Co-Kinetic Journal Issue 66 - October 2015 by Co-Kinetic

ISSUE 66/46 OCTOBER 2015

medicine & dynamics

published on

SPORTEX JOURNAL WELCOME

OCTOBER 2015 ISSUE 66MD ISSN 1471-8138 46DY ISSN 1744-9383

editorial

So most of you will probably have noticed that we’ve consolidated both sportEX medicine and sportEX dynamics into one journal. The front section of this new combined journal is dedicated to the physical therapy content (ie. the articles we’d usually publish in sportEX medicine) and the back section is dedicated to the manual therapy content (ie. the articles we’d usually publish in sportEX dynamics). The main reason for the decision is that firstly an overwhelming majority of our readers subscribe to both journals (not really that surprising given the discounts we offered to do this), secondly because most of our jobs include quite a lot of cross-over, it seemed to make sense. A third reason is that because there is much more flexibility in terms of content segmentation on the new website, we wanted one journal which brought everything together, instead of risking repeating content across two journals, which I’ve always tried very hard not to do. For example I frequently deliberated when I had to decide which journal I should publish content on either taping or the psychology of rehabilitation. Both are key channels of content on the new site and both are relevant to physical and manual therapists. The last reason is that it is significantly more expensive and environmentally more toxic for several reasons, to print and mail two magazines, many of which were ending up going through the same letterbox, but due to the fact that we had some individual subscribers on each list, we always had to post them separately. We’ve done our best to make the transition as smooth as possible but if you have any questions, comments or feedback then please feel free to email me directly (tor@sportex.net). I hope you like the changes and enjoy a packed October issue of the print journal. Tor Davies, physio-turned publisher and sportEX/Co-Kinetic founder Publisher/editor TOR DAVIES tor@sportex.net Art editor DEBBIE ASHER debbie@sportex.net Sub-editor ALISON SLEIGH PHD Journal Watch BOB BRAMAH Subscriptions & Advertising support@sportex.net +44 (0) 845 652 1906

COMMISSIONING EDITORS AND TECHNICAL ADVISORS Tim Beames - MSc, BSc, MCSP Dr Joseph Brence, D PT, COMT, DAC Simon Lack - MSc, MCSP Dr Markus W Laupheimer MD, MBA, MSc in SEM, MFSEM (UK), M.ECOSEP Dr Dylan Morrissey - PhD, MCSP Dr Sarah Morton - MBBS Brad Neal - MSc, MCSP Dr Nicki Phillips - PhD, MSc, FCSP

contents 4 Physical therapy journal watch 8 Medical screening and differential diagnosis of a patient following a cervical fusion who developed arterial thoracic outlet syndrome 10 The hidden influence of metaphor within rehabilitation 15 Identifying the primary driver of symptoms in patellofemoral pain: a possible method of patient subgrouping 20 Client advice handout on patellofemoral pain 24 Rehabilitation adherence: is it time to prioritise? 29 Physical therapy highlights on Co-Kinetic.com 30 Manual therapy journal watch 34 Dry needling for myofascial pain 36 Transverse soft tissue release and ITB syndrome: a case study 41 Manual Therapy Student Handbook: Introduction to manual therapy 44 Manual Therapy Student Handbook: Definitions – mobilisation manipulation and massage 48 Manual therapy highlights on Co-Kinetic.com 49 Co-Kinetic news

ISSUE 66/46 OCTOBER 2015

medicine & dynamics

published on

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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.

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT Read this online http://spxj.nl/1LdZasc RADIAL EXTRACORPOREAL SHOCKWAVE THERAPY COMPARED WITH MANUAL THERAPY IN RUNNERS WITH ITB SYNDROME. Weckström K, Söderström J. Journal of Back and Musculoskeletal Rehabilitation 2015;doi:10.3233/BMR-150612 [Published online: 6 July, 2015] DOSE RELATED EFFECTS OF EXTRACORPOREAL SHOCKWAVE THERAPY IN PATIENTS WITH PLANTAR FASCIITIS. Prajapati MJ, Shah N. International Journal of Therapies and Rehabilitation Research 2015;4(4):164166 Thirty subjects with clinically diagnosed plantar fasciitis and symptoms lasting 3 months were included in the trial. Subjects with a history of ankle or foot fracture, referred pain due to sciatica and other neurological disorders were excluded. Group A were given shock wave therapy with a dosage of 1000 shocks, energy flux density 0.16mj/ mm2 and 6Hz, and Group B were given a dosage of 2000 shocks, energy flux density 0.16mj/mm2 and 6Hz, for 2 weeks total six sessions. Pre- and post-VAS, foot function index and pain pressure threshold was taken. Both groups improved in all outcomes but there was no significant difference between groups.

Twenty-four runners with iliotibial band syndrome (ITBS) received three treatments at weekly intervals of either radial shockwave therapy (RSWT) or manual therapy (ManT) (n = 13). In addition, all subjects followed an exercise programme for at least 4 weeks. The RSW group reported a 51% decrease in pain at week 4, and a 75% decrease at week 8. The ManT group showed a 61% reduction in pain at week 4 and a 56% reduction at week 8. Therefore, there was no significant difference between the two groups. Both reduced the pain.

sportEX comment More on shockwave. It seems to work, but the importance of this study is that the manual therapy works as well and it’s cheaper!

sportEX comment So the low dose worked on these patients. This confirms earlier research. You could spend thousands on a machine (or hundreds a month to rent one) or you could try doing the same thing with a bit of soft tissue therapy! While on the subject, what is the difference (if any) between ‘extracorporeal shockwave’ and ‘radial shockwave’, because we have another paper that says the latter works on rotator cuff tendinopathy? [The treatment of chronic rotator cuff tendinopathy of the shoulder with radial shockwave therapy. Sanzo P. Clinical Practice 2015;4(1):6-11]

THE ACCURACY OF SELF-REPORTED ADHERENCE TO AN ACTIVITY ADVICE. Zandwijk P, Van Koppen B, Van Mameren H, Mesters I, et al. European Journal of Physiotherapy 2015;doi:10.3109/21679169.2015.10755 88 [Published online: 10 August 2015] Previous research suggests that inadequate adherence to home-based activity advice during an intervention period might diminish the effectiveness of an intervention. Most data consist of self-reporting and interviews, so to gain objective data 51 patients who reported non-specific low back pain were advised to complete a home-based activity for 1 week and wore activity monitors. This resulted in 357 (51 × 7) walking days during which accurate participant reports were made on 233 days. Only 22% of the participants reported accurately on all 7 consecutive days.

sportEX comment Any therapist worth their salt develops an intuitive feeling about whether or not their patients have been following advice. The question of why they don’t is another matter. The health and wellness industry rightly or wrongly is moving increasingly to a self-management strategy. Maybe evidence like this will prompt a rethink. We can but hope! 4

sportEX journal 2015;66(October):4-7

JOURNAL WATCH PHYSICAL THERAPY RESEARCH INTO PRACTICE

Journal Watch RESISTED SIDE-STEPPING: THE EFFECT OF POSTURE ON HIP ABDUCTOR MUSCLE ACTIVATION. Berry JW, Lee TS, Foley HD, Lewis CL. Journal of Orthopaedic & Sports Physical Therapy 2015;45(9):675–682 Twenty-four healthy adults had kinematics and surface electromyographic data obtained from their gluteus maximus, gluteus medius, and tensor fascia lata while performing side-stepping with a resistive band around the ankle in an upright standing and squat posture. The mean Twenty male race walkers aged 21.19 ± 3.66 years and with a mean height of 178.85 ± 14.07 participated in a race walking event with functional or normal insoles. The functional insoles varied in thickness from about 4mm at the forefoot to about 8mm at the arch and 6mm at the heel. The middle of the heel was embedded with a round cushion, and the edge of the arch and heel areas rise to form a ‘heel cup’. The height of the cup edge was 25mm, and the foot arch was further supported with

normalised electromyographic signal amplitude of the gluteus maximus, gluteus medius, and tensor fascia lata was higher in the stance limb than in the moving limb. Gluteal muscle activity was higher, whereas tensor fascia lata muscle activity was lower, in the squat posture compared to the upright standing posture. Hip abduction excursion was greater in the stance limb than in the moving limb.

sportEX comment According to the authors this

exercise is used to increase strength and endurance of the hip abductors which may be weak in various musculoskeletal conditions, including femoroacetabular impingement, iliotibial band syndrome, patellofemoral pain and chronic ankle sprains. They add that the therapeutic exercises are commonly used by clinicians to increase functional muscle recruitment patterns. What is functional about this exercise? We haven’t noticed many people walking like crabs down the high street.

COULD INSOLES OFFLOAD PRESSURE? AN EVALUATION OF THE EFFECTS OF ARCH-SUPPORTED FUNCTIONAL INSOLES ON PLANTAR PRESSURE DISTRIBUTION DURING RACE WALKING. Song Q, Xu K, Yu B, Zhang C, et al. Research in Sports Medicine 2015;23(3):278 an arch pad. The normal insoles matched the race walking shoes and were a flat surface about 3mm thick. Plantar pressure insoles were used to collect vertical plantar pressure data. The results were that the functional insoles reduced the peak pressure and the impulse in the metatarsophalangeal joints and heels. The first ground reaction force peak also decreased.

sportEX comment The theory is that reducing the pressures helps in injury prevention, which is needed because – contrary to popular belief that race walking is low injury risk activity – previous studies cited in this paper show that in fact there is a high prevalence of below the knee injury. So, cushioning the force is an obvious aid, but do the insoles need to be tailored to the individuals or will an ‘off the shelf’ one do? More research please.

THE EFFECTS OF TRAINING AND DETRAINING AFTER AN 8 MONTH RESISTANCE AND STRETCHING TRAINING PROGRAM ON FORWARD HEAD AND PROTRACTED SHOULDER POSTURES IN ADOLESCENTS: RANDOMISED CONTROLLED STUDY. Ruivo R, Carita AI, Pezarat-Correia P. Manual Therapy 2015 [In press; corrected proof available online: 13 May 2015]

One hundred and thirty adolescents with forward head and protracted shoulder posture were randomly assigned to a control or experimental group. Their sagittal head, cervical and shoulder angles were measured before and after a 32week intervention period. The control group (n = 46) did only physical education (PE) classes whereas the exercise group (n = 42) received a posture corrective exercise programme in addition to PE. This was stretching and strengthening exercises done twice a week during the last 15 minutes of their PE class. The strengthening exercises were targeted to activation of rotator cuff, (teres minor and infraspinatus), the scapula stabilisers (mainly the medium and lower trapezius), the rhomboids and the deep cervical flexor muscles. The

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stretching exercises were directed to the pectoralis minor and the neck muscles (sternocleiomastoid and levator scapulae). Significant increases were observed in the cervical and shoulder angle of the posture group. A 16-week detraining period followed after which no significant differences were observed in the three postural angles of the posture group.

sportEX comment A study of its time. Kids with a forward head posture what a shock. This study shows that you can do something about it.

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT Read this online http://spxj.nl/1LdZasc DRY NEEDLING EFFECTS ON NON-SPECIFIC CERVICAL RADICULOPATHIC PAIN AND DYSFUNCTION: A CASE REPORT. Shanmugam S, Shetty K. Mathias L. International Journal of Therapies and Rehabilitation Research 2015;4(4):21–25 A case study involving a 19-year-old student with signs and symptoms of 7th cervical nerve root radicupathic pain. There was localised pain over the left C6-7 junction radiating down to the dorsal aspect of ring finger. Spurling and upper limb tension tests were positive indicating cervical nerve root irritation. Initial treatment over 2 weeks was intermittent cervical traction, stretching for neck muscles, mobilisation of the cervical and thoracic spine, and trigger point massage without success. Further examination revealed maximum tender points over paraspinal muscle in the cervical region and altered function of cervical spine. She was then treated with two sessions of dry needling, 72 hours apart. Post-needling pain and neck disability scores were reduced compared to before intervention. Assessment 3 months later showed that the effects were sustained.

sportEX comment Case studies; they are the way forward. Take away all the problems of randomisation and subject selection and document what was done to real patients who actually have the problem you are trying to solve, effectively sharing good practice. This is great example. One approach fails, try another.

CONSENSUS RECOMMENDATIONS ON TRAINING AND COMPETING IN THE HEAT. Racinais S, Alonso JM, Coutts AJ, Flouris AD, et al. British Journal of Sports Medicine 2015;49:1164–1173

MUSCLES AND THEIR ROLE IN EPISODIC TENSION-TYPE HEADACHE: IMPLICATIONS FOR TREATMENT. Bendtsen L, Ashina S, Moore A, Steiner TJ. European Journal of Pain 2015;doi:10.1002/ejp.748 [Published online: 6 July 2015] This article explores the reason why muscles can cause headaches. The culprits are muscle nociceptors, myofascial tenderness and hardness, and muscle contractions, which may cause an acute headache. Sensitisation of the central nervous system can then result in progression of a headache to a chronic form. Recommended treatments are simple analgesics and non-steroidal antiinflammatory drugs, prescription of which is based on treatment effect, safety profile and costs. Non-pharmacological therapies include electromyographic biofeedback, physiotherapy and muscle relaxation therapy.

sportEX comment This goes some way to explaining why the various therapies reported in the case study by Ganer (included in the online version) may work. Physical therapy is good at relieving the muscular problems. We have to shout this from the roof tops because the authors conclude, “Future studies should aim to identify the triggers of peripheral nociception and how to avoid peripheral and central sensitization”. We can do that! We need to promote this because their second conclusion is, “there is a need for more effective, faster acting drugs for acute episodes”. SAY NO TO DRUGS.

These are guidelines for training in the heat. Doing so induces thermoregulatory and other physiological strain that can lead to impairments in endurance exercise capacity. The most effective strategy is to acclimatise to the heat. This should be repeated exercise-heat exposures over 1–2 weeks. In addition, athletes should initiate competition and training in a euhydrated state and minimise dehydration during exercise. Cooling strategies should also be considered, including the use of cooling-vests. There is also a plea for event organisers to consider potential heat hazards and plan for large shaded areas, along with cooling and rehydration facilities, and schedule events in accordance with minimising the health risks of athletes, especially in mass participation events and during the first hot days of the year. More

controversially there is a request for governing bodies to follow the examples of the 2008 Olympics and the 2014 FIFA World Cup and allow additional time for drinks breaks and longer recovery times post event.

sportEX comment Sorry for publishing this one just as winter knocks on the door but there are lot of lucky athletes who de-camp for warm weather training and the summer will be back before you know it (we hope), so get your planning done. Most of the strategies here are obvious but sometimes you need to reiterate the dangers of training and competing in the heat especially to coaches and event organisers. The article is open access and well worth a read.

sportEX journal 2015;66(October):4-7

PHYSICAL THERAPY RESEARCH INTO PRACTICE

DIAGNOSIS OF ACUTE GROIN INJURIES. A PROSPECTIVE STUDY OF 110 ATHLETES. Serner A, Tol JL, Jomaah N, Weir A, et al. American Journal of Sports Medicine 2015;43(8):1857–1864 This study looked at data from 110 male athletes (mean age, 25.6 ± 4.7 years) with sports-related acute groin pain who were examined within 7 days of injury from August 2012 to April 2014. Standardised history taking, a clinical examination, magnetic resonance imaging (MRI), and/or ultrasound (US) were performed. The most frequent injury mechanism in football was kicking (40%), and change of direction was most frequent in other sports (31%). Clinically, adductor injuries accounted for 66% of all injuries and primarily involved the adductor longus on imaging (91% US, 93% MRI). The iliopsoas and proximal

rectus femoris were also frequently injured according to all examination modalities (15–25%). Acute injury findings were negative in 22% of the MRI and 25% of the US examinations. Of the clinically diagnosed adductor injuries, 3% (US) and 6% (MRI) showed a radiological injury in a different location compared with 35% to 46% for clinically diagnosed iliopsoas and proximal rectus femoris injuries.

sportEX comment Treat the patient not the picture. More than 1 in 5 injuries showed no imaging signs of an acute injury. Clinically diagnosed adductor injuries were often confirmed on imaging but more than a third of the iliopsoas and rectus femoris injuries often showed a different radiological injury location.

MUSCULOSKELETAL PHYSIOTHERAPISTS’ USE OF PSYCHOLOGICAL INTERVENTIONS: A SYSTEMATIC REVIEW OF THERAPISTS’ PERCEPTIONS AND PRACTICE. Alexanders J, Anderson A, Henderson S. Physiotherapy 2015;101:95–102 The databases AMED, CINAHL, EMBASE, MEDLINE and PsychINFO were searched for papers published between January 2002 and August 2013 looking for qualitative, quantitative and mixed methodology studies looking into musculoskeletal physiotherapists’ perceptions regarding their use of psychological interventions within physiotherapy practice. Six studies, all with a low risk of bias, met the inclusion criteria but meta-analysis was not possible due to study heterogeneity. These studies highlighted that physiotherapists appreciate the importance of using psychological interventions within their practice, but report inadequate understanding and consequent underutilisation of these interventions.

sportEX comment Any therapist working in sport will tell you that psychology plays a huge part in the rehabilitation process for athletes. Injury is devastating. It can be the end of the world to not play. The weekend warriors live for the competition and for the pro’s it is their livelihood. What this study shows is that musculoskeletal physiotherapists are aware of the potential benefits of incorporating psychological interventions within their practice but feel insufficiently trained to optimise their use of such interventions. Is it time to look at basic training? Should there be dedicated modules in the degree programmes aimed at linking mind and body?

A COMPARISON OF MUSCLE ACTIVITY IN USING TOUCHSCREEN SMARTPHONE AMONG YOUNG PEOPLE WITH AND WITHOUT CHRONIC NECK–SHOULDER PAIN. Xie Y, Szeto GPY, Dai J, Madeleine P. Ergonomics 2015;doi:10.1080/00140139.2015.1056237 [Published online: 28 July 2015] Using surface electromyography from three proximal postural muscles and four distal hand/thumb muscles on the right side, 40 young people with and without neck–shoulder pain (n = 20 in each group), had their neck and shoulder muscle activity compared when they performed texting on a smartphone using both hands (‘bilateral texting’), one hand (‘unilateral texting’) and also using computer typing. Those with pain showed altered motor control consisting of higher muscle activity in the cervical erector spinae and upper trapezius when performing texting and typing tasks. Generally, unilateral texting was associated with higher muscle loading compared with bilateral texting especially in the forearm muscles. Compared with computer typing, smartphone texting was associated with higher activity in neck extensor and thumb muscles but lower activity in upper and lower trapezius as well as wrist extensors.

sportEX comment

A study of the times. All this texting is not good for you. The authors suggest that contemporary ergonomic guidelines should include advice on how to interact with handheld electronic devices to achieve a relaxed posture and reduced muscle load in order to reduce the risk of musculoskeletal disorders.

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This article summarises a case study of a patient who had had anterior cervical discectomy and fusion but was subsequently found to have thoracic outlet syndrome, highlighting the importance of timely and proper medical screening. Read this online http://spxj.nl/1PPvGjK

MEDICAL SCREENING AND DIFFERENTIAL DIAGNOSIS OF A PATIENT FOLLOWING A CERVICAL FUSION WHO DEVELOPED ARTERIAL THORACIC OUTLET SYNDROME FORMATS WEB MOBILE PRINT

horacic outlet syndrome (TOS) has been a widely debated topic in musculoskeletal medicine (1–3). It has two potential mechanisms: vascular and neurogenic. Vascular TOS is subcategorised into arterial, making up less than <5% of cases, and venous, making up 3–5% of cases. (3) The other 90% of cases are neurogenic, and are subcategorised as true and disputed (1–4). True neurogenic TOS is rare and confirmed with anatomical and electrodiagnostic abnormalities (5). Disputed neurogenic is poorly understood but makes up the majority of patients presenting with TOS (5). This case report is about a patient who was treated surgically with an anterior cervical discectomy and fusion (ACDF) but had increased pain and disability post-operatively. To our knowledge, the surgeon made no attempt to rule out TOS or provide physical therapy before or immediately after the ACDF. When we examined the patient 7-months post-surgery, his symptoms were worse than before surgery and he had developed psychosocial issues of pain catastrophising and fear of movement. In this case report, we detail the medical screening and differential diagnosis of this patient by a physical therapist.

PATIENT PRESENTATION An athletic, 40-year-old male with lefthanded numbness and pain, presented to a physical therapist 7 months after an ACDF of C5–7. The patient reported he had originally presented to his surgeon with a primary complaint of persistent left ring and fifth digit

BY DR FRANCOIS PRIZINSKI DPT, OCS, COMT, FAAOMPT UPPER-BODY | NECK | 15-10-SPORTEX | CASE-STUDY numbness. Upon MRI, the surgeon had discovered multi-level disc bulges in the cervical spine and immediately recommended a multi-level fusion. The patient consented to surgery but reported immediately following the procedure that he experienced a worsening of symptoms. After several months of worsening symptoms, the patient was referred to a physiatrist, who diagnosed him with cervicalgia, spasm of muscle and meralgia paresthetica. The physiatrist ordered an MRI, which was negative for cervical spine myelopathy, disc protrusion or disease, as well as an EMG, which was normal (ruling out true neurogenic TOS). The physiatrist referred the patient to physical therapy, to address noticeable mobility impairments of the thoracic spine. Upon examination, the patient rated his current pain as 5/10, worst as 8/10, and best as 3/10 on a numerical rating scale (which has been proven to be valid and reliable) (6). He rated his current physical health as fair and reported he wanted to return to a physically active lifestyle. He completed a Neck Disability Index (NDI) Questionnaire and indicated a 60% disability, with most notable deficits involving activities of sleep, recreation and pain intensity. The NDI has fair to moderate test–retest reliability in patients who present with mechanical neck pain (7) and moderate reliability for patients with mechanical neck pain with upper extremity (UE) referred symptoms (8). He also indicated

positive signs for pain catastrophising and fear avoidance, upon completion of the pain catastrophising scale and fear-avoidance belief questionnaire, respectively. The patient reported activities such as raising arms overhead resulted in a worsening of numbness to ring and little fingers bilateral (left > right). His medical history questionnaire revealed a recent history of anxiety, fatigue/ weakness, shortness of breath, and hypersensitivity to heat/cold. He reported that he went to a cardiologist who screened him with a cardiac stress test, which was negative.

Objective examination Upon active range of motion (AROM) testing, cervical left rotation and extension produced symptoms into his left shoulder and thoracic spine. As a result of this, the examiner performed passive accessory intervertebral movements (PAIVMs) from T1 to T7, which reproduced the patient’s chief complaint when at T1–2 unilaterally on the left and at T6 on the right. No symptoms were elicited with any other PAIVMs. Symptoms were also reproduced locally with passive accessory movement of the left first rib with inferior gliding. The patient demonstrated a loss of left sidebending with a hard end-feel when his cervical spine was placed in a position of right rotation, which indicated a possible elevated hypomobile first rib on the left [cervical rotation–lateral flexion (CRLF) test] (9).

sportEX journal 2015;66(October):8-9

PHYSICAL THERAPY MSK DIAGNOSIS, TREATMENT, REHABILITATION

Due to suspicions of an elevated first rib and possible TOS, the patient was referred back to the referring physiatrist. A computed tomography (CT) angiography was performed with contrast, and the impression reported a 60% narrowing of the left subclavian artery, as it passes between the left first rib and left clavicle. The interval space between the left first rib and left clavicle measured approximately 5–6mm wide at its narrowest portion, as compared to 12mm on the right.

