Co-Kinetic Journal Issue 67 - January 2016 by Co-Kinetic

ISSUE 67 JANUARY 2016

ISSN 2397-138X

Formerly published as....

medicine & dynamics

C0-KINETIC JOURNAL WELCOME

JANUARY 2016 ISSUE 67 ISSN 2397-138X

editorial

Great to see so many of you at Therapy Expo in Birmingham in November, thanks for coming to say hi and introducing yourselves to our new recruit, Sheena Mountford, who has fitted in superbly in the 6 short weeks that she’s been with us (at the time of writing this editorial). As those of you who know me can probably imagine, there’s no small amount of ‘tech’ to get used to when working at Co-Kinetic and Sheena has absolutely hit the ground running! The most obvious outcome that you’ll already be able to see if you’ve visited the Co-Kinetic website, is that Sheena has freed me up to spend time developing more content partnerships. The first two of these went live in December and include a collaboration with the Fortius Clinic to make available through our site, the full 2-day, 155 video programme from the brilliant Fortius International Sports Injury Conference (FISIC) 2015 which took place in London in October. We look forward to forging similar agreements in 2016 where we can leverage the power of our content platform in collaborations that benefit everyone and most of all our subscribers. The second collaboration is with one of Australia’s leading soft tissue therapists, Stuart Hinds, who has agreed to let us publish several of his video masterclasses. In March we will begin our podcast collaboration with Chews Health, the producers of the excellent Physio Matters podcast. We have a load more partnerships in store for 2016 but if you know of anyone producing great quality, practically applicable content, whatever the format, please put them in touch with us, or let us know who they are so we can get in touch with them directly. In the meantime I wish you a very healthy and happy start to 2016 and look forward to sharing the year ahead with you.

contents 4 Physical therapy journal watch 8 Manual therapy journal watch 12 Diagnostic imaging: don’t rush to associate findings with low back pain 14 More imaging of asymptomatic subjects indicates more abnormal findings 15 Physical therapy or advanced medical imaging: How should low back pain be managed? 16 Iliotibial band syndrome: a narrative review 21 Conservative management of iliotibial band syndrome: a clinical reasoning journey 26 Novel bedside tests to explore bodily perception in pain and rehabilitation 32 Highlights of a case report involving low back pain and cancer 34 Muscle energy technique for joint mobilisation 42 Manual Therapy Student Handbook: Musculoskeletal assessment 46 Book review Massage Fusion 47 Co-Kinetic Social Watch 49 Co-Kinetic news

Tor Davies, physio-turned publisher and sportEX/Co-Kinetic founder Publisher/editor TOR DAVIES tor@sportex.net Marketing and sales SHEENA MOUNTFORD sheena@sportex.net Art editor DEBBIE ASHER 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

ISSUE 67 JANUARY 2016

ISSN 2397-138X

Formerly published as....

medicine & dynamics 67SPX01FrontCover.indd 1

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

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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

Journal Watch WHAT INFLUENCES PATIENT-THERAPIST INTERACTIONS IN MUSCULOSKELETAL PHYSICAL THERAPY? QUALITATIVE SYSTEMATIC REVIEW AND META-SYNTHESIS O’Keeffe M, Cullinane P, et al. Physical Therapy 2015;doi:10.2522/ptj.20150240 [Epub ahead of print] This is a qualitative systematic review and meta-synthesis investigating patient and physiotherapist perceptions of factors that influence the patient–therapist interaction. Eleven databases were searched independently for papers in English. This identified 13 studies. Two reviewers independently selected articles, assessed methodological quality using the Critical Appraisal Skills Programme (CASP), and performed the three stages of analysis: extraction of findings, grouping of findings (codes), abstraction of findings. Four themes were perceived to influence patient–therapist interactions: 1. Physiotherapist interpersonal and communication skills: presence of skills such as listening, encouragement, confidence, being empathetic and friendly and non-verbal communication; 2. Physiotherapist practical skills: physiotherapist expertise and level of training, whereas the ability to provide good education was considered as important only by patients; 3. Individualised patient-centred care: individualising the treatment to the patient and taking patient opinions into account; and

4. O rganisational and environmental factors: time and flexibility with care and appointments.

sportEX comment How many of these boxes do you tick? The authors say that physiotherapist awareness of these factors could enhance patient interactions and treatment outcomes. So get working on it if you didn’t tick them all.

A KINEMATIC ANALYSIS OF THE SPINE DURING RUGBY SCRUMMAGING ON NATURAL AND SYNTHETIC TURFS. Swaminathan R, Williams JM, et al. Journal of Sports Sciences 2015;doi:10.1080/02640414.2015.1088165 Artificial surfaces are now an established alternative to grass (natural) surfaces in Rugby Union. Little is known, however, about their potential to reduce injury. This study characterises the spinal kinematics of Rugby Union hookers during scrummaging on thirdgeneration synthetic (3G) and natural pitches. The spine was sectioned into five segments, with inertial sensors providing three-dimensional kinematic data sampled at 40Hz/ sensor. Twenty-two adult, male community club and university-

level hookers were recruited. An equal number were analysed while scrummaging on natural or synthetic turf. Players scrummaging on synthetic turf demonstrated less angular velocity in the lower thoracic spine for right and left lateral bending and right rotation. The general reduction in the range of motion and velocities, extrapolated over a prolonged playing career, may mean that the synthetic turf could result in fewer degenerative injuries. It should be noted, however, that this conclusion considers only the scrummaging scenario.

sportEX comment Artificial surfaces get a bit of bad press. This is mainly historic. The first generation pitches, especially those used at pro football clubs like QPR and Luton Town, were not very good and the players hated them. They tended to burn the skin if you slid on them. The new third and now fourth generation (hence 3G and 4G) pitches behave much closer to a ‘real’ grass surface. Even the concept of ‘real’ is becoming distorted because the pitches at Manchester United, Wembley, Twickenham and many others in elite sport are hybrids with around 3% of the surface being synthetic fibres that intertwine with the natural grass.

Co-Kinetic journal 2016;67(January):4-11

PHYSICAL THERAPY RESEARCH INTO PRACTICE

This is a case report detailing a calcaneal osteoid osteoma, a small, common, benign osteoblastic tumour. They account for approximately 10–15% of all benign bone tumours. Foot osteoid osteomas represent a minority of cases, mainly localised in the talus. They usually affect children and young adults within the third decade. This patient was a normal-weighted Caucasian 18-yearold male student and basketball player, who consulted a physical therapist for pain in the right ankle that prevented him training. He reported an inversion sprain that had occurred 6 months earlier which had resolved in 3 weeks. Two months previously during intensive preseason training he complained of the reappearance of a slight pain in the midfoot. The pain increased to a point where he was unable to train.

CALCANEAL OSTEOID OSTEOMA HIDDEN BY CONFUSING SYMPTOMS IN AN 18-YEAR-OLD BASKETBALL PLAYER: A CASE REPORT. Testa MDO, Rondoni A, Francini L. Journal of Sports Medicine & Doping Studies 2015;5(165):1000165 There was no visible inflammation and no pain on palpation of any ligaments. Active ROM and manual strength tests were complete and painless. Passive ROM had a slight diffused end-feel stiffness in the hindfoot and the midfoot. X-rays were negative. MRI revealed an oedema of the third and fourth metatarsal bone. Initial diagnosis and treatment were for a repetitive strain injury, related to stiffness caused by the previous ankle sprain but the problem remained unresolved. A more detailed history revealed sleep disturbances due to the pain. Further scans revealed an intramedullary osteoid

osteoma of the calcaneus, which was treated successfully and he returned to sport in 2 months.

sportEX comment Sportsman with ankle injury. It gets better but then a similar pain reappears. Assume it’s the same thing and treat accordingly. Everyone has done that but just occasionally the corner you cut with a less than detailed history returns to haunt you. The moral of this story is take a detailed history in the first place and if the condition is not responding after a few treatments have a rethink.

THE EFFECT OF PSYCHOLOGICAL SUPPORT AND MENTAL TRAINING ON ANXIETY REGULATION OF INJURED TUNISIAN ATHLETES. Hamrouni S, Alem J, et al. British Journal of Education, Society & Behavioural Science 2016;12(3):1–12 Forty-eight Tunisian male and female athletes, mostly professional sports players who had knee, shoulder or ankle injuries that resulted in them being on the side-lines for 2 months, were divided into two groups: an experimental group of 24 athletes were given psychological support and a mental training-relaxation programme for 5 weeks, and a control group of 24 injured athletes without psychological and mental training. The Profile of Mood State Questionnaire (POMS) and a 10 cm self-rating of subscales of anger, confusion, depression, fatigue and vigour. There was little difference between the groups in week 1 but by week 8 there was a very significant difference in favour of the psychological support group.

sportEX comment Congratulations to the BJESBS, which has become the 150th published journal we have found that carries articles relevant to the sport and performance injury rehabilitation and training community. That’s a lot of reading to keep up to date with the latest research. The results of this one shouldn’t be a surprise. The use of Tunisian professionals is a new twist. Studies like this are often on US College students so it is nice to see that sports psychology is useful across a broad spectrum.

ILIAC CREST AVULSION FRACTURE IN A YOUNG SPRINTER. Casabianca L, Rousseau R, et al. Case reports in Orthopedics 2015;2015:302503 This is a case report of a 16-year-old male competitive sprinter. He had an avulsion of a part of the iliac crest and the anterior superior iliac spine during a competition. It occurred during the acceleration phase out of the blocks, which is the maximum traction phase on the tendons. He experienced a total loss of function of the lower limb, forcing him to stop the run. An X-ray and CT scan confirmed the rare diagnosis of avulsion of the quasitotality of the iliac crest apophysis, corresponding to a Salter 2 fracture. Surgically he received an open reduction and internal fixation with two screws. The postoperative instructions were no weight bearing for 6 weeks without immobilisation and no active flexion of the hip. He began muscular reinforcement and proprioception with a physio allowing a return to sport after 3 months and his personal

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best in the 100m at the 6th postoperative month.

sportEX comment Great result and it shows that there is a way back from this serious but rare injury. Unfortunately the report contains insufficient detail to really be any more than general help to others faced with the same injury. There is no detail about the protocol other than a comment in the discussion about conservative treatment being bed rest or being on a chair for a period of 3 weeks, with the affected hip at a 70° flexion followed by careful physiotherapy and ambulation with crutches, and it is not clear if this is in fact what was done for this patient. If you are going to do case reports – and generally we like them – there is little point unless they are a help to other clinicians.

TREATMENT OF RUPTURED ACHILLES TENDON: OPERATIVE OR NON-OPERATIVE PROCEDURE? Cukelj F, Bandalovic A, et al. Injury 2015;doi:10.1016/j.injury.2015.10.070 Ninety professional or amateur athletes with rupture of the Achilles tendon were included in the study between 1998 and 2013. The athletes were aged between 25 and 40 years (mean 34.83). Thirty underwent an open procedure, thirty were treated with a percutaneous method and thirty were treated non-operatively (in a cast for 9–11 weeks). All were tested a minimum of 1 year after the surgical procedure using an isokinetic dynamometer. The results for the patients who were treated using the percutaneous method were 15% better than those for the patients who underwent the open procedure; the results for the group treated conservatively were 20% better than those for the group treated percutaneously. The percutaneous method was easier technically than the open method. Time spent in hospital was 14.5 times shorter with the percutaneous procedure compared with the open procedure (percutaneous procedure: range 0.5–2 days; open procedure: range 10–24). Return to sport activities was twice as fast with the percutaneous procedure compared with the open procedure. There were no postoperative infections or re-ruptured Achilles tendon in the group treated with the percutaneous procedure. One patient in the group treated with the open procedure had postoperative infection (4.2%). In the nonsurgical (conservatively treated) group, there were three re-ruptures of the Achilles tendon within 1 year, and one patient developed adhesions that resulted in loss of function and had to undergo an operation.

sportEX comment The surgical procedures are well described in the paper and there are diagrams to help. Bottom line seems to be go conservative if you can but if you have to have the op, opt for the percutaneous version.

RISK FACTORS FOR KNEE INJURIES IN CHILDREN 8–15 YEARS: THE CHAMPSSTUDY DK. Junge T, Runge L, et al. Medicine and Science in Sports and Exercise 2015;doi:10.1249/ MSS.0000000000000814 [Epub ahead of print] Data for this study came from 1326 school children (8– 15 years) in Denmark reporting weekly musculoskeletal pain, sport participation and sports type. Knee injuries were classified as traumatic or overuse. Multinomial logistic regression was used for analyses. There were 952 (15% traumatic, 85% overuse) knee injuries. Period prevalence for traumatic and overuse knee injuries were 0.8/1000 and 5.4/1000 sport participations, respectively. Participation in tumbling gymnastics was a risk factor for traumatic knee injuries (OR 2.14). For overuse knee injuries, intrinsic risk factors were sex (girls OR 1.38), and previous knee injury (OR 1.78); whereas participation in soccer (OR 1.64), handball (OR 1.95), basketball (OR 2.07), rhythmic (OR 1.98) and tumbling gymnastics (OR 1.74) were additional risk factors. For both injury types, participation above two times/week increased odds (OR 1.46–2.40).

sportEX comment If you participate in sport, there is a risk of injury and that is not good for the player but 2–5 injuries out of a 1000 is minimal and the benefits of sports participation far, far outweigh the risks. The important point here is that overuse injuries are the most prevalent so maybe we are asking kids to do too much!

DYNAMIC PATTERNS OF FORCES AND LOADING RATE IN RUNNERS WITH UNILATERAL PLANTAR FASCIITIS: A CROSSSECTIONAL STUDY. Ribeiro A, Amado Joao AM, et al. PLoS one 2015;doi:10.1371/journal.pone.0136971 Forty-five runners with unilateral plantar fasciitis (PF) (30 acute and 15 chronic) and thirty healthy control runners were evaluated while running at 12km/h for 40m wearing standardised running shoes and Pedar-X insoles. The contact area and time, maximum force, and force-time integral over the rearfoot, midfoot, and forefoot were recorded and the loading rate (20–80% of the first vertical peak) was calculated. Groups were compared by ANOVAs. The results were that maximum force and force-time integral over the rearfoot and the loading rate was higher in runners with PF (acute and chronic) compared with controls. Runners with PF in the

acute stage showed lower loading rate and maximum force over the rearfoot compared to runners in the chronic stage. The conclusion was that runners with PF showed different dynamic patterns of plantar loads during running over the rearfoot area depending on the injury stage (acute or chronic). In the acute stage of PF, runners presented lower loading rate and forces over the rearfoot, possibly due to dynamic mechanisms related to pain protection of the calcaneal area.

sportEX comment Not surprisingly the prevalence of lower-limb injuries has risen with running’s increased popularity over the last few years. Hardly a spring and

summer weekend goes by without a charity run going on somewhere. PF is the third most common injury after patellofemoral pain and Achilles tendinitis. The aetiology of PF has been related to several risk factors, one of which is plantar loads over the calcaneal area. It is thought that excessive loads promote stretching of the plantar fascia, which stimulates microtraumas and subsequent changes in the connective tissues, which in turn initiates an acute inflammatory response with fibroblast proliferation. This study shows that the load pattern changes with the onset of PF and its progression, which may exacerbate the problem.

Co-Kinetic journal 2016;67(January):4-11

PHYSICAL THERAPY RESEARCH INTO PRACTICE

SNAPPING HIP SYNDROME: A REVIEW FOR THE STRENGTH AND CONDITIONING PROFESSIONAL. Cheatham SW, Cain M, Ernst MP. Strength and Conditioning Journal 2015;37(5):97–104 Snapping hip syndrome (SHS) or coxa saltans is a condition characterised by a palpable or audible ‘snapping’ that occurs around the hip with movement. It is further described as either internal or external (ISHS or ESHS, respectivley). With ISHS, the ‘snapping’ is felt in the anterior hip region and often involves a tight iliopsoas muscle. With ESHS, the sensation is felt over the lateral hip region and often involves a tight iliotibial band (ITB). Published data on the prevalence of SHS among athletes and active individuals estimate that SHS occurs in about 5–10% of the population, but current research suggests that the incidence may be higher. It is commonly caused by repetitive overuse activity and occurs frequently in soccer players, dancers, runners, football players, golfers, and weightlifters. Sufferers tend to report a ‘non-painful’ sensation or audible snapping, clicking, or popping with

activity, which may eventually lead to discomfort. It is rarely an acute injury and is often insidious in nature with the pain getting worse over time. With ISHS, the sensation may be provoked during deep squats and hip external rotation movements. Specific movements that may be difficult include getting in/out of a car, sit to stand, and running. This is primarily caused from snapping of the iliopsoas tendon over the iliopectineal eminence, anterior hip capsule, femoral head, or iliofemoral ligament. With ESHS, the sensation may be provoked during hip flexion, external, or internal rotation. Specific movements that may be difficult include carrying heavy loads, climbing stairs, playing golf, and running. The sensation may be caused by the ITB or gluteus maximus tendon snapping over the greater trochanter or the proximal hamstring subluxating over the ischial tuberosity during rotational movements. Physiotherapy focus is on decreasing

pain with modalities (eg. ice), restoring myofascial mobility, muscle length, strength, and function of the lower kinetic chain. Therapeutic interventions include massage, stretching, self-myofascial release, strengthening, and functional activity that does not cause pain.

sportEX comment This is the perfect article for busy frontline professionals. It is the sort of thing we publish in sportEX and rarely see in peer-reviewed journals. It is easy to read and gives information about presentation and causes. It relates to everyday activities as well as the movements you would do in a gym. The therapeutic interventions are described in sufficient detail for even the most inexperienced therapist or S&C coach to follow and there are pictures to make it even easier. Please, please can we have more like this.

PHYSICAL TRAINING FOR LONG-DURATION SPACEFLIGHT. Loehr JA, Guillams ME, et al. Aerospace Medicine and Human Performance 2015;86(Suppl 1):A14–A23(10) All you need to know to train an astronaut. Physical training has been conducted on the International Space Station for the past 10 years as a countermeasure to the physiological deconditioning that occurs during space flight. The various space agencies, such as NASA and ESA, have developed their own protocols. This article looks at three distinct phases of physical training (preflight, in-flight, and post flight) and provides a description of each phase with its constraints and limitations. Generally the pre-flight training is about cardiovascular (CV) and strength training which will prepare the astronaut for the movements required in the zero gravity environment with enough in reserve to help to compensate for the inevitable detraining effect. Once on the mission the crews were scheduled for around 1 ½ hours a day of resistance training and 1 hour a day of CV work for 6 days, although most performed extra on what was deemed to be a rest day. The aim Co-Kinetic.com

of the programme was to maintain or minimise the loss of bone mineral density, aerobic and anaerobic capacity, muscle strength, muscle power, and local muscle endurance, as well as to minimise neuromuscular dysfunction. Problems are highlighted such as fitting in the time for all the crew to work out, and hardware and software failures that necessitated adaptations to programmes and equipment that might wait a very long time for repair Post-flight, all crewmembers returning from long-duration space flight have neurovestibular, orthostatic, back/neck pain, coordination, balance/agility, aerobic, strength, endurance, power, and flexibility issues to some degree and these issues affect each crewmember differently. Following a long-duration mission, each crewmember was scheduled for 2 hours of physical training 7 days a week for 45 days. The goal of the reconditioning programme was to return each crewmember back to pre-flight status as quickly and as safely as possible.

sportEX comment Forget aiming to work in the NHS or at EIS or with a Premier footie team. Space is the final frontier. This is a great read. We have mixed up the aims and protocols of the various agencies to give a general picture. The actual article discussed the differences in much greater detail and gives specific exercise regimes. To infinity and beyond… 7

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT EFFECTS OF BALANCE TRAINING ON POST-SPRAINED ANKLE JOINT INSTABILITY. Faizullina I, Faizullina E. International Journal of Risk & Safety in Medicine 2015;27:S99–S101 This review searched PubMed and Scopus for full text randomised controlled trials (RCT) published in English from 2009 to 2014 using various terms centred around balance training for the ankle. This resulted in the discovery of eight articles but three of them were disregarded because they couldn’t be downloaded for free via the FriedrichAlexander University of ErlangenNuremberg library system. Two more were dumped. One because it turned out to be a systematic review per se rather than an RCT, although that fact was not mentioned either in the article title or in the abstract. The other turned out to be a descriptive study rather than an RCT. Of the three studies that survived the cull one looked at an 8-week course of neuromuscular training (n = 122), a brace (n = 126) and a combination of the two (n = 136). The second study looked at how proprioceptive exercises affect the postural balance and

isokinetic strength in athletes with ankle an sprain. Sixteen participants were recruited in the study and divided into two equal groups. One group had an injured ankle, the other didn’t. The third paper aimed to examine the effectiveness of the neuromuscular prevention strategy in youth soccer players using 384 players divided into two groups. One group did a training programme that included dynamic stretching exercises, agility, jumping and balance and eccentric strength. The control group undertook a standardised warm-up including static, dynamic and aerobic components and homebased stretching programme using 16-inch diameter wobble board used for 15 minutes during exercises. The combined results of all this was that although the balance training elements varied slightly it is an effective training method for rehabilitation of an unstable ankle.

sportEX comment First of all, top marks to the reviewers for discarding papers that could not be accessed via their institution. Universities pay for access to journals. If you publish your work in one that it not in the system, don’t expect it to get read. Secondly, they score more marks for getting rid of the studies that didn’t do what it said on the tin. Thirdly, well it only really confirms what we know. Balance training should be an integral part of an ankle injury rehab protocol.

