sportEX dynamics highlights - Jan 09 by Tor Davies

ISSU E 19 Jan

200

tHe BeiJ experie iNG olympic Nce oly mp ics

By PAULA CLAyTON

JANUARY 2009

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This article his was my offers an second Olym but my appr pic cycle, insider’s vie Sports ma oach to this ssa w compared one with Athe experience ge practitioner Pau of the Beijing Olymp ns was com different. la Clayton ic Games. at pletely Five years on, I am a compares and explain Beijing with that better soft much tissue ther at the Ath s what makes apist. I am more exp ens Game her far erienced her team s four yea now, and after 63 athle work suc looking rs ago tes in Mac cessfully. enough to was not as au and Beiji deal intimidating ng that we may with any differenc to others. as it may es face. This sound I know mos outside the makes for extremely t of the athle with who village, such an comfortable m I work, was defin and my relat tes and supp environm with the rest itely not the organisation ortive ent, which ionship of the med case. Taxi is paramou who were when you developed ical team drive brought in nt rs are away has so we are from surr areas to from hom extended now a clos team in ever ounding help with e for an period of e-knit the load didn y sense of time and where the to go thro the word. ’t know are likely village was Before 200 ugh a num 3 I hadn’t or how to the different ber of emo along the much time spent get to tions gates due way. travelling to the secu and one-wa with athle situations I was told rity y systems tes in where we of the deat that were place. This family frien ate, slept h breathed of in a meant large and d while I the same was time were amounts air, in the champion space, for of taken just same ships in Osa at the world extended travelling A to B. not ka 2007. other envi periods of I was nerv from In any having accr ronment, time. ous on my this devastat editation and only would have first trip – the Olym having day ion sent me to pic training passes produced spiralling emotiona camp in Pap and the Aph into its own set l turm hos rodite Hills of nightmare without hesi oil. Instead, I was – and I felt like a fish processe given, tation, the out of wate s, which had time, spac support that r. The inten of the athle to be follo e and sity enabled me tes, coac wed. do my job hes, cam luckily for to continue treatment ps and in an alrea us, we to schedules had none dy highly emotiona was com alien to me, of these char l, competit pletely and at time ive environm ged, problems was a pers overwhelmed s I was . Having full ent. I on first and . accredita an seco emp nd. tion loyee The lead-up meant to Athens that we coul such a fast The stability mov d trave ed at pace. The l of the med freely and lays down pressure intensity ical team easily a foundatio and increased without so n that is daily, but and certain. in it. This strong I revelled Having no was where much as concerns who you I knew I shou I gained conf an about might work ld be. idence in afterthought with, or wha of athlete my ability the team . t type you migh and in around me. t come acro Buses were having a By the time ss, or difficult mem Athens desc always on ber in your allows you us, I had ended on team, the space been on time, and several inter to do your a very high trips and as job to national standard it was seco soon as one and to cope other pote nd nature I fitted in, ntial prob with to me. and my skills lems alon left another were a perf match for Working and g the way the track ect . living in the arrived. The and field village is Olympic The medical athletes. like being in a bubb food was team as Beijing ever has been le. In it stands ything was a unit for now organised three year well that we regularly life and daily so s, and travel toge activities effortless ther out any chal became . Athens was lenges early . We ironed similar, but threw inord now have China inate amo relationships on, and we unts of mon at organisa that are stro ey tion ng Unfortunately and it came across. www.spo rtEX.net , for thos e statione d

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n a sses smen n o t of lymp the ic the foot beiji games n r ehab ng expe 2008 – rien belo ilitatio ce w kn n n a ee in of th bnor jury e low mal fo er prob back ot mo tio lems and n m pelv n and assa ic ge th erap y ed ucat ion

The foot contains many bones, joints and tendons that work together to enable gait. Dysfunction of any of these aspects How abnormal foot motion can be a major contributor to of the foot may lower back and pelvic problems cause problems anywhere along the The FOOT IS A kinetic chain and mASTerPIece OF engIneerIng AnD A wOrk in the lower back OF ArT (Fig.1). This article reviews the basic anatomy of the foot and discusses some of the lowerback problems associated with abnormal foot motion. foot motion back pain

WOrkInG And lIvIn THe IS lIke Be OlyMPIC vIllAGG In e BUBBle InG In A

The foot contains many bones, joints and tendons that work together to enable gait. Dysfunction of any of these aspects of the foot may cause problems anywhere along the kinetic chain and in the lower back (Fig.1). This article reviews the basic anatomy of the foot and discusses some of the lower-back problems associated with abnormal foot motion.