DISCUSSION This case report investigated the medical screening and differential diagnosis of an athletic 40-yearold male with worsened left-handed numbness and pain following ACDF. Upon medical screening by a physical therapist, suspected symptoms of vascular TOS were found, which was confirmed upon imaging. In addition, this patient’s expectations to correct his complaints with surgery were not met, which may have lead to a fear of movement and pain catastrophising, which have been shown to increase the potential for long-term disability (10–11). This case demonstrates the necessity of medical screening and differential diagnosis by a physical therapist, even when a patient is referred postsurgically. After appropriate medical intervention, this patient was referred back to the physical therapist for care. References 1. Hooper TL, Denton J, et al. Thoracic outlet syndrome: a controversial clinical condition. Part 1: anatomy, and clinical examination/diagnosis. Journal of Manual & Manipulative Therapy 2010;18(2):74–83 2. Hooper TL, Denton J, et al. Thoracic outlet syndrome: a controversial clinical condition. Part 2: non-surgical and surgical management. Journal of Manual & Manipulative Therapy 2010;18(3):132–138 3. Sanders RJ, Hammond SL, Rao NM. Diagnosis of thoracic outlet syndrome. Journal of Vascular Surgery 2007;46:601–604 4. Wilbourn AJ. The thoracic outlet syndrome is over diagnosed. Archives of

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Neurology 1990;47:328–330 5. Vanti C, Natalini L, et al. Conservative treatment of thoracic outlet syndrome: a review of the literature. Europa Medicophysica 2007;43:55–70 6. Williamson A, Hoggart B. Pain: a review of three commonly used pain rating scales. Journal of Clinical Nursing 2005;14:798– 804 7. Cleland JA, Childs JD, Whitman JM. Psychometric properties of the neck disability index numeric pain rating scale in patients with mechanical neck pain. Archives of Physical Medicine and Rehabilitation 2008;89:69–74 8. Young BA, Walker MJ, et al. Responsiveness of the neck disability index in patients with mechanical neck disorders. The Spine Journal 2009;9:802–808 9. Lindgren KA, Leino E, Manninen H. Cervical rotation lateral flexion test in Brachialgia. Archives of Physical Medicine and Rehabilitation 1992;73:735–737 10. Leeuw M, Goossen MEJB, et al. The fearavoidance model of musculoskeletal pain: current state of scientific evidence. Journal of Behavioral Medicine 2007;30(1):77–94 11. Severeijns R, Vlaeyen JWS, et al. Pain catastrophizing predicts pain intensity, disability, and psychological distress independent of the level of physical impairment. The Clinical Journal of Pain 2001;17:165–172.

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THE AUTHOR Dr Francois Prizinski DPT, OCS, COMT, FAAOMPT gained his doctorate degree in physical therapy (DTP) from Temple University, Pennsylvania, USA. Francois then specialised in medical screening and become certified in Direct Access Physical Therapy (DAC). Subsequently he assisted in developing an interdisciplinary management team for Mon Valley Hospital and The Orthopedic Group in Pittsburgh, PA USA, in 2012 to form a comprehensive Sports & Spine Care Division in the areas of physical therapy triage management, diagnostic ultrasound, plasma injection therapy, and differential movement diagnosis to optimise non-surgical and post-surgical outcomes. Currently, practising in Charlotte, NC USA, Francois has collaborated in the formation of the Nxt Gen Institute of Physical Therapy for advanced postgraduate certification programs, orthopaedic residency, and manual therapy fellowship training across the United States. His active research interests are firmly rooted in clinical reasoning and interdisciplinary management of painful movement, in addition to applied pain science, neurodynamics, and the principles behind a biopsychosocial approach to motor control from a manual therapy perspective.

THE HIDDEN INFLUENCE OF METAPHOR WITHIN REHABILITATION Communication about a patient’s pain experience is a fundamental component of rehabilitation, but often requires the use of metaphoric expressions. However, whilst the meaning of some metaphors is clear, for others it can be obscure. This article will allow the reader to understand the influence that metaphors have on rehabilitation and how they can be used for pain reconceptualisation and behavioural change. It will also allow the development of strategies that enable better communication. Read this online http://spxj.nl/1LzGHok BY MIKE INTRODUCTION STEWART Metaphors live a concealed existence MCSP SRP PG all around us. On average we articulate CERT six metaphors a minute (1). Metaphorical thinking is essential to how we communicate, learn, discover and create meaning. Metaphors are a fundamental part of human expression. A metaphor is something relatively more concrete or conceivable which stands for something more elusive (2). The word metaphor originates from the Greek words ‘meta’ (to transfer) and ‘pherin’ (to carry PAIN | PSCYHOLOGY | 15-10-SPORTEX | COMMUNICATION FORMATS WEB MOBILE PRINT

MEDIA CONTENTS YouTube video ‘Installation art: McGill Pain Questionnaire 2012 – barbed wire’. Courtesy of YouTube user Eugenie Lee. http://spxj.nl/1Uu6gJL ouTube video ‘James Geary, metaphorically speaking’ Y (Courtesy of YouTube user TED, 2009). http://spxj.nl/1L6RNOP YouTube video ‘Robert Sapolsky. How metaphors work in psychology and the brain’ (Courtesy of YouTube user Camelot radio, 2011). http://spxj.nl/1KLog1n Podcast ‘Session 4: Know Pain part 1 – Mike Stewart & Jack Chew (Courtesy of YouTube user The Physio Matters Podcast, 2014). http://spxj.nl/1fWWt12 Podcast ‘Session 5: Know pain part 2 – Mike Stewart & Jack Chew’ (Courtesy of YouTube user The Physio Matters Podcast, 2014). http://spxj.nl/1LNkAec Continuing education quizzes This article has two certificated eLearning assessments that can be found in the Media Contents box in the online version of the article (online access is required to launch the assessment). http://spxj.nl/1LzGHok

beyond). Within physical rehabilitation, people living with pain frequently resort to metaphor in an attempt to express the challenges they face when confronted with a myriad of distressing thoughts and experiences. As clinicians, the process of facilitating a meaningful reframing of persistent pain often involves metaphoric expression. The complex and abstract scientific theories that underpin our current understanding are frequently transferred into tangible cognitions in order to help us make sense of our experiences (3–5). Whilst, for some, metaphors can help the process of pain reconceptualisation, they can also hinder the process for others (6). With this paradox in mind, we must consider the impact that our metaphoric expressions have on our practice, and how they might influence the rehabilitation process. We must also consider the potent significance of our patient’s selfgenerated metaphors, and examine how best to use these for therapeutic gains (7,8). This article explores the implicit influence of metaphor within healthcare and physical rehabilitation. Through a greater appreciation of metaphor’s role within healthcare, clinicians can gain a valuable insight into the lived experiences of people in pain. Equally, by enabling people in pain to express their frequently distressing, idiosyncratic perceptions, we can enhance communication and understanding. With a heightened

awareness of metaphor’s concealed influence on physical rehabilitation, we may begin to move beyond a language of fear and isolation, and begin to develop a language of hope.

SCIENCE AND METAPHOR Metaphors are generally considered to be the domain of poetic, linguistic expressions. However, it is short sighted to limit metaphoric thinking to artistic expression alone. When considering the place of the metaphor within science, Albert Einstein remarked, “Combinatory play seems to be the essential feature in productive thought.” (9). Our desire to make sense of the world through metaphor encompasses scientific reasoning. Some of science’s greatest paradigm shifts have stemmed from metaphoric thinking. From Newton’s translation of a simple apple to express planetary gravitation, to Max Planck’s inception of Quantum theory through vibrating cello strings acting like electron orbits, metaphor and science are intrinsically linked. Banville (10) argues, “Of course, art and science are fundamentally different in their methods, and in their ends. The doing of science involves a level of rigor unattainable to art. A scientific hypothesis can be proven—or, perhaps more importantly, disproven— but a poem, a picture, or a piece of music, cannot. Yet in their origins art and science are remarkably similar.” He concludes, “Art and science are alike in their quest to reveal the world.” sportEX journal 2015;66(October):10-14

PHYSICAL THERAPY PAIN, BRAIN AND SPORTS PERFORMANCE

In order to promote understanding of abstract scientific models, scientists use metaphors as well as equations and graphs. Table 1 illustrates a range of metaphoric expressions that exist within scientific thinking related to the human body. The process of metaphoric transfer extends to the science of rehabilitation and pain. Melzack and Wall’s (11) Gate Control Theory of Pain provides an excellent example of how a metaphoric expression can help explain an otherwise impermeable and abstract model for much of the population. Rathmell (12) describes Melzack and Wall’s 1965 paper as “the most influential ever written in the field of pain.” With this in mind, we can see how Melzack and Wall’s (11) pain gate theory has transfused common consciousness regarding pain neurobiology. In a comprehensive, longitudinal analysis of pain gate theory’s adaptations within educational texts, Semino (13) found that, despite an updated understanding through Melzack’s redefined ‘neuromatrix’ and ‘neurosignature’ metaphors, many texts continue to use pain gate theory (14,15). This poses a widely held and well documented dilemma regarding the application of metaphor within science and healthcare. Although strong advocates of metaphoric expression, Lakoff and Johnson (2) warn that metaphors may obscure other lines of inquiry. Taylor (16) argues that metaphors can be “seductively reductionistic”, whilst Paivio and Walsh (17) see them as a “solar eclipse [which] hides the object of study, and at the same time, reveals some of the most salient and interesting characteristics, when viewed through the right telescope.”

SELF-GENERATED METAPHORS Although they remain frequently implicit, metaphors influence how we facilitate others and how others attempt to reach out to make sense of their experiences. Metaphors are used when conveying experiences most resistant to expression (1). Pain is one such experience. With this in mind, we must consider how we can elicit self-generated metaphors in people living with pain. Shinebourne Co-Kinetic.com

and Smith (18) suggest self-generated metaphors offer a “safe bridge” through which people express emotions that are too distressing to communicate literally. With a limited ability to detect when people are attempting to cross this bridge through metaphoric expression, healthcare professionals risk squandering opportunities for a meaningful reconceptualisation of pain and ultimately, a safe and confident return to physical activities. As clinicians, we must strive to identify our patients’ self-generated metaphors in order to explore meaning, and to foster empathetic and therapeutic connections. As the pain ‘gate’ metaphor highlights, the perpetual use of our linguistic expressions leads to their literalisation within common language. Gibbs (19) argues that, “scientific metaphors are made to be overused.” Such frequent and ubiquitous usage conceals the metaphor from view. For example, we don’t literally stand under something to ‘understand’ it. Whilst linguistically interesting, we should not fall into the trap of considering such points as mere trivia. Far from it, the literalisation of metaphor within healthcare can have profound consequences (4,13). The person who perceives that physiotherapy cannot repair her damaged pelvic ‘floor’ (Table 1) requires considered guidance towards a more realistic and optimistic cognitive reconstruction. For some, the ‘floor’ metaphor generates images of shattered building construction that requires structural repair via surgical intervention. However, once deconstructed, this metaphor can be helpfully reinterpreted as a muscle that can, like any other, be developed through the process of physical rehabilitation (20). However, whilst self-generated metaphors permit access to personal narratives, it is essential that we remain aware of their intrinsic ability to obstruct and regress the therapeutic process (21). Continual, Socratic exploration of the patient’s understanding of pain is an indispensable component of therapeutic pain reconceptualisation through metaphor. When writing about his own experiences of pain, both as a doctor and a patient, Biro (3) argues, “Pain is an all-consuming interior experience that threatens to destroy everything except itself and can only be described through

PAIN IS AN ALLCONSUMING INTERIOR EXPERIENCE THAT THREATENS TO DESTROY EVERYTHING EXCEPT ITSELF AND CAN ONLY BE DESCRIBED THROUGH METAPHOR metaphor.” In her recent historical exploration of the language of pain, Bourke (4) suggests that our commonly used vocabulary to express pain has become increasingly restricted over time. The emergence of the biomedical model brought with it a gradual containment of metaphor’s fundamental role in human expression. Bourke (4) argues, “Bodies are not pure soma but are constituted by social interactions and linguistic processes.” If we are to empower people in pain to express their experiences in order for them to move forward, healthcare must embrace and encourage their assorted and idiosyncratic self-generated metaphors. However, when visiting healthcare professionals, many people in pain are expected to find a simple linguistic solution that both expresses and labels the myriad of distressing experiences that they live with. In order to measure the different qualities of the subjective pain experience, the McGill Pain

TABLE 1: COMMONLY USED SCIENTIFIC METAPHORS (M. Stewart, 2015) Scientific concept (body part)

Metaphor

Heart Pump Cell membrane

Wall

Brain Computer Eye Camera Immune system

Defence force

DNA

Blueprint code

Blood vessels

Highways

Nerves Wires Sound/light Waves Pelvic musculature

Floor

Video 1: Installation art: McGill Pain Questionnaire 2012 – barbed wire. Courtesy of YouTube user Eugenie Lee. http://spxj.nl/1Uu6gJL (a)

(b)

Figure 1a, b: McGill Pain Questionnaire by Eugenie Lee in Sydney, Australia, 2012. (E. Lee 2012, reproduced with permission)

Patient-generated metaphors

“Way too much on my plate”

“I’m up against a wall”

“Everything’s falling apart”

“I’m in a dark place”

Figure 2: Patient-generated metaphors. (M. Stewart, 2014 Adapted by Co-Kinetic.com) 12

Questionnaire (MPQ) uses three classes of words that aim to describe the sensory, affective and evaluative aspects of pain (22). Yet whilst the MPQ provides both healthcare professionals and people in pain with a valid, linguistic measurement tool, both Bourke (4) and Biro (3) argue that no matter which sense we use, all attempts to express our perceptual experiences fall short of the mark through constrained linguistic means. Scarry (23) adds, “pain is outside of language, absolutely private and untransmittable.” When faced with the ‘unsharability’ of pain (23), we must seek mediation of its ineffable nature through art, music and metaphor. Bras et al., (24) argue that whilst striving to attain personcentred pain management, healthcare professionals must recognise the ability of art to communicate the range of distressing emotions that are so characteristic of pain experiences. In our desperate attempts to both understand, and to be understood, art provides a means of expression that words alone cannot accomplish. Biro (3, p.15) states, “Pain erects a wall between us and the outside world. At the same time, it prevents us from breaching that wall by communicating the experience to others.” Art and imagery can equip people in pain, clinicians and researchers with the necessary tools to break through pain’s perceptual barricades (25). Driven by her desire to move beyond the linguistic constraints of the MPQ, the artist Eugenie Lee merges contemporary pain neuroscience with artisitic endeavour. Figure 1 and Video 1 show Lee’s 2012 installation entitled ‘McGill Pain Questionnaire’. In their recent qualitative study exploring patient perceptions about pain, Darlow et al. (26) found a variety of negative assumptions existed amongst those with low back pain (LBP). Feelings of vulnerability, protection and uncertainty were expressed by the participants. The authors concluded that clinicians need to approach consultations with an appreciation of these beliefs as people with LBP display an attentional bias towards threatening nocebic information that supports their perceptions. As Eccleston and Crombez (27) so eloquently stated, “Pain is an

ideal habitat for worry to flourish.” With a meaningful reconceptualisation of pain as a threat output (28), clinicians can begin to acknowledge the implicit threat contained within their words and metaphoric constructions. Throughout their study, Darlow et al. (26) use direct quotes from people living with LBP. Whilst these comments highlight a range of anxious and worrying beliefs, the words used by the participants to express their experiences of living with pain also unveil the frequent use of self-generated metaphors within healthcare. Table 2 highlights these comments and proposes the variety of linguistic safe-bridges (18) that might be in use. Through the exploration of selfgenerated metaphors (Fig. 2) and with an increased therapeutic detection of these subtle linguistic nuances, healthcare professionals may begin to make sense of the lived experiences of people in pain. Furthermore, they may use people’s metaphoric safe-bridges by using guided, Socratic discovery to explore collaborative means of reconceptualisation thus fostering selfdetermined methods of behavioural change towards self-efficacy. For example, those who express feelings of loss of control (as those shown in Table 2) can, with skilled guidance, consider a range of strategies that they might develop to help regain control. This involves further exploration of their chosen metaphor with therapeutic facilitation (8,29,30). What strategies might they use to turn the amplification down? Which methods might they consider when next frozen in one place? Kopp (29) argues that, when using dialogical metaphors for therapeutic gain, clinicians should frame the discussion within a third person context. By suggesting, “What advice would you give to a someone else in this situation?”, we can begin to help others step outside the confines of their personal experience and facilitate change through a more comfortable and distant advisory scope. Loftus (7) calls for a dialogical approach to metaphoric expression within pain management. He argues that a monological, didactic approach “restricts perspective and narrows our vision.” Instead, conceptual thinking is needed for effective biopsychosocial sportEX journal 2015;66(October):10-14

PHYSICAL THERAPY PAIN, BRAIN AND SPORTS PERFORMANCE

management (31). Tompkins and Lawley (8) feel a more tailored, collaborative approach is needed. They suggest training to help clinicians identify patients’ own use of metaphors. Autogenic (self-generated) metaphors have been suggested by Hejmadi and Lyall (32) and Southall (30). Unfortunately, whilst these suggestions might facilitate patients towards a worthwhile pain reconceptualisation, they remain as speculative opinions and further research is needed to investigate their use within rehabilitation. Whilst patient-generated metaphors permit access to personal narratives, it is essential that we remain aware of their intrinsic ability to obstruct and regress the therapeutic process (21). Continual, Socratic exploration of the patient’s understanding of pain is an indispensable component of therapeutic pain reconceptualisation through metaphor.

CULTURAL DIVERSITY Culture and language affect perception, thought and cognition. They also affect the experience of pain. If we accept that metaphors, when appropriately coconstructed, can help us make sense of the world, we must also examine their sociocultural implications for pain reconceptualisation. The complexity of divergent cultural interpretations adds to the already challenging task facing clinicians when attempting to explain pain. Most of the evidence-base regarding persistent pain management emanates from Western cultures (33). As Western societies face an expansion of multiculturalism, we must consider how we can facilitate all patients to make sense of their pain, regardless of cultural background, and within their cultural comprehension (34). Lakoff and Johnson (2) argue that language is rooted in our cultural beliefs, and that our interpretations of metaphoric expression can easily be lost. If we are to fulfil our biopsychosocial aims for all people in pain, it is essential that we improve cultural competence (35). This is particularly true of metaphoric expression, and will likely become more prevalent with increasing global migration (36). Bourke (4) highlights the linguistic Co-Kinetic.com

TABLE 2: SELF-GENERATED METAPHORS AND THEIR SAFE-BRIDGES [M. Stewart, 2015. Adapted with permission from Darlow et al. Easy to harm, hard to heal: patient views about the back. Spine 2015;40(11):842–850] Self-generated metaphor

Expressive safe-bridge

“It feels like it’s crumbling. Like my back is crumbling and it can’t support me.”

n Body as a broken machine. n Life is falling apart. n Seeking support beyond biomechanical development.

“I have to think about how I get down, use my legs as opposed to my back as a winch, or else I will do myself an injury.”

n Body as an adaptable machine.

“The spinal part of my back, it can go as quick as sneezing.”

n Body as a broken machine. n “Gone” and “Went” as an expression of loss beyond biomechanical failure (Stewart M. J Physio Pain Assoc 2014;36:24–31 ).

“I guess just the worrying about it just kind of amplifies that a little bit.”

nD esire to regain control through change in the ‘volume’ of experience.

“I’ve finally come to a place where I can manage it, I feel rather good about that.”

n Pain experience as a learning journey. n Optimisitic cognitive reconstruction (Reisfield G, Wilson G. J Clin Oncol 2004;22:28–39).

“I couldn’t sit, I couldn’t stand, I couldn’t bend, I was frozen in one place.”

n Loss of control. n Stalled journey metaphor. n Strategies to ‘unfreeze’ required.

“It’s almost like it’s whipping me, saying ‘no, lie down’”

n T he language of agency (Biro D. The language of pain. W. W. Norton & Company 2010). n An external, incidious force inflicting harm.

“It was so sensitive that if I misbehave with my back…then, again my back will go rebellious.”

n Loss of control and resilience. n Battlefield metaphor with the spine as an attacking, external entity (Bourke J. The story of pain. Oxford University Press 2014).

differences between Western and Japanese cultures when using metaphor to describe headaches (Table 3). Historically, germ theory ushered in invasive and mechanistic metaphors to describe pain and disease within Western civilisations. Bourke (4) suggests that since the word ‘painkiller’ was first used in 1845, pain has been viewed as an enemy which must be relentlessly fought and defeated. Healthcare is often regarded as a battlefield. Wiggins (37) calls for an end to military metaphors to describe disease by arguing that battle metaphors give the impression that the ‘war’ can be won with biomedical escalation. The language of healthcare and physical rehabilitation speaks of analgesic ladders, bed blockers and failed back surgery syndrome. People in pain frequently experience an escalation of passive healthcare interventions that often leads to false hope, amplified

worry and entrenched beliefs (27). People climb the analgesic ladder from paracetamol towards opioids. Unavailing attempts at physical rehabilitation (the ground troops) frequently lead onto

TABLE 3: CULTURAL DIFFERENCES: THE METAPHORIC LANGUAGE OF HEADACHES (M. Stewart, 2015. Sourced from Bourke J. The story of pain. Oxford University Press 2014)) Western n Shooting n Stabbing n Lancinating n Pounding

Japanese nB ear headaches – resemble heavy steps of a bear nD eer headaches – like the galloping of running deer and headaches with a chill...

n Burning

nO ctopus headaches – sucking

n Crushing

nC rab headache – prickling

n Pinching Mechanistic and invasive

Natural and environmental

SUMMARY The sheer prevalence and characteristic concealment that metaphors exhibit within day-to-day communication requires our attention. When viewed within the context of rehabilitation and pain reconceptualisation, metaphoric expressions can provide helpful, communicative links between patients, clinicians and researchers. Through a greater appreciation of metaphor’s hidden influence within rehabilitation, we can begin to develop the neccesary

KEY POINTS nM etaphors shape how people make sense of experiences. n People use metaphors to communicate complex pain experiences. n Healthcare professionals use metaphors to help people make sense of pain. n Metaphors are a fundamental part of human expression. n Rehabilitation can be both helped and hindered by metaphors. n People use metaphors as ‘safe-bridges’ to express emotions that are too distressing to communicate literally. n Different cultures use different metaphors. n Healthcare professionals require training to develop their understanding of how to use patient-generated metaphors.

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Surgery Injections Oploids Rehabilitation

worry escalation

skills to facilitate behaviour change. Further research is required to determine the impact of metaphor training for healthcare professionals. Research is also needed to investigate if such training leads to improved clincial outcomes and reduced disability. When using metaphors, as we all inevitably must (2), it is prudent to remember Arturo Rosenblueth and Norbert Wiener’s warning: “The price of metaphor is eternal vigilance.” Metaphors provide a frame through which we paint unique cognitive landscapes (39). With this in mind, we must remain mindful of our eagerness to impose our brush strokes onto the canvases of others. Bakhtin (40) argues that language which is not spoken by the individual “exists in other people’s mouths, in other people’s contexts, serving other people’s intentions: it is from there that one must take the word, and make it one’s own.” As healthcare professionals, we need to recognise that the answers to people’s problems often lie in their words and metaphors, not ours.

biomedical escalation

steroid injections (the tank division) and epidurals (the fighter jets) before finally, the patient is facing the nuclear warhead option in the form of surgical intervention (Fig. 3). This broad, militarised metaphor lies at the heart of many healthcare models and drives passive dependency and an overreliance on interventional medicalised escalation (37). Reisfield and Wilson (38) believe that military metaphors lead us to assume that failure lies with the patient, and not the treatment. Equally, they might lead some clinicians to perceive themselves as incompetent soldiers.

