Journal of Bodywork and Movement Therapies, Volume 15, issue 2 (2011)

Journal of Bodywork and Movement Therapies Official journal of the: ® Association of Neuromuscular Therapists, Ireland ® Australian Pilates Method Association ® Hands On Seminars, USA ® National Association of Myofascial Trigger Point Therapists, USA ® Pilates Foundation, UK Volume 15 Number 2 2011 EDITOR-IN-CHIEF

Leon Chaitow ND, DO

c/o School of Life Sciences, University of Westminster, 115 New Cavendish Street, London W1M 8JS, UK Preferred mailing address: P.O.Box 41, Corfu, Greece 49100 ([email protected])

ASSOCIATE EDITORS Geoffrey M. Bove, DC, PhD Kennebunkport, ME, USA ( [email protected]) John Hannon DC San Luis Obispo, CA, USA ( [email protected]) Glenn M. Hymel EdD, LMT Department of Psychology, Loyola University, New Orleans, LA, USA ([email protected])

Dimitrios Kostopoulos PhD, DSc, PT Hands-on Physical Therapy, New York, NY, USA ([email protected]) Craig Liebenson DC Los Angeles, CA, USA ([email protected])

ASSOCIATE EDITORS: PREVENTION & REHABILITATION Warrick McNeill MCSP London, UK ([email protected])

Matt Wallden MSc, Ost, Med, DO, ND London, UK ([email protected])

International Advisory Board D. Beales MD (Cirencester, UK) C. Bron PT (Groningen, The Netherlands) I. Burman LMT (Miami, FL, USA) J. Carleton PhD (New York, USA) F. P. Carpes PhD (Uruguaiana, RS, Brazil) Z. Comeaux DO FAAO (Lewisburg, WV, USA) P. Davies PhD (London, UK) J. P. DeLany LMT (St Petersburg, FL, USA) M. Diego PhD (Florida, USA) J. Dommerholt PT, MS, DPT, DAAPM (Bethesda, MD, USA) J. Downes DC (Marietta, GA, USA) C. Fernandez de las Peñas PT, DO, PhD (Madrid, Spain) T. M. Field PhD (Miami, FL, USA) P. Finch PhD (Toronto, ON, Canada) T. Findley MD, PhD (New Jersey, USA) D. D. FitzGerald DIP ENG, MISCP, MCSP (Dublin, Ireland) S. Fritz LMT (Lapeer, MI, USA) G. Fryer PhD. BSc., (Osteopath), ND (Melbourne City, Australia)

C. Gilbert PhD (San Francisco, USA) C. H. Goldsmith PhD (Hamilton, ON, Canada) S. Goossen BA LMT CMTPT (Jacksonville, FL, USA) S. Gracovetsky PhD (Ocracoke, NC, USA) M. Hernandez-Reif PhD (Tuscaloosa, AL, USA) P. Hodges BPhty, PhD, MedDr (Brisbane, Australia) B. Ingram-Rice OTRLMT (Sarasota, FL, USA) J. Kahn PhD (Burlington, VT, USA) R. Lardner PT (Chicago, IL, USA) P. J. M. Latey APMA (Sydney, Australia) E. Lederman DO PhD (London, UK) D. Lee BSR, FCAMT, CGIMS (Canada) D. Lewis ND (Seattle, WA, USA) W. W. Lowe LMT (Bend, OR, USA) J. McEvoy PT MSC DPT MISCP MCSP (Limerick, Ireland) L. McLaughlin DSc PT (Ontario, Canada) C. McMakin MA DC (Portland, OR, USA) J. M. McPartland DO (Middleburg, VT, USA)

C. Moyer PhD (Menomonie, WI, USA) D. R. Murphy DC (Providence, RI, USA) T. Myers LMT (Walpole, ME, USA) C. Norris MSc CBA MCSP SRP (Sale, UK) N. Osborne PhD DC (Bournemouth, UK) B. O’Neill MD (North Wales, PA, USA) J. L. Oschman PhD (Dover, NH, USA) D. Peters MB CHB DO (London, UK) M. M. Reinold PT, DPT, ATC, CSCS (Boston, MA, MD, USA) G. Rich PhD (Juneau, AK, USA) C. Rosenholtz MA, RMT (Boulder, CO, USA) R. Schleip PhD, MA, PT (Munich, Germany) J. Sharkey MSc, NMT (Dublin, Ireland) D. Thompson LMP (Seattle, WA, USA) C. Traole MCSP, SRP, MAACP (London, UK) P. W. Tunnell DC, DACRB (Ridgefield, CT, USA) E. Wilson BA MCSP SRP (York, UK) A. Vleeming PhD (Schoten, Belgium)

Officially recognised and supported by: The Alliance of Massage Therapy Education The American Massage Therapy Association Associated Bodywork and Massage Professionals The British Orthopaedic Association The Institute of Sport and Remedial massage The International Society of Clinical Rehabilitation Specialists The New Zealand Manipulative Physiotherapists Association The Organisation of Chartered Physiotherapists in Private Practice The Rolf Institute The Sports Massage Association The Upledger Institute

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EDITORIAL

A rich seam Reflecting on the content of this month’s JBMT has evoked a sense of respect for the multiple ways in which manual and movement methods are being beneficially used and researched e a truly rich seam of therapeutic approaches, deriving from a wide range of disciplines, and backgrounds. A major feature, in this issue, is the debate around a topic raised by Eyal Lederman in his paper The fall of the postural-structural-biomechanical model in manual and physical therapies: Exemplified by lower back pain. This provocative assertion e which challenges the basis of the clinical work of many practitioners and therapists e has been responded to by an expert interdisciplinary panel: Gary Fryer, John Hannon, Robert Irvine, Diane Lee and Stuart McGill - who provide counter-arguments. By setting out the hypothesis, and providing responses, it is hoped that a degree of clarity will emerge. To be sure, not all the commentators disagree with all of Professor Lederman’s assertions e since he highlights aspects of a very real schism in the way musculoskeletal dysfunction and pain are thought to best be managed. At the heart of the debate is the question as to whether painful musculoskeletal conditions e with low back pain being the focal point of this discussion e should be treated passively (manipulation, mobilisation, massage etc) or actively e for example by means of education, rehabilitation and enhanced motor control? Is this an ‘either/or’ question e or is there ample scope for manual treatment of dysfunction to be employed alongside, or before, the introduction of less passive approaches? The theme explored by Matt Wallden, in his Prevention & Rehabilitation editorial, is also at the heart of this discussion. Readers are invited to evaluate the different perspectives that have been thoughtfully set out in this debate, and to actively participate in this important discussion by writing to the editor with additional points of view. The remainder of this issue contains detail of a range of models of care that have been studied, researched and describede deriving from a spectrum of geographical and professional origins:  The countries represented by authors in this issue include Australia, Brazil, Canada, Greece, India, Iran, Israel, Italy, New Zealand, Sweden, UK and the USA

1360-8592/$36 ª 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2011.01.017

 Professions, topics and methods represented in the published papers include: Acupuncture, Bowen Therapy, Breathing Rehabilitation, Chiropractic, Exercise Physiology, Dance Therapy, Dentistry, Feldenkrais, Gerontology, Massage Therapy, Medicine, Occupational Therapy, Osteopathy, Physiotherapy, Sports Medicine and Yoga The topics covered include:  measurement of pelvic floor muscle strength  the effect of knee misalignment on stance  the effect of saddle height on lower limb function during rehabilitation cycling  joint responses to the various poses during performance of the sun salutation exercise  the possible role of fascia in acupuncture  the effects of Feldenkrais methods on chronic pain, in group settings  the physical and psychological benefits of Greek dance on breast cancer survivors  the relationship between massage therapy and health outcomes in older adults  the relationship between breathing patterns and temporomandibular joint disease  the connection between dental occlusion and the plantar arch  the effect of Bowen technique on hamstring flexibility  the feasibility (and possible benefits) of kickboxing exercise for individuals with multiple sclerosis  the association of manual muscle testing and mechanical neck pain. What emerges is a sense of diversity, as well as unity e since all the therapeutic methods employed, when appropriately applied, appear to offer benefit to some individuals. The common unspoken theme is of course self-regulation e the ability for repair and recovery that can be encouraged when treatment enhances function without overloading adaptation potentials. Leon Chaitow, ND DO , Editor-in-Chief JBMT, University of Westminster, School of Integrated Health, Journal of Bodywork and Movement Therapies, 115 New Cavendish Street, London W1M 8JS, United Kingdom E-mail address: [email protected]

Journal of Bodywork & Movement Therapies (2011) 15, 130e152

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Is a postural-structural-biomechanical model, within manual therapies, viable?: A JBMT debate Leon Chaitow, ND DO Honorary Fellow, University of Westminster, UK Eyal Lederman DO: The fall of the postural-structuralbiomechanical model in manual and physical therapies: Exemplified by lower back pain With invited responses from: Gary Fryer PhD John Hannon DC Robert Irvin DO Diane Lee PT Stuart McGill PhD

Introduction to the debate Leon Chaitow ND DO In recent years, a number of leading thinkers within manual and physical therapies have questioned traditional models of care. Professor Eyal Lederman DO PhD is one such critic, of what he has termed the postural-structural-biomechanical (PSB) model. Using low back pain as a focus he has asserted that the PSB model is not viable e in fact that there is no reliably proven relationship between low back pain and posture, structure or biomechanical features. e and by implication, that attempts to treat and normalize such features, are meaningless, and a waste of time and resources. Lederman asserts: “We can no longer justify the use of manual techniques to readjust, correct or balanceout the misaligned structure.” The suggestion is that rehabilitation strategies, motor re-education approaches, behaviorally focused methodologies e are the best means of achieving resolution and prevention of dysfunctional states such as low back pain, and that manual modalities have - at most - short-term effects, and are largely redundant (Lederman, 2010)

It can be counter-argued that unless and until postural balance, mobility (i.e. more normal ranges of motion, including fascial) strength and endurance features are restored, via manual therapy strategies, normal pain-free function may be far more difficult to achieve by means of rehabilitation strategies. (Irvin et al., 2007; Chaitow, 2010) Dr Lederman’s assertions challenge the practices of many e probably most e manual and physical therapists. Indeed, in his presentation of these ideas he challenges the very foundation of much of what is currently practiced by the majority of physiotherapists, osteopaths, chiropractors, massage therapists, as well as those engaged in many of the prevention and rehabilitation methodologies currently in use. What Lederman suggests, as a replacement for what he terms the postural-structural-biomechanical model, can be evaluated in his invited article (below), that sets out his considered thoughts. Basically he proposes that what is required in any given case, is identification of the processes underlying the patient’s condition, followed by provision of “the stimulation/signals/management/care that will support/assist/facilitate change” e what he terms a ‘process approach’. In itself this argument is not controversial e however the implications Lederman draws from his thesis goes on to suggest that passive manual treatment has little value in the healing, recovery, process. Anyone who attended the recent (November 2010) 7th Interdisciplinary Congress on Low Back and Pelvic Pain would have heard presentations that, in many ways, echo and support Lederman’s position (as well as many presentations that did not agree with it). For example O’Sullivan (2010) has advocated a biopsychosocial approach to back pain with particular focus on underlying mechanisms that may be driving pain disorders. Included in that model are evaluations of whether there have been adaptive or maladaptive motor responses to the condition. O’Sullivan’s emphasis is therefore to divert patient care away from

1360-8592/$ - see front matter ª 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2011.01.004

Is a postural-structural-biomechanical model, within manual therapies, viable manual treatment, towards cognitive and re-educational strategies - which is a less extreme position to that taken by Lederman. In order to unpick these arguments, JBMT has invited five leading experts from the world of manual medicine to respond to Dr Lederman’s thesis. These clinicians (from the world of osteopathy, chiropractic and physiotherapy) as well as researchers into biomechanical dysfunction and therapeutic methods, offer their perspectives,in alphabetical order, following Dr Lederman’s paper. It is important to observe that by no means all of these expert responses are wholly critical of Dr. Lederman’s arguments, and ultimately it is for you, the reader, to decide which aspects of the debate are most persuasive, and where the relative clinical truth lies. It is hoped that this examination of controversial ideas will lead to a better understanding of what we hold to be true, based on current evidence, as well as what we need

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to question, what we need to know, and how we need to practice.

References Chaitow, L., 2010. Fascia Directed Therapies for the Treatment of Low Back Pain: Review and New Directions. Presentation: 7th Interdisciplinary World Congress on Low Back and Pelvic Pain. Los Angeles. November 11 2010. Irvin, R.E., 2007. Why and how to optimize posture, chapter 16. In: Vleeming, et al. (Eds.), Movement, Stability and Lumbopelvic Pain, second ed. Elsevier, Edinburgh. Lederman, E., March 2010. The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain. CPDO Online J. http://cpdo.net/jour/jour1.html. O’Sullivan, P., 2010. Diagnosis and Classification of Chronic Low Back Disorders. Proceedings Book 7th Interdisciplinary World Congress on Low Back and Pelvic Pain, pp. 160e177.

The fall of the postural-structural-biomechanical model in manual and physical therapies: Exemplified by lower back pain Eyal Lederman, PhD DO CPDO Ltd, 15 Harberton Road, London N19 3JS, UK

Summary Manual and physical therapists often use a postural-structural-biomechanical (PSB) model to ascertain the causes of various musculoskeletal conditions. It is believed that postural deviations, body asymmetries and pathomechanics are the predisposing/maintaining factors for many musculoskeletal conditions. The PSB model also plays an important role in clinical assessment and management, including the choice of manual techniques and the exercise prescribed. However, the most important question is consistently being ignored e can a person’s physical shape/posture/structure/biomechanics be the cause of their lower back pain? .

Is development of LBP associated with PSB factors? In the last two decades the PSB model has been eroded by clinical studies examining the relationship between PSB factors and lower back pain. The balance of evidence suggests that there is no association between LBP and PSB factors (see summary, Figure 1).

E-mail address: [email protected].

Prospective studies are particularly useful to examine the causal relationship between PSB factors and LBP. In these studies groups of asymptomatic individuals are assessed for PSB factors initially and tracked over several years noting the episodes of LBP. Other less ideal studies compare subjects with LBP to an asymptomatic group. However these studies can only be used to inform us about the changes that are due to the condition but they cannot indicate its cause, i.e. the consequence of LBP is not necessarily its cause. This distinction is important clinically. Often the PSB assessment is made when the patient is already in pain, once the individual/body has reorganized to cope with the condition.

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E. Lederman

Figure 1

PSB actors not associated with LBP.

Spinal curves, asymmetry and motion There was the lack of association between postural spinal asymmetry, thoracic kyphosis and lumbar lordosis in teenagers and developing LBP in adulthood (Papaioannou et al., 1982; Dieck, 1985; Poussa, 2005). Even obvious increases in lordosis and sagittal pelvic tilt during pregnancy lack an association with back pain (Franklin and Conner-Kerr, 1998). Stronger predictors of the development of back pain during pregnancy were body mass index, history of hypermobility and amenorrhea, low socioeconomic class, previous LBP, posterior fundal location of placenta and fetal weight to LBP with radiation to leg (Orvieto et al., 1990; Mogren and Pohjanen, 2005). In adults, the extent of lumbar lordosis as well as the presence of scoliosis failed to show an association with back pain (Dieck, 1985; Haefeli et al., 2006; Norton, 2004; Christensen and Hartvigsen, 2008, syst. rev.) Also differences in regional lumbar spine angles or range of motion between the segments

failed to show an association with the future development of LBP (Hellsing, 1988b; Burton and Tillotson, 1989; Hamberg-van Reenen HH 2007, syst review; Mitchell et al., 2008).

Segmental pathomechanics One important area to examine is whether the profound biomechanical changes brought about by segmental biomechanics can give rise to lower back symptoms. A systematic review from 1997 suggests an association between disc degeneration and non-specific low back pain (van Tulder et al., 1997). However, it might not be the cause of it -there is strong evidence that X-ray and MRI findings have no predictive value for future LBP or disability (Waddell and Burton, 2001, review). Several studies since have failed to show a clear relationship between spinal/ disc degeneration and LBP (Savage et al., 1997; Borenstein et al., 2001; Jarvik et al., 2005; Carragee et al., 2005;

Is a postural-structural-biomechanical model, within manual therapies, viable Kanayama et al., 2009; Kalichman et al., 2010). In a population-based study of 34,902 Danish twins 20e71 years of age there were no meaningful differences in the frequency in LBP between younger and older individuals (Leboeuf-Yde et al., 2009), although greater degenerative changes are expected in older individuals. In studies that show some relationship between disc degeneration and LBP it has been suggested that the genes that play a part in the heritability of back pain also play a part in disc degeneration, i.e. pain may not be due to the mechanical changes in the spine but to shared biological factors (Battie et al., 2007). These hereditary factors are not associated with the shape of the back but linked to variations in the collagen and immune-repair system/ processes between individuals (Paassilta et al., 2001; Valdes et al., 2005; Battie ´ et al., 2009; Videman, 2009). It was demonstrated in twins that as much as 47%e66% of spinal degeneration is due to hereditary and shared environmental factors, whereas only 2%e10% of the degeneration can be explained by physical stresses imposed by strenuous occupations or sporting activities (Battie ´, 1995; Battie ´ et al., 2009; Videman et al., 2006 and 2007). No association has been found between congenital abnormalities in the lumbar spine and pain in that area (spina bifida, transitional lumbar vertebra, spondylolysis and spondylolisthesis: van Tulder et al., 1997, syst. review, Luoma et al., 2004; Brooks et al., 2009). Although spina bifida and transitional vertebra may not be the cause of LBP, they may determine the pain levels (Taskaynatan et al., 2005, weaker study). Another popular and enduring biomechanical concept is the spinal “neutral zone”. It claims to be related to stability and LBP (Panjabi, 1992a and b; Panjabi, 2003; Suni et al., 2006). This mechanical concept is derived from mathematical models and cadaver experiments on which an extensive amount of spinal joint damage had to be inflicted before the findings could fit the model (Gracovetsky, 2005). Since its inception three decades ago, no study exists to show a correlation between mechanical changes in the neutral zone changes and LBP (Leone et al., 2007, review). The disparity between pathomechanics and symptomatology can be observed in other segmental conditions. For example, in an MRI study of patients with nerve root pain it was found that the degree of disc displacement, nerve root enhancement or nerve compression did not correlate with the magnitude of the patients’ subjective pain or level of functional disability (Karppinen et al., 2001; see also Beattie et al., 2000). However there is a strong association between severe nerve compression, disc extrusion and distal leg pain (Beattie et al., 2000).

Non-spinal structures Studies have also failed to identify an association between other structures beyond the spine and back pain. For example, there is no correlation between pelvic obliquity/ asymmetry and the lateral sacral base angle and lower back pain (Dieck, 1985; Levangie, 1999a and b; Fann, 2002; Knutson, 2002). Leg length differences as a cause for back pain has been debated for the last three decades. It is estimated that about 90% of the population has a leg length inequality with

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a mean of 5.2 mm. The evidence suggests that for most people anatomic leg length inequality is not clinically significant (Papaioannou et al., 1982; Grundy and Roberts, 1984; Dieck, 1985; Fann, 2002; Knutson, 2005, review), until the magnitude reaches approximately 20 mm (Gurney, 2002 review; Knutson, 2005, review). Although some earlier studies comparing people experiencing back pain with asymptomatic controls suggest a correlation (Giles and Taylor, 1981; Friberg, 1983 and 1992), more relevant are prospective studies in which no correlation was found between leg length inequality and LBP (Hellsing, 1988a; Soukka et al., 1991; Nadler, 1998). Patients who have acquired their leg length differences later in life as consequence of disease or surgery may also help to shed light on the relationship between pathomechanics and LBP. Individuals who developed a shorter leg due to Perthe’s disease had a poor correlation between leg length inequality, lumbar scoliosis and low-back disorders, assessed several decades after the onset of the condition (Yrjo ¨nen et al., 1992). In studies of patients who had marked changes in leg length due to hip fractures or replacement, such changes were not associated with back pain assessed several years after surgery (Gibson et al., 1983; Edeen et al., 1995; Parvizi et al., 2003). One of the arguments in favor of an association between leg length differences and LBP is the supposed success of heel lifts in reducing back pain (Giles and Taylor, 1981; Gofton, 1985; Helliwell, 1985; Friberg, 1983 and 1992; Brady et al., 2003 review). However, all these studies failed to include controls or sham heel lift (such as inefficient soft foam lift). Prospective studies of inflexibility of the lower extremities and hamstrings and psoas tightness also fail to predict future episodes of LBP (Hellsing, 1988c; Nadler, 1998). As for foot biomechanics there is strong evidence that orthotic corrections have no effect on preventing back pain (Sahar et al., 2007, syst. review). Surprisingly even whole body changes such as overweight/obesity have a low association with LBP (LeboeufYde, 2000 syst. review). Contrary to common beliefs, a recent study has shown that cumulative or repetitive loading due to higher body mass (nearly 30 pounds on average) was not harmful to the discs. The study found a slight delay in disc desiccation (L1-L4) in the heavier men when compared with their lighter twin brothers (Videman et al., 2009).

Neuromuscular factors Although not fully within the scope of this article, motor control of the trunk is relevant in relation to muscle function and posture. Certain neuromuscular components also failed to show a clear association with LBP. Although earlier studies demonstrated an association between muscle endurance and LBP (Biering-Sørensen, 1984; Alaranta et al., 1995), a recent systematic review found strong evidence that low trunk muscle endurance is not associated with LBP (Hamberg-van Reenen, 2007 syst. rev). This review found inconclusive evidence for an association between low trunk muscle strength and LBP. Also there is no association between erector spinae pairs imbalances during extension and LBP (Reeves et al., 2006;

134 Hamberg-van Reenen, 2007 syst. rev; Van Nieuwenhuyse et al., 2009). Furthermore, no study to date has shown that back pain is due to timing differences in specific muscle such as transversus abdominis (see discussion Lederman, 2010b). These control changes have been observed only in individuals who already have back pain. They probably represent the outcome rather than the cause of back pain (see discussion Lederman, 2010a). Two studies using the same methodology appear to demonstrate that in athletes a delayed reflex muscle response at the trunk could increase the risk of lower back as well as knee injury (Cholewicki et al., 2005; Zazulak et al., 2007). Unfortunately, the obvious was not examined in these studies e the reflex response to a sudden perturbation of the trunk should have been examined in other body areas (e.g. a control recording from the leg). This would have helped establish whether the injuries are due to delayed muscle onset-timing, specific to the trunk or, the alternative more plausible explanation that athletes with sluggish muscle reaction times/reflexes may be more susceptible to injury.

Postural behavior factors An area that is often assessed in manual and physical therapy is how “correctly” a person is using their body e their “postural behavior”. It is believed that prolonged postural stresses at work or sporting activities could be the cause of LBP. The results of recent systematic reviews challenge these widely held beliefs. These studies demonstrate lack of association between work-related posture and LBP. They include postures such as prolonged standing, bending, twisting, awkward postures (kneeling or squatting) sitting posture at work and prolonged sitting at work and leisure time (Hartvigsen et al., 2000 syst. review; Chen et al., 2009 syst. review; Bakker et al., 2009 syst. review; Roffey et al., 2010 syst. review; Wai et al., 2010, syst. review). Also physical leisure time activities such as sport or exercises, sitting, and prolonged standing/walking were found not to be associated with LBP (Bakker et al., 2009 syst. review). Heavy manual lifting is strongly associated with LBP, however the effect size is considered to be modest (Waddell and Burton, 2001 review).

Prediction of back pain by PSB assessment In a recent prospective study on young workers (n Z 692) examined by physical therapists, PSB factors failed to show a correlation with future development of LBP (Van Nieuwenhuyse et al., 2009). A number of factors were evaluated including iliac crest height inequality, scoliosis, lumbar flexion, extension and lateral flexion, length of hamstring muscles and strength testing in the motor distribution of L4/L5/S1. Biological not mechanical There seems to be a disparity between pathomechanics and the experience of a low back condition. In this biomechanical model the musculoskeletal system is seen as a precision engine where every system, organ and cell

E. Lederman works in perfect harmony within itself and other body systems. However, the research suggests that biological systems contain reserve capacity to accommodate for loss and imperfections without failure or symptoms. Furthermore, within a biological dimension, structures such as the spine are capable of self-repair and are able to adapt and change according to needs and demands. Hence, the spine can undergo profound physical changes that are well tolerated without the development of a symptomatic condition. Perhaps there is a critical level where PSB factors will exceed the reserve of the system. Clinically, this still remains unquantified (and probably unquantifiable). If we were to overlook this obstacle, the next hurdle to overcome is the reliability of assessing PSB factors. It is now well established that many of the examinations that assess PSB factors are either low on validity or reliability (McCaw and Bates, 1991; Mannello, 1992; Panzer, 1992; Levangie, 1999a; Hestbaek and Leboeuf-Yde, 2000; Seffinger et al., 2004; Dunk et al., 2004; van Trijffel et al., 2005; Hollerwo ¨ger, 2006; May et al., 2006; Paulet and Fryer, 2009). A third clinical hurdle to overcome is whether manual techniques or specific exercise are effective in modifying inherent PSB factors. Can foot mechanics, leg length differences, pelvic tilts, vertebral positions and spinal curves be permanently changed, solely, by these clinical tools? There are no known studies that examine the influence of manual techniques on PSB factors in the medium- or long-term, in particular at the cessation of the treatment. However we know from the allied sciences that a herculean effort would be required to modify many of the inherent PSB factors (Maruyama et al., 2008; Maruyama, 2008; Lonstein, 1999; Marks and Qaimkhani, 2009; Willy et al., 2001; Harvey et al., 2002; Williams et al., 1986; Goldspink et al., 1992; Arnoczky et al., 2002; Bosch et al., 2002; Magnusson et al., 1995; Magnusson, 1998; Light et al., 1984; Roberts and Wilson, 1999. see full discussion of this topic and references in, Lederman, 2010a). As such, the therapeutic investment in correcting PSB factors is irrational, in particular, as it is unlikely to influence the course of the patient’s LB condition.

Implications for practice The lack of association between PSB factors and back pain has far-reaching implications for the way we conceptualize musculoskeletal conditions, the clinical examination and the goals/objectives of the techniques and the exercise prescribed. From the evidence so far many of the clinical examinations assessing PSB factors have no obvious value in explaining why the patient has developed their back condition. It implies that the PSB model and the related clinical examinations are mostly redundant. The lack of association between PSB factors and LBP has also important implications for what we aim to achieve and for our choice of techniques and exercise used to manage the condition. We can no longer justify the use of manual techniques to readjust, correct or balance-out the misaligned structure. There is an urgent need to redefine what

Is a postural-structural-biomechanical model, within manual therapies, viable the therapeutic goals are, beyond relieving the patient’s symptoms, e.g. is there any value in providing long-term maintenance/preventative treatments for asymptomatic individuals? Furthermore, the therapeutic ideal of a “cure” may not be possible, as the underlying condition could still be present but is asymptomatic. Perhaps research and treatment should be directed towards finding better approaches to provide symptomatic relief during periods of pain as well as increasing the patient’s participation in social, occupational and recreational activities (Waddell and Burton, 2001; Waddell et al., 2008; Kendall et al., 2009). This attitude may be more realistic than the idealized clinical aspiration to provide a permanent cure by correcting PSB factors. Finally and more complex is the therapists’ education in the various manual and physical therapies where the PSB model is dominant. If this model is flawed what is the alternative clinical model and who is capable of teaching it?

The alternative: a process approach A clinical alternative to the PSB model is a Process Approach model. In this approach the aim is to identify the processes underlying the patient’s condition and provide the stimulation/signals/management/care that will support/assist/facilitate change. This approach has been extensively discussed in Lederman E (2005) and will be discussed in a future article.

Summary and conclusion points PSB asymmetries and imperfections are normal variations e not a pathology. Neuromuscular and motor control variations are also normal. The body has surplus capacity to tolerate such variation without loss to normal function or development of symptomatic conditions. Pathomechanics do not determine symptomatology. There is no relationship between the pre-existing PSB factors and back pain. Correcting all PSB factors is not clinically attainable and is unlikely to change the future course of a lower back condition. Clinically: Observational or physical assessments of PSB factors have no value in elucidating the causes for back pain. Clinical assessment of PSB factors assessed by manual and visual means may be unreliable. Such assessments are likely to be redundant and can be safely removed from clinical practice. This excludes assessment that aim to identify serious pathologies. PSB factors are unlikely to change in the long-term by manual techniques or even exercise, unless rigorously maintained (exercise). A PSB model may introduce an element of therapeutic failure as the aims and goals of this approach may not be attainable by manual therapy or even exercise.

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Further Reading Full article Lederman, E., 2010. The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain. CPDO Online J. http://cpdo.net/jour/ jour1.html March 2010. Lederman, E., 2005. The Science and Practice of Manual Therapy. Elsevier, Edinburgh. Lederman, E., 2010. Neuromuscular Rehabilitation in Manual and Physical Therapies. Elsevier, Edinburgh.

Invited response Gary Fryer, PhD, BSc(Osteopathy), ND a,b,c a

School of Biomedical and Health Sciences, Victoria University, Melbourne, Australia Institute of Sport, Exercise and Active Living, Victoria University, Melbourne, Australia c A.T. Still Research Institute, Kirksville, MO, USA b

The philosophical foundations of many manual therapy disciplines, including osteopathy, have been deeply rooted in the postural structural model (PSM) paradigm, which emphasizes the role of altered posture, anatomical structure, and biomechanics as a cause of pain and disturbed function. This paradigm has been reinforced by catch cries such as ‘structure governs function’ and by enduring concepts of misaligned or malpositioned joints. Lederman has highlighted the lack of scientific support for abnormal posture as a cause of low back pain and provided a well-reasoned argument that research has eroded many aspects and practices associated with PSM. While I applaud Lederman’s critical approach to this model and agree that postural and biomechanical factors have been overemphasized in the past, I believe it would be a mistake to conclude that posture and biomechanical factors have no relevance in the assessment of patients with pain. The causes of spinal pain are unclear, but pain is multifactorial, and an overemphasis of any one aspect, such as mechanical factors, is inappropriate. Lederman correctly draws attention to the literature that shows most diagnostic findings associated with PSM cannot be used to differentiate individuals with pain from those without pain or to predict whether individuals are more likely to have pain. This literature does not, however, demonstrate that postural factors have no influence on pain. Lederman

E-mail address: [email protected].

states that the most important question is consistently being ignored: ‘can a person’s physical shape/posture/ structure/biomechanics be the cause of their lower back pain?’ The cause of back pain is multi-factorial and may involve genetic, biopsychosocial, and environmental factors. The key questions, therefore, are not whether physical shape or posture can cause lower back pain, but whether these factors influence or contribute to back pain and, if so, whether practitioners can identify and treat these factors to influence the health of patients. The studies reviewed by Lederman typically examine the influence of a single PSM factor (e.g., pelvic asymmetry), without accounting for other PSM factors or other multidimensional aspects of pain. Comparison of posture between individuals may not be meaningful because posture is highly variable and idiosyncratic, but exaggeration of an individual’s postural pattern may be more clinically relevant, as may treatment aimed at minimizing deviations. For example, examination of head carriage in a group of office workers may not reveal those individuals with pain, but exaggeration of head forward posture in a worker with recurrent pain will likely aggravate the pain, whereas attention to better posture alleviates it. Although direct evidence for the association of posture with low back pain is lacking, there is a strong theoretical rationale of why posture may influence pain. Mechanical loading on ligaments, either sustained or cyclic, causes viscoelastic change, hysteresis, strain, inflammation, and abnormal motor activity (Solomonow, 2006). Thus,

Is a postural-structural-biomechanical model, within manual therapies, viable abnormal load on ligaments and other structures may occur due to chronic asymmetrical or suboptimal posture, and may contribute to exhausting an individual’s adaptive reserve, which results in strain and pain. Evidence also suggests that asymmetrical or suboptimal posture may affect function. Increases in thoracic kyphosis are associated with higher multisegmental spinal loads and trunk muscle forces in upright stance (Briggs et al., 2007). Although there is considerable controversy about assessment of the sacroiliac joints, asymmetrical sacroiliac motion may be predictive for pelvic pain (Buyruk et al., 1995; Buyruk et al., 1999; Damen, Stijnen et al., 2002; Damen, Buyruk et al., 2002). Additionally, subtle pelvic torsion has been reported to cause asymmetrical loading on the lumbar and thoracic tissues (Al-Eisa, Egan et al., 2006a; 2006b). Pain clearly affects movement. Subjects with low back pain have been reported to have greater asymmetry between right and left paraspinal muscle contraction (Oddsson and De Luca, 2003) and altered activation during trunk flexion and re-extension. Pain affects proprioception and the precision of the control of movement (Gill and Callaghan, 1998; Taimela et al., 1999; Leinonen et al., 2002; Grip et al., 2007; Lee et al., 2007). Although these motion abnormalities are consequences of pain rather than causes, motion and postural control are assessed as part of PSM and are potentially useful to guide management and assess the success of treatment. The influence of suboptimal posture on pain is more clearly demonstrated for the head and neck. Several studies support these clinical observations and demonstrate associations with altered cervical posture and neck pain. Yip et al. (Yip et al., 2008) reported that subjects with neck pain demonstrated greater forward head posture (CV angle) than those without pain and that the greater the forward head posture the greater the disability. Lau et al. (Lau, Cheung et al., 2010) found the upper thoracic angle was a good predictor for presence of neck pain, even better than the CV angle. Other researchers have also reported greater cervical lordosis in neck pain patients. Maintaining a neutral head posture and avoiding a forward head position is advantageous in reducing sustained upper and lower trapezius activity (Weon et al., 2010). Furthermore, structural and biomechanical factors, such as knee valgus motion, knee flexion (Myer, Ford et al., 2010a; 2010b), altered joint kinematics, and postural stability (Paterno et al., 2010), have been useful in predicting athletes at risk of anterior cruciate ligament injury. I believe a broad interpretation of PSM assessment, including observation of global posture (during standing and in occupational tasks), range of motion, and movement patterns, provides useful information to the clinician. As Lederman highlights, the lack of reliability and validity of many of our diagnostic palpatory tests should concern practitioners who use this therapeutic paradigm to detect minute differences in asymmetry of landmarks or motion of spinal segments. However, the clinical usefulness of identifying minor asymmetry of pelvic and spinal landmarks is highly dubious, may lead to erroneous beliefs by therapists and patients of ‘bones out of place’,

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and may contribute to fear avoidance behavior. Assessment of global posture (during standing and in occupational tasks), functional movement, muscle strength, and palpation for tenderness are likely to have clinical utility, and although these factors may be consequences of pain and injury rather than causes, they are biomechanical findings that may help guide management. However, any physical findings must be placed in context with clinical history and a biopsychosocial approach. There is no question that the importance of PSM factors have been overstated by sub-groups of manual therapists in the past and consideration of the multidimensional nature of pain is essential for holistic, patient-centered care.

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Myer, G.D., Ford, K.R., et al., 2010b. Development and validation of a clinic-based prediction tool to identify female athletes at high risk for anterior cruciate ligament injury. Am. J. Sports Med. 38 (10), 2025e2033. Oddsson, L.I.E., De Luca, C.J., 2003. Activation imbalances in lumbar spine muscles in the presence of chronic low back pain. J. Appl. Physiol. 94, 1410e1420. Paterno, M.V., Schmitt, L.C., et al., 2010. Biomechanical measures during landing and postural stability predict second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport. Am. J. Sports Med. 38 (10), 1968e1978.

Solomonow, M., 2006. Sensory e Motor control of ligaments and associated neuromuscular disorders. J. Electromyogr. Kinesiol. 16 (6), 549e567. Taimela, S., Kankaanpaa, M., et al., 1999. The effect of lumbar fatigue on the ability to sense a change in lumbar position. Spine 24 (13), 1322e1327. Weon, J.H., Oh, J.S., et al., 2010. Influence of forward head posture on scapular upward rotators during isometric shoulder flexion. J. Bodyw Mov Ther. 14 (4), 367e374. Yip, C.H., Chiu, T.T., et al., 2008. The relationship between head posture and severity and disability of patients with neck pain. Man. Ther. 13 (2), 148e154.

Invited response: (Without science, there must be art) John C. Hannon, DC * 1141 Pacific Street, Suite B, San Luis Obispo, CA 93401, USA

KEYWORDS Lederman; Lower back pain; Asymmetry; Posture; Manual therapy; Relaxation; Predictability; Movement excellence

Summary In the target article, Lederman reminds us we do not know the causes of back pain. Further, we cannot count on perceived asymmetry, biomechanical dysfunction and muscle imbalance to guide treatment. Early osteopaths and chiropractors believed where there is no science, there must be fervor. This reviewer suggests where there is no science, there must be art. We can train ourselves, as Professor Lederman has done, to read widely, think deeply and debate well. We can open communication between scientists and clinicians. And, we also can find inspiration in artistry. Artists spend decades discovering how to steer their craft. An early student of movement control, Nicholai Bernstein showed that expert blacksmiths have neither intra-operator nor inter-operator repeatability. They never swing their arms exactly the same yet every expert predictably produces the desired outcome. This paper encourages learning from the artistry of expert massage therapists. Instead of a narrow focus detecting diagnoses and dysfunction, they have a softer and wider focus. They create a comfortable ambiance and they tend to spend more time with their clients. In addition to learning from bodyworkers and movement therapists, cultivation of the arts may also deepen empathy, communication skills and personal conviction in ways that wordlessly help patients find our work trustworthy. .

Introduction For more than 23 years Professor Lederman has spoken in a strong and clear voice about issues at the core of rehabilitation. He can be counted on to ask searching questions that derive from a deep concern with the quality of

* Tel.: +1 805 542 9925; fax: +1 805 541 2391. E-mail address: [email protected].

physical examination and manual therapy. In the target article, Lederman (2010) speaks out again, this time about what he sees as three hurdles to effective manual therapy. First, he notes the impossibility of defining the causes of back pain. Humans are resourceful and work around asymmetries and imbalances. Lederman reminds us that perceived asymmetry (be it postural, structural or biomechanical) cannot be counted on to guide treatment. He cautions us that muscle imbalance (be it strength, length or endurance) also is an untrustworthy guide. Therefore, what he calls the ‘postural-structural-

Is a postural-structural-biomechanical model, within manual therapies, viable biomechanical model’ (PSB) is bound to be erratic and ineffective in guiding treatment. His second hurdle is the lack of reliability in the assessment tools used in manual therapy. Lastly, he notes that remodeling aberrant muscles and connective tissues is too time-intensive to expect good compliance. It is true, manual therapy is in a dreadful mess. It always has been and always will be. That is one of its splendors. Its complexity prevents convenient packaging; its metaphors change with time to accommodate the latest assumptions (and sometimes even scientific findings). Perhaps the urge to classify; to economize the intellect, produced the chimeric1 aberrations spotlighted by his paper. In any case, we have Lederman to thank for his collection of articles2 that deride the idea of simple causation. Before addressing his concerns, consider another example of muddle-headed health care masquerading as science; one where even vast investments of money, prestige and power have proved useless: America’s unsuccessful 35 years fighting the War on Cancer3. Even with annual spending of up to 20 billion dollars on research (and 200 billion dollars on treatment) cancer incidence in the USA leads the world and American cancer death rates refuse to drop. Despite these staggering costs in treasure and misery, organized medicine refuses to shift its focus to cancer prevention through tobacco abstinence, dietary improvements and environmental remedies.

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Chimeric in that a false tidiness was created by those manual therapists who strove to yoke the concepts (and tests) of two different species: bone-cutting orthopedists and the vitalists of yore. 2 In support of his claim of the absence of scientific support he cites (but does not summarize) about 60 articles and systematic reviews. This reviewer is not a scientist, but this seems too meager a serving for so important a topic. 3 The research, diagnosis and treatment of cancer and low back pain share characteristics that Professor Lederman describes. Each demonstrates muddle-headed thinking, prejudicially rigid behaviors and vested interests. Aggarwal et al., (2009) explain the “War on Cancer” was declared by President Nixon, in 1974, as an attempt to make the wealthiest country into the healthiest country. In the last 20 years, 60,000 compounds have been tested against 60 human cancer cell lines without a single effective anticancer candidate identified. Many cell-lines are cross-contaminated and the cell-lines spontaneously mutate over time. But, despite these confounding factors, note that cell-line research forms the basis of 75% of all cancer research publications. It is not surprising that these studies are poor indicators of efficacy in humans. Making things more muddle-headed is the absence of any animal model that is predictive of cancer. Nor are there any biomarkers reliable enough to assess cancer risk or to assess treatment. Why are rational scientists, despite their access to prestige, funding, and sophisticated scientific tools, unwilling to move forward and stake out new territory? Perhaps it is an aggressive refusal to consider what Nabokov (1983) calls the “most dread enemy of the visionary: the snake of doubt, the coiled consciousness that his quest is an illusion”.

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Pain and psychology Wall (1977) discusses the emotions that surround pain4 (such as fear, anxiety, dislike and urgency). This paper echoes Wall’s wish to move away from merely studying pain stimuli, instead, we gain advantage by learning to recognize (and calm) the reactive states triggered by pain. Unmentioned in Lederman is how to address these tense body reactions although psychology5 is mentioned (in two sentences): “[B]eing a human . means that the structure is within the awareness. It is also under the influence of our emotions as well as the will.”

3 straw men and the fall of PSB? Lederman’s title states a fall is coming. But was a single model ever raised up? Consider the three straw man fallacies found in the target paper. Contrary to his title, no model is shared by manual therapists. Lederman notes PSB is a ‘basic belief’ and it is ‘frequently used in clinic’ but without citations backing up this claim. It is more likely that practitioners, at different points in their careers, believe in some aspects of what Lederman presents as the PSB model. Similarly, no one is identified who believes Lederman’s portrayal of PSB’s mechanical model as the “utopian view of the body [working] in perfect precision/synchrony.” Lastly, he oversimplifies; for instance, he manhandles the vast field of clinical management into a tiny and impossible dyad where lower back problems are either too severe to treat or too minor to matter.

4 Wall notes that “I have never sensed a pure pain. If I sense a pain, it comes in a packet with such changes as fear, loathing, anxiety, dislike, urgency, etc. . There is a second peculiarity of pain which differentiates it from most of our sensory experience. Pain is given. Most of our sensory experience is taken.’ And, on p. 366 he states: “A great deal of the body’s machinery is involved in maintaining a stable internal environment. If this shifts from its normal range, a series of more and more complex and elaborate reactions are triggered. These states of awareness have many properties in common. One is urgency. . So great is the urge to do something that these states have been associated each with its drive and we would add to the commonly accepted drives to eat and drink, a drive to preserve the body intact. . Pain is associated with the turning on of the drive for reaction. The nature of the reaction will depend on a different set of circumstances. This shifts pain away from the stage of event detection towards a stage of reaction decision.” 5 Psychology is also mentioned on p.10 of the target article. But notice a trend in his books. Over time there has been a whittling away of his discussion of the psychological side of manual therapy. Psychology shared in the book’s title and fully one third of the 1997 book. The 2005 edition retains a section entitled Psychology and Psychophysiological Processes but the section shrinks to about 20% of the text. The 2010 edition’s table of contents no longer highlights psychology although the subject still crops up in the text. The cpdo.net website (home to Lederman’s online journal which published the target article) lists Tsafi Lederman (UKCP registered psychotherapist) as co-author of the Lederman 2005 psychology section. The 2005 preface states: “I would like to acknowledge Tsafi Lederman’s special contribution to Section 3 of both editions [2005 and 1997] of the book.”

142 As refreshing as it is to see straw men swept away with energy and vigor, that energy would have been better used in the describing his Process Approach model. Similarly, more clarification is needed to understand lower back pain through Lederman’s biological rather than mechanical lens.

The value of art in manual therapy Current perceptions of manual therapy are not always elevated. Recent survey articles (Duffy, 2010; Hulen, 2008) consign manual therapy (with minimal commentary) to a nondescript grab-bag of complementary and alternative therapies. But, this is squabbling between competing interests since both allopathic medicine and manual therapy (physical therapy, osteopathy and chiropractic) share heroic assumptions. They often take on disease and shoot for a cure. But consider the other form of manual therapy that is either too humble (or too smart) to join the fracas: massage. Interestingly, preference for massage (mostly paid outof-pocket rather than by insurance) sometimes beats out manipulation6. Massage therapy training builds competency based upon not only science7 but also art. Perhaps it is time for some chiropractors, osteopaths and physical therapists to take lessons from massage therapists8.

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The following studies suggest that, for some, massage has a more elevated status than manual therapy: 1/. Chenot et al., 2007 studied Germans with low back pain and found the prevalence of these modalities (descending order): local heat (34%), massage (31%), spinal manipulation (26%). 2/. Fleming et al., 2007 in a study of 908 chronic pain patients receiving opioids as a primary treatment (lower back pain was the largest group). Massage therapy was used by (27%), followed by chiropractic treatment (18%), acupuncture (7%), and yoga (6%). 3/. Wang et al., 2005, in a survey of pregnant women, listed acceptance in descending order: massage (61.4%) compared to acupuncture (44.6%), relaxation (42.6%), yoga (40.6%), and chiropractic (36.6%). 4/. Carneiro and Rittenberg 2010 considered the role of exercise and alternative treatments for lower back pain and endorsed yoga and acupuncture rather than manual therapy. 5/. Wang et al., 2003, in a follow-up survey (1235 respondents) of the use of complementary and alternative treatments by surgical patients at Yale-New Haven hospital, found the most prevalent treatment was self-prayer followed by relaxation techniques, herbal medicine, massage/reflexology followed by chiropractic. 6/. Nichols and Harrigan 2006 found athletic usage of massage 25% higher than manual therapy. 7/. Rawsthorne et al., 1999, surveyed alternative medicine use by patients with inflammatory bowel disease at clinics in Winnipeg, Cork, Stockholm and Los Angeles. They found that half the patients (n Z 289) used some form of alternative medicine. In descending order: exercise (28%), prayer (18%), counseling (13%), massage (11%), chiropractic (11%), and relaxation (10%). 7 Some might say this science is merely descriptive as in gross anatomy and basic biomechanics but, massage therapists, bodyworkers and movement therapists have joined the collaborative table as evidenced by their attendance at the recent International Fascia congresses and their authorship (and readership) of this Journal. 8 Lederman 1997 suggested: “Manual therapists are encouraged to use all manual techniques, even those which are traditionally outside their own discipline: the most effective techniques can be used to facilitate the patient’s health.”

J.C. Hannon Consider the typical massage table, it is well padded, wide and often heated; all features designed to encourage relaxation and a feeling of security. The massage therapist, freed from the responsibility of diagnosis, has the luxury of being solicitous of the client’s comfort. Another luxury often enjoyed by massage therapists is a longer treatment time. Much can happen in an hour, particularly for those who find it difficult to relax. The most important asset the best massage therapists have, in this reviewer’s opinion, is their ability to sense what is right about their clients. Diagnosis-driven manual therapy tends to focus on dysfunction/disorder/disease. Instead of finding fault, we can also look for optimal function contributing to movement excellence. Using this as our starting point, perhaps we can amplify, and distribute this ease and coordinated function into other regions of the body.

Huygens and Goldstein Meijer (2001) tells the story of Charles V. Almost 450 years ago, this inveterate clock collector, wanted his many clocks to synchronize while striking the hours. This problem vexed him to the point of springing him out of bed to adjust the laggards. Sadly for Charles, it was a century later when Huygens found a solution. He suspended clocks from a metal bar. Suspension permitted gravity to orient each clock in concert while the resonance of the metal bar entrained their rhythms. Huygens found an esthetic solution to an engineering problem. It is possible that a similar artistic solution may aid earnest manual therapists, dizzied by Lederman’s divergent findings. Goldstein (1939/1995) describes a central dilemma in biology; that is, life must be taken apart to be studied scientifically and this process has generated “a multitude of isolated facts . but [w]hat do the phenomena, arising out of the isolating procedure, teach us about the essence (the intrinsic nature) of an organism? How, from such phenomena, do we come to an understanding of the behavior of the individual organism?”

The internal arts Lederman echoes Goldstein. One way out of this quandary is to devote a career to understanding movement excellence, the better to recognize and encourage it in our patients. Patients trust our skills, knowledge and intuition when they believe we are doing our best for them. Empathetic9 conversation, as well as touch, helps patients to trust.

9 Lewit 2010 notes “The locomotor system . is the largest and most intricate system in the human body. . [describing current therapists] we have learned to utilize increasingly complicated equipment while at the same time neglecting the evidence of our eyes and in particular of our hands, as well as forgetting to communicate with our patients. However, by comparison with communicating with the patient, observing with our eyes and sensing with our hands, no piece of hightech equipment is able to yield such a wealth of varied information. All this is heightened by the capacity for feedbackdindeed empathydbetween practitioner and patient.”

Is a postural-structural-biomechanical model, within manual therapies, viable This contemplates that we choose to consciously mature our qualities of patience, sincerity, honesty and serenity. We ourselves may need to deepen these qualities to recognize excellence of movement, particularly of the minuscule respiratory excursions and the diminutive postural releases that accompany the act of relaxation10. We can learn from Huygens whose innovation bridged esthetics and engineering. Plumbing profound applications from basic principles also takes time. This reviewer believes that learning how to observe, palpate and respond to the patient’s varying levels of relaxation is a fruitful use of time. This inward focus may balance the need to stay current with research findings; Donald Knuth, the computer science pioneer, explains on his website why he does not respond to (most) emails. He says that unlike most people, he does not want to stay on top of things; instead, he wants to get to the bottom of things. An additional way to get to the bottom of things may be cultivation of the arts. Not only by watching dance, martial arts and Olympic sporting events in slow-motion but also by reading sufficient poetry, music or drama11 to be deeply moved by art. The point is to develop empathy and increase our points of view by cherishing art. There are scientists and clinicians who, like Professor Lederman, teach, treat and train. We can learn from these people. For instance, Lee et al. (2008) help women with pregnancy-related pelvic girdle pain. Without compromising continence or respiration, they accomplish effective lumbopelvic transfer of loads by maintaining optimal joint axes and sufficient intra-abdominal pressure. Also interested in force transmission are Brown and McGill (2010) who compared ultrasound and electromyography findings in the examination of abdominal wall contraction. They suggest that the composite laminate-like organization of the wall may affect force transmission. They too merge their findings and those of other researchers into therapeutic approaches. But we should also develop the art of encouraging patients to reach beyond passivity. Salmonsen et al. (2010) make a distinction between patients as passive recipients of treatment and those that choose to become explorers. They note that such explorers “have claims to knowledge and actions in which science does not have a privileged place”. Instead, explorers scout for techniques and concepts that are meaningful in their everyday life.

Conclusion Like an unkempt bazaar where idealists and freebooters rub shoulders and caveat emptor reigns, manual therapy is a blooming confusion where the earnest either wrangle their patients within paradigmatic constraints or forge new beginnings from the broken remnants of old exemplars. This reviewer believes the healing arts reach their potential when practitioners find passion and devotion in

10

One exploration of these distinctions is described in Hannon (2006). 11 Please substitute whatever forms of art fit.

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being of service. Empathy and communication are needed to inspire those we serve and this takes time. We need to move beyond passive care and to harness curiosity, will and imagination. A scientific background may be essential but, when causation is confused and reliability nonexistent, the foundations of healing must be based on art.

Competing interests This reviewer has no competing interests.

References Aggarwal, B.B., Danda, D., Gupta, S., Gehlot, P., 2009. Models for prevention and treatment of cancer: problems vs promises. Biochem. Pharmacol. 78 (9), 1083e1094. Brown, S.H.M., McGill, S.M., 2010. A comparison of ultrasound and electromyography measures of force and activation to examine the mechanics of abdominal wall contraction. Clin. Biomech. (Bristol, Avon) 25 (2), 115e123. Carneiro, K.A., Rittenberg, J.D., 2010. The role of exercise and alternative treatments for low back pain. Phys. Med. Rehabil. Clin. N. Am. 21 (4), 777e792. Chenot, J.F., Becker, A., Leonhardt, C., Keller, S., DonnerBanzhoff, N., Baum, E., Pfingsten, M., Hildebrandt, J., Basler, H.D., Kochen, M.M., 2007. Use of complementary alternative medicine for low back pain consulting in general practice: a cohort study. BMC Complement. Altern. Med. 7, 42. doi:10.1186/1472-6882-7-42. Duffy, R.L., 2010. Low back pain: an approach to diagnosis and management. Prim. Care Clin. Off. Pract. 37, 729e741. Fleming, S., Rabago, D.P., Mundt, M.P., Fleming, M.F., 2007. CAM therapies among primary care patients using opioid for chronic pain. BMC Complement. Altern. Med. 7, 15. doi:10.1186/14726882-7-15. Goldstein, K., 1939/1995. The Organism: A Holistic Approach to Biology Derived from Pathological Data in Man. Zone Books. MIT Press, Cambridge, p. 27. Hannon, J.C., 2006. Wartenberg Part 3: relaxation training, centration and skeletal opposition: a conceptual model. J. Bodywork Move. Therapies 10, 179e196. Hulen, C.A., 2008. Nonoperative treatment of low back pain. Semin. Spine Surg. 20 (2), 102e112. Lederman, E., 1997. Fundamentals of Manual Therapy: Physiology, Neurology and Psychology. Churchill Livingstone, New York, p. viii. Lederman, E., 2005. The Science and Practice of Manual Therapy. Elsevier, Edinburgh, p. xiv. Lederman, E., 2010. The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain. CPDO Online J., 1e14. www.cpdo.net. Lee, D.G., Lee, L.J., McLaughlin, L., 2008. Stability, continence and breathing: the role of fascia following pregnancy and delivery. J. Bodywork Move. Therapies 12 (4), 333e348. Lewit, K., 2010. Manipulative Therapy. Elsevier, Edinburgh. p. 380. Meijer, O.G., 2001. Making things happen: an introduction to the history of movement science. In: Latash, M.L., Zatsiorsky, V.M. (Eds.), 2001 Classics in Movement Science. Human Kinetics, Champaign, pp. 1e57. Nabokov, V., 1983. In: Bowers, F. (Ed.), Lectures on Don Quixote. Harcourt Brace Jovanovich, San Diego, p. 68. Nichols, A.W., Harrigan, R., 2006. Complementary and alternative medicine usage by intercollegiate athletes. Clin. J. Sport. Med. 16 (3), 232e237.

