massage on Blood pressure in The paTienTs wiTh primary hyperTension in 2012-2013: a randomized clinical Trial. mohebbi z, moghadasi m, et al. international Journal of community Based nursing and midwifery 2014;2(4) This was a non-blind clinical trial on 90 patients with primary hypertension. The patients were randomly divided into a control and an intervention group.

In both groups, blood pressure was measured and recorded twice a week

before and after a 10min Swedish back massage and rest for 6 weeks. In the intervention group, systolic and diastolic blood pressure decreased to 6.44 and 4.77mmHg, respectively after back massage.

u undersTanding fiBroBlasTs in order To comprehend The osTeopaThic TreaTmenT of The fascia. Bordoni B, zanier e. evidence-Based complementary and alternative medicine. 2014;id:860934 This paper examines the current literature regarding the function and structure of the fascial system and of the fibroblasts that form its foundation. The fibroblasts play a key role in the transmission of the tension produced by muscles and in the management of the interstitial fluids. They are a source of nociceptive and proprioceptive information as well, which is useful for proper functioning of the body system. They have the ability to

rapidly remodel their cytoskeletons.

sportEX comment If you are already tuned into the wonders of myofascial release or wondering what all the fuss is about then this paper is for you. It’s available free. If you want to see for yourself fascia’s ability to alter its structure, search ‘YouTube’ for, ‘Strolling under the skin’. It is film of ‘live’ connective tissue being explored with a ×30 magnification camera.

sportEX comment Of course it did. It seems at lot of massage research is being done by the nursing community these days. Is that because physiotherapy has given up on it despite the weight of evidence in its favour?

is puBerTy pu a risk facTor for Back pain in The young? a sysTemaTic criTical liTeraTure review. lardon a, leboeuf-yde c, et al. chiropractic & manual Therapies 2014;22:27 doi:10.1186/s12998-014-0027-6 Literature searches were performed in March 2014 in PubMed, Embase, CINAHL and PsycINFO for studies on back pain for subjects less than 19 years old, written in French or English. Four articles reporting five studies were included, two of which were longitudinal. Some studies show a weak and others a strong positive association between puberty and back pain, which remains after controlling for age and sex.

sportEX comment This is not fully conclusive but it does suggest a possibility of a causal link between puberty and back pain.

The effec effecT of kinesio Taping in forward Bending of The lumBar spine. lemos Tv, gonçalves albino ac, eT al. Journal of physical Therapy science 2014;26:1371–1375 Thirty-nine subjects were divided into three groups [control, Kinesio Without Tension (KWT), and Kinesio Fascia Correction (KFC)]. The subjects were assessed by Schober and fingertip-tofloor tests and left the tape in place for 48h before being reassessed 24h, 48h and 30 days after its removal. In all three experimental groups no significant differences were observed with the Schober test, but it was possible to observe an increase in lumbar flexion after 30 days. With the fingertip-tofloor distance assessment, the KFC and KWT groups showed significantly improved flexibility 24 and 48h after tape removal.

sportEX comment According to the introduction of www.sportEX.net

this paper the tape seeks to free fascia of any movement limitations by means of mechanical tension generated by the tape. It does this because it ‘deforms the fascia, stretches the bonds between molecules, promoting a gentle flow of electrons and generating a piezoelectric charge’. The charge is interpreted by cells, which causes them to respond by increasing, reducing, or changing their local intercellular elements’. OK but does it work? Well of course it does. It should be renamed ‘Ubiquitous Tape’ because it seems every athlete in every sport you see on TV is covered in the stuff. Would it really be so popular if it wasn’t having some effect? Now it’s up to the researchers to find out how.

Over to you guys!

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Professional standards Have we lost tHe opportunity to create a reputable brand? background the following letter from one of our regular australian contributors provides an interesting insight into some of the difficulties facing the australian massage therapy industry. this introduction describes how the australian healthcare and education systems have contributed to creating this situation and how we in the uk can perhaps avoid ending up in a similar position.

tHe australian HealtHcare system in australia, healthcare is provided by both private and government institutions. universal healthcare is provided through the governmentfunded medicare scheme, which funds free universal access to hospital treatment. medicare also subsidises out-of-hospital medical treatment and the patient pays the remainder of the cost; however, private insurance can be taken out to cover this out-of-pocket payment. individuals who can afford to take out private health insurance are encouraged to do so by the government and not to resort to the public health system. in order for private insurance companies to pay a patient’s costs for massage therapy, the patient has to go to a therapist who is an approved provider for that insurance company. Hence the need for massage therapists to be members of accredited associations.

tHe australian education system Further or tertiary education in australia is provided by traditional universities, institutes of technology,

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by brad Hiskins bsc, rmt and colleges of technical and further education (taFes) and privately operated registered training organisations (rtos). taFes and rtos are the main providers of vocational education courses, which are based on endorsed sets of competency standards (or training packages). the re-introduction of fees for students from the 1980s onwards has resulted in some institutions competing for students by offering shorter and therefore cheaper courses, which in turn has led to a wide range of standards among ‘qualified’ therapists. this recently caused medibank private (an australian private health insurance company) to put a halt to all new therapists gaining any status with them because of their belief that the profession was abusing the system and that graduates were not sufficiently educated to provide an adequate service.

wHat does tHis mean For tHe uk? are we, in the uk, following this route? we now have to pay a considerable amount for a degree course and nHs services are being increasingly contracted out to the private sector. waiting times for nHs therapy often means that private practice is the patient’s first port of call. will private health insurance soon play a larger role in the uk and if so will the problems facing australia’s massage therapists become our problems too? this article provides an incisive analysis of the industry in australia – can we learn from it and better prepare ourselves for facing (or forestalling) a similar situation?

t

he Remedial Massage Profession has many challenges. Not the least is branding. For decades the debates have raged over the terminology to be used by our profession. The outcomes have been non-uniform, divisive and have achieved little but separatism and confusion.

Confusion predominantly for our own members, but more importantly for our customers, referral networks, insurance companies, authoritarian bodies and future students of the trade.

So why the lack of unity in debate and outcome? I believe the answer is threefold.

Firstly, tHere is an obvious lack oF correlation and collaboration between associations With the amalgamation of seven associations in the early 2000s to form the Australian Association of Massage Therapists (AAMT), there was optimism that the profession was on track to unify its policies and future directions.

This was in concert with the formation of the ‘competency standards’ which were to distinguish between the two main areas of our profession, relaxation and remedial, and provide a framework for each registered training organisation (RTO), or school, to formulate a curriculum. The profession would have a standardised education format and two well defined areas of education and service delivery: Certificate IV in Massage Therapy and a Diploma in Remedial Massage. Our lobby group could then be concise with its delivery to government, insurance companies, customers and all other relevant bodies.

Times were promising. We had a developing brand. sportEX dynamics 2015;43(January):8-11

OpiniOns

What happened over the next few years didn’t realise that potential.

Although AAMT formed a formidable new association, there were still many other associations that held enough members to pose a political standoff.

The Association of Massage Therapists (AMT), with a relatively New South Wales-based membership, decided not to join the amalgamated group forming AAMT. The Australian Natural Therapists Association (ANTA) and the Australian Teachers of Meditation Association (ATMS), associations of numerous professions, had no real necessity to amalgamate. It’s not their core business.

The Association of Remedial Masseurs (ARM), although small, remained a single entity. Massage Australia (MA), originally a magazine that later became an association, remained. There were also a few smaller associations including the Australia Massage Association (AMA), and the Massage Association of Australia (MAA). The Royal Melbourne Institute of Technology (RMIT), a Technical and Further Education (TAFE) provider, was delivering the Myotherapy advanced diploma and had formed their own association, the Institute of Registered Myotherapists of Australia (IRMA). Curiously, many of the Chinese Massage associations held influence with our profession. There were still too many associations with their own political agendas, membership bases, financial influences and power plays.

We didn’t compromise. We didn’t unite. We didn’t take advantage of a

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rare opportunity to mobilise more than 25 thousand people: to mobilise their opinions and formulate a strategic plan that would see a profession cut itself free from the third-bedroom cottage mentality to a respected body that demanded attention through well versed professional rhetoric. The opportunity to meet, debate, formulate, strategise and implement, was not realised. We missed the opportunity to be goods and services tax (GST) free. We missed the opportunity to be on the professional list for the Chronic Health scheme. We missed many opportunities. We had too many associations claiming to be the ‘peak body’. We had too many mixed messages. There were too many agendas and I can only imagine the perception of authoritarian bodies of our lack of unity and policy. Let alone our lack of basic definition and Brand.

In recent times with the profession being attacked from all angles, especially with the Medibank Private situation (where this private insurance company has put a halt to all new therapists gaining approved status because of the belief of poor quality service provision), we had another chance to join forces. Although some associations suggest this did occur to some degree, the message to members from each association has not reflected this. A simple example is many of the associations hiring their own lawyers to sift through the legal ramifications of decisions made by Medibank Private.

A prime opportunity to use one legal

firm, for one overriding outcome. It didn’t occur. AMT, for instance, still has not signed the agreement with Medibank Private, suggesting there may be legal implications. Some associations, such as ANTA, signed the agreement the moment it was released. Was there a representative from each association providing information to Medibank Private? Our sources suggest it was only ANTA. Why? Who decided that?

What process was used to allow this to happen? How did they represent us?

What information was given and with what authority? Was there any due process?

This lack of association unity and compromise, in my opinion, was a major factor in our inability to formulate a well defined brand. Unfortunately we are still Masseurs, Masseuses, Massage Therapists, Remedial Massage Therapists, Soft Tissue Therapists, Myotherapists, Clinical Myotherapists, Musculoskeletal Therapists, Deep Tissue Therapists, Body Workers, Sports Therapists. You get the picture.

secondly, tHe inclusion oF tHe word ‘interpretation’ in tHe competency This means that a training organisation can write their own curriculum based on their personal opinion rather than the opinion of the overall membership.

Plus, employers have lost the ability to influence the education facilities to teach to employers ‘wants and needs’.

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The competency standard was an attempt to deliver a minimum standard of education to our two defined areas of service delivery, Massage Therapy and Remedial Massage Therapy. The profession signed off on the final competency standards. For once we all agreed, we all compromised.

RTOs could now deliver training to a particular standard and graduates would be of a minimum level of education. We would have Massage Therapists to work in the relaxation industry and Remedial Massage Therapists to assess and treat common aches and pains.

Unfortunately a competency package can be ‘interpreted’ by an RTO. A competency package also does not have a defined number of hours.

It is not a curriculum. It is a guideline at best. When RTOs realised this, we ended up with some schools reaching up to 2000 face-to-face hours for the diploma and some a few weeks. That was their interpretation. Hence, in theory the competency package delivered the same graduate but in practice the outcome was far from standardised.

What was thought to achieve a standard of education, actually transpired into a chaotic mess that for all intents and purposes could not be controlled. Our associations have no authority to challenge each RTO with regard to the standard of their graduate or their interpretation of the competency package. The Australian Skills Quality Authority (ASQA; a 10

government regulatory body) does not audit the curriculum developed by the RTOs, it only checks that the school is acting in accordance with RTO rules and regulations.

The RTOs could provide whatever education they wanted. And they did. Graduates were and are still of remarkably different levels of basic anatomy (if any), pathology, assessment, protocol and treatment skill set. The competency did not deliver its intended purpose – a minimum standard of graduate.

Therefore graduates deliver a markedly different service. Some have little to no note-taking skills, some don’t even understand the legal necessities to do so. Some can assess to current clinical ‘gold standards’ and some have not been taught the very basics, some don’t assess at all. Some have an understanding of many treatment techniques, when they are indicated or contraindicated, the likely physiological change that positively affects the client, some have little to no idea.

When your members are of such markedly different levels of education, your ability as a profession to create a deliverable brand is limited. I would argue impossible.

This lack of education minimum standard and the incompetence that is produces, was the emphasis for Medibank Private to set a minimum education standard of its own. A standard that I personally believe is still well below what we should be striving for. A standard that does not reflect the impression we try to communicate to our clients, our referrers and our authoritarian bodies.

tHirdly, our proFession is Fracturing into numerous pockets Once again, the competency standard and amalgamation of those seven associations was to unify our profession.

With unification comes the ability to create a lobby group that delivers one message. There would be one CEO, with one president, one board with one administration. This would create an efficient machine with financial clout

and a huge membership base. A true peak body that would represent us and forge new opportunities for us and our future graduates. A body that would stabilise our political opinion. A robust organisation that would debate and rationalise our place in healthcare.

We don’t have this. As already stated, we have numerous associations with different agendas, membership bases, professions, financial situations, etc.

Beyond this, however, we have a considerable and divisive fracture of the members themselves. We have massage therapists (MTs), remedial massage therapists (RMTs), myotherapists (Myos), musculoskeletal therapists (MSTs), soft tissue therapists (STTs) and numerous other acronyms reflecting divergent mind sets. There are verbal swipes between each, political power plays, and belittling and downright defamatory behaviour in some circumstances. The word ‘massage’ is still highly debated. In some circumstances that word is suggested to be the greatest restraint to our professional standing. The term ‘remedial massage’ is hardly ever used by our associations – we don’t actually have an association that describes itself as the ‘Association of Remedial Massage’ although it is the agreed term for our diploma level graduates. We have some associations recognising some advanced diplomas and not others, some recognising some degrees and not others. Insurance companies are awash with a plethora of terms and divergent professions, some of which I have never heard of, but they all are apparently born of the same diploma.

It’s a mess. It’s embarrassing. It’s divisive and destructive.

