sportEX Dynamics Journal Issue 45 - July 2015 by Co-Kinetic

ISSUE 45 JULY 2015 ISSN 1744-9383

promoting

best practice in

HIGHLIGHTS

manual therapy

n BIOTENSEGRITY PART 3 n KINESIO TAPE STRETCH PROPERTIES n MASSAGE IN SPORT PART 2 n PHYSICAL THERAPY SERVICES AT LONDON 2012 - A REVIEW

CONTENTS JULY 2015 ISSUE 45

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

The world of soft tissue therapy has long espoused an ethos of continuity and connectiveness related to the human body. The concept of continuity is easier to agree with than describe, particularly at the clinical practice level. We can appreciate that a patient’s right shoulder pain could be due to an issue some distance away in the contralateral hip. Medicine has long influenced the education of soft tissue therapists. We align ourselves to be seen as complementary rather than alternative to medical practitioners. Hence we learn traditional anatomy based on parts, some connected locally some less connected. This is at odds with what we firmly hold true, which is that everything is connected. Recent and current articles in sportEX dynamics by myself, Antonio Stecco and the most recent in a series by Jo Avison, are providing us with a new and rich language allowing a more comprehensive understanding of how the body is connected. New models including Levin’s BioTensegrity provide research-based explanations of anatomy and living motion that are a reflection of our profession’s long held ethos that the body is one. Myers model based on myofascial trains is also an important piece of this jigsaw. Perhaps the time is nearing when our profession will influence medical training and the medical curriculum so that we may claim responsibility for changing out-dated terms such as “musculoskeletal”. Any thoughts?

COMMISSIONING EDITORS AND TECHNICAL ADVISORS Bob Bramah - MCSP, MSMA Dr Joseph Brence - DPT, COMT, DAC Susan Findlay - MSMA Stuart Hinds - BSc, SMT Brad Hiskins - BSc, RMT Whitney Lowe - LMT Anna Maria Mazzieri - ITEC MISRM CNHC Reg. Paul Medlicott - MBA, MSMA John Sharkey - MSc Joan Watt - MCSP, MSMA

John Sharkey, clinical anatomist and sportEX technical advisor

is published by Centor Publishing Ltd 88 Nelson Road Wimbledon, SW19 1HX Tel: +44 (0)845 652 1906 Fax: +44 (0)845 652 1907 https://co-kinetic.com OTHER TITLES IN THE SPORTEX RANGE

JUL 2015

ISSUE 63 JAN 2015 ISSN 1471-8138

prom

ng exceotille n in

sports ce

HIGHLIGH

sportEX medicine - ISSN medicin e 1471-8138. Written specifically for professionals working in the field of soft-tissue injury diagnosis, treatment and rehabilitation

n VITAMIN D LEVELS IN ATHLETES n YOUTH PSYCHOL OGY n TENNIS ELBOW n PFP REHABILI REHABILITATION TATION n CASE FOR ASSESSM NEUROIMA GING ENT OF CONCUSSIN THE ION?

FIND US o n Facebook www.facebook.com/sportex.net

on Twitter www.twitter.com/sportexjournals

THE ENVIRONMENT

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.

CONTENTS

therapy 4 Journal watch 23 Phyiscal at London 2012 8 Biotensegrity Part 3 Dry Needling 30 Taping 13 Social watch 34 18 Swedish massage in sport The latest soft tissue research

Levers or closed kinematic chains? K-tape stretch properties

Use of ‘Swedish’ techniques in treating injury

An analysis of the medical data Treatment of MTrPs and chronic pain Practical resources from the social networks

TO FIND OUT MORE ABOUT SPORTEX VISIT

co-kinetic.com

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

online

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

THE COMPARISON OF SCAPULAR UPWARD ROTATION AND SCAPULOHUMERAL RHYTHM BETWEEN DOMINANT AND NONDOMINANT SHOULDER IN MALE OVERHEAD ATHLETES AND NONATHLETES. Hosseinimehra SH, Anbarian M, Norasteh AA, Fardmal J, Khosravi MT. Manual Therapy 2015;doi:10.1016/j. math.2015.02.010 [Epub ahead of print]

Seventeen overhead athletes and 17 non-athletes had humeral abduction and scapular upward rotation in rest position, 45°, 90° and 135° humeral abduction in frontal plane measured. There was no significant asymmetry in scapular upward rotation and scapulohumeral rhythm in different abduction angles between the dominant and nondominant shoulder in non-athletes. In contrast, overhead athletes’ dominant shoulders have more downward rotation in scapular rest position and more upward rotation in 90° and 135° shoulder abduction than non-dominant shoulders. Also, overhead athletes presented scapulohumeral rhythm asymmetry between dominant and non-dominant shoulder in 90° and 135° humeral abduction as dominant shoulders have less scapulohumeral

EFFECTS OF THAI MASSAGE ON PHYSICAL FITNESS IN SOCCER PLAYERS. Hongsuwan C, Eungpinichpong W, Chatchawan U, Yamauchi J. Journal of Physical Therapy Science 2015;27(2):505–508 Thirty-four soccer players (aged 26.02 ± 3.89 years) were randomly assigned to receive either rest (the control group) or three 30min sessions of Thai massage over a period of 10 days. Seven physical fitness tests consisting of sit and reach, hand grip strength, 40 yards technical agility, 50m sprint, sit-ups and push-ups. The massage consisted of whole body Thai massage which lasted for 30min and mainly covered four body parts, the shoulder (5min), back (5min), arms (10min), and legs (10min). Treatments were applied once every 3 days within a period of 10 days. The massage was given by two certified traditional Thai massage therapists who had ≥2 years of experience and were tested for quality of Thai massage skills before the study. The control group rested for the same 30min period. All the physical fitness tests were significantly improved after a single session of Thai massage, whereas only the sit-and-reach, and the sit-ups tests were improved in the control group.

sportEX comment Physically, Thai massage is basically compressions. On the face of it this is yet another study proving massage is good for sports people but it should be treated with some caution. It describes improvements after just one session but that session was in fact three treatments over 10 days with a crossover design and a 3-week wash-out period between the alternate treatments. The results would have had more weight if they had measured after each treatment.

rhythm ratio than non-dominant shoulders. And, overhead athletes dominant shoulders have more scapular downward rotation in scapular rest position, more scapular upward rotation in 90° and 135° humeral abduction and less scapulohumeral rhythm ratio in 45°, 90° and 135° humeral abduction than non-athletes in dominant shoulders.

sportEX comment Previous studies have stated that the scapulohumeral rhythm dysfunction can make a person prone to glenohumeral joint pathologies. What this suggests is that some scapular asymmetry may be common in overhead athletes. It is not, therefore, necessarily a pathological sign but rather an adaptation to extensive use of the upper limb.

QUANTIFYING THE PLACEBO EFFECT IN PSYCHOLOGICAL OUTCOMES OF EXERCISE TRAINING: A META-ANALYSIS OF RANDOMIZED TRIALS. Lindheimer JB, O’Connor PJ, Dishman RK. Sports Medicine 2015;45(5):693–711 Google Scholar, MEDLINE, PsycINFO, and The Cochrane Library Databases were searched for articles published before 1 July 2013 that contained randomly assigned participants to exercise training, placebo, and control conditions and an assessment of a subjective (ie. anxiety, depression, energy, fatigue) or an objective (ie. cognitive) psychological outcome. Meta-analytic and multi-level modelling techniques were used to analyse effects from nine studies involving 661 participants. The conclusion reached was that a small body of research suggests both that the placebo effect is approximately half of the observed psychological benefits of exercise training and there is an urgent need for creative research specifically aimed at better understanding the role of the placebo effect in the mental health consequences of exercise training.

sportEX comment If you like statistical analysis and graphs this study is for you. If not, then just take it that the bottom line is that the placebo effect is much greater than was previously thought. sportEX dynamics 2015;45(July):4-7

JOURNAL WATCH

Journal Watch EFFECT OF MODIFIED HOLD-RELAX STRETCHING AND STATIC STRETCHING ON HAMSTRING MUSCLE FLEXIBILITY. Ahmed H, Iqbal A, Anwer S, Alghadir A. Journal of Physical Therapy Science 2015;27(2):535–538 Forty-five male subjects with hamstring tightness were randomly placed into three groups: a modified hold-relax stretching, static stretching and control groups. All three received stretching, moist heat via a hot pack (71°C) applied over the posterior aspect of the thigh for 20min for each session. Then the hold-relax group performed 7s of isometric contraction followed by 5s relaxation, repeated five times daily for five consecutive days. The static stretching group received 10min of static stretching with the help of a pulley and weight system also for five consecutive days. The control group received only moist heat. Passive knee extension (PKE) with the hip at 90° was measured before intervention, immediately post-intervention and on days 1, 3, 5, 12. At baseline there was no difference between the three groups. At day 5 there was no difference between the two stretching

groups but both were superior to control. Post hoc analysis revealed an insignificant difference between the modified hold-relax stretching and static stretching groups. There was a significant difference between the two stretching groups and the control groups. This was the same at day 12.

sportEX comment The take-home message is stretch no matter how and the effects last for some while after treatment. The holdrelax treatment is quicker but requires a partner. You can do the active stretch alone without the palaver of the equipment used here but unless you are fan of Yoga, holding a stretch for 10min takes a fair bit of mental effort. Try it and when you have done the hammies you still have the quads and calves to do.

EFFECTS OF CORE STRENGTH TRAINING USING STABLE VERSUS UNSTABLE SURFACES ON PHYSICAL FITNESS IN ADOLESCENTS: A RANDOMIZED CONTROLLED TRIAL. Granacher U, Schellbach J, Klein K, Prieske O, et al. BMC Sports Science, Medicine & Rehabilitation 2014;6:40 Fourteen healthy girls and 13 boys (mean age: 14 ± 1 years, age range: 13–15 years) were randomly assigned to a group performing core strength training on a stable surface (n = 13) or a group doing the same exercises on an unstable surface (n = 14) namely a TOGU© DYNAIR CUSSIONS, THERABAND© STABILITY TRAINER. The training period lasted 6 weeks (two sessions a week) to induce training-

www.sportEX.net

related changes in measures of strength, speed, flexibility, coordination and balance. Each training session lasted 30min, starting with a brief, standardised warm-up programme mainly consisting of low-intensity core strength exercises to prepare the neuromuscular system for the training loads and ending with a cool-down programme of dynamic stretching. Every session consisted of frontal, dorsal, and lateral core exercises mainly the curl-up, side bridge and quadruped position. Participants exercised in pairs so that one subject trained and the other one provided support by motivation, spotting. Training intensity was progressively and individually increased over the 6 weeks by modulating lever lengths, movement velocity, contraction times and repetitions.

Outcomes measures included the Bourban trunk muscle strength (TMS) test, standing long jump test, 20m sprint test, stand-and-reach test, jumping sideways test, Emery balance test and the Y balance test. The results were that significant main effects of time (pre vs. post) were observed in favour of the stable group in the TMS tests, the jumping sideways test, and the Y balance test. Trends towards significance were found for the standing long jump test and the stand-and-reach test. Significant time × group interactions were detected for the stand-andreach test in favour of the unstable group.

sportEX comment Core strength training improves physical fitness in adolescents. Of course it does. The gimmick of the unstable surface isn’t worth setting up the equipment.

online

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

INCREASED TREATMENT DURATIONS LEAD TO GREATER IMPROVEMENTS IN NONWEIGHT BEARING DORSIFLEXION RANGE OF MOTION FOR ASYMPTOMATIC INDIVIDUALS IMMEDIATELY FOLLOWING AN ANTEROPOSTERIOR GRADE IV MOBILISATION OF THE TALUS. Holland CJ, Campbell K, Hutt K. Manual Therapy 2015;20(4):598–602 [Epub ahead of print] Sixteen asymptomatic male football players (aged 27.1 ± 5.3 years) were given grade IV anteroposterior talocrural joint mobilisation of three different treatment durations to increase dorsiflexion range of movement (ROM) in non-weightbearing and weight-bearing positions. Measurements were taken at baseline as a control in which no treatment was given and after 30s, 1min, 2min of mobilisation being applied. For the nonweight-bearing a universal goniometer was used. For weight-bearing it was a lunge test using a knee to the wall test. A within-subjects design was employed so that all participants received each of the treatment conditions 1 week apart. Only one measurement was taken to reduced cumulative effects.

There was a significant improvement in ROM following all AP mobilisation treatments. For the non-weight-bearing condition increases in treatment duration were associated with statistically significant improvements. However, in the weightbearing condition improvements were below the minimal detectable change scores needed to conclude that improvements were not a consequence of measurement error.

sportEX comment You will have noticed that an increasing number of the articles we report are cited as being published before the final version that appears in a particular dated journal edition. When you obtain these most come with a

disclaimer saying something along the lines of this is how it looks so far but by the time it is tidied up and peer reviewed errors may be discovered which could affect the content. Fair enough so why not wait until final publication before issuing stuff? We bring it to you now because it’s out there now and it may be months and months before the final version is published, but don’t blame us if the final version is different. Anyway back to this study. Do more mobs and you get a greater ROM.

MASSAGE INDUCES AN IMMEDIATE, ALBEIT SHORT-TERM, REDUCTION IN MUSCLE STIFFNESS. Eriksson Crommert M, Lacourpaille L, Heale LJ, Tucker K, Hug, F. Scandinavian Journal of Medicine & Science in Sports 2014;doi:10.1111/sms.12341 A 7min massage protocol was performed unilaterally on the medial gastrocnemius of 18 healthy volunteers. (6F, 12M; aged 28.0 ± 6.4 years). Their contralateral leg was used as a control. The massage protocol was 2min of effleurage, 2min of petrissage, 2min of deep circular friction, and 1min of effleurage. 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, directly after (follow-up 1), and following 3min of rest (follow-up 2). Participants were also asked to rate pain experienced during the massage. The results were that muscle shear 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 which indicates that muscle stiffness returned to baseline values. Shear elastic modulus was not different between time points in the 6

control leg. There was no association between perceived pain during the massage and stiffness reduction.

sportEX comment

bridges between actin and myosin filaments that occur spontaneously when muscles are at rest, increased intramuscular temperature or a combination of all of them.

Supersonic shear imaging is an ultrasound-based technique for real-time visualisation of soft tissue viscoelastic properties. It’s been around for over 10 years and was originally used to identify breast cancer. Credit to this paper because it is yet another that shows that something is going on when mechanical force is applied to tissue. On the downside there is no attempt to calculate dose/outcome relationships and this may have an effect on how long the treatment effects last. There is speculation as to why the effects occurred and, therefore, the ultimate effect that massage has. These include, a decrease in motor neuron excitability as the result of a greater general sense of relaxation, a local reflex inhibition within the massaged limb, breaking down stable crosssportEX dynamics 2015;45(July):4-7

JOURNAL WATCH

WHICH HAS THE GREATER EFFECT ON HAMSTRING FLEXIBILITY – COMPRESSIONS OR STRETCHING? Sloman E, Annetts S. Poster presented at the Chartered Society of Physiotherapy Annual Congress 2014, Birmingham, UK A convenience sample (N = 16) from an adult student population took part in a same subject crossover design, counterbalanced with a washout period of 24h. The outcome measure was a sit and reach test. The two interventions were a static stretching condition in which the participant was taught a ‘hurdlers stretch’ and compression massage applied to the hamstrings musculotendinous junction. For each condition the pre-test mean was subtracted from the post-test mean. Mean difference between pre and post-test conditions for static stretching was 1.28cm (SD ± 1.21), and for compression massage was 2.19cm (SD ± 1.66).

sportEX comment Reporting on a poster presentation is a new one for us mainly because we don’t get out much so we don’t get to see them. If you do come across one you think we should share take a pic and send it in. This one shows that a brief session of compression massage can improve range of motion without some of the nasty side effects like lack of subsequent power that can be a result of stretching or deep tissue massage. It supports earlier work – see ‘Effect of acute static stretching on force, balance, reaction time, and movement time’ by Behm DG, Bambury A, Cahill F, Power K, Medicine & Science in Sports & Exercise 2004;36:1397–1402.