EFFECTS OF MOBILIZATION WITH MOVEMENT ON PAIN AND RANGE OF MOTION IN PATIENTS WITH UNILATERAL SHOULDER IMPINGEMENT SYNDROME: A RANDOMIZED CONTROLLED TRIAL. Delgado-Gil JA, Prado-Robles E, et al. Journal of Manipulative and Physiological Therapeutics 2015;38(4):245–252 Forty-two patients (mean ± SD age, 55 ± 9 years; 81% female) with shoulder impingement syndrome (SIS) were randomised into a mobilisation with movement (MWM) group (n = 21) or sham manual contact (n = 21). The primary outcome measures included pain intensity, pain during active range of motion, and maximal active range of motion and were assessed by a clinician blinded to group allocation. Outcomes were captured at baseline and after 2 weeks of MWM treatment or sham intervention (4 sessions). For the MWM group, an accessory posterior-lateral gliding movement in the humeral head combined with a movement of active shoulder flexion was performed by a physical therapist with more than 10 years of experience in manual therapy. The sham condition replicated the treatment condition except for the hand positioning. The therapist located one hand over the belly of the pectoralis major muscle and the other over scapula without applying any pressure. Three sets of 10 reps with a rest interval of 30

seconds between sets were applied at each treatment session. The primary analysis was the group × time interaction. The results revealed a significant group × time interaction for pain intensity during shoulder flexion, pain-free shoulder flexion, maximum shoulder flexion, and shoulder external rotation in favour of the MWM group. No other significant differences were found.

sportEX comment MWM works. One of the inclusion criteria for participants was that they had a positive medical diagnosis of SIS with at least two positive impingement tests including Neer, Hawkins, or Jobe test. Because no single test had shown high specificity, a cluster of two or more tests is recommended to properly identify patients with SIS. The big question, however, is what is causing the impingement?

Co-Kinetic journal 2016;67(January):4-11

MANUAL THERAPY RESEARCH INTO PRACTICE

Journal Watch REVISITING REFLEXOLOGY: CONCEPT, EVIDENCE, CURRENT PRACTICE, AND PRACTITIONER TRAINING. Embong NH, Soh YC, et al. Journal of Traditional and Complementary Medicine 2015;5(4):197–206 Reflexology is basically a study of how one part of the human body relates to another part of the body. Reflexology practitioners rely on the reflexes map of the feet and hands to all the internal organs and other human body parts. They believe that by applying the appropriate pressure and massage certain spots on the feet and hands, all other body parts could be energised and rejuvenated. This review aimed to revisit the concept of reflexology and examine its effectiveness, practices, and the training for reflexology practitioners. The usual data bases were searched using search terms: foot massage, reflexology, foot reflexotherapy, reflexological treatment, and zone therapy, for articles published for the last 10 years. The authors conclude that from the ten systematic reviews unearthed, it is safe to conclude that reflexology does not have sufficient evidence to support its clinical use. This is despite the fact that there are some small-scale trials and anecdotal evidence of reflexology for some common ailments including, low back pain management, migraine/ headache, stress reduction, peripheral neuropathy in diabetes mellitus and asthma. Some contraindications were identified including first trimester

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pregnancy, diarrhoea and vomiting, localised skin disease at hands, feet and ears, localised inflammation or swelling of the feet, hands, and ears.

sportEX comment This is a controversial subject that sends the aficionados of reflexology and their opponents in the evidence-based medicine camp into apoplexy when they meet. There is no doubt that it works on some patients and no doubt either that the evidence base is thin but that applies to a lot of manual therapy techniques. This paper holds its hands up on the evidence issue while documenting what little there is. It also gives an overview on how reflexology is supposed to work and a summary of its use in various parts of the world. Here’s a thought. Reflexologists claim that there are links between mapped areas of the hands and feet and other parts of the body; the doubters say that’s impossible. But there is a link, it’s called fascia. Maybe this is where the research should go.

RECENT ADVANCES IN MASSAGE THERAPY – A REVIEW. Liu SL, Qi W, et al. European Review for Medical and Pharmacological Sciences 2015;19(20):3843–3849 This is an essay which considers the many benefits of massage therapy and quotes enough current evidence to keep the evidence-based medicine sceptics happy. It refers to studies suggesting a positive effect on peripheral blood flow, lymph drainage, improvements regarding pain, health status, and health-related quality of life for women with fibromyalgia, anxiety and other psychological disturbances, headaches, joint pain and limited range of motion including osteoarthritis and periarthritis. Almost everything and anything you are likely to come across as a musculoskeletal therapist. For good measure there is also a section on the benefits of massage for cancer victims.

sportEX comment Any paper that includes the following in its introductions gets our attention, “Massage therapy is becoming a number one choice for stress reactions, anxiety issues, sleep problems, pain management, injury repair for trauma, enhancing recovery time for athletes in training and more importantly to enhance one’s feeling of well being”. When it follows that up with, “Some people even suggest that massage can replace modern medicine. As it is non-invasive and inexpensive compared to other treatments”, it should be placed on the desk of every GP, clinical commissioner, and Physio Dept head in the NHS.

SHORT-TERM EFFECTS OF KINESIO TAPING AND CROSS TAPING APPLICATION IN THE TREATMENT OF LATENT UPPER TRAPEZIUS TRIGGER POINTS: A PROSPECTIVE, SINGLE-BLIND, RANDOMIZED, SHAM-CONTROLLED TRIAL. Halski T, Ptaszkowski K, et al. Evidence-Based Complementary and Alternative Medicine 2015;2015:191925 An experienced physiotherapist assessed the trapezius muscle bilaterally on 105 volunteers to determine if myofascial trigger points (MTrPs) were present. Four diagnostic criteria for the MTrPs were assumed: a hypersensitive spot in a taut band, pain on spot palpation, restricted range of motion, and a referred pain distant to the spot. The participants were randomly divided into a group who had kinesio taping (KT) applied, a group who had cross taping applied and a control group who had medical adhesive tape applied. The

latter was considered to be a sham treatment group. KT is a therapeutic taping technique developed by Dr Kenzo Kase. Cross tapes are small, polyester tapes with an adhesive acrylic coating. In all patients, tape was applied on the MTrPs of the upper part of the trapezius muscle for three days (72 hours). The primary outcome was resting bioelectrical activity of upper trapezius (UT) muscle as assessed by surface electromyography (sEMG) in each group and pain intensity on a visual analogue scale (VAS). Assessments were collected before and after intervention and after the 24-hour followup. No significant differences were observed in bioelectrical activity of UT between pre- and post-treatment, and followup results. In three groups patients had significantly lower pain VAS score after the intervention. The Kruskal–Wallis ANOVA showed no significant differences in almost all measurements between groups. The application of all three types of tapes does not influence the resting bioelectrical activity of UT muscle and may not lead to a reduction in muscle tone in the case of MTrPs.

sportEX comment A mixed result. There appears to be no measurable physiological change but pain reduction is reported, which may make the taping worthwhile. Unless, of course, you are the person paying for it, because it is not cheap.

MANAGEMENT OF LATERAL ELBOW TENDINOPATHY: ONE SIZE DOES NOT FIT ALL. Coombes BK, Bissett L, Vicenzino B. Journal of Orthopaedic & Sports Physical Therapy 2015;45(11):938–949 This article collates the evidence and expert opinion on the pathophysiology, clinical presentation, and differential diagnosis of lateral elbow tendinopathy (LET). It includes factors that might provide prognostic value or direction for physical rehabilitation, such as the presence of neck pain, tendon tears or central sensitisation. Clinical recommendations for physical rehabilitation are provided, including the prescription of exercise and adjunctive physical therapy and pharmacotherapy. It includes a preliminary algorithm, including targeted interventions, for the management of subgroups of patients with LET based on identified prognostic factors is proposed. It suggests

that the pathophysiology of LET is multidimensional.

sportEX comment This is another article that is so good it could have been published in sportEX. It is everything you need to know about the diagnosis and management of LET. It is an excellent accompaniment to the one we did in fact publish in issue 63 (Jan 15) of sportEX medicine (‘A practical model for managing tennis elbow’ pp18–21). We particularly like it because it recommends that corticosteroid injection should not be a first-line intervention and that there is moderate evidence for the immediate effects of several manual therapy techniques

on pain and grip strength and for short-term clinical benefits when used in conjunction with graduated exercise. It has nice pictures of ulnar-humeral lateral glides and radial head posteroanterior glides performed as Mulligan mobilisations with movement, which it says should produce a ‘substantial immediate improvement (eg. 50%) in pain and impairment (eg. pain-free grip force).’ It also quotes moderate evidence that manual therapy techniques targeting the cervical and thoracic regions provide additional clinical benefits beyond local elbow treatment alone in patients with LET and coexisting cervical or thoracic spine impairment.

Co-Kinetic journal 2016;67(January):4-11

MANUAL THERAPY RESEARCH INTO PRACTICE

Tender spots were identified in 150 university-aged and recreationally active participants’ plantar flexor muscles (gastrocnemius or soleus). They were randomly assigned to one of five interventions with 30 people in each group. Rolling massage was applied by a registered massage therapist using a Theraband® roller massager, which is a hard rubber material (24 cm in length and 14 cm circumference) with low amplitude, longitudinal grooves surrounding a plastic cylinder. It was rolled proximal to distal at a slow pace (2 seconds up and 2 seconds down) over the muscle belly. They were massaged for 3 sets of 30 seconds with 30 seconds rest in between. The intensity of massage for the manual massage and heavy rolling groups was adjusted to ensure 7/10 on a visual analogue scale (VAS) was maintained.

PAIN PRESSURE THRESHOLD OF A MUSCLE TENDER SPOT INCREASES FOLLOWING LOCAL AND NON-LOCAL ROLLING MASSAGE. Aboodarda SJ, Spence AJ, Button DC. BMC Musculoskeletal Disorders 2015;16(1):265 Group 1: were given a heavy rolling massage on the calf that exhibited the higher tenderness. Group 2: received a heavy rolling massage on the contralateral calf. Group 3: received light stroking of the skin with roller massager on the calf that exhibited the higher tenderness. (This was deemed to be sham treatment.) Group 4: had manual massage (a combination of compressions and petrissage) on the calf that exhibited the higher tenderness. Group 5: had no treatment (asked to lie still for 3 minutes, the control group). Their pain pressure thresholds (PPT) were measured at 30 seconds and up to 15 minutes post-intervention via a pressure algometer. The results were

that at 30 seconds post-intervention, both heavy roller groups demonstrated a higher PPT values compared with control and sham. Similar results were present at 15 minutes post-intervention and the manual massage group was higher as well. There was no difference between the effects of three deep tissue massages.

sportEX comment Ten out of ten for trying to do something about the problem of dosage. It would have been even better had they found a way of measuring the pressure exerted by the massage therapist when working deep. The authors speculate that the reason for the increased PPT might be attributed to the release of fibrous adhesions but the effect on the contralateral limb suggests that other mechanisms (such as a central pain-modulatory system) play a role in mediation of perceived pain following brief tissue massage.

A SYSTEMATIC REVIEW AND QUALITY ASSESSMENT OF SYSTEMATIC REVIEWS ON ANKLE SPRAIN INJURY PREVENTION AND TREATMENT. Holden S, Delahunt E, Doherty C. British Journal of Sports Medicine 2015;49:A6 Forty-five review papers (containing 307 separate reports) were included in this systematic review of reviews. The included reviews had a mean score of 7/11 on the AMSTAR quality assessment tool. There is strong evidence for bracing and moderate evidence for neuromuscular training in preventing recurrence of an ankle sprain injury. For the combined

outcomes of pain, swelling and function after an acute sprain there is strong evidence for non-steroidal anti-inflammatory drugs and early mobilisation, with moderate evidence supporting neuromuscular training and manual therapy techniques. The efficacy of surgery and acupuncture are controversial in the treatment of acute ankle sprains. There is insufficient

evidence to support the use of ultrasound in the treatment of acute ankle sprains.

sportEX comment Key words here are ‘evidence for early mobilisation and manual therapy’. Shout it from the roof tops.

THE EFFECT OF A PROGRAM USING SOME THERAPEUTIC METHODS TO REHABILITATE PATIENTS SUFFERING FROM NECK PAIN. Omar A, Haross A. International Journal of Science Culture and Sport 2015; 3(3):69–77 Twelve patients with neck pain in Ain Zara Physiotherapy Centre and Tripoli Clinic (in Tripoli city), age range 30–50 years, were divided into two groups, an experimental group who received ultrasound, infrared, rehabilitation exercises and therapeutic massage and a control group who received the same treatment except the massage. There was a statistically significant improvement in range of motion in all directions of neck movement and in muscle strength of the neck and back area in both groups, but more so in the massage group.

sportEX comment This study is a confirmation of things that good therapists know already. Massage is good for neck pain. We include it here because it is from Tripoli and according to the media in Europe and the USA nothing good happens in Libya. Well it does, so can we have some more stuff from there or Egypt or Syria or Iraq or Afghanistan or any other places that we only see the bad side of.

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Our regular research reviewer, physical therapist Joseph Brence, reviews research looking into the correlation between imaging results and low back pain. Read this online http://spxj.nl/1PPvXmH

DIAGNOSTIC IMAGING: DON’T RUSH TO ASSOCIATE FINDINGS WITH LOW BACK PAIN

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INTRODUCTION Diagnostic imaging [radiography, computed tomography (CT), magnetic resonance imaging (MRI)] is routinely used by clinicians to help determine possible mechanisms that could be leading to a painful condition, such as low back pain. But despite this routine use, several organisations have called for imaging to be used only for patients who present with severe or progressive neurological deficits or signs/symptoms of a potentially serious underlying condition (1). This has been recommended based upon research demonstrating that routine imaging does not improve clinical outcomes (2). Along with this idea, there is a growing consensus that while diagnostic imaging is a sensitive tool, it is not very specific. In this article, I am going to review some of the literature that has investigated the topic of diagnostic imaging for low back pain. As we look at rising incident rates and costs of treating this condition, we must begin to better understand what the research states about these tests.

ABNORMAL FINDINGS IN ASYMPTOMATIC INDIVIDUALS When considering the potential relationship between diagnostic imaging findings and low back pain, we should

BY JOSEPH BRENCE DPT, FAAOMPT, COMT, DAC UPPER BODY | LOW BACK PAIN | 16-01-COKINETIC begin by investigating MRI findings in healthy, asymptomatic individuals. Let’s begin this journey by going back to the year 1990. Over 24 years ago, the Journal of Bone & Joint Surgery published a prospective investigation of asymptomatic individuals, who had never experienced low back pain, sciatica or neurogenic claudication (3). Each of the participants underwent diagnostic imaging of the lumbar spine and the findings of the researchers were quite interesting (considering the growing popularity of MRIs at this time). In the study, the researchers found the following abnormalities in participants 60 years old or older: 36% had a herniated nucleus pulposus, 21% had spinal stenosis, and all but one of the participants had degeneration or bulging of a disc at at least one lumbar level. Although some might consider this study ‘out-of-date’, similar findings have since been made. In 1994, a very similar study was performed. This study looked at the MRI findings of the low back of 98 asymptomatic individuals. The findings were similar to the 1990 study, with 52% of the subjects having a disc bulge at one level, and 27% having a disc protrusion. The researchers found the

prevalence of disc bulging was related to an increase in age.

SO ONCE THESE ABNORMALITIES ARE FOUND, DO THEY EVENTUALLY MANIFEST INTO PAIN? A prospective study published in Spine in 2005 set out to answer this question. The researchers in this study took baseline MRIs of 148 asymptomatic individuals (defined as not having LBP for at least 4 months). They then contacted the participants after 3 years for a follow-up session (with follow-up MRI). One hundred and twenty-three individuals returned for a follow-up MRI and after analysing the statistics gathered, the researchers found depression to be an important predictor for the development of low back pain, whereas MRI findings were found to be less important (4).

MAYBE IT’S THE TYPE OF LESION WHICH RESULTS IN PAIN… A recent article published in The Spine Journal set out to investigate if the characteristics of the disc

Co-Kinetic journal 2016;67(January):12-15

PHYSICAL THERAPY RESEARCH INTO PRACTICE

injury could determine symptomatic from asymptomatic individuals (5). Unfortunately, the findings in this study demonstrated discs in symptomatic and asymptomatic individuals to be similar. The researchers did find that “utilizing pressure-controlled manometric discography, using strict criteria, may distinguish asymptomatic discs among morphologically abnormal discs with Grade 3 annular tears in patients with suspected chronic discogenic LBP.” Seems to be a far stretch to me…

WHAT ABOUT ATHLETES? In 2007, an observational study looked at the MRI findings of asymptomatic, adolescent, elite tennis players. This study recruited 33 elite tennis players who had no history of low back pain. The participants ranged between 16–23 years old and the findings were similar to other studies: 84.8% had abnormal findings upon MRI. Nine participants had a pars lesion (predominately at L5: 3 of the 10 lesions found were complete fractures), 23 participants had showed early signs of facet arthropathies at L4/5 to L5/S1. 13 participants had disc desiccation and bulging (6).

WHAT DOES THIS ALL MEAN… While we would like to be able to blame tissues for our conditions, more and more research is finding there may be little correlation between abnormal imaging findings and pain. I suspect we must continue to educate our patients and consumers so that we can move past the image. References 1. Chou R, Qaseem A, et al. Clinical efficacy assessment subcommittee of the American College of Physicians. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine 2007;147:478–491 2. Chou R, Fu R, et al. Imaging strategies for low-back pain: systematic review and metaanalysis. Lancet 2009;373:463–472 3. Boden QDS, Davis DO, et al. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective

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investigation. The Journal of Bone & Joint Surgery (Am) 1990;72:403–408 4. Jarvik JG, Hollingsworth W, Heagerty PJ. Three-year incidence of low back pain in an initially asymptomatic cohort: clinical and imaging risk factors. Spine 2005;30(13):1541–1548 5. Derby R, Kim BJ, et al. Comparison of discographic findings in asymptomatic subject discs and the negative discs of chronic LBP patients: can discography distinguish asymptomatic discs among morphologically abnormal discs? The Spine Journal 2005;5(4):389–394 6. Alyas F, Turner M, Connell D. MRI findings in the lumbar spines of asymptomatic, adolescent, elite tennis players. British Journal of Sports Medicine 2007;41 (11):836–841.

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THE AUTHOR Joseph Brence DPT, FAAOMPT, COMT, DAC is a physical therapist and clinical researcher from Pittsburgh, PA, USA. He is also a fellowship candidate with Sports Medicine of Atlanta, GA, USA. Joseph’s primary clinical interests involve a better understanding of the neuromatrix and determining how it applies to physical therapy practice. He is currently involved in a wide range of clinical research projects investigating topics such as the effects of verbalising pain, the effects of mobilising versus manipulating the spine on body image perception and validation of an instrument which will assess medical practitioners’ understanding of pain. Clinically, Joseph treats a wide range of painful conditions in multiple settings including complex regional pain syndrome, fibromyalgia and chronic fatigue syndrome. Joseph also runs the Forward Thinking PT blog http://forwardthinkingpt.com/. Email: joebrence9@hotmail.com

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MORE IMAGING OF ASYMPTOMATIC SUBJECTS INDICATES MORE ABNORMAL FINDINGS

n the previous review, I discussed the growing amount of research assessing abnormal findings on diagnostic imaging in asymptomatic subjects. Although some of these numbers may have been quite surprising at first glance, our evolving understanding of pain has allowed us to understand why some people hurt, whereas others do not. A study published this month in the journal Spine, has further solidified the idea that abnormal pathology on diagnostic imaging may not be responsible for much of our patient’s pain (1). Although similar research has been discussed in sportEX, I wanted to share the findings of this study – because the numbers are quite staggering.

THE STUDY This prospective study set out to determine the prevalence and distribution of abnormal findings in the cervical spine upon magnetic resonance imaging (MRI). The researchers enrolled 1,211 healthy volunteers between 20 and 79 years old. The researchers excluded any patients with a history of brain or spinal surgery, comorbid neurological disease, symptoms related to sensory or motor disorders, severe neck pain, pregnant females, and individuals who received workmen’s compensation, or presented with symptoms after a motor vehicle accident. In enrolling the participants, the researchers assessed the participants’ occupations, noting that 50% had passive occupations, whereas 28% had physically demanding occupations. Each of the participants underwent a clinical examination, and imaging analysis of the cervical spine was performed.