The divergence occurs for many reasons. Commonly people want to be perceived as professionals in the health community and the word massage does not engender such a response.

The early myotherapy developers pushed this to a level not seen before, by completely banishing the word and creating a three-year advanced diploma (now 18 months). The term Soft Tissue Therapist was coined by a group of Sports Physicians and then used mainly in the sporting arena and eventually at Canberra Institute of Technology (CIT) as sportEX dynamics 2015;43(January):8-11

OpiniOns

an Advanced Diploma. The MST group is relatively new and with the relaxation of rules governing who can provide a degree, that group is now calling their course a degree. There are many other examples but all are compelled to create a graduate that is perceived to be beyond that of an RMT and therefore shown more respect and hopefully more integration into the health system.

Although the intent is admirable, the outcome has seen infighting and destructive behaviour that has fractured much of the profession.

In terms of creating a brand, this has been our greatest enemy. Our associations have not listened and acted on the members’ demands, so the members create their own entities.

And the ability to create a brand is lost.

If there is the means to compromise and re-unite members with regards to ‘naming’ our profession, it needs to be done. We need to compromise.

We need to be consistent. We need to be well versed in strong policy and

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rhetoric. We need to unite. Until we do so we will remain vulnerable to attacks from insurance companies and be poor political competition to our peer professions. We won’t be able to represent our profession adequately. Our graduates will continue to be disillusioned with our profession.

Our profession will not be perceived as worthy members of the health community (and yes, to all those who are arguing that you as an individual are doing well, there are many who are guiding us well, but this argument is about the whole).

A well defined and respected brand is the envy of any business, any organisation or company. It is the primary action item of any marketing.

It is what provides the springboard for all sales. We need to develop a strong reputable brand. But with the three factors I have mentioned above diminishing or even halting our attempts, we will struggle to achieve any such outcome.

These need to change. If we are to ever develop a reputable brand, the change needs to start with us demanding compromise and unity from our associations.

Let your voice be heard.

Th AuThor ThE BrAd hiskins Br iskins Bsc, rMT Brad is one of Australia’s most experienced soft tissue therapists. he has a Bsc B (majoring in exercise physiology), an advanced diploma of health science (soft tissue therapy) and a diploma in remedial massage. he e was head of the soft tissue therapy service at both the 2004 (Athens) and the 2008 (Beijing) olympic games and the Manchester and Melbourne Commonwealth Games. he has also been a soft tissue therapy service provider to the Australian team at the Atlanta, sydney, Athens and Beijing olympic Games. he e was president of the ACT branch of sports Medicine Australia between 2007 and 2009, a soft tissue therapist at the Australian institute of sport from 1994 to 2005 and the soft tissue therapist to the national triathlon team between 1998 and 2012. he also was an author of the first competency standards for rMT and MT in Australia.

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Why massage research is flaWed

BY BoB Bramah BSc, mSma mSmm mcSP

IntroductIon The use of massage in sport and exercise is widespread.

Coaches, athletes and medical professionals believe that it has beneficial effects, for example enhancement of preparation and performance as well contributing to the prevention and treatment of injury. This belief has persisted since the first recorded medical text produced in China in 2500BC and in ancient Indian and Greek texts including the work of Hippocrates who reputedly said, “Medicine was the art of rubbing”. The Greeks, founders of the Olympic sporting ideal, regularly rubbed their athletes’ bodies in olive oil as both preparation for their events and as a post-exercise recovery strategy. So important was this deemed to be that the philosopher Philostratus in his book Gymnastics-Epistolai provided instructions on how to do it: “The trainer should apply rubbings for the athletes of light and heavy events, with a moderate amount of oil, especially the lower parts, and wipe them well” (1).

In modern times studies have confirmed this belief in a number of sports, eg. BMX cycling (2), running (3) and Taekwondo (4). All report extensive use of massage in elite and non-elite athletes. Nichols (5) surveyed athletes from 20 sports at an American University and found that 38% used massage during their training and it was by far the most widely used modality. Galloway et al. (6) reported that massage was the treatment choice for physiotherapists for 45% of their time at major athletics events between 1987 and 1998. In the Polyclinic of the London Athletes Village for the 2012 Olympic Games 23.3% of all patient encounters were described as ‘therapeutic soft tissue treatment’, which was the most widely used modality (7). Smith and Hillman (8) reported that 71% of treatments on the European PGA Golf Tour in 2005/6 involved massage. Away from competition, Cahalan and Sullivan (9) reported that 83% of professional Irish dancers used massage to prevent and treat injury.

Despite the popularity of massage, the authors of many original studies concerning its use come to the conclusion that the treatment is not justified for facilitating athletic performance. Why is it that study after study reaches this conclusion? The answer is that the vast majority of, if not all, research into the use of massage is flawed. It is not asking the right questions of the right people and it is coming to the wrong conclusions.

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Massage is used extensively in sport but a huge number of experimental studies reach the conclusion that it has little or no actual benefit. This is because virtually every study is methodologically flawed – not for the usually stated reasons of a lack of randomisation or blinding but because of a lack of consensus about what massage actually is, a lack of understanding about what is being tested and on whom, and above all a total disregard for the dose of application.

Figure 1: And with flawed research then there’s a high risk of this happening.... (copyright Jorge Cham, www.phdcomics.com)

sportEX dynamics 2015;43(January):12-16

opinions

What’S In a name?

The first problem facing researchers is that there is no commonly accepted definition of what constitutes ‘massage’.

The American Massage Therapy Association states that it is “the manual soft tissue manipulation that includes holding, causing movement and/or applying pressure to the body”. In the UK the Sports Massage Association’s description is “the management, manipulation and rehabilitation of soft tissues of the body including muscles, tendons and ligaments”.

Study authors giving their own definition tend to stress the therapeutic effects, “a mechanical manipulation of body tissues with rhythmical pressure and stroking for the purpose of promoting health and well-being” (10). “Massage therapy is the manual manipulation of soft tissue intended to promote health and well-being” (11). “Sports massage is defined as a collection of massage techniques performed on athletes or active individuals for the purpose of aiding recovery or treating pathology” (12). The widest definition is provided by a medical subject heading in MEDLINE which is “a group of systematic and scientific manipulations of body tissues best performed with the hands for the purpose of affecting the nervous and muscular systems and general circulation” (13).

That is very wide ranging definition. It means in effect that anything to do with soft tissue can be classed as ‘massage’.

Eisenberg et al. (14) state that there are over 100 different types of massage, yet most massage research concentrates on the group of techniques known as ‘Swedish Massage’, (effleurage, petrissage, tapotment, frictions, vibration). This list highlights another difficulty in massage research. Which techniques used within the varying definitions are applied during trials? Weerapong (15) lists only the first four in his review of massage evidence. Brummitt (16) only three (effleurage, petrissage, and deep transverse frictions) and Robertson (17) only one (effleurage). A further problem is that according to Fritz (18) there are seven variables in the application of any of the above techniques (depth, duration, direction, drag, frequency, speed and rhythm), yet no study allows for this variation.

In addition to the lack of consensus concerning the general definition of the word massage there is also a lack of consistent terminology for describing the treatments given by massage therapists. An example of this is Ischemic Compression which is also known as Nimmo technique, Trigger Point Therapy or Acupressure (19), Manual Pressure Release (20), and Thai Massage (21). Although this problem is highlighted in almost all studies [and Sherman (22) attempted to describe a common terminology], the difficulties persist.

Volume of reSearch The amount of available research is phenomenal. There have been a number of systematic reviews into the evidence for massage published in the last few years. They all start with a literature review searching for articles in the medical databases. Best (23) found an initial 44,016 articles in MEDLINE and 46,633 in Embase before whittling the results down into a slightly more manageable 4,022. Brummitt (16) found 14,032 using the word ‘massage’ and Torres (24) 5,790. The fact that most of the systematic reviewers finally review between 5 and 30 papers suggests that, as Moraska www.sportEX.net

THERE IS NO COMMONLY ACCEPTED DEFINITION OF WHAT CONSTITUTES ‘MASSAGE’ (25) states, the majority of published research involving massage is plagued by poor methodological design and questionable interpretation of results.

Given the number of reported studies in these reviews it could be expected that a meta-analysis would obtain a better understanding of effectiveness of massage as an intervention but the variety of massage types and massage conditions makes this virtually impossible (23,26,27). Only Torres (24) on the subject of delayed onset muscle soreness (DOMS) was able to synthesise results.

comBIned treatmentS A number of studies use combined treatments which, despite their positive outcomes and the fact that this is how athletes are treated in real situations, does not really answer the question of whether or not massage works. A study using, for example, massage plus manipulations plus stretching rarely has enough participants to treat using each of those variables separately or in various combinations so although it may be possible to state that this treatment regime is beneficial for a particular condition it doesn’t tell us if the treatment would have been successful with or without the massage element.

traInIng leVel of the theraPIStS The training and experience of the therapists involved in the studies can have an effect (28). There is a human element in the delivery of the treatment with each individual therapist developing a unique method of delivering massage strokes which can vary depending on time of day, mood or room temperature (29). Although some studies attempt to take account of such variables by ensuring that experimental treatments take place at the same time of day, in rooms where the temperature is maintained, by rehearsing routines or by playing taped instructions there is still a doubt over exactly duplicating treatment on each subject. A combination of therapist training and experience and the difference in tissue response in patients means that each massage experience is unique. The reported work of one therapist may not be transferable or reproducible by other therapists (30).

Often the level of training and experience is impossible to determine. Hinds (31) describes the therapist used in the study as a ‘chartered physiotherapist’, Young (32), as an ‘experienced’ osteopath; however, that does not mean anything in terms of their competence and skill. It is possible that the therapist is in fact vastly experienced but the fact is not mentioned. For example, Robertson (17) has a coauthor, Joan Watt, who is a leader in the field of massage in sport and the author of a text book on the subject (33) but it is not stated that she did the massage which she did. Often the person performing the massage is described only as a chartered physiotherapist. In the UK that could be someone of very limited experience. A survey conducted in 2008 concerning undergraduate physiotherapy training at UK universities found that two didn’t teach any massage at all 13

THE VAST MAJORITY OF RESEARCH INTO THE USE OF MASSAGE IS FLAWED and the majority taught between 1 and 3 hours of theory and 1 and 9 hours of practical classes (34). This contrasts with the USA where a licensed massage therapist receives 600 hours initial training on average (35).

Moraska (36) showed that there was a significant difference in outcomes surrounding post-race muscle soreness when massage was applied by student therapists with 950 hours of didactic training in massage compared with those with 700 or 450 hours of education. It should be noted that the majority of the therapists with the higher number of hours also received 30 hours of specific sports massage training and had 15 hours of internship experience with athletes.

BlIndIng Reviewers of research mark the methodology of a study against set criteria to assess whether or not the results can be biased one way or another. There are many different scales for this but they all include marks for the blinding of subjects and providers of the treatment. Even though the necessity for blinding was questioned as long ago as 1996 (37), subsequent reviews continue to downgrade ratings because of the lack of blinding. This is especially relevant in massage research given that it is difficult to blind subjects to the fact that they are receiving massage in some form and absolutely impossible to blind the therapists. There have been attempts to go some way towards blinding: Paoli (38) and Dawson (39) did not fully inform the therapists about the experiment they were taking part in but they were still asked to massage the subjects and those subjects were aware that they were receiving massage.

SuBjectS The patient population used in a study may have an effect on the outcome of massage research. In any hands-on therapy the relationship between patient and therapist is enhanced by the power of touch. It creates a powerful bond that can create potential bias in massage research because the patients have a desire to reward the therapist.

Many studies examine recovery strategies after exercise comparing, say, massage with an active or passive recovery regime. The psychological effects of completing some sort of recovery strategy may be pertinent to subsequent performance, which could be a reason why control conditions do well (40).

It is also possible that results of massage research could be swayed by the subject population whose attitudes and beliefs are culturally embedded and may thus harbour positive or negative attitudes to massage that will be reflected in the results of psychological experiments.

Dawson (41) questions if the treatment effects of massage on a trained athlete, especially one who may be 14

used to receiving regular massage, will be the same as those reported by an untrained athlete. This is supported

by Boulanger (42) who designed a questionnaire to test the theory [Client Expectations of Massage Scale (CEMS)] and found in a study of 321 subjects (data collected by 21 USA registered massage therapists) that the client’s positive expectations of massage treatment strongly affected their pain and serenity.

Most of the experimental studies into massage make attempts to equalise pre-intervention conditions in terms of standardising exercise protocol, and morphological qualities of the subjects. However, as Hinds (31) points out, all subjects are individuals and can respond in different ways to both the exercise and the intervention.

Another issue is whether or not the subjects have a treatable condition or whether they are healthy. Is it reasonable to expect the same response to treatment from both groups? This is especially relevant when it comes to pain. Subjects experiencing experimental pain have a different biopsychosocial status than those experiencing real pain emanating from a dysfunction (43).

Many of the reviews into massage and pain deal with ‘non-specific’ pain. What this means in reality is that the underlying problem has not been diagnosed. Cyriax (44) stated that all pain has a source and treatment should be directed at that source. If the presenting complaint is reported as idiopathic or the pain described as ‘non-specific’ then according to Cyriax no treatment will be totally effective.

Kassolik (30) studied the clinical outcomes of a group of subjects with idiopathic shoulder pain. One group received treatment directly to the painful shoulder. Another group received treatment based on the ‘tensegrity’ principle, which means treating all the structures that may be supporting the painful area including muscles, ligaments and fascia. Pain decreased in both groups but the group receiving treatment over a wider area demonstrated statistically significant improvement in active and passive shoulder movement. The probability is that the extended area of treatment contained the source of the pain.