144 Rawsthorne, P., Shanahan, F., Cronin, N.C., Anton, P.A., Lofberg, R., Bohman, L., Bernstein, C.N., 1999. An international survey of the use and attitudes regarding alternative medicine by patients with inflammatory bowel disease. Am. J. Gastroenterol. 94 (5), 1298e1303. Salamonsen, A., Launso, L., Kruse, T.E., Eriksen, S.H., 2010. Understanding unexpected courses of multiple sclerosis among patients using complementary and alternative medicine: a travel from recipient to explorer. Int. J. Qual. Stud. Health Well-being 5, 5032. doi:10.3402/qhw.v5i2.5032.

R.E. Irvin Wall, P.D., 1977. Why do we not understand pain? In: Duncan, R., Weston-Smith (Eds.), The Encyclopaedia of Ignorance. Pocket Books, New York, pp. 363, 366. Wang, S.M., Caldwell-Andrews, A.A., Kain, Z.N., 2003. The use of complementary and alternative medicines by surgical patients: a follow-up survey study. Anesth. Analg 97 (4), 1010e1015. Wang, S.M., DeZinno, P., Fermo, L., William, K., CaldwellAndrews, A.A., Bravemen, F., Kain, Z.N., 2005. Complementary and alternative medicine for low-back pain in pregnancy: a crosssectional survey. J. Altern. Complement. Med. 11 (3), 459e464.

Invited response (The postural structural model, with boundary conditions) Robert Edwin Irvin, DO * Department of Osteopathic Manipulative Medicine, Oklahoma State University Health Science Center, 1111 W. 17th St., Tulsa, OK 74107, USA

Introduction I do not rebut Dr. Lederman’s conclusions from the clinical science of posture (Lederman, 2010), but rather the contemporary science and therapeutics of posture itself. Research within the last 30 years of the predictive value of postural imbalance for back pain yields results interpreted by several investigators (Grundy and Roberts, 1984, and Dieck et al., 1985), as evidence that posture is, at best, a weak player in the etiology of such pain. Grundy and Roberts found that disparity of the lower limbs is not a significant predictor for the history of low back pain. Dieck found that postural asymmetries in the coronal plane, after 25 years, had no predictive value for back or neck pain. Fann (2002) found that the history of low back pain does not correlate with the amount of pelvic unlevelness. Interpretation of these findings as being evidence of absent or weak causality of postural imbalance for pain is overly narrow for reason that while postural imbalance, an ubiquitous finding, is not predictive of pain (an example of observational causality: See A and you routinely see B) (Rapoport, 1954), clinical research evidences (Irvin, 1986, Hoffman, 1994, Irvin, 1998, Lipton et al., 2009) that sufficient reduction of postural imbalance is strongly predictive of enduring reduction or alleviation of musculoskeletal pain throughout the body, where no primary biologic disease of the musculoskeletal system otherwise exists (an example of manipulable causality: Change A and B routinely changes).

* 6620 Bryant Irvin Road, Suite 100, Fort Worth, Texas 76132, USA. Tel.: +1 817 346 6656. E-mail address: [email protected].

The preponderance of studies with outcomes of therapeutic strategies aimed to reduce the tissue changes associated with postural imbalance show weak or no benefit because of several problems in what is presupposed about the causality of postural imbalance for pain. Experimental design and the postural therapeutics that ensue from these presuppositions are then similarly weakened and are mistaken as evidence of lack of determination between postural imbalance and pain. One problem is that postural imbalance as etiology of pathomechanical disease is more complex than is presumed by the dyad of cause and effect. Fundamentally at play is postural imbalance as origin of most mechanical stress throughout the body, in contrast to cause in terms of tissue changes that that are proximate to the effect. How is postural imbalance the origin of most mechanical stress? Except for astronauts, those in air flight, and aquanauts, most mechanical activity occur on the ground (and also in the field of gravity). The shape, attitude and activity of the body with respect to gravitation (posture), and ground support are the initial and ongoing conditions from which all mechanical actions proceed. Logically, posture, and its corollary, imbalanced posture, is the origin of most human mechanical actions, and thereby of much, even most, mechanically mediated disease. For which origin, experimental design and the therapeutic methods to be tested must be informed of the postural systematic (see Figure 1) (Irvin, 1998, Irvin, 2007) if they are to be a valid test of postural imbalance as it relates to pathomechanical disease. The postural systematic as origin is comprised of multiple and interacting factors which cannot be reduced to a single cause.

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Figure 1 A schematic of the essential constituents of the postural systematic that extends from a common origin that represents their operational linkage and which is comprised of 6 essential characters for human posture: intrinsic structures, intrinsic functions, boundary conditions, extrinsic attitude, extrinsic activity, and extrinsic shape.

Central to the postural systematic is a composite of six natures in their environs of gravitation and ground support. 1. Extrinsic shape, in terms of convex, concave, and flat. 2. Extrinsic attitude, in terms of vertical, inclined, and horizontal.

3. Extrinsic activity, in terms of gait, upright stance (standing or seated) and recline. 4. Intrinsic structures, with respect to the 3 spatial freedoms, x, y, and z. 5. Intrinsic functions, with respect to the 3 freedoms that are translation, rotation, and oscillation.

Figure 2 An illustration of the 3 central boundaries of posture: the feet, the sacral base, and the CNS; all having ground support in the field of gravity.

146 6. Boundary conditions, which are initial and ongoing, and which limit and regulate overall postural array, these boundaries being the feet, the sacral base, and the CNS (see Figure 2). The pivotal character of the feet, sacral base and CNS as boundary conditions for overall posture is a function of these structures being central to each of 3 sub-systems that comprise the postural system. By virtue of this operational centrality for postural systematics, each boundary is linked directly to all aspects of the musculoskeletal system. These 3 central postural boundaries are the feet, comprised of 3 arches, the sacrum with 3 articular surfaces, and the CNS, comprised of the right and left motor cortices and the postural control system within the brainstem which regulates postural array via motor control. 1) The feet are central to the equal and opposing vectors of body weight and ground support. 2) The sacral base is approximately geometrically central to the outstretched frame. 3) The postural control system in the brainstem of the central nervous system interacts with the entirety of posture via motor control, to affect the most economic stance, activity and shape, and thereby to minimize mechanical stress An immediate therapeutic advantage from awareness of this postural schematic is that each aspect of the postural system is operationally linked with all other aspects. This linkage provides potential for its coherent manipulation towards an improved posture. An additional advantage is from recognition and according treatment of the boundary (initial and ongoing) conditions for posture, and thereby routinely achieves broad and enduring correction of postural imbalance. This concerted method for treatment of mechanically mediated disease is in contrast to a causal strategy aimed primarily to treat tissue changes proximate to the respective effect, and without synchronous correction of the boundary conditions that mediate postural imbalance. Where causality is assumed to be the sole determinative mode, a number of difficulties in experimental design occur, which difficulties disappear in the context of origin. For instance, the tissue changes associated with imbalanced posture, and which are emphasized in contemporary treatment, are intermediate between the imbalanced posture and the effect that is pain. Hence, treatment of these changes is not directly corrective of the core postural imbalance, but instead reduces the accumulated disorder that can proceed from postural imbalance. While sufficient reduction of the disordered load can affect pain in individual cases, this benefit is less certain in a representative population because the origin (postural imbalance) is still in play. A second difficulty, and a misstep, is to reduce the frame of reference for causality to a cause that is physically proximate (contiguous) to effect. Origin can yield the effect of pain, with or without intermediate processes, (e.g. tissue changes proximate to pain) a fact complicating experimental design. For instance, does manipulation of the low back enduringly reduce low back pain? The preponderance of previous studies conclude not. By not

R.E. Irvin recognizing that postural imbalance is a pan-systemic disorder, being neither proximate to nor remote from effect, this partial view does not take into account that the effects on tissues are typically not for a single region, but instead are multi-regional. Treatment aimed to modify a local manifestation of postural imbalance, such as tissue restriction or skeletal asymmetry proximate to where there is pain, is susceptible to failure as the pan-systemic imbalance is an ongoing pressure towards the continuance of a given effect. Thirdly, the network of disordered tissues throughout the body constitutes a load of disorder, which is resistant to change from treatment of a single region. Within which network, focal or local treatment is an inadequately small frame of reference for the embedded focus of pain. A fourth problem, and one for experimental design, is that, practically, rather than treating one region for one pain, operators that provide manual or physical manipulation more commonly employ complex, pan corporeal therapeutics directed to counter multi-regional tissue disorder associated with postural imbalance. There is poor inter-operator reproducibility and uniformity for this complex therapeutics. Further, such therapeutics are tailored to each individual case, and thereby cannot practically follow a protocol for uniformity of treatment of multiple subjects, albeit with similar symptoms. This complexity is a nightmare for those who would apply the austere model of causality that prefers a singular therapeutic variable in order to test a singular and hypothetical causality. If the operator is informed of this postural systematic and accordingly corrects the boundary conditions for posture, implementation of a pelvic lift has little complexity. Taking an imprint of the feet from which the orthotics are crafted routinely individualizes custom foot orthotics. The chief objective for additional physical and manual manipulation is to reduce the accumulated load of tissue disorder, and thereby decrease resistance to postural symmetrization as the postural boundaries are corrected. Thereby, operators can coherently reduce from many directions the pan-systemic load of tissue disorder, and by whatever accepted therapeutic modes available, even as the boundary conditions are being corrected. A fifth problem is that prior studies of the effects either of foot orthotics or pelvic leveling alone neglects the contribution of the boundary not corrected, which can obscure the benefits from this partial correction. Nonetheless, where the pelvic obliquity alone is corrected, in combination with manual reduction of disorders of soft tissue, pan-systemic alleviation of the greater portion of chronic pain routinely follows (Irvin, 1998). Adults with multi-regional chronic pain, not due to metabolic disease, and for whom the sacrum is leveled by a pelvic lift beneath the heel on the low side, have enduring reduction of the number of regions with pain by w70% (experimental results), and with marked reduction of pain for those regions remaining symptomatic (the later being anecdotal) (see Figure 3). Where the feet and ankles are corrected, the sacral base is leveled (both seated and standing), and accrued restriction of soft tissues relieved, >90% of mechanically mediated pain is enduringly relieved (anecdotal).

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Figure 3 A graphic reflection of pan-systemic alleviation of the greater portion of chronic pain by correction of pelvic obliquity, combined with manual manipulation to reduce tissue restriction throughout all regions.

Independent research of the effects of leveling the unlevel standing pelvis, estimated by physical exam, combined with use of custom orthotics to correct the shape of the feet and promote the vertical alignment of the ankles, with manual manipulation to reduce accumulated restriction, results in alleviation of w80% of reported chronic pain (Lipton et al., 2009). A final problem is that two (Irvin, 1998; Lipton et al., 2009) of three (Hoffman and Hoffman, 1994) studies that demonstrate the strong effect of postural balancing on chronic pain by correction of boundary conditions in addition to manual reduction of disordered tissues, do not include either a control population or a sham heel lift. Perhaps for reason of this, and for reason of the significant effects reflected by all three, these studies are not mentioned in Dr. Lederman’s paper that asserts the fall of the posturaldstructuraldbiomechanical model. This claim follows reasonably from the preponderance of experimental outcomes for most studies with the aforementioned flaws, relative to the actual nature of postural imbalance. Admittedly, to demonstrate a cause and effect hypothesis, an experiment must often show that, for example, a phenomenon occurs after a certain treatment is given to a subject, and that the phenomenon does not occur in the absence of the treatment. A reasonable exception to this requirement for a control population is where the phenomenon being tested is known not to occur, otherwise. For instance, if one were to evidence that a particular treatment returns the dead to life, it would add no

credence to the experimental outcome to assemble a control population of corpses for which treatment was withheld. Further, one might ably fool a corpse with a soft foam lift, but not a conscious human. Strong reduction or enduring alleviation of chronic pain throughout all regions of the body that is mechanically mediated is known not to occur spontaneously for a representative population, nor has it been achieved experimentally by any other therapeutic method. Another practical example of a lack of need for controls is the significant reduction of lumbar scoliosis by use of a pelvic lift to level the sacral base (Irvin, 1991). For a representative population, scoliosis is known not to significantly reduce spontaneously, or by any non-surgical method, other than by leveling the sacral base. Altogether, manual and physical therapeutics for postural imbalance and its effects, while often effective on a case-by-case basis, are short a necessary practice of synchronously correcting the boundary conditions for posture. Where both the pes planovalgus and the sacral base obliquity are corrected via orthotics, there are routinely achieved large and enduring reductions of chronic, multi-regional pain in representative populations. Contemporary experimental design, aimed to validly test the operational linkage between postural imbalance and pain, must be in accord with a broadened model for determinism that is informed of the nature of origin systematics and its pan-systemic and widely varied potential for generation of intermediate causes and eventual effects. While we cannot reliably predict the intermediate causes and effects

148 from postural imbalance (observational causality), we can reliably predict the large and enduring reductive outcomes for these effects from correction of postural imbalance, satisfying the determinism for manipulable causality. The postural-structural-biomechanical model has not fallen, but rather shall rise like the Phoenix from the ashes of prior research and of therapeutic methods that were not, until the near future, sufficiently informed of a more full nature of posture than is recognized contemporarily. Our proper concern is not with the success and failure of past practices, but rather with the advancement of future practices so informed and thereby having the greatest efficacy, least cost, and least risk for our patients.

References Dieck, G., et al., 1985. An epidemiologic study of the relationship between postural asymmetry in the teen years and subsequent back and neck pain. Spine 10, 872e877. Fann, A.V., 2002. The prevalence of postural asymmetry in people with and without chronic low back pain. Arch. Phys. Med. Rehabil. 83 (12), 1736e1738.

D. Lee Grundy, P.F., Roberts, C.J., 1984. Does unequal leg length cause back pain? A case-control study. Lancet 2, 256e258. Hoffman, K., Hoffman, K., 1994. Effects of adding sacral base leveling to osteopathic manipulative treatment of back pain: a pilot study. J. Am. Osteopathic Assoc. 3, 217e322. Irvin, R.E., 1991. Reduction of lumbar scoliosis by the use of heel lift to level the sacral base. J. Amer. Osteo. Assoc. 91 (1), 34e44. Irvin, R.E., 1986. Postural Balancing: a regimen for the routine reversal of chronic somatic dysfunction, abstracted. J. Am. Osteopathic Assoc. 86 608/125. Irvin, R.E., 1998. The origin and relief of common pain. Elsevier Science Ireland. J. Back Musculoskelet. Rehabil. 11, 89e130. Irvin, R.E., 2007. Why and how to optimize posture, chapter 16. In: Vleeming, et al. (Eds.), Movement, Stability and Lumbopelvic Pain, second ed. Elsevier, Edinburgh. Lederman, E., March 2010. The fall of the postural-structuralbiomechanical model in manual and physical therapies: exemplified by lower back pain. Online J., 1e14. WWW.CPDO.net. Lipton, J.A., et al., 2009. The use of heel lifts and custom orthotics in reducing self-reported chronic musculoskeletal pain scores. Am. Acad. Osteopathy J. 19 (1), 15e20. Rapoport, A., 1954. Operational Philosophy: Integrating Knowledge and Action. Harper and Brothers Publishers, New York. pp. 57e64.

Invited response (Evidence and clinical experience: the challenge when they conflict) Diane Lee, BSR, FCAMT, CGIMS Diane Lee & Associates, Discover Physio, White Rock, BC, Canada According to the Canadian Institutes of Health Research, Knowledge translation is defined as a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically-sound application of knowledge to improve the health of Canadians, provide more effective health services and products and strengthen the health care system. (CIHR, 2009, Salbach, 2010). In his article, The fall of the postural-structural-biomechanical model in manual and physical therapies: Exemplified by lower back pain, Lederman attempts to translate knowledge gained from some research pertaining to a postural-structural-biomechanical (PSB) model and makes conclusions regarding: 1. the role a PSB may or may not play in causing lower back pain and 2. how effective a PSB model is for the treatment of lower back pain. What is the PSB model and who uses it? According to Lederman, the PSB model is somewhat vague and appears to

E-mail address: [email protected].

encompass almost every approach known for the assessment and treatment of low back pain including physiotherapy, osteopathy, chiropractic, massage therapy, manual therapy, bodywork, craniosacral therapy, visceral therapy, Rolfing, Structural Integration, and all forms of exercise or movement training including, but not limited to, motor control training, neurodynamics, McKenzie back exercise, personal training, kinesiology, Yoga, and Pilates. Simply put, he uses certain studies to support his conclusion that: 1. factors inherent to his defined PSB model do not cause back pain and furthermore, that 2. the ‘therapeutic investment in correcting posturalstructural-biomechancal factors is irrational, in particular, as it is unlikely to influence the course of the patient’s condition’. He summarizes by suggesting that a PSB model is unnecessarily complex, has no value in elucidating the cause of low back pain, that the assessment tools (manual and visual) are unreliable and can be removed from clinical practice, and that PSB factors are unlikely to change in the long term with exercise and warns that this model may introduce an element of therapeutic failure as the aims and goals of this approach may not be attainable by manual therapy or even exercise.

Is a postural-structural-biomechanical model, within manual therapies, viable This is a potentially dangerous interpretation of a limited, and specifically chosen, number of studies, and while it is important to reflect on the knowledge gained from these studies, it is also important to note that they do not represent the entire body of scientific evidence we now have for understanding the multi-factorial nature of individuals with back pain. This paper has clearly reinforced why nothing significant is gained when individuals with the same pain are grouped together for any investigation. Individuals with low back pain clearly are not a homogenous group; and it is not new knowledge that PSB factors do not cause pain. As we all know, general diagnoses such as low back pain or hip pain do not often relate to the cause or to the underlying nature of the condition (Sahrmann, 1988). Clinicians have long recognized, and it is becoming more evident in recent scientific research, that patients with low back pain are heterogenous, and consist of multiple subgroups with different combinations of underlying impairments, or mechanisms, driving their pain (physical and psychosocial), and these sub-groups require different treatment approaches for best outcomes (Dankaerts et al., 2006, 2007; Fersum et al., 2009; Fritz et al., 2003; Lee D and Lee LJ, 2011, O’Sullivan, 2005). The pursuit of valid ways to identify sub-groups of patients with low back pain has become increasingly prominent in the literature. In fact, a large part of the recent 7th Interdisciplinary World Congress on Low Back and Pelvic Pain (Vleeming and Fitzgerald, 2010) was dedicated to research that investigated sub-groups of individuals with LBP so that the multiple, and diverse, biopsychosocial factors that dominate the multiple sub-groups could be better understood and subsequently managed. Given that multiple factors are known to contribute to pain, it is also unrealistic to expect that one single type of treatment (manual therapy, dry needling, exercise training, or education about pain etc.) will resolve a patient’s presenting pain and improve their quality of life. Thus studies which apply a single modality within the PSB model to all subjects with low back pain and then compare the outcome of one intervention to another, rarely show a consistent positive effect across repeated studies. The evidence cited by Lederman in this article clearly supports this. But does that mean that the intervention investigated was ineffective and should therefore be abandoned as he suggests, or should we consider the methodology of the particular study and perhaps question the validity of the findings? There is a large body of evidence not cited in this article that provides a bigger, more accurate picture of the state of the science pertaining to individuals with back and pelvic pain and how this knowledge is being translated into clinical practice (see the reference lists provided in the proceedings of the 7th Interdisciplinary World Congress on Low Back and Pelvic Pain as well as recent European Guidelines for pelvic pain (Vleeming et al., 2008) for a broader view of the current evidence on this topic). You may ask, is there evidence to ever support the use of a postural-structural-biomechanical model? What is a postural-structural-model anyway? What is evidence? Where do we gain knowledge to practice our professions? What knowledge should we pay attention to? Every day in clinical practice, health care practitioners meet patients seeking help for their loss of function

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(disability) and pain. Clinicians are keenly aware of the need to be effective in clinical practice and many feel that this requires being evidence-based, that is why we read articles that summarize evidence and why it is so important that the knowledge gained from the evidence be accurately translated. Sackett, Straus, Richardson, Rosenberg and Haynes (Sackett et al., 2000) define evidence-based practice as ‘the integration of best research evidence, with clinical expertise and patient values.’ They note that, External clinical evidence can inform, but can never replace individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the patient at all, and if so, how it should be integrated into a clinical decision. It is unlikely that there will ever be enough research evidence for every situation met in clinical practice and therefore sound clinical reasoning skills will be needed together with clinical expertise to bridge the gap between what science suggests and what we need to know practically to treat patients with disability and pain. What is clinical expertise? According to Ericsson and Smith (1991), ‘expertise has been defined as having the ability to do the right thing at the right time.’ Given the diversity of individuals with low back pain, is it possible to classify, or subgroup, every individual who presents with low back pain? Clinically, I strongly agree with Jones and Rivett (2004) who note that: Given the same painful impairment, no two individuals will have exactly the same experience and behavior because how they manifest their pain or illness is shaped in part by who they are. So, how do we resolve the dilemma of knowing what to do when someone presents in our office with low back pain? What evidence, protocol or guideline should we follow? Is there, or will there ever be, enough evidence to totally guide clinical practice? This is not likely and, actually, is highly unrealistic. We need frameworks within which to organize all the knowledge being accumulated both from research and clinical expertise as well as the ability to use sound clinical reasoning skills to develop prescriptive, individual treatment programs that address the multiple and diverse mechanisms driving the low back pain; one person at a time (Lee LJ and Lee D 2011). While many therapists may use components of what Lederman has vaguely defined as a PSB model, in reality the interventions are used in an integrated and variable manner specific to the individual’s needs, in context of the health of the whole person. This is very different to the assertion made by Lederman that clinicians view the body as a mechanical entity. It is highly likely that the research on individual components of the PSB model that Lederman cites is not at all reflective of the multi-modal, patient centered approach that integrates postural, structural and biomechanical factors used by clinicians. Clinicians need to publish more individual case reports and collaborate with researchers so that the scientific evidence can more accurately reflect what is occurring in clinical practice. Science can provide us with an abundance of knowledge to challenge, refine, reshape, and validate our clinical

150 practice, but it cannot provide all of the information needed in any individual patient encounter; it does not paint the whole picture of the patient. In order to effectively treat patients, clinicians need to have well-organized knowledge including propositional (knowledge ratified by research trials), non-propositional (professional craft or ‘knowing how’ knowledge) and personal (knowledge gained from personal experiences) (Jones and Rivett, 2004). It is indeed a process, one that requires you to be informed (read the evidence or systematic reviews, journals, attend conferences), skilled (expose yourself to multiple approaches, techniques, training and integrate what is effective for you and your patients in the clinic) and capable of critical thinking (don’t merely accept everyone’s conclusions, reflect on how they resonate with your own experience in the clinic) to know when the evidence, or interpretation of the evidence, should, or should not, transform your clinical practice. The evidence cited in this article, as well as the interpretation of its author, have not convinced me that his representation of the posturalstructural-biomechanical model in manual and physical therapies is accurate, or that it should fall.

References Canadian Institutes of Health Research, 2009. About knowledge translation 2009 Ottawa: The Institutes. http://www.cihr-irsc. gc.ca/e/29418.html. Dankaerts, W., O’Sullivan, P.B., Straker, L.M., Burnett, A.F., Skouen, J.S., 2006. The inter-examiner reliability of a classification method for non-specific chronic low back pain patients with motor control impairment. Man. Ther. 11 (1), 28. Dankaerts, W., O’Sullivan, P., Burnett, A., Straker, L., 2007. The use of a mechanism-based classification system to evaluate and direct management of a patient with non-specific chronic low

S. McGill back pain and motor control impairment - A case report. Man. Ther. 12 (2), 181. Ericsson, K.A., Smith, 1991. Towards a General Theory of Expertise: Prospects and Limits. Cambridge University Press, New York. Fersum, K., O’Sullivan, P., Kva ˚le, A., Skouen, J., 2009. Interexaminer reliability of a classification system for patients with non-specific low back pain. Man. Ther. 14, 555e561. Fritz, J., Delitto, A., Erhard, R., 2003. Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain: a randomized clinical trial. Spine 28 (13), 1363e1372. Jones, M.A., Rivett, D., 2004. Introduction to clinical reasoning. In: Jones, M.A., Rivett, D.A. (Eds.), Clinical Reasoning for Manual Therapists. Elsevier, Edinburgh, p 3. Lee, L.J., Lee, D., 2011. Clinical practice - the reality for clinicians. Ch. 7. In: Lee, D. (Ed.), The Pelvic Girdle, fourth ed. Elsevier, Edinburgh. Lee, D., Lee, L.J., 2011. Clinical reasoning, treatment planning and case reports. Ch. 9. In: Lee, D. (Ed.), The Pelvic Girdle, fourth ed. Elsevier, Edinburgh. O’Sullivan, P., 2005. Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism. Man. Ther. 10 (4), 242e255. Sackett, D.L., Straus, S., Richardson, W.S., Rosenberg, Haynes R B, 2000. Evidence-based Medicine. How to Practice and Teach EBM. Elsevier Science, New York. Sahrmann, S.A., 1988. Diagnosis by the physical therapist e a prerequisite for treatment. Phys. Ther. 68 (11), 1703. Salbach, N.M., 2010. Knowledge translation, evidence-based practice, and you. Physiother. Can. 62 (4), 293. Vleeming, A., Albert, H.B., Ostgaard, H.C., et al., 2008. European guidelines for the diagnosis and treatment of pelvic girdle pain. Eur. Spine 17 (6), 794. Vleeming, A., Fitzgerald, C. http://www.worldcongresslbp.com.

Invited response Stuart McGill, BPE, MSc, PhD Spine Biomechanics Laboratory, University of Waterloo, Canada

I have generalized philosophical concerns together with concerns over substantive issues regarding this paper. The topics are worthy of discussion, however, the sensational title sets the expectation for solid evidence and rigor in developing an issue and the counterpoint. The author repeatedly used a strategy in the framing of a question to make it easily dismissible, and then declared that “there is no evidence to support XXXX”. The arguments put forth in many instances were unidimensional, incomplete, based on undeveloped expressions of concepts, and neglectful of developed bodies of knowledge together with their interactions. Critique of cited works was, for the most part,

E-mail address: [email protected].

absent. I will also declare at the outset that I am sympathetic to several positions that the author took. But this must not affect the job assigned to me here. My points are largely directed towards the process of creating compelling argument e the appropriate treatment and interpretation of specific papers and quotes I will leave largely to others. Back pain is not a homogeneous condition. Any therapeutic approach that helps one individual will exacerbate another. Epidemiological studies of “back pain” will never reveal cause and effect, or efficacy, since each individual will respond to a different approach, and different dosage. Thus a controlled study on “back pain” will result in the conclusion of “no effect”. However, when patients are categorized into sub-groups based on pathomechanics, or pain patterns, or history, or even psychosocial variables,

Is a postural-structural-biomechanical model, within manual therapies, viable results in the evolving literature are generally positive. This paper ignored these studies together with those showing the role of biomechanical factors in the causation pathway. As an exercise in logic let’s replace the discussion of “back pain” with “leg pain”. No study of non-specific leg pain would be expected to reveal cause/effect (the genesis of pain could be due to mechanical, vascular, hereditary, or many other factors). Similarly no credible individual would use such logic to state there is no evidence of links between mechanical factors and non-specific leg pain. Nor would it be published. However, a very specific “leg disorder” such as subsequent ACL disruption in female basketball players has been substantially reduced by a specific intervention to alter biomechanics (e.g. Hewett et al., 1999). One could argue that the treatment effect is underestimated. Even in these controlled clinical trials everyone in the group received the same treatment. However, in excellent clinical practice each intervention is tuned and adjusted to each patient suggesting that efficacy in real life on a patient by patient basis is probably better than any controlled trial would suggest. Well presented examples of the interactions between individual anatomical, morphological, mechanical and neuro-mechanical factors have been compiled by McLean and Beaulieu (2010), implying the need for individual assessment and treatment. Dr. Lederman contends that these relationships do not exist for the spine. The evolution of the spine literature lags that on the knee. Yet evidence exists on disc shape, to choose just one example from our own laboratory (Yates et al., 2010), influencing the patterns of annulus disruption from specific modes of loading resulting from specific movement patterns. This supports individual assessment of anatomical features to justify appropriate clinical effort to alter offending movement. The author rightly questions the ability of pained individuals to change movement patterns over longer terms but studies of the barriers and variables leading to success do exist and acknowledge the need for more study to elucidate the optimal motor learning approach for each individual. This does not mean that “no evidence exists”. The complex interactions of structure and biomechanics ignored in the paper under consideration suggest that evidence from controlled trials of back pain must be coupled and interpreted with treatment studies of appropriately sub-classified patients, even to the point of case studies, to delineate the complex interactions. Definitions of terms are needed particularly when entire bodies of science are summarily dismissed. “Biomechanics” includes kinematics and kinetics. The links between movement patterns, resultant tissue stresses, and pain are well documented in the injury pathway literature but were ignored in this paper. “Biomechanics” in the title, following “The fall of” infers a discussion of this literature. The title does not match the content of the paper. The links between optimal health and biomechanical factors form a “U” shaped function. Too little loading causes mechanical disruption at the cellular level and disease, and too much also creates mechanically modulated tissue disruption and disorders. Flawed movement (biomechanics) creates stress concentrations well documented to alter the course of back pain. The literature is extensive describing detrimental changes from too little and too much load on an individual’s spine that was

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obtained from many experimental approaches. However, interpretation of the literature on the effects of biomechanics and loading need to be rigorous enough to critique the load exposure, and whether it was leading toward the bettering or worsening of the symptoms. The authors’ treatment of this concept throughout the paper was inappropriately dismissive. This paper neglected the complexity of the many systems and interactions that obscure clear explanations. Having been involved in spine research I am aware of the limitations of capturing the complexities in a short paper. However, the author’s example of interpretation of medical images forms a case in point. The static images are commonly acquired in an unloaded, recumbent posture. Dynamic images (multiple x-ray, fluoroscopy, dynamic MRI) show much more movement pathology where the dynamics can be directly related to pain. These techniques, developing literature and evidence were ignored. Discogenic pain, for example, has been shown to follow a natural history where the zenith of pain is associated with the unstable phase but that eventually ends with a very desiccated disc on a medical image and where the pain has subsequently “burned out”. Then, abundant evidence shows, the history continues as changes in joint function influence the mechanical loading of the facet joints. Eventually these become arthritic shifting the pain source from disc to facet. Central sensitization further influences the process and links between pain, mechanical/ functional factors and patient corrections to wind down the heightened neural response. The implication of this literature is that the links between pain and biomechanical factors are variables over the natural history of back pain. Integrated natural history concepts were ignored in the paper and obscured a mature interpretation of what this collection of evidence really shows e that being that the links between pain, biomechanics and an image are complex variables, are patient specific, and rigor is required to understand them. Professor Lederman selected a few studies that suggested no causation of back pain from structural and neuromuscular asymmetry. Yet he chose not to report or critique those studies that have shown predictive links, particularly asymmetry in hip related variables that predict future back pain. Some studies were reported suggesting that neuromuscular asymmetry does predict subsequent first time back injury but these were dismissed. One example was his dismissal of Cholewicki et al’s (2005) and Zazulak et al’s (2007) work that suggested those athletes with delayed muscle reflex response rates were more likely to develop back or knee injuries. This is difficult longitudinal work. Dr Lederman writes “Unfortunately, the obvious was not examined in other body areas (e.g. controlled recording in the leg). This would have helped establish whether the injuries are due to delayed muscle response onset timing specific to the trunk or, the alternative more plausible explanation that athletes with sluggish muscle reaction times/reflexes may be more susceptible to injury”. First, the Cholewicki study noted the predictive variable was in muscle shut-off latency time e not onset timing. Second, the Zazulak study never mentioned muscle response. Zazulak et al reported predictive associations between back pain and future knee pain/injury based on movement parameters. These substantial inaccuracies aside, the back is part of a skeletal linkage and skilled

152 clinicians assess the linkage e they are familiar with the literature linking restricted hip motion for example, with the development of future back pain (the literature from sport and military examples was ignored). A broader integration of the neuromuscular/biomechanical literature offers insight into the mechanisms and consequences of anatomical linkages (knees and back in this case), and neuromuscular variables that impact the entire linkage. Extending Dr Lederman’s logic, and dismissive word choice - In response, “Is this not obvious”? Dr Lederman chose to write about the “unfortunate” oversights of others who have dedicated themselves to performing difficult work and holding it up for peer review. Errors in misrepresenting cited work followed by criticism is not forgivable. Credibility of those who choose to dismiss others within academic debate requires evidence of their own contributions to the scientific literature. The scientific process incorporates the principle that the critic of a widely held position bears the “burden of proof” to support an alternate view. Dr Lederman concludes “The PSB model introduces unnecessary complexity and hurdles to practice. The first hurdle. is the inability to identify/define the critical level where PSB factors contribute to the individuals back pain. This critical level is impossible to predict on an individual basis”. This opinion was stated in the face of broad evidence regarding provocative testing of the patient that determines the motions, postures or applied loads that cause pain. This was ignored. Further there is more literature pertaining to the pain being eliminated or reduced when the offending trigger level of the biomechanical variable is removed. A critique of this literature would have been essential for the authors’ opinion to be credible and demonstrative that the burden was carried. This is the second paper from Dr Lederman where he has declared an approach to practice mythical (the myth of core stability) or fallen (this paper). As with the “Myth of core stability” failure to really define what is meant by core stability defeated a rigorous discussion to pull out elements that are helpful e an entire clinical approach was soiled.

S. McGill Similarly, this paper ignored important research findings and confused posture, therapeutic exercise mechanism and efficacy, movement kinematics and kinetics, static anatomic structure, dynamic joint function, neurological function, pain mechanisms, natural histories of different spine structure damage, patient classification, and tissue loading, to name just a few. The process of establishing cause and effect, understanding of mechanism and creating an evidence base for clinical practice, requires a scholarly integration of the evidence. Dismissing singular papers, without the integrative context does not pass the test of appropriate rigor. In a positive sense the scientific community will work to further understanding of the relationships that form the evidence. Discussion is wonderful e exciting, educational and entertaining. However, sensational titles, and similarly sensational concluding statements, sets the expectation of critical analysis, fairness and rigor.

References Cholewicki, J., Silfies, S.P., Shah, R.A., Greene, H.S., Reeves, N.P., Alvi, K., Goldberg, B., 2005. Delayed trunk muscle reflex responses increase the risk of low back injuries. Spine 30 (23), 2614e2620. Hewett, T.E., Lindenfeld, T.N., Riccobene, J.V., Noyes, F.R., 1999. The effect of neuromuscular training on the incidence of knee injury in female athletes: a prospective study. Am. J. Sports Med. 27, 699e706. McLean, S., Beaulieu, M.L., 2010. Complex integrative Morphological and mechanical contribution to ACL injury risk. Exerc. Sports Sci. Rev. 38 (4), 192e200. Yates, J., Giangregorio, L., McGill, S.M., 2010. The influence of international disc shape on the pathway of posterior/posterior lateral partial herniation. Spine 35 (7), 734e739. Zazulak, B., Hewett, T.E., Reeves, N.P., Goldberg, B., Cholewicki, J., 2007. Deficits in neuromuscular control of the trunk predict knee injury risk: a prospective biomechanical-epidemiologic study. Am. J. Sports Med. 35 (7), 1123e1130.

Journal of Bodywork & Movement Therapies (2011) 15, 153e161

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

CHRONIC PAIN MANAGEMENT

Feldenkrais therapy as group treatment for chronic pain e A qualitative evaluation ¨ hman, PT, PhD a,b, Lena A ˚stro ¨m, PT, MSc c, Eva-Britt Malmgren-Olsson, Ann O PT, PhD d,* a

Dept. of Public Health and Clinical Medicine, Division of Epidemiology and Global Health, Umea˚ University, Sweden Umea˚ Centre for Gender Studies, Umea˚ University, Sweden c Va¨nna¨s Primary Health Care Centre, Va¨sterbotten County Council, Sweden d Dept. of Community Medicine and Rehabilitation, Physiotherapy, Umea˚ University, SE-901 87 Umea˚, Sweden b

Received 2 November 2009; received in revised form 26 February 2010; accepted 12 March 2010

KEYWORDS Feldenkrais method; Neck and shoulder pain; Primary health care; Women; Empowerment; Grounded theory; Diary; Qualitative interview

Summary Purpose: This qualitative study describes and analyses the experiences and selfreported effects of those participating in a Feldenkrais group intervention. Method: Fourteen women with non-specific neck and shoulder pain participated in a group treatment design using the Feldenkrais Awareness Through Movement (ATM) method. Data were collected in two ways: diary notes directly after the sessions and thematic interviews 4e6 months after the intervention. Data were analysed with a Grounded Theory approach. Results: One core category and two sub-categories emerged. The core category ‘‘Feldenkrais is wholesome, but difficult’’ represents the participants’ major opinions about the group intervention. The sub-categories ‘‘More erect without effort’’, and ‘‘Extended space for myself’’, represent participants’ descriptions of effects of the movement therapy. The women described changes in posture and balance, a feeling of release and increased selfconfidence. Some ambivalence about the method was expressed, especially regarding the difficulty to continue the exercises at home. The women feelings of improved body awareness remained after 4e6 months. They were also more aware of their attitudes towards activities in daily life. This resulted in them not ‘‘sacrificing themselves’’ as they did before. In addition, the bodily and psychological changes and the concept of empowerment are discussed. Conclusions: Positive experiences from the Feldenkrais group treatment were reported, especially concerning movement ability and body awareness. The exercises were however regarded as difficult to perform as self-training on a daily basis. ª 2010 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: þ46 907869136; fax: þ46 907869267. E-mail address: [email protected] (E.-B. Malmgren-Olsson). 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.03.003

¨ hman et al. A. O

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Introduction The prevalence of musculoskeletal disorders has increased rapidly in Sweden during the last 20 years (The National Board of Health and Welfare, 2009). Musculoskeletal disorders are the most common reasons for long term sick leave and early retirement and they constitute a severe societal problem. In addition, they cause suffering among those affected (Grahn, 1999; Kjellman et al., 2002). A significant proportion of these patients will have recurring or continual pain and one study found that about half of those seeking primary care for back or neck pain reported pain and disability in a 5-year follow-up study (Enthoven et al., 2004). Some studies have confirmed that patients with musculoskeletal disorders have markedly poorer physical and mental health than the general population and even lower than other chronic diseases with more well-defined diagnoses such as respiratory diseases, cardiovascular and neurological conditions (Sprangers et al., 2000; Jo ¨rgensen et al., 2001). Also stress related disorders have continuously increased in the Swedish population and especially among women, causing long term sick leaves (The National Board of Health and Welfare, 2009; Stenlund et al., 2007). Psychological distress and psychosomatic problems have proven to be predictors of neck problems (Grahn, 1999). Long term, unspecified musculoskeletal problems are related to a high prevalence of psychological ill-health (Malmgren-Olsson and Armelius, 2001). Back pain and neck problems are the most prevalent complaints among patients seeking physiotherapy treatment at primary health care centres in Sweden. Most of the patients have unspecified problems, i.e. no organic aetiology is found and only 11e20% of patients have a verified diagnosis (Kjellman et al., 2002; Enthoven et al., 2004). Therefore, it is often difficult to achieve sustainable treatment effects. A variety of treatment techniques in physiotherapy provide neck and shoulder pain therapy, but few studies have shown effective interventions (The Swedish Council on Technology Assessment in Health Care, 2000). There are some comprehensive systematic literature reviews that have been published on interventions for neck and shoulder pain during the past decade (Hurwitz et al., 2008). The most convincing evidence suggests therapies involving individually tailored information about exercise and therapies which include educational interventions that address function and self-efficacy (Jensen and Harms-Ringdahl, 2007). A few treatment methods in physiotherapy focus on strengthening the patient’s own resources in terms of increased body- and movement awareness, of which one is the Feldenkrais method (Mattsson, 1998; Rosberg, 2000). This article deals with 13 women’s experiences of Feldenkrais pedagogy in group therapy. Moshe Feldenkrais (1904e1984) developed the Feldenkrais method (Feldenkrais, 1990; Gro ¨nholm, 1996). It is a movement pedagogy designed to improve function in activities of daily living, work and recreation through an increasing awareness about movement habits, as well as to find alternative ways of using the body (Buchanan and Ulrich, 2001). There are two complementary styles of teaching; as

individual treatment called Functional Integration (FI) and as group therapy e ‘‘Awareness Through Movement’’ (ATM). The Feldenkrais method is regarded as a learning process and is therefore labelled a pedagogical method. The overarching goal is to help people become self-directed learners through specific use of sensimotor experiences and exploratory processes of moving. Both approaches purport to enhance people’s awareness of their habitual solutions to motor problems and to help them to select more efficient movement positions (Lyttle, 1997; Buchanan and Ulrich, 2001). Case reports on the positive effects of Feldenkrais pedagogy exist, but few studies with scientific rigour have been presented (Ellis, 1995; Ives and Shelley, 1998). To date, systematic qualitative studies on the effects of Feldenkrais are rare. However, a number of studies incorporating larger groups and random control studies have been conducted with clinical outcomes within the area of pain management (De Rosa and Porterfield, 1992), motor and postural control (Stephens et al., 2001), functional mobility (Batson and Deutch, 2005) and psychological and quality of life effects (Kerr et al., 2002; Malmgren-Olsson and Bra ¨nnholm, 2002). One such study on female industry workers with neck and shoulder pain showed that they experienced significant improvement of the problems after Feldenkrais group treatment, compared to those receiving physiotherapy in group or no treatment at all, 12 months after treatment (Lundblad et al., 1999). Another study compared Feldenkrais groups with two other groups; one receiving Body Awareness Therapy as presented by Roxendal and one receiving individual conventional physiotherapy (Malmgren-Olsson et al., 2001). The three patient groups were followed up after 6 months and after 12 months. Both Body Awareness Therapy and Feldenkrais yielded significantly better results than did individual physiotherapy. In this study our ambition is to shed light on the subjective experiences reported by patients with nonspecific neck and shoulder pain seeking physiotherapy treatment in primary care. The aim of this study was thus to describe and analyse opinions, experiences and selfreported effects of participation in a Feldenkrais group.

Method The study design was qualitative and the data material comprises written diary entries and individual research interviews (Figure 1). Diary entries were made directly after each group session whereas the interviews were conducted 4e6 months after completion of the group intervention. In total the material consists of 10 diaries and 13 individual interviews. This two-step study design enhanced participants’ reflections about the method and its effects over time. Thus, the results will focus on the immediate experiences of the group sessions as well as on reported effects after 4e6 months.

Procedure and participants Fourteen women with prolonged and non-specific neck and shoulder pain participated in two Feldenkrais courses with

Feldenkrais therapy as group treatment for chronic pain

14 women in group sessions

1 drop out

13 women

10 women both diaries and interviews

Figure 1

13 women only interviews

155 conducted at the informant’s work place and one in the home of the informant, in accordance with their wishes. Each interview lasted between 30 and 75 min. The interviews were tape recorded. In accordance with an emergent research design, the interviews were open-ended and sensitive to emerging topics. The thematic interviews (Kvale, 1996) were based on the content of the written ˚ ) probed on themes from diaries diaries. The interviewer (LA and from previous interviews and asked for elaborations. To get an overall understanding of their experiences, the following themes were however covered in all interviews: - Experiences of the Feldenkrais method - Effects of the movement exercises immediately after the lessons and in the long run - Self-practice - Comparison with other methods - Opinions about the Feldenkrais method and its role in health care

Data collection and sampling.

Data analyses ATM lectures. The primary health care centre physicians and physiotherapists referred participants to two intervention groups. Participants were informed about the aim of the group intervention and they were offered individual initial instructions in order to get an overall understanding of the Feldenkrais method. They were informed about the ˚). study, orally and in writing, by the second author (LA The courses were held at a primary health care centre in the Northern part of Sweden. The women were required to have a good understanding of the Swedish language and be motivated to work for a change of their health problems. An authorised Feldenkrais pedagogue was the leader of the two courses that consisted of 10 group sessions over a period of 6e7 weeks. Each lesson lasted 90 min. The 14 women who attended the Feldenkrais groups were asked to participate in the present study and all of them accepted. They were between the ages of 32 and 57 years, (mean age 44 years). They had musculoskeletal problems in combination with stress related symptoms such as sleeping difficulties and depression symptoms. Six of the participants were sick-listed, seven worked and one had taken early retirement. They were not allowed to go to any other bodily treatment during the group intervention.

Data collection Participants were asked to write down their thoughts and experiences after every group session, in notebooks handed ˚ . Some of the women chose to write their out by LA reflections on a computer. Keeping a diary was optional and four participants declined without any further explanation. Thus, 10 diaries were submitted after the completion of the group sessions. The Feldenkrais pedagogue did not take any part in the diary data collection. Four to 6 months after the completion of the group intervention, the women were ˚ ) conducted interviewed individually. The second author (LA all the interviews. The ambition was to interview all 14 women, but one was unavailable during the interview period. Thus, 13 women were interviewed. Eleven were held at the primary health care centre, one interview was

The diaries and the interview tapes were analysed in accordance with the Grounded Theory method of constant comparisons (Glaser and Strauss, 1967). See Box 1. As the study followed an emergent research design (Lincoln and Guba, 1985), the analyses started during the data collection phase and continued simultaneously with data collection throughout the entire research process. This design enhanced flexibility so that proceeding data collection could build on emerging results from previous data. In a first step, we analysed the diaries before starting the interview. In a second step, the three authors performed individual open coding of the interviews, and then met several times for constant comparisons and negotiations. The open codes were thereafter grouped together into categories. In a third step, we conducted a selective coding of the emerging categories to extract one core category, sub-categories and properties (Dahlgren et al., 2004). In addition, we extracted quotations for each of the sub-categories. All authors are physiotherapists by training, but have different professional backgrounds and expertise. The first author is senior researcher in the fields of public health and medical sociology. The second author is clinician in primary health care and has long experience in body awareness treatment. The third author is senior researcher specialised in musculoskeletal pain disorders with special reference to body awareness treatment. None of the authors is trained in the Feldenkrais method. In order to increase trustworthiness, we made use of these differences by triangulation in the design as well as in all steps of analysis (Lincoln and Guba, 1985). To further increase trustworthiness member checking was conducting (Lincoln and Guba, 1985). A summary of each interview comprising 2e3 pages of text was sent back to the informants respectively for confirmation of the content. Seven of the informants added comments for clarification. These summaries are included in the analyses, in conjunction with the diaries and the interviews. One of the informants however did not find the Feldenkrais method useful for her purposes and therefore dropped out before the end of her group session. To get

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Box 1. Naturalistic inquiry Qualitative research methodology is naturalistic in that it studies phenomenon and groups of people in their natural settings. Naturalistic inquiry is the opposite of experimental research where the investigator attempts to completely control the condition of the study. Lincoln and Guba (1985) compare natural inquiry with positivism and stress that naturalistic inquiry builds on the following premises (as opposed to a positivist approach: (a) there is no single truth, but realities are multiple, constructed and holistic, (b) researcher and informant are interactive and inseparable, (c) research is time- and context bound, (d) due to the mutual and simultaneous shaping of all entities, it is impossible to establish once and for all causal linkages, (e) research is value-bound. The researcher conducts the research in a natural setting and uses him/herself as the research instrument in interaction with the people under study. Literature  Lincoln, Y.S., Guba, E., 1985. Naturalistic Inquiry. SAGE, London.  Patton, M.Q., 1999. Enhancing the quality and credibility of qualitative analysis. Health Services Research 34, 1189e1208.  Sogoric, S., Middleton, J., Lang, S., Ivankovic, D., Kern, J., 2005. A naturalistic inquiry on the impact of interventions aiming to improve health and the quality of life in the community. Social Science and Medicine 60, 153e164. Grounded theory (GT) GT is a qualitative method that includes all stages from formulating the research questions through sampling procedures, data collection, analyses and final development of concepts, hypotheses or theories. The purpose of using GT is threefold: (1) to find categories about social phenomenon and relate the categories to each other, (2) to construct models, hypotheses and theory, (3) to obtain new knowledge in fields with little or no knowledge so far. The method emphasises a constant comparison of data in order to find similarities and differences. The open and selective coding procedures as well as categorising of the findings are essential components in the different stages of analyses. The American sociologists Glaser and Strauss developed the grounded theory method in the 1960s and it has since then been further developed by researchers such as Corbin, Charmaz and Clarke. In the words of Strauss and Corbin: ‘‘A Grounded Theory is one that is inductively derived from the study of the phenomenon it represents. That is, it is discovered, developed, and provisionally verified through systematic data collection and analysis of data pertaining to that phenomenon’’ (Strauss and Corbin, 1990, p. 23). Literature  Glaser, B., Strauss, A., 1967. The discovery of Grounded Theory e Strategies for Qualitative Research. Aldine, Chicago.  Strauss, A., Corbin, J., 1990. Basics of Qualitative Research: Grounded Theory Procedures and Techniques. SAGE, Newbury Park, California.  Charmaz, K., 2006. Constructing Grounded Theory: a Practical Guide Through Qualitative Analysis. SAGE, London.  Clarke, A., 2005. Situational Analysis: Grounded Theory after the Postmodern Turn. SAGE, Thousand Oaks, California.

a broader picture of the variation of experiences in the material and to contrast with the main results, her negative experiences were analysed in a negative case analysis, as described by Lincoln and Guba (1985) The Ethical Committee at the Faculty of Medicine and Odontology at Umea ˚ University, Sweden, approved the study (dnr 01-134).

Results One core category and two sub-categories emerged from the analyses. The core category is labelled Feldenkrais is wholesome, but difficult. It describes the participants’ general opinions about the Feldenkrais method. It contains notions about the relationship between body and mind and of feelings of dependence and independence in relation to

the group leader. The first sub-category is labelled More erect without effort and describes changes in posture, muscle tension and breathing. Further, it describes pain relief and an acquired ability to relax. It has three properties labelled ‘‘Standing on one’s own’’, ‘‘Liberating’’ and ‘‘Ability to move without pain’’. The second sub-category, which is called Extended space for myself, describes changes in behaviour among the interviewed women. It contains the properties ‘‘Improved body awareness’’, ‘‘Re-claimed movement ability’’ and ‘‘No more sacrificing’’. The main impression is that Feldenkrais was useful and that is helped the participants in a process of change. An overview of results is presented below. A conceptual model was constructed, representing the opinions and experiences as described by the participants (Figure 2). The quotations represent the most commonly shared views among the participants.

Feldenkrais therapy as group treatment for chronic pain

Body as well as mind

157 Dependence and Independence

Feldenkrais is wholesome, but difficult Standing on one’s own

Liberating

Improved body awareness

More erect without effort

Ability to move without pain

Figure 2

Extended space for myself

Re-claimed movement ability

No more sacrificing

Model representing the main result of the joint analyses from interviews and diaries.

Feldenkrais is wholesome, but difficult The Feldenkrais exercises were experienced positively and were reported as very different exercises from all other physical exercise the participants had tried. They expressed great surprise at the fact that such small body movements could be so wholesome. It engaged the body as well as the mind, they claimed. Each week there were new exercises and they appreciated the explorative design of the method. Some participants felt insecure about whether they performed them correctly and even when the movements were very small and slow, they were often hard to gauge in a proper way. In the beginning, the participants often made too much effort, which in turn resulted in more pain. Sometimes the exercises were complicated and required considerable concentration. ‘‘It took a few lessons before you started to understand what this all is about.’’ (Diary J). ‘‘this was the hardest session ever. Unfortunately there are still clear remnants of my old motto, that you are able to do twice as much as you think and three times as much as your mother thinks. But I will improve. Next time I will not push myself as hard.’’ (Diary A). When the participants compared the Feldenkrais method with other methods they were familiar with, they saw similarities with Tai Chi, Yoga and the Swedish method called Body Awareness Treatment (BAT). They thought that all these methods combine body and mind and that they have similar effects. When they previously had tried more passive treatment methods, e.g. massage, the effect had usually been quicker than those received from Feldenkrais, but the effects of Feldenkrais lasted longer. In spite of this, the informants still asked for methods such as massage and acupuncture. They felt that a combination of Feldenkrais and passive methods would be the best. ‘‘ I think that I wouldn’t have been this careful with myself (if I hadn’t taken part in this treatment).that is the disadvantage if you want somebody to fix you. I have been wanting to get repaired and maybe continued being tough on myself at home. So I would not have understood that I have to work a lot with myself at home in a gentle way.’’ (Interview E).

The participants felt dependent on the group leader in order to perform the exercises. It was difficult to remember them when they came home and therefore home training was difficult. They lacked a written home training program or an audio-tape with the exercises. They wished for a program they could do independently of the leader. As they experienced several positive effects and for increased accessibility, they felt that Feldenkrais should be offered at primary health care centres. Even though they expressed a feeling of dependence on the group leader, they also felt that the Feldenkrais pedagogy could reduce dependence on formal health care in the long run. If it would be possible to retain what they had learned from the training, it would be a help to selfhelp, they felt. This might result in changes in behaviour that could facilitate better self-care and thereby increased well-being, both physically and mentally. ‘‘Consciousness reduces fear.and maybe it becomes easier to take care of yourself if you are aware of where to start. If I am having pain up here and don’t know where it comes from I’ll take pain medication and then it will be the same story soon again because you will still not change your behaviour.’’ (Interview M).

