ISSUE 3 7 July 2008
promoting
excellence in
sports
highlights n correct bicylcle set-up to reduce the risk of injury n hip rotation deficits and low back pain in golf
medicine n using goal setting to enhance rehabilitation
n mobility stretching and warm-up: application in sport & exercise
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sportEX medicine 2008;issue(37):2
contents July 2008 Issue 37 Publisher Tor Davies BSc (Hons) tor@sportex.net Editor LYNN BOOTH MCSP lynn@sportex.net Art editor DEBBIE Asher debbie@sportex.net Advertising manager Paul Harris paul@sportex.net 020 8144 3391 Sales and marketing Sally Humphries BSc (Hons) sally@sportex.net 0845 652 1906 Subscriptions Sandra Greatorex subs@sportex.net 0845 652 1906 Technical advisors
Richard Bolton MCSP, MAPA Steve Aspinall BSc (BASRaT), MSc Sophie Cox BSc (podiatry), SRCh, MChS Dr Bryan English Dip Sports Med, DO Joanne Elphinston BPhty MA, MCSP Viv Lancey MCSP, SRP Dr Dylan Morrisey MCSP, MSc PhD Prof Graham Smith FCSP, SRP Joan Watt MCSP, SRP Dr Nick Webborn MRCGP, Dip Sports Med, MSC Dr Greg Whyte PhD, BSc (Hons)
Welcome
to the summer edition of sportEX medicine and thank you to all those of you who gave us feedback about the new look and feel of the UK’s widest read professional publication on sports medicine. The feedback has been overwhelmingly good with more than 97% of people approving of the new look. We have a particularly practical issue this time featuring two practical tools intended to make your life easier! The first is a two-page photocopiable advice handout which you can give to your patients and clients on setting up their bike correctly in order to avoid or reduce injury risk. The second is a template letter outlining a possible ‘Rehabilitation contract’ that you can use with clients as part of a goal-setting orientated rehabilitation process. Finally for those of you interested in sports massage, check out the back cover of this issue of sportEX medicine for details of our soft tissue conference. We are bringing back to of the leading Australian soft tissue therapists who have both proven extremely popular at past conferences and we’re focusing on intensive hands on workshops. Visit our website (www.sportex.net) for details. We hope you enjoy this summer issue. Tor Davies, publisher
is published by Centor Publishing Ltd 88 Nelson Road Wimbledon, SW19 1HX Tel: 0845 652 1906 Fax: 0845 652 1907 www.sportex.net other Titles in the SportEX range sportEX dynamics - ISSN 1744-93838 Written specifically for professionals working with a wide variety of athletes and sports people to help them get the most out of their athletic performance - personal annual subscription £30, practice subscription £55 sportEX health - ISSN 1471-8154 For people working in the physical activity health promotion sector, health and fitness industry as well as in primary care and occupational health - annual subscription £35 for individuals, £60 for departments
Contents
4 Journal watch 6 Injury risk and bike set up
A look at some of the latest research
A review of the types of injury caused by incorrect bike set up and a photocopiable practical leaflet on correct bike set up
rotation and back pain in golf: a review 10 Hip
A review of the evidence looking at the relationship between back pain and hip rotation in golfers and other sports professionals
goal setting to enhance rehabilitation 15 Using
Again a practical look at the role that goal setting can play in enhancing adherence and improving rehabilitation outcomes
stretching and warm-up – the evidence 20 Mobility
This has been a controversial topic in the popular press - this article reviews the evidence and gives the facts as they currently stand
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.
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Single-point acupuncture and physiotherapy for the treatment of painful shoulder: a multicentre randomized controlled trial. Vas J, Ortega C, Olmo V, Perez-Fernandez F, et al. Rheumatology 2008;47(6):887-893 Four hundred and twenty five participants with a clinical diagnosis of unilateral subacromial syndrome received 15 sessions of physiotherapy during the 3 weeks that the treatment lasted and were randomised to additionally receive, once a week,
acupuncture or mock TENS. The primary outcome measure was the change in the Constant–Murley Score (CMS) for functional assessment of the shoulder, at 4 weeks after randomisation (see sportEX comment for more details). The CMS had increased by 16.6 points among the acupuncture group, compared with 10.6 points in the control group, and the mean difference between the two groups was statistically significant. By the end of the treatment, 53% of the patients in the acupuncture group had decreased their consumption of analgesics, compared with a corresponding 30% among the control group.
Genetic aspects of tendinopathy. Magra M, Maffulli N. Journal of Science and Medicine in Sport 2008;11(3)Jun:243-247 Tendinopathy is characterised by a disorganised, haphazard healing response with no histological signs of inflammation. Research on tendon injuries is limited to the description of the condition and its management, and the pathogenesis is still ill defined. Together with known intrinsic and extrinsic factors, genetics may play a significant role in the aetiopathogenesis of tendinopathy. ABO and other closely linked genes, COL5A1, and tenascin-C have all been implicated in the aetiopathogenesis of tendinopathy. However the precise role of these genes in causing or protecting individuals from developing tendinopathy is yet to be defined. An interaction between the various intrinsic and extrinsic factors with the genetic make-up of an individual may increase the likelihood of one individual developing tendinopathy over another. Tendinopathy may well be polygenic, involving complex interactions between multiple genes, and could possibly run in families. Further investigations should determine the exact role played by genetic influences in maintaining tendon homeostasis and pave the way for gene transfer therapy to be developed for the management of tendinopathies.
sportEX comment It’s now fairly conclusive that most of the conditions previously referred to as tendonitis are in fact degenerative rather than inflammatory conditions. This research article begins to look at possible underlying causes and speculates on a genetic pre-disposition which if correct may have a considerable effect on athletic screening.
Prevention of Injuries Among Male Soccer Players. Engebretsen AH, Myklebust G, Holme I, Engebretsen L, Bahr R. The American Journal of Sports Medicine 2008;36:1052-1060 This randomised controlled trial was conducted to investigate whether the most common injuries in soccer could be prevented, and to determine if a simple questionnaire could identify players at increased risk and therefore reduce injury. A total of 508 players representing 31 teams were included in the study. A questionnaire indicating previous injury and/or reduced function as inclusion criteria was used to divide the players into high-risk (HR) (76%)
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and low-risk (LR) groups. The HR players were randomised individually into an HR intervention group or HR control group. Results: A total of 505 injuries were reported, sustained by 56% of the players. The total injury incidence was a mean of 3.2 in the LR control group, 5.3 in the HR control group, and 4.9 in the HR intervention group. For the main outcome measure, the sum of injuries to the ankle, knee, hamstring, and groin, there was also a significantly lower injury risk in the LR control group compared with the two other groups, but no difference between the HR intervention group and the HR control group. Compliance with the training programmes in the HR intervention group was poor, with only 27.5% in the ankle group, 29.2% in the knee group, 21.1% in the hamstring group, and 19.4% in the groin,
sportEX comment This isn’t from one of our usual journals but it highlights a growing body of evidence for the use of acupuncture. Here it seems to enhance physiotherapy treatment. The Constant–Murley scoring system consists of four variables that are used to assess the function of the shoulder. The shoulders are assessed separately. The subjective variables are pain and ADL (sleep, work, recreation/ sport) which give a total of 35 points. The objective variables are range of motion and strength which give a total of 65 points. For more information on this test: www.shoulderdoc.co.uk
Effect of spectators on the performance of a physiotherapy exercise. Walsh J, Gill G. Physiotherapy 2008;94(2)Jun:163-167 Thirty six female adult volunteer subjects were timed performing single leg stance once with only the investigator present and once with 3 spectators added. The results showed no difference between the tests.
sportEX comment This was a great idea. In team sports most treatments take place in the presence of other team members. Research into the effects of an audience is therefore welcomed. Unfortunately this didn’t have the added variables of the sort of barracking and banter which goes on in practise but it’s a start.
defined as having carried out the minimum recommended training volume. The Effects of Generalised Joint Laxity on Risk of Anterior Cruciate Ligament Injury in Young Female Athletes. Myer GD, Ford KR, Paterno MV, Nick TG, Hewett TE. The American Journal of Sports Medicine 2008;36:1073-1080 It is known from previous research that women who participate in high-risk sports suffer anterior cruciate ligament injury at a 4-6 fold greater rate than men. This case control study set out to determine if female athletes with decreased passive knee joint restraint (greater joint laxity) and greater side-
sportEX medicine 2008;37(Jul):4-5
Journal watch
Journal Watch A comparative study of whole body vibration training and conventional training on knee proprioception and postural stability after anterior cruciate ligament reconstruction. Moezy A, Olyaei G, Hadian M, Razi M, Faghihzadeh S. British Journal of Sports Medicine 2008;42:373-385 The objective of this study was to compare the effect of a whole body vibration training (WBVT) programme with a conventional training (CT) programme on knee proprioception and postural stability after anterior cruciate ligament (ACL) reconstruction. Twenty athletes with unilateral ACL reconstruction were randomly assigned to the WBVT or CT group; all participants received 12 sessions of WBVT or conventional training.
Pre and post-intervention they measured joint repositioning at 30° and 60° using a Biodex dynamometer and bilateral dynamic postural stability (anteroposterior, mediolateral and overall stability using the Biodex Stability System which is basically and electronic wobble board). Results: The improvement in postural stability in the WBVT group was significantly greater than that in the CT group.
sportEX comment More research on ACLs, but perhaps of greater value is that this paper validates the use of whole body vibration training given that vibration plates are becoming popular in many health centres and private clinics. It also highlights the importance of proprioception training in the rehab process.