A review by van den Dolder et al. (45) is titled ‘Effectiveness of soft-tissue massage and exercise for the treatment of non-specific shoulder pain’ and yet the search criteria used to find relevant studies includes not just groups of patients with undiagnosed and therefore ‘non-specific’ shoulder pain but also a range of diagnosed conditions.

These included rotator cuff tendonitis, tendinopathy, tears, impingement, bursitis, adhesive capsulitis, periarthritis and ‘frozen shoulder’, whether or not some or all of these conditions are likely to respond to soft tissue therapy is open to debate.

exPerImental exercISe condItIonS Large numbers of massage studies use a crossover model where the same subject receives a different treatment or acts as a control at different sessions but there is a possibility that the subjects’ experience of the one treatment can affect subsequent ones even if periods of time are allowed between the interventions (43). A ‘between sportEX dynamics 2015;43(January):12-16

opinions

subjects’ model may capture greater variation of subjects and therefore result in greater effect sizes but it requires a large number of subjects (41). Many use the contralateral limb as the control but this can produce a carryover effect especially for blood markers. There needs to be time delay between interventions but there could still be a placebo effect because people will expect some effect from massage and psychological effects cannot be separated entirely from physiological ones (46).

Nelson (29) questions the expectation of subjects in experimental conditions where muscle fatigue is induced.

The subjects may be aware that there will be decreased performance following repeated bouts of exercise and therefore subconsciously perform at less than maximal level.

Haas (47) used rabbits who presumably didn’t know this and subsequently performed much better than expected when exercised and immediately massaged and retested compared to controls.

Chiu et al. (48) and Howatson and van Someren (26) suggest that the use of a purely eccentric exercise to create a fatigue or muscle damage situation before intervention is unrealistic and the results are therefore suspect because an athlete will, in a real training environment, use a mixture of eccentric and concentric contractions. It is logical to suggest that a purely concentric regime is equally unrealistic.

Behm (49) created an isometric boot apparatus for an experiment in which the subjects were seated with the hip and knee at 90° and the lower limb encased in scaffolding that stabilised the knee while allowing massage treatment with the ankle at 90° and at maximal dorsiflexion for a stretching intervention. Electrical stimulation probes and eletromyography electrodes were attached. The therapist applied massage to the posterior calf while crouching to gain access to the leg. This could create problems in three areas. The unrealistic situation of being clamped into the apparatus, the placement of electrodes affecting the area to be treated or at least causing cutaneous receptors to send signals to the brain and finally the difficulty the therapist has in delivering an effect treatment in a cramped and unrealistic situation.

The area of the body to be treated may also have an effect. Generally, studies testing effects of massage on fatigue conditions have the subjects perform a Wingate test (cycling) or repeated muscle contractions. The muscles exercised are then the ones treated, often with negative results. Micklewright (50), however, found that performance was improved following a Wingate test and a 30-minute back massage. The difference between the results may be because the treated area wasn’t directly linked to the muscle creating the effort.

There also appears to be an optimal time after exercise when massage will be most beneficial to tissue. Haas (51) applied a 10N load either immediately or at 48 hours postexercise. The immediate treatment produced the better results. There may also be different results with multiple sessions and single sessions Nelson (29).

THE qUESTION OF DOSE IS NEVER FULLY ADDRESSED detrimental influence on the interpretation of results. In his pain review, Lewis (13) stated that low numbers of subjects led to studies being underpowered with the subsequent possibility of a type II error, which is a failure to detect an effect that is present (false negatives). Only one study in the Lewis review had over 20 subjects in each treatment group, yet Ebert (52) in a study on post-operative manual lymph drainage felt that at n=43 (53 operated knees split into a treatment and control) the sample was not large enough to detect some of the required outcome measures. Hettinga

SamPle SIze Moraska (36) noted that small study groups may have a www.sportEX.net

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(53) believes that for manual therapy research to be rated as high quality there should be ≥40 subjects in the manual therapy group. Rarely does a massage study approach anywhere near this number.

oBtaInIng PhYSIologIcal data Massage and blood flow are difficult to measure especially during treatment. Measurement by laser Doppler does not penetrate deep tissue and ultrasound Doppler, as used by Hinds (31), may not be sensitive enough to measure blood flow in small vascular spaces. However, in a more recent study Taspinar (54) used a colour Doppler ultrasound with promising results.

Hinds (31) exercised and subsequently massaged the quadriceps. Local anaesthesia was used to insert temperature probes into the muscle. Wiltshire (55) followed a similar protocol to massage the forearm. This could have an adverse effect on results. They also obtained blood lactate measures from a sample taken from a finger not from the muscle being massaged. It is therefore possible that although there was no systemic change there may well have been a change in the exercised and treated muscle, which is the objective of massage treatment .

doSe

Virtually all of the studies concerned with massage describe the application of strokes such as effleurage or petrissage.

These described strokes are, in effect, a delivery system not a treatment modality. What they are doing is applying

KeY PoIntS n massage is a popular and widespread therapy, but studies do not confirm its effectiveness. n most research into massage is flawed. n there is no commonly accepted definition of what constitutes ‘massage’. n the training level of therapists is crucial, but often impossible to determine. n Blinding patients and therapists is not really possible. n the expectations and attitudes of patients will have an effect on the outcome of the therapy. n the effectiveness of a treatment will depend on how accurately the problem has been diagnosed, which can be difficult when dealing with non-specific pain. n to generate meaningful data, studies should include at least 40 patients. n Studies need to take into account the ‘dose’ of massage applied.

DISCUSSIONS

online

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n In your personal experience as a therapist, do you think massage is beneficial, and if so why? n What do most studies concerning the use of massage conclude? Do you think their conclusions are justified? n Have you considered writing a case study about your treatment of a particular patient? Click here for a case study template provided by Bob Bramah: http://spxj.nl/1wodHf9

a dose of force that activates mechanosensory and mechanotransduction mechanisms. According to Kumar (56), the direction in which the load is applied can alter cellular signalling patterns in the receptors. The dosage of a particular massage application therefore is a combination of force magnitude, duration and frequency of the load applied.

Few authors classify the pressure, time, speed or technique parameters but unless dosage is stated it is impossible to draw any conclusion from the results because there is no way of knowing if the applied dosage was insufficient to produce an effect or at the opposite end of the scale excessive and counterproductive.

concluSIon There is a huge amount of research into the effects of massage and some of it is positive. Unfortunately the vast majority of it, positive or negative is flawed and of little use to clinicians. Each massage treatment is unique. Its outcomes depend on the ability of the therapist and the mind-set and treatability of the subject. Above all, the question of dose is never fully addressed. The real problem, however, is not that the evidence is flawed it is that too many people don’t know that it is. Too many people read a study title saying ‘Massage does not work for X’ and believe it without looking critically at how that conclusion was reached.

online references Owing to space limitations in the print version, the references that accompany this article are available at the following link and are also appended to the end of the article in the web and mobile versions. Click here to access the references http://spxj.nl/1G6Pmvs

further reSourceS 1. Greenhalgh T, Howick J, Maskrey N. Evidence based medicine: a movement in crisis? The BmJ 2014;348:g3725.

2. Ioannidis JPA. Why most published research findings are false. plos medicine 2005;2(8):e124.

Th AuThor ThE BoB BrAmAh BSc, mSmA mSmm mCSP B Bob is a chartered physiotherapist specialising in sports soft tissue therapy. he has worked in Premiership rugby and Football and with the GB National teams for Basketball, Volleyball and Wheelchair rugby and the England Cricket team. In addition to a private practice in Wigan, Bob is a lecturer in manual Therapy at the university of Salford and is the editor of the Journal Watch section of sportEX. he was a founder member of the Sports massage Association and is Vice-Chair of the Chartered Society of Physiotherapy professional network for massage and Soft Tissue Therapy. sportEX dynamics 2015;43(January):12-16

Literature review

the continuing research for the use of kinesio tape An updAte

This article discusses recent studies on the effectiveness of kinesio tape used to treat medial tibial stress syndrome, osteoarthritis of the knee, calf pain and low back pain in order to assess the evidence base for this therapy.

by rIchard Moore bsc, Gosc Io

IntroductIon The use of kinesio tape (KT) continues to grow in popularity despite a lack of clear evidence of efficacy or mode of action. Previous reviews (1,2) have identified a total of 14 randomised controlled trials (RCTs) that focus on the application of KT in a musculoskeletal setting but the results have been far from conclusive.

Some positive results have been demonstrated (predominantly in treating pain and disability) but no indisputable evidence has yet appeared. Poor study design and small participant groups have hampered the impact of existing studies.

It is the aim of this update to identify any new trials published since my previous article to add to the growing body of research into KT.

Method A search using PubMed identified six additional papers published since the previous review, looking at the application of KT to symptomatic subjects. Of these, three looked at the effect of KT on pain and disability in the lower limb, two addressed taping for lower back pain whereas a single study focused on medial epicondylar tendinopathy.

MedIal tIbIal stress syndroMe The study by Griebert et al. (3) hypothesised that excessive pronation is a risk factor for medial tibial stress syndrome (MTSS) and investigated the time to peak force (TTPF) in six areas of the foot in loading during gait, when walking over a force plate. It compared 20 healthy individuals with 20 current or recent MTSS sufferers, using a single Y-strip of KT along the medial aspect of the lower leg on the symptomatic side. Measurements were taken at baseline, immediately after taping and 24 hours later.

Before taping, symptomatic individuals were found to have a higher rate of medial foot loading (lower TTPF) when compared to healthy individuals.

This was significantly improved by the application of KT immediately, and also 24 hours later.

Although no pain or disability was investigated, this study suggests that KT can directly influence biomechanical factors that may be associated with musculoskeletal pathology. Whether these corrections remain after the KT has been removed remains to be seen but it suggests that KT could offer short-term relief from those suffering from MTSS or attempting to train with the condition.

POOR STudY deSIGn And SMAll PARTICIPAnT GROuPS hAve hAMPeRed The IMPACT OF exISTInG STudIeS www.sportEX.net

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STudIeS SuGGeST ThAT KT CAn dIReCTlY InFluenCe BIOMeChAnICAl FACTORS ThAT MAY Be ASSOCIATed WITh MuSCulOSKeleTAl PAThOlOGY Knee osteoarthrItIs The effect of KT on knee osteoarthritis (OA) was investigated across a cohort of 40 subjects, divided into equal experimental and control groups (4). using a pre- and post-intervention testing model, the study compared KT to sham KT across peak isokinetic quadriceps torque, time to complete the ‘standardised stair climbing task’ (SSCT) and pain during the SSCT. All subjects were aged 45–60 and diagnosed according to American College of Rheumatology guidelines, with extensive exclusion criteria.

Three strips of KT were applied to the quadriceps muscles of the symptomatic side in each participant.

The results indicated that KT significantly improved the concentric and eccentric quadriceps torque production in knee OA sufferers at angular velocities of 90°/s and 120°/s, respectively. Pain during and time taken for the SSCT also improved in the OA group compared to the control group.

An interesting feature of this study was the control intervention used. To allow the assessor to be blinded to the groups and to remove any potential ‘placebo’ effects in the participants, KT was used in both groups, applied in the same pattern. The control group, however, had KT applied with no stretch in the tape and without activation of the glue. Activation of the glue is an important part of the application process, and is performed

WeARInG The TAPe On The SKIn InCReASeS neuROMuSCulAR FeedBACK, WhICh hAS A POSITIve eFFeCT On FunCTIOnAl MOveMenTS 18

by rubbing the tape to warm it up.

Therefore, this study goes some way to suggest that it is not merely the presence of KT that is important but also the manner in which it is applied, with glue activation and stretch being important factors.

calf paIn A study by Merino-Marban et al. (5) focused on duathletes, as calf muscle soreness in this discipline is a common occurrence after races. KT was applied in a single I-strip up the calf in 28 asymptomatic duathletes before a race. One leg was taped per athlete, so each participant acted as both the experimental and control group.

Ankle dorsiflexion and pain were measured before the race, 10–15min after taping (which was approximately 20–90min before the race began) and immediately after the event. There was an immediate improvement on ankle dorsiflexion after KT in the experimental side only, but this was not present at the end of the race. There was also some reduction in pain initially after KT, but there was an overall increase in pain in both legs after the race. however, the increase in pain was less in the experimental leg compared with the control.

These results reinforce the findings from the earlier trial (3) that KT can play a role in improving biomechanical factors, in this case ankle mobility, which may help to improve function, although the effects on pain and disability are less clear. The relative reduction in pain after activity suggests that KT could have a role in improving recovery, although long-term effects have not been recorded.

MedIal epIcondylItIs The efficacy of KT against sham taping in the treatment of medial epicondylar tendinopathy (MeT) was evaluated by applying a single Y-strip of both KT and sham KT along the wrist flexors of the affected arm (6). Twenty-seven athletes, 17 of whom were healthy and 10 with symptoms of MeT for more than two weeks, were assessed before and after taping using a dynamometer to assess maximal grip strength and force sense (absolute and relative), with a week between each assessment (3

weeks in total). no significant improvements were seen in maximal grip strength or relative force sense errors in either group, although absolute force sense errors improved in both KT and sham KT groups.

As seen earlier (4), this study used KT in both the experimental and control groups. In this case the only difference was in the pattern of the tape itself. Some brands of tape have a wave-like grain said to mimic the structure of skin, but others have a less complex, straight grain. It was felt that the lack of this distinctive grain was enough to consider it sham taping, meaning that this study essentially offered a comparison between two different brands of KT. This goes someway to explaining the lack of difference in results between the two groups, although both failed to have an impact on grip strength.

low bacK paIn The remaining two studies by Parreira Pdo et al. (7) and Bae et al. (8) looked at the effect of KT on the lower back but are very different in design.

