sportEX Dynamics Journal Issue 44 - April 2015

ISSUE 44 Apr 2015 ISSn 1744-9383

promoting

best practice in

highlights

manual therapy

n LeArning through dissection n Kinesio tApe And fLexibiLity n mAssAge in sport n dry needLing

contents april 2015 issue 44

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

We take another leap forward this month with the launch of our new website (which I’ve described in more detail on pages 33-34). As a result of the launch, and the expansion of our content commissioning plan, we’re about to increase the volume of content we publish under each journal by a further 30% and for all those of you with a subscription, this will be included at no extra cost as part of your current subscription. I’ve always believed strongly in supporting the people who have supported me and it’s become something of a sportEX tradition that whenever we increase prices, we hold our old prices for our current customers, the same will be true here.

Having said that, one of the main objectives of the new site was to give you greater flexibility regarding the content you purchase. If you want to downsize your subscription to just a given section of content or even a specific keyword, you can but you can rest assured that as we make the cutover to the new site, those of you with a current subscription will have access to the most content at a price than is unavailable to anyone else. It’s one of our small but important ways of saying thank you for sharing this journey.

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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Apr 2015

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 8 The anatomy experience 14 Kinesio tape & flexibility 17 swedish massage Journal Watch

The latest soft tissue research

Discover how therapists benefit from performing human dissection How K-tape enhances flexibility

ConTenTs 24 Dry needling standards R 31 professional 33 The new sporteX website

Discover how yoga can complement rehabilitation esponse to Brad Hiskins’ article in last issue

sportEX of the future

Evidence for use in sport: Part 1

To finD ouT more abouT sporTeX visiT

DISCLAIMER While every effort has been made to ensure that all information and data in this magazine is correct and compatible with national standards generally accepted at the time of publication, this magazine and any articles published in it are intended as general guidance and information for use by healthcare professionals only, and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. To the extent permissible by law, the publisher, editors and contributors to this magazine accept no liability to any person for any loss, injury or damage howsoever incurred (including by negligence) as a consequence, whether directly or indirectly, of the use by any person of any of the contents of the magazine.

Copyright subsists in all material in the publication. Centor Publishing Limited consents to certain features contained in this magazine marked (*) being copied for personal use or information only (including distribution to appropriate patients) provided a full reference to the source is shown. No other unauthorised reproduction, transmission or storage in any electronic retrieval system is permitted of any material contained in this publication in any form.

The publishers give no endorsement for and accept no liability (howsoever arising) in connection with the supply or use of any goods or services purchased as a result of any advertisement appearing in this magazine.

www.sportEX.net

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online

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

THE EffECT Of mASSAGE THERApy ON pSyCHOLOGICAL OuTCOmES IN pATIENTS AfTER CARdIAC SuRGERy: A mINI REvIEw. Kavei p, Ebadi A, moradian ST, Rahimabadi mS. International Journal of medical Reviews 2015;1(4) This is a literature review looking at the effects of massage as a non-pharmacological post-operative therapy that is both cost effective and minimises side effects. The search was done by using keywords such as ‘massage therapy’, ‘CABG’, ‘patient outcomes’ (‘pain’, ‘stress’, ‘anxiety’ and ‘depression’) in academic databases such as PubMed, CINAHL/Nursing, Science Direct and Scopus during the years 2004 to 2014.

Among 174 papers touching on the subject, 8 fully related to the subject of the research and were ultimately selected.

The findings revealed that massage therapy can lead to a reduction of pain, stress and anxiety in patients, as well as the reduction of need for sedatives in patients in line for heart surgeries.

sportEX comment Elsewhere in this edition there is an article that examines the use of massage in sport. It concludes that there are many studies that are not directly related to sport whose findings can be extrapolated to apply to common situations found in the sporting domain. This is one such study. Heart surgery is pretty serious stuff so if massage can reduce stress, anxiety and pain in cardiac patients it is a ‘shoe-in’ to do the same thing to a footballer with a broken ankle.

KINESIO TApING IN muSCuLOSKELETAL pAIN ANd dISABILITy THAT LASTS fOR mORE THAN 4 wEEKS: IS IT TImE TO pEEL Off THE TApE ANd THROw IT OuT wITH THE SwEAT? A SySTEmATIC REvIEw wITH mETA-ANALySIS fOCuSEd ON pAIN ANd ALSO mETHOdS Of TApE AppLICATION. Lim ECw, Tay mGX. British Journal of Sports medicine 2015;doi:10.1136/bjsports-2014-094151 A search of eight major databases was conducted. Seventeen clinical-controlled trials were identified and included in the meta-analyses. When compared to minimal intervention, kinesio taping provided superior pain relief but the pooled disability scores were not significantly different. No significant differences were found when comparing kinesio taping to other treatment approaches for pain and disability.

sportEX comment Is the kinesio tape bubble bursting?

dOSE Of JOGGING ANd LONG-TERm mORTALITy: THE COpENHAGEN CITy HEART STudy. Schnohr p, O’Keefe JH, marott JL, Lange p, Jensen GB. Journal of the American College of Cardiology 2015;65(5):411–419 Researchers looked at 5,048 healthy participants in the Copenhagen City Heart Study and questioned them about their activity. They identified and tracked 1,098 healthy joggers and 413 healthy but sedentary nonjoggers for 12 years. They found that strenuous joggers were as likely to die as sedentary non-joggers, whereas light joggers had the lowest rates of death. Jogging from 1 to 2.4h per week was associated with the lowest mortality and the optimal frequency of jogging was no more than three times per week. Overall,

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significantly lower mortality rates were found in those with a slow or moderate jogging pace, while the fast-paced joggers had almost the same mortality risk as the sedentary non-joggers.

During the research period there were 28 deaths among joggers and 128 among sedentary non-joggers. In general, the joggers were younger, had lower blood pressure and body mass index, and had a lower prevalence of smoking and diabetes.

sportEX comment We have never been convinced

that running fast when no one is chasing you is a good thing.

A bit of a light jog, however, does you the world of good.

sportEX dynamics 2015;44(April):4-7

JOURNAL WATCH

Journal watch Eff EffECTS Of mASSAGE THERApy ANd OCCLuSAL SpLINT THERApy ON ELECTROmyOGRApHIC ACTIvITy ANd THE INTENSITy Of SIGNS ANd SympTOmS IN INdIvIduALS wITH TEmpOROmANdIBuLAR dISORdER ANd SLEEp BRuXISm: A RANdOmIzEd CLINICAL TRIAL. de paula Gomes CAf, El Hage y, Amaral Ap, politti f, BiasottoGonzalez dA. Chiropractic & manual Therapies 2014;22(1):1–7 Sixty individuals with severe temporomandibular disorder (TDM) and sleep bruxism were randomly distributed into a massage group, a conventional occlusal splint (that’s basically a gum shield for us sporty types), a massage + conventional occlusal splint group, and a silicone occlusal splint group. Those wearing the splints did so for 4 weeks. The massage groups received 30min of treatment 3 times a week for 4 weeks by a specially trained physiotherapist. The massage routine is well described and repeatable. All groups were evaluated before and after treatment through electromyographic analysis of the masseter and anterior temporal muscles and the Fonseca Patient History Index. Massage therapy and the use of an occlusal splint had no significant influence on electromyographic activity of the

masseter or anterior temporal muscles.

However, the combination of therapies led to a reduction in the intensity of signs and symptoms among individuals with severe TMD and sleep bruxism.

sportEX comment Temporomandibular disorder is the most common source of orofacial pain of a non-dental origin and sleep bruxism, which is clenching and/or grinding the teeth during sleep, is often a related occurrence. The sports injury bible, ‘Bruckner & Khan’s Clinical Sports Medicine’ states that TMD can also be called ‘myofascial pain dysfunction syndrome’. Patients complain of pain, reduced ROM, clicking and locking. Like any myofascial pain manual therapy and exercise can be invaluable but it is probably best to refer to a dentist as well to rule out malocclusion.

mASSAGE INduCES AN ImmEdIATE, ALBEIT SHORT-TERm, REduCTION IN muSCLE SHORT STIffNESS. Eriksson Crommert m, Lacourpaille L, Heales LJ, Tucker K, Hug f. Scandinavian Journal of medicine & Science in Sports 2014;doi:10.1111/sms.12341 Eighteen healthy volunteers were subjected to a 7min massage protocol performed unilaterally on the medial gastrocnemius (MG). Using ultrasound shear wave elastography, measurements of muscle shear elastic modulus (stiffness) were performed bilaterally (control and massaged leg) in a moderately stretched position at three time points: before massage (baseline), directly after massage (follow-up 1), and following 3min of rest (follow-up 2). Directly after massage, participants rated pain experienced during the massage. MG shear elastic modulus of the massaged leg decreased significantly at follow-up 1.

There was no difference between follow-up 2 and baseline for the massaged leg indicating that muscle stiffness returned to baseline values. Shear elastic modulus was not different between time points in the control leg. There was no association between perceived pain during the massage and stiffness reduction.

sportEX comment Massage reduces muscle stiffness but the effect doesn’t last long. Let’s hope someone builds on this and starts to vary the dose to see if the effect can be extended.

dAyLIGHT SAvING TImE AS A pOTENTIAL puBLIC HEALTH INTERvENTION: AN OBSERvATIONAL STudy Of EvENING dAyLIGHT ANd OBJECTIvELy-mEASuREd pHySICAL ACTIvITy AmONG 23,000 CHILdREN fROm NINE COuNTRIES. Goodman A, page AS, Cooper AR, International Children’s Accelerometry database Collaborators.

International Journal of Behavioural Nutrition and physical Activity 2014;11(1):84 In a large study, 23,188 children aged 5–16 years from 15 studies in nine countries (Europe and Australia) were brought together in the International Children’s Accelerometry Database. All children provided objectively-measured physical activity data from Actigraph accelerometers. Date of accelerometer data collection was matched to time of sunset, and to weather characteristics including daily precipitation, humidity, wind speed and temperature. The results were that longer evening daylight was independently associated with a small increase in daily physical activity.

www.sportEX.net

sportEX comment There is absolutely no reason why we have to both go to work or school in the dark and come home in the dark. Here is a piece of evidence that says lighter nights equals more physical activity in kids which we know is good for them.

Lobby the politicians.

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online

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

EffECT Of BALANCE TRAINING ON NEuROmuSCuLAR fuNCTION AT REST ANd duRING ISOmETRIC mAXImum vOLuNTARy CONTRACTION. Behrens m, mau-moeller A, wassermann f, Bader R, Bruhn S. European Journal of Applied physiology 2015; Epub ahead of print Twenty-six young adult subjects were randomly assigned to an intervention group and a control group. During neuromuscular testing, rate of torque development (RTD), isometric maximum voluntary torque (iMVT) and muscle activation were measured.

Triceps surae muscle activation and tibialis anterior (TA) muscle coactivation were assessed duing the initial phase of contraction

(0–100, 0–200ms) and maximum voluntary contraction (MVC) of the plantar flexors. In addition evoked spinal reflex responses of the soleus muscle (H-reflex evoked at rest and during MVC, V-wave), peak twitch torques induced by electrical stimulation at rest and balance performance were evaluated.

Measurements were taken at the onset and after 8 weeks of balance training.

The balance training was held twice a week for 8 weeks with each session lasting approximately 60min. Exercises were done on a balance board, soft mat and other training devices that induced postural instability. There were seven different exercises with four sets per exercise initially done on both legs and progressed by supervisors who were all experienced instructors. Eventually additional motor tasks (throwing a ball, bouncing a ball, etc.) were performed during the tasks. The control group was

asked to maintain their individual level of physical activities.

There were significant differences in the results between groups in RTD of the plantar flexors during MVC in the time interval 0–100ms. This change was accompanied by reduced antagonistic muscle co-activity. The normalised H-reflex the soleus muscle at rest as well as the sway of the centre of pressure during balance performance assessment were significantly lower for the intervention group compared with controls.

sportEX comment The conclusion was that the training reduced antagonistic muscle coactivity at the onset of triceps surae contraction and, in turn, and this is the most important bit, increased isometric explosive voluntary strength of the plantar flexors.

EffECTS Of mASSAGE AT TwO dIffERENT HAmSTRING pOSITIONS ON HIp fLEXION ANGLE IN HEALTHy AduLT mALES. Akazawa N, Okawa N, Oka T, Nakatani K, et al. Journal of the Japanese physical Therapy Association 2014;17(1):43 Thirty-two healthy adult males were randomly allocated to one of three groups. Each were massaged for 3min using the same pressure. The groups were: (1) massaged at the musculotendinous junction of the hamstrings (n = 11); (2) massaged at the muscle belly of the hamstrings (n = 11); and (3) a control group being massaged at the muscle belly of the contralateral hamstrings (n = 10). Hip flexion angles (HFA) values were assessed by blinded raters before treatment; immediately after and at 3, 6, 9, and 15min after.

The results were that HFA value in the group being massaged at the musculotendinous junction of the hamstrings was significantly greater than that of the either groups immediately after massage and 3 and 6min after massage.

sportEX comment These results suggest that massage at the musculotendinous junction of the hamstrings can induce greater HFA. The big question is why?

IS THE REARfOOT pATTERN THE mOST fREquENT fOOT STRIKE pATTERN AmONG RECREATIONAL SHOd dISTANCE RuNNERS? de Almeida mO, Saragiotti BT, yamato Tp, Lopes AS. physical Therapy in Sport 2015;16(1):29–33 A convenience sample of 514 recreational shod runners older than 18 years and free of injury had their foot strike patterns evaluated with a high-speed camera (250 Hz) and photocells to assess the running speed of participants. Personal and training characteristics were collected through a questionnaire. The visual method of evaluation was found to have inter-rater reliability of the visual foot strike pattern classification method of 96.7% and intrarater reliability was 98.9%. The results were that 489 (95.1%) of the participants were rearfoot strikers, 21 (4.1%) were 6

midfoot strikers, and 4 runners (0.8%) were forefoot strikers. There were no significant differences between strike patterns for personal and training characteristics.

sportEX comment ‘Shod’ runners means that they were wearing running shoes. The sample was derived from public spaces such as parks in São Paulo, Brazil so presumably there were unshod runners as well. The question is how easy is it to change the pattern as suggested by Landreneau L, et al.? (See review in this edition.) sportEX dynamics 2015;44(April):4-7

JOURNAL WATCH

INTROduCTION TO JApANESE ANmA mASSAGE THERApy. donoyama N. The Journal of The Japanese Society of Balneology, Climatology and physical medicine 20132014;77(5):433–434 This is an introduction to Anma massage therapy, the massage technique most widely practised by nationally certified massage therapists in Japan. The name comes from its two main manual techniques: ‘an’, which is the Japanese term for applying pressure, and ‘ma’, for stroking. Its origins are in Ancient Chinese medicine and the consideration of acupuncture meridians. It has developed into a system applied over the whole body, focusing not on meridians but instead on anatomy, especially muscles. Standard Anma massage techniques involve mainly kneading, with lesser amounts of stroking and pressing through clothing using rhythmic massaging motions, and occasionally, brief joint exercises. The intensity of stimulation is adjusted according to each patient’s comfort level.

The author reports studies showing that Anma massage: (1) significantly reduced VAS score for their subjective symptom of muscle stiffness in the neck and shoulders, state anxiety scores, and salivary cortisol concentrations, as well as significantly increased secretory IgA concentrations; (2) may affect immune function, as indicated by gene expression investigations; and (3) significantly alleviated the severity of Parkinson’s disease patients’ subjective symptoms of muscle stiffness, movement difficulties, pain and fatigue, and also improved motor functions of the upper and lower limbs.

sportEX comment What is noticeable is that the Anma massage technique is almost identical to that used in the modern Swedish massage (which of course originally came from the Far East). The author makes a good point in that each Anma massage is different because it is tailored to meet the physical and mental state of individuals and therefore it is difficult to develop standardised therapy protocols for studies.

You could make a good argument to say that applies to all manual therapy research because the standard human body comes in an infinite variety of models.

LOwER LImB muSCLE ACTIvITy duRING fOREfOOT ANd REAR fOOT STRIKE RuNNING TECHNIquES. Landreneau LL, watts K, Heitzman JE, Childers wL. International Journal of Sports physical Therapy 2014;9(7):888–897 Fourteen healthy adults (6 M, 8 F; age, 24.2 ± 0.8 years; height, 170.1 ± 7.8cm; mass 69.8 ± 10.9kg; BMI 24.1 ± 3.0kg/m2) performed a rearfoot strike (RFS) and a forefoot strike (FFS) running trial at 8.85kph. A 3D motion capture system was used to collect kinematic data and electromyography was used to define muscle activity focusing on the biceps femoris, semitendinosus, rectus femoris, vastus medialis oblique, tibialis anterior, medial head of gastrocnemius, lateral head of gastrocnemius , and soleus.

The results were that the ankle was significantly more plantarflexed during FFS running but there were no significant differences in knee and hip angles.

There was significantly less activity in tibialis anterior and greater activity in the medial gastronemius during FFS running.

The lateral gastrocnemius and soleus did not change activity.

sportEX comment The suggestion is that FFS and RFS running have the potential to offload injury prone tissues by changing between techniques. How easy that is for someone to do is another matter especially in view of the findings reported by de Almeida. (See review in this edition.)

Sp SpORT pSyCHOLOGy EduCATION fOR SpORT INJuRy REHABILITATION pROfESSIONALS: A SySTEmATIC REvIEw. Heaney CA, walker NC, pRO Green AJK, Rostron CL. physical Therapy in Sport 2015;16(1):72–79 The paper presents a review of existing literature relating to the content and mode of delivery for a sport psychology education programme for sports injury rehabilitation professionals. In addition to topics only really of interest to educators (such as how to deliver sports psychology education) it includes three broad areas that sport psychology education should cover: (1) understanding of the psychological impact of injury; (2) interventions and psychological skills/ techniques such as imagery, positive selftalk, goal setting, relaxation strategies

and social support; and (3) referral and professional boundaries, which really means a knowledge of what is in your scope of practice and knowing when to refer (and to who).

sportEX comment This is great for the future of sports injury education and the three areas highlighted above are a CPD guide for those of us long past the university stage. So if sports psychology is your thing how about writing some articles for sportEX!