A heat acclimation protocol for team sports. Sunderland C, Morris JG Nevill ME. British Journal of Sports Medicine 2008;42:327-333 The impact of four short heat acclimation sessions were examined using 30–45 minutes of the Loughborough Intermittent Shuttle Test (LIST), which is a mixture of periods of intermittent running, consisting of sprinting, interspersed with periods of jogging and walking designed to stimulate game conditions. Seventeen female well-trained games players were split into three groups: an acclimation group working at 30°C, 24% relative humidity (RH), a moderate training group (18°C, 41% RH) and a control group
who did not complete any training between the main trials. The pre-acclimation (A) and post-acclimation (B) trials were separated by 28 days to control for menstrual phase and verified using hormonal analysis. The four acclimation or moderate training sessions utilising the LIST were completed with one or two rest days interspersed between each session in a 10-day period prior to the postacclimation trial (B). Results: In the post-acclimation trial distance run was increased by 33% in the acclimation group but was unchanged in the moderate and control groups. The acclimation group had
to-side differences in knee laxity would be at increased risk of anterior cruciate ligament injury. From 1558 female soccer and basketball players who were prospectively screened, 19 went on to tear their anterior cruciate ligaments. Four height and mass-matched control subjects were selected from the uninjured screened athletes for comparison with each of the 19 injured subjects, making a total of 95 subjects (19 injured; 76 uninjured). Generalised joint-laxity tests at the wrist and hand and anterior-posterior tibiofemoral translation were quantified using the CompuKT knee arthrometer. This detects the relative motion between two sensor pads, one on the patella and the other on the tibial tuberosity and measures the amount of anterior and posterior tibial translation. In other papers it has been given a high intra-rater reliability so
the results should be valid. From the results, a statistical modal was constructed to determine predictors of anterior cruciate ligament injury status. Results: For every 1.3-mm increase in sideto-side differences in anterior-posterior knee displacement, the odds of anterior cruciate ligament–injured status increased 4-fold. A positive measure of knee hyperextension increased the odds of anterior cruciate ligament–injured status 5-fold.
www.sportEX.net
sportEX comment Injury prevention is a hot topic in research at the moment and there is lots of work on ACL problems in the literature. In the first of these papers from The American Journal of Sports Medicine, the players with a significantly increased risk of injury were
a lower rectal temperature and an increase in thermal comfort after acclimation. There was no difference in serum progesterone, aldosterone or cortisol concentrations following acclimation or between groups. The suggestion was that the lower rectal temperature and a concomitant rise in thermal comfort may be partly responsible for the improvement in exercise capacity.
sportEx comment The protocol seems to work. The message here is keep training functional and specific to the sport you play.
able to be identified through the use of a questionnaire, but player compliance with the training programmes prescribed was low and so effect of the intervention on injury risk could not be detected. A group with greater compliance may well have given a great deal more information from which to plan prevention programmes. In the second paper, the results indicate that increased knee-laxity measures may contribute to increased risk of anterior cruciate ligament injury, but the authors do suggest using the measures in conjunction with measures of neuromuscular control of the knee joint to identify high-risk female athletes with high accuracy. Once this is done and the athletes identified, appropriate interventions to reduce injury risk can be planned.
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correct bicycle set-up to minimise the risk of injury By Fran Moore MCSP
W
ithin the sport of cycling, be it road, track or touring, ensuring that the bike is correctly fitted to the cyclist is of prime importance. For cyclists of all abilities, ages and gender, correct bike set-up is paramount in promoting comfort, enhancing performance and preventing injury. A practical guide clarifying key points for any cyclist is provided. Knee pain has been advocated as being the most commonly reported overuse problem in cyclists (1), having been reported to occur in 25% of the cycling population (2). This is closely followed by back and neck complaints (3). It has been suggested that many of these injuries can be prevented or cured if the bike is correctly set-up for the individual cyclist (3). Obtaining the correct bike position for cyclists is a complex process. ‘Posture height’ refers to saddle
For cyclists, correct bike set-up is paramount in promoting comfort, enhancing performance and preventing injury. Many cyclists when starting out, and even when they gain more experience, have little insight into how to set-up their bike correctly. There is a multitude of often conflicting information available on this topic which can be difficult to follow and could appear confusing to someone who has limited knowledge in the area. Furthermore, much of the information fails to stress the relationship between poor bike set-up and injury. This article will look at the reasons why correct bike set-up is essential, with particular reference to injury. A practical guide clarifying key points for any cyclist is provided.
It has been suggested that many injuries can be prevented or cured if the bike is correctly set-up for the individual cyclist 6
position, cleat alignment and pedal position. ‘Posture length’ refers to reach and handle bar position (3). Addressing both of these components should ensure that the bike is correctly set-up for the cyclist. If any of these factors are not correctly adjusted or fine tuned to the cyclist, this can predispose the cyclist to injury (3). The first category of injuries relating to the lower limb often occurs as a result of a poor ‘posture height’, especially a poorly fitted saddle (3). Poor saddle set-up has been linked to overuse injuries at the knee (4,5). A saddle set too low has been associated with increased knee flexion and loading through the patellofemoral joint, creating a risk of developing
patella and quadriceps tendonitis (4) and (6). Similarly, having the saddle too far forward increases the knee flexion angle, which has been linked with quadriceps tendonitis (4). Injuries falling into the second category affecting the lumbar spine and neck are commonly related to poor ‘posture length’, normally as a result of over or under reaching from saddle to handle bars (3). If the cyclist adopts a position that is over-flexed and shortened s/he may develop low back pain and/or neck pain due to the effect that this position will have on the vertebral column (3). The shoe pedal interface is another important factor in the prevention of injuries (7). Incorrect cleat alignment sportEX medicine 2008;37(Jul):6-9
injury prevention cycling
and position has been a factor commonly cited as being a cause of injury at the knee (2). Significant changes in the evolution of cycling have formulated a float system allowing rotation within the shoe and pedal system. This has assisted in reducing the number of injuries, but still relies upon the cyclist to position them correctly in the first instance (7). Although the importance of correct bike set-up has been widely acknowledged, the real challenge is in finding the correct cycling position incorporating all these factors whilst allowing for the individual differences of each cyclist. Methods have been formulated for obtaining correct setup for each of the aforementioned variables. The complexity of such methods varies considerably and to date there is no universally agreed formula. Saddle height, for example, can be calculated using the ‘Inseam method’ or the ‘Greg LeMond method’, or a more simple approach using the heel position and leg length, the latter being much more easy to understand and perform (8). However many of these approaches are not very reliable, especially if the cyclist calculating the measurements is inexperienced. All of the saddle height formulas are estimates only and further adjustments may need to be undertaken (9). Measuring many of the other factors can be equally as challenging. Calculating the reach for the cyclist can be difficult as this often depends upon the cyclists own riding preferences as well as their natural posture. To date, little attention has been placed upon the concept of obtaining optimum reach (3). Much of the literature documented in scientific papers relating to correct bike set-up has not been proven empirically, with the majority of the literature based upon anecdotal www.sportEX.net
evidence. Further research is needed to substantiate such findings. Different measuring systems have been formulated to assist this process such as ‘Fitkit’ and more recently ‘Cyclefit’ (9). A ‘Cyclefit’ is a comprehensive measuring system that integrates anthropometric measurements and a computer program. This formulates the exact position for the individual cyclist (3). However, this system has not been evaluated with regards to its reliability and validity and is currently only accessible through the ‘Cyclefit’ premises in London. It is also important that the cyclist is comfortable when cycling. Cycling is a sport where cycling for many hours at a time is a normal occurrence. Adjusting the bike correctly is important to provide comfort, which will in turn encourage participation (8). As well as injury prevention and comfort, it is essential that bike set-up assists in enhancing performance, especially for those cyclists who begin to take their cycling more seriously. Although correct bike set-up information is readily available, the importance of the prevention of injuries is not emphasised. Much of the literature does not draw any parallels between bike set-up and the potential for injury. It is for this reason that the practical guide explains the potential correlation between correct bike set-up and injury prevention. Other factors such as promoting comfort and briefly discussing the importance of establishing the optimal position in order to enhance performance are also mentioned. The guide has been designed for new cyclists and those who are more experienced. It allows cyclists to check their bike by looking at frame size, reach, saddle height and cleat position,
and provides a ten step guide on what to look out for in order to avoid injury. Cyclists new to the sport will gain basic information on how to get started with setting-up their bike and all cyclists will benefit from the advice on avoiding injury. The practical guide has been gathered from different sources, including scientific papers, bike shops and cycling clubs who often develop their own guidelines and make them available on the internet. All of the sources used have been cited.
KEY POINT The practical guide has been designed for new cyclists and those who are more experienced. It allows cyclists to check their bike by looking at frame size, reach, saddle height and cleat position, and provides a ten step guide on what to look out for in order to avoid injury. References 1. Holmes J, Pruitt A, Whalen N. Lower extremity overuse in bBicycling. Clinics in Sports Medicine 1994;13(1):187-203 2. Gregor R, Wheeler J. Biomechanical factors associated with shoe/ pedal interfaces: Implications for injury. Journal of Sports Medicine 1994;17(2):117-131 3. Mestagh K. Personal perspective: In search of an optimum cycling posture. Applied Ergonomics 1998;29(5):325-334 4. Holmes J, Pruitt A, Whalen N. Iliotibial band syndrome in cyclists. American Journal of Sports Medicine 1993;21:419-421 5. Sanner W, O’Halloran W. The biomechanics, aetiology, and treatment of cycling Injuries. Journal of the American Podiatric Medical Association 2000;90(7):354-376 6. Bailey M, Maillardet , Messenger N. Kinematics of cycling in relation to anterior pain and patellar tendinitis. Journal of Sports Sciences 2003;21:649-657 7. Balthazaar B. The effect of shoe/pedal interface position on overuse knee injuries during cycling. Australasian Journal of Podiatric Medicine 2000;34(4):118-124 8. Burke E. Proper fit of the bicycle. Clinics in Sports Medicine 1994;1(13):1-13 9. Mellion M. Common cycling injuries: management and prevention. Sports Medicine 1991;11(1):52-70.
Further Reading Too D. Biomechanics of cycling factors affecting performance. Sports Medicine 1990;10(5):286-302 7
Practical Guide – bike set-up in cycling Introduction Setting your bike up correctly can be a challenging and somewhat complex task. Many different methods have been proposed. Many of these methods are difficult to follow and even harder to perform. Bike set-up will vary depending upon whether you are road racing, time trailing or merely touring throughout the countryside. Either way, bike set-up is important for the following reasons: n injury prevention n comfort n enhance performance.
Injury prevention The repetitive nature of cycling means that even a slight inconsistency in bike set-up can quickly lead to injury (1). A large amount of energy is transferred through the lower extremities through the bike; as a result the knee joints in particular have high loads placed through them and are therefore prone to injury (2). The incidence of lower limb injuries is very high in cyclists, with knee pain being the most common reported injury (3). Injuries to the lower limb are commonly related to a poor saddle set-up, normally being too high or low. Whereas back and neck problems are commonly related to poor frame size or over/under-reaching of the handle bars (4). For a cyclist who doesn’t have any significant anatomical asymmetries, such as one leg longer than the other, correctly adjusting the bike to the cyclist can cure and prevent injuries from occurring (4).
Comfort One of the most important principles of correct bike set-up is comfort. Not only will it be difficult to cycle over a long period of time if not comfortable, it could also potentially lead to injury. Both of these factors may reduce the enjoyment of cycling and ultimately reduce participation (5).
Enhance performance During pedalling, the hip, knee and ankle joints move through a given range of motion. As a result, the muscles of the leg will work optimally within a certain range of motion. This will mean that the muscles will be able to produce maximal power output. Similarly, if the bike position is not setup optimally it will require greater effort by the cyclist, thus reducing the overall efficiency and cycling performance.
What is correct bike set-up? Many different factors need to be considered when attempting to set-up your bike appropriately. The following information is a rough guide only. Should you develop any problems as a result of this information it is advisable you should seek further help. At the end of this information there is a number of websites that will provide you with further information. The following factors will be addressed: n Frame size n Saddle height n Reach n Cleat position
Remember the bicycle is adjustable and the cyclist is adaptable, the bicycle should be adjusted to the cyclist! (5) 8
Frame size Many different methods have been devised to determine correct frame size, such as the inseam method, but for a simplified method for a standard racer or touring bicycle there should be approximately 2.5-5cm clearance between the crotch and the top tube of the frame.