The first study taped 148 low back pain sufferers with KT under 10–15% stretch (experimental group) or 0% stretch (control) (7). So far, this is the largest RCT looking at the use of KT for musculoskeletal (MSK) conditions.

Participants were taped twice a week for 4 weeks with measurements taken before initial taping, after 4 weeks and again after 12 weeks. Outcomes recorded were pain, disability, global impression of recovery and adverse events during the trial.

Both groups demonstrated improvements in pain and disability both at 4 and 12 weeks but no significant difference was seen between the two groups. This suggests that although KT clearly has a benefit when used for chronic (over 3 months) low back pain there is no evidence that the amount of stretch applied to the tape affects outcomes. This contradicts an earlier trial (4).

The final paper discussed here,

by Bae et al. (8), is arguably the most interesting of all. A small cohort of 20 chronic low back pain patients was divided into two groups of 10: the sportEX dynamics 2015;43(January):17-19

Literature review

experimental group was subjected to KT in a star application over the area of most pain, whereas the control had a single, lateral I-strip of inelastic tape applied three times a week for 12 weeks. Both groups were also treated with heat, ultrasound and TenS. Alongside pain and disability, outcomes measured included anticipatory postural control (APC) of the anterior deltoid, transverse abdominis (TrA) and external obliques (eO), measured by electromyography, as the time taken for these named muscles to respond as the arm was raised and lowered, triggered by a sound. Additionally, changes in the cerebral cortex potential were recorded using electroencephalography before taping and again 12 weeks later.

Significant improvements in pain and disability were demonstrated in both groups with the biggest changes observed in disability of the experimental group. On top of this, improvements in muscle contraction initiation time were seen in TrA and eO in both groups, but the greatest changes were seen in TrA of the experimental/KT group.

Significantly and uniquely, changes were noted in the cerebral cortex of the KT group suggesting the presence of continual feedback to the cerebrum when the tape was worn. This is consistent with the hypothesis that wearing the tape on the skin increases neuromuscular feedback, which in this instance had a positive effect on functional movements. Inelastic tape does not seem to produce the same results.

conclusIon The studies discussed above bring the total number of papers looking at KT within an MSK framework to 20 and there are positive outcomes reported in each of these additional studies.

The range of conditions treated and outcomes measured indicate that KT can have a significant role in reducing pain, improving disability, correcting biomechanical issues and improving neurological feedback in some scenarios.

Small cohort numbers and complex study design continue to hamper the impact of the studies but www.sportEX.net

it is encouraging to see the largest published study to date with almost 150 participants (7).

Interestingly, a number of these new studies look at the detail of how KT is applied, to identify which factors influence results, whether it is the amount of stretch applied, activation of the glue or pattern of the grain of the tape itself. The results of these studies should help to inform how KT is taught and used in the clinic environment.

It seems that the ‘grain’ of the tape has little impact on results (6) but activating the glue after application (4) is significant. The amount of stretch applied to the tape and its importance is still called into question after contradictory results from two studies (4,7). Further studies looking specifically at the amount of stretch applied are required to address this issue.

In conclusion, these six studies add depth and breadth to the evidence base for KT but further studies with greater numbers are required to improve confidence in the technique in an MSK environment. references 1. Moore R. What is the current evidence for the use of kinesio tape? A literature review. sporteX dynamics 2012;34:24–30 2. Moore R. The evidence for the use of kinesio tape, an update. sporteX dynamics 2013;37:18–19 3. Griebert MC, needle AR, et al. lowerleg Kinesio tape reduces rate of loading in participants with medial tibial stress syndrome. physical therapy in sport 2014;doi:10.1016/j.ptsp.2014.01.00 4. Anandkumar S, Sudarshan S, nagpal P. efficacy of kinesio taping on isokinetic quadriceps torque in knee osteoarthritis: a double blinded randomized controlled study. physiotherapy theory and practice 2014;30(6):375–383 5. Merino-Marban R, Mayorga-vega d, Fernandez-Rodriguez e. effect of kinesio tape application on calf pain and ankle range of motion in duathletes. Journal of human kinetics 2013;37:129–135 6. Chang hY, Cheng SC, et al. The effectiveness of kinesio taping for athletes with medial elbow epicondylar tendinopathy. international Journal of sports Medicine 2013;nov;34(11):1003–1006 7. Parreira Pdo C, Costa lda C, et al. Kinesio Taping to generate skin convolutions is not better than sham taping for people with chronic non-specific low back pain: a randomised trial. Journal of physiotherapy 2014;60(2):90–96 8. Bae Sh, lee Jh, et al. The effects of

kinesio taping on potential in chronic low back pain patients anticipatory postural control and cerebral cortex.

Journal of physical therapy science 2013;nov;25(11):1367–1371.

further resources 1. Moore Osteopathy (www.mooreosteopathy.co.uk) 2. Basic kinesio taping applications. videos showing how to apply kinesio tape in the ‘how To’ section of SPORTTAPe PRO’s website (http://spxj.nl/1eZoGMu)

Key poInts n a total of 20 papers have now been identified that assess the use of kinesio tape (Kt). n positive results were seen in each study. n the largest study published to date has 150 participants. n Kt has positive effects on pain and disability. n no effect was seen on grip strength. n one study also noticed changes in the brain as a result of using Kt. n Glue activation is an important factor in the effectiveness of the therapy. n the grain of the tape appears to have no impact on results. n the importance of stretch in the tape is called into question but further investigation is required.

DISCUSSIONS

n Is there enough evidence for the use of kinesio tape (KT) in a musculoskeletal setting? n If not, what needs to be investigated? n Should these results change how KT is currently taught and used?

ThE AuThor Th richArd MoorE BSc, Gosc io r richard is a registered osteopath based r in Nottingham. he has been using kinesio tape since 2011 after seeing its potential within a musculoskeletal setting. he currently teaches the principles of kinesio taping for Sport Tape and on a freelance basis. www.mooreosteopathy.co.uk

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Yoga as therapY Yoga is an ideal form of exercise for stretching tight muscles and improving flexibility, gaining strength and also providing psychological benefits. This article describes how yoga can be used in a rehabilitation setting.

BY Dr Chris Norris PhD, MC MCsP P

e

xercise therapy is frequently a keystone to treatment, and one of the original four pillars of the physiotherapy profession outlined in 1922, when the physiotherapy society was first granted a Royal Charter.

Much has changed since that time, with various exercise types coming into and out of fashion. Yoga has been around for thousands of years, but over the last 10 years we have seen a rapid growth in yoga classes in the Western world with this type of exercise becoming the latest exercise fashion. In parallel with this growth has been an interest in the use of yoga as therapy, building yoga exercises into a structured rehabilitation programme. In this article we will look at this exercise form, and the evidence of its use in rehabilitation. We will also take a brief look at how yoga exercises are practised, and what modifications are required to bring this ancient exercise form into the fold of evidence-based practice.

What is Yoga?

The term yoga literally means union (yoke) and refers to the union between body, mind, emotion and breath. It is a system of exercise originally based on Hindu teaching, but nowadays a modified form of yoga is normally practised, which falls into the category of mind–body exercise alongside

Box 1: DefiNitioN: MiNDfulNess Mindfulness is a psychological term inherited from the Buddhist tradition. It is paying attention to the present moment in a non-judgmental way. (C. Norris, 2014)

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activities such as Pilates, and Tai Chi. Yoga can be seen as mindful activity, in that it combines both physical exercise and a mindfulness approach to movement (Box 1). Participants are encouraged to pay attention to the feeling of their body during exercise with special attention to the breath.

This concept of awareness of the breath is central to the mindfulness approach used in stress management (1). Classical yoga postures (asana) are linked to breath awareness and control (pranayama), concentration (dharana) and relaxation/meditation (dhyana).

A typical yoga class begins with a centring activity designed to act as a gap between the activities of daily living and the focus required in the yoga class. This is typically a seated posture requiring the participant to close their eyes and focus on their breathing for example, thus turning their attention inward towards their body and away from environmental stimuli. The body of the yoga class uses exercises typically practised on a non-slip (sticky) mat and often uses basic props such as foam blocks, wooden bricks and webbing belts. Exercises are practised in a number of starting positions including lying, floor sitting, chair sitting, kneeling and both free and wall-supported standing. Yoga poses are normally taught within a class format but may also be practised on a one-to-one personal training basis. Exercises are typically practised individually but partner work can also be used.

Generally a yoga class will involve several postures progressing in intensity and finishing with a relaxation and/or meditation session.

The postures are often held for a number of seconds and clients are encouraged to relax and breathe normally throughout performance.

Breath-holding (Valsalva manoeuvre), straining, facial expressions of effort and verbal responses are discouraged.

Postures are normally practised symmetrically with emphasis on good alignment as well as range of motion. In addition counter poses are often used to prevent stress accumulation within the tissues. For example postures emphasising spinal flexion are often countered by those which emphasise extension.

Body alignment when performing poses is usually compared to an idealised version typically presented by a yoga book, organisation or senior practitioner. Sometimes the reasoning behind the idealised postures lacks clear scientific evidence. Classical yoga usually claims that poses are passed down over the centuries from teacher (master) to pupil, and many organisations claim to represent the true postures. However, scientific scrutiny has challenged the claim of all yoga postures being ancient and the techniques unchanged over millennia (2). Where yoga poses are used for rehabilitation it is essential that an emphasis is placed on good body alignment using knowledge of anatomy, physiology and body mechanics.

Yoga Postures Yoga postures (asanas) have individual names which may describe the general body shape, an animal that the posture is said to resemble or an individual after whom the pose is named. Poses

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taBle 1: saNskrit NaMes useD iN Yoga Poses (C. NORRIS, 2014)

Box 2: DefiNitioN: saNskrit

Bodypart

animal

Pada: foot Hasta: hand Janu: knee Sirsa: head Mukha: face Anga: limb Bhuja: arm Sarvanga: whole body Sava: corpse

Svana: dog Bheka: frog Baka: crow Ustra: camel Bhujanga: snake (serpent) Matsya: fish Shalabha: locust (grasshopper)

Sanskrit is one of the original languages of the Indian subcontinent. Classical Sanskrit is rarely used nowadays except in traditional ceremonies in mainly Hindu and Buddhist practice.

Versions of the language can be traced back to 1500CBe. (C. Norris, 2014)

object

Position

Parigha: gate latch Hala: plough Vrksa: tree Tada: mountain Setu: bridge Nava: boat Dhanu: bow Danda: rod (staff) Vira: hero

Adho: downward Urdva: raised/ upward Utthita: extended, stretched.

Parivrtta: revolved Baddha: tied/ bound Supta: reclining/ sleeping Uttana: intense stretch Upavistha: seated Prasarita: spread out Ardha: half Salamba: with support Kona: angle

have both Western and Sanskrit names (Table 1), so for example Mountain pose is also called Tadasana, from the Sanskrit Tada meaning mountain and asana meaning posture (Box 2).

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weight onto their hands even though their flexion range is limited (Fig. 1).

Similarly, in the Sitting forward bend (Pashimotonasana) an individual who cannot reach their feet can be given a yoga belt, and someone who cannot rest their head onto their legs a folded blanket or bolster to allow them to rest in a higher (less flexed) body position (Fig. 2).

Yoga is described as a mind– body activity and mindfulness is an awareness of body sensations

taBle 2: iMPortaNt faCtors iN Yoga PraCtiCe [C. Norris, 2014: sourCeD iYuk (3) aND kaBat-ZiNN (4)] factor

Meaning

alignment

n Position of body parts relative to each other, and of the body relative to the floor or supporting surface. n Use supports such as yoga blocks/bricks/wedges/ blanket/belt to improve alignment of pose. n Consider alignment at each stage of pose: going into, holding, and coming out of pose.

extension

n n n n

Direction

n Connected to both alignment and extension, direction begins at the floor and moves through the body and limb.

stability

n Holding the pose quietly (mindfully) with minimal muscle work, sensitivity, and normal breathing. n Stability of the body centre (pelvic and/or shoulder girdle) for the limbs to move upon.

asana performance Several factors should be considered when performing a yoga asana (Table 2). Some of these concern body mechanics and are fairly universal to good exercise practice. Others differ from standard exercise practice due to the mind–body nature of yoga.

One of the similarities with modern practice is the use in yoga of bandhas or body locks. These will be familiar to any therapist or exercise professional, although perhaps not in name. Mula bandha (root lock) is essentially engaging the pelvic floor, Uddiyana bandha (abdominal lock) the lower abdominal muscles, and Jalandhara bandha (throat lock) the deep neck flexors through the use of a chin tuck action. Bandhas are often used during exercise to aid firmness of a posture and to provide its root; expressions familiar to any exercise professional

using core stability for example.

Good alignment is essential to yoga practice and often props are used to allow an individual to perform a yoga pose even where they have physical characteristics that would limit them.

So for example when reaching into a Standing forward bend (Uttanasana) an individual with tight hamstring muscles is unable to touch the floor to take their body weight. Wooden yoga bricks may be used to bring the floor up to the student so they can take their

THE TERM YOGA REFERS TO THE UNION BETWEEN BOdY, MINd, EMOTION ANd BREATH

Precision

Gradual lengthening (stretching) of body soft tissues.

Expansion and lift of chest.

Elongation of limbs to create space for movement to occur.