The aim of this study was to out find out how often German physicians injured themselves performing manual therapy. A total of 301 physicians (20% female; mean age 46 years) participated in this study. Of these, 11% of the participants experienced some kind of injury during their career. The three worst cases were fractures and were classed as moderate injury (tough guys the Germans!). Mild injuries were joint dysfunction syndromes (n = 30), distortions of fingers (n = 7), and shoulder pain (n = 3). Subgroup analyses showed no significant differences in the rate injuries by gender, provider organisations for postgraduate courses, and medical disciplines. Of the

www.sportEX.net

ISCHEMIC COMPRESSION AND JOINT MOBILISATION FOR THE TREATMENT OF NONSPECIFIC MYOFASCIAL FOOT PAIN: FINDINGS FROM TWO QUASI-EXPERIMENTAL BEFORE-AND-AFTER STUDIES. Hains G, Boucher PB, Lamy AM. The Journal of the Canadian Chiropractic Association 2015;59(1):72–83 Two groups of patients at a private clinic were used for this study. One group (n = 31) were given custom orthotics and received 15 experimental treatments immediately after enrolment consisting of ischaemic compressions on trigger points and mobilisation of articulations through the foot. The second group (n = 10) were given a soft prefabricated insole and monitored for 5 weeks before subsequently receiving the 15 experimental treatments after the initial 5-week delay. The outcome measure was the Foot Function Index (FFI) and patients’ perceived improvement score (PIS) on a scale from 0% to 100% assessed at three follow-up evaluations at 0, 1 and 6 months. The ischaemic compression involved pressure administered by supported thumbs for 15s. Pressure was initially light and then deeper dependant on pain tolerance. The first group maintained a significant reduction in the FFI at all three follow-up evaluations. Mean

improvement from baseline in FFI was 47%, 49% and 56% at 0, 1 and 6 months, respectively, post-treatment. Mean PIS was 58%, 57%, and 58%, at 0, 1 and 6 months post-treatment. For the other group, mean improvement in FFI was only 19% after the monitoring period, and 64% after the experimental treatment period. Mean PIS was 31% after monitoring, and 78% after experimental treatment.

sportEX comment They have complicated things a bit here with the different orthotics and the treatment delay and we don’t like ‘nonspecific myofascial foot pain’. It just means that you haven’t found the true cause and in this case made assumptions that it is trigger points in the foot. However, the bottom line is that a combined treatment involving ischaemic compression and joint mobilisation for chronic foot pain made a significant difference.

MANUAL MEDICINE RELATED INJURIES EXPERIENCED BY PHYSICIANS: A MISSING ASPECT IN THERAPIES USING MANIPULATION OF JOINTS. Steinhaeuser J, Goetz K, Oser A, Joos S. Evidence-Based Complementary and Alternative Medicine 2015;doi:10.1155/2015/507051 participants, 52% injured themselves more than once. Three injuries could not be classified in the grading system. They were a degenerative cervical spine, carpal tunnel syndrome and an inguinal hernia.

sportEX comment Reading this paper gives a fascinating insight into the training of health providers in other countries. In Germany, therapies using mobilisation or manipulation of joints are called Manual

Medicine if provided by a specially trained physician. The postgraduate training consists of 320h of theory and practice. It is the second most popular qualification with over 19,000 physicians having it. UK GPs please take note. The authors add that one injury was caused when the physician got slapped in the face by a frightened patient. Seriously, though, be careful out there you can fix the patients without breaking your fingers!

Biotensegrity part 3: Introduction A clock mechanism includes levers, pendulums, counter-weights and wheels in various arrangements and complexities. These were considered the basis of human movement during the Renaissance. A lever is a 2-bar open chain. The cuckoo spring mechanism (Fig. 1), however, is a ‘closed kinematic chain’ and we will see that this model better describes the human body, given the role of the fascial matrix as a tensional bodywide structural system. These are the fundamentals of the new Science of Body Architecture, evolving from Fascia Research. Fascia has become something of a new buzzword in the world of movement and manual therapy. Its role as the largest sensory organ of the body is changing many notions of how the traditional views of the nervous system have been classically considered. That is not just in and of that system in isolation. Indeed, the idea that the body architecture itself is innately sensory, intelligent and ‘aware’, ends the notion that nerves merely pass through it, to and from the brain and spinal cord to the particular muscle or part they are activating or responding to. That changes everything.

Expanding contexts On further investigation down this path of a sensory connective tissue joining muscles to bones or anything else in the moving body, Dr Robert Schleip endorses these new perspectives for movement, manual and medical practitioners to view and treat the body. He cordially invites his audience to consider the commonly accepted idea that the nervous system ‘actions’ various muscle units (as described in 8

levers and pendulums Biotensegrity is a compelling model that explains structure and motion in non-linear biologic forms such as the human body. The problem with many of the classical theories of biomechanics is that they are largely based on outmoded notions, such as the widely accepted idea that muscles act on the human limb joints as if they are levers. This article (Part 3 in a series) explains that there are no levers in biologic forms and proposes the idea of recognising closed kinematic chains as an alternative model of structure. By Joanne Avison KMI, ERYT500 many anatomy books) as “outmoded”.

huge and dynamic game changer.

“The simple questions discussed in musculoskeletal textbooks such as ‘which muscles’ are participating in a particular movement thus becomes almost obsolete. Muscles are not functional units, no matter how common this misconception may be. Rather, most muscular movements are generated by many individual motor units, which are distributed over some portions of one muscle, plus other portions of other muscles. The tensional forces of these motor units are then transmitted to a complex network of fascial sheets, bags and strings that convert them into the final body movement.” (1)

A game changer

When it comes to the traditional descriptions of the ‘musculoskeletal system’ and explanations of biomechanical movement, the fascia challenges the very depths of classical theory. The architecture of these fascial sheets, bags and strings becomes part of the sensory network guiding and signalling the movements. That is a

If muscles are not connected to bones (which they are not) and healthy bones in the living body do not touch each

How much does the game change, if the material out of which the organism is made (ie. fascia), is sensory?

Figure 1: The Cuckoo spring mechanism is a ‘closed kinematic chain.

sportEX dynamics 2015;45(July):8-12

Professional development (non-clinical)

other (which they do not) and the various fasciae wrap everything from the microscopic fibrils to the largest muscle groups (which they do) – then how can the reductionist term ‘musculoskeletal system’ do justice to the actual sensory architecture that moves it into being? All these units and all the systems they form are intimately connected to each other via the fascial matrix. However, the way in which they connect and relate begins to matter hugely in this new paradigm. They are pre-stressed under tension, which effectively challenges any notions that fail to account for the closed continuous nature of biological forms. It calls forth new questions about all the physiological systems; not least the basis of assessing locomotion. The notion that the muscles at the elbow joint activate a ‘bend at the elbow’ as if the joint is a lever is still accepted as a model of human movement (Fig. 2). (A lever is a 2-bar open chain mechanism). Is this idea also outmoded? A lever is a 2-bar open chain device. The elbow is a joint that lies amidst a line of other joints (approximately seven) in the arm. Even if it is referred to as the ‘upper appendage’ and attributed all kinds of specific and complex innervations, they do not account for the fact that if you made a 7-bar open chain lever mechanism and held it at one (proximal) end, you would have progressively less control at (or of) the other (distal) end. How exactly do antagonistic and agonistic pairs explain how to thread a needle and, indeed, stitch embroidery silks into exquisite tapestries or mend a boat sail while at sea (counterbalancing the rest of the body)? Precise control of the movements is readily achieved, at the fingertips, by someone focused on the distal end of the arm, as typing an email will demonstrate. At the most simplistic level, how does a joined-up and interrelated system of levers account for such detail and complexity at the distal end of such a mechanism? If the tissue is sensory, how does a 2-bar model feed back information if the chain or links are open? The www.sportEX.net

reality is that it doesn’t.

A universal pattern The 4-bar closed kinematic chain refers to the type of mechanism that allows the cuckoo to spring out of the clock on the hour!! It resembles a lattice and allows motion (deformation) of the whole spring-loaded mechanism to take place, under one control (Fig 3). The mechanism can then go back to where it was before the movement (reformation). It is, however, a hinge model of a non-biological mechanical solid structure. If the lattice is imagined as a tubular arrangement of soft, sensory tissues (Fig 4) it moves towards an explanation of movement integrity in which one motor controls the whole, joined-up, structure in a responsive organisation.

Figure 2: The classical lever depicted at the elbow joint, for example. (Credit: Avison J. YOGA: Fascia, Anatomy and Movement (5). Reproduced with kind permission from the author.)

Control at both ends A 4-bar closed kinematic chain is demonstrated by a pantograph; which also has one fixed bar and adds a greater range via bars of different lengths, to the final type and shape of the movement. A movement at one end of a pantograph can be replicated precisely at the other end, on a different scale. This is determined by the specific (and different) lengths of the bars – as a whole mechanism. Elliptical motion and other more complex shapes can be made in space by the rules of these more sophisticated configurations; much more akin to the range that human beings demonstrate in dance or gymnastics, for example. This suggests a more complex variety of movements, modifications and closed chains than levers can begin to account for. How much is the game changed, if the material out of which the organism is made, is sensory? The joint mechanisms in these solid models are locked in time as examples of inert materials. How can we thoughtfully extrapolate human movement principles, given that we are made of soft, sensitive, pre-tensioned matter that feels itself feeling its way into forms? We are not solid matter; rather soft matter at varying degrees of stiffness. That demands a completely different view.

Figure 3: Image shows a 4-bar linkage system like that of the cuckoo clock mechanism. There is one fixed bar allowing this linked movement. (Credit: Avison J. YOGA: Fascia, Anatomy and Movement (5). Reproduced with kind permission from the author. Figure 4: A biotensegrity lattice. This image is a biotensegrity model of a tube. Its direction provides chirality which is a spiral direction. It models the tunicae of the blood vessels, for example, each layer having a different chirality. Note the cross-section of this spiraling structure is a lattice which forms a type of 4-bar linkage system, in three dimensions. It allows motion that is communicated to every part of the enclosed linkage system. (Credit: Avison J. YOGA: Fascia, Anatomy and Movement (5). Reproduced with kind permission from the author.)

The 4-bar closed kinematic chain refers to the type of mechanism that allows the cuckoo to spring out of the clock on the hour!! It resembles a lattice and allows motion (deformation) of the whole spring-loaded mechanism to take place, under one control “Biological linkages frequently are compliant. Often one or more bars are formed by ligaments, and often the linkages are three-dimensional. Couple linkage systems are known, as well as five, six and even sevenbar linkages. Four-bar linkages are by far the most common though.” (2)

Everything changes everything else In a closed-chain mechanism every change in movement and force that is transmitted through the living architecture, is reflected everywhere else, by virtue of their intimately connected linkages and the integrity of the spaces between structures. To give a mechanical example, the wheels of a steam train are driven by a multi-bar linkage system, which allows for motor control at one end to manage several linked units throughout the structure. All the linkages remain organised as one cohesive whole. Where does that leave us in terms of moving bodies? Simplistically speaking, it suggests that a 2-bar open chain mechanism doesn’t have enough to it, to explain our range

and means of movement. It invites us to enter the world of biotensegrity and triangulated structures. That points to closed mechanical systems for an enclosed architecture in multidimensional expressions. A 3-bar closed-chain mechanism (a triangle) is rigid; however, a 4-bar closed chain mechanism elevates a lattice arrangement to a position of structural integrity in organised motion. Consider one such organisation at the cruciate ligaments in the knee, for example. These are described as an X-bar linkage, where they abide by the rules of a 4-bar closed kinematic chain, when in situ as part of the knee complex (Fig. 5). This begins to open up explanations of the kind of movement possibilities a joined-up body actually does. The emerging Science of Body Architecture (5) calls us to consider the one internal environment and its adaptations and responses to and from the external world with new eyes. These eyes are ‘seeing’ in more dimensions, calling for new ways of understanding the connecting tissues and new questions in the light of their ubiquity and continuity and organisation. If the actual connecting tissue is sensory and can respond instinctively to where it is in space and its relative movement to the rest of the body, it suggests something far more complicated than a 7-bar open chain mechanism can explain, if that is the model of the arm. The laws of biotensegrity, however, link all those chains which are enclosed by the tissues [see previous article (6)].

Box 1: Inaccurate theories from inaccurate hypotheses? (J. Avison, 2015)

Figure 5: The X-bar (4-bar) linkage of the knee as an example of a closed kinematic chain linkage system. (Credit: Dr Stephen Levin. Image reproduced with kind permission.)

Once removed from their original context and isolated rather than integrated, the motion analysis of a given part might then be deduced by the anatomist. There is a vast rift between the explanations of how someone moves a body under anaesthetic and how it moves itself aesthetically. Many classical notions of biomechanics grew out of the former study. As Serge Gracovetsky (3) points out, the notion that muscles move bones as levers, meant that formative theories were developed as if that is accurate. Thus measuring devices have been developed for the living body based upon muscle signalling and action. What of the electromyographic silence of a muscle acting as a brake? Indeed, if they don’t act in isolation as Schleip points out, then studying their actions as if they do, can only provide partial information. Does the notion of levers become redundant in the light of biotensegrity? As Dr Stephen Levin points out, “there are no levers in biologic forms” (4).

sportEX dynamics 2015;45(July):8-12

Professional development (non-clinical)

Biotensegrity: a tension–compression integrity Given the current knowledge of the fascial matrix as a tensional network, might the reader find themselves soon to be cordially invited to consider such biomechanical theories as outmoded along with old ideas of the nervous system’s limitations? Is Newton’s 3rd law (to every force in the known universe there is an equal and opposite force) innate to the very architecture in which we assemble ourselves to move around? Rather than considering this law represented by the gross antagonism between paired muscles (such as biceps and triceps) is it inherent to a much more sophisticated model?

New laws In biotensegrity systems, the compression members ‘float’, fully supported in a sea of tension. They are completely surrounded and unified as whole parts of a whole structure, in stillness and motion. They retain a role of mutually compressing and tensioning each other in reciprocal balance, throughout passive and dynamic motion. The components are structurally organised in a hierarchy that can transition constantly and yet retain their relatedness and tensional integrity. They are invariably (if paradoxically) interdependent and independent. The compression members are discontinuous and the tensional members are continuous so Newton’s 3rd law remains constant and continuously expressed, albeit in relentlessly changing relationships. It is hard to imagine intellectually, but what must be remembered is the living body’s ability to shift, or transition the functioning of these internal structures, to adapt. We might consider ourselves ‘flux in motion’; moment by moment and movement by movement. This idea doesn’t rely upon a notion that takes one joint as a lever out of context. No joint in the human body can be moved without implicating another. A tensional matrix means that every tissue forms under the laws of biotensegrity architecture. It also, in its detail and complexity, honours the way the human www.sportEX.net

form expresses motion, motility and movements as animated presentations that never repeat themselves exactly – in time or space. Biotensegrity offers cogent ways to model the variety of adaptations in biologic forms. Where does it all begin? In the next article we will consider the impact of compression models on biologic structures, beginning with the embryo. A historic opportunity to consider the anatomy of the human body through the lens of Biotensegrity will take place in July at the University of Dundee, UK. Medical, manual and movement practitioners are cordially invited to consider this groundbreaking event; the first of its kind. Thiel dissection methods enable a more life-

like tissue quality in the cadaver forms. For more information see www.ntc.ie/dissection. References 1. Schleip R. Introduction. In: Schleip R, Findley TW, et al. (eds) Fascia: the tensional network of the human body. Churchill Livingston 2012. ISBN 978-0702034251 (Print £35.75 Kindle £33.96). Buy from Amazon http:// spxj.nl/1HHnWuQ 2. Wikipedia. Biological linkages: Linkage (mechanical) http://spxj.nl/1JeGR62 3. Gracovetsky S. The spine engine theory. Open workshop presentation 2011, Brighton, UK 4. Levin S. The scapula is a sesamoid bone. Journal of Biomechanics 2005;38(8):1733–1734. This provides interesting references in great detail http://spxj.nl/1HHl014. 5. Avison J. The science of body architecture, chapter 3. In: Avison J. Yoga: f

In a closed-chain mechanism every change in movement and force that is transmitted through the living architecture, is reflected everywhere else, by virtue of their intimately connected linkages and the integrity of the spaces between structures. Box 2: The classical models. (J. Avison, 2015) In her book Molecules of Emotion Dr Candace Pert described the sanction that Descartes (1596– 1650) received from the pope to dissect human bodies, as a ‘turf deal’ (7). In essence the deal was that the church would retain jurisdiction over the mind, body and emotions while ‘science’ could authorise the academic analysis of the body, as if it is separate. Descartes studied clocks among his many talents. As the author of Cartesian Reductionism, he declared: “I desire you to consider, I say, that these functions imitate those of a real man as perfectly as possible and that they follow naturally in this machine entirely from the disposition of the organs no more nor less than do the movements of a clock or other automaton, from the arrangement of its counterweights and wheels.” (8) Borelli (1608–1679) stated that “muscles do not exercise vital movement otherwise than by contracting”. With these and other ideas of the time, the models of classical biomechanics developed alongside growing Industrialisation. The body was effectively sanctioned as a type of machine, capable of movement under separate laws to those of the emotions, thoughts, desires and intentions of the being that motivated it. The presiding theory was to consider the joints as hinges and the contraction of one muscle (agonist) and its passively stretched counterpart (antagonist) over that hinge sufficiently met Newton’s criteria that to every force there is an equal and opposite counter force. Thus levers were treated as the basis of movement at hinged joints; acting as if there were a pin at the hinge (see Fig. 2). As clinical anatomist, John Sharkey (9) points out, “we readily discuss the importance of the joint space in anatomical investigation. Where is the pin? A 2-bar open chain mechanism (a lever) can’t be such, without one. There are no pin joints in the human body.”