Saddle height Several different formulas have been devised to calculate saddle height. The most basic formula is the heel method. This involves the cyclist sitting on the bike in a normal riding position. Rotate the pedal backwards, unclip and place the heel flat on the pedal. Correct saddle height is the point that the heel remains in contact with the pedal at the bottom of the peddle stroke. This should also equate to the knee joint being in a bent position of approximately 20300 at the bottom of the pedal stroke (figure 1). Ensure that the saddle is not tilted, but in a level position (figure 2) (5).
Reach Reach is often referred to as posture length. This is defined as the distance sportEX medicine 2008;37(Jul):6-9
injury prevention cycling from the back of the saddle to the handle bars. Full arm length and torso length also need to be considered. It is important that the back and neck resume a relaxed position. If the posture is too short it will place more strain on the lower back, the pelvis will tilt backwards cramping the lower part of the spine. This will in turn force the head and neck forwards into an unnatural position (6).
tilt
Figure 1: Heel of foot on pedal
adjust
Figure 3: Cyclist has adopted an over-flexed position. Note the curved spine and forward head posture
Figure 2: Correct saddle position Figure 5: Cleat position
Cleat position The ball of the foot should be directly positioned over the pedal (1).
Measuring systems Many different measuring systems have been formulated to provide the correct bike set-up for individual cyclists. Measuring systems such as ‘fitkit (6), and more recently ‘cyclefit’ (4) have devised an anthropometric measuring system and corresponding computer programme that calculates the optimal cycling posture. These systems are not easily accessible and currently cyclefit is based in London.
Useful contacts: n British Cycling Federation: www.cobr.co.uk/e-cobr_information/t_ and_r_section/sections/intro_mtb/ setting_your_bike_up.shtml n British Cycling website: www.britishcycling.org.uk/ n Bioracer (website looking at bike set-up): www.bioracer.com n Cyclefit (shop based in London who assess bike set-up): www.cyclefit.co.uk n Bikefit (shop assessing bike set-up): www.bikefitkit.com
References 1. Balthazaar B. The effect of shoe/pedal interface position on overuse knee injuries during cycling. Australasian Journal of Podiatric Medicine 2000;34(4):118-124 2. Gregor R, Wheeler J. Biomechanical Factors Associated with Shoe/Pedal Interfaces: Implications for Injury. Journal of Sports Medicine 1994;17(2):117-131 3. Holmes J, Pruitt A, Whalen N. Lower Extremity Overuse in Bicycling. Clinics in Sports Medicine 1994;13(1):187-203 4. Mestagh K. Personal perspective: In search of an optimum cycling posture. Applied Ergonomics 1998;29(5):325-334 5. Krivickas L. Anatomical factors associated with over use injuries sports injuries. Sports Medicine 1997;24:132-146 6. Mellion M. Common Cycling Injuries: Management and Prevention. Sports Medicine 1991;11(1):52-70 www.sportEX.net
Figure 4: Cleat position – the ball of foot on pedal
The Author Fran Moore is a Chartered physiotherapist who graduated from the University of the West of England (UWE) in 1999. She has been working in the field of musculo-skeletal outpatients and sports injuries for the last five years and is currently in the process of completing a sports physiotherapy MSc dissertation at the University of Wales College of Health. She has a clinical interest in sports injuries and is undertaking a research project investigating hip muscle strength and function in cyclists with knee pain. She currently works for Courtyard Clinic and Bupa Wellness treating sports people of all levels, as well as pitchside rugby physio for UWE.
10 point step by step guide to avoid injury 1. Avoid over-flexing the spine - try not to be too bunched up on the bike. Either get a longer stem or readjust the seat post so that it is positioned slightly further back. Being over-flexed can cause neck, thoracic (mid back) and lower back problems. 2. Try to avoid over-reaching, as this can also create low back pain or hip pain. 3. Make sure your saddle is the correct height. Having a saddle too high or too low can cause knee pain, ITB (iliotibial band) problems and hamstring injuries. 4. Make sure that when your foot is at the bottom of the revolution you can get your foot flat on the cleat. Having an excessively plantarflexed (pointed) foot can cause calf related injuries (5). 5. Keep your saddle in a neutral position. Having your saddle tilted can not only create injuries but can cause problems in the more delicate areas of the anatomy (5). Make sure your saddle has adequate padding! 6. Cleats need to be positioned correctly. Those with more floatation can be beneficial particularly if you are prone to knee pain (1). 7. Look for rocking of the pelvis on the bike whilst you are riding. This is an indication that the saddle may be too high (5). 8. Make sure that your foot is positioned centrally on the cleat, as cyclists often adopt a pigeon toed riding position (riding with your foot rotated inwards). This can pre-dispose to injury, especially knee pain (1). 9. Check to make sure you are not adopting a toe out position, as this can cause as many problems as a toe in riding position (1). 10. Finally make sure you are comfortable on the bike, the repetitive nature of cycling means that you will be prone to injury if the bike does not fit you correctly. Be aware that adjustments may be required to ‘fine tune’ the bicycle to the rider. Make sure that adjustments are made gradually changing one thing at a time (6).
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Golf injuries have received little attention in the literature. Low back injuries in golf are both common and disabling but the specific mechanisms responsible for these injuries are unclear (1-3). It has been suggested that the mechanics of the golf swing may predispose to spinal injury when subjects have restricted movement in an adjacent part of the kinetic chain. Hip rotation deficits have been postulated as one possible risk factor and cause of low back pain in golfers. The aims of this study were to systematically review the evidence that investigated either the incidence of or correlation between, hip rotation deficit and low back pain (LBP) in golfers and to highlight any mechanisms of such. Studies were identified through a search on Medline, Cinahl, Embase, Web of Knowledge and Sport Discus data bases from the earliest date to December 2007. The key search terms were golf; injury; low back pain and hip rotation. No language restrictions were imposed. The preliminary evidence suggests that hip rotational deficits have been found to be significantly correlated with low back pain in both the sporting and non-sporting golfing population, although the studies are few in number (4-8). No studies have been carried out on amateur golfers, where alternative symptom mechanisms may exist to those of professionals. Future studies are necessary to investigate whether there is a relationship between hip rotation range and back pain in amateur golfers. 10
hip rotation deficits and low back pain in golf: a review of the literature Eoghan Murray, BSc (Hons) MSc MSCP SRP
G
olf has increased in popularity and participation raised considerably over recent years because it is an activity which allows a variety of individuals to play simultaneously regardless of skill, gender or age (9). Golf ranks as the third highest participation sport amongst Australian adults (10) and England boasts the highest number of golf courses in Europe (2). Golf presents many potential cardiovascular health benefits, though conversely can also pose an injury risk (11). Golf injuries have received limited attention in the literature, however three epidemiological studies (1-3) have shown the most commonly injured area to be the lower back (1, 3). Injury is common among both amateur and professional golfers. Low back injuries account for 23.7-34.5% of all injuries in one study (3) with another study suggesting a prevalence of 55% (12). Lower back injury has been shown to result in longer absences from golf than any other area (2), being responsible for missed play up to 55% of the time (12). Yet despite its prevalence there is little research concerning why this is the case (13). Golf injury is both common and disabling, but the specific mechanisms responsible for these injuries still remain unclear (14). It is postulated that the mechanism of injury in professionals and amateurs is different. The most common mechanism in professional golfers is overuse (3), which is deemed to be compounded in amateurs by poor technique (1). Amateur golfers who exhibit such poor swing mechanics have been shown to develop a greater torque in the lumbar
spine that may result in overstrain to the spinal region (15). Studies have demonstrated contrasting findings with regard to determining golf injury risk (1, 2). One retrospective study with 1444 respondents found a slightly higher rate of injury among the lower handicap golfers (1). Another study found no difference in injury rate with handicap (2), though this study did have a smaller cohort, with only 703 golfers interviewed. There is little published research into why low back injury/pain is so prevalent in golf (13), and the specific mechanisms responsible for these injuries are not well understood. This review will attempt to correlate any associated hip range of movement deficits and compensated or supramaximal range in adjacent regions with a history of low back pain in amateur golfers.
Golf Swing Mechanics and Low Back Pain It has been suggested that the mechanics of the golf swing may predispose to back injury when subjects have limitation of movement in an adjacent part of the kinetic chain. In the golf swing, the lead leg (the left leg of a right handed golfer) provides a fulcrum around which the pelvis rotates. This acts as a pivot point about which rotation of the lumbar spine and pelvis can occur (3, 16). The hips are of great importance in the initiation of the swing providing power to drive the ball (17). The modern swing dictates greater shoulder turn relative to the hips which results in a greater potential sportEX medicine 2008;37(Jul):10-14
rehabilitation golf injuries for increased torque to the lower back. This has long been suspected as a major source of injury. The modern swing or ‘reverse C’ position of the follow through produces a hyperextension and right lateral flexion moment to the lumbar spine in the right handed golfer, having the potential to result in facet joint irritation if consistently repeated (3, 16, 18). It is thought that the twisting motion of the lumbar spine at the top of the back swing and subsequent derotation and hyperextension through the downswing and follow-through is the basis to such lower back complaints in golf (18). The modern swing has been shown to be associated with increased lumbar torque, which can increase low back pain in susceptible golfers (9, 15). This distinct asymmetric trunk motion during the golf swing, a combination of counter-clockwise axial rotation and right lateral flexion, is referred to as the crunch factor (12). The axial velocity and right lateral flexion angle increases during the forward swing through to the follow through (12). A high crunch factor is damaging to the lumbar spine and may result in injury and pain (13). The asymmetric mechanics of the golf swing subjects the lumbar spine to large amplitudes of movement and force, with peak compressive loads measured during the golf swing of up to eight times one’s bodyweight at the finish or terminal swing position (3, 12). It has been found that back problems most frequently occur during this follow through phase, with 29% of injury occurring during the terminal finish phase of the golf swing (1). It is apparent from the literature that low back injuries in golf are related to poor swing mechanics and/ or repetition of the swing, though the exact causes of low back pain have not yet been fully addressed or determined.