THE FINDINGS The findings of this study were quite

BY JOSEPH BRENCE DPT, FAAOMPT, COMT, DAC

Our regular research reviewer, physical therapist Joseph Brence, reviews research looking into the poor correlation between cervical spine imaging results and the presence of clinical symptoms. Read this online http://spxj.nl/1iIUUGt UPPER BODY | LOW BACK PAIN | 16-01-COKINETIC FORMATS

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interesting and are detailed below: n 87.6% of the participants had significant disc bulging. Although there was a large variation in age of participants, 73.3% of males and 78% of females in their 20s already exhibited disc bulging. Frequency increased with age. n 5.3% of the participants presented with spinal cord compression (SCC), which also increased with age. This compression predominately occurred in the lower cervical spine with 41% in C5/6 and 27% in C6/7. n The patient with the most severe presentation of SCC on imaging, had no clinical symptoms, such as gait disturbance or numbness in extremities. His muscle testing indicated no weakness and although his lower extremity deep tendon reflexes were hyperreflexive, his upper extremity deep tendon reflexes, as well as his Hoffman’s reflex, were negative.

MY IMPRESSION As you can see, the results of this study indicated that diagnostic imaging revealed that the prevalence of abnormality of the cervical spine is quite high (and was occupation independent). I suspect that there are various practice patterns around the world, but the reliance upon imaging should never outweigh our ability to perform a thorough clinical examination (listening to the patient’s subjective complaints, comparing those to an objective examination and using

imaging to rule out serious or systemic pathology). We must be very cautious when making clinical decisions on diagnostic imaging alone and should instead treat the patient based upon their comprehensive clinical presentation. References 1. Nakashima H, Yukawa Y, et al. Abnormal findings on magnetic resonance images of the cervical spines in 1211 asymptomatic subjects. Spine 2015;40:392–398.

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Co-kinetic journal 2016;67(January):12-15

PHYSICAL THERAPY RESEARCH INTO PRACTICE

s the costs associated with the use of healthcare continue to rise, models of practice and reimbursement are shifting. This is especially true for low back pain (LBP), whose predicted direct costs in the United States was over $86 million dollars in 2005 (1). One suggested strategy to reduce costs, is to reduce the amount of inappropriate diagnostic imaging. Although this reduction is necessary, patients may have expectations that they need an image, and offering an alternative to imaging may be important (to replace the broken expectation) (2). A recently published article set out to compare healthcare use and charges for patients with LBP, who received either advanced imaging or physical therapy (PT), as a first management strategy, following a primary care consultation (3).

THE STUDY FINDINGS Fritz et al. began by retrospectively assessing electronic medical record (EMR) information in patients who sought care from a primary care clinician for LBP. The authors included patients who were seen between 2004 and 2010 and analysed data such as the patient’s problem list, medication record, sex, height and weight. They excluded any claims that demonstrated the presence of red flags or pregnancy, as well as those who died or entered into a hospice within a year. After identifying patients and covariates, the authors then assessed the initial care received within the first 6 weeks. They evaluated if the patients received advanced imaging (CT or MRI of the pelvis, lumbar or thoracic spine) or physical therapy and identified which was used first if both occurred. They then looked at use outcomes related to LBP such as surgery, spine surgeon visits or spine specialist visits. The authors included 2,893 patients and then used a propensity-matched comparison (n = 406). From this cohort, they

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PHYSICAL THERAPY OR ADVANCED MEDICAL IMAGING: HOW SHOULD LOW BACK PAIN BE FIRST MANAGED? BY JOSEPH BRENCE DPT, FAAOMPT, COMT, DAC UPPER BODY | LOW BACK PAIN | 16-01-COKINETIC

Our regular research reviewer, physical therapist Joseph Brence, reviews research looking into the increased healthcare usage and costs that seem to be associated with diagnostic imaging, possibly as a result of the ‘labelling effect’. Read this online http://spxj.nl/1MmbWnl found if a participant began with advanced imaging versus physical therapy, the odds of surgery, injections, specialist and emergency department visits all increased. They found that the advanced imaging subgroup used a much higher amount of money, as compared to the physical therapy group ($4,700 more). The authors suspect the ‘labelling effect’ associated with advanced medical imaging, may be a partial explanation for the higher costs. For example, when a ‘label’ is given to a patient’s LBP, which otherwise might be seen as non-specific and uncomplicated, heightened patient concern may result in additional care. Unfortunately, this can result in more costly, invasive procedures, which may or may not result in superior outcomes.

MY ANALYSIS The results from this study shouldn’t be too surprising. As we are learning, LBP is quite complicated, as it involves biological, psychological and social variables. I suspect that, once red flags have been ruled out, early movement is key. As the authors indicated, early care provided by a physical therapist can reduce care seeking and associated costs. We must also understand the potential influence of our language over outcomes, and as the authors suggest, non-specificity of ‘labelling’ may reduce the risk of fear or catastrophising. Overall, physical

therapy should precede imaging, if serious pathology is not suspected to be present. References 1. Martin BI, Deyo RA, et al. Expenditures and health status among adults with back and neck problems. JAMA 2008;299(6):656– 664 2. Santa JS. Communicating information about “what not to do” to consumers. BMC Medical Informatics and Decision Making 2013;13(Suppl. 3):S2 3. Fritz JM, Brennan GP, Hunter SJ. Physical therapy or advanced imaging as first management strategy following a new consultation for low back pain in primary care: associations with future health care utilization and charges. Health Services Research 2015;doi:10.1111/14756773.12301.

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ILIOTIBIAL BAND SYNDROME: A NARRATIVE REVIEW BY BRADLEY S. NEAL MSC, MCSP

LOWER LIMB | KNEE | RUNNING | 16-01-COKINETIC FORMATS WEB MOBILE PRINT

MEDIA CONTENTS Continuing education quiz This article also has a certificated eLearning assessment that can be found in the Media Contents box, or under the eLearning Assessment area in your Account area, on the Co-Kinetic website. The eLearning assessment(s) can be completed on all platforms including mobiles when accessed through the Co-Kinetic site; however, they are NOT accessible through the sportEX mobile app as you have to be logged into the actual website for the results to be recorded and the certificate to be generated. http://spxj.nl/1iISGXI

ARTICLE WEB LINKS T ranslational article with image/video content on step width modification: http://spxj.nl/1Ys47SA Functional running assessment & gait re-education is Brad Nealâ&#x20AC;&#x2122;s post-graduate 2-day CPD course for healthcare professionals wishing to learn the practical application of gait assessment and rehabilitation. http://spxj.nl/1OeMqDl

Historically, friction at the lateral femoral condyle has been thought to be the cause of iliotibial band syndrome (ITBS). This review presents the reader with evidence that, rather than friction, compression of the lateral femoral condyle caused by altered biomechanics (as well as excessive loading) is responsible for ITBS. This review also summarises the treatment modalities for ITBS, with a significant focus on gait retraining and biomechanics. A conservative treatment paradigm is also presented to guide clinical reasoning in relation to symptom severity and irritability. Read this online http://spxj.nl/1iISGXI BACKGROUND Iliotibial band syndrome (ITBS) is an injury characterised by pain presenting at the lateral aspect of the knee during activity, often in an insidious, atraumatic fashion (1). Symptoms typically increase as the duration of activity progresses (1) and as such, the pathology is thought to arise as a result of excessive training volume. Consistent with the principle of tissue overload, those who progress their weekly running volume by more than 10% have been identified to be at risk (2). ITBS is the most common pathology noted in military recruits, with an incidence of 6.2% identified during basic training (3) and the overall incidence of the pathology is thought to be as high as 14% in active persons (4). This makes ITBS the most common running-related injury experienced in clinical practice behind patellofemoral pain (PFP) (5,6) and, in keeping with the data on PFP, is twice as likely to affect women compared to men (5,7). In reading this narrative review, the audience will gain an insight into the up to date science that challenges the historic belief that friction at the lateral femoral condyle is responsible for ITBS development. An argument around compression at the lateral femoral condyle will be presented, supplemented by a summary of the evidence which suggests that altered biomechanics (in conjunction with excessive loading) is the primary causative

factor behind compression and nociceptive pain in ITBS. A summary of treatment modalities to supplement the associated case study http://spxj.nl/1SuIeOY will be presented, with a significant focus placed on gait retraining and biomechanics.

ANATOMY It is essential to revisit the anatomy of the iliotibial band (ITB) (Fig. 1), as misconceptions about symptoms onset, pain drivers and treatment targets seem to be driven by classic anatomic teaching as opposed to recent scientific anatomy discoveries. Proximally, the ITB commences in the lateral hip, receiving the insertion of the tensor fascia lata and gluteus maximus muscles, having both superficial and deep layers. The fascia is anchored securely at multiple points to the lateral aspect of the femur through the linea aspera and is continuous with the expansive fascia that covers the entirety of the thigh region (8). The ITB inserts distally on the proximal head of the fibula and onto Gerdyâ&#x20AC;&#x2122;s tubercle, but also has several fibrous attachments to the lateral femoral condyle (9). As a passive structure, the ITB will resist hip adduction and internal rotation, as well as tibial internal rotation and anterior translation.

PAIN DRIVERS IN ITBS The primary mechanism of pain development in ITBS is historically described as one of friction, resulting from the band sliding over the lateral femoral condyle as the knee goes

Co-Kinetic journal 2016;67(January):16-20

through a given range of flexion (10). However, the most recent study of ITB anatomy in relation to ITBS development (9) identified that the fascial anchorage of the tract prevents such movement and that compression of the tract against the highly innervated layer of fat located beneath is more likely to be the cause of nociceptive pain, as a result of chemical inflammation. This compression was shown to be highest at 30° of knee flexion and is primarily due to increased tibial internal rotation (9). A more recent article from the same authors (11) has subsequently made the suggestion that ITBS should be solely considered a pathology of compression and that interventions which seek to optimise hip biomechanics and muscle function should therefore be a focal point of management.

BIOMECHANICS There is a growing body of evidence to support the hypothesis that the primary factor leading to ITBS development is altered lower limb biomechanics. Only one prospective study (to allow for inferences on causation) has been performed (8), which identified that increased peak hip adduction and knee internal rotation were risk factors for the pathology, although it must be stated that this can only be applied to female runners at present. Although prospective studies are the gold standard for determining causal relationships, this work is supported by a variety of retrospective work, best summarised by the systematic review completed in 2014 by Louw and Deary (1). The mechanism behind abnormal biomechanics resulting in ITBS development is thought to be as a result of increased mechanical strain (tissue deformation), leading to compression against the lateral femoral condyle. Musculoskeletal modelling studies have shown that the ITB strain rate is significantly higher in those with ITBS when compared to controls (12), a finding that was echoed by a recent high quality study using ultrasonographic elastography in vivo (13), which identified that increasing hip adduction moments leads to an increase in ITB ‘hardness’ (stiffness). Co-Kinetic.com

Despite the growing argument surrounding altered biomechanics and ITBS, the link between muscle strength and altered biomechanics remains unknown. A single case-control study (14) comparing hip strength in runners with and without ITBS identified no differences in hip abductor strength, regardless of whether the variable was measured in an isometric, concentric or eccentric fashion. This directly conflicts the more recent findings of Noehren et al. (15), who identified significantly reduced hip external rotator strength in runners with ITBS when compared to asymptomatic controls. This study also identified a correlation between hip external rotator weakness and increased peak hip internal rotation, but it must be reinforced that both of these works were performed in a retrospective fashion, meaning that they cannot be used to infer causation.

HOW DO WE TREAT ITBS EFFECTIVELY? Gait retraining Given the suggested intrinsic risk factor of altered lower limb biomechanics presented above, a plausible strategy for the management of ITBS is attempting to modify running biomechanics. It should be highlighted that emerging research suggests that attempting to modify running biomechanics through the use of strengthening exercise would seem to be futile (16). Thus, it would seem that it is necessary to view running as a skill that requires modification through the use of internal and/or external feedback, often termed gait retraining. Several observational trials have reported that it is possible to

PHYSICAL THERAPY: MSK DIAGNOSIS, TREATMENT, REHABILITATION

Figure 1: The iliotibial band (ITB)

reduce peak hip adduction using gait retraining, through the use of a variety of feedback mechanisms. Both Noehren et al. (17) and Willy et al. (18) achieved significant reductions in peak hip adduction in females with PFP using differing forms of external feedback; real-time hip adduction and mirror feedback respectively. This result has recently been repeated in a group of military recruits deemed to be ‘at risk’ of tibial stress fracture (19), this time using metronome feedback to cue an increase in step rate (cadence). Only one study has investigated the role of feedback in the form of gait retraining directly on a biomechanical variable involving the ITB. Meardon et al. (20) analysed the effect of step width on ITB strain in a group of asymptomatic runners. Results identified that ITB strain was highest during the narrow step-width condition and lowest

HOWEVER, THE MOST RECENT STUDY OF ILIOTIBIAL BAND ANATOMY IN RELATION TO ITBS DEVELOPMENT IDENTIFIED THAT THE FASCIAL ANCHORAGE OF THE TRACT PREVENTS SUCH MOVEMENT AND THAT COMPRESSION OF THE TRACT AGAINST THE HIGHLY INNERVATED LAYER OF FAT LOCATED BENEATH IS MORE LIKELY TO BE THE CAUSE OF NOCICEPTIVE PAIN, AS A RESULT OF CHEMICAL INFLAMMATION 17

exercise for gait-width modification. Corticosteroid injection

ITBS

Excessive volume load

High severity and/or irritability

Low severity and/or irritability

Oral NSAIDS

Altered biomechanics

Volume/load management

Exercise

Gait retraining

Figure 2: Conservative treatment pathway for iliotibial band syndrome (ITBS) (B. Neal, 2007)

during the wide step-width condition. Given the proposed link between ITB strain and compression at the lateral femoral condyle, this is a form of feedback that is potentially of great interest. However, it must be reinforced that this research looked at the effects of step width in asymptomatic subjects and it should not be assumed that results could simply be replicated in those suffering with ITBS. It must also be highlighted that the form of feedback used in this observational research was internal in nature, which may potentially be detrimental to skill acquisition (21). See the translational article listed in ‘Article Web Links’ for more on this subject including a video showing theraband crab walks, a useful

ONLY ONE PROSPECTIVE STUDY (TO ALLOW FOR INFERENCES ON CAUSATION) HAS BEEN PERFORMED, WHICH IDENTIFIED THAT INCREASED PEAK HIP ADDUCTION AND KNEE INTERNAL ROTATION WERE RISK FACTORS FOR THE PATHOLOGY, ALTHOUGH IT MUST BE STATED THAT THIS CAN ONLY BE APPLIED TO FEMALE RUNNERS AT PRESENT 18

Rehabilitative exercise As with the role of muscle weakness in the development and persistence of ITBS, the role of exercise as a management strategy is also poorly understood. Only one historic study has looked at the role of rehabilitative exercise in the management of ITBS (22), with their treatment protocol summarised succinctly in the review of van der Worp (4). Although a 92% success rate was achieved in this study with regards to a return to running at six weeks post diagnosis, there are some methodological issues to highlight. Subjects received nonsteroidal anti-inflammatory drugs (NSAIDS), ultrasound therapy with a corticosteroid gel and were instructed to cease running for the duration of the trial and, as a result, it is impossible to identify where the positive effects of this treatment protocol were derived from. The protocol was also not tested against any control group, which means that any identified results could simply be due to a regression to the mean.

to target the chemical inflammation that arises as a result of pathologic compression. One randomised controlled trial has investigated the effects of this technique at a shortterm follow-up (23). In comparison to sham injection, a significant reduction in running-related ITBS was achieved with corticosteroid injection, but it must be highlighted that both groups improved in comparison to baseline. The authors suggest that this is likely to be due to the advised daily application of ice and rest and acknowledge the limitation of a short-term follow-up (14 days) (23). Despite this, the inclusion of a corticosteroid injection in the management of ITBS seems positive and would appear to be targeting the most plausible mechanism behind symptom development. It makes the most sense to consider this intervention in those with high symptom severity and/or irritability, but the potential ethical considerations of using such invasive interventions to allow for continued provocative activities must be acknowledged.

Surgery Volume management Given that another likely extrinsic factor for ITBS is excessive volume progression, it would seem sensible to modify this variable in conjunction with any gait retraining or exercisebased rehabilitation. Considering the risks identified by Nielsen et al. (2), suggesting that runners do not increase their running volume by more than 10–20% each week should be advised, accepting that this variable will require an element of individualisation and clinical reasoning from the involved clinician or coach. As all the observational trials investigating the early effects and mechanisms of gait retraining have used a faded feedback design successfully (17–19) (where run volume gradually increases while feedback decreases), it is a sensible suggestion that combining modulation of load with gait retraining should be straightforward.

Steroid injections A common invasive intervention used clinically in the management of ITBS is corticosteroid injection, designed

It is generally accepted that surgical intervention for ITBS should only be considered in cases where quality conservative management has failed. An arthroscopic release of the iliotibial band from its insertion on the lateral femoral condyle was evaluated by Michels et al. (24), who describe a 100% return to sport at three months post-surgery and an 89% success rate based on the need for good or excellent subjective rating. An arthroscopic procedure is known to offer superior results to open debridement (24,25) and offers the benefit of allowing for full examination of the joint to assess for concomitant pathology (25). Although these surgical outcomes are positive, it must again be reinforced that at present they lack evaluation in comparison to a control group and as a result, should not be considered before a minimum of 6 months’ failed conservative care (4,24). Despite the reported incidence of ITBS, no treatment modality has been evaluated beyond an observational trial. Overall, the quality of research into the management of ITBS is poor, Co-Kinetic journal 2016;67(January):16-20

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IF THE STRENGTH OF EVIDENCE SURROUNDING THESE RISK FACTORS INCREASES, THEN A MANAGEMENT STRATEGY BASED AROUND IMPROVING RUNNING BIOMECHANICS VIA STRUCTURED FEEDBACK AND MODULATING TRAINING LOADS WOULD SEEM TO BE THE MOST PLAUSIBLE with results leading to conflicting suggestions for clinicians (4). Strategies to bring about a change in lower limb biomechanics in conjunction with advice on load management seem to have the strongest evidence based support, although both need evaluating in comparison to control. Pain management strategies such as a corticosteroid injection where indicated show promise and whilst the outcomes from surgical intervention seem positive, it is not clear whether they are superior to conservative management. Based on the information presented above, a plausible conservative treatment pathway for patients with ITBS is presented in Figure 2.

TAKE HOME MESSAGES It is clear that, at present, the evidence base available does not allow for an appropriate understanding of risk or contributing factors for ITBS; nor does it inform appropriately on the effects and mechanisms of interventions. As such, clinicians are forced to rely on clinical experience and anecdote when treating runners or active individuals suffering with ITBS. The two main risk factors discussed in this narrative review, an excessive increase in running volume and altered hip biomechanics, should be the priorities for future research into the development of ITBS. If the strength of evidence surrounding these risk factors increases, then a management strategy based around improving running biomechanics via structured feedback and modulating training loads would seem to be the most plausible, although at present advocating this strategy is based on nothing more than observational research and complimentary data based on other pathologies such as PFP.