Extension occurs from the ground up.

n Subtle adjustments to alignment to refine the pose. n An understanding of mental and emotional effects on asana practice (mind/body nature of yoga).

Mindfulness n Focus attention internally to ‘listen to the body’. n Aim to think in the present rather than focusing attention to the final exercise position (future) or being distracted by thoughts of daily activity (past).

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GOOd ALIGNMENT IS ESSENTIAL TO YOGA PRACTICE ANd PROPS ARE OFTEN USEd TO AId INdIVIdUALS WITH LIMITEd FLExIBILITY Figure 1: Forward bend (utanasana) performed with wooden blocks.

Yoga aids (such as wooden blocks) allow individuals with limited flexibility to perform the exercises. (Photo credit: C. Norris, 2014)

Figure 2: Sitting forward bend (Pashimotonasana) performed with a yoga belt.

(Photo credit: C. Norris, 2014)

and the breath as you practise the asanas. In traditional gym training there are often distractions that take a user’s attention outside their body.

Music, TV screens playing music videos and mirrors are all features that take the attention away from the body. By focusing on bodily sensations such as the firmness of a muscle or the precise position of the limb, as well as noticing the breath and the effect that this has on the posture, the user’s attention is drawn within themselves. Further, anxiety can occur in general life by constantly thinking of what the future may bring or regretting what the past has already brought. One of the aims of mindfulness meditation is to focus attention on the present moment. Again yoga can help with this by stressing to the user that they focus on the body sensations of the exercise stage they are in at the moment, rather than being goal-focused on the end result of an asana performance.

Focusing the attention on body sensation also aids proprioception.

This can be further enhanced by the yoga emphasis on movement precision during practice. It is interesting to note that exercises that contain “an intuitive search for

Box 3: DefiNitioN: CueiNg A cue is a signal which facilitates an action. Cues may be verbal (spoken), visual (seen), auditory (heard) or tactile (felt) in nature. When a number of cues are used at the same time, the approach is termed multisensory cueing [see Norris pages 70–71 (6) for more details].

(C. Norris, 2014) Figure 3: Mountain pose (tadasana).

(Photo credit: C. Norris, 2014)

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Figure 4: Mountain pose (tadasana) using a slim yoga block for tactile cueing. (Photo credit: C. Norris, 2014)

Figure 5: Mountain pose (tadasana) using a yoga belt. The belt helps the posture to be performed correctly for individuals with tight, rounded shoulders. (Photo credit: C. Norris, 2014)

elegance, pleasure and beauty” (5) such as yoga, martial arts and dance have been found to be amongst the most effective at enhancing proprioception.

Yoga is obviously an exercise associated with stretching and a high degree of flexibility in practitioners.

In addition to range of motion, the emphasis on extension of an asana is important. Reaching upwards and outwards to lengthen the body and limbs during a pose, and allowing unrestricted chest movement to facilitate unhindered breathing should be emphasised throughout yoga practice.

Posture exaMPles To illustrate the points introduced above, let’s look at five yoga postures and their modifications for use within rehabilitation.

Mountain pose (Tadasana) Purpose To teach standing body alignment, is a preparation for further poses and to increase appreciation of optimal posture.

Preparation Begin standing with your feet together and hands by your sides, palms facing inwards.

Action Take your weight equally between your right and left foot, and between the toes and heel on each foot. Tighten your quadriceps to draw your knees straight and together. Lengthen your spine reaching the crown of your head upwards, draw your shoulder blades together slightly to open your chest.

Straighten your arms reaching your fingertips downwards towards your lateral malleoli. Maintain the position breathing normally (Fig. 3).

Tips Some individuals hyper-extend their knees when they tighten the quadriceps muscles. To avoid this action, focus on maintaining a straight vertical line from your hips through your knees to your ankles (posture

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line). In addition avoid over arching your lumbar spine (hollow back posture) by gently drawing your abdominal muscles inwards and tailbone downwards (minimal posterior pelvic tilt towards neutral lumbar position). Tactile cueing can be used by placing a slim yoga block between the inner thighs (Fig. 4) (Box 3). The action is a simultaneous contraction of the quadriceps and hip adductors to squeeze onto the block and draw the knees together.

For those with very tight, rounded shoulders it is helpful to practice the pose with your back against a wall.

Focus on drawing the shoulders back to press against the wall (retraction) before reaching the fingertips downwards to the outer ankles. An additional method is to grip a yoga belt in each hand and loop it beneath the feet (Fig. 5). The belt holds the scapulae in a depressed position, preventing elevation as the shoulders are braced.

triangle (Trikonasana) Purpose To lengthen the side trunk and outer hip.

Preparation Begin standing on a yoga mat with your feet approximately one leg-length apart, toes facing forwards. Stretch your arms out sideways (shoulder abduction) keeping your elbows straight and palms facing the floor.

Action 1. Turn your right leg outwards (lateral rotation of the hip) so that your toes face the short edge of the mat, and turn your leg in slightly (minimal medial rotation of the hip).

Reach your right hand out to the side, and then downwards placing it onto your right shin, while at the same time reaching your left hand upwards towards the ceiling. Avoid allowing the left side of your pelvis to roll forwards, or the lower side of your trunk to shorten (side flexion, concave towards the floor). The action of reaching out horizontally with the arm is a useful tactile cue to avoid shortening the lower side of the trunk. Keep the pelvis aligned so that the hip joints are stacked

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(right and left joints aligned in a vertical position). Open your chest and extend your thoracic spine into a light shoulder retracted position.

Reach with your left arm upwards and press with your right hand onto your shin to come out of the pose.

Repeat the action on the left side of the body (Fig. 6).

2. Perform a limited range action taking the right hand down to a chair, placing your hand in the centre of the chair and keeping your arm straight. The upper arm may be straightened as in the classic pose, or kept bent to aid balance (Fig. 7). To increase range further use a wooden yoga block placed with its long edge aligned vertically. The block should be aligned with your centre shin.

3. To improve alignment, perform the pose with your back towards the wall, trying to press the upper pelvis backwards against the wall to maintain the stacked hip position.

4. To reduce balance demand, perform the standard pose but keep your left hand on your hip, or place your hand behind your tailbone (sacrum) to encourage chest opening.

5. To perform the Revolved triangle pose (Parvritta trikonasana), begin with your feet wide apart and your arms stretched out horizontally in line with the long edge of a yoga mat. Turn your back (left) foot in well (60°) and your right foot out fully (90°) and at the same time turn your body to the right to bring your chest and outstretched arms to face the short end of your mat. Place your right hand on your hip and reach your left hand down to the floor on the outside of your leading foot. To maintain the alignment of your spine you may chose to place your hand onto a yoga block, your finger tips, or the flat of your hand depending on your flexibility (Fig. 8). Finally, reach your right arm upwards keeping it straight and point your fingertips to the ceiling.

Tips The Triangle pose requires a combination of leg firmness and

Figure 6: Triangle (trikonasana). (Photo credit: C. Norris, 2014)

Figure 7: Triangle (trikonasana) using a chair. This allows the pose to be performed with a more limited range of motion. (Photo credit: C. Norris, 2014)

Figure 8: Revolved triangle (Parvritta trikonasana).

(Photo credit: C. Norris, 2014)

stability, with flexibility of the lateral trunk. The pose can be effectively split into two portions, practising leg stability with the hands on the hips initially.

Once this has been attained the trunk movement and arm stretch may be brought in.

Warrior (Virabhadrasana) Purpose To build flexibility and strength in the legs while maintaining upper body alignment.

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Preparation Begin standing on a yoga mat with your feet wide apart (distance approximately one-and-a-half leg lengths). Turn your right leg outwards (lateral rotation of the hip) so that your toes face the short edge of the mat, and turn your leg in slightly (minimal medial rotation of the hip). Reach your hands out sideways so that your arms are straight, elbows locked and palms facing the floor.

Figure 9: Warrior II (Virabhadrasana).

(Photo credit: C. Norris, 2014)

Figure 10: Warrior I (Virabhadrasana).

(Photo credit: C. Norris, 2014)

Figure 11: Warrior III (Virabhadrasana).

(Photo credit: C. Norris, 2014)

Figure 12: Assisted Warrior III. (Photo credit: C. Norris, 2014)

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Action 1. Bend your right knee pressing the knee forwards over the right foot ensuring that the knee does not drop inwards into a knock knee position.

Stop when the knee is at 90° and your shin is vertical, thigh horizontal.

As you bend your right knee, keep your left leg straight, making sure that you do not roll inwards (pronation) onto your foot, but instead maintain the contour of the medial arch. Press on the right foot to straighten the leg and draw yourself back to standing, reverse the movement bending the left leg. This pose is Warrior II (Fig. 9).

2. Lower your arms and place your hands onto your hips. Turn your right leg outwards (outward rotation of the hip) to face your toes towards the short edge of the mat. Turn your trunk to the right aiming to get your pelvis and shoulders facing the short edge of the mat, and turn your left toes well in (45–60° medial hip rotation). Bend your right knee pressing the knee over the right foot.

Stop when the knee is at 90° and your shin is vertical, thigh horizontal.

Reach both arms overhead keeping them shoulder width apart with your fingers straight, palms facing each other. Press on the right foot to straighten the leg and draw yourself back to standing, reverse the movement bending the left leg. This pose is Warrior I (Fig. 10).

3. Perform Warrior (I), and from the final pose lower your trunk towards your right thigh and step in with you left foot. Press hard with your right leg and lift your left leg into a horizontal position keeping your thigh muscles tight. Reach forwards

with your hands and aim to form a straight horizontal line from your hands through your shoulders, trunk, and left leg. Release the pose by reversing the action. This pose is Warrior III (Fig. 11).

4. Both Warrior I and Warrior II may be performed as limited range of motion poses, bending the knee only as far as is comfortable. To provide additional support the right hand may be placed on a chair when moving to the right. As leg strength increases the knee may bend further until the 90° angle of the classical pose is obtained. Warrior III may be performed with the hands placed on a wall to aid balance and alignment, or with the hands on the seat of a chair, in each case creating three points of balance (single leg and two hands) (Fig. 12). Placing the heel on a wall or on a chair seat also creates two points of balance (single leg on floor, single leg on wall) while the full pose has only a single balance point (single foot on floor) making it an advanced pose.

Tips There are three common errors that occur in Warrior I and II poses. The first is allowing the knee to drift inwards into a knock knee position. This places extra stress on the inside (medial aspect) of the knee. To prevent this ensure that the knee passes over the centre of the foot. The second error is allowing the upper body to drop into a round-shouldered position which restricts the chest and breathing. Avoid this by lengthening the spine reaching the crown of the head upwards and keeping the chest open the shoulders drawn back slightly. Finally, the training leg is placed on stretch (hip adductors), but must be active. If the leg is placed on stretch without quadriceps activity, the downward direction of the body weight can force the inside of the knee to overstretch (valgus stress) potentially damaging the inner (medial) knee ligaments. It is important therefore that the action of the trailing leg is to press against the yoga mat to lock the knee and lift the body upwards rather than allowing it to sag.

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standing forward bend (Uttanasana) Purpose To lengthen the hamstring muscles, hips and spine from a standing position.

Preparation Begin standing in Mountain pose, above.

Action 1. Reach your arms forwards and then overhead keeping your hands shoulder-width apart, palms facing inwards. Angle your trunk forwards keeping your spine long and arms reaching in front of you to encourage thoracic spine extension (pelvis moving on hip). Reach forwards and downwards moving your hands towards the floor. Place your hands on the floor and pause in this position, keeping your arms straight and thorax extended.

2. For the final pose, reach your hands behind your heels and draw your trunk downwards onto your thighs. To come out of the pose release your hands from your heels and reach your arms forwards and upwards to extend your spine as you stand back to the upright position.

Pause in Mountain pose to recover.

3. To reduce the intensity of the stretch reach your hands downwards onto wooden yoga blocks either placed on their long side (lower lift) or short side (higher lift) (Fig. 13). Where your hips are very stiff, begin the position with your feet shoulder-width apart. If your hamstrings are very tight, allow your knees to bend slightly (unlock or soften the knee) to partially release the pull of the hamstrings onto the pelvis and allow better lumbo-pelvic alignment.

4. Where standing balance is impaired the pose may be performed leaning against a wall (Fig. 14). Stand back towards the wall with your feet slightly forwards. Position your sitting bones (ischial tuberosities) against the wall by anteriorly tilting your pelvis. As you move into the stretch, move your sitting bones up the wall.

Tips This is an intense stretch for the

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hamstring muscles, and a high degree of hamstring flexibility is required to allow the pelvis to anteriorly tilt sufficiently to maintain spinal alignment.

Where the hamstrings are very tight anterior pelvic tilt is limited and movement downwards can only be obtained by increasing spinal flexion.

Where excessive spinal flexion occurs, it is important to reduce the movement range and maintain good overall body alignment rather than sacrificing alignment simply to reach further towards the ankles.

Downward dog (Adho mukha svanasana) Purpose To mobilise the chest, shoulders and hips while stretching the calf muscles and Achilles.

Preparation Begin lying on your front on a yoga mat. Position your hands at the sides of your chest palms flat, and tuck your toes under tightening your quadriceps muscles to straighten your legs.

Action Simultaneously press with your hands and feet driving your hips upwards.

Keep pushing until your arms are straight and level with your ears, and your hips are as high as possible.

Tighten your quadriceps and calf muscles lifting high onto your toes.

Maintain this high pelvic position and gradually allow your heels to lower downwards placing a stretch on your calf and Achilles (Fig. 15).