CHINESE mASSAGE COmBINEd wITH CORE STABILITy EXERCISES fOR NONSpECIfIC LOw BACK pAIN: A RANdOmIzEd CONTROLLEd TRIAL. zhang y, Tang S, Chen G, Liu y. Complementary Therapies in medicine 2015;23(1):1–6 Ninety-two participants with non-specific low back pain were divided into experimental and control group. The experimental group were treated using Chinese massage combined with core stability exercises, whereas the control group were treated using Chinese massage alone.

The results were that 2 weeks after treatment, both VAS and ODI scores decreased significantly in two groups, when compared with the values before treatment, but there was no difference between the two groups. Eight weeks later, the VAS and ODI scores decreased significantly in both groups; at the www.sportEX.net

same time, both VAS and ODI scores were significantly lower in the experimental group than those in the control group. At the final follow-up, 5 cases recurred in the experimental group and 19 cases in the control group.

sportEX comment Chinese massage, Swedish massage, Thai massage, it is all basically the same ‘rolling, rubbing, pushing, oblique-pulling, stroking and tapotement’ AND IT WORKS! Chuck a bit of ‘core’ work on and it’s even better.

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Dissecting the anatomy experience What can therapists learn?

This article promotes the importance, for therapists, of experiencing human dissection as a teaching and professional development aid. With the empathy of a clinical anatomist and a doctor, who are also manual therapists, the opinions expressed in this article gain gravitas as these experienced professionals understand and appreciate what therapists need to know. Touching a body is the key to most, if not all, movement and physical therapies; understanding the architecture beneath the skin must surely provide a great depth and breadth of knowledge for the practitioner.

Thiel dissection is a rare educational opportunity usually only open to medical students. John Sharkey will be providing such an opportunity in July 2015 and the details are at the end of this article.

BY John SharkeY MSc and dr antonio Stecco Md

Background There is no substitute for the rare pedagogic experience of cadaveric dissection. Physiotherapists are likely to have an interest in the biomechanics of human movement, and a course of cadaveric dissection using the soft-fix Thiel technique would be expected to add significantly to a deeper understanding of how the body works. Touching a body is the key to most, if not all, movement and physical therapies. Our hands trace the subtle nuances cueing us to take up the changing contour of the underlying topography made up of skin, fat, fascia, muscles, nerves, blood vessels and lymph tissue. The listening fingertips, an extension of our brain, fall into septal spaces or bump into unexpected hills, valleys or mountains. The skin itself is the first to be touched. We touch through the skin. We can trace the skin, unbroken, continuous, unifying and 8

embracing. We see and touch only one side of the skin but what lies beneath?

It is worth noting that the opportunities to participate in a course of human dissection are dimishing. According to Kennedy and Olson (1): “Numerous medical schools in the United States and abroad have determined that anatomy taught through cadaver dissection is untenable. Concerns for cost effectiveness, educational efficacy, the shortage of trained anatomist teachers, the increasing demand for cadavers, and pressure to convert dissection rooms to research laboratories, all argue for minimizing or eliminating cadaver dissection.�

As the opportunities to participate in human dissection are diminishing these authors argue for the benefits to those attending such a course, particularly a course with a unique focus on fascia and biotensegrity. sportEX dynamics 2015;44(April):8-13

opinions

PreParation Before participating in a dissection course it is helpful to prepare for the experience. Clinical anatomist John Sharkey provides instructions concerning the safe use and handling of the cadaver by using disposable gloves and aprons to ensure that a barrier exists between the participant and the cadaver.

Instruction and demonstration is also provided concerning the safe use, application, cleaning and/or disposal of the instruments of dissection. The preparation can conclude with a short period of reflection thanking the donors and families for the rare gift and acknowledging the gratitude of the participant.

Feedback to these authors from participants of previous dissection courses supports the objective that the dissection experience does provide participants with an a unique, 3D image of what lies deep to their fingers. This experience is important to anyone whose work involves manual/touch therapies. In the initial phase of manual assessment or treatment, therapists may move the skin in various directions, assessing movement preference, involving multiple digital contacts and pressure in all planes.

Therapists have reported feeling ‘restrictions’ in their patients’ tissues in one or more planes. Such restrictions have been explained in terms of tissue adherence or fascial restriction or ‘densification’ (2).

These restrictions are said to lead to abnormal strain patterns, loss of normal range of motion and loss of normal proprioception or, as Beach (3) puts it, “biomechanical peril”.

During a dissection fascial restrictions and adhesions, superficial and deep, become evident. The anatomist resorts to ‘pulling apart’ adhered tissues that would, in normal circumstances, glide relative to each other. Dissection is an effective way to appreciate the functional anatomy and the important role of the loose connective tissue that permits gliding between different tissues. Many of the adhesions seen in the cadaveric specimens could be as a result of previous surgery, long periods of hospitalisation, lack of motion, tissue compression or injury. During the www.sportEX.net

dissection, through the full view of the area and applied passive movement, it is possible to appreciate the alteration of the lines of force that the adhesion has created along the deep fascia. This is a unique possibility for understanding the variety of symptoms that patients describe to the therapist.

The dissection experience often results in a change concerning the therapist’s appreciation and understanding of connective tissue relationships. This is achieved through tactile and visual evidence of continuity and connectivity.

Feedback to these authors from participants of previous dissection courses supports this view.

Although participation in a dissection course will not be suitable for everyone, recent investigations found that participants experiencing their first dissection class did so with little stress(4). In fact, in one study the majority of students described this initial experience as positive (5).

Learning from an anatomy text, while beneficial, is an impersonal acquisition of knowledge compared to the dissection experience that allows for the inclusion of the tactile element so important to the art of any physical or movement therapy. The dissection experience provides the opportunity to test hypothesis concerning the nature of biotensegrity and the continuity of fascia. Investigating the architecture of joints and joint spaces provides the basis for discussion concerning the BioTensegrity model. Observations made concerning the ‘connectiveness’ of shared epimysium, differences of fascial thickness in various anatomical regions or variations in the direction and depth of fibre content can lead to the formation of new hypotheses (Fig 1).

Such observations can build confidence in the therapeutic outcome of particular soft tissue techniques or call into question the efficacy of another soft

Figure 1: Unique image demonstrating the shared perimysial connections between muscles. (Photo credit: J. Sharkey, 2011)

tissue approach or model.

Care taken to dissect in a manner that allows for the tissues to be returned to their original position allows for a reconstruction of the anatomy.

Achieving a ‘clean’ view of muscles so familiar from textbooks requires hours of meticulous, laborious and elaborate dissectional removal of the coverings, fascia, fat and skin. A muscle does not suddenly appear (Fig. 2). It is sculpted into being, presenting a false reality of an independent structure that seems to lack any relationship or connectedness to the missing tissues. What is seen in the dissection experience is not currently expressed in anatomy texts.

Fascia lata

Vastus lateralis

Gluteus medius

Tensor fascia lata

Figure 2: Lateral portion of the fascia lata within the profundity gluteus medius and vastus lateralis. (Photo credit: C. Stecco, 2012)

The DISSeCTIOn exPerIenCe reSuLTS In A ChAnge COnCernIng The TherAPIST’S APPreCIATIOn AnD unDerSTAnDIng OF COnneCTIve TISSue reLATIOnShIPS. ThIS IS AChIeveD ThrOugh TACTILe AnD vISuAL evIDenCe OF COnTInuITy AnD COnneCTIvITy 9

traditional diSSection The traditional method of teaching anatomy, used for undergraduate medical students, is one that is uniformly systematic. As way of example, van Der Wal (6) commenting on his own early experience as an anatomist stated: “When I received my first training as an anatomist, it was not customary to focus one’s methodologic attention on the anatomy of connective tissue in general or of fasciae in particular.

On the contrary, one was more or less trained to consider fasciae to be connective layers that had to be removed.”

There was little motivation to stop and consider the role of connective tissues generally and fascia specifically.

Fascia was seen as a packing material to be removed. even today, anatomy students learn what are considered the ‘important’ fascial structures, such as Scarpa’s and Camper’s fascia, mostly from an embryonic perspective.

At the same time students are not able to appreciate the real location and extension of these two types of fasciae (Fig. 3). unfortunately

reCenT InveSTIgATIOnS [LeBOuLAnger (4)] FOunD ThAT PArTICIPAnTS exPerIenCIng TheIr FIrST DISSeCTIOn CLASS DID SO WITh LITTLe STreSS

Deep layer of hypoderma Superficial layer of hypoderma

Retinacula cutis profundus Superficial fascia

Retinacula cutis superficialis Figure 3: Scarpa’s fascia: ante-lateral side of the abdomen region. (Photo credit: C. Stecco, 2012)

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confusion is still present in the Atlas terminology that makes it difficult for the student concerning their view of the human fascial system, something that dissection can give. The dissection experience permits participants to distinguish the deep fascia from the superficial fascia (that includes, for example, Scarpa’s and Camper’s fascia).

The anatomic nomenclature uses the same terminology for the superficial and deep fascia, although the two are very different from a mechanical point of view. The superficial fascia on palpation feels very elastic and can be manipulated, whereas the deep, because it is lacking in elastic fibres, looks like a flat tendon (7).

The study of clinical anatomy follows a strict syllabus. The same dissection instructions and directions are taken every time a new cohort of medical students arrive into the department of anatomy. The fascia is cut or scraped away for a better view of the muscle. This raises the question: “During surgical procedures could it be that the same mindset can prevail as the surgeon ‘scrapes’ away the unimportant fatty fascia in order to get a better view?”

What are the possible outcomes of scraping and removing the fascia in this manner? Could it result in the patient experiencing pain, at a later date and time, in a more distant body part due to this fascial insult? According to Lederman (8), Spencer et al. (9), Stecco et al. (10), and Sharkey (11) functional instability may result from altered proprioception following trauma such as surgery.

The dissection experience highlights obvious and not so obvious differences of ‘individualness’ in each human form. At many levels humans share commonality, yet in dissection no two bodies appear the same. Some cadavers may display two psoas minors, some only one and some none.

Muscle attachments can vary from one cadaver to the next. Fascial thickening can provide evidence of right- or lefthandedness or a lifelong right or left rotational bias as well low back pain (12).

Fascial continuity is not a new concept. For example, an original work (Anatomical Investigations, Comprising

Descriptions of Various Fasciae of the Human Body) published before 1923 by John D. goodman MD (13) states: “I am by no means anxious to claim great merit for proving the continuity of fascia … I do expect thanks of anatomists and physiologists for having pointed out the mode in which the capsular ligaments are made up from the coverings of the muscles and thus rendering their natural conditions more intelligible and opening the way to new views of their possible situations resulting from disease or accident.”

It would seem that this view of fascial continuity has to a large extent been lost along the way. however, we are now witnessing a renewed interest in the wider role of fascia in human movement and BioTensegrity. This tide of interest has been surged by many researchers and clinicians including guimberteau (14), Langevin et al. (15), Stecco et al. (16), huijing et al. (17), Ingber et al. (18), Beach (3), Schleip et al. (19), Levin (20) and others and we are all being swept along on this fascial current (Fig. 4).

Cadaveric dissection with a fascial focus has allowed for an architectural description of the muscular and connective tissues that are: “organised in series to enable the transmission of forces over a joint or multiple joints which is more appropriate when compared to the classical concept of ‘passive’ forceguiding structures, such as ligaments organised in parallel, to actively force-transmitting structures such as muscles with tendons”.

(Modified comment, from personal communication, attributed to JC van der Wal MD PhD, 2009. Department of Anatomy & embryology, Faculty of health Medicine and Life Sciences, university Maastricht, The netherlands).

A dissection study by Stecco et al.

(21) demonstrated “the existence of an anatomical continuity between all the muscles of the flexor region of the upper limb.” During dissection, whether the cadaver is a fresh frozen or an embalmed specimen, it is clear to see that each muscle, bundle of muscle fibres and each individual muscle fibre sportEX dynamics 2015;44(April):8-13

opinions

is separated by, and yet attached to, the fascia. The fascia, in turn, is continuous with the sarcolemma.

An important physiological characteristic of muscle is the ability of the myocells to convert ATP (adenosine triphosphate) into mechanical energy resulting in the production of forces.

In dissection, it seems obvious that forces generated within an individual muscle fibre, or group of muscle fibres, will translate across the associated fascia in a 3D fashion in all vectors.

This would seem to raise questions concerning the authenticity of the classical model of muscle contraction and resulting movement.

The process of dissection leads to levels, connections and layers.

Layers that have never existed in the living organism. For example, it is impossible to separate the tendons of a muscle from its associated bone without cutting them apart. The dissection experience clearly provides the evidence of continuity but one can

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understand why students, on reading an anatomy text book, come to the conclusion that the muscular system and skeletal system are separate. As a result of dissection what was once a unified, cohesive lifelong relationship is no more. The reason they can now be viewed as separate entities is due to the anatomist sculpting them into being.

This is the way anatomy has been studied, certainly since the renaissance.

The very nature of the study of anatomy is reductionist. The nervous system, the central and peripheral nervous system, the autonomic nervous system, the sympathetic and parasympathetic nervous system.

These labels are part of a language of convenience, a man-made language.

This reductionist language may at times be useful but it can also dilute the reality and vision that the human form is one continuous organism. Movement in one part affects the entire organism.

Cadaveric dissection alerts perceptions concerning the role of skin,

Figure 4: The fractal nature of fascia. This image reflects the model of BioTensegrity: compression and tension. (Image reproduced with kind permission of Dr JC. Guimberteau and Endovivo Productions)

fat and fascia in human movement.

For example, body fat is not simply an insulator. Fat provides stability and holds in place specific organs such as the kidney. Fat is subtle and can give way for movement of organs allowing appropriate compression and tension. Fat is held in capsules and each capsule has an outer skeleton or scaffolding. This scaffolding is the retinacula cutis that connects the skin with the superficial fascia and

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the superficial fascia with the deep fascia (2,7) (Fig. 3). The role of the retinacula cutis is to permit a sort of independence between the skin, superficial fascia and the deep fascia permitting, for example, the gliding of the skin during manual therapy as well acting as a conjunction. In fact the retinacula cutis provides passage to the travelling blood vessels and nerves that need to arrive at the skin.

SuMMarY The dissection experience is not for everyone. These authors believe that participation in a well structured cadaveric course, taking into account personal individuality, will provide a unique insight concerning the human form. A unique insight that translates into a new level of understanding in a manner that no other educational

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experience can hope to achieve.

Details of John Sharkey’s biotensegrity Thiel soft-fix dissection course with guests Stephen Levin MD and Joanne Avison in July 2015 in the university of Dundee, Scotland can be found here: http://www.ntc.ie/ dissection.

References 1. Kennedy gJ, Olson Tr. ‘Cadaver conference day’: a psychiatrist in the gross anatomy course. primary psychiatry 2009;16(1):26-30 2. Stecco A, Stecco C, et al. rMI study and clinical correlations of ankle retinacula damage and outcomes of ankle sprain. surgical and Radiologic Anatomy 2011;33:881–890 3. Beach P. Muscles and meridians.

The manipulation of shape.

Churchill Livingstone 2010 2010. ISBn 978-0702031090 (£32.48). Buy from amazon http://spxj.nl/1BA1cjh

4. Leboulanger n. First cadaver dissection: stress, preparation, and emotional experience. European Annals of otorhinolaryngology, Head and neck Diseases 2011;128(4):175–183 5. reverón rr. Anatomical dissection: a positive experience for venezuelan first year medical students. international Journal of Morphology 2010;28(1):213–217 6. van der Wal J. The architecture of the connective tissue in the musculoskeletal system—an often overlooked functional parameter as to proprioception in the locomotor apparatus. international Journal of Therapeutic Massage and Bodywork 2009;2(4):9–23 7. Stecco C, Macchi v, et al. The fascia: the forgotten structure. italian Journal of Anatomy and Embryology 2011;116(3):127–138 8. Lederman e. Fundamentals of manual therapy: physiology, neurology and psychology Churchill Livingstone 1997 1997.

ISBn 978-0443052750 ISB (£38.89) Buy from amazon http://spxj.nl/1zKurQD 9. Spencer JD, hayes KC, Alexander IJ. Knee joint effusion and quadriceps reflex inhibition in man. Archives of physical Medicine Rehabilitation 1984;65:171–177 10. Stecco C, Stern r, et al. hyaluronan within fascia in the etiology of myofascial pain. surgical and Radiologic Anatomy 2011;33(10):891-896 11. Starlanyl DJ, Sharkey J. healing through trigger point therapy: a guide to fibromyalgia, myofascial pain and dysfunction. Lotus publishing 2013 2013. ISBn 9781905367399 (Print £16.58 Kindle £11.83). Buy from amazon a http://spxj.nl/1eurrny http://spxj.nl/1 12. Langevin hM, Stevens-Tuttle D, et al. ultrasound evidence of altered lumbar connective tissue structure in human subjects with chronic low back pain. BMC Musculoskeletal Disorders 2009;10:151 13. goodman JD. Anatomical investigations, comprising descriptions of various fasciae of the human body. Originally published before 1923.

Reprinted nabu press 2014.