Further resources 1. Scarr GM. Biotensegrity: the structural basis of life. Handspring 2014. ISBN 978-1909141216 (Print £25.00). Buy from Amazon http://spxj.nl/1cu2q42 2. Websites for the early pioneers of Biotensegrity: Kenneth Snelson http://kennethsnelson.net/ and Tom Flemons http://www. intensiondesigns.com. 3. Sharkey J. A new anatomy for the 21st century. sportEX dynamics 2014;39:14–17. 4. YouTube video by Steve Levin. Conversation about Biotensegrity: Steve Levin & Tom Flemons. http://spxj.nl/1QklvTt

References continued fascia, anatomy and movement. Handspring Publishing 2015. ISBN: 9781909141018 (Print £39.95). Buy from Amazon http://spxj. nl/1AG5Hc8 6. Avison J. Fascia and biotensegrity: considering the role of the fascia in the science of body architecture. sportEX dynamics 2015;43(January):29–33 7. Chopra D, Pert C. Molecules of emotion:

Key Points

why you feel the way you feel. Pocket Books 1999. ISBN 978-0671033972 (Print £8.99 KIndle £6.33). Buy from Amazon http://spxj.nl/1dHdYSR 8. Descartes R. Treatise of Man (First published in French in 1664). Harvard University Press 1972. ASIN: B0010IIEMC. 9. John Sharkey BSc NMT MSc, BACA. Clinical anatomist www.ntc.ie.

The Author JOANNE AVISON KMI, ERYT500 Joanne Avison KMI, ERYT500 extensively studied human development as a CMED graduate and specialised in soft tissue and the links between archetypal behaviour and physiological patterns. Her studies also included Human Dissection and movement research in Fascial Fitness with Dr Robert Schleip. Joanne is a fully accredited Professional Structural Integrator (Kinesis Myofascial Integration School) and has taught at the KMI School of Structural Integration (Maine, USA) and also taught Anatomy Trains™ in the UK, pioneering its application to Movement Practitioners in Yoga, Pilates and professional sports, including English Premier League Soccer Clubs and golf professionals. Jo is an experience trainer of yoga teachers, holding E-RYT500 status and is the co-founder and director of the accredited Art of Contemporary Yoga Teacher Training School (AOCY). Joanne is author of Yoga: fascia, anatomy and movement (Handspring Publishing 2015) and currently teaches regular workshops and webinars around the world on Structural Anatomy, Biotensegrity and Fascial Fitness. See www.fasciasymposium.co.uk and www.bodyworkcpd.co.uk for recent presentations.

n Levers are 2-bar open chain mechanisms. n Closed kinematic chains offer a more sophisticated model of animal motion. n Many biologic structures comply with 4-bar or multi-bar closed kinematic chain models. n There are no levers in biologic structures. n Levers and upright inverted pendulums liken human movement to a clock mechanism; a relic of Cartesian Reductionism. n The body is made of soft matter and conforms to the laws of soft matter, in which there are no levers, bending moments, or shear forces. n The biotensegrity model of biomechanics offers explanations of how a unified structure enjoys the ability to move on land, in water or air without relinquishing structural integrity. n A tensional matrix means one in which every tissue forms under the laws of biotensegrity architecture.

nW hen does the human body move any one part in structural isolation from the rest? n I f the fascia is a sensory organ with the combined assets of being ubiquitous and in complete continuity, how can the entirely enclosed structure be adequately represented by a one-joint open chain 2-bar mechanism (ie. a lever)? n I f anatomical discussion refers to joint spaces, and bones do not touch each other in a healthy body, where is the pin in a hinge joint – or are we invited to seek a more DISCUSSIONS sophisticated model?

Want to share on Twitter? Here are some suggestions Tweet this: Fascia is the largest sensory organ of the body. Tweet this: Is the idea of a joint as a lever outmoded? Tweet this: A 4-bar closed-chain is a better model than a lever for the actions a human body actually performs.. Tweet this: Under the laws of biotensegrity architecture, the human body is a tensional matrix.

sportEX dynamics 2015;45(July):8-12

MANUAL THERAPY (NON SPORT)

STRETCH CHARACTERISTICS OF KINESIOLOGY TAPE: A PRACTICAL APPLICATION BY DR LANCE DOGGART BSC, PGCE, MED, PHD AND SARAH CATLOW BSC, PGCE, MSC

INTRODUCTION A significant amount of literature exists reporting the use of Kinesiology tape (K-tape) in a rehabilitation and performance setting (1–3). The use of K-tape could be viewed as an ergogenic aid in that it is reported to assist in the recovery process. However, a standardised method of application, based on the properties of the tape (eg. elasticity, tape integrity, duration for maximum effect), does not exist. Studies have reported variations in average tension length from 12.5% to 70% (4–6), and the average duration of the tape on the skin tissue ranged from 45min to 7 days (6–10). Furthermore, the manufacturers of the tape do not report on the mechanical properties of the tape to aid the application procedure in respect of maximum effectiveness (11). This article attempts to provide guidance on factors to consider when applying K-tape specific to its elastic/stretch characteristics.

METHOD In order to inform an application protocol reflective of K-tape stretch properties, a preliminary study was

The use of Kinesiology tape (K-tape) has expanded massively in recent years. However, there is little information about the best way to apply it. This article discusses the literature and presents research results about the importance of calculating how much tape to use and how to apply it with the optimum stretch. If you use or are interested in using K-tape, this article will help you get the best out your K-tape applications. undertaken to identify the stretch length, and accompanying tensile force, of a specific length of one brand of K-tape. Three testing sessions recorded the stretch length and tensile force of 60 strips (3 testing sessions each using 20 strips of tape) of 28cm length K-tape. Stretch length was noted as the maximum length the tape could be stretched whilst maintaining tape integrity. Tape integrity was defined as the point at which the tape reached its elastic limit noted visually by a qualified and experienced practitioner. In order to standardise the procedure, temperature and humidity were recorded along with two set ‘anchor’ points at either end of the 28cm piece of tape. The anchor points were 4cm in length and this was regulated with one attachment point at the radial styloid process while the

Figure 1: Representation of equipment and procedure for measuring stretch characteristics. (Credit: L. Doggart, 2015)

TABLE 1. K-TAPE STRETCHING RESULTS. (Credit: L. Doggart and S. Catlow, 2015) Measurement factor

Mean stretch length

Range

Percent stretch from active tape length (20cm)

Range of percent stretch (20cm)

Percent stretch from total tape length (28cm)

Stretch length (cm)

30.45*

28–33

52.3%

40–65%

8.8%

Tensile Force (N)

2.59

1.58–3.64

N/a

*Indicates significant difference between the three testing sessions www.sportEX.net

K-TAPE CAN BE STRETCHED TO ~50% OF RESTING LENGTH, MAINTAINING TAPE INTEGRITY, AND ALLOWING THE MECHANISMS ASSOCIATED WITH TAPE EFFECTIVENESS TO ACT other end was inserted into the strip tester. The strip tester was then attached to the force transducer to record tensile force (Fig. 1). The active tape length, ie. the length of tape to stretch to provide the purported effect, was therefore 20cm. Stretch length and tensile force were recorded for each of the 60 strips.

RESULTS AND DATA ANALYSIS Table 1 illustrates the mean stretch length and tensile force for the 60 strips (n = 3 × 20) of K-tape used in the protocol. The results noted that the average (mean) stretch length for the 20cm of active tape was 30.45cm. However, the 5cm range (28–33cm) suggested a significant variability, which was substantiated following statistical analysis (12–14). This equated to a percentage tape stretch range of between 40–65% with an average percentage value of 52.3%. Further statistical analysis revealed no significant difference in the force applied by the practitioner across the three testing sessions suggesting that the practitioner was consistent in the force used (tension) to stretch the tape.

DISCUSSION AND PRACTICAL CONSIDERATIONS The data presented suggest that the mechanical properties associated with the stretching of the tape influence effective stretch length when the force applied is consistent. The results also suggest that the tape can be stretched to ~50% of resting length, maintaining tape integrity, and allowing the mechanisms associated with tape effectiveness to act. There are, however, a number of further influences that the practitioner may wish to consider in the practical application of the tape in relation to standardising an application protocol. These include: n The ability to identify tape integrity end point n Humidity n Temperature (environmental and localised at the tissue) n Time to maximum adhesion of the tape and adhesion duration n Anchor point length n Age of the tape being used (shelf life n Roll size (length in metres) n Roll tightness (roll diameter).

THERE ARE, HOWEVER, A NUMBER OF FURTHER INFLUENCES WHICH THE PRACTITIONER MAY WISH TO CONSIDER IN THE PRACTICAL APPLICATION OF THE TAPE IN RELATION TO STANDARDISING AN APPLICATION PROTOCOL. THESE INCLUDE: THE ABILITY TO IDENTIFY TAPE INTEGRITY END POINT; HUMIDITY; TEMPERATURE; TIME TO MAXIMUM ADHESION OF THE TAPE AND ADHESION DURATION; ANCHOR POINT LENGTH; AGE OF THE TAPE BEING USED; ROLL SIZE AND ROLL TIGHTNESS 14

Tape integrity The loss of tape integrity was evidenced by the visual change in thickness, density and transparency of the tape by the trained applicator. Once stretched, these aspects could be identified as the weave and pattern of the fibres of the tape were clearly visible. This was noted as going beyond its elastic limit and therefore losing its functional capability. If the tape is applied to the tissue in this state, ie. beyond its elastic limit, it loses its ability to function longitudinally and its ability to ‘lift’ the tissue around the injured area allowing for the increased blood flow (15). The tape could therefore be deemed ineffective and would illustrate a poor application protocol. CLINICAL TIP 1: Practice identifying the elastic limit of the tape at various tape lengths, and apply the tape in a well illuminated area/clinic to help identify the elastic limit evidenced by the amount of light passing through it – transparency level.

Adhesion factor The adhesion factor associated with the time to maximum bonding of the tape to the skin, and the bond duration in terms of the time the tape should remain on the skin, are important factors in implementing an effective protocol for K-tape application. The tape has an optimum time for adhesion (brand dependent) before allowing movement and any deviation from that could have significant effects on the benefits of its application. CLINICAL TIP 2: Note the duration for maximum adhesion of the tape to the skin tissue and ensure this is adhered to fully for optimal effect.

Time to maximum adhesion In addition research has reported there is a time limit to its effectiveness (72– sportEX dynamics 2015;45(July):13-17

MANUAL THERAPY (NON SPORT)

120 hours) once applied, specifically linked to the adhesion properties of the tape to the skin (15). Therefore, based on published research, and manufacturers’ guidelines (11), having the tape remain on the skin tissue could be ineffective and as such would need replacing. As a practitioner regular re-application should be considered to maintain its effect on the injured site. CLINICAL TIP 3: Re-application of the tape should occur every 72–120 hours.

Temperature and humidity Temperature and humidity, both localised and environmental, will have an effect on the mechanical properties of most adhesive materials. K-tape stretch characteristics and its subsequent adhesion could be affected by changes in environmental temperature and humidity; for example, storage areas in clinics are often cooler and more humid when compared to the treatment area within a clinic. These changes will affect the ease (applied force) with which the tape can be stretched and the amount (stretch length) it can be stretched because of this change in pliability, ie. tape stored at a higher temperature will stretch more readily/quickly and reach its elastic limit more rapidly than tape stored at a cooler temperature. Therefore, practitioners are at risk of overstretching the tape and losing tape integrity affecting the positive benefits of the tape. Inevitably, if using the tape away from a controlled environment such as a sports hall or

outdoor event, overstretching could occur so a practitioner may wish to be aware of this possibility and adapt the application of the tape (tensile force applied) as necessary to counteract the environmental effects. CLINICAL TIP 4: Store the tape at a similar temperature to the environment in which it will be applied.

Shelf life Shelf life of the tape should also be considered. Adhesive effectiveness, or ‘stickiness’, on most adhesive coated materials have an optimal duration or ‘best before’ date. For industrial-based manufacturers this is regulated and a ‘best before’ date is often printed on the material. Although there is no published research specific to K-tape on this aspect, and K-tape manufacturers do not have to show a ‘best before’ or ‘use by’ date, there is no reason why the same degradation on ‘stickiness’ cannot have an adverse effect over time. K-tape is packaged already bonded to a thin paper strip. If the tape comes off the paper strip in one go and smoothly then a user could be confident that the tape has maintained its adhesive integrity; however, anything other than this, excepting practitioner error, could indicate a loss in adhesive effectiveness. CLINCIAL TIP 5: Note the date when the tape was purchased and the ease with which the paper backing can be removed.

Anchor point length If the tape brand is consistent, in terms of its stretching characteristics, then practical consideration should be given to the ratio of anchor point length to active tape length and tissue area to be covered. In the example noted in this article the tape length was 28cm but the active tape length that would be used to apply to the injured area was 20cm (~70%); ie. the anchor points could reflect ~30% of the total tape length used before stretching. Extrapolating this would suggest that if a 1m strip of tape was cut, then there would need to be two 15cm anchor points with only 70cm of the tape providing effective, or active, support for the injured area before stretching. However, the 70cm active tape length could stretch up to an additional 35cm (~50%), allowing for a total tissue length of 105cm to be influenced/supported by the tape. Conversely if a tissue area of ~40cm required the support of K-tape then a total un-stretched tape length of 37cm would need to be used [anchor points = 5.5cm × 2; un-stretched active tape length = 26cm (stretched = ~39cm)]. Although these examples could be viewed as extreme and simplistic the role and use of the anchor points should be considered in the application of K-tape. This data, however, is within a narrower range of the tension length reported by Lim and Tay (3) in their systematic review of K-tape literature.

THE LOSS OF TAPE INTEGRITY WAS EVIDENCED BY THE VISUAL CHANGE IN THICKNESS, DENSITY AND TRANSPARENCY OF THE TAPE BY THE TRAINED APPLICATOR. ONCE STRETCHED, THESE ASPECTS COULD BE IDENTIFIED AS THE WEAVE AND PATTERN OF THE FIBRES OF THE TAPE WERE CLEARLY VISIBLE. www.sportEX.net

of between 40–65% for the active tape length. Until there is universal agreement on the application of K-tape for maximum affect it may be prudent for a practitioner to purchase the tape in pre-cut lengths to alleviate some of the potential influencing factors that can impact on tape effectiveness. Furthermore the pre-cut lengths could help standardise the recommended stretch length and anchor points for optimal effect. Alternatively practitioners may wish to pre-cut from a purchased roll and allow the tape to acclimatise to the environmental conditions to reassure their practice in the application specific to the injured site.

THE ROLE AND USE OF THE ANCHOR POINTS SHOULD BE CONSIDERED IN THE APPLICATION OF K-TAPE

FURTHER RESEARCH

CLINICAL TIP 6: Note the anchor point length in relation to tape length and length of injured area to be covered.

Roll properties Finally the size/length of the roll, and its corresponding ‘tightness factor’ based on roll diameter, can also influence the pre-stretch characteristics of the K-tape material. The conversion of stored elastic energy, whilst on the roll, to kinetic energy during its application has been noted by Grellman et al. (16) as a potential influencing factor dependent on the material properties and composition. Roll lengths, for purchase, can vary from 5m to 35m and these differences affect the overall diameter of the tape roll around which the tape is wound. The longer the roll of tape, ie. up to 35m, the tighter the starting point (small diameter), and then

IT MAY BE PRUDENT FOR A PRACTITIONER TO PURCHASE THE TAPE IN PRECUT LENGTHS TO ALLEVIATE SOME OF THE POTENTIAL INFLUENCING FACTORS THAT CAN AFFECT TAPE EFFECTIVENESS 16

the larger the final roll diameter. Tape at the beginning of the roll will have a larger pre-stretch length than tape at the end of the roll which has been wound tightly. This difference could affect the optimum stretch length, whilst maintaining tape integrity, at either end of the tape roll: ie. tape at the beginning of the roll may not be able to stretch to its full capacity because of its pre-stretch when compared to the final piece of tape at the end of the roll. Therefore elastic to kinetic energy conversion may be reduced and overstretching the tape may be more easily achieved beyond its elastic limit. CLINICAL TIP 7: Note from which part of the roll the portion of the tape to be applied was cut.