Tips Where you find it difficult to press with your arms, place your hands onto yoga bricks positioned against the wall to avoid slippage. The heel of your hands should be at the front edge of the block to provide purchase (Fig. 16).

The higher block position encourages greater activity from your arms. Where you are unable to lower your heels to the ground place a block or folded blanket beneath your heels (Fig. 17).

This exercise can also be performed as a partner action. For this your partner stands behind you, grips in

Figure 13: Forward bend (uttanasana) with blocks. The use of blocks reduces the intensity of the stretch. (Photo credit: C. Norris, 2014)

Figure 14: Assisted Forward bend (uttanasana).

Individuals with impaired balance can perform this stretch against a wall. (Photo credit: C. Norris, 2014)

Figure 15: Downward dog (adho mukha svanasana).

(Photo credit: C. Norris, 2014)

Figure 16: Downward dog (adho mukha svanasana) with blocks. For patients who find it difficult to push down through their hands. (Photo credit: C. Norris, 2014) Figure 17: Downward dog (adho mukha svanasana) with a folded blanket. For patients who find it difficult to lower their heels to the ground. (Photo credit: C. Norris, 2014)

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front of your hips and draws your pelvis towards himself increasing the body weight you put over your heels. Where gripping the hip region in painful (or ticklish) use a yoga belt placed around your hips (at the level of the iliac crest) instead.

BreathiNg exerCises Breathing exercises in yoga are called pranayama (from the Sanskrit words meaning extension of the breath or extension of life force) and we will look briefly at different types. Clinically the techniques have been shown to be useful in the management of stress/ anxiety disorders and in the treatment of respiratory conditions. Looking at asthmatic patients, pranayama practised for 15 minutes twice daily for a two-week period has been shown to improve respiratory variables (forced expiratory volume, peak flow rate and inhaler usage) compared to control (7). Favourable respiratory changes (oxygen saturation) have also been shown in patients with chronic obstructive pulmonary disease (COPd) during a 30-minute yoga breathing session (8).

As pranayama involves an expansion of the breath, asana is often used before pranayama practice to open the chest. Pranayama itself may be practised in a sitting or lying position, with a focus on keeping the chest open (shoulder retraction and thoracic extension). If you have a very round-shouldered posture it can be useful to sit against a wall and straighten your spine to expand your chest. When lying on your back in Corpse pose (Savasana) fold a towel or yoga blanket lengthways and place it on the floor beneath your spine to gently press your spine into extension and retract your shoulders.

Breath awareness Initially it is important to make the patient aware of their own breathing.

They may practise lying flat on their back (Savasana) placing their hands on their abdomen to feel the abdominal wall move as they breath, and then locate movement in the lower rib cage, sides of the rib cage and upper rib

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cage. Once they are aware of these movements they should relax their arms onto the floor, close their eyes and focus their attention internally on these body movements. To facilitate ribcage expansion (open the chest) Savasana may be performed lying over a blanket folded lengthways, or a yoga bolster (supported Savasana). The support is placed along the length of the spine so that the sacrum and lower lumbar spine remain on the floor. A blanket or folded towel may be placed under the head to prevent the neck moving into extension.

expansive breath (Ujjayi) Expansive breath follows on from breath awareness and the student is encouraged to breathe in through their nose and out their mouth, increasing the volume of the breath. The in breath (inhalation) should be performed slowly and gradually without forcing or gulping air into the lungs. The abdomen is relaxed but not bloated, to allow the diaphragm to move unhindered. Aim to fill the lower (basal) part of the lungs by expanding the lower ribs, before the middle ribs, and finally the upper ribs.

Chest expansion should include lifting of the sternum (pump handle action), sideways and backwards expansion of the ribcage (bucket handle movement).

Finally the top portion of the ribcage lifts (apical breathing).

As air passes over the roof of the palate it makes a rushing sound ‘sssa’ said to resemble an ocean, hence the alternative name of this pranayama ‘ocean breath’. If air is forced in rapidly it will rush over the palate sometimes causing throat irritation and coughing, so the action must be deliberate and controlled.

interrupted breath (Viloma) There are two stages to this technique.

Firstly interrupted inhalation is used. The sequence is to inhale-pause-inhalepause with each in breath and pause lasting approximately 2 seconds. The breath is held at full inhalation for 3 to 5 seconds. The patient exhales slowly but continuously and then breathes normally for 2 to 3 breaths to recover, and prevent hyperventilation. For

interrupted exhalation the sequence is reversed. The patient takes a single deep breath and holds it briefly before the interrupted exhalation cycle begins with the rhythm exhale–pause–exhale– pause with each period again lasting for 2 seconds.

alternate nostril breathing (Nadi sodhana or Anuloma viloma) Many individuals have blocked sinuses, and it is typical for people to favour one nostril when they breathe normally throughout the day. Alternate nostril breathing helps to clear the sinuses and provide symmetry of breathing through all the nasal passages. In addition research has shown that there is alteration between right and left brain activity during this pranayama technique (9). In the sitting position the client raises their right hand and places the thumb against the side of one nostril and the fourth and fifth fingers against the other, bending the middle and index fingers into the palm to allow room for the nose. The right nostril is blocked with the thumb as your client breaths in. Pause while opening the right nostril and closing the left with the fourth and fifth fingers to exhale.

Pause and then reverse the technique.

Eight to ten breaths should be taken using this alternate nostril method before resting and breathing normally to recover. Commonly the breath is retained and exhalation increased, using a ratio of 1 to inhale, 4 to retain, and 2 to exhale.

relaxatioN aND MeDitatioN Most yoga sessions finish with a period of relaxation, typically in the Corpse pose. As a mindful activity yoga encourages individuals to relax and this process can be taken more deeply in the relaxation period. Relaxation can then naturally progress to forms of introductory meditation.

With the client in the Corpse pose begin using a process of progressive relaxation. This involves repeatedly tightening (isometric contraction) and then releasing the muscles to induce a feeling of relaxation due to reduced muscle tone (post-isometric relaxation).

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Begin pointing and then pulling up the toes, followed by tightening the quadriceps, hip abductors, and gluteal muscles. At each point tighten the muscle firmly, hold the contraction briefly and then relax. Progress the sequence through the abdomen to the shoulders retracting the shoulder blades, straightening the arms to tighten the triceps and then forming a fist and straight finger action relaxing forearm and arm muscles. Finally encourage your client to frown, and then bite, to identify and release the facial and jaw muscles.

When the muscular sequences have been completed draw the patient’s attention to the general feeling of warmth throughout the muscles due to increase blood flow and finish by bringing their attention to their breathing as a precursor to meditation.

Meditation is introduced by focusing the attention on an internal body rhythm, and breathing is most often used in a classical method called mindfulness of breathing (Anapanasati). draw your client’s attention to their breathing encouraging them to notice movements in the abdomen and rib cage, and to feel the passage of the breath through the nostrils and over the top lip. Ask them to breath in and then out and to count ‘one’ out loud. They then repeat this action for a second breath counting ‘two’, and the third breath counting ‘three’ until they have completed 10 breaths. The sequence is then repeated. This action creates a deliberate pause after exhalation as well as focusing the mind on the breathing sequence. Secondly they change the order counting one before they take a breath, two prior to taking the second breath and continue the sequence for 10 breaths before repeating. This method again inserts a deliberate pause, this time prior to inspiration.

Having mastered this technique they then continue counting the breath in their mind, and then progress to simply noticing the passage of the breath through the nostrils and upper lip. It is normal for the attention to waver and they can return to the counting method to draw their attention back within themselves once more.

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Yoga for BaCk rehaBilitatioN A major systematic review of yoga for low back pain was conducted in Essen, Germany in 2013 looking at a total of 967 chronic low back pain patients over ten scientific studies.

The analysis showed that there was strong evidence for short-term effects of yoga on pain, back-specific disability, and global improvement. There was strong evidence for a long-term effect on pain and moderate evidence for a long-term effect on back-specific disability. This major study concluded that yoga can be recommended as an additional therapy to chronic low back pain patients (10). A meta-analysis of eight randomised controlled trials (RCT) looking at yoga for chronic low back pain by Holtzman and Beggs (11) showed yoga to have a medium to large effect on functional disability and pain, with follow-up effect sizes remaining significant. The studies involved a total of 743 patients.

Individual studies have shown yoga to be an effective tool in the management of low back pain. In a study looking at 313 adults with chronic low back pain, (12), yoga was given as a 12-week programme and included postures, breathing exercises and guided relaxation. The yoga group recorded better back function at follow-up measured at 3, 6, and 12 months following intervention. A study of a 1-week intense period of yoga for 80 chronic low back pain patients showed it to be superior to a physical exercise programme when measured as spinal flexibility (13). Yoga has been shown to be effective for war veterans with low back pain, improving pain, energy levels and mental health after a 10-week programme (14). An RCT in the USA showed a 14-week yoga programme to give a clear improvement measured on a standard clinical research scale (Roland and Morris disability Questionaire or RMdQ) (15) and a study which followed participants for 48 weeks shown improvement in functional disability measures, pain intensity and depression scores (16).

INdIVIdUAL STUdIES HAVE SHOWN YOGA TO BE AN EFFECTIVE TOOL IN THE MANAGEMENT OF LOW BACK PAIN aCkNoWleDgeMeNt This article is modified from Chris Norris’ forthcoming book Complete Guide to Back Rehabilitation (Bloomsbury) due for publication in 2015.

References 1. Williams M, Penman d.

Mindfulness: a practical guide to finding peace in a frantic world. piatkus 2011. ISBN 9780749953089 (Print £6.99, Kindle £6.64). Buy from Amazon http://amzn.to/1xVu5B2 2. Singleton M. Yoga body: the origins of modern posture practice. oxford University press 2010. ISBN 9780195395341 (Print £11.99, KIndle £5.93). Buy from Amazon http://amzn.to/1v26uPs 3. Iyengar Yoga UK. Iyengar yoga teaching syllabus (Introductory levels 1 & 2). iY(UK) 2013 4. Kabat-Zinn J. Full catastrophe living: how to cope with stress, pain and illness using mindfulness meditation (revised edn). piatkus 2013. ISBN 9780749958411 (Print £16.32, KIndle £12.99). Buy from Amazon http://amzn.to/1uiLjU0 5. Schleip R, Muller dG. Training principles for fascial connective tissues: scientific foundation and suggested practical applications. Journal of Bodywork and movement therapies 2013;17:103–115 6. Norris CM. The complete guide to exercise therapy. Bloomsbury 2013. ISBN 9781408193785 2013 (Print £17.57, Kindle £9.26). Buy from Amazon http://amzn.to/1Fa6z6I 7. Singh V, Wisniewski A, et al. Effect of yoga breathing exercises (pranayama) on airway reactivity in subjects with asthma. the Lancet 1990;335(9):1381–1383 8. Pomidori L, Campigotto F, et al. Efficacy and tolerability of yoga breathing in patients with chronic obstructive pulmonary disease: a pilot study. Journal of cardiopulmonary rehabilitation and prevention 2009;29(2):133–137

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9. Naveen K, Nagarathna R, et al. Yoga breathing through a particular nostril increases spatial memory scores without lateralized effects. psychological reports 1997;81:555–561 10. Cramer H, Lauche R, et al. A systematic review and meta-analysis of yoga for low back pain. clinical Journal of pain 2013;29(5):450–460 11. Holtzman S, Beggs RT. Yoga for chronic low back pain: a meta analysis of randomized controlled trials. pain research management 2013;18(5):267–272 12. Tilbrook HE, Cox H, et al. Yoga for chronic low back pain: a randomized trial. annals of internal medicine 2011;155(9):569–578 13. Tekur P, Singphow C, et al. Effect of short-term intensive yoga program on pain, functional disability and spinal flexibility in chronic low back pain: a randomized control study. the Journal of alternative and complementary medicine 2008;14(6):637–644 14. Groessl EJ, Weingart KR, et al. The benefits of yoga for women veterans with chronic low back pain. Journal of alternative and complementary medicine 2012;18(9):832–838

further resourCes 1. Norris CM. Complete guide to back rehabilitation. Bloomsbury 2015 2. Yoga as Therapy: courses for therapists and Pilates teachers for the Australian Physiotherapy and Pilates Institute by C. Norris. details are available at his website, Norris Health (http://spxj.nl/1tdMj59).

3. Wörle L, Pfeiff E. Yoga as therapeutic exercise. churchill Livingstone c 2010. ISBN 9782010 0702033834 (Print £37.99, Kindle £31.92).

Buy from Amazon http://spxj.nl/1yudCiI 4. Groessl EJ. Yoga for chronic low back pain: new evidence in 2011.

15. Sherman KJ, Cherkin dC, et al.

Comparing yoga, exercise, and a selfcare book for chronic low back pain: a randomized, controlled trial. annals of internal medicine 2005;143:849–856 16. Williams K, Abildso C, et al. Evaluating the effectiveness and efficacy of Iyengar yoga therapy on chronic low back pain. spine 2009;34(19):2066–2076.

DISCUSSIONS

n What are the benefits of practising yoga? n How can the practice of yoga be useful in rehabilitation? n How can you adapt the exercises to suit an individual with a limited range of motion?

keY PoiNts n Yoga has been around for thousands of years but interest in the Western world has grown rapidly during the last decade. n Yoga combines stretching to improve flexibility with holding poses to increase strength. n the exercises are centred around an awareness of the breath and attention to the body known as mindfulness, which also gives psychological benefits to patients. n When using yoga for rehabilitation, good body alignment (through a knowledge of anatomy, physiology and body mechanics) is essential. n Yoga postures (asanas) have descriptive sanskrit names. n individuals with a limited range of movement can use aids (such as blocks and belts) to allow them to perform the exercise. n focusing attention on the body also aids proprioception. n the practice of yoga also includes breathing exercises and meditation, which are useful in stress management. n Yoga is an effective tool in the management of low back pain.