Non-oploid analgesics

The war on pain Figure 3: The escalating battlefield of pain management. (M. Stewart, 2015)

IF A PICTURE PAINTS A THOUSAND WORDS, A METAPHOR PAINTS A THOUSAND PICTURES 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/1Nz6kYg

RELATED CONTENT he brain, pain and movement part 1 (and 2) T http://spxj.nl/1R0f20d isk, response and recovery: the psychology of sports R injury http://spxj.nl/1Kq57jR he challenges of youth: psychosocial response to injury T and rehabilitation in youth athletes http://spxj.nl/1cSnpi4 eaching out for a helping hand: the role of social R support in sports injury rehabilitation http://spxj.nl/1cSm3DL Mike Stewart MCSP SRP PG Cert is a state registered physiotherapist (SRP) and visiting university lecturer with over 15 years of experience managing complex, persistent pain conditions. In addition, he is a dedicated practice-based educator committed to providing evidence-based education to a wide variety of health professionals. His Know Pain workshops have provided clinicians around the world with practical and innovative pain education skills. He is currently studying for an MSc in Physiotherapy and Practicebased Education at The University of Brighton and is planning a PhD focusing on pain and communication. Website: www.knowpain.co.uk Email: mike@knowpain.co.uk Twitter: @knowpainmike Facebook: knowpainmike

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REFERENCES 1. Geary J. I is an other. The secret life of metaphor and how it shapes the way we see the world. Harper Collins 2011. ASIN B00DIKX54M. Buy from Amazon (£18.74). http://spxj.nl/1UoZSc5 2. Lakoff G, Johnson M. Metaphors we live by. University of Chicago Press 1980. ISBN 978-0226468006. Buy from Amazon (Print 23.69 Kindle £10.92). http://spxj.nl/1PNkbcn 3. Biro D. The language of pain. W. W. Norton & Company 2010. ISBN 978-0393070637. Buy from Amazon (Print 13.99 Kindle £13.29). http://spxj.nl/1hWS6VG 4. Bourke J. The story of pain. Oxford University Press 2014. ISBN 978-0199689422. Buy from Amazon (£16.59 Kindle £11.39). http://spxj.nl/1JPuXyG 5. Casarett D, Pickard A, et al. Can metaphors and analogies improve communication with seriously ill patients? Journal of Palliative Medicine 2010;13(3):255–260 6. Stewart M. The road to pain reconceptualisation: do metaphors help or hinder the journey? Journal of the Physiotherapy Pain Association 2014;36:24–31 7. Loftus S. Pain and its metaphors: a dialogical approach. Journal of Medical Humanities 2011;32:213–230 8. Tompkins P, Lawley J. The Mind, Metaphor & Health. Positive Health Online 2002;78 9. Singer I. Modes of creativity: philosophical perspectives, p.236. MIT Press 2011. ISBN 978-0262014922. Buy from Amazon (Print £24.95 Kindle £17.05). http://spxj.nl/1hWTA2n 10. Banville J. Beauty, charm, and strangeness: science as metaphor. Science 1998;281(5373):40–41 11. Melzack R, Wall PD. Pain mechanisms: a new theory. Science 1965;150(699):971– 979 12. Rathmell JP. Review of Wall and Melzack’s Textbook of Pain, 5th Edition. Anesthesia and Analgesia 2006;102:1914–1915 13. Semino E. The adaptation of metaphors across genres. Review of Cognitive Linguistics 2011;9(1):130–152 14. Melzack R. From the gate to the neuromatrix. Pain Supplement 1999;6:121– 126 15. Melzack R. Evolution of the neuromatrix theory of pain. Pain Practice 2005;5(2):85–94 16. Taylor P. Metaphors of educational discourse, p.11. In: Taylor W (ed.) Metaphors of education (p.4–20). Heineman 1984. ISBN 978-0435808808. Co-Kinetic.com

Buy from Amazon (£49.49) http://spxj.nl/1PNmegK 17. Paivio A, Walsh M. Psychological processes in metaphor comprehension and memory, p.307. In: Ortony A (ed.) Metaphor and thought (p.307– 328). Cambridge University Press 1993. ISBN 978-0521405614. Buy from Amazon £49.99) http://spxj.nl/1JPz3Xx 18. Shinebourne P, Smith J. The communicative power of metaphors: an analysis and interpretation of metaphors in accounts of the experience of addiction. Psychology and Psychotherapy 2010;83:59–73 19. Gibbs RW Jr. The poetics of mind: figurative thought, language, and understanding, p.137. Cambridge University Press 1994. ISBN 978-0521429924. Buy from Amazon (£89.99). http://spxj.nl/1Up3gDP 20. Price N, Dawood R, Jackson S. Pelvic floor exercises for urinary incontinence. A systematic literature review. Maturitas 2010;67(4):309–315 21. Haigh C, Hardy P. Tell me a story – a conceptual exploration of storytelling in healthcare education. Nurse Education Today 2011;31(4):408–411 22. Burckhardt C, Jones K. Adult measures of pain. Arthritis & Rheumatism (Arthritis Care & Research) 2003;49(55):96–104 23. Scarry E. The body in pain: the making & unmaking of the world. Oxford University Press 1985. ISBN 978-0195036015. Buy from Amazon (Print £12.08 Kindle £11.03). http://spxj.nl/1EDpCKH 24. Bras M, Dordevic V, Janjanin M. Personcentered pain management. Science and art Croatian Medical Journal 2013;54(3):296–300 25. Lankston L, Cusack P, et al. Visual arts in hospitals: case studies and review of the evidence. Journal of the Royal Society of Medicine 2010;103(12):490–499 26. Darlow B, Dean S, et al. Easy to harm, hard to heal: patient views about the back. Spine 2015;40(11):842–850 27. Eccleston C, Crombez G. Worry and chronic pain: a misdirected problem solving model. Pain 2007;132(3):233–236 28. Moseley GL. A pain neuromatrix approach to patients with chronic pain. Manual Therapy 2003;8(3):130–140 29. Kopp R. Metaphor therapy: using client generated metaphors in psychotherapy. Routledge 1995. ISBN 978-0876307793. Buy from Amazon (Print £28.50 £27.08). http://spxj.nl/1N5hzrb 30. Southall D. The patient’s use of metaphor within palliative care settings: theory, function and efficacy. A narrative literature review. Palliative Medicine 2013;27(4):304–313

31. Warmington S. Practicing engagement: infusing communication with empathy and compassion in medical students’ clinical encounters. Health 2012;16(3):327–342 32. Hejmadi AV, Lyall PJ. Autogenic metaphor resolution. In: Bretto C, et al. (eds) Leaves Before the Wind. Metamorphous Press 1994. ISBN 978-1555520519 Buy from Amazon (£70.74). http://spxj.nl/1JQ3GI4 33. Waddell G. Low back pain: a twentieth century health care enigma. Spine 1996;21(24):2820–2825 34. Moore Free M. Cross-cultural conceptions of pain and pain control. Baylor University Medical Center Proceedings 2002;15(2):143–145 35. Narayan M. Culture’s effects on pain assessment and management. American Journal of Nursing 2010;110(4):38–47 36. Gurung RA. A multicultural approach to healthcare psychology. American Journal of Lifestyle Medicine 2013;7(4):4–11 37. Wiggins N, M. Stop using military metaphors for disease. BMJ 2012;345(7867):31 38. Reisfield G, Wilson G. Use of metaphor in the discourse on cancer. Journal of Clinical Oncology 2004;22(1):28–39 39. Bolton G. Reflective practice. Writing & professional development, 3rd edn. Sage Publications 2010. ISBN 9781848602120. Buy from Amazon (£34.92). http://spxj.nl/1PNovbL 40. Bakhtin MM. The dialogic imagination, p.294. University of Texas Press 1982. ISBN 9780292715349. Buy from Amazon (£16.99 Kindle £13.25). http://spxj.nl/1UupU8w

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PHYSICAL THERAPY MSK DIAGNOSIS, TREATMENT, REHABILITATION

IDENTIFYING THE PRIMARY DRIVER OF SYMPTOMS IN PATELLOFEMORAL PAIN: A POSSIBLE METHOD OF PATIENT SUBGROUPING TO GUIDE TAILORED INTERVENTIONS Subgrouping individuals who suffer with patellofemoral pain has been identified as an important clinical tool to improve treatment effectiveness. This article presents the reader with a possible method to achieve subgrouping, considering the common deficits that have been identified in these patients. The article encourages the reader to consider the proposed, evidence informed, approach as part of a clinically reasoned assessment and tailored patient-centred intervention. Read this online http://spxj.nl/1NeouQC BY SIMON LACK BSC MSC

AN INTERNATIONAL GROUP OF CLINICIANS AND RESEARCHERS AGREE THAT PATIENT SUBGROUPING IS A PRIORITY FOR DELIVERING PATIENT SPECIFIC TAILORED INTERVENTIONS AND MAY BE KEY TO ACHIEVING BETTER LONG-TERM OUTCOMES KNEE | LOWER-LIMB | 15-10-SPORTEX FORMATS WEB MOBILE PRINT

MEDIA CONTENTS YouTube video ‘Dr Christian Barton presents ‘Patellofemoral pain: common deficits’, at the Danish Sports Medicine Congress 2013’. Courtesy of YouTube user Eilif Hedermann. http://spxj.nl/1L9pZtp Patient Advice handout Proximal muscle rehabilitation for patellofemoral pain http://spxj.nl/1NepDrr Continuing education quiz This article also has a certificated eLearning assessment that can be found in the Media Contents box in the online version of the article (online access is required to launch the assessment). http://spxj.nl/1NeouQC

Co-Kinetic.com

INTRODUCTION Patellofemoral pain (PFP) is common and challenging to treat. Conservative management has proven effectiveness within the current evidence base (1). However, despite its reported effectiveness, pain symptoms have been shown to persist in as many as 73% of patients at 5.7 year follow-up (2). The consensus of opinion of an international group of clinicians and researchers is that patient subgrouping is a priority for delivering patientspecific tailored interventions and may be key to achieving better long-term outcomes (3). This article introduces a possible method for achieving patient subgrouping. The factors that influence the symptoms that a patient with PFP reports can be defined as the ‘drivers’ of the symptoms. Multiple drivers are reported to result in the development and persistence of PFP symptoms (3). With ever increasing evidence identifying effective conservative interventions, poor long-term outcomes could be indicating that either the interventions are not correcting the driver of the symptoms, or the effective change to the patient’s driver(s) that led to

short-term symptom reduction does not ‘stick’ in the longer term (3). Consequently, effectively identifying the driver(s) of the individual’s symptoms, subgrouping the individual based upon the driver(s) identified and delivering interventions targeted towards the driver(s) could significantly improve conservative management outcomes.

IDENTIFICATION OF SYMPTOM DRIVERS AND REHABILITATION TARGETS The current literature highlights four key domains that are likely to drive a patient’s symptoms (Fig. 1). These include the patient’s underlying anatomy (Structure) (4,5), the way in which they move about that anatomy (Biomechanics) (6), the amount, frequency or intensity with which they do particular activities (Load/Volume/ Intensity) (1), and their underlying psychological robustness (Psychosocial) (1,7). With consideration of Dye’s 2005 model of tissue homeostasis (8), in combination with the accepted impact of psychological and social factors on pain (9,10), insufficiencies in any one or multiple of these domains could plausibly be the driver of PFP symptoms. The clinical challenge, 15

GIVEN THE LONG DURATION OF PAIN THAT IS COMMONLY REPORTED BY PFP SUFFERERS … THE PSYCHOSOCIAL BURDEN OF THE PAIN MAY BE SUFFICIENT TO REPRESENT THE PRIMARY DRIVER OF THEIR ONGOING SYMPTOMS

BIOMECHANICS

LOAD/VOLUME/INTENSITY

PSYCHOSOCIAL

STRUCTURE

Figure.1: Structure, Biomechanics, Load/Volume and Psychosocial drivers within an ‘Envelope of Function’. (S. Lack, 2015)

therefore, is to best identify which of these domains is likely to be the primary driver of symptoms, and which could be considered as secondary, tertiary or quaternary to the individuals pain presentation. Furthermore, the clinician needs to determine to what extent deficits co-exist and, consequently, which are likely to benefit from specific interventions. The complexity of this task requires sound clinical reasoning, using the available evidence to inform the decision-making process.

not (7). Given the extent of orthopaedic literature that has explored the association of structure and PFP symptoms, it is perhaps unsurprising – but remains very interesting – to see the little positive evidence that exists linking the two. Whilst the available evidence indicates that structure should be considered when assessing individuals with PFP, a lack of strong correlations or associations should further encourage the clinician to look more broadly for pain drivers.

STRUCTURE

BIOMECHANICS

Existing firmly within biomedical models of pain, structural deficits have been explored extensively to identify an associative relationship with PFP symptoms. However, even with observation through arthroscopy, confusion has resulted. In some individuals without pain cartilaginous lesions have been identified, and in patients with PFP, normal cartilage has been found (11,12). Furthermore, in patients with both cartilaginous lesions and symptoms, no correlation appears to exist between the severity of the lesions and symptoms (13). These findings would suggest that it is impossible for the clinician to predict patient symptoms by looking at structure alone. Having given due consideration for the limitations of directly linking structure and pain, some structural variants have been shown within the literature to correlate with PFP symptomology (4,6,7). These variables may be important when educating the patient about drivers of pain, discussing characteristics that may be prognostic of outcome and guiding the clinician on the intervention most likely to positively affect symptoms. In particular, a longer patella tendon relative to the patella length (ratio >1.5; Insall–Salvati measure for patella alta) has been shown to correlate with PFP severity when a comparison was made within subjects between the ipsilateral symptomatic and the contralateral asymptomatic knee (4). Increased ‘general joint laxity’ was also cited from one study in a systematic review of risk factors for PFP development; however, specific measures of patella mobility/laxity was

An extensive body of research has explored the way individuals move and how these movement parameters correspond with the development and persistence of PFP (14–20). Prospectively, kinematic analysis at the hip and foot has been completed in running (15) and military (14,20) populations only, but key findings indicate greater vertical peak force under the 2nd metatarsal (MT), shorter time to vertical peak force in the lateral heel (14), decreased knee flexion angle (20) and increased hip internal rotation and adduction angles (15) in those who develop PFP symptoms. These variables offer clinicians some indicators for assessing an individual’s risk, but importantly allows for comparison to be made with retrospective studies to determine the resultant effects of pain development on biomechanics. Interestingly, prospective data of isometric hip strength has not identified a link between weakness and the development of symptoms; however, in both men and women who have PFP, weakness in isometric strength has been reported (16). From these studies it can be postulated that hip weakness is not the primary driver of poor kinematics that leads to PFP development, instead it is more likely the movement patterns that are adopted by the individual. In patients with PFP, retrospective studies would suggest that these altered movement patterns persist when compared to asymptomatic populations (6) and the resultant pain would appear to lead to isometric hip muscle weakness (16). It is important to acknowledge that sportEX journal 2015;66(October):15-19

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LOAD/VOLUME/INTENSITY The model of load/volume/intensity introduced by Dye (8) proposes a zone of ‘optimal’ loading that maintains tissue homeostasis. Within this model he describes how prolonged or repeated periods of time spent in either an over-loaded or under-loaded environment may ultimately result in symptom development – largely irrespective of which tissue is being exposed to this environment in the anterior knee region (Fig. 2). Given the complex biomechanical work that has been done to investigate the load patterns across the patellofemoral articular surface during a squatting task (23), it can be conceptualised how the combination of altered PFJ mechanics and excessive/prolonged/ frequent activity result in altered tissue homeostasis and consequently pain. What is perhaps more challenging to explain is how symptoms may develop in individuals who are less active or more sedentary. Prospectively, a single study was reported to show that individuals who completed fewer hours of sport were more likely to develop PFP (7), demonstrating that this phenomena does exist. Theoretically pain resulting from under-loading or inactivity could be due to a number of different variables, and very likely be due to a number of different variables occurring together. One example could be due to weakness associated with inactivity, on top of suboptimal biomechanics, during only a few hours of sport or low-level activity. The resultant load that follows any activity (no matter how innocuous) may be sufficient to ‘tip’ the individual into a zone of focal overload and subsequent pain. Given the mechanosensitive nature of musculoskeletal tissue (24), prolonged periods of under-loading or low loading could plausibly result in an ever increasing reduction in capacity to tolerate load, and would require a very

load/volume

the limitation of these findings may well be in the method of assessment. Given that the gluteal muscles function eccentrically to control hip and pelvic motion during gait, measures of isometric strength may not be reflective of functional capacity. Particularly relevant to this hypothesis is a single prospective study that reported that those who demonstrated greater than average peak eccentric hip abduction strength were less likely to develop PFP (21). Consequently, exploration of eccentric gluteal strength could be the link between kinematics and muscle function that is currently not evident in the literature. What is consistent within the literature is that individuals with PFP, on average, move differently from those who do not have pain during activities that load the patellofemoral joint (PFJ) – including, but not exclusively, running, squatting, stair ascent or decent. Furthermore, a growing body of prospective evidence would suggest that some of these altered movement patterns exist before symptom development. As discussed, the link between altered patterns of movement, hip muscle strength and PFP development is less clear. However, what has remained consistent within the literature is that when PFP symptoms are present, hip muscle weakness is more common (16), larger hip adduction angles are evident during functional tasks and a more pronated foot posture is observed in relaxed stance (6). When considering identification of these biomechanical deficits clinically, assessment of triplanar motion using functional tasks such as the singleleg squat that have been reported to correlate with hip muscle strength (22) could be useful. In summary, a battery of clinical tests, including global movement assessment in combination with isolated musculoskeletal function should be used with appropriate consideration for the common deficits identified within PFP populations. This process builds a clinical picture of the patient’s biomechanics, their associated functional capacity and the most appropriate target for tailored intervention.

time Figure 2: Demonstrating the load/ volume capacity following periods of overload (blue line) or underload (green line). (S. Lack, 2015)

graded exposure to prevent symptoms developing. It is our hypothesis, that the domain of training load, volume and intensity is very likely to be integral in the successful management of PFP, and for some individuals the primary driver of their pain. Within the current evidence base however, this has been inadequately explored, limiting the strength of evidence to support or refute this statement. For load, volume and/or intensity to be identified appropriately, it will require clinicians to take thorough histories and integrate the findings into a clinically reasoned, tailored intervention approach. To identify it as a primary driver, patterns of rapid increase or change in training volumes, load or intensity, must correlate closely with the development of symptoms. Consideration of this change relative to their preceding activity levels may indicate if the resultant pain is due to higher load on an already high-load environment, or a period of high load that has followed a prolonged period of relative underloading.

PSYCHOSOCIAL The science of pain has been investigated extensively over recent

WHAT IS CONSISTENT WITHIN THE LITERATURE IS THAT INDIVIDUALS WITH PFP, ON AVERAGE, MOVE DIFFERENTLY FROM THOSE WHO DO NOT HAVE PAIN 17

STRUCTURAL, BIOMECHANICAL, LOAD/VOLUME/INTENSITY AND PSYCHOSOCIAL DEFICITS HAVE BEEN REPORTED WITHIN THE CURRENT LITERATURE TO EXIST OUTSIDE OF AN ‘ENVELOPE OF FUNCTION’ IN SYMPTOMATIC INDIVIDUALS years with an increasing body of work being published to explore the impact of psychological and social factors on pain modulation. In particular, scientists have examined the ability of these elements to increase the central-nervous-system mediated drive of pain via the forebrain (10). The extent to which these factors contribute to pain development, or are consequential to the existence of pain is subject to much debate. Given the limited prospective evidence exploring psychological risk factors for PFP development (25), it is not possible to accurately gauge the extent to which the origin of individuals’ PFP symptoms is purely psychosocial. However, given the long duration of pain that is commonly reported by PFP sufferers and the persistence of pain despite traditional physiotherapy interventions (26), in some, the psychosocial burden of the pain may be sufficient to represent the primary driver of their ongoing symptoms. Consequently, use of questionnaires such as the Örebro Musculoskeletal Pain Questionnaire (27) may offer the clinician useful insight into the patient’s psychology, the possible role it is playing in their presentation and potential targets for treatment.

CONCLUSIONS Successful identification of the primary driver of PFP symptoms, in combination with appropriate consideration for contributory drivers, should be used to subgroup patients allowing for the delivery of a patient-centred rehabilitation programme. Structural, biomechanical, load/volume/intensity and psychosocial deficits have been reported within the current literature to exist outside of an ‘envelope of function’ in symptomatic individuals. 18

This article has presented a method of subgrouping that offers the clinician a structure upon which to deliver a targeted intervention directed at specific deficits, maximising the likelihood of successful conservative management in both the short and long term. References 1. Barton CJ, Lack S, et al. The ‘Best Practice Guide to Conservative Management of Patellofemoral Pain’: incorporating level 1 evidence with expert clinical reasoning. British Journal of Sports Medicine 2015;49(14):923–934 2. Blond L, Hansen L. Patellofemoral pain syndrome in athletes: a 5.7-year retrospective follow-up study of 250 athletes. Acta Orthopaedica Belgica 1998;64(4):393–400 3. Witvrouw E, Callaghan MJ, et al. Patellofemoral pain: consensus statement from the 3rd International Patellofemoral Pain Research Retreat held in Vancouver, September 2013. British Journal of Sports Medicine 2014;48(6):411–414 4. Kannus PA. Long patellar tendon: radiographic sign of patellofemoral pain syndrome--a prospective study. Radiology 1992;185(3):859–863 5. Ward SR, Terk MR, Powers CM. Patella alta: association with patellofemoral alignment and changes in contact area during weight-bearing. Journal of Bone & Joint Surgery (Am) 2007;89(8):1749– 1755 6. Lankhorst NE, Bierma-Zeinstra SM, van M. Factors associated with patellofemoral pain syndrome: a systematic review. British Journal of Sports Medicine. 2013;47(4):193–207 7. Lankhorst E, Bierma-Zeinstra MA, Van MM. Risk factors for patellofemoral pain syndrome: a systematic review. Journal of Orthopaedic & Sports Physical Therapy 2012;42(2):81–95 8. Dye SF. The pathophysiology of patellofemoral pain: a tissue homeostasis perspective. Clinical Orthopaedics and Related Research 2005(436):100–110 9. Zusman M. Forebrain-mediated sensitization of central pain pathways: ‘non-specific’ pain and a new image for MT.