SUMMARY There is a wealth of factors to consider, as a practitioner, when applying K-tape. These range from pre-application aspects such as shelf life, roll size and environmental storage conditions to the procedure for effective application, eg. anchor point length, and stretch length whilst maintaining tape integrity. Published research (3) suggests that there has been little consistency on the exact length the tape can be stretched with no mention of maintaining tape integrity or tape duration in situ. However, the study noted in this article suggests a maximum stretch

Areas of further research that would be of interest include: n Objective measure of tape integrity to support skilled practitioners’ observations. n Time to maximum tape adhesion and optimum duration of tape effectiveness. n Maximum tape stretch length for different tape lengths. n Tape characteristics and the effect of twisting the tape around an injured site. n Effect of roll length and diameter on tape effectiveness. n The effect of material properties and composition on stretch length.

FURTHER RESOURCES 1. For videos on how to use K-tape, visit the RockTape website http://rocktape.net/how-to-use.html. References 1. Wong OM, Cheung RT, Li RC. Isokinetic knee function in healthy subjects with and without Kinesio taping. Physical Therapy in Sport 2012;13(4):225–228 2. Williams S, Whatman C, Hume PA, Sheerin K. Kinesio Taping in treatment and prevention of sports injuries: a meta-analysis of the evidence for its effectiveness. Sports Medicine 2012;42(2):153–164 3. Lim EC, Tay MG. 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 metaanalysis focused on pain and also methods of tape application. British Journal of Sports Medicine 2015;doi:10.1136/ bjsports-2014-094151 [Epub ahead of print] 4. Aytar A, Ozunlu N, Surenkok O, et al. sportEX dynamics 2015;45(July):13-17

TAPING

Initial effects of kinesio® taping in patients with patellofemoral pain syndrome: a randomised double blind study. Isokinetics and Exercise Science 2011;19(2):135–142 5. Shakari H, Keshavarz R, Arab AM, Ebrahami I. Clinical effectiveness of kinesiological taping on pain and painfree shoulder range of motion in patients with shoulder impingement syndrome: a randomised double blinded placebo controlled trial. International Journal of Sports Physical Therapy 2013;8(6):800 6. Anandkumar S, Sudershan S, Nagpal P. Efficacy of kinesio taping on isokinetic torque in knee osteoarthritis: a double blind randomized controlled study. Physiotherapy Theory and Practice 2014;30(6):375–383 7. Paoloni M, Bernetti A, Fratocchi G, et al. Kinesio taping applied to lumbar muscles influences clinicial and electromyographical characteristics in chronic low back pain patients. European Journal of Physical Rehabilitation and Medicine 2011;47:237– 244 8. Castro-Sanchez AM, Lara-Palomo IC, Matarán-Peñarrocha GA, et al. Kinesio Taping reduces disability and pain slightly in chronic non-specific low back pain: a randomised trial. Journal of Physiotherapy 2012;58(2):89– 95 9. Homayouni K, Zeynali L, Mianehasz E. Comparison between Kinesio taping and physiotherapy in the treatment of de Quervain’s disease. Journal of Musculoskeletal Research 2013;16:1–6

10. Shahane S. The effect of myofascial release technique and stretching versus myofascial release technique and taping in patients with chronic plantar fasciitis: a comparative study. Thesis submitted to Rajiv Gandhi University of Health Sciences, Bangalore, India 2013 11. The RockTape website http://rocktape.net/ 12. Atkinson G, Nevill A. Statistical methods for assessing measurement error (reliability) in variable relevant to sports medicine. Sports Medicine 1998;26(4):217–238 13. Batterham AM, Atkinson G. How big does my sample need to be? A primer on the murky world of sample size estimation. Physical Therapy in Sport 2005;6:153–163 14. Vincent WJ, Weir JP. Statistics in kinesiology, 4th edn). Human Kinetics 2012. ISBN 9781450402545 (Print £27.39 KIndle £17.99). Buy from Amazon http://spxj.nl/1M4nWZ2 15. Kase K, Wallis J, Kase T. Clinical therapeutic application of the Kinesio Taping method, 2nd edn. Kinesio 2003. ASIN B00PKJNGPW (Spiral Bound £15). Buy from Amazon http://spxj.nl/1BKvElO 16. Grellman W, Heinrich G, et al. Fracture mechanics and statistical mechanics of reinforced elastomeric blends. Springer 2013. ISBN 9783642379093 (Print £90). Buy from Amazon http://spxj.nl/1K9g1eC).

KEY POINTS nT here is no universal agreement on the protocol, or optimum stretch length capacity, for K-tape. n Manufacturers of the tape do not report on the mechanical properties of the tape to aid the application procedure in respect of maximum effectiveness. n Tape integrity was defined as the point at which the tape reached its elastic limit which was evidenced by the visual change in thickness, density and transparency of the tape by the trained practitioner. Once stretched these aspects could be identified as the weave and pattern of the fibres of the tape were clearly visible. n The results note that the average (mean) stretch length for the 20cm of active tape was 30.45cm. However the 5cm range (28–33cm) suggests significant variability which was substantiated following statistical analysis. n Statistical analysis revealed no significant difference in the force applied by the practitioner across the three testing sessions suggesting that the practitioner was consistent in the force used (tension) to stretch the tape. n Storage temperature and humidity will affect the stretch characteristics of the tape. n Be careful to use the correct length of tape for the area to be covered – calculate length of anchor points and how much the tape will be stretched. nS even key practical tips: ability to note the point of elastic limit; duration for maximum adhesion; tape storage conditions; best before date; tape re-application every 24–72hours; anchor point length; size and section of the roll from which the tape was cut.

www.sportEX.net

nW hat is the over-arching influencing factor on maximising K-tape effectiveness? nW hat are the key mechanical factors affecting tape integrity and what is their priority of impact/ influence? n I s there a need to store precut tape to a standard length to assist in consistent application DISCUSSIONS procedures and effectiveness?

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: K-tape can be stretched to ~50% of resting length, maintaining tape integrity and tape effectiveness. Tweet this: If K-tape is applied stretched beyond its elastic limit, it will lose its ability to lift tissue and be ineffective. Tweet this: Re-application of K-tape is needed every 72-120 hours to maintain efficacy. Tweet this: Temperature is an important factor: warm K-tape will stretch more readily, so be careful to avoid overstretching it.

THE AUTHORS DR LANCE DOGGART BSc, PGCE, MEd, PhD Dr Lance Doggart BSc, PGCE, MEd, PhD graduated in 1992 with a BSc (Hons) Sport Science from Liverpool Polytechnic (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. SARAH CATLOW BSc, PGCE, MSc Sarah Catlow BSc, PGCE, MSc is the programme leader of the Sports Therapy and Rehabilitation degrees at the 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.

SWEDISH MASSAGE IN A SPORTING CONTEXT In previous editions of sportEX dynamics we looked at why the majority of massage research is flawed and the evidence to justify the use of ‘Swedish’ massage in sport as part of a general conditioning programme and before, during and after activity. In this final article in the series, we look at the evidence for the use of the ‘Swedish’ techniques of effleurage, petrissage, tapotement and frictions in treating injury and after travel and asks if there is any evidence of adverse effects. BY BOB BRAMAH BSC, MSMA MSMM MCSP

INTRODUCTION The research papers discussed here were found in a literature search covering the period 2004–2013. Full details of the methods were given in the previous article. According to Sandy Fritz (1) there are six contexts in which massage is used in sport, which are as part of a general conditioning programme, before sport or exercise as part of a warmup routine, during the competition itself, afterwards as part of a warmdown routine, as part of a injury recovery regime or to counteract the debilitation effects of travel. Here the last two, injury and travel are examined. In addition evidence was also obtained to see if there were any instances where massage would have adverse effects.

INJURY RECOVERY There is no study that looks specifically at the use of massage alone as part of an injury recovery strategy but there is evidence for its use on the components of the process.

Pain None of the studies found that are directly related to sport are concerned with pain but there is a large evidence base for the efficacious use of massage in pain management outside sport which may be applied in a sporting context. In a review of the clinical effectiveness of therapeutic massage for musculoskeletal (MSK) pain, Lewis and Johnson (2) concluded that because of problems with poor methodological quality, sample size and dosing, the evidence base is ‘confused’. However, 10 out of 20 studies in the review judged massage to be effective at reducing MSK pain. Of these positive studies, 4 of 9 followed experimentally induced pain and 6 of 11 used patients with MSK pain originating from underlying conditions. Other reviewers found a trend towards positive effects on pain. Tsao (3) concluded that there was good evidence for the effect of massage on low back pain (LBP), moderate evidence for shoulder pain and headaches and modest evidence for mixed chronic pain, neck pain and carpel tunnel pain. LBP is a common complaint in athletes (4) and Brosseau et al. (5)

THERE IS A LARGE EVIDENCE BASE FOR THE EFFICACIOUS USE OF MASSAGE IN PAIN MANAGEMENT OUTSIDE SPORT WHICH MAY BE APPLIED IN A SPORTING CONTEXT 18

agreed that massage therapy is effective at producing pain relief and improving functional status for LBP. Furlan et al. (6), in an update of an earlier Cochrane Review, concluded that massage might be beneficial for patients with non-specific LBP especially when combined with exercises and education. Kumar et al. (7) concurred with regard to nonspecific LBP in the short term but added that because of methodological flaws recommendations arising from the evidence base should be treated with caution. Brosseau et al. (8) found that therapeutic massage can decrease pain, tenderness, and improve range of motion for sub-acute and chronic neck pain. Van den Dolder et al. (9) found a similar result for shoulder pain plus improvements in flexion and abduction range of motion (ROM) and functional scores, although the papers were described as ‘low quality’. Kong et al. (10) were able to extract sufficient information to perform a metaanalysis using data from 12 studies and concluded that massage therapy may provide immediate effects for neck and shoulder pain when compared to inactive therapies (standard care or sham myofascial release) but no more so than other active therapies (acupuncture, exercise, traction). This is a different result to Ezzo et al. (11) who felt that no recommendation for practice in the management of neck pain can be made because the effectiveness of massage remains uncertain. The difference may be that a number of

sportEX dynamics 2015;45(July):18-22

MANUAL THERAPY IN SPORT

high quality trials have recently been published and Kong et al. therefore were able to produce a meta-analysis, whereas Ezzo et al. felt the data was insufficient to do so. Field et al. (12) explored the use of massage on sufferers of hand pain. The aetiology of the conditions was mainly overuse, but patients with arthritic pain and pain of unknown aetiology were also included. This finding supports earlier work by Brooks et al. (13) but contrasts with Young et al. (14). This may be because the study by Young et al. only gives massage to the posterior portion of thumb adductors, whereas the positive outcomes come from massage applied to a much wider area. To understand what is happening during the post-injury process Crane and his colleagues looked at the molecular effects of massage (15). They obtained biopsies from quadriceps muscles that had been exercised to exhaustion and then massaged. By tracking gene expression they found that mechanical manipulation of tissue can produce metabolic responses which include activating cellular signalling pathways, regulatory mechanisms of protein synthesis, glucose uptake, immune cell recruitment, mitochondrial biogenesis and muscle growth which taken together promote faster recovery from muscle damage. These responses are largely due to mechanical stretch and strain during the massage treatment which is why dose is such an important factor. The dose needs to be sufficient to create an effect. Much of the pain associated with injury especially of the lumbar region is associated with muscle spasm. It is suggested by Sefton et al. (16) that massage reduces muscle tension by stimulating sensory receptors which in turn reduce alpha-motor neuron pool excitability via the Hoffmann reflex (H-Reflex). The Sefton study performed a twenty-minute massage on the upper back, neck and shoulders and found that changes occurred distally in the flexor carpi radialis muscle, therefore supporting the alpha-motor neuron reflex theory and suggesting a centralised effect on the

www.sportEX.net

BOTH ISCHAEMIC COMPRESSION AND SWEDISH MASSAGE HAD, OVER A SIXSESSION PERIOD, A POSITIVE EFFECT WITH PRE-/POST-TREATMENT PAIN INTENSITY LEVELS BEING REDUCED BY 50% nervous system. There was also a decrease in electromyography (EMG) signal amplitude in the areas treated suggesting a reduction of activity (relaxation) of the muscles, a finding supported by an increase in cervical spine ROM. Behm et al. (17) confirmed that massage affected the H-reflex especially if combined with stretching.

Trigger points Simons (18) described myofascial trigger points (MTrPs) as “points of spot tenderness in a palpable taut band of tissue.” He added that they are an often overlooked but major cause of MSK pain. In addition to pain they can cause muscle weakness. Both pain and muscle weakness contribute to a restricted ROM, which can in turn interfere with the agonist/antagonist relation and therefore affect fine motor control and coordination. Studies report between 55–85% of MSK pain may be as a result of TrP activity (19). Although their aetiology remains speculative, the most popular theory is that the taut band is made up of a series of intensely contracted sarcomeres thought to be located at or near the motor endplate zone. This local contraction is thought to be caused by acetylcholine at the motor endplate, and an inhibition of acetylcholine esterase resulting in an alteration of the feedback control of neurotransmitter release related to endplate discharge frequency. Pain at the MTrPs is due to the release of neuropeptides, cytokines, inﬂammatory substances and protons that create local acidity (20). Local ischaemia results from capillary compression within the taut band, which in turn triggers vasodilation in surrounding areas. (21). Within the taut band there is a lack of glucose and oxygen for

metabolism (22). The characteristic referred pain associated with MTrPs is a result of central sensitisation and hypersensitivity within the same or adjacent spinal segments, which can be mapped in a myotomal and/or dermatomal distribution (21). The underlying causes of the taut band are many including, muscle overuse, stress, and posture especially if static positions are held for an extended period (23), which makes identifying the exact cause and eliminating it impossible. What can be achieved is the deactivation of the MTrP to reduce pain and re-educate the muscle to restore normal function. There are numerous modalities that claim to be able to do this including dry needling and electrotherapy (24), which are outside the scope of this study. Fernández-de-las-Peñas et al. (25) conducted a systematic review into the use of manual therapies in the treatment of MTrPs and concluded that results did not produce rigorous evidence for the efficacy of any of them beyond placebo. Therapies included ischaemic compression, spray and stretch, strain/counter strain, muscle energy techniques, TrP release and Cyriax transverse friction massage. However, it was conceded that MTrP treatment is effective in reducing the pressure pain threshold (PPT) and scores on visual analogue scales. The only paper discussed that is relevant to the present study was Hou et al. (26) who reported in a large study (N = 119) that ischaemic compression therapy with a quantified pressure and duration did reduce PPT. A later review by Rickards (24) found a further three papers that confirmed ischaemic compression as a useful therapeutic modality. One of these, Chatchawan et al. (27), compared

SYSTEMATIC REVIEW INTO THE USE OF DEEP TRANSVERSE FRICTIONS (DTF) TO TREAT TENDINOPATHY FOUND THAT, AS WITH MANY OTHER REVIEWS, THE DIFFERING STUDY DESIGNS AND METHODOLOGY MADE THE POOLING OF RESULTS IMPOSSIBLE traditional Thai massage with Swedish techniques for treatment of back pain associated with MTrPs. Thai massage was excluded from the present study but the techniques used [as described in Chatchawan (27)] are effectively ischaemic compression. Both the ischaemic compression and the Swedish massage had, over a six-session period, a positive effect with pre-/post-treatment pain intensity levels being reduced by 50%. PPT was significantly higher in the ischaemic compression group. Another study compared a single treatment of ischaemic compression technique with transverse friction massage (28). Both showed a significant improvement in PPT and a decrease in visual analogue scale (VAS) scores with no difference between the two groups. Fryer and Hodgson (19) and Hains et al. (29) achieved similar results as did Bron et al. (30) although the latter added post-compression effleurage, ice-cube massage and stretching. In practical terms it is likely that this combined treatment will have the most beneficial effects. The subjects in Hains et al. (29) received 30 treatments at a rate of three per week consisting of 15 seconds of thumb pressure into each identified TrP. This appears to be an excessive amount of treatment considering that the other studies managed the same effect in one session, although, unlike the others, Hains et al. do publish a follow-up at 3 months and 6 months which indicated the effects had continued. How ischaemic compression works remains speculative. Simons (18) suggests a lengthening of the sarcomeres, similar to poking a balloon and causing the sides to expand, which reduces energy consumption and which in turn stops the release of noxious

substances. Hou et al. (26) suggests reactive hyperaemia due a counterirritant effect or a spinal reflex mechanism that produces reflex relaxation. In a proofof-principle case study, Moraska et al. (31) inserted a microdialysis catheter into active upper trapezius MTrPs of two subjects in such a way that interstitial fluid could be collected during the application of ischaemic compression. Samples were collected continuously in twenty-minute fractions over the next hour and for the hour following treatment. The compression applied during treatment did not alter the dialysate flow rate, volume collected or the appearance of the sample. Local blood flow increased for 20 minutes post-treatment and continued to do so for the duration of the study for subject 2. The result from subject 1 was more erratic. Similarly, glucose concentration increased for subject 2 but only minimally in subject 1. Lactate concentration increased for both. This would appear to support Simons (18). When the ischaemic compression is removed and the TrP released there is increased substrate perfusion and oxygen delivery. There are some caveats to this study. There are only two subjects and a local anaesthetic was injected into their dermal layer to allow insertion of the probe. An hour was allowed before treatment to allow the anaesthetic to dissipate but it may still have influenced the results. Interestingly the therapist could not detect the probe.