ISB ISBn 9781295700349 (£10.07). Buy from a amazon http://spxj.nl/1BgF5MZ 14. guimberteau JC. Strolling under the skin, bilingual edn. elsevier Masson 2004. ISBn 978-2842996499 15. Langevin hM, Bouffard nA, et al. Dynamic fibroblast response to subcutaneous tissue stretch ex vivo and in vivo. American Journal of physiology. Cell physiology 2005;288:C747–C756 16. Stecco C, Porzionato A, et al. histological characteristics of the deep fascia of the upper limb. Italian Journal of Anatomy and Embryology 2006;111(2):105–110 17. huijing PA. epimuscular myofascial force transmission between antagonistic and synergistic muscles can explain movement sportEX dynamics 2015;44(April):8-13

opinions

limitation in spastic paresis. Journal of Electromyography and Kinesiology 2007;17(6):708–724 18. Ingber De. Tensegrity and mechanotransduction. Journal of Bodywork and Movement Therapies 2008;12(3):198–200 19.

Schleip rD, Findley TW, Chaitow L. Fascia: the tensional network of the human body: the science and clinical applications in manual and movement therapy. Churchill Livingstone 2012. ISBn 9780702034251 (Kindle £30.89). Buy from amazon http://spxj.nl/1AvAKvw 20. Levin SM. The Ida P. rolf library of structural integration. Bulletin of structural integration 1982;8(1):31–33 21. Stecco A, Macchi v, et al. Anatomical study of myofascial continuity in the anterior region of the upper limb. Journal of Bodywork and Movement Therapies 2009;13:53–62.

Further reSourceS 1. For details of John Sharkey’s BioTensegrity Thiel soft-fix dissection

course with guests Stephen Levin MD and Joanne Avison in July 2015 in the university of Dundee, Scotland visit national Training Centre website, http://www.ntc.ie/dissection.

2. Barnes M. The basic science of myofascial release: morphologic change in connective tissue. Journal

3. Tank PW. grant’s Dissector, 15th edn. Lippincott Williams & Wilkins 2012. ISBn 9781609136062 (£40.91). Buy from amazon http://spxj.nl/1LIJkSM 4. Jayakumari S, rath g, Arora J. unilateral double axillary and double brachial arteries. embryological basis and clinical implications. international Journal of Morphology 2006;24(3):463–468.

5. Maraspin Le. A report of an anomalous bifurcation of the right

n although reading a book or watching a dVd on anatomy is useful, there is no substitute for actually seeing what lies beneath. n Seeing the connective nature of the epimysium is an astonishing demonstration that the epimysial tissue of one muscle is the epimysial tissue of another and another. n What we see in anatomy text books needs to be put into perspective and only a course in dissection can accomplish that. n opportunities to participate in a course of human dissection are diminishing. n this article promotes the fact that the dissection experience will provide participants with an accurate, 3d image of what lies deep beneath their fingers. n dissection allows you to see what lesions and adhesions look like and how they affect surrounding tissues. n dissection allows the learner to experience depth of tissue and to learn there are no layers in the human form. n the cadaveric dissection exploration provides visual and tactile evidence of the one muscle hypothesis. n Seeing the continuity of superficial to deep tissue opens up a new understanding of relationships and function. n in dissection, it seems obvious that forces generated within an individual muscle fibre, or group of muscle fibres, will translate across the associated fascia in a 3d fashion in all vectors.

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Endovascular surgery 1971;5:133-136.

6. Sinnatamby CS. Last’s anatomy. regional and applied, 12th edn. Churchill Livingstone 2011. ISBn 978-0702033957 (Print £53.50 Kindle £33.83. Buy from amazon http://spxj.nl/1LLMTcn

of Bodywork and Movement Therapies 1997;1(4):231–238.

keY PointS

DISCUSSIONS

axillary artery in man. Vascular and

n Does current anatomy as expressed in text books promote parts or a holistic view? n Are there really 659 muscles in the human body? n What does a ligament really look like? n Why does a space exist between bones that make up joints?

ThE Th AuThoRS AuT ThoRS John ShARkEy MSc Sh John Sharkey is a clinical anatomist with thirty years’ experience in bodywork and movement therapies.

A graduate of the centre for Anatomy and human Identification, university of Dundee, John is also an exercise physiologist and a graduate of the university of Liverpool. he is a senior tutor and programme director for the MSc in neuromuscular Therapy accredited by the university of chester.

John is a member of the editorial board and reviewer for The Journal of Bodywork and Movement Therapies, International Journal of Therapeutic Massage and Bodywork and International Journal of osteopathic Medicine. John is a founding member of the BioTensegrity Interest Group (B.I.G.).

DR AnTonIo STEcco MD D Dr Stecco is a graduate in Medicine and Surgery, and specialised in Physical Medicine and Rehabilitation at the university of Padua, Italy. his areas of prevalent scientific and clinical interest are anatomy of the fascia corporis via dissections and histological studies, including immunohistochemical and molecular biology; study and clinical application of hyaluronic acid; as well as myofascial syndrome.

Since 2000, Dr Stecco has collaborated with the Descartes university, Paris, to study the macroscopic anatomy of fasciae through cadaver dissection. Since 2008, Dr Stecco has been on the Scientific committee of the Fascial Manipulation Association, which brings together researchers interested in studying diseases of the fascia and myofascial origin. he is the author of more than 12 articles published in international journals. Author of one book (Manipolazione fasciale, Piccin, 2010), Antonio is also the co-author of three books for which he wrote chapters about the fascial anatomy or the Fascial Manipulation Technique. he has also worked as an assistant reviewer for The Journal of Bodywork and Movement Therapies.

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A review of the impAct of kinesiology tApe on fAsciAl chAins And flexibility

BY Sarah Catlow MSC and dr lanCe doggart Phd

IntroduCtIon Kinesiology tape (K-tape) has gained global attention, as an alternative taping method, since its endorsement at the 2008 Olympic Games. It continues to feature at the highest level of competition across a multitude of sports (1,2). K-tape is designed to mirror the body’s skin properties by using thin adhesive elastic material capable of stretching between 30 and 40% of its resting length (3).

This distinctive elastic feature is the key factor behind claims that K-tape can potentially increase circulation, reduce pain, enhance sensorimotor feedback, increase power output and correct mechanical dysfunction (3–6). Such effects are attributed to the elastic recoil which occurs as a result of tension within the tape. Once applied this recoil effect lifts the skin releasing the pressure around the injured area permitting the underlying muscle and fascial (myofascial) tissue to function more effectively including the circulatory, lymphatic and nervous systems within the human body (6).

The concept of tape, capable of mirroring the body externally to enhance functions internally, is attractive

Kinesiology tape (K-tape) has been increasingly applied to both amateur and elite athletes since its rise to popularity at the Beijing Olympics in 2008. K-tape has been reported to enhance muscular flexibility, through mechanisms which are not well understood, but are thought to be due to fascial manipulation. This article discusses the current research and ideas about flexibility and how K-tape might enhance it to athletes who require all systems within the body to be functioning at an optimum rate. Furthermore, athletes will look to enhance all areas of their physical capabilities where possible (7).

One area that has exemplified optimum functioning is that of flexibility.

Flexibility is a crucial component of performance across numerous areas including running velocity; technical execution and body positioning; movement efficiency and posture and a functionally balanced kinetic chain (8–11). Furthermore, muscle flexibility provides tissue maintenance, therefore lowering the risk of spasms and trigger points and subsequent injury (12–14).

There are substantial levels of interest in terms of defining the relationship between K-tape and flexibility; however, to date research within this field has failed to provide definitive evidence (3,15–20).

The existence of fascial chains suggests flexibility throughout the body may not be linked to the behaviour of

K-TApE IS dESIGnEd TO MIRROR ThE BOdy’S SKIn pROpERTIES By uSInG ThIn AdhESIvE ElASTIc MATERIAl cApABlE OF STRETchInG BETwEEn 30 And 40% OF ITS RESTInG lEnGTh 14

muscle tissue around a specific joint as tested in previous K-tape investigations (3,15–21). Instead, this intricate web of connective tissue presents the possibility that flexibility may ultimately result from the condition of entire links of myofascial tissue and, therefore, suggests that to enhance flexibility, at a joint locally, it must also be enhanced throughout the whole body.

K-taPe and flexIBIlItY At a fundamental level flexibility is simply how much range of motion (ROM) is present at an isolated joint or multiple joints in series (22). Extensive research exists around flexibility, its manipulation and the use of reliable measurement techniques (11,22–29).

The theories attempting to explain the adaptive mechanisms remain varied and in cases speculative (11,22–29).They can be broadly separated into two main schools of thought whereby adaptation is either structural or sensational (30).

This may allow for the relationship between flexibility and K-tape to be more easily identified.

The premise behind this theory is that flexibility results from the physical adaptation of myofascial tissue structure allowing for the associated muscle groups connected to a particular joint to achieve a longer resting length. This permits the joint to move through a greater ROM (11,24). sportEX dynamics 2015;44(April):14-16

literAture review

The specific mechanisms that occur within the body during structural adaptation can be further separated into several possible explanations.

The first and most popular explanation is that additional muscle fibres, known as sarcomeres, are further recruited or re-aligned in series (meaning ‘length ways’) within the tissue (11,22,24,28). In order for this to take place it is suggested that ‘myofibrillogenesis’ must occur at a molecular level within the tissue (31).

The molecular reaction is stated to be a series of ‘signal sensing’ mechanisms evolved by the human body to react to the regular external stress or forces experienced by the body (31,32).

This is reported to occur at a cellular level through neural pathways within myofascial tissue prompting gene transduction and transcription (31,32).

Schleip (33) states that the nervous system should primarily be seen as a ‘liquid system’ where blood and lymph also act alongside further neural pathways to provide fluid transmission of nerve signals throughout the body, particularly signals that prompt the process of myofibrillogenesis and protein synthesis. Muscle tension has been stated to have a dysfunctional and debilitating effect on neural signalling within myofascial tissue (13,14,34). K-tape proposes improved circulation and lymphatic flow whilst also relaxing muscle to restore normal function (5,18).

The second explanation essentially results from myofascial tissue ‘relaxing’.

An altered or reduced amount of messaging from the central nervous system (cnS) allows muscles to lengthen past their normal ROM causing ‘viscoelastic deformation’, or more simply put a permanent reshaping of muscle fibres (22,29).

The cause of altered or reduced cnS messaging is specifically about overcoming an autonomous defence strategy known as the ‘stretch reflex’ mechanism. The mechanism suggests afferent and efferent signalling between the cnS and muscle spindles creating a reflexive muscle contraction designed to protect a muscle from rupture by stretching too far too quickly (35,36).

Another alternative theory embraces the idea that flexibility is www.sportEX.net

purely a subjective reflection based on an individual’s ‘tolerance’ of end-range positions. This suggests that myofascial tissue has the potential to reach further end points but is prevented by doing so by the sensation experienced by each individual, therefore preventing them from extending past that point (30,37,38).This mechanism could, at ‘end point’, reduce or stop the increase in flexibility. It is further suggested that routinely stretching the myofascial tissue promotes a change in the perceived sensation of discomfort, or pain, by the subject as the muscle reaches its stretch end point. This routine stretching would then reduce or stop the signals of pain from the increased tension at the end point, permitting further stretching and flexibility (30,37,38). Kase et al. (6) state a direct pain reduction effect by relieving the pressure off pain and discomfort receptors; it may, therefore, be logical to speculate that K-tape could create more relaxed conditions and fewer afferent signals of pain being transmitted, thus the subject’s end point and flexibility may be altered.

PhYSIologICal ProPertIeS of K-taPe The physiological properties that facilitate flexibility, and are purported to be affected by K-tape, suggest that the application of K-tape directly to local muscles around a joint would result in an increase in the ROM of that specific joint. however, this view of flexibility may be limiting the potential of K-Tape application.

The discovery of the fascial network, running throughout the body has prompted a modern re-evaluation of the complexity and integration of the muscular system. The understanding of anatomy in terms of movement and architecture is moving towards a more interlinked, sophisticated system governed by fascia (33,39–42). Fascia is intrinsically involved in both posture and movement and is abundantly innervated by sensory receptors (21,39). This has been proven to exist as a number of continuous force transmitting ‘chains’ throughout the body (40–42). Stecco et al. (42) state that the presence of referred pain often some distance away from its

origin, such as that seen with trigger points, is confirmation of fascial chains. wadsworth (21) adds that even altered muscle tonus is a component capable of referring restriction distally from its origin to another distal segment of the chain. In other words, tension within one aspect of the body could create restriction elsewhere in the body.

This is known as a ‘tension continuity effect’.

Flexibility is potentially not just a property defined by the behaviour of localised muscle connected to a joint, but is in fact a global network defined by the fluid continuity of the fascial chains that binds the human body and supports our movement.

The recognition of fascia’s place within flexibility, combined with the enhancements stood to be gained from K-tape, suggests that a tape application which embraces this global network could provide a far deeper and more comprehensive approach to increasing an individual’s ROM and quality of movement.

This ultimately translates as a stronger approach to increasing an athlete’s ROM and therefore links to the chain reaction of biomechanical events and flexibility. Enhancing this link leads to enhanced movement and enhanced performance. The significance of K-tape to fascial chains and flexibility is an under-researched field. If the ‘tension continuity effect’ underlying ‘fascial chains’ does exist then it stands to reason that taping methods, incorporating full ‘chains’, should enhance the flexibility of all joints accommodated within that ‘chain’. published research in this field remains limited and inconclusive (15,18).

Garcia-Muro et al. (18) present a case report attempting to document effects of K-tape on restricted shoulder ROM in patients with myofascial pain. The visual analogue scale (vAS) was used to gauge the individual’s

15

pain where measurements are based on a subject’s responses which then equate to numerical ratings on a scale of pain (43,44). Subjective responses in this way, however, are largely open to subjective interpretation as there is little way of guaranteeing one subject’s score of 10 on the pain scale will equally be how another subject feels.

Therefore any associated gains in ROM through pain reduction would be difficult to support. It should be noted, however, that this report states no change in vAS score post-intervention.

Another methodological void is the lack of definitive protocols which ensure a measured amount of tension is running throughout the tape upon application (3,15–20). Kase et al. (6) outlined tape tension as one of the most critical factors towards gaining successful effects from its use. Tension in previous research is both conflicting and unclear. Some research has used the ‘paper off’ method, which relies on the stretch placed and held within the tape whilst on the backing paper (15,19).

Research using the paper off method has reported stretches between 10 and 25% (3,15,19). In addition, further research proceeded to investigate the effects of K-tape on ROM whilst declaring no known or intended degree of tension during research at all, leading to a high degree of irrelevance within their results (16–18,20).

The most questionable aspect from previous research is the understanding of the factors associated with facilitating flexibility (3,15–20). Experimental designs have, in all circumstances, simply applied K-tape to subjects in a bid to then measure a potential increase in ROM. however, as noted earlier, flexibility is ultimately a product of some form of regular, consciously applied force, which stimulates the muscle to adapt either its length or neural and cellular functioning (11,22–25,28–30,45). K-tape cannot be viewed separately from these factors, specific to ROM, as in doing so would be to omit the crucial stimulants that are fundamentally needed for increasing ROM. Furthermore, despite the supported existence of fascial chains and the role they may well have in creating global flexibility, none of the research 16

presented in this article incorporates a taping method that reflects or acknowledges this issue (21,33,39–42).

SuMMarY Existing studies are fraught with undermining features leading to an inability to conduct a reliable, valid or ‘true’ assessment of K-tape and its impact on flexibility. The inferential power of research is often highly questionable and therefore in many cases the questions surrounding K-tape themselves are still largely unanswered.

K-tape in many investigations has been tested under conditions where it was under-appreciated and misplaced. The mechanisms of flexibility appear to operate under the architecture of fascia yet none of these issues are reflected in the research. It would therefore seem appropriate to conduct further research that incorporates improved, standardised, valid and reliable testing methods to investigate K-tape’s relationship towards both flexibility and fascial chains.

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/1BFZQdF

further reSourCeS 1. visit the RockTape website for videos on how to use K-Tape (http://rocktape.net/how-to-use.html).

2. visit Tom Myers’ website and see the ‘Anatomy Trains Myofasial Meridians A Revolution in Soft Tissue patterning’ video for more information on fascial and myofascial linkages (http://www.anatomytrains.com).

DISCUSSIONS

ThE AuThoRs Th sARAh CATlow BsC PGCE MsC sARA s sarah is the programme leader of the sports Therapy and Rehabilitation degrees at the u university of st Mark and st John. The development of these degrees and her clinical work has led her research into the area of Kinesiology tape and the material properties linked to the application of tape in a clinical setting.

DR lAnCE DoGGART PhD D lance graduated in 1992 with a Bsc (hons) l sport science from liverpool Polytechnic s (now liverpool John Moores university). As a research assistant he completed a PGcert in teaching and learning in hE in 1996 and completed a PhD in 2002 on the biomechanics of sports injuries. lance moved to Plymouth and the university of st Mark and st John in 2001. In 2012 he completed an MEd focusing on the role of the student feedback process. The development of the very successful sports Therapy and Rehabilitation degrees at the university of st Mark and st John has led his research down the path of Kinesiology tape and predominantly the material properties associated with the tape in relation to injury prevention and rehabilitation.

KeY PoIntS n the concept of K-tape mirroring the body externally to enhance functions internally, is attractive to athletes who require all systems within the body functioning at and optimum rate. n there are substantial levels of interest in terms of defining the relationship between K-tape and flexibility. n the significance of K-tape to fascial chains and flexibility is an under-researched field. n a major methodological void is the complete lack of definitive protocols within K-tape research. n the effects of K-tape are attributed to the recoil effect lifting the skin and releasing pressure around the injured area. n the idea that K-tape increases roM when directly applied to local muscles around a joint might limit the potential benefits of K-tape use. n the existence of fascial chains suggests that to enhance flexibility at a particular joint, flexibility must be enhanced throughout the whole body. n the application of K-tape that embraces the idea of a global fascial network could provide better gains in roM and movement quality.

n what is the definitive role of K-tape in enhancing ROM or flexibility? n what are the key factors affecting K-tape application for optimising its performance? n what is the key, underpinning physiology influencing the application of K-tape and where is the research to support this?

sportEX dynamics 2015;44(April):14-16

Literature review

References 1. Williams S, Whatman C, et al. Kinesio taping in treatment and prevention of sports injuries: a meta-analysis of the evidence for its effectiveness. Sports Medicine 2012;42(02):153–164 2. O’Sullivan D, Bird SP. Utilization of kinesio taping for fascial unloading. International Journal of athletic therapy & training 2011;16(04):21–27 3. Thelan MD, Dauber JA, Stoneman PD. The clinical efficacy of kinesio tape for shoulder pain: a randomized, double-blinded, clinical trial.