Manual Therapy 2002;7(2):80–88 10. O’Sullivan P. Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism. Manual Therapy 2005;10(4):242–255 11. Stougard J. Chondromalacia of the patella. Physical signs in relation to operative findings. Acta Orthopaedica Scandinavica 1975;46(4):685–694 12. Leslie IJ, Bentley G. Arthroscopy in the diagnosis of chondromalacia patellae. Annals of the Rheumatic Diseases 1978;37(6):540–547 13. Pihlajamaki HK, Kuikka PI, et al. Reliability of clinical findings and magnetic resonance imaging for the diagnosis of chondromalacia patellae. Journal of Bone & Joint Surgery (Am) 2010;92(4):927–934 14. Thijs Y, Van Tiggelen D, et al. A prospective study on gait-related intrinsic risk factors for patellofemoral pain. Clinical Journal of Sports Medicine 2007;17(6):437–445 15. Noehren B, Hamill J, Davis I. Prospective evidence for a hip etiology in patellofemoral pain. Medicine & Science in Sports & Exercise 2013;45(6):1120–1124 16. Rathleff MS, Rathleff CR, et al. Is hip strength a risk factor for patellofemoral pain? A systematic review and meta-analysis. British Journal of Sports Medicine 2014;48(14):1088 17. Lankhorst NE, Bierma-Zeinstra SM, van Middelkoop M. Factors associated with patellofemoral pain syndrome: a systematic review. British Journal of Sports Medicine 2013;47(4):193–206 18. Lankhorst NE, Bierma-Zeinstra SM, van Middelkoop M. Risk factors for patellofemoral pain syndrome: a systematic review. Journal of Orthopaedic & Sports Physical Therapy 2012;42(2):81–94 19. Meira EP, Brumitt J. Influence of the hip on patients with patellofemoral pain syndrome: a systematic review. Sports Health 2011;3(5):455–465 20. Boling MC, Padua DA, et al. A prospective investigation of biomechanical risk factors for patellofemoral pain syndrome: the Joint Undertaking to Monitor and Prevent ACL Injury (JUMP-ACL) cohort. American Journal of Sports Medicine 2009;37(11):2108–2116 21. Ramskov D, Barton C, et al. High eccentric hip abduction strength reduces the risk of developing patellofemoral pain among novice runners initiating a self-structured running program: a 1-year observational study. Journal of Orthopaedic & Sports Physical Therapy 2015;45(3):153–161 22. Claiborne TL, Armstrong CW, et al. Relationship between hip and knee strength and knee valgus during a single leg squat. Journal of Applied Biomechanics 2006;22(1):41 23. Farrokhi S, Keyak JH, Powers CM. Individuals with patellofemoral pain exhibit greater patellofemoral joint stress: a finite element analysis study. Osteoarthritis Cartilage 2011;19(3):287–294 sportEX journal 2015;66(October):15-19

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24. Khan KM, Scott A. Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. British Journal of Sports Medicine 2009;43(4):247–252 25. Witvrouw E, Lysens R, et al. Intrinsic risk factors for the development of anterior knee pain in an athletic population. A two-year prospective study. American Journal of Sports Medicine 2000;28(4):480–489

26. Stathopulu E, Baildam E. Anterior knee pain: a long-term follow-up. Rheumatology (Oxford) 2003;42(2):380–382 27. Linton SJ, Boersma K. Early identification of patients at risk of developing a persistent back problem: the predictive validity of the Orebro Musculoskeletal Pain Questionnaire. The Clinical Journal of Pain 2003;19(2):80–86.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Subgrouping of PFP patients according to symptom drivers is a priority for delivering patient-specific interventions. http://spxj.nl/1NeouQC Tweet this: Poor long-term outcomes could indicate that the interventions are not correcting the driver of the PFP symptoms. http://spxj.nl/1NeouQC Tweet this: The 4 groups of PFP symptom drivers are: structure, biomechanics, load/volume/intensity of activity, and psychosocial. http://spxj.nl/1NeouQC Tweet this: There is little positive evidence to link structural deficits with PFP symptoms. http://spxj.nl/1NeouQC Tweet this: A battery of clinical tests is needed to identify biomechanical drivers of PFP and to tailor specific treatment. http://spxj.nl/1NeouQC Tweet this: PFP symptom onset must correlate with a change in training for load/volume/intensity to be a primary driver. http://spxj.nl/1NeouQC Tweet this: A patient’s psychological burden of pain may be sufficient to be the primary driver of their PFP symptoms. http://spxj.nl/1NeouQC

THE AUTHOR Simon Lack BSc MSc is a PhD student at Queen Mary University London (QMUL), studying the interaction of hip and foot biomechanics in the presentation and management of patellofemoral pain. He graduated from Brunel University in 2005 with a degree in physiotherapy, and went on to study for an MSc in Sports and Exercise Medicine at QMUL in 2010. Simon works as a physiotherapist in two London-based private clinics, having previously worked in New Zealand with professional golfers, national rugby and local football teams.

KEY POINTS

RELATED CONTENT I dentifying the primary driver of symptoms in patellofemoral pain: a possible method of patient subgrouping to guide tailored interventions http://spxj.nl/1NeouQC Proximal muscle rehabilitation for patellofemoral pain (phases 1-4) client advice leaflets http://spxj.nl/1NepDrr P roximal Intervention for the management of patellofemoral pain http://spxj.nl/1HchrzZ reating adolescent patellofemoral T pain http://spxj.nl/1KfDlbA aping to treat patellofemoral T pain: does the science support the hype? http://spxj.nl/1KfD7kI hat can we predict when it W comes to patellofemoral pain? http://spxj.nl/1Hdma6T

In the mobile app and in the author profile on Co-Kinetic, this panel is a live Twitter feed.

nP FP is common and currently has poor long-term treatment success. n Subgrouping has been identified as important to maximise treatment effectiveness. n Identifiable deficits can be grouped into four groups. n The factors that influence the symptoms that a patient with PFP reports can be defined as the ‘driver’. n The link between structure and PFP is poor. n Individuals with PFP, on average, move differently from those who do not have pain. n The way individuals move (biomechanics) may be a driver of symptoms. n The amount, frequency and/or intensity of activity are important considerations for some individuals with PFP. n For some, the psychosocial burden of the pain may be sufficient to represent the primary driver of their ongoing symptoms.

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CLIENT ADVICE HANDOUT

Proximal muscle rehabilitation for patellofemoral pain – Phase 1 This programme is divided into 4 phases Phase 1 – Static loading in lying Phase 2 – Static loading in standing Phase 3 – Dynamic loading standing Phase 4 – Weighted dynamic loading in standing The objective of the programme is to improve the proximal musculatures capacity to optimise lower limb mechanics. It is advised that this is used in conjunction with movement re-education at the appropriate time in the rehabilitation programme. Discomfort in the knee should never exceed 3/10

severity, where 10 is a lot of pain, and 0 is no pain at all, during any of the exercises – if this level of discomfort is exceeded you should work for longer on the exercises that are the phase before the painful phase, or seek professional guidance. For all exercises n You should feel the muscles in your bottom working n Hold for 10sec in each position and repeat 3 times n Steadily increase the duration of the holds until you are able to hold the position for 3x45secs

PHASE 1A – STATIC LOADING IN LYING nC lam with band – in side lying, have knees in line with hips. Place the loop of band above both knees. Bend the knees to 90˚. Raise the top knee away from the bottom knee without rotating the pelvis and keeping your knees together.

n F ire hydrant with band – on your hands and knees with the band above both knees. Turn your knee out, and kick your heel towards the sky.

nH ip abduction/ extension with band – on your side bend your bottom leg to 90˚ and fully straighten your top leg. Lift the top leg up and backwards without rotating the pelvis.

n When you have achieved this goal move on to Phase 1b.

1B – PROGRESSION OF STATIC LOADING IN LYING IN LYING nS ide plank clam – in side lying, have knees in line with hips and your elbow tucked under your shoulder. Place the loop of band above both knees. Bend the knees to 90˚. Raise yourself into a side plank position and lift the top knee away from the bottom knee without rotating the pelvis and keeping your feet together.

nS ide plank hip abduction/extension - on your side, bend your bottom leg to 90˚ and fully straighten your top leg. Tuck you elbow under your shoulder and lift up your hips to adopt a side plank position. Lift the top leg up and backwards without rotating the pelvis. nC ontinue with Fire hydrant with band as previously described

The information contained in this article is intended as general guidance and information 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 accept no liability for any loss, injury or damage howsoever incurred (including negligence) as a consequence, whether directly or indirectly, of the use by any person of the contents of this article. http://spxj.nl/1NepDrr

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CLIENT ADVICE HANDOUT

Proximal muscle rehabilitation for patellofemoral pain – Phase 2 This programme is divided into 4 phases Phase 1 – Static loading in lying Phase 2 – Static loading in standing Phase 3 – Dynamic loading standing Phase 4 – Weighted dynamic loading in standing The objective of the programme is to improve the proximal musculatures capacity to optimise lower limb mechanics. It is advised that this is used in conjunction with movement re-education at the appropriate time in the rehabilitation programme. Discomfort in the knee should never exceed 3/10

severity, where 10 is a lot of pain, and 0 is no pain at all, during any of the exercises – if this level of discomfort is exceeded you should work for longer on the exercises that are the phase before the painful phase, or seek professional guidance. For the first 5 exercises n You should feel the muscles in your bottom working n Hold for 10sec in each position and repeat 3 times n Steadily increase the duration of the holds until you are able to hold the position for 3x45secs

PHASE 2A – STATIC LOADING IN STANDING

PHASE 2B – PROGRESSION STATIC LOADING

nS quat – with the band around your thigh, stand with feet shoulder width apart and squat down to ≈60˚ knee bend. Concentrate on keeping the knee over the middle toes.

nS quat with trunk activation – with the band wrapped around your thigh, crossed across your body and held in each hand, descend into a squat position with knees over your toes. Simultaneously raise your arms above your head.

n Gluteal Wall Press – with the band around your thigh, position yourself close to the wall. Assume a ¼ squat position with your knees over your toes. Lean on the wall with your inside shoulder and lift your inside leg up and forwards. Press the inside knee into the wall whilst maintaining the outside leg in the initial position. n S urfer Squat – with the band around your thigh, position your feet one facing forward and one out to the side. Sit back into a squat position distributing your weight evenly between the two feet keeping both knees over your toes. n When you have achieved these goals move on to Phase 2b.

n F ire Hydrant standing – with the band around your thigh, stand on one leg and descend into a ¼ squat with knee over toes. Simultaneously turn your ‘none stance’ leg outwards and backwards to tension the band. Lean forward through the trunk. nS ingle leg squat – standing on one leg, tip your trunk forwards and descend into a ¼ squat keeping your knee over your middle toes. n Crab Walk – with the band around your thigh assume a ¼ squat position. Take medium size strides out to the side and back again. For this exercise only n You should feel the muscles in your bottom working n Complete 10 strides in each direction and repeat 3 times n Steadily increase the number of strides to be a total of 30 in each direction 3 times. n When you have achieved these goals move on to Phase 3.

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CLIENT ADVICE HANDOUT

Proximal muscle rehabilitation for patellofemoral pain – Phase 3 This programme is divided into 4 phases Phase 1 – Static loading in lying Phase 2 – Static loading in standing Phase 3 – Dynamic loading standing Phase 4 – Weighted dynamic loading in standing The objective of the programme is to improve the proximal musculatures capacity to optimise lower limb mechanics. It is advised that this is used in conjunction with movement re-education at the appropriate time in the rehabilitation programme. Discomfort in the knee should never exceed 3/10 severity, where 10 is a lot of pain, and 0 is no pain at all, during any of the exercises – if this level of discomfort is

exceeded you should work for longer on the exercises that are the phase before the painful phase, or seek professional guidance.

For all exercises n You should feel the muscles of your bottom, front and back of thigh working n The exercise should be performed with good control at a speed of 2-3sec for the descent and 2-3 sec for the ascent phase n Start at 3x6 reps per exercise and build to 3x12 reps steadily.

PHASE 3 – DYNAMIC LOADING STANDING n Squat with trunk activation – with the band wrapped around your thigh, crossed across your body and held in each hand, descend into a squat position with knees over your toes. Simultaneously raise your arms above your head. Squat to a depth of 90˚ knee bend and then raise back up into an upright standing position with your arms by your side.

n L unge with back leg support – start with the back of your legs against the box/bench/chair, take a full stride forwards, and hook the back leg up onto the apparatus. With the knee tracking over the toes, decend into a lunge position leaning the trunk forwards. Your hands should end around your mid shin/ ankle. Push through the heel back into a straight leg position.

n Romanian Deadlift – with light weight in your hand, slightly flex the stance leg. Keeping your back straight, tip through the hip to lean forwards keeping your back leg straight behind you. Feel the tension build into the back of the stance leg, and then return to an upright position.

n F ire Hydrant squat – with the band around your thigh, stand on one leg, simultaneously turn your ‘none stance’ leg outwards and backwards to tension the band. Lean forward through the trunk and squat down through the stance leg to a ¼ depth squat. Ensure the knee tracks over the toes, then return to an upright position. n When you have achieved these goals move on to Phase 4.

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CLIENT ADVICE HANDOUT

Proximal muscle rehabilitation for patellofemoral pain – Phase 4 This programme is divided into 4 phases Phase 1 – Static loading in lying Phase 2 – Static loading in standing Phase 3 – Dynamic loading standing Phase 4 – Weighted dynamic loading in standing The objective of the programme is to improve the proximal musculatures capacity to optimise lower limb mechanics. It is advised that this is used in conjunction with movement re-education at the appropriate time in the rehabilitation programme. Discomfort in the knee should never exceed 3/10 severity, where 10 is a lot of pain, and 0 is no pain at all, during any of the exercises – if this level of discomfort is

exceeded you should work for longer on the exercises that are the phase before the painful phase, or seek professional guidance. For all exercises n Ensure the additional load is challenging to a level of 6-7/10 effort, where 10 is your maximal effort, and 0 is no effort at all n The exercise should be performed with good control at a speed of 2-3sec for the descent and 2-3 sec for the ascent phase n Start at 3x6 reps per exercise and build to 3x12 reps steadily.

PHASE 4 – WEIGHTED DYNAMIC LOADING IN STANDING nR omanian Deadlift – with weight in your hands, slightly flex the stance leg. Keeping your back straight, tip through the hip to lean forwards keeping your back leg straight behind you. Feel the tension build into the back of the stance leg, and then return to an upright position.

nW eighted Lunge with Trunk Lean – take a large stride forwards carrying weights in both hands. Keeping the weight through the heel of the front leg, bend your front knee over your toes and rock your trunk forwards at the pelvis. With the knee bent to 90˚ push through your heel to straighten up your front leg.

nW eighted Sumo Squat – Stand with you feet wider than your hips, turn your toes outward slightly. With a single weight in both hands, squat down keeping your knees tracking outwards over your toes. Squeeze your bum muscles to initiate the upward motion whilst keeping the weight through your heels.

nW eight Step Down with Trunk Lean – carrying weights in both hands, rock your trunk forwards from your pelvis, keep your weight through your heel of the lowering leg, and slowly descend keeping your knee over your toes. Get to approximately 90˚ on the stance leg and then stand back upright again pushing through the heel.

nW hen this goal is being achieved you should be able to return to your normal physical activity with appropriate movement re-education

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REHABILITATION ADHERENCE: Adherence to long-term rehabilitation programmes is notoriously one of the key challenges faced by health care practitioners. The pressures associated with returning patients to pain-free function as efficiently as possible requires competence and understanding of the practitioner in developing realistic home exercise programmes. The developing age of technology to assist rehabilitation prescription means that too often, inadequate time within a clinical setting is dedicated towards effectively prescribing, instructing and teaching the home exercise programme and reviewing its effectiveness in subsequent sessions. This article explores the challenges associated with maximising the adherence to home exercise programmes. Read this online http://spxj.nl/1ilmKb7 BY SARAH MARTIN BSC GST, MED

BACKGROUND An individually tailored evidence-based exercise programme is paramount when designing a musculoskeletal rehabilitation plan. Many practitioners in clinical practice or authors in published research papers fail to report the adherence levels of their participants and, therefore, it is difficult to determine true effectiveness of programmes. Adherence to a prescribed rehabilitation regimen is essential to achieve successful recovery from a sports injury and a patient’s adherence to a rehabilitation programme is directly related to the success of the treatment PSYCHOLOGY | 15-10-SPORTEX FORMATS WEB MOBILE PRINT

MEDIA CONTENTS YouTube video ‘Proprioception exercise programme for chronic ankle instability’ (Courtesy of YouTube user UoP Sports Therapy, 2011). http://spxj.nl/1O881g0 Handout 1 Exercise programme for chronic ankle instability, weeks 1–5 (S. Martin, 2013 http://spxj.nl/1ilmKb7 Handout 2 Exercise programme for chronic ankle instability, weeks 8–10 (S. Martin, 2013) http://spxj.nl/1ilmKb7 Continuing education quiz This article also has a certificated eLearning assessment that can be found in the Media Contents box in the online version of the article (online access is required to launch the assessment). http://spxj.nl/1ilmKb7

priority within the session rather than and the speed of the recovery process a conclusive aspect of an appointment. (1). The effectiveness of this process It is difficult to gauge the extent that relies on commitment from the a patient has followed their prescribed patient as well as proficiency from the home exercise programme and this practitioner (Fig. 1). The practitioner must adds to the complex judgement the treat the patient as an individual and practitioner has to make regarding tailor their rehabilitation programme to the effectiveness of the prescribed suit their daily lifestyle (2) and focus on exercises on a session-by-session adopting a multitude of strategies to basis. There is a distinct lack of quality motivate patients to adhere to their plan. Attendance at clinic-based sessions measures available to measure a patient’s adherence to a programme is generally easy to monitor with a but simply asking them “Did you relatively high commitment to sessions perform your exercises?” as only 5.8% to 14.3% of is insufficient as a means patients fail to attend their of determining their appointments (3), although Quality of adherence. Despite the others have reported this exercises increasing frequency of figure to be approximately practitioners integrating 50% (4). However, it is home-management as important to remember part of their rehabilitation, that attendance at a clinicshort-term adherence based session with the Athletes’ rates to home exercise practitioner present does commitment programmes is reported not necessarily ensure to be as low as 58% quality of exercises or (5) and long-term an adequate quantity of unsupervised home-based treatment is received exercise programmes to improve the patient’s Practitioner demonstrates even lower condition. This direct ability to adherence rates towards contact between the enhance preventative measures. patient and the practitioner commitment With the majority of is the only time available responsibility for a to specifically guide the standard rehabilitation patient towards their home Figure 1: The process of programme being in exercise programme and commitment. (S. Martin, 2015) the patient’s control, should, therefore, be a sportEX journal 2015;66(October):24-28

PHYSICAL THERAPY MSK DIAGNOSIS, TREATMENT, REHABILITATION

educating the patient is of paramount importance. Over 200 variables have been identified which may prevent a patient fully adhering to their home exercise programme (Fig. 2). Individual reasons for this non-adherence require careful consideration for all patients and barriers towards adherence should be identified and integrated in the programme (6).

BARRIERS TOWARDS ADHERENCE ‘Time’ is highlighted as one of the main barriers to successful adherence and therefore fitting home exercise programmes into patients’ daily routines so the exercises become habitual must be a priority (7). Married or cohabiting individuals demonstrate better adherence as they are provided with social support to complete their exercises (7) but those with dependents demonstrate lower levels of adherence (3). Older individuals are believed to be more committed towards fulfilling the expectations of an exercise programme (8) but there is inconclusive evidence to suggest that gender has any relationship with levels of adherence. Social support plays a key role in encouraging motivation and adherence and integration of external involvement from coaches, team-mates and family should be considered when designing a programme. Patients who have low levels of physical activity, previously reported inadequate rehabilitation to a programme, demonstrate low self-efficacy or display signs of low self-efficacy, depression or anxiety are amongst those who tend to present with poor adherence to their rehabilitation. Activities which increase the patient’s pain levels also deter them from performing the exercises and lead to failure of programme completion. The practitioner should consider these predictors of adherence in the early stages of rehabilitation after sports injury, identifying personal and situational factors which may affect the efficacy of their return to function (1). However, many practitioners feel that their education on the psychological aspects of injury, including adherence, is inadequate and they felt untrained to identify predictors of poor adherence in patients. Co-Kinetic.com

OPTIMISING ADHERENCE Partial adherence to a programme is not enough to induce successful effects of rehabilitation outcome when using home exercise programmes (9). Although the terms are used interchangeably, the definitions of ‘compliance’ and ‘adherence’ should be considered (Fig. 3). A shared responsibility between the practitioner and the patient is required to optimise adherence and must include three key principles: n Communication n Education n Monitoring. Conversations regarding the patient’s lifestyle and commitments are essential to identify potential barriers to full adherence. Building a relationship with the patient encourages the development of achievable goals and enhances loyalty by the patient to the practitioner which sees higher adherence levels to the programme. Educating the patient and enabling them to understand their injury and the rationale for their long-term exercise programme assists in them taking control over their return to function and enables them to see the purpose of the exercises being prescribed (3). Explaining the process and components of rehabilitation to a patient may enhance adherence. Patients who expect to be provided with exercises and accept that the process of healing is largely their own responsibility demonstrate significantly higher adherence rates than those who do not know what to expect from the rehabilitation programme (10). As such, it is useful to prioritise patient education, goal-setting and mutually agreeing targets to optimise the process. Monitoring adherence through the use of diaries to record performance of their exercises on a daily or weekly basis often acts as a

Therapist trust/loyalty (short term) *Campbell et al. 2001

Lack of pain cure *Bassett. NZJ Physiother 2003;31:60

Time *Alexandre et al,. 2002 *Bassett. Phys Ther 2007;87:1132

Education Support (from family and coaches) *Bull. Adherance issues in sport exercise. Wiley 2001 ISBN 978-0471560197

*Alexandre et al. Pan Am J Pub Health 2002;12:86

Doesn’t suit daily routine *Campbell et al. J Epidemiol Community Health 2001;55;32

Quick initial improvements No. of dependents

* Kingston et al. J Rural Trop Pub Health 2009;8:1

*Alexandre at al., 2002 *Bassett, 2007

Gender (inconclusive) *Hartigan et al. Med Sci Sports Exerc 2000:32:551

Marital status (social support) *Bull, 2001 *Bassett, 2003

Figure 2: Factors affecting adherence. (S. Martin, 2015)

KEEP THE NUMBER OF EXERCISES TO A MINIMUM TO INCREASE ADHERENCE prompt to the patient to complete their exercises if the diary or their exercise sheet is placed in a noticeable location (3). However, self-report reliability should be treated cautiously – patients tend to overestimate their adherence or view full adherence differently from the practitioner. If reports are completed on a weekly basis patients may have difficulty recalling their commitment to the programme or they may exaggerate their adherence to impress the practitioner or because they may feel embarrassed by their lack of adherence (7).

The practitioner’s knowledge of the skill acquisition process and competency in executing the prescribed exercises is paramount. Psychological models such as Bandura’s Observational Learning Theory should be adopted when teaching unfamiliar skills to the patient. It takes learners approximately 12 observations and then performing a skill correctly for 6 repetitions for the information to be retained (11). The complexity of the skill or exercise being prescribed is important. A patient with experience in exercise and training is likely to accept being provided with a complex skill but an untrained, inexperienced or unmotivated patient requires simple tasks to be prescribed to avoid information overload or an inability to perform the activity, leading to them giving up. Sufficient time must be spent reviewing the instructions given and assessing the patient’s understanding and ability to recall, process and implement the provided information (12). Performing the tasks within the clinic session can significantly assist in improving the memory of the exercises and key technical considerations, as well as allowing the practitioner to identify and correct errors in the technique. Keeping the number of exercises to a minimum will enhance exercise adherence as excessive information can stress the patient’s ability to attend to the information (13). There are four fundamental points to consider when prescribing exercises (14): n Clear instruction

n Constant feedback n Correct technique instruction n Quality and relevance of exercises. In the early stages of rehabilitation, pain acts as a cue to prompt patients to perform their rehabilitation exercises. In the latter stages, with the absence of pain, other triggers must be built into the programme to enhance adherence and prevent commitment levels declining (15). The practitioner must provide an empathetic approach and value goal-setting within the rehabilitation process. During the early stages of injury rehabilitation, a patient’s motivation to recover and return to pain-free function may be high so it is important for patients to see results and improvements in their condition from early on to motivate them (16). The use of simple and regular objective marker measures to monitor this progression should be included within the rehabilitation programme to motivate the patients and allow them to see improvements and set achievable targets.