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References 1. Louw M, Deary C. The biomechanical variables involved in the aetiology of iliotibial band syndrome in distance runners - a systematic review of the literature. Physical therapy in sport 2014;15(1):64–75 2. Nielsen RO, Parner ET, et al. Excessive progression in weekly running distance and risk of running-related injuries: an association which varies according to type of injury. The Journal of Orthopaedic and Sports Physical Therapy 2014;44(10):739–747 3. Sharma J, Greeves JP, et al. Musculoskeletal injuries in British Army recruits: a prospective study of diagnosisspecific incidence and rehabilitation times. BMC Musculoskeletal Disorders 2015;16:106 4. Van der Worp MP, van der Horst N, et al. Iliotibial band syndrome in runners: a systematic review. Sports Medicine 2012;42(11):969–992 5. Taunton JE, Ryan MB, et al. A retrospective case-control analysis of 2002 running injuries. British Journal of Sports Medicine 2002;36(2):95–101 6. Saragiotto BT, Yamato TP, et al. What are the main risk factors for running-related injuries? Sports Medicine 2014;44(8):1153– 1163 7. Foch E, Milner CE. Frontal plane running biomechanics in female runners with previous iliotibial band syndrome. Journal of Applied Biomechanics 2014;30(1):58–65 8. Noehren B, Davis I, Hamill J. ASB clinical biomechanics award winner 2006 prospective study of the biomechanical factors associated with iliotibial band syndrome. Clinical Biomechanics 2007;22(9):951–956 9. Fairclough J, Hayashi K, et al. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. Journal of Anatomy 2006;208(3):309–316 10. Orchard JW, Fricker PA, et al. Biomechanics of iliotibial band friction syndrome in runners. The American Journal of Sports Medicine 1996;24(3):375–379 11. Fairclough J, Hayashi K, et al. Is iliotibial band syndrome really a friction syndrome? Journal of Science and Medicine in Sport 2007;10(2):74–6; discussion 7–8 12. Hamill J, Miller R, et al. A prospective 19

study of iliotibial band strain in runners. Clinical Biomechanics 2008;23(8):1018– 1025 13. Tateuchi H, Shiratori S, Ichihashi N. The effect of angle and moment of the hip and knee joint on iliotibial band hardness. Gait & Posture 2015;41(2):522–528 14. Grau S, Krauss I, et al. Hip abductor weakness is not the cause for iliotibial band syndrome. International Journal of Sports Medicine 2008;29(7):579–583 15. Noehren B, Schmitz A, et al. Assessment of strength, flexibility, and running mechanics in men with iliotibial band syndrome. The Journal of Orthopaedic and Sports Physical Therapy 2014;44(3):217–222 16. Willy RW, Davis IS. The effect of a hip-strengthening program on mechanics during running and during a single-leg squat. The Journal of Orthopaedic and Sports Physical Therapy 2011;41(9):625–632 17. Noehren B, Scholz J, Davis I. The effect of real-time gait retraining on hip kinematics, pain and function in subjects with patellofemoral pain syndrome. British Journal of Sports Medicine 2011;45(9):691–696 18. Willy RW, Scholz JP, Davis IS. Mirror gait retraining for the treatment of patellofemoral pain in female runners. Clinical Biomechanics 2012;27(10):1045–1051 19. Willy R, Buchenic L, et al. In-field

gait retraining and mobile monitoring to address running biomechanics associated with tibial stress fracture. Scandinavian Journal of Medicine & Science in Sports 2015;doi:10.1111/sms.12413 20. Meardon SA, Campbell S, Derrick TR. Step width alters iliotibial band strain during running. Sports Biomechanics 2012;11(4):464–472 21. Wulf G, Shea C, Lewthwaite R. Motor skill learning and performance: a review of influential factors. Medical Education 2010;44(1):75–84 22. Fredericson M, Cookingham CL, et al. Hip abductor weakness in distance runners with iliotibial band syndrome. Clinical Journal of Sport Medicine 2000;10(3):169–175 23. Gunter P, Schwellnus MP. Local corticosteroid injection in iliotibial band friction syndrome in runners: a randomised controlled trial. British Journal of Sports Medicine.2004;38(3):269–72; discussion 72 24. Michels F, Jambou S, et al. An arthroscopic technique to treat the iliotibial band syndrome. Knee Surgery, Sports Traumatology, Arthroscopy 2009;17(3):233–236 25. Cowden CH, 3rd, Barber FA. Arthroscopic treatment of iliotibial band syndrome. Arthroscopy Techniques.2014;3(1):e57–60.

KEY POINTS n I liotibial band syndrome (ITBS) is a common pathology in specific groups of patients. n The pathology is one of compression as opposed to friction. n Altered lower limb biomechanics appears to be an intrinsic risk factor for the pathology. n Excessive training volume appears to be an extrinsic risk factor for the pathology. n Gait retraining is a plausible strategy for managing ITBS. n The role of exercise in managing ITBS is currently under-evaluated and thus unknown. n There is a place for guided corticosteroid injections in high severity/ irritability cases. n Surgery should not be considered prior to 6 months of conservative management.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Recently it has been suggested that ITBS should be solely considered a pathology of compression rather than friction. http://spxj.nl/1iISGXI Tweet this: There is growing evidence to suggest that the primary factor for ITBS development is altered lower limb biomechanic. http://spxj.nl/1iISGXI Tweet this: As altered lower limb biomechanics is a suggested risk for ITBS, gait retraining is a plausible management strategy. http://spxj.nl/1iISGXI Tweet this: Emerging research suggests that attempting to modify running biomechanics through strengthening exercises is futile. http://spxj.nl/1iISGXI

DISCUSSIONS hat future research is required to improve upon the W understanding and management of ITBS? ow might a patient with ITBS differ from a patient H with patellofemoral pain? hat factors might you choose when deciding W to refer a patient with ITBS for a corticosteroid injection?

THE AUTHOR Bradley S. Neal BSc MSc (Adv Phys) is a physiotherapist and clinical academic who has worked in a combination of NHS, elite sport and private practice settings for the past 9 years. He completed his MSc in Advanced Musculoskeletal Physiotherapy at Hertfordshire University in 2011 before joining Pure Sports Medicine as a specialist musculoskeletal physiotherapist and research lead the same year. Brad acts as a lower quadrant specialist at Pure Sports Medicine, taking a special interest in knee pathology, tendinopathy and overload conditions such as medial tibial stress syndrome (MTSS). Brad commenced his PhD studies at Queen Mary University London (QMUL) as part of #TEAM_PFP investigating the effects and mechanisms of running gait retraining in the management of patellofemoral pain in April 2014. He combines his research and clinical roles with regular teaching on the BSc and MSc programmes at QMUL and tutors a number of independent post-graduate courses. Brad has published twice as a lead author thus far and has multiple lead and secondary author papers due within the next year. Email: b.s.neal@qmul.ac.uk Twitter: @Brad_Neal_07; @puresportsmed LinkedIn: Brad Neal https://uk.linkedin.com/pub/brad-neal/49/575/524 Facebook: Pure Sports Medicine https://www.facebook.com/puresportsmed

RELATED CONTENT onservative management of C iliotibial band syndrome: a clinical reasoning journey http://spxj.nl/1SuIeOY ateral hip pain and ITB syndrome L http://spxj.nl/1MFPGVE ransverse soft tissue release and T ITB syndrome: a case study http://spxj.nl/1JDATas oft Tissue Treatments with S Stuart Hinds: ITB Syndrome Video Masterclass http://spxj.nl/1OPZIVh

Co-Kinetic journal 2016;67(January):16-20

PHYSICAL THERAPY: MSK DIAGNOSIS, TREATMENT, REHABILITATION

CONSERVATIVE MANAGEMENT OF ILIOTIBIAL BAND SYNDROME: A CLINICAL REASONING JOURNEY This case study will describe the conservative management of a runner with iliotibial band syndrome (ITBS), from diagnosis to return to running. In reading this article the audience will be shown how to practically employ the ITBS conservative management framework outlined in the accompanying narrative review in a running-specific setting http://spxj.nl/1iISGXI. A particular emphasis will be placed on integrating specific facets of the evidence base into the assessment and treatment process, outlining which objective tests, outcome measures and interventions sit comfortably within an evidence-informed framework. Read this online http://spxj.nl/1SuIeOY LOWER LIMB | KNEE | RUNNING | 16-01-COKINETIC FORMATS WEB MOBILE PRINT

MEDIA CONTENTS Podcast 1: Session 16 – Biomechanics and pain: the ongoing dilemma with Greg Lehman. (ChewsHealth, 2015). http://spxj.nl/1Og8YUg Podcast 2: TPMP special edition: Session 16.5. A response to session 16 with Brad Neal & Jack Chew. (YouTube user The Physio Matters Podcast, 2015). http:// spxj.nl/1NOHQXE Podcast 3: Session 2 – Patellofemoral pain syndrome with Dr Lee Herrington – part 2. (ChewsHealth, 2014). http://spxj.nl/1lhsxjj Podcast 4: Session 19 – Managing runners with Matt Phillips and Tom Goom. (ChewsHealth, 2015). http://spxj. nl/1Qkpdj8 ontinuing education quiz C This article also has a certificated eLearning assessment that can be found in the Media Contents box, or under the eLearning Assessment area in your Account area, on the Co-Kinetic website. The eLearning assessment(s) can be completed on all platforms including mobiles when accessed through the Co-Kinetic site; however, they are NOT accessible through the sportEX mobile app as you have to be logged into the actual website for the results to be recorded and the certificate to be generated. http://spxj.nl/1SuIeOY

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BY JACK CHEW BSC, MCSP

INTRODUCTION This case study discusses the clinical journey of a 40-year-old female runner who presented to a musculoskeletal physiotherapist having been referred by her GP 2 weeks previously. The patient is referred to in this case study as Mrs X and is unidentifiable throughout. Mrs X reported a 6-month history of right lateral knee pain. The patient’s presentation, assessment and diagnosis will be discussed with reference to the evidence base and only pertinent clinical findings are presented in order to prioritise discussion of treatment and management choices.

SUBJECTIVE HISTORY Presenting condition The patient is a 40-year-old, female, full-time lawyer with right-sided, anterolateral knee pain aggravated by running, cross-legged sitting and walking in high heels. Symptoms are eased by swimming, oral analgesia and general avoidance of known aggravators. Symptoms remained constant for 2 days following running for longer than 20 minutes, suggesting high irritability.

History of presenting condition The patient reported a history of similar symptoms 8 years previously, which was diagnosed as iliotibial band syndrome (ITBS) and treated to resolution by an orthopaedic team, including physiotherapists, with

corticosteroid injection followed by rehabilitation. Since recommencing recreational running 9 months ago, the problem returned insidiously and was now limiting sporting function significantly with some impact on dayto-day function in the last 2 months. Mrs X rested from running for 3 weeks on two occasions but with no positive symptom change when she returned to running. The patient is medically fit and well with no significant medical history or medication use, but was currently using an oral analgesic, averaging two a day.

OBJECTIVE EXAMINATION Physical examination The patient’s symptoms were not influenced by provocation testing of the lumbar spine or hip joints. No visible or palpable joint effusion, surface temperature changes or discoloration was noted. The joint was laterally stable with no laxity upon varus stress testing (1). The absence of knee-joint-line tenderness, negative findings on respected meniscal tests [McMurray’s and Thessely’s tests (2,3)], alongside a low experiential likelihood from subjective findings meant that meniscal pathology was considered unlikely. Mrs X did present with tenderness on palpation local to the lateral femoral condyle and when combined with passive extension of the knee (which forms the Noble compression test),

THE PATIENT PRESENTED WITH RIGHT-SIDED, ANTEROLATERAL KNEE PAIN AGGRAVATED BY RUNNING, CROSS-LEGGED SITTING AND WALKING IN HIGH HEELS 21

MRS X DID PRESENT WITH TENDERNESS ON PALPATION LOCAL TO THE LATERAL FEMORAL CONDYLE AND WHEN COMBINED WITH PASSIVE EXTENSION OF THE KNEE, SYMPTOMS WERE REPRODUCED TO GIVE A POSITIVE CLINICAL FINDING FOR DISTAL ITBS

IN ALL ISOMETRIC, THROUGH-RANGE AND FUNCTIONAL TESTING, MRS X’S GLUTEAL MUSCLES WERE FOUND TO BE WEAK AND OF POOR ENDURANCE BILATERALLY 22

symptoms were reproduced to give a positive clinical finding for distal ITBS (4). A degree of dynamic knee valgus was noted on an observed single-leg squat. This was evident bilaterally but more so on the right hand side. The single-leg squat provoked symptoms between 20 and 40° of knee flexion and was most painful when combined with palpation over the lateral femoral condyle to give a positive Renne’s test (5). A similar demonstration of dynamic knee valgus was noted when Mrs X’s running gait was analysed on a treadmill. Dynamic knee valgus with internal rotation of the weight-bearing hip at midstance was observed. There is a known biomechanical link between knee valgus (hip adduction +/− hip internal rotation) and iliotibial band (ITB) tension (6), however, there is no consistent clinical correlation to symptoms (7). There is an ongoing dialogue amongst clinicians and academics regarding the aforementioned correlative links, with some presenting a strong case that dynamic knee valgus both correlates with, and has causal links with patellofemoral pain syndrome. An example of this debate can be found in session 16 of The Physio Matters Podcast with Greg Lehman (Podcast 1) with a response by Brad Neal (Podcast 2). Ober’s and modified Ober’s tests for ITB length were negative for both pain and range of motion limitation. In terms of sensitivity and specificity, the tests had a reliability of 0.90 and 0.91, respectively, in the most robust trials (8) and, as mentioned above, ITB length does not appear to correlate with ITBS. It can, however, be considered a helpful biomechanical test to inform clinical reasoning, especially when comparing to an unaffected limb (9). In all isometric, through-range and functional testing, Mrs X’s gluteal muscles were found to be weak

and of poor endurance bilaterally. A specific example is that the right side was approximately 30% weaker than the left when tested with handheld dynamometry in side-lying hip abduction. Additionally, Mrs X was unable to complete 10 full repetitions of right hip abduction against a moderate band resistance before fatigue, a task she was able to complete with the left side. Hip strength and, more specifically, comparative deficits in lateral gluteal endurance have been found in female patients with an often related pathology, patellofemoral pain syndrome (10). Therefore, these findings again inform clinical reasoning to assist the identification of diagnosis and potential causative factors.

RADIOLOGY Three weeks following Mrs X’s initial physiotherapy assessment, the images and report of a right knee MRI scan, arranged by the GP at point of referral, were viewed. A consultant radiologist had reported an area of inflammation deep to the distal ITB but with no clear definition of an ITB bursa. An area of high signal was noted between the distal ITB and the lateral femoral condyle and reported as potential fat pad irritation. The MRI report, which mentions both bursal and fatty tissue is a good example of the current lack of clarity regarding ITBS and its pathogenesis. Progress from traditional understanding of the pathology (11) has resulted in changes to radiographic reporting (12) and this will be detailed further in the ‘Iliotibial band syndrome’ section.

CLINICAL REASONING The subjective history in this case informed clinical reasoning in several ways. For example, the history of similar symptoms, and resolution of said symptoms, is likely to have influenced the patient’s perception of the problem Co-Kinetic journal 2016;67(January):21-25

PHYSICAL THERAPY: MSK DIAGNOSIS, TREATMENT, REHABILITATION

and the solution (13). The gradual onset, seemingly coinciding with increased running, suggests an overload component to causation (14). The location, nature and onset pattern of the symptoms described was in keeping with one of the most common running injuries, ITBS (15), which became the primary hypothesis early in the assessment process. Tenderness local to the commonly problematic interface between the ITB and the lateral femoral condyle strengthened the diagnostic decision, especially in the presence of positive combined movement and palpation tests (Renne’s and Noble’s). Mrs X also demonstrated several movement tendencies and dysfunctions that are commonly associated with ITBS and more broadly anterior knee pain (16,17). A medial or valgus knee drift on single-leg squat and during running gait, could suggest a lack of proximal control of the hip and pelvis. This finding was in keeping with isometric and functional testing of Mrs X’s gluteal power and endurance. On movement observation it was noted that valgus tendency on singleleg squat and midstance running gait was not combined with a contralateral ‘hip-hitch’ compensation at the pelvis; therefore, it can be sensibly deduced that the ITB is not structurally short, in keeping with a negative Ober’s test (8). The oft-debated relationship between the ITB and the patella is discussed at length in session 2 of The Physio Matters Podcast with Dr Lee Herrington (Podcast 3).

ILIOTIBIAL BAND SYNDROME Pathogenesis and pathophysiology The pathogenesis and pathophysiology of ITBS is elaborated thoroughly in the attached narrative review and, therefore, needn’t be exhausted here. However, the mechanisms in which the chosen interventions influence our best understanding of these factors should underpin clinical reasoning in the absence of a robust and thorough evidence base. One of the few consensuses in ITBS as a condition is that the irritated lateral recess structures, Co-Kinetic.com

rather than the ITB itself, are considered pathological (15). Therefore, inflammation remains a key clinical feature and, in keeping with logic, modalities to decrease inflammation have been shown to be effective in symptom modification (18). Another general consensus both clinically and amongst the evidence base, is that corticosteroid injection (CSI), a known anti-inflammatory intervention, is an adjunctive option to facilitate further conservative rehabilitation (6,19–21). It could, therefore, be counterproductive to only consider a CSI once conservative rehabilitation has been exhausted, as often occurs on clinical pathways for other common mechanoinflammatory pathologies.

TREATMENT Treatment selection As mentioned above, despite ITBS being a common problem, the interventional literature is sparse and there are no long-term, comparative randomised controlled trials (RCTs) that can inform the entirety of the treatment process. Expert opinion pieces or ‘masterclass’ articles are more commonplace and several on the assessment and treatment of ITBS are generally well regarded in the literature. Fredericson & Wolf; Baker et al. and Van der Worp et al. propose that control of extrinsic factors, in this case relative rest from running, alongside an inflammation modifying medication such as an NSAID course or a CSI would be best practice in an ‘acute phase’ (15,19,22). Although Mrs X’s symptoms had been present for 6 months, she had recently experienced an increase or flare in symptoms that research into the nature of the pathology suggests would be due to increased nociception, secondary to chemical inflammatory irritation (23). The author recognises that this is maybe a somewhat narrow assumption in light of contemporary pain science; however, in this case, few other mechanisms could be identified to account for increased symptoms, both at the time and in hindsight. In light of the examination findings and with careful consideration of the patient’s values and preferences, it was decided that a CSI would be administered which, if successful, would

MRS X ALSO DEMONSTRATED SEVERAL MOVEMENT TENDENCIES AND DYSFUNCTIONS THAT ARE COMMONLY ASSOCIATED WITH ITBS allow for more comfortable rehabilitation. The following post-intervention rehabilitation was proposed and agreed ahead of time: n Strength and conditioning training with a view to increasing robustness under cumulative loading (24). n Gait retraining with a view to decrease short-term anterior knee impact forces and/or ITB strain (25,26). n Promotion of regular, varied, positive movement experiences as a means to reassure, reorganise and promote re-evaluation of a potentially sensitive central and peripheral nervous system (27).

Injection therapy for ITBS In keeping with the evidence base surrounding ITBS, there is little supportive or negating literature around the use of injection therapy for the condition. An RCT conducted by Gunter and Schwellnus (28) concluded that local CSI significantly decreased reported pain when running compared to control, in athletes with recent onset ITBS, 2 weeks following intervention. Although there are several differences between the case of Mrs X and the study sample, namely time of symptom onset, this remains the only trial to investigate CSI on ITBS and was, therefore, used in part to inform the injection intervention. The injection was administered by an injection trained musculoskeletal physiotherapist in accordance with an organisational ‘patient group directive’ and policy for the use of medication.

POST-INTERVENTION Follow-up Mrs X returned to physiotherapy 2 weeks later and reported abolition of symptoms 30 minutes post-injection and remained asymptomatic on follow-up.

Subsequent rehabilitation A rehabilitation regime was devised in 23

A REHABILITATION REGIME WAS DEVISED TO IMPROVE RIGHT TO LEFT DEFICITS IN CERTAIN LOWER LIMB STRENGTH PARAMETERS collaboration with the patient with a view to improving right to left deficits in certain lower limb strength parameters. A combination of split squats, side-lying hip abduction against resistance, single leg-press and lateral resistance band walks were completed in a 15-minute session every second day. These home/gym exercises were unsupervised and Mrs X was encouraged to vary form, pace, exercise order and time of day as symptoms allowed. Over three fortnightly reviews and two subsequent monthly reviews, Mrs X was progressed to single-leg squats, alternate jump lunges, lateral box jumps and a variety of multi-directional agility drills. Alongside this, a graded return to running programme was loosely scheduled and carried out to scale from 2 × 10-minute runs a week to the patient’s goal of 3 × 30-minute runs a week. This increased volume was scaled over a 10-week period at approximately 15% increase per week (29). Self-selected cross training was encouraged and took the form of swimming and cycling, each once weekly. Gait analysis post-injection proved interesting as a more comfortable assessment meant relative fatigue was induced before pain halted the run. In TABLE 1: RESULTS OF THE EQ-5D-4L AND THE LOWER EXTREMITY FUNCTIONAL SCALE (LEFS) QUESTIONNAIRES USED IN PATIENT ASSESSMENT. (J. Chew, 2015) TIME OF ASSESSMENT Initial assessment

OUTCOME MEASURE EQ-5D-5L LEFS 21231

2 weeks post-injection

11111

6 weeks post-injection

11121

14 weeks post-injection

11111

the final few minutes of two assessed runs, Mrs X demonstrated a crossover gait and resultant reduced stride width. In light of these findings, Mrs X was encouraged to foot strike either side of a central line on a treadmill, particularly in the latter part of her runs. This example of an external cue is practical application of Richard Willy and his team’s work on gait retraining (30,31) and the intention is somewhat justified by the findings of Meardon et al. who found that narrow stride width increased ITB strain (26). These papers and the majority of treatment techniques used in this management plan are discussed and debated at length in session 19 of The Physio Matters Podcast ‘Managing Runners’ with Matt Phillips and Tom Goom (Podcast 4).

Outcome At 6 weeks post-injection, Mrs X was comfortably managing 3 × 15 minute runs per week with mild (2/10) discomfort post-run which cleared overnight with no next-day consequences, suggesting a positive change to symptom irritability. On final review, 14 weeks postinjection and 16 weeks after presenting to her GP, Mrs X was pain free in both sporting and non-sporting function, was running 3 × 30 minutes weekly alongside two dance classes a week. Two formal questionnaire outcome measures were used on assessment: the EQ-5D-4L and the ‘lower extremity functional scale’ (LEFS), the results of which are shown in Table 1. EQ-5D-5L numeric data is noncumulative; however, the codes in the table demonstrate significant functional and symptom-related progress. LEFS is scored 0–80 and, therefore, the scores in Table 1 not only demonstrate significant functional progress, they also highlight a near full score at 6/52 post-injection with running volume the only deficit.