(Leonardo da Vinci)

This article offers an insider’s view of the Beijing Olympic Games. Sports massage practitioner Paula Clayton compares her experience at Beijing with that at the Athens Games four years ago and explains what makes her team work successfully.

By Nick DiNsDale, Bsc

NORMal FOOT MecHaNics DURiNG GaiT Pronation and supination are normal

IntRoDUCtIon Foot assessment is often necessary because actions, movements and problems of the feet can cause symptoms in other regions of the body. The same fundamental assessment pattern is followed as discussed in previous articles (1-4), with a subjective examination focusing on the relevant history and an objective examination centred on the following: n Inspection of equipment n Observation n Measurement n Functional activities n Palpation n Specific tests.

InSPECtIon oF EQUIPMEnt It is often helpful to start the objective assessment of the foot by inspecting the patient’s footwear. Don’t forget to check shoes worn regularly as well as sports shoes. Differing wear patterns can indicate problems and reveal biomechanical flaws. Gait analysis and correction to footwear, including providing orthotics, is the province of the specialist podiatrist. It is vital to refer the patient to a podiatrist if examination of footwear demonstrates any marked abnormal wear pattern. Remember that asymmetrical wearing of the shoes can be an indication of leg-length discrepancy.

oBSERVatIon Have a good look at each foot at rest. Remember: claw toe, hammer toe, hallux valgus, hallux rigidus, athlete’s foot and ingrown toenail can all lead to alteration of movement and a change of gait pattern. All of these problems, as well as the symptoms reported by the patient, must be treated. Check for the following: n The Achilles tendon from behind: medial curving of this tendon indicates overpronation (Figure 1). n Particular areas of blisters, corns or callus formation: these indicate areas of pressure and are possibly causes of problems or the result of another problem. Failure to address the causes of callus formation, blisters and corns can lead to recurrent symptoms. n Obvious deformity, swelling, contours and bruising.

MEaSUREMEnt Range of movement See Box 1.

Size of feet Some people have as much as one full size difference Figure 1: Medial curving of the achilles tendon

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abnormal pelvic tilt

imbalance of pelvic muscles

malalignment of hip

internal rotation of thigh malalignment of knee

internal rotation of leg

The foot combines mechanical complexity and structural strength. The human foot makes up an eighth (26 bones) of all the bones in the body, more than 30 joints, and 10 major extrinsic muscle tendons. These musculoskeletal structures work together with the neurovascular elements to provide support, balance and locomotion during gait. The foot has three very demanding roles: 1) it must be a loose adaptor to accommodate uneven terrain 2) it must be able to absorb shock on impact 3) it has to form a rigid lever during push-off (1). If the foot fails to function correctly, problems can arise anywhere along the kinetic chain and in the lower back. Both low-arched and high-arched feet have been reported to be major factors in making an individual more prone to injury (2,3). People involved in increased levels of physical activity, such as athletes, tend to be more susceptible to gait-related injuries (2,4).

subtalar pronation (flat everted foot)

Figure 1: The kinetic chain - foot dysfunction predisposes the kinetic chain to abnormal repetitive stresses

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CLIENT ASSESSMENT FOOT By Joan Watt, Ma MCSP MSMa

spinal scoloiosis

iNTRODUcTiON

ASSESSMENT of ThE fooT STrICTLy ACTIvE

Joan Watt continues her series of regional assessments with an examination of the foot, highlighting observations and clinical and functional tests and linking the foot to biomechanical problems that may present elsewhere.

movements of the foot that occur at the subtalar joint with every step. At the beginning of the gait cycle, the foot is in a supinated position. As the heel strikes the ground, the foot immediately begins to pronate: the foot rolls inwards in order to gain ground contact, the tibia rotates internally, the heel everts, the arches tend to flatten, and the midfoot “unlocks” and becomes slightly unstable (Fig. 2). Pronation allows the foot to become a flexible mobile adaptor to absorb ground impact and accommodate uneven terrain. As the body weight moves forward over the forefoot, resupination should occur (Fig. 3). Supination converts the foot from a flexible mobile adaptor into a rigid lever in preparation for the propulsive phase of gait. The tibia starts to externally rotate, the medial arch lifts along with the navicular bone, the heel starts to invert, the first ray drops, and the peroneal longus contracts to “lock” the cuboid bone, making the foot stable and thus creating a secure platform. This is important because the other foot is now swinging forward for the next step and the pelvis must remain level and stable throughout the midstance phase. Once this has occurred, the heel can lift and the big toe joint extends (windlass mechanism) to 11

between their feet, and this can lead to problems with shoe fit.