Review of Relevant Literature The literature contains very little reliable research on golf injuries. The relationship between hip mobility and lower back pain has been examined in only a few reports. Studies undertaken in non-athletes have shown that patients who had a Type III pattern of total hip rotation, less medial hip rotation than lateral rotation, were more likely to develop low back pain (6-8). www.sportEX.net
These studies showed that asymmetry of medial and lateral rotation range of movement is prevalent in patients with low back dysfunction. However, in one study 27% of the healthy subjects also demonstrated this hip rotation pattern, as opposed to 48% in the low back pain group (6). The patient group did have a high proportion of Type III rotation pattern, but was also generally older than the healthy subject group. It has been suggested that age can be a determinant of hip rotation (6). In another study the methodology is questionable (7); a goniometer was used instead of an inclinometer which has been shown to be more reliable (6). It is thought that this range of movement pattern (Type III) may lead to deleterious cumulative stress or strain to the soft tissue and bone of the lumbar spine (6). It has been theorised that any loss of rotation at the hip may place excessive mechanical stress on the lumbar spine (6). Normal values for medial and lateral hip rotation range of movement vary among different reports, with no real consensus determined. The American Academy of Orthopaedic Surgeons report medial and lateral hip range of movement to be equal (15) and the Committee on Medical Rating of Physical Impairment describe more lateral than medial hip range of movement in their report on normal ranges (19). Without a normal standard measure, it is questionable whether one can determine if there is a deficit. In studies such as these, using subjects from the non-golfing population, there are issues of generalisability to be raised, as this cohort will not necessarily be representative of the golfing population. A lack of a specific diagnosis may also limit the generalisability of the studies (7). It is certainly questionable whether the findings can be applicable to subjects outside the studies. It has been found that unilateral hip range asymmetry is prevalent in patients
Figure 1: The modern swing or ‘reverse C’ position of the follow through
with low back dysfunction (6-8). In the majority of studies there is only speculation with regard to the various diagnoses and cause for the back pain as well as for the limitations of range of motion (5, 6, 7, 18), with only one study (6) providing a specific diagnosis for each subject. Range of movement deficits have also been implicated in repetitive injuries in various sports. It has been observed in professional tennis players that internal rotation range of movement deficits in the dominant lead shoulder and lead hip correlated to the presence of respective shoulder and low back pain (5). The lead hip had a 7.6o deficit compared to the non lead leg in the symptomatic low back pain group whereas there was only a 3.2o difference for the asymptomatic group (5). It is thought that similar mechanisms may exist in golf, although study numbers are small (18). An anecdotal case report (14) hypothesised that an increase in hip rotation reduced torsional load on the lumbar spine of a professional golfer who was unable to complete a round of golf or a practice session without severe pain. Consequently an increased range of hip turn resulted in a cessation of his back pain. A case study alone does not present a picture of injury patterns from which conclusions can be generalised, but does allow a hypothesis to be
Preliminary evidence suggests that hip rotational deficits are significantly correlated with low back pain in golfers, tennis players and the non-sporting population 11
generated. The hypothesis is that the lead hip (left leg in a right handed golfer) acts as the primary pivot point and so experiences a significant amount of torque. Repetitive motion and overuse may result in micro-trauma that presumably leads to capsular contracture and range of movement deficits (18). It has therefore been postulated that lower back pain in golfers may be secondary to limited rotation range of
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movement in the hip joint (7), with one study finding that professional golfers demonstrated a significant correlation between hip inward rotation range of movement deficit and the incidence of lower back pain (18). This is the only such study undertaken with golfers. In this instance the subjects were professionals and are therefore not necessarily representative of the total golfing population and may not be transferable or inferred to the amateur golfing population as a whole. This study (18) again speculates about the various diagnoses and causes for the back pain as well as the limitations of range of movement. This is a conceptual problem, as no clinical diagnosis or attempt to define/categorise the nature of the low back pain has been made. This would have severely increased the duration of testing, the financial cost of the study and ultimately its viability. It was therefore unrealistic to make a diagnosis at this time. A lack of a specific diagnosis may also limit the generalisability of the study. The study (18), like most of the published literature in this area is further compounded by the fact that as an observational cross sectional study, the findings are only indicative of one moment in time. The data collection is undertaken at one point in time and only allows a snap shot of reference. It
can only provide prevalence data, with no information about incidence. These observational studies cannot determine the order in which elements occurred, whether low back pain was as a result of hip rotation deficit or vice versa. There is no inference of causality and it cannot be ascertained as to which variable is having an effect on the other and therefore the relationship direction cannot be determined. All that can be established is whether there is a correlation between the two variables. A ‘self reported’ history of injury, will also induce an element of recall bias, which is especially significant in a study which asks to report injury throughout a subject’s entire career (4). In this particular study (4), dancers had to report any back or lower limb injury that impacted on their ability to practice or perform during their whole dance career. This was in contrast to most of the other studies which only requested a self reported injury history within the previous twelve months (1, 2, 3, 5, 18). There is likely to be a variation in injury recall between study subjects; those who sustained a more severe injury may be more likely to remember the incident than those who had suffered a relatively mild injury, and an injury which was notable to one subject may not be deemed notable to another. Self defining an injury is largely subjective and once again raises the issue of study applicability and generalisability to the larger population. Unrelated subject design means that individual differences among the non-randomised groups may distort the results. Such confounding variables between the groups may mean they are neither in fact comparable nor representative. Ideally participants should only differ with respect to the variable of interest. The study subjects were not matched, therefore did not avoid these potential confounding variables. The relationship between low back pain and hip rotation deficit may well be confounded by age or gender, although this was not found to be the case in a number of studies (1, 2). The most important aspect of defining an injury is identifying that the injury can be in fact attributable to golf. It must be considered that golfers may have physically demanding jobs or may regularly participate in other sports that could combine with golf sportEX medicine 2008;37(Jul):10-14
rehabilitation golf injuries to cause the injury. Comprehensive characterisation questionnaires are required to determine this and other such confounding variables (2). It is speculated that an increased load on the lumbar spine is a major factor that contributes to lower back pain in professional golfers; these forces may be then transmitted to the lumbar spine when lead hip rotation range is decreased (18). No studies to date have been performed on amateur golfers, where an alternative symptom mechanism may indeed exist.
ballet dancers; those with a self reported history of injury had a greater ‘compensated’ turnout than dancers with no history of self reported injury. It was found that 70% of subjects had a functional turnout that exceeded their passive hip external rotation range (4). As a consequence of hip rotation deficits, it is suggested that compensated rotational stress proximal or distal to the hip joint can lead to high joint stresses that increase the risk of damaging forces at the lower back (4).
Compensated/ Supramaximal Joint Range
Conclusion
A study found that golfers with lower back pain tended to use considerably more thoracic rotation in their swings than the maximum rotation range they were able to obtain from a neutral posture and controlled speed (13). Maximum thoracic rotation range of motion was found to be more restricted in the group with lower back pain. This resulted in players using a ‘supramaximal’ range of spinal motion when swinging. This compensated range may result in an overloading and consequential failure of structures. Once again one cannot conclude whether the position or velocity differences between the professionals with and without low back pain were a cause of, or a result of pain. This reiterates the lack of causality inference in the study, which is a common theme in the published literature (18, 13, 5). Due to a Type II error this ‘supramaximal’ range was not found to be significant due to insufficient numbers recruited for the study (13). With such low recruitment numbers it is not possible to randomly select the subject population. This would therefore limit any generalisability of the study, if in fact it was found to be significant. The study (13) also made no attempt to diagnose or categorise the nature of the low back pain, a common theme found throughout the literature. As in other literature concerning low back pain, subclassification may result in improved results and findings, avoiding the “washout” effect often created by the use of heterogeneous groupings. This compensated or supramaximal range was also found in a retrospective cohort study involving www.sportEX.net
required to investigate whether there is a relationship between hip rotation range and back pain in amateur golfers
The review found little evidence of reliable high quality investigations into the role of associated hip rotation range of movement deficits and low back pain in golfers or even the wider demographic as a whole. The preliminary evidence does suggest that hip rotational deficits have been found to be significantly correlated with low back pain in professional golfers, tennis players and also the non-sporting population. The causes of the low back pain and the range of movement deficit still remain unclear, with capsular shortening and muscular hypertonicity hypothesized. There are a few studies emerging on the role of compensated and supramaximal ranges in overloading structures as a potential mechanism and cause of low back injury. Future prospective studies that demonstrate a decrease in low back pain after addressing such range of movement deficits and compensations are required to validate these theories. Low back pain is prevalent among amateur golfers, but the mechanism still remains unclear. No studies have been performed in amateur golfers, where an alternative symptom mechanism may exist to those of professionals. Future studies are Figure 2: The stages of a golf swing
References 1. Carroll MC, Rettig AC, Shelbourne KD. Injuries in the amateur golfer. The Physician and Sportsmedicine 1990;18;122-126 2. Gosheger G, Liem D, Ludwig K, et al. Injuries and overuse syndromes in golf. American Journal of Sports Medicine 2003;31;438-443 3. McHardy A, Pollard H, Luo K. Golf injuries a review of the literature. Sports Medicine 2006;36;171-187 4. Coplan JA. Ballet dancer’s turnout and its relationship to self reported injury. Journal of Orthopaedic and Sports Physical Therapy 2002;32;579-584 5. Vad VB, Gebeh A, Dines D, et al. Hip and shoulder internal rotation range of motion deficits in professional tennis players. Journal of Science and Medicine in Sport 2003;6;71-75 6. Ellison JB, Rose SJ, Sahrmann SA. Patterns of hip rotation range of motion: a comparison between healthy subjects and patients with low back pain. Physical Therapy 1990;70;537-541 7. Cibulka MT, Sinacore DR, Cromer G. Unilateral hip rotation range of movement asymmetry in patients with sacro-iliac joint region pain. Spine 1998;23;1009-1015 8. Mellin D. Hip rotation and lower back pain. Spine 1998;12;134-139 9. Parziale JR. Healthy swing: a golf rehabilitation model. American Journal of Physical Medicine and Medical Rehabilitation 2002;81;498-501 10. Batt ME. Golf injuries an overview. Sports Medicine 1993;16:64-71 11. Fradkin AJ, Cameron PA, Gabbe BJ. Golf injuries common and potentially avoidable. Journal of Science and Medicine in Sport 2005;2:163-170 12. Sugaya H, Tschiya A, Moriya H, et al. Low
The most important aspect of defining an injury is identifying that the injury can be attributable to golf 13
back injury in elite and professional golfers an epidemiological and radiographic study. In: Farrally MR, Cochran AJ, editor. Science and Golf III: Proceedings of the World Scientific Congress of Golf;1998Jul:20-24; Human Kinetics 1998;83-91 13. Lindsay D, Horton J. Comparison of spine motion in elite golfers with and without low back pain. Journal of Sports Sciences 2002;20:599-605 14. Grimshaw P, Burden AM. Case report: reduction of low back pain in a professional golfer. Medicine and Science in Sports and Exercise 2000;32;1667-1673 15.Joint Motion Method of Measuring and Recording. Chicago III. American Academy of Orthopaedic Surgeons; 1965 16. McHardy A, Pollard H. Muscle activity during the golf swing. British Journal of Sports Medicine 2005;39;799-804 17. Bechler JR, Jobe FW, Pink M, et al. Electromyographic analysis of the hip and knee during the golf swing. Clinical Journal of Sports Medicine 1995;5;162-166 18. Vad VB, Gebeh A, Dines D et al. Low back pain in professional golfers the role of associated hip and low back range of movement deficits. American Orthopaedic Society for Sports Medicine 2004;32:494-497 19. The Committee on Medical Rating of Physical Impairment. A guide to the evaluation of permanent impairment of the
extremities and back. JAMA. 1958;166 (Special Ed).