SUPPORTING MATERIALS Practitioners need to carefully consider how they will instruct the exercises to the patient. The ideal scenario within a clinical setting would be for practitioners to have the patient practice the activities provided before they leave the appointment and take home written and pictorial guidelines to act as a reinforcement tool but this is not always achievable. Often

Used interchangeably Compliance Very prescriptive in nature

Active voluntary involvement of patient

HCP provides instruction, individual obeys the prescribed protocol

Involved in planning & implementing treatment programme

Alexandre et al. Pan Am J Pub Health 2002;12:86

Bassett. NZJ Physiother 2003;31:60

Figure 3: Compliance versus adherence. (S. Martin, 2015)

Adherence

the time restraints on practitioners mean that the patient leaves with the majority of their programme having been prescribed by handouts and verbal instructions or they are given a generic pre-written programme to follow. With so many standardised image and video databases (such as PhysioTools and Rehab Software Pro) available to practitioners now, there is a danger that the process of teaching a skill is becoming under-prioritised and, therefore, these resources must be used to supplement rather than substitute exercise prescription. Visual prompts such as image handouts are effective for retention purposes but these should not be a substitute for live instruction as they do not offer technique guidance or feedback. Placing accompanying handouts in noticeable locations is an effective prompt for patients to perform their rehabilitation. When provided with a simple stretching and strengthening programme, just 50% of subjects who viewed handouts with images were able to perform the exercises correctly (14). Patients demonstrated a preference for using videotape instruction over illustrations to learn exercises as there are greater visuals but considerations with accessibility to these videos, time taken to produce videos, individualisation of the activities for the specific pathology and the lack of opportunity for corrective feedback means that the practitioner should consider how they can use this. With the developing use of smartphone technology, considering taking photos or filming the patient performing their exercises with associated text or voiceover feedback from the practitioner during the session may act as a useful reminder (Fig. 4). However, very little evidence is currently available to establish the effectiveness of these different instructional methods on maximising adherence to a home exercise programme.

METHODS OF INSTRUCTION INFLUENCING ADHERENCE My aim was to perform a preliminary investigation into the effects that different forms of media and instructional aids have on a patient’s motivation to adhere to a home sportEX journal 2015;66(October):24-28

PHYSICAL THERAPY MSK DIAGNOSIS, TREATMENT, REHABILITATION

Co-Kinetic.com

this time, the live instruction group were provided a 15-minute session to administer the new exercises. The DVD and handout groups were both provided relevant details for the progression (Handout 2). Upon commencement of the 8-week programme, all daily self-report diaries were collected in. The live instruction group revealed the highest level of adherence over the 8-week period (Fig. 5). The adherence levels showed a decline throughout the programme over the 8-week period but the live instruction group demonstrated consistently higher adherence to the programme throughout. At the week 5 point when groups were given a new set of exercises, the live instruction group showed an increase in adherence that week, demonstrating the value of interaction between the practitioner and the patient to maximise adherence.

CONCLUSION The responsibility of maximising adherence levels towards a home exercise programme lies mutually between the practitioner and the patient. It is important to consider the definition of adherence being a twoway communication. Given that the majority of the patient’s recovery is self-guided and performed at home, it is the practitioner’s responsibility during the clinic session to dedicate sufficient time to instruct the patient. One-toone sessions need to last a minimum of 15 minutes to ensure that the exercises are fully administered (5) and the patient is capable of performing the programme independently. It is important that the patient is fully educated and understands the purpose of their rehabilitation exercises. Their ability to recall and perform the exercise programme must be evaluated before they leave the clinic session to ensure that correct execution of the activity can be demonstrated. An extensive knowledge of exercise rehabilitation is essential as widely available generic rehabilitation programmes are inadequate; exercises must be individualised to fit in with the patient’s daily routine so the exercises become habitual. The practitioner must also make the judgement about how

Video 1: YouTube video ‘Proprioception exercise programme for chronic ankle instability’ (Courtesy of YouTube user UoP Sports Therapy, 2011). http://spxj.nl/1O881g0

motivated and competent a patient is before choosing the complexity of the skill being prescribed so the activities are achievable for the patient and avoiding a ‘one size fits all’ generic programme design at all costs. Methods of monitoring a patient’s adherence to a programme should be included. The use of daily selfreport is a reasonably effective way of monitoring the commitment to the programme and also acts as a prompt to the patient to perform their exercises if they feel they are being monitored by their practitioner. The development of innovative software programs and resources is ever-increasing but practitioners must not use these to replace the value of effective live instruction. These sources may be effective at assisting adherence to a home exercise programme but neither still images nor video clip instructions can provide the invaluable corrective advice that live instruction with supplementary

Figure 4: Using a patient’s smartphone to record their exercises. (S. Martin, 2015)

10 9 Adhearance score (out of 10)

exercise programme. Given that there is a 13% chance of reinjury from ankle sprain in the first 12 months, a longterm pre-habilitation programme is essential. I used a standard 8-week conditioning rehabilitation programme for patients who had suffered multiple lateral ankle sprains, had at least one recurrence in the last 12 months, and presented with chronic ankle instability. The Cumberland ankle instability tool (CAIT) (17) was used to recruit female subjects displaying the symptoms of unilateral chronic ankle instability and participants self-reported previous inadequate rehabilitation for their injury. The 96 participants fulfilling the inclusion criteria were randomly assigned to one of three groups: (1) live instruction with a handout, (2) DVD instruction, or (3) a handout-only group. Four exercises to be performed five times per week were provided. An alternative activity was provided for each exercise which patients could choose to perform if they wished to vary their programme. The programme consisted of commonly used exercises published for the rehabilitation of chronic ankle instability. All participants were briefed in week 1 where the live instruction group were offered group rehabilitation instruction during a 15-minute session by the researcher. This session allowed for demonstration, practice and corrective feedback as would mimic a standard rehabilitation session. Participants were provided with a handout prompt featuring only images of the exercise and the prescription required (Handout 1). The DVD group were provided with a DVD and a link to the video clip on YouTube so they could access this from their Smartphone (Video 1). The DVD included written coaching points to consider and details of the exercise prescription. The handout-only group were provided with image stills from the DVD along with guidance, coaching points and prescription details of the programme. All participants were provided with a daily self-report diary using a 10cm visual analogue scale to record the extent they felt they adhered to the programme each day. To prevent tedium the exercises were changed after 4 weeks. During

8 7 6 5 4 3 2

1 0

Wk 1

Wk 2

Wk 3

Wk 4

Wk 5

Wk 6

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n Live instruction n DVD instruction n Handout instruction Figure 5: The weekly adherence levels per instruction group. (S. Martin, 2015)

written material can offer. These are essential though as patients tend to forget their provided exercises once they leave the clinic session so require a prompt. Creating a relatively quick image handout or videoing the patient performing the exercise on their smartphone using voiceovers or notes with essential coaching points and details of the exercise prescription are the most effective method of maximising adherence to a home exercise programme as they can be accessed on the move. Insufficient evidence is available to suggest that any one strategy works to maximise long-term adherence to a home exercise programme but practitioners must be aware of a wide range of methods and strategies within their instruction to enhance the patient’s motivation as much as possible. References 1. Marshall A, Donovan-Hall M, Ryall S. Exploration of athletes’ views on their adherence to physiotherapy rehabilitation after sport injury. Journal of Sport Rehabilitation 2012;21:18–25 2. Moore JE, Von Korff M, et al. A randomized trial of a cognitive-behavioural program for enhancing back pain self care in a primary care setting. A randomized trial of a cognitive-behavioural program for enhancing back pain self care in a primary care setting. Pain 2000;88(2):145–153 3. Bassett SF, Prapavessis H. Homebased physical therapy intervention with adherence-enhancing strategies versus clinic-based management for patients with ankle sprains. Physical Therapy 2007;87(9):1132–1143 4. Holden MA, Haywood KL, et al. Recommendations for exercise adherence measures in musculoskeletal settings: a systematic review and consensus

meeting (protocol). Systematic Reviews 2014;3(10):1–6 5. Roddey TS, Olson SL, et al. A randomized controlled trial comparing 2 instructional approaches to home exercise instruction following arthroscopic full-thickness rotator cuff repair surgery. Journal of Orthopaedic and Sports Physical Therapy 2002;32(11):548–559 6. McLean SM, Burton M, et al. Interventions for enhancing adherence with physiotherapy: a systematic review. Manual Therapy 2010;15(6):514–521 7. Bassett SF. The assessment of patient adherence to physiotherapy rehabilitation. NZ Journal of Physiotherapy 2003;31(2):60–66 8. Alexandre NMC, Nordin M, et al. Predictors of compliance with short-term treatment among patients with back pain. Pan American Journal of Public Health 2002;12(2):86–95 9. Hupperets MDW, Verhagen EALM, van Mechelen W. Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial. BMJ Online 2009;339:b2684 10. Schneiders AG, Zusman M, Singer KP. Exercise therapy compliance in low back pain patients. Manual Therapy 1998;3:147– 152 11. Carroll WR, Bandura A. Role of timing of visual monitoring and motor rehearsal in observational learning of action patterns. Journal of Motor Behavior 1985;17(3):269–281 12. Nadar MS, McDowd MS. ‘Show me, don’t tell me’; is this a good approach for rehabilitation? Clinical Rehabilitation 2008;22(9):847–855 13. Weeks DL, Brubaker J, et al. Videotape instruction versus illustrations for influencing quality of performance, motivation, and confidence to perform simple and complex exercises in healthy subjects. Physiotherapy Theory and Practice 2002;18(2):65–73 14. Friedrich M, Cermak T, Maderbacher,P. The effect of brochure use versus therapist teaching on patients performing

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Adherence to a prescribed rehabilitation regimen is essential for achieving successful recovery from a sports injury. http://spxj.nl/1ilmKb7 Tweet this: Simply asking “Did you perform your exercises?” is insufficient for determining adherence to a rehab programme. http://spxj.nl/1ilmKb7 Tweet this: Activities that increase pain levels deter patients from completing the rehab programme. http://spxj.nl/1ilmKb7 Tweet this: Models such as Bandura’s Observational Learning Theory should be adopted when teaching new skills to a patient. http://spxj.nl/1ilmKb7 Tweet this: The practitioner must provide an empathetic approach and value goal-setting within the rehabilitation. process. http://spxj.nl/1ilmKb7

therapeutic exercise and on changes in impairment status. Physical Therapy 1996;76(10):1082–1088 15. Mazières B, Thevenon A, et al. Adherence to, and results of, physical therapy programs in patients with hip or knee osteoarthritis. Development of French clinical practice guidelines. Joint Bone Spine 2008;75(5):589–596 16. Kingston GA, Tanner B, Gray MA. A pilot study evaluating a home exercise DVD for patients who reside in a rural and remote location. Journal of Rural and Tropical Public Health 2009;8(1):1–7 17. Hiller CE, Refshauge KM, et al. The Cumberland Ankle Instability Tool: a report of validity and reliability testing. Archives of Physical Medicine and Rehabilitation 2006;87(9):1235–1241.

KEY POINTS n F ull adherence is crucial to achieve a successful rehabilitation programme. n There is no effective substitute for live instruction. n Barriers towards adherence in every individual must be identified and addressed. n Technology such as smartphone use should be embraced to enhance adherence to a home exercise programme. n Careful programme design should be made – simplistic and minimal exercises are crucial to adherence. n Adherence is a two-way process – loyalty and commitment between the practitioner and patient is required. n Image and video supplementary handouts provide excellent reinforcements of the exercise programme. n Exercises should fit into a patient’s daily routine and should become habitual.

RELATED CONTENT Effective patient communication http://spxj.nl/1Dz0Has It’s all in the mind: psychosocial interventions to improve recovery http://spxj.nl/1HdmLFz eaching out for a helping hand: the role of social R support in sports injury rehabilitation http://spxj.nl/1cSm3DL THE AUTHOR Sarah Martin BSc GST, MEd is a Sports Therapist (BSc Hons, PGCE, MEd) who graduated from the University of Birmingham in 2007. She has lectured in Sports Therapy and Rehabilitation at the University of St Mark and St John since 2008 and offers Sports Therapy support within Professional Motorcycle Speedway. In 2012 she completed an MEd focusing on the instructional methods associated with maximising adherence to sports injury rehabilitation programmes.

sportEX journal 2015;66(October):24-28

PHYSICAL THERAPY CO-KINETIC.COM HIGHLIGHTS

PHYSICAL THERAPY HIGHLIGHTS ON

THIS QUARTER’S MOST POPULAR ARTICLES IN THE PHYSICAL THERAPY CATEGORY IN POPULARITY ORDER 1. F emoroacetabular impingement: mechanisms, diagnosis and treatment options using Postural Restoration Part 2 http://spxj.nl/1GtFGZJ 2. Femoroacetabular impingement: mechanisms, diagnosis and treatment options using Postural Restoration Part 1 http://spxj.nl/1AMWG0F

RECENT ARTICLES WITH CERTIFICATED ELEARNING ASSESSMENTS A case study of a longitudinal medial collateral ligament sprain in a professional footballer http://spxj.nl/1K4a4B5

3. Tendinopathy loading programmes: an overview of current concepts http://spxj.nl/1cpkWe0 4. Practical model for managing tennis elbow http://spxj.nl/1Yb93ft

5. D iagnosing Achilles tendinopathy: a ‘how to’ guide http://spxj.nl/1QIA0m7

6. G ait retraining in medial osteoarthritis of the knee http://spxj.nl/1Gt3jBF

7. Concussion in sport: putting the guidelines into action http://spxj.nl/1GUlS2A

SUPPLEMENTS Supplements are made up of a series of articles that have been published under the Physical Therapy section. If you have a subscription to either the Full Site or the Physical Therapy (sportEX medicine) category they are included in your subscription. If you don’t yet have a subscription, you can purchase the articles individually or as a supplement.

Co-Kinetic.com

oncussion in sport: C putting the guidelines into action http://spxj.nl/1GUlS2A T endinopathy loading programmes http://spxj.nl/1cpkWe0 iagnosing Achilles D tendinopathy http://spxj.nl/1QIA0m7 hould Sports Consider S Neuroimaging in the Assessment of Concussion? http://spxj.nl/1Hdnmae sychosocial Response P to Injury & Rehab in Young Athletes http://spxj.nl/1cSnpi4

PATELLOFEMORAL PAIN SUPPLEMENT http://spxj.nl/1NCs1bx 1. I dentifying the primary driver of symptoms in patellofemoral pain: a possible method of patient subgrouping to guide tailored interventions http://spxj.nl/1NeouQC 2. P roximal muscle rehabilitation for patellofemoral pain (phases 1-4) - client advice leaflets http://spxj.nl/1NepDrr 3. P roximal Intervention for the management of patellofemoral pain http://spxj.nl/1HchrzZ

UPCOMING ARTICLES DUE FOR PUBLICATION ON THE CO-KINETIC WEBSITE Iliotibial band syndrome: a narrative review (with client advice leaflets) Iliotibial band syndrome: a case study Three bedside tests designed to explore bodily perception in pain and rehabilitation How to deal with performance pressure by psychologically tipping the balance Prevention and management of anterior cruciate ligament injury Femoroacetabular impingement: mechanisms, diagnosis and treatment options using Postural Restoration Part 3

4. T reating adolescent patellofemoral pain http://spxj.nl/1KfDlbA 5. Taping to treat patellofemoral pain: does the science support the hype? http://spxj.nl/1KfD7kI 6. What can we predict when it comes to patellofemoral pain? http://spxj.nl/1Hdma6T 7. Does your patient have patellofemoral pain? Don’t forget the hip. http://spxj.nl/1KfDqMs

TENDINOPATHY SUPPLEMENT http://spxj.nl/1QFnLXa 1. D iagnosing Achilles tendinopathy: a “how to” guide http://spxj.nl/1QFnLXa 2. T endinopathy loading programmes http://spxj.nl/1cpkWe0 3. The tendinopathy continuum http://spxj.nl/1HdmMtf

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

The usual suspect databases were searched and found 48 studies using randomised controlled trials (RCTs) involving adults with temporomandibular disorders (TMD) comparing any type of manual therapy (MT) intervention (eg. mobilisation, manipulation) or exercise therapy compared to a placebo intervention, controlled comparison intervention or standard care were included. The main outcomes of this systematic review were pain, range of motion and oral function. The overall evidence for this

Read this online http://spxj.nl/1LdXdfw

EFFECTIVENESS OF MANUAL THERAPY AND THERAPEUTIC EXERCISE FOR TEMPOROMANDIBULAR DISORDERS: SYSTEMATIC REVIEW AND META-ANALYSIS. Armijo-Olivo S, Pitance L, Singh V, Neto F, et al. Physical Therapy 2015;doi:10.2522/ptj.20140548 [Published online: 20 August 2015] systematic review was considered low. Many trials had unclear or high risk of bias. Therefore, the evidence was generally downgraded based on risk of bias assessments. Most of the effect sizes were low to moderate with no clear indication of superiority of exercises vs other conservative treatments to treat TMD. However, MT alone or in combination with exercises at the jaw or cervical level showed promising effects.

sportEX comment The problem with this study was the usual one for meta-analysis. The RCTs on the subject suffer from low quality and are lacking in heterogeneity. The authors describe the finds as having ‘great uncertainty about the effectiveness of exercise and manual therapy’ but what is there is ‘promising’. What this means in practice for clinicians is that if you are involved in TMD issues you can use this piece of evidence to make a case for or against MT!!

DOES CHANGING THE PLANE OF ABDUCTION INFLUENCE SHOULDER MUSCLE RECRUITMENT PATTERNS IN HEALTHY INDIVIDUALS? Reed D, Cathers I, Halaki M, Ginn KA. Manual Therapy 2015;doi:http://dx.doi. org/10.1016/j.math.2015.04.014 [Published online: 16 April 2015] The purpose of this study was to determine if muscle activation differs during abduction shoulder in the scapular plane or in the coronal (scapular −30°) and scapular +30° planes. Electromyographic recordings were taken from eight shoulder muscles of fourteen healthy volunteers at 50% of maximum load. The result was that abduction can be performed within a 30° arc of the scapular plane with no change in shoulder muscle

activation patterns. Only middle deltoid activation levels change between the scapular and coronal planes and middle deltoid and upper trapezius between the scapular and scapular +30° planes.

sportEX comment One for the body builders. You don’t need to worry too much about accurate angles.

EFFECTS OF A SINGLE-SESSION MASSAGE FOR SEDENTARY OLDER WOMEN WITH PREHYPERTENSION: A PILOT STUDY. Caromano FA, Monte F, Morgani de Almeida MH, Jerônimo da Costa JC, et al. International Archives of Medicine 2015;8(158):doi:10.3823/1757 Fifty-eight sedentary older women with prehypertension were treated with a Swedish massage performed on all parts of the body except the genitals by a physiotherapist with 30 years’ experience with massage techniques. Blood pressure and heart rate were collected immediately before and after the intervention. The results were that systolic blood pressure decreased 13%, whereas diastolic blood pressure decreased 9.4%. Heart rate decreased by 17%.

sportEX comment On the face of it yet

more evidence that massage reduced blood pressure. But can we please make a plea to massage researchers: ‘Sixty minutes of Swedish Massage’ is meaningless. You need to think about dose. What was the depth and speed of the strokes, how long on each body part, etc? Not putting that in is like saying you gave people medication without stating which drugs and how big the pill was. And why, oh why, did they feel the need to say that all of the body was treated except the genitals? When they expand the pilot study into a larger one are they going to include that area? Not sure what that will do to the blood pressure and heart rate.

sportEX journal 2015;66(October):30-33

JOURNAL WATCH MANUAL THERAPY RESEARCH INTO PRACTICE

Journal Watch COMPARISON OF THE EFFECTS OF MASSAGE AND CRYOTHERAPY ON THE KNEE EXTENSOR MUSCLES FATIGUE AND ISOKINETIC PARAMETERS IN SOCCER PLAYERS. Razeghi M, Nouri H. Journal of Rehabilitation Sciences and Research 2015;2(1):1–7 Fifty-four healthy athletes aged 20–30 years were randomly divided into three groups: cooling (ice therapy), massage, and control (resting). Each was evaluated in two sessions. The first was to familiarise the participants with isokinetic contraction. The second session started with a brief warm-up, and subsequently, using Biodex Isokinetic System, average peak torque (APTQ), average power (AP) and total work (TW) were measured. Then, the fatigue protocol was applied. Afterwards, interventions were performed for 15 minutes. Cooling was achieved with an ice pack on the knee extensor muscle bulk for 15 minutes. Massage was on the front of the thigh from the groin to the top of the patella for 15 minutes: stroking techniques for 2 minutes, effleurage for 3 minutes, petrissage which consists of rolling and ringing each for 2 minutes, compression for 3 minutes, and finally effleurage for 3 minutes. The control group rested for 15 minutes in a supine position. After the intervention, isokinetic parameters were evaluated again. In addition perceived fatigue and fatigue index (FI) were recorded before and after the intervention. The performance measures significantly increased for the massage and cryotherapy groups after the intervention, whereas perceived fatigue and FI decreased significantly in both conditions. There was no difference in the performance results for the control group but perceived fatigue and FI decreased significantly. There was no difference between the massage and cryotherapy groups.

sportEX comment Sorry, the ice baths produce results. However, massage is just as good so get your club to hire a massage therapist. There are lots of them out there.

THE CLINICAL EFFICACY OF THORACOLUMBAR FASCIA RELEASE FOR SHOULDER PAIN. Choi DM, Jung JH. Physical Therapy Rehabilitation Science 2015;4(1):55–59 Thirty subjects with shoulder pain were allocated to thoracolumbar fascia release (TLFR) group (n = 15) plus manual therapy and a manual physical therapy (MPT) only group (n = 15). Shoulder pain and disability index (SPADI) and the score on the visual analogue scale (VAS) were measured before and after treatment. Both groups improved post-treatment on the SPADI scored but there was no significant difference between groups. The actual interventions were an osteopathy fascia relaxation technique called ‘Stills technique’ which is basically a 3D facial stretch held for 60–90 seconds until the tissue relaxes. This was repeated two or three times for 10 minutes. The manual therapy was joint mobilisation to the shoulder plus traction and gliding movements and therapeutic massage to induce muscle relaxation to the pectoralis major, pectoralis minor, rotator cuff, latissimus dorsi and teres major and minor applied for 40 minutes. There were three treatment sessions a week for 4 weeks.

sportEX comment Manual therapy including massage works and the results are even better if you add some myofascial release. Sadly they don’t describe what they call ‘therapeutic massage’ so that could have been anything.

EFFECTS OF THE ACTIVE RELEASE TECHNIQUE ON PAIN AND RANGE OF MOTION OF PATIENTS WITH CHRONIC NECK PAIN. Kim JH, Lee HS, Park SW. Journal of Physical Therapy Science 2015;27(8):2461–2464 Twenty-four subjects with chronic neck pain were randomly assigned to an active release (ART), a joint mobilisation (JM), or a control group. The treatment groups received two sessions of 20 minutes a week for 3 weeks. Both demonstrated improvement in VAS pain scores and range of movement with no change in the control group. Significant differences were found in pressure pain threshold (PPT) of all muscles in the ART group, and significant differences in all muscles other than the trapezius were found in the JM group. No significant difference in PPT was observed in any muscle of the control group. The post-hoc test indicated no statistically significant difference between the ART and JM group. The JM was performed using Kaltenborn’s techniques of traction and gliding with movements of flexion, extension, Co-Kinetic.com

side bending, and rotation, traction at Grade I or II performed for 10 seconds. Plus, in order to recover hypomobility, traction and gliding were performed at level 3 and maintained for 7 seconds. Both treatments included 2–3 seconds of rest and were repeated 10 times. ART is not described other than to say that it is a manual therapy for the recovery of soft tissue function that involves the removal of scar tissue, which can cause pain, stiffness, muscle weakness, and abnormal sensations including mechanical dysfunction in the muscles, myofascia and soft tissue.

sportEX comment If you are a manual therapist seeking evidence in an increasingly ‘hands off’ therapy world, then go for the headline.