Journal of Orthopaedic & Sports Physical therapy 2008;38(07):389–395 4. Wong OMH, Cheung RT, Li RC. Isokinetic knee function in healthy subjects with and without Kinesio taping. Physical therapy in Sport 2012;13(4):255–258 5. Yasukawa A, Patel P, Sisung C. Pilot study: investigating the effects of kinesio taping® in an acute pediatric rehabilitation setting. the american Journal of Occupational therapy 2006;60(01):104–110 6. Kase K, Wallis J, Kase T. Clinical therapeutic application of the kinesio taping method, 2nd edn. Kinesio 2003. ASIN B00PKJNGPW 7. Soylo AR, Irmak R, Baltic G. Acute effects of kinesiotaping on muscular endurance and fatigue by using surface electromyography signals of masseter muscle. Medicina Sportiva 2011;15(01):13–16 8. Dantas EHM, Daoud R, et al. Flexibility: components, proprioceptive mechanisms and methods. Biomedical Human Kinetics 2011;3:39–43 9. Caplan N, Rogers R, et al. The effect of proprioceptive neuromuscular facilitation and static stretch training on running mechanics.

Journal of Strength and Conditioning research 2009;23(04):1175–1180 10. Cools AM, Geerooms E, et al. Isokinetic Scapular Muscle Performance in Young Elite Gymnasts. Journal of athletic training 2007;42(04):458–463 11. Reid DA, McNair PJ. Passive force, angle, and stiffness changes after stretching of hamstring muscles. Medicine & Science in Sports & exercise 2004;36(11):1944–1948 12. Celik D, Yeldan I. The relationship between latent trigger point and muscle strength in healthy subjects: a double-blind study. Journal of Back and Musculoskeletal rehabilitation 2011;24:251–256 13. Fernandez De-Las-Penas C. Interaction between trigger points and joint hypomobility: a clinical perspective. the Journal of Manual and Manipulative therapy 2009;17(02):74– 77 14. Knutson GA, Owens EF. Active and passive characteristics of muscle tone and their relationship models of subluxation/ joint dysfunction: part I. the Journal of the Canadian Chiropractic association 2003;47(03):168–179 15. Merino-Marban R, Fernandez-Rodriguez E, et al. The acute effect of kinesio taping on hamstring extensibility in university students.

Journal of Physical education and Sport 2011;11(02):133–137 16. Nelson DK. The effect of kinesio tape on www.sportEX.net

quadriceps muscle power output, length/ tension, and hip and knee range of motion in asymptomatic cyclists. Masters Thesis, Durban University of Technology 2011 17. Merino R, Mayorga D, et al. Effect of kinesio taping on hip and lower trunk range if motion in triathletes. a pilot study. Journal of Sport and Health research 2010;2(2):109–118 18. Garcia-Muro F, Rodriguez-Fernandez AL, Herrero-de-Lucas A. Treatment of myofascial pain in the shoulder with kinesio taping. a case report. Manual therapy 2010;15(3):1–4 19. Gonzalez-Iglesias J, Fernandez De-LasPenas C, et al. Short-term effects of cervical kinesio taping on pain and cervical range of motion in patients with acute whiplash injury: a randomized clinical trial. Journal of Orthopaedic & Sports Physical therapy 2009;39(07):515–521 20. Yoshida A, Kahanov L. The effect of kinesio taping on lower trunk range of motions. research in Sports Medicine 2007;15:103– 112 21. Wadsworth D. Locomotor slings: a new total body approach to treating chronic pain.

Massage therapists 2007;winter:17–21 22. Youdas JW, Haeflinger KM, et al. The efficacy of two modified proprioceptive neuromuscular facilitation stretching techniques in subjects with reduced hamstring muscle length. Physiotherapy theory and Practice 2010;26(4):240–250 23. Nakamura M, Ikezoe T, et al. Effects of a 4-week static stretch training program on passive stiffness of human gastrocnemius muscle-tendon unit in vivo. european Journal of applied Physiology 2012;112:2749–2755 24. Marques AP, Vasconcelos AAP, et al. Effect of frequency of static stretching on flexibility, hamstring tightness and electromyographic activity. Brazilian Journal of Medical and Biological research 2009;42:949–953 25. Davis DS, Ashby PE, et al. The effectiveness of three stretching techniques on hamstring flexibility using consistent stretching parameters. Journal of Strength and Conditioning research 2005;19(1):27–32 26. Chalmers G. Re-examination of possible role of Golgi Tendon organ and Muscle spindle reflexes in Proprioceptive Neuromuscular Facilitation muscle stretching. Sports Biomechanics 2004;03(01):159–183 27. De Weijer VC, Gornial GC, Shamus E. The effect of static stretch and warm-up exercise on hamstring length over the course of 24 hours. Journal of Orthopaedic & Sports Physical therapy 2003;33:727–733 28. Kubo K, Kanehisa H, et al. Influence of static stretching on viscoelastic properties of human tendon structures in vivo. Journal of applied Physiology 2001;90:520–527 29. Spernoga SG, Uhl TL, et al. Duration of Maintained Hamstring Flexibility After a OneTime, Modified Hold-Relax Stretching Protocol.

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online and its implications for muscle fibers. Physical therapy 2001;81:819–827 32. Myhre JL, Pilgrim DP. At the start of the sarcomere: a previously unrecognized role for myosin chaperones and associated proteins during early myofibrillogenesis. Biochemistry research international 2011;1–16 33. Schleip R. Fascial plasticity – a new neurobiological explanation: part 1 & 2.

Journal of Bodywork and Movement therapies 2003;11–116 34. Celik D, Yeldan I. The relationship between latent trigger point and muscle strength in healthy subjects: a double-blind study. Journal of Back and Musculoskeletal rehabilitation 2011;24:251–256 35. Taube W, Leukel C, Gollhofer A. How neurons make us jump: the neural control of stretch-shortening cycle movements. exercise and Sports Science reviews 2012;40(02):106–115 36. Moore M. Golgi tendon organs neuroscience update with relevance to stretching and proprioception in dancers.

Journal of Dance Medicine Science 2007;11(03):85–92 37. Ben M, Harvey LA. Regular stretch does not increase muscle extensibility: a randomized controlled trial. Scandinavian Journal of Medicine & Science in Sports 2010;20:136–144 38. Folpp H, Deall S, et al. Can apparent increases in muscle extensibility with regular stretch be explained by changes in tolerance to stretch? australian Journal of Physiotherapy 2006;52:45–50 39. Price D. Whole-Body strength training using myofasical lines. Eight practical keys to understanding and training connective tissue. iDea Fitness Journal 2012;april:24–30 40. Myers T. Bodyreading the meridians.

Massage & Bodywork 2011;September/ October:70–81 41. Myers T. Fascial fitness: training in the neuromyofascial web. iDea Fitness Journal 2011;april:36–43 42. Stecco A, Macchi V, et al. Anatomical study of myofascial continuity in the anterior region of the upper limb. Journal of Bodywork and Movement therapies 2007;13:53–62 43. Breckenridge JD, McAuley JH. Shoulder pain and disability index (SPADI). Journal of Physiotherapy 2011;57(03):197 44. Ekeberg OM, Bautz-Holter E, et al.

Agreement, reliability and validity in 3 shoulder questionnaires in patients with rotator cuff disease. BMC Musculoskeletal Disorders 2008;9:68 45. Nelson RT, Bandy WD. Eccentric training and static stretching improve hamstring flexibility of high school males. Journal of athletic training 2004;39(3):254–258.

Literature review

BY BoB BraMah Bsc, MsMa MsMM McsP

introduction Massage can be used in six areas of sport. The evidence relevant to the first four of these is detailed below. Massage applied as part of a general conditioning programme has a very similar aim to that applied post-exercise, and to an extent during competition, which is to assist the body in returning to a pre-exercise condition as soon as possible in order that further exercise or competition can be undertaken. Therefore, many of the studies discussed in the general, during and post-exercise sections are interchangeable.

Methods Three literature reviews published in the middle of the last decade, Moyer (1), Weerapong (2) and Moraska (3) examined the use of massage in general and sport in particular and found that although there were a lot of studies with positive results many lacked crucial elements required to state whether or not the treatment has been effective. So the present study used the above reviews as a starting point to examine what, if any research was now available.

A literature search was undertaken of the CINAHL, SPORTDiscus, Ovid and PEDro databases from January 2004 to December 2013 for articles in English or translated from other languages in which the techniques of, effleurage, petrissage, tapotement, and frictions were used. Key words were, massage, sports massage, injury, psychological effects, performance, blood flow, lactate, DOMS, delayed muscle soreness, muscle fatigue, exercise, recovery, sport, and pain.

Once duplicates had been removed this search resulted in 122 studies.

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SwediSh maSSage in a Sporting context Part 1 In the previous edition of sportEX dynamics Bob Bramah looked at why the majority of massage research is flawed. Despite this, massage remains a popular treatment modality at all levels of sport and exercise especially within the elite and professional ranks. In this, the first of two further articles, the author looks at what research evidence is available to justify massage as part of a general conditioning programme and before, during or after activity. Part 2 will look at the use of massage following injury and travel. As discussed in the previous article there are over 100 types of massage described in the literature but the majority of techniques used are those described as ‘Swedish’ namely, effleurage, petrissage, tapotement, and frictions.

Therefore, it is evidence for the use of these methods which will examined.

Massage for general conditioning High-intensity or long-duration exercise can produce immunosuppression, which therefore increases the risk of catching infections (4). Arroyo-Morales (5) found that massage had a favourable effect on recovery from the transient immunosuppression state induced by exercise. Unfortunately the massage techniques used are described as a ‘myofascial induction protocol’ which is outside the inclusion criteria of the present study. It should be noted that the technique involves a sustained tension force being applied to tissue.

Further research into this area is recommended.

Rapaport (6,7) examined the results of a single session and multiple sessions of massage on biological markers and found that a weekly session of Swedish massage

for 5 weeks had similar effects to a single session. The effects seen were that it stimulated a sustained pattern of increased circulating phenotypic lymphocyte markers and decreased mitogen-stimulated cytokine production.

This suggests a positive effect on the immune system while having minimal effect on hypothalamic–pituitary–

A LOT OF STUDIES PRESENT POSITIvE RESULTS BUT MANy LACKED THE CRUCIAL ELEMENTS REqUIRED TO STATE WHETHER OR NOT THE TREATMENT HAS BEEN EFFECTIvE 17

adrenal function. A twice-weekly session for 5 weeks had little effect on circulating lymphocyte phenotypic but increased oxytocin (a hormone responsible, amongst other things, for an increase in pain threshold) and induced general relaxation. It decreased arginine vasopressin, whose two primary functions are to retain water in the body and to constrict blood vessels, and also decreased cortisol, a steroid hormone released in response to stress. The double sessions also saw a slight increase in mitogenstimulated interferon-c and tumour necrosis factor-alpha and interleukin suggesting increased production of pro-inflammatory cytokines.

Bogueszewski (8) reported on a group of kickboxing and judo players trying to reduce body mass before a competition. Those in the massage group had reduced anxiety during the process and more of them achieved their weight goals compared to the non-massage control group.

Dawson et al. (9) examined the effects of massage on a group of novice runners. The difference between this study and others is that the authors recognised that treatment was an ongoing process rather than looking at the effect after a one-off exercise session. Here, 28 novice runners were split into two groups one of which received regular massage over 10 weeks of a training programme readying them for a 10km race. Although there were no differences between the groups for the majority of outcome measures (muscle

strength, pain running and at rest, daily function and running confidence), the massage group all achieved their goal of completing the race whereas only 58.3% of the control group did.

Whether or not this can be attributed to the massage intervention is conjecture. The treatments, and the training, were individualised to the runners’ needs and all participants kept a training journal which showed that the running behaviour of both groups was similar. As far as the methodology of the study is concerned the groups came from a similar demographic, the groups and the therapists were blinded to the activities of the other (the groups trained at two separate running clinics 15km apart), drop-outs were recorded and it was ascertained that no member of the control group received massage from outside the study.

One factor that might account for the difference in performance was that there was an insignificant trend for the massage group to train more frequently and to run further during sessions. Both groups reported similar levels of pain during the training but the massage group felt that they could deal with it better. This could be because they could obtain advice from the therapist on minor injury and pain management or that the one to one regular session with a therapist served as motivation towards achieving the set goal of race completion.

Although the results may not be directly attributed to the massage treatment it is noteworthy that the

SzABO (11) FOUND THAT A 10-MINUTE ‘WARM-UP’ MASSAgE BEFORE A 20-MINUTE RUN INCREASED POSITIvE EFFECT AND DECREASED PERCEPTIONS OF PHySICAL EFFORT BOTH DURINg AND AFTER RUNNINg 18

runners considered the massage as a beneficial part of the training programme and over 90% of the massage group would recommend that massage be part of a running programme and 75% said they would use massage in the future. The ones who stated they would not use it indicated that this was because of the cost.

Pre-event or Preexercise Massage Brummitt (10) found six studies from 1999–2006 related to pre-event massage and concluded that there was ‘paucity’ in the literature addressing the effects. Overall the conclusion was that there was a failure to demonstrate significant effects. The point was made that many positive studies were undermined by design flaws.

effect on mood and anxiety Szabo (11) found that a 10-minute ‘warm-up’ massage before a 20-minute run increased positive effect and decreased perceptions of physical effort both during and after running.

In this particular study the running effort was self-selected and the actual performance was no different to a group warming up with stretching.

What was different was the way the participants felt about their efforts.

These are similar findings to Dawson (9). However, Micklewright (12) found there was no change in mood state as determined by a Profile of Mood State (POMS) questionnaire taken pre-/ post-treatment but there was a 2% improvement on Wingate performance.

Micklewright attributes the difference in mood and performance data to the athletes’ knowledge of an impending maximal effort test after the massage.

range of motion Insufficient range of motion (ROM) because of poor muscle flexibility has been suggested as a possible cause of muscle strain during activity (13).

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Passive tension increase through contraction affects the agonist/ antagonist relationship and in addition when a muscle length is shortened to 85% of its resting rate there is a loss of up to 50% of muscle strength.

(14). Static stretching can be used to increase ROM but can impair force production (15) and when used as a warm-up can impair balance and reaction/movement time. (16).

Increasing ROM with massage, which does not have the same side-effects, would therefore be beneficial although no data is available to indicate just how much ROM needs to be increased to reduce injury risk. (17).

Huang (18) showed that it is possible to increase ROM by the application of as little as 10 seconds frictional massage to the musculotendinous junction, a finding similar to McKechnie (19) who used either a petrissage or tapotement technique. The reason for this increase is speculative. Huang suggests an increase in local temperature and blood flow, a reduction in the muscles ability to detect pain and a decrease in muscle-tendon stiffness. McKechnie agrees with the stiffness theory at a fibre level when petrissage is used resulting in increasing muscle compliance. For tapotement, muscles and cutaneous neural structures are superficially stimulated. It may be that an overload of cutaneous receptors makes recognising the end point of the stretch more difficult (20,21).

Both Arabaci (22) and Arazi (23) improved results of a sit-and-reach test following a 15-minute massage to the legs. This contrasts with Barlow (24) who found the opposite following a 15-minute treatment only on the hamstrings. The massage treatment given was described as ‘specific’ but was not actually stated other than to be called effleurage and petrissage.

Arabaci and Arazi included other strokes which may account for the difference (22,23).

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MUSCLE BIOPSIES WERE OBTAINED FROM qUADRICEPS MUSCLES AFTER ExERCISE AND TREATMENT. IT WAS FOUND THAT MASSAgE HAD NO EFFECT ON MUSCLE LACTATE LEvELS Hopper (17) compared two soft tissue techniques to extend hamstring muscle length. Both can be considered as ‘massage’ under the criteria for this study. One involved effleurage and petrissage strokes performed in a static position (as in all the other reported studies). The other was performed on areas of tension within the hamstring identified by the therapist. These areas were first treated with similar strokes to the massage group but performed quicker and followed by longitudinal and cross friction directed to the areas of increased tension. This was followed by the application of long effleurage strokes applied simultaneously with a passive then active knee extension movement and finally an eccentric contraction of the hamstring as the knee was passively extended. Neither intervention improved a passive straight leg raise but both improved hamstring length when the test was a passive knee extension conducted with the hip in 90° of flexion. The improvement was short term as it was not detected at 24 hours post-intervention.

The reasons for the difference in knee extension and straight leg raise results are not clear. Subjects were screened for neural signs, although it is not stated how. They were all able to achieve full knee extension and ankle planter grade. Pelvic movement was deducted from the straight leg raise score. Barlow (25) showed that there was no change in biceps femoris electromyography (EMg) activity following 15 minutes of massage.

The answer may be in the effects of myofascial work, which is beyond the scope of the present study.

Performance Arroyo-Morales (26) and Arabaci (22) found that massage tends to take the strength out of muscle. The reason for this may be that muscle detection

thresholds are altered and thus so is motor-unit activation (26). Micklewright (12), however, found that performance was improved following a 30-minute back massage. The difference between the results may be because the treated area was not directly linked to the muscle creating the effort (cycling).

What was not responsible was the athlete’s mood as a pre-/post-POMS questionnaire registered no change.

Hunter (27) found that a knee extension at a velocity of 60°/s was adversely affected by massage. There was also a trend towards a change at 120°/s. The results were not replicated at other speeds (180°/s and 240°/s) and there was no change in a vertical jump height before and after the intervention. Such a jump involves knee extension velocity at closer to 240°/s.