Other interesting articles n Evans K, Refshauge KM, Adams R, et al. Predictors of low back pain in young elite golfers: a preliminary study. Physical Therapy in Sport 2005;6:122-130 n Hume PA, Keogh J, Reid D. The role of biomechanics in maximising distance and accuracy of golf shots. Sports Medicine 2005;35:429-449 n Burden AM, Grimshaw PN, Wallace ES. Hip and shoulder rotations during
the golf swing of sub 10 handicap players. Journal of Sports Sciences 1998;16:165-176 n Grimshaw P, Giles A, Tong R, et al. Lower back and elbow injuries in golf. Sports Medicine 2002;32;655-660 n Lindsay DM, Horton JF, Vandervoort AA. A review of injury characteristics, aging factors and prevention programmes for the older golfer. Sports Medicine 2000;30:89-103. n Batt ME. A survey of golf injuries in amateur golfers. British Journal of Sports Medicine 1992;26:63-65.
The Author Eoghan Murray is a specialist musculoskeletal physiotherapist working for Pure Sports Medicine (London). He undertook his physiotherapy degree (BSc Hons) at the University of Liverpool (2002) and has recently completed his MSc (Sports and Exercise Medicine) at Barts and The London (2007). His original research paper for his MSc dealt with the relationship between hip rotation deficits and low back pain in amateur golfers.
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sportEX medicine 2008;37(Jul):10-14
medicine in sport sports psychology
The aim of the article is to introduce the concept and present the psychological principles of rehabilitation goal-setting. The article will mainly focus on presenting practical suggestions as to how goal setting could be used to enhance athletes’ rehabilitation adherences.
Back to Basics: Using Goal Setting to Enhance Rehabilitation BY Monna Arvinen-Barrow
F
or the past four years I have dedicated a big part of my life to researching the role of therapists in providing psychological support to athletes when injured. Coming from a non-physiotherapy background myself (apart from being on the receiving end in late 1980s when seriously rupturing my ankle ligaments); I believe my perspective on these issues has been that of a learner, observer, and now after few years of extensive research, hopefully of an informer. By no means am I trying to place myself into “therapists’ shoes”, but rather give some suggestions as to how could psychology be used as part of rehabilitation physiotherapy. How to conveniently implement such within practice, in my opinion is up to the individual therapist in question.
Background In recent years the number of people taking part in sport and exercise related activities has been on the increase (1). Such trends are encouraging given the research and evidence supporting the role of activity in health and the risks of physical inactivity (2). Unfortunately, along with increased levels of sport and exercise participation, the risk of encountering sport and exercise related injuries has also increased. In the UK, sport and exercise related injuries account for nearly 33% of all injuries (3), and the likelihood of injury has significantly increased over the past 15-20 years (4). As a result, the risk of sustaining a sport injury is a real and ongoing threat for recreational and elite athletes alike (5) and it has even been suggested by Brown (6) that “serious athletes come in two varieties: those who have been injured, and those who have not www.sportEX.net
been injured yet”. There is no question that sport injury is often a result of a range of external and internal factors. In most cases, due to advanced medical technology, full physical recovery can usually be seen as a likely outcome. However, despite the potential for full physical recovery, many athletes are unable to return to their pre-injury level of performance (7). Often the inability to return to sport is due to psychological factors such as re-injury anxiety, lack of motivation, or feelings of self-doubt. In essence, “the impact of injury is far more than physical; it can jeopardise an athlete’s confidence, self-esteem, and sense of identity” (6). Over the past few decades, the interest in the role of psychosocial factors as part of the injury process has rapidly increased (8, 9). Early psychological research into sport injuries has focused largely on trying to determine a variety of psychosocial antecedents (10). It has been proposed that individuals with inadequate personal resources and skills and who have experienced several recent stressors in their lives are more likely to encounter injuries than those with converse characteristics (9). In addition to the above, an injury itself is also regarded as a stressor. That is, an injury is the cause of stress, and the ways in which individual athletes evaluate the injury can vary greatly. According to the integrated model of psychological response to sport injury and rehabilitation (11), the athlete’s evaluation of the injury and rehabilitation is influenced by personal and situational factors. These include injury characteristics, personal demographics, psychological and physical differences, and a range of social, environmental and sport related aspects. An outcome from the evaluation process will then in turn have an effect on the athlete’s emotional and behavioural responses, all of which will have 15
an impact on the actual recovery outcomes. In other words, the success of any injury rehabilitation programme is largely influenced by the ways in which athletes think, behave, and feel during the rehabilitation process.
The ultimate goal: getting back in play A successful rehabilitation is often characterised by therapists and athletes alike as getting back to the pre-injury level of performance. As an example, one of the therapists I interviewed as part of my thesis stated that for her, successful rehabilitation meant that the athletes “return to the level of which they had been playing previously. And, particularly if they are youngsters, not only that they return to that level but that they have the potential to go on… to achieve the potential they would have done before the injury”. Such is often reflected by the athletes in general, as their expectations of rehabilitation outcome are often linked with their ability to get back in play (12): “I just expect to be able to play… back at the level that I was before I think… just… just to go back to what, I think you just want to be back able to do what you did before the injury” (an injured female football player). Literature in general tends to agree with the above, as often rehabilitation is seen as a treatment or treatments designed to facilitate the process of recovery from injury, illness, or disease to as normal a condition as possible.
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Adherence and treatment compliance: ensuring rehabilitation success One of the ways in which successful rehabilitation can be achieved is to ensure that athletes comply and adhere well with the treatment and the rehabilitation programme. Much research, investigating health related behaviours, tends to suggest that in order to achieve the desired outcome, individual adherence to the treatment programme is necessary (13). A wealth of research exists to suggest that athletes who comply with their rehabilitation exercises and adhere to their rehabilitation programme also tend to cope better with their injuries (14). I recently completed a comprehensive UK national survey (15) on the role of psychology as part of rehabilitation physiotherapy. The findings suggested that 143 (39.61%) of the therapists surveyed believe that compliance with the rehabilitation/treatment programme is one of the most common characteristics among athletes who cope well with their injuries. Similarly, 126 (34.9%) therapists indicated that non-compliance with the rehabilitation/ treatment programme was often regarded as a characteristic of an athlete who does not cope with their injury. In other words, it appears that rehabilitation adherence, athletes’ coping skills, and successful rehabilitation are interlinked. To an extent, a successful rehabilitation is dependent on how an athlete is coping with his/her injury, and how the coping ability is having an effect on treatment compliance and rehabilitation adherence. This in turn is seen as influencing the rehabilitation outcomes. Existing research has also identified a range of personal and situational factors which can be either facilitative or debilitative for rehabilitation adherence. For example, self-motivation has been regarded as having a major impact on the rehabilitation process and treatment compliance (16). According to Taylor and Taylor (7), having motivation during rehabilitation is essential, as it “enables an athlete to offer sustained effort in the face of compelling and competing obstacles, including pain, fatigue, boredom, frustration, setbacks, and the desire to do other less pleasant activities” (p.118). In short, if an athlete is not motivated to partake in the rehabilitation programme, even the most effective programmes will fail to be successful. Some of the
situational factors influencing rehabilitation adherence include the rehabilitation environment (home, treatment sessions), rehabilitation scheduling, and the therapistathlete relationship (13). Of the above, the relationship between the therapist and the athlete has been highlighted as important by both the athletes and the therapists (17, 18). In order to build a successful rehabilitation relationship, an athlete needs to have trust and confidence in the therapist. If the athlete does not like the therapist, or believe that he/ she knows better than the therapist, achieving treatment compliance is an unlikely outcome (19). For that reason, building a good, or should I say an excellent rapport with the injured athlete is crucial for compliance, and ultimately a core element for successful rehabilitation. I believe a quote from a therapist working with high level athletes encapsulates this well: “Certainly it (successful rehabilitation) comes down to compliance, and I think the quality of the relationship that is built between the therapist and the athletes, is probably the most important thing; because it’s that relationship that will either get you compliance or not compliance.” To summarise, a key (or at least one of the keys) to successful rehabilitation depends on the athlete’s rehabilitation adherence and treatment compliance. As therapists are often the primary medical professionals looking after the injured, they are in an ideal position to ensure that athletes comply with their treatment, and to facilitate rehabilitation adherence. The question now is, how?
Psychological interventions in rehabilitation: focus on goal setting A bulk of research exists to indicate that a range of psychological intervention techniques have been found to be useful during sport injury rehabilitation. These include the use of goal setting, imagery, relaxation techniques, positive self-talk, and seeking social support. All of the above methods have been found to be useful, and are often associated with effective and rapid recovery from sport injury (6). I will focus on the use of goal setting as a means for improving rehabilitation adherence and treatment compliance for six main reasons: n Goal setting has been found to have a positive effect on increasing athletes motivation, rehabilitation adherence and compliance during injury rehabilitation (20) n Setting goals during rehabilitation can have a positive effect on the athlete’s physiological and psychological healing (7) n Therapists themselves feel that goal setting sportEX medicine 2008;37(Jul):15-19
medicine in sport sports psychology
In order to build a successful rehabilitation relationship, an athlete needs to have trust and confidence in the therapist. is a useful tool in improving rehabilitation adherence (19) n Therapists are already reporting frequent use of goal-setting (15, 21, 22) n Although therapists are frequently using goal setting, it is often utilised in an unstructured and unorganised way (23) n Existing research tends to suggest that despite frequent use of goal setting, many therapists feel that further training in using goal setting in practice could be useful (15, 21, 22).
Why set systematic goals during rehabilitation? Goal setting is vital and very effective because it is something that athletes can measure themselves and see how they are doing (23). According to Hardy, Jones, and Gould (24), goals should identify specific targets that lie within the performer’s control. Goals should also be set in a staircase format, ie. easy and attainable short-term goals leading towards harder and challenging medium and long-term goals (25). When applied to sport injury rehabilitation, a flexible approach to goal setting should be applied (26), as injury rehabilitation process is hardly ever a linear progression towards the desired outcome. In fact, the rehabilitation process itself is a complex process and consists of a range of physical, psychological, and emotional needs. At all times the medical professionals working with injured athletes should keep in mind that each individual athlete and his/her injury are unique. Therefore in order for a goal setting programme to be successful, therapists should ensure that any planned interventions meet the athlete’s needs.
Types of goals for rehabilitation When planning rehabilitation goal setting, both the therapist and the athlete should be aware of the different types of rehabilitation goals. According to Taylor and Taylor (7) at its best, a rehabilitation goal setting programme incorporates all areas of rehabilitation. The aim of such goal setting should be to identify clear objectives for the rehabilitation through physical, psychological, and performance goals.
conversation between the therapist and the athlete in which crucial physical aspects of rehabilitation are discussed and explained. This should be followed by setting clear goals for each of the components of physical recovery: range of motion, strength, stability, stamina, flexibility, and any other relevant physical parameters (7).
2) Psychological rehabilitation goals Addressing psychological aspects of the recovery process should be done in a similar manner to physical aspects. Often issues associated with motivation, self-confidence, focus, and anxiety (re-injury) should be discussed and included in the goal setting. One of the most effective ways to initiate psychological rehabilitation goals is through rehabilitation profiling (7).