Journal of Yoga and physical therapy 2012;2(2):1–3.

5. Iyengar BKS. Light on yoga. thorsons 2001.. ISBN 9780007107001 (£10.49).

Buy from Amazon http://spxj.nl/1vB14Lx 6. Mehta S, Mehta M, Mehta S. Yoga: the Iyengar way. dorling Kindersley 1990. ISBN 9780863184208 (£4.23). Buy from Amazon http://spxj.nl/1FJ0ZZj 7. Sengupta P. Health impacts of yoga and pranayama: a state-of-the-art review. international Journal of Preventive Medicine 2012;3(7):444–458.

THE AUTHOR Dr CHRis NORRis PhD, MCsP Dr Norris is a physiotherapist specialising in musculoskeletal treatment. He is a medical writer and lecturer and has published 12 therapy books. He runs several postgraduate courses for therapists and teaches a twoday course called Yoga as Therapy for therapists and Pilates teachers for the Australian Physiotherapy and Pilates institute (APPi). Details are available at Chris’s website, Norris Health (http://spxj.nl/1tDMj59) 28

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Fascia and biotensegrity Considering the role of the fasCia in the sCienCe of body arChiteCture

BY Joanne avison KMi, e-RYT500

F

ascia is the name given to the living body’s connective tissue; the collagen matrix of the soft tissue human architecture. The human body and limbs are formed under tension [(see my previous article (1)], so fascia is generally referred to as the ‘collagenous tensional network of the human form’. It has also been affectionately named ‘the Cinderella Tissue of the Locomotor System’ and is receiving major publicity due to the exponential increase in research over recent decades (2). It is the tensional nature of that form that is the basis of this series of articles, centred around the concept of ‘biotensegrity’. (Needless to say this applies to animals as well as humans. Indeed, at its most fundamental principles of structure, it refers to the hidden geometry of all forms).

Fascia references the fibrous nature of the tissue links between all the structures of the body. In a workshop environment, questions often arise that reveal an underlying assumption that this somehow resembles a fibreglass-like material, woven together like a kind of hidden webbing, made up of various types of collagen. However, that would be a somewhat misleading conception; as if fascia is a dry packing or wrapping or connecting material that merely provides cross-links attaching things to each other or padding out the spaces between them. That would imply that all the parts of us (as traditionally laid out in the anatomy books) are simply ‘tied together’ (or stacked); bound with this connecting tissue as if that might be where its functional role ends. All of the human systems of the living body reside in an essentially fluid medium.

That is a protein-based collagenous milieu consisting of all kinds of substances, colloids and emulsions held in the internal space in a miraculous world of ground substance, extracellular matrix and strands, bands, and diaphanous sheaths of moving material something like egg-white in consistency. It is not just dry fibrous mesh. It includes fibres and fibrils, tubules and tensional sheaths as part of its suite of expressions (3). Thus the more mechanical notions of separate parts linked together by fibres through which cabling, tubing and organs are ‘wired’ or ‘plumbed’ or simply cross-linked, is really outmoded. (Possibly this is why in workshops the notions of a dry internal system for nerves or tissues arises). How the parts and systems relate to each other, within the internal spatial arrangements of our organisation, is the basic question that fascia and biotensegrity intimately correspond to. That is the geometry of fluids, proteins and liquid crystal-type organisations that allow all the human forms to remain in appropriate formation (and function) within the basic blueprint. Those complex and intricate spatial arrangements reside in the deeper study of geometry. Thus the www.sportEX.net

This second article about the concept of biotensegrity, considers the fascia, or tensional network of the living body. Many traditional concepts of biomechanics and musculoskeletal anatomy are evolving rapidly. There are challenges in naming the fascia and relating this ubiquitous fabric of human form to structure and natural function in living movement. Some key questions arising are explored here, before more detailed discussion of biotensegrity is elaborated on in later articles. The question is, is biotensegrity the missing link? idea of the Science of Body Architecture is gradually gaining traction, although it is a soft non-linear architecture, far from the biomechanical theories of linear non-biologic organisation that have dominated some aspects of traditional science.

The paRadigM shiFT What is actually happening in the study of the body, of movement and therefore Sports Science and Medicine, is the recognition of this fabric of our form as far more than any limiting notions of a connecting material. The fascia has a variety of attributes and fundamental roles configured as different kinds of building materials.

These building materials could be said to unite structure and function in a very intimate, co-creative and co-responsive way. The materials open up new possibilities to explore the questions arising about how we move. A compelling contribution to how that might be so, is in the growing understanding of biotensegrity. It is a plausible basis for a new view of biomechanical movement of living and vital beings-in-bodies. Noone arrives flat-packed awaiting assembly; we are all essentially self-assembled from conception. It is the continuum within which our growth occurs (and the growth within which that continuum can be identified) that becomes the basis of this new paradigm.

When the discovery was made that the world might be round, rather than flat, it may have seemed to many that there was no direct reason necessarily to change that belief, since the local architecture appears unaffected by either notion. The global view, however, changed dramatically and the difference in progress permitted by that paradigm shift was exponential. The shift being brought about by a fuller understanding of the fascial 29

changes throughout the form, constantly. It is ubiquitous and continuous – literally everywhere: holding the body and all its parts together (and apart at the same time). However, before any meaningful progress can be made in agreement about its various functions and applications, there is confusion and conjecture around what is and isn’t fascia and why it can and can’t qualify as such. Biotensegrity is the basis of one such challenge for exactly the reasons the tissue is recognised as being under tension. It has to be, or muscles would not have any means to contract. They wouldn’t have anything to pull against. The challenge appears as something of a ‘catch-22’ situation and raises some important and compelling ideas (Fig. 1; Box 2) The shift in understanding that is currently arising from research into the fascial network is on every scale and calls forth more than new theories. It demands a deeper grasp of the context in which the more traditional notions of anatomical arrangement and physiological systems are established. One of the difficulties of seeing these many shifts and new views is that each area of specialisation has different emphasis in the study of fascia. As such, it can be difficult to contextualise how fundamentally it affects and makes sense of both the classical wisdom and the new information flooding in from a range of research fields. One example of this is the very basis of learning practical anatomy.

Generally speaking the first level in learning anatomy is to name the bones of the body and then the muscles of the ‘musculoskeletal system’. Each muscle is assigned an origin and an insertion (or distal and proximal attachments) and an action, according to which branch or sub-branch of the nervous system innervates it. A typical anatomy chart, such as can be found on Wikipedia, is shown in Figure 2.

Box 1: neTwoRKing The sciences (Avison J. Yoga: fascia, anatomy and movement. Handspring Publishing 2015) Fascia research is even bringing the worlds of physiology and psychology together (4). It plays a vast and ubiquitous part in organic organisation. It unites and distinguishes, connects and disconnects the parts of us that organise our internal world and integrate our external world. Thus it is shifting many of the concepts of human anatomy and physiology (and epigenetics).

The being-in-the-body is essentially expressed by this living, adaptable and sensory matrix; the organ of the very organisation of the living breathing individual. How a person uses their unique body changes its behaviour and structure, just as that structure can change them. In a culture that understands networks, it calls for a whole new way of thinking; one that goes beyond reductionist theories based upon dead bodies, moved by anatomists. Humans (and animals) are essentially self-motivated and it seems that biography and biology meet somewhere in this fabric of the living architecture. matrix and its biomechanical implications is a similar kind of new paradigm. It may be the body’s world in question, but it changes the very basis upon which the movement, manual and medical sciences treat that body globally (Box 1).

naMe ThaT Tissue The growing global understanding of fascia is challenging how conventional annotation names the different tissues of the body for their functions. Even the naming of the fascia itself is a complex issue. In search of universally acceptable definitions, justifying classifications are not entirely obvious. By nature fascia is part of an adaptable and responsive milieu. It responds variously to various forces, from conception. These might be described, at least, as genetic and kinetic, (chemical and biomechanical). The sentient environment of embryonic growth, within and around the ‘embryonic soup’ contributes in many different ways to the variable expressions of forms of the human blueprint. This appears as a basic attribute of the human ability to adapt to its environment and the forces moving through it. The fascia is considered as a force transmission system; a body-wide tensional network that communicates

“The simple questions discussed in musculoskeletal textbooks ‘which muscles’ are participating in a particular movement thus becomes almost obsolete. Muscles are not functional units, no matter how common this misconception may be. Rather, most muscular movements are generated by many individual motor units, which are distributed over density

“a more encompassing definition of the term fascia was recently proposed as a basis for the first Fascia Research Congress (Findley & Schleip 2007) and was further developed (Huijing & Langevin 2009) for the following congresses.

The term fascia here describes the ‘soft tissue component of the connective tissue system that permeates the human body’. One could also describe these as fibrous collagenous tissues which are part of a body-wide tensional force transmission system” (5) Traditionally, the “white stuff” (fascia and connective tissue) and the “yellow stuff” (adipose tissue, or fat) are removed in the anatomy laboratory in order to provide “clean” dissection and reveal the important parts that comprise the study of anatomy of the locomotor system. Biomechanics, anatomy and the related physiological basis of structure and function have all been, at least in part, deduced in the absence of this “in-between” fabric or wrapping. Historically, it has been assigned to the cadaveric bins.

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superficial Fascia intramuscular Fascia visceral Fascia

dense

(Extract from Yoga: fascia, anatomy and movement by J. Avison, Handspring Publishing. due to be published in Jan 2015)

loose

Box 2: naMing The Fascia

proper Fascia aponeurosis irregular

Ligament regular

Tendon

Regularity

Figure 1: The different types of connective tissues considered

by Schleip et al. to be included in the term ‘fascia’ (5). (Image reproduced with kind permission from Robert Schleip at Fascialnet.com)

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some portions of one muscle, plus other portions of other muscles. The tensional forces of these motor units are then transmitted to a complex network of fascial sheets, bags and strings that convert them into the final body movement.” (6) Thus the way in which the fascial matrix is structured, inclusive of all the tissues of the locomotor system, is bringing forth some compelling notions for re-explaining human (and animal) motion.

The nature of the fascia, as research expands the understanding of its characteristics, is providing a much fuller and more subtle context in which to describe how human beings move and experience movement, than perhaps can be fully answered by some of the more traditional theories of classical musculoskeletal anatomy. In some cases these traditional theories have become so time-honoured by the centuries of historical emphasis they have acquired that it is challenging to even refer to them as theories, rather than facts. However, as Schleip suggests, these theories are evolving to include the idea of the ‘neuromyofascial web’ or the ‘osteomyofascial system’; terms which, although unofficial, are variously used to describe the locomotor system.

Fascia is fast becoming a new buzzword in the bodywork industry as a whole. It is as if this new discovery is allowing many schools to justify their own theories and ‘climb on the bandwagon’ of this ‘newly discovered’ tissue. For some schools, it is replacing the muscle as the new hero in understanding movement and manual practice. However, it is essential to understand that fascia is not new. It was always there. It is mentioned in anatomy books, albeit mostly as discreet ‘sections’ of the tissues in the locomotor system.

The paradigm shift we are currently experiencing as research explores fascia further is the recognition of how it was overlooked. It is a shift in the significance of fascia and its multiple roles in anatomy and physiology. That shift means we have to ‘recalibrate’ notions of how fascia behaves. One of the things that makes this recalibration difficult, is that it changes deep seated beliefs about other systems. The paradigm shift doesn’t really replace anything other than some of the historical theories that have been central to the classical studies of anatomy. This view of fascia expands and clarifies the beauty and nuance of human and animal form. This perhaps embellishes the understanding of movement; it was lost in translation rather than ‘not there’. It is anything but new.

The practices of yoga, martial arts and other ancient and contemporary modalities have long embraced the subtleties that fascial research is now distinguishing and, to some extent, accounts for. This may give rise to seeing the physiological systems (such as the nervous system for example) in a new light. However, it does not mean there is any wisdom in an ‘out with the old and in with the new’ approach. That may well be a case of throwing out the baby with the bathwater. Nonetheless, there is clear value in recognising what seems like new ways.

That is new views of how those physiological systems account for human variation and motion, physical structure and even emotion. Fascia and its ubiquitous continuity, in a culture attuned to networks, arrives differently.

Apples and leaves have been falling from trees for millennia.

Newton animated, through the experience of watching this www.sportEX.net

Latin

Musculus triceps brachii

gray’s

[Subject reference]

origin

Long head: infraglenoid tubercle of scapula Lateral head: above the radial sulcus Medial head: below the radial sulcus

insertion

Olecranon process of ulna

artery

Deep brachial artery (Profunda brachii)

nerve

Radial nerve and axillary nerve (long head)

actions

Extends forearm, long head extends shoulder

antagonist Biceps brachii muscle Figure 2: Typical presentation of a muscle in classical anatomical terms. (Wikipedia: http://en.wikipedia.org/wiki/ Triceps_brachii_muscle)

time-honoured and natural ‘happenstance’, a new meaning, or significance to it. It could be said that fascia, the connective tissue matrix of a multitude of living forms, is as ubiquitous in nature as gravity. It is the ability of scientists and practitioners to animate its relevance to movement, form, function and structure that is undergoing a transformation. It is giving rise to a new Science of Body Architecture; a different perspective altogether on how our form is organised. The question in this series is what might biotensegrity have to do with it?

whaT does BioTensegRiTY have To do wiTh Fascia?