Deep transverse frictions Joseph et al. (32) completed a systematic review into the use of deep transverse frictions (DTF) to treat tendinopathy and found that, as with many other reviews, the differing study designs and methodology made the

pooling of results impossible. Of the studies reviewed, none examined DTF alone. In practice this reflects reality in that it is unlikely that for any injury situation a single treatment modality will be administered. Joseph et al. found that there was evidence of a benefit for elbow conditions when the DTF was given in combination with a Mills manoeuvre and for supraspinatus tendinopathy in the presence of outlet impingement along with joint mobilisation. An important point raised by Joseph et al. is that when frictions as a treatment for tendon problems were first proposed the belief was that the underlying problem was inflammation (33); now, however, the problem is thought to be a maladaptation to mechanical loading with an increased cross-linking of collagen. It is possible therefore to speculate that the frictions and manipulations combine to affect local blood supply and tissue adhesion. The research by Crane et al. (15) into what is happening at the cellular level may go some way to explaining why DTF has an effect. Previous research into the effects on rat tendons showed that loading tissue using massage techniques increased fibroblasts and extracellular matrix adhesion proteins (32), but there is no guarantee that animal responses transfer to humans (15). Elliott and Burkett (34) used DTF as a means of treating TrPs; however, it is not clear from the treatment description if TrPs were actually present at the areas to which the treatment was applied. This particular study improved symptom severity and functional status but notably the patients had suffered symptoms for an average of over 6 years. It is possible that the pain of peripheral nerve entrapment altered upper limb functions over that time. Treatment involved the entire arm musculature including the rotator cuff. If these had not been used optimally in that time, any soft tissue work to the area would lead to improved outcomes.

Tissue healing Best (35) reports previous studies by the same research group into the effects on muscle healing of muscle-derived

sportEX dynamics 2015;45(July):18-22

MANUAL THERAPY IN SPORT

stem cells (MDSCs) injected into skeletal and heart muscle. One of the things this does is that the MDSCs produce a group of mitogenetic proteins that can induce proliferation of endothelial cells and regulate formation of new blood vessels. In vitro they investigated the effects of mechanical stimulation via an applied strain force on the production of such proteins and found that it was stimulated. They speculate that the application of force via massage therapy may have the same effect in vivo citing their groups own work in animal studies (15,36,37). This is clearly a promising avenue of research as it suggests a role for massage as a non-invasive therapy to accelerate the healing process. Surgical procedures following injury in sport are common and any intervention that hastens return to play should be considered. One such is manual lymph drainage (MLD). Although this is promoted as a specialist technique it is in reality the application of light compression and a tension force around lymphatic pathways designed to promote lymphatic tissue movement (38). No studies were found that related directly to the postoperative treatment of sports injuries. One paper worth noting, however, found that MLD resulted in significant improvement in post-operative flexion patients following total knee replacement surgery (39). Unfortunately it was rejected from the present study because it includes a combination of standard physiotherapy treatment.

AFTER TRAVEL Although there is research on the debilitating effects of travel on athletic performance (40–42), there is little in the literature to suggest that any form of manual therapy will make a difference (43). It could be argued that research quoted in Part 1 into sleep enhancement, ROM, muscle fatigue and moods states is applicable in the sporting environment.

ADVERSE EFFECTS The diverse claims of massage as a therapeutic treatment may or may not stand up to scrutiny but what is clear from the evidence base is that it rarely

www.sportEX.net

has serious side effects. None of the studies or reviews cited in this article report adverse effects although it is not always clear whether there were no effects or they have not been reported. Ernst (44) concluded that the incidence of adverse effects is unknown but probably low. Ezzo et al. (11) in a study of massage for mechanical neck disorders, an area that is probably the most vulnerable, reported no adverse effects. Cambron et al. (45) in a cross-sectional study of 100 clients of a USA massage clinic reported no major side effects. Some minor discomfort was reported by 10% of the subjects. It should be noted, however, that the therapists used in the study were all students. Posadzki and Ernst (46) in an update of Ernst (44) conducted a systematic review of massage therapy safety and reported 17 case studies of serious adverse effects. Individual examination of these suggests that the patients should not have been receiving the treatment (eg. a 77-yearold man with a history of polycystic kidney disease, coronary artery disease, post-coronary artery bypass graft, hypertension and pulmonary embolism); treatment was applied in the wrong location (eg. DTF for lateral epicondylitis which resulted in posterior interosseous nerve palsy); or the patient received treatments that were described as inappropriately vigorous (eg. a session where a 50-year-old woman received a facial massage during which the therapist rotated the woman’s head to the left, placed her shin on the woman’s shoulder and applied posterior-toanterior pressure against the woman’s forehead). This was then repeated on the right. Later examination revealed stenotic dissection of bilateral internal

carotid and vertebral arteries. None of the serious effects came from a sportrelated background and, despite the examples given, the authors conclusion was that although massage is not entirely free of risk, adverse effects are rare.

CONCLUSION Methodological problems persist, especially concerning the issue of dose. Despite this as Furlan et al. (6) point out, the most natural reaction when experiencing pain is to rub or squeeze the area in order to reduce the unpleasant sensation. There is plenty of evidence to back this statement up and if you combine pain reduction, lymph drainage and the ability to increase joint ROM (reported in Part 1), the possibilities for the use of massage following injury are endless. Overall massage is a safe therapeutic modality with few – if any – risks or adverse effects and when two interventions have been tested and little difference has been found between them it should be remembered that patients express a strong preference for massage (47).

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/1eDluij

FURTHER RESOURCES 1. Duncan R. Myofascial Release. Human

OVERALL, MASSAGE IS A SAFE THERAPEUTIC MODALITY WITH FEW IF ANY RISKS OR ADVERSE EFFECTS. WHEN TWO INTERVENTIONS HAVE BEEN TESTED AND LITTLE DIFFERENCE HAS BEEN FOUND BETWEEN, PATIENTS EXPRESS A STRONG PREFERENCE FOR MASSAGE 21

Kinetics 2014. ISBN 9781450444576 (Kindle £11.99). Buy from Amazon http://spxj.nl/1Qq2IpO 2. Myers TW. Anatomy Trains. Churchill Livingstone 2011. ISBN 9780702046544 (Print £34.47 Kindle £29.09). Buy from Amazon http://spxj.nl/1ePPCXf 3. Granter R. The Massage Therapist’s Survival Guide. Available online from sportEX http://spxj. nl/1KN0LoU 4. Findlay S. Sports Massage. Human Kinetics 2010. ISBN 9780736082600 (Kindle £10.96). Buy from Amazon http://spxj.nl/1Qq3KSJ 5. Fritz S. Sports & Exercise Massage: Comprehensive Care in Athletics, Fitness, & Rehabilitation. Mosby 2012. ISBN 978-0323083829 (Kindle £27.64). Buy from Amazon http://spxj.nl/1HL1a5b 6. Lowe WW. Orthopaedic Massage: Theory and Technique. Churchill Livingstone 2009. ISBN 978-0443068126 (Print £27.39 Kindle £26.02). Buy from Amazon http://spxj.nl/1HL1uAW 7. Riggs A. Deep Tissue Massage: A Visual Guide to Techniques. North Atlantic Books 2007 (Print £24.65 Kindle £17.35). ISBN 978-1556436505. Buy from Amazon http://spxj.nl/1AO8ekn

KEY POINTS nM assage can be used in six contexts in sport: (1) in general conditioning, (2) before sport o r exercise, (3) during competition, (4) after the event or activity, (5) in injury recovery and (6) after travel. n I n injury recovery, massage is not usually used alone, but in combination with other treatment modalities. n Problems with comparing studies mean that it is difficult to define a consistent evidence base, but reviewers have found a trend towards a positive effect of massage for pain, particularly low back pain. nK ong (10) concluded that massage therapy may provide immediate effects for neck and shoulder pain when compared to inactive therapies but no more so than other active therapies. nT he metabolic responses to massage are largely because of mechanical stretch and strain, which is why massage dose is such an important factor. n The characteristic referred pain associated with MTrPs is a result of central sensitisation and hypersensitivity within the same or adjacent spinal segments, which can be mapped in a myotomal and/or dermatomal distribution. n A systematic review into the use of manual therapies in the treatment of MTrPs and concluded that results did not produce rigorous evidence for the efficacy of any of them beyond placebo. However, it was conceded that MTrP treatment is effective in reducing the pressure pain threshold (PPT) and scores on visual analogue scales. n Joseph et al. (32) found that there was evidence of a benefit for elbow conditions when the DTF was given in combination with a Mills manoeuvre and for supraspinatus tendinopathy in the presence of outlet impingement along with joint mobilisation. nS tudies suggest a role for massage as a non-invasive therapy in tissue healing. nA dverse effects associated with massage are rare.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Brosseau et al. agreed that massage therapy is effective at producing pain relief and improving function for LBP. Tweet this: Ischaemic compression is a useful therapeutic modality for treating myofascial trigger points. Tweet this: Tendon problems are thought to be caused by maladaptation to mechanical loading with increased collagen cross-linking. Tweet this: Studies suggest a role for massage as a non-invasive therapy in tissue healing.

nW hat are some of the problems encountered when trying to review the evidence base for the effectiveness of massage? n What are the conclusions for the effectiveness of massage for low back pain? In your own practice, do you use massage alone or in combination with other approaches? n In the treatment of pain, why is ‘dose’ such an important factor? n What treatment modality was found to be effective for treating trigger points and how is it similar to massage? n What effect is massage thought to have on tissue healing? n What is likely to be the main benefit of massage after DISCUSSIONS travel?

THE AUTHOR BOB BRAMAH BSC, MSMA MSMM MCSP Bob is a chartered physiotherapist specialising in sports soft tissue therapy. He has worked in Premiership Rugby and Football and with the GB National teams for Basketball, Volleyball and Wheelchair Rugby and the England Cricket team. In addition to a private practice in Wigan, Bob is a lecturer in Manual Therapy at the University of Salford and is the editor of the Journal Watch section of sportEX. He was a founder member of the Sports Massage Association and is Vice-Chair of the Chartered Society of Physiotherapy professional network for Massage and Soft Tissue Therapy.

sportEX dynamics 2015;45(July):18-22

LITERATURE REVIEW

online

SWEDISH MASSAGE IN A SPORTING CONTEXT

Part 2

References 1. Fritz S. Sports & exercise massage: comprehensive care in athletics, fitness & rehabilitation. Mosby 2012. ISBN 9780323083829. Buy from Amazon http://spxj.nl/1AO8ekn 2. Lewis M, Johnson M I. The clinical effectiveness of therapeutic massage for musculoskeletal pain: a systematic review. Physiotherapy 2006;92(3):146– 158 3. Tsao JC. Effectiveness of massage therapy for chronic, non-malignant pain: a review. EvidenceBased Complementary and Alternative Medicine 2007;4(2):165–179 4. Daniels JM, Pontius G, et al. Evaluation of low back pain in athletes. Sports Health: A Multidisciplinary Approach 2011;3(4):336–345 5. Brosseau L, Wells GA, et al. Ottawa Panel evidencebased clinical practice guidelines on therapeutic massage for low back pain. Journal of Bodywork and Movement Therapies 2012;16(4):424–455 6. Furlan AD, Imamura M, et al. Massage for low back pain: an updated systematic review within the framework of the Cochrane Back Review Group. Spine (Phila Pa 1976). 2009;15;34(16):1669–1684 7. Kumar S, Beaton K, Hughes T. The effectiveness of massage therapy for the treatment of nonspecific low back pain: a systematic review of systematic reviews. International Journal of General Medicine. 2013;4;6:733–741 8. Brosseau L, Wells GA, et al. Ottawa Panel evidencebased clinical practice guidelines on therapeutic massage for neck pain. Journal of Bodywork and Movement Therapies 2012;16(3):300–325 9. van den Dolder PA, Ferreira PH, Refshauge KM. Effectiveness of soft tissue massage and exercise for the treatment of non-specific shoulder pain: a systematic review with meta-analysis. British Journal of Sports Medicine 2014; 48(16):1216–1226 10. Kong LJ, Zhan HS, et al. Massage therapy for neck and shoulder pain: a systematic review and metaanalysis. Evidence-Based Complementary and Alternative Medicine 2013;2013:613279 11. Ezzo J, Haraldsson BG, et al. Massage for mechanical neck disorders: a systematic review. Spine (Phila Pa 1976) 2007;1;32(3):353–362 12. Field T, Diego M, et al. Hand pain is reduced by massage therapy. Complementary Therapies in Clinical Practice 2011;17(4):226–229 13. Brooks CP, Woodruff LD, et al. The immediate effects of manual massage on power-grip performance after maximal exercise in healthy adults. Journal of Alternative and Complementary Medicine 2005;11:1093–1101 14. Young R, Gutnik B, et al. The effect of effleurage massage in recovery from fatigue in the adductor muscles of the thumb. Journal of Manipulative and Physiological Therapeutics 2005;28:696–701 15. Crane JD, Ogborn DI, et al. Massage therapy attenuates inflammatory signaling after exerciseinduced muscle damage. Science Translational Medicine 2012;4(119):119–113 16. Sefton JM, Yarar C, et al. Physiological and clinical changes after therapeutic massage of the neck and shoulders. Manual Therapy 2011;16(5):487–494 17. Behm DG, Peach A, et al. Massage and stretching

www.sportEX.net

reduce spinal reflex excitability without affecting twitch contractile properties. Journal of Electromyography and Kinesiology 2013;23(5):1215–1221 18. Simons DG. Understanding effective treatments of myofascial trigger points. Journal of Bodywork and Movement Therapies 2002;6(2):81–88 19. Fryer G, Hodgson L. The effect of manual pressure release on myofascial trigger points in the upper trapezius muscle. Journal of Bodywork and Movement Therapies 2005;9(4):248–255 20. Gerwin R. Myofascial pain syndrome: here we are, where must we go? Journal of Musculoskeletal Pain, 2010;18(4):329–347 21. Simons DG, Travell JG. Travell and Simon’s myofascial pain and dysfunction: upper half of body volume 1: the trigger point manual 2nd edn. Lippincott, Williams & Wilkins 1998. ISBN 978-0683083637. Buy from Amazon http://spxj.nl/1RLHfu1 22. Simons DG. Review of enigmatic MTrPs as a common cause of enigmatic musculoskeletal pain and dysfunction. Journal of Electromyography and Kinesiology 2004;14(1):95–107 23. Gerwin RD. The taut band and other mysteries of the trigger point: An examination of the mechanisms relevant to the development and maintenance of the trigger point. Journal of Musculoskeletal Pain 208;16:115–121 24. Rickards LD. The effectiveness of non-invasive treatments for active myofascial trigger point pain: A systematic review of the literature. International Journal of Osteopathic Medicine 2006;9:120–136 25. Fernández de las Penas CF, Sohrbeck Campo M, et al. Manual therapies in myofascial trigger point treatment: A systematic review. Journal of Bodywork and Movement Therapies 2005;9(1):27–34 26. Hou CR, Tsai LC, et al. (2002). Immediate effects of various physical therapeutic modalities on cervical myofascial pain and trigger-point sensitivity. Archives of Physical Medicine and Rehabilitation 2002;83(10):1406–1414 27. Chatchawan U, Thinkhamrop B, et al. Effectiveness of traditional Thai massage versus Swedish massage among patients with back pain associated with myofascial trigger points. Journal of Bodywork and Movement Therapies 2005;9(4):298–309 28. Fernández-de-las-Peñas C, Alonso-Blanco C, et al. The immediate effect of ischemic compression technique and transverse friction massage on tenderness of active and latent myofascial trigger points: a pilot study. Journal of Bodywork and Movement therapies, 2006;10(1):3–9 29. Hains G, Descarreaux M, Hains F. Chronic shoulder pain of myofascial origin: a randomized clinical trial using ischemic compression therapy. Journal of Manipulative and Physiological Therapeutics 2010, 33:362–369 30. Bron C, De Gast A, et al. Treatment of myofascial trigger points in patients with chronic shoulder pain: a randomized, controlled trial. BMC medicine 2011;9(1):8 31. Moraska AF, Hickner R.C, et al. Changes in blood flow and cellular metabolism at a myofascial trigger point with trigger point release (ischemic compression): a proof-of-principle pilot study. Archives of Physical Medicine and Rehabilitation 2013;94(1):196–200