3) Performance goals An injury and the subsequent rehabilitation period should not be treated as a layoff from training and a time when an athlete will fall behind in their development. On the contrary, rehabilitation, if managed and utilised effectively, can be a time in which substantial performance gains can be made in areas which, during regular training, might have not received priority. According to Taylor and Taylor (7) the four primary areas for performance goals are technical and tactical development, physical conditioning, mental training, and return-to-form. In addition, well planned and structured rehabilitation goal setting will also consider physical, psychological, and performance goals for different levels of rehabilitation. These include: goals in relation to the ultimate level of recovery (long-term goals), goals for different stages of rehabilitation (medium-term goals), and daily goals (short-term goals). In addition, goals in relation to their lifestyle should also be considered and set, as often existing lifestyle (ie. sleep, diet, alcohol and drug use, relationships, work and school commitments) can either assist or hinder rehabilitation adherence and ultimately have an effect on the outcome.
1) Physical rehabilitation goals
Principles of rehabilitation goal setting
Physical goals can enable a clear direction for the physical aspects of recovery. The process for setting physical goals should begin with a
Gould (27) put forward six main guidelines for setting effective goal setting for rehabilitation. First, goals should be challenging, realistic, and
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attainable. As the therapists are the experts in relation to the physiological aspects of the healing process, their knowledge and opinion in relation to the above should be one of the primary matters to consider. Second, the goals should be specific and concrete. Setting target dates enables the athlete to see beyond the present, and thus their motivation with the rehabilitation is likely to uphold during moments when the pain and discomfort take over. Gould also suggested that the athletes should focus on the degree of, rather than the absolute, attainment of the goals. Evidence to support the above has also been found in the literature (23). it is important to stress that even if the athlete hasn’t necessarily achieved the goal you emphasis the progress eg. “We got eighty percent of the way there, it may be for the last twenty percent you manage to achieve on your own before I see you again next time”. It is very important that you never send an athlete out with an impression that the goal was never reached. When setting goals, one should always remember that goal setting is a dynamic process. In order for goal setting to be successful it is imperative for the athlete to be an active part of the process. An athlete should have an understanding of how
Six Steps for Successful Rehabilitation Goal Setting (for more details see Gould (27) 1. Set challenging, but realistic and attainable goals 2. Set goals that are specific and concrete 3. Focus is on the degree of, rather than on the absolute attainment of goals 4. Remember that the goal setting process is dynamic 5. Prepare a written contract with the injured athlete 6. Provide regular feedback to set goals, and how these goals can have a positive impact on the rehabilitation outcome. If the goals are not accepted by the athlete, the goal setting programme is likely to be ineffective. Thus, therapists should place great emphasis on including the athlete in the process of goal setting. By discussing goal setting with the athlete a therapist is more likely to be able to produce a programme that not only is effective, but is also tailored to the individual in question. Once goals have been set and agreed upon, it is advisable to prepare a written contract with the athlete. Having a written contract is beneficial to the athlete and the therapist in a number of ways. A contract can hold the athlete accountable for the fulfilment of the contract. Finally, in order to ensure rehabilitation success, constant evaluative feedback is essential. This could be done through tangible physical measures (ie. changes in range of motion) or through psychological measures. Most importantly, it should be done through effective communication between the athlete and the therapist. By clearly demonstrating the progress so far to the athlete, he or she is then able to see rewards for their efforts, thus making these efforts worth while. Regular feedback also provides useful opportunity to assess the accuracy of the goals and any possible need for goal adjustment.
conclusion Working with injured athletes requires a holistic approach. In order to achieve successful rehabilitation outcome, therapists are often required to address injured athletes psychological issues and concerns as part of the treatment. Research has found rehabilitation adherence and treatment compliance as being crucial for successful rehabilitation outcome. 18
Amongst other factors, issues with selfmotivation and the athlete-therapist relationship can both have an impact on adherence and subsequently on the rehabilitation outcome. Using goal setting for treatment planning is crucial. Through effective goal setting, athlete self-motivation can be significantly improved, which will in turn have an effect on rehabilitation adherence and treatment compliance. In addition, goal setting can facilitate open and honest communication between the athlete and the therapist, which in turn has an effect on their relationship. Good rapport between the therapist and the athlete has also been found to have an impact on rehabilitation adherence. And finally, for most athletes, goal setting forms an integral part of their everyday training programmes. For that reason integrating goal setting into the physiotherapy process is not only profitable, but also easily transferable (7). Part of the therapist’s role when dealing with injured athletes, is to ensure that the individual athlete’s wellbeing comes first. According to Cathy Bulley and colleagues (28), a central part of sports therapists’ thinking and behaviour is the ability to be sensitive and to understand the range of implications of injury for the athlete. After all, when first entering the treatment room after an injury, there is only one thing an athlete wants an answer to: When can I play again? References 1. Kolt GS. Psychology of injury and rehabilitation. In: Kolt GS, Snyder-Mackler L, eds. Physical therapies in sport and exercise. Churchill Livingstone 2003; 165-183. ISBN: 0443071543 2. Blair SN, LaMonte MJ, Nichaman MZ. The evolution of physical activity recommendations: how much is enough? American Journal of Clinical Nutrition 2004; 79(5):913S-920 3. Uitenbroek DG. Sports, exercise, and other causes of injuries: results of a population survey. Research Quarterly for Exercise and Sport 1996;67:380-385 4. Orchard JW, Powell JW. Risk of knee and ancle sprains under various weather conditions in American football. Medicine and Science in Sports and Exercise 2003;35:1118-1123 5. Walsh M. Injury rehabilitation and imagery. In: Morris T, Spittle M, Watt AP, eds. Imagery in sport. Human Kinetics 2005;267-284. ISBN: 0736037527 sportEX medicine 2008;37(Jul):15-19
medicine in sport sports psychology 6. Brown C. Injuries: the psychology of recovery and rehab. In: Murphy S, ed. The sport psych handbook. Champaign, IL: Human Kinetics 2005; 215-235. ISBN: 0736049045 7. Taylor J, Taylor S. Psychological approaches to sports injury rehabilitation. Gaithersburg, MD: Aspen 1997. ISBN: 083420973X 8. Brewer BW, Andersen MB, Van Raalte JL. Psychological aspects of sport injury rehabilitation: toward a biopsychological approach. In: Mostofsky DI, Zaichkowsky LD, eds. Medical aspects of sport and exercise. Morgantown WV: Fitness Information Technology 2002. ISBN: 188569329X 9. Kolt GS, Andersen MB. Psychology in the physical and manual therapies. Philadelphia: Churchill Livingstone Inc 2004;369 10. Williams JM, Andersen MB. Psychosocial antecedents of sport injury: review and critique of the stress and injury model. Journal of Sport and Exercise Psychology 1998;10:5-25 11. Wiese-Bjornstal DM, Smith AM, Shaffer SM, Morrey MA. An integrated model of response to sport injury: psychological and sociological dynamics. Journal of Applied Sport Psychology 1998;10:46-69 12. Arvinen-Barrow M, Penny G, Hemmings B, Corr S. Injured athletes experiences of psychological aspects of rehabilitation physiotherapy: an interpretative phenomenological analysis. Manuscript in preparation 2008 13. Levy A, Polman RCJ, Clough PJ, McNaughton LR. Adherence to sport injury rehabilitation programmes: a conceptual review. Research in Sports Medicine 2006;14:149-162 14. Ford IW, Gordon S. Perspectives of sport trainers and athletic therapists on the psychological content of their practice and training. Journal of Sport Rehabilitation 1998;7:79-94 15. Arvinen-Barrow M, Hemmings B, Weigand DA, Becker CA, Booth L. Views of chartered therapists on the psychological content of their practice: a national follow-up survey in the United Kingdom. Journal of Sport Rehabilitation 2007;16:111-121 16. Brewer BW. Review and critique of models of psychological adjustment to athletic injury. Journal of Applied Sport Psychology 1994;6:87-100 17. Fisher AC, Hoisington LL. Injured athletes’ attitudes and judgements toward rehabilitation adherence. Journal of Athletic Training 1993;28(1):48-54 18. Fisher AC, Mullins SA, Frye PA. Athletic trainers’ attitudes and judgements of injured athletes’ rehabilitation adherence. Journal of Athletic Training 1993;28(1):43-47 19. Niven A. Rehabilitation adherence in sport injury: sport therapists’ perceptions. Journal of Sport Rehabilitation 2007;16:93-110 20. Ievleva L, Orlick T. Mental links to enhanced healing: an exploratory study. The Sport Psychologist 1991;5:25-40 21. Hemmings B, Povey L. Views of chartered therapists on the psychological content of their practice: a preliminary study in the United Kingdom. British Journal of Sports Medicine 2002;36: 61-64 22. Arvinen-Barrow M, Hemmings B, Becker CA, Booth L. Sport psychology education: a preliminary survey into chartered therapists’ preferred methods of training delivery. Journal of Sport Rehabilitation in press 23. Arvinen-Barrow M, Penny G, Hemmings B, Corr S. Interpretative phenomenological analysis in sport psychology: therapists’ personal experiences in using psychological interventions with injured athletes. Manuscript submitted for publication 2008
www.sportEX.net
Rehabilitation Contract
Injured athlete
I, ___________________________ agree to diligently fulfil my responsibilities in the rehabilitation of my injury. These responsibilities include: 1. Taking full control of all aspects of my rehabilitation 2. Precise adherence to the rehabilitation programme designed for me 3. Attendance at all scheduled physiotherapy sessions 4. Completion of all exercises outside the rehabilitation facility 5. Full effort, focus, and intensity with all aspects of my rehabilitation regimen 6. Consistent pursuit of the goals I set in my rehabilitation goal setting program 7. Developing psychological areas that impact my recovery and return to sport (eg. addressing re-injury anxieties) 8. Improving myself as an athlete during rehabilitation 9. Seeking out assistance from others when difficulties arise.
Rehabilitation Professional
I, ___________________________ agree to diligently fulfil my responsibilities as the rehabilitation professional in the rehabilitation of ___________________’s injury. These responsibilities include: 1. Designing an individualised rehabilitation programme for the injured athlete 2. Educating the athlete about all relevant aspects of the rehabilitation process 3. Helping to establish a series of goals that will progressively lead to full recovery and return to sport 4. Creating a rehabilitation team with other relevant professionals 5. Being sensitive and responsive to psychological and emotional needs 6. Assisting the athlete in overcoming physical and psychological obstacles that may arise during rehabilitation 7. Providing the athlete with the information and skills to facilitate physica l, psychological, and performance contributors to a successful return to sport Athlete Therapist
Date
Date
Figure 1: An example of a rehabilitation contract (Taylor & Taylor, 1997 (7))
24. Hardy L, Jones G, Gould D. Understanding psychological preparation for sport: theory and practice of elite performers. John Wiley & Sons, 1996. ISBN: 0471957879 25. Weinberg RS, Gould D. Foundations of sport and exercise psychology, 4th ed. Human Kinetics 2007. ISBN: 0736064672 26. Gilbourne D, Taylor AH, Downie G, Newton P. Goal-setting during sports injury rehabilitation: a presentation of underlying theory, administration procedure, and an athlete case study. Sports Exercise and Injury 1996;2:92-201 27. Gould D. Goal setting for peak performance. In: Williams J, ed. Applied sport psychology: personal growth to peak performance. Mayfield, 1993;158169. ISBN: 1559341327 28. Bulley C, Donaghy M, Coppoolse R, et al. Sports
physiotherapy competencies and standards: sports physiotherapy for all project 2005.