This result would concur with the static extension only being affected at lower velocities. The reason for the change is speculated as being a change in muscle architecture with massage causing a lengthening of the muscle and a subsequent reduction in actin and myosin cross bridges. This would concur with research that suggests that static stretching also impairs force production and performance (15,16,28).

The 60°/s speed was the first to be tested and it may be that the subjects adapted to the subsequent test speeds. A lack of change in EMg results suggests that the change in muscular contraction was not due to a change in neural recruitment.

Arazi (23) found that a 15-minute massage decreased performance of a ‘T’ agility test. vertical jump height and sprint times were also down when compared to resting control. This confirmed findings by Arabaci (22) and Fletcher (29). goodwin (30) found no negative effect on sprint times.

This might be because of the order of treatment before the test. Arazi

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RAPAPORT (6,7) SUggESTS THAT MASSAgE HAS A POSITIvE EFFECT ON THE IMMUNE SySTEM and Arabaci both had subjects warm up and then be massaged whereas goodwin did the reverse. It may be that the warm-up taking place after the massage allowed time for any negative effects of massage to be dissipated.

Massage during coMPetition A number of studies consider recovery from exercise, Micklewright (31) Arroyo-Morales (26) and Ali (32) deal with recovery strategies that can be applied between bouts of exercise or afterwards. They are discussed in the ‘Post-event or post-exercise massage’ section. Studies primarily involving muscle fatigue are reported here.

coping with stress An athlete’s ability to cope with stress and emotion is an important component of performance (33). Moraska (34) reviewed 25 papers examining the physiological markers of stress following massage and found that singletreatment reductions in salivary cortisol and heart rate were consistently noted.

However, a sustained reduction for these measures was not supported in the literature, although the single-treatment effect was repeatable within a study. Moraska found that there was insufficient data to make definitive statements regarding the multiple treatment effects on urinary cortisol, but that there was some evidence for a positive effect on diastolic blood pressure.

The majority of the reviewed papers reported on 5 massage sessions, a few 10 and one had 22. In practice this means that there have been documented effects for a single treatment.

In a sporting context of regular contact between therapists and athletes over the course of a season those singlesession effects can be repeated.

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This was supported by Noto (35) who found that salivary amylase and cortisol levels did not change following massage but the heart rate was reduced and the level of salivary chromogranin, a substance that has antibacterial and antifungal properties, also increased. There is no description of the treatment other than to be described as a back massage.

Muscle fatigue Ogai (36) compared massage to passive rest and found power output and perceived lower limb fatigue improved in the massage group.

Bielik (37) found no significant difference in a fatigue index following three interventions of active recovery, passive recovery and massage. This may be because that their subjects were elite junior off-road cyclists well used to extreme cycling and rapid recovery. young (38) fatigued a thumb adductor muscle and tested strength in a piece of equipment designed to isolate the muscle. The results were that massage made little difference to the maximal force produced after intervention. This contrasts with Brooks (39) who found a significant difference in grip strength. The differing result may be because young only treated a portion of the dorsal aspect of the muscle whereas Brooks treated the whole hand and forearm. It is clear from the accompanying pictures provided by young that other muscles are firing during the thumb adduction process. The contracted tendon of extensor pollicis longus can clearly be seen yet it was not treated.

Another factor may be the motivation of the subjects. Power grip used by Brooks may have been viewed as more functional movement and during the grip test subjects were verbally encouraged to raise their performance level whereas those in the young study were not. The Brooks study highlighted the fact that the massage effect was greatest in the non-dominant hand.

They were unable to find literature to explain this phenomenon so more research is necessary.

Post-event or Postexercise Massage lactate clearance This is one of the most contentious issues in the literature. Numerous studies state that massage has no effect on the rate of removal of blood lactate when compared to other interventions such as active and passive recovery (40–42). Wiltshire (43) goes as far as to state that massage impairs blood flow because of its compressive nature which therefore prevents the removal of lactate. The Wiltshire study is refuted by both Morsaka (44) and Cè (45) who query the statistical analysis of the results given that baseline measurements of the three interventions (massage, active recovery, passive recovery) were unequal, which is not accounted for in the subsequent analysis.

Ali (32) found that massage increased lactate removal when compared to passive recovery but that the optimal recovery method was active. In this study the active recovery strategy was better than a massage intervention, which in turn was better than a passive recovery as judged by a subsequent swimming performance test. An earlier study by Micklewright (31) found a combination of active recovery at 30–45% of vO2 max combined with a 10-minute massage to the legs resulted in greater lactate removal than active recovery alone or passive recovery.

Seo (46) found that after massage and electrical stimulation lactate removal was greater than in the resting control but unfortunately this study does not describe the massage protocol, the therapist or the duration of application, so evaluation of the results is not possible. Pinar (47) and Ogai (36) found that massage and electrical stimulation were no better than passive rest at removing lactate. Cè (45) agreed that deep and superficial massage in the form of myofascial release (MFR) did not affect post-exercise lactate levels when compared to active exercise.

The aim of the study by Paoli (48)

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was to assess whether their objective measures of power output, heart rate, pain and blood lactate clearance were greater using an ozonised massage oil than not. In addition to a group of athletes subjected to treatment with or without the oil they had a control group that used passive rest as a recovery strategy. Blood samples were taken at 5, 13 and 20 minutes postexercise. Blood lactate reduced for all conditions and at the 13-minute mark the clearance level was greater for the passive rest group than the massage group, which agrees with the findings of Hemmings (40) and Robertson (42).

However, at the 20-minute mark the massage group had superior lactate clearance, which suggests that the dose/outcome relationship comes into effect. Interestingly, the massage with oil group had superior results to both of the other conditions at the 13- and 20-minute mark suggesting that the biological effects of the oil have an influence. The effects of topical ozone therapy are beyond the scope of this study but the reported effects include activation of micro-circulation and improved cellular oxygen uptake (49).

Lane (50) raises the issue of blood lactate not necessarily equating to the levels of lactate in the muscle. This is important because it is the lactate in muscles that interferes with enzyme activity. However, Crane (51) answered this by producing the most definitive study to date. Muscle biopsies were obtained from quadriceps muscles after exercise and treatment. It was found that massage had no effect on muscle lactate levels.

The inevitable conclusion from the above is that there is evidence that massage does not affect lactate removal. The last word on lactate clearance should go to Moraska (44) who stated that, “from a simple practical standpoint, lactate clearance after massage does not warrant investigation.”

creatine kinase Creatine kinase (CK) levels have been used as a measure of muscle damage in a number of studies

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including zainuddin (52) who found that massage reduced CK levels. Nelson (53) questions if CK measurement as a marker is valid, given that individual levels vary in the subjects taking part in the same exercise protocols and it can be influenced by factors other than tissue damage such as genetics, age and sex. gatterer (54) examined the effects of massage in hypoxic conditions.

Although the outcome measures of levels of creatine kinase, urea and uric acid reduced during massage conditions under both normal and hypoxic conditions there was no significant difference between the two and there was no non-massage control group with which to make a comparison. In fact no detail of the massage protocol or the therapists is given.

Blood flow One of the popular claims by massage practitioners is that massage improves blood flow (1,2,55,56) and therefore post-exercise recovery is enhanced because oxygen delivery to tissues and metabolite removal speed the process of homeostasis (57). However, the research is equivocal. Robertson (42), Hinds (57) and Wiltshire (43) do not the support the claim whereas Taspinar (58) and Mori (59) do. A reason for the conflicting results lies in how the data is collected especially data to measure blood flow in deep tissue. Hinds (57) and Wiltshire (43) used probes which are invasive and could affect results, especially as a local anaesthetic was used to insert them. Laser Doppler does not penetrate deep tissue and ultrasound Doppler, as used by Hinds (57) may not be sensitive enough to measure blood flow in small vascular spaces (60). However, in a more recent study Taspinar (58) used colour Doppler ultrasound to measure blood flow during massage of the hamstrings and triceps surae and saw an increased flow in the popliteal artery of 17.84% ± 17.23% and in the posterior tibial artery of 16.07% ± 10.28%. The figures were even higher using a

mechanical massage device. The large range of results does make the point that the combination of subjects and massage therapist results in each treatment being individual and that despite attempts to standardise treatment the same method applied in exactly the same way may give a different result in subject A compared to subject B. Buckle (61) used an ‘expensive and cumbersome’ photon emission computed tomography scanner to measure blood flow which involved injection of a medium that could be seen by the scanner. Results for both ‘conventional’ (not further described) massage and a very light technique called ‘M’ massage were that cerebral blood flow was increased.

Two other measurement approaches may reduce some of the methodological problems noted above and show positive results for massage improving blood flow. For peripheral blood flow, Sefton (62) used dynamic infrared thermography to visualise heat changes following massage. The thermal images showed heat increases in the areas massaged and the adjacent ones that were not.

The heating effect peaked 15 minutes after the completion of a 20-minute massage. A second intervention was tested that involved a therapist using light touch on the same areas treated in the massage group. The thermal image of this group did not differ significantly from a non-treated control group showing that the heat effect was not as a result of conduction from the therapist’s hands.

The other measuring tool is described by Munk (60) as a ‘novel hybrid near-infrared diffuse optical instrument’. It is claimed to be able to provide dynamic information about oxygen and haemoglobin concentration and blood flow in deep tissue via the emission and collection of photons passed through the tissue. It does require a small probe to be attached to the skin surface of the muscle being investigated but this is small enough for a therapist to work around. In a single subject pilot study massage of

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the gastrocnemius muscle showed a relative increase in blood flow from 100% to 149% and an increase in tissue blood oxygen saturation from 75.9% to 77.3%. Further validation of this measuring system is required.

Munk proposed a full study but this has not yet been published. gregory (63) used an animal modal to show that massage increased the diameter and cross-sectional area of muscle capillaries in rabbit vastus lateralis muscles. Immediately after treatment, luminal diameters increased by an average of 19% and their crosssectional area by 35%. Twenty-four hours later the luminal diameter was 11% and the cross-sectional area 30%.

This increase cannot be attributed to a corresponding skin temperature increase because the massage force was delivered by compressed air which actually cools the skin. Nor could it be endothelial cell oedema as the specimens were examined with a transmission electron microscope which only showed evidence of this in a small number of the vessels. As with all animal studies care should be taken when extrapolating these results to a human population.

delayed onset muscle soreness Delayed onset muscle soreness (DOMS) is the pain felt in muscles following unaccustomed exercise. It has been linked to predominantly eccentric exercise and usually develops between 8 and 24 hours post-exercise, peaking at 2–3 days before gradually resolving. given that its symptoms can range from mild discomfort to excruciating pain with accompanying strength loss it can be a major barrier to athletic training especially in novices. The exact mechanisms of the cause are as yet unknown, which creates difficulty in directing treatment. Amongst the proposed mechanisms are muscle damage, local inflammation, neural adaptation and psychosocial mediators (53).

In a 1998 study Ernst (64) described the use of massage as a treatment modality to prevent DOMS as ‘promising’. This trend was supported by another systematic review (65). Here a total of 10

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randomised controlled trails (RCTs) provided moderate data in support of massage to facilitate the recovery from repetitive muscular contractions but 17 case series studies provided little support. Howatson (66) reports in a study comparing the effects of various treatment modalities on alleviating muscle soreness that only massage had a positive effect, whereas the results for other modalities were equivocal. A review by Nelson (53) also uses the word, ‘promising’ to describe the present state of research into the treatment of DOMS. Torres (67) (unusually for reviewers) was able to complete a meta-analysis on ‘muscle soreness’ and ‘muscle strength’ using data from 35 papers published between 1987 and 2011, nine of which included massage. The results were that six of the massage papers found positive effects and the metaanalysis found a significant positive effect on muscle soreness if the massage was performed at 24 hours post-exercise and on muscle strength if performed 1 hour post-exercise. zainuddin (52), using a protocol where massage was given 3 hours after exercise, found no difference in ROM or function as determined by a combination of strength and ROM but did reduce reported muscle soreness by approximately 30%. Frey Law (68) induced DOMS with sets of eccentric wrist extensor exercise. Although they found that their treatment intervention did not produce a difference in posttreatment torque they did find that mechanical hyperalgesia measured by pressure pain threshold (PPT) was reduced in both a deep massage and superficial touch compared to control.

Andersen (69) created DOMS with eccentric shoulder shrugs and 48 hours later performed either an undescribed massage on one shoulder or an active recovery regime using Thera-band. The contralateral shoulder acted as a control. Two hours later the treatments were reversed. Both groups reported immediate post-treatment reduction in perceived soreness. PPT adapted more slowly and peaked at 20 minutes. The treatment effects diminished within 60 minutes. It is

difficult to draw conclusions from this given that there is no information on the massage protocol or dose and the contralateral shoulder control and counterbalance treatment was administered within 2 hours, which could influence the results with a carryover effect. In fact the nontreatment control shoulder showed improvement in the tested outcome measures over time. This placebo effect may be a product of the expectation of the group. Polled before the study, 90% expecting massage to reduce soreness and 55% expected an active recovery to do likewise.

Butterfield (70) created a device that stimulates compression and shear massage and applied it to an animal model using a contralateral limb as control. The rabbits were exercised and subsequently massaged before being exercised again. At the dose given, there was a significantly greater recovery of function as measured by peak torque production for the massaged limb when compared to the untreated limb. In addition, histological analysis of the tissues showed ‘striking visual differences’ between the treated and the untreated limbs. In crosssection the fibres of the treated leg appeared to have an absence of torn fibres whereas the untreated leg displayed a large number. To accompany this damage the untreated leg had a considerably larger number of leucocytes present in the interstitial spaces and infiltrating into the muscle.

No infiltrating leucocytes were observed in the treated muscle, which had an appearance similar to healthy unexercised muscle. Promising though this is in terms of answering questions about both dose and the efficacy of massage for enhancing recovery and performance there is no guarantee that the results will transfer into humans.

Why pain thresholds are changed is speculation. One theory is the pain gate (71). Lund (72) adds the idea that with more intense treatment there is activity in small diameter Ad fibres with subsequent activity in the descending inhibitory control system and thus a reduction in pain perception. Animal studies have suggested a release

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of oxytocin (a hormone responsible amongst other things for an increase in pain threshold and to induce general relaxation). Slow stroking movements activate C-tactile afferent nerve endings found in human hairy skin which are perceived in the insular cortex area of the brain as a pleasurable experience (73).

Fritz (56) stated that when massage is given as a treatment three things occur simultaneously: mechanical force is applied tissue; a host of tissue receptors are stimulated; and a therapeutic relationship is established.

A good therapeutic relationship can enhance patient satisfaction and compliance (74). When compared to other medical procedures the therapeutic relationship generated by massage treatment is enhanced by the power of human touch which is perceived as a special form of tactile sensation typically perceived as pleasurable (75). In particular very light effleurage strokes classed as ‘touch massage therapy’ or ‘tactile massage’ has been found to decrease pain, anxiety and stress in clinical nursing situations. (76–78). This is probably because areas of the brain have been found to be activated during touch stimulation including the somatosensory cortex which is the main processing area for proprioception, thermoception, mechanoreception and nociception and the orbitofrontal cortex which is involved in a wide range of processes including olfaction and emotion and the cognitive processing of decision-making (75).

conclusion If you read deeply into the various human studies quoted above, many of the methodical problems highlighted

in the previous reviews still exist. One contentious issue has been resolved: massage has little effect on blood lactate removal. There are better ways to deal with it, such as active recovery.

There are, however, many positives. There is evidence of positive psychological effects following massage to alter mood state and promote wellbeing that can be utilised in a sporting context. Care should be taken with pre-event massage when muscular strength is required but evidence exists that massage can be beneficial for performance during training and competition. The examination of what happens at a cellular level and the animal studies prove that massage is having an effect on tissue. There is no doubt that joint ROM can be increased, that perceptions of fatigue are reduced and if you get the dose and timing right there is a positive effect on DOMS, so it all looks good for the continued use of massage in sport.

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/1N8f9Hx

further resources 1. JRB Training. (http://www.jrbtrainingsolutions.co.uk/) 2. JRB Training Facebook page: sign up for regular posts. (https://www. facebook.com/JRBTrainingSolutions)

n What are the different areas of sport when massage can be used and what are the aims of massage in these areas? n What is the effect of exercise on the immune DISCUSSIONS system and is massage beneficial? n What is the effect of massage on mood/anxiety? n How does post-exercise massage benefit the athlete? n What role does the good therapeutic relationship play in the perceived benefits of massage?

www.sportEX.net

Th AuThoR ThE BoB BRAmAh BSc, mSmA Bo mSmm mcSP m 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

KeY Points n Massage can be used in six areas of sport: (1) general conditioning, (2) before exercise/event, (3) during activity, (4) after exercise/event, (5) following injury, and (6) after travel. n Massage applied in the first four areas has a similar aim, which is to assist the body in returning to a pre-exercise condition as soon as possible. n in the study by dawson et al. (9), the authors recognised that treatment was an ongoing process rather than looking at the effect after a one-off exercise session. n in dawson’s study, both groups reported similar levels of pain during the training but the massage group felt that they could deal with it better. n not many studies have been done on pre-event massage. n Massage can improve range of motion, but the effects seem to be short term. n an athlete’s ability to cope with stress and emotion is an important component of performance. n Moraska (44) stated that, “from a simple practical standpoint, lactate clearance after massage does not warrant investigation.” n the use of massage to prevent delayed onset muscle soreness seems to be ‘promising’, if performed very soon after exercise. n there is evidence of positive psychological effects following massage to alter mood state and promote wellbeing that can be used in a sporting context.