CONCLUSION Despite contention over the pathogenesis, diagnostic relevance and especially the best practice treatment of ITBS, this case study demonstrates a successful collaboration of clinical reasoning and logical integration of the

available research evidence. The limitations of a singular case study must be acknowledged, and it is not known what Mrs X’s outcomes would have been without the addition of CSI to her rehabilitation, or what natural symptom progression would have led to. To date, there have been no adverse consequences of the CSI in this case; however, a growing body of evidence proposes that CSI may have detrimental long-term effects on certain tissues, such as load bearing tendons (32). The injection performed in this case is anatomically removed from major load bearing tendons, the nearest being the patellar tendon; however, recent biopsy and ultrasound studies suggest that the distal ITB itself shares many physiological and structural similarities with tendon entheses (33). In this case, the rehabilitation process involved a combination of techniques from gait retraining and rehabilitation, alongside the introduction of structured training periodisation. All of these methods were somewhat novel to this patient and, therefore, it cannot be assumed that this was the perfect recipe that is ready for widespread use. This record is, however, an example of real-time patient care which demonstrates a version of contemporary musculoskeletal practice without any assignment to a specific style, camp or named technique. Finally, to reflect on the most scrutiny-vulnerable element of the treatment: introducing corticosteroid to the lateral recess may well be deemed ineffective or even deleterious by future research, such is the nature of the progress of our young profession. However, in light of current evidence and the overwhelming consensus that exercise is our most powerful medicine, could injection therapy, as used in this case study, be a minor and sometimes necessary adjunct used to promote compliance?

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/1U347Gc Co-kinetic journal 2016;67(January):21-25

PHYSICAL THERAPY: MSK DIAGNOSIS, TREATMENT, REHABILITATION

THE AUTHOR Jack Chew BSc, MCSP is a physiotherapist who has pursued a specialism in musculoskeletal and sports medicine since he qualified from the University of Nottingham in 2010. Following a brief but insightful stint working in Kent under the mentorship of Mike Stewart, Jack moved efficiently through the ranks of an innovative, NHS commissioned, social enterprise service in Nottingham City. Here he extended his clinical skills to involve medical triage, imaging requisition and injection therapy, before moving to Manchester where he co-founded the innovative Chews Health network. Since 2013, Jack and his associates at Chews Health have provided ‘in-house’ second-opinion consultancy for sports teams and independent athletes across the north-west. Jack’s passion for developing others led him to produce the online educational platform ‘The Physio Matters Podcast’ which, with the help of a core team, has changed the face (and voice!) of musculoskeletal and sports medicine education. With an average monthly listenership of 25,000, The Physio Matters Podcast and its affiliated projects continue to cover the toughest topics for the betterment of clinicians, their patients and, therefore, society. Alongside his managerial commitments to Chews Health and Physio Matters, Jack holds a part-time extended scope practitioner (ESP) position with Staffordshire and Stoke-on-Trent partnership NHS trust as part of their award winning Integrated Physiotherapy Orthopaedic Pain Service (IPOPS). When invited, and time allows, Jack is a visiting lecturer at the University of Nottingham and hosts various presentations and debates discussing his areas of special interest which include: critical thinking, the mechanisms of intervention effect, the language of pain and perhaps most controversially, his ‘Excuse based practice’ workshop in which his ambition to promote critical but balanced reasoning is most flamboyantly demonstrated! Email: enquiries@chewshealth.co.uk Website: Chews Health http://chewshealth.co.uk/ Twitter: @Chews_Health; @TPMPodcast Facebook: The Physio Matters Podcast https://www.facebook.com/TPMPodcast

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RELATED CONTENT I liotibial band syndrome: a narrative review http://spxj.nl/1iISGXI L ateral hip pain and ITB syndrome http://spxj.nl/1MFPGVE ransverse soft tissue release and T ITB syndrome: a case study http://spxj.nl/1JDATas oft Tissue Treatments with Stuart Hinds: ITB S Syndrome Video Masterclass http://spxj.nl/1OPZIVh

DISCUSSIONS hat objective markers might you now use for deciding when to refer a W patient with ITBS for a corticosteroid injection? This case study presents a very straightforward case with no adverse reactions seen: how might clinical reality differ? Where does modern pain science thinking fit within the conservative management paradigm presented in this article?

KEY POINTS n I TBS is often recurrent, even in the presence of ‘optimal’ care. n MRI and ultrasound are useful imaging modalities in the diagnosis of ITBS. n Acute high severity symptoms or prolonged low severity symptoms are diagnostic markers for corticosteroid injection. n Rehabilitative exercise, gait retraining and advice/education remain essential even post steroid injection for true conservative management success. n There remains a clear lack of evidence informed guidance for clinicians treating ITBS. n Orthopaedic or surgical intervention proved unnecessary in this single case study. n The EQ-5D-4L and the lower extremity functional scale (LEFS) are reliable objective markers to be used with ITBS patients. n The patient in this case study was asymptomatic and at full function 16 weeks post-injection.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: ITB length does not appear to correlate with ITBS. However, it can be a helpful test to inform clinical reasoning. http://spxj.nl/1SuIeOY Tweet this: Deficits in lateral gluteal endurance have been found in female patients with an often related pathology, PFPS. http://spxj.nl/1SuIeOY Tweet this: Gradual onset of symptoms, seemingly coinciding with increased running, suggests an overload component to causation. http://spxj.nl/1SuIeOY Tweet this: The location, nature and onset pattern described was in keeping with one of the most common running injuries: ITBS. http://spxj.nl/1SuIeOY Tweet this: In ITBS, the irritated lateral recess structures, rather than the ITB itself, are considered pathological. http://spxj.nl/1SuIeOY Tweet this: Modalities that decrease inflammation have been shown to be effective in ITBS symptom modification. http://spxj.nl/1SuIeOY Tweet this: A rehabilitation regime was devised to improve right to left deficits in certain lower limb strength parameters. http://spxj.nl/1SuIeOY

REFERENCES 1. Calmbach WL, Hutchens M. Evaluation of patients presenting with knee pain: part i. history, physical examination, radiographs, and laboratory tests. American Family Physician 2003;68(5):907– 912 2. Hegedus EJ. Physical examination tests for assessing a torn meniscus in the knee: a systematic review with meta-analysis. Journal of Orthopaedic & Sports Physical Therapy 2007;37(9):541–550 3. Karachalios T. Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears. The Journal of Bone & Joint Surgery 2005;87(5):955–962 4. Noble CA. The treatment of iliotibial band friction syndrome. British Journal of Sports Medicine 1979;13:51–54 5. Lucas CA. Iliotibial band friction syndrome as exhibited in athletes. Journal of Athletic Training 1992;27(3):250–252 6. Fredericson M, Cookingham et al. Hip abductor weakness in distance runners with iliotibial band syndrome. Clinical Journal of Sport Medicine 2000;10;169–175 7. Powers CM. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. Journal of Orthopaedic & Sports Physical Therapy 2010;40(2):42–51 8. Reese NB, Brandy W. Use of an inclinometer to measure flexibility of the iliotibial band using the Ober test and the modified Ober test: differences in magnitude and reliability of measurements. Journal of Orthopaedic & Sports Physical Therapy 2003;33(6):326–330 9. Herrington L, Rivett N, Munro S. The relationship between patella position and length of the iliotibial band as assessed using Ober’s test. Manual Therapy 2006;11(3):182–186 10. Rathleff MS, Rathleff CF, et al. Is hip strength a risk factor for patellofemoral pain? A systematic review and meta-analysis. British Journal of Sports Medicine 2014;10:1136 11. Fairclough J. Is iliotibial band syndrome really a friction syndrome? Journal of Science and Medicine in Sport 2007;10(2):74–76 12. Lavine R. Iliotibial band friction syndrome. Current Reviews in Musculoskeletal Medicine 2010;3(1–4):18–22 13. Parsons S. The influence of patients’ and primary care practitioners’ beliefs and expectations about chronic musculoskeletal pain on the process of care: a systematic review of qualitative studies. The Clinical Journal of Pain 2007;23(1):91–98 14. Adams WB. Treatment options in overuse injuries of the knee: patellofemoral syndrome, iliotibial band syndrome, and degenerative meniscal tears. Current Sports Medicine Reports 2004;3(5):256–260 15. Baker RL, Souza RB, Fredericson M. Iliotibial band syndrome: soft tissue and biomechanical factors in evaluation and treatment. PM&R, 2011;3:550–561 16. Bolgla LA. Hip strength and hip and knee kinematics during stair descent in females with and without patellofemoral pain syndrome. Journal of Orthopaedic & Sports Physical Therapy 2008;38(1):12–18 17. Barton CJ, Levinger P, et al. Kinematic gait characteristics associated with patellofemoral pain

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syndrome: A systematic review. Gait & Posture 2009;4(105):116 18. Cosca DD, Navazio F. Common problems in endurance athletes. American Family Physician 2007;76(2):237–244 19. Fredericson M, Wolf C. Iliotibial band syndrome in runners: innovations in treatment. Sports Medicine 2005;35, 451–459 20. Fredericson M, Weir A. Practical management of iliotibial band friction syndrome in runners. Clinical Journal of Sport Medicine 2006;16:261–268 21. Strauss EJ Kim S, et al. Iliotibial band syndrome: evaluation and management. Journal of the American Academy of Orthopaedic Surgeons 2011;19(12):728–736 22. Van Der Worp MP, Van Der Horst N, et al. Iliotibial band syndrome in runners: a systematic review. Sports Medicine 2012;42:969–992 23. Fairclough J, Hayashi K, et al. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. Journal of Anatomy 2006;208:309–316 24. Cook JL, Docking SI. Defining ‘tissue capacity’: a core concept for clinicians. British Journal of Sports Medicine 2015;doi:10.1136/ bjsports-2015-094849 25. Noehren B, Scholz J, Davis I. The effect of real-time gait retraining on hip kinematics, pain and function in subjects with patellofemoral pain syndrome. British Journal Of Sports Medicine 2011;45(9):691–696 26. Meardon SA, Campbell S, Derrick TR. Step width alters iliotibial band strain during running. Sports Biomechanics 2012;11(4):464–472 27. Moseley GL. Reconceptualising pain according to modern pain science. Physical Therapy Reviews 2008;12(3):169–178 28. Gunter P, Schwellnus MP. Local corticosteroid injection in iliotibial band friction syndrome in runners: a randomised controlled trial. British Journal of Sports Medicine 2004;38:269–272 29. Neilson RO, Parner ET, et al. Excessive progression in weekly running distance and risk of running-related injuries: an association which varies according to type of injury. The Journal of Orthopaedic & Sports Physical Therapy 2014;44(10):739–747 30. Willy RW, Scholz JP, Davis IS. Mirror gait retraining for the treatment of patellofemoral pain in female runners. Clinical Biomechanics 2012;27(10):1045–1051 31. Willy RW, Davis IS. Varied response to mirror gait retraining of gluteus medius control, hip kinematics, pain, and function in 2 female runners with patellofemoral pain. The Journal of Orthopaedic & Sports Physical Therapy 2014;43(12) 32. Dean BJ F, Franklin SL, et al. Glucocorticoids induce specific ion-channel-mediated toxicity in human rotator cuff tendon: a mechanism underpinning the ultimately deleterious effect of steroid injection in tendinopathy? British Journal of Sports Medicine 2014;48(22):1620–1626 33. Falvey EC. Iliotibial band syndrome: an examination of the evidence behind a number of treatment options. Scandinavian Journal of Medicine & Science in Sports 2010;20(4):580– 587. Co-Kinetic journal 2016;67(January):XX-XX

NOVEL BEDSIDE TESTS TO EXPLORE BODILY PERCEPTION IN PAIN AND REHABILITATION We are all experts in how our own body feels, but how does this come about and what happens to this when we’re in pain? As a clinician you use specific assessment techniques to understand and validate your patient’s pain experience. Are these always appropriate or subtle enough? Read this online http://spxj.nl/1LNDoqJ BY TIM BEAMES BSC MSC PAIN | PSYCHOLOGY | 16-10-COKINETIC FORMATS WEB MOBILE PRINT

MEDIA CONTENTS Video 1. Left/right judgement task for the hands on an iPhone. (T. Beames, 2015) Video 2. Two-point discrimination of the right arm – measuring increasing and then decreasing distances. (T. Beames, 2015) Video 3. Two-point discrimination of the right arm – measuring increasing distance only. (T. Beames, 2015) Video 4. Localisation of touch on the right arm – good accuracy. (T. Beames, 2015) Video 5. Localisation of touch on the left arm – reasonable accuracy. (T. Beames, 2015)

This article introduces three bedside tests that explore bodily perception: left/right judgement tasks, two-point discrimination, and localisation of touch. These tests help to identify those patients at risk of developing persistent pain and where rehabilitation may be failing. Having a better understanding of what helps construct our body perception and how this can change in pain, helps guide the rehabilitation process.

BODILY PERCEPTION

ody in Mind http://www.bodyinmind.org has a number B of free articles pertaining to the three different bedside tests and regular blogs relating to pain and rehabilitation.

Take a moment and consider how your body feels. Are you currently aware of any part of your body? If you are, then what does it feel like? Why is it that you are aware of this part of your body? Now place your attention on your left shoulder. Were you aware of your left shoulder before this? Can you take your attention away from your left shoulder? Or are you now primed to be aware of your left shoulder? This simple task allows you to explore how your body currently feels. In this article I will refer to this as bodily perception. Most of the time we’re not aware of how our body feels until we need to attend to it. In this respect we are dynamically disembodied (1). It is likely that your awareness drifted away from your left shoulder – until I mentioned it again!

owerPoint presentation: Beames T. Altered body P perception & pain. Presented at the Physio First Conference 2015, Nottingham, UK. http://spxj.nl/1PZ99oL

CONSTRUCTING BODILY PERCEPTION

Video 6. Localisation of touch on the left arm – inaccurate at the wrist. (T. Beames, 2015) Continuing education quiz This article also has a certificated eLearning assessment that can be found in the Media Contents box, or under the eLearning Assessment area in your Account area, on the Co-Kinetic website. The eLearning assessment(s) can be completed on all platforms including mobiles when accessed through the Co-Kinetic site; however, they are NOT accessible through the sportEX mobile app as you have to be logged into the actual website for the results to be recorded and the certificate to be generated. http://spxj.nl/1LNDoqJ

ARTICLE WEB LINKS noijam http://noijam.com/ is a lively blog about pain and rehabilitation. noigroup http://www.noigroup.com/en/Home provides information about using the ‘Recognise’ program for left/ right judgement tasks.

So what helps construct the experience 26

of our bodies? We are continuously bombarded by stimuli in our environment, both internally and externally. These range from (but are not limited to) the proprioceptive feedback from our muscle spindles when we move (internal) to the auditory information we receive from verbal instructions (external) (2,3). These influences from our environment help inform our ability to predict (feed forward) and monitor (feedback) our interaction with the world around us. On the whole this information is processed out of our awareness. In fact, it would be incredibly inefficient if we had to be aware of and to consciously evaluate the meaning of all the information that we are continually processing. However, there are times that we become aware of elements of our environment (just as I brought attention to your left shoulder). The processing of this information occurs at the same time or in parallel (rather than serially – one after another). As a result this is an incredibly fast and efficient process. The parallel processing of environmental stimuli helps to create an ever-changing, online bodily perception. It is thought that several bodily representations ultimately help construct the overall experience of our body. Head and Holmes (4) famously split these into body image and body schema: n Body image relates to how the body feels when we consciously access Co-Kinetic journal 2016;67(January):26-31

PHYSICAL THERAPY PAIN, BRAIN AND SPORTS PERFORMANCE

the experience (ie. when it is in our awareness) n Body schema are the implicit rules and understanding that we hold relating to our bodies and as such are usually not aware of.

and vision play an important role. Can shifts in bodily perception lead to pain? Or does pain lead to shifts in bodily perception?

One illusion that helps portray the everchanging perception is how you feel when sitting on a stationary train as the neighbouring one begins to move. There is a very strong sense that you are moving. This is built up through visual cues, bodily position, auditory information and cognitively from previous experience and expectation of riding on a train and how it moves in relation to the environment. But when do these shifts in bodily perception reach significance to impact a person?

People in pain share certain characteristics. First, they attribute pain to a particular part of their body, ie. pain is embodied. It would be uncommon for someone to describe a pain as occurring outside of his or her body. Even phantom limb pain is attributed to a place where the limb would have been (it is thought that the limb is maintained in a cortical representation). Second, pain affects the way the body feels and our experience of it (7). Descriptions used by patients regarding the painful area often include feelings such as a change in the size, position, and sense of swelling or temperature (8). To best understand a personâ&#x20AC;&#x2122;s pain experience it is suggested that clinicians take these subjective, firstperson descriptions and integrate them with the objective findings obtained in the third-person (9). This enables validation of the pain experience and creates a window into the livedexperience of that person in pain, including any changes in how their body feels.

EXPERIMENTALLY ALTERING BODILY PERCEPTION Manipulating a shift in bodily perception experimentally helps elucidate the link between the subjective (first-person) experience and objective (third-person) measurement. One of the most established experiments is the rubber hand illusion (5). This is where a rubber hand is positioned near to the real hand and both are synchronously stimulated in the same areas as the participant looks at the rubber hand being stimulated. After a short time, when asked, most people begin to feel as though the touch they receive occurs nearer to the rubber hand. This is known as a proprioceptive drift and links to the perceived ownership of the rubber hand. The stronger the sense of ownership, the larger the proprioceptive drift (6). Moseley et al. (2) have shown that when the stroking is asynchronous the participant does not assume ownership of the rubber hand. However, when the stroking is performed synchronously and the subject feels a sense of ownership there is also a significant change in temperature of the hidden hand, which gets colder. This demonstrates a link between how the body feels and the underlying physiology. It also highlights the importance of multisensory integration in bodily perception; in this case touch Co-Kinetic.com

PAIN AND BODILY PERCEPTION

BEDSIDE TESTS TO EXPLORE BODILY PERCEPTION There are a number of bedside clinical tests that can be used to explore bodily perception in a pain experience. In this article we are going to explore three of them: n left/right judgement tasks n two-point discrimination n localisation of touch.

A CONSIDERATION OF WHAT HELPS CONSTRUCT BODY PERCEPTION MAY BENEFIT MORE TRADITIONAL REHABILITATION APPROACHES Video 1: Left/right judgement task for the hands on an iPhone. (T. Beames, 2015)

LEFT/RIGHT JUDGEMENT TASKS Left/right judgement tasks assess implicit motor imagery ability (10). During these tasks subjects are presented alternating images of a chosen (affected) body part and required to choose if they think the image shown is either a right or left (or whether the image shows the person bending or twisting to the right or left if it is an 27

TABLE 1: A SUMMARY OF STUDIES OF IMPLICIT MOTOR IMAGERY ABILITY USING LEFT/RIGHT JUDGEMENT TASKS. (T. Beames, 2015) Study

Condition

Population

Findings

Moseley GL. Neurology 2004;67:2129

Complex regional pain syndrome (CRPS) Type 1 of wrist

18 + 18 controls

Increased response time for hand images on affected side and compared to controls.

Fiorio et al. Brain 2006;129:47

Focal hand dystonia

15 + 15 controls

Increased response time for hand images compared to controls but not feet.

Coslett et al. Eur J Pain 2010;14:1007

Chronic musculoskeletal and radiculopathic arm or shoulder pain

19 + 24 chronic pain not involving arm or shoulder + 41 pain-free controls

Increased response time of hand images relative to pain controls and normal subjects.

Coslett et al. JINS 2010;16:603

Chronic leg or foot pain

40 + 42 chronic pain not involving legs + 38 pain-free controls

Increased response time and decreased accuracy of feet images compared with pain controls and normal subjects.

Schwoebel et al. Brain 2001;124:2098

CRPS arm greater than 3 months

13 + 18 controls

Increased response time of hand images on affected side and compared to controls.

Nico et al. Brain 2004;127:120

Upper limb amputees

16 + 7 controls

Increased response time of hand images and decreased accuracy compared to controls.

Bray & Moseley. Br J Sports Med 2011;45:168

Back pain

21 + 14 controls

Similar response times of back images to controls but decreased accuracy.

Stanton et al. Rheumatol 2012;51:1455

Painful osteoarthritis of the knee

20 + 20 arm pain controls + pain-free controls

Decreased accuracy of feet images for both pain groups compared to pain-free controls.

Schmid & Coppieters. Clin J Pain 2012;28:615

Carpal tunnel syndrome

27 + 27 controls

Decreased accuracy of hand images compared to controls.