The Author Monna Arvinen-Barrow is a Senior Lecturer in Sport and Exercise Psychology at the University of Northampton. For the past 4 years, she has been conducting her PhD research into the role of the therapists in providing psychological support for athletes during injury rehabilitation.
19
BY Lynn Booth, MSc MCSP
Learning Outcomes In recent years there have been several headlines in the national press and medical journals/magazines questioning the use of stretching. Although the headlines have been rather provocative, on closer reading the articles have only suggested that stretching is not the panacea of all ills. Stretching is an important aspect of an athlete’s general conditioning programme. However, why and when this type of programme should be undertaken is open to debate (2). Herbert and Gabriel (3) concluded that stretching before or after exercise did not prevent muscle soreness and that stretching before exercise did not reduce the risk of injury or improve sporting performance. In his literature review, Shrier (4) concluded that an acute bout of stretching (just prior to the activity) did not improve force or jump height and that although regular stretching improved jump height and speed, there was no evidence that it improved running economy. Other authors have been unable to show that stretching reduces injury (3, 5, 6, 7). Nevertheless, stretching to reduce injury remains a commonly held belief within sport. One of the reasons for the controversy regarding the benefits of stretching may be in the terminology itself. As a definition of terms, mobility is the facility of movement and stretch is the elongation or linear deformation that increases length. Importantly there is a difference between “stretching” as part of a warm-up prior to training/competition, and “stretching” as a means of improving mobility/flexibility. Exercises to improve mobility should not be a part of warming-up. Nevertheless, maintaining or improving joint, muscle and neural mobility should be an integral part of an athlete’s general conditioning programme. For the purpose of this article, only joint and muscle mobility will be considered. Stretching may enhance performance in athletes with insufficient range to maintain correct movement patterns or to perform a given task with maximum efficiency. After training, particularly high intensity training, athletes, whether hypomobile, normal or hypermobile, should stretch in order to return muscles to their normal resting length. Athletes with ‘normal’ flexibility or those who are considered to be hypermobile do not need to stretch to increase range. However their flexibility should be monitored on a regular basis. Athletes identified as having reduced flexibility need to stretch regularly to increase muscle length. Athletes should be made aware that although there are benefits from improving mobility there are also risks associated with: n Poor techniques n Allowing non-essential structures to become hypermobile (8) n Having inadequate strength and control in the new range of movement.
Mobility, Stretching and Warm-up: Application in Sport and Exercise Mobility, stretching and warm-up are deemed to be important in sport and exercise. However, the practical implementation does not always follow established physiology and/or recent research. This article outlines some factors to be considered when developing stretching regimes or advising on warm-up prior to activity. on maintaining or improving flexibility. Body types differ and athletes should concentrate on maintaining and/or improving mobility rather than trying to be the best in the group. In particular, flexibility regimes for young performers take on more significance following the onset of peak height velocity (PHV) (5). (The term PHV refers to “growth spurts” and is now commonly used in the Long Term Athlete Development (LTAD) plans of sports.) Athletes should concentrate on maintaining and/or improving mobility rather than trying to be the best in the group. It is prudent to ensure that exercises to improve mobility should be under the control of the athlete, rather than relying on another person forcing the joint or muscle into an extreme of position. The exercises must not involve unstable starting positions, which can lead to increased muscle tension as the athlete tries to retain his/her balance (an extreme example would be a hamstring stretch with the foot balanced on a high bar).
JOINT AND MUSCLE MOBILITY It is important to differentiate between mobility exercises for joints and those for muscles. Increasing joint mobility may be ineffective if the appropriate muscles cannot move and work functionally through the new range. Ideally all mobility regimes should be sport-specific, encourage left/right symmetry and use sporting patterns of movement. It is important for athletes to appreciate that age, gender, somatotype and existing joint mobility may have an effect 20
sportEX medicine 2008;37(Jul):20-23
sports medicine stretching
Joint Mobility Maintaining a good range of joint movement can have long-term beneficial effects on articular cartilage. If limited joint mobility in older athletes results in the periphery of the articular cartilage being denied nutrition, encouraging good joint mobility in younger athletes may help to alleviate future problems of joint “wear and tear”.
Muscle Mobility Muscles that usually require most attention are the ones that pass over more than one joint or have a multi-action effect. The most beneficial static stretching exercises influence the viscous properties of the parallel elastic components of muscle, resulting in plastic deformation (9). The most suitable exercises are those which: n Reduce the effects of the stretch reflex n Take advantage of the inverse stretch reflex (using the Golgi tendon organ), frequently termed autogenic inhibition n Occur at increased muscle temperature, which enhances the viscous stress relaxation of collagen tissue. In other words, LOW forces for LONG duration at HIGHER than normal muscle temperatures. Reviewing the literature, there is a lack of consistency in the selection of stretching durations and whether active or passive movement is assessed. According to Roberts and Wilson (10), recommendations for the duration of static stretches range from 5 to 60 seconds, yet justifications have been largely absent. McNair (11) suggests that when undertaking holds toward the end of range of motion, the most economical time to hold a stretch is between 20-30 seconds and that whether the athlete is performing static holds or dynamic stretches, the greatest reductions in resistive torque occur in the first repetition. The total amount of time spent in a stretched position (ie. the duration of the hold x the number of repetitions) appears to be important, although this is not supported by Bandy et al’s study (12). Kibler and Chandler (13) suggested that the effectiveness of static stretching appeared to be related to the period of time it was practised, ie. weeks/month, rather than the number of repetitions per day. The optimal duration for stretching may vary by muscle group because their viscoelastic response to heat plus stretching may differ (14). Shrier and Gossal (15) stated that with longer duration of stretching there would be an increase in the stretch tolerance, resulting in less pain for the same force applied to the muscle, allowing more force to be applied to the muscle. Roberts and Wilson (10) suggested that active stretching produced an exercise overload in the agonist muscle group that was contracting to sustain the stretch position. A longer hold time (15 seconds compared to 5 seconds) would result
in greater improvement in muscular strength, which would then help to increase the active range of movement, but not the passive. Practically, the following regimes have been suggested: n Perform the stretches immediately after training/ competition or after a warm/hot bath or shower (9, 16) n Practice a minimum of four repetitions per exercise (17) n Longer duration static stretching (ie. 45 seconds) appears to be significantly better than shorter duration stretches in improving hamstring flexibility, as shown in studies where static stretching duration is altered, and the total amount of time spent in a stretched position is controlled (18) n Higher number of repetitions appears to be significantly better at maintaining the gain in hamstring flexibility (18). The principles described above are very different to ballistic stretching exercises, which are repetitive, short duration, high velocity exercises that take muscles beyond their normal range of movement in an effort to improve mobility. Although ballistic stretching exercises may improve muscle flexibility, they cause muscle soreness as the muscle reflexly contracts to protect itself. Any stretching exercise that puts a “bounce” at the end of the stretch could be defined as ballistic and it is wise to avoid this type of exercise when trying to improve mobility. Compared to ballistic stretching, static stretching is unlikely to exceed the muscle’s extensibility limit, requires less energy to perform and alleviates muscle soreness (19). Many sports now incorporate proprioceptive neuromuscular facilitation (PNF) techniques into their mobility programmes. The active and passive techniques used in sport are modifications of the slow reversal-hold relax and hold relax techniques. Active PNF stretching utilises reciprocal inhibition and is perceived as the safer method because the athlete is in control. Passive PNF stretching is not under the control of the athlete and relies on the integrity and sensible approach of the second person (coach or other athlete). Feland and Marin (20) showed that using sub-maximal contractions during contract-relax PNF stretching of the hamstrings (three 6-second stretches with a 10-second rest between contractions, once a day for five days) was as beneficial at improving hamstring flexibility as maximal contractions. Athletes would probably derive even greater benefit if they also used the PNF patterns of movement - utilising three planes of movement, in particular rotation, in one pattern is more realistic and more applicable to almost all sporting actions. Waddington (21) outlines PNF patterns from a medical perspective, and athletes can use the patterns during active exercise/dynamic warm-up as well as during exercises to improve muscle mobility. Different areas of a muscle can also be targeted by fixing either the proximal or
Mobility allows us to attain and modify general and local posture in order to perform the skills of any sport, and improve the aesthetic impression of many www.sportEX.net
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distal attachments during the stretch. The numerous studies comparing stretching techniques show mixed results. For example, PNF stretching appeared more beneficial than the static stretch (22, 23, 24), whilst static, dynamic and PNF stretching all produced significant improvement in a study by Lucas and Koslow (25). However the studies have not always taken into account the effect of positioning, undertaking other activity and the variations in the total amount of time spent in a stretched position. Stretching to improve mobility should be done at the end of training/competition when the performer is hot (sweating). Fitter athletes are more efficient at regulating body temperature, and may have to keep “topping up” their muscle temperature by further exercise as they change from one specific stretch to another. Alternatively, they could use artificial means to raise muscle temperature by practice a stretching regime after a warm/hot bath or shower. Stretching programmes must ensure that excessive mobility in one area of the body is not compensating for poor mobility and/or lack of strength in another area eg excessive protraction of the left scapula compensating for limited trunk rotation during the backswing of right-handed golfers or increased lumbar-pelvic mobility compensating for limited hamstring flexibility in running sports. Improving joint or muscle mobility without strengthening in the new range of movement can create injury problems: n Ligaments can be strained as they try to protect a joint that is vulnerable due to lack of muscle strength in the new range n Muscles can be strained when they are too weak to protect themselves in outer range Flexibility training may vary according to the athlete’s training phase. Although microtrauma may occur when athletes stretch to increase range immediately after a high intensity training session, currently no research has been found to prove that this is a problem, particularly as the nature of training is overload, and hence microtrauma is to be expected. Providing the athletes are in training, rather than in competition, the benefits of stretching outweigh any potential risks. It is accepted that muscles will have an increased tendency to tighten as training volume and/or load increases. By stretching immediately after training it is easy to ensure that the amount of stretching meets the requirements at that time. Athletes may choose to work on increasing flexibility as a separate session but it is recommended that they increase their muscle temperature first. Discipline is required for mobility regimes and it may take several weeks to see an improvement. This means that physiotherapists need to be discriminating: avoid designing inappropriate and ineffective exercise programmes and be aware that there are substantial individual differences in response to stretching techniques.