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online

SwediSh maSSage in a Sporting context Part 1

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British Journal of Sports medicine 2004;38(3):349–351 25. Barlow A, Clarke R, et al. Effect of massage of the hamstring muscles on selected electromyographic characteristics of biceps femoris during sub-maximal isometric contraction. international Journal of Sports medicine 2007;28(03):253–256 26. Arroyo-Morales M, Fernandez-Lao C, et al. Psychophysiological effects of preperformance massage before isokinetic exercise. Journal of Strength and conditioning research 2011;25 (2):481– 488 27. Hunter AM, Watt JM, et al. Effect of lower limb massage on electromyography and force production of the knee extensors.

British Journal of Sports medicine 2006;40(2):114–118 28. Behm Dg, Peach A, et al. Massage and stretching reduce spinal reflex excitability without affecting twitch contractile properties.

Journal of electromyography and Kinesiology 2013;23(5):1215–1221 29. Fletcher IM. The effects of pre-competition massage on the kinematic parameters of 20m sprint performance. Journal of Strength and conditioning research 2010;24(5):1179–1183 30. goodwin JE, glaister M, et al. Effect of pre-performance lower-limb massage on thirty-meter sprint running. the Journal of Strength and conditioning research 2007;21(4):1028–1031 31. Micklewright D, Sellens M, et al. Blood Lactate removal using combined massage and lactate recovery. Biology of Sport 2006;23(4):315–325 32. Ali RS, Koushkie JM, et al. Influence of massage, active and passive recovery on swimming performance and blood lactate. the Journal of Sports medicine and physical Fitness 2012;52(2):122–127 33. Neil R, Hanton S, et al. Competition stress and emotions in sport performers: The role of further appraisals. psychology of Sport and exercise 2011;12(4):460–470 34. Moraska A, Pollini RA, et al. Physiological adjustments to stress measures following massage therapy: a review of the literature. evidence-Based complementary and alternative medicine 2008;7(4):409–418 35. Noto y, Kudo M, Hirota K. Back massage therapy promotes psychological relaxation and an increase in salivary chromogranin A release. Journal of anesthesia 2010;24(6):955–958 36. Ogai R, yamane M, et al. Effects of petrissage massage on fatigue and exercise

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Dry neeDling Dry needling is a technique similar to acupuncture that is used for the treatment of trigger points and muscle pain. This article describes its effects, dangers and technique as well as providing details of how to treat common trigger points.

BY Dr Chris Norris PhD, MCsP

What is DrY NeeDliNg?

Figure 1: Filiform needle used for dry needling (left) and a hypodermic needle for injections (right).

(Photo credit: C. Norris, 2015)

trigger point location

referral zone with sensitive areas

Figure 2: Pain referral pattern from a supraspinatus trigger point. (sportEX, 2015) 24

Dry needling (DN) is becoming increasingly popular amongst manual therapists, with CPD (continued professional development) postgraduate courses offered by several educational providers (DNI 2014) (1).

Guidelines for its practice are issued by the major physiotherapy/physical therapy regulatory bodies in the UK (AACP 2014), USA (APTA 2013), and Australia (ASAP 2007) (2–4). The principles outlined in these documents are equally applicable to any healthcare practitioner who has DN within their scope of professional practice.

DN uses a thin filiform needle that penetrates the soft tissues.

Filiform needles are solid, flexible, and have a pointed tip in contrast to an injection needle which is inflexible and has a bore through the centre for the passage of a fluid drug. Injection needles have a cutting edge at their tip, whereas a filiform needle has a rounded tip (Fig. 1). Needles typically used for DN are acupuncture type, although some companies produce filiform needles aimed exclusively at the DN market. Needles are normally described in terms of length and width (gauge) of the needle shaft in millimetres, with common needle sizes ranging from 15 × 0.22mm for the head, face, hands and feet, and up to 60 × 0.32mm for the buttock. Needles used for DN are single use and disposable. Each comes pre-sterilised (by ethylene oxide gas) and protected in a plastic guide tube, which is used in the process of needle insertion. The needle and guide tube are wrapped in peel-open blister packs that are generally colour coded in some way.

The combination of needle tip shape, polishing, and insertion technique has

led to the term ‘painless insertion’ being applied to filiform needling, and although not strictly pain free, the sensation is usually that of a small local scratch on the skin surface followed by a diffuse dull ache.

The depth of needle penetration into the soft tissues has led to the differentiation into superficial (SDN) and deep (DDN) dry needling types of therapy, with SDN typically less than 1cm depth through the skin and into the subcutaneous tissue touching onto the muscle and DDN typically greater than 1cm into the muscle bulk. Needles are inserted either perpendicular to the skin or at an angle, and once in place the needle may be stimulated manually or using an electrical impulse generated by a purpose-designed electrical stimulator (electroacupuncture or EAP) unit.

DN typically has effects on pain, healing and in the release of myofascial trigger points. The precise effect of DN depends on the target tissue penetrated, and the method used.

DrY NeeDliNg effeCts One of the primary reasons for applying DN is to release trigger points.

To understand needling effects in this area we need to take a brief look at trigger points themselves.

trigger points A trigger point (TrP) or myofascial TrP, is a hypersensitive region within a muscle or myofascial region. They are characterised by pain which is familiar to the patient and present as nodules or tight bands within a muscle. Pain is typically referred into a distal area with lessening intensity the further from the TrP the pain travels (Fig. 2). The referral pattern may change with movement and throughout the day. The muscle containing the TrP sportEX dynamics 2015;44(April):24-30

eviDence informeD practice

taBle 1: trigger PoiNt ClassifiCatioN. (C. Norris, 2015) Character

Name

location

Anatomical position

n Central

n Within the thickest portion of the muscle.

Close to the motor point within a fusiform muscle. n Close to the musculotendinous (MT) to tenoperiosteal (TP) junction.

Clinical importance

n Primary

n Secondary (satellite)

n Reproduces most intense patient familiar pain, close to body centre at most proximal region of pain distribution. n Reproduces patient familiar pain, distal to primary TrP.

n Active n Latent

n Painful at rest (spontaneously painful). n Painful when stimulated.

Effect on pain production

is typically tight and overactive, but may be lax on occasions where the muscle is failing to stabilise a joint, for example. Altered postural alignment is often a sequela of TrP formation, and should be included in the patient assessment. When stimulated through direct manual therapy or DN, the TrP may respond with a sudden, brief local muscle contraction called a local twitch response (LTR), said to be a defining characteristic of TrP identification (5).

The discomfort of the LTR may cause the patient to wince or withdraw their limb, demonstrating a jump sign. TrPs may be classified by their position (Table 1).

Central TrPs are located within the thickest portion of the muscle, often close to the motor point. In a fusiform muscle, such as the biceps for example, this will be within the welldefined belly central to the muscle, but in a flat sheet-like muscle such as the supraspinatus, it is likely to be over the thickest portion of the muscle close to the scapular spine rather than within the centre of the suprascapular fossa.

Knowledge of the underlying muscle structure is therefore an essential aid to palpation when assessing TrP location in a patient. An attachment TrP is found within the fascial layers of the muscle at its tendon (musculotendinous) or bone (periosteal) regions.

A primary TrP can be considered as the most important from the symptomatic perspective. It is the dominant point and will normally produce an area of dermatomal referral. www.sportEX.net

Where this referral area extends across another muscle, a secondary TrP may be formed to create a symptomatic chain. For example, a TrP from the piriformis muscle (primary) may extend from the buttock to the posterior thigh, exciting a hamstring TP (secondary) which refers below the knee. In extreme circumstances this in turn may excite a gastrocnemius TrP (tertiary) referring to the ankle.

Releasing the primary TrP using DN will often desensitise the remaining points within the symptomatic chain.

Many TrPs produce pain at rest and the patient will have often been able to identify these themselves. These are active TrPs, a typical example of which is the TrP within the middle trapezius which occurs as a painful, burning knot when sitting at a computer for a prolonged time. A TrP may also exist, but not produce local symptoms. This type is termed latent, an example being the supraspinatus TrP above. This may not be painful locally at rest but may give pain referred to the front of the shoulder, which is familiar to the patient when it is stimulated.

TrPs may be identified in the clinic by their effects on patient symptoms, and the tissue feel to palpation. In the laboratory, however, a TrP can

ONE OF ThE PRIMARy REASONS FOR APPLyING DRy NEEDLING IS TO RELEASE TRIGGER POINTS demonstrate spontaneous electrical activity (SEA) or endplate noise, which changes as a result of DN. Typically a TrP demonstrates 10–100 times greater electrical frequency than a normal motor endplate. The taut band in which the TrP lies shows a low amplitude of background activity (10–50μV) which increases to a high amplitude spike (500μV) upon discharge (5), as a result of acetylcholine imbalance at the neuromuscular junction. DN has been shown to discharge the SEA, often giving rise to a LTR where the area of the TrP is seen to contract while the rest of the muscle bulk remains inactive. Using a rabbit model, Chen et al. (6) showed reduction in SEA of active TrP from 0.93μV down to 0.56μV (mean average integrated value from 15 different points) inserting needles deep into muscle, while Fu et

KeY PoiNt 1 a muscle motor point (motor entry point) is the region within a muscle where the motor branch of the nerve enters. it is traditionally used for the placement of an electrode to stimulate muscle contraction when applying neuromuscular electrical stimulation (NMes).

25

al. (7) showed similar discharge of SEA (5.79μV down to 4.73μV) inserting the needle superficially through the skin to simply touch the muscle layer.

Additional DN effects are seen on local tissue healing, and on general pain reduction; the latter response being similar to that of classical acupuncture.

local tissue effects Needling into local soft tissue elicits a classic triple response (redness, heat, swelling and pain) demonstrating the beginning of an inflammatory reaction. The response is due to the release of pro-inflammatory mediators including prostaglandin [see Norris 2011, chapter 1 (8)] for details of tissue healing responses). Additionally, calcitonin gene-related peptide (CGRP) is released as a response to needling giving trophic (healing) effects, and nitric oxide (NO) begins to reverse ischaemic effects which occur commonly with musculoskeletal conditions. Ischaemia changes are the result of the ability of NO to relax smooth muscle cells, causing local vasodilatation of the capillary bed (9). In studies of DN, blood flow was assessed using near-infrared reflectance spectroscopy and showed increased blood flow and oxygen saturation which remained for 30 minutes following needle removal. DN treatment of a burn skin lesion in mice has been shown to decrease wound size and induce epidermal regeneration with significantly increased levels of fibroblast growth factor and leukocyte infiltration (10).

A TRIGGER POINT (TRP) OR MyOFASCIAL TRP, IS A hyPERSENSITIVE REGION WIThIN A MUSCLE OR MyOFASCIAL REGION KeY PoiNt 2 Purinergic signalling is a form of extracellular (outside the cell) communication between cells through the release of chemicals (called purine nucleotides) from the cell membrane. the chemicals are taken up by receptors (purinergic receptors) in adjacent cells.

26

KeY PoiNt 3 opioids are morphine-like chemicals such as ß-endorphin, enkephalin, and dynorphin, which act on the nervous system to relieve pain through decreased pain perception, decreased pain reaction and increased pain tolerance.

The physical act of needling also affects the soft tissue mechanically. As the needle is inserted through the skin it passes into the loose subcutaneous fascia. Stimulating the needle by twisting or thrusting (as is common practice) winds and adheres the fascial fibres to the needle shaft to create a whorl (11). Once the fascial fibres are attached to the needle, further movement pulls the fibre along the tissue plane from the periphery towards the needle. The loose connective tissue glides independently of the skin creating a localised tissue stretching effect (12). Maintaining the fascial stretch by leaving the needles in place causes viscoelastic relaxation and change in the shape of the fibroblast cells. This process in turn gives rise to remodelling of the cellular cytoskeleton, and extracellular ATP signalling, also called purinergic signalling (13).

effects on pain The effects of DN on pain have been well researched with reference to acupuncture. Pain relief essentially occurs at four levels: local, spinal, brain stem and higher centre (Fig. 3). At a local level, the release of opioid chemicals (neuromodulators) has an effect on pain mechanisms.

This effect builds to a peak within 20 minutes of needle retention and then subsides after the needles have been removed, and is reversed by the opioid antagonist naloxone.

At a spinal level, the sensory nerve synapses in the dorsal horn of the spinal cord, and at that point desensitisation occurs, reducing the pain experience. Through interneuron effects at the dorsal horn, the sympathetic nervous system is also stimulated, opening the possibility for effects on internal organs, and changes in skin responses such as sweating.

The pain pathway from the dorsal horn ascends in the spinal cord via the spinothalamic tract to the brain stem.

Brain

Pain stimulus

spinal cord

Figure 3: The pain pathway. [Figure credit: David Gardner. Reproduced with permission from Norris CM. The Complete Guide to Sports Injuries. A&C Black 2011 (14)]

In the brain stem, pain suppression occurs not just to the injured body part, but to the whole body. This type of ‘top down’ pain inhibition occurs via several brainstem structures including the periaqueductal gray matter (PAG) and the rostral ventromedial medulla (RVM).

The effect is not especially powerful, but from this region neurons ascend to higher centres in the brain to affect the pituitary gland and hypothalamus.

Through action on these two centres, and by affecting the limbic system deep within the brain, neurohormonal effects are created which target not the pain sensation per se, but the emotional experience of pain. This later effect is particularly important where long-lasting or chronic pain is part of the clinical picture.

DaNgers aND CoNtraiNDiCatioNs Manual therapists have a variety of techniques that can TrPs. Importantly, however, these techniques do not penetrate the skin and so are said to be non-invasive. The big difference with DN is that it is an invasive technique, sportEX dynamics 2015;44(April):24-30

EvidEncE informEd practicE

taBle 2: risKs assoCiateD With DrY NeeDliNg. [C. Norris, 2015; sourced McEvoy 2013 (18)] Common

less common

rare

Very rare

Approximate rate 1 in 100

Approximate rate 1 in 1000

Approximate rate 1 in 10,000

Approximate rate less than 1 in 10,000

n Bleeding at insertion point n Bruising around site n Needle site pain

n n n n n n

Inflammation and swelling Strong post treatment pain Nerve irritation or injury headache Fatigue Dizzyness and nausea

puncturing the skin and entering the body tissues. This change from non-invasive to invasive techniques brings with it some important potential dangers that the therapist must consider to make the technique safe.

Several studies have been conducted into the safety of needling (acupuncture and DN), and a number of negative events described. White et al.

(15) investigated adverse effects from 32,000 acupuncture consultations, stating that minor negative events including bleeding and bruising occurred in 7% of treatments. MacPherson et al. (16) reviewed 34,000 treatments finding similar incident rates of 1.3 events per 1000 treatments (43 total events). Ernst et al. (17) examined 3535 acupuncture treatments and recorded minor adverse effects in 11.4% which included bruising, bleeding, dizziness, mild nausea, and pain. McEvoy (18) provides a synopsis of risks associated with needling (Table 2).

DrY NeeDliNg teChNique Risks associated with DN can be minimised by good technique. Firstly, before needle insertion a clean field should be established ensuring that the immediate treatment area is clean and any potentially infectious material such as dirty towels/clothing within a sporting environment is removed.

The patient is treated in a recumbent position (prone/supine/side lying/long sitting) supported by pillows or folded towels to discourage movement.

The risk of infection due to resident bacteria on the skin surface is low unless the patient’s immune system in compromised, so disinfection of clean skin in not generally a requirement (19). Infection with micro-organisms not www.sportEX.net

n n n n n n n

Local skin infection Redness Itching Blood pressure change Vomiting Breathing difficulty Loss of consciousness

normally resident on the skin (known as transient microflora) can pose a greater risk. The skin region to be needled should be clean and exposed, with the use of direct skin swabbing the choice of the practitioner. Gloves (single-use and disposable) may be used, especially on the palpating hand, and a hand-sanitising gel must be applied to all surfaces of the hands and fingers. A five-second application of hand-sanitising gel has been shown to reduce the microbial population by over 90% (20). Single-use disposable needles are used, which are protected by a plastic guide tube. The insertion technique is to hold the guide tube and tap the needle into the skin. Once the guide tube is removed, the portion of the needle shaft (sterile) that will enter the patient’s tissues is never touched by the therapist, to minimise the risk of infection. Where the needle is manipulated the needle handle, rather than shaft, is gripped. As the needle is withdrawn, pressure is applied over the needle area using a sterile cotton wall ball or Q-tip until bleeding has stopped (haemostasis is established). The used needle is disposed of in a sharps bin and removed, and any cotton wool used in placed in a clinical waste container. All needle sites are inspected and the patient’s general condition is assessed before they are allowed to move from the treatment couch.

Anatomical considerations are vital, as the risk of penetrating a neurovascular structure or the pleura is very real. Pneumothorax has resulted from DN to the intercostal region and also when treating scapular TrP (21).

It is important to remember that the lung depth is 15–20mm below the chest surface, and this distance may be

n n n n

Pneumothorax Broken needling Systemic infection Affected speech

reduced by tissue compression caused

by TrP examination. At post-mortem a 10mm needle can reach the lung.

As filiform needles are flexible and non-traumatic (no cutting edge) slow/ low force entry is less likely to damage neurovascular structures. As an example, Kessler and Streitberger (22) demonstrated perforation of the median nerve using an ultrasound-guided acupuncture needle without resultant

KeY PoiNt 4 Pneumothorax is air entry into the pleural space between the chest wall and lung. it results in lung collapse, giving symptoms of chest pain, breathing difficulty and alteration of lung sounds dependent on the size of the injury. investigations include X-ray and blood gas analysis. treatment may be by observation (mild), or insertion of the chest drain (more severe).

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Figure 4: Dry needling of the hamstrings.

(Photo credit: C. Norris, 2015)

Figure 5: Dry needling of the upper trapezius using a pinch grip. (Photo credit: C. Norris, 2015)

Figure 6: Dry needling of the supraspinatus using the step block technique (Photo credit: C. Norris, 2015)

nerve damage, neurological impairment or radiating pain. Knowledge of the underlying neurovascular anatomy is, however, vital for the practice of DN to reduce the potential for injury. During palpation for TrPs close to an artery, a pulse should palpated and one finger kept over the pulse point to avoid needling the artery. Consideration of needle depth, angle of insertion, and insertion method reduces the risk of injury.