Reinersmann et al. Pain 2012;153:2174

CRPS & phantom limb pain (PLP)

CRPS 12 PLP 12 Controls 38

Increased response time and decreased accuracy for affected side on hand images.

axial body part like the lumbar spine). The test requires the patient to perform it as quickly as they can, almost as though they are guessing. This speed takes the task out of awareness and as such is said to be implicit. The task is a motor imagery activity as the person mentally positions their limb to match the image that they are viewing (Video 1). There are two main quantitative measures that come from this: the response time of the correct answers and the accuracy or error rate for the two sides of the body. These measures give different information. The response time demonstrates both the ability to process incoming information (11) and the relative attention given to the body part (12). Accuracy reflects the precision of the working body schema (13). Implicit motor imagery ability has been explored using left/right judgement tasks in a number of pain conditions. Table 1 shows a list of several of these studies with the main findings. 28

PAIN AFFECTS THE WAY THE BODY FEELS AND OUR EXPERIENCE OF IT Video 2: Two-point discrimination of the right arm â&#x20AC;&#x201C; measuring increasing and then decreasing distances. (T. Beames, 2015)

Co-Kinetic journal 2016;67(January):26-31

PHYSICAL THERAPY PAIN, BRAIN AND SPORTS PERFORMANCE

One recent study of left/right judgement tasks in low back pain revealed that people with persistent back pain have significantly lower accuracy than people who have never experienced back pain or those that have recovered from a previous episode of back pain (14). Interestingly, people with a new onset of back pain have a wide distribution of accuracy rates, with some performing much better than normal and others with a significantly reduced accuracy rate. The suggestion from the authors is that people experiencing a new episode of back pain and demonstrating reduced accuracy may be at risk of developing persistent pain. If a person in pain presents with altered accuracy of left/right judgement tasks and this reflects an altered body schema, movement planning may become impaired. Rehabilitation for people demonstrating these changes could therefore be directed either more towards the cortical challenges, such as training implicit motor imagery for the affected body part, or to mindfully explore and re-educate movement in relation to the affected body part.

Two-point discrimination Two-point discrimination assesses tactile acuity, in particular the ability to accurately judge whether one or two points are touching you. The measurement of this ability is the smallest possible distance that you can accurately discriminate between one or two points. This test is often performed using a Vernier caliper, where the examiner begins with prongs of the caliper a minimum distance apart. The two prongs are then pressed synchronously against the body, hard enough to just blanch the skin. It is held briefly (under 1 second) before withdrawing and asking the patient if they felt that one or two points touched them. This process is repeated several times before increasing the width of the caliper. The distance between the prongs of the caliper are increased gradually (eg. by 5mm) until the patient can accurate discriminate that two points are touching them. Within the test procedure the examiner uses Co-Kinetic.com

‘catch’ tests whereby only one prong is pressed against the skin as a way of negating any guessing (Videos 2 & 3) (15). This test has been validated as a useful tool to assess tactile acuity (16). A recent systematic review and metaanalysis suggested that this ability was diminished in three chronic pain conditions (arthritis, complex regional pain syndrome and chronic low back pain) but not in burning mouth syndrome (17). Moseley (18) demonstrated diminished tactile acuity on a small group of back pain subjects and that the changes in two-point discrimination correlated with their symptomatic areas. Moreover, using an explicit imagery task consisting of drawing the outline of where they felt their backs to be, showed changes in their ability to ‘find’ the normal outline at the same symptomatic areas with altered tactile acuity. A recent experiment explicitly asking back pain subjects about their bodily image demonstrated that people with a sense of an expanded bodily part had significantly reduced two-point discrimination compared with those in pain but without a change in the sense of the size of their body (19). It has also been shown that people with back pain and the presence of reduced two-point discrimination demonstrated poorer motor control of the lumbopelvic region (20). These studies suggest that changes to bodily perception in pain may correlate with changes in tactile acuity, picked up through assessment of two-point discrimination. There may also be a link to altered motor control in the presence of diminished tactile acuity.

TESTS OF BODILY PERCEPTION ACT AS A WINDOW INTO THE FIRSTPERSON EXPERIENCE OF THE PERSON IN PAIN nS ubjects pointing on themselves where they felt they were touched (Videos 4–6). Clearly each procedure places different demands on the subject. The last variation is particularly interesting, as it requires the ability to represent the body as both the goal of the movement and the effector of the movement. It requires the access of different bodily representations (21) including the spatial orientation of the person within their local environment. Mislocalisation of touch has been identified using different methods in chronic low back pain, complex regional pain syndrome (22) and following injuries to the peripheral nerves of the hand (23). Despite the paucity of studies, this complex test (which assesses the interaction of a person and their motor, sensory and spatial awareness) appears appropriate when there is a suspicion of altered body perception.

What do these tests reveal? The construction of a dynamic bodily perception necessarily includes continual processing of internal and external environmental factors and Video 3: Two-point discrimination of the right arm – measuring increasing distance only. (T. Beames, 2015)

Localisation of touch Localisation of touch is the ability to accurately discriminate where on your body you have been touched. As with the other tests there are a number of variations to the test routine. These include: n Subjects verbally reporting where on their body they felt they were touched. n Subjects pointing on a picture of their bodies where they felt they were touched. 29

Video 4: Localisation of touch on the right arm – good accuracy. (T. Beames, 2015)

Video 5: Localisation of touch on the left arm – reasonable accuracy. (T. Beames, 2015)

predicting the possible consequences of our actions within them. Clark (24) suggests that we are ultimately “probabilistic prediction machines” and require the access of stored knowledge about our world, including that of our body. If these predictions go wrong, ie. the consequences of our actions don’t meet our expectations, then this creates a prediction error (25). If these errors are significantly large they may lead to the recruitment of the saliency network (26) that is thought to contribute to the recruitment of defensive behaviours, such as altered movement. In some people this may be linked to a pain experience. Tests of bodily perception act as a window into the first-person experience of the person in pain and allow us to access a better understanding of how they experience their body. In doing so, these tests may identify ongoing prediction errors (possibly due to cortical changes relating to body representations) that can be targeted or monitored during the rehabilitation process.

REHABILITATION CONSIDERATIONS FOR ALTERED BODY PERCEPTION

Video 6: Localisation of touch on the left arm – inaccurate at the wrist. (T. Beames, 2015)

Therapeutic approaches aimed at altered body perception in pain are still in their infancy but support for their use is growing (27,28). They are often incorporated as specific exercises within the rehabilitation process such as training left/right judgement tasks during graded motor imagery (30). Rehabilitation considerations in view of altered body perception in pain are: n I nclude discrimination. The person must think about what they are required to do and be made to make choices (29,30). n Repeat but keep it novel. This will facilitate a learning process and feed into the need to discriminate. n Reduce prediction errors. Make the right and left sides of the body feel more similar and familiar. Giving feedback about the task performance may be important to raise awareness of the errors (31). Reducing the prediction errors should help to reduce the recruitment of the saliency network (32).

n E xperience success and acknowledge it. This will help recruit the reward systems and cement learning (33). n Find relief where pain was expected. This stimulates a positive prediction error and recruits our reward systems and is linked to pleasurable experiences (34).

CONCLUSION Clinicians should be aware of the presence of bodily perception and have tools to be able to assess for the presence of changes. This may help to predict those patients in pain who require more novel treatment approaches aimed at normalising bodily perception change. A consideration of what helps construct body perception may benefit more traditional rehabilitation approaches. References 1. Thacker MS, Centre of Human & Aerospace Physiological Sciences, Kings College London, London, UK. Personal communication 2012 2. Moseley GL, Gallace A, Spence C. Bodily illusions in health and disease: physiological and clinical perspectives and the concept of a cortical ‘body matrix’. Neuroscience & Biobehavioral Reviews 2011;36(1):34–46 3. Tsakiris M. My body in the brain: A neurocognitive model of body-ownership. Neuropsychologia 2010;48:703–712 4. Head H, Holmes HG. Sensory disturbances from cerebral lesions. Brain 1911;34:102–254 5. Botvinik M, Cohen J. Rubber hands ‘feel’ touch that eyes see. Nature 1998;391;756 6. Bekrater-Bodmann R, Foell J, et al. The perceptual and neuronal stability of the rubber hand illusion across contexts and over time. Brain Research 2012;1452:130–139 7. Haggard P, Iannetti GD, Longo MR. Spatial sensory organization and body representation in pain perception. Current Biology 2013;23:R164–R176 8. Förderreuther S, Sailer U, Straube A. Impaired self-perception of the hand in complex regional pain syndrome (CRPS). Pain 2004;110:756–761 9. Thacker MS, Moseley GL. First-person neuroscience and the understanding of pain. The Medical Journal of Australia 2012;196(6):410–411 10. Parsons LM, Fox PT, et al. Use of implicit motor imagery for visual shape discrimination as revealed by PET. Nature 1995;375:54–58 11. Parsons LM, Fox PT. The neural basis of implicit movements used in recognising hand shape. Cognitive Neuropsychology 1998;15:583–615 12. Hudson ML, McCormick K, et al. Co-Kinetic journal 2016;67(January):26-31

PHYSICAL THERAPY PAIN, BRAIN AND SPORTS PERFORMANCE

Expectation of pain replicates the effect of pain in a hand laterality recognition task: bias in information processing toward the painful side. European Journal of Pain 2006;10:219–224 13. Bray H, Moseley GL. Disrupted working body schema of the trunk in people with back pain. British Journal of Sports Medicine 2011;45:168–173 14. Bowering KJ, Butler DS, et al. Motor imagery in people with a history of back pain, current back pain, both, or neither. The Clinical Journal of Pain 2014;30:1070– 1075 15. Moberg E. Two-point discrimination test: a valuable part of hand surgical rehabilitation, e.g. in tetraplegia. Scandinavian Journal of Rehabilitation Medicine 1990;22:127–134 16. Catley MJ, Tabor A, et al. Assessing tactile acuity in rheumatology and musculoskeletal medicine – how reliable are two-point discrimination tests at the neck, hand, back and foot? Rhematology 2013;52(8):1454–1461 17. Catley MJ, O’Connell NE, et al. Is tactile acuity altered in people with chronic pain? A systematic review and meta-analysis. The Journal of Pain 2014;15(10):985–1000 18. Moseley GL. I can’t find it! Distorted body image and tactile dysfunction in patients with

back pain. Pain 2008;140:239–243 19. Nishigami T, Mibu A, et al. Are tactile acuity and clinical symptoms related to differences in perceived body image in patients with chronic nonspecific lower back pain? Manual Therapy 2015;20:63–67 20. Luomajoki H, Moseley GL. Tactile acuity and lumbopelvic motor control in patients with back pain and healthy controls. British Journal of Sports Medicine 2011;45(5):437–440 21. de Vignemont F. Body schema and body image – pros and cons. Neuropsychologia 2010;48:669–680 22. Wand BM, Keeves J, et al. Mislocalization of sensory information in people with chronic low back pain: a preliminary investigation. Clinical Journal of Pain 2013;29(8):737–43 23. Maihöfner C, Neundörfer B, et al. Mislocalization of tactile stimulation in patients with complex regional pain syndrome. Journal of Neurology 2006;253:772–779 24. Jerosch-Herold C, Rosén B, Shepstone L. The reliability and validity of the locognosia test after injuries to peripheral nerves in the hand. Journal of Bone & Joint Surgery(Br) 2006;88-B:1048–1052 25. Clark A. Mindware: an introduction to

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: The parallel processing of environmental stimuli helps to create an ever-changing, online bodily perception. http://spxj.nl/1LNDoqJ Tweet this: Left/right judgement tasks assess motor imagery ability when exploring bodily perception in a pain experience. http://spxj.nl/1LNDoqJ Tweet this: Studies suggest that changes to bodily perception in pain may correlate with changes in tactile acuity. http://spxj.nl/1LNDoqJ Tweet this: Clinicians should be aware of bodily perception and have tools to be able to assess for the presence of changes. http://spxj.nl/1LNDoqJ

KEY POINTS nB ody perception is constructed through processing of internal and external environmental stimuli. n We predict and monitor our interactions in the world - this happens mainly unconsciously. n Body perception can be modulated through illusions like the rubber hand illusion. n A shift in body perception during illusion demonstrates the tight link between experience of the body and its physiology. n People in pain often describe feelings of altered body perception. n Bedside tests can be used to validate these verbal reports of bodyperception change in pain. n Left/right judgement tasks assess implicit motor imagery ability and can pick up changes in body schema. n Two-point discrimination tasks assess tactile acuity. n Changes in tactile acuity can correlate with motor control changes. n Localisation of touch explores the interaction of motor, sensory and spatial awareness.

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DISCUSSIONS re body-perception changes present in all people A in pain? Are we only interested in cortical involvement when discussing body perception? Can body-perception changes improve without a change in pain?

RELATED CONTENT he hidden influence of metaphor within T rehabilitation http://spxj.nl/1LzGHok The brain, pain and movement part 1 http://spxj.nl/1R0f20d The brain, pain and movement part 2 http://spxj.nl/1cSjwJO Chronic pain in sport: What’s the story? http://spxj. nl/1EalA6O

THE AUTHOR Tim Beames BSc MSc lives in London where he works as a physiotherapist in private practice as co-founder of Pain and Performance providing treatment for people with persistent and complex pain problems, support and guidance for clinicians dealing with complex pain patients and delivering bespoke courses for departments and organisations on pain related topics. These diverse interests were fostered at King’s College London studying his Masters in Pain: Science & Society with Dr Mick Thacker. He is the principal instructor for NOI UK and teaches the Mobilisation of the Nervous System, Neurodynamics and the Neuromatrix, Explain Pain and Graded Motor Imagery courses throughout the UK, Europe and Australia. He is co-author of the Graded Motor Imagery Handbook (2012) alongside Lorimer Moseley, David Butler and Tom Giles and has contributed the chapter on neck pain alongside Robin Blake in Maitland’s Vertebral Manipulation (2013). Previously Tim has worked as a specialist physiotherapist and orthopaedic physiotherapy practitioner in the NHS, lectured at Kings College London, University College London and Sheffield Hallam University and set up and managed several successful pain management programmes. He has a particular interest in bodily perception and pain’s effect on it. Email: tim.beames@gmail.com LinkedIn: Tim Beames http://spxj.nl/1NfR0Af Twitter: https://twitter.com/timbeames Facebook: Pain and Performance https://www.facebook.com/painandperformance

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Our regular research reviewer, physical therapist Joseph Brence, reviews a case study concerning low back pain and cancer. Read this online http://spxj.nl/1iIT88i

HIGHLIGHTS OF A CASE REPORT INVOLVING LOW BACK PAIN AND CANCER LOW BACK PAIN | 16-01-COKINETIC FORMATS WEB MOBILE PRINT

ypically, the literature reviews I write are on articles that have high levels of evidence, including randomised controlled trials and systematic reviews. For this post, I have chosen to review and highlight a case study, published in the Journal of Manual & Manipulative Therapy (1). I have decided to do this because it truly highlights the important obligation we have to medically screen each of our patients before providing interventions.

THE CASE (SUMMARY OF THE WRITTEN REPORT) The patient in this report was a 48-year-old female who was referred to physical therapy for an insidious onset of low back pain (LBP). She reported that she was unemployed but did enjoy occasional walking for activity. She reported that she has smoked 15 cigarettes per day for the past 34 years and had a medical history of anxiety and major depression. The patient reported that she was initial evaluated in the Emergency Department of a hospital. Radiographs were taken showing degenerative changes and a urinalysis was unremarkable. She reported that she was prescribed naproxen, and told to follow up with her primary care physician if she did not improve. After 1 month, the patient reported to her primary care physician (PCP)

WE MUST BE DILIGENT AND ATTENTIVE TO BEHAVIOURS THAT MAY NOT BE MUSCULOSKELETAL 32

BY JOSEPH BRENCE DPT, FAAOMPT, COMT, DAC with complaints of: n Fatigue (limiting daily activities) n Pain that was unchanged with activity. This physician prescribed her cyclobenzaprine, provided an exercise handout and referred her to a physical therapist (PT). When the patient arrived at the PT, she had the following subjective complaints: n Symptoms that began 8 weeks earlier. n Insidious onset of upper lumbar pain centred at L1â&#x20AC;&#x201C;2, described as an intermittent, dull, ache. n Lifting and sitting aggravated pain; standing and sleeping relieved it. n Increased symptoms in the evening, causing her difficulty in falling asleep. n No previous episodes of LBP. n Denied fatigue (despite being a complaint upon referral by her PCP). n Denied fevers/chills/sweats, shortness of breath, upper/lower extremity weakness, or changes in bladder function. n No change in weight and no history of cancer. n Recent onset of constipation. n Recent onset of difficulty maintaining balance while walking, which she attributed to her medications. Upon objective examination, the clinician reported that she had: n Normal gait pattern and transitional movements. n Normal spinal curvature. n No signs of inflammation. n Active lumbar flexion and left lateral flexion causes slight pain.

nN ormal hip motion. n Prone press-ups completely alleviated symptoms. n No upper motor neuron signs and normal dermatomes and myotomes. The clinician reported that despite some red flags being present, they were of little concern when looking at the patientâ&#x20AC;&#x2122;s entire case. The clinician acknowledged the reported fatigue levels and onset of constipation, but attributed them to her history of depression and recent medication changes, respectively. The clinician gave this patient exercises and education and had the patient follow up 3 weeks later.

FOLLOW-UP At the follow-up visit, the patient noted a slight increase in symptoms and reported the exercises were no longer effective. The clinician provided lumbar traction, which then resulted in decreased symptoms, and the patient attended two additional sessions for these treatments. Despite short-term relief, the patient did not have any lasting relief. Upon her sixth visit, the patient had new complaints: nH eadache with left-sided upper extremity numbness and tingling. nS ensation of being unbalanced. nD ropping items. Because of these new symptoms, the patient was sent to the emergency room where a magnetic resonance image of the brain revealed multiple lesions throughout the brain. Additional

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MANUAL THERAPY RESEARCH INTO PRACTICE

[THIS ARTICLE] DEMONSTRATES THE IMPORTANCE OF NOTING AND MONITORING SINISTER FINDINGS, RED FLAGS AND REFERRING OUT WHEN NECESSARY images revealed a left mid-lung mass and lesions on L1–2. A biopsy indicated non-small cell carcinoma of the lung with metastases to the spine and brain. The author reports she succumbed to the cancer 6 months after first seen by the PT.

ANALYSIS I wanted to highlight this recently published case report because of its importance to us as clinicians. This article highlights our constant need to reassess and medically screen. It also demonstrates the importance of noting and monitoring sinister findings, red

flags and referring out when necessary. Sometimes our patients’ cases don’t follow a ‘text-book’ pattern, so we must be diligent and attentive to behaviours that may not be musculoskeletal. References 1. Mabry LM, Ross MD, Tonarelli JM. Metastatic cancer mimicking mechanical low back pain: a case report. Journal of Manual & Manipulative Therapy 2014;22:162–169.

THE AUTHOR Joseph Brence DPT, FAAOMPT, COMT, DAC is a physical therapist and clinical researcher from Pittsburgh, PA, USA. He is also a fellowship candidate with Sports Medicine of Atlanta, GA, USA. Joseph’s primary clinical interests involve a better understanding of the neuromatrix and determining how it applies to physical therapy practice. He is currently involved in a wide range of clinical research projects investigating topics such as the effects of verbalising pain, the effects of mobilising versus manipulating the spine on body image perception and validation of an instrument which will assess medical practitioners’ understanding of pain. Clinically, Joseph treats a wide range of painful conditions in multiple settings including complex regional pain syndrome, fibromyalgia and chronic fatigue syndrome. Joseph also runs the Forward Thinking PT http://forwardthinkingpt.com/. Email: joebrence9@hotmail.com.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: We have an important obligation to medically screen each of our patients before providing interventions. http://spxj.nl/1iIT88i Tweet this: We must be diligent and attentive to behaviours that may not be musculoskeletal. http://spxj.nl/1iIT88i

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MUSCLE ENERGY TECHNIQUE FOR JOINT MOBILISATION This article outlines the benefits of muscle energy technique (MET) in the clinical setting and its diverse use in a variety of clinical presentations as well as its versatility in terms of its application (isometric, isotonic, isolytic, pulsed variations, etc.). The application of METs to a number of tissues and joints is described, with explanation of how the technique is carried out, clinical reasoning and a kinetic chain comment. The reader will better understand how METs can be applied in a wider setting of joint mobilisation, where joint manipulation techniques are contraindicated or not available to the practitioner, or where METs can be integrated into the manipulative therapistâ&#x20AC;&#x2122;s repertoire. Read this online http://spxj.nl/1TusTPk BY DAVID ANDERSON MSC, NAMMT BASES

INTRODUCTION 16-01-COKINETIC FORMATS WEB MOBILE

ARTICLE WEB LINKS For more information on European neuromuscular therapy, see the National Training Centre website http://www.ntc.ie

Muscle energy technique (MET), as originally developed by osteopathic practitioner Fred Mitchell Sr in the 1940s and 1950s has, in the modern age, become a fairly ubiquitous component of numerous manual and physical therapy training courses throughout Ireland and the UK. Practised not only by osteopaths, but also by neuromuscular therapists, physiotherapists, chiropractors, sports therapists and massage therapists, MET is considered a safe and effective technique for the treatment of musculoskeletal pain or dysfunction. MET can be used as an alternative to high-velocity thrust joint manipulations (1), where the use of high-velocity techniques is not available to the practitioner or deemed unsuitable for the patient. Whatever the case,

WHEN USED IN CONJUNCTION WITH MOBILITY, STABILITY OR FUNCTIONAL EXERCISE PRESCRIPTION, METS CAN BE EFFECTIVE IN THE RESOLUTION SOFT TISSUE AND JOINT DYSFUNCTION 34

conclusive agreement on how MET actually works remains somewhat elusive.