FUnCtIonal aCtIVItIES Ask the patient to walk forwards, backwards and sideways. Check foot placement and alignment for any anomalies. Ask the patient to stand on each foot in turn, to hop on the spot, and to alternately rise on the toes and heels in weightbearing. All of these tests can help to identify the presence of overuse injury if there is asymmetry, localized pain, instability or functional problems. If applicable to the patient’s activities, ask the patient to run, weave, jog, sprint, jump, run in a figure-of-eight, and perform stop-and-start movements. Note any areas of hesitation, pain, discomfort or protection of one side. Ask about the types of surface on which the patient normally walks, trains and competes. Hard, resistant surfaces can produce different problems from springy, mushy surfaces. Camber bias can produce one-sided symptoms.

online

PalPatIon As well as checking areas by palpation and doing specific tests, it is worthwhile checking foot pulses and temperature. These may be indicators of circulatory problems, which can contribute to symptoms and may require referral to the appropriate specialist.

SPECIFIC tEStS If assessment of other areas has led to the need for a foot assessment, keep previous results to hand and refer to them as required. As with all areas, there are numerous tests that can be used to assess the feet. The following are a few of the most helpful and commonly required tests.

Box 1: Foot JoInt RangE-oF-MotIon ValUES talotibial joint

Plantar flexion: 40o

Dorsiflexion: 20o

Subtalar joint

Inversion: 30o

Eversion: 15o

Metatarsophalangeal joint

Flexion: 75o

Extension: 35o

Interphalangeal joint

Flexion: 60o

Extension: 20o

n Articles - related articles in the sportEX archive - references 1-4 including a series of template printable patient assessment forms n Presentation - PDF presentation from La Trobe University, Australia http://tinyurl.com/8znoade n Videos - showing over pronation during gait, the metatarsal squeeze test and Mulder’s click test

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Every physiotherapist needs to adopt a threedimensional approach to rehabilitation. This utilises the therapist’s ability to devise specific functional exercises. The key areas to consider are muscle function, speed of movement, multi-joint linkage, sport-specific skills and reactive neuromuscular training. A general rehabilitation programme for the lower limb is presented.

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n Videos - All the exercises shown on this rehabilitation programme are videos in the online version.

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.net www.sportEX

massage training usa v uk By HUMPHREy BACCHUS BA, CMT Having moved back from Colorado at the beginning of last year there has been an opportunity to reflect on the difference in attitudes and training institutes in both areas, particularly in terms of the models of education, the regulations and licensing procedures as well as the role of massage therapy in medical establishments and rehabilitation. As research increasingly supports the beneficial role of massage in critical illness and immune system support, as well as in remedial applications like the treatment of pain and posture, it is clear that massage is entering an increasingly exciting era which could see it become integrated into many parts of primary care. I believe it is therefore helpful for us to start to review the educational standards in the UK with a view to thinking about how to move forward in the coming years to make sure we position ourselves as well as possible to take advantage of the new environment. The UK has a strong tradition in the development and application of soft tissue therapies. This can be evidenced from the work of leading figures such as Dr James Cyriax and Stanley Lief through to more recently Leon Chaitow. Like the USA though, this century has seen a demise in the role of massage in healthcare with a proliferation of pharmaceutical and technological interventions. With massage being marginalised even within the delivery of physiotherapy services within the the NHS, it has been left to private schools and independent practitioners to lead delivery within the public domain. It is perhaps the responsibility of those educators to have a vision of the future of massage and bodywork in the UK and its role in public health. That vision determines how we garner respect as professionals and how we develop training programs for students. The UK at present has many training institutes ranging from diplomas in sports or holistic massage to a three year BSc in neuromuscular therapy and remedial massage. There appears to

raising the standard of massage therapy education

stages rather from day one. This offers a breadth of vision and depth to each practitioner when working with the public as well as extensive opportunities to study pathology, conduct research projects and develop complex assessment skills. The USA or Canada has very marked differences in training compared to the UK. most courses are full time and require basic training in many different areas of expertise before specialisation in specific fields. most of the massage standards come from the state licensure which has been around in some states for the last 50 years. even in states where there is no licensure, there are training institutes and schools of massage that provide programmes with a minimum 500 hour attendance. Some states like New york require 1000+ hours of supervised training. In vancouver, the state has registered massage therapists (rmTs), with 3000 supervised hours. These professionals are in many ways more like nurses in the way that they are registered. A 500+ hour programme will contain essential anatomy, physiology and psychosocial aspects of touch in supervised clinics as well as varying modality programmes including perhaps Swedish massage, neuromuscular