ART and Mobs work to decrease pain and increase range of motion. However, if you dig a bit deeper into this study you may have some concerns regarding ART which is not really described. This may be because according to the Active Release Techniques website (http://www.activerelease.com) it is a ‘patented’ technique because it is different from anything else. The web site says “Shorten the tissue, apply a contact tension and lengthen the tissue or make it slide relative to the adjacent tissue. It’s as simple as playing a piano and just as difficult”. OK, it sounds very similar to what is known in the UK as ‘soft tissue release’ or ‘positional release’. Maybe an ART practitioner could write an article for us comparing and contrasting? 31

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT THE LOCATION OF THE INFERIOR ANGLE OF THE SCAPULA IN RELATION TO THE SPINE IN THE UPRIGHT POSITION: A SYSTEMATIC REVIEW OF THE LITERATURE AND METAANALYSIS. Cooperstein R, Haneline M, Young M. Chiropractic & Manual Therapies 2015;23:7 It is a popular belief that the upright inferior scapular angle (IAS) aligns with the spinous process (SP) of T7. However, some sources specify the T7–8 interspace or the T8 SP. So this study sought to pool the data and find out which was right. Eight-hundred and eighty articles of interest were identified, 43 abstracts were read, 22 full text articles were inspected, and 5 survived the final cut. Each article (with one exception) was rated for quality using the quality assessment of diagnostic accuracy studies (QUADAS) instrument. Pooling data from the five papers resulted in normal distribution in which the upright IAS on average aligns closely with the T8 SP, range T4– T11. Since on average the IAS most closely identifies the T8 SP in the upright position, it is very likely that health professionals, both manual therapists and others, who have been diagnosing and treating patients based on the IAS = T7 SP rule were wrong.

sportEX comment Oh dear, we have all been a segment out. Who cares? Palpate and treat the bit that hurts.

Read this online http://spxj.nl/1LdXdfw

THE EFFICACY OF MANUAL THERAPY FOR ROTATOR CUFF TENDINOPATHY: A SYSTEMATIC REVIEW AND META-ANALYSIS. Desjardins-Charbonneau A, Roy JS, Dionne CE, Frémont P, et al. Journal of Orthopaedic & Sports Physical Therapy 2015;45(5):330–350 A literature search using terms related to shoulder, rotator cuff tendinopathy and manual therapy was conducted in four databases to identify randomised controlled trials that compared manual therapy to any other types of treatment. Twenty-one studies were included. The majority had a high risk of bias. Only five studies had a score of 69% or greater, indicating a moderate to low risk of bias. A small but statistically significant overall effect for pain reduction of manual therapy compared with a placebo or in addition to another intervention was observed (n = 406), which may or may not be clinically important. Adding manual therapy to an exercise program (n = 226) significantly decreased pain as reported on a 10cm VAS, which may or may not

be clinically important. Based on qualitative analyses, it is unclear whether manual therapy used alone or added to an exercise programme improves function.

sportEX comment Forget the bias bit. Most of the scales used to judge research harp on about getting the base characteristics of the subjects to be equal at the start which is close to impossible because everyone is different. They also like subjects and therapists to be blinded to what is going on, which is difficult when you are getting hold of someone’s joints and jiggling them about. Take home the important message from this study, manual therapy works on pain.

EXCURSION OF THE SCIATIC NERVE DURING NERVE MOBILIZATION EXERCISES: AN IN VIVO CROSS-SECTIONAL STUDY USING DYNAMIC ULTRASOUND IMAGING. Coppieters MW, Andersen LS, Johansen R, Giskegjerde PK, et al. Journal of Orthopaedic & Sports Physical Therapy 2015;doi:10.2519/jospt.2015.5743 [Epub ahead of print] High-resolution ultrasound imaging was used to quantify longitudinal sciatic nerve movement in the thigh in 15 asymptomatic participants during six different mobilisation techniques for the sciatic nerve involving the hip and knee. Healthy volunteers were selected to reveal normal nerve biomechanics and to eliminate potentially confounding variables associated with dysfunction. The techniques were: 1. Simultaneous knee extension with hip flexion. 2. Simultaneous knee extension with hip extension. 3. Knee extension with the hip prepositioned in a neutral position. 4. Knee extension with the hip prepositioned in flexion. 5. Hip flexion with the knee prepositioned in flexion. 6. Hip flexion with the knee 32

prepositioned in extension. No. 1 lengthens the sciatic and tibial nerve bed and is regarded as a tensioning technique. In No. 2, knee extension loads the tibial and sciatic nerve, while hip extension unloads the sciatic nerve and is an example of a sliding technique. With a tensioning technique, nerve mobilisation is obtained by moving one or several joints in such a manner that the nerve bed is elongated, forcing the nervous system to slide relative to its surrounding structures. In a sliding technique, at least two joints are moved simultaneously in such a manner that one joint movement counterbalances the increase in nerve strain caused by another movement. Sliding techniques are associated with much larger excursions of the nervous system relative to surrounding structures, but

without the potentially large increases in nerve strain. The techniques resulted in markedly different amounts of nerve movement. The tensioning technique was associated with the smallest excursion. The sliding technique resulted in the largest excursion, which was approximately 5 times larger than the tensioning technique, and on average twice as large as for individual hip or knee movements.

sportEX comment This comes with a great big warning sign from the authors. Although the differences in nerve excursion might be clinically meaningful, it should not be interpreted as one technique being superior to another until further research equates the techniques with therapeutic effects. sportEX journal 2015;66(October):30-33

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EFFECTS OF THAI MASSAGE ON SPASTICITY IN YOUNG PEOPLE WITH CEREBRAL PALSY. Malila P, Seeda K, Machom S, Salansing N, Eungpinithpong W. Journal of the Medical Association of Thailand 2015;98(Suppl. 5):S92-S96 Seventeen people aged 6–18 years old with spastic diplegia had the spasticity of their right quadriceps femoris muscles measured using a modified Ashworth scale (MAS) before and immediately after a 30-minute session of Thai massage applied to the lower back and lower limbs. There was a significant difference of MAS was observed between preand post-treatment. No adverse events were reported.

sportEX comment We always have to remind people when we highlight studies such as this one that ‘sport’ is a broad church and there are lots and lots of athletes with cerebral palsy. We also have to add that Thai massage is basically compressions. It’s a soft tissue therapy and it works. Spread the word – especially the last part. Even if it doesn’t work on a particular athlete there are no adverse effects. It’s safe. In

the same edition of the journal there is another study showing that Thai massage reduces psychological stress and heart rate in healthy individuals and a lot of that is needed in sport as well. They introduced stress by giving the participants a 10-minute mental arithmetic test. There are also a lot of people who get stressed doing sums! [Psychological stress can be decreased by traditional Thai massage. Sripongngam T, et al. Journal of the Medical Association of Thailand 2015;98(Suppl. 5):S29–S35]

THE ACUTE EFFECTS OF DEEP TISSUE FOAM ROLLING AND DYNAMIC STRETCHING ON MUSCULAR STRENGTH, POWER AND FLEXIBILITY IN DIVISION 1 LINEMEN. Behara B, Jacobson BH. Journal of Orthopaedic Trauma 2015;doi:10.1519/JSC.0000000000001051 [Post acceptance: 24 June 2015] Myofascial restrictions are thought to be brought on by injuries, muscle imbalances, over recruitment, and/or inflammation, all of which can decrease sports performance. Fourteen USA college offensive linemen (big guys) took part in a randomised crossover design. Vertical jump power and velocity, knee isometric torque, and hip range of motion were assessed before and after: (a) no treatment, (b) deep tissue foam rolling, or (c) dynamic stretching. The result was that there was no pre- to post-test significant differences for the jump peak power, average power, peak velocity or Sixteen patients (9m, 7f; aged 18–50 years) diagnosed with lateral epicondylalgia had pain recorded using a VAS scale plus pressure pain threshold and pain free grip strength measurements were taken before and immediately after taping and after 30 minutes of each taping application. Two taping techniques were used: Kinesio and Athletic. Tape was applied on two consecutive days with the order of technique chosen at random. Athletic tape was applied in a diamond box pattern as per McConnell’s reloading procedure with four strips of non-elastic, adhesive-backed sports tape laid distally to proximally in a diamond shape with traction force on the soft tissues towards lateral epicondyle and

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average. Nor was there a difference in peak knee extension torque, average knee extension torque, peak knee flexion torque, or average knee flexion torque. However, hip flexibility was statistically significant when tested after both dynamic stretching and foam rolling.

sportEX comment Expected results really but yet more evidence that foam rolling and therefore myofascial work can have at least a short term effect on flexibility.

EFFECT OF KINESIO TAPING VERSUS ATHLETIC TAPING ON PAIN AND MUSCLE PERFORMANCE IN LATERAL EPICONDYLALGIA. Goel R, Balthilaya G, Shankar Reddy R. International Journal of Physiotherapy and Research 2015;3(1):839–44. perpendicular to the line of the tape. For the kinesio tape the application was tape was applied from insertion to origin to inhibit extensor carpi radialis brevis (ECRB) muscle function. For fascia correction the base of the fascia correction was applied in front of the pain point. The fascia was pulled towards the free direction. The tape ends were affixed without tension. The results showed significant pain reduction and increase in grip strength after both the taping techniques but no statistically significant differences for any

outcome measure between the two taping techniques. Also the immediate pain reduction was more after athletic taping (21%) than kinesio taping (10%) that corresponded to the immediate increase in pain-free grip strength more after athletic taping (14.5%) than kinesio taping (9.7%). 30 minutes later both the outcome measures gave similar percentage changes.

sportEX comment They both work – apply the cheapest.

BROUGHT TO YOU BY

Nxt Gen Institute of Physical Therapy

Our regular research review summarises research looking into the effectiveness of dry needling for myofascial pain. Read this online http://spxj.nl/1Nesdxv

DRY NEEDLING FOR MYOFASCIAL PAIN BY MATT ZANIS PT, DPT, ATC, CSCS DRY-NEEDLING | FASCIA | PAIN | 15-10-SPORTEX FORMATS WEB MOBILE PRINT

n healthcare, many fields of practice often overlap in their sharing of interventions, which can create turf wars and controversy. In the United States, one aspect of physical therapy practice that has been included in a lot of recent discussion is dry needling. Despite this rise in popularity, evidence is still sparse for its role in modern practice. A recent article written by Kietrys et al. (1) called ‘Effectiveness of dry needling for upper-quarter myofascial pain: a systematic review and meta-analysis’ outlines the physical therapist’s role when it comes to dry needling, along with proposed effectiveness for both immediate and long-term relief.

THE STUDY When gathering relevant studies to include in this systematic review, the researchers used comprehensive databases such as OvidSP MEDLINE, HealthSTAR and PubMed. They used very specific inclusion criteria: all of the articles were randomised controlled trials (RCTs), used human subjects, had a control or comparison group and included participants with upper-quarter myofascial symptoms. To be included, articles also had to contain the key term ‘dry needling’ and must have been written in English (an interesting choice as acupuncture is an Eastern practice similar to dry needling – one would think researchers would want to include that vast knowledge base). Their initial search actually included a systematic review and meta-analysis regarding dry needling and acupuncture, but only produced two relevant articles (that did not discuss acupuncture specifically) to include in their own investigation. The researchers of this particular metaanalysis were even so bold as to say “it is unlikely that any relevant articles were overlooked.” In the end, the authors included 12 studies for analysis, which is quite small compared to other clinically meaningful meta-analyses and Cochrane Reviews. Despite the small sample size, each article was then

reviewed by at least three different evaluators using The MacDermid Quality Checklist to determine internal validity and was assigned a levelof-evidence rating as described by Sackett et al. (2). Within the 12 selected articles, the authors performed four separate meta-analyses that focused on pain, via a visual analogue scale (VAS), as the main outcome measure. Only outcomes immediately and at 4 weeks were used, along with comparisons to a sham control group or another treatment group. This does not allow for any conclusions about the long term (greater than 4 weeks) to be extrapolated from this review. Lastly, two points on the VAS were used as the cut-off value for clinical meaningfulness. This is a good reference point for positive outcomes. However, pain is so subjective that it needs to be regarding closely to the context in which it is reported (ie. environmental stressors, time of day, mechanism of injury, and chronicity). In this meta-analysis outcome measures (pain on a VAS) were considered the dependent variables, while the intervention groups were the independent variables (3). When it comes to how the intervention and control groups were established, the parameters were inconsistent. Most importantly, the control groups used in some of the articles were other participants, while other articles studied controls using the contralateral extremity of the same participant. Controls also varied between lidocaine injection, botox injection, and nonlocalised acupuncture (3). The authors found a moderate immediate effect of dry needling compared to the other treatments. This is difficult to determine because we cannot be certain if that positive effect was due to the lidocaine or merely the insertion of the needle. It is difficult to establish validity and effectiveness when all controls are still receiving a needle inserted into bodily structures, which may actually be efficacious. The authors even realised this stating, “in many cases,

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comparison groups also received an improvement in pain.” (1, p.624). This is reflected by other research by Audette et al. (4) who found mirror-image, EMG activity (local twitch response potentials) associated with unilateral dry needling stimulation of active myofascial trigger points (4) and Venancio et al. (5) who discovered that “dry needling had the most reduction in frequency, intensity and duration of headaches at 12 weeks, not the lidocaine or Botox-A group.” Within these 12 articles were the demographics and aetiologies of the included participants. Among these, aetiology was not consistent across the board. We still must consider context of the population we are working with when it comes to treatment. For example, one of the articles by DiLorenzo et al. (6) included patients status post-cerebrovascular accident with myofascial pain syndrome (MPS) versus someone with MPS of musculoskeletal origin. The participants in all 12 studies were over the age of 60, with sub-acute to chronic symptoms (between 3 and 63 months), which may or may not reflect the patient demographics physical therapists commonly encounter routinely. The results of these studies indicated dry needling to have a wide array of usefulness in the treatment of painful conditions. While the authors suspect this to be related to effects of the gate control theory, the effects may also be related to other potential variables, such as beliefs and expectations.

MY ASSESSMENT When we attempt to understand effectiveness of interventions such as dry needling, we must consider the influence of nociceptive stimulation and the environment on pain perception. In another study by Napadow et al. in 2007 (7), the authors found they could affect the limbic system (specifically the amygdala) by stimulating key muscles and acupuncture points in patients with carpal tunnel syndrome, which also

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resulted in a decrease in pain. This makes sense because the amygdala translates somatosensory stimuli into affective states, or fear and defensive behaviour, highlighting the possibility for dry needling to reduce the affective component of chronic pain by deactivating a sensitised, hyperactive amygdala. In their conclusions, the authors of the above systematic review believe “the goal of dry needling is rapid relief of pain so that patients can be progressed to other forms of therapy, such as exercise and postural correction.” I agree with this statement, in which pain relief is just a means to an end. I suspect the ultimate goal should be to correct regionally interdependent impairments and educate our patients on healthy movement patterns in order to make our patients self-sufficient. I concluded from this study that dry needling is a useful tool in not only breaking the vicious pain–spasm cycle of overloaded muscle, but also in restoring the length–tension relationship of muscles to improve motor control. In doing so, long-term success with combined interventions is achievable. After processing all of the information given, interpretation from this review is complicated given the small number of studies included, variance among groups, control conditions, dosage, outcomes and internal validity. Additional high quality RCTs, as well as in-depth studies of acupuncture literature are needed to fully grasp the depth of this topic and to draw any solid conclusion with its application to clinical practice. References 1. Kietrys DM, Palombaro KM, et al. Effectiveness of dry needling for upperquarter myofascial pain: a systematic review and meta-analysis. Journal of Orthopaedic & Sports Physical Therapy 2013;43(9):620–634 2. Sackett DL, Rosenberg WM, et al. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312(7023):71–72 3. Tough EA, White AR, et al. Acupuncture and dry needling in the management of

myofascial trigger point pain: a systematic review and meta-analysis of randomized controlled trials. European Journal of Pain 2009;13:3–10 4. Audette JF, Wang F, et al. Bilateral activation of motor unit potentials with unilateral needlestimulation of active myofascial trigger points. American Journal of Physical Medicine & Rehabilitation 2004;83(5):368–374 (quiz 375–7, 389) 5. Venancio RA, Alencar FG Jr, Zamperini C. Botulinum toxin, lidocaine, and dry-needling injections in patients with myofascial pain and headaches. Cranio 2009;27(1):46–53 6. DiLorenzo L, Traballesi M, et al. Hemiparetic shoulder pain syndrome treated with deep dry needling during early rehabilitation: a prospective, open-label, randomized investigation. Journal of Musculoskeletal Pain 2004;12:25–34 7. Napadow V, Kettner N, et al. Hypothalamus and amygdala response to acupuncture stimuli in carpal tunnel syndrome. Pain 2007;130(3):254–266.

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THE AUTHOR Matt Zanis PT, DPT, ATC, CSCS is a full time staff physical therapist, per diem athletic trainer, and orthopaedic specialist in training. He has recently finished his formal residency preparation and transitioned into the American Academy of Orthopedic Manual Physical Therapists (AAOMPT) fellowship programme offered through NxtGen Institute of Physical Therapy. Passionate about yoga and CrossFit, Matt relates very well to the athletes and has already grown a big following during his short career as a licensed physical therapist.

RELATED CONTENT ry needling http://spxj.nl/1HmV0KW D Treating myofascial pain with myofascial trigger point needling http://spxj.nl/1HNYQ1p

Does stretching the ITB conjure up scenes of torture? For many clients it seems to be a rite of passage, if the treatment has not taken a client’s breath away it can lead to doubts about how good a therapist is or how successful the treatment was. This article will challenge the old school of thought that deeper is better and giving it a bit of elbow will sort it out. I am proposing a different intention, how to deliver the best treatment with minimal discomfort. I will be demonstrating how transverse soft tissue release can offer an effective form of treatment while dispelling the ‘deep is better’ myth. Read this online http://spxj.nl/1JDATas LOWER-LIMB | CASE-STUDY | 15-10-SPORTEX FORMATS WEB MOBILE PRINT

MEDIA CONTENTS Video 1: Iliotibial band syndrome and transverse soft tissue release of the hamstrings (NLSSM, 2015) http://spxj.nl/1JDATas ontinuing education quiz C This article also has a certificated eLearning assessment that can be found in the Media Contents box in the online version of the article (online access is required to launch the assessment). http://spxj.nl/1JDATas

BY SUSAN FINDLAY BSC RGN, DIP SMRT, DIRECTOR NLSSM

lliotibial band (ITB) syndrome is a common condition often associated with runners, cyclists and weight lifters (those who perform a lot of squats). The tension felt in the ITB is often mistaken for the problem rather than the symptom. All too often I hear from the lips of my athletes “my ITB needs to be stripped” – an aggressive word that conjures up a medieval approach to resolving what is not so much a muscle but a connective band. The word ‘connective’ is key and plays a vital role in our decision making process when determining the best approach for treatment. In this case study I have highlighted how transverse soft tissue release (STR) can be an effective tool in the rehabilitation of ITB syndrome.

CASE STUDY History and presentation A relatively new runner had just 36

TRANSVERSE SOFT TISSUE RELEASE AND ITB SYNDROME: A CASE STUDY completed his first marathon, he has no history of any serious injuries that prevent him from running or training, but recently he suffered a sharp pain around the outside of his left knee leaving him barely able to walk after a 5-mile run. He found it hard to bend his leg when walking and continues to find it difficult to go down hills or flights of stairs. The problem started after returning to training 1 week after the marathon. He had an X-ray and an MRI scan, and although neither showed any sign of significant pathologies, the MRI did show a slight thickening of the tissue on the lateral side of the knee. At this point, despite the inconclusive medical investigations, the current severity of the injury continued to interfere with his everyday life and he had not been able to train for 3 weeks. He had been to see a physiotherapist and acupuncturist, which helped and the exercises and stretches given to him had also helped, but he continued to be limited in his ability to run

because of the pain. He had then been recommended to see a sports massage therapist. Despite having stated in his original interview that he did not have a history of any previous injuries upon further questioning the client admitted to having an earlier episode of an ITB problem the previous year. This was resolved by a period of rest and making adjustments to his stretching routine. Findings from palpation and ROM testing showed a tendency to overpronate and he had a mild case of bunions bilaterally (more severe on the left). There were rough calluses on the medial edges of the hallucis

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– calluses often indicate that there is excessive rubbing usually as a result of poor mechanics. Both ankles were stiff with a restricted glide in dorsiflexion and the Achilles tendons were tight bilaterally. Further up to the knee, the patella moved freely medially but was very restricted laterally by the ITB and vastus lateralis; poor muscle tone was felt on the medial and central quadriceps and further exploration revealed a lack of gluteus medius engagement and weak hip strength.

Iliotibial band syndrome These findings point toward ITB syndrome, a suggestion made to him by his consultant. This condition is common in both cyclists and runners; for the former it can be the result of having the seat too high forcing the leg into full extension while pedalling, and for the latter it can be caused by the knee turning inward as a result of poor foot mechanics, uneven surfaces or worn-out shoes. All of these conditions place repeated stress on the outside of the knee where the ITB inserts, often causing inflammation. One of the goals of treatment is to reduce the inflammation, a conventional approach recommends the use of antiinflammatories and rest.

What is the best treatment for ITB syndrome? Pain is often thought to be indicative of a short ITB yet despite studies finding that the ITB is often long in these circumstances, therapists often try to stretch the ITB to loosen it off. This activity is comparable to trying to stretch a tough piece of leather and, inevitably, the therapists make virtually no impression. Studies confirm that despite the use of stretching techniques, equipment or manual therapy, the length of the ITB was found to remain the same. Interestingly enough another study showed that if you stretch the hamstrings, 240% of the resulting strain is on the iliotibial tract and 145% is on the ipsilateral lumbar fascia (1). My questions for you are, after considering the information from above, “Is the restricted movement in the ankles, the overpronation, the lack of muscle strength in gluteus medius?”, Co-Kinetic.com

and “What would happen if we released the ITB – where is his stability going to come from?” Therefore, after considering this information do you want to stretch or soften it? What role has the ITB been forced to take on in this situation? A ‘tight’ ITB can be telling you that it is working hard to stabilise the action between the hip and knee. A study conducted by the University of Calgary’s Running Injury Clinic found that the problem was due to a lack of strength in the hips, rather than the ITB tension. The runners that they worked with in their study started with 30% less hip strength than an average healthy runner and after correcting the deficiency using strength exercises they returned to running pain-free. The study has its weaknesses in reporting its results but it does highlight that there is more to consider than just resolving the condition by stretching. The intention of my sports massage sessions is to lessen the stress being placed on the knee, encourage proprioception to the weak muscles and encourage hydration and softness to the areas that are tight. This does not involve ‘stripping’ the ITB, but lessening the tension using techniques that encourage a softening rather than making it slack. It is important to maintain the stability of the knee joint while trying to bring an equality of function to the surrounding muscles and tissue. Typically, therapists find that the deep work they do only temporarily resolves the problem with the pain returning all too soon. The next step is to introduce strengthening exercises. Muscle Energy Techniques can prepare the muscles by initiating proprioception responses within, often it is a bit like turning the light switch on, triggering a neuromuscular response within the tissue. Further and more complex strength exercises are best taken over by those in the profession who specialise in this type of work such as a strength and conditioning coach, physiotherapist and/ or a personal trainer. Some of the key exercises might include the use of resistance bands with the main focus in strengthening the hip abductors, extensors and gluteus medius. Sports massage can be the magic pill that resolves many issues, but with

THE INTENTION OF MASSAGE TECHNIQUES FOR ITB SYNDROME IS TO LESSEN THE ITB TENSION BY ENCOURAGING A SOFTENING RATHER THAN MAKING IT SLACK ITB syndrome, although we can play a significant role, sports massage is not a complete solution. Remember, the intention of your session should be to leave your client better than when they came in by decreasing tension, not necessarily just in the ITB but also in joints or soft tissue that restrict functional movement. This is one of my primary goals with any session. With that in mind, one of my favourite techniques is transverse soft tissue release (STR). The main intention of transverse STR is to affect fascia, a major component of connective tissue. As we know, manual methods stimulate tissue repair and remodelling in both hard and soft tissue. Transverse STR uses this principle by applying a mechanical load, compression, and a shearing transverse movement that specifically targets the Ruffini endings and interstitial mechanoreceptors. The mechanocoupling will agitate cells resulting in releasing chemical signals within and amongst the cells creating cell-to-cell communication from one location to distant areas. What this means for us as therapists is that our work is not just about the area we are working on but affects the body globally. For example, if you are working on the hips you will have an effect on tissue further afield. Massage assists the healing process through mechanical loading which stimulates the effector cells to respond by increasing protein synthesis at a cellular level promoting tissue repair and remodelling. From a neurophysiological viewpoint, soft tissue and manipulative approaches appear to 37

Figure 1: This transverse STR movement is good for both the hamstrings and the edge of the ITB. Place the heel of the hand where the tissue is stuck or tight and push the tissue and lock away from you, then pull the leg towards you, once you feel a stretch release. If you want more emphasis placed on the ITB then change your stance so you are facing up towards the head of the couch (this will protect your posture and wrist) then place the heel of the hand with the fingers pointing down towards the couch and push the leg away from you. (NLSSM, 2014)

evoke a nerve response in the fascia, resetting patterns or stimulating new ones. Transverse STR can be both a direct and indirect fascial approach which helps to loosen the area and rehydrate the tissue, encouraging oxygen to return stimulating the healing process. ‘Hypoxia can amplify the early inflammatory response, thereby prolonging injury by increasing the levels of oxygen radicals’ (2,3). The latest research is helping us to understand the nature of fascia and also the type of techniques that are effective in releasing restrictions. According to Schleip et al. (4): > “Fascia is densely packed with mechanoreceptors that we know ARE responsive to manual therapy. In particular the Ruffini and Interstitial Receptors.” > “These mechanoreceptors also influence local fluid dynamics and vasodilation.” What is lacking? Nowhere has it been mentioned that heavy-handed stripping is needed in order to evoke a change. The alternative choices are a lot easier to apply and don’t require you to use the heel of your hand to drill into the thigh in a most painful manner.