More erect without effort Participants’ posture and balance clearly improved after Feldenkrais sessions, according to the women. They felt that they were ‘‘standing on one’s own’’. Their feet felt grounded to the floor and weight was distributed symmetrically. Their spine felt straight without effort and it seemed as if their field of vision had become wider, according to the informants. They were surprised that these changes seemed to have occurred without them having specifically trained posture and balance. The changes also remained directly after coming home from the sessions, but disappeared after a few days. ‘‘When we were all finished with the exercises and we got up, I rested my weight on both feet for the first time in six years.’’(Diary A). ‘‘My arms were relaxed and hung down. My whole spine was straight without effort. I felt as if my chest was

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158 broader, more room to breath. My head and eyes horizontal, straight ahead. My legs and feet more sturdy and stable. I felt much taller.’’ (Diary B). In the follow-up interviews, some of the informants explained that walking and standing were still different from the time prior to participation in the Feldenkrais group. The exercises improved the whole body so that they experience less pain. They had become more aware of their posture and some body changes continued, without them having to actively think about them. ‘‘On the whole I feel more erect in my posture. My head is a little bit higher up.’’ (Interview J). Another important result was a liberating feeling. Relief from muscle tension and strained breathing were other positive effects of the group treatment. This was expressed as feelings of relief and ease. Participants became aware of muscle tensions they had not noticed before and when the soft movements relieved the tension, it felt wonderfully liberating, they wrote. It felt as if their blood circulation increased which caused a warming sensation in their muscles. In one of the sessions, the focus was on breathing, and after this session the women experienced a clear improvement in breathing. They felt that their chest expanded and breathing became easier. ‘‘I also get a feeling of release from tensed muscles. Imagine if I could get out and escape the feeling of confinement it creates.’’ (Diary G). ‘‘It was such a feeling of release to expand my chest.’’ (Diary I). A few of the informants reported in their diaries that the exercises resulted in a relief from pain; it was however more common that entries expressed increased pain from specific exercises. The informants emphasised that it was nice to come to the sessions and be allowed to think only of themselves. In the sessions, they were allowed to lie down and relax and then they realised how tired they actually were. The sessions felt relaxing even though the main goal was not relaxation. In order to be able to perform minimal movements of the body, they had to calm down and relax. After the sessions, they usually felt a comfortable tiredness and calmness. Their gait became slower and they started to sleep better during the treatment period. They also reported a sensation of increased energy during the period. In the interviews 4e6 months later, the informants explained that their ability to relax persisted to a certain degree and that they now and then used the Feldenkrais exercises to relax. ‘‘Then when I am working more or using my body more, I experience pain and again I feel tense e then I do those Feldenkrais exercises.’’ (Interview B). According to the informants, one effect of the Feldenkrais course was an increased ability to move without pain, i.e. an increased ability to control muscle tension. Thus, the prior fear of moving because of pain was reduced due to the fact that they discovered painless ways of moving. This new experience instilled hope and a sense of security and the effects were to a large extent still present at the time of the

interviews. The participants still used the methods for pain reduction that they had learnt during the sessions. In this way they experienced that they were capable of more. This new feeling was expressed as ‘‘I can’’. ‘‘I have discovered that I have a body. And how much you can use it for, in ways I did not know before. I can!’’ (Diary D). ’’I feel I have become braver in a way. I am not that scared anymore.’’ (Interview A). ‘‘Now I do not have to think about my pain. Before I was more worried. Now I know there is a method to get the muscles to relax. I have not had the need for a chiropractor or masseur since I attended Feldenkrais.’’ (Interview B).

Extended space for myself Improved body awareness, movements and breathing were the most obvious effects of the Feldenkrais sessions. To their surprise, participants discovered during the sessions that they tended to restrict their breathing and they associated this with stress and demands in their lives. The respondents had never paid much attention to breathing before. They had now learnt to breathe in a more relaxed manner and they allowed themselves to pay mote attention to their bodily experiences. ‘‘Spontaneously I have discovered my tensed face, with my jaws pressed together and my staring eyes. (Being aware of this) helps me to relax more often.’’ (Diary G). ‘‘I have noticed an interesting difference, before my muscles and jaw were tensed even though I didn’t know it. Now I am tensed but try to trick myself that I am relaxed! Hopefully the third step will be that I really am relaxed!’’ (Diary E). The improved body awareness was to a certain degree still present at the follow-up interviews, they claimed. It was regarded as one of the most important effects. They reflected more on the body than prior to the course. They felt ‘‘more present in the body’’ as they expressed it. Before participating in the Feldenkrais group they had a notion that it was best not to think about the body too much. ‘‘If you don’t think so much about how it feels, it will hurt less’’, they had thought. They also expressed the fear that too much reflection and thought would result in a loss of mental control. Through an increased awareness they realised that it was not dangerous to feel the body and reflect upon it. On the contrary, they became able to interpret their behaviour in a better way, which in return reduced the pain, they said. They realised that there is a connection between what they do and how they feel. ’’I have better contact with my body now, I am able to regulate myself a little bit more, to respond a little bit to the signals from my body, that I really want to move.I had forced the body for a long time, I believe.and then when it ended I couldn’t even with all my will make it do something.’’ (Interview H). ‘‘Now I dare to feel and I’m in some way able to interpret and understand it.and think that this is a consequence,

Feldenkrais therapy as group treatment for chronic pain this is how it can be. That I don’t have to be scared either, I know that there are not so many dangerous things happening.’’ (Interview D). One of the participants, who did not find the method useful, thought she already had a good awareness of her body, but she also said that the Feldenkrais method could be useful for those who do not have so much knowledge of their body. The Feldenkrais sessions led to an increased ability to move specific parts of the body. The informants wrote in their diaries that after small, careful movements, range of motion seemed to increase. This increase lasted for a long time for some and caused a feeling of re-claimed movement ability and freedom. Sometimes the change meant discovering that it did not hurt when they moved, and by that they stopped keeping the aching part of the body. ‘‘But after different variations and combinations of almost the same movements, I had substantially increased the mobility in my hips.’’ (Diary A). ‘‘After every stage I could move my arm about 5 cm more and in the end I stretched it 20 cm backwards more than usual, without effort. It is amazing what those gentle exercises do for mobility!’’ (Diary E). One of the informants discovered in one of the sessions that she found a previous movement scheme that she had lost long time ago. It was a wonderful feeling to find the way back to a freer body language, she wrote. ‘‘I am much more bouncy than my body shows. I feel like I have put up a shield over the years, for how much I am able to move.We had done both diagonals and were like stretching and bending in some way and then we let everything come loose at the same time in all directions and then I felt like I could take more space, that I could find a bigger sphere around myself where I could move, there was something that loosened up.now the movement of my body is in harmony with how I feel.’’ (Interview H). In the interviews, the informants described that they have developed a new attitude towards themselves, which means that they do not make as many sacrifices that reduce their own freedom, as they did before the group sessions. They have become more careful with themselves and do not force themselves to do more than they can handle. They have decided ‘‘No more sacrifices’’. On a physical level this means that they are more prone to ‘‘listen’’ to their body and its restrictions. They also ask people around them for help, for instance when lifting heavy things, something they were hesitant to do prior to the treatment. If they have to do heavy work, they think twice prior to doing it. They allow themselves to take breaks and rest more. On a mental level the new insights received in the group intervention have made them set limits in relation to other people. Instead of always doing things for others without paying any attention to the costs in terms of tiredness and pain, they have started reflecting upon what they actually can handle. ‘‘.like you should avoid heavy lifting and too much stretching. I more often take a chair instead of jumping for things.’’ (Interview C).

159 ‘‘In general, I don’t push myself as much as before.today I try to restrict my amount of work, I really do.I give up earlier. Before I could like steel myself, I’ll just finish this and then I’ll rest. Today I am able to adopt a more philosophical attitude.I let my body recover much more often.’’ (Interview H).

Discussion The results from this qualitative study show that the participants experienced several positive effects from the Feldenkrais sessions. They felt less tensed and that their posture had improved. They had also become more inclined to listening to their own needs and feelings, which in turn had resulted in them taking more space. However, a certain degree of ambivalence towards the method was expressed in terms of difficult exercises and dependency on the group leader. They were not free from pain after the treatment period, but they had gained a sense of control over their pain problems and life situation. The results are in line with the aim of the Feldenkrais method, namely through movements that create increased awareness and a change of habitual posture and movement schemes (Feldenkrais, 1990; Gro ¨nholm, 1996). The theoretical base for the Feldenkrais pedagogy emphasises that a person’s self-image changes as a result of the movements and through that, feelings, emotions and thoughts are also influenced (Feldenkrais, 1990; Gro ¨nholm, 1996). Ives (2003) proposes that the positive effects in pain and wellness aspects following Feldenkrais interventions can be ascribed to self-regulation theory. Self-regulation refers to psychological processes meaning that people can harness and selfregulate their own thoughts, actions and emotions towards achieving goals. Increasing bodily as well as mental awareness can be a first step in the self-regulation process. Main findings indicate changes over time among the participants, with initial bodily changes, followed by psychological and behavioural changes in a later stage. The most prominent changes were found in an experienced improvement of posture and balance. Gyllensten has found similar results in a qualitative study of Body Awareness Training (Gyllensten et al., 2003). A dysfunction in posture can be regarded as a result of negative habits and patterns of muscle tension (Feldenkrais, 1990; Gro ¨nholm, 1996). Several authors share the understanding that negative patterns of tension might be a psychological defence against threats from the surrounding or inner life (Roxendal, 1985; Dropsy, 1987; Feldenkrais, 1990; Bunkan, 1996). Through increased awareness about these patterns, the tensions might be changed. One important psychological change among the participants in this study was their strengthened self-image and self-reliance. A negative pattern of tension and poor posture might, according to Rosberg (2000), be a result of a lack of trust in one’s body and in the body’s relation to gravity. Feeling firmly anchored entails biomechanical as well as psychological aspects. When a person experiences being physically anchored, she might also be able to broaden her ways of being, Rosberg argues. Hedlund and Gard (2000) argue, in line with Rosberg, that distrust of one’s own body might lead to pain and muscle tension. Distrust of the body might also result in difficulties in

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160 interpreting bodily signals. Awareness of the relations between tension, trust and posture, can strengthen selfreliance (Hedlund and Gard, 2000). Feldenkrais researchers commonly refer behaviour changes to dynamic system principles, meaning that different subsystems always interact with each other and that physical and psychological changes cannot be separated from each other (Buchanan and Ulrich, 2001). Gyllensten shows in a randomised control study that outpatients in psychiatric care that practiced Body Awareness Training significantly improved body functions as well as trust in their own abilities (Gyllensten et al., 2001). That a negative self-image can improve through body awareness training has been shown in two studies (Mattsson et al., 1995; Malmgren-Olsson et al., 2001). In follow-up studies 6 months after treatment, the participants of the Feldenkrais treatment reported that they are more considerate of themselves and that they do not make as many sacrifices as previously. In physiotherapy theory building on a phenomenological understanding of the relations between body, mind and environment, the body is regarded as a subject as well as an object, through which humans experience themselves and their environment (Rosberg, 2000). If the body notion changes, potentials for action also change, it is argued. Increased potential for alternative courses of action must be regarded as important for women with pain and stress related health problems. Gustafsson et al. (2004) found that pain problems among women with fibromyalgia were associated with feelings of shame, as they could not perform the kind of work they had previously been able to do. In the same way as the informants in this study reported less self-sacrifice than before the treatment, the informants in Gustafsson et al.’s study reported the same change in behaviour after body awareness training in a rehabilitation programme. The informants’ experiences of improved self-reliance and the alternative lines of action, which were the main results from the Feldenkrais group sessions could be summarised as a process of empowerment, i.e. strategies for empowering someone’s position. The concept has been discussed in physiotherapy and rehabilitation research in recent years (Fosnaught, 1997; Spalding, 2000; Jones et al., 2000). The point of departure is a self-reflective stance and self-criticism of the role of health care as paternalistic and authoritarian. Rehabilitation and physiotherapy efforts need to become more sensitive to patients’ demands and needs. A change that entails strategies for empowerment of the patients is vital. An important role for health care should be to increase patients’ awareness of their situation and their possibility to influence it through education. The Feldenkrais method is regarded to be in line with strategies for empowerment. Mattsson et al. (2000) focus on the concept empowerment in a qualitative study of women with pelvic pain treated with Body Awareness Training. They found that patients experienced improved trust in their own abilities and that the group sessions created a sense of belonging. Ten sessions with Feldenkrais exercises must be regarded as a short intervention period. Still, it seems it started a process of change among the women. Even few treatment sessions have proven to have an effect (Mattsson and Mattsson, 1994). The informants in our study asked for Feldenkrais treatment as an alternative to other types of

bodily treatment in primary health care settings, which would increase accessibility. A weakness with the method is that it often requires instructions and guidance from an experienced Feldenkrais pedagogue. Patients would perhaps benefit from a format that includes more selfinstructive exercises. However to change unfavourable movement behaviour and to explore more sufficient ways of moving more easily without tension, guidance from a competent teacher is often necessary (Lyttle, 1997). In the long run, those who practice Feldenkrais hopefully become self-directed learners with acquired knowledge and experience of managing their own health problems.

Methodological considerations One of the strengths with this study is that we were able to do individual follow-up interviews after 4e6 months to check remaining perceived effects and experiences. This longitudinal and still iterative approach is rare in qualitative research. The results emanate from a constant comparison procedure with a negotiated outcome. The conceptualisation follows the grounded theory tradition as described by Glaser and Strauss (1967) and does not have a pre-set standard or pre-set criteria to search for when analysing the material. We developed properties as described by Glaser, but no dimensions. The effort to increase trustworthiness through triangulation and member checking is strength (Lincoln and Guba, 1985). The interviewer was not engaged in the intervention. The fact that not all participants contributed with both diaries and interviews is of course a drawback. We have not discriminated completely between diaries and interviews, but view them as one full data set. As participation was optional and there was an agreement that they could stop their participation at any point without reporting motives, we do not know why three women chose to not write diaries. And finally, it is important to emphasise that this is not a controlled clinical study, but qualitative evaluation of an intervention programme. This kind of emergent design can add important insights into treatment and rehabilitation as it aims to give participants and patients a voice.

Conclusion The Feldenkrais method was experienced as helpful in different ways, involving bodily as well as psychological learning aspects. The positive changes of body awareness and increased self-confidence remained over time. However some ambivalence about the method concerned the dependency on the leader and the difficulty to continue the exercises at home. This result shows the importance of tailoring treatment approaches to the needs of the individual patients. Strategies for empowering patient’s ability and position are also important treatment elements.

References Batson, G., Deutch, J.E., 2005. Effects of Feldenkrais awareness through movement on balance in adults with chronic neurological deficits following stroke: a preliminary study. Complementary Health Practice Review 10, 203e210.

Feldenkrais therapy as group treatment for chronic pain Buchanan, P.A., Ulrich, B.D., 2001. The Feldenkrais method: a dynamic approach to changing motor behaviour. Research Quarterly for Exercise and Sport 72, 315e323. Bunkan, B.H., 1996. Kropp, respirasjon og kroppsbilde e Resursorientert kroppsunderso ¨kelse og behandling. (Body, Respiration and Body Image e Resource Orientated Body Examination and Treatment). Universitetsforlaget, Oslo. Dahlgren, L., Emmelin, M., Winkvist, A., 2004. Qualitative Methodology for International Public Health. Department of Public Health and Clinical Medicine, Umea ˚ University. De Rosa, C., Porterfield, J., 1992. A physical therapy model for treatment of low back pain. Physical Therapy 72, 261e272. Dropsy, J., 1987. Leva i sin kropp. (Living in Your Body). Natur och Kultur, Stockholm. Ellis, B.K., 1995. Feldenkrais physical therapy and research e a literature review. Vetenskapligt Supplement 2, 34e41. ¨ berg, B., 2004. Clinical course in Enthoven, P., Skargren, E., O patients seeking primary care for back or neck pain: a prospective 5-year follow-up of outcome and health care consumption with subgroup analysis. Spine 28, 2458e2465. Feldenkrais, M., 1990. Awareness Through Movement e Easy-to-do Health Exercises to Improve Your Posture, Vision, Imagination and Personal Awareness, paperback ed. Harper Collins, San Fransisco (first published 1972). Fosnaught, M., Nov 1997. From paternalism to advocacy: patient empowerment. Magazine of Physical Therapy 5, 70e77. Glaser, B.G., Strauss, A.L., 1967. The Discovery of Grounded Theory, Strategies for Qualitative Research. Aldine Publishing Company, New York. Grahn, B., 1999. Quality of Life, Motivation and Costs in Multidisciplinary Occupational Rehabilitation. Dissertation, Department of Physical Therapy, Lund University, Sweden. Gro ¨nholm, J., 1996. Feldenkraismetoden e Att la ¨ra sig la ¨ra igen. (Learning to Learn Again). Natur och kultur, Falun. ¨ hman, A., 2004. From shame to Gustafsson, M., Ekholm, J., O respect. musculoskeletal pain patients’ experience of rehabilitation programme, a qualitative study. Journal of Rehabilitation Medicine 36, 97e103. Gyllensten, A.L., Hansson, L., Ekdahl, C., 2001. Outcome of Basic Body Awareness Therapy. A randomised Controlled Study of Patients in Psychiatric Outpatient Care. Dissertation, Department of Physical Therapy, Lund University, Sweden. Gyllensten, A.L., Hansson, L., Ekdahl, C., July 2003. Patient experiences of basic body awareness therapy and the relationship with the physiotherapist. Journal of Bodywork and Movement Therapies, 173e183. Hedlund, L., Gard, G., 2000. Tillit till den egna kroppen. (Trusting one’s own body). Nordisk Fysioterapi 4, 67e74. Hurwitz, E.L., Carragee, E.J., van der Velde, G., et al., 15 Feb 2008. Treatment of neckpain: noninvasive interventions: results of bone and joint decade 2000e2010 task force on neck pain and its associated disorders. Spine 33 (4 Suppl.), 123e152. Ives, J.C., Shelley, G.A., 1998. The Feldenkrais method in rehabilitation: a review. WORK: A Journal of Prevention Assessment and Rehabilitation 11, 75e90. Ives, J.C., 2003. Comments on ‘‘the Feldenkrais method: a dynamic approach to changing motor behaviour’’. Research Quarterly for Exercise and Sport 74, 116e123. Jensen, I., Harms-Ringdahl, K., 2007. Neck pain. Best Practice and Research Clinical Rheumatology 21, 93e108. Jones, F., Mandy, A., Partridge, C., 2000. Who’s in control after a stroke? Do we disempower our patients? Physiotherapy Research International 5, 249e253. Jo ¨rgensen, C., Fink, P., Olesen, F., 2001. Patients in general practice in Denmark referred to physiotherapists: a description of patient characteristics based on general health status, diagnosis and sociodemographic characteristics. Physical Therapy 81, 915e923.

161 Kerr, G.A., Kotonia, F., Kolt, G.S., April 2002. Feldenkrais awareness through movement and state anxiety. Journal of Bodywork and Movement Therapies, 102e107. ¨ berg, B., 2002. Prognostic factors for Kjellman, G., Skargren, E., O perceived pain and function at one-year follow-up in primary care patients with neck pain. Disability and Rehabilitation 24, 364e370. Kvale, S., 1996. InterViews. An Introduction to Qualitative Research Interviewing. Sage Publications, Thousand Oaks. Lincoln, Y.S., Guba, E.G., 1985. Naturalistic Inquiry. Sage Publication, London. Lundblad, I., Elert, J., Gerdle, B., 1999. Randomized controlled trial of physiotherapy and Feldenkrais interventions in female workers with neckeshoulder complaints. Journal of Occupational Rehabilitation 9, 179e194. Lyttle, T.S.K., October 1997. The Feldenkrais method: application, practice and principles. Journal of Bodywork and Movement Therapies, 262e269. ˚ ., Armelius, K., 2001. Malmgren-Olsson, E.-B., Armelius, B.-A A comparative outcome study of body awareness therapy, Feldenkrais, and conventional physiotherapy for patients with non-specific musculoskeletal disorders: changes in psychological symptoms, pain, and self-image. Physiotherapy Theory and Practice 17, 77e95. ˚ ., 2001. Physical and Malmgren-Olsson, E.-B., Armelius, B.-A psychological health and social relations in patients with prolonged musculoskeletal disorders. Scandinavian Journal of Caring Sciences 15, 181e189. Malmgren-Olsson, E.-B., Bra ¨nnholm, I., 2002. A comparison between three physiotherapy approaches with regard to healthrelated factors in patients with non-specific musculoskeletal disorders. Disability and Rehabilitation 24, 308e317. Mattsson, M., Mattsson, B., 1994. Physiotherapeutic treatment in out-patient psychiatric care. Scandinavian Journal of Caring Sciences 8, 119e126. Mattsson, M., Egberg, K., Armelius, K., Mattsson, B., 1995. Longterm effects of physiotherapeutic treatment in outpatient psychiatric care. Nordic Journal of Psychiatry 49, 103e110. Mattsson, M., 1998. Body Awareness e Applications in Physiotherapy. Dissertation, Department of Psychiatry and Family Medicine, Umea ˚ University, Sweden. Mattsson, M., Wikman, M., Dahlgren, L., Mattsson, B., 2000. Physiotherapy as empowerment e treating women with chronic pelvic pain. Advances in Physiotherapy 2, 125e143. Rosberg, S., 2000. Body, Being and Meaning in a Physiotherapeutic Perspective (Kropp, varande och mening i ett sjukgymnastiskt perspektiv). Dissertation, Department of Social Work University of Gothenburg, Sweden. Roxendal, G., 1985. Body Awareness Therapy and the Body Awareness Scale, Treatment and Evaluation in Psychiatric Physiotherapy. Dissertation, Department of Psychiatry, University of Gothenburgh, Sweden. Spalding, N., April 2000. The empowerment of clients through preoperative education. British Journal of Occupational Therapy 63, 148e154. Sprangers, M.A.G., de Regt, E.B., Andries, F., et al., 2000. Which chronic conditions are associated with better or poorer quality of life? Journal of Clinical Epidemiology 53, 895e907. Stenlund, T., Ahlgren, C., Lindahl, B., et al., 2007. Patients with burnout in relation to gender and a general population. Scandinavian Journal of Public Health 35, 516e523. Stephens, J., DuShuttle, D., Hatcher, C., et al., 2001. Use of awareness through movement improves balance and balance confidence in people with multiple sclerosis: a randomised controlled study. Neurology Report 25, 39e49. The National Board of Health and Welfare, Sweden. Public Health Report 2009, Stockholm. The Swedish Council on Technology Assessment in Health Care, 2000. Back and Neck Pain Nr 145/2. SB Offset AB, Stockholm.

Journal of Bodywork & Movement Therapies (2011) 15, 162e167

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

GREEK TRADITIONAL DANCES AND BREAST CANCER

Physical and psychological benefits of a 24-week traditional dance program in breast cancer survivors Antonia Kaltsatou a,*, Dimitra Mameletzi a, Stella Douka b a

Sports Medicine Laboratory, Department of Physical Education and Sport Sciences, Aristotle University of Thessaloniki, 54006 Thessaloniki, Greece b Human Studies Laboratory, Department of Physical Education and Sport Sciences, Aristotle University of Thessaloniki, 54006 Thessaloniki, Greece Received 11 November 2009; received in revised form 25 February 2010; accepted 12 March 2010

KEYWORDS Breast cancer; Traditional dances; Physical function; Psychological condition; Mixed exercise program; Bodywork

Summary The purpose of the present study was to evaluate the influence of a mixed exercise program, including Greek traditional dances and upper body training, in physical function, strength and psychological condition of breast cancer survivors. Twenty-seven women (N Z 27), who had been diagnosed and surgically treated for breast cancer, volunteered to participate in this study. The experimental group consisted of 14 women with mean age 56.6 (4.2) years. They attended supervised Greek traditional dance courses and upper body training (1 h, 3 sessions/week) for 24 weeks. The control group consisted of 13 sedentary women with mean age 57.1 (4.1) years. Blood pressure, heart rate, physical function (6-min walking test), handgrip strength, arm volume and psychological condition (Life Satisfaction Inventory and Beck Depression Inventory) were evaluated before and after the exercise program. The results showed significant increases of 19.9% for physical function, 24.3% for right handgrip strength, 26.1% for left handgrip strength, 36.3% for life satisfaction and also a decrease of 35% for depressive symptoms in the experimental group after the training program. Significant reductions of 9% for left hand and 13.7% for right hand arm volume were also found in the experimental group. Consequently, aerobic exercise with Greek traditional dances and upper body training could be an alternative choice of physical activity for breast cancer survivors, thus promoting benefits in physical function, strength and psychological condition. ª 2010 Elsevier Ltd. All rights reserved.

Introduction

* Corresponding author. 22 Dim. Gounari str, 54621 Thessaloniki Greece. Tel.: þ306938767967. E-mail address: [email protected] (A. Kaltsatou).

Each year, more than one million women worldwide are diagnosed with breast cancer (Cheema and Gaul, 2006). In addition, for any woman free from other life-threatening diseases, the risk of developing breast cancer up to the age

1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.03.002

Greek traditional dances and breast cancer of 74 is approximately 8% (Harris et al., 1998). According to another study, one out of every 10 women will develop breast cancer and 79% of them will have a further life expectancy of at least 5 years (Rietman et al., 2003). Breast cancer is a prevalent disease that requires intense and prolonged treatments (Courneya et al., 2003). Although the outlook for surviving cancer is often very good, it almost always requires medical intervention. The most common treatment modalities for cancer are surgery, radiation therapy, chemotherapy and hormonal therapy. Such prolonged and intensive medical treatments may take a heavy toll on the physical, functional, emotional, spiritual and social well-being of cancer survivors (Courneya et al., 2003). Thus, such treatments are responsible for a plethora of physiological and psychological problems, which have a negative impact in the patient’s quality of life (Cheema and Gaul, 2006; Courneya et al., 2003). Exercise is an effective intervention to improve quality of life, cardiorespiratory fitness, physical functioning and fatigue in breast cancer patients and survivors (McNeely et al., 2006). Moreover, anxiety, depression and all aspects that are typically aggravated in patients with cancer are decreased by exercise (Segar et al., 1998). Furthermore, exercise improves physical and psychological functioning in breast cancer survivors and it helps control body weight by decreasing body fat (Cheema and Gaul, 2006). It is therefore suggested that regular is beneficial to breast cancer survivors, who have to deal with many psychological and physical problems, such as fatigue (Bower et al., 2000), depression and anxiety (Burgess et al., 2005), weight gain (Irwin et al., 2005) and reduced quality of life (Ganz et al., 2004). All these physical and psychological side effects may ameliorate with exercise. However, the effectiveness of exercise programs depends on the motivation and adherence of participants (Courneya et al., 2001). Exercise adherence is a difficult challenge in healthy adults and even more difficult after cancer diagnosis and treatment (Courneya et al., 2001). The exercise program should be enjoyable and agreeable for the participants, in order to ensure regular participation and obtain all benefits of exercise. It has been thought that dance-based exercise approach could make the process more interesting and be a beneficial form of physical activity (Judge, 2003). Dance appears to be a pleasurable and enjoyable activity. Social dance improved quality of life and promoted adherence to an exercise program, while providing cardiovascular benefits to those at risk for cardiovascular failure (Belardinelli et al., 2008). It has also been suggested that dance movement programs have a positive effect on psychological distress in people with mild depression (Jeong et al., 2005). In addition, it has been shown that a dance movement program addressing the physical and emotional needs of breast cancer survivors improved their quality of life (Sandel et al., 2005). All these studies emphasized the benefits of dance movements programs. However, there are no studies concerning the efficacy of social dancing on breast cancer survivors. In the present study, Greek traditional dances were selected, because they are considered a pleasant and popular form of physical activity among Greek people and they have been part of their lives since their childhood.

163 Moreover, exercising with Greek traditional dances ensures high levels of adherence, because they are integral parts of Greek culture and express the Greek spirit and history. Previous research has demonstrated that Greek traditional dances have a positive effect in elderly individuals’ psychological condition (Mavrovouniotis et al., 2009). In addition, the psychosocial benefits of traditional Greek dances have been shown in a study that reported improved perception of life in older women of Greek origin participating in Greek dance courses (Konstantinidou and Harahousou, 2004). The purpose of this paper was to assess the influence of a mixed exercise program, which includes Greek traditional dances and upper body training, in physical function, strength and psychological condition in breast cancer survivors.

Method Sample Breast cancer survivors from 3 different centers from the city of Thessaloniki were asked and agreed to volunteer to participate in this study. Twenty-seven women were randomly selected from the three breast cancer survivor centers of the city. They fulfilled all the inclusion criteria, such as participating only in the dancing exercising program and none of the participants had prior physical practice or experience in traditional Greek dances (see Table 1). All participants had been diagnosed and surgically treated for breast cancer. They had completed cancer therapies, including surgery, radiotherapy and chemotherapy and stopped all medical treatments at least 3 months before the beginning of the study (mean time post-treatment: 2.2 years). All participants were informed about the purpose and the procedures of the study and signed an informed consent form according to guidelines approved by the Aristotle University Ethical Committee. Exclusion criteria included poorly controlled hypertension and any health condition that would deter them from performing the exercises.

Procedure The total duration of the exercise program was 24 weeks. The 27 women were randomly separated in two groups, the experimental group who completed the supervised exercise program and consisted of 14 women with a mean age 56.6 (4.2) years (range from 50 to 63 years) and the control group who consisted of 13 women with mean age 57.1 (4.1) years (range from 52 to 63 years). The participants in the experimental group attended supervised exercise sessions, three days per week for a period of 24 weeks. The duration of each session was 60 min and included check-in, warm-up, aerobic training with Greek traditional dances, upper body training and cooldown. The dancing exercise program and the upper body training were specifically designed to meet the abilities of breast cancer survivors, jointly by a physical education teacher, who is professional experienced dance instructor and has an extensive experience in fitness, dancing and rehabilitation, and a specialist physical therapist. Patients in the control group continued their usual daily schedule.

164

A. Kaltsatou et al.

Table 1 Means for general and medical characteristics of the participants in the two groups (standard deviations in parentheses).

Age (years) Time since surgery (months) Dominant hand (right/left) Operation side (right/left)

Experimental Group (N Z 14)

Control Group (N Z 13)

56.6 (4.2) 24 (1.2)

57.1 (4.1) 28 (1.4)

12/2

12/1

8/6

7/6

measured with a measuring tape (Basen-Engquist et al., 2006) to estimate the arm volume. Concerning the psychological condition, the Beck Depression Inventory (BDI) was used to evaluate the severity of depression. The BDI is a validated and reliable 21-question multiple choice self-report inventory measure of depression that has been used in many populations, including cancer patients (Beck et al., 1961; Donias and Demerdjis, 1983). In addition, participants completed the Life Satisfaction Inventory (LSI). The LSI is a 13-item multidimensional inventory that validates the satisfaction that the participant receives from his lifestyle (Muthny et al., 1990).

Data analysis Each session lasted 60 min. Blood pressure and heart rate were recorded during check-in from the instructor. The warm-up period lasted 10 min and included range of motion exercises and stretching. The aerobic training phase lasted 25 min and included learning and practicing Greek traditional dances. The dance phase consisted of basic, low impact steps, performed in a single group while holding hands in a semi-cycle. All dances were circle dances, they started with the right foot moving counter-clock-wise and they were accompanied by traditional Greek music from different areas of Greece. The steps of the selected Greek dances were simple, such as stepping to the side, followed by a closing of the foot together or a passing of the foot in front or behind the other, single limb standing, hopping, jumping and trunk extension. The duration of each dance was 3e4 min and the breaks between dances lasted 15 s. The dances were practiced in a progressive order from the simplest and least physically demanding to the most complex and dynamic (in terms of movement elements). All dances, practiced throughout the intervention, were of moderate intensity (between 65 and 80% of maximum heart rate). At the beginning of the program, the intensity of the dances was low and after week 15 it became high. The upper body exercise training and the cool-down lasted 25 min and they emphasized in stretching and resistance training with the use of variable resistance machines. At the beginning and the end of the 24-week study period, all patients underwent a physical examination, a 6min walking test, a handgrip strength testing, arm volume measurement and a psychological condition testing. Resting blood pressure (BP) and heart rate (HR) were measured after the individual had been sitting calmly for 5 min (American Heart Association, 1981). HR was estimated by palpation for four 15-s periods and blood pressure was determined by a sphygmomanometer. The 6-min walking test (Enright, 2003) was used to estimate the physical function of the subjects. Participants completed a 6-min endurance walk test, walking as comfortably as possible in 6 min. The 6-min test is a useful measure of functional capacity, targeting people with at least moderately severe impairment (Enright, 2003). Handgrip strength was assessed in both sides, using a baseline handheld dynamometer (Gill et al., 1985). The participants were seated with the forearm in neutral position and the elbow at 90 . They squeezed the handgrip as hard as they could. The mean of 3 measurements was used for further analysis. The upper arm circumference was

In order to test for differences between the experimental and the control group on the post-test scores, an analysis of covariance (ANCOVA) was employed. The two groups comprised the independent variable; the post-test scores the dependent variable; pre-test scores, age, height, and weight represented the covariates. The purpose in using the covariates was to ensure (in the statistical sense) that both groups (experimental and control) were equivalent across these variables. In essence then, the adjusted means (adjusted for the presence of the covariates) were compared with each other using an analysis of variance. In addition to the ANCOVA, a power analysis was conducted to ensure that effects were both statistically significant, but also meaningful (Cohen, 1992; Sideridis, 1999). To this effect, we estimated that in order to attain levels of power at 0.80, for a large effect size (i.e., 0.80 SD) at a one-tailed test, working on a 5% level of significance, we needed 20 participants per group. Our sample estimates were very close to our hypothetical suggestions, ensuring that there were adequate levels of power for the detection of large effects only1. A p value of <0.05 was considered as statistically significant.

Results All parameters were evaluated and analyzed in the beginning and in the end of the 24-week program. Table 2, shows the findings from the analysis of covariance. Specifically, there were significant differences between groups on posttest scores, favouring the experimental group on handgrip strength, both right (Cohen’s ES2 Z 1.41) and left (Cohen’s ES Z 1.20). These effects sizes (ES) were way above the cutoff point of a large effect size (suggested by Cohen) indicating that the experimental group changes on strength were immense. With regard to systolic blood pressure both groups were essentially equivalent (Cohen’s ES Z 0.00) after controlling for the covariates. Furthermore,

1 The probability of committing a Type-II error was likely, but in this case the error is on the conservative side, in that, only effects that were strong, significant and meaningful had a high probability of being detected. Every other effect, that could not exceed levels of significance, was not considered ‘‘meaningful’’. 2 Cohen’s conventions for small, medium and large effect are as follows: (small Z 0.2, medium Z 0.5, large Z 0.8).

Greek traditional dances and breast cancer

165

Table 2 Unadjusted and adjusted means between experimental and control groups on post-test after adjusting for the presence of the covariates (standard deviations in parentheses). Variables

Handgrip strength right (lb) Handgrip strength left (lb) Rest DBP (mmHg) Rest SBP (mmHg) Arm volume right hand (cm) Arm volume left hand (cm) 6-min walking test (m) BDI LSI

Ab-F

Grouping Experimental Group

Control Group

Experimental Group

Control Group

Ua-Mean

Ua-Mean

Ab-Mean

Ab-Mean

p

59.50 (7.47)

47.85 (9.06)

59.08

48.23

85.70

0.001*

59.75 (9.69)

47.38 (10.91)

59.32

47.78

110.53

0.001*

78.75 (11.10) 125.00 (9.04) 33.69 (6.37)

81.15 (7.11) 126.92 (7.51) 38.33 (6.77)

80.00 125.14 35.31

80.00 126.80 36.58

e 4.32 3.10

N.S. 0.052 0.095

35.31 (5.33)

38.42 (7.06)

36.18

37.47

5.66

0.028*

483.33 (85.95)

403.08 (71.92)

470.31

415.10

91.69

0.001*

16.54 (1.66) 45.42 (4.98)

22.33 (7.73) 33.31 (4.01)

10.57 45.72

17.39 33.03

1.70 193.65

0.001* 0.001*

*Indicates significant effect (p < 0.05). N.S.: Non-significant (because it could not be computed due to the equivalence of the two groups after controlling for the covariates). BDI: Beck Depression Inventory. LSI: Life Satisfaction Inventory. a Unadjusted parameters. b Parameters that are adjusted for the contribution of pre-test scores on each dependent variable, age, weight and height. None of Levene’s tests for equality of variances was significant suggesting that the data met this assumption.

borderline differences were observed with regard to diastolic blood pressure (Cohen’s ES Z 0.23). There were also significant differences between groups on arm volume, but only for the left hand (Cohen’s ES Z 0.50) and not the right (Cohen’s ES Z 0.71), although the later effect was between medium and large3. Last, with regard to psychological condition, there were significant differences on the LSI (Cohen’s ES Z 2.69), and the BDI (Cohen’s ES Z 2.36).

Discussion The aim of this study was to examine whether practicing Greek traditional dances, as a non-common physical activity, is beneficial for breast cancer survivors. The results revealed useful evidence according to which, dance practice had a positive impact on breast cancer survivors. More specifically, a 24-week combined exercise program, which includes a combination of practicing Greek traditional dances and upper body training, had benefits in the physical function, depressive symptoms and life satisfaction in breast cancer survivors. To our knowledge, this is the first study to show the positive effect of traditional Greek dance practice on physical and psychological condition in breast cancer survivors. As a result of practicing traditional Greek dances, a significant increase of 19.9% was found in the walking distance of the experimental group, compared to the control group. The patients in the experimental group improved the 3

In essence, reflecting a likely Type-II error in that, there was not adequate power for an effect of medium to large effect to exceed conventional levels of significance.

6-min walk distance, walking as comfortably as possible, and significantly increased the distance they could walk in 6-min after the program. This improvement is attributed to the practice of Greek traditional dances, which offers a promising alternative choice as a physical activity for cancer survivors. Decreased activity and increased weight represent some of the side effects of cancer treatments and are in particular concern, as they both have negative effect on cardiovascular system (Shapiro and Recht, 2001) and there is an association observed between body mass and breast cancer mortality (Whiteman et al., 2005). Thus, an improvement in functional capacity is essential and eligible for this target group. Functional improvement is also desirable in breast cancer survivors with regard to the ability to maintain daily activities independently. In contrast to other studies that used other types of physical activity to improve physical function in cancer survivors (Milne et al., 2008; Sandel et al., 2005), this was the first one demonstrating that traditional Greek dance is an effective way of improving physical function in breast cancer survivors. Dance has always played an important role in the life of Greeks and has passed from generation to generation maintaining their national identity. From antiquity, Greeks are used to dance in celebrations and ceremonies in order to express their feelings. However, besides the enjoyable and pleasant time Greek dances may offer, they also affect the oxygen transport system and could be used as an aerobic exercise (Pitsi et al., 2008). The life satisfaction and depressive symptoms were measured with the Life Satisfaction Inventory (LSI) and Beck Depression Inventory (BDI). After the 24-week exercise program, life satisfaction showed a significant increase of 36.3% and depression symptoms demonstrated a decrease

166 of 35% in the experimental group, compared to the control group. These findings could be associated with the improvement of physical function, as regular physical activity improves cardiovascular and muscular function together with the psychological condition (Pate et al., 1995). Furthermore, according to other studies, physical function is associated with emotional well-being and quality of life in breast cancer survivors (Blanchard et al., 2004; Humpel and Iverson, 2007). The findings of this study support prior studies with exercise interventions that demonstrated improved quality of life with increased physical function (Courneya and Friedenreich, 1999). In a retrospective research study, Young-McCaughan and Sexton (1991) reported that breast cancer survivors, who were engaged in aerobic exercise 2e4 times/week had a higher quality of life compared with those, who did not perform any exercise. In addition, another study (Courneya et al., 2002) supported that exercise may be associated with improvements in emotional well-being and enhanced quality of life in cancer patients. Besides, dance programs have been effective in beneficially modulating concentrations of serotonin and dopamine and improving psychological condition (Jeong et al., 2005). Thus, dance, which is associated with improved psychological condition, could be a therapeutic strategy to address both emotional well-being and body image in breast cancer survivors. Breast cancer survivors are experiencing limitations in upper-body strength and report severe difficulty in lifting heavy objects (Satariano et al., 1996). This is a condition that reduces physical function (Satariano et al., 1996) and limits the ability to participate in usual activities in home and community (Ness et al., 2006). Recent studies have noted that shoulder weakness is a long-term consequence of treatment for breast cancer (Hack et al., 1999; Merchant et al., 2007) and it is particularly associated with a reduction in quality of life, owing to the fact that the patients have to face many difficulties every day, as the majority of daily activities are bimanual (Kilbreath et al., 2006). Grip strength and arm volume (Benz and Olsen, 2002) are important indicators of the upper limb strength. After the 24-week exercise program, the experimental group showed an increase of 24.3% in right handgrip strength and 26.1% in left handgrip. These results can be attributed to neuromuscular adaptation and muscular hypertrophy, which both have important implications for survivors of breast cancer, since cancer therapies can result in peripheral neural impairments that are associated with muscle atrophy (Cheema and Gaul, 2006). In addition, reductions of 9% in left hand arm volume and of 13.7% in right hand arm volume were revealed, probably due to body fat reduction, as gain and loss of weight can affect arm volume (Benz and Olsen, 2002). Our results support previous studies that demonstrated that a combined aerobic and resistance exercise program (Milne et al., 2008), as well as low-intensity exercise training may contribute to the improvement of the quality of life in breast cancer survivors (Culos-Reed et al., 2006; Demark-Wahnefried et al., 2003). In conclusion, the current study showed that a combined exercise program that includes aerobic exercise with Greek traditional dances and upper body training has a beneficial effect in physical function, life satisfaction and depressive symptoms in breast cancer survivors. Consequently, Greek traditional dances could be an effective means of exercise

A. Kaltsatou et al. training, contributing to the improvement of the physical function and psychological condition in this target population. In general, traditional dances, as an aerobic activity, may be considered an alternative and pleasant choice of aerobic physical activity for cancer survivors, promoting important benefits on their quality of life. This study was the first attempt to assess the effects of Greek traditional dances in breast cancer survivors. Despite the fact that the sample size was small, the patients in the present study were representative of a large population of breast cancer survivors. Nevertheless, further research is required to clarify the precise impact of upper body training versus Greek traditional dances. Moreover, the potential for Greek traditional dance programs to improve other parameters in breast cancer patients remains to be demonstrated. Future research is required to address the beneficial effects of Greek traditional dances in other cancer patient populations too. In addition, future studies could explore alternative activities, in the hope of promoting increased exercise participation and improving quality of life in cancer survivors.

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167 Mavrovouniotis, F.H., Argiriadou, E.A., Papaioannou, C.S., 2009. Greek traditional dances and quality of old people’s life. Journal of Bodywork and Movement Therapies 20, 1e10. McNeely, M.L., Campbell, K.L., Rowe, B.H., Klassen, T.P., Mackey, J.R., Courneya, K.S., 2006. Effects of exercise on breast cancer patients and survivors: a systematic review and metaanalysis. Canadian Medical Association Journal 175 (1), 34e41. Merchant, C.R., Champan, T., Kilbreath, S.L., Refshauge, K.M., Krupa, K., 2007. Decreased muscle strength following management of breast cancer. Disability and Rehabilitation 1, 1e8. Milne, H.M., Wallman, K.E., Gordon, S., Courneya, K.S., 2008. Effects of a combined aerobic and resistance exercise program in breast cancer survivors: a randomized controlled trial. Breast Cancer Research and Treatment 108, 279e288. Muthny, F., Koch, U., Stump, S., 1990. Quality of life in oncology patients. Psychotherapy and Psychosomatics 54, 145e160. Ness, K.K., Wall, M.W., Oakes, J.M., Robison, L.L., Gurney, J.G., 2006. Physical performance limitations and participation restrictions among cancer survivors: a population-based study. Annals of Epidemiology 16 (3), 197e205. Pate, R., Pratt, M., Blair, S., Haskell, W., Macera, C., Bouchard, C., Buchner, D., Ettinger, W., Heath, G., King, A., Kriska, A., Leon, A., Marcus, B., Morris, J., Paffenbarger, R., Patrick, K., Pollock, M., Rippe, J., Sallis, J., Wilmore, J., 1995. Physical activity and public health e a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 273, 402e407. Pitsi, A., Smilios, I., Tokmakidis, S.P., Serbezis, V., Goulimaris, D., 2008. Heart rate and oxygen consumption of middle aged people during the performance of Greek traditional dances. Inquiries in Sport & Physical Education 6 (3), 329e339. Rietman, J.S., Dijkstra, P.U., Geertzen, J.H.B., Baas, P., Vries de, J., Dolsma, W., Groothoff, J.W., Eisma, W.H., Hoekstra, H.J., 2003. Short-term morbidity of the upper limb after sentinel lymph node biopsy or axillary lymph node dissection for stage I or II breast carcinoma. American Cancer Society 98 (4), 690e696. Sandel, S.L., Judge, J.O., Landry, N., Faria, L., Ouellette, R., Majczak, M., 2005. Dance and movement program improves quality-of life measures in breast cancer survivors. Cancer Nursing 28 (4), 301e309. Satariano, W.A., Ragland, D.R., DeLorenze, G.N., 1996. Limitations in upper-body strength associated with breast cancer: a comparison of black and white women. Journal of Clinical Epidemiology 49 (5), 535e544. Segar, M.L., Katch, V.L., Roth, R.S., Garcia, A.W., Portner, T.L., Glickman, S.G., Haslanger, S., Wilkins, E.G., 1998. The effect of aerobic exercise on self-esteem and depressive and anxiety symptoms among cancer survivors. Oncology Nursing Forum 25 (1), 107e113. Shapiro, C.L., Recht, A., 2001. Side effects of adjuvant treatment of breast cancer. New England Journal of Medicine 344 (26), 1997e2008. Sideridis, G.D., 1999. On establishing non-significance. Dyslexia 5, 47e52. Whiteman, M.K., Hillis, S.D., Curtis, K.M., McDonald, J.A., Wingo, P.A., Marchbanks, P.A., 2005. Body mass and mortality after breast cancer diagnosis. Cancer Epidemiology, Biomarkers & Prevention 14 (8), 2009e2014. Young-McCaughan, S., Sexton, D., 1991. A retrospective investigation of the relationship between aerobic exercise and quality of life in women with breast cancer. Oncology Nursing Forum 18, 751e757.

Journal of Bodywork & Movement Therapies (2011) 15, 168e176

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FASCIAL HYPOTHESIS

Fascia and the mechanism of acupuncture Steven Finando, Ph.D., L.Ac*, Donna Finando, M.S., L.Ac., L.M.T. Heights HealthCare, 11 Hill Lane, Roslyn Heights, NY 11577, United States Received 7 December 2009; received in revised form 11 March 2010; accepted 12 March 2010

KEYWORDS Acupuncture; Fascia; Sham; Placebo; Mechanism; Soft tissue; Qi; Palpation

Summary In light of the recent results consistently produced by meta-analyses of clinical acupuncture studies, acupuncturists have been challenged to re-evaluate the principles of acupuncture practice. This paper reconsiders acupuncture, positing that the fascia is the mechanism of action of acupuncture therapy. Acupuncture is defined behaviorally, and recent research findings related to the form and function of the fascia are applied to explain the mechanism of action of acupuncture therapy. Acupuncture is then viewed from a historical perspective, and fundamental principles of acupuncture therapy are reconsidered in terms of the fascia model. A conception of acupuncture emerges that is linked to a renewed understanding of ancient acupuncture principles and is characterized by a return to diagnosis and treatment rooted in skilled palpation. ª 2010 Elsevier Ltd. All rights reserved.

Introduction

Key issues

There is a logical fallacy that is common to the thinking of clinicians of any medical practice. If a clinician applies a treatment strategy that is based upon some explanation of the mechanism of treatment and finds the treatment to be somewhat effective, then the effectiveness of the treatment is assumed to validate the explanation. In the case of acupuncture, its various transformations over centuries may have resulted in explanations and associated principles that belie reality. An examination of the issues surrounding the extensive findings regarding sham acupuncture may provide a unique opportunity for the reconsideration and perhaps the revitalization of this ancient art.

Acupuncture: a placebo?

* Corresponding author. Tel.: þ1 516 626 2106. E-mail address: [email protected] (S. Finando).

Recently there have been an extensive number of clinical studies and meta-analyses (Cherkin et al., 2009; Linda et al., 2009; White et al., 2004) that have failed to find significant differences between acupuncture (independent variable) and sham acupuncture (control). In a systematic review of 38 clinical trials by Moffet (2009) sham acupuncture was about as efficacious as ‘true’ acupuncture. Moffet goes on to suggest that the fundamental principles of acupuncture need to be reconsidered. In a systematic review by Lao (2008), acupuncture clinical studies were categorized according to the type of control. One group of studies used a type of time-series design, where acupuncture was withheld from some of the

1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.03.001

Parallels between acupuncture and fascia subjects and applied to others. A second group of studies employed placebo acupuncture as control, where there was neither stimulation nor insertion of needles. The final set of studies employed sham acupuncture, where points were needled or stimulated in some way. The first two groups demonstrated significant differences between acupuncture treatment and control virtually in every study. The sham acupuncture studies however demonstrated no significant differences in all but one study. What is important about these findings is that both the acupuncture and sham acupuncture groups demonstrated significant effects in comparison to no treatment or conventional medical approaches. For example, Scharf et al. (2006) found that both the real and sham acupuncture treatment groups showed double the improvement over a conventional medicine treatment group. Similar results were found by Haake et al. (2007). In addition to the extensive human clinical studies demonstrating the effectiveness of acupuncture for a wide range of conditions, there are numerous animal studies demonstrating physiological and clinical effects (Lao et al., 2003; Liu et al., 1995; Stener-Victorin et al., 2000; Tatewaki et al., 2003; Wu et al., 2001). The effectiveness of acupuncture has been repeatedly demonstrated. The extensive number of animal studies reporting such effects can allow us to minimize the role of placebo as the explanation of its effectiveness. While the placebo effect is a possibility in any form of treatment, it is very unlikely that it is the fundamental mechanism of acupuncture, as some have suggested. Findings such as these have sparked a debate about both the placebo effect of acupuncture and the application of reductionist research models to non-linear, whole-system phenomena. What is missed, however, is the significance of the findings regarding sham acupuncture. They point to the remarkable power of needle stimulation of the soft tissue. Such findings do indeed necessitate a reconsideration of the fundamental principles and practices of acupuncture treatment.

The problem of defining acupuncture One of the great difficulties facing the clinical acupuncture researcher is the definition of the independent variable. How is acupuncture to be defined in a valid and reliable way? Unschuld (1986, p. 5) describes the ‘efforts to squeeze an enormous array of concepts and schools of thought in traditional Chinese medicine which are sometimes mutually contradictory, antagonistic or exclusive into the kind of homogenous, logically coherent system of ideas and practices that is so attractive to the Western mind’ [emphasis ours]. Perhaps the problem does not lie exclusively with the Western mind set. Examination of the historical development of the varied schools and styles of acupuncture, and the evolution of the numerous and sometimes contradictory principles of practice provides some insight regarding the problem of defining acupuncture. While the practice of acupuncture was rooted in evaluation through extensive palpation and clinical observation, it was also molded and modified by religious, philosophical and cultural influences (Birch and Felt, 1999). Acupuncture principles have been influenced by social,

169 economic and political issues and they have been adjusted by misinterpretations, individual theories, fragmentary texts and faulty translations. In addition, Chinese thinkers were immensely practical and capable of absorbing apparently opposing ideas without replacing or negating earlier ones. To understand acupuncture, then, we must accept it as a unique admixture of both fantasy and fact developed over the course of thousands of years. The longevity of the acceptance of many of the theories and practices may be explained by the general effectiveness of patterned needling of the soft tissue. Successful treatment reinforces the belief in the explanations regarding such treatment. An example of a style of acupuncture that is the product of diverse influences is also perhaps the most popular form of acupuncture practiced today. Traditional Chinese Medicine (TCM) is the name of a particular approach to acupuncture that was invented at the time of the Cultural Revolution (ca. 1949) in the People’s Republic of China (PRC). TCM was created as a result of political and economic circumstances and was aimed at both maintaining the cultural legacy of Chinese medicine and providing some form of health care to a huge population with insufficient modern medical facilities. TCM became the only type of acupuncture that was permitted in the PRC, and was therefore the only system that was taught in developing schools of acupuncture. One of the governmental requirements for the development of TCM was that the principles of acupuncture and herbalism be integrated under a central set of principles. Herbalists had greater political influence in the PRC at this time, and the resulting acupuncture practice was one that was grounded upon the principles that had previously been applied to the use of herbal medicines. It was focused on organ function rather than channel disruption and was strongly connected to modern biomedicine. It connected pattern pathology to modern disease diagnosis and textbooks were produced that described treatments for Western-defined diseases. Pirog (1996) refers to this as a ‘herbalized’ approach to acupuncture. TCM is currently the predominant approach used in the West, and is the most common approach used in acupuncture clinical research. Understanding the background of TCM is important, because it marks a clear departure from palpation-based, meridian style approaches to acupuncture, allowing for mass education models as opposed to apprenticeship education that emphasizes palpation. Using the TCM paradigm, point selection decisions are based primarily on symptom/sign pattern recognition and a formulary of commonly known point combinations applied to specific patterns. The application of formula points to particular pathologies or dysfunctions may be moderately effective, and as metaanalyses imply, demonstrate little difference from the nonspecific stimulation of point patterns used in sham acupuncture control groups found in some clinical studies.