Use of a pinch grip (as demonstrated in Fig. 5) reduces the risk of injury to underlying structures.

The muscle is held between the fingers and thumb and drawn away from the body. The needle is inserted halfway into the muscle aiming its tip towards the therapist’s fingertip. Drawing the muscle away from the body places it at a distance to underlying structures, such as the pleura, and aiming at the fingertip provides a tactile cue to reduce the likelihood of the needle tip deviating away from its intended path. A step block (as demonstrated in Fig. 6) depresses the tissue at one point while maintaining a defined anatomical location at another. This is useful where deviation of the needle tip may endanger an underlying structure.

Palpation accuracy is improved by maintaining contact with a bony landmark (less moveable) as the soft tissues (more moveable) are assessed.

Following DN treatment, the targeted muscle should be lengthened using static or PNF (proprioceptive neuromuscular facilitation) techniques to prevent the TrP reforming. Correction of movement dysfunction should follow.

Details of stretching exercises may be found in the author’s book, The complete guide to stretching (23).

Dry needling examples

Figure 7: Dry needling of the tibialis anterior.

(Photo credit: C. Norris, 2015)

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Hamstring belly A hamstring TrP refers into the back of the thigh and knee, and pain may travel as far as the calf, causing a secondary TrP within the gastrocnemius muscle.

The pain may mimic that of sciatica or present alongside this condition.

Deep insertion of a needle into the hamstrings can endanger the sciatic nerve and in the case of the medial hamstrings the long saphenous vein, and for the lower hamstrings the

femoral artery leading into the popliteal artery. To avoid the neurovascular bundle a pinch grip action is applied with the subject lying on their back in the FABER (Flexion, ABduction, External Rotation) position for the medial hamstrings or side lying with the knee flexed for the lateral hamstrings. In each case the leg is supported by a bolster or pillow to prevent movement during treatment. The muscle TrP is identified using palpation, and the muscle confirmed using manual muscle testing, in the case of the hamstrings resisted knee flexion. The pinch grip is applied using the whole hand rather than the fingertips (Fig. 4), and the needle is inserted halfway into the muscle fold in a frontal plane direction (across the body surface) rather than a sagittal place inwards towards the body centre. A 40mm needle is used of 0.32–0.35 gauge. Following needling the hamstrings are stretched using a straight leg raise action with the knee either fully (distal muscle emphasis) or partially (proximal muscle emphasis) locked.

Upper trapezius A trapezius TrP often refers pain between the shoulder blades, with the upper portion referring into the neck and to the point of the shoulder. When needling the trapezius it must be borne in mind that the pleura extend above the lung apex to sit above the first rib. Deep needling of the upper trapezius with the needle angled in the frontal plane, towards the body centre, runs the risk of pneumothorax in lean or elderly subjects. Position the patient in prone lying, and elevate (shrug) the shoulder slightly to relax the muscle fibres. Identify the TrP and apply a pinch grip using the hand hold to draw the muscle bulk upwards and away from the body (Fig. 5). Needle halfway into the muscle fold aiming, the needle tip towards your finger tips, in a posteroanterior (PA) direction. An anteroposterior (AP) needle direction may also be used with the subject lying on their back, if this is more comfortable for the patient and/or therapist. As an alternative, a side lying position may be used with the upper arm placed on a pillow in front of the subject (flexion abduction). The sportEX dynamics 2015;44(April):24-30

eviDence informeD practice

subject’s head is placed on a high pillow to side flex the neck and relax the upper trapezius. Again a pinch grip is applied and the needle inserted half way into the muscle fold in an AP or PA direction towards the finger tips. A 30mm needle is used of 0.30–0.32 gauge. The upper trapezius may be stretched following needling by laterally flexing the neck away from the muscle and holding it in this position, and then passively depressing the scapula.

Supraspinatus Supraspinatus TrPs refer pain into back of the shoulder and arm. The muscle sits above the scapular spine with the upper scapular body (suprascapular fossa) seemingly protecting the lungs and pleura from needle injury. however, the presence of a non-ossified scapula (scapular foramen) makes deep needling directly towards the scapula a risk. In addition a needle direction towards the top of scapula (PA) also risks damage to the suprascapular nerve and artery running through the suprascapular notch. With the subject in side lying on the unaffected side, the muscle location is confirmed using manual muscle testing (resisted lateral rotation). A medially directed oblique insertion is used close to the frontal plane. The needle is advanced through the upper trapezius fibres and into the supraspinatus, angling towards the scapular spine for safely.

To aid palpation accuracy a step block is used, where one finger is placed flat over the edge of the scapular spine and the other depresses the supraspinatus (Fig. 6). The needle is introduced between the two fingers directed towards the scapular spine. A 30–40mm (0.32–0.35 gauge) needle is used depending on body size. The supraspinatus is placed on stretch using passive medial rotation of the shoulder joint with varying degrees of abduction.

Erector spinae Erector spinae TrPs may give local spot pain within the low back, and refer distally into the sacral and buttock regions, and on into the leg. TrPs in the erector spinae are either located within the longissimus fibres 2–3 finger widths from the spine, or the more laterally www.sportEX.net

ThE EFFECTS OF DRy NEEDLING ON PAIN hAVE BEEN WELL RESEARChED WITh REFERENCE TO ACUPUNCTURE placed iliocostalis 4–5 finger widths from the spine. The longissimus is a thicker muscle running the length of the spine centrally, whereas the iliocostalis attaches to the ribs and therefore has a more lateral location. The longissimus is needled using a 30–40mm needle angled at 45° towards the spine while the iliocostalis is needled using a 25–30mm needle angled at 30° to the skin surface, again towards the spine.

The subject may be positioned in prone with a pillow beneath their abdomen to flatten their lumbar lordosis, or in side lying with the affected side uppermost. Where the iliocostalis is needled over the ribcage, the muscle taut band is gripped between the sides of the fingers using a scissor action.

The fingers stay within the rib spaces, and the needle is inserted in the gap between the fingers ensuring that it always remains over a rib. The insertion over the ribcage is shallow and oblique to avoid advancing the needle between the ribs and endangering the pleura.

The erector spinae are lengthened using spine flexion. For the upper portion of the muscle, lumbar flexion should be initiated by thoracic flexion first (movement from L1 downwards), while for the lower portion lumbar flexion is initiated by posterior pelvic tilt (movement from L5 upwards).

Achilles tendon The Achilles may be treated using a local herringbone technique to stimulate local blood flow (see above).

The patient is in prone lying with their foot over the couch end, shin resting on a folded towel. A series are needles is inserted to a depth of 2–5mm in lines posteriorly, posterolaterally and posteromedially, with 3–5 needles in each line depending on the subjects height and body build. Small 15mm × 0.20 needles may be used, and stimulated using a limited range thrusting or twirling technique. As pain

subsides, progressive Achilles loading may be begun. Modifications in the gait pattern, which coincide with Achilles tendinopathy, may often give rise to gastrocnemius and/or soleus TrPs which require separate management.

Tibialis anterior The tibialis anterior is a common site of TrPs with anterior compartment syndrome. TrPs are located within the upper one third of the muscle approximately 1–1.5 hand widths below the lateral knee joint line. Referral is along the anterolateral aspect of the shin towards the lateral foot. The subject is positioned in crook lying with a pillow or rolled towel beneath their knee for comfort. The TrP is located and muscle identified using manual muscle testing to resisted ankle dorsiflexion. A 30mm needle is inserted perpendicular to the skin and slightly medially to avoid the anterior tibial artery and vein and the deep peroneal nerve which is positioned laterally (Fig. 7). Subsequent to DN, the tibialis anterior muscle is lengthened using passive ankle plantarflexion, typically kneeling and sitting back towards the feet.

References 1. Dry Needling Institute. www.thedryneedlinginstitute.net 2. Acupuncture Association of Chartered Physiotherapists (AACP) Guidelines for Safe Practice 2012. http://www.aacp.org.uk/ 3. American Physical Therapy Association (APTA). Description of dry needling in clinical practice: An educational resource paper 2013. http://www.apta.org/ 4. Australian Society of Acupuncture Physiotherapists (ASAP). Guidelines for safe acupuncture and dry needling practice 2007. http://www.acupuncturephysio.org/ 29

5. Simons DG, Travell JG, Simons LS. Travell and Simon’s myofascial pain and dysfunction: upper half of body volume 1: the trigger point manual, 2nd edn. lippincott Williams & Wilkins 1998.

1998 ISBN 978-0683083637 (£73.00). Buy from amazon http://spxj.nl/1F0UIap 6. Chen J, Chung K, et al. Inhibitory effect of dry needling on the spontaneous electrical activity recorded from myofascial trigger spots of rabbit skeletal muscle. american Journal of physical medicine and rehabilitation 2001;80(10):729–735 7. Fu Z, hsieh yL, et al. Remote subcutaneous needling to suppress the irritability of myofascial trigger spots: an experimental study in rabbits. evidenceBased complementary and alternative medicine 2012;doi:10.1155/2012/353916 8. Norris CM. Managing sports injuries: a guide for students and clinicians.

4th edn. churchill livingstone 2011. ISBN 978-0702034732 2011 (Print £53.09 KIndle £50.44).

Buy from amazon http://spxj.nl/1F0V1lu 9. Kubo K, yajima h, et al. Effects of acupuncture and heating on blood volume and oxygen saturation of human Achilles tendon in vivo. european Journal of applied physiology 2010;109:545–550 10. Lee JA, Jeong h, et al. Acupuncture accelerates would healing in burn injured mice. Burns 2011;37(1):117–125 11. Langevin h. Connective tissue: a body-wide signaling network? medical Hypotheses 2006;66:1074–1077 12. Langevin hM, Konofagou EE, et al.

Tissue displacements during acupuncture using ultrasound elastography techniques.

Ultrasound in medicine & Biology 2004;30:1173–1183 13. Langevin hM. Effects of acupuncture needling on connective tissue (Chapter 3, Part 1). In: Dommerholt J, Fernandez de las Penas C (eds) Trigger point dry needling: an evidence and clinical-based approach. churchill livingstone 2013.

ISBN 978-0702046018 (Print £52.19 Kindle£49.58). Buy from amazon http://spxj.nl/1B1wyf4

14. Norris 2011. The complete guide to sports injuries. a & c Black 2011. ISBN 9781408130773 (Print £19.99 KIndle £17.99). Buy from amazon http://spxj.nl/1FNGSIE 15. White A, hayhoe S, et al. Survey of adverse events following acupuncture (SAFA): a prospective study of 32,000 consultations. acupuncture in medicine 2001;19:84–92 16. MacPherson h, Thomas K, et al. The york acupuncture safety study: prospective survey of 34 000 treatments by traditional acupuncturists. BmJ 2001;323:486 17. Ernst G, Strzyz h, hagmeister h.

Incidence of adverse effects during acupuncture therapy – a multicentre survey. complementary therapies in medicine 2003;11(2):93–97 18. McEvoy J. Trigger point dry needling: safety guidelines, Chapter 4. In: Dommerholt J, Fernandez de las Penas C (eds) Trigger point dry needling: an evidence and clinical-based approach. churchill livingstone 2013. ISBN 9780702046018 (Print £52.19 Kindle £49.58).

Buy from amazon http://spxj.nl/1B1wyf4 19. hoffman P. Skin disinfection and acupuncture. acupuncture in medicine 2001;19(2):112–116 20. Kovisto VA, Felig P. Is skin preparation necessary before insulin injection? lancet 1978;1(8073):1072–1075 21. Peuker E. Case report of tension pneumothorax related to acupuncture. acupuncture in medicine 2004;22:40–43 22. Kessler J, Streitberger K. Perforation of the median nerve with an acupuncture needle guided by ultrasound. acupuncture in medicine 2008;26(4):231–233 23. Norris CM. The complete guide to stretching, 4th edn. a & c Black 2015. ISBN 9781472906656 (£20.00).

Buy from amazon http://spxj.nl/1M3Dn4M

further resourCes 1. Norris, CM. Managing sports injuries. elsevier 2011. ISBN injuries 978-0702034732. (Print £53.09 Kindle £50.44). Buy from a amazon mazon http://spxj.nl/1F0V1lu 2. The Dry Needling Institute website (www. thedryneedlinginstitute.net).

3. Dr Norris’s course on Dry Needling (http://spxj.nl/1wDIvZX).

T AUTHoR THE DR CHRiS NoRRiS PHD, MCSP D Dr Norris is a physiotherapist with over 35 years’ experience. He has an MSc in Exercise Science and a PhD in Backpain Rehabilitation, together with clinical qualifications in manual therapy, orthopaedic medicine, acupuncture, and medical education. He is the author of 12 books on physiotherapy, exercise, and acupuncture and lectures widely in the UK and abroad. He is a visiting lecturer and external examiner to several universities at postgraduate level. He runs private clinics in Cheshire and Manchester and his postgraduate courses for therapists are on his website www. norrisassociates.co.uk.

KeY PoiNts n Dry needling (DN) uses a solid, flexible filiform needle. n Different depth of needle penetration has led to two types of DN – superficial (<1cm) and deep (>1cm). n Needles are inserted either perpendicular to the skin or at an angle. n once in place, the needles may be stimulated manually or electrically. n trigger points (trPs) are characterised by pain felt by the patient and present as nodules or tight bands within a muscle. n Needling into local soft tissue elicits a classic triple response (redness, heat, swelling and pain) demonstrating the beginning of an inflammatory reaction. n the physical act of needling also affects the soft tissue mechanically. n Pain relief essentially occurs at four levels: local, spinal, brain stem and higher centre. n DN is an invasive technique, puncturing the skin and entering the body tissues. this involves some important potential dangers that the therapist must consider to make the technique safe. n anatomical considerations are vital, as the risk of penetrating a neurovascular structure or the pleura is very real. use of a pinch grip reduces the risk of injury to underlying structures.

DISCUSSIONS

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n how do the needles used for dry needling differ from other types of needle and how are their sizes described? n List the different types of trigger points and how they affect the type of pain felt by the patient. n What are the risks associated with dry needling? n What is good dry needling technique and how can it minimise the risks?

sportEX dynamics 2015;44(April):24-30

opinions

BY Paul Medlicott MBa, MSMa

introduction Reading Brad Hiskins’ article in the previous issue of sportEX dynamics left me with mixed emotions. So much of what he said resonated, loudly, with me and many of my colleagues. My first thought was, “How could you snatch defeat from the jaws of victory?”

Insurance companies paying (in part) a patient’s costs for massage therapy?

We in the UK would give our collective right arms to be in a similar situation – and yet the professional associations (PA) and training providers somehow conspired in their own downfall.

Once the slightly unworthy feeling of Schadenfreude had passed my next question was, ”Are we doing any better in the UK?” Well, yes … and no. The Australian massage industry was where we aspire to be, but appears to have shot itself in the foot. We need to look to their experience and ensure that we learn. Let’s start with the issue that acted as a catalyst for Brad’s article.

Private health inSurance and caSh PlanS We are in a very different situation to Australia. Private health insurers do not as a general rule cover massage. There are policies that have a complementary therapy ‘allowance’ for named therapies, which may include massage, and there are Cash Plans that may include massage. There is anecdotal evidence that some Insurance companies will pay for massage treatments if linked to physiotherapy treatment, and there are examples of entrepreneurial individuals negotiating the payment of client’s treatments directly with insurance companies. The overall picture is one of chaos.

The situation is further complicated by a lack of meaningful communication (we are trying) between the industry and the insurance companies. If you visit the websites of any major Cash Plan provider and look for a list of ‘approved providers’ you will see that it will include, amongst others, an eclectic mix of PAs, awarding organisations (AOs), regulators and training providers. There is no clear understanding by the insurance companies of the roles played by these 31

Professional standards In the previous issue (sportEX dynamics 2015;43:8–11), Brad Hiskins wrote about the situation concerning professional standards in the soft tissue industry in Australia. In a response to his article, Paul Medlicott voices his thoughts about the situation in the UK – how is it similar or different and what can we learn from Australia? individual organisations, or indeed what constitutes a minimum level of competence in massage education.

From a client’s perspective they will be playing a variation of ‘Russian Roulette’ unaware if their massage therapist has had a year of training or ‘qualified’ in a weekend. In Australia it was more straightforward ‘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 (whose members had achieved agreed minimum standards of educational competence)’. Not only was massage therapy paid for but therapists had a compelling reason to join a professional association!

It must also be recognised that the private health insurers are commercial organisations. They rely on regular premiums and infrequent claims to make a profit – regular massage treatments do not sit comfortably within this financial model. Cash Plans where the financial burden is more skewed towards the plan holder, and are designed to pay for frequent treatments may be where the best opportunities lie for our profession.

Soft tiSSue theraPiSt? SPortS MaSSage Practitioner?

One of the issues Brad referred to was ‘Title’. There is no protection of title in the UK for our profession, we are not regulated by statute and within reason therapists can call themselves whatever they want. So we have a range of titles including Sports Massage Practitioner, Sports Massage Therapist, Sports and Remedial Massage Therapist, Clinical Sports and Remedial Massage Therapist, Remedial Massage Therapist, Remedial Therapist, Massage Therapist – I’m sure you can come up with others. This situation has arisen for a number of reasons including ‘advice’ from other bodies on what we can call ourselves – the inclusion of the word

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‘therapy’ is in certain situations considered misleading, implying that we are acting beyond our brief. Confusingly the use of the word therapy does not appear to be contentious in other countries. There has also been a desire to remove the words ‘sports’ and ‘massage’ from titles. ‘Sports’ because it is clear that most of us do not deal exclusively with sports people and ‘massage’ because of the continuing association with the sex industry. The term ‘remedial’ is favoured by some and discouraged by others primarily because remedial implies, to some, a curative treatment, and in these days of advertising standards and professional sceptics we all have to be careful about what we claim unless backed by robust research evidence.