32. Joseph MF, Taft K, et al. Deep friction massage to treat tendinopathy: a systematic review of a classic treatment in the face of a new paradigm of understanding. Journal of Sport Rehabilitation 2012;21(4):343–353 33. Cyriax J. Textbook of orthopaedic medicine. Volume 2: treatment by manipulation, massage and injection, 11th edn. Baillière Tindall 1984. ISBN 9780702010378. Buy from Amazon http://spxj.nl/1M7bsQw 34. Elliott R, Burkett B. Massage therapy as an effective treatment for carpal tunnel syndrome. Journal of Bodywork and Movement Therapies 2013;17(3):332–338 35. Best TM, Gharaibeh B, Huard J. Stem cells, angiogenesis and muscle healing: a potential role in massage therapies? British Journal of Sports Medicine 2013;47(9):556–560 36. Haas C, Butterfield TA, et al. Dose-dependency of massage-like compressive loading on recovery of active muscle properties following eccentric exercise: rabbit study with clinical relevance. British Journal of Sports Medicine 2012;47(2):83–88 37. Haas C, Butterfield TA, et al. Massage timing affects postexercise muscle recovery and inflammation in a rabbit model. Medicine & Science in Sports & Exercise, 2012;45(6):1105 38. French R. The complete guide to lymph drainage massage. Cengage Learning 2011. ISBN 978-1439056714. Buy from Amazon http://spxj.nl/1HM9Zvs 39. Ebert JR, Joss B, et al. Randomized trial investigating the efficacy of manual lymphatic drainage to improve early outcome after total knee arthroplasty. Archives of Physical Medicine and Rehabilitation 2013;94(11):2103–2111 40. Youngstedt SD, O’Connor PJ. The influence of air travel on athletic performance. Sports Medicine 1999;28(3):197–207 41. Bishop D. The effects of travel on team performance in the Australian national netball competition. Journal of Science and Medicine in Sport 2004;7(1):118–122 42. Leatherwood WE, Dragoo JL. Effect of airline travel on performance: a review of the literature. British Journal of Sports Medicine 2013;47(9):561–567 43. Straub WF, Spino MP, et al. The effect of chiropractic care on jet lag of Finnish junior elite athletes. Journal of Manipulative and Physiological Therapeutics 2001;24(3):191–198 44. Ernst E. The safety of massage therapy. Rheumatology 2003;42(9):1101–1106 45. Cambron JA, Dexheimer J, Coe P. Changes in blood pressure after various forms of therapeutic massage: a preliminary study. Journal of Alternative & Complementary Medicine 2006;12(1):65–70 46. Posadzki P, Ernst E. The safety of massage therapy: an update of a systematic review. Focus on Alternative and Complementary Therapies 2013;18(1):27–32 47. Hanley J, Stirling P, Brown C. Randomised controlled trial of therapeutic massage in the management of stress. British Journal of General Practitioners 2003;53:20–25.

MANUAL THERAPY IN SPORT

DEVELOPING AN INTERDISCIPLINARY APPROACH TO THE PHYSICAL THERAPY SERVICES AT THE LONDON 2012 OLYMPIC AND PARALYMPIC GAMES At the London 2012 Olympic and Paralympic Games, the interdisciplinary Physical Therapy Service was provided by chiropractors osteopaths, physiotherapists and sports massage practitioners. This article describes how the service was created and delivered, and discusses an analysis of the medical records data. BY LYNN BOOTH MSC, MCSP AND NICK MOONEY BSC DIP SMRT, MSMA

BOX 1: MEMBERS OF THE PHYSICAL THERAPY SERVICES CLINICAL WORKSTREAM. (L. Booth, 2013)

INTRODUCTION

Jonathan Betser:

osteopath (dec. December 2011)

As far as we are aware, London 2012 was the first Olympic and Paralympic Games where four discrete disciplines, chiropractic, osteopathy, physiotherapy and sports massage, worked as one service. Chiropractic and osteopathy had not been a core service offered at previous Games by the Organising Committee of the Olympic Games (OCOG). Although sports massage had been provided at previous Games, London 2012 was the first time that the service had come under the auspices of the OCOG Medical Services. Meetings of the Physical Therapy Services Clinical Workstream commenced in May 2009, with representatives from all four disciplines involved in planning the physical therapies service (Box 1). The Workstream members brought experience of previous Olympic and Paralympic Games, working within elite sport, coordinating previous multisport Games, and knowledge of their own professional and regulatory bodies and relevant legislation within the UK. The Workstream set out to provide an interdisciplinary approach to treatment, in which the four professions completely integrated to provide the best possible service to the athletes.

Lynn Booth:

physiotherapist and clinical lead

Helen Bristow: physiotherapist Lynda Daley: physiotherapist Tom Greenway: chiropractor Simeon Milton:

osteopath (joined January 2011)

Linda Norfolk: physiotherapist Paul Medlicott:

sports massage practitioner

Nick Mooney:

sports massage practitioner (joined January 2012)

Therapy Service Games Makers providing treatment (chiropractors, osteopaths and physiotherapists) to be registrants of the appropriate UK regulatory body and have professional liability insurance to a minimum of £5 million. Sports massage practitioners were required to have a minimum of £2 million. In the UK, chiropractors, osteopaths and physiotherapists have primary diagnostician or ‘first contact’ practitioner status, allowing direct access (self-referral) to their services.

SPORTS MASSAGE HAD BEEN PROVIDED AT PREVIOUS GAMES, BUT LONDON 2012 WAS THE FIRST TIME THAT THE SERVICE HAD COME UNDER THE AUSPICES OF THE OCOG MEDICAL SERVICES

POLICY AND RECRUITMENT The London Organising Committee for the Olympic Games and Paralympic Games (LOCOG) required all Physical www.sportEX.net

THE WORKSTREAM SET OUT TO PROVIDE AN INTERDISCIPLINARY APPROACH TO TREATMENT, IN WHICH THE PROFESSIONS COMPLETELY INTEGRATED TO PROVIDE THE BEST POSSIBLE SERVICE TO THE ATHLETES The International Olympic Committee (IOC) Medical Commission insisted that chiropractors and osteopaths in the core Physical Therapy Service could only be based in the Polyclinics (rather than at venues) and that they must forgo the ‘first contact’ practitioner status. This meant that all athletes had to be assessed by either a physiotherapist or sports medicine doctor before being referred to a chiropractor or osteopath and that before any subsequent treatment for the same condition they had to be reassessed by the same physiotherapist or sports medicine doctor or by the lead physiotherapist working on that shift. This policy was explained at length to all the physical therapy practitioners at the LOCOG training days. In practice, the physiotherapist and chiropractor or osteopath used joint consultations to prevent the athlete being overassessed. The policy was implemented because it was the first Games to involve chiropractors and osteopaths as part of the OCOG Medical Services, but it should be reviewed for future Games as at times it was excessive (and occasionally frustrating and unnecessary) for the

athletes – especially if the athlete was accustomed to being treated by a chiropractor or osteopath. However, the policy definitely helped with communication between the professions and improved the teamwork and understanding of each profession’s skill set. Without an overview, usually from the lead physiotherapist on each shift, there was the danger of each practitioner running separate clinics within the Polyclinic, rather than working in a true interdisciplinary practice. We believe we succeeded in providing an interdisciplinary service most of the time. The sports massage practitioners (SMPs) were required to be qualified and experienced enough to be able to meet the membership requirements of the Sports Massage Association (SMA) and abide by the SMA code of practice, although they were not required to be SMA members. SMPs also worked to a restricted remit: the term sports massage practitioner was used rather than sports massage therapist or soft tissue therapist to indicate that they would not be involved in providing injury treatment, but would provide pre-, inter- and post-event massage as part of an athlete’s preparation and/or recovery. All aspects of treatment were

provided by chiropractors, osteopaths or physiotherapists even though all SMPs were qualified to provide treatment massage and some were also qualified in additional skills such as taping and strapping. On the understanding of the restricted practice, the IOC Medical Commission and LOCOG allowed athletes to self-refer directly to the sports massage service. All four disciplines worked in the three Polyclinics in the Olympic, Rowing and Sailing Villages. Physiotherapists and SMPs also worked at the competition and training venues. If a prospective Games Maker (the name given to London 2012 volunteers) applied to be a chiropractor, osteopath, physiotherapist or SMP they were emailed an electronic application form. This form asked specific questions about their professional registration, qualifications and experiences in sport. Curriculum vitae were not accepted. Over 3,000 people initially applied to be Games Makers (105 for chiropractic, 96 for osteopathy, 1,762 for physiotherapy and 1,082 for sports massage). The 3,000 applications were reviewed and either invited to interview or returned to the main volunteer site to be reallocated to another Games Maker role. LOCOG interviewed all prospective Games Makers. However, the interview was generic, with questions aimed at assessing the LOCOG ‘values’. The Physical Therapy Service initially discussed having a practical element to the interviews but this was not considered feasible. It was agreed that if the Physical Therapy Service wished to make the interview more profession-specific, the interviewers would have to be from that profession. A total of twenty-seven people, all with experience of working within elite and/ or professional sport, volunteered to help with the interviews. It was decided that all interviewees living in the catchment area for interview at Excel (in London) would have a face-to-face interview whereas those interviewees living outside London would have a telephone interview. The Physical Therapy Service interview followed the same format as the LOCOG generic interviews with two of the questions modified to sportEX dynamics 2015;45(July):23-29

MANUAL THERAPY IN SPORT

STAFFING LOGISTICS AND THE WORKING ENVIRONMENT The Physical Therapy Service at Stratford Polyclinic required a lot of space and was spread across three floors; this was not ideal but was the most effective use of space. The basement contained the hydrotherapy pool, ice baths and anti-gravity treadmills. The first floor had the treatment rooms for chiropractors, osteopaths and physiotherapists and a rehabilitation gym. The sports massage service was on the second floor. Discussions held before the Games about practitioners moving to the patient, rather than the patient moving between providers, ensured that athletes avoided moving between floors www.sportEX.net

as much as possible. The Rowing Polyclinic was based in student accommodation, and the Physical Therapy Services had to work within the confines of smaller rooms – converting a communal kitchen area for students into a small rehabilitation gymnasium. Temporary walls had to be built at the Sailing Village Polyclinic to provide visual privacy for the athletes receiving treatment. The three Polyclinics provided a physical therapy service between 07.00 and 23.00 daily, with all four disciplines [chiropractors, osteopaths, physiotherapists and sports massage practitioners (C.O.P.S.)] being available during this time. An appointment and drop-in service operated at all times; the waiting time for treatment was always less than 15 minutes, with most athletes seen on arrival. Figure 1 shows the average daily demand throughout the Games. On occasions, the service could have continued beyond 23.00, but after this time treatment was only provided to athletes with acute injuries referred from the medical staff at the competition venues. The two-shift pattern of 06.30–15.15 and 14.30–23.15 caused some problems, with the highest demand for services occurring in the cross-over period. More staff were available at this time but it did complicate the hand-over. The treatment area for the chiropractors, osteopaths and physiotherapists had single consulting rooms giving auditory and visual privacy and a more open-plan area where beds were separated by curtains – giving visual privacy. In practice, these curtains were often not used and the space became an open-plan treatment area. A true interdisciplinary working environment ensued with informal inservice training in quieter times. In the Rowing & Canoe Sprint and Sailing Villages all the medical services worked in very close proximity. In the Stratford Polyclinic, the chiropractors, osteopaths and physiotherapists worked on the same floor as the sports medicine doctors and the imaging department, which allowed easy access to other professionals. The sports massage service was provided on the second floor which meant that

Olympic games

500

Paralympic games

450 Total number of medical encounters

be more clinical in nature (1). Greater consideration was given to how interviewees answered the clinical questions. Anecdotally, the interview score tended to be a good reflection of the Games Makers’ clinical abilities and their ability to work within a high pressure team environment: implying that the interview process was able to identify suitable Games Makers for the Physical Therapy Service. Using the profession-specific interview forms and the results from their interviews, physiotherapists and SMPs were allocated to a Polyclinic or a sport that best suited their abilities and LOCOG’s needs. In most cases, a Games Maker with experience of working with an Olympic or Paralympic sport at elite level was asked to work with that sport. To ensure a variety of experiences for all Games Makers, those working with individual sports were rostered to work at both the training and competition venues. Workbooks were provided for the Games Makers with role-specific and venue-specific information relating to the Physical Therapy Services as a whole rather than to the four individual disciplines. As an electronic medical records system was used during the Games, the Workstream produced a booklet of anatomical abbreviations and glossary of terms to provide consistent terminology in the treatment notes – important when the service had four separate disciplines.

400 350 300 250 200 150 100 50 0

13 14 15 16 Time of day (h)

Figure 1: Stratford Polyclinic Physical Therapy Services activity by time of day. (N. Mooney, 2013)

all four disciplines from the Physical Therapy Services were close enough for consultation and referral between practitioners to occur. However, it discouraged any sports massage inservice training for the chiropractors, osteopaths and physiotherapists. It was mutually beneficial for individual practitioners to interact with colleagues from other backgrounds. ”I’m embarrassed to admit that my view of osteopaths and chiropractors was not the best, based on the general feeling in the physiotherapy world but, having worked with you, [name], I can honestly say my view has completely changed. I hope to work in more teams with such a good skill mix as I think it makes us all better clinicians” (a physiotherapy Games Maker) Quick referral from one sports medicine service to another led to the possibility of exacerbating the injury due to overassessing or over-treating the athletes as they were transferred from one professional to another: an unforeseen consequence of the multidisciplinary environment. This was particularly relevant when assessing acute injuries. When the history of injury suggested that other sports medicine services might be required, it became prudent to involve relevant personnel in combined consultations before starting the full assessment. Over-treating athletes was also a possibility because of the number of practitioners involved: most Games Makers volunteered for 10 days across a variety of shift patterns. An athlete could be treated by many different 25

AS AN ELECTRONIC MEDICAL RECORDS SYSTEM WAS USED DURING THE GAMES, THE WORKSTREAM PRODUCED A BOOKLET OF ANATOMICAL ABBREVIATIONS AND GLOSSARY OF TERMS TO PROVIDE CONSISTENT TERMINOLOGY IN THE TREATMENT NOTES practitioners – each re-assessing and modifying treatment. This possibility was overcome by regular discussions between practitioners as the athlete’s care was handed over. The staff rosters tried to take into account the need to provide an excellent clinical service for the athletes while providing a rewarding experience for the individual Games Makers. Rostering took the following considerations into account: n The Games Makers: - Previous experience of working with a particular sport - Sports-trauma experience and certification - Experience in other aspects of their profession, eg. amputees, neurology n If working with a particular sport, the opportunity to be involved at both the training and competition venues n Wherever possible, Game Makers

with experience of working at a high level of sport were rostered to the opening days of that particular sport’s competition and training venues and to the three Polyclinics n Whether the Games Makers were living away from home or were based more locally. Placing the physiotherapy Games Makers with a sport they were familiar with allowed them to educate others on the international governing body rules regarding entry onto the field of play and the type of strapping, etc., that could be used for competition. This was effective, although the shift system meant that the more experienced Games Maker did not always come into contact with the less experienced. Some of the sports required specific skills. Physiotherapists working with contact and collision sports had to be familiar with treating acute contact injuries in a high pressure situation – making decisions regarding continuing or withdrawing an athlete from the competition arena (not necessarily from the competition itself) and being confident to enter the field of play as a first contact practitioner before the emergency medical services were summoned. Providing cover at training venues for most of the team sports required physiotherapy Games Makers with sports-trauma experience and certification. The issues with the shift pattern did not arise for the chiropractors and osteopaths. One chiropractor and one osteopath for each Polyclinic shift, with the lead chiropractor and lead osteopath available to provide extra cover at the Stratford Polyclinic, was appropriate for the demand. Extra physiotherapy and sports massage Games Makers were rostered to the Stratford Polyclinic to act as back-up to replace staff at training and competition venues who were unable to fulfil their shifts or to supplement existing staff when the demand exceeded the number of people rostered, eg. when the International Fencing Federation requested that additional physiotherapists be available in the competition arena. Providing they had suitable qualifications, Games