The fascia is defined under what is referred to as the ‘Boston Nomenclature’ as shown in Figure 3, where formal terms are in black and explanations are in red.

This means basically that the term fascia refers to all soft tissue materials formed in the body under tension. That tensional nature is the aspect often misunderstood and this is where biotensegrity comes in as a compelling metaphor, for how it might answer many of our questions of structural health and human performance. This article will attempt to clarify some of the misunderstanding and new questions arising from the idea of biotensegrity. Then more detailed implications of this can be explored in subsequent articles (Box 3).

conTRoveRsies in FasciaL noMencLaTuRe There is a great deal of controversy over the naming of fascial tissues, under the rules and constraints of scientific terminology.

Without going into too much detail of the historical progress here, suffice to indicate that the diagram above (Fig. 3) presents the nomenclature proposed by Huijing and Langevin at the second International Fascia Research Congress in 2009.

One question arising from this proposal is the exclusion of blood and bone – both of which are considered to be part of our connective tissue matrix. Whereas blood can be more readily assigned to the field of biology as a distinct form of connective tissue that is not fascia, bone presents some more difficult questions. From an architectural point of view, without the bone tensioning the very structure of the connective tissues, we do not have the volume in space we enjoy, in order to move around. Bones provide the compression element that allows the 31

The back of the skin non-dense, eg. between Superficial skin and fascia deep fascia Areolar connective tissue densley packed Dense irrregular, connective eg. lumbar tissue fascia

surrounding the inner body Deep fascia

Tissue between muscles

Intermuscular septa

Fascia

Tissue between bones

Interosseal membrane

Epimysium Specifying terms proposed by Huijing & Langevin, 2009

around muscle fibres; enveloping muscles

Periost

Tissue around bone

Neurovascular tract Extramuscular Endomysium Reinforcement of blood, lymph aponeurosis and nerve Microscopic Multi-layer tissue vessels fibrils with preferential honeycomb directions arrangement

Intramuscular aponeurosis

Figure 3: Boston Nomenclature for fascial tissues with explanations. Terms proposed by Huijing and Langevin at the second International Fascia Research Congress in 2009. (Reproduced with kind permission from Art of Contemporary Yoga Ltd)

matrix itself to be a tensional network. The logic of excluding bone is based in its ‘discontinuity’ versus the ‘continuity’ of the fascial matrix.

This is difficult to reconcile as soon as any understanding of biotensegrity architecture is brought to the questions around human movement and the maintaining of body volume in space.

Embryologically, bone arises within the matrix of fascial architecture. It is never separate from the periosteum that surrounds or ensheaths it. Reductionist methodology loves to separate and reduce to component parts. The fascial matrix is the hallmark of whole, continuous, ubiquitous integration and containment of our entire moving, living architecture.

Notwithstanding the embryological question, the basis of query coming from the biotensegrity specialists is the fundamental understanding of how the body comes to be organised as a tension–compression system.

As explained in the previous article (1) a marquee, a tent, a spider’s web – are all examples of a tension–compression

architecture, tensioned into structural integrity. (Think how the tent poles have to be slightly longer than the pockets of the fabric they reside in, to tension the structure so it can stay open.

Add guy wires to the ground and it is possible to construct a space containing architecture that a circus can use as a theatre to acrobats and animals; with a large audience inside it). However, because these structures rely on the ground or an external frame, they are not tensegrity structures as such.

The human form qualifies as a biotensegrity architecture, because it is self-sustaining under tension and holds itself upright and open with no external frame (Fig. 4). So does a daisy and an oak tree; a dormouse or a dinosaur. We do not require an outside frame; but hold ourselves open (to breathe and function at the most basic level) and upright in the gravitational field. Imagine a neoprene wetsuit. When it is worn, it is filled and animated by us. When it is discarded, it becomes lifeless and deflated. Even at rest, humans and animals do not reduce to this flaccid, unstiffened form. In nature they take up space, they can lie down, hang upside down, jump around and sleep for hours; but never deflate – due, in part, to this intelligent structural design. This, in the most general terms when applied to humans (being and moving) means that there must be discontinuous compression members, tensioning continuous tensional members. Otherwise, the architecture cannot hold itself up independent of gravity. A dog can’t wag its tail, an arm can’t be put out or up to raise a tennis racquet or hail a taxi. The architecture has to be pre-stiffened by something; or the very nature of its ‘tensionality’ is undermined.

The very rule that has been used to disqualify bones from their place in the fascial nomenclature list, is precisely how fascia gets to have its powerful new role and qualifies as the ‘Cinderella Tissue of the Locomotor Apparatus’ with reference to human movement and tensegral embodiment. They go hand in hand, so the argument is less about ‘for and against’ and more about a whole new paradigm, or lens, through which to perceive human structure.

In other words; fascia is designated as ‘continuous tissue’, thus suggesting that bones are omitted because they are discontinuous. However, unless the bones (as compression members) are discontinuous, they cannot hold the body up the way they do. As self-motivated structures that move around, pre-stressed or pre-stiffened, such that they don’t deflate; it calls the omission of bone into serious question. From

Box 3: appLicaTions oF BioTensegRiTY coveRed in suBsequenT aRTicLes (J. Avison, 2014) stretching: why we should and when we shouldn’t; the big debate. This article will emphasise the questions around fascia types and hyper versus hypomobility. It will include valuable information about the emphasis on strength or flexibility. embryology: how we all began as human architects – has that changed? This article will investigate the origins of the fascia in its role as the largest sensory organ of the body. Why is the concept of biotensegrity so essential to this aspect of the tensional network?

Levers and pendulums: why the cuckoo rather than the clock has the key.

This article will consider the importance of kinematics in the human movement repertoire. Why do they challenge some of the notions upon which more traditional biomechanics are based?

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Figure 4: This shows the body inside a tube of tensioned fabric, as a visual metaphor towards understanding how the body (and each cell, organ and system) contains (and is contained by) the tensional network of the fascia.

(Reproduced with kind permission from Art of Contemporary Yoga Ltd.)

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conception, during the embryonic developmental period, through to elderhood, humans occupy space by living in it. The ability to dance in response to gravity and resist its relentless pull to the centre of the earth resides here. Gravity neither crushes nor releases the forms on earth, because they live in biological tension–compression balance in neutral response to it. Only because (like every plant, tree, animal, fish, fowl and flying bird) humans contain and fill the space of their form independentlyof gravity somehow. That is in profound mutual relationship between the compression and tensional forces within the structure. Together these mutually balancing forces give rise to the ability to balance from moment-to-moment and movementto-movement.

Perhaps this is more than a paradigm shift. Rather it is a catch-22 that calls for science, engineering, art, ancient wisdom and new knowledge to form a web and meet somehow in order to understand each other. Fascia, as the tensional network of the human form (neutral servant of every single part of the body, ensuring it keeps its own act together – both literally and symbolically) might just be the means of unifying these apparently disparate branches of science and culture.

References 1. Avison J. Biotensegrity. sporteX X dynamics 2014;42:29–33 2. The number of papers on fascia indexed in Ovid (from the MEDLINE and Scopus databases) has grown from 200 per year in the 1970s and 1980s to almost 1000 in 2010.

Schleip R, Findley TW, et al. Fascia: the tensional network of the human body. Churchill livingstone 2012. ISBN 9780702034251 (Print £31.66 Kindle £41.39). Buy from Amazon http://spxj.nl/1AjMDeT 3. See Dr Guimberteau’s work. Jean-Claude Guimberteau, MD (www.guimberteau-jc-md.com/en/). Both English and French versions are available. His DVD ‘Interior Architectures’ is available on the same site. See also: Guimberteau JC, Armstrong C. The architecture of living fascia: the extracellular matrix and cells revealed through endoscopy. handspring publishing 2014. ISBN 978-1909141117 (£49.56). Buy from Amazon http://spxj.nl/1vqEt4D 4. Schleip R, Jäger H. Interoception: a new correlate for intricate connections between fascial receptors, emotion and self recognition, Chapter 2.3. In: Schleip R, Findley TW, et al. (eds) Fascia: the tensional network of the human form. Churchill livingstone 2012. ISBN 9780702034251 (as ref. 2) 5. Introduction, xvii. In: Schleip R, Findley TW, et al. (eds) Fascia: the tensional network of the human form. Churchill livingstone 2012. ISBN 978-0702034251 (as ref. 2) 6. Introduction, xv. In: Schleip R, Findley TW, et al. (eds) Fascia: the tensional network of the human form. Churchill livingstone 2012. ISBN 978-0702034251 (as ref. 2).

FuRTheR ResouRces 1. Avison J. Yoga: fascia, anatomy and movement. handspring publishing 2015. ISBN 9781909141018 (£37.80). Buy from Amazon http://spxj.nl/1FRJJBc 2. Schleip R, Findley TW, et al. Fascia: the tensional network of the human body. Churchill livingstone 2012.

ISBN 978-0702034251 (Print £31.66 Kindle £41.39).

Buy from Amazon http://spxj.nl/1AjMDeT 3. DVDs by Dr Jean-Claude Guimberteau: ‘Interior Architectures’, ‘Muscle Attitudes’ and ‘Strolling under the Skin’ (www.guimberteau-jc-md.com).

www.sportEX.net

THE AUTHOR JOAnnE AvisOn KMi, E-RYT500 J As a CMED graduate, Joanne extensively studied human development and specialised in soft tissue and the links between archetypal behaviour and physiological patterns. Her studies also included Human Dissection and movement research in Fascial Fitness with Dr Robert schleip. Joanne is a fully accredited Professional structural integrator (Kinesis Myofascial integration school) and has taught at the KMi school of structural integration (Maine, UsA) and also taught Anatomy Trains™ in the UK, pioneering its application to Movement Practitioners in Yoga, Pilates and professional sports, including English Premier League soccer Clubs and golf professionals. Jo is an experienced trainer of yoga teachers, holding E-RYT500 status and is the co-founder and director of the accredited Art of Contemporary Yoga Teacher Training school (AOCY).

Joanne is author of Yoga: fascia, anatomy and movement (Handspring Publishing 2015) and currently teaches regular workshops and webinars around the world on structural Anatomy, Biotensegrity and Fascial Fitness. see www.fasciasymposium.co.uk and www.bodyworkcpd.co.uk for recent presentations.

KeY poinTs n Fascia is considered to be the ‘cinderella’ tissue of the human form. n Fascia is not new; however, its roles and characteristics are newly recognised.

Untitled-1 1 n Misunderstandings arise around the nature of the fascia. n There are multiple. characteristics of the fascia as a building material of the body. n Fascia as a tensional network includes spatial arrangements that profoundly affect many classical concepts of movement and structure. n structure and function in the

body are more intimately linked than can be understood from more classical notions of the musculoskeletal system. n The classical wisdom is valuable and so is the new knowledge; however, it is necessary to expand thinking to include this new context provided by fascia research. n There is an intimate relationship between fascia as a tensional network and biotensegrity as a metaphor for how that tensioned structural material can move in space, contain space and maintain its living volume in space.

n What are the two fundamental principles of biotensegrity? n How do they relate to the fascial network of the living form? n Consider the importance of finding an appropriate universal nomenclature for both science and clinical practice in movement, manual and medical forums.

This is complicated by the distinctions that make fascia continuous – and continuously tensioned. Why is DISCUSSIONS this tensioned, or pre-stiffened nature of the form so essential to movement?

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Manual therapy improves proprioceptive awareness, thereby affecting performance @WorldAthleticsC

@advantagephysio

For manual therapy and pain 2 things come to mind: 1. Don’t worry about being specific 2. There’s more than one way to skin a cat

@YLMSportScience

Infographic: How to Select the Best Pair of Shoes? | Footwear, Running Economy & Performance http://t.co/tKvSXse8Ff

@sportexjournals

@DoctorsofPT

Dry needling (referred to as Intramuscular Manual Therapy in this study) with better results than conventional... http://fb.me/71gUJwG7N

The Mulligan Concept of Manual Therapy – new book from Elsevier http://t.co/ X7smqHoEJL tweets

@PhysioWorld

Manual therapy and exercise for adhesive capsulitis (frozen shoulder) (Review) For your interest and CPD.... http://fb.me/2DScOr2TV

@ErikDalton_PhD

Myoskeletal Alignment Videos @ http://tp://daltonmyoskeletalvideos. com/

@AdamMeakins

Manual therapy doesn’t release, loosen, lengthen or put anything back in place... Let’s change our explanations... http:// http://t.co/CleEhGgktF

@sportexjournals

Exercise and Manual Therapy Improve Pain and Function in Osteoarthritis http://t.co/9TFOEVPup8

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@kcrehabexpert

JOSPT RCT comparing dry needling and manual TrP release showed no difference in outcomes. Let the debate begin! http://ow.ly/F3M8z

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Finding great resources for our Social Watch pages, came across 20 Rules of Manual Therapy by @ NAIOMT - worth reading http://spxj.nl/165BhBC

sportEX dynamics 2015;43(January):34

Best of

manual therapy Includes the “best of the best” of published articles for the manual therapist both in practice and in training. Easy to read and informative articles that bring topics to life and provide you with hands on tips and techniques to use in your day to day practice or study. n 29 articles, many with multimedia animations, technique video clips and related quizzes to reinforce learning and retention of key points n Authors include world class practitioners such as Whitney Lowe (USA), Tom Myers (USA), Paula Clayton (UK), Bob McAtee (USA), Brad Hiskins (Aus) and Chris Norris (UK), amongst others n Access online or as an app on your mobile device

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TRANSLATING MANUAL THERAPY RESEARCH INTO HANDS ON PRACTICE