Defining acupuncture: a behavioral approach The consideration of a model of acupuncture in which the fundamental mechanism of action is the movement and release of fascial constrictions may provide an explanation

170 of the apparent contradictions and extraordinary effectiveness of acupuncture treatment, and possibly offer a renewed appreciation of this ancient art. The fundamental requirement for the acceptance of any new theory is that it better explains the phenomena under examination. We suggest that the fascia mechanism offers such an explanation regarding the action and efficacy of acupuncture. However in order to support this model, the practice of acupuncture would have to be reconsidered. By examining the observable phenomena common to acupuncture practice, noting what acupuncturists do, rather than what they believe, acupuncture can be defined behaviorally. Such an examination may provide an objective perspective of acupuncture and its often confusing practices and effects. Acupuncture may be defined in terms of the characteristics that are common to all styles of practice. Acupuncture needles always puncture the skin, the superficial fascia, and occasionally muscle tissue. In doing so, acupuncturists stimulate soft connective tissues whether or not they recognize that they are doing so. Needle stimulation is most often applied along defined channels, and needles are most often inserted into defined points along these channels. Needles are generally stimulated in some fashion and they are generally left in place for some time before removal. Stecco (2004) defines the parallels between acupuncture channels and fascial planes and between acupuncture points and centers of coordination. Langevin and Yandow (2002) found an 80% correlation between acupuncture points and intermuscular or intramuscular septa, along fascial planes (see Fig. 1a and b). The clue to the mechanism of acupuncture is therefore anatomical. Loci where maximum stimulation of the fascia may occur are the focus of treatment. Although any needle insertion, at virtually any point on the surface of the body provides stimulation of the fascia, acupuncture points and channels have a unique anatomical correlation to fascial anatomy. Regardless of the inconsistencies in the acupuncture literature concerning needle depth, stimulation, retention or frequency of visits, all fundamental characteristics of acupuncture treatment are consistent with treatment of the fascia. In essence, everything that the acupuncturist does, apart and distinct from any explanations regarding what they believe they are doing is completely consistent with stimulation of the fascia. All of this might have seemed interesting but without great significance as recently as ten years ago. Indeed, in the past there have been some who have speculated that the fascia is the basis of the multiple and varied effects of acupuncture treatment (Pischinger, 2007; Larson, 1990; Nagahama, 1956). However, it is in recent years with an expansion of research and interest in the fascia, that the real significance of connective tissue stimulation becomes clear.

The fascia Anatomy Recent research has challenged some fundamental ideas of human anatomy and physiology. It has overturned the concept of the fascia as a static, structural support for the

S. Finando, D. Finando

Figure 1 Acupuncture point Lung 3 (arrow) approximated by acupuncture units of measurement. Note relationship to fascial septum. Fig. 1a is a coronal section of the human shoulder. Fig. 1b is an axial section of the human upper torso and arms. Images by permission of the Visible Human Project, National Library of Medicine, United States.

body and has shed light upon a new organ, a continuous sheath of tissue that moves, senses and connects every organ, blood vessel, nerve, lymph vessel, muscle and bone. Fascia has been defined as the soft tissue component of the connective tissue system, forming a whole-body continuous matrix that interpenetrates and surrounds all organs, muscles, bones and nerve fibers (Findley and Schleip, 2007). It can usefully be considered a single organ, a unified whole, the environment for all body systems functioning, connected to every aspect of human physiology (Guimberteau, 2007). The fascia has also been conceived as a complex communication network that influences and is influenced by every muscle, organ, blood vessel and nerve. Langevin (2006) suggests the fascia to be a metasystem, connecting and influencing all other systems. Incorporating this view would change our core understanding of human physiology. Chen and Ingber (2007), in studies of fascia cellular structure, describe a cytoskeleton under continuous tension that is capable of transmitting mechanical forces through the system. Forces applied to the cytoskeleton can

Parallels between acupuncture and fascia produce biochemical changes on the cellular level by mechanochemical transduction. Guimberteau (2003) demonstrates the complex fractal structure of the tissue and how it allows for movement, adaptation, lubrication and repair. Schleip (2008) refers to the fascia as our richest sensory organ, permeated with four types of sensory receptors. The vascular, nervous and lymphatic systems all end in the ground substance, providing nutrients to the ground substance as well as information from the periphery (Paoletti, 1998). It is both interesting and highly significant to note that acupuncture is based upon the conception of a metasystem that links and influences every aspect of human physiology. The fascial system provides the anatomical basis of that metasystem.

171 The fascia offers a physiological basis for explaining the clinical phenomena and effects of acupuncture treatment. It offers an explanation for the most fundamental characteristic of acupuncture treatment, the ability to treat numerous, diverse conditions: The fascia is the connection between the surface and the viscera; it provides the means of treating the viscera and countless forms of human pathology and disease through the treatment of the surface; it is an organ that reacts to stimulation, wherever it is applied. It has been shown however that therapeutic effectiveness and efficiency is clearly linked to accurately localizing deformations and dysfunctions of the fascia and using an appropriate strategy to promote its release and restore proper activity (Stecco, 2004; Paoletti, 1998; Larson, 1990). Table 1 summarizes these relationships.

Function The diversity of conditions that respond to acupuncture treatment may be explained by a review of the recently understood functions of the fascia. The involvement of the fascia in dysfunction and disease is pervasive. Paoletti (1998) suggests that to some extent, the fascia will necessarily be involved in every type of human pathology. Some support for this position can be found in research regarding the development of myofibroblasts and disrupted apoptosis, thereby linking the fascia to chronic disease via fibrosis of visceral tissue (Gabbiani, 2003; Hinz, 2006; Tomasek et al., 2002). The exchange of substances across the intercellular ground substance connects the fascia to cellular nutrition and metabolism (Guimberteau, 2007; Paoletti, 1998; Pischinger, 2007). The fascia is responsible for the initial, non-specific immune response of the body to the invasion of pathogens (Pischinger, 2007). It is also involved with hemodynamic processes, particularly venous and lymphatic circulations (Paoletti, 1998). On a structural level, the fascia allows muscles to function, and is central to physical movement (Stecco, 2004). The fascia protects the body, both from internal stresses and the dissipation of external forces; it provides insulation, lubrication and structural integrity across the entire system (Paoletti, 1998). It is influenced by the external environment, and indeed is the link between the external and internal environments (Pischinger, 2007). This concept parallels fundamental principles in acupuncture which view the human being as part of the environment, rather than isolated from it. This remarkable and complex metasystem is capable of the transmission of local and distal effects. An example is the transmission along fascial planes of referred pain patterns and impaired movement due to myofascial deformations (Travell and Simons, 1983; Stecco, 2004). Other such examples are the somatovisceral and viscerosomatic reflections that research has demonstrated since the early 20th century (Good, 1950; Gutstein, 1944; Travell and Simons, 1983). Myofascial tissue deformations on the surface of the body have been linked to a variety of visceral and autonomic dysfunctions that are resolved when the myofascial impairment is rectified (Travell and Simons, 1983). Similarly, it has been demonstrated that visceral pathology may be reflected to the surface (Dworken et al., 1952; Melnick, 1957; Mendeloff and Seligman, 1974).

Acupuncture reconsidered Overview Acupuncture is a medical art that has withstood centuries of diverse pressures that produced multitudinous branches of practice. The longevity of acupuncture may be demonstrated by three fundamental realities. First, by its nature as a palpation-based form of treatment, it has been subject to intense scrutiny, being shaped by exhaustive clinical observations over millennia. Second, its basis of treatment is a metasystem that has shown itself to be fundamental to human health. Third, its effectiveness has been demonstrated for numerous and varied types of dysfunction through research and clinical experience. A reconsideration of some fundamental acupuncture principles in light of the fascia model is necessary. Such reconsideration is not intended to justify each and every principle of treatment, but to encourage practitioners to reflect upon some fundamental ideas that have guided this safe and effective medical art for centuries, and possibly stimulate new research hypotheses.

Qi Lying at the conceptual core of Chinese medicine is the idea of qi. The notion of qi as some sort of energy/ substance is a completely modern idea, probably introduced by De Morant and Grinnel (1994) in the early 20th century. It is an idea that certainly helped the dramatic development of acupuncture in the West, but may have diverted both acupuncture practice and research into some less productive directions. Therefore, any effort to engage in a discussion of qi must begin by confronting two issues: The issue of language and the issue of preconception. We must recognize that qi, like many words in other languages, has no direct translation into English. It is a term that we can only approximate conceptually rather than by direct definition. The second issue involves the existing concept of qi in minds of both the practitioner and the public. When a term such as qi comes into the common usage it is difficult to break habits of language that imply some understanding of its meaning. Acupuncturists refer to qi as commonly as a plumber refers to water, e.g., as something that can be manipulated, ‘energy.’ The public has a similar

172 Table 1

S. Finando, D. Finando Parallels between acupuncture and the fascia.

Areas of comparison

Acupuncture

Fascia

The channel system

A metasystem that links and integrates the human body

The channels

Access and affect deeper aspects of the body; are anatomically highly correlated to fascial planes; exist in body lining e ‘‘fat, greasy’’ tissue; between bones and sinew Highly correlated to interstices within fascial planes. Needle stimulation of the points effect the physiology

A whole-body continuous living matrix; a continuous metasystem that integrates every aspect of the physiology Fascial planes are conduits that have multiple, diverse connections to deeper fascia

The points

Mechanism of treatment Treating physiological dysfunction Surface treats internal viscera Function Immune function Blood circulation

Stimulation of acupuncture points used to treat numerous and diverse conditions. Channels demonstrate the location of disorders. Treatment of surface points affects the viscera. Wei qi connected to immune function. Acupuncture used to treat immune issues. Acupuncture related to blood movement e ‘‘where the qi goes the blood goes’’.

Temperature regulation Protection

Qi warms the body. Qi protects the body.

Digestion/metabolism

Qi is the source of harmonious transformation in the body. Qi governs retention of substances/organs. Qi is the source of movement in the body.

Structure Movement Environmental influence Qi

Acupuncture was based on the effects of environmental influences on human health. Best understood as proper movement or activity at every level of anatomy and physiology.

habit of usage, using the term ‘energy’ without any understanding of what energy may be. Unschuld (1983) states ‘.the customary translation of ch’i by some Western (and Asian) authors as ‘energy’ represents a basic misconception that is not supported by Chinese ancient sources.’ O’Connor and Bensky (1981) state that ‘qi is an untranslatable word in the Chinese medical lexicon. It signifies a tendency, a movement, something on the order of energy.’ And Birch and Felt (1999) point out that ‘our. inevitable Western search for the material or energetic basis of qi need not look for something that is strong enough to perform work. We can look instead for signals that stop, start or moderate a process. In this regard, the closest parallel to qi in Western thought is a generative matrix in which all things interact with all other things through the exchange of information.’ Qi may be best understood within the context of its philosophical roots. Qi is a concept fundamental to Taoist

Fascial interstices connect to deeper tissue. Heine cylinders connect surface to viscera and influence cellular metabolism via matrix.

Tensegrity and mechano-transduction models allow for mechanical stimulation of the surface to effect cellular physiology. Fascia reflects surface constrictions to the viscera and the viscera reflects dysfunction to the surface. Matrix considered ‘‘first line of defense’’ related to immune function. Fascia connected to hemodynamic processes, venous and lymphatic circulation. Fascia insulates, maintains temperature. Fascia protects the body, acts as shock absorber, is connected to immune function. Fascia is connected to metabolism, nutrient transfer and organic functioning. Fascia provides structure at every level. Fascia is connected to all bodily movement from cellular level to gross movement. Fascia connects the physiology with environmental influences. Fascia is connected to maintaining optimum activity at every level of anatomy and physiology.

cosmology related to the creation of the universe. The cosmology begins with Wu Qi, the state of nothingness, the Void, a state a priori to existence, similar to the state before the Big Bang. Existence, Tai Qi, represented by the well-known Yin/Yang symbol, begins with movement. Movement is a statement of duality; movement can only exist relative to something else. Thus, the beginning of existence, creation, from nothingness to duality, is marked by the introduction of movement into the Void. Wu Qi is quiescence, no movement, no activity. Tai Qi, the first principle of existence, symbolizes duality, the balanced relationship between two complementary forces, active and passive. This balanced activity provides insight into the meaning of qi. Qi refers to movement, activity: not just any movement, but the proper movement or activity of any thing. It is activity that cannot be separated from the thing, as the tides cannot be separated from the oceans. Qi is not an amorphous substance separate and distinct from

Parallels between acupuncture and fascia human anatomy. Rather it is the proper movement and activity of every aspect of human anatomy. In the human being it refers to functional movement at every level of the anatomy and physiology, superficial and deep, systemwide and cellular. The fascia metasystem is the matrix in which all physiologic activities take place. When there are restrictions or deformations within the fascia movement is impaired therefore function is impaired. The use of acupuncture is an effort to effectuate proper movement and to restore balanced activity of the fascia. Needles stimulate movement, release deformations and induce reactions in the extraordinary fascia metasystem to correct itself and to restore proper function at every level of the physiology. If we understand qi from the perspective of the proper functioning of the fascia, we do not discover a new acupuncture, but rather a system of treatment based upon careful palpation and observation, a system whose most fundamental principles are in complete accord with fascia mechanism model. Consider the major functions of qi as summarized by Kaptchuk (1983): ‘Qi is the source of all movement in the body, protects the body, is connected to harmonious transformation (metabolism), retains the body’s substances and organs, and warms the body.’ Given our previous discussion of the functions of the fascia, we could literally substitute ‘proper activity and function of the fascia’ for ‘qi.’ Such balanced movement is the basis of health. Qi may therefore be considered to be the proper activity of every aspect of bodily functioning. When it functions in harmony, there is health; when it is impaired, there is disease; when it ceases, there is death.

Yin/Yang balance With the advent of TCM, for the first time in its history, the use of acupuncture was connected to the treatment of Western-defined pathologies. From a historical perspective however, it is more accurate to say that acupuncture has always sought to correct only one condition: imbalance. A model of balance is a reflection of the Yin/Yang duality; it seeks to maintain the proper equilibrium between action and rest. This is a perfect expression of fascia therapy. Any fascial deformation can be seen to be an imbalance. In the presence of a fascial deformation, a state of excess, such as a build up of blood, lymph or muscular stress develops, as well as a concomitant and related deficiency elsewhere along the fascial pathway. The fascia model of acupuncture is concerned with alleviating deformations or constrictions of the fascia, regardless of whether they are related to dysfunctions associated with pain, proprioception, movement, or visceral disturbance. Its aim is to restore balanced activity and proper movement within the fascial metasystem, thereby restoring proper function. Because of the wide-ranging effects that a therapy of this type has on overall health, principles and strategies for effecting balance need to be explored and evaluated in order to effectuate a profusion of treatments of this type.

Channels and points The extraordinary anatomical correlation between acupuncture channels and points to fascial planes and septa

173 (Langevin and Yandow, 2002) and myofascial sequences and centers of coordination (Stecco, 2004) demonstrate the careful observation and palpation by early Chinese medical physicians. The earliest Chinese medical classics, the Su Wen, Ling Shu and Nan Jing all make reference to the location of the channels in ‘fatty and greasy’ tissue, the ‘body lining,’ or the ‘space between the organs, bones and flesh’ (Birch and Felt, 1999; Matsumoto and Birch, 1988). Rather than the simple treatment of local or reflex points on the body surface, the superficial channels, where virtually all acupuncture treatment takes place, represent a complex system of fascial pathways (Figs. 2 and 3). Stimulation along such pathways is capable of inducing fascial movement within both the surface myofascial aspects and the deeper visceral aspects. The channels’ coincidence with relatively modern conceptions of fascial planes is a testament to the oldest continually practiced form of medical treatment and the skill of those physicians who were practicing it. Ni (1996) describes the function of the channels as (1) Integrating the whole body; (2) Involved in the circulation of qi and blood; (3) Demonstrating the location of disorders; and (4) Transmitting the needle sensation. All of these functions, given a new understanding of qi, may all be ascribed to the fascia. Oschman, in Pischinger (2007), states that ‘acupuncture meridians are the main channels of the [connective tissue] matrix’ (p. xiii), and refers to acupuncture points as the ‘windows on the matrix system’ (p. xiv). The relationship of the points to fascial septa demonstrates fascinating interconnections to deeper anatomical structures as a function of their location (Langevin and Yandow, 2002). Birch and Felt (1999) remind us that the word normally translated as ‘point,’ really means ‘hole’ or ‘cave.’ It alludes to a chamber into something, consistent with the fascial relationships discussed by Langevin and Yandow (2002) and Stecco (2004), and Pischinger’s (2007) description of the Heine cylinder. Pirog (1996) states that the original functions of acupuncture points were based upon their anatomical location, rather than some innate quality of the point. Acupuncture points have been known to be anatomically present as loci that affect certain aspects of the body’s terrain (Pischinger, 2007). They are similar to trigger points in that they become ‘active’ in response to fascial deformations. Pirog (1996) states that when treating pain, acupuncture points must be located by palpating for tenderness or tissue change. Toyohari practitioners in Japan use the textbook location of points only as a starting point for feeling the currently live point, which is accomplished by palpation. The location of the point may change as the patient’s condition changes. This is verified by Pischinger (2007), who describes the palpable characteristics of an active point and notes that ‘.the non affected e inactive e point is not palpable, while the activated point e regulatorily changed e can be discerned by palpation.’ It is worth recognizing that classical acupuncture points were chosen for use by skilled palpation of the body. The method of proportional measurement for locating points, currently in use today, did not appear until the seventh century (Birch and Felt, 1999). This suggests that acupuncture was practiced for at least eight or nine centuries without

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Figure 2

Comparison of fascial plane (a) (based on Myers, 2001) and Bladder channel (b).

precise measurement for points. Points were considered to be ‘dynamic structures on the body.’ Acupuncturists chose points by how they felt, similar to Toyohari practitioners’ ‘currently live points,’ rather than by simple measurement or approximation (Birch and Felt, 1999). Rather than a static fixed entity, the point/channel system may well be viewed as a map of potential sites of fascial activity. It allows us to identify, through careful palpation of the natural topology of the body, areas of fascial/visceral dysfunction, and to treat locally and distally along the fascial plane. A unique aspect of acupuncture as a fascial therapy is the simultaneous use of multiple needles that provide continuous stimulation for a period of time. These patterns of stimulation produce a form of ‘microtrauma’ that prods the fascia to return to proper activity (Pischinger, 2007). Clinical experience has shown us that it is this unique, three-dimensional prodding of the fascia, coaxing movement through patterns of minor stimulation, that is central to effective treatment.

Deqi (the arrival of Qi) and needle stimulation It is a curiosity that those that believe qi to be an energy so subtle that it escapes detection by the most sensitive scientific instruments also find it capable of physically grabbing a steel acupuncture needle. Langevin et al. (2001) relates deqi to the wrapping of soft tissue around the needle as it is manipulated. While this may be the case

when using a particular needle technique, clinical experience has demonstrated other varied reactions to acupuncture needling. Deqi can be understood as the arrival of movement, the indication that the fascia has reacted to stimulation. Depending on how ‘active’ a particular acupuncture point may be, the deqi response may be powerful, where the patient experiences movement similar to myofascial release, spreading away from the location of the needle, usually along a fascial plane. Or it may be a more subtle response experienced by the practitioner who, through the feel of the needle, senses a subtle reaction of the fascia. It may barely occur at all if it is a point related to properly active fascia. These patterned, subtle microtraumas, gently inducing movement of the soft tissue, is unique to acupuncture. Pischinger (2007) states that needle puncture produces a reaction in the entire intercellular-extracellular matrix. The smallest injury produces the longest lasting effect, at least five days. Thus, microtrauma produced by the acupuncture needle apparently differs from other forms of mechanical stimulation in some way. The rapid release of myofascial trigger points through minimal stimulation of the fascia by an acupuncture needle demonstrates that the simple prodding of the fascia to react can produce a dramatic effect (Travell and Simons 1983). It is in this sense that acupuncture may differ from techniques that affect the fascia through deep tissue compression, stretching or vibration. Acupuncture needling is seeking a reaction from the fascia through a minor puncturing of the skin and prick of the fascia. It is an elegant method of

Parallels between acupuncture and fascia

Figure 3

175

Comparison of fascial plane (a) (based on Myers, 2001) and Lung channel (b).

fascial stimulation, systematically prodding the tissue to correct its deformations and return itself to balanced function.

Fascia based acupuncture The acupuncture that recognizes the fascia as its mechanism of its action and the basis of both diagnosis and treatment differs from some acupuncture styles in a few basic ways. Fascia acupuncture, first and foremost, relies on the direct experience of the body. This means that skillful, attentive palpation is essential for the practitioner in both treatment and evaluation. In addition to the palpation of channels (fascial planes) and active points, the practitioner palpates the body to assess skeletal structure, fascial deformations, myofascial constrictions and visceral restrictions. Point selection is connected to understanding anatomy, physiology, pathology, fascial planes, fascial sequences and biomechanics as well as basic organ/channel functions and relationships. As in every field, attentive clinical experience enriches and deepens the understanding. This approach to acupuncture bears great similarity to a number of acupuncture approaches that are not as pervasive as TCM, partially because they require skill sets not readily accessible in mass education settings. In short, it is an acupuncture of touch, of skillful palpation, guided by the maps created by both our current understanding of anatomy and centuries of clinical experience. Just as modern medicine has lost much of the heritage of touch due to technological, social and even legal influences, much of modern acupuncture has wandered from its roots as a palpation-based therapy. In this sense, fascia based acupuncture represents a return to its fundamental principles, one in which the terrain rather than the map takes precedence as the focus of treatment.

Future research Clinical acupuncture research would be better served by the use of palpation-based approaches as the independent variable, rather than standardized treatments from a formulary. Double-blind, controlled designs are a poor fit for the study of any procedural therapy, and are better suited to drug or herbal clinical trials. Multiple regression analysis, identifying significant aspects of treatment, where efficacy as well as effectiveness and individual therapist differences are evaluated, may be a more fruitful approach. The issues raised by the meta-analyses of clinical acupuncture studies have sparked reconsideration of the value of acupuncture research. An enlightened examination would include the current information available to us regarding this elegant organ, the fascia, and acupuncture’s effect on it as a system. Basing future studies on the fascia model represents a new and exciting direction for acupuncture research. In addition, a new avenue for anatomical study could be opened using acupuncture principles previously thought to exist only in metaphor.

References Birch, S., Felt, R., 1999. Understanding Acupuncture. Churchill Livingstone, London. Chen, C., Ingber, D., 2007. Tensegrity and mechanoregulation from skeleton to cytoskeleton. In: Findley, T., Schleip, R. (Eds.), Fascia Research. Elsevier, Munich, pp. 20e32. Cherkin, D., Sherman, K., Avins, A., Erro, J., Ichikawa, L., Barlow, W., Delaney, K., Hawkes, R., Hamilton, L., Pressman, A., Khalasa, P., Devo, R., 2009. A randomized trial comparing acupuncture, simulated acupuncture and usual care for chronic low back pain. Archives of Internal Medicine 169 (9), 858e866. De Morant, S.G., Grinnel, L., 1994. Chinese Acupuncture. Paradigm Publications, Brookline (trans).

176 Dworken, H., Biel, F., Machella, T., 1952. Subdiaphragmatic reference of pain from the colon. Gastroenterology 22, 222e228. Findley, T., Schleip, R., 2007. Introduction Fascia Research Conference. Elsevier, Munich. Gabbiani, G., 2003. The myofibroblast in wound healing and fibrocontractive diseases. Journal of Pathology 200, 500e503. Good, M., 1950. The role of skeletal muscles in the pathogenesis of diseases. Acta Medica Scandinavia 138, 285e292. Guimberteau J., 2003. Strolling under the skin. Video film DV/ADF Video Productions. Guimberteau, J., 2007. Human subcutaneous sliding system. The basic stone: the microvacuolar concept. Plea for a new perception of the human anatomy and of the living matter architecture. In: Findley, T., Schleip, R. (Eds.), Fascia Research. Elsevier, Munich, pp. 237e240. Gutstein, R., 1944. The role of abdominal fibrositis in functional indigestion. Mississippi Valley Medical Journal 66, 114e124. Haake, M., Muller, H., Schade-Brittinger, C., Basler, H., Schafer, H., Maier, C., Endres, H., Trampisch, H., Molsberger, A., 2007. German acupuncture trials for chronic low back pain. Archives of Internal Medicine 167 (17), 1892e1898. Hinz, B., 2006. Masters and servants of the force: the role of matrix adhesions in myofibroblast force perception and transmission. European Journal of Cell Biology 85, 175e181. Kaptchuk, T., 1983. The Web That as No Weaver. Congdon & Weed, New York. Langevin, H., 2006. Connective tissue: a body-wide signaling network? Medical Hypotheses 66 (6), 1074e1077. Langevin, H., Churchill, D., Cipolla, M., 2001. Mechanical signaling through connective tissue: a mechanism for the therapeutic effect of acupuncture. The FASEB Journal 15, 2275e2282. Langevin, H., Yandow, J., 2002. Relationship of acupuncture points and meridians to connective tissue planes. The Anatomical Record (New Anatomy) 269, 257e265. Lao, L., 2008. Current status of acupuncture clinical research e challenges and methodology. American Acupunturist Summer, 26e31. Lao, L., Zhang, G., Wong, R., 2003. The effect of electroacupuncture as an adjunct to cyclophosphamide-induced emesis in ferrets. Pharmacology Biochemistry and Behavior 74 (3), 691e699. Larson, D., 1990. The role of connective tissue as the physical medium for the conduction of healing energy in acupuncture and Rolfing. American Journal of Acupuncture 18 (3), 251e265. Linda, K., Allais, G., Brinkhaus, B., Manheimer, E., Vickers, A., White, A., 2009. Acupuncture for tension type headache. Cochrane Database for Systematic Reviews (Issue I). Liu, L. Guo, C., Jiao, X., 1995. Effect of acupuncture on immunologic function and histopathology of transplanted mammary cancer in mice. PubMed Abstract. Matsumoto, K., Birch, S., 1988. Hara Diagnosis: Reflection on the Sea. Paradigm Publications, Massachusetts. Melnick, J., 1957. Trigger areas and refractory pain in duodenal ulcer. NYS Journal of Medicine 57, 1073e1076.

S. Finando, D. Finando Mendeloff, A., Seligman, A., 1974. In: Weintraub, M., et al. (Eds.), Acute Appendicitis in Harrison’s Principals of Internal Medicine. McGraw Hill, New York, p. 1486. Moffet, H., 2009. Sham acupuncture may be as efficacious as true acupuncture: a systematic review of clinical trials. Journal of Alternative Comparative Medicine 15 (3), 213e216. Myers, T., 2001. Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists. Churchill Livingstone, London. Nagahama, Y., 1956. Western Studies of Acupuncture and Moxibustion. Sogen Sha, Osaka. Ni, Y., 1996. Navigating the Channels of Traditional Chinese Medicine. Oriental Medical Center, San Diego. O’Connor, J., Bensky, D., 1981. Acupuncture e A Comprehensive Text. Eastland Press, Seattle. Paoletti, S., 1998. (2006 English edition) The Fasciae: Dysfunction and Treatment. Eastland Press, Seattle. Pirog, J., 1996. Meridian Style Acupuncture. Pacific View Press, Berkeley. Pischinger, A., 2007. The Extracellular Matrix and Ground Regulation. North Atlantic Books, Berkeley. Scharf, H., et al., 2006. Acupuncture and knee osteoarthritis: a three-armed randomized trial. Annals of Internal Medicine 145, 12e20. Schleip, R., 2008. The nature of fascia e a review of recent scientific discoveries. DVD. Stecco, L., 2004. Fascial Manipulation. Piccin Nuova Libraria, Padova. Stener-Victorin, E., Lundeberg, T., Waldenstrom, U., 2000. Effects of electro-acupuncture on nerve growth factor and ovarian morphology in rats with experimentally induced polycystic ovaries. Biology of Reproduction 63 (5), 1497e1503. Tatewaki, M., Harris, M., Uemura, K., Ueno, T., Hoshino, F., Shiotani, A., Pappas, T., Takahashi, T., 2003. Dual effects of acupuncture on gastric motility in conscious rats. American Journal of Physiology Regulatory Integrative Comparative Physiology 285 (4), R862e872. Tomasek, J., Gabbiani, G., Hinz, B., Chaponnier, C., Brown, R., 2002. Myofibroblasts and mechano-regulation of connective tissue remodeling. Nature Reviews Molecular Cell Biology 3, 349e363. Travell, J., Simons, D., 1983. Myofascial Pain and Dysfunction: The Trigger Point Manual. Williams and Wilkins, Baltimore. Unschuld, P., 1983. Medicine in China. University of California Press, Berkeley. Unschuld, P., 1986. (trans) Nan-Ching. University of California Press, Berkeley. White, P., Lewith, G., Prescott, P., Conway, J., 2004. Acupuncture versus placebo for the treatment of chronic mechanical neck pain. A randomized controlled trial. Annals of Internal Medicine 141, 911e919. Wu, P., Cao, Y., Wu, J., 2001. Effects of moxa-cone moxibustion at guanyuan on erythrocytic immunity and its regulative function in tumor bearing mice. Journal of Traditional Chinese Medicine 21 (1), 68e71.

Journal of Bodywork & Movement Therapies (2011) 15, 177e185

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MASSAGE THERAPY

Relationship between massage therapy usage and health outcomes in older adults Niki Munk*, Faika Zanjani 1 Gerontology Department, University of Kentucky, 900 S Limestone, 306 Wethington Health Sciences Bldg, Lexington, Kentucky 40536, United States Received 8 July 2009; received in revised form 17 November 2009; accepted 18 January 2010

KEYWORDS Elderly; Elders; Emotional health; Well-being; Depression

Summary Physical and emotional decline in older adults is a serious issue affecting not only quality of life but also susceptibility to injury. Non-pharmacological interventions addressing the needs of older adults are important for reducing medication burden and possible drug interactions. This study (N Z 144) examines the potential of massage therapy as such an intervention for older adults by comparing self-reported health outcome scores among adults 60 and older who have and have not utilized massage therapy in the past year. When controlling for age and cumulative morbidities, older adults who reported massage therapy usage in the past year had significantly better health outcome scores in the following domains: 1) emotional well-being, 2) limitations due to physical issues, and 3) limitations due to emotional issues. Because previous massage therapy research has not included or focused on older adults, studies examining massage therapy and emotional health, specifically among this population, are warranted. ª 2010 Elsevier Ltd. All rights reserved.

Introduction The use of complementary and alternative medicine (CAM) in older adults has risen over the past several years with further increases expected in the future (Barnes et al., 2004; AARP, 2007). This increase is due to the fact that

* Corresponding author. Tel.: þ1 859 257 1450x80148. E-mail address: [email protected] (N. Munk). 1 BIRCWH Scholar (Building Interdisciplinary Research Careers in Women’s Health).

usage is high in the Baby Boomer generation (Kessler et al., 2001), and this population is beginning to age into older adulthood (Wellman et al., 2001). CAM is defined as ‘a group of diverse medical and health care systems, practices, and products that are not generally considered to be part of conventional medicine’ (NIH et al., 2007). Among the Baby Boomer and current geriatric population, massage therapy is one of the most frequently utilized CAM modalities (AARP, 2007; Andrews, 2002; Astin et al., 2000; Williamson et al., 2003). While massage therapy investigations have shown benefits in many physical outcomes including back pain (Furlan et al., 2008), carpal tunnel

1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.01.007

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syndrome (Moraska et al., 2008), and fatigue (Brooks et al., 2005), few, if any, older adults are included in massage intervention studies. Due to physical changes that accompany aging (e.g., decreases in metabolism, muscle mass, resistance, and resilience [Carmeli et al., 2002; Hayflick, 1994]), it is impossible to generalize results from massage therapy studies to the older adult population. Massage effects and considerations for older adults is the focus of many books discussing massage therapy (Miesler, 1990; Nelson, 2004, 2006; Rose, 2010), establishing a base of clinical knowledge upon which scientific evidence has begun to build. While older adult specific studies exist in the massage therapy research literature (Fraser and Ross Kerr, 1993; Field et al., 1998; Mok and Woo, 2004; Sharpe et al., 2007), their numbers are few in comparison to other subsets of the population and are often limited by small sample sizes. Because of this relatively smaller evidence-based body of understanding, the benefits of massage therapy, specifically for older adults, are less understood. Considering the link between increased susceptibility to decline (physical, emotional, and cognitive) and advancing age, in addition to age-specific considerations such as multiple morbidities, frailty, and mobility restrictions; studies examining the benefits of massage therapy in older adults are necessary to determine the extent to which massage could serve as an effective, non-pharmaceutical approach to addressing gerontological health concerns. Descriptions of who uses CAM and why, is rich in older adult specific studies (AARP, 2007; Astin et al., 2000; Bell et al., 2006; Cherniack et al., 2001; Cheung et al., 2007; Grzywacz et al., 2006), but none examine health outcomes in relation to a specific therapeutic modality such as massage. Thus, whether massage is utilized, especially in older adult populations in regard to health outcomes are difficult to ascertain. The purpose of the current study is to examine the relationship between massage usage and self-reported health in adults 60 years old and older. Specifically, this study seeks to determine the extent to which self-reported health differences exist between older

Figure 1

adults who have and have not utilized massage therapy over the past year (massage therapy usage status; MTUS). In order to determine these outcomes, the current study: 1) compares the demographic characteristics of older adults across MTUS, 2) compares self-report health outcomes across MTUS, and 3) discusses the possibility that it is massage therapy that lead to the significant differences in health domain outcomes across MTUS within this study. The last aim seeks to introduce a translational perspective by linking study findings to quality of life issues for older adults. It is hypothesized that 1) older adults who received massage therapy in the past year will have higher incomes than those who did not, 2) differences in self-reported health will be found in older adults across MTUS, and 3) differences in self-reported health across MTUS will not be affected by potentially confounding factors such as age, income, and health.

Methods Design and sample Two populations were targeted for study recruitment: registered voters and known massage therapy patrons. Fig. 1 is a flow chart representing recruitment from the two populations. Data for this study were collected as part of a one-time, self-report, mail survey. No identifying information was collected, and University of Kentucky IRB approval was obtained. Registered voters Five hundred (500) adults, sixty years and older were selected via random number generator for recruitment from the voter registration list of Lexington, Kentucky. To avoid attempting to recruit deceased individuals, mortality status was determined by the Social Security Death Index. To improve response rates, a notification postcard was mailed 10 days prior to the mailing of surveys. Three weeks after surveys were mailed, reminder postcards were sent to

Recruiting Flow Chart. )The survey had a 24% response rate.

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those who had not returned their packets or their requests for non-participation. Known massage therapy patrons To ensure statistically adequate responses from older adults who received massage therapy in the past year, 100 additional survey packets were distributed to various massage therapy clinics in the Lexington, Kentucky area. Eight clinics participated in the study, including a massage school, several multi-therapist private practice clinics, and a clinic within a chiropractic office.

Measures The survey used in the current study was developed and piloted specifically for the purposes of preliminary data collection and is outlined in Table 1. Responses to the RAND 36-Item Health Survey 1.0 (RAND-36) were used as outcomes variables for this study. The RAND-36 is a wellvalidated health-related quality of life measure (Hays et al., 1993; Hays and Morales, 2001) that produces outcome scores for the following domains: physical functioning, bodily pain, role limitations due to physical issues, emotional well-being, role limitations due to emotional/ personal problems, social functioning, energy/fatigue, general health, and change in health. Higher scores indicate better health. Variables and coding MTUS was categorized as a dichotomous variable based on participant response to a question inquiring about massage usage. If the participant indicated they received massage therapy in the past year, they were coded ‘yes’ for MTUS. All other responses to this question (i.e., ever and no) were coded ‘no’ for MTUS. A cumulative morbidity variable was created and coded as continuous. Respondents were asked to indicate diagnoses they had received from a physician from the

Table 1

following list: arthritis, fibromyalgia, hypertension, depression, heart disease or stroke, diabetes, respiratory disorder, thyroid disorder, renal disease, Parkinson’s, Alzheimer’s, or gastrointestinal disorders. Cumulative morbidity was the sum of the self-reported diagnosed health conditions.

Analysis All analyses were completed using SAS 9.1 and were conducted in four steps. First, in order to combine responses for massage users from the two samples (voter registration and known massage patrons) and form the ‘yes’ group for MTUS, homogeneity had to be determined. In other words, the combination would be appropriate only if no significant differences existed between voter registration massage users and known massage patrons regarding the study’s dependent variables (domain scores) or confounding variables. Thus, odds ratios from single variable logistic regressions were examined for Rand-36 domain scores in addition to income, education, cumulative morbidity, and age between those who received massage therapy in the past year from the two recruited samples. Second, chi-square and ANOVA analyses were used to determine descriptive statistics for the sample overall and based on MTUS. Next, single variable linear regression was used to determine between-group differences in RAND-36 domain scores (dependent variables) based on MTUS (independent variable). Finally, multiple linear regression (MLR) was used to examine the relationship between MTUS and domains significant or approaching significance (p < 0.1) in the previous step when controlling for potentially confounding variables. MLR portrays the linear relationship of a particular outcome with a ‘‘package’’ of independent variables while assessing the strength and probability of influence for each independent variable with consideration for all the

Study survey breakdown.

Part One: demographics

Part Two: general health

Part Three: health behaviors

Age Gender Race Marital Status Living Situation & Environment Education Employment Status Income

Height Weight Current Conditions Diagnoses RAND 36-Item Health Survey Physical functioning Limitations due to physical issues Emotional well-being Limitations due to emotional issues Bodily pain Energy/fatigue Social functioning General health perception Perceived change in health

Medication Usage Alcohol Consumption Smoking Status CAM usage Massage Therapy (MT) Specific Reasons for MT usage Barriers to MT usage Frequency of MT visits Duration of MT sessions Length of MT utilization

Part Four: qualitative portion (four questions) 1) What do you feel contributes to a good massage treatment? 2) What do you feel contributes to a bad massage treatment? 3) What outcomes (positive/negative) have you experienced with massage treatments? 4) Do you feel massage can positively contribute to public health? Why or why not?

180 others included in the model. In other words, by including other independent variables that have influence on domain scores in a MLR model, it lessens the chance that differences found in these scores are due to some factor other than MTUS. These potential confounds were determined by Pearson Correlation coefficients, which measure the strength of linear relationship between two variables. Variables found to have significant correlation with domain scores were included in the MLR models in addition to MTUS.

Results One-hundred six (106) of the 108 packets returned from the voter registration mailing and all 38 survey packets returned from massage patrons (those distributed through massage therapy clinics) were used in analysis. Twenty five (25) participants from the voter registration mailing and all massage patron (38) participants were coded ‘yes’ for MTUS, for a total of 63 out of 144 participants who had received massage in the past year.

Step 1: Logistic regression to determine homogeneity of those who utilized massage therapy in the past year Analysis indicated (data not shown) that no significant differences existed between those who received massage in the past year based on recruitment sample for RAND-36 domain scores, income, education, age, or cumulative morbidity. Therefore, respondents from the voter registration mailing who reported ‘yes’ to massage therapy in the past year were combined with those responses returned from clients of local massage therapy clinics.

Step 2: Sample characteristics (Table 2) All participants were community-dwelling with over 95% owning their residence. A majority was retired and over 36% reported working full- or part-time. Mean annual income and years of education were significantly higher (p Z 0.02

N. Munk, F. Zanjani and p Z 0.002, respectively) for those who utilized massage therapy in the past year compared to those who did not indicate massage usage in the past year. Frequency of self-reported diagnoses did not differ across MTUS. Almost twenty percent of the total sample (19.44%) was free from diagnosed conditions. However, 57% reported having received more than one diagnosis, indicating that more than half of the sample was living with multiple morbidities at the time of the survey.

Step 3: Differences in self-reported health across MTUS (Fig. 2) Those who received massage therapy in the past year had higher average scores in all Rand-36 health domains (indicating better health) compared to those who did not utilize massage in the past year (Fig. 2). However, only selfreported limits due to emotional issues differed significantly across MTUS (p Z 0.02), as revealed by single variable linear regression. Specifically, the mean score for the limitations due to emotional health domain of participants who did not receive massage in the past year were significantly lower (82.29) than those who had received massage therapy in the past year (94.09). While not significant at the 0.05 level, differences between scores in the limitations due to physical issues and emotional well-being domains across MTUS showed a notable trend. Specifically, non-massage users reported a mean score of 64.2 for limitations due to physical issues while those who received massage therapy in the past year had a reported mean score of 75.4 (p Z 0.08). Furthermore, those who received massage therapy in the past year reported a mean score of 84.3 for emotional well-being compared to 80.1 for non-users (p Z 0.09).

Step 4 e Differences in self-reported health across MTUS when controlling for confounding variables (Table 3) The following were considered in addition to MTUS for the MLR model: age, gender, income, years of education, and

Figure 2 Graphic representation of RAND-36 scores for users and non-users of massage therapy. Note: x Higher scores signify better health; ) indicates p < 0.05 between-group difference; y indicates p < 0.1.

Massage therapy usage and health outcomes cumulative morbidity. Pearson Correlation coefficients (data not shown) revealed significant linear relationships between a) increased age and lower outcome scores for the domains of limitations due to emotional (p Z 0.03) and physical issues (p < 0.0001) and b) increases in cumulative morbidities and lower outcome scores for the domains of limitations due to emotional (p Z 0.0001) and physical (p < 0.0001) issues and emotional well-being (p Z 0.0027). Therefore, age and cumulative morbidity were included in the MLR models to control for their effect on the relationship between MTUS and health domain scores. When age and cumulative morbidity were added to the regression model, significant differences between mean outcome scores for those who did and did not receive massage therapy were observed for the three selected domains investigated (Table 3). Specifically, when controlling for increased age and cumulative morbidity, participants who received massage therapy in the past year reported fewer limitations due to emotional (p Z 0.006) or physical issues (p Z 0.04) and better emotional well-being (p Z 0.05) than those who did not receive massage therapy in the past year.

Discussion It was hypothesized that some demographic differences would be found for participants in this study based on

Table 2

181 MTUS. Unsurprisingly, participants who utilized massage therapy in the past year had significantly higher incomes and more years of education (which has a strong positive correlation with income) than those who did not report massage usage. It is logical that people with higher incomes are more apt to receive massage therapy because payment burden for treatments is primarily out-of-pocket and due to the continued notion (especially in the older adult community) that massage is a luxury. With the positive health outcomes associated with massage, as delineated by the current study, it is unfortunate that many older adults are unable or unwilling to invest in the ‘‘luxury’’ of massage therapy. Findings from this study begin an evidence-based discussion on the potential for massage therapy to improve health outcomes in the older adult population. It was hypothesized that differences in self-reported health would exist between those who did and did not receive massage therapy in the past year. All RAND-36 domain scores were higher for older adults who received massage therapy in the past year. Furthermore, massage therapy was significantly associated with fewer limitations due to emotional issues while improvements in emotional wellbeing and limitations due to physical issues approached significance. This implies that massage may improve overall health, particularly in relation to the perception of being limited by either emotional or physical health.

Participant demographics.

Variable

All N Z 144

Massage in Past Year, n Z 63 (43.75%)

No Massage Past Year, n Z 81 (56.25%)

Age Range Mean (SD)

60e92 68.67 (7.14)

60e92 68.51 (7.56)

60e84 68.79 (6.84)

Age group 60e64 years 65e74 years 75 years and over

56 (38.89%) 56 (38.89%) 32 (22.22%)

27 (42.86%) 22 (34.92%) 14 (22.22%)

29 (35.80%) 34 (41.98%) 18 (22.22%)

Gender Female

80 (55.56%)

39 (61.90%)

41 (50.62%)

Race White

134 (93.06%)

62 (98.41%)

72 (88.89%)

Married Yes

100 (69.44%)

48 (76.19%)

52 (64.20%)

Live alone Yes

39 (27.08%)

12 (19.05%)

27 (33.33%)

Mean annual income* Mean (SD) Missing

70,947 (49,121) 25

82,736 (50,111) 10

61,480 (46,552) 15

Years of education* Mean (SD)

15.40 (3.32)

16.35 (3.22)

14.65 (3.23)

Cumulative morbidities Mean (SD)

2.01 (1.75)

2.12 (1.83)

1.93 (1.70)

Note: *indicates significant between-group differences of p  0.05.

182 Table 3 scores.

N. Munk, F. Zanjani Multiple linear regression e the significance of MTUS when controlling for age and cumulative morbidity on domain

Domain (DR2)

Parameter estimate

95% Confidence interval

P value

Physical limitations (.2178) Intercept Age Cumulative morbidity Massage status

116.31 1.28 7.27 11.97

110.520, 222.108 2.108, 0.454 10.652, 3.898 0.604, 23.343

<0.0001 <0.0001 0.0026 <0.0001 0.0392

Emotional limitations (.1363) Intercept Age Cumulative morbidity Massage status

116.55 0.36 4.99 12.73

72.437, 160.661 1.015, 0.292 7.683, 2.298 3.719, 21.746

<0.0001 <0.0001 0.2761 0.0004 0.0060

Emotional health (.0697) Intercept Age Cumulative morbidity Massage status

76.73 0.11 2.31 4.75

53.389, 100.074 0.233, 0.460 3.717, 0.896 0.004, 9.489

0.0044 < 0.0001 0.5177 0.0015 0.0498

It was further hypothesized that differences in selfreported health across MTUS would not be affected by confounding factors. Although analysis revealed that increased age and more diagnosed morbidities were associated with decreased domain scores and therefore included in the MLR to control for these variables, significant relationships still existed between MTUS and domain scores. Older adults who reported receiving massage in the past year had significantly better reported health in regards to limitations due to emotional or physical issues and emotional well-being when accounting for age and cumulative morbidity compared to older adults who did not receive massage in the past year. The take-home point from these results is that regardless of increased age and cumulative morbidities, older adults in this study who received massage therapy in the past year had significantly better emotional health than did those older adults who did not receive massage. Of the eight domains in the RAND-36, only two are exclusive to emotional health, while the other six relate either to physical/general health or social function. While not to diminish the significance or importance of other health domains in the lives of older adults, the fact that significant differences in both domain scores pertaining to emotional health were found between those who did and did not receive massage therapy in the past year highlights this area as one for further study. The verbiage used in the RAND-36 gives ‘feeling depressed or anxious’ as examples of emotional problems for the questions pertaining to the limitations due to emotional issues domain, while using words and phrases such as ‘blue’, ‘down in the dumps’, ‘downhearted’, ‘cheer’ and ‘happy’ in questions pertaining to the emotional well-being domain. Sadness and depression are key components of emotional health, with anxiety, self-esteem, mood, and outlook also contributing to the construct. Although causation cannot be established from a cross-sectional study, these results encourage future investigation of massage therapy as an intervention to promote the emotional health of older adults.

Depression is an aspect of emotional health that receives ample attention in research. Clinically significant depressive symptomatology has a high prevalence in the older adult population and contributes to illness burden, decreased quality of life, increased risk for mortality, and increased use of hospital/outpatient medical services (Blazer, 2003; Crystal et al., 2003). Depression in this population can stem from loss, decline in physical and/or cognitive function, illness, and other negative life experiences (Hybels and Blazer, 2003). Current treatment options for depression in late life include antidepressant medications (mainly selective serotonin-reuptake inhibitors [SSRIs]), psychotherapy, or a combination of the two (Crystal et al., 2003; NIMH, 2009). As the name implies, SSRIs inhibit serotonin reuptake near postsynaptic terminals, thus resulting in increases in serotonin levels. Serotonin is a neurotransmitter that stimulates neurological pathways involved in muscle control and inhibits neurological pathways that mediate sensation (Widmaier et al., 2006). In addition, serotonergic pathways contribute to the regulation of emotional states (e.g., mood and depression), reproductive behavior, and appetite (Widmaier et al., 2006). Several studies have found that massage therapy treatments increase serotonin levels (Field et al., 1996, 2004; Hernandez-Reif et al., 1998, 2001, 2004) and thus may be a mechanistic pathway through which massage therapy effects depressed individuals. Field et al. (1996) found significant increases in urine serotonin levels for infants receiving twice weekly, 15-min massage sessions for sixweeks, compared to a control group. In two separate studies, Hernandez-Reif and colleagues found that serotonin levels significantly increased in migraine headache sufferers who received five weeks of twice weekly, 30-min massage sessions (1998) and in breast cancer patients who received three, 30-min massage sessions per week for five weeks (2004). No significant serotonin increases occurred in these studies’ control groups. Most massage studies using measures of depression as primary outcomes investigate depression in relation to

Massage therapy usage and health outcomes pregnancy. Several other massage studies investigating various populations include measures of depression but usually as a secondary or additional outcome measure rather than being the primary focus of the study. These studies have generally reported positive results in regards to the efficacy of massage for addressing depression. For example, Diego et al. (2002) found that patients with spinal cord injuries who received two, 40-min massage sessions per week for five weeks reported significantly lower anxiety and depression scores after the first and last treatments compared to participants in an exercise control group. A study by Field et al. (2007) investigating arthritis pain also found significant decreases in depression and anxiety for those who received massage therapy. A recent publication found significant decreases in depression and anxiety scores for mothers caring for seriously ill children after receiving a 20 min palm and shoulder massage (Iwasaki, 2005). Of the limited number of massage studies involving only older adults, a few include measures of depression and/or anxiety. Fraser and Ross Kerr (1993) found that older adults in an extended care facility receiving five-minute back rubs before bed for four consecutive nights had significant declines in mean anxiety scores compared to a no treatment control group. In older adults who received three weeks of 30-min massage three times per week and then gave massage therapy to infants for three weeks, depression and anxiety scores significantly decreased (Field et al., 1998). More recently, Sharpe et al. (2007) found twice weekly, 50-min massage for four weeks significantly lowered depression and anxiety scores in community-dwelling adults 60 and older compared to those in a guided relaxation control group. The brief review above supports the notion that few studies examining massage therapy effects isolate depressed populations. The one depressed population that has enjoyed several massage therapy studies is pregnant/ post-partum women (Coelho et al., 2006). While studies report positive results for multiple sessions of massage on depression measures among pregnant and post-partum women (Field et al., 1996, 2004), closer inspection of the analyses and data provided reveal that results are unclear or lacking in appropriate post hoc analysis (Coelho et al., 2006). In addition, while some pregnant and post-partum women are a legitimately depressed population, findings from this population cannot, and should not, be generalized to other depressed populations such as those with bipolar disorder, post-traumatic stress disorder, clinical depression, or those experiencing grief. However, future investigations are warranted in these mental health populations, especially those examining massage therapy effects on depressed older adults. It is important to point out that several of the above studies investigate multiple massage treatments on the studied outcomes. This is an improvement over studies investigating massage effects that provide only one, often short, massage treatment expecting to detect significant and measurable change. While research has yet to suggest the most effective dosage and technique guidelines for massage application in regards to specific conditions, research is moving in a direction to reflect reasonable, real life treatment scenarios. This being said, it is difficult to ignore the fact that several of the reviewed studies do not

183 reflect such real life treatment scenarios and provide the massage intervention multiple times per week for several weeks. This application strategy of exaggerating normal treatment frequency may be an effective approach for desired outcomes, as stronger study results are achieved faster by this method; however, it is not likely that individuals will be able to replicate these treatment schedules in a non-experimental setting. Because massage therapy is rarely included in insurance coverage plans, most people receiving massage pay for it out of their own pocket. In light of massage treatment costs, which average approximately $63 per hour (AMTA, 2009), few people, especially older adults who have less average income that younger adults, would be able to cope with the costs associated with receiving multiple and/or frequent treatments. Additionally, when considering older adults, access to treatment application sites and transportation must be factored into the design of realistic treatment scheduling. While it is likely that evidence-based studies will incorporate more realistic treatment schedules as data from real situations and clients emerge, future studies would also benefit from designs that incorporate either solutions to massage treatment barriers (e.g. accessibility and transportation) or examine less frequent treatment schedules or lower number of required treatments.

Suggested future studies Massage therapy is a rich minefield of research potential and possibility with intervention studies a clear need. Based on this study, further investigation into the efficacy of massage to promote the emotional health of older adults is warranted. One possible topic for future massage research is investigation of massage as a treatment therapy for depression through increased body image esteem, pain management, or as a means of providing touch to older adults. Additionally, trial designs would benefit greatly from consideration of strategic intervention points (i.e., when to implement the intervention) for massage application in regards to the emotional health of older adults. For example, bereavement is a common trigger, or antagonist, for depression in older adults (Hybels and Blazer, 2003). An intervention study using subjective measures of depression, such as the Geriatric Depression Scale or aspects of the RAND-36, in addition to objective measures associated with depression, such as serotonin levels, on recent older adult widows or widowers could help determine the extent to which massage therapy might influence the emotional health of older adults coping with the loss of a spouse. Other strategic intervention points for research in this area include: assessing the impact of massage therapy just prior to or after relocation (e.g., from independent living to an assisted living facility), during rehabilitation post-surgery or after a fall, after condition diagnosis (e.g., presbycusis, cognitive impairment), or the loss of driving privileges. Finally, future studies would benefit from the discussion of strategies to increase accessibility to massage for older adults by way of insurance/Medicare coverage inclusion, decreased cost of treatments, and/or on-site therapists in older adult community living environments.

184

Limitations Due to the cross-sectional design of the current study, causation regarding massage therapy usage and health outcomes can only be asserted, but not confirmed. Furthermore, non-White individuals were underrepresented in this study and future studies would benefit from increased participation from a variety of races, as it is likely that non-Whites could experience emotional health benefit from receiving massage therapy.

Conclusion It is commonly believed and asserted by practitioners and advocates of massage therapy that such therapy improves health outcomes in most, if not all, populations. However, few massage research studies specifically examine older adults as a study population. The current study is a first step in identifying health outcomes for older adults that may be associated with massage therapy treatments by comparing those who did and did not receive massage therapy in the past year. As a population at higher risk for decline compared to younger people, older adults stand to benefit from identifying health domains that may be affected by massage. Future intervention studies should investigate the protective effects of massage therapy on decline and quality of life in this population.

Acknowledgements Special thanks are extended to Tina Kruger for review and editorial contributions, the individuals who participated in this study, and the massage clinics that made surveys available to their clients; Lexington Healing Arts Academy, In Touch, Inc., Inner Dimensions, Body Systems Therapeutic Massage, and Stewart Massage Therapy. This study was generously supported by start-up funds awarded by the University of Kentucky to Faika Zanjani, PhD.