HOW DOES MET WORK? Explanations of the therapeutic effect of MET have historically been based on the principle of post-isometric muscle relaxation and reciprocal inhibition (2), or changes in viscoelastic properties of the soft tissues (3) or simply due to increases in stretch tolerance. Current hypotheses speculate how the application of MET may have an influence on how the central nervous system interprets pain signals from the periphery; muscle mechanoreceptor and/or joint mechanoreceptor activation incites sympathetic nervous system activity via feedback mechanisms (afferent activity) from the periphery. Incoming sensory data received at the dorsal horn ascends the spinothalamic tract to the brain (specifically the periaqueductal grey). From here, descending signals cause inhibition of nociceptors at the dorsal horn (at the relevant segment of the spinal cord), which in turn stimulate an analgesic response in the tissues (4). The second hypothesis proposes that

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muscle contraction increases drainage from interstitial spaces, which reduces accumulated pro-inflammatory and pro-pain substances, thus decreasing sensitivity of peripheral nociceptors. Also of interest in the wider context of bodywork and movement therapies, McPartland suggests an upregulated endocannabinoid response as the means by which pain relief is achieved through the use of various techniques including MET, myofascial release techniques, high-velocity lowamplitude (HVLA) techniques, exercise prescription and stretching (5).

MET PROTOCOL FOR ACUTE PAIN Where MET is applied in the acute or subacute phase of injury, clinical anatomist and founder of European Neuromuscular Therapy John Sharkey (6) suggests the following protocol: a light isometric contraction of the target muscle (agonist) or an antagonist muscle (using reciprocal inhibition) is applied, after which the patient relaxes and the practitioner passively moves the soft tissue to a new resting length. The practitioner should seek to avoid lengthening the soft tissues in the acute scenario. The technique can be repeated once or twice more. For joint applications, the practitioner should move the joint to a new barrier following isometric contraction and repeat the technique.

MET PROTOCOL FOR CHRONIC PAIN A variety of contractions and cocontractions can be used with great success in the chronic pain setting. In addition to isometric contraction, the practitioner may choose isolytic (7) and isotonic (8) variations (where either the practitioner overcomes the patient’s tissue contraction or the patient overcomes the practitioner’s resistance) and Ruddy’s pulsed technique (9). These variations can be useful where joint mobilisation is the preferred outcome as opposed to tissue lengthening. Demonstrating the versatility and adaptability of MET, a 2013 study by Parmar and Shyam showed how isolytic

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and isotonic METs could be used in the rehabilitation of the knee joint following surgery to increase joint range of motion, prevent fibrosis and remove adhesions (9). As the term might suggest, pulsed MET requires the patient to carry out approximately 20 contractions in a 10-second period (2 contractions per second) using minimal effort after which the joint is moved to a new barrier. Pulsed MET can also be useful in terms of facilitating inhibited antagonists, or before application of HVLA manipulation. Where METs are used to treat chronic soft tissue insults, Sharkey recommends taking the tissues beyond the bind or resistance barrier to encourage lengthening of the tissues (6).

HOW LONG SHOULD THE CONTRACTION BE HELD? There is a difference of opinion amongst experts as to how long the isometric contraction should be held. Greenman suggests a window of 3 to 7 seconds (8), Ballantyne et al. specifies 5 seconds (10), Mehta and Hatton suggest anywhere from 5 to 20 seconds is effective (11), Schmitt et al. suggests 6 to 12 seconds (12), whereas Ferber et al. advocate a time of 20 seconds (13). Whatever the case, the optimal time appears to be somewhere between 8 to 12 seconds, using approximately a third of one’s perceived maximal effort. The practitioner can adapt these protocols to suit the needs of their patient; a longer contraction period may induce a degree of fatigue in the dysfunctional tissues and larger muscle groups may respond more effectively to a stronger contraction effort; for example, in the chronic phase, one may engage the hamstrings group at 50% effort, rather than 20 or 30% to achieve a therapeutic outcome.

1950s, who used the technique in the treatment of polio patients (14, 15). Whereas PNF shares some similarities with MET, PNF techniques can be broadly categorised as hold – relax; contract – relax; and hold – relax and contract – relax with antagonist contraction. Kabat, Knott and Voss based much of their research on the work of Sir Charles Sherrington (14). Sherrington’s laws of irradiation, successive induction and reciprocal innervation continue to influence how we view neuromuscular function today (15).

APPLICATION OF MET According to Czech physician Vladimir Janda, hypertonicity in the tissues can be attributed to a number of sources (14). Firstly, psychological stress may interfere with normal limbic system function (the part of the brain that is involved in control of emotions and formation of memories). This may manifest itself in the soft tissues as increased tone in the shoulder, neck, low back and pelvis. Secondly, aberrant proprioceptive and nociceptive stimuli received from dysfunctional spinal or peripheral joints bombard spinal cord interneurons with noxious stimuli, which in turn may cause reflexive

PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION TECHNIQUES Proprioceptive neuromuscular facilitation (PNF) remains popular in physiotherapy and sports therapy clinics and finds its roots in the work of Kabat, Knott and Voss in the

changes in the tone of associated muscle tissues. Maladapted movement patterns are increasingly fortified as the central nervous system maintains this state of imbalance in the soft tissues. By offering intervention, the practitioner seeks to ‘break’ this dysfunctional cycle, thereby facilitating a restoration of normal neuromuscular function. Thirdly, Janda proposes that muscle spasm as a consequence of increased nociceptive activity may, for example, offer a ‘splinting’ effect (an antalgic response) following the onset of acute low back pain. However, the increased muscle tissue hypertonicity may remain after the acute pain episode recedes. Improper movement patterns can be adopted by the neuromusculoskeletal system. Fourthly, muscle tightness

Figure 1: Assessment of the muscle activation pattern in hip extension using prone straight leg raise. (D. Anderson, 2015)

(hypertonicity) associated with overuse can cause the antagonist muscle to be reciprocally inhibited, leading to maladapted movement patterns and joint dysfunction (16). The European Neuromuscular Therapy approach takes the following view. Firstly, neuromuscular therapy (NMT) encourages the adoption of a science and human-physiology based approach to pain management and injury treatment, where treatment protocols are informed by research evidence. Secondly, NMT does not view human movement from a single muscle/joint perspective, rather it looks at human movement from a multiple muscle/connective tissue, synergistic, kinetic chain perspective. NMT seeks to understand how structure and function integrates in order to facilitate optimal human movement and function. It also seeks to address altered length–tension relationships (reciprocal inhibition), altered force-couple relationships (synergistic dominance), neuromuscular inefficiencies, muscle fatigue and chronic pain and injury cycles. Neuromuscular efficiency can be facilitated by addressing issues in length–tension relationships, force-couple relationships and arthrokinematic function (6). We will now consider some of the more common clinical applications of MET to muscle groups and joint structures of the lower limb and lumbar and thoracic spine, a kinetic chain comment is also included, where appropriate.

Hamstring group

Figure 2: Thomas test position for MET of hip flexor group and rectus femoris. (D. Anderson, 2015)

The hamstrings are often indicated where patients present with injuries as a result of over-exertion due to sports and exercise, or work-related physical activity. Patients often complain of recurrent pulled hamstrings, or perhaps knee pain that prevents them from kneeling or squatting. The hamstrings may compensate for weak or inhibited gluteal muscles or be shortened because the patient is in a sitting position for long periods of time. The patient may also complain of pain at the proximal and distal tendon attachment sites. In addition to

lengthening the hamstrings, evaluation of gluteal function and examination of the hip flexor mechanism may be required, as well as addressing predisposing factors such as sitting for extended periods. The gluteus maximus is involved in stabilisation of the sacroiliac and knee joints, via the aponeurosis of the sacrotuberous ligament and the iliotibial band (ITB), although research by Eng et al. suggests that the ITB may act like a spring, storing and using elastic energy during walking and running (17). In the gait cycle, the hamstrings eccentrically contract to control knee extension and hip flexion as well as decelerating internal rotation as the heel strikes the ground. The hamstrings, along with the contralateral latissimus dorsi muscle, provide a force closure mechanism that assists in sacroiliac joint stabilisation. Hamstring dysfunction can affect function of erector spinae, multifidus, gluteus medius, and may be implicated in plantar fascia issues. The clinician may choose to evaluate the firing sequence of hamstrings, gluteus maximus and the contralateral and ipsilateral quadratus lumborum and erector spinae musculature as part of the functional examination procedure (Fig. 1). For illustration, the application of MET (using post-isometric relaxation) is as follows: the patient is supine on the treatment table, hip flexed and knee extended (straight leg raise) on the affected side, the practitioner stands at the side of treated limb; while the practitioner supports the limb, she/he passively moves the limb through range of motion, seeking the first area of bind. At this point an isometric contraction is maintained by the patient matching the effort offered by the practitioner. After the prescribed time, the contraction ceases and the practitioner moves the limb to the next area of bind.

Hip flexors The hip flexor group can be indicated in cases of lumbar and sacroiliac joint pain. The practitioner will often note the patient’s inability to fully extend the hip, or adaptations in lumbo-pelvic

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posture (observe anterior pelvic tilt in standing). Other perpetuating factors to be aware of include intervertebral disc pathology, swayback postures, ‘lower crossed syndrome’, long periods of sitting, and repetitive strain from sporting or work-related activities. Overactivity in the hip flexor group can often be seen when the patient carries out a classic sit-up motion. Excessive shortness of the iliopsoas can affect arthrokinematic function of the hip joint and the lumbar vertebrae. MET can be applied to the hip flexor musculature in prone, side-lying or by using a modified Thomas test position (Fig. 2). Although most practitioners choose which variation they use based on preference and ease of application, should the patient experience joint pain, an alternate variation must be used. In addition to treating the hip flexor group, assessment of erector spinae (lower thoracic and lumbar vertebrae and associated musculature), gluteal and abdominal function may be required.

Piriformis Of all the lateral hip rotators, the piriformis is often singled out from its brethren because of its proximity to the sciatic nerve. It is often implicated by clinicians not only in cases of pseudo-sciatica (entrapment neuropathy) but also where sacroiliac joint dysfunction manifests. On the face of it, the piriformis is a relatively easy muscle to treat; however, as part of your differential diagnostic procedure, be mindful of referred pain throughout the gluteal region to the posterior thigh and lower limb, and consider possible sacroiliac joint and L4/L5 joint dysfunction. Practitioners may also differentially diagnose short-leg discrepancies, abductor and internal hip rotator musculature insufficiencies, proprioceptive deficiencies, or other kinetic chain issues involving the knee and ankle joints. Medical exercise interventions may be required to address additional observations following appropriate manual therapy applications to this muscle. METs can be applied with the patient in prone or

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supine (Fig. 3) and the piriformis muscle will respond well not only to postisometric relaxation but also to other variations (reciprocal inhibition, pulsed and isotonic applications). Practitioners may choose to prescribe dynamic piriformis stretches as home care thus empowering the patient in their own recovery. The piriformis eccentrically contracts to decelerate internal rotation and hip adduction when the hip is flexed. The short piriformis can pull on the sacrum causing it to tilt, and give the appearance of a ‘short leg’. The twisting action caused by the unilaterally short piriformis can set up additional sacroiliac stress, again influencing adaptations along the kinetic chain – so it might be worth considering the piriformis when treating an unresolved, chronic shoulder pain that hasn’t responded to the usual care protocols that one might adopt!

METS ARE A VALUABLE AND HUGELY VERSATILE APPLICATION IN THE TREATMENT OF MUSCULOSKELETAL PAIN AND INJURY

Hip adductor Patients may present with referred pain to the groin, the thigh and knee, or may have difficulty performing squatting and lunging actions. Inhibition in the gluteus medius may be noted (positive Trendelenburg sign), or a shift of the pelvis towards the painful side may be noted. Perpetuating factors can include direct trauma or overload, and additionally the clinician should consider the possibility of underlying pathology in the articulating joints. Tendon inscriptions at the pubic symphysis and medial knee may be tender to touch. To locate bind, the patient is positioned supine with the knee flexed and hip guided into abduction. The patient attempts to adduct the limb against the practitioners resistance, after which the patient relaxes and the practitioner guides the limb to the next area of bind (Fig. 4). Following the prescribed time (anywhere from 6 to 25 seconds), an isometric contraction can be performed once again to commence the next cycle. The practitioner may also need to address inhibitory dysfunction affecting the abductor mechanism. From a kinetic chain perspective, the

Figure 3: MET with patient supine for piriformis muscle. (D. Anderson, 2015)

Figure 4: MET for the hip adductor group. (D. Anderson, 2015)

METS CAN BE USED AS AN ALTERNATIVE TO HIGH-VELOCITY THRUST JOINT MANIPULATIONS

adductor group of muscles decelerate external rotation of the femur and abduction of the thigh. Generally speaking, the clinician should also investigate the status of the gluteus minimus (it decelerates external rotation and adduction of the femur), and the gluteus medius (provides iliofemoral stability and can be indicated in low back and knee pain), amongst others discussed elsewhere in this article.

Erector spinae/quadratus lumborum

Figure 5: Side-lying MET for quadratus lumborum muscle. (D. Anderson, 2015)

Figure 6: MET for lumbar multifidi musculature. (D. Anderson, 2015)

Figure 7: MET for extension of the thoracic spine. (D. Anderson, 2015)

Pain can refer from the erector spinae musculature across the low back, into the buttocks and sacroiliac joint. The clinician may also note an increase in lumbar lordosis, other pelvic adaptations such as torsion of one innominate (additionally inflares and outflares should be considered). Other perpetuating factors may include inhibited gluteus medius, acute trauma or strain, and postural strain (increased ligament laxity due to constant slouching). To assess overactivity, lay the patient prone and have them actively extend their hip (prone straight leg raise). This muscle activation pattern (see Fig. 1) can be used to evaluate function of the erector spinae and quadratus lumborum in relation to the gluteal muscles and hamstring. Medical exercise prescription may address simple full body kinetic chain motion and neuromuscular efficiency [according to Sharkey we should not attempt to increase strength in individual links in the early stages (6)], postural correction of the lumbar– sacroiliac complex (including sitting posture) and introduction of movement strategies for bending and lifting. A short quadratus lumborum can lead to a functional short leg on the same side; in turn, the contralateral adductors may shorten to try to pull the femur more posteriorly in the acetabulum (‘shortening’ the contralateral leg), but the knock on effect is pubic symphysis and sacroiliac joint dysfunction. Side-lying and prone variations can be applied to treat the erector spinae and quadratus lumborum musculature. For the side-lying variation, lay the

patient on the non-treated side, close to the edge of the table. The practitioner stands facing the patient at torso/pelvis level. Flex the hips and knees to 90° with ankles side by side or crossed for stability. The patient’s knees should pass over the side of the treatment bed. The practitioner grasps the ankles and raises the lower limbs so that side bending of the lumbar vertebrae is introduced. The patient is asked to push their feet down to the floor against the practitioner’s resistance. Following isometric contraction, the practitioner takes up the slack and the technique can be repeated (Fig. 5). As a variation, the patient can be requested to push up, or resist gravity to induce a reciprocal inhibition effect, or degree of knee and hip flexion can be modified to address specific fibres or joints. Another side-lying variation requires the practitioner to hook their interdigitated fingers and hands over the uppermost iliac crest and ask the patient to hike their hip against resistance, after which the practitioner takes up the slack by applying a caudal distraction before the next isometric contraction is applied.

Lumbar multifidi The patient is placed side-lying, non-treated side down. The torso is rotated backwards, the pelvis rotated forwards (should not induce pain). The practitioner faces the patient with caudad hand and forearm on top of the ilium drawing the pelvis forwards and the cephalad forearm stabilising the patient’s top side shoulder with the hand placed on the spinal column. The patient attempts to rotate the torso forwards while moving the pelvis backwards. The practitioner takes up the slack after the patient relaxes and the next cycle can begin (Fig. 6). The lumbar multifidus muscle plays an important role in neuromuscular efficiency of the core. In a synergistic fashion, multifidus (and rotators) stabilise the lumbar spine, whilst, with transverse abdominus, help create ‘lift’ at the L3 segmental level. Be mindful that the transverse abdominus muscle

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expresses fascial continuities with the lumbar vertebrae, iliac crest, inguinal ligament and rib cage, potentially implicating transverse abdominus in both upper abdominal and groin pain.

Throracic spine extension This technique can be used to address thoracic spine dysfunction, particularly where extension is limited or is painful for the patient. The patient sits with elbows and shoulders flexed overhead so that the palms of the hands rest on the back of the shoulders. The patient attempts to push their elbows down against the practitioner’s resistance, after which the practitioner guides the spine into further extension while further raising the patient’s arms (Fig. 7). Medical exercise prescription should incorporate activities that focus on extension of the spine such as the cat and camel or sphinx exercises.

CONCLUSION METs are a valuable and hugely versatile application in the treatment of musculoskeletal pain and injury. When used in conjunction with mobility, stability or functional exercise prescription, METs can be effective in the resolution soft tissue and joint dysfunction. For the novice practitioner, the basic techniques are simple to administer, satisfactory outcomes can be gained relatively quickly and the techniques can be taught to patients for home care. For the more experienced practitioner, the MET variations discussed in this article can be applied to patients where chronic functional pathologies present that require not only a global (body-wide) approach but also a multi-modal application to treatment.

FURTHER RESOURCES 1. Lewit K. Manipulative therapy: musculoskeletal medicine. Churchill Livingstone 2009. ISBN 978-0702030567 (Print £43.61 Kindle £38.39. Buy from Amazon http://spxj.nl/1jthkLh 2. Sharkey J. The concise book of neuromuscular therapy: a trigger point manual. North Atlantic Press/ Lotus Publishing 2008. ISBN 978-

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1556436734 (£53.76). Buy from Amazon http://spxj.nl/1PVNOw9 3. Chaitow L, DeLaney J. Clinical application of neuromuscular techniques: the upper body, volume 1, 2nd edn. Churchill Livingstone 2008. ISBN 978-0443074486 (£150). Buy from Amazon http://spxj.nl/1XrubjS 4. Chaitow L, DeLaney J. Clinical application of neuromuscular techniques: the lower body, volume 2, 2nd edn. Churchill Livingstone 2008. ISBN 978-0443068157 (Print £73.49 Kindle £67.19. Buy from Amazon http://spxj.nl/1XruCKQ References 1. Scott-Dawkins C. Comparative effectiveness of adjustments versus mobilisations in chronic mechanical neck pain. Proceedings of the Scientific Symposium, World Chiropractic Congress, Tokyo 1997 2. Fryer G. Muscle energy techniques, an evidence-informed approach. International Journal of Osteopathic Medicine 2011;14(1):3–9 3. Taylor DC, Brooks DE, Ryan JB. Viscoelastic characteristics of muscle: passive stretching versus muscular contractions. Medicine and Science in Sports and Exercise 1997;29(12):1619–1624 4. Fryer G, Fossum C. Therapeutic mechanisms underlying muscle energy approaches. In: Fernandezde-las-Penas C, Arendt-Nielsen L, Gerwin R (eds.) Tension type and cervicogenic headache: pathophysiology, diagnosis, and management (Chapter 19). Jones and Bartlett 2008. ISBN 9780763752835 (£9.96). Buy from Amazon http://spxj.nl/1PVPRAi 5. McPartland J. Expression of the endocannabinoid system in fibroblasts and myofascial tissues. Journal of Bodywork and Movement Therapies 2008;12(2):169–182 6. Sharkey J. The concise book of neuromuscular therapy: a trigger point manual. North Atlantic Press/Lotus Publishing 2008. ISBN 978-1556436734 (£53.76). Buy from Amazon. Buy from Amazon http://spxj.nl/1PVNOw9 7. Parmar S, Shyam A, et al. The effect of isolytic contraction and passive manual stretching on pain and knee range of motion after hip surgery: A prospective, double blinded, randomised study. Hong Kong Physiotherapy Journal 2011;29(1):25–30 8. DeStefano LA. Greenman’s principles of

manual medicine, 4th edn. Lipincott, Williams and Wilkins 2010. ISBN 9780781789158 (Print £90 Kindle £85.50). Buy from Amazon http://spxj.nl/1Iv6YRF 9. Parmar S, Shyam A. MET in postsurgical rehabilitation. In: Chaitow L (ed.) Muscle energy techniques, 4th edn. Churchill Livingstone 2013. ISBN 978-0702046537 (Print £39.97 Kindle £37.37). Buy from Amazon http://spxj.nl/1LIqdqX 10. Ballantyne F, Fryer G, McLaughlin P. The effect of muscle energy technique on hamstring extensibility: the mechanism of altered flexibility. Journal of Osteopathic Medicine 2003;6(2):59–63 11. Mehta M, Hatton P. The relationship between the duration of sub-maximal isometric contraction (MET) and improvement in the range of passive knee extension. Journal of Osteopathic Medicine 2002;5(1):40 12. Schmitt G, Pelham T, Holt L. A comparison of selected protocols during proprioceptive neuromuscular facilitated stretching. Clinical Kinesiology 1999;53(1):16–21 13. Ferber R, Osternig LR, Gravelle DC. Effect of PNF stretch techniques on knee flexor muscle EMG activity in older adults. Journal of Electromyography and Kinesiology 2002;12(5):391–397 14. Page P, Frank CC, Lardner R. Assessment and treatment of muscle imbalance. Human Kinetics 2010. ISBN 978-0736074001 (£45.35). Buy from Amazon http://spxj.nl/21ozEY3 15. McAtee RE. Facilitated stretching, 4th edn. Human Kinetics 2014. ISBN 9781450434317 (Print £20.66 Kindle £16.99). Buy from Amazon http://spxj.nl/1Tg51hy 16. Liebenson C. Rehabilitation of the spine: a practitioner’s manual. Lippincott Williams and Wilkins 2007. ISBN 9780781729970 (£88.00). Buy from Amazon http://spxj.nl/1OzzMNk 17. Eng CM, Arnold AS, et al. The human iliotobial band is specialised for elastic energy storage compared with the chimp fascia lata. Journal of Experimental Biology 2015;218:2382–2393 18. Klein R, Bareis A, et al. Straincounterstrain to treat restrictions of the mobility of the cervical spine in patients with neck pain: a sham-controlled randomised trial. Complementary Therapies in Medicine 2013;21(1):1–7 19. Nagrale AV, Glynn P, et al. The efficacy of an integrated neuromuscular inhibition technique on upper trapezius trigger points in subjects with non-specific neck pain: a randomised controlled trial. Journal of Manual Manipulative Therapy 2010;18(1):37–43 20. Lederman E. Osteopathic neuromuscular rehabilitation. International Journal of Osteopathic Medicine 2010;13(1):3–10.