Makers from all four Physical Therapy Service disciplines were also used to provide additional cover as First Responders (first-aiders for spectators) in the Olympic Park and at some competition venues – particularly during the Paralympic Games, when spectator numbers were suddenly increased to meet demand. Although the Games Makers were happy to help provide this cover and the number of Games Makers rostered for the Polyclinic had anticipated this eventuality, the number required to go out to other venues did occasionally place a strain on Physical Therapy Services at the Stratford Polyclinic. The number of Physical Therapy Services staff at the competition and training venues varied depending on the sport and the number of competing athletes. There was always at least one physiotherapist present, but the type of service normally required by a particular sport was taken into account and at some venues there were more SMPs than physiotherapists per shift. Athletics at the Olympic Stadium (including the warm-up track and callup room) had the largest number of Physical Therapy Services staff at a venue: on the busiest shifts there were eight physiotherapists and six SMPs per shift at the Olympic Games. Some venues may at times have appeared to have been over-staffed – it was not possible to predict the volume of athletes presenting with injuries or the severity of those injuries and it was important to ensure that there was always adequate cover. There were over 200 Physical Therapy Services Games Makers based at the Stratford Polyclinic during the Olympic Games and over 110 during the Paralympics. They provided clinical cover at the Stratford Polyclinic, at training venues for team sports and at other competition and training venues, requiring extra clinical cover. This organisation would not have been possible without the lead clinical staff from each physical therapy discipline volunteering to be available for large portions of both Games. Either the lead chiropractor or the lead osteopath, and sometimes both, attended the Stratford Polyclinic every day from 9 July until 12 September. The two lead sportEX dynamics 2015;45(July):23-29

MANUAL THERAPY IN SPORT

physiotherapists and the lead sports massage practitioner volunteered to work from the 15 July until the 12 September, having approximately 1 day off in every 7 or 8 days and a 5-day break between the two Games. This degree of cooperation was an important part of integrating the four disciplines into the Physical Therapy Service and helped to make the service provision effective. The Physical Therapy Service Games Makers were also involved in interdisciplinary work with other medical Games Makers. At the competition venues, the entire athlete medical team worked well together. Field-ofplay (FOP) physiotherapists, nurses and doctors, interacted well with the physiotherapists, sports medicine doctors and SMPs based in the Athlete Medical Rooms: working together on possible injury/recovery/treatment scenarios, ‘what if’s’ and continued professional development (CPD) sessions. Most practitioners seemed to use their spare time as an opportunity for collaborative working and discussions. Hopefully even the Games Makers who were not particularly busy treating athletes will have gained valuable professional development from their Games time experience. Practitioners attending the Games from countries with limited sports medicine education worked with Games Makers from all four disciplines of the Physical Therapy Services to treat their own athletes while gaining some CPD themselves – including returning postcompetition for rehabilitation advice.

POST-EVENT DATA ANALYSIS The Olympic Games dataset contains 9,257 medical encounters for chiropractors, osteopaths, physiotherapists and SMPs (Table 1), of which 8,972 were from the ‘injury/ musculoskeletal diagnosis’ category. There are a further 7,941 encounters which may have been undertaken by Physical Therapy Services Games Makers – although some of the encounters could have been undertaken by other medical services staff. There is a high probability that at most training venues the encounter was performed by a physiotherapist www.sportEX.net

or a sports massage practitioner. This could account for an additional 1,500–2,000 records. The Paralympic Games dataset contains 4,295 medical encounters for chiropractors, osteopaths, physiotherapists and SMPs (Table 1): by the Paralympic Games we had identified that in the electronic medical records system, the ‘provider’ field required manual input by volunteers and additional training ensured that this dataset was more accurate. A large percentage of athletes arrived at the Games with pre-existing injuries that required treatment before competition and whom may then have required treatment and advice for longterm issues (Table 2). It is difficult to look at the ratio of staff numbers against activity per day. Figure 4 shows the number of encounters per physical therapy discipline in the Stratford Polyclinic, using the number of physiotherapists and SMPs rostered to the Polyclinic – although many of the physiotherapy and some SMPs would have been working away from the Polyclinic at training (and some competition) venues and joint consultations between disciplines would only record the lead practitioner’s profession. Hence, the graph is not quite a true reflection of work activity per practitioner through a typical shift. Figures 5 and 6 show the average daily activity for all four Physical Therapy Service disciplines based at the Olympic Village (Stratford) Polyclinic during the Olympic and Paralympic Games.

TABLE 1: C.O.P.S. OLYMPIC AND PARALYMPIC GAMES MEDICAL ENCOUNTERS. (N. Mooney, 2013)

Olympic Games

Paralympic Games

Chiropractor 518

328

Osteopath 587

324

Physiotherapist 4810

1871

Sports massage practitioner 3342

1772

Grand total

4295

9257

Chiropractor

Osteopath

Physiotherapist

Sports massage practitioner

Osteopath, 587, 6% Physiotherapist, 4810, 52%

Chiropractor, 518, 6%

Sports massage practitioner 3342, 36%

Figure 2: Clinical contacts for the four Physical Therapy Service disciplines at the Olympic Games. (N. Mooney, 2013)

Chiropractor

Osteopath

Physiotherapist

Sports massage practitioner

Osteopath, 324, 7% Physiotherapist, 1871, 41%

Chiropractor, 328, 8%

Sports massage practitioner 1772, 44%

Figure 3: Clinical contacts for the four Physical Therapy Service disciplines at the Paralympic Games. (N. Mooney, 2013)

TABLE 2: SYMPTOMS ONSET. (N. Mooney, 2013) Medical category Chief complaint Providers Symptoms onset

Athletes only used for this analysis

Athletes Injury C.O.P.S.

Only chief complaint listed as injury used in this analysis Chiropractor, Osteopath, Physiotherapist & SMPs only

Olympic Games

Paralympic Games

Grand total

01 Pre-Games

897 (47%)

246 (48%)

1143 (47%)

02 Training

695 (36%)

220 (43%)

915 (38%)

03 Pre-comp. warm-up

97 (5%)

9 (2%)

106 (4%)

04 Competition

182 (9%)

22 (4%)

204 (8%)

05 Other

40 (2%)

15 (3%)

55 (22%)

1911

512

2423

Grand total

GOING FORWARD Post-Games, all Physical Therapy Service Games Makers were encouraged to record their Games experiences for CPD purposes. The Chartered Society of Physiotherapy (CSP) produced a template, which they shared with the other professions to help with this record keeping. At the first Games where all four disciplines worked as one service, verbal feedback from providers and participants showed that the interdisciplinary environment was a success for athletes and Games Number of encounters per therapist in Stratford Athletes’ Village Polyclinic Chiropractor

Osteopath

Physiotherapist

Sports massage practitioner

12 10 8 6 4 2

In particular, a huge ‘thank you’ goes to: n Helen Bristow (physiotherapist & LOCOG trail blazer) n Lynda Daley (physiotherapist & VMM at North Greenwich Arena) n Tom Greenway (lead chiropractor)

n Simeon Milton (lead osteopath) n Nick Mooney (lead sports massage practitioner) n Nicki Phillips (lead physiotherapist at Stratford Polyclinic) n Julie Sparrow (lead physiotherapist at Stratford Polyclinic). Without them, the whole Physical Therapy Service would never have worked.

ACKNOWLEDGMENT This article is taken from the London 2012 Olympic and Paralympic Games: Physical Therapy Services Report and is reproduced here with permission. References 1. Phillips N, Grant ME, Booth L, Glasgow P. Using criteria-based interview models for assessing clinical expertise to select physiotherapists at major multisport games. British Journal of Sports Medicine 2015;49(5):312–317.

/7 17 /12 /7 18 /12 /7 19 /12 / 20 7/1 /7 2 21 /12 / 22 7/12 / 23 7/12 / 24 7/1 / 2 25 7/1 / 2 26 7/1 / 2 27 7/12 / 28 7/1 / 2 29 7/1 / 2 30 7/12 /7 31 /12 /7 / 1/8 12 2/ /12 8/ 3/ 12 8 4/ /12 8 5/ /12 8 6/ /12 8/ 7/ 12 8 8/ /12 8 9/ /12 10 8/12 /8 11/ /12 8 12 /12 /8 13 /12 /8 14 /12 /8 /12

Number of encounters per therapist

Makers. This success was based on the good humour and accommodating nature of the Games Makers, who used their combined expertise to provide a service they can be very proud of. Hopefully the Games Makers have taken their experiences and enthusiasm from the Games and continue to work in a sporting environment – whether at grass-roots or elite level. During the Paralympics, many Games Makers expressed an interest to become more involved with working with Paralympic sport. It is imperative that the four professions capitalise on this enthusiasm and ensure that appropriate education programmes, mentoring and opportunities are provided in order to fulfil this legacy.

Date

Figure 4: Encounters per Physical Therapy Service discipline in the Polyclinic at the Olympic Village (Stratford). (N. Mooney, 2013)

250 Total number of medical encounters

Chiropractor

Osteopath

Physiotherapist

Sports massage practitioner

200

150

100

13 14 15 16 Time of day (h)

Figure 5: Stratford Polyclinic within-day activity at the 2012 Olympic Games. (N. Mooney, 2013) Chiropractor

Osteopath

Physiotherapist

Sports massage practitioner

Total number of medical encounters

160 140 120 100 80 60 40 20 0

14 15 16 Time of day (h)

Figure 6: Stratford Polyclinic within-day activity at the 2012 Paralympic Games. (N. Mooney, 2013)

THE AUTHORS LYNN BOOTH MSc, MCSP Lynn Booth MSc, MCSP has an MSc in Sports Injury and Sports Therapy from Manchester Metropolitan University and an Honorary Fellowship from the University of Central Lancashire. She is a member of the Association of Chartered Physiotherapists in Sports Medicine (having held a variety of posts over the years) and is a Board member of the Sports Massage Association. Lynn chaired the British Olympic Association’s (BOA’s) Physiotherapy Committee, becoming the BOA’s physiotherapy consultant (1992–2004). She was the Great Britain Women’s Hockey Squad physiotherapist at the 1988 and 1992 Olympics and was Team GB Head Physiotherapist at the 1996, 2000 and 2004 Summer Olympic Games. She was Physical Therapy Services clinical lead for the London Organising Committee of the Olympic Games and Paralympic Games (LOCOG), clinical medical manager at the 2014 Commonwealth Games and lead physiotherapist at the 2015 European Games. Her main clinical interests are injury prevention and management and functional rehabilitation. She currently works with the National Age Group Squads of England Hockey. NICK MOONEY BSc Dip SMRT, MSMA Nick Mooney BSc Dip SMRT, MSMA had an eclectic career ranging from research chemistry to European weather risk management, and then retrained and qualified in Sports Massage & Remedial Therapy at the London School of Sports Massage (LSSM) in 2005. Since 2006 he has been a tutor at the North London School of Sports Massage (NLSSM) teaching Sports and Remedial Massage Therapy and is currently lead marker for the BTEC Level 5 Diploma Course. He was clinical lead for sports massage at the London 2012 Olympic and Paralympic games, venue medical manager for gymnastics at Glasgow 2014 Commonwealth Games and is lead sports massage practitioner for the Baku 2015 European Games.

sportEX dynamics 2015;45(July):23-29

MANUAL THERAPY IN SPORT

KEY POINTS n I t is thought that the London 2012 Olympic and Paralympic Games were the first Games where four discrete disciplines, chiropractic, osteopathy, physiotherapy and sports massage, worked as one interdisciplinary service. nJ oint consultations with practitioners from different disciplines were used to prevent over-assessment of the athlete and to provide a more interdisciplinary approach to injury management. nT o ensure a variety of experiences for all Games Makers, those working with individual sports were rostered to work at both the training and competition venues. nT he Stratford Polyclinic was spread over five floors. To keep unnecessary movement of the athletes to a minimum it was decided that practitioners would move to patients. nS taffing was provided through a two-shift pattern. However, peak demand occurred at the cross-over period and complicated the handover. n I t was mutually beneficial for individual practitioners to interact with colleagues from other backgrounds. nA lthough rooms were available for private consultations, openplan treatment areas provided an environment which encouraged interdisciplinary practice. nV erbal feedback from providers and participants showed that the interdisciplinary environment was a success for athletes and Games Makers.

www.sportEX.net

n T he IOC Medical Commission insisted that chiropractors and osteopaths forgo their â&#x20AC;&#x2DC;first contactâ&#x20AC;&#x2122; practitioner status. This policy could be viewed as frustrating, but what were some of the benefits to arise from it? nD iscuss how the working environment and practices resulted in the provision of an interdisciplinary service. nW hat improvements might be made for the provision of Physical Therapy DISCUSSIONS Services for the next Games?

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: London 2012 was the first time that sports massage had come under the auspices of the OCOG Medical Services. Tweet this: It is beneficial to interact with colleagues from other backgrounds. Tweet this: Beware of over-treating athletes in a multi-practitioner environment.

TREATING MYOFASCIAL PAIN WITH MYOFASCIAL TRIGGER POINT DRY NEEDLING This article discusses the role of dry needling in the effective treatment of myofascial trigger points specifically and chronic pain states generally. The article details when dry needling is suitable but, more importantly, when it is contraindicated. A special emphasis is placed on the safety of the patient and the interests of the sportEX reader. The author highlights the need for tutors of dry needling to have an excellent knowledge of anatomy giving examples of why this is vitally important. BY JOHN SHARKEY BSC MSC

he term ‘dry needling’ means different things to different therapists. To ensure clarity within this article the term ‘dry needling’ refers specifically to the use of a solid filament needle for the identification and exclusive treatment of myofascial trigger points. Myofascial trigger point dry needling involves the insertion

RESEARCH HAS CHANGED THE WAY WE THINK ABOUT PAIN. PAIN IS A CHILD OF THE BRAIN. TO FULLY UNDERSTAND PAIN WE MUST MEET THE ENTIRE FAMILY BOX 1: NATIONAL TRAINING CENTRE GUIDELINES FOR SAFE NEEDLE APPLICATION. [Reproduced with permission from the National Training Centre (14)] Place the delivery tube against the skin and release the needle. Firmly tap the needle into the tissue/target muscle. Remove the delivery tube and place between your fingers. Use straight in and out motions to direct the needle to its target. Elicit a twitch response and eliminate all twitch responses. Avoid bending the needle and avoid inserting the needle completely while keeping a firm grip on the needle handle. If you wish to redirect the needle withdraw to just below the skin and redirect. Always finish with the application of ischaemic pressure (homeostasis). Treat and eliminate all myofascial trigger points in the target muscle/s.

of a solid filament needle into the skin, which continues into muscle fibres housing the intended target/s (Box 1) (Fig. 1). The needle becomes an extension of the listening fingers providing a unique opportunity to confirm the presence of, and provide treatment for, myofascial trigger points. More and more therapists are becoming increasingly interested in introducing dry needling techniques to their clinical practice. The older and wiser therapist wishes to remove the strain and subsequent joint pain that inevitably arises from using their fingers and thumbs over many years. Younger, upcoming therapists aspire to a long pain-free career. Numerous clinical studies support the therapeutic benefit of dry needling. Take, for example, the case of a 28-year-old female patient with a history of a left axillary vein thrombosis, a subsequent venoplasty, and a trans-axillary resection of the left first rib. The patient experienced chronic chest pain with accompanied left upper limb and hand pain. From the beginning, the symptoms were thought to be the result of traction on the intercostobrachial nerve, rotator cuff atrophy, Raynaud’s phenomenon and the possibility of scarring around the C8/T1 nerve root. A myofascial trigger point specialist identified left pectoralis major muscle myofascial trigger points. The patient received two short treatments of dry needling and after a couple of weeks this, combined with a home stretching programme and one additional treatment, the symptoms

were resolved (1).