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185 http://nccam.nih.gov/health/whatiscam/D347.pdf (accessed 05.06.09). National Institute of Mental Health (NIMH), 2009. Older Adults: Depression and Suicide Facts (Fact Sheet) Available at: http://www.nimh.nih.gov/health/publications/older-adultsdepression-and-suicide-facts-fact-sheet/index.shtml (accessed 13.04.09). Nelson, D., 2004. Therapeutic Massage in Facility Care: Benefits, Effects and Implementation. Massage Review Publications, Inc, Sunrise, FL. Nelson, D., 2006. From the Heart Through the Hands: The Power of Touch in Caregiving. Findhorn Press, Scotland. Rose, M.K., 2010. Comfort Touch: Massage for the Elderly and the Ill. Lippincott Williams & Wilkins, Philadelphia, PA. Sharpe, P.A., Williams, H.G., Granner, M.L., Hussey, J.R., 2007. A randomized study of the effects of massage therapy compared to guided relaxation on well-being and stress perception among older adults. Complementary Therapies in Medicine 15, 157e163. Wellman, B., Kelner, M., Wigdor, B.T., 2001. Older adults’ use of medical and alternative care. Journal of Applied Gerontology 20, 3e23. Widmaier, E.P., Raff, H., Strang, K.T., 2006. Vander’s Human Physiology: The Mechanisms of Body Function, tenth ed. McGraw Hill, New York. Williamson, A.T., Fletcher, P.C., Dawson, K.A., 2003. Complementary and alternative medicine: use in an older population. Journal of Gerontological Nursing 29, 20e28.

Journal of Bodywork & Movement Therapies (2011) 15, 186e191

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

SPORTS PHYSIOLOGY

Does saddle height affect patellofemoral and tibiofemoral forces during bicycling for rehabilitation? Aline Cavalheiro Tamborindeguy, BPhyEd, BPhTher, MHSci a, Rodrigo Rico Bini, BPhyEd, MHSci a,b,* a

Laborato´rio de Pesquisa do Exercı´cio, Escola de Educac¸a˜o Fı´sica, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil b Institute of Sport and Recreation Research, Auckland University of Technology, 90 Akoranga Drive, Northcote, North Shore City, Auckland 0637, New Zealand Received 10 June 2009; received in revised form 27 July 2009; accepted 31 July 2009

KEYWORDS Knee; Inverse dynamics; Kinematics

Summary The aim of the present study was to measure saddle height effects on knee joint load. Nine uninjured non-cyclists were evaluated in three saddle heights: 100% of trochanteric height-REF; 103% of REF-HIGH; and 97% of REF-LOW. Two-dimensional sagittal plane force applied on the pedal and kinematics were recorded. After inverse dynamics of the lower limb, knee resultant force was computed as tibiofemoral normal and shear components and compressive patellofemoral force. Peak patellofemoral compressive force and peak compressive and shear tibiofemoral forces did not differ when saddle height was changed. Knee angle at the lower crank position increased at LOW compared to REF and HIGH saddle height (p < 0.02). Small saddle height changes (3%) did not affect knee joint load, at low workloads on uninjured subjects, while changes in knee angle did not relate to effects on joint forces. These findings suggest that setting saddle height by knee angle secures the maintenance of joint load at low workloads on uninjured subjects. ª 2009 Elsevier Ltd. All rights reserved.

Introduction

* Corresponding author. Institute of Sport and Recreation Research, Auckland University of Technology, 90 Akoranga Drive, Northcote, North Shore City, Auckland 0637, New Zealand. Tel.: þ64 09 921 9999x7295.

Bicycle ergometers have been employed for conditioning and rehabilitation based on the possibility to perform aerobic exercise under a controlled condition of workload and pedaling frequency (Gregor, 2000; McLeod and Blackburn, 1980). Few studies have focused on

1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.07.009

Saddle height affect patellofemoral and tibiofemoral forces during bicycling for rehabilitation employing bicycles as a rehabilitation strategy (McLeod and Blackburn, 1980; Mimmi et al., 2004; Sanner and O’Halloran, 2000). Johnston (2007) reviewed the main studies on bicycle biomechanics for rehabilitation and outlined that bicycle components set up affects joint kinematics, resultant moments and muscle activity. Fleming et al. (1998) reported evidence that bicycles can be safely used for injured subjects since it produces lower peak strain on the ACL compared to usual rehabilitation activities. Johnston (2007) also indicated that one of the aspects that must be considered for the set up of bicycle components is the body position. Saddle height has been described as one of the most important components on the bicycle set up that affects joint kinetics and kinematics (Burke and Pruitt, 2003; De Vey Mestdagh, 1998; Mellion, 1991; Wanich et al., 2007). Unfortunately, different methods have been employed for the set up of saddle height (Burke and Pruitt, 2003) with different results for ‘‘optimal’’ position (Peveler et al., 2005). In this regard, Peveler (2008) compared saddle height set up by two knee flexion angle joint references (25 and 35 when the pedal is at the bottom dead centre) and by 109% of the inseam leg length. His results indicated that cycling economy is optimized when saddle height is set by 25 of the knee flexion angle. Nevertheless, the effects of saddle position on knee joint loads still remain unclear in the literature. Ericson and Nisell (1987) were the only to report evidences supporting an inverse relationship between saddle height and patellofemoral compressive force. Two studies addressed the influence of saddle height management on tibiofemoral force components (Ericson and Nisell, 1986; McCoy and Gregor, 1989). Ericson and Nisell (1986) observed an inverse relationship between saddle height and compressive tibiofemoral force with no significant effects for the tibiofemoral shear component. Moreover, McCoy and Gregor (1989) reported that when the saddle height is set at 100% of trochanteric to floor length, there is a minimum shear component on the tibiofemoral joint, with no effects for the compressive forces on this joint. Controversial results of tibiofemoral components (shear and compressive) and the lack of evidences about patellofemoral must be addressed. It is also important to pay attention to the different methods employed for setting the saddle height and the range of changes performed in these studies. The range of saddle heights described as optimal in research studies (about 5e6% of trochanteric length) (Ericson and Nisell, 1986, 1987; McCoy and Gregor, 1989; Nordeen Snyder, 1977; Sanderson and Amoroso, in press), is increased from what is usually employed for performance optimization of trained cyclists or during rehabilitation procedures. The aim of the present study was to compare the effects of saddle height management on the knee joint load of uninjured non-cyclists riding with low workload. The main hypothesis of the present study was that small changes in saddle height compared with that reported in the literature would affect knee joint loads. Also an inverse relationship between saddle height and patellofemoral and shear tibiofemoral forces was expected. No effects of saddle height were expected on the tibiofemoral compressive component.

187

Methods Participants Nine uninjured male non-cyclists age between 22 and 36 years, 1.7 (5.7) m height, 76.7 (13) kg weight, right leg dominant, without competitive experience and no history of knee joint injuries, volunteered for the study. They were all physical education students who maintained physical activity for health without competitive training in any sport. The participants were verbally invited to the University campus. After agreement to participate in the study, they signed an Informed Consent Term in agreement with the Committee of Ethics in Research with Humans of the University in accordance with the Declaration of Helsinki.

Protocol Body weight and height, and trochanteric height to the floor were measured at the beginning of the evaluation session. For the trochanteric height, the distance from the right side greater trochanter to the floor was measured with the participants barefoot (Nordeen Snyder, 1977) with an average of 0.89 (0.04) m. A Monark stationary bicycle ergometer (GIH e Stockholm, MONARK, Sweden), with weight brakes and crank length of 0.17 m was employed for cycling exercise at the following set-ups: (1) 100% of trochanteric height-REF, (2) 103% of trochanteric height-HIGH and (3) 97% of trochanteric height-LOW. Previous to data collection session, the participants were submitted to 5 min of warm up on the bicycle ergometer in the REF saddle height, with 70 rpm of pedaling cadence and weight brake selected on the ergometer (zero load). For the three saddle heights, pedaling cadence and workload were set at 70 rpm and 70 W, respectively, for 1 min of cycling. As the study proposed to measure the effects of saddle height on knee joint loads with focus on rehabilitation, a lower workload was selected compared to previous studies (Ericson and Nisell, 1986, 1987; McCoy and Gregor, 1989; Nordeen Snyder, 1977; Sanderson and Amoroso, in press). For changes in saddle height, the subjects were requested to stand up from the saddle and to place their weight on the handlebars and on both pedals. The changes in saddle height were achieved within 30 s following random selected order.

Data collection Normal and tangential components of force applied on the pedal were recorded from an instrumented two-dimensional right clipless pedal which was designed for force measurement based on Look Delta road pedals and cleats with fixed float (Candotti et al., 2007). For both pedals, the ball of the feet was placed over the pedal spindle. Force signals were amplified (with gain  1000), and recorded by WINDAQ acquisition system (Dataq Instruments, Akron, OH, USA) at sample rate of 540 Hz per channel. This data was digitized with resolution of 16-bits by an analogical to digital converter (DI720, Dataq Instruments, USA) during the last 30 s of each trial.

188

A.C. Tamborindeguy, R. Rico Bini

Sagittal kinematic variables were acquired from the right limb of cyclists by a single video camera (Peak HSC180, Peak Motus e Peak Performance Technologies, Englewood, USA), positioned perpendicular to the movement plane, in a standardized manner, and distanced 3.5 m from the subject. The images were acquired at 180 Hz of sample rate. Landmarks were attached over the most prominent anatomical references on the right lower limb of the participants’ great trochanter, lateral femoral condyle, lateral malleolus, and pedal spindle, anterior and posterior pedal stick and at the crank spindle (Bini et al., in press). Kinematic data were acquired for ten complete crank cycles during pedal force acquisition. Pedal forces and kinematics were simultaneously recorded and triggered for off-line synchronization.

Data analysis Pedal forces and kinematic data were smoothed by a Butterworth low-pass digital filter with a cutoff frequency of 10 Hz and 4 Hz, respectively (Bini et al., in press). Linear and angular velocities and accelerations were computed from smoothed data (van den Bogert and de Koning, 1996). Pedal angle in the global coordinate system was used to convert the forces on the pedal reference system to forces on the global reference system by means of trigonometric procedures (Bini et al., in press). Right lower limb was modeled as a three-segment rigid body system with segments’ mass and centre of mass estimated (De Leva, 1996). Conventional inverse dynamics was conducted to calculate the net joint moments and resultant force at the knee and ankle joints as reported elsewhere (Redfield and Hull, 1986). The knee joint was modeled as three segments (tibia, femur and patella) as previously reported (Bressel, 2001). Knee flexion angle was employed to calculate patella angle by Matthews et al. (1977) model (Patella angle Z 30.46 þ 0.53 knee flexion angle). Quadriceps force was calculated by the extensor joint moment and patellar moment arm (Bressel, 2001). Patellar tendon force was corrected based on Sharma et al. (2008) estimation relative to quadriceps force and introduced for the calculation of patellofemoral compressive force. In Figure 1, the knee model including reference system for tibiofemoral and patellofemoral force is depicted. Maximal peak of patellofemoral compressive component, as compressive and anterior shear components of tibiofemoral force were extracted from eight consecutive pedal revolutions. The knee flexion angle for maximal force components and the knee flexion angle when the crank was at the bottom dead centre were also calculated based on the flexion angle. Off-line data analysis was conducted using WINDAQ (WINDAQ, DataQ Instruments Inc., USA), Peak Motus (Peak Performance Technologies, Englewood, USA) and MATLAB 7.3 (MathWorks Inc., USA) softwares.

Statistical analysis Data normality distribution and sphericity for peak patellofemoral, compressive and shear tibiofemoral forces, knee flexion angle for each peak force component as the knee flexion angle when the crank was at the bottom dead centre were evaluated by ShapiroeWilk and Mauchly tests,

Figure 1 Representative illustration of the knee model including tibiofemoral compressive (Z axis) and shear (X axis) components, as patellofemoral compressive force (dotted line e Patcomp).

respectively. When data normality was not confirmed, a logarithm transform was applied to the data, with GreenhouseeGeisser corrections employed when data violated sphericity assumption. Descriptive statistics were used to report data as mean and standard deviation (SD), while ANOVA for repeated measures followed by Least Significant Difference (LSD) post hoc test and Holm’s correction (Atkinson, 2002; Knudson, 2009) were employed for inferential statistics. For statistical procedures, the SPSS 12.0 package was used. Significant results were considered when p was lower than 0.05 and the observed power of the test was higher than 0.8, based in Type I and Type II error assumption of 5% and 80% respectively.

Results The results of the maximal peak compressive and anterior shear force components on the tibiofemoral joint are depicted in Figure 2a and 2b, while the knee angle for the maximal peak of each component is depicted in Figure 2c and 2d. The comparison of saddle height effects on maximal peak tibiofemoral compressive (N Z 9, F2,16 Z 0.72, p Z 0.93, h2 Z 0.009, 1  b Z 0.059) and anterior shear components (N Z 7, F2,12 Z 0.117, p Z 0.891, h2 Z 0.019, 1  b Z 0.064) did not report significant interactions. For the knee angle in which compressive (N Z 7, F2,12 Z 0.42, p Z 0.666, h2 Z 0.065, 1  b Z 0.103) and shear components (N Z 9, F2,16 Z 1.019, h2 Z 0.383, 1  b Z 0.196) were maximal, no significant interactions with saddle height were observed. Maximal peak patellofemoral compressive force and the knee angle for the peak component are depicted in Figure 3. Saddle height effects on patellofemoral maximal peak compression (N Z 7, F2,12 Z 1,43, p Z 0.276, h2 Z 0.193, 1  b Z 0.249) and on the knee angle for the maximal peak component (N Z 7, F2,12 Z 3.712, p Z 0.055, h2 Z 0.382, 1  b Z 0.566) were not significant. The knee flexion angle when the crank was at the bottom dead centre is depicted in Figure 4.

Saddle height affect patellofemoral and tibiofemoral forces during bicycling for rehabilitation

189

Figure 2 Maximal peak tibiofemoral compressive (a) and anterior shear (b) components of the force, as the knee angle for each component (c e compressive and d e shear). N Z 9. No significant differences were observed for any variables comparing the three saddle heights.

For the knee joint flexion angle when the crank was at the bottom dead centre, there was interaction in relation to saddle height (N Z 9, F2,16 Z 23.808, p < 0.01, h2 Z 0.748, 1  b Z 1). After Holm’s correction for LSD post hoc test, there was significantly higher knee flexion angle at LOW saddle height compared to REF and HIGH saddle height (p < 0.02).

Discussion Based on controversial results of saddle height effects on tibiofemoral joint force components and the lack of evidence for patellofemoral compressive force, the aim of the present study was to compare the effects of saddle height management on knee joint load of uninjured non-cyclists riding with

Figure 3 Maximal peak patellofemoal compressive force (a) and the knee angle for peak component (b). N Z 9. No significant differences were observed for any variables comparing the three saddle heights.

190

Figure 4 Knee joint flexion angle when crank angle was at the bottom dead centre (180 ). N Z 9. *Indicates significant differences in relation to LOW saddle position.

low workload. The main hypothesis of the present study was that small changes on the saddle height compared with the reports of previous studies would affect knee joint loads, which was not confirmed by our results. We measured tibiofemoral compressive and shear force as well as patellofemoral compressive force when saddle height was 3% higher or lower in relation to the trochanteric length. The use of stationary bicycle for rehabilitation and conditioning has been common amongst health science professionals (McLeod and Blackburn, 1980). The smallest range of changes in saddle height management reported in research studies is about 5e6% of trochanteric length (McCoy and Gregor, 1989; Nordeen Snyder, 1977), which is higher than usually set for performance and rehabilitation. Moreover, Ericson and Nisell (1986); McCoy and Gregor (1989) observed differences in tibiofemoral components when changing saddle height by 4e5%. For patellofemoral compressive force, Ericson and Nisell (1987) also observed that 5% of changes in saddle height would result in significant interactions. Our results indicate that changes in saddle height smaller than those reported in the literature do not affect knee joint load at lower workload in uninjured subjects. Saddle height management was related to changes in knee and ankle joint kinematics with effects in muscle length and force production (Sanderson and Amoroso, in press). Our results (Figure 4) indicate that knee joint kinematics was changed only for LOW saddle height (higher knee flexion angle when crank was at 180 ), compared to REF and HIGH. The lack of interactions for HIGH saddle height and the knee flexion angle could be explained by compensatory changes in the ankle joint (i.e. increase plantar flexion) to maintain the knee joint angle. Nordeen Snyder (1977) reported that 5% of changes in saddle height affects knee and ankle joint kinematics. For the knee angle, Nordeen Snyder (1977) described up to 16 (36%) of changes in the knee flexion angle when the crank is the bottom dead centre for HIGH saddle height compared to the REF. Since we also observed changes in knee flexion angle when managing saddle height without significant effects on joint forces, the workload needs to be analyzed in relation to previous studies. Ericson and Nisell (1986); McCoy and

A.C. Tamborindeguy, R. Rico Bini Gregor (1989) measured knee joint load for healthy subjects cycling at 200 W and 240 W, respectively, which is higher than the selected in the present study (70 W). Based on the need to simulate an application for rehabilitation prescription, the low workload selected in the present study indicates that the relationship between saddle height and workload may be concern. We would speculate that for low workload, small changes in saddle height would not be sufficient to affect knee joint load. In this regard, there was no evidence of saddle height effects on knee joint load for low workload before the present study. Mimmi et al. (2004) reported that high workload (w300 W) elicited pathological constraints of evaluated subjects while Hunt et al. (2003) also observed significant differences between injured subjects’ and healthy legs for low workload (75 W at 60 rpm). These results indicate that the similarities observed for the three saddle heights in the present study only relate to the evaluation of healthy subjects cycling at a low workload. For future studies, the evaluation of injured subjects would indicate the range of changes in saddle height that might result in changes of knee joint load. The small changes proposed in the present study would be improved in the attempt to optimize saddle height based on minimal knee joint load. One limitation of the present study that should be addressed in future studies is to measure possible discrepancies in bilateral trochanteric height for setting saddle height. In our study we only account for the right side measurement and qualitative analysis of bilateral differences. A second limitation was the small sample size, which results in reduced possibility to extrapolate the results as general guidelines. Future studies should concern on this issue.

Conclusions and practical implications Two main conclusions emerged from the results of the present study: 1. Small changes in saddle height associated with low workload might not result in significant effects on knee joint load in uninjured subjects; 2. Significant changes in joint kinematics were not related to changes in joint forces. For practical application of the present study, the knee flexion angle seems to be sensitive to changes in saddle height which can be selected as the gold standard method for setting bicycle configuration. Ankle angle evaluation when setting saddle height must be considered since increased plantar flexion could compensate higher saddle height. Both kinematics variables analysis secure the maintenance of knee joint load for low workload cycling.

Acknowledgements The authors would like to dedicate this work to the memory of Prof. Anto ˆnio Carlos Guimara ˜es who introduced cycling biomechanics research in our university and was the primary supervisor of this project until he passed away. Special thanks

Saddle height affect patellofemoral and tibiofemoral forces during bicycling for rehabilitation to Dr. Antony van den Bogert for extensive help with inverse dynamics and to Dr. Carlos Bolli Mota for lending kinematics systems for data collection. The authors also thank Mateus Wiest and Elisandro Martins for helping on kinematics data analysis. This study was funded by Cnpq.

References Atkinson, G., 2002. Analysis of repeated measurements in physical therapy research: multiple comparisons amongst level means and multi-factorial designs. Physical Therapy in Sport 3 (4), 191e203. Bini, R.R., Diefenthaeler, F., Mota, C.B. Fatigue effects on the coordinative pattern during cycling: kinetics and kinematics evaluation. Journal of Electromyography and Kinesiology, in press. Bressel, E., 2001. The influence of ergometer pedaling direction on peak patellofemoral joint forces. Clinical Biomechanics 16 (5), 431e437. Burke, E.R., Pruitt, A.L., 2003. Body positioning for cycling. HighTech Cycling, 69e92. Candotti, C.T., Ribeiro, J., Soares, D.P., De Oliveira, A.R., Loss, J.F., Guimara ˜es, A.C.S., 2007. Effective force and economy of triathletes and cyclists. Sports Biomechanics 6 (1), 31e43. De Leva, P., 1996. Adjustments to ZatsiorskyeSeluyanov’s segment inertia parameters. Journal of Biomechanics 29 (9), 1223e1230. De Vey Mestdagh, K., 1998. Personal perspective: in search of an optimum cycling posture. Applied Ergonomics 29 (5), 325e334. Ericson, M.O., Nisell, R., 1986. Tibiofemoral joint forces during ergometer cycling. American Journal of Sports Medicine 14 (4), 285e290. Ericson, M.O., Nisell, R., 1987. Patellofemoral joint forces during ergometric cycling. Physical Therapy 67 (9), 1365e1369. Fleming, B.C., Beynnon, B.D., Renstrom, P.A., Peura, G.D., Nichols, C.E., Johnson, R.J., 1998. The strain behavior of the anterior cruciate ligament during bicycling. An in vivo study. American Journal of Sports Medicine 26 (1), 109e118. Gregor, R.J., 2000. Biomechanics of cycling. In: Garret, W.E., Kirkendall, D.T. (Eds.), Exercise and Sports Science. Lippincott Williams & Wilkings, Philadelphia, pp. 549e571. Hunt, M.A., Sanderson, D.J., Moffet, H., Inglis, J.T., 2003. Biomechanical changes elicited by an anterior cruciate ligament deficiency during steady rate cycling. Clinical Biomechanics 18 (5), 393e400. Johnston, T.E., 2007. Biomechanical considerations for cycling interventions in rehabilitation. Physical Therapy 87 (9), 1243e1252.

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Knudson, D., 2009. Significant and meaningful effects in sports biomechanics research. Sports Biomechanics 8 (1), 96e104. Matthews, L.S., Sonstegard, D.A., Henke, J.A., 1977. Load bearing characteristics of the patello-femoral joint. Acta Orthopaedica Scandinavica 48 (5), 511e516. McCoy, R.W., Gregor, R.J., 1989. The effects of varying seat position on knee loads during cycling. Medicine and Science in Sports and Exercise 21 (S2), S79. McLeod, W.D., Blackburn, T.A., 1980. Biomechanics of knee rehabilitation with cycling. American Journal of Sports Medicine 8 (3), 175e180. Mellion, M.B., 1991. Common cycling injuries. Management and prevention. Sports Medicine 11 (1), 52e70. Mimmi, G., Pennacchi, P., Frosini, L., 2004. Biomechanical analysis of pedalling for rehabilitation purposes: experimental results on two pathological subjects and comparison with non-pathological findings. Computer Methods in Biomechanics and Biomedical Engineering 7 (6), 339e345. Nordeen Snyder, K.S., 1977. The effect of bicycle seat height variation upon oxygen consumption and lower limb kinematics. Medicine and Science in Sports and Exercise 9 (2), 113e117. Peveler, W., Bishop, P., Smith, J., Richardson, M., Whitehorn, E., 2005. Comparing methods for setting saddle height in trained cyclists. Journal of Exercise Physiology Online 8 (1), 51e55. Peveler, W.W., 2008. Effects of saddle height on economy in cycling. Journal of Strength and Conditioning Research/National Strength & Conditioning Association 22 (4), 1355e1359. Redfield, R., Hull, M.L., 1986. On the relation between joint moments and pedalling rates at constant power in bicycling. Journal of Biomechanics 19 (4), 317e329. Sanderson, D.J., Amoroso, A.T. The influence of seat height on the mechanical function of the triceps surae muscles during steadyrate cycling. Journal of Electromyography and Kinesiology, in press. Sanner, W.H., O’Halloran, W.D., 2000. The biomechanics, etiology, and treatment of cycling injuries. Journal of the American Podiatric Medical Association 90 (7), 354e376. Sharma, A., Leszko, F., Komistek, R.D., Scuderi, G.R., Cates Jr., H.E., Liu, F., 2008. In vivo patellofemoral forces in high flexion total knee arthroplasty. Journal of Biomechanics 41 (3), 642e648. van den Bogert, A.J., de Koning, J.J., 1996. On optimal filtering for inverse dynamics. In: Paper Presented at the IXth Biennial Conference of the Canadian Society for Biomechanics, Vancouver. Wanich, T., Hodgkins, C., Columbier, J.A., Muraski, E., Kennedy, J.G., 2007. Cycling injuries of the lower extremity. Journal of the American Academy of Orthopaedic Surgeons 15 (12), 748e756.

Journal of Bodywork & Movement Therapies (2011) 15, 192e200

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

CLINICAL ASSESSMENT: PILOT STUDY

Association of manual muscle tests and mechanical neck pain: Results from a prospective pilot study Scott C. Cuthbert, D.C.*, Anthony L. Rosner, Ph.D., LL.D.[Hon.], LLC, Donald McDowall, D.C., DIBAK, FACC Chiropractic Health Center, P.C., 255 West Abriendo Avenue, Pueblo, CO 81004, United States Received 6 July 2010; received in revised form 9 November 2010; accepted 19 November 2010

KEYWORDS Neck pain; Neck muscles; Muscle weakness; Cross-sectional studies; Diagnostic techniques and procedures; Chiropractic; Kinesiology, applied

Summary Objective: To determine whether there was a statistical difference for manual muscle test (MMT) findings for cervical muscles in subjects with and without mechanical neck pain (MNP), and to use confidence intervals to evaluate the sensitivity and specificity of the MMT in this group of subjects. Clinical features: Manual muscle strength tests were conducted on two groups of patients who reported to two outpatient chiropractic clinics. In group 1, 148 patients were evaluated for MMT data (50 males and 98 females, average age 37), 127 with “whiplash”-type injuries (average duration 16 weeks) and 21 with non-traumatic chronic neck pain (average duration 36 weeks). In group 2, 100 patients were evaluated for comparative MMT data (39 males and 61 females, average age 38) with no current MNP or remarkable history of MNP. Methods: Standardized MMT assessments of the strength of the sternocleidomastoid, anterior scalene, upper trapezius, and cervical extensor muscles bilaterally were performed on all subjects in groups 1 and 2. Results: In group 1, 139 of 148 patients reporting neck pain also showed positive results in at least one of four MMT tests (sternocleidomastoid, anterior scalene, upper trapezius, and cervical extensors). In group 2, 30 of the 100 patients without MNP showed positive results in one or more of the four MMT tests. Confidence intervals were calculated and showed that, in terms of MMT findings, there was a significant difference between the two groups of patients. Conclusions: A symptomatic group of patients with MNP demonstrated significantly increased MMT findings in the form of reduced strength levels compared to a control group. This evidence suggests that the MMT is potentially a sensitive and specific test for evaluating cervical spine muscular impairments in patients with MNP. ª 2010 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: þ1 719 544 1468. E-mail addresses: [email protected] (S.C. Cuthbert), [email protected] (A.L. Rosner), [email protected] (D. McDowall). 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.11.001

Association of manual muscle tests and mechanical neck pain

Introduction The Bone and Joint Decade 2000e2010 Task Force on Neck Pain and Its Associated Disorders recently published its findings (Haldeman et al., 2008a,b). In the executive summary of this review, a challenging judgment was made for manipulative physicians and manual therapists: “The clinical physical examination is more predictive at excluding a structural lesion or neurologic compression than at diagnosing any specific etiologic condition in patients with neck pain. All other assessment tools such as electrophysiology, imaging, injections, discography, functional tests, and blood tests lack validity and utility” (Haldeman et al., 2008a,b). Notwithstanding the Task Force’s assessment, it may still be reasonable to investigate whether there are specific tissuebased impairments related in particular to mechanical neck pain (MNP) revealed upon further examination. Abnormal cervical postures and muscular activity are commonplace in patients with MNP (Haldeman et al., 2008a,b). Because muscular imbalances, articular disturbances, trigger points, tender points, muscle injuries, referred pain and postural distortions manifest themselves in individual muscles, these offer themselves as individual criteria to determine whether these muscle dysfunctions are evident in patients with MNP compared to patients without MNP (Carroll et al., 2008). The incidence of neck pain is high in the general population. Neck and shoulder problems occur in nearly as many individuals as low back pain, with lifetime prevalence between 50% and 71% of the population (Lidgren, 2008). Hill estimates that 48% of these neck pain patients have their pain persisting for at least one year (Hill et al., 2004). Like low back pain, the natural history of neck pain is generally persistent with only one-third of patients experiencing a complete resolution of symptoms (Co ˆte ´ et al., 2000, 2004). Many researchers have suggested that neck pain has a local physio-pathologic cause, and that this cause can be identified and treated (Travell and Simons, 1983). Others consider neck pain as a primarily nonorganic problem with psychological and social roots (biopsychosocial model) and that psychosocial disturbances have the major influence on MNP (Hogg-Johnson et al., 2008). The relationship between psychosocialepsychological variables, physical impairment, and neck pain and disability is complex and not yet fully understood (Linton, 2000). Where MNP derives from irritation of pain receptors and where this results in measurable functional changes (such as from inhibited muscles that fail to stabilize the joints they are meant to move), Lewit offers the descriptive term “functional pathology of the motor system” (Lewit, 1999). If there is a modifiable risk factor for MNP then it would be prudent to develop preventive strategies to help identify and target important subgroups of the population at greatest risk for MNP (Guzman et al., 2008), Guzman et al. note that there is a profound need to translate the results of clinical and epidemiologic studies into meaningful and practical information for clinicians. One such result could be muscle strength impairments as a modifiable risk factor in patients with MNP. Chaitow’s recent discussion of Clinical Prediction Rules e clinical examination findings that can

193 predict the presence of a condition e may link muscle strength impairments in patients with MNP as a modifiable risk factor (Chaitow, 2010). Several studies have in fact related measurements of impaired muscle strength to MNP. In 2008, a literature review on neck muscle strength by Dvir confirms that, “overall studies indicate that compared to normal subjects, patients suffering from neck-related disorders present with significant reduction in cervical strength” (Dvir and Prushansky, 2008). This is consistent with previous research offered by Dvir in his review (Nederhand et al., 2002, 2003; Vorro and Johnston, 1998; Vernon et al., 1992). Barton et al. also measured strength deficits in patients with neck pain (Barton and Hayes, 1996). They showed that all force values were significantly lower in the neck pain population. Specifically, for the deep neck flexor test and the SCM muscles, the peak force in the control group (mean Z 45.3  17.6N ) was reduced by 50% in the neck pain subjects (mean Z 22.4  13.1N ) (p  0.004). Falla has similarly reported that both the SCM and anterior scalene muscles’ strength was significantly reduced in patients with neck pain at 25% of maximum voluntary contraction (p < 0.05) (Falla et al., 2003, 2004a,b). Falla suggests that “reduced neuromuscular efficiency in the superficial cervical flexor muscles in patients with neck pain may be a measurable altered muscle strategy for dysfunction in other muscles. This aberrant pattern of muscle activation appears to be most evident under conditions of low load. Neuromuscular efficiency, when measured at 25% maximum voluntary contraction, may be a useful objective measure for future investigation of muscle dysfunction in patients with neck pain”. In addition, Prushansky et al. have demonstrated cervical muscle weakness in chronic whiplash patients (Prushansky et al., 2005). Silverman et al. also found that individuals with neck pain had reduced neck flexor strength compared to asymptomatics (Silverman et al., 1991). Further support linking MNP to reduced muscle strength was offered by Edgerton et al. who found altered muscle activation ratios of synergist spinal muscles during a variety of motor tasks in whiplash patients (Edgerton et al., 1996). Their study showed that underactivity of agonists and overactivity of synergists was able to discriminate chronic neck pain patients from those who had recovered from neck pain with 88% accuracy. Ylinen et al. pointed out that decreased isometric strength in neck flexion, extension, and rotation distinguished female chronic neck pain patients from those without pain (Ylinen et al., 2004). Jull and colleagues have offered a substantial body of evidence showing that patients with neck pain demonstrate reduced electromyographic activity of the deep cervical flexor and extensor muscles during performance of the craniocervical flexion test (a form of MMT) (Jull et al., 2008). Following cervical trauma and with postural strain, numerous myofascial trigger points (MTrPs) in the cervical region are commonly identified (Travell and Simons, 1983). In addition to pain, numerous remote symptoms can be caused by trigger points. Travell, Simons and Mense state that weakness is generally characteristic of a muscle with active MTrPs (Mense and Simons, 2001; Travell and Simons, 1983).

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To our knowledge, there are sparse published data pertaining to manual muscle test (MMT) findings in patients with MNP (Garten, 2008; Waddell, 2005; Dobson, 1999; Cyriax, 1920). Furthermore, these previous studies lacked a control group for normative data comparisons. A reliable direct measure of the cervical muscles could provide the opportunity for further research into the role of impairments of these muscles, which is believed to exist in people with neck pain (Carroll et al., 2008). This investigation asked whether MNP was associated with measurable muscular inhibition in the head and neck and whether this could be detected using the MMT as it is used in applied kinesiology (AK). The muscles in this study were tested according to the method outlined in the texts by Walther, Kendall, and Daniels and Worthingham (Kendall et al., 2005; Daniels and Worthingham, 2002; Walther, 2000). This method of MMT has been previously investigated in numerous reliability studies (Jepsen et al., 2004; Bohannon, 2001; Caruso and Leisman, 2000; Lawson and Calderon, 1997; Kelly et al., 1996; Hsieh and Phillips, 1990; Leisman et al., 1989; Wadsworth et al., 1987; Iddings et al., 1961). A recent review of the validity and inter-examiner reliability of the MMT by Cuthbert and Goodheart (2007) included the studies just mentioned. The correlation coefficients ranged from 0.63 to 0.98 for individual muscle groups, and from 0.57 to 1.0 for a total MMT score (comprised of the sum of individual muscle grades). The results in the studies reviewed demonstrated good inter- and intra-examiner reliability for the MMT. The operational definition of the AK MMT as used in this study is identical to the so-called “break test” described in the literature cited above; this operational definition has been part of the International College of Applied Kinesiology’s (ICAK) training program since its first mission statement was written in the early 1970s (ICAK-International website, 2010). Two recent papers (Schmitt and Cuthbert, 2008; Cuthbert and Goodheart, 2007) review the operational definitions of the AK MMT and show that they are identical to the ones originally offered by Kendall and Kendall, Daniels and Worthingham, and later Janda and others (Janda, 1983). Within the chiropractic profession, the International College of Applied Kinesiology (ICAK) has established an operational definition for the use of the MMT (ICAKInternational website, 2010): “Manual muscle tests evaluate the ability of the nervous system to adapt the muscle to meet the changing pressure of the examiner’s test. This requires that the examiner be trained in the anatomy, physiology, and neurology of muscle function. The action of the muscle being tested, as

Table 1

well as the role of synergistic muscles, must be understood. Manual muscle testing is both a science and an art. To achieve accurate results, muscle tests must be performed according to a precise testing protocol. The following factors must be carefully considered when testing muscles in clinical and research settings:  Proper positioning so the test muscle is the prime mover  Adequate stabilization of regional anatomy  Observation of the manner in which the patient or subject assumes and maintains the test position  Observation of the manner in which the patient or subject performs the test  Consistent timing, pressure, and position  Avoidance of preconceived impressions regarding the test outcome  Nonpainful contacts e nonpainful execution of the test  Contraindications due to age, debilitative disease, acute pain, and local pathology or inflammation” In physical therapy research, the “break test” is the procedure most commonly used for MMT, and it has been extensively studied (Kendall et al., 2005; Daniels and Worthingham, 2002; Harms-Ringdahl, 1993). This method of MMT is the one used in chiropractic, developed originally from the work of Kendall and Kendall (Walther, 2000; Goodheart, 1998).

Methods/design This study included 248 patients who consecutively reported to two chiropractic outpatient clinics in Canberra, Australia, and Pueblo, Colorado for treatment. Data was collected between January and December 2009. All participants were made aware of the experimental details prior to assuming their involvement in the study, and they were required to fill out a symptom questionnaire and a consent form before the testing was administered. The examination for MMT impairments was recorded on the patients’ first visit. For group 1, 148 new patients were admitted to the study that came for chiropractic treatment in Canberra, Australia who met the inclusion criteria of a primary complaint of MNP. The following symptom clusters were required for inclusion in group 1 (Table 1). 1. Neck pain. 2. Arm pain originating from the neck.

Subgroups of MNP cohort.

# of patients Duration of complaint

Mechanical neck pain

Whiplashtype

Nontraumatic/ occupational

Arm pain radiating from neck

Cervicocranial headaches

MNP associated with shoulder pain

MNP associated with low back pain

148

127 16 week (1 week to 25 years)

21 36 weeks (1 day to 45 years)

7 9 weeks (3 weeks to 2 years)

30 42 weeks (1 week to 18 years)

43 15 weeks (1 week to 5 years)

70 7 weeks (3 weeks to 3 years)

Association of manual muscle tests and mechanical neck pain 3. Thoracic pain associated with neck pain and originating from the neck. 4. Headaches associated with neck pain and originating from the neck. 5. Generalized symptoms originating from the neck. For group 2, 100 otherwise healthy new patients were admitted to the study that came for chiropractic treatment in Pueblo, Colorado, who met the inclusion criteria of a primary complaint other than MNP nor did they have a previous history of MNP or injury.

Experimental procedure Assessment of the participants involved standard MMT of four predetermined muscle pairs of the anterior and posterior neck bilaterally (the sternocleidomastoid or SCM, anterior scalene, upper trapezius, and cervical extensor muscles). From the basic texts on MMT (Walther, 2000; Kendall et al., 2005; Daniels and Worthingham, 2002), these are the individual neck muscles for particular neck motions that are the prime movers whose strength can be differentiated from their synergists. Each test was conducted twice, with a 15 s rest period in between tests.

Description of manual muscle test procedures All muscles were tested from a starting contracted position as described by Kendall, Daniels and Worthingham, Walther, and Goodheart (Kendall et al., 2005; Daniels and Worthingham, 2002; Walther, 2000; Goodheart, 1998) among others, with pressure applied toward lengthening. If the subject maintained the starting position against gradually increasing pressure for the duration of the test, it was graded as “strong” corresponding roughly to grade 5 of 5 (American Medical Association, 2007). If the muscle failed to hold the starting position and broke away, the muscle was rated as “weak” corresponding to a grade of less than 5. The MMT began with a position designed to place the prime mover into its greatest advantage for the testing activity, while the synergist muscles were at the greatest possible disadvantage. Janda has emphasized that prime movers and synergists are tested with the MMT, not individual muscles (Janda, 1983). However, it should be pointed out that every muscle functions as a prime mover in some specific action (Kendall et al., 2005). The MMTs used were designed to replicate the primary vector of motion of the muscles tested while minimizing the contribution of secondary mover muscles. During the individual MMT, the designated primary mover muscle should have the highest level of activity compared with the secondary mover or synergist muscles (Schmitt and Cuthbert, 2008; Walther, 2000). During the MMT procedure, the examiner applied a vector of force specifically designed to test the prime mover. The examiner used this knowledge of what synergists would attempt to take over if the prime mover was weak e keeping in mind that many testing procedures rely upon fixation of specific body parts by adequate action of the patient’s fixator muscles. All these considerations were applied with a specific speed and vector and at the correct point of contact on the patient.

195 In order to optimize subject performance, the examiner provided verbal instructions and demonstration of each test procedure. To reduce recruitment of trunk, pectoral, and lower limb muscle forces and to maximize isolation of the neck musculature for all the flexor and extensor muscle tests, the subject’s arms were lifted off the examination table and the hands placed level with the head. This eliminated the recruitment of the scapular and pectoral muscles during the test (Chaffin, 1975). Subjects were instructed to produce a level of resistance that reached, but did not exceed, tolerable pain. The SCM muscle was tested supine with the head lifted from the table and rotated away from the muscle to be tested. Pressure was applied against the temporal area in a posteromedial direction (Altered muscular movement patterns (what Janda called “trick patterns of substitution”) have long been evaluated in proper MMT and are a common finding in patients with muscle inhibitions as they attempt to use synergist muscle substitution during the MMT.) (Walther, 2000; Daniels and Worthingham, 2002; Kendall et al., 2005; Schmitt and Cuthbert, 2008; Cuthbert and Goodheart, 2007). Careful monitoring for slight changes of patient position was necessary, as they could have indicated a subconscious effort to recruit synergist activity. In the case of the SCM, the examiner scrutinized the patient’s attempts to turn his head medially, recruiting more synergistic action from the scalene group and other neck flexors (Figure 1). The anterior scalene muscles were tested supine with the head lifted from the table by neck flexion and rotated 10 away from the side being tested. Pressure was applied against the forehead in the direction of neck extension directly toward the table and not in alignment with the 10 rotation of the patient’s head. Observation was made for the patient’s attempt to rotate his head, thereby recruiting more activity from synergist muscles in substitution during the MMT (Figure 2). The upper trapezius muscles were tested in a seated position. The patient elevated his shoulder and laterally flexed his neck and head, with rotation of the head slightly away from the side being tested. The patient was not allowed to bring the ear and shoulder into such close proximity that the upper trapezius would be in compressed and relatively immobilized position (Figure 3). The cervical extensor muscles were tested bilaterally together and then unilaterally with the patient in the prone position. For the unilateral cervical extensor test, the face was turned toward the side being tested, and the neck was extended by lifting the head off the table. For the bilateral test, the neck was extended off the table without any rotation. Pressure was directed against the posterior or posterolateral aspect of the head toward the table in the direction of the muscle’s action (Figure 4A and B).

Results For group 1 (MNP) One-hundred and thirty-nine of 148 patients reporting MNP showed inhibition on MMT in at least one or more of the four tests (MMT of the sternocleidomastoid, anterior scalene, upper trapezius, and cervical extensor muscles), yielding

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Figure 1

Sternocleidomastoid MMT and muscle.

a sensitivity of 93.9%. The total number of positive MMT findings in the MNP group was 222, because many of the members of this group had positive MMT results on more than one test. Weaknesses were broadly and to a large extent equally distributed (32.4e43.2%) across the four muscle groups tested (Table 2). If the 148 MNP patients in this cohort were truly representative of the overall patient population, then it would be possible to compute a confidence interval. In so doing, we chose the ClopperePearson two-sided interval, the methodology being appropriate for binomial (yes/no) data and making no assumptions about any data distributions being normal or approximately normal (Newcombe, 1998). To arrive at the confidence interval, we used the binom.test function from the “R” statistical program (www.r-project.org). Under these circumstances and using a 95% confidence interval, we would estimate that between 88.8% and 97.2% of all patients have positive MMT findings in one or more of the four muscle pairs tested (Figure 5).

For group 2 (no MNP) Thirty of the 100 patients without MNP showed positive results in one or more of the four MMT tests, yielding

Figure 2

a specificity of 70%. The total number of positive MMT findings in the control group was 37. However, there were only 30 patients with positive MMT findings, because several patients had positive results from more than one test. In this instance, positive findings were generally confined to the sternocleidomastoid and anterior scalene muscles (Table 2). Using the assumptions discussed above, the 95% confidence interval for this group would be between 21.2% and 40.0% (Figure 5). The apparently wide gap of confidence intervals between those patient cohorts with or without MNP is noteworthy, keeping in mind that (1) the specificity of the MMT in patients without MNP was 70%, and (2) the sensitivity of the MMT in patients with MNP was 93.7%. The “sensitivity” of the MMT proved to be high for subjects in group 1. Sensitivity indicates the likelihood of receiving a positive MMT result in one or more of the cervical muscles tested when MNP was truly present. The “specificity” of the MMTwas not as high but still significant for group 2. Specificity indicates the likelihood of receiving a negative MMT result when MNP was not present. Under these circumstances, our data as shown in Figure 5 suggest that MMT was a sensitive and moderately specific test for differentiating the two groups of patients with and without MNP.

Anterior scalene MMT and muscle.

Association of manual muscle tests and mechanical neck pain

Figure 3

Upper trapezius MMT and muscle.

Discussion The apparent ability of MMT applied across the four muscle groups in this investigation to discriminate MNP from nonMNP patients supports both our hypotheses that (1) MNP is associated with a measurable muscular inhibition, and (2) the MMT, in identifying these muscular inhibitions, may lead to the discovery of a modifiable risk factor for MNP.

Figure 4

197

While the incidence of muscle weakness appeared to be roughly distributed across all four of the muscle groups tested in MNP patients, this was not the case in the nonMNP patients (see Limitations section below). The MMT expands the scope of traditional EMG-type biofeedback (Maffetone, 2009; Kendall et al., 2005; Daniels and Worthingham, 2002; Walther, 2000; Basmajian, 1985). Although a large number of instruments have been developed

A. Cervical extensor (unilateral) MMT and muscle; B. Cervical extensor (bilateral) MMT and muscle.

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Table 2 Number and percentages of patients with positive MMT findings, by muscle group. Control group Mechanical neck pain (100 patients) group (148 Patients) Sternocleidomastoid 18 (18%) Anterior scalene 13 (13%) Upper trapezius 4 (4%) Cervical extensors 2 (2%)

61 49 64 48

(41.2%) (33.1%) (43.2%) (32.4%)

that can measure resistance, the majority are not suitable for practical use because they are difficult to handle, and not all muscles can be tested with them. In place of electrodes and mechanical sensors used in computerized devices, the MMT integrates the practitioner’s sensory system as the sensor. The process is similar and in many cases identical to traditional EMG testing of active muscles. The concurrent validity of the MMT (its comparison to various mechanical instruments of muscle strength testing) has been found to be good and frequently comparable to dynamometer and EMG findings in 8 studies (Cuthbert and Goodheart, 2007). In one study, for practitioners with five or more years of experience, there was a virtual perfect correlation of the results of MMT and those obtained with a force transducer and electrogoniometer for over 700 muscle tests (Caruso and Leisman, 2001). Kendall et al. (2005) state, “As tools, our hands are the most sensitive, fine tuned instruments available. One hand of the examiner positions and stabilizes the part adjacent to the tested part. The other hand determines the pain-free range of motion and guides the tested part into precise test position, giving the appropriate amount of pressure to determine the strength. All the while this instrument we call the hand is hooked up to the most marvelous computer ever created. It is the examiner’s very own personal computer and it can store valuable and useful information of the basis of which judgments about evaluation and treatment can be made. Such information contains objective data that is obtained without sacrificing the art and science of MMT to the demand for objectivity”. According to Walther (2000), “Presently the best ‘instrument’ to perform MMT is a well-trained examiner,

Figure 5 Comparison of positive MMT findings between MNP and non-MNP groups.

using his perception of time and force with knowledge of anatomy and physiology of muscle testing” (Walther, 2000). When properly performed (Schmitt and Cuthbert, 2008), the MMT is also thought to better isolate a muscle compared to a dynamometer, strain-gauge, and other instrumental testing, because the examiner can observe the MMT by visual and tactile senses combined, guiding and thereby eliminating the recruitment of synergistic muscles (Kendall et al., 2005; Daniels and Worthingham, 2002; Walther, 2000). A general evaluation of neck strength with a dynamometer may not reveal the same information that MMT does if, for instance, the injury is to a single nerve, an individual muscle, or even a portion of a muscle. Several human muscles, including the upper trapezius and anterior scalenes, have broad fan-like attachments dividing the muscle into serial segments, and each section of a dysfunctional muscle may be assessed for strength using the MMT with precise patient positioning. Even in a severe MNP syndrome, only a portion of the fibers may be involved, allowing some muscles to function very well. These may be the muscles primarily tested by instruments evaluating the gross muscle strength in group muscle tests; yet significant changes in individual muscles may be present when manually tested. The muscle strength impairments in MNP patients in this pilot study, shown to be commonplace in clinical practice and the research literature, were supported by our data in this report. If these findings are confirmed in more controlled clinical trials, then an easy-to-use, inexpensive, and in-office clinical tool for the measurement of an important component in MNP would be available and buttressed with greater rationale than previously.

Limitations All individuals were recruited and treated at separate clinics by different practitioners, raising the possibility of confounding of such factors as (1) patient demographics, (2) the environment, and (3) the practitioner involved. Of similar concern is the fact that patients who did not have MNP were still under treatment for complaints in other locations rather than being pain-free altogether. This could have produced muscle weaknesses in the neck in some instances, a possibility corroborated by our finding that the rather unexpectedly high number of 30 patients without MNP tested positive for muscle weakness as well as by the apparently different distribution of muscle weaknesses shown in Table 2. Further research should address a fully asymptomatic patient population to strengthen the hypothesis that weakness of the 4 muscle pairs taken together may be a specific indicator of MNP. An additional limitation of this study was the duration. Because this was an in-office pilot cohort study, treatment for the muscle weaknesses found was immediately given. In cases of MNP, the natural history of muscle weakness and MMT findings must be studied over longer periods. It is possible that the practitioners performing the MMT were doing so with differing criteria for the determination of “weak” and “strong” MMT findings, and this may have altered the results. The operational definition of the standard MMT as taught in the International College of Applied Kinesiology (ICAK) and in the chiropractic colleges that

Association of manual muscle tests and mechanical neck pain teach MMT were followed (Schmitt and Cuthbert, 2008), and the examiners for study 1 and 2 had 35 and 10 years of experience, respectively, using this type of MMT. The most intriguing question raised in our study pertains to whether muscle weakness as a proposed risk factor for MNP is reversible. This would be answered by the treatment of a cohort of patients with MNP using a variety of interventions to treat MNP (spinal manipulative therapy, cranial manipulative therapy, mobilization, myofascial release and others). This treatment would be immediately accompanied by examination of the four muscle groups to see if muscle strength is regained using the MMT. Every patient with MNP who visits an applied kinesiology practitioner faces this clinical examination and treatment sequence. This question will be answered in a forthcoming paper (using the MNP cohort from the present study) from the authors. Resolution of MNP accompanied by the return of muscle strength after such treatment would further establish the role of these four muscle groups as a specific indicator of MNP. An additional refinement could include a control group of MNP patients subjected to a sham treatment in which pain resolution and the regaining of muscle strength would not be expected.

Conclusion The standardized MMT test protocols used were applied to a symptomatic and non-symptomatic population and revealed significantly more weakness in the MNP sufferers. The wide gap of confidence intervals between these cohorts with and without MNP is noteworthy. The specificity of the MMT in patients without MNP was 70%, and the sensitivity of the MMT in patients with MNP was 93.7%. The MMT proved to demonstrate high sensitivity for patients with MNP. The specificity of the MMT was not as high but still significant for group 2. Our data suggest that MMT was a sensitive and moderately specific test for differentiating the two groups of patients with and without MNP. The present study suggested that the use of the MMT in the clinical setting could be a useful tool for assessment of one of the components that may underlie MNP. Muscle weakness in the neck as one such component may prove to be a modifiable risk factor for patients with MNP. Further study in more controlled environments with less heterogeneous cohorts is recommended.

Competing interests SCC is a Board Member for the ICAK-USA. DM is a diplomate of the International College of Applied Kinesiology (ICAK). AR is the Research Director of the ICAK-USA. SCC and DM both employ MMT and AK methods in their evaluation and treatment of patients.

Authors’ contributions DM and SCC conceived the research idea. DM evaluated group 1, and SCC evaluated group 2 in their respective clinics. SCC, AR and DM drafted the manuscript and approved the final version for publication. George Heine was the statistician, and he holds an MA in applied

199 mathematics and a PhD in applied probability from the University of Colorado.

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Journal of Bodywork & Movement Therapies (2011) 15, 201e208

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

EXERCISE PHYSIOLOGY

A mathematical model of effects on specific joints during practice of the Sun Salutation e A sequence of yoga postures S.N. Omkar a,*, Meenakshi Mour b, Debarun Das b a b

Department of Aerospace Engineering, Indian Institute of Science, Bangalore 560012, India Department of Mechanical Engineering, National Institute of Technology, Durgapur, India

Received 4 July 2008; received in revised form 12 July 2009; accepted 12 July 2009

KEYWORDS Yoga; Sun Salutation; Dynamic moments; Joint loading; Osteogenesis

Summary The ‘Sun Salutation’ consists of a sequence of ten yoga postures, each posture counteracting the preceding one producing a balance between flexion and extension, performed with synchronized breathing and aerobic activity. As this sequence is often performed and recommended by many yoga practitioners, there is a need for the development of a biomechanical model to support its reported clinical benefits. This requires a detailed knowledge of the nature of the forces and moments at the various joints involved. A simple mathematical model based on rigid body mechanics is developed for each of the Sun Salutation postures. Dynamic moments with high magnitudes and rates, applied with unusual distribution patterns, optimal for osteogenesis, are found to occur. Also, the joints are subjected to submaximal loadings thus ensuring that none of the joints are overstressed. ª 2009 Elsevier Ltd. All rights reserved.