THE AUTHOR David Anderson MSc, NAMMT BASES has been involved in manual therapy practice and education for almost 20 years. A graduate of the University of Chester, David holds a Master of Science degree in Neuromuscular Therapy and also a graduate diploma in Manipulative Therapy. In addition to maintaining a private practice, he is a currently a senior lecturer at the National Training Centre in Dublin. Although his clinic specialism is in the treatment of chronic somatic pain, David has also worked in sport and performance arts at the highest level, having worked with the casts of many well known West End and Broadway productions. David lives with his wife and family in County Down, Northern Ireland. Email: davidandersontherapy@gmail.com Blog: Manipulative Therapy NI http://manipulativetherapyni.com LinkedIn: David Anderson MSc http://spxj.nl/1jtm1EZ Facebook: David Anderson MSc Neuromuscular and Manipulative Therapy Clinic http://spxj.nl/1NifW5S

KEY POINTS n I n the modern day, use of muscle energy technique (MET) is commonplace in massage and manual therapy clinics in the UK and Ireland. However, Fred Mitchell Sr DO is credited with developing MET in the 1940s and 1950s. n Although a number of hypotheses offer explanation as to how MET works, conclusive agreement on how the technique actually works has not yet been reached. n MET and other variations such as proprioceptive neuromuscular facilitation (PNF) are influenced by the work of neurophysiologist Sir Charles Sherrington (Sherrington’s laws of irradiation, successive induction and reciprocal innervation). n MET is a safe, easy to administer, manual therapy technique that can be used by practitioners from all physical therapy backgrounds and disciplines. n MET can be used in both the acute and chronic pain/injury setting. n It can be used on its own or integrated with other mobilisation techniques including massage, spinal and joint manipulation, strain/ counter-strain, trigger point therapy, soft tissue release and so on. n MET can be used to treat hypertonic/hypotonic musculature, joint dysfunction, myofascial trigger points, spasm, muscle shortness, and may mediate analgesic responses in painful tissues. n It can be used to facilitate mobility, stability, or strength and stamina in the soft tissues as part of a programme of treatment and rehabilitation/exercise prescription.

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DISCUSSIONS J anda suggested that hypertonicity (sometimes described as ‘splinting’) in the soft tissues following an acute trauma or pain episode, may provide increased stability to the tissues and structures involved. That hypertonic state may, however, prevail after the acute phase has passed or tissue trauma has healed. Why might this be the case? What else might you suspect? Many practitioners find MET a useful method of restoring normal range of motion in a shortened tissue. We also know MET can be effective in the mobilisation of joints. What other therapeutic outcomes might you expect to find? Clinicians have a number of modalities at their disposal to treat myofascial trigger points or dysfunctional tissues such as manipulation techniques, stretch and spray, electrotherapeutic/ultrasound modalities, wet and dry needling and so on. METs are a versatile application that can be generally used in massage or manual therapy sessions, or specifically applied as part of integrated neuromuscular inhibition technique (INIT). This is a sequential application that combines ischaemic/inhibitory pressure, strain/counterstrain and post-isometric relaxation. There are a number of recent research papers (18,19) that investigate the therapeutic efficacy of INIT, consider how the integration of INIT into your clinical repertoire may influence treatment outcomes for your patients. Prof. Eyal Lederman (20) discusses the effectiveness of combining manual therapies with medical exercise prescription, not only to resolve the pain or injury our patients present with, but also to reduce the potential for reoccurrences. For what reasons might our patients return with the same issues? Consider the value of teaching a movementbased rehabilitative technique like MET or soft tissue release (STR) to your patients for selfrehabilitation purposes. What are the positives and negatives of doing so?

HERE ARE SOME SUGGESTIONS Tweet this: MET is a safe and effective technique for the treatment of musculoskeletal pain or dysfunction. http://spxj.nl/1TusTPk Tweet this: MET is an alternative to high-velocity thrust joint manipulations, where the use of such techniques is not available. http://spxj.nl/1TusTPk Tweet this: The practitioner should seek to avoid lengthening the soft tissues when using MET in the acute pain scenario. http://spxj. nl/1TusTPk Tweet this: Pulsed MET can be useful for facilitating inhibited antagonists, or before application of HVLA manipulation. http://spxj.nl/1TusTPk

RELATED CONTENT Swedish massage in a sporting context: part http://spxj.nl/1AMZbQL wedish massage in a sporting context part 2 http:// S spxj.nl/1TlbB7w Best of Manual Therapy http://spxj.nl/1GFVehL yofascial techniques for hip mobility http://spxj. M nl/1cSmmi8

Co-Kinetic journal 2016;67(January):34-40

MANUAL THERAPY STUDENT HANDBOOK: In order to treat a patient effectively, the clinician must first make an accurate assessment of the patient’s condition. This article, the third in a series from our Manual Therapy Student Handbook (see the ‘Contents panel’ for further details), will take you through all the steps required for making a proper musculoskeletal assessment and give you the best chance of solving your patient’s problems. Read this online http://spxj.nl/1iIU78j 16-01-SPORTEX FORMATS WEB MOBILE PRINT

FUNCTIONAL ANATOMY A sound knowledge of anatomy is a necessary skill for the competent manual therapist. As a result, functional anatomy of each region should be revised before continuing with assessment and treatment techniques. This will be covered at the start of the ‘Assessment and treatment’ articles for each anatomical region.

CLINICAL ASSESSMENT PROCEDURES Another major skill that a competent manual therapist must have, is the ability to assess conditions that are presented. Needless to say, these come in various clinical presentations. In addition to this variety of signs and symptoms, there are numerous ways of assessing these conditions. To make life a little simpler, we will be using the logical systems first advocated by the late James Cyriax. It is by no means meant to be a definitive method of assessment; however, it will help the manual therapist to reach a

BY JULIAN HATCHER GRAD DIP PHYS MPHIL, MCSP FOM diagnosis in over 90% of cases. It must also be stated that this is only the basic assessment; there are many additional tests that can be added to the end of each of these assessments.

FUNDAMENTALS OF ASSESSMENT Before we progress, let us look at some fundamentals of assessment. Firstly, how useful are X-rays when it comes to assessment and diagnosis? The problem with X-rays is that they only show dense body tissues, eg. the bones. All soft moving tissues are radio-translucent! If pain arises from a soft tissue, then X-rays reveal only one of two things: n Bones appear normal, ie. no anomaly detected (NAD) or negative X-ray, or

nX -ray shows some symptomless abnormality, eg. cervical spondylosis Secondly, how useful is palpation in assessment and diagnosis? The problem here is that not all pain is felt at the site of origin; hence palpation can very often be deceptive. Soft tissues have the habit of referring pain to other areas; often they refer pain on a segmental basis. Following on from that, it should be obvious that any treatment needs to be directed at the source of origin and not necessarily the site of symptoms. There are, however, certain circumstances when the latter may be appropriate, but it cannot be assumed to be enough. Treatment should have a beneficial effect on the particular tissues. Again this sounds obvious, but too often therapists

THERE ARE NUMEROUS WAYS OF ASSESSING CONDITIONS, BUT THE ONE ADVOCATED BY JAMES CYRIAX IS A GOOD, LOGICAL SYSTEM 42

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have been guilty of performing treatments without really taking this into full consideration.

PRIMARY DECISIONS FOR ASSESSMENT In our quest of diagnosis, some primary decisions need to be made even before the assessment can begin: 1. About which joint does the lesion lie? 2. In what sort of tissue does the lesion lie? (Contractile/inert) 3. Is the pain reproduced by the test? The first question should really be answered by the initial subjective history. If the right sorts of questions are asked, then an initial impression may become evident, at least to the extent where the manual therapist can decide at least which joint assessment to do. The next two questions are answered by applying the principle of selective tissue tensioning. Each tissue is selectively stressed, while at the same time not allowing any tension to occur at other tissues. Tissue types include those shown in Table 1.

Characteristic patterns of loss of range of motion: capsular and non-capsular patterns One of the inert structures in Table 1 also displays an additional characteristic that is significant in diagnosis: namely the joint’s fibrous capsule. Cyriax observed that joints loose range of motion (ROM) in predictable ways – which he termed ‘capsular patterns’: n When the capsule of a joint becomes inflamed, whether by trauma, infection or degeneration, it contracts and restricts the available range of motion in a set pattern. This pattern is the same for that joint but may be different for different joints. n For example: shoulders display the same capsular pattern as each other, yet this differs from all knees. Loss of range not in common with the known ‘capsular pattern’ is called a ‘noncapsular pattern’.

Active, passive and resisted movements Active movements are often not very

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helpful in diagnosis – all tissues are under tension simultaneously. However, they can give an indication of willingness to move, in addition to onset of pain, available range and end-feel to joint motion. Passive movements stress the inert structures mainly, and give us an idea of onset of pain, range and end-feel. Resisted movements put the contractile components under tension and give an idea of pain and power. Palpation may then be used to further localise the lesion if this is useful. Further additional tests may then also be carried out to aid this process. The normal feel to the end of joint ROM is often called the end-feel and Table 2 shows terms that describe normal and abnormal (or pathological) end-feels.

CLINICAL ORTHOPAEDIC EXAMINATION Clinical orthopaedic assessment consists of subjective and objective examination.

Subjective examination Take account of the points in Table 3 to complete your subjective examination of the patient.

Objective examination Take account of the points in Table 4 to complete your objective examination of the patient.

REFERRED PAIN This is described as an error in perception; pain perceived elsewhere than at its true site is termed ‘referred’. Different parts of the brain are involved in pain perception: n Site of pain – the sensory cortex is the area of the brain responsible for determining this. n Memory of pain – the temporal lobes are the area of the brain for this. n Degree of pain – the frontal lobes are where this is determined (the amount of tension in these frontal lobes may govern the patient’s response to pain). Referred pain follows a few rules; it: n Does not cross the mid-line of the body. n Has a tendency to refer distally.

n Always refers segmentally. n May be felt in all or part of dermatome. n Is often felt or perceived as being deep. The nature of referred pain is summarised below: n Usually, the deeper the site of lesion, the more vague the reference of pain and the greater the spread of reference. n This is also true of the location of the lesion, ie. the more proximal, the vaguer and greater the spread of reference. n In most cases, the stronger the stimulus, the greater the spread of reference.

FURTHER RESOURCES 1. Hatcher J. Musculoskeletal assessment, chapter 11. In: Comfort P, Abrahamson E (eds) Sports rehabilitation and injury prevention. Wiley Blackwell 2010. ISBN 978-0470985632 (Print £36.45 Kindle £36.43). Buy from Amazon http://spxj.nl/1OAdzib 2. Palmer ML, Epler ME. Fundamentals of musculoskeletal assessment techniques, 2nd edn. Lippincott, Williams & Wilkins 1998. ISBN 9780781710077 (£45.00). Buy from Amazon http://spxj.nl/1NDZSlo 3. Atkins E, Kerr J, Goodlad E. A practical approach to musculoskeletal medicine: assessment, diagnosis, treatment, 4th edn. Elsevier 2015. ISBN 978-0702057363 Print £48.59 Kindle £46.16) Buy from Amazon http://spxj.nl/1NYy8SS.

Recommended reading 1. Anderson MK, Parr GP. Fundamentals of Sports Injury Management. Lippincott, Williams & Wilkins 2011. ISBN 978-1451109764 (Print £60.30 Kindle £63.83). Buy from Amazon http://spxj.nl/1N14xZ5

TABLE 1: TISSUE TYPES (J. Hatcher, 2015) Contractile Inert n Muscles n Tendons n All corresponding junctions o musculotendinous o teno-osseous

n n n n

Bones n Ligaments n Bursae n Dura mater n

Cartilage Capsule Fasciae Nerve root

TABLE 2: NORMAL AND ABNORMAL JOINT END-FEELS (J. Hatcher, 2015) Normal

Abnormal, or pathological

n Hard n Soft n Elastic

n Springy n Spasm n Empty

PASSIVE MOVEMENTS STRESS THE INERT STRUCTURES MAINLY, AND GIVE US AN IDEA OF ONSET OF PAIN, RANGE AND END-FEEL. RESISTED MOVEMENTS PUT THE CONTRACTILE COMPONENTS UNDER TENSION AND GIVE AN IDEA OF PAIN AND POWER TABLE 3: SUBJECTIVE EXAMINATION (J. Hatcher, 2015) 1. Observation n Face, posture and gait Look for signs of pain, or lack of sleep on the patient’s face; observe the position they adopt or hold themselves in; and look for signs of an antalgic gait pattern (limp). 2. History n Age Gain rapport in the way this is asked, eg. “How many years young are you?” Some conditions are specifically age-related, eg. Osgood–Schlatter’s disease of the knee affects young adolescent males and degenerative conditions are often present in the over 50 age group. n Occupation Again, gain rapport, find out about job, sport, leisure or hobbies. This will help to indicate clearly what level of rehabilitation is needed. This may also be a contributing factor to onset of symptoms, or in some cases cause delay in the recovery process. n Site This will help to identify the patient’s perception of where they perceive their pain to be, rather than exactly where the source of pain is. This will help you answer your first primary question of, “around which joint does the lesion lie?” (See earlier in this section). Pointing with one finger generally indicates a localised or superficial lesion, whereas indicating with sweep of the hand may indicate pain that is referred from a more proximal lesion. Knowledge of rules of referred pain may help diagnosis (See later section on ‘Referred pain’). n Spread Again, together with the site of pain, this may indicate the patient’s perception of where they perceive their pain to be coming from. That said, it still needs to be established whether the pain remains localised, or does it spread over large area, and exactly where this area is. Understanding both the rules of referred pain and the dermatome pattern on the body may aid your diagnostic reasoning. n Onset There are essentially three types of onset: a) Sudden – often associated with injury (in which case identify the mechanism involved) b) Gradual – may be overuse c) Insidious – may be sinister in nature. It may be better to consider the latter to have a combination with one of the other two. For example, osteoarthritis is often a gradual but insidious onset (ie. there is no cause, but it creeps up slowly on a patient). Gout, however, is often a sudden insidious onset that occurs overnight. Knowledge of the specific pathology of various musculoskeletal disorders is vital here for good clinical diagnostic reasoning.

nD uration This may give some indication of how likely you are to either cure, or at least reduce the patient’s symptoms. Generally, the longer the duration, the less likely you are to be able to change the condition. You should also note how the condition has changed for the better or worse during the period of time they have suffered with this particular problem. n Behaviour There are essential three key elements to this: a) Is pain constant or intermittent? Mechanical pain is not normally constant, but is posture or movement dependent. b) What aggravates and what eases the pain? This can give an indication as to how severe and irritable the problem is. How easy is it to recreate the pain, and, once there, how long does it take to settle down again? c) Diurnal variation. What is the pain like over a 24-hour period? What is it like first thing in the morning, what is it like once up and moving around? What is it like towards the end of the day? What is it like at night? n Symptoms Symptoms are something that a patient feels or perceives subjectively; by nature they are not measurable objectively. Examples of symptoms are pain, paraesthesia (pins and needles), anaesthesia (numbness), locking/giving way, crepitus (noises such as clicks, cracks or pops). Signs, however, are what you measure objectively in your objective assessment. n Past medical history The ‘THREAD’ mnemonic may be useful here in that you are looking for any previous major injuries, illness or operation. T Thyroid or Thrombosis H Hypertension or Heart problems R Respiratory disorders E Epilepsy A Asthma or Abdominal disorders D Diabetes or Degenerative disorders Most patients don’t realise how important these questions are, so use of the question, “Are you sure?” at the end, makes them just re-check their answers. Knowledge of these conditions may aid in your diagnosis, or may help you identify potential contra-indications to some treatment and rehabilitation. 3. Inspection n Bony deformity, colour changes, wasting and swelling. 4. Initial palpation n Heat, swelling, synovial thickening and pulses (not tenderness or pain).

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TABLE 4: OBJECTIVE EXAMINATION (J. Hatcher, 2015) 1. Active movements (if appropriate) Look for willingness to move. 2. Passive movements Look for pain, range and endfeel. (Passive stretching/squeezing may occur to inert tissues.) 3. Resisted movements Look for pain and power. (Isometric contraction of contractile tissue components without passive stretching.) 4. Neurological tests Eg. reflexes, sensation. 5. Palpation to localise lesion 6. Further additional tests Eg. X-ray, scans, blood tests, etc.

nA competent manual therapist must be able to assess the conditions that are presented to them. n Some primary decisions need to be made even before the assessment can begin. These are: – About which joint does the lesion lie? – In what sort of tissue does the lesion lie? (Contractile/inert) – Is the pain reproduced by the test? n Clinical orthopaedic assessment consists of subjective and objective examination. n X-rays are not usually helpful in assessment, as the pain usually arises from the radio-translucent soft tissues. n Palpation can be misleading as soft tissues often refer pain to other areas.

2. Cyriax J. Textbook of orthopaedic medicine, vol. 1: diagnosis of soft tissue lesions, 8th ed. Balliere Tindall 1982. ISBN 978-0702009358 (£21.31) http://spxj.nl/1UGmrnr 3. Boyling J, Jull G. Grieve’s modern manual therapy: the vertebral column, 3rd ed. Churchill Livingstone 2005. ISBN 978-0443071553 (£90.59). View on Amazon http://spxj.nl/1NEbBQM 4. Higgs J, Jones A, et al. Clinical reasoning in the health professions, 3rd ed. Butterworth-Heinemann 2008. ISBN 978-0750688857 (Print £54.99 Kindle £42.39). Buy from Amazon http://spxj.nl/1PoOhXA 5. Abrahams PH, McMinn RMH. McMinn and Abrahams’ Clinical atlas of human anatomy, 7th ed. Mosby 2013. ISBN 978-0723436973 (Print £44.09 Kindle £41.89). Buy from Amazon http://spxj.nl/1l2Yexc 6. Magee DJ. Orthopaedic physical assessment, 6th ed. Saunders 2014. ISBN 978-1455709779 (print £51.89Kindle 49.30. Buy from Amazon http://spxj.nl/1jv0iwg 7. Hengeveld E, Banks K. Maitland’s Vertebral Manipulation: management of neuromusculoskeletal disorders – volume 1, 8th ed. Churchill Livingstone 2013. ISBN 978-0702040665 (Print £61.19 Kindle £58.13). Buy from on Amazon http://spxj.nl/1IkjVmr 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 http://spxj.nl/1PWBFqz 9. Kapandji IA. The physiology of the joints, volume 3: the spinal column, pelvic girdle and head. Churchill Livingstone 2008. ISBN 978-0702029592 (£335.64). Buy from Amazon http://spxj.nl/1MRhd6M.

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