So where does that leave us?

My good friend and colleague at the Sports Massage Association (SMA) Paula Clayton mentioned some years ago that the term used in elite sport was ‘Soft Tissue Therapist’ and that perhaps we should consider giving this title greater exposure. This was to some extent a ‘light bulb’ moment … a title that was already in use, no mention of massage, no mention of sports, no mention of remedial. Still the dreaded use of the word Therapist, but hey you can’t have everything, and perhaps the concerns about the use of the term should be tested in the public domain. The title is also inclusive providing an umbrella terminology for all of us involved in hands on soft tissue work. So for the last 2 years my own professional association has been the SMA, ‘the association for soft tissue therapists’ and the General Council for Massage Therapies (GCMT) is ‘the Council for soft tissue therapies’. This is a ‘soft sell’, it is a term we can all get behind but does not demand that therapists have to change the title they prefer to use for commercial or personal reasons. Of course we hope that in time we will all use the same title, but without legislation the choice remains in the hands of the therapists.

rePreSentation The industry is over-represented.

When individuals graduate from their courses they are faced with a multitude of choices (if they decide 32

to join a PA at all). Some will simply join the association recommended, and sometimes run, by their training provider. For others cost will be an issue or they may feel that their needs are better suited by a multi-disciplinary association. Whatever the decision making process is we have been left with a multitude of small associations run on a largely voluntary basis. This is not a criticism of these associations or the individuals that run them, but the lack of financial and human resources available to them mean that their influence and credibility on the national stage is very limited. It is also clear that there is an element of competition between PAs that can prove unhelpful.

Competition is fine in some instances and can lead to lower subscription, insurance and supplier costs, but it can also lead to division.

It is clear that Australia has experienced similar problems with associations unwilling to cooperate with each other for the greater good – and let’s not mince words here it is some of the individuals who run these associations, both in Australia and in the UK, who are at the root of the problem. For many, the concepts of cooperation and collaboration are alien ones – where they may have invested many years in the development of an association they are unwilling to give up control without a fight. But what does this achieve? If you are not in this business for the development of your members and the broader profession then why are you here in the first place?

So what have we done to address this issue? For many years there has been an organisation called the General Council for Massage Therapies (GCMT), it has in recent years had a chequered history with all the schisms and confrontation far too familiar to many of us in the soft tissue industry, but now we have managed to pull together many of the associations along with the AOs and training providers. It provides a forum for the soft tissue industry to discuss the issues that affect us all. We currently focus on education issues with an objective of achieving standardised content at the core of every qualification. We work with the AOs and training providers

to achieve this. We also debate a variety of issues including codes of ethics, policies on informed consent, regulation, etc. but more importantly we are developing working relationships and an appreciation of what each of us can bring to the debate. With changes in education the role and influence of the GCMT will only increase, particularly with AOs and others looking to us for support on the development and approval of qualifications.

This is a good start, but is it enough? I don’t think so. I believe there is a need for radical thinking including the merger of small associations into a larger representative body. The combining of financial and human resources will provide members and the profession with infinitely better representation and credibility. Will it happen? I think it will – it won’t happen in a hurry, but I would expect to see the first mergers happening in the next couple of years

concluSion We are, slowly, moving in the right direction in the UK, but as we are currently structured ‘slowly’ will continue to be the operative word.

There needs to be, in my opinion, radical change in the way the industry is represented and this will require bold thinking rather than parochialism and self interest. We need committed, skilled individuals who can represent their members eloquently and effectively. We need financial and human resources to achieve this.

However, above all we must remember, this isn’t about us – it’s about the members.

THE AUTHOR Paul Medlicott MBA, MSMA Paul is chair of the Sports Massage Association (SMA), chair of the General Council for Massage Therapies and a profession specific board member for massage for the Complementary and Natural Healthcare Council (CNHC). Before becoming a soft tissue therapist in 2002 he worked for Barclays Bank, Santander, Flemings, Chase Manhattan and JP Morgan specialising in change management and strategic planning and has an MBA from Loughborough University. He has retired from ‘hands on’ work to focus on industry issues and is passionate about the ‘professionalisation’ of the soft tissue industry and the organisations that represent it.

sportEX dynamics 2015;44(April):31-32

Sportex update

tHe All

New

Singing & dancing

By Tor Davies, puBlisher anD sporTeX founDer over the last 6 months there’s been a huge amount of work going on behind the scenes at sporteX, stimulated by 4 main motivations: 1. A desire to vastly increase the flexibility and options for people wanting to engage with our content 2. A strong yearning to create a totally different type of business model, one built on a basis of cooperation and ethiconomics* and driven by a “virtuous circle”.

3. A quest to build a state of the art publishing platform that harnesses the last 5 years of web developments in delivering and building community through learning and professional development.

4. An aspiration to use our new platform to widen our content framework into areas outside just sport.

In order to achieve our goals, we’ve completely rethought and restructured just about every aspect of what we do from the financial modeling, planning and budgeting, to the way we commission and pay for content, and finally through to the way we deliver this content.

The sTarTing poinT At the heart of everything we do is the interaction between you and the

www.sportEX.net

content we produce. We want to create the very best content we can to help you do your job in the most effective way possible. In order to achieve this we’ve done several things: refined and expanded our content structure: In collaboration with some of our longest serving most committed subscribers, we’ve identified the ‘streams’ of content that you feel would add most value to your work (see Box 1 for details of the content streams) appointed hand-picked content commissioners: We’ve identified 1-2 commissioning editors per content stream who are responsible for commissioning articles under that topic area. These are people who have a strong track record for developing ‘translational’ content. ‘Translational’ content has always been our USP – the ‘read it now, use it in an hour’ approach.

We publish for practitioners, these are hands on people who want to know how to translate the research evidence into practical application.

Throughout we’ve focused on the “virtuous circle” approach: Authors will earn up to 25% of all sales of their content and commissioning editors will earn 1-2% of sales for every article they have commissioned for the entire time that the content is live and available through our platform. The clever bit is in the algorithm that calculates how these royalties are divided particularly when content is sold as part of a ‘subscription’ to a bigger product.

Here we use an algorithm that takes total sales and then divides it proportionally based on number of times that piece of content has been

1

2

3

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purchased as either a single item or as part of a group, combined with a range of engagement measures like social media influence, discussion activity and viewing statistics. The end goal is that great content is rewarded - the more an article is purchased, read, engaged in and shared, the more of the content royalty pot it will earn. implemented a self-refining, constantly improving content model: The platform allows (and actively encourages) authors to regularly update, enhance and improve their content so that not only does it always remain current but the author always has the power to make it better (and encourage more sales). If the content isn’t updated then after a period it expires and ceases to earn royalties.

It’s a simple philosophy both in functional as well as economic terms that is designed above all to be fair, transparent and one in which everyone wins.

so where Does The oTher 75% go? n 25% is for our affiliates who help to promote and sell our content through their own channels (if you’re interested in becoming an affiliate email me tor@sportex.net) n 25% is set aside for costs relating to publishing the content, mobile app publishing, supplementary content resources such as images and animations n 25% goes towards business administration including customer technical and billing support, salaries, ongoing platform hosting and support costs and marketing.

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Key feaT ures

of The n ew siTe

n co om mm muunnit ity y building Througho ut the site you’ll no and content engage tice a start on the ment through the community building discussion forums aspect are also many socia at the end of all pie l media sharing op ces of content. Th portunities through n flexible purcha ere out the articles. sing From a purch asing perspective as you want right yo u ca n no w buy as little or as down from a single much content article, a stream of to the journals. content, a ‘tag’ or a bundled subscripti n a simplified pa on yment system Ou r previous system based on paymen ha d 7 dif fer ent payment types t methods. It was over-complicated (if with discounts methods, don’t wo you’re currently pa rry, we’ll continue ying by one of the to su pp or se t it and you don’t ne going forward it’s no ed to change anyth t only much simple ing r bu ), bu t als t next-generation pa o much more flexib yment system know le thanks to the ex istence of a n as Stripe. (see Bo n archving Initially x 2 for more detai we will be working ls) . ba ck wa rd s content archives. Ou from recent to the older material, to ad r goal is that Jan 2012 up to April 20 d the will also be a fully 15 will be available searchable databas at launch. The archiv e going back to ou n multi-media fri e r launch in 1999! endly While we’ve launched initially wi main format of conte th art icle s (as historically this nt), the platform is has been our built to host all typ audio, presentation es of media secure s and any type of ly inc luding video, me dia yo u media offerings as want to throw at us we take on more and we’ll be expand content creators. ing the Our goal with this new platform has been simplicity, transparency, mutuality and ongoing self-refinement.

new TargeTeD aDverTising opporTuniTies At last we have a whole range of advertising opportunities available also.

You can advertise at any point on the site. This could be within a given content stream, under a given tag (keyword section) or even down to a specific article (particularly useful for authors of articles wanting to promote other activities such as books they’ve written or courses they’re running).

And as you’d hope, the process is simple and transparent. sTep 1: Navigate on the site to the position you want to place your advert sTep 2: Pick the advert type you want ie. Banner size – just under the existing banner will be an “Advertise here” link – go ahead and click it! sTep 3: Choose the start and end dates for your ad and the system will calculate the price and display this as well as some other options in the same area so you can adjust your booking to fit your budget sTep 4: Once you’re happy, place the booking and you will be asked to upload your artwork which once approved will go live at the time designated.

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in summary This is a very short overview of the foundations of a much more complicated project that I believe will form a new way of publishing and growing communities in professional sectors not only in our core area of physical and manual therapy but across a whole range of vocational groups. This is just the start. I hope you enjoy the new site! * Ethiconomics = a name given by author Philip Birch, for the principles and practice of ethical business

conTenT sTreams

n Musculoskeletal Diagnosis, Treatment and Rehabilitation Articles n Musculoskeletal Diagnosis, Treatment and Rehabilitation Case Studies n Current Trends in Sports Medicine n Research Reviews n Pain and Brain n Sports Performance n Journal Watch – Sports Medicine

n n n n n n n

Journal Watch - Manual Therapy Current Trends in Manual Therapy Movement - Assessment and Retraining Manual Therapy Case Studies (non-sport) Sports Massage Case Studies (sports-specific) Sports Massage Articles (sports-specific) Soft Tissue Practice Articles (non-sport)

We will also be adding two new dedicated streams of content on taping and business development commencing later in 2015.

suBscripTions anD paymenT wiTh sTripe n The first BIG benefit is that Stripe takes responsibility for adhering to the stringent PCI Compliance rules that in the past has made the wonderful but hugely expensive ability to store credit card details completely prohibitive for small companies. Only behemoth retailers like Amazon could afford the sort of security this requires, that is until Stripe came along to give us ‘little guys’ access to the same convenience and security. n This means once you’ve entered your details once, Stripe securely stores these, meeting all the required PCI standards, and when you login to make a new purchase, there’s no need to enter your details again. It simply looks at your existing plan with Stripe, updates it to take account of the new content and off you go. One click purchasing! This means you can add content streams to your subscription, or delete them at any time in the year and all the billing will adjust accordingly at that exact point in time. n It does however mean that your subscription expires the minute you lapse it – if money is owed against unused days this is credited to your card. Transparent and fair, as we like it.

sportEX dynamics 2015;44(April):33-34

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

InjuryRefresher_proofed AS.indd 1

®

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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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 in 150 (see is achie n(5th cles. t st be mo demonstr cune id joint ing Simo um es n From ction/flexion roer arti , hip join and wri patient Pictur Sacr functio g position can either wing rap hume joint

By Dr nt injured abdu d the Primal e w ral erview : l refresh ue 44) allo behin ts well.

Fifth ©2010 radia lloy ov monly ular ligame ple tarsofaltwo joints ral joint n of femo is T1-3. n from injury the elbo of the spin Pate allowin Propulsion the foot men t (iss ortio meta tom com m, rvatio ding Kay femo ists move ral prop -fib st n ies of ulder join 46) and ana cons the tibioabulu ilium Obse provi title joint ly sim femo of the as Simo the tibia 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 cles running vement d into 1. the ists iform to furth acet uction flexible of the uppe lifting and carrybility and head lised (behind The anker limb, the d ankle) severity the mortic as cov is the cons cune with the er arti ing. stabi femur e mo ps are involvbe divide , ank acting give muscle ioned 1-2). lla) , introDlder the mostof motion like throwing, nse of insta my which This we have GP further tissue, pate les tures in kick refresh Dr Simon m (figs. hip is more id r, cush muSclmuscle grout can roughly ue 45) we have articulate anato ted the low sic spraine but as the joint and ch can be le, musc expe ective n Kay, of the Cubo the femu cular struc The shoua wide range ments ent which ome tomy ilising acetabulu of the conn men Simo at the reviews the in entS neck r r, and series e joint (issAlthough Differ clas associa /stab ces on two avas r move comes r mino e bec difficult to s ana le and hip, wrist and en the ral position r projected the injury - sub-talar upted whi r the ank vem are involved

By Dr a more us with actor (the surfa is lder. Move briefly powe Navicula . and hav femu us kne ility deep by teres mo e viou into I , lity e radio contr shou joint femu e dsneut t ion 49) mob nto (IS), ps rating from Talus thejoint be disr articl 47) -a The – the e going various soft : gene uct to its stabi ly. of the stabilisedsici es,ulnar dorsi, conside our pre r, knee, ank ts of the regions pinatus tely this ntial. This nd tha gmatic but ctical, han s on laterally l joint (RC) (issue ligame muSclmuscle grou the spin e e areas . s imus infras les ie. facet lder befor s to the join mora the neck ly and outlin 1) other. , knee e fou introDmostly due at least acute ent tor cuff increas joint can ry. We will Unfortuna injury pote ing on pra ulde the men r, latiss triceps. Thes pra joints re about ical musc lla-fe ulate aped with . We erior video s Calcaneu Differ of the the shou of injurie 1. Rota spinatus (SS),(see Video le tring each cle. herapy , injury nosu Follow g the sho issue, at the h anatom inju tly post the pate ralis majo s and ch I hav ies in a it is a move mo to ow V-sh which artic patella ment The hip, injured joint, of femoro- injuries )) Pictures ank osis arti hams lder girdle mpanying and high ments of , 2. e siot to mbra is sligh tibio supra roa shall Primal n (SSc pecto lla n move ted y from shou bicep on, diagn m. it rap ory this of – of and phy r, acco ©2011 ) een laris app pate flexio fashi ral h. The rela g 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, riorthe 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 Man the knee femur in a slow rus into Primal spec id fossa rotator cuff jump of Note of the which artic on the tibia longitudinthe ulna Figur ankle Simo mius the shou ©2011 partic n of fixed. the which anatom Tibia nipu techniques sports, are ential. fibula les act the hume the head 2. Ilio-fe femoral ligam tighten with h lder or make up d at heel n) medialis gastrocne of the ulatio e rang d to joint running, to greater ma ces – the the gleno ts. The

By Dr ice) foot is musc whic stand shou ir ion legs of artic linke whol (teno aroun ing, level force of joints the surfa -ulna to ents mort ents RC ess pulled a is ns t his that men move The The of the the r rigid : 3. Pubo e ligam the r. radio n is each t. ligam e joint ruen ing us ) and 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 a the tendo is effected The tibiacrossing 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 Talus ligament (whic to prov propulsiv PM musc en as the different five secti knee is, I beli depe prime allow ted g spin introD g how vitallopment, i.e. ion, it is facet straig (see of musc joint fashi ndly ent (PCL 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 for this injury is moren. . Exce ionticula : flexio joint the shin ments of ction n the knee in spina defic-500themiss of the along femur (see showposit disar is desig positionin Move in one direc plane) (vide alar ation s. r ntothe ical joint bea 400 le the mentPerfeactio occurs that this in full exte ior and and limbs glide 1) Prote n of the S twist flexio the directions trans facet spine role, use that in mind t withi toultim ttal subt leg, ately cerv rs the cuff musc knee movegrip. anter the move and supin strain on ents allow rciSe of powe Theuse on the stops llent ibutio r limbs , and ements elbow jointon occu beca joint end of entS in six ‘basic’ n (coronal fermen and hand’s of the and anterior, with a or cervical skull and segm eXe t on kneeility of the ligaments the ion (sagi good a positioned s trunk tibia exce also distr ation move t is uppe the the mov the ently joint of , trans G put and ive vem sion true The at rotat limbs at ss effec w ote nG Look uctio the rs l pron not is, traum tesy rmos of the trunk of the can relatjoint nin lbow oses ro’t inher ie. tibial dorsi-flex dimension for inver elbo exce lesr from rni prom to r and lower arms. of the 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 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 femu y called It is the to the occu lex. From lop entS NG EXE joint, bone anatomic s tilted to back (palm sepa The move movemenrough grou stret y ove of: ments. occurs prima joints in fused s Try examcan and the pelvi : ation ) elbow from front al. are comp e, they deveeen ss The hip six joints consists ting the two they are tom ow allow move ple anatom movemt of the knee LEarNI joints ment vertic of the brae d vertical and has exce of terac hold . ectiv to take esthetic): which fully and pron ). The ana ttal plane. which betw elB joints ng men three move Rotation involve multi from the o to the verte girdle when one coun aroun up) riorly : foot of (kina joint) foot persp 4a+b is (sagi the fuse (FA) are hip d The Move n ante tions ut putti 30 faces twist gical s the tly, to of the tighten ch receptors ulate lation of the consists joint (a hinge rity of which vertebrae . The (Figure of from: ments direc tilted etabular 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 articu into acco faces of age.

2 x femo -iliac joints of GH with the degr ple durin hume the from n Flexi ll amount be prise e the 3-D 0 degr of the ratio r. lates 1. the 15 years 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

intr And – An ssment Asse

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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

and

dia

© 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.

+

31

et

tEX.n

.spor www

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

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