When we start looking at the level of massage therapy training in the UK, it is hard not to cast a watchful eye to the education process over the Atlantic in both to the United States and Canada.

be large disparity between many of the courses in terms of contact classroom hours, modalities taught and length of course. There is no single professional organisation that oversees licensure or educational standards or provides a clear and defined area of expertise. A holistic massage course can have a 50 hour minimum requirement and a sports massage course can be part of a personal training certificate or as an independent 9 month course over 10 weekends. Holistic massage courses for example will study anatomy and physiology with massage techniques over 10 weekends. Sports massage courses will focus more on injuries, treatment and applied anatomy. In the UK massage therapists can take a one day course in neuromuscular techniques or take a degree in neuromuscular therapy. The courses appear to be very directed at one specific demographic, are part time and require a large percentage of non-supervised study. At the other extreme, the School of Integrated Health at the University of Westminster runs a three year BSc course in

neuromuscular therapy and remedial massage. The school was set up by osteopath and leading soft tissue practitioner, Leon Chaitow. Sports massage or reflexology for example is more likely to be taken within a broader bodywork studies programme, rather than as a primary study. These disciplines are electives as such that can be specialised in at later

THe USA or CANADA HAS very mArKeD DIffereNCeS IN TrAININg CompAreD To THe UK 20

sportEX dynamics 2009;19(Jan):20-22

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mASSAge THerApy IN NorTH AmerICA, IS INCreASINgLy BeINg SeeN AS A vIABLe INTerveNTIoN for HeALTH CAre therapy, sports and orthopaedic massage, neo-reichian bodywork or shiatsu. This allows a practitioner to develop many skills of touch and variations in ways in which to approach the care of patients. The focus in the USA and Canada is increasingly on competency. This has led Canada to try and create a national standard for massage therapy. The Canadian massage Therapy Alliance (CmTA) advocates a 2200 hour programme which includes regulation and stipulations on continuing education. There is also an interest in Canada for a multi-tiered category system for massage therapists. This could promote different levels of training from a basic therapeutic massage practitioner through to an advanced clinical massage therapist. There are undoubtedly pros and cons for singular or multi-tiered education which this article doesn’t have the opportunity to explore at this time. Whitney Lowe, from the orthopaedic massage education & research Institute in the USA, states that “the divergence in practice of massage as health or personal care is one of the largest issues facing the profession”. This may well be the case even though legislation and the development of professional bodywork practice is many years ahead in the USA. North America reflects this divergence through the varied programmes that offer 500 hour therapeutic massage courses through to associate degrees. many massage schools see the inclusion of kinesiology, movement and psychosocial studies as key to their programmes, bring together different disciplines to educate the student in both the science and art of working with the body. The Boulder College of massage Therapy in Colorado is one school that runs a degree programme with advanced

programs in neurophysiology, trauma and medical applications of massage, through to specific 150 hour modules in massage for orthopaedic conditions or massage through pregnancy. The course requires students to have a certain level of competency before embarking on the associate degree programme. This degree allows the massage therapist to explore their profession in more depth. According to Whitney Lowe, writing earlier this year, ‘massage therapy programmes in this case also start to prepare practitioners to be able to conduct, read and integrate research to their practices. This commitment to the development of massage in the wider health care communities and within medical establishments is mirrored by the programme at the University of Westminster where a research project is fundamental to the degree. This can be undertaken as an interdisciplinary model with students conducting research with the Acupuncture or Herbal medicine departments at the School of Integrated Health for example. massage therapy in North America, is increasingly being seen as a viable intervention for health care, with therapists working within a myriad of settings including hospitals, addiction clinics, sports medicine and neurological rehabilitation amongst other places. This is alongside the more traditional place of massage for wellness and relaxation in spas and natural health centres. In the UK we have relatively limited access to massage in healthcare services apart from in private sports settings and specific local health projects. It seems that massage has fallen from favour in the modern era with increasingly less specific soft tissue manipulation being conducted by physiotherapists or osteopaths, not assisted by, in my view, a lack of high quality training for massage therapists in the UK. I have noted a significant difference in competency and knowledge between therapists from North America

When we start looking at the level of massage therapy training in the UK, it is hard not to cast a watchful eye to the education process over the Atlantic in both to the United States and Canada.

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