WHY CONSIDER MYOFASCIAL TRIGGER POINT DRY NEEDLING Dry needling is an effective treatment of myofascial trigger points and chronic pain of neuropathic origin. Dry needling has been demonstrated to have few side effects. This technique is unequalled in eliminating neuromuscular dysfunction of myofascial trigger point origin resulting in pain, functional adaptations and neuromuscular deficits. I urge all doctors and surgeons to take the time to become familiar with myofascial trigger points. In clinical practice, pain management – or the eradication of pain – is the focus for many patients and health care practitioners. It is worth noting that changes in sensation, such as a constant itch, numbness, tingling, burning, crawling or feelings of water running on skin are all components across the spectrum of pain. These are real sensations that patients feel on an ongoing daily basis, and for some, 24 hours a day every day. Not necessarily a pain per se but rather a variation on the theme of pain. A pain experienced radiating down the anterior upper limb terminating in the wrist and palm connotes a brachial nerve insult. When all avenues of traditional medical assessment have been exhausted without identifying any underlying pathophysiological cause, or aetiology, myofascial trigger points should be considered. According to Travel and Simons, sportEX dynamics 2015;45(July):30-33

MANUAL THERAPY (NON SPORT)

in 1998, and supported by numerous researchers over the following years (2,3), myofascial trigger points are responsible for or play a role in as much as 85% of musculoskeletal pain. My teaching colleague and researcher Dr Jay Shah and his co-workers have demonstrated that active myofascial trigger points have a noxious chemical milieu including phosphate, substance P, bradykinins and other molecules that are at the root of pain (4). Much research is still to be done. For example, no research concerning the existence and consequence of myocardial myofascial trigger points yet exists. My hypothesis is that they do exist and that they mimic the signs and symptoms of numerous cardiac problems such as arrhythmias, angina, fatigue, rapid heartbeat, shortness of breath and referred pain.

Author request: I call on researchers to investigate this hypothesis and I would be delighted to give assistance to anyone who would like to contact me regarding this proposal.

PAIN â&#x20AC;&#x201C; NO ONE LEFT TO LIE TO Research has changed the way we think about pain (4). Pain is a child of the brain. To fully understand pain we must meet the entire family. While peripheral tissues are close relations, tissues such as muscle fibres and sarcomeres are first and second cousins. Nerves may be the irritating younger family members constantly taking information to and fro to mum and dad concerning annoying older siblings. The younger members of the family can have a tendency to exaggerate or distort the truth. Mum and dad (ie. the brain) can react, over-react, under-react or misread the situation dishing out a response that is not appropriate to the reality. Constant noxious bombardment of the dorsal horn neuron causes a release of glutamate and substance P (a neuropeptide) at the segmental level. By binding to their respective receptors on post-synaptic neurons, these chemicals induce sensitisation of wide dynamic range neurons (WDRN), thus further sensitising adjacent www.sportEX.net

spinal segments. Sustained release of glutamate and substance P leads to apoptosis (programmed cell death) of inhibitory neurons. This perturbation leads to a sustained sensitised state lowering neuronal pain thresholds, activating previously inactive synapses (expansion of the receptive field of pain) and leading to allodynia and hyperalgesia (4). Chronic pain states are defined by significant changes in neuronal activity. Such changes are profoundly influential in pain matrix mechanisms. Neuroplastic changes occur in the spinal cord, thalamic nuclei, cortex and limbic system and can alter pain thresholds, degree of sensitivity to pain and the overall pain experiences of our patients (5). Recent research by Staud (6) describes spinal segmental

sensitisation as being caused by heightened dorsal horn activity, brought about by constant bombardment of nociceptor impulses from the periphery (due to damaged or sensitised somatic or visceral tissues). Too few therapists, medical doctors and surgeons are aware of the perpetuating role of myofascial trigger points as a combining source of sensory bombardment (4) with the possible result of chronic pain in various guises.

CENTRAL SENSITISATION AND THE MYOFASCIAL TRIGGER POINT CONNECTION Chronic pain syndromes display significant neuroplastic changes, altered neuron activity, and excitability (a) P lace the delivery tube firmly against the skin allowing gravity to assist the motion. Release the needle and tap the top of the needle handle with a quick and firm application.

(b) R emove the delivery tube ensuring the needle is securely inserted just beneath the skin. If the patient experiences burning or undue pain immediately withdraw the needle and reposition when the patient is ready and relaxed.

(c) Direct the needle in a straight in and out motion. Avoid trying to bend the needle or change needle direction when it is already in the muscle.

(d) Returning the needle to the tube using the opposite end to the handle must be avoided as this significantly increases the risk of a needle stick for the therapist. The therapist should always wear gloves. Figure 1: Dry needling application. (Photo credits: J. Sharkey, 2006)

and adaptations affecting pain matrix structures – spinal cord, thalamic nuclei, cortical areas, amygdala and periaqueductal gray areas. In essence, central sensitisation is characterised by an amplification of normal neurological activity (7). Continuous bombardment of the dorsal horn by noxious afferent activity leads to a release of glutamate and substance P, leading to activation of previously inactive synapses in the WDRN, leading to central sensitisation. In normal circumstances, there is a balance between inhibitory and facilitatory neuronal activity in terms of pain management and control (8). This results in spinal segmental sensitisation. Spinal segmental sensitisation is a hyperactive state of the dorsal horn caused by constant noxious afferent bombardment. This bombardment originates from damaged or sensitised tissues (eg. myofascial trigger points or other soft tissue/ connective tissue trauma, or from visceral structures such as a gall bladder containing a gall stone that has become inflamed). Diagnosis of spinal segmental sensitisation includes observation of dermatomal allodynia, hyperalgesia, soft tissue pain, tenderness upon palpation and the presence of myofascial trigger points (7). Hypersensitivity initially occurs at the local segmental level. Through the process of sensitisation of adjacent spinal segments (spill-over), a state of ‘wind-up’ is caused by temporal sensory summation. Temporal sensory summation is an increased rate of nociceptive pulsing at the dorsal horn. This facilitates widespread segmental sensitisation, leading to body-wide peripheral pain (9). Temporal sensory summation is caused by increased C-fibre input at the dorsal horn and can maintain a state of hyperalgesia in chronic pain patients (6). The stimuli that activate and sensitise the WDRN ascend the spinothalamic tract to reach the higher brain centres, where the thalamus and limbic system are activated (anterior cingulate gyrus, insula and amygdala). The limbic system is involved in modulating muscle pain, but it also modulates fear, anxiety and 32

stress. Therefore, increased activity in the limbic system, influencing the perpetuation of pain syndromes, can contribute to fear of, or emotional stress associated with, chronic pain syndromes (10).

DOES DRY NEEDLING WORK AND IF SO HOW? Yes, it certainly has been shown to work in both clinical practice and supported by systematic review and meta-analysis (11). For example, in a 2013 systematic review and metaanalysis of 12 randomised controlled studies on patients with upper quarter myofascial pain it was reported that dry needling is effective in reducing pain (especially immediately after treatment) in patients with upper quarter pain (11). The key to successfully treating myofascial trigger points is heavily dependent on having excellent palpation skills coupled with accurate knowledge of the pathophysiology involved. Anatomical precision and accurate visualisation regarding needle depth and location is vital. Before inserting the needle the therapist must first have established the location of the myofascial trigger point using their fingers. Understanding the cardinal signs of the myofascial trigger point will ensure differentiation from tender points or other structures (12).

CONCERNS IN DRY NEEDLING Dry needling is not for everyone, especially those with needle phobia. Other people who may not be suitable for dry needling could include cancer patients and patients with a heart pacemaker. The main concerns related to dry needling are for the most part obvious and should be dealt with in more detail as part of a formal course of study in the technique and application of dry needling (13). Concerns include, but are not limited to, allergic reaction to the needle, fainting, haematoma, damage to a nerve or blood vessel, fenestration or infection. In the wrong hands dry needling can cause spinal cord or brain insults, again highlighting the need for appropriate training and qualification in this technique. As a clinical anatomist I

cannot overstate the need for excellent knowledge of anatomy including surface, topographical and gross anatomy. I feel duty bound to recommend that training providers of dry needling courses should have an expert in clinical anatomy to teach that aspect. According to the standards and guidelines set down by the National Training Centre http://www.ntc.ie dry needling should be avoided when there is knowledge or evidence of infection, ulcers, osteoporosis, trauma/ open wounds, aneurysm or malignancy. Patients with psychological disorders may not be potential candidates for dry needling. Emotional stress and anxiety may render dry needling unsafe (14). Taking time to become accustomed to the various lengths of the needles coupled with the ability to visualise the needle once in the tissue will prove to be a vital skill. This skill requires excellence in clinical anatomy. There is a growing demand for qualified therapists trained to treat the chronic pain patient. This growing demand is currently not being met as training providers for the most part focus on the treatment of acute insults such as the sport injury or road traffic accident. For the patient with ongoing unresolved pain meeting a myofascial trigger point specialist will be a great day. References 1. Cummings M. Myofascial pain from pectoralis major following trans-axillary surgery. Acupuncture in Medicine 2003;21(3):105–107 2. Travell JG, Simons DG. Myofascial pain and dysfunction: the trigger point manual. Vol 2: The lower extremities. Lippincott Williams and Wilkins 1998. ISBN 978-0683307719 (£152.03). Buy from Amazon http://spxj.nl/1dRIKIR 3. Simons DG. Review of enigmatic myofascial trigger points as a common cause of enigmatic musculoskeletal pain and dysfunction. Journal of Electromyographic Kinesiology 2004;14(1):95–107 4. Shah JP, Gilliams EA. Uncovering the biochemical milieu of myofascial trigger points using in-vivo microdyalysis: an application of muscle pain concepts to myofascial pain syndrome. Journal of Bodywork and Movement Therapies 2008;12(4):371–384 5. Woolf CW. Central sensitization: implications for the diagnosis and treatment of pain. Pain 2011;152(3):S2–S15

sportEX dynamics 2015;45(July):30-33

MANUAL THERAPY (NON SPORT)

6. Staud R. Peripheral pain mechanisms in chronic widespread pain. Best Practice & Research. Clinical Rheumatology 2011;25(2):155–164 7. Giamberardino MA, Affaitati G, et al. Myofascial pain syndromes and their evaluation. Best Practice & Research. Clinical Rheumatology 2011;25(2):185– 198 8. Willard F. Basic mechanisms of pain, pp.19–62. In: Audette JF, Bailey A, eds) Integrative pain medicine: the science and practice of complementary and alternative medicine in pain management. Human Press 2008. ISBN 9781588297860 (Print £166.50). Buy from Amazon http://spxj.nl/1FZ9Tm4 9. Bishop MD, Beneciuk JM, George SZ. Immediate reduction in temporal sensory summation after thoracic spinal manipulation. The Spine Journal 2011;11(5):440–446 10. Niddam DM, Chan RC, et al. Central modulation of pain evoked from myofascial

trigger points. The Clinical Journal of Pain 2007;23(5):440–448 11. Kietrys DM, Palombaro KM, Mannheimer JS. Dry needling for management of pain in the upper quarter and craniofacial region. Current Pain and Headache Reports 2014;18(8):437 12. Sharkey D. Fibromyalgia: the myofascial trigger point connection. sportEX dynamics 2014;41:13–16 13. National Training Centre. Dry needling courses http://spxj.nl/1Bl8Cr6 14. National Training Centre. Standards and guidelines for the safe, effective and appropriate treatment of myofascial trigger points. Course manual 2014.

FURTHER RESOURCES 1. Sharkey J. Dry needling for myofascial trigger points: clinical applications for manual therapists. Due for publication in 2015 by North Atlantic Books and Lotus Publishing.

Want to share on Twitter?

KEY POINTS nD ry needling is effective in the treatment of myofascial trigger points. n Dry needling is not for everyone. n The safety of the patient is our primary concern. nT here is a growing demand for dry needling therapists. nD ry needling is not acupuncture. n E xcellent knowledge of clinical anatomy is essential. nM yofascial trigger points have cardinal signs. nM yofascial trigger points are key perpetuating factors in Central Sensitisation. nP ain is a child of the brain.

online 2. Video: ‘Myofascial trigger point dry needling’ by J. Sharkey. https://vimeo.com/112484915

HERE ARE SOME SUGGESTIONS Tweet this: The needle is an extension of the fingers allowing treatment of myofascial trigger points Tweet this: Dry needling benefits both patient and therapist. Tweet this: Chronic pain states are defined by significant changes in neuronal activity. Tweet this: Success with dry needling needs excellent palpation skills and anatomical precision. Tweet this: Dry needling should be avoided when there is infection, ulcers, osteoporosis, open wounds, aneurysm or malignancy

DISCUSSIONS

nH ow do you know you are treating a myofascial trigger point and not something else? nW hat causes body-wide chronic pain? nW hich patients are not suitable candidates for dry needling? nW hat risks are involved in myofascial trigger point dry needling?

CONTINUING EDUCATION MULTIPLE CHOICE QUESTIONS This article also has a certificated eLearning test which can be found under the eLearning section of our website. For more information on how to access the test click this link http://spxj.nl/1TAikLP

THIS QUIZ IS ACCESSIBLE

www.sportEX.net

FREE

WITH A SUBSCRIPTION THAT INCLUDES ONLINE ACCESS TO THIS JOURNAL.

THE AUTHOR JOHN SHARKEY BSC MSC John Sharkey BSc MSc is a recognised author and authority on the topic of myofascial trigger points and the treatment of chronic pain. John holds master’s degrees in clinical anatomy (BACA), exercise physiology (BASES) and is the programme leader of the masters degree in Neuromuscular Therapy accredited by the University of Chester. John is a member of the Olympic Councils Medical and Science Team and runs a successful chronic pain clinic. An International presenter and keynote speaker John has proven to be a popular figure at conferences, workshops and masterclasses worldwide. He is a member of the editorial team Journal of Bodywork and Movement Therapies (JBMT) and the BioTensegrity Interest Group (B.I.G) under the guidance of his mentor Dr Stephen Levin. Contact John at: john. sharkey@ntc.ie.

SOCIAL WATCH

SOCIAL

WATCH

There are some great resources on social media sites. Here are some of the best ones most recently published... @Strengthry

@AndyLane27

New article on the site: The new approach to training volume. http://spxj.nl/1BGLtzq

Podcast 003: Understanding Anxiety in Sport with Professor Andy Lane http://spxj.nl/1SCLZ5z

@AdamMeakins

Fantastic read in @TheLancet on the cultural differences of pain & the reality of reducing & eliminating it http://spxj.nl/1IZ6W6t

@ChrisAndAnn

Enjoy my short video of Olympic hopeful running/hurdling personal bests after taking FST workshop last week http://spxj.nl/1BGLQdt

@puresportsmed

Nordics work in preventing hamstring injuries - but clubs need to implement the programme ! http://spxj.nl/1Fwvyyy

@FeetFirstChirop

Women experience foot problems 4 times more than men, 9 out of 10 wear shoes that are too small for them! #footfacts http://spxj.nl/1Iu5aHD

TWEETS

2000

FOLLOWING

1,011

FOLLOWERS

4,213

Join in! @karenlitzyNYC

My new podcast is ready Dr. Louie Puentedura: Treating the Low Back via the Brain the-lowback-via-the-brain on #SoundCloud http://spxj. nl/1THOSU8

@knowpainmike

NEW BLOG: Turn me on! http://spxj.nl/1BwR4bj @ErikDalton_PHD

Myoskeletal Alignment Videos http://spxj.nl/1LfEUG1

@Peter_Gettings

I’d highly recommend listening to @benedsmith on ‘core stability’ http://spxj.nl/1I9BzYn

sportEX dynamics 2015;45(January):34

WANT TO WORK WITH

YOU! DO YOU? n n n n

RUN FURTHER OR HIGHER EDUCATION COURSES? RUN PRIVATE TRAINING? ORGANISE CPD GROUPS? M ANAGE A MEMBERSHIP OR SPECIALIST INTEREST GROUP REGARDLESS OF HOW SMALL?

IF SO, we can develop customised ‘units’ of content including elearning to specifically support your training outcomes or provide a regular value-add to membership packages.

DO YOU? n EMPLOY PHYSICAL OR MANUAL THERAPISTS? nH AVE ACCESS TO A NETWORK OF PHYSICAL OR MANUAL THERAPISTS? IF SO, we’d love to talk to you about becoming an affiliate on our new affiliate programme.

AND FINALLY DO YOU? nH AVE PHYSICAL OR MANUAL THERAPY RESOURCES YOU’D LIKE TO MAKE AVAILABLE FOR SALE? nH AVE ONE OR MORE PRACTICAL RESOURCES (*MORE DETAILS BELOW) THAT YOU THINK OTHER THERAPISTS WOULD LOVE THAT’S YOU’D LIKE TO DISSEMINATE? IF SO, we’d love to talk to you about how we could work together.

Just email tor@sportex.net and and we can take it from there *Practical resources could be anything from a photocopiable client advice handout, a spreadsheet you use in your work, a Powerpoint presentation you did for an event, videos, photos or podcasts you’ve created or learning material of any kind such as course booklets or learning tools that you would like to promote to a wider audience. However small the resource, if it’s got a practical application, we’d love to chat. You’d be amazed at how small some things can be that can help someone do their job more easily, efficiently or quickly.