Introduction Many metals, when combined appropriately and in the right proportion yield an alloy, which usually has novel properties. The best of orchestras is a harmonious combination of various instruments. Likewise, the ‘Sun Salutation’ consists of a specific sequence of yoga postures performed with synchronized breathing. This sequence consists of 10

* Corresponding author. Tel.: þ91 80 22932416/22932417/ 22932873; fax: þ91 80 23600134. E-mail address: [email protected] (S.N. Omkar).

postures set in a dynamic form, performed in a single, conscious and graceful flow (Figure 1). The postures ingeniously combine forward-bending poses countered with backward-bending ones. It is claimed that just as the rays of the sun reach every part of the globe, the sequence of these postures ensure that ‘energy’ reaches every part of the body. Hence, the name Sun Salutation. The sequence does not require any gadgets, takes only a few minutes to perform and can be done in a limited space. With regular practice, it is claimed that all the parts of the human body are felt to be exercised and rejuvenated (Omkar, 2007). Studies have shown that the practice of yoga may be associated with an improvement in cardio respiratory

1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.07.008

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Figure 1

Cycle representing the 10 postures of the Sun Salutation.

fitness (Prasad et al., 2001; Tran et al., 2001), as well as muscular strength and endurance (Birch, 1995). A study that evaluated heart rate for standing yoga postures found lower heart rates and higher rates of perceived exertion for the yoga postures, as compared to treadmill walking (DiCarlo et al., 1995). Thus, researchers have felt the need for work on fitness-related outcomes associated with yoga practice (Cowen and Adams, 2007). The amount of calories burned during a session of Sun Salutation in which the sequence of postures is repeated 120 times, classified by the weight group is given in Table 1 (Omkar, 2007). Though research has found yoga to be equivalent to modern forms of exercise in terms of energy expenditure (DiCarlo et al., 1995; Rai et al., 1994; Raju et al., 1986), energy expenditure during the various aspects of yoga e ‘asana’ (the physical practice of postures), ‘pranayama’ (breathing exercises) and ‘savasana’ (relaxation), varies.Cowen and

Table 1 Energy expenditure during the Sun Salutation (Omkar, 2007). Weight (Kg)

Energy expenditure for 120 Cycles (Kcal)

55 65 77

185 275 380

Adams (2007) in their study pointed out that a vigorous style of yoga is equivalent to modern exercises as far as heart rates are concerned but due to the varied physiological responses of the body to different styles of yoga ‘asanas’, different levels of physical fitness can be achieved (Cowen and Adams, 2007). The movement patterns involved in the Sun Salutation and its impact on calorie burning makes it very attractive for all practitioners (Omkar, 2007). It has also been found to decrease climacteric symptoms, perceived stress, and neuroticism in perimenopausal women, more effectively than physical exercise (Chattha et al., 2008). Experience shows that it is also an excellent warm up exercise, promoting flexibility of the spine and limbs. Since motions at joints are all rotary, rotary moment is the product of the linear force and the moment arm or mechanical advantage of the muscle about the joint’s centre of rotation. The calculation of joint forces and moments during a movement is a classical process in human movement analysis. Moments experienced by the lower extremity joints during five common yoga postures have been evaluated (Westwell et al., 2006). In this pilot study, three-dimensional motion data of joint moments obtained from a single subject were normalized to body mass (Nm/kg). Large moments generated at the hip and knee during the five postures studied were found to be comparable to those that are experienced during running. However, their study found minimal power absorption and impact forces at these joints. Thus, they concluded that

A mathematical model of effects on specific joints yoga may be considered as a favorable alternative to running thereby minimizing joint deterioration. Hence, it is not only important but also interesting to quantify the moments and forces acting on various joints while performing the Sun Salutation. In this paper, we develop a simple mathematical model for all the postures in the Sun Salutation and compute the forces and moments occurring at various joints using the basic principles of mechanics.

Development of a mathematical model Measurement of forces and moments can be complex and thus mathematical models are often used to estimate these loads which involve rigid body mechanics. The rigid body mechanics approach makes various assumptions about the body, including non-deformability, fixed center of mass, and homogeneity of the material. To perform an accurate analysis we must determine information such as structural loads, geometry and support conditions. For calculation of forces and moments, the principle of superposition is considered, which states ‘‘The moment on any bar due to the total load is the algebraic sum of the moments due to several parts of the load’’. In the case of a body subjected to several loads, the principle of superposition is very helpful in calculating the moment acting at any point. The bending moment at a section through a structural element may be defined as ‘‘the sum of the moments about that section of all external forces acting to one side of that section’’. The forces and moments on either side of the section must be equal in order to counteract each other and maintain a state of equilibrium. So the same bending moment will result from summing the moments, regardless of which side of the section is selected. The Sun Salutation consists of ten postures. As such, the moment considered on the joints depends on the configuration of the body in each posture. Accordingly we vary the load to be considered while calculating the moments. As the body is divided into multiple segments and each segment is subjected to a different load, the bending moment at each point must be the sum of that due to each taken separately. When a joint is simply supporting the body at the ends, it plays a role of transmitting the load and no moment is generated there. But in case there is an overhang near that joint which is supporting the body, then there will be a small amount of moment due to the weight of the overhang. An analysis of the factors that influence normal and prosthetic joint function requires an understanding of freebody diagrams. A free-body diagram can be used to schematically represent all the forces and moments acting on a joint. We have considered six different joints namely the wrist, elbow, shoulder, hip, knee and the ankle joint. For the analysis of these six joints, the body can be divided into four major segments-head, arm, trunk and legs. The concept of equilibrium (Halliday et al., 2008) is important in understanding and determining the forces and moments occurring during specific postures of the Sun Salutation. Using the equations of plane static equilibrium, the joint reaction forces and moments can be determined for different conditions.

203 Table 2 Segmental relative weight and relative length of human body (Ferreira et al., 2007). Segment

Relative weight

Relative length

Head Arm Trunk Leg

0.08 0.0325  2 0.4074 0.2238  2

0.182 0.441 0.288 0.530

We need to know the body weight distribution and length distribution in order to determine the loads at each segment. This has been done with the help of the distribution chart given in Table 2 (Ferreira et al., 2007). The following assumptions have been made while computing the joint moments:  The body has been idealised as an arrangement of rigid links connected by the six major joints namely wrist, elbow, shoulder, hip, knee and ankle, which are considered to be hinge joints. The hip and lower back have been idealised as one joint.  The body has been idealised as a one-dimensional system moving about the saggital plane. We have considered the saggital view because the movements during the Sun Salutation primarily take place in this plane. The results of saggital plane kinetic analysis have provided very useful profiles for examining motor patterns of normal and pathological gait (Winter and Eng, 1995).

Normalization of moments Joint moments, commonly used to characterize gait, are affected by factors such as height and weight (Moisio et al., 2003). The un-normalized moments (expressed in Newtonmeters) have significantly greater variability due to both height and weight. Normalization is done to reduce the effect of height and weight on joint moments. Two commonly used normalization methods are  Body Mass Normalization (BMN) where joint moment is expressed in N m/kg  Body WeighteHeight Normalization (%BWHT) where joint moment is expressed as a percentage of Body Weight times Height The percent Body Weight times Height normalization scheme is able to account for the variability of height and weight in the saggital and frontal planes (Sum et al., 1998) and hence the same has been used in the present study.

Sample calculation To illustrate the analysis of the postures of Sun Salutation, we show a sample calculation of the moments at each of the six joints resulting from posture 8 (Figure 1). The corresponding free-body diagram considering the data from Table 2 is shown in Figure 2. Consider the moment balance equation about the ankle joint:

204

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Figure 2 Schematic representation of Posture 8. Index: W0 Z Wrist, E Z Elbow, S Z Shoulder, H Z Hip, K Z Knee, A Z Ankle, W Z Weight of Body, L Z Length of Body.

X

MA Z0

ð0:4476WÞð0:1425:LÞ þ ð0:4074WÞð0:3753LÞ þ ð0:08WÞð0:4856LÞ þ ð0:065WÞð0:5553LÞ  RW ð0:625LÞZ0 where RW (Ground Reaction Force on wrist) Z 0.4666W; RA (Ground Reaction Force on ankle) Z 1  RW Z 0.5334 W. Based on the computed ground reaction forces and segmental loads of the body, we calculate the moments on the various joints, as follows: MK (Knee Moment) Z RA (0.1425 L) Z (0.5334 W) (0.1425 L) Z 0.076 WL MH (Hip Moment) Z RA (0.265 L)  (0.4476 W) (0.1225 L) þ 0.076 WL Z 0.1625 WL ME (Elbow Moment) Z RW (0.1394 L/2) Z 0. 0325 WL MS (Shoulder Moment) Z RW (0.1394 L)  (0.065 W) (0.0697 L) þ 0.0325 WL Z 0.093 WL MA (Ankle Moment) Z 0 WL MW (Wrist Moment) Z 0 WL In a similar manner, the joint moments and ground reaction forces (GRF) can be calculated for all the postures. These are shown in Table 3 and Figure 3 respectively.

Results for each posture In posture 1, the subject is standing upright, and hence there is no moment acting on any of the joints. The foot is experiencing a reaction force due to the weight of the

body. This posture reinforces the postural muscles and promotes a healthy lower back. In posture 2, the subject is trying to bend backwards stretching the back as much as possible with the arms stretched above the head. As is evident from this posture, the hip is subjected to the maximum moment, which is in agreement with the data shown in Table 3. In order to keep the legs straight, the knee and ankle joints are simultaneously subjected to a significant amount of resisting force resulting in a moment. Also, due to an effort to stretch the arms backwards, there is a significant moment on the shoulder and the elbow. This posture provides a good stretch for the complete spinal column. This is useful for the muscles and organs of the pelvic, abdominal and chest cavities. The legs and arms are also benefited. In postures 3 and 10, the subject bends forward and places the palms beside the feet. In this posture, the role of the arm is subdued and the majority of the load and the moment generated due to this posture are taken up by the hip, knee and the ankle. This posture promotes increased flexibility in the hamstrings and the gluteal muscles. In posture 4, the subject takes one leg back and places the other in front. In this posture, the body tries to stretch forward on account of the hip (which is reflected by the peak hip moment in the Table 3) and legs. The leg which is placed forward experiences a significant moment at the knee and ankle. This posture promotes mobility of lower back, knee and ankle. The hip flexors and extensors are also benefitted. The analysis of posture 4 holds true for posture 9 as well, with the difference being that the leading leg in the former

A mathematical model of effects on specific joints

205

Table 3 Variation of the moments (%BWHT) on the wrist, elbow, shoulder, hip, knee and ankle joint for one cycle of the Sun Salutation. Posture

Wrist

Elbow

Shoulder

Hip

Knee

Ankle

1 2 3 4 5 6 7 8 9 10 11

0 0.007 0.003 0 0.007 0.025 0 0 0.007 0.003 0

0 0.06 0.017 0.042 0.007 0.025 0.011 0.0325 0.007 0.017 0

0 0.077 0.012 0.042 0.007 0.007 0.0085 0.093 0.007 0.012 0

0 0.085 0.06 0.031 0.174 0.095 0.066 0.163 0.174 0.06 0

0 0.068 0.06 0.011 0.094 0.072 0.172 0.076 0.094 0.06 0

0 0.077 0.06 0.016 0 0 0.04 0 0 0.06 0

now makes way for the other leg and itself goes backward. We study the moments on the same leg which is now trailing and observe that there is a significant increase in the knee moment as it is subjected to the reaction force which was taken up by the ankle in posture 4. In posture 5, the shoulder and ankle support the whole body keeping the trunk parallel to the ground. As a result the hip is subjected to a prominent moment. Although the moments on the shoulder, elbow and wrist are found to be low, they experience a high reaction force (about 62% of body weight). This posture strengthens the upper body, abdominal, and lower back muscles. It is also beneficial to the arm and feet. In posture 6, the elbow is bent and the body is parallel to the ground. As a result there is an increase in the elbow and wrist moment with a decrease in hip and knee moments because now the majority of the ground reaction force (about 75% of body weight) is at the arm. This posture strengthens the abdomen, back, shoulders, and arms. In posture 7, the head is raised and bent backward as much as possible, bending the spine to the maximum with

Figure 3 Variation of ground reaction force (%BW) on the ankle, knee and wrist joint while performing one cycle of the Sun Salutation. (W Z Weight of Body).

the body taking the shape of an arch. The lower end of this arch is supported by the knee and ankle which are subjected to the maximum moment. Also, due to the spine stretching there is an appreciable amount of moment on the hip. This posture promotes increased lower back flexibility. In posture 8, the hips are moved as high as possible and the spine is stretched downward taking the head as close to the ground as possible. Due to this, the hip is subjected to high moment. In this posture, an effort is made to keep the arms straight and fixed, which results in a greater resisting force developed in the arms which is translated into a high shoulder moment as shown in Table 3. The ground reaction force is shared between the wrist and the ankle, with the ankle taking a slightly more load. This posture stretches the hamstrings, increases upper body strength and promotes increased flexibility to the chest and mid back.

Discussion Figure 4 shows a very interesting pattern in the variation of moments for the joints of the upper body. It reflects that the elbow and shoulder joint moments vary almost in a similar manner. Since the arms are being extended beyond the shoulder in the second and third posture, the shoulder experiences a slightly greater moment than the elbow, hence it is subjected to a greater resisting force. In the sixth posture, the elbow joint shows a higher value of moment compared to the other stages as it is in flexion and at the same time experiences a ground reaction force with the hand in contact with the ground, supporting the body. The eighth posture shows a significant difference in the moments of the elbow and the shoulder joint. With a high moment being generated, the shoulder joint plays a key role in this posture. This is because an effort is made to keep the arms straight and fixed while the hip joint is lifted up. In all other stages the moments on the elbow and the shoulder joints are nearly equal. Meanwhile, there is almost negligible moment on the wrist for the entire cycle except for the sixth posture. In the second and third posture, the palm is just resting on the ground without supporting any load, hence it accounts for the moment only due to the weight of the arm which is negligible in comparison to the moments on the other joints.

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S.N. Omkar et al.

Figure 4

Variation of moments on the wrist, elbow and shoulder joint during one cycle of the Sun Salutation.

The posture in which the wrist acts as a simple support, the wrist plays the role of transmitting the load. Hence the wrist experiences a moment only due to overhang, if any. Similarly, Figure 5 shows the pattern of variation of moments for the joints of the lower body. The hip and knee joint moments show almost a similar pattern of variation during the cycle of Sun Salutation. The hip joint shows a greater value of moment in all the postures except in the seventh posture where the knee joint supports the body. The hip is the major joint which is subjected to peak moments during the Sun Salutation. The moment on the ankle doesn’t show any characteristic curve due to its

Figure 5

variable role in transmitting reaction forces in certain postures while transmitting moments in others. Studies have shown that dynamic moments with high magnitudes and rates, applied with unusual distribution patterns, are optimal for osteogenesis, and that these strain-loading histories play an important role in determining bone morphology (Wang et al., 2006). Persistent, low-amplitude, high-frequency mechanical strains have also been found capable of increasing bone formation rates (Fritton et al., 2000). During the Sun Salutation the joints are subjected to dynamic strains and moments as the body executes different postures during the cycle.

Variation of moments on the hip, knee and ankle joint during one cycle of the Sun Salutation.

A mathematical model of effects on specific joints

207

Table 4 Comparison of moments during the sun salutation with average moments during daily activities (Chou et al., 2005; Finley et al., 2001; Simoneau et al., 2000; Westwell et al., 2006) and peak moments which joints sustain during daily activities (Escamilla et al., 2001; Holzbaur et al., 2007). Joint

Ankle Knee Hip Shoulder Elbow Wrist

Moments (%BWHT) Average during daily activities

Average during the Sun Salutation

Peak during the Sun Salutation

Peak values during daily activities

0.08 0.09 0.098 0.08 0.012 0.013

0.023 0.064 0.083 0.024 0.02 0.004

0.077 0.172 0.174 0.093 0.06 0.025

0.13 0.496 0.416 0.097 0.07 0.031

The moments which the joints are subjected to during the Sun Salutation are comparable to that of daily living activities and exercises as shown in Table 4 e Average during Daily Activities (Chou et al., 2005, Finley et al., 2001, Simoneau et al., 2000, Westwell et al., 2006). However, the power absorption and impact forces experienced during yoga are minimal since the poses are held in a static position whereas daily living activities and exercises involve higher power absorption and impact forces during loading response (Westwell et al., 2006). As seen from Table 4 e Peak Value during Daily Activities (Escamilla et al., 2001, Holzbaur et al., 2007), the joints are subjected to submaximal loadings during the Sun Salutation thus ensuring that none of the joints are overstressed.

Conclusions A mathematical model for each of the postures in the Sun Salutation is developed based on rigid body mechanics and free-body diagrams. The forces and moments encountered by various joints are computed based on the concept of static equilibrium. A number of assumptions have been made in the development of the model described in this paper. However, the fact that the ankle and wrist, when modeled, are found to play a primary role in transmitting the ground reaction forces during the Sun Salutation, while the hips bear the highest joint moment, mirrors what is found in practice. As such it would suggest the model to be a useful tool for predicting the forces and moments that occur not only during the Sun Salutation but for other yoga postures too, as well as in predicting the benefits of yoga in general. Certainly, the present data would suggest that an important benefit of the Sun Salutation postures are that the joints involved are subjected to submaximal loadings as compared to more high impact exercises for which the energy expenditure is comparable. Practicing the Sun Salutation postures regularly, therefore, by producing high joint moments yet submaximal joint loading, would suggest they could have a beneficial role to play in bone remodelling and osteogenesis.

References Birch, B.B., 1995. Power Yoga. Fireside, New York. Chattha, R., Raghuram, N., Venkatram, P., Hongasandra, N.R., 2008. Treating the climacteric symptoms in Indian women with

an integrated approach to yoga therapy: a randomized control study. Menopause 15 (5), 862e870. Chou, P.P., Chou, Y., Chen, S., Kuo, C., 2005. Relationship between elbow flexion angle and joint loading of the upper extremity during a close-chain exercise. In: Proceedings of American Society of Biomechanics. Cleveland State University, Cleveland, Ohio. Cowen, V.S., Adams, T.B., 2007. Heart rate in yoga asana practice: a comparison of styles. Journal of Bodywork and Movement Therapies 11, 91e95. DiCarlo, L.J., Sparling, P.B., Hinson, B.T., Snow, T.K., Rosskopf, L.B., 1995. Cardiovascular, metabolic, and perceptual responses to hatha yoga standing poses. Medicine, Exercise, Nutrition and Health 4, 107e112. Escamilla, R.F., Fleisig, G.S., Lowry, T.M., Barrentine, S.W., Andrews, J.R., 2001. A three-dimensional biomechanical analysis of the squat during varying stance widths. Medicine and Science in Sports and Medicine 33 (6), 984e998. Ferreira, J.P., Crisostomo, M., Coimbra, A.P., Carnide, D., Marto, A., 2007. A human gait analyzer. IEEE International Symposium on Intelligent Signal Processing, 1e5. doi: 10.1109/WISP.2007.4447537. Finley, M.A., McQuade, K.J., Rodgers, M.M., 2001. Peak shoulder kinetics and kinematics in during wheelchair propulsion. In: Proceedings of American Society of Biomechanics. University of California, San Dielgo. Fritton, S.P., McLeod, K.J., Rubin, C.T., 2000. Quantifying the strain history of bone: spatial uniformity and self-similarity of low-magnitude strains. Journal of Biomechanics 33 (3), 317e325. Halliday, D., Resnick, R., Walker, J., 2008. Fundamentals of Physics. John Wiley & Sons. Holzbaur, K.R.S., Delp, S.L., Gold, G.E., Murray, W.M., 2007. Moment-generating capacity of upper limb muscles in healthy adults. Journal of Biomechanics 40 (11), 2442e2449. Moisio, K.C., Sumner, D.R., Shott, S., Hurwitz, D.E., 2003. Normalization of joint moments during gait: a comparison of two techniques. Journal of Biomechanics 36 (4), 599e603. Omkar, S.N., 2007. An analysis of Sun Salutation. In: Proceedings of Asia-Pacific Congress on Sports Technology. Nanyang Technological University, Singapore. Prasad, K.V.V., Venkata Ramana, Y.P.S., Venkata Reddy, M., Murthy, K.J.R., 2001. Energy cost and physiological efficiency in male yoga practitioners. Journal of Exercise Physiology online 4 (3), 38e44. Rai, L., Ram, K., Kant, U., Madan, S.K., Sharma, S.K., 1994. Energy expenditure and ventilatory responses during siddhasanada yogic seated posture. Indian Journal of Physiology and Pharmacology 38 (1), 29e33. Raju, P.S., Kumar, K.A., Reddy, S.S., Madhavi, S., Gnanakumari, K., Bhaskaracharyulu, C., 1986. Effect of yoga on exercise tolerance in normal healthy volunteers. Indian Journal of Physiology and Pharmacology 30 (2), 121e132.

208 Simoneau, G.G., Hambrook, G.W., Harris, G.F., 2000. Quantifying upper extremity efforts when using a walking frame. In: Pediatric Gait: a New Millennium in Clinical Care and Motion Analysis Technology, pp. 210e216. doi:10.1109/PG.2000.858900. Sum, J.A., Lee, M.I., Hurwitz, D.E., Andriacchi, T.P., 1998. Effects of normalization on joint moments during level walking. Gait & Posture 7 (2), 184. Tran, M.D., Holly, R.G., Lashbrook, J., Amsterdam, E.A., 2001. Effects of hatha yoga practice on the health-related aspects of physical fitness. Preventive Cardiology 4 (4), 165e170.

S.N. Omkar et al. Wang, M., Flanagan, S.P., Song, J., Greendale, G.A., Salem, G.J., 2006. Relationships among body weight, joint moments generated during functional activities, and hip bone mass in older adults. Clinical Biomechanics 21 (7), 717e725. ˜ unpuu, S., 2006. Evaluation of lower Westwell, M., Bell, K., O extremity joint moments experienced during several yoga postures. Gait & Posture 24 (2), S213eS215. Winter, D.A., Eng, J.J., 1995. Kinetic analysis of the lower limbs during walking: what information can be gained from a threedimensional model. Journal of Biomechanics 28 (6), 753e758.

Journal of Bodywork & Movement Therapies (2011) 15, 209e214

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

RELIABILITY STUDY

Application of perineometer in the assessment of pelvic floor muscle strength and endurance: A reliability study Nahid Rahmani a, Mohammad A. Mohseni-Bandpei b,* a

Physiotherapy Department, The University of Social Welfare and Rehabilitation Sciences, Evin, Tehran, Iran Physiotherapy Department, The University of Social Welfare and Rehabilitation Sciences, PO Box 1985713834, Evin, Tehran, Iran b

Received 18 January 2009; received in revised form 8 July 2009; accepted 8 July 2009

KEYWORDS Perineometer; Pelvic floor muscle; Reliability; Strength; Endurance

Summary Despite different studies on the reliability of pelvic floor muscle assessment, there is still no general consensus on the most valid and reliable method. The purpose of this study was to investigate the intra-rater (within-day and between-days) reliability of perineometer in the assessment of pelvic floor muscle strength and endurance. Following ethical approval, 15 healthy women aged from 22 to 50-years old, with no history of low back pain were recruited. The Peritron perineometer instrument was used to measure pelvic floor muscle strength and endurance. Two measurements were taken on the same day with an hour interval to assess within-day reliability and the third measurement was taken five days later to determine between-days reliability. Intraclass Correlation Coefficients (ICCs) and the level of agreement between measurements were used for data analysis. The high ICC values (0.95 for strength and 0.94 for endurance) and high level of agreement between measurements indicated high within-day reliability for pelvic floor muscle strength and endurance. The perineometer was also shown to be reliable for between-days measurements with high ICC (0.88 for strength and 0.83 for endurance) and high level of agreement between measurements. The results demonstrated that the perineometer appears to be a highly reliable method of measuring pelvic floor muscle strength and endurance when measurements are taken in healthy subject by the same investigator. ª 2009 Elsevier Ltd. All rights reserved.

Introduction * Corresponding author. E-mail address: [email protected] (M.A. Mohseni-Bandpei).

Epidemiological aspects of low back pain (LBP) have been reported in numerous studies, worldwide (Jin et al., 2004; Mohseni-Bandpei et al., 2006; Gourmelen et al., 2007;

1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.07.007

210 Mohseni-Bandpei et al., 2007; Schmidt et al., 2007). At least half of the general population will experience LBP at some point in their lifetime, with reported prevalence rates ranging from 51% to 84% (Cassidy et al., 1998; MohseniBandpei et al., in press). Around 33% of a community sample will report having experienced LBP in the past month, while between 39% (Hillman et al., 1996) and 67% will report an episode during the past 12 months (Ihlebaek et al., 2006). There is also adequate evidence to support the idea that LBP has huge economic impact (both direct and indirect costs) on patients and societies (Luo et al., 2004; Ekman et al., 2005; Wenig et al., 2009). It has become clear that stability of the spine is a dynamic process that includes both static positions and controlled movements (Sahrmann, 2002). Muscles provide support and stiffness at the intervertebral level to sustain forces commonly encountered in life (Barr et al., 2005). A large number of muscles cross the spine, and all contribute to the modulation of lumbar stability. This is a complex system consisting of deep and global muscle systems (Bergmark, 1989). The local group of muscles that are thought to contribute to spinal stability are Transversus Abdominis, Lumbar Multifidus, Diaphragm and Pelvic floor muscles (Hodges et al., 2007). These muscles have a synergistic function and the isolated function of one of these muscles cannot occur (Bergmark, 1989). In addition to the well documented role for pelvic floor muscles in patients with urinary and faecal incontinence, the pelvic floor muscles have also an important role in proper muscular activation for lumbar stabilization (Sapsford and Hodges, 2001; Hodges et al., 2007). The pelvic floor forms the base of the abdominal cavity and during different tasks that elevate intra-abdominal pressure, muscles must contract to maintain continence and contribute to pressure increases. In healthy subjects, strong voluntary abdominal muscle contraction causes pelvic floor muscle activity at the same intensity as maximal pelvic floor muscle’s effort (Sapsford and Hodges, 2001). Evaluation of pelvic floor muscle strength and endurance provides information on the severity of muscle weakness and form the basis of patients specific exercise programs. Therefore, in order to assess the pelvic floor muscle’s function and also to monitor the effect of any rehabilitation programme, the ability to reliably determine the strength and endurance of these muscles is of great value. Different methods are available in the assessment of pelvic floor muscle strength and endurance including: manual muscle test by vaginal palpation (Bø and Finckenhagen, 2001; Morin et al., 2004); manometer (Dougherty et al., 1986), perineometer (Laycock and Jerwood, 1994); cones (Plevnik, 1985); electromyography (EMG) (Haslam, 2002); ultrasound (Vierhout and Jansen, 1989; Whittaker et al., 2007; Dietz and Shek, 2009), and magnetic resonance imaging (MRI) (Khullar, 2002). As Bø and Sherburn (2005) reported, these methods have their own advantages and disadvantages. Perineometer is a simple, minimal invasive and non-expensive device to evaluate pelvic floor muscle strength and endurance. It is designed to measure pressure changes in the vagina in response to voluntary pelvic floor muscle contractions. There has been limited study into the reliability and validity of the perineometer as a tool for the quantitative evaluation of pelvic floor muscle strength and endurance.

N. Rahmani, M.A. Mohseni-Bandpei The purpose of this study was to investigate the intrarater reliability of the perineometer (within-day and between-days) in the assessment of pelvic floor muscle strength and endurance. This study formed part of the preliminary work for a larger study. The latter was a prospective randomised controlled clinical trial, investigating the effectiveness of two therapeutic approaches including pelvic floor muscle exercises in patients with chronic LBP. This major study required a practical and reliable method of perineometer measurement as one method of assessment.

Material and methods Study design and sampling Following ethical approval from the Medical Ethics Board of the University of Social Welfare and Rehabilitation Sciences, 15 healthy women were randomly recruited according to the inclusion and exclusion criteria of the study. Women were included if they were healthy, married and at age range 22e50 years. The sample characteristics are summarized in Table 1. Subjects were excluded if they had any history of a sacroiliac joint dysfunction, vaginal cavity size inadequate to comfortably insert the perineometer, pregnancy, major neurological and respiratory diseases, metabolic disease, and a degree of pelvic organ prolapse, sufficient to prevent maintenance of the perineometer inserted intravaginally at rest, a history of abdominal or back surgery, intervertebral disk herniation and malignancies or other major medical conditions. All subjects were given written information about the aims and plans of the study and then they were asked to sign a consent form if they agreed to participate.

Procedure The examination was performed in crook lying position for all subjects using a vaginal pressure measurement device. The Peritron perineometer (Cardio Design Pty Ltd, Oakleigh, Victoria, Australia), which is a conical vaginal insert, 28 mm in diameter and 108 mm in length with an active surface measurement length of 55 mm, was used. The vaginal insert is connected to a handheld microprocessor with latex tubing, allowing for transmission of pressure readings in centimeters of water when the insert is compressed by external pressure. The insert was covered with a sterile latex sleeve for each patient. The perineometer was inserted into the vaginal canal until the full extent of the compressible portion of the device was above the level of the hymeneal ring. The baseline pressure reading was recorded and then the device was zeroed. Table 1

Characteristics of the subjects.

Variable

Mean

SD

Range

Age (years) Weight (kg) Height (cm)

29.53 66.06 165

6.65 7.51 6.49

22e50 52e79 156e175

Application of perineometer in the assessment of pelvic floor muscle strength and endurance Subjects were instructed to contract their pelvic floor muscles and to squeeze with maximum perceived effort for two to three seconds. They were asked to pull their pelvic floor muscles in and up as much as possible. Three squeezes were recorded in succession with a 10-s rest interval between efforts (Bø and Finckenhagen, 2001). The peak of the three successive contractions was recorded as maximum perceived strength of pelvic floor muscles. In order to measure the endurance, 60% of maximum perceived strength was calculated. Subjects were then instructed to maintain this squeeze pressure until fatigue occurred or the squeeze pressure returned to 50% of the primary effort. For each effort, a maximum perceived pressure and duration of squeeze were considered as strength and endurance of pelvic floor muscles. In order to minimize any increase in perineometer recording caused by excessive raises in intra-abdominal pressure, each pelvic floor muscle contraction was checked through observation of a perineal lift and the use of a pressure biofeedback device placed in the lumbar spine, to ensure maintenance of a neutral spine. Two measurements were taken on the same day with an hour interval to assess within-day reliability and the third was taken five days later to determine between-days reliability.

Data analysis Intraclass Correlation Coefficients (ICCs) were used to assess within-day (between the first and second measurements) and between-days (between the first and third measurements) reliability of measuring pelvic floor muscle strength and endurance using perineometer. The values suggested by Richman et al. (1980) were used to identify the quality of the reliability coefficients of the results of this study. They suggested that reliability coefficient values of 0.80e1.00 indicate high, 0.60e0.80 moderate, and less than 0.59 questionable reliability. As Bland and Altman (1986) suggested, the high correlation does not mean that the two sets of data agree, as correlation measures the strength of a relation between two data, not the agreement between them. Therefore, an additional method was used to demonstrate how closely the measurements agree on different occasions. They recommend use of the 95% confidence interval (95% CI) of the range of differences between the two measurements (Bland and Altman, 1986).

Results Fifteen healthy women with age range 22e50 years, were recruited for this study. Sample size estimation indicated that with intra-rater ICC that exceeded 0.7, an alpha level of 5%, a power of 80%, and an effect size of 0.5, 15 subjects were required (Cohen, 1977). None of the subjects had any history of LBP. Table 2 summarizes the strength and endurance measurements obtained on the three occasions. The ICC values result for within-day reliability and also for between-days reliability are shown in Table 3. Within-day pelvic floor muscle strength and endurance measurements using perineometer were shown to be very reliable with

211

Table 2 Mean and Standard Deviation (SD) of pelvic floor muscles strength and endurance measurements (from all subjects). Variable

Measurement

Mean

SD

Range

Strength

First Second Third

41.73 42.48 41.28

13.84 12.71 12.22

16.9e60.1 17.6e65.5 18.4e63.7

Endurance

First Second Third

62.76 64.62 67.72

33.91 34.52 35.89

17.3e 130.4 22.8e 129.7 24.8e 125.9

high ICC values (0.95 for strength and 0.94 for endurance). The high ICC values (0.88 for strength and 0.83 for endurance) indicated high reliability for between-days measurements. A simple plot of the results of pelvic floor muscle strength measurements for the same day and different days are shown in Figures 1 and 2. These plots show the line of equality on which all measures would lie if two measurements gave exactly the same reading every time and help to estimate the degree of agreement (Bland and Altman, 1986). As can be seen in Figs. 1 and 2, the measurements taken on the same day are closer to the line of equality than those were taken over five days. This indicates the higher reliability values for within-day measurement compared with between-days measurements. Figs. 3 and 4 are examples which display an agreement between the measurements of pelvic muscle endurance for both occasions. The limits of agreement were defined as the mean difference of the two measurements 2 standard deviations. The mean difference should be zero or no significant difference between two means. For example, Fig. 3 shows a comparison of pelvic floor muscle endurance measurements between the first and second measurements. The mean difference is 3.1 with 95% CI of 9.25 to 2.98 s, which indicates a good level of agreement between the two measurements (Bland and Altman, 1986).

Discussion In clinical practice it is essential that valid and reliable techniques be employed if any conclusions about the effectiveness of rehabilitation programs are to be drawn. A reliable and valid method of measuring pelvic floor muscle strength and endurance is important in assessing both Table 3 Within-day and between-days reliability of the pelvic floor muscles strength and endurance using the Perineometer.

Within-day Reliability Between-days Reliability a b c

Variable

ra

ICC

Strength Endurance Strength Endurance

0.96 0.95 0.89 0.87

0.96 0.94 0.88 0.83

r Z Pearson r. P > 0.05 for all paired t-tests. Standard Error of Measurement.

t-testb value SEMc 0.68 0.27 1.06 2.15

3.01 7.74 4.45 16.67

N. Rahmani, M.A. Mohseni-Bandpei Differences between first and second measures

212

Strength as measured on first occasion

80.0

60.0

40.0

20.0

0.0 0.0

20.0

40.0

60.0

8.00 6.00 4.00

Mean + 2SD

2.00 0.00 -2.00

Mean

-4.00 -6.00 -8.00

Mean - 2SD

-10.00 -12.00 20.00

80.0

40.00

60.00

80.00

100.00

120.00

140.00

Average of first and second measures

Strength as measured on second occasion

Figure 1 Regression plot showing a close relationship between measurements of pelvic muscle strength (water centimeter) as measured on the same day.

Figure 3 Differences between pairs of measures plotted against the mean of those pairs of measures for pelvic floor muscle endurance measured on the same day.

pelvic floor muscle function and evaluating the effectiveness of therapeutic interventions. As there is a lack of evidence on the reliability of perineometer, the current study was designed to examine the reliability of perineometer in the assessment of pelvic floor muscle strength and endurance. Results demonstrated that the perineometer could be considered as a reliable method in measuring pelvic floor muscle strength and endurance for both within-day and between-days measurements. Previous studies on perineometers demonstrated that intravaginal balloon devices could produce reliable pressure recordings when measuring pelvic floor muscle function through vaginal pressure measurement (Bø et al., 1990). Dougherty et al. (1986) investigated the reliability of maximum pressure measurements for Kegel efforts on 20 healthy volunteers. They used an intravaginal balloon device and reported a high correlation (r Z 0.85) for repeated maximal pressure measurements. On 263 women,

Isherwood and Rane (2000) have compared perineometer and Oxford scale digital examination in the assessment of pelvic floor muscle strength and reported a good agreement between the two modalities (k Z 0.73). In a study conducted by Sartore et al. (2003) on 197 primiparous women, pelvic floor muscle function was assessed shortly after delivery. They demonstrated moderate agreement between Oxford ratings and vaginal pressure measures with an air-filled perineometer (k Z 0.47). Kerschan-Schindl et al. (2002) and found a high correlation between perineometer measurements and digital assessment of strength (r>0.7) in a small group of 37 elderly women. Hundley et al. (2005) demonstrated a good correlation between the maximum perineometer pressure and the total Brink score, suggesting that these two methods of assessment have similar levels of reproducibility. Additionally, the perineometer was shown to have good short-term testeretest reliability. However, different reported results may be Differences between first and third measures

Strength as measured on first occasion

80.0

60.0

40.0

20.0

0.0 0.0

20.0

40.0

60.0

80.0

Strength as measured on third occasion

Figure 2 Regression plot showing a close relationship between measurements of pelvic floor muscles strength (water centimeter) as measured over five days.

2.00 Mean + 2SD

0.00 -2.00 -4.00

Mean

-6.00 -8.00 Mean - 2SD

-10.00 -12.00 20.00

40.00

60.00

80.00

100.00

120.00

140.00

Average of first and third measures

Figure 4 Differences between pairs of measures plotted against the mean of those pairs of measures for pelvic floor muscle endurance measured over five days.

Application of perineometer in the assessment of pelvic floor muscle strength and endurance attributed to different sample sizes, different study designs, poorly defined inclusion and exclusion criteria (heterogeneous sample), lack of a standard method of measuring pelvic floor muscle function, lack of a commonly accepted method of measuring correct contraction of pelvic floor muscles with no co-contraction, etc. The results of the present study are consistent with those that previously reported high intra-rater reliability for perineometer. However, different approaches with different control groups, different times of interval exams, as well as on heterogonous sample issues, makes it difficult to draw conclusion on the reliability of perineometer in the assessment of pelvic floor muscle function. A short-term interval of 5e10 min (as it is used in the study carried out by Hundley et al.) may be a confounding factor and potentially have a negative influence on the accuracy of reliability of perineometer. A longer duration of recovery time between assessments may provide a chance to minimize the effects of fatigue on testeretest reliability. In order to control such an effect on the reliability and optimize the results, in the present study an interval of an hour and five days was considered quite appropriate for within-day and between-days reliability. Due to the small sample size of this study, further analysis to determine the effect of some factors including age, body mass index, size of genital hiatus and parity was not carried out, although Hundley et al., reported that none of these variables were found to have an effect on the reliability of perineometer in the assessment of pelvic floor muscle function. As highlighted by Hundley et al. (2005), another obvious concern in all studies of this nature is whether the device in question is isolating and measuring the desired parameter. It seems that this issue is of particular importance when analysing pelvic floor muscle strength, as the pelvic floor is made up of a collection of several muscle groups. Additionally, abdominal pressure transmitted to the device could potentially be a confounding factor, although every attempt should be made to minimize this effect. It is not claimed that perineometer is as precise in its isolation of the pelvic floor musculature as more technically elaborate devices, but a degree of imprecision does not preclude its value as a simple, inexpensive, and painless way to reliably assess general pelvic floor muscle strength. In the current study, the correct pelvic floor muscle contraction was obtained through both observation and biofeedback pressure. However, the ability of perineometer to provide quantifiable and objective measures of pelvic floor muscle strength for clinical purposes makes it a valuable instrument in clinical settings.

Conclusion The current study evaluated the intra-rater reliability of perineometer measuring pressure in centimeters of water in the assessment of pelvic floor muscle strength and endurance. The results suggested high intra-rater reliability, both for within-day and between-days. Because of its simplicity, quickness minimal invasiveness, minimal inconvenience, inexpensive and high reliability, compared to other approaches the perineometer appears to be an

213

appropriate objective method for measuring pelvic floor muscle strength and endurance.

Acknowledgements The authors acknowledge the University of Social Welfare and Rehabilitation Sciences for financial support of this study. They are also grateful to Dr. Lucy O’Driscoll at the University of East Anglia for reviewing the manuscript.

References Barr, K.P., Griggs, M., Cadby, T., 2005. Lumbar stabilization: core concepts and current literature, part 1. American Journal of Physical Medicine and Rehabilitation 84, 473e480. Bergmark, A., 1989. Stability of the lumbar spine. A study in mechanical engineering. Acta Orthopaedica Scandinavaica Supplementum 230, 1e54. Bland, J.M., Altman, D.G., 1986. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 8, 307e310. Bø, K., Finckenhagen, H.B., 2001. Vaginal palpation of pelvic floor muscle strength: inter-test reproducibility and comparison between palpation and vaginal squeeze pressure. Acta Obstetricia et Gynecologica Scandinavica 80, 883e887. Bø, K., Kvarstein, B., Hagen, R.R., Larsen, S., 1990. Pelvic floor muscle exercise for the treatment of female stress urinary incontinence: II. Validity of vaginal pressure measurements of pelvic floor muscle strength and the necessity of supplementary methods for control of correct contraction. Neurourology and Urodynamics, 479e487. Bø, K., Sherburn, M., 2005. Evaluation of female pelvic-floor muscle function and strength. Physical Therapy 85, 269e282. Cassidy, J.D., Carroll, L.J., Co ˆte ´, P., 1998. The Saskatchewan health and back pain survey. The prevalence of low back pain and related disability in Saskatchewan adults. Spine 23, 1860e1866. Cohen, J., 1977. Statistical Power of the Behavioral Sciences. Academic Press, New York (revised edition). Dietz, H.P., Shek, K.L., 2009. Tomographic ultrasound imaging of the pelvic floor: which levels matter most? Ultrasound in Obstetrics and Gynecology 33, 698e703. Dougherty, M.C., Abrams, R., McKey, P.L., 1986. An instrument to assess the dynamic characteristics of the circumvaginal musculature. Nursing Research 35, 202e206. Ekman, M., Jo ¨nhagen, S., Hunsche, E., Jo ¨nsson, L., 2005. Burden of illness of chronic low back pain in Sweden: a cross-sectional, retrospective study in primary care setting. Spine 30, 1777e1785. Gourmelen, J., Chastang, J.F., Ozguler, A., Lanoe ¨, J.L., Ravaud, J.F., Leclerc, A., 2007. Frequency of low back pain among men and women aged 30e64 years in France. Results of two national surveys. Annales de Readaptation et de Medicine Physique 50, 640e644. Haslam, J., 2002. ‘‘Biofeedback’’. In: Laycock, J., Haslam, J. (Eds.), Therapeutic Management of Incontinence and Pelvic Pain. Springer Verlag, London. Hillman, M., Wright, A., Rajaratnam, G., Tennant, A., Chamberlain, M.A., 1996. Prevalence of low back pain in the community: implications for service provision in Bradford, UK. Journal of Epidemiology and Community Health 50, 347e352. Hodges, P.W., Sapsford, R., Pengel, L.H., 2007. Postural and respiratory functions of the pelvic floor muscles. Neurourology and Urodynamics 26, 362e371. Hundley, A.F., Wu, J.M., Visco, A.G., 2005. A comparison of perineometer to brink score for assessment of pelvic floor muscle

214 strength. American Journal of Obstetrics and Gynecology 192, 1583e1591. Ihlebaek, C., Hansson, T.H., Laerum, E., Brage, S., Eriksen, H.R., Holm, S.H., Svendsrød, R., Indahl, A., 2006. Prevalence of low back pain and sickness absence: a ‘‘borderline’’ study in Norway and Sweden. Scandinavian Journal of Public Health 34, 555e558. Isherwood, P.J., Rane, A., 2000. Comparative assessment of pelvic floor strength using a perineometer and digital examination. British Journal of Obstetrics and Gynecology 107, 1007e1011. Jin, K., Sorock, G.S., Courtney, T.K., 2004. Prevalence of low back pain in three occupational groups in Shanghai, People’s Republic of China. Journal of Safety Research 35, 23e28. Kerschan-Schindl, K., Uher, E., Wiesinger, G., Kaider, A., Ebenbichler, G., Nicolakis, P., Kollmitzer, J., Preisinger, E., Fialka-Moser, V., 2002. Reliability of pelvic floor muscle strength measurement in elderly incontinent women. Neurourology and Urodynamics 21, 42e47. Khullar, A.H., 2002. ‘‘Investigations’’. In: Laycock, J., Haslam, J. (Eds.), Therapeutic Management of Incontinence and Pelvic Pain. Springer Verlag, London. Laycock, J., Jerwood, D., 1994. Development of the Bradford perineometer. Physiotherapy 80, 139e142. Luo, X., Pietrobon, R., Sun, S.X., Liu, G.G., Hey, L., 2004. Estimates and patterns of direct health care expenditures among individuals with back pain in the United States. Spine 29, 79e86. Mohseni-Bandpei, M.A., Fakhri, M., Shirvani, M., BagheriNesami, M., Khalilian, A.R., Shayesteh-Azar, M., 2006. Occupational low back pain in Iranian nurses: an epidemiological study. British Journal of Nursing 15, 914e917. Mohseni-Bandpei, M.A., Bagheri Nessami, M., Shayesteh Azar, M., 2007. Nonspecific low back pain in 5000 Iranian School age Children. Journal of Pediatric Orthopedics 27, 126e129. Mohseni-Bandpei, M., Fakhri, M., Ahmad-Shirvani, M., Bagheri Nessami, M., Khalilian, A., Shayesteh-Azar, M., et al. Low back pain in 1100 Iranian pregnant women: prevalence and risk

N. Rahmani, M.A. Mohseni-Bandpei factors. The Spine Journal, in press, doi:10.1016/j.spinee.2009. 05.012. Morin, M., Dumoulin, C., Bourbonnais, D., Gravel, D., Lemieux, M.C., 2004. Pelvic floor maximal strength using vaginal digital assessment compared to dynamometric measurements. Neurourology and Urodynamics 23, 336e341. Plevnik, S., September 1985. A new method for testing and strengthening of pelvic floor muscles (Abstract). In: Proceeding of the 15th Annual Meeting of the International Continence Society, London, United Kingdom. pp. 267e268. Richman, J., Mackrides, L., Prince, B., 1980. Research methodology and statistics. Part 3: measurement procedures in research. Physiotherapy Canada 32, 253e257. Sahrmann, S.A., 2002. Diagnosis and Treatment of Movement Impairment Syndromes. Mosby, St. Louis. Sapsford, R.R., Hodges, P.W., 2001. Contraction of the pelvic floor muscles during abdominal maneuvers. Archives of Physical Medicine and Rehabilitation 82, 1081e1088. Sartore, A., Pregazzi, R., Bortoli, P., Grimaldi, E., Ricci, G., Guaschino, S., 2003. Assessment of pelvic floor muscle function after vaginal delivery. Clinical value of different tests. Journal of Reproductive Medicine 48, 171e174. Schmidt, C.O., Raspe, H., Pfingsten, M., Hasenbring, M., Basler, H.D., Eich, W., Kohlmann, T., 2007. Back pain in the German adult population: prevalence, severity, and sociodemographic correlates in a multiregional survey. Spine 32, 2005e2011. Vierhout, M.E., Jansen, H., 1989. Supine and sitting transrectal ultrasonographic evaluation of the bladder neck during relaxation, straining and squeezing. Neurourology and Urodynamics 8, 301e302. Wenig, C.M., Schmidt, C.O., Kohlmann, T., Schweikert, B., 2009. Costs of back pain in Germany. European Journal of Pain 13, 280e286. Whittaker, J.L., Thompson, J.A., Teyhen, D.S., Hodges, P., 2007. Rehabilitative ultrasound imaging of pelvic floor muscle function. Journal of Orthopaedic and Sports Physical Therapy 37, 487e498.

Journal of Bodywork & Movement Therapies (2011) 15, 215e216

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BOOK REVIEW Fascial Release for Structural Balance, James Earls, Thomas Myers, Lotus Publishing, Chichester, UK, 2010, RRP £24.99/ US$39.95, ISBN 978 1 905367 18 4. This book represents the long-awaited ‘day in, day out’ reference manual for fascia-orientated bodywork and movement practitioners, virtually irrespective of their structural persuasion or professional background. For indeed, it does appear to tick just about every box in the repertoire. Notably: Presentation: the most immediately striking feature is its multi-faceted clarity. Pages are uncluttered, and the text is in a generous font size. The abundant, equally liberally-sized photos and illustrations appear in carefully selected ‘calming’ pastel and dark colour schemes, once again with readily legible size legends. Chapter titles, headings, and sub-headings are distinct, and break the text into comfortably manageable portions, further enhanced by the frequency of well separated paragraphs, and exemplary line spacing. Structure: Chapter 1 provides a reader-friendly update on the key anatomical concepts, models, and recent research findings underpinning fascia-oriented bodywork, including essential notions such as ‘human patterning’, ‘fascial webbing’, and ‘tensegrity’. The fundamental components of Fascial Release are then described in Chapter 2, followed by an insightful assessment guide to ‘BodyReading’ in Chapter 3 (Figure 1). Chapters 4e9 then take the reader methodically through an in-depth journey up the body from foot to head or arm, commencing in each case with a fascial, model-based, illustrated, anatomical presentation of the relevant body region. This is followed by photo-assisted ‘BodyReading’ assessments of associated common patterns, before a detailed step-bystep guide into how to apply a variety of techniques, once again illustrated with clear colour photographs. The technique illustrations faithfully reflect features of calmness, gentleness, slow pace, softness of contact, clienttherapist continuity, and tissue ‘melting’ and responsiveness. The very useful concluding Appendices bear further witness to the authors’ attention to detail.

trainers who have already embraced the fascial ‘bio-tensegrity’ model within their sphere of practice, its versatile content should be of interest and practical value to a wide spectrum of manual and movement therapists at all levels of experience e from the manual therapy or massage student intrigued by ‘myofascia’, to the advanced healthcare researcher, perhaps seeking an alternative approach to pharmaceutical, surgical, or other invasive intervention, via the experienced clinician, potentially disillusioned with the limitations of currently ‘trendy’ therapeutic models. This work also offers fascinating anatomical insights, challenges long-held biomechanical concepts, and offers new ways of viewing, thinking, and interpreting the ‘familiar’. It provides unexpected answers, and invites a wide range of questions. In the reviewer’s experience, the manual merits the status of classroom textbook for any suitably validated, professional manual therapy course or module. Alongside Thomas Myers’ more theoretical Anatomy Trains (2009)

Whom is the book written for? While Fascial Release for Structural Balance will undoubtedly appeal first and foremost to clinicians and movement

doi:10.1016/j.jbmt.2011.01.001

Figure 1 Active release of the posterior ‘lateral raphe’ using bench work.

216 title, it is a must-have reference tool for any present, future, or former student of this approach to bodywork. Its breadth and level of detail could not fail to benefit e and no doubt challenge e the most experienced of bodywork or movement therapists. Sincere congratulations to the authors for achieving such a widely-appealing ‘companion’! Finally. Perhaps the cover should carry the Health Warning: ‘Readers may develop an irrepressible, incurable passion for “Anatomy according to fascia”!’

Book Review

Reference Myers, T.W., 2009. Anatomy Trains. Churchill Livingstone, Edinburgh.

Tanya Ball Sports & Remedial Care/Time 4 Change Structural Integration, c/o 86 Windermere Avenue, Kempshott, Basingstoke, Hampshire RG22 5JH, United Kingdom E-mail address: [email protected] 2 December 2010

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FASCIAL RELEASE CASE STUDIES

Structural integration-based fascial release efficacy in systemic lupus erythematosus (SLE): Two case studies Tanya M. Ball, MSc BCSI LSSM* Sports & Remedial Care, c/o 86 Windermere Avenue, Kempshott, Basingstoke, Hampshire RG22 5JH, UK Received 14 December 2009; received in revised form 17 September 2010; accepted 21 October 2010

KEYWORDS Structural Integration; Rolfing; Fascial release therapy; Auto-immune; Scleroderma; Raynaud’s

Summary Auto-immune conditions such as Scleroderma and SLE induce fascial sclerosis and fibrosis, with related vascular, lymphatic, neural, joint, and visceral compression. Ensuing ischaemic pain, necrosis, autonomic and immune dysfunction in turn account for much of patients’ pain, functional impairment, and psychological distress. Fascial Release Therapy (FRT) is a hands-on therapeutic model focused on restoring postural and functional integrity by addressing fascial imbalance, with hypothesized efficacy for SLE patients in:
Reducing pain, stiffness, fatigue, anxiety.
Enhancing functional mobility, autonomy, quality of life, emotional state, autonomic and immune function. Two SLE patients who received FRT treatment along KMI
SI methodology, reported improvements to seven symptoms, namely:
Reduced pain, fatigue/exhaustion, anxiety.
Enhanced functional mobility, autonomy, emotional state, and quality of life. While ‘spontaneous recovery’ cannot be ruled out without controls, these anecdotal results support further, broader-based clinical research with stringent evaluation tools to enhance outcome validity.

* Tel.: þ44 0 77 10 22 97 04. E-mail addresses: [email protected], [email protected]. URL: http://www.tmb-src.co.uk. 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.10.006

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T.M. Ball Therapeutic mechanisms may includefascial relaxation as key to decreasing myofascial pain; myofibroblast response to ‘stress’; inter- and trans-fascial plane transfer of enhanced ‘ease’ and ‘glide’. Psycho-neuro-immunological factors reversing adverse auto-immune response. ª 2010 Elsevier Ltd. All rights reserved.

Introduction

nowadays (Abu-Shakra, 2008; Bernatsky et al., 2006; Merrell and Shulman, 1955; Urowitz et al., 1997).

‘Scleroderma’ is a generic term encompassing a spectrum of complex auto-immune conditions with similar, or overlapping clinical features, from relatively localised disorders such as ‘primary Raynaud’s phenomenon’, to significantly more debilitating systemic diseases, including ‘systemic sclerosis’ (SSc) and ‘systemic Lupus Erythematosus’ (SLE) (Denton et al., 2002). Because of the considerable ‘overlap syndrome’ between scleroderma and SLE in particular, as well as among the ‘spectrum’ of scleroderma-type conditions in general (Assassi et al., 2007; Denton et al., 2002; Ball, in press), any generic references to ‘scleroderma’ in this text will be deemed to include SLE. Notwithstanding variations from one disease and patient to another, all conditions classified under the ‘scleroderma umbrella’ generally share the following characteristics:

Beyond patient presentation and scleroderma ‘overlap’ variations, the condition’s impact on the ‘connective tissues’ (CTs) or ‘fasciae’ is clearly of greatest significance for MT. Therefore a sound understanding of ‘fascia types’ (http:// www.fasciacongress.org/2009)1, and how these are affected is critical to appropriate clinical reasoning, effective treatment, and management planning. Martin’s (2009) case study with a diffuse systemic sclerosis (dSSc) patient aptly summarises some of the pathological processes involved.

a) All are chronic, inflammatory, auto-immune conditions. b) Although their aetiology is thought to be multifactorial, with potential genetic, environmental, physical, and emotional health predisposing factors, to date they have no known ‘cause’. c) Gender appears to be a factor, with a female-male 8:1 ratio, and the mid-twenties to mid-fifties being deemed the most susceptible age group. d) Although medical intervention including pharmaceutical drugs can usually stabilize and manage these conditions, to date they remain ‘chronic conditions’. e) Their pathology inter alia affects three essential systems of immediate relevance to manual therapy (MT):
The vascular system.
The immune e including the lymphatic e system.
The fascial system (Denton, 1996; Denton et al., 2002; Assassi et al., 2007; Abu-Shakra, 2008; Ball, in press).