TRANSVERSE SOFT TISSUE RELEASE

Figure 2: This is a great approach for working with attachments where the tension is more superficial and you want the shearing action to be applied using a more open angle. The most important consideration here is to maintain softness with the hand that is in contact and use the top hand to apply the power. You can apply your lock using either a pushing or pulling action just make sure your clients movement is in the opposite direction. (NLSSM, 2014)

Transverse STR is similar to other forms of STR, wherein a lock is achieved, but where it differs is in the direction of the lock. Rather than putting pressure through the muscle that changes its length (its origin), the lock creates a shape change, taking up the slack across the fibres so that when you perform the movement transversely wherein you can achieve a stretch. This is ideal when you have big muscles, like the hamstrings and quadriceps, as you can use both hands to get a good depth without stressing your hands or thumbs. Other advantages of using transverse STR are listed below: 1. M ore control of muscle when there is a greater range of movement 2. Useful when the depth of muscle is shallow 3. C an help in preventing overstretching or lengthening of the tissue

MASSAGE SOFTENS THE ITB, BUT FULL REHABILITATION THEN REQUIRES MUSCLE STRENGTHENING EXERCISES FOR THE HIP ABDUCTORS, EXTENSORS AND GLUTEUS MEDIUS longitudinally but conversely can help to release tension or separate adhesions 4. Can be applied when there is no solid or supportive structure beneath the hands 5. Useful when the muscle fibres are multi-pennate or circular.

The application of transverse STR In the case of ITB syndrome it can be used to target a tight area or applying a broader method to encourage softness and more circulation to the area. Looking at Figures 1 and 2, the idea is to lift the tissue to create a ‘C’ curve into the targeted muscles, in this case the hamstrings. Lock into position with the heel of your hand, pushing the tissue away from you (taking up the slack) and then pull the leg towards you with the other hand until you feel a stretch. In this situation the action is passive but you can perform the same technique with a straight leg asking your client to rotate towards you as

Figure 3: The important consideration here is to stabilize the hip and leg to minimise any excessive movement. A top tip for an effective transverse STR lock is to minimise the amount of movement, this gives you more control thus you can be more subtle and specific. Lock into the ITB at a 45° angle and then ask the client to push their heel into your leg using only enough force to feel the stretch. (NLSSM, 2014)

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you push away. When using this on vastus lateralis and ITB, stand on the opposite side of the couch, extend your arms and place both hands, one on top of the other, across to the outside of the opposite leg. Use a minimal amount of tension in your bottom hand, just enough to hold and engage the tissue, it is the job of the top hand to apply your depth and strength. This allows the bottom hand to have a softer yet more powerful contact with the tissue. If your base hand stiffens too much it will feel pokey and the muscles will react by tensing up. You just want enough of a connection that when you create your lock the tissue does not slip underneath your hand. Next take up the slack by pulling and creating a ‘C’ shape with the tissue. Then ask your client to externally rotate their leg, moving slowly until you or they feel a stretch. If you have taken up the right amount of slack and your lock is the right depth, your clients’ leg will only be able to move slightly (and I mean slightly). Repeat this in a rhythmical fashion until you have reached the desired change in the tissue. It is important to mention at this stage not to over treat. Ensure that any changes you do make allow the corresponding muscles to cope with their newfound freedom. It is better to perform transverse STR in smaller doses so the body is capable of making the appropriate adaptations (Video 1). Transverse STR can also be used to target a more refined and delicate area such as working around the knee. As there is very little muscle mass in which you can get a traditional lock, the transverse method can allow you to approach the lock more superficially. In Figure 3 you can see the hands are placed flat against the ITBs insertion point. Apply a superficial lock ask the client to move, in this case, medially until a mild stretch is felt. If this area is inflamed do not use an aggressive lock, but rather choose an approach that will flush the area and place minimal stress on the tissue. Some of the tricks that get you the best out of this technique is to slowly and sensitively apply a specific lock that is both stable and subtle. Keep it simple, really simple. Co-Kinetic.com

ITB CLIENT ADVICE AND HOMECARE What sort of advice would you give your client? Some examples might include:

SLOWLY APPLY A SPECIFIC LOCK THAT IS STABLE AND SUBTLE

1. Running should only take place if there is no pain. Decrease the mileage if pain is felt or take a rest period of a few days (or more), do not push through it otherwise you will do more damage and slow down the recovery process. 2. Warm up. Walk a quarter mile before you start to increase your pace, so avoid leaving the house at a full run – you will need to gradually increase your speed before you engage into a full run. 3. Make sure your shoes are appropriate for you. Shoes are made to fit different types of feet and mechanical patterns, make sure you have the right trainers for you, seek advice from a professional shop that can assess you and kit you out appropriately. 4. Train according to the type of surface you are competing. However, initially start on flat surfaces that offer a more predictable route. If you are running on a track, change direction regularly. 5. Increase gradually. Use the FITT (frequency, intensity, time and type) principle and only change one of these at a time. For instance, increase frequency gradually, if this does not cause a return of your symptoms then move onto increasing one of the other variables. 6. Fluid intake/nutrition. Make sure you are taking on an appropriate amount of hydration. Increase your protein intake especially while you are going through the rehabilitation process. 7. Most importantly, have regular massage or self-massage. This will help to mobilise and maintain optimum performance. It is all about prevention and getting the most out of your performance – having regular massage will help with this and keep your tissue healthy and fit.

This is a general list of advice but each client needs to have a personalised plan, so whatever intrinsic or extrinsic factors have led to their condition will need to be included as homecare. To recap, look at the contributing factors both externally and internally and address these as part of your homecare, incorporate other modalities for a more sustained change (ie. strength work), use a variety of techniques within your treatment, consider the overall global functional movement patterns when making decisions about where to treat. Remember ITB syndrome is usually the symptom rather than the problem.

Video 1: Iliotibial band syndrome and transverse soft tissue release of the hamstrings. (NLSSM, 2015) http://spxj.nl/1JDATas

References

FURTHER RESOURCES

1. Franklyn-Miller A, Falvey E, et al. The strain patterns of the deep fascia of the lower limb. In: Huijing P, Hollander P, et al. (eds.) Fascia research ii: basic science and implications for conventional and complementary health care. Elsevier 2009. ISBN 9783437550225. Buy from Amazon (£105.68) http://spxj.nl/1IVP6OC 2. Mathieu D, Linke JC, Wattel F. Non-healing wounds. In: Matthieu D (ed.) Handbook on hyperbaric medicine. Springer 2006. ISBN 978-1402043765. Buy from Amazon (£242.50) http://spxj.nl/1Nnjlpn 3. Woo K, Ayello EA, Sibbald RG. The edge effect: current therapeutic options to advance the wound edge. Advances in Skin & Wound Care 2007;20(2):99–117 4. Schleip R, Klingler W, Lehmann-Horn F. Active fascial contractility: Fascia may be able to contract in a smooth muscle-like manner and thereby influence musculoskeletal dynamics. Medical Hypotheses 2005;65(2):273–277.

1. Fritz S. Sports & exercise massage: comprehensive care for athletics, fitness, & rehabilitation, 2nd ed. Mosby 2013. ISBN 978-0323083829. Buy on Amazon (Print £39.99 Kindle £34.50). http://spxj.nl/1QlMS15 2. Johnson J. Soft tissue release: hands-on guides for therapists. Human Kinetics 2009. ISBN 9780736077125. Buy from Amazon (£25.99). http://spxj.nl/1IVQ4ds 3. Avison J. Yoga: fascia, anatomy and movement. Handspring Publishsing 2015. ISBN 978-1909141018. Buy from Amazon (£39.95) http://spxj.nl/1KBHSXb 4. Journal website: Journal of Bodywork and Movement Therapies http://spxj.nl/1OajqMc).

THE AUTHOR SUSAN FINDLAY BSc RGN, Dip SMRT, Director NLSSM has worked as a sport and remedial massage therapist for over 15 years and runs her own clinic in north London. She was involved in the 2012 Olympics as a volunteer in the Polyclinic. She has a passion for teaching and is currently the founder and director of North London School of Sports Massage (NLSSM). Her goal is to enable therapists to deliver quality therapy that will help clients reach their goal. She is the author of ‘Sports Massage’, a practical guide that gives thorough instruction about the correct application of massage techniques. She currently sits on the General Council of Massage Therapies serving as Chair of Communications. She is actively involved in the setting up of the next British Fascia Symposium in 2016. 40

KEY POINTS nT ransverse soft tissue release (STR) can be both a direct and indirect fascial technique which helps to loosen the area and rehydrate the tissue, encouraging oxygen to return stimulating the healing process (2,3). n Transverse STR can also be used to target a more refined and delicate area such as working around the knee and ankle to assist in changing joint function. n An effective method that allows you to treat a specific area instead of the full length of the ITB. n It is particularly suitable for challenging locations where accessibility is restricted due to their location and range of movement. n This method maintains optimum control, maximum effectiveness with minimal discomfort. n When does loosening up become too much, what is the real intention of this treatment? n It will demonstrate how treatment can give ease to the ITB without working directly on it. n Work with ease, minimise your effort. n Success equates with working at a depth the tissue can respond favourably to.

RELATED CONTENT ase study of a longitudinal medial collateral ligament C sprain in a professional footballer http://spxj.nl/1K4a4B5 edial tibial stress syndrome in a national tennis player M http://spxj.nl/1UsAhM2

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Illiotibial band (ITB) syndrome is a common condition often associated with runners, cyclists and weight lifters. http://spxj.nl/1JDATas Tweet this: Transverse soft tissue release (STR) can be an effective tool in the rehabilitation of ITB syndrome. http://spxj.nl/1JDATas Tweet this: A ‘tight’ ITB can be telling you that it is working hard to stabilise the action between the hip and knee. http://spxj.nl/1JDATas Tweet this: Massage works through mechanical loading, stimulating effector cells to increase protein synthesis and tissue repair. http://spxj.nl/1JDATas Tweet this: Massage techniques for the ITB lessen the tension by encouraging a softening rather than making it slack. http://spxj.nl/1JDATas Tweet this: Transverse STR is similar to other forms of STR, wherein a lock is achieved, but differs in the direction of the lock. http://spxj.nl/1JDATas

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MANUAL THERAPY STUDENT HANDBOOK

MANUAL THERAPY: Introduction to manual therapy 15-10-SPORTEX FORMATS WEB MOBILE PRINT

This article is the first in a series from our Manual Therapy Student Handbook (see the ‘Contents panel’ for further details). It provides a short introduction to what manual therapy is and who some of the influential practitioners have been. Subsequent articles will discuss terminology, musculoskeletal assessment, musculoskeletal diagnosis as well as assessment and treatment of the different parts of the body. It has been designed as a step-by-step manual for all students studying physical and manual therapy but also acts as a useful aide memoire for qualified practitioners. Read this online http://spxj.nl/1OTcXU6 BY JULIAN HATCHER GRAD DIP PHYS MPHIL, MCSP FOM

WHAT IS MANUAL THERAPY? If a literal definition of the two words, ‘manual’ and ‘therapy’ is taken from the Oxford English Dictionary, it is easy to see that a reasonable working definition may be obtained. ‘Manual’ adjective. Of or done with the hands, worked by the hands, not by automatic equipment. From the Latin word, ‘manualis’; derived from, ‘manus’ meaning ‘hand’ ‘Therapy’ noun. Curative medical treatment. From the Greek word, ‘therapeia’ meaning ‘healing’. The working definition of ‘manual therapy’ could therefore be taken as, ‘Curative medical treatment done with the hands’. As will be seen later, there are many different therapeutic modalities that fit the criteria of this working definition. As such, many of these methods of treatment will be dealt with later in the article series; however, reference will be made to

THERE IS SOME EVIDENCE TO SUGGEST THAT SOME FORMS OF MANUAL THERAPY WERE BEING PRACTISED IN THAILAND AS EARLY AS 2000 BC Co-Kinetic.com

many more that are beyond the scope of these articles. The omission of these methods is by no means meant to indicate a lower credibility for these techniques, or indeed, philosophies, they are left for you to pursue if that is the direction you wish to take. Obviously, there is so much to cover without these, it makes life somewhat easier to progress through this article series, allowing you to understand, and put into practice, a smaller number of techniques that may be suited to your needs.

A SHORT HISTORY OF MANUAL THERAPY Manual therapy has been around for many years. There is some evidence to suggest that some forms of manual therapy were being practised in Thailand as early as 2000bc. Indeed, we know that the ancient Greeks and Egyptians used forms of manual therapy to ‘set bones’. There is a lot of reference made to Hippocrates who was probably one of the earliest known advocates of traction and manipulation of bones and joints. The early 1800s was probably the time when ‘bonesetters’ were commonly sought by people suffering from a variety of conditions, even those which may now be referred to as medical rather than musculoskeletal. Bonesetters would use various forceful manoeuvres of the bones in order to ‘re-align’ bones. The mal-alignment was considered to be the cause of the illness or pain that the patient

was suffering from. In addition to this, bonesetters would also be called upon to set bones that had fractured. Two bonesetters from this period in history came to the fore, and both, independently of each other, became the forefathers of modern manual therapy: n Canadian, Daniel Palmer n American, Andrew Still. Both gentlemen were considered as ‘magnetic healers’ and seemingly well-respected practitioners. Daniel Palmer was almost certainly the first practitioner to use the transverse and spinous processes of the spine as a lever to produce the forceful manoeuvres that later became known as ‘chiropractic’. Around the same time, Andrew Still was developing similar techniques, although not necessarily spinal, that became known as ‘osteopathy’. Essentially, both were manipulating the bones and joints, but using a different philosophy or rationale. Around 1920, osteopathy was ‘imported’ to the UK by another practitioner who was practising as a colleague of Andrew Still. John Littlejohn became the founder of the British School of Osteopathy. This may then have become the catalyst that spawned the many authors who have since developed the various philosophies that many manual therapists use in their practice today. The next section gives a perspective on who came first, and which of the others influenced whom.

OSTEOPATHY WAS ‘IMPORTED’ TO THE UK BY JOHN LITTLEJOHN (A COLLEAGUE OF ANDREW STILL) WHO BECAME THE FOUNDER OF THE BRITISH SCHOOL OF OSTEOPATHY CONTEMPORARY AUTHORS Many authors have advocated manual therapy over the years. However, it is not often known which authors came first, and, indeed, who was influenced by whom. The following describes some of those authors who are probably most well-known.

Robin MacKenzie

In the early part of the 20th century, circa 1930, a relatively unknown house officer, Dr James Cyriax, became fascinated with musculoskeletal conditions. In particular, he became increasingly frustrated that the origin of the condition of the majority of his patients was not in the radioopaque tissues – the bones – which would normally become evident on X-ray. Indeed, very few of his patients had unequivocal radiographs. He therefore concluded that there was no satisfactory way of assessing the radio-translucent tissues, or softtissues, and he set about solving this puzzle. A few short years later, Dr James Cyriax had coined the phrase, ‘Orthopaedic Medicine’ and many of the principles and assumptions he made at that time still hold true today.

Maitland became particularly popular during the 1970s. A great many physiotherapists became familiar with the Australian therapist’s techniques and theories, and indeed, were often adopted by teachers of physiotherapy all over the world, and particularly in the UK. During this period of time, Robin MacKenzie, a practitioner from New Zealand, was advocating a slightly different approach to modern manual therapy. He was using techniques that were more patient-involved, active movements, rather than passive movements. Robin’s initial theories were identified by accident during his student days, although the reasoning behind these came following some considerable research. He was not against any ideas of therapist involvement, however, he did advocate the approach that minimised therapist intervention. His approach would use patient involvement first until this proved to be unsuccessful.

Geoffrey Maitland

Brian Mulligan

Around 1960, Grieve had become a great advocate of Cyriax, and was practised in the techniques he developed. He then met another author, Geoffrey Maitland, and became fascinated by his thinking, and delved a little deeper into the theories Maitland was writing about. Maitland’s philosophy was different from Cyriax in that he did not feel it was necessary for therapists, who did not diagnose back then, to formulate an opinion that was exact, more that assessment confirmed the presence of a musculoskeletal problem. The problem could then be treated using techniques that were almost a continuation of the assessment

The next author to influence the thoughts and practices of manual therapists in the early 1980s was another New Zealander, Brian Mulligan. He was much more concerned with a therapist-based approach, much like that of Maitland. However, the major difference to Maitland’s approach was that he felt that the techniques performed should mimic the ‘real life’ situation. In this, he thought techniques should be performed in a weight-bearing position, and movements should follow the joint planes anatomically. He also introduced us to the concepts of mobilisation with movements. This meant that

Dr James Cyriax

methods. Another difference was his use of oscillatory techniques, which differed from Cyriax’s sustained stretches of the joint capsules.

techniques could be performed in a passive manner in conjunction with active movements to assist. Some of these movements could be sustained, much like Cyriax’s capsular stretches, although some may be repetitive if not oscillatory.

David Butler In the early 1990s came another author, David Butler. Butler was one of the first authors to introduce the concept of neurodynamics. In other words, when joints move, it may not always be the ligaments, capsules or indeed the contractile units that are the source of pain and discomfort, but that the nerves themselves may be the problem. If normal movement of the nervous structures within their natural muscular and soft tissue tunnels does not occur when moving joints, then pain results. Butler therefore introduced us to the concept of adverse mechanical or neural tension. This has since been developed into techniques specifically aimed at these structures rather than the joints or soft-tissues themselves.

WHAT NEXT? What will be the next developments in manual therapy? Well, one hot topic in the early 21st century has got to be ‘muscle imbalance’. It seems to make some sense that when joint stiffness, or displacement, or mal-alignment has been overcome, it needs some control from the surrounding musculature to allow correct kinematics of that segment. Muscle imbalance, at present, is outside the realms of the scope of this series of articles but it covered regularly in the sportEX journal

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RECOMMENDED READING 1. Anderson MK, Parr GP. Fundamentals of Sports Injury Management. Lippincott, Williams & Wilkins 2011. ISBN 978-1451109764. Buy from Amazon (Print £60.30 Kindle £64.34) http://spxj.nl/1UANMg7 2. Cyriax J. Textbook of orthopaedic medicine, vol. 1: diagnosis of soft tissue lesions, 8th ed. Balliere Tindall 1982. ISBN 978-0702009358 (£17.70). http://spxj.nl/1JSrLz4 3. Boyling J, Jull G. Grieve’s modern manual therapy: the vertebral column, 3rd ed. Churchill Livingstone 2005. ISBN 978-0443071553. Buy from Amazon (£94.44). http://spxj.nl/1K73UdZ 4. Higgs J, Jones A, et al. Clinical reasoning in the health professions, 3rd ed. Butterworth-Heinemann 2008. ISBN 9780750688857. Buy from Amazon (Print £54.99 Kindle £42.39). http://spxj.nl/1NhBpzM 5. Abrahams PH, McMinn RMH. McMinn and Abrahams’ Clinical atlas of human anatomy, 7th ed. Mosby 2013. ISBN 9780723436973. Buy from Amazon (Print £47.69 Kindle £45.31). http://spxj.nl/1g8UPJX 6. Magee DJ. Orthopaedic physical assessment, 6th ed. Saunders 2014. ISBN 9781455709779. Buy from Amazon (£62.99). http://spxj.nl/1UAP1vN 7. Hengeveld E, Banks K. Maitland’s Vertebral Manipulation: management of

neuromusculoskeletal disorders – volume 1, 8th ed. Churchill Livingstone 2013. ISBN 978-0702040665. Buy from Amazon (Print £61.19 Kindle £58.13). http://spxj.nl/1g8VFWW 8. Hengeveld E, Banks K. Maitland’s Peripheral manipulation: management of neuromusculoskeletal disorders – volume 2, 5th ed. Churchill Livingstone 2013. ISBN 978-0702040672. Buy from Amazon (Print £61.19 Kindle £58.13). http://spxj.nl/1Np97ol 9. Kapandji IA. The physiology of the joints, volume 3: the spinal column, pelvic girdle and head. Churchill Livingstone 2008. ISBN 978-0702029592. Buy from Amazon (£317.58). http://spxj.nl/1K75GM7

FURTHER RESOURCES 1. McGrew R. Encyclopaedia of Medical History. McGraw-Hill 1985. ISBN 978-0070450870. Buy from Amazon (£3.07). http://spxj.nl/1EO6qKw 2. Grieve GP. Common Vertebral Joint Problems, 2nd ed. Churchill Livingstone 1988. ISBN 9780443033650. Buy from Amazon (£155). http://spxj.nl/1OxYehb 3. The Mulligan concept, website: http://www.bmulligan.com/ 4. The McKenzie method of mechanical diagnosis and therapy, website: http://spxj.nl/1KrYHly.

RELATED CONTENT orking in Sport: From Student to W Practitioner http://spxj.nl/1WeWe2K Anatomy and Soft Tissue Review (animated) http://spxj.nl/1RkC4B3

KEY POINTS nA working definition of the term ‘manual therapy’ could be ‘Curative medical treatment done with the hands’. n Many different therapeutic modalities fit the definition of ‘manual therapy’. n In the 1800s, ‘bonesetters’ Daniel Palmer and Andrew Still developed techniques that eventually became known as ‘chiropractic’ and ‘osteopathy’, respectively. n In the early 20th century, Dr James Cyriax realised that the origin of the conditions afflicting most of his patients was not in the bones, but in the radio-translucent or ‘soft’ tissue.