WARM-UP The warm-up is not an appropriate time to try to improve 22
mobility. Athletes should only move joints and/or muscles through a range they are already capable of achieving. Trying to improve mobility during the warm-up is often counterproductive, with muscles feeling stiff and sore - the opposite of what the athlete hoped to achieve! It is not recommended to statically stretch prior to competing or training where strength and/or power are required eg prior to weights. In fact, static stretching immediately prior to activity has been shown to reduce vaulting speed in gymnasts (26), to have a negative influence on explosive force and jumping performance (27) and to impair balance, reaction and movement time (28). Larsen et al (29) showed that a static stretching regime had no effect on joint position sense in healthy volunteers, whilst Ghaffarinejad et al (30) showed improved joint position sense in the knee following a static stretching regime for the quadriceps, hamstring and adductors in healthy subjects. Stretch-induced impairments have been reported to occur as early as 1 minute (28) continuing for 120 minutes poststretching (31). Behm et al (32) investigated whether the stretchinduced impairments reported in the literature were a training-specific phenomenon; athletes with a high level of flexibility or tolerance to stretch might be better able to sustain the stress of an acute bout of stretching or that a musculotendinous unit with greater range, or that is more tolerant to stretch, might accommodate the stresses associated with an acute bout of stretching more successfully. Their results showed that an individual’s initial level of joint ROM was not correlated with the stretchinduced deficits and that four weeks of flexibility training did not reduce the stretch-induced impairments. They proposed that if individuals hold stretches to the point of personal discomfort, the relative stress will be similar with flexible or inflexible muscles. Warm-up routines should be athlete and sport specific. Not all the hamstring exercises that are suitable for a sprinter will be suitable for rugby player. Certain elements of the warm-up will be relevant to every athlete, but there should also be sport/discipline/position specific elements to the warm-up. Prior to training/competition, the warm-up routine should follow a set pattern, or at least use exercises/ routines with which the athlete is fully familiar. This enables the athlete to focus on the event without having to worry about which exercises to perform. The time to experiment with new warm-up routines is during training. Many sports use dynamic warm-up in preparation for training/competition. Dynamic warm-up tends to follow a similar pattern and should use the sport’s patterns of movement: n Easy aerobic work eg walking, striding, bounding, skipping and jogging, all performed at low intensity n As the warm-up session progresses, the exercises move to a higher intensity n Non-sport-specific full range (“normal”) movement of relevant muscles and joints e.g. arm circling, leg swinging, rotating the whole body whilst standing - without moving sportEX medicine 2008;37(Jul):20-23
sports medicine stretching beyond normal range n Exercises that ensure that all relevant joints and muscles are taken through the largest range of movement that will be required during the sport n Sport-specific drills at high intensity - skill rehearsal. Athletes must appreciate the difference between exercises used in a dynamic warm-up, when muscles and joints work within their current range, and ballistic stretching exercises. Some athletes falsely believe that if stretching is inappropriate in the warm-up it is of no value at all. It is important that we stress that athletes using dynamic warm-up still require mobility/flexibility work in their general conditioning programmes. Obviously it is important that the timing of the warm-up has been well thought out. There is no benefit in increasing cardiovascular output, enhancing blood flow to joints and muscles, making demands of neuromuscular pathways and mentally preparing for practice or play if the athlete then has to wait before commencing training or competition. References 1. Hartley O’Brien S. Six mobilisation exercises for active range of hip flexion. Research Quarterly for Exercise and Sport 1980;51:4, 625-635 2. Shrier I. Flexibility versus stretching (letters to the Editor). British Journal of Sports Medicine 2001;35,5,364 3. Herbert RD and Gabriel M. Effects of stretching before and after exercising on muscle soreness and risk of injury: systematic review. British Medical Journal 2002;325,468-470 4. Shrier, I. Does Stretching Improve Performance?: A Systematic and Critical Review of the Literature. Clinical Journal of Sport Medicine 2004;14(5):267-273 5. Balyi I, Hamilton A. Long-term athlete development update. SportscoachUK FHS 2003;20:6-8 6. Bird S, Black N, Newton P. Sports Injuries. Causes, diagnosis, treatment and prevention. Stanley Thornes Ltd, Cheltenham 1997. ISBN 0748731814. Page 122 7. Shrier I. Stretching before exercise does not reduce the risk of local muscle injury: a critical review of the clinical and basic science literature. Clinical Journal of Sport Medicine 1999;9:(4)221-227 8. Stewart DR and Burden SB. Does generalised ligamentous laxity increase seasonal incidence of injuries in male first division club rugby players? British Journal Sports Medicine 2004;38:457-460 9. Sapega AA, Quendenfeld TC, Moyer RA, Butler RA. Biophysical factors in range-of-motion exercise. The Physician and Sportsmedicine 1981;9:12,57-65 10. Roberts JM, Wilson K. Effect of stretching duration on active and passive range of motion in the lower extremity. British Journal of Sports Medicine 1999;33:259-263 11. McNair P. Acute responses to stretches with isokinetic dynamometers. sportEX medicine 2007;34:6-9 12. Bandy WD, Irion JM, Briggler M. The effect of time and frequency of static stretching on flexibility of the hamstring muscles. Physical Therapy 1997;77:10,1090-1096 13. Kibler WB, Chandler TJ. Range of motion in junior tennis players participating in an injury risk modification program. Scandinavian Journal of Medicine and Science in Sports 2003;6:(1),51-62 14. Henricson AS, Fredriksson K, Persson I. The effect of heat and stretching on the range of hip motion. Journal of Orthopedic and Sports Physical Therapy 1984;6:110-115 15. Shrier I, Gossal K. Myths and truths of stretching. The Physician and Sports Medicine 2000;28:(8),21-26 16. Strickler T, Mallone T, Garrett WE. The effects of passive warming on muscle injury. American Journal of Sports Medicine 1990;1:2,141-145 17. Taylor DC, Dalton JD, Seaber AV, Garrett WE. Viscoelastic properties of muscle-tendon units: the biomechanical effects of stretching. American Journal of Sports Medicine 1990;18:3,300www.sportEX.net
309 18. Al Frihidy Y. The effect of static stretching duration on active and passive flexibility of the hamstring muscles. Unpublished dissertation in part completion of the MSc in Sports Physiotherapy, Manchester Metropolitan University 2005 19. Bandy WD, Irion JM. The effect of time on static stretch of the flexibility of the hamstring muscles. Physical Therapy 1994;74:845850 20. Feland JB and Marin HN. Effect of submaximal contraction intensity in contract-relax proprioceptive neuromuscular facilitation stretching. British Journal of Sports Medicine 2004;38:460 21. Waddington PJ. in Practical Exercise Therapy. Ed by M Hollis. Blackwell Scientific Publications, 1976. ISBN 0632001895. Chapters 22,23,25 22. Feland B, Myrer W, Merrill M. Acute changes in hamstring flexibility: PNF versus static stretch in senior athletes. Physical Therapy in Sport 2001;2: 186-193 23. Funk DC, Swank AM, Mikla BM, Fagan TA. Impact of prior exercise on hamstring flexibility: A comparison of proprioceptive neuromuscular facilitation and static stretching. Journal of Strength and Conditioning Research 2003;17:(3),489-492 24. Sady SP, Wortman M, Blanke MD. Flexibility training: ballistic, static or proprioceptive neuromuscular facilitation. Archives of Physical Medicine and Rehabilitation 1982;63:261-263 25. Lucas R, Koslow R. Comparative study of static, dynamic and proprioceptive neuromuscular facilitation stretching techniques on flexibility. Perceptual and Motor Skills 1984;58:615-618 26. Siatras T, Papadopoulos G, Mameletzi D, Gerodimos V, Kellis S. Static and dynamic acute stretching effect on gymnasts’ speed in vaulting. Pediatric Exercise Science 2003;15:(4),383-391 27. Young WB, Behm DG. Effects of running, static stretching and practice jumps on explosive force production and jumping performance. Journal of Sports Medicine and Physical Fitness 2003;43:(1),21-27 28. Behm DG, Bambury A, Cahill F. and Power K. Effect of acute static stretching on force, balance, reaction time, and movement time. Medicine and Science in Sports and Exercise 2004;36:13971402 29. Larsen R, Lund H, Christensen R, Røgind H, DanneskioldSamsøe B and Bliddal H. Effect of static stretching of quadriceps and hamstring muscles on knee joint position sense. British Journal of Sports Medicine 2005;39:43-46 30. Ghaffarinejad F, Taghizadeh S and Mohammadi F. Effect of static stretching of muscles surrounding the knee on knee joint position sense. British Journal of Sports Medicine 2007;41:684-687 31. Power K, Behm D, Cahill F, Carroll M. and Young W. An acute bout of static stretching: effects on force and jumping performance. Medicine and Science in Sports and Exercise 2004;36:13891396 32. Behm DG, Bradbury EE, Haynes AT, Hodder JN, Leonard AM and Paddock NR. Flexibility is not related to stretch-induced deficits in force or power. Journal of Sports Science and Medicine 2006; 5:33-42.
The Author Lynn Booth is a chartered physiotherapist currently working with the national teams of the English Ladies’ Golf Association and the Ladies’ Golf Union (Great Britain and Ireland squad) and with four of the regional boys’ squads and the national U16, U18 and U21 squads for the English Golf Union. She also works with squads from English hockey. Lynn was Chairman of the British Olympic Association’s Physiotherapy Committee from 1992-2004. She worked at the 1988 and 1992 Olympic Games with the Great Britain Women’s Hockey Squad and was head physiotherapist for Team GB at the 1996, 2000 and 2004 Olympic Games. This article has been modified from an original article first published in In Touch, Spring Issue 2007 No 118. The Journal for Physiotherapists in Private Practice. Our thanks go to In Touch for permission to reproduce this article 23
2008
conference key features n 4 internationally trained and renowned practitioners n 8 x 3 hour hands-on workshops across the two days n 6 hours of full hands-on time n 35 people per workshop with one couch between two n 2 x repetition of each workshop each day to give you the best chance to see what you want n 20 x half price student places available each day
One day regional workshops
One day workshops with Rob Granter and Stuart Hinds teaching together. A unique chance to work with two of the most experienced soft tissue practitioners in the world. 30% discount for conference attendees who also wish to book on a workshop. n 4th November 2008 - London - Cervical Pain and Headache n 12th November 2008 Edinburgh - Shoulder pain, Dysfunction and Treatment of the Frozen Shoulder
Stuart Hinds Rob Granter Stuart Robertson Ruth Duncan
8-9 November
University of Salford Manchester
Saturday
Sunday
Peripheral nerve entrapments of the upper limb Treatment of the thoracic spine Wind Down – a manual approach to stress reduction The modern approach to myofascial release
Treatment of hamstring injuries Treatment of psoas major and iliacus Come to your senses – movement driven by sensory intput The modern approach to myofascial release
What you need to do:
1) Decide how many days you want to attend 2) Choose which workshops you want to attend (2 per day) 3) Decide which to do in the morning and afternoon 4) Ring us on 0845 652 1906 to book or book online at www.sportex.net. Please note that workshops will be booked on a first come, first served basis so please book early. Conference rates University of Salford (Sat/Sun 8th-9th Nov 2008) Delegate 1 day Delegate 2 day BASRaT members - 1 day* BASRaT members - 2 day* Students* - 1 day only
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