The single widest common denominator, with regard to how auto-immune ‘self-destruction’ activity in scleroderma affects the skin and CTs, irrespective of ‘fascia type’, is characterised by fibrotic changes associated with fibroblastic cell over-activity, leading to collagen overproduction within those tissues (Denton et al., 2002). Ensuing adverse tissue changes include thickening, shortening, hardening, and scarring, resulting in reduced range of motion (RoM), and vascular, lymphatic, neural, joint, and visceral compression and constriction. Ischaemic pain, tissue necrosis, increased risk of infection with potentially critical complications, sensory, motor, and autonomic dysfunction, and further immune deregulation, complete the ‘downward spiral’ (Denton et al., 2002; Martin, 2009; Evans et al., 2000). This intricate neuro-vascular-fascial pathology in turn accounts for much of patients’ pain, functional impairment, and psychological distress (Adams et al. 2002; LeMoon 2008; Ball, in press).

Aetiology, pathology, and ‘overlapping’ clinical features In ‘auto-immune’ diseases, a failure occurs within the immune system whereby it ‘mistakes’ healthy tissue for foreign, threatening entities to be destroyed by the generation of antibodies. Hence, diagnosis is assisted by a blood test identifying such abnormal antibodies. This ongoing ‘misguided internal war’ leads to chronic inflammation of the affected tissues, with debilitating consequences including severe pain, fatigue, further immune system overload, irreversible tissue damage, loss of functional autonomy, and quality of life. Complications arising from systemic forms of lupus and scleroderma, usually associated with infection, critical cardio-respiratory or renal failure, can even prove fatal. Fortunately however, SLE survival rates have risen from <50% at five years in the 1950ies, to 85% at ten years

Clinical features of special relevance to MT

Fibrotic changes

1

Source: http://www.fasciacongress.org/2009. ‘The modern reader and author need to be aware of possible ambiguities and misunderstandings stemming from different meanings of the word “fascia” because the general meaning of the term can be so vague as to imply little more than some form of connective tissue. “Fascia” encompasses both loose and dense, superficial and deep, and multiple- and single-layered connective tissues.’ Of the comprehensive list of fascia types of proposed, the following are of particular relevance to the present discussion:
Areolar connective tissue
Superficial (sub-cutaneous) fascia
Dense connective tissue
Intermuscular septum
Interosseous membrane
Periosteum
Neurovascular tract e epineurium and epithelium
Epimysium
Intra- and extramuscular aponeurosis
Visceral fascia
Skin

Structural integration-based fascial release efficacy in systemic lupus erythematosus (SLE): Two case studies It is essential that the MT clinician appreciate, beyond the general pattern described above, the nature and process of damage to the varying fasciae, structures, and organs. a) Vasculitis: With scleroderma, this inflammatory condition of blood vessel walls is associated with the fibrotic and chronic inflammatory processes previously discussed. Collagen over-production leads to thickening, stiffening, and narrowing of the internal diameter of capillary walls, causing ischaemia to the tissues supplied. It is the very fine capillaries supplying oxygen at cellular level that are the most susceptible, notably in the fingers and/or toes, gastro-intestinal (GI) tract, lungs, heart, kidneys, as well as muscles and joints. b) The myofascial system: Fibrotic myofascial change (and associated myositis) can vary in severity, both in terms of area(s) affected and ensuing dysfunction. In the author’s experience, the global pattern of shortening and restriction tends to target the flexor muscle groups, with the key exception of increased secondary lumbar and mid-upper cervical curves, ‘locking’ these into hyperextension and ‘forcing’ the head forwards. Extremity joint inflammation mimicking rheumatoid arthritis, usually associated with secondary Raynaud’s phenomenon (Raynaud’s) is common with SLE, sometimes progressing to permanent deformities (Denton et al., 2002). c) Raynaud’s: Possibly the most prevalent scleroderma feature, Raynaud’s presents as sudden, abnormal, severe vasoconstriction of the finger or toe capillaries from exposure to cold(er) ambient temperatures. Other factors including emotional stress, fatigue, can precipitate ‘attacks’. Distinctive signs and symptoms (S&S) include: Sudden, clearly linear discolouration of any/all fingers or toes, or distal phalanges to a ‘waxy corpsewhite’. Affected digits feel ice-cold to the touch and can become blue or even purple in severe or prolonged cases. Severe ischaemic pain, usually with tingling, numbness, and stiffness. Chronic swelling of the affected extremities further compromises vascular and lymphatic circulation. Fibrotic changes induce toe/fingertip capillary narrowing or occlusion. Ischaemia then impairs cellular metabolism, resulting in necrosis and painful digital ulcers which fail to heal, becoming prone to infections. Compromised blood and lymphatic flow render these difficult to treat with antibiotics, with (rarely) surgical amputation the only safe solution if gangrene sets in. d) Sclerodactyly: This Raynaud’s-related feature involves aggressive fibrotic changes to the skin and sub-cutaneous fascia of the extremities, presenting as swelling, tightening, hardening, and thinning of the skin, which takes on a waxy, shiny appearance. Associated fibrosis of underlying fasciae can lead to ‘claw-like’ finger deformities. e) Pulmonary sclerosis: Fibrotic damage to the alveolae and/or adjacent capillaries presents two serious risks: (i) excessive breathlessness due to O2 Co2 transit

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impedance through the thicker epithelial layers; (ii) swift, abnormal, potentially fatal rise in pulmonary arterial pressure as blood powerfully pumped from heart to lungs eventually has ‘nowhere to go’. f) Myo/pericardiac damage: In rarer cases, interstitial pulmonary fibrosis can progress to severe lung damage, triggering an immuno-inflammatory response in the heart (Stamenkovic, 2006). g) Gastro-intestinal (GI) tract: Fibrotic damage to the GI smooth muscle tissue and capillaries can present in the upper, mid, and/or lower tract as follows: (i) Upper GI tract: (secondary) oesophageal dysmotility: atrophy and fibrosis to the distal oesophageal smooth muscle, including the lower sphincter manifests as:
‘Acid reflux’ e backflow of stomach contents into the oesophagus from gravity or mechanical pressure. Marked sphincter atrophy can result in a ‘hyatus hernia’, normally diagnosed via oral endoscopy (Gaumnitz and Fayyad, 2009).
Variable swallowing difficulties, particularly solid food, which feels ‘stuck’. (ii) Mid/lower GI tract: smooth muscle atrophy and fibrosis causing intestinal distension and sluggish, erratic, sometimes ‘bi-directional’ peristalsis, with cyclical over-proliferation of non-beneficial bacteria. Symptoms can include alternating constipation and diarrhoea, nausea and/or vomiting, excruciating abdominal bloating, swelling, debilitating exhaustion, and weight loss. (iii) Lower GI tract/anal canal: damage to the relevant neuro-vascular-fascial structures can lead to varying degrees of loss of bowel control, inhibiting a normal ‘closure’ motor reflex. Psycho-social consequences of such ‘relative incontinence’ can be immense. h) Other potential organ involvement: Rarely, the brain, epineurium, liver, or kidneys can succumb to similar fibrotic processes, while white blood cell (leucopenia) or platelet (thrombocytopenia) deficiency e with increased risk of bleeding/bruising e are relevant to the MT clinician. Finally, painless, non-inflammatory, and non-itchy, but unsightly ‘butterfly rash’ affects over 50% of SLE sufferers, with cosmetic implications.

What can FRT and structural integration (SI) offer scleroderma patients? FRT techniques and the SI process are therapeutic modalities intrinsically focused on the CTs/fasciae in their theoretical underpinning, clinical reasoning, and hands-on application (Myers, 2009; Masi and Hannon, 2008; LeBauer et al., 2008). Through manual manipulation and movement re-education, they aim to restore ‘tensegrity’ e integrity of length, symmetry, balance, and equal tension in all planes between the fascial ‘guy ropes’ pulling, and hence applying compressive forces on, the skeletal structure, about its vertical axis (Myers, 2009). The Kinesis Myofascial Integration (KMI)
SI model developed by Thomas Myers (2009; www.anatomytrains. com/kmi), which underpins the approach to the present case studies, rests on ‘reading and treating the cohesive

220 myofascial continuities of the Anatomy Trains’ (Myers, 2009 p. 259). These form a system of twelve myofascial continuities or ‘meridians’ that, it is suggested, drape the body either from head or neck to foot/toe, or from trunk to hand/finger, along relatively straight, spiralling, curving, or ‘basket-weave’ alignments (Myers, 1997, 2009). The process therefore involves accurate ‘body reading’ to identify departures from tensegrity due to areas of shortened, congested CT, compensated by overstretched, lengthened fascia elsewhere. ‘Interactive’ manual manipulative techniques e involving active client participation e are then applied according to a structured treatment strategy devised by sound clinical reasoning. Treatment is supported by tailored self-management advice to engage client participation in the therapeutic process, and ensure optimal outcomes. It should be noted however that with regard to technique, this manual approach differs little from other forms of Structural Integration (formerly known as ’Rolfing’) and can be quite similar to the many techniques of myofascial release or deep tissue work used by the wider context of body workers.

SI e (in this instance KMI
) based FRT efficacy for SLE patients was hypothesised on the following ‘snow ball effect’ clinical reasoning basis Addressing and potentially reversing the adverse CT and skin changes discussed, by applying appropriate softening, releasing, spreading, and/or lengthening techniques (De Lany et al., 2002; Schleip, 2003). This would in turn:
Enhance joint RoM and overall mobility.
Relieve musculo-skeletal, neuro-vascular, lymphatic, and visceral compression and constriction (Fourie, 2009). Thereby enhancing:
Vascular and lymphatic supply to and from chronically ischaemic tissues, in turn promoting healing.
Sensory-motor and autonomic neural conduction.
Visceral function including respiratory and GI tract. Neuro-vascular-fascial decompression would decrease ischaemic and other pain by nociceptor de-sensitisation (Chaitow and De Lany, 2000). Previous research discussed below suggests that the above could correlate with:
Reduced pain, stiffness, fatigue, anxiety (Martin, 2009).
Enhanced tissue healing, functional mobility, autonomy, quality of life, emotional state, autonomic and immune function (Martin, 2009; Walton, 2007; Ball, in press). Supporting evidence includes: Walton’s (2007) case study reporting briefer Raynaud’s attack episodes following FRT treatment; Martin’s (2009) impressive results with a dSSc patient in chest expansion, TMJ, wrist, and finger RoM gains, reduced digital ulcerations and other Raynaud’s symptoms, and pain decrease or elimination in all affected areas. Elsewhere, increased parasympathetic activity and

T.M. Ball associated autonomic and other beneficial changes following MT intervention e including FRT e were recently reviewed by Moyer et al. (2004).

Case studies Case 1 History: a 55 year-old female with thirteen years since SLE diagnosis, was referred for FRT as part of her rehabilitation process following hospitalisation for life-threatening respiratory and digestives complications. Presenting signs & symptoms: Significant fascial contracture over the right (R) thoraco-lumbo-pelvic-hip region, with associated asymmetry and rotations. Debilitating pain, requiring round-the-clock prescription medication in addition to ongoing steroid and other drugs, physical deformity, and permanent exhaustion, had become major limiting factors to her autonomy, quality of life, self-esteem, and emotional state. Constant pain throughout the R pelvic and thoraco-lumbar region, postero-lateral thigh, groin, and antero-lateral lower leg and foot was exacerbated by weight-bearing. Intermittent neck and shoulder pain were also reported. Chronic breathlessness was attributed to established lung and associated vascular fibrosis, and physical exhaustion. Collectively, the above were detrimentally affecting the patient’s quality of life, psychological state, and mental concentration.

Case 2 History: a 22 year-old female with SLE diagnosed at age 13, self-referred for FRT therapy, hoping for pain relief and enhanced mobility, with any further improvement deemed ‘a bonus’. She was under periodical rheumatology review and on associated medication. Signs & symptoms: a global sense of skin inelasticity enforcing a ‘locked’ posture and limited comfortable movements. Worst areas included bilateral ‘shin splint’ type pain over the antero-medial lower legs, prohibiting running and limiting walking, and the L thoraco-lumbopelvic, and shoulder/neck region. Generalised aching would rise from moderate to severe pain, predominantly affecting the L postero-lateral aspect, from pelvis to shoulder girdle. Besides limiting her mobility and activities, her increased tightness and pain, and worsening GI tract malfunction were potentially threatening her career, and more immediately, an overseas volunteer ‘field work’ project two months in the future. Collectively, these symptoms were inevitably impacting adversely on her psychological state.

Intervention objectives In both cases, symptom alleviation, postural tensegrity and functional performance enhancement, focused on assistance towards achieving patients’ short, medium, and longterm goals were the prime objectives.

Structural integration-based fascial release efficacy in systemic lupus erythematosus (SLE): Two case studies

Methodology Interventions rested on SI methodology as described earlier, correlating patient-specific presentation with departure from Anatomy Trains tensegrity according to the KMI
model, and included:
Hands-on FRT treatment.
Remedial exercise and self-management advice.
Self-awareness and psychological mentoring. The seven following monitoring indicators were used, based on patient reporting and clinical (re-)assessment where applicable:









Pain, on a 0e10 reported scale. Functional mobility/RoM. Functional autonomy. Episodes of exhaustion. Emotional state. Quality of life. In Case 1: use of pain medication. In Case 2: GI tract malfunction.

Indicator levels were established at Week 1 and reviewed at each subsequent session, on the combined basis of patient feedback and clinical re-assessments. Indicator levels for Cases 1 and 2 at Week 1 and at the final session are represented in Graphs 1A,B and 2A,B, respectively, while Graphs 1C and 2C illustrate level variations throughout the treatment periods.

Intervention Case 1: eight treatments were provided over a fourteenweek span. Case 2: four treatments in seven weeks, plus three treatments in five weeks some two months later due to patient’s interim overseas trip. Session duration was 1 h except for the initial consultation (75 min), and timings were determined by best clinical judgment in correlation with mutual availability. Case 1 key ‘body reading’ findings included:
Bilateral medial femoral rotation relative to pelvis, greater on R, R foot abduction (lateral rotation) and calcaneal adduction (medial tilt) relative to tibia, with loss of transverse and medial longitudinal arches, hallux valgus, shortened heel and lateral aspect of foot.
Marked R thoracic/trunk rotation and side-bend, with L translation (shift) relative to pelvis.
Bilateral increased lower thoraco-lumbo-pelvic lordosis, anterior pelvic tilt, greater on R, posterior thoracic tilt.
Increased mid-thoracic-lower cervical kyphosis, bilateral shoulder girdle lateral translation (shift), downward and medial rotation, greater on R.
L cervical bend (tilt) relative to thorax, upper cervical hyperextension with mild R rotation.

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Summary of Case 1 interventions e applied bilaterally but with greater emphasis on R unless otherwise stated: Superficial front line (SFL): lifting and lengthening, with particular emphasis on decreasing postural hip, thoracic, and lower cervical flexion. Superficial back line (SBL): releasing sub-occipitals to reduce upper cervical hyperextension; generally working downward e inward over upper-mid thoracic area, outward over lower thoracic-ilio-sacral region, to reduce kypholordotic and anterior pelvic tilt strain; downward from the sacro-tuberous ligament with greater emphasis on the lateral ‘strand’ of the lower SBL. Spiral line (SPL): Focus on lifting and lengthening the tibialis anterior-ilio-tibial band (ITB)-tensor fasciae latae (TFL) strand of the lower SPL ‘sling’, with downward work along the biceps femoris-peronei strand, to enhance arch support, weight distribution, and pelvic balance. Opening the obliques to decrease trunk rotation and release breathing. ‘Lifting back’ the L ‘rhombo-serratus’ (Myers, 2009) unit and R splenius for scapulo-cervical-head alignment. Lateral line (LL): detailed attention to balancing the postero-lateral v. antero-lateral hip rotators/abductors for pelvic balance (Myers, 2010), and opening/lengthening the lateral trunk to ease side-bend, enhance rib expansion, breathing range and ‘orientation’. LL neck work for headcervical-thoracic, and scapular alignment. The L highly congested iliac crest fasciae required considerable attention. Deep front line (DFL): not surprisingly, the DFL called for significant input throughout to address the asymmetries identified, facilitate postural, functional, and breathing re-education, and potentially ease visceral compression. As a lower clinical priority, the arm lines received limited treatment focused primarily over the more proximal portions, primarily for shoulder girdle balance and ease, upper rib expansion, and head-cervical-thoracic alignment. Case 2 key ‘body reading’ findings included:
Bilateral foot abduction (lateral rotation) and calcaneal adduction (medial tilt) relative to tibia, relative loss of transverse arch, all greater on L, minor L hallux valgus, and bilateral shortened heel and lateral aspect of feet.
Bilateral anterior tibio-femoral shift, medial femoral rotation relative to pelvis, greater on L, knee valgus, greater on R.
Anterior pelvic shift relative to malleoli, giving an ‘appearance’ of anterior pelvic tilt, greater on L, R pelvic tilt.
L thoracic/trunk rotation and side-bend, posterior thoracic tilt reflected by increased lower thoracolumbo-pelvic lordosis.
Shoulder girdle lateral translation (shift), downward and medial rotation, greater on R.
Mid-upper cervical hyperextension and mild L side-bend. Summary of Case 2 interventions e applied bilaterally but with greater emphasis on L unless otherwise stated. Mobilisation in all directions of the exceptionally ‘bound down’ skin, subcutaneous, and superficial (‘deep investing layer’) fasciae was the initial priority.

222

Graph 1 progress.

T.M. Ball

A: Case 1 symptoms prior to treatment; B: Results: Case 1 symptoms post-treatment; C: Results: Case 1 symptom

SFL: as per Case 1, plus focus on relieving lower leg strain and anterior pelvic shift, separating/differentiating the various fascial interfaces. SBL: same emphasis as SFL and greater downward lengthening and freeing the lateral SBL ‘strand’. SPL: greater emphasis to the L spiral line, but bilateral lower SPL ‘sling’ work to relieve tibialis anterior symptoms, enhance arch support and weight distribution, reduce

medial femoral rotation, knee and calcaneal valgus. Upper SPL similar (but contralateral) to Case 1, to decrease trunk rotation, enhance breathing, and scapula-thoraco-cervicalhead alignment. LL: lower body as per SPL work, plus detailed attention to hip abductors/rotators for pelvic balance (Myers, 2010), and to lateral trunk, contralaterally as per Case 1.

Structural integration-based fascial release efficacy in systemic lupus erythematosus (SLE): Two case studies

Graph 2

223

A: Case 2 symptoms prior to treatment; B: Results: Case 2 symptoms post-treatment; C: Results: Case 2 symptom progress.

DFL: detailed releasing and lifting throughout, notably to alleviate deep compartment periostitis, address trunkpelvic misalignment, and open diaphragm and breathing. Scalenes lengthening and inhibitory work. Arm lines: as with Case 1, the more proximal myofascial segments were prioritised due to global treatment objectives, although limited attention was devoted to the distal portions.

Results Case 1 Although Weeks 1e14 saw improvements in all seven parameters, as illustrated in Graphs 1A and B, an unexplained setback occurred between Weeks 5 and 7, as reflected in Graph 1C. The greatest gains occurred between Weeks 1 and

224 4, with steadier further enhancements from Weeks 7e14. Overall progress of individual indicators over the intervention period was as follows on a 0e10 scale:
Pain decreased from 8.5 to 1.5.
Use of pain medication was reduced from 9.2 to 1.9.
Functional mobility/RoM rose from 2.0 to 8.1; RoM in specifically, unilaterally restricted joints, directions of movement, and/or body areas increased to at least 80e90% of the contralateral side, where RoM gains had likewise been achieved.
Functional autonomy (daily, leisure, social activities) improved from 2.5 to 7.8.
Episodes of exhaustion diminished from 9.3 to 3.5.
Positive emotional state improved from 1.0 to 7.5.
Quality of life recovered from 2.2 to 7.8.

Case 2 Again, all seven parameters improved from Weeks 1e18, as shown in Graphs 2A and B. Fluctuations reflected in Graph 2C occurred between Weeks 8 and 13, coinciding with treatment discontinuation due to the patient’s overseas commitment. While pain and positive emotional state attained the greatest gains, overall progress of individual indicators for the period was as follows on a 0e10 scale:
Pain decreased from 8.0 to 2.0.
GI tract malfunction regressed from 7.5 to 3.8.
Functional mobility/RoM rose from 2.8 to 7.5; R trunk side-bending improved by 20% and spinal ‘elevation’ by over 2 cm after Session 1; bilateral ankle plantar/dorsiflexion increased by an estimated 20%þ, as did ‘true’ hallux extension; L hip extension and lateral rotation attained over 90% of RoM on the R.
Functional autonomy improved from 4.5 to 8.0.
Episodes of exhaustion diminished from 9.1 to 4.0.
Positive emotional state improved from 2.8 to 8.0.
Quality of life recovered from 3.9 to 7.5. In addition, both Cases demonstrated the following significant fascia-related improvements:
Softness, pliability, extensibility, and mobility of the skin, subcutaneous, and superficial (‘deep investing layer’) fasciae.
Softness and ‘fluidity’ of areolar fascia.
Independent gliding between adjacent fasciae and structures.
Muscle tone, resting length, softness, flexibility, proprioception, recruitment, and performance.

Discussion While ‘placebo’ may have contributed to the above outcomes, it is not unreasonable to enquire what potential therapeutic mechanisms might have been involved. Enhanced fascial softening, pliability, extensibility, glide, etc. suggest tissue remodelling involving a structural

T.M. Ball reorganisation favouring greater flexibility consistent with Martin’s (2009) study (De Lany et al., 2002; Schleip, 2003; Fourie, 2008, 2009). Pioneering research by Wipff and Hinz (2009) on factors determining myofibroblast ‘contractile phenotype’ retention on maturation, offers appealing supporting evidence, as mechanical stress e such as FRT therapy e is confirmed as one of two principal factors. Even more promising for future SI-based FRT validation in this context is that deregulation of ‘normal’ fibroblast reparative activities ‘results in tissue contracture and development of fibrosis, which makes the fibroblast an important target for anti-fibrotic therapies.’ (Wipff and Hinz, 2009, p. 121). With regard to enhanced glide between adjacent myofasial structures, Myers (2009 p. 29) likens the effect of SI/ FRT therapy on areolar fascia, inter-muscular septae, and epimysia to ‘rolling’ a grapefruit to break up the membrane layers prior to juicing it. Decrease in myofascial pain could be attributable to multiple factors. LeMoon (Findley and Schleip Eds. 2007), proposes a ‘fasciagenic’ pain model where unremitting fascial thickening and stiffening generates myofascial pain, alleviated by fascial relaxation: ‘Fascial remodelling can occur rapidly or gradually as determined by the sum of proprioceptive, mechanoreceptive, chemoreceptive, thermoceptive, nociceptive, and psycho-emotional input to the central nervous system. Fascia thickens and stiffens as it contracts, exerting pressure on muscles, nerves, and blood vessels. If the pressure is unremitting, metabolic and functional deficits can occur in these structures, creating the symptoms of MPS.’ (Findley and Schleip, 2007, p. 84). Building on Rijkelijkhuizen’s (2005) earlier work, Van der Wal’s ‘revolutionary’ recent research presented at the recent (October 2009) Fascia Congress (Huijing et al., 2009; Van der Wal, 2009a,b), provides scientific credence to the reality of SI FRT influencing deep, manually ‘unreachable’ intra-thoracic/abdominal visceral or myofasciae. Compelling ‘in vivo’ and ‘in vitro’ images and video clips refuted the traditional ‘in parallel’ anatomical model of ‘active’ muscle/tendon units overlying ‘passive’ ligaments, demonstrating instead an ‘in series’ architecture of muscles, aponeuroses, ligaments, and periosteum, in an ever-continuous, uninterrupted body-wide pattern, whereby ligament tissue fulfils key functional roles in any and every joint position. This testament to an omnipresent trans-muscular tensile force transmission ‘in series’, both ‘around’ joints and from one joint to the next, via the fascial matrix (Van der Wal, 2009a,b), supports a corresponding diffusion of therapeutically induced ‘release’ along and between fascial planes and meridians. Lastly, that enhanced psychological state may in part be attributable to the collective benefit of reduced symptoms (Chaitow and De Lany, 2000), is potently supported by PsychoNeuro-Immunology (PNI). Evidence that ‘physical’ and ‘emotional’ states are inextricably correlated via an intricate two-way communication system involving psyche, nervous, and immune systems is a key finding in pioneering PNI research. Any ‘physical change’ is neurologically perceived and communicated to the central nervous system (CNS), whose response triggers specific hormonal/biochemical

Structural integration-based fascial release efficacy in systemic lupus erythematosus (SLE): Two case studies releases via the endocrine system, impacting at physiological, immune, and psychological levels. In turn, ‘mood’ change is conveyed to the CNS, with ensuing endocrinal response. Through this two-way pathway, sustained stress states can generate a downward spiral process resulting in sympathetic (stress response) overload, with ensuing detriment to the immune system. Undisputed correlation between scleroderma-type disease and sympathetic over-activity (Denton, 1996; Denton et al., 2002), may endorse strategic SI/FRT focus on psychological enhancement and parasympathetic stimulation to elicit auto-immune regulation.

Conclusion While ‘spontaneous recovery’ cannot be ruled out in the absence of control subjects, these anecdotal outcomes suggest FRT efficacy, alongside ongoing medical management, in alleviating specific symptoms and/or effects of scleroderma-type auto-immune diseases, notably SLE. FRT appears to be instrumental in particular in decreasing ‘myofascial pain’, restoring RoM, functional mobility, reducing fatigue, enhancing autonomy and activity levels, quality of life, and emotional state, supporting broader-based clinical studies using more stringent objective and subjective evaluation tools. Barring prohibitive ethical, logistical, and/or economical considerations, these could include:
Landmark referencing and measuring tape to monitor fascial stretch, as successfully used by Martin (2009).
Ultrasound or alternative scanning to monitor fascial remodelling.
Goniometric, measuring tape, or similar to monitor RoM.
Validated SSc disability questionnaires such as developed by Prof. CP Denton.
Salivary cortisol or other stress hormone level monitoring (Evans et al., 2000).
Parasympathetic activity monitoring.
HPA axis and pituary gland activity monitoring (Evans et al., 2000).

References Abu-Shakram, 2008. Do improved survival rates of patients with systemic lupus erythematosus reflect a global trend? J. Rheumatol. 35, 1906e1908. Adams, M., et al., 2002. The Biomechanics of Low Back Pain. Churchill Livingstone, Edinburgh. Assassi S. et al., 2007. SSc and SLE have distinct gene expression profiles in the peripheral blood cells. ACR ASM Presentation. Ball T.M. Scleroderma and related conditions. In: Findley, Schleip, Huijing & Chaitow (Eds) Fascia in Manual Therapy. Edinburgh: Churchill Livingstone, Ch. 5e6, in press. Bernatsky, S., et al., 2006. Mortality in systemic lupus erythematosus. Arthritis. Rheum. 54, 2550e2557. Chaitow, L., De Lany, 2000. Clinical Application of Neuromuscular Techniques, vol. 1. Churchill Livingstone, Edinburgh.

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De Lany, et al., 2002. Connective tissue perspectives. J. Biochem. Mol. Toxicol. 6 (4), 220e227. Denton, C.P., 1996. Systemic sclerosis: current pathogenetic concepts and future prospects for targeted therapy. The Lancet 347 (9013), 1453e1458. Denton, C.P., et al., 2002. Systemic sclerosis. Medicine, 36e41. Evans, P., et al., 2000. Mind, Immunity, and Health. Free Association Books, London. Findley, T.W., Schleip, R. (Eds.), 2007. Fascia Research. Elsevier, Munich. Fourie, W.J., 2008. Fascia lata: merely a thigh stocking, or a coordinator of complex thigh muscular activity? J. Biochem. Mol. Toxicol. 12 (3), 265e273. Fourie W.J., 2009. Fasciae in recovery from cancer surgery.In: 2nd International Fascia Congress presentation, Amsterdam. Gaumnitz E.A., Fayyad A., 2009. Oesophageal motility disorders. In: Medscape. Huijing, P.A., et al. (Eds.), 2009. Fascia Research II. Elsevier, Munich. LeBauer, A., et al., 2008. The effect of MFR on an adult with idiopathic scoliosis. J. Biochem. Mol. Toxicol. 12 (4), 356e363. LeMoon, K., 2008. Clinical reasoning in massage therapy. International Journal of Therapeutic Massage & Bodywork 1 (1), 112e118. Martin, M.M., 2009. Effects of myofascial release in diffuse systemic sclerosis. J. Biochem. Mol. Toxicol. 13 (4), 320e327. Masi, A.T., Hannon, J.C., 2008. Human resting muscle tone (HMRT): narrative introduction and modern concepts. J. Biochem. Mol. Toxicol. 12 (4), 320e332. Merrell, M., Shulman, L.E., 1955. Determination of prognosis in chronic disease, illustrated by SLE. J. Chron. Dis. 1, 12e32. Moyer, C.A., et al., 2004. A meta-analysis of massage therapy research. Psychol. Bull. 130 (1), 3e18. Myers, T.W., 1997. The ‘Anatomy Trains’. J. Biochem. Mol. Toxicol. 1 (2), 91e101. Myers, T.W., 2009. Anatomy Trains. Churchill Livingstone, Edinburgh. Myers, T.W., 2010. Extensor coxae brevis: treatment strategies for the deep lateral in pelvic tilt. J. Biochem. Mol. Toxicol. 14 (3), 262e271. Rijkelijkhuizen, J.M., et al., 2005. Extramuscular myofascial force transmission for in situ rat medial gastrocnemius and plantaris muscles in progressive stages of dissection. J. Exp. Biol. 208, 129e140. Schleip, R., 2003. Fascial plasticity e a new neurobiological explanation. J. Biochem. Mol. Toxicol. 7 (1), 11e19 (Part 1) & 7 (2): 104e116 (Part 2). Stamenkovic B.N., 2006. Cardiopulmonary Manifestations in Systemic Sclerosis (SSc) e Correlation with Disease Duration and the Extent of Skin Involvement. In: AB0291 EULAR. Urowitz, M.B., et al., 1997. Mortality studies in SLE. III. improved survival over 24 years. J. Rheumatol. 24, 1061e1065. Van der Wal, J., 2009a. The architecture of the connective tissue in the Musculoskeletal system e An often overlooked functional parameter as to proprioception in the locomotor apparatus. Int. J. Ther. Massage Bodywork: Res. Educ. Pract. 2 (4). Van der Wal J. 2009b. The Architecture of Connective Tissue as a Functional Substrate for Proprioception in the Locomotor System. In: 2nd International Fascia Congress presentation. Walton, A., 2007. Efficacy of MFR in the treatment of primary Raynaud’s phenomenon. J. Biochem. Mol. Toxicol. 12 (3), 274e280. Wipff, J.-P., Hinz, B., 2009. Myofibroblast mini-review: myofibroblasts work best under stress. J. Biochem. Mol. Toxicol. 13 (2), 121e127. http://www.fasciacongress.org/2009.

Journal of Bodywork & Movement Therapies (2011) 15, 226e230

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EDUCATIONAL METHODS

A qualitative investigation into the usefulness and impact of the performance intervention zone system used in the diagnostic assessment of internationally educated massage therapists Paul Finch, Ph.D., M.Sc., D.Pod.M a,*, Amanda Baskwill, B.Ed., RMT b a b

Chair, Health Sciences, Conestoga College Institute of Technology and Advanced Learning, Canada Coordinator, Massage Therapy Program, Humber College Institute of Technology and Advanced Learning, Canada

Received 2 February 2010; received in revised form 28 April 2010; accepted 7 July 2010

KEYWORDS Massage; Health care; Internationally educated; Assessment; Education

Summary Purpose: Previous work (Finch, 2008) reported on the development and implementation of a safety oriented system of performance intervention zones (PIZ), which was used in the assessment of internationally educated massage therapists. The study reported in this paper explores the usefulness and impact of the system as experienced by the evaluators involved in the diagnostic assessment. Method: This exploratory research was of a qualitative design in which data were collected during a series of individual semi-structured interviews with evaluators who used the performance intervention zone system during the diagnostic assessment of internationally educated massage therapists in Ontario. After obtaining informed consent, interviews were taped, transcribed and analyzed, resulting in identification of a number of themes and recommendations regarding future use and development of the system. Results: Analysis revealed four themes within the data. These were that the performance intervention zone system 1) enhanced the confidence of examiners in their ability to conduct the comprehensive clinical examination effectively, 2) assisted and improved examiner decision making during the examination, 3) was a useful aid to communication regarding candidate performance, and 4) could be improved by clarifying the nature of intervention and implementing more extensive examiner training prior to the examination. Conclusion: The performance intervention zone system was found to be useful in orienting examiners to the evaluation process, in supporting decision making during the comprehensive clinical evaluation and as an aid to communication in the post-examination review of

* Corresponding author. E-mail addresses: [email protected] (P. Finch), [email protected] (A. Baskwill). 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.07.004

A qualitative investigation into the usefulness and impact of the performance intervention zone system

227

candidate performance. The system could be improved through implementation of a preexamination workshop focused on use of the PIZ and by delineation of levels of examiner intervention during the examination. ª 2010 Elsevier Ltd. All rights reserved.

Introduction Ontario’s Ministry of Training Colleges and Universities, Ministry of Citizenship and Immigration, and health professions regulators, including the College of Massage Therapists of Ontario, have identified the need to increase access to the regulated health professions in general, and specifically to massage therapy, by internationally educated practitioners (Dryden and Baskwill, 2005; Ministry of Training, Colleges and Universities, 2005). Recognition of this need has led to the development and implementation of a diagnostic assessment process focused on determining the competency of internationally educated individuals self-identifying as massage therapists. The diagnostic assessment process involves three primary components: written examination, objectively structured clinical evaluation [OSCE] and comprehensive clinical evaluation [CCE], and is therefore an example of a composite approach to assessment (Wass et al., 2001). Detailed discussion of the diagnostic assessment process is beyond the scope of this paper, suffice to say that the intervention zone approach to decision making was used in the CCE. This is an approach to evaluation similar in some respects to the Direct Observation Clinical Encounter Examination [DOCEE] (Hamdy et al., 2003), the commonality being that both are based on direct observation of candidate performance involving actual patients in a clinical setting. In the CCE, candidates were required to perform a complete massage therapy treatment while being observed by two examiners. The massage therapy treatment consisted of the usual components, including history and physical examination, consent, treatment, home care advice and charting. Interspersed throughout the session were a number of defined discussion periods, in which the candidate was required to present his or her findings, discuss and rationalize the proposed treatment plan, and suggest a prognosis. In any examination the concept of inter-rater reliability (Domholdt, 2000) is important to consider, and in the context of the CCE this relates in particular to the question of intervention. That is to say, if multiple evaluators are involved in examining a number of candidates, a consistent basis for decision making is required with respect to when and how to intervene if observed performance deviates from the expected competency, standard or other measure reflecting professional skills. In order to provide a template for decision making regarding when intervention should occur during the CCE, a system of performance intervention zones was created (Finch, 2008). This straightforward system, diagrammatically represented below, is intended to assist examiners in deciding when to intervene, to facilitate inter-examiner consistency in decision-making, and to create the basis and language for shared understanding of candidate performance.

Observed Performance Categorization

Zone 1 Performance aligned with expectations.

Zone 2

Zone 3

Performance Significant deviates from departure from expectations but expectations. is substantially similar.

No intervention No intervention

Intervene and redirect

Zone 4

Zone 5

Significant Multiple Zone 4 departure from infractions: expectations, representing a threat to safety. Immediate intervention and redirect

Intervene and terminate treatment / exam

The application of the intervention zone system during the CCE was contextualized by evaluation forms, which were reflective of the provincially set competency requirements for entry-level practice (College of Massage Therapists of Ontario, 2002). The examiner’s task was to assess whether each applicable competency had been met, within the framework of the intervention zone system. To this end, the examiners referenced observed performance against the intervention zones in order to decide upon a course of action. In this way it was intended that a balance be achieved between ensuring patient safety, accommodating equally valid and reliable ways of achieving a required clinical outcome or effect, and allowing the candidate sufficient scope to make a mistake and recover from it. The focus of the exploratory research reported in this paper is related to the usefulness and impact of the intervention zone system described above.

Method Design and procedures The research was of a qualitative design in which data were collected during a series of individual semi-structured interviews with evaluators who used the performance intervention zone system during the diagnostic assessment of internationally educated massage therapists in Ontario. Each participant was contacted by an individual other than the researchers and asked if they wished to participate in the study. All agreed to do so, and appointments were arranged at a time convenient to the participants and the researchers. On the day of the interviews, participants were welcomed and informed consent obtained. The interview then proceeded, and after collection of basic demographic information, participant data regarding the intervention zone system was gathered. This involved a series of consistently asked questions focused on the

228 participant’s experience of using the system in previous examination episodes. These questions were structured such that participants were asked to reflect on use of the intervention zone system during orientation to the examination, the examination itself and the post-examination debrief. Interviews were taped, transcribed, and analyzed, resulting in identification of a number of themes and recommendations regarding future development of the system.

Participants A total of seven individuals had acted as evaluators in the comprehensive clinical examinations, and all participated in the study. The group was composed of three males and 4 females with a mean age of 36.3 years (range 26e56), and on average had graduated from a massage therapy school/ college 10.7 years previously (range 5e14 years). The group as a whole had considerable experience in massage therapy education, individuals having been involved for an average of 7 years (range 2e13), and spending on average 46% of their working week involved in school/college based educational activities (range 5e90%). As educators with considerable experience, all had been previously involved in some form of evaluative process focused on clinical skills. This being said, the CCE was new to everyone, the norm within the local massage therapy milieu being to evaluate competency within a continuous assessment model during clinical sessions, and/or in an OSCE or Oral/ Practical format.

Data analysis and results Recordings of the interviews were transcribed and subject to thematic analysis. This iterative process resulted in identification of four themes within the data which indicated that the performance intervention zone system: enhanced the confidence of examiners in their ability to conduct the comprehensive clinical examination effectively, assisted and improved examiner decision making during the examination, was a useful aid to communication regarding candidate performance, and could be improved by clarifying the nature of intervention and implementing more extensive examiner training prior to the examination. Findings are presented below, in relation to each of the themes identified. It should be noted that when quotations are presented, these are representative of the cluster of data coded to the theme in question.

Enhanced confidence This theme related to the confidence of the examiners in relation to conducting the examination effectively, and is referenced primarily to the pre-examination orientation. Although an experienced group of educators, the comprehensive clinical examination, focused, as it was, on internationally educated massage therapists, is not a process to which the examiners had much prior exposure. Use of the performance intervention zone system enhanced confidence in a number of ways that were

P. Finch, A. Baskwill consistently reported by the group. The inclusion of the PIZ system within the orientation provided an overview in which expectations could be made explicit, and as such, enabled examiners to conceptualize the appropriate boundaries and limits of candidate performance. This is represented by the following quotes: “It gave me a kind of guideline, like a framework for looking at things” “I was able to see [imagine] what categories these folks would fall into” Less directly, the existence and intent of the system engendered a sense of consistency within the group that had the effect of raising confidence. This is clear in the following statement: “It made me feel that the group was going to be on the same page, and this was kind of a green light for everybody”

Improved decision making This theme related to the examiners’ perspective that decision making during the CCE was improved by the PIZ system. The majority of decisions required during the examination related to an assessment of candidate competency and intervention in the treatment process on the part of the examiner. As previously indicated, competency assessment was based on a standardized evaluation form, which covered all aspects of the treatment session, including history and physical, treatment, and so forth. The PIZ provided a lens through which the candidate’s performance, in relation to the competency profile, could be viewed. In this fashion, performance could be classified according to a particular zone, and a decision made as to whether intervention was required. Having made this initial decision, second level decisions, focused on whether or not competency equivalent to the Ontario standard was demonstrated were more straightforward. Most importantly, the question of when examiner intervention (during the treatment session) was appropriate was clarified by the PIZ system. This is reflected in the following representative quotes: “I found it was pretty clear as far as .when no intervention was needed, and when intervention was needed ...” “I think knowing what the zones were made it clear to say. yes they [the candidates] can carry-on on their own, or . at this point some intervention is needed .. having the zones laid out made this easier.”

Aid to communication The examiners perceived the PIZ as assisting them in their communication regarding candidate performance during the examination and in the post examination de-brief. The essence of this theme is that the system created a common language and a framework for discussion, evident in the following representative statements:

A qualitative investigation into the usefulness and impact of the performance intervention zone system “It’s like . giving it [the conversation] a context or language [so] that we’re all able to speak in the same language. We know. exactly what we’re talking about.” “The zones just make it a common language that everybody understands. You’re not putting it into your own words.”

Levels of Intervention and Examiner Training: The final theme related to improvements and future development of the system. While the examiners were unanimously positive about the PIZ system, they were equally so with respect to its further development. There were two suggested improvements e the first relating to the development of a straightforward guideline as to how, rather than when, to intervene during the treatment session. The second relates to the need for an enhanced examiner training/ orientation process. The former point is reflected by the following quote: “There is something about the level of specificity of the intervention that is then questioned” This reflects the reality that while the PIZ as it currently exists speaks to when to intervene during the session, the question of how to intervene remains. Core to this is the level of specificity in intervention that is required. The examples and details of clinical circumstances when intervention was needed gave rise to three generic levels of intervention, which covered the majority of situations. These are indicated below: Level A: Stop the activity; prompt the candidate to consider what is necessary; ask him/her to adopt a different approach. Level B: Stop the activity; provide specific direction; ask the candidate to proceed accordingly. Level C: Stop the activity; do what is necessary; and if not zone 5, have the candidate continue. The levels of intervention indicated above reflect, from AeC, an escalating need to intervene which may or may not reflect a high level of concern for patient safety. As indicated earlier in this paper, intervention is required if observed performance is in either zone 3 or 4, the latter representing a definite threat to safety. In both these zones the initial action on the part of the examiner is to have the candidate cease what they are doing. Thereafter, level A provides for less directive interaction, whereby the candidate is given the opportunity to reflect on the requirements of the case and modify their approach. If the candidate were unable to respond to a level A intervention effectively, the examiner would provide specific direction in order to ascertain if the candidate is able to respond appropriately. At level C, the examiner would step in and do what is necessary to allow the examination to continue safely. This being said, the nature of the infraction, or repeated infractions of a similar nature, may move the performance from zone 4 to zone 5, at which point the examination would be terminated. An example drawn from the data illustrates the above. The patient in question reported a history consistent with vascular pathology, which provided the context for the primary complaint of unilateral pain in the posterior

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compartment of the left lower leg. After the candidate completed history and physical examination she suggested a treatment plan inconsistent with a high index of suspicion for deep vein thrombosis. The examiner introduced what has now been classified as a level A intervention, and asked the candidate to reflect on the case and consider if s/he needed to gather any further information (either through history or examination) before continuing. This is reflected in the quote below: “I advised them to come back and look at the health history to see if there were any red flags” This did not result in the candidate proceeding appropriately, so a level B approach followed in which the examiner was specific in their direction, as indicated below: “I then specifically said .. I think we need to do this . [perform a special test to rule out deep vein thrombosis (DVT)]”. The candidate was unable to comply, so a level C intervention was indicated. The examiner performed the special test, the results proving to be negative. The examination could have been terminated at that point, but in order to gain fuller perspective of the candidate’s strengths and weakness, the treatment continued, but only after having ruled out DVT. This sequence of interventions occurred a number of times across the examiner group, and although each situation had its own unique points, the three levels of intervention capture their essence. Clarity regarding intervention is one improvement the data speak to, the second being the need for enhanced examiner training/orientation. The data suggest that examiners would benefit from a pre-examination workshop or extended orientation session during which scripted clinical scenarios, either live or pre-recorded could be observed as a group, and discussed in the context of the PIZ system. This is represented by the following excerpts: “Perhaps .. having a group of examiners sitting looking at the recording ...” “If you had certain scenarios to work through.. you could talk about, okay, this is definitely a zone 2, this is definitely a zone 3”

Summary and conclusion The performance intervention zone system was found to be useful in orienting examiners to the evaluation process, in supporting decision making during the comprehensive clinical evaluation and as an aid to communication in the postexamination review of candidate performance. The system could be improved through implementation of a pre-examination workshop focused on use of the PIZ system and by delineation of levels of examiner intervention during the examination.

Limitations The researcher conducting the interviews was known to participants as he was the Director of Education at one of

230 the schools at which the participants/evaluators were employed as faculty. Additionally, based on previous interactions and publication, it was generally known that the researcher was also the developer of the intervention zone system. Although participants were told that the researcher’s perspective was neutral, it is conceivable that the factors noted above could have resulted in data that was more positive than if the researcher was unknown to the participants. This being said, the consistency of the data gathered suggests that this is unlikely to have been an important influence.

Financial support This research was supported by funding from the College of Massage Therapists of Ontario.

Conflict of interest The authors declare that no conflict of interest exists.

P. Finch, A. Baskwill

References College of Massage Therapists of Ontario, 2002. Competency Standards Document. College of Massage Therapists of Ontario, Toronto, Ontario. Domholdt, E., 2000. Physical Therapy Research. W.B. Saunders Co;, Philadelphia, pp. 232e233. Dryden, T., Baskwill, A., 2005. Improving Access: an Evaluation Programme for Internationally Trained Massage Therapists. College of Massage Therapists of Ontario, Toronto. Finch, P., 2008. A system of performance intervention zones for use during student evaluation in the clinical environment. Journal of Bodywork and Movement Therapies 12 (4), 295e298. Hamdy, H., Prasad, K., Williams, R., Salih, F.A., 2003. Reliability and validity of the direct observation clinical encounter examination. Medical Education 37 (3), 205e212. Ministry of Training, Colleges and Universities, 2005, May 20. Opening doors e an investment in prosperity: welcoming internationally trained individuals into Ontario’s workforce. Retrieved June 27, 2007, from. http://www.edu.gov.on.ca/ eng/document/reports/getresults/index.html. Wass, V., McGibbon, D., Van der Vleuten, C., 2001. Composite undergraduate clinical examinations. Medical Education 35 (4), 326e330.

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PREVENTION & REHABILITATION: EDITORIAL

Laterality

Primal Lifestyle, Unit 5 Glebelands, Vincent Lane, Dorking, Surrey RH4 3HW, UK

Setting the scene It is only right that the editorial role should demand linguistic dexterity, yet even in modern times it is interesting to note the “goofy”, if not sinister, prejudice with regard to employee selection in many major organizations. (See Table 1 for clarification and context of “goofy”.)

The context As recently as the 1960s, large Western organizations made the suggestion to management that it should be no longer acceptable to refuse employment to someone just because they were left handed (Wallden, Personal Communication, 2000). The concept of laterality is deeply embedded, not only into our culture, but into our language. See Table 1. While anyone in their “right” mind would consider that any of these terms used for left handedness are now inappropriate and irrelevant in the modern world, the realities of laterality are deeply embedded (Hannaford, 1997).

Laterality and symmetry As bodywork and movement therapists, an understanding of laterality may be of great benefit when considered in the context of gravitational strain pathophysiology. Gravitational forces are “straight”. Despite the best efforts of “orthopaedics” to create straight (ortho) children (paedics), humans frequently are not very “straight”, and a primary causative factor in this may be that they do not use their bodies in a symmetrical way; they have “laterality patterns” (Kuchera, 1997).

E-mail address: [email protected].

Whenever there is asymmetry, there will be increased loading to certain structures, and decreased loading to other structures. The result may be that the loaded structures become more prone to compression injuries, while the unloaded structures become more prone to traction injuries (Wallden, 2008). So, just how far back does asymmetry go, and does it have a function? Handedness is often described as a human trait, one theory suggesting that the prevalence of around 88% of people being right handed is due to the human need and development of the language centers which predominate in the left hemisphere. Since the left hemisphere controls the right side of the body, it is proposed that this facilitation of the left side of the brain creates a dominance for use of the right side of the body (Haywood and Getchell, 2005). In addition, during the birth process, the fetus must push with its feet against the walls of the uterus to engage the head and must follow a characteristic rotational movement of descent through the pelvic brim (Miller and Callander, 1989). If the two feet are used with equal preference there will be no asymmetry in the push and rotation of the head may not be facilitated. However, there is ample evidence that laterality extends in to mammals too. For example, Desert Orchid, the famous racehorse won 27 out of his 29 races on clockwise (right handed) courses, and just two on anti-clockwise (left handed) courses. Hares use a 90 escape maneuver when being chased by a predator, which involves a sudden change of direction to a “preferred side”. Hesitation over which way to turn may be costly, even catastrophic. Similarly, to go further back in evolutionary development, fish use an escape maneuver to evade their prey which, by nature, means that since their mode of locomotion is frontal plane contraction, they must contract one side of the body alone; and quickly (Kent and Carr, 2001). Again, there is no margin for error, no room for being caught in “two minds”.

1360-8592/$ - see front matter ª 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2011.01.002

PREVENTION & REHABILITATION - EDITOR: MATT WALLDEN

Matt Wallden, MSc Ost Med, BSc (Hons) Ost Med, DO, ND

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M. Wallden

Table 1 Definitions of terms used for “right” and “left” demonstrating inherent prejudice in language.

PREVENTION & REHABILITATION - EDITOR: MATT WALLDEN

Right The “right” hand to use A Droit To the right Adroit Having or showing skill, cleverness or resourcefulness in handling situations Dexter The hand that dexterous people use Dexterity Readiness and grace in a physical task [Autonym unthreatening]

Natural In accordance with nature. Standing left foot forward (usually found in right-footed people)

Left The hand that is left over when you use the correct hand A gauche To the left Gauche Lacking social grace, sensitivity, or acuteness; awkward; crude; tactless Levo The hand non-dexterous people use [Autonyms: butterfingered, ham-fisted, ham-handed, heavy handed] Sinister Unfavorable, unlucky, fraudulent, singularly evil or productive of evil, of or relating to the left or the left side of something. Goofy Foolish, silly, stupid. Standing right foot forward (usually found in left-footed people)

As far as evolutionary discussion is concerned, it would seem there is little sense in taking the concept of laterality further back in time than fish, since the advent of fish saw the first architectural design (or bauplan) to allow for frontal plane, or a left-right split, movement dynamic. However, we do know that molecules may have a left or right-sided preference (such as a trans fatty acid), and even atoms exhibit polarity and spin. From the micro to the macro, planets have a left or right spin; indeed even galaxies exhibit a characteristic handedness. Hence, the discussion of laterality, or polarity, could lead all the way back into the very deepest questions of life and its origins, which is of course beyond the scope of this piece. To turn to more practical matters, a brief insight into infant development may be useful.

Laterality in development A left-footed person will tend to favor their left foot to kick and their right foot to stand. An oft-mistaken concept is that, in such an instance, the left foot is used to kick because it is “stronger”, yet the more likely reality is that an infant wanting to strike a football or other kickable object doesn’t select the foot it is “better at kicking with” but, more likely, picks the leg it is best at standing on, first. A right-handed person will tend to favor their right hand to manipulate objects and to hold things and it may be for

this reason that the dominant leg is often mistakenly thought of as the “stronger”. The upper limb is used throughout childhood (beyond the 1 year mark) primarily in the open chain. This means that the dominant, or most utilized arm becomes stronger and more developed. If humans retained a tetrapod stance then, like the legs, the “non-dominant” arm would be the preferred standing arm and hence would be the stronger. Indeed, research into infant development has shown that when infants fall they will tend to put out their nondominant hand to break their fall; in highly polarized ratios; as if the upper limb girdle never forgot we are of tetrapod design (Goldfield, 1995). What relevance does a favored arm or leg have to the movement therapist?