Co-Kinetic.com

THE AUTHOR Julian Hatcher Grad Dip Phys MPhil, MCSP FOM is a senior lecturer at the University of Salford and the programme leader for BSc Hons Sport Rehabilitation programme, having created it 1997. Previously he was senior physiotherapist in Orthopaedic Medicine at Warrington Hospital Trust from 1987–1997. He also worked in Rugby League (including Great Britain BARLA Rugby League) for 7 years as well running his own Sports Injuries Clinic in Warrington up until 1997. Julian became a Fellow of Orthopaedic Medicine (FOM) in 2000, and Certified Strength & Conditioning Specialist in 2005. After starting with a Graduate Diploma in Physiotherapy (Grad Dip Phys), he gained his Master of Philosophy (MPhil) from the University of Salford in 2007 and has several publications around the knee particularly concerning topics such as ‘ACL deficiency: detection, diagnosis and proprioceptive acuity’ and ‘Osteoarthritis longterm outcomes’. Julian is also an Honorary Member of British Association of Sport Rehabilitators and Trainers (BASRaT). For more information see his profile at the University of Salford website: http://www.seek.salford.ac.uk/profiles/JHATCHER.jsp.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Manual therapy has been around for many years. Evidence suggests some forms of it were being practised in 2000bc. http://spxj.nl/1OTcXU6 Tweet this: An increasingly hot topic in manual therapy is muscle imbalance http://spxj.nl/1OTcXU6

CONTENTS PANEL ARTICLES IN THE MANUAL THERAPY STUDENT HANDBOOK INCLUDE: 1. Introduction to manual therapy 2. Definitions: mobilisation, manipulation and massage 3. Musculoskeletal assessment 4. Musculoskeletal diagnosis 5. Assessment and treatment of the hip 6. Assessment and treatment of the knee 7. Assessment and treatment of the ankle and foot 8. Assessment and treatment of the shoulder 9. Assessment and treatment of the elbow 10. Assessment and treatment of the wrist and hand 11. Assessment and treatment of the cervical spine 12. Assessment and treatment of the lumbar spine 13. Assessment and treatment of the thoracic spine

MANUAL THERAPY: Definitions – mobilisation, manipulation and massage 15-10-SPORTEX BY JULIAN HATCHER GRAD DIP PHYS MPHIL, MCSP FOM FORMATS WEB MOBILE MOBILISATION PRINT There is a degree of confusion around the terms ‘mobilisation’ and ‘manipulation’. For the purposes of these articles we will use the following definitions based around the definitions used by Maitland: Mobilisations are movements of joints performed either as oscillatory movements of varying amplitude, or as sustained stretches. They are passive movements done as physiological or sometimes accessory movements.

This article is the second in a series from our Manual Therapy Student Handbook (see the ‘Contents panel’ for further details). It discusses the terms ‘mobilisation’, ‘manipulation’ and ‘massage’. As these terms are used commonly, although not always consistently, it is important that their meanings are clearly defined. Read this online http://spxj.nl/1Le22Ft

of amplitude of the movements and the range of movement in which the movements take place. The movement is performed at slow velocity and is always within the control of the patient. Manipulations are movements that are forceful passive movements just beyond the range of normal physiological range. They are done at high velocity and hence outside of the control of the patient. They are commonly known as high velocity thrusts of low amplitude.

Maitland Grades Maitland himself actually grades these movements with respect to the size

Figure 1: The Maitland Grades of mobilisation

Maitland Grades are described relative to the overall available movement at any joint (however large or small this may be). The concept can be easily visualised by referring to Figure 1, where the overall range of motion is represented by the pink box; specifically along the horizontal axis. The section labelled ‘R’ is the point where resistance is experienced when performing a passive movement. The ‘depth’ of this resistance section may be relatively ‘thin’ in joints with firm elastic capsular end-feels, and ‘thicker’ in joints where soft tissue is opposed. From that concept, the notions of passive

oscillatory mobilisations are created relative to this point of onset of resistance. Definitions are as follows: n Grade I A small amplitude passive oscillatory movement within the resistance-free range. n Grade II A large amplitude passive oscillatory movement within the resistance-free range. nG rade III A large amplitude passive oscillatory movement going into the resistance range. nG rade IV A small amplitude passive oscillatory movement going into the resistance range. nG rade V A small amplitude, high velocity thrust performed at the end of full available range (ie. at the end of the pink box in Figure 1). Various orthopaedic medicine educational groups have similarly attempted to apply this grading for treatments that are not just passive movements, but exercises too. These are simplified in that they map easily to Maitland’s grading structure thus: nG rade A A movement or exercise performed within the pain-free range. nG rade B A movement or exercise performed into the resistance range. sportEX journal 2015;66(October):44-47

MANUAL THERAPY STUDENT HANDBOOK

MAITLAND GRADES THE MOBILISATION MOVEMENTS WITH RESPECT TO THE SIZE OF AMPLITUDE OF THE MOVEMENTS AND THE RANGE OF MOVEMENT IN WHICH THE MOVEMENTS TAKE PLACE

some may become mechanical joint movement.

Concave–convex rule At this point, we should remind ourselves of the ‘concave–convex’ rule: When the convex surface is fixed, and the concave surface moves, the component of glide that accompanies the component of roll is in the same direction as the angular movement of the limb or the overall movement of the joint. When the concave surface is fixed, and the convex surface moves, the component of glide that accompanies the component of roll is in the opposite direction to the movement of the joint or limb.

nG rade C A small amplitude, high velocity thrust performed at the end of full available range. Grade As are similar to Grades I and II, Grade Bs are the same as Grade III and IV, and Grade C is identical to Grade V.

What occurs during mobilisation? Having decided upon our definition of joint mobilisation, what actually occurs? What are the biomechanical movements at the joint surfaces? Well, firstly there is movement defined as ‘gliding’ of joint surfaces. However, do both joint surfaces move or is one the prime mover and the other more fixed? Generally speaking, the aim of mobilisation is to have a causative effect at the joint by holding one joint surface fixed, and making the other joint surface move in relation to it. In reality, it is near impossible to hold one joint actually fixed perfectly, and undoubtedly there will be some movement. It is likely, though, that any movement occurring is likely to be opposite to the moving segment, which may enhance the effect. So what is being achieved by this movement of two adjacent segments? It is believed that the movement causes the stimulation of joint mechanoreceptors. This, in turn, is Co-Kinetic.com

believed to have the effect of reducing the perception of pain. The actual mechanism of how this is achieved is not precise; however, the effect may bombard the central nervous system with afferent signals that block out the pain signals (pain gate theory). In addition to this, it is believed that movement of joint capsule may decrease its viscoelastic properties or mechanical resistance (what we may call stiffness). It has certainly been shown that there is a measurable variation of force with time, which may have effect on both pain and stiffness. It appears that repetitive movement of the joint causes a reduction in the joint stiffness (in the biomechanical sense) so that less force is required to produce the same amount of movement (or displacement). It has also been shown that manual therapists are able to vary the amount of displacement caused by the technique of choice. Therapists may grade movement as Maitland or Cyriax would, however, how good and accurate therapists are in terms of these grades is not known. What is known, though, is that energy is transferred from therapist to client. This energy may be transferred from mechanical to heat caused by resistance and friction, and

Essentially this means that use of accessory mobilisations should match these rules to be effective. If moving the convex joint surface to increase range of movement, the choice of direction is opposite to the limited movement. The converse is true if moving the concave surface. In summary, mobilisation of joints has an effect both on pain and stiffness, in that it can cause a reduction in both. The actually mechanisms of how this is achieved are not fully known.

MANIPULATION As stated in the section on ‘Mobilisation’, there is a good deal of confusion over the terms, ‘manipulation’ and ‘mobilisation’. For the purposes of this series of articles we will use the definitions used by Maitland as stated in the section on ‘Mobilisation’, where ‘manipulation’ occurs at the Maitland Grade V level. nG rade V A small amplitude, high velocity thrust performed at the end of full available range (ie. at the end of the pink box in Figure 1). Again, we now have a definition for joint manipulation, but what really happens in biomechanical terms? Movement of joint surfaces (which?) causing: n correction of joint position (static) n correction of abnormal vertebral movement (dynamic) n release of soft tissue abnormalities 45

(tenderness, spasm, trigger points) n c orrection of muscle imbalance or contraction in opposing muscle groups. There is also evidence to show that manual therapists can produce consistent sudden application of force following pre-load force causing capsular distension. Another interesting point to raise here is the issue of ‘cracks’. Are cracks necessary to gain results in manipulation? The answer most therapists would give would be ‘no’. The scientific evidence on the other hand is inconclusive. However, many therapists actually feel they get a better result if cracks are heard, and nearly all agree that cracks are beneficial to the patient. Whether the latter is a psychological benefit or not is unclear. There is also some debate as to the source of these cracks. Nothing yet has been proven, but two main schools of thought exist. The first uses the explanation that nitrogen gas dissolved in the synovial fluid forms a gas bubble due to the decrease in volume as a result of the distension of the joint. The noise heard is something to do with the sudden formation of these bubbles. The second explanation is explained by the sudden return of the capsule to its original position after the release of negative pressure. The latter does not, however, explain how the pressure is released. One thing that has been proven by scientific experimentation is that release of muscle spasm is not directly related to cracking of joints. It is seemingly independent of the cracking phenomenon.

MASSAGE Massage is probably one of the most popular styles of manual therapy that is commonly used by all sorts of people. A definition of massage could be the manipulation of soft tissue for therapeutic purposes. Like all other forms of manual therapy, massage has a long history. It is probably the oldest form of medical treatment. It has been used throughout history by all cultures, including Greek, Chinese, Indian, Egyptian and Roman. The word massage comes from the Arabic word ‘masah’ – which means 46

stroke with the hand, press softly. In the 18th and 19th centuries, massage was used in Europe by a Swede, Per Henrik Ling; hence the term ‘Swedish massage’. This became an extremely popular medical treatment by the end of the 19th century. Johann Mezger, a Dutch Physician, introduced terminology that described different techniques of massage: n effleurage n petrissage n tapotment n frictions, etc. Unfortunately for bona fide masseurs, the word ‘massage’ was also a term freely used by prostitutes to hide other activities. Unfortunately there is still some evidence that this may still be the case in some establishments of ill repute! Indeed, back in 1894, eight women banded together to form the Society of Trained Masseurs. They were the founders of what is now known as the Chartered Society of Physiotherapy. There are many more contemporary forms of massage such as: n Rolfing n deep tissue massage n sports massage n reflexology n neuromuscular massage n connective tissue massage n lymphatic massage. The philosophies behind these different techniques may be somewhat varied; however, they can all be summarised as being effective in two ways: the mechanical and the reflexive response. The scientific evidence behind the effectiveness of massage is somewhat limited. Clinical observations are much more extensive. It is generally accepted that this anecdotal evidence is at least based on sound clinical reasoning and physiological principles.

Mechanical response This is the direct response brought on by force or pressure increasing blood circulation, softening and breaking up scar tissue.

Reflexive response This is the reaction to a stimulus that is governed by the nervous system. The effect is decreased arousal of the

sympathetic nervous system, which in turn reduces blood pressure and induces relaxation. More specifically, the purported physiological effects include the following: 1. Cardiovascular and lymph - improved circulation - improved delivery and removal of products in blood - decreased blood pressure and heart rate - increased stroke volume - increase in white blood cells and other elements of immune system - stimulates circulation in lymph system - improved removal of waste products 2. Nervous and endocrine systems - stimulates or soothes nervous system through activation of sensory receptors n reduction in pain through release of endorphins n suppression of pain n stimulation of parasympathetic system promoting relaxation and improved sleep n increased dopamine and serotonin levels 3. Muscular and connective tissue n relieves muscular stiffness, soreness and spasms – direct pressure and reflex response n enhanced blood circulation – increased oxygen and nutrients available to tissue n increased flexibility n rapid disposal of waste products helps reduce soreness n breakdown of fibrous adhesions. Two main forms of massage will be addressed in this article series; effleurage and frictions. Effleurage is a type of deep stroking, often used to apply oil to skin and to prepare the body for more vigorous techniques. It is often performed in specific directions in order to move fluid towards lymph nodes such as the popliteal fossa or femoral triangle. It is often reported to have relaxational effects and may help reduce swelling. Frictions are an uncomfortable massage technique often performed in either unidirectional or circular directions. Deep transverse frictions are performed in a unidirectional manner and are purported to stimulate mechanoreceptors which reduces pain, may cause breakdown of scar tissue by sportEX journal 2015;66(October):44-47

MANUAL THERAPY STUDENT HANDBOOK

weakening cross-linkages of scar while promoting strong fibre formation. It may be used in preparation for manipulative techniques.

RECOMMENDED READING 1. Anderson MK, Parr GP. Fundamentals of Sports Injury Management. Lippincott, Williams & Wilkins 2011. ISBN 978-1451109764. Buy from Amazon (Print £60.30 Kindle £64.34) http://spxj.nl/1UANMg 2. Cyriax J. Textbook of orthopaedic medicine, vol. 1: diagnosis of soft tissue lesions, 8th ed. Balliere Tindall 1982. ISBN 978-0702009358 Buy from Amazon (£17.70). http://spxj.nl/1JSrLz4 3. Boyling J, Jull G. Grieve’s modern manual therapy: the vertebral column, 3rd ed. Churchill Livingstone 2005. ISBN 978-0443071553.Buy from Amazon (£94.44). http://spxj.nl/1K73UdZ 4. Higgs J, Jones A, et al. Clinical reasoning in the health professions, 3rd ed. Butterworth-Heinemann 2008. ISBN 978-0750688857. Buy from Amazon (Print £54.99 Kindle £42.39). http://spxj.nl/1NhBpzM 5. Abrahams PH, McMinn RMH. McMinn and Abrahams’ Clinical atlas of human anatomy, 7th ed. Mosby 2013. ISBN 9780723436973. Buy from Amazon (Print £47.69 Kindle £45.31). http://spxj.nl/1g8UPJX

6. Magee DJ. Orthopaedic physical assessment, 6th ed. Saunders 2014. ISBN 9781455709779. Buy from Amazon (£62.99). http://spxj.nl/1UAP1vN 7. Hengeveld E, Banks K. Maitland’s Vertebral Manipulation: management of neuromusculoskeletal disorders – volume 1, 8th ed. Churchill Livingstone 2013. ISBN 978-0702040665. Buy from Amazon (Print £61.19 Kindle £58.13). http://spxj.nl/1g8VFWW 8. Hengeveld E, Banks K. Maitland’s Peripheral manipulation: management of neuromusculoskeletal disorders – volume 2, 5th ed. Churchill Livingstone 2013. ISBN 978-0702040672. Buy from Amazon (Print £61.19 Kindle £58.13). http://spxj.nl/1Np97ol 9. Kapandji IA. The physiology of the joints, volume 3: the spinal column, pelvic girdle and head. Churchill Livingstone 2008. ISBN 978-0702029592. Buy from Amazon (£317.58). http://spxj.nl/1K75GM7.

FURTHER RESOURCES 1. Audible sounds associated with spinal manipulation – a snap-shot summary report. National Council for Osteopathic Research 2012 http://spxj.nl/1Ka0fMz 2. Bakker M, Miller J. Does an audible release improve the outcome of a chiropractic adjustment? The Journal of the Canadian Chiropractic Association 2004;48(3):237–239 3. Chiropractic on NHS Choices website http://spxj.nl/1OeSpXX

KEY POINTS n ‘ Mobilisations’ are movements of joints performed either as oscillatory movements of varying amplitude, or as sustained stretches. They are passive movements done as physiological or sometimes accessory movements. n ‘Manipulations’ are movements that are forceful passive movements just beyond the range of normal physiological range. They are done at high velocity and hence outside of the control of the patient. n Maitland defined ‘grades’ of movement, but it is difficult to know how good or accurate therapists are in terms of these grades. n Mobilisation of joints causes a reduction in both pain and stiffness. n A definition of massage could be the manipulation of soft tissue for therapeutic purposes. n There are many different massage techniques but they can all be summarised as being effective in two ways: the mechanical and the reflexive response.

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THE AUTHOR JULIAN HATCHER Grad Dip Phys MPhil, MCSP FOM is a senior lecturer at the University of Salford and the programme leader for BSc Hons Sport Rehabilitation programme, having created it 1997. Previously he was senior physiotherapist in Orthopaedic Medicine at Warrington Hospital Trust from 1987–1997. He also worked in Rugby League (including Great Britain BARLA Rugby League) for 7 years as well running his own Sports Injuries Clinic in Warrington up until 1997. Julian became a Fellow of Orthopaedic Medicine (FOM) in 2000, and Certified Strength & Conditioning Specialist in 2005. After starting with a Graduate Diploma in Physiotherapy (Grad Dip Phys), he gained his Master of Philosophy (MPhil) from the University of Salford in 2007 and has several publications around the knee particularly concerning topics such as ‘ACL deficiency: detection, diagnosis and proprioceptive acuity’ and ‘Osteoarthritis long-term outcomes’. Julian is also an Honorary Member of British Association of Sport Rehabilitators and Trainers (BASRaT). For more information see his profile at the University of Salford website: http://spxj.nl/1LlU2xW.

RELATED CONTENT orking in Sport: From Student to Practitioner W http://spxj.nl/1WeWe2K Anatomy and Soft Tissue Review (animated) http://spxj.nl/1RkC4B3

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Repetitive movement of a joint causes a reduction in joint stiffness. http://spxj.nl/1Le22Ft Tweet this: In manipulations, the release of muscle spasm is not directly related to ‘cracking’ of joints. http://spxj.nl/1Le22Ft

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THIS QUARTER’S MOST POPULAR ARTICLES IN THE PHYSICAL THERAPY CATEGORY IN POPULARITY ORDER 1. Have we lost the opportunity to create a reputable brand? http://spxj.nl/1MrsVr2

2. Myofascial techniques for hip mobility http://spxj.nl/1cSmmi8

RECENT ARTICLES WITH CERTIFICATED ELEARNING ASSESSMENTS Treating myofascial pain with myofascial trigger point needling http://spxj.nl/1HNYQ1p yofascial Techniques M for hip mobility http://spxj.nl/1cSmmi8

3. A review of the impact of kinesiology tape on fascial chains and flexibility http://spxj.nl/1J8zZW8 4. Anatomy and Soft Tissue Injury Review http://spxj.nl/1RkC4B3

5. Professional standards in massage http://spxj.nl/1FMtlAx

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7. Journal Watch - sportEX dynamics Jan 2015 http://spxj.nl/1FfhOim

anual Therapy for M Shoulder Impingement http://spxj.nl/1Hdn6Z1 UPCOMING ARTICLES DUE FOR PUBLICATION ON THE CO-KINETIC WEBSITE anual Therapy Handbook M assessment and treatment by anatomical area (11 articles (see listing above)) Highlights of a case report involving low back pain and cancer Posture and Movement Assessment Handbook - divided into 6 articles Muscle energy techniques Biotensegrity - Part 4 Exploring the anatomy of fascia

SUPPLEMENTS/HANDBOOKS MANUAL THERAPY HANDBOOK FOR STUDENTS Mission: The goal of this handbook is to provide students with a thorough foundation on musculoskeletal assessment and treatment. Each article is accompanied by videos throughout each article and where videos aren’t available, images are included. Students need look no further for a learning resource and lecturers for a teaching support resource. We will be publishing these articles in order, one

per week for the next 11 weeks. * Note: These articles are purchasable individually, or as a standalone supplement. They are included with a subscription to the Manual Therapy (sportEX dynamics) category and within a Full Site subscription. http://spxj.nl/1ivbIR5

1. Introduction to manual therapy (published) 2. Definitions: mobilisation, manipulation and massage (published) 3. Musculoskeletal assessment 4. Musculoskeletal diagnosis 5. Assessment and treatment of the hip 6. Assessment and treatment of the knee 7. Assessment and treatment of the ankle and foot 8. Assessment and treatment of the shoulder 9. Assessment and treatment of the elbow 10. Assessment and treatment of the wrist and hand 11. Assessment and treatment of the cervical spine 12. Assessment and treatment of the lumbar spine 13. Assessment and treatment of the thoracic spine

sportEX journal 2015;66(October):48

NEWS OCTOBER 2015

NEWS FROM ANNOUNCEMENTS

Merging of sportEX medicine and sportEX dynamics into one printed publication

As mentioned in the editorial, we have merged the two print journals into one bumper journal. The reasons are outlined in much more detail in my editorial on page 3. We’re teaming up with a whole host of new content providers to collaborate on content production, so increasingly there will be significantly more content available through the website, where we can offer so much more in terms of linking complimentary content together, including multi-media, adding eLearning assessments, and generally allowing a piece of content to develop and grow over time. The printed journal will feature the very best articles that we’ve published online and flag up content that you may not be aware of. For those of you with a double subscription to both sportEX medicine and sportEX dynamics please read the next piece of news...

ISSUE 66/46 OctOber 2015

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UPGRADE FOR PEOPLE WITH A COMBO SUBSCRIPTION TO SPORTEX MEDICINE AND SPORTEX DYNAMICS

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FULL SITE SUBSCRIBERS This really is a massive value subscription as it includes literally everything that is published on the site as well as a free upgrade to the print journal. If you have a Full site subscription this also includes access to the mobile versions of the six manuals on our sportEX app (available on Apple iOS, Google Android and Kindle Fire).

SPORTEX MOBILE APP For new subscribers (and existing subscribers who haven’t yet downloaded our mobile app) don’t forget that the journals (and Manuals if your subscription includes access to them i.e. full site subscribers) are available on our mobile app. Just search for and download the sportEX app on your device’s app store (available on Apple iOS, Google Android and Kindle Fire). Read on for more info about new features on the mobile app, including live Twitter feeds. Co-Kinetic.com

If you currently have a double subscription to sportEX medicine and sportEX dynamics then over the course of the next month, we’ll be upgrading you to a Full site subscription which does exactly what it says on the tin! It also includes access to all the Manuals, Supplements and new categories of content that we introduce. This includes a whole host of video presentations from upcoming conferences along with some collaborations with online learning providers both in the UK as well as overseas. This will take a bit of administration to change over but it’s important to me to return the support you’ve given the journals. I will email each of you individually as I complete the transition just to confirm your account is ready to go with the new Full Site subscription. Any queries please don’t hesitate to email me directly.

CERTIFICATED ELEARNING ASSESSMENTS NOW FULLY LIVE We have completely rebuilt our SCORM compliant Elearning platform on the new Co-Kinetic website. If you log into CoKinetic and click on the Elearning Assessments link, you will see all the Elearning Assessments available to you under your subscription When you pass an assessment it will appear as shown in the second image on the right. Click the Download Certificate button and you will be able to download a time-stamped certificate containing details of the content of the quiz, your name and details of accreditation by national and international organisations where applicable.

Therapy Expo 2015 is a dramatically expanded CPD education and trade event, dedicated to sports therapists and physiotherapists, taking place at the NEC Birmingham on 25th & 26th November. Welcoming thousands of therapy professionals â&#x20AC;&#x201C; from both NHS and private practice all over the country, and from a wide range of specialist areas, to educate, inspire, and have fun. Access over 40 hours of CPD and education Four streams covering: Musculoskeletal, Sports Injuries, Neuro Rehabilitation and latest Innovations in Practice and Business Management Learn from world-class speakers and experts in their field Network with colleagues and peers Research and source new products and services from over 100 industry suppliers Hear industry and regulation updates Gain FREE entry to the co-located Occupational Therapy Show

n o i s s e f o r P OUR n o i s s a P R U O o p x E Y P A R E H OUR T Book your early bird ticket by Wednesday 30th September using discount code SE1 at www.therapyexpo.co.uk/sportex for just ÂŁ109 + VAT!