Pattern recognition When working with a system with the complexity of a human being (note, not just a human body, but a human being), the possibilities for identifying causative agents in pain cases or injury are infinite. With such complexity and potential chaos, it is important to be able to gather data in as unbiased a manner as possible and then to identify patterns of dysfunction within it. The phenomenon most clinicians have experienced, of being trained in a specific diagnostic methodology, and then finding that every patient coming into the clinic for the next week seems to have that very problem, flags up the fact that humans are good at pattern recognition, but that in particular, they are good at finding what they’re looking for. Gathering data, without chasing a diagnosis, is likely to be one of the key skills that distinguish a good clinician from an excellent clinician. Patterns of use, patterns of motor control, and so on, not only help to predict the way someone will move, but also may predict the way someone won’t move e or, certainly, would prefer not to move, and therefore how they may become injured; and indeed rehabilitated. Handedness, footedness and other laterality patterns, such as those described by Kendall et al. (1993), may prove of use to the discerning bodywork and movement specialist to provide insight into etiological mechanisms of injury. For example, in football, right-footed players rarely have the same accuracy or power when kicking with their left foot. When asked to stand on their right foot and kick with their left foot, or even to simply squat on their right (favored kicking) leg, clinically, a lack of stability will commonly be noted through the entire lower limb; a Trendelenburg sign at the hip, a medial rotational instability through the femur into the knee and a pronation at the subtalar joint. This could be termed a descending pronation pattern (Chek, 2001). Such patterns do seem to have clinical relevance, as research has shown higher incidence of injury on the dominant leg (Woods et al., 2004). This descending laterality pattern has multiple potential ramifications, but the two points of this editorial which link it to the two papers selected for this Rehabilitation and Prevention section are: 1) Asymmetry, commonly driven by laterality patterns, may provide clues to help the bodywork and movement

therapist to identify and correct causative mechanisms of cumulative trauma, and to prevent injury and optimize performance in those who wish to realize their movement potential. 2) Descending patterns of dysfunction may be the rule, rather than the exception. Zink and Lawson (1979) observed postural patterning that they believed to be determined by fascial compensation and decompensation (Chaitow, 2007). Somewhat contrary to this discussion on symmetry, Zink & Lawson proposed that fascial compensation should be seen as a useful, beneficial and, above all, functional adaptation (i.e. no obvious symptoms) on the part of the musculoskeletal system, for example, in response to anomalies such as a short leg, or to overuse. In this “functional” compensation, the transitional areas of the spine alternate in their direction of adaptation. On the contrary, decompensation describes the same phenomenon but only in relation to a situation in which adaptive changes are seen to be dysfunctional (spinal junctions rotate in one direction only), to produce symptoms, evidencing a failure of homeostatic adaptation (Chaitow, 2007). This view is distinct from the laterality pattern described in this editorial where neuromuscular mechanisms would be seen as preliminary to fascial adaptation; fascial dysfunction being a more chronic sequela to imbalanced use of the neuromuscular system across time; due to laterality patterns or lateral dominance stemming from between the first 3 months to the first 5 years of life (Haywood and Getchell, 2005). In the two featured papers in this section, Siqueira et al. (2011) show that in their group of subjects with knee hyperextension versus controls, the hyperextended group had poorer motor control at the knee, while, in his paper, Cuccia (2011) shows that manipulation of the temporomandibular joint, whether functional or dysfunctional, affects motor control at the foot. Though Siqueira et al. (2011) do not describe any assessment of their subjects’ knees in a single leg stance, which would both highlight laterality patterns and magnify instabilities, they do note that the hyperextended group have more problems with motor control. This may not come as a surprise when it is recognized that hyperextension of the knee is often a secondary feature of an anterior pelvic tilt, which is a common sequel to a weak or inhibited lower abdominal wall and/or gluteal muscles. Additionally, hyperextension at the knee may be a strategy in which there is greater reliance on the passive subsystem of the joint for stability, over and above the neural and active (neuromuscular) components. Similarly, Cuccia (2011) in his excellent paper has collated data presented in order to show the mean values. The result is that, without the raw data, the reader is unable to ascertain whether a left sided TMJ problem had a greater effect on the arches of the left foot or the right foot, or both identically. An important interpretation of these papers is that both highlight the possibility of descending patterns in the causative mechanisms of dysfunction that the bodyworker or movement therapist may see regularly in their work. When the human body is viewed more as a dynamic biocomputer, rather than a static building, it becomes clear that, neurally, the operating platform (the head) and more

233 cephalad tissues have a higher sensorial investment (with certain specialized exceptions, such as palms, soles, genitals and nipples (Beach, 2010)) than more caudal tissues; yet experience would suggest that, clinically, manual clinicians seem to spend most of their time working on caudal or peripheral tissues, such as low backs, hips, knees and ankles, shoulders elbows and wrists. With this in mind, it may be that proximal or cephalad operating systems are spared in preference to distal or caudal systems. Put in other terms, caudal and appendicular musculoskeletal function may be “sacrificed” in order to maintain optimal higher neurological function. The ability to spot such patterns is based both on seeing them first-hand in practice, or in having the possibility raised in theory, through learning from others’ experiences. This JBMT section raises that awareness, and in the spirit of sharing such observations, this editorial concludes with a pattern this author has observed clinically many times; and that, hopefully, may prove to be of use in your own future observation and assessment.

Laterality pattern in descending fashion  Non-dominant shoulder is higher, .which may be associated with:  Weak and/or inhibited anterior oblique sling from nondominant should to dominant hip, (as assessed on Active Straight Leg Raise test) (Lee, 2004)  Weak and/or inhibited posterior oblique sling from nondominant shoulder to dominant hip, (as assessed using a Supine Lateral Ball Roll) .which may be associated with:  Dominant innominate is more anteriorly tilted; and therefore decreased form closure at dominant side sacro-iliac joint (Lee, 2004) .which may be associated with:  Medial rotational instability through the dominant leg (as assessed on single leg squat, for example). [Note: Kendall et al. (1993) also describe weakness of the dominant leg gluteus medius which may also contribute to this medial rotational instability pattern.] .which is usually associated with:  A greater pronation pattern into the subtalar joint of the right foot. This is a simple pattern that may be observed with a high frequency in many patients; and often may show correlations with their presenting injury patterns and so, if identified, may be corrected as part of a more global rehabilitation process. Arguably, a better use of this kind of observation is to identify it in athletes and movement-based disciplines as part of a preventive screening program, where injuries may be avoided and performance enhanced by correcting these laterality imbalances before they become clinical issues.

References Beach, P., 2010. Muscles and Meridians: The manipulation of shape. Elsevier. Chek, P., 2001. Functional Stability Seminar. Organizer: www. chekeurope.com Maidenhead, UK.

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Chaitow, L., 2007 (Upper Body). In: Chaitow, L., DeLany, J. (Eds.) Clinical Applications of Neuromuscular Techniques, second ed., vol. 1. Churchill Livingstone. Cuccia, A.M., 2011. Interrelationships between dental occlusion and plantar arch. Journal of Bodywork and Movement Therapies 15 (2). Goldfield, E., 1995. Emergent Forms. Oxford University Press, p. 274. Hannaford, C., 1997. The Dominance Factor: How Knowing Your Dominant Eye, Ear, Brain, Hand & Foot Can Improve Your Learning. Great River Books. Haywood, K., Getchell, N., 2005. Life Span Motor Development, fourth ed. Human Kinetics, pp. 165e166. Kent, G., Carr, R., 2001. Comparative Anatomy of the Vertebrates, nineth ed. McGraw-Hill International Edition. Kendall, F., McCreary, E., Provance, P., 1993. Muscles Testing and Function (4h Edition). Williams & Wilkins, p. 81. Kuchera, M., 1997. Treatment of gravitational strain pathophysiology. In: Vleeming, Mooney, Dorman, Snijders, Stoeckart (Eds.), Movement, Stability & Low Back Pain. Churchill Livingstone, pp. 477e499.

M. Wallden Lee, D., 2004. The Pelvic Girdle. Elsevier. Miller, A., Callander, R., 1989. Obstetrics Illustrated. Churchill Livingstone, pp. 258e262. Siqueira, C.M., Moya, G.B.L., Caffaro, R.R., Fu, C., Kohn, A.F., Amorim, C.F., Tanaka, C., 2011. Misalignment of the knees: does it affect human stance stability. Journal of Bodywork and Movement Therapies 15 (2). Wallden, C. 2000. Personal Communication. Head of Management Training, Barclays Bank. Wallden, M. 2008 Rehabilitation and movement re-education approaches. In: Naturopathic Physical Medicine. Woods, C., Hawkins, R., Hulse, M., Hodson, A., 2004. The Football Association Medical Research Programme: an audit of injuries in professional football-analysis of preseason injuries. British Journal of Sports Medicine 36 (6), 436e441. 2002 Dec; discussion 441. Zink, G., Lawson, W., 1979. An osteopathic structural examination and functional interpretation of the soma. Osteopathic Annals 12 (7), 433e440.

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POSTURE PHYSIOLOGY

´ssio Marinho Siqueira a,*, Gabriel Bueno Lahoz Moya a, Ca ´ Fa ´bio Kohn b, Rene Rogieri Caffaro a, Carolina Fu a, Andre ´sar Ferreira Amorim c, Clarice Tanaka a Ce a Department of Physical Therapy, Communication Science & Disorders and Occupational Therapy, Faculty of Medicine, University of Sa˜o Paulo, Sa˜o Paulo, Brazil b Department of Biomedical Engineering, Escola Polite´cnica, University of Sa˜o Paulo, Sa˜o Paulo, Brazil c Department of Mechanical Engineering , Sa˜o Paulo State University e UNESP e FEG, Guaratingueta´, Sa˜o Paulo, Brazil

Received 5 June 2009; received in revised form 21 August 2009; accepted 25 August 2009

KEYWORDS Posture; Balance; Equilibrium; Knee; Standing stability; Postural alignment

Summary Introduction: Data describing the relationships between postural alignment and stance stability are scarce and controversial. Objective: The aim of this study was to evaluate the effects of sensory disturbances on knee alignment in upright stance and the effects of knee hyperextension on stance stability. Method: Kinetic and kinematic data of 23 healthy adult women were collected while quietly standing in four sensory conditions. Kinematic data: knee angle (dependent variables) variations were analyzed across sensory conditions. Kinetic data: as subjects with hyperextended knees showed a clear tendency to flex their knees as balance challenge increased, center of pressure (COP) parameters (dependent variables) were analyzed in each sensory condition among trial sub-groups: Aligned-Trials (knee angle < 180 ), Hyperextended-Trials (>180  ) and Adjusted-Trials (>180 initially, turned <180 under challenging conditions). Results: Differences were found in mean velocity of COP in two conditions showing that knee alignment can affect stance stability. Conclusion: Knee hyperextension is a transient condition changing under postural challenges. Knee hyperextension affected postural control as mean velocity was the highest in the hyperextended group in natural standing sensory condition and lowest with sensory disturbance. ª 2009 Elsevier Ltd. All rights reserved.

* Correspondence to: Ca ´ssio Marinho Siqueira, Av. Dr. Ene ´as de Carvalho Aguiar, 255, Cerqueira Ce ´sar, 05403-000, Sa ˜o Paulo-SP, Brazil. Tel.: þ55 11 3069 6867; fax: þ55 11 3069 7969. E-mail address: [email protected] (C.M. Siqueira). 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.08.005

PREVENTION & REHABILITATION e POSTURE PHYSIOLOGY

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Introduction Postural alignment is thought to affect postural control as it determines the effort required to support the body against gravity (Kantor et al., 2001). In addition, it is known that postural alignment affects sensory afferent inputs to the central nervous system, the location of the center-ofgravity (Danis et al., 1998) and it is related to the postural adjustments necessary to control body balance (Kantor et al., 2001; Raymakers et al., 2005; Saha et al., 2007). However, reports of the relationship between postural alignment and stability are scarce and remain inconclusive. Postural alignment has been reported not to correlate with stability in able-bodied subjects (Ferreira et al., 2007), or to have low correlation in able-bodied and vestibularly impaired patients (Danis et al., 1998). Daniel et al. (1998) also noted that the six most unstable vestibularly impaired patients revealed the highest correlation between trunk inclination and stability. Yet, higher center of pressure (COP) displacement, and more frequent correlations between stability and posture parameters, were found in scoliotic, compared with non-scoliotic girls (Nault et al., 2002; Allard et al., 2004; Dalleau et al., 2007). Biomechanical and neurological factors have been reported to affect postural responses; similar muscle activation patterns were observed between healthy children simulating the crouched posture of cerebral palsy, and children with cerebral palsy (Woollacott et al., 1998). It is possible that, environmental conditions affect postural alignment and that postural alignment affects stance stability. A better understanding of the relationship between postural alignment and stability is crucial for clinical practice (see Box 1). Because stability depends on postural chain mobility (Kantor et al., 2001), misalignment of a given segment may demand compensatory movements in other segments in order to maintain stability. On the other hand, postural instabilities may demand positions of segments other than the ideal alignment. Thus, postural alignment should be considered to improve stability and postural stability may have an important role in postural alignment. We evaluated stance stability in subjects with knees hyperextension, a postural misalignment in which the knees are extended beyond 180 . In this condition, knee

stabilization becomes more dependent on passive structures, and quadricep muscle activation is no longer necessary (Kapandji, 1980; Loudon et al., 1998; Nguyen and Shultz, 2007). Knee hyperextension is clinically relevant due to increased risk of injury, especially to the anterior cruciate ligament (Cowan et al., 1996; Bonci, 1999; Devan et al., 2004; Ramesh et al., 2005). Additionally, it seems to be related to increased risk of falls in elderly populations (O’Brien et al., 1997). The objective of this study was to evaluate the effects of visual and proprioceptive disturbance on knee alignment and on postural control during upright stance.

Methods Subjects Twenty-three healthy women (22.7  3.2 years, BMI 20.3  1.5) were recruited to participate in this study. Subjects were included using a clinical assessment to guarantee participants with aligned and hyperextended knees. Exclusion criteria were neurological, musculoskeletal or respiratory pathology, sensory systems diseases, previous surgery in lower limbs or trunk, dizziness, cognitive impairments, consumption of alcohol 24 h prior to the test, complaints of any pain or fatigue at the moment of the test. All subjects read and signed an informed consent form that was approved by the Ethics Committee of the Clinics Hospital, School of Medicine, University of Sa ˜o Paulo.

Procedures Information from three 30-s trials was acquired in each of four test conditions when subject stood still: 1) on the force plate with eyes open (NO FOAM/EO), condition with all sensory inputs available; 2) on the force plate with eyes closed (NO FOAM/EC); 3) on foam (Airex balance pad, 6 cm thick, density 57 g/ dm3) placed on top of the force plate with eyes open (FOAM/EO); and 4) on foam placed on top of the force plate with eyes closed (FOAM/EC), the most challenging condition with vision and proprioceptive inputs disturbed.

Box 1. Clinical relevance. The understanding of the relationship between knee hyperextension and postural control will assist the clinical work of the practitioner taking in consideration that:  Knee hyperextension is a postural condition highly dependent on postural control. Thus, it should not be treated as an isolated musculoskeletal condition.  As clinical practice guidelines suggest, knee hyperextension has to be treated to improve knee alignment as such patients are more vulnerable to knee injuries.  Knee hyperextension changes according to postural challenges. Thus, it is important to consider the need of a diversity of postural conditions when treating knee hyperextension.  Diversity of postural conditions includes visual and proprioceptive perturbations.  Treatment of knee hyperextension needs to include dynamic conditions.  All these considerations have to be taken seriously into account in the final phase of knee injury rehabilitation.

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Subjects were asked to stand quietly on the force plate, barefoot, with feet parallel, forward oriented, apart at hip width (Prieto et al., 1996) and arms crossed against the chest.

Kinematic data were collected using a Panasonic PV-GS250 digital camcorder at 60 Hz placed to the right side of subject. Spherical retro-reflective landmarks were placed at the right side of the subjects at the lateral malleolus, the head of the fibula, and the greater trochanter. Signal was digitized and 2D-analyzed using Ariel Posture Analysis System software with the appropriate calibration. The mean angle (A-knee) and range of motion (ROM-knee) of knee were calculated for each trial. Kinetic data were sampled at 100 Hz using an AMTI OR6-7 1000 force plate (AMTI, Newton, MA). Instant COP and the following COP variables were calculated in Matlab (6.5, Mathworks) environment: 1) root mean square (RMS) of the anterioreposterior COP displacement, 2) mean velocity (MV), mean of COP displacement velocities between each two consecutive sample points in the anterioreposterior direction; and 3) area of the ellipse containing 85% of the total COP displacement (Area) (Oliveira et al., 1996).

Data analyses Sensory disturbance and knee alignment (kinematic analyses) To analyze the effects of visual and proprioceptive disturbance on knee alignment during upright stance, two groups of subjects based on the knee angle in the NO FOAM/EO condition, in all natural sensory inputs which are integrated, were considered: aligned group (knee angle < 180 ) and hyperextended group (knee angles > 180 ). Kinematic variables (A-knee and ROM-knee) were compared across test conditions in each group using General Linear Models Analysis of Variance (Anova) and Tukey post hoc tests with significance level of 0.05. Sensory disturbance and postural control (kinetic analyses) Visual and proprioceptive disturbance showed an effect on knee alignment across trials, revealing a tendency to flex the knees when the balance challenge was increased. Knee angle could oscillate within-trial from >180 to <180 under challenging conditions. Therefore, to verify the effects of visual and proprioceptive disturbance on knee alignment and postural control during upright stance, trials based on the behavior of knee angles, across test conditions, were assessed in three study sub-groups. Example of knee angle variation across trials in test conditions is shown in Figure 1. Trials were assigned to Aligned-Trials or HyperextendedTrials if the knee angles were <180 or >180 throughout the entire acquisition time of the trial, respectively. Trials presenting knee angle >180 previously that changed to <180 throughout the entire 30-s of acquisition time, were assigned as Adjusted-Trials. Trials in which the knee angle fluctuated around 180 were excluded.

Figure 1 Example of knee angle variation across trials (subject 7). The horizontal dotted line marks the limit between the hyperextension (above the line) and alignment of the knees (below the line). Initially hyperextended, in the last five trials the subject behaved as aligned. In the trial 5 knee angles fluctuated below and above the line being excluded.

The COP variables were compared among the trials groups in each sensory condition using ManneWhitney and KruskalleWallis tests with significance level of 0.05. Also, Spearman correlation tests were performed to verify correlations between kinetic and kinematic variables.

Results All subjects were able to maintain balance during the 30-s trials without any retake.

Sensory disturbance and knee alignment (kinematic analyses) Regarding kinematic analysis, there were significant between-groups differences in knee angle (p < 0.001), but none in knee range of motion, in all test conditions. Figures 2 and 3 show the variation of knee angle and knee range of motion throughout the test conditions in both groups.

Figure 2 Mean knee angle for the aligned and hyperextended subjects across test conditions. *Significant intra-group difference from NO FOAM/EO (p < 0.001) and from NO FOAM/EC (p < 0.05).

PREVENTION & REHABILITATION e POSTURE PHYSIOLOGY

Data acquisition and signal processing

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C.M. Siqueira et al.

Figure 3 Mean range of motion of knee for the aligned and hyperextended subjects across test conditions. *Significant intra-group difference from NO FOAM/EO (p < 0.001). **Significant intra-group difference from NO FOAM/EO (p < 0.001), from NO FOAM/EC (p < 0.001) and from FOAM/EO (p Z 0.004). Note the tendency for knee flexion and increased knee range of motion when balance is threatened.

Within-groups analysis showed that while knee angle tended to decrease with sensory disturbance, knee range of motion tended to increase in both groups. Knee angle did not vary in the Aligned group, whereas the Hyperextended group showed significantly lower knee angles in the FOAM/ EC than in NO FOAM/EO (p < 0.001) or NO FOAM/EC (p < 0.05) conditions. There was no significant difference in knee range of motion across test conditions for the Aligned group, but the Hyperextended group had higher knee range of motion in the FOAM/EC condition, than in the FOAM/EO (p < 0.004), NO FOAM/EC (p < 0.001), and NO FOAM/EO (p < 0.001) conditions. Knee range of motion was also higher in the FOAM/EO condition than in the NO FOAM/EO (p < 0.001) condition.

Kinetic analyses Table 1 shows the distribution of the number of trials, based on the behavior of knee angles during trials, across test conditions. Table 2 shows the COP variable outcomes in each sensory condition for the three groups. Between-groups comparisons in each test condition showed that in the NO FOAM/EO condition, the Hyperextended group had a significantly higher MV than the Aligned group (p < 0.001).

Table 1

Aligned-Trials Hyperextended-Trials Adjusted-Trialsa Excluded-Trialsb Total of trials a

Discussion This study provides original information about the relationship between knee alignment and stance stability; it assessed changes in knee motion and effects of knee alignment on stability during sensory disturbances. There was a clear tendency for knee flexion and knee motion to increase when challenges to balance increased. Additionally, the mean velocity of COP displacement varied among groups depending on their knee alignment in two conditions of different sensory disruptions. The results suggest that knee flexion with increased motion was a motor strategy used to endure threats to balance under more demanding test conditions. In fact, subjects performing balance-demanding tasks such as skating and surfing, keep their knees semi-flexed. Healthy and vestibularly impaired subjects were reported with greater knee flexion with feet together and eyes closed, than with feet apart and eyes open (Danis et al., 1998) and the authors argue that body segments such as the knee or

Sub-groups distribution and number of trials based on the behavior of knee angles during trials across test conditions.

Sub-group

b

In the NO FOAM/EC condition, there were no differences between-groups. Only a trend (p < 0.079) was found, with the Aligned group tending to present a higher mean ellipse Area than the Hyperextended group. In the FOAM/EO condition, there were no significant differences among the three sub-groups. In the FOAM/EC condition, however, there were significant differences in the MV-ap of the three sub-groups (KruskaleWallis, p < 0.003). ManneWhitney tests showed that the Aligned-Trials sub-group had a higher and marginally lower VM-ap than the Hyperextended group (p < 0.016) and the Adjusted group (p Z 10), respectively. The Adjusted group had a higher VM-ap than the Hyperextended group (p < 0.003). Spearman tests showed significant negative correlations between the COP variables and knee angle. For Hyperextended group, the correlation coefficient (r) ranged from 15% (Area) to 18% (MV). For Aligned group, r ranged from 29.8% (RMS) to 37.3% (MV). For the whole sample, r ranged from 17.3% (MV) to 19.4% (Area). The correlations between COP variables and knee range of motion were higher, especially for Hyperextended group (r Z 68% for RMS, 64% for MV, and 67% for Area). For Aligned group, r values were 38% for RMS, 44.5% for MV, and 46% for Area. When considering the whole sample, r ranged from 55.5% for RMS to 59.6% for Area.

Knee angle 

<180 >180 <180 Inconsistent

No of trials per test condition NO FOAM/EO

NO FOAM/EC

FOAM/EO

FOAM/EC

27 40

27 38

2 69

4 69

27 31 6 5 69

27 25 10 7 69

Trials of subjects who had knee angle > 180 in previous test conditions and turned <180 in challenging test conditions. Trials in which knee angle oscillated within-trial from >180 to <180 . No case of <180 to >180 was registered.

Misalignment of the knees Mean and standard deviations of COP variables in which sensory condition for each group and sub-groups.

Test conditions

Groups

COP variables MV-ap (cm/s)

RMS-ap (cm)

Area (cm2)

NO FOAM/EO

Aligned Hyperextended

0.59  0.16 0.70  0.12*

0.35  0.28 0.32  0.14

0.92  1.21 0.82  0.57

NO FOAM/EC

Aligned Hyperextended

0.81  0.27 0.87  0.19

0.47  0.37 0.43  0.17

2.4  4.79 1.7  1.43***

Test conditions FOAM/EO

Sub-groups Aligned-Trials Hyperextended-Trials Adjusted-Trials

MV-ap (cm/s) 1.05  0.41 1.15  0.32 1.20  0.50

RMS-ap (cm) 0.57  0.33 0.61  0.23 0.52  0.19

Area (cm2) 2.99  2.38 3.32  1.98 2.31  1.20

FOAM/EC

Aligned-Trials Hyperextended-Trials Adjusted-Trials

2.47  0.58 2.07  0.62 2.95  0.78**

1.41  1.95 0.93  0.28 1.07  0.29

9.29  4.52 8.63  4.41 11.87  5.78

MV-ap: mean velocity in anterioreposterior direction; RMS-ap: root mean square in anterioreposterior direction; Area: area of COP displacement. *Significant difference between-groups (p Z 0.001). **Significant difference among sub-groups (KruskaleWallis, p Z 0.003). ***Trend toward significance between-groups (p Z 0.079). Adjusted-Trials  Hyperextended-Trials (ManneWhitney, p Z 0.003); Adjusted-Trials  Aligned-Trials (ManneWhitney, p Z 0.10); Aligned-Trials  Hyperextended-Trials (ManneWhitney, p Z 0.016).

trunk can move in only one direction when fully extended. However, individuals use other degrees of freedom to adjust their body sway under challenging standing positions. The knee flexion of the majority of our subjects (19 out of 23) in the most challenging condition reinforces this idea. In the NO FOAM/EO condition 57% of trials showed hyperextended knees against 36% in the FOAM/EC condition. It is likely that the subjects who still kept their knees hyperextended in the most challenging condition did not sense a sufficient threat to change their motor strategy. Given test conditions with higher postural demands, they might have flexed their knees. However, other studies must be done to evaluate the balance parameters underlying this change of motor strategy. Subjects initially classified as hyperextended, flexed their knees in more challenging conditions. Even in the same sensory condition, subjects initially hyperextended, sometimes had trials in which the knees were kept hyperextended and others in which knees turned aligned, leading to the establishment of an Adjusted-Trials sub-group. Despite similar biomechanics between the Aligned and Adjusted-Trials sub-group (both with flexed knees), the neural control over the knees might not be similar. Subjects with hyperextended knees, who were led to flex them as a response to a postural challenge, explored a new motor experience in order to adopt an unusual knee position. It is likely that, in this unusual position, the sensory acquisition and integration and motor processes may be different than for those subjects spontaneously aligned. This result was revealed in quite standing conditions and might be clinically and functionally more relevant when performing dynamics tasks. This is the idea underlying the decision to consider the Adjusted-Trials sub-group instead of considering only biomechanical parameters of knee alignment and include

these trials into the Aligned group when evaluating the effects of knee alignment on stability. The mean velocity of the COP has been reported to be the most discriminating variable between conditions and subject populations in terms of balance control (Hufschmidt et al., 1980; Prieto et al., 1993; Prieto et al., 1996; Cornilleau-Peres et al., 2005; Raymakers et al., 2005). While RMS has been related to the postural stability achieved by the postural control system, the mean velocity has been linked to the amount of regulatory activity associated with the level of stability (Hufschmidt et al., 1980; Prieto et al., 1993; Prieto et al., 1996; Cornilleau-Peres et al., 2005; Raymakers et al., 2005; Mezzarane and Kohn, 2008). In this study, the Hyperextended group had a higher MV than the Aligned group in the NO FOAM/EO condition. In the two intermediary conditions, no differences were found for MV. However, in the most challenging condition (FOAM/EC) results revealed the lowest MV in the Hyperextended-Trials sub-group and the highest in the Adjusted-Trials sub-group. Our results showed only a tendency for lower COP amplitude displacement (Area and RMS) in the NO FOAM conditions in the Hyperextended group. Significant differences other than those in the MV were not found, probably, due to the high variability in the Aligned group (coefficient of variance in some cases above 100%). p-values ranged from 0.079 to 0.20 in the comparisons of RMS and AREA between Aligned and Hyperextended groups. The higher MV in the Hyperextended group in the NO FOAM/EO condition might possibly be due to the constriction of knee and ankle motion, by knee hyperextension leading to compensatory movements in proximal segments (Danis et al., 1998; Kantor et al., 2001). A possible hypothesis to explain the inversion of the MV results in the most challenging condition (FOAM/EC condition) is that, as the foam is not a firm support, it is deformed by the movements of the distal

PREVENTION & REHABILITATION e POSTURE PHYSIOLOGY

Table 2

239

PREVENTION & REHABILITATION e POSTURE PHYSIOLOGY

240 segments of the lower limb which require faster movements that are reflected in the higher MV of the Adjusted-Trials and Aligned-Trials sub-groups, while the constriction of the distal segments in the Hyperextended-Trials sub-group prevents this from happening. The Romberg quotient is a classical computation of the visual contribution to posture and when calculated from the mean velocity leads to a more reliable measurement (Romberg quotient Z MV(EC)/MV(EO)) (Cornilleau-Peres et al., 2005). The calculation of the Romberg quotient from the means of the groups showed that closing the eyes while standing on foam increased MV by 146% in the Adjusted, 135% in the Aligned-Trials sub-group and only 80% in the Hyperextended-Trials sub-groups. These results reinforce the idea that knee alignment affects stance stability because subjects with knee hyperextension showed more regulatory activity as demonstrated by their higher MV in the NO FOAM/EO condition. During challenging balance conditions they exhibited a motor strategy by flexing their knees, and even when showing knee angles similar to the aligned subjects (Adjusted-Trials sub-group) they tend to show higher MV. Of the rare reports available that address this topic, few reach the same conclusion. We believe that the discrepancy might arise as much from variations in postural and stability parameters as from the level of challenges to balance. Able-bodied individuals under easy balance tasks might compensate for existing misalignment effects with movements of other segments in order to maintain a safe balance position (Tarantola et al., 1997; Danis et al., 1998; Kantor et al., 2001), as also suggested by higher energy expenditure without differences in COP displacement in flexed trunk positions (Saha et al., 2007). We believe that changes in stance stability will be noticeable only when the compensatory mechanisms reach their limits under more challenging stance conditions (Danis et al., 1998) or in severe postural misalignment (Nault et al., 2002; Allard et al., 2004; Dalleau et al., 2007; Saha et al., 2007). This may also be the reason that MV is the most discriminative COP variable. The central nervous system must safely maintain center-of-gravity when performing balance tasks; therefore misalignments would likely require more regulatory activity, as expressed by the mean velocity, to ensure stability (Tarantola et al., 1997; Saha et al., 2007). We, like other investigators (Danis et al., 1998; Nault et al., 2002; Ferreira et al., 2007), were primarily examining correlations between postural alignment and stability; however we found greater correlations between COP variables and the range of motion of the knee rather than the knee angle itself. Therefore, in future studies the amount of regulatory activity associated with a given postural misalignment should be considered. Additionally, it would be interesting to examine how postural misalignment affects responses of dynamic posture to internal and external threats.

Limitations A large sample size would be needed to increase the statistical power of these results. Moreover, an increased

C.M. Siqueira et al. postural challenge, by adding a higher sensory disturbance, would enhance the differences found in this study.

Conclusion Our study has revealed that knee hyperextension is a transient condition showing a tendency to flex as postural challenge increases. Also, knee hyperextension affects postural control as mean velocity is the highest in the hyperextended group in natural standing sensory conditions, and lowest with sensory disturbance. This study reinforces that, when treating knee hyperextension, either with the purpose of obtaining alignment, or treating knees for a hyperextension injury, postural control has to be taken into consideration.

References Allard, P., Chavet, P., Barbier, F., Gatto, L., Labelle, H., Sadeghi, H., 2004. Effect of body morphology on standing balance in adolescent idiopathic scoliosis. Am. J. Phys. Med. Rehabil. 83 (9), 689e697. Bonci, C.M., 1999. Assessment and evaluation of predisposing factors to anterior cruciate ligament injury. J. Athl. Train. 34 (2), 155e164. Cornilleau-Peres, V., Shabana, N., Droulez, J., Goh, J.C., Lee, G.S., Chew, P.T., 2005. Measurement of the visual contribution to postural steadiness from the COP movement: methodology and reliability. Gait. Posture 22 (2), 96e106. Cowan, D.N., Jones, B.H., Frykman, P.N., Polly Jr., D.W., Harman, E.A., Rosenstein, R.M., Rosenstein, M.T., 1996. Lower limb morphology and risk of overuse injury among male infantry trainees. Med. Sci. Sports Exerc. 28 (8), 945e952. Dalleau, G., Allard, M.S., Beaulieu, M., Rivard, C.H., Allard, P., 2007. Free moment contribution to quiet standing in ablebodied and scoliotic girls. Eur. Spine J. 16 (10), 1593e1599. Danis, C.G., Krebs, D.E., Gill-Body, K.M., Sahrmann, S., 1998. Relationship between standing posture and stability. Phys. Ther. 78 (5), 502e517. Devan, M.R., Pescatello, L.S., Faghri, P., Anderson, J., 2004. A prospective study of overuse knee injuries among female athletes with muscle imbalances and structural abnormalities. J. Athl. Train. 39 (3), 263e267. Ferreira, E., Duarte, M., Marques, A.P., Maldonado, E.P., 2007. Correlation of postural alignment in sagittal view and postural control. Santos-SP, Brazil, The International Journal for the Multidisciplinary Study of Voluntary Movements. Prog. Motor Control VI 11, S162. Hufschmidt, A., Dichgans, J., Mauritz, K.H., Hufschmidt, M., 1980. Some methods and parameters of body sway quantification and their neurological applications. Arch. Psychiatr. Nervenkr. 228 (2), 135e150. Kantor, E., Poupard, L., Le Bozec, S., Bouisset, S., 2001. Does body stability depend on postural chain mobility or stability area? Neurosci. Lett. 308 (2), 128e132. Kapandji, I.A., 1980. Fisiologia Articular. Manole, Sa ˜o Paulo. Loudon, J.K., Goist, H.L., Loudon, K.L., 1998. Genu recurvatum syndrome. J. Orthop. Sports Phys. Ther. 27 (5), 361e367. Mezzarane, R.A., Kohn, A.F., 2008. Postural control during kneeling. Exp. Brain Res. 187 (3), 395e405. Nault, M.L., Allard, P., Hinse, S., Le Blanc, R., Caron, O., Labelle, H., Sadeghi, H., 2002. Relations between standing stability and body posture parameters in adolescent idiopathic scoliosis. Spine 27 (17), 1911e1917.

Nguyen, A.D., Shultz, S.J., 2007. Sex differences in clinical measures of lower extremity alignment. J. Orthop. Sports Phys. Ther. 37 (7), 389e398. O’Brien, K., Culham, E., Pickles, B., 1997. Balance and skeletal alignment in a group of elderly female fallers and nonfallers. J. Gerontol. A Biol. Sci. Med. Sci. 52 (4), B221eB226. Oliveira, L.F., Simpson, D.M., Nadal, J., 1996. Calculation of area of stabilometric signals using principal component analysis. Physiol. Meas. 17 (4), 305e312. Prieto, T.E., Myklebust, J.B., Hoffmann, R.G., Lovett, E.G., Myklebust, B.M., 1996. Measures of postural steadiness: differences between healthy young and elderly adults. IEEE Trans. Biomed. Eng. 43 (9), 956e966. Prieto, T.E., Myklebust, J.B., Myklebust, B.M., 1993. Characterization and modeling of postural steadiness in the elderly: a review. Trans. Rehabil. Eng. 1 (1), 26e34.

241 Ramesh, R., Von Arx, O., Azzopardi, T., Schranz, P.J., 2005. The risk of anterior cruciate ligament rupture with generalised joint laxity. J. Bone Joint Surg. Br. 87 (6), 800e803. Raymakers, J.A., Samson, M.M., Verhaar, H.J., 2005. The assessment of body sway and the choice of the stability parameter(s). Gait. Posture 21 (1), 48e58. Saha, D., Gard, S., Fatone, S., Ondra, S., 2007. The effect of trunkflexed postures on balance and metabolic energy expenditure during standing. Spine 32 (15), 1605e1611. Tarantola, J., Nardone, A., Tacchini, E., Schieppati, M., 1997. Human stance stability improves with the repetition of the task: effect of foot position and visual condition. Neurosci. Lett. 228 (2), 75e78. Woollacott, M.H., Burtner, P., Jensen, J., Jasiewicz, J., Roncesvalles, N., Sveistrup, H., 1998. Development of postural responses during standing in healthy children and children with spastic diplegia. Neurosci. Biobehav. Rev. 22 (4), 583e589.

PREVENTION & REHABILITATION e POSTURE PHYSIOLOGY

Misalignment of the knees

Journal of Bodywork & Movement Therapies (2011) 15, 242e250

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

ORIGINAL RESEARCH

Interrelationships between dental occlusion and plantar arch PREVENTION & REHABILITATION e ORIGINAL RESEARCH

Antonino Marco Cuccia, DDSc * Orthodontic and Gnathology Section, Department of Stomatological Sciences "G. Messina", University of Palermo, Via del Vespro 129, 90128 Palermo, Italy Received 30 August 2010; received in revised form 24 October 2010; accepted 26 October 2010

KEYWORDS Posture; Temporomandibular joint disorders; Baropodometric platform

Summary Objective: The aim of this study was to evaluate the influence of different jaw relationships on the plantar arch during gait. Methods: 168 subjects, participating in this study, were distributed into two groups: a control (32 males and 52 females, ranging from 18 to 36 years of age) and a Temporomandibular joint disorders group (28 males and 56 females, ranging from 19 to 42 years of age). Five baropodometric variables were evaluated using a baropodometric platform: the mean load pressure on the plantar surface, the total surface of feet, forefoot vs rearfoot loading, forefoot vs rearfoot surface, and the percentage of body weight on each limb. The tests were performed in three dental occlusion conditions: mandibular rest position (REST); voluntary teeth clenching (VTC); and cotton rolls placed between the upper and the lower dental arches without clenching (CR). The variables were analyzed through repeated measures ANOVA. The ManneWhitney test was used to compare the postural parameters of the two groups. The level of significance was p < 0.05. Results: As to the intra-group analysis of TMD group, all posturographic parameters in both lower limbs showed a significant difference between REST vs CR (P < 0.001) and between VTC vs CR (p < 0.001), except for the percentage of body weight on each limb. The control group showed a significant difference between REST vs VTC, REST vs CR and VTC vs CR (p < 0.001) in the mean load pressure on the plantar arch, forefoot surface, rearfoot surface and total surface of feet. The mean load pressure on the plantar arch in VTC, and the forefoot and total surfaces of feet in CR (p < 0.05) were significantly higher in the TMD group in both limbs. The results of this study indicate that there are differences in the plantar arch between the TMD group and control group and that, in each group, the condition of voluntary tooth clenching determines a load reduction and an increase in surface on both feet, while the inverse situation occurs with cotton rolls. The results also suggest that a change in the load distribution between forefoot and backfoot when cotton rolls were placed between the dental arches can be considered as a possible indicator of a pathological condition of the stomatognathic system (SS) which could

* Tel.: þ39 0 916552232/0 91 348282; fax: þ39 0 91 348282. E-mail address: [email protected]. 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.10.007

Interrelationships between dental occlusion and plantar arch

243

Introduction Temporomandibular joint disorders (TMD) are a group of diseases affecting masticatory muscles, temporomandibular joint, and surrounding structures (Okeson, 1993). Patients with TMD showed a significantly smaller loading surface in the foot and a consequent increase of load pressure, than control subjects during walking, after insertion of cotton rolls between the upper and the lower dental arches (Tecco et al., 2008). Subsequently the same researchers showed that in healthy subjects without TMD symptoms, there are detectable interrelationships between occlusion and locomotion (Tecco et al., 2010). Both static and dynamic postural stability are the result of many types of sensory information emanating from the visual, vestibular and proprioceptive systems and from the plantar surface of the foot. The vestibular and the visual systems signal changes in head and eye position with respect to the external world; the somatosensory system signals motion of the joints as well as changes in the muscle state, while the plantar surface signals contact between the feet and the ground. The stomatognathic system (maxilla and mandible, dental arches, salivary glands, nervous and vascular supplies, temporomandibular joint and masticatory muscles) may influence muscular function in other parts of the body (Ishijima et al., 1998), range of movement in the hip (Ferna ´ndez-de-las-Pen ˜as et al., 2006), balance control (Bracco et al., 2004), gaze stabilization quality (Gangloff et al., 2000), ocular convergence, and fusional reserves (Cuccia and Caradonna, 2008). A close correlation has been recognized between trigeminal input and the activities of the neck muscles (trigemino-cervical reflex) (Alstermark et al., 1992; Abrahams et al., 1993): the activities of the muscle spindles and mechanoreceptors of the periodontal ligament all influence the activities of the motor neuron pool of the sternocleidomastoid muscles through the central ramus of the mesencephalic trigeminal neurons. This contributes to the prevention of excessive head movements and body sway (Manni et al., 1975), and plays an effective role in the enhancement of sports performance (Ishijima et al., 1998). The loss of the occlusal support and instability of mandibular position might influence weight distribution at the feet during clenching, and cause deterioration of quickness (Yoshino et al., 2003). On the other hand, only few studies have investigated the effect of occlusal conditions on the plantar arch during gait. Gait is a complex motor skill, frequently used to evaluate general motor function. Gait requires the integration of mechanisms of locomotion with those of balance, motor control, and musculoskeletal functions, in order to keep the projection of the centre of gravity of the subject over ¨ berg et al., 1993). the base-of-support (O

A functional correlation between temporal and masseter EMG activity, interdental occlusal plane, and the plantar arch have been reported. The authors hypothesized the existence of connections between the afferent proprioceptive impulse of the muscles governing the configuration of the plantar arch and the trigeminal motor nucleus that innervates the masticatory muscles (Valentino et al., 1991). It has been reported that mandibular position affects gait stability (Ferrario et al., 1996), and that wearing complete dentures influences gait by improving the stability of edentulous patients under both static and dynamic conditions (Fujimoto et al., 2001; Okubo et al., 2010). The aim of the present study was twofold: to identify the effects of TMD on plantar pressure and surface compared to a healthy control group during gait, and to verify if different jaws relationships may modify the plantar arch in the same sample.

Material and methods The Ethics Committee of the University of Palermo approved the protocol. Written informed consent was obtained from each subject after a full explanation of the experiment.

Subjects Inclusion criteria for both groups were as follows: age beween18 years and 40 years, absence of any kind of removable prosthetic restoration, presence of a bilateral molar support, absence of periodontal disease, neuropathology, postural and gait disorders, vestibular dysfunction, oculomotor abnormalities and other diseases that could affect balance, negative history of macro trauma in the head region or in the vertex. The Temporomandibular group was selected from 2 February 2007 to 1 December 2009 from among those referred to the Department of Orthodontics, University of Palermo, Italy. The control group consisted of randomly recruited university students who agreed to participate in the study. They were selected after evaluation of their plaster dental cast and questionnaire assessment. The presence of TMD in these subjects was confirmed using a clinical examination conducted to measure any signs and symptoms according to the American Academy of Orofacial Pain:  Painful symptomatology (spontaneous or upon digital palpation) in the masticatory muscles or in the TMJ  Internal sounds detectable by manual palpation of lateral and/or posterior poles of the TMJ  Inharmonious or constrained mandibular movements.

PREVENTION & REHABILITATION e ORIGINAL RESEARCH

influence posture. Therefore the use of posture monitoring systems during the treatment of stomatognathic system is justified. ª 2010 Elsevier Ltd. All rights reserved.

244

A.M. Cuccia

The same examination was performed on the control group. There were no signs or symptoms of TMD during history and clinical examination. The study sample includes 168 patients: 84 (28 males and 56 females) with TMD (TMD group) and 84 healthy subjects (32 males and 52 females, control group). Table 1 shows the variables considered for the two groups (age, height, weight, age and shoe size).

PREVENTION & REHABILITATION e ORIGINAL RESEARCH

Measurements In the present study, a quantitative method was adopted to analyze walking at a natural pace. A baropodometric platform was used to measure the distribution of pressure and load on the plantar surface during locomotory activities (dynamical analysis) by the same examiner, aiming at minimizing possible methodological problems. For the present study an Electronic Modular Baropodometer (Diagnostic Support S.r.l. Via Dora 1 e 00198 Roma, Italy) was used. The baropodometer consisted of a platform (720  75 cm), with a recording surface (120  40 cm) in the middle. This platform was characterized by load cells with an internal circuit that changed electrical resistance upon the application of foot pressure. The resolution was of one sensor per cm2. The platform interfaced with a computed workstation and dedicated software for data storage and subsequent analysis (Milletrix, Diagnostic Support). The software separated each foot in two regions: forefoot (FF) and rearfoot (RF). For postural evaluation, we selected seven parameters for each occlusal condition on the right and left foot: the mean load pressure on the plantar surface (ML, measured as g/cm2), the total surface of feet (TS, measured as cm2), FF vs RF loadings (L), FF vs RF surfaces (S), and the percentage of body weight placed on each limb (L, measured as %). The dynamic baropodometric variables of subjects were tested under three experimental conditions: (a) habitual occlusion after swallowing without clenching (mandibular rest position, REST); (b) voluntary teeth clenching (VTC); (c) occlusion by cotton rolls (diameter 1 cm, length 3.7 cm) placed bilaterally between the upper and the lower dental arches without clenching (CR).

Table 1

In order to assess for method error, a pilot study was performed on a sample of 12 subjects randomly selected in the department. An examiner placed the subject on the platform and performed all the measurements (REST, VTC and CR) following the same protocol of the sample study. Then, the subject was asked to step down the platform and to take several steps. After 2 min, the subject stepped back up on the platform and the recording in REST, VTC and CR was performed again. The method error (ME) for all these measurements was assessed by means of the formula pffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi P MEZ ð d 2 =2nÞ where d is the difference between the two measurements and n is the number of recordings. Systematic differences between replicated measurements were tested with paired Student’s t-test setting the alpha error at 0.1.

Test procedure The baropodometric examinations were performed in the department of Orthodontics and Gnathology, University of Palermo. The examiner taking stabilometric measurements was blind about the TMD/control group status of the subjects. Each subject received instructions about the procedures to become familiar with the testing protocol and was instructed to swallow two to three times and to relax his/her trunk, upper and lower limbs before beginning the examination. The subject was asked to take several steps on the platform in order to calibrate the system. With the objective of diminishing variability of the data, the subjects walked without shoes to and fro for three times (for a total of six deambulations) onto the platform during the recording: the software provided to measure the mean values of these three parameters (Figure 1). For all three tests the subjects were asked to walk along the platform in as stable a manner as possible, maintaining a natural head and body posture with both arms hanging freely beside the trunk while looking to the horizon, according to the protocol supplied by the manufacturer. A resting period of 1min was observed between each recording in REST, VTC and CR. All subjects were asked to avoid alcohol and heavy exercise during the 24 h before the clinical recording. The order of testing was similar for all subjects.

Subject demographics (n Z 84).

TMD group

Male Z 28

Age (years) Height (cm) Weight (Kg) Shoe size

Mean 28.9 165.3 60.8 36.3

Control group

Male Z 32

Age (years) Height (cm) Weight (Kg) Shoe size

Mean 27.1 167.1 62.1 37.3

Females Z 56 St. dev 10.3 9.3 13.3 8.3

Min. 19 145 40 35

Max 42 189 98 43

NS NS NS NS

Max 36 194 87 45

NS NS NS NS NS

Females Z 52 St. dev 9.2 9.6 12.4 9.4

Min. 18 152 43 36

Interrelationships between dental occlusion and plantar arch

245 between VTC vs CR (p < 0.001), except L (Table 2). The control group showed significant differences between REST vs VTC, REST vs CR and VTC vs CR (p < 0.001) in the ML, FFS, RFS, TS, while there were no significant interactive effects between mandibular positions and distribution of load on the foot (FFL and RFL, P > 0.05), and between feet (L < 0.05) (Table 3). No significant differences were observed between the two groups in the right and the left limbs in all occlusal conditions, except in the TMD group, where significantly higher values of ML in VTC, and TS and FFS in CR took place (Tables 4 and 5).

Figure 1 The plantar profile from a baropodometric record. The baropodometric imprints also show the pressure distribution on the foot plantar surface, by means of a color scale (dark peak, maximum pressure of the foot plant).

Data analysis Descriptive statistics (mean and SD) were computed for all variables. The differences in age average, foot measurements, weight and height between the control group and the group with TMD was analyzed through Student’s t-test. The analysis of variance for repeated measures (ANOVA) test with the Student-NewmaneKeuls Multiple Comparisons post-test were used in order to verify whether eventual postural variations in the different mandibular positions were statistically significant. The ManneWhitney test was used to compare the postural parameters of the two groups. Data were analyzed using Primer of Biostatistics for Windows (version 4.02, McGraw-Hill Companies, New York). Statistical significance was set at 5 percent error level (p < 0.05).

Results The mean method error was 5.5% for the ML, 8.8% for TS, 15.5 for the FFL vs RFL, 18.8 for the FFS vs RFS and 28.2 for L. There was no systematic error for duplicate baropodometric measurements (Student’s t-test; p > 0.1). No statistical differences were found for age, height, weight and foot measure between the two groups (Table 1). A detailed analysis showed that dental occlusion modifies the postural conditions and that the condition of VTC determines a significant load reduction and a significant increase in surface on both feet, while the inverse situation occurs in CR, thus indicating that the plantar surface of the foot was differently affected by the dental occlusion. For the intra-group analysis of TMD group, all posturographic parameters in both lower limbs, showed significant differences between REST vs CR (P < 0.001) and

The present study has shown that there are differences in the plantar arch between the TMD group and control group and that, in each group, the condition of voluntary tooth clenching determines a load reduction and an increase in surface contact on both feet, while the inverse situation occurs with cotton rolls. The results also suggest that a change in the load distribution between forefoot and backfoot, when cotton rolls were placed between the dental arches, can be considered as a possible indicator of a pathological condition of the stomatognathic system which could influence the posture. Sensory information issuing from proprioceptors of muscles and articulations and from the plantar surface of the foot are important for postural control. A role of such functional sensory information could be to inform the central nervous system about ground reaction forces when the body sways while standing on a stable support. Posture analysis deriving from baropodometrical digital techniques offers various advantages:  It is free from any influence deriving from contact between patient and examiner  It allows the investigation of plantar arch, postural and locomotor biomechanics  The entire sample may be uniformly analyzed through a standardization of procedures. The foot, from a postural point of view, may cause postural imbalance, or may be an adaptive response to pathological alterations in other parts of the body (especially stomatognathic and oculomotor systems) (Bricot, 1998). Rothbart (2008) showed a positive correlation among foot pronation, innominate rotation and vertical facial dimension, theorizing an ascending foot-cranial model to explain these findings. Rothbart has demonstrated that pronation creates problems in the knees (Rothbart and Estabrook, 1988). Such relationship may be reciprocal. Chaitow (2005) has noted a link between temporomandibular joint disorders, together with pedal disorders, as well as sinusitis, headaches, facial pain, hypertension, shoulder/arm syndrome. Dysfunctions in the stomatognathic system (eg, asymmetrical loss of an occlusal supporting zone, occlusal interferences) were linked to changes in the distribution of the

PREVENTION & REHABILITATION e ORIGINAL RESEARCH

Discussion

246 Table 2

A.M. Cuccia Mean values (S.D.) for the baropodometric parameters of 84 subjects with TMD. VTC

F

P

SNK Post test

186.206 8.97327 2.85331 7.92672 2.80206 3.28499 16.3208

22.33 13.16 7.75 8.94 4.15 N.S. 11.52

0.000 0.000 0.005 0.000 0.017

VTC/CR VTC/CR VTC/CR VTC/CR VTC/CR

0.000

VTC/CR REST/CR

169.7432 8.753276 3.76704 7.346517 3.53464 3.284993 15.59077

N.S. 15.23 7.29 9.34 5.90 N.S. 12.96

0.000 0.000 0.000 0.003

VTC/CR VTC/CR VTC/CR VTC/CR

0.000

VTC/CR REST/CR

Right plantar surface (mean values)

REST

CR

Mean

D.S.

Mean

D.S.

MEAN

D.S.

ML(g/cm2) FFS (cm2) FFL (%) RFS (cm2) RFL (%) L (%) TS (cm2)

642.338 52.5599 50.531 47.1862 47.569 50.85 99.7461

178.46 11.95 2.64 9.6 2.58 2.84 21.25

614.54 54.0774 50.394 48.7537 47.7893 50.8167 102.83

148.6014 10.47339 2.071165 8.410715 2.033693 3.003726 18.66224

779.9471 46.19118 49.35294 43.26412 48.61765 51.46471 89.45706

650.521 51.5093 50.7167 46.9169 47.3464 49.15 98.4276

179.984 11.9369 2.75309 9.2658 2.79291 2.8437 20.8187

636.461 52.4265 50.3217 47.6523 47.7639 49.1602 100.08

159.7988 11.20759 2.535458 8.904446 2.462033 3.014475 19.82342

791.541 44.1035 48.9941 42.3912 48.8647 48.5353 86.4959

REST/CR REST/CR REST/CR REST/CR REST/CR

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Left plantar surface (mean values) ML(g/cm2) FFS (cm2) FFL (%) RFS (cm2) RFL (%) L (%) TS (cm2)

REST/CR REST/CR REST/CR REST/CR

REST Z mandibular rest position; VTC Z maximal intercuspal position; CRZ cotton rolls; ML Z mean load pressures; FFL Z forefoot surface; RFS Z backfoot surface; FFL Z forefoot load; RFL Z backfoot load; L Z limb load, percentage of body weight placed on each ; TS Z total surface.

Table 3

Mean values (S.D.) for the baropodometric parameters of 84 subjects without TMD.

Right plantar surface (mean values)

REST

VTC

CR

Mean

D.S.

Mean

D.S

Mean

D.S.

ML(g/cm2)

626.6708

101.7606

567.9917

66.67307

771.661

149.7735

F

P

74.5

0.000 VTC/CR REST/CR VTC/REST 0.000 VTC/CR REST/CR VTC/REST

FFS (cm2)

50.07583

9.154053

53.22792

8.119759

42.1079

8.953978

36.5

FFL (%) RFS (cm2)

50.87917 44.6225

2.413004 7.788115

50.9375 47.11958

1.981614 5.983222

49.8761 41.9732

5.767664 9.873456

N.S. 8.60

RFL (%) L (%) TS (cm2)

47.16667 51.15833 94.69917

2.433224 47.30833 1.98032 2.996363 51.0625 2.267696 16.54507 100.3483 13.85999

47.8747 50.7673 84.0723

7.937654 6.297656 15.59077

SNK Post test

0.000 VTC/CR REST/CR VTC/REST

N.S. N.S. 24.27 0.000 VTC/CR REST/CR VTC/REST

Left plantar surface (mean values) ML(g/cm2) FFS (cm2)

621.35 48.2754

FFL (%) RFS (cm2) RFL (%) L (%) TS (cm2)

49.9333 45.4342 48.0167 48.9875 93.7113

106.55 9.9883 2.59693 6.34391 2.2738 3.04849 16.0468

562.9583 72.21199 739.921 138.8735 52.99417 8.763289 41.0965 9.994568 50.60417 2.356947 47.205 7.087694 47.49583 2.14425 48.9375 2.267696 100.2 15.5888

49.9654 40.9342 48.8557 50.8983 82.1563

N.S. 28.43 0.000 VTC/CR REST/CR VTC/REST 7.794565 N.S. 9.8987676 14.00 0.000 VTC/CR REST/CR 6.922234 N.S. 6.987656 N.S. 11.99977 30.08 0.000 VTC/CR REST/CR VTC/REST

REST Z mandibular rest position; VTC Z maximal intercuspal position; CRZ cotton rolls; ML Z mean load pressures; FFL Z forefoot surface; RFS Z backfoot surface; FFL Z forefoot load; RFL Z backfoot load; L Z limb load, percentage of body weight placed on each ; TS Z total surface.

Interrelationships between dental occlusion and plantar arch Table 4

247

Mean values (S.D.) for baropodometri parameters of subjects with and without TMD. REST Subjects with TMD

Subjects without TMD

Mean

D.S.

Mean

D.S.

t

ML (g/cm ) FFS (cm2) FFL (%) RFS (cm2) RFL (%) L (%) TS (cm2)

642.338 52.5599 50.531 47.1862 47.569 50.85 99.7461

178.46 11.95 2.64 9.6 2.58 2.84 21.25

626.6708 50.07583 50.87917 44.6225 47.16667 51.15833 94.69917

101.7606 9.154053 2.413004 7.788115 2.433224 2.996363 16.54507

N.S. N.S. N.S. N.S. N.S. N.S. N.S.

VTC ML (g/cm2) FFS (cm2) FFL (%) RFS (cm2) RFL (%) L (%) TS (cm2)

614.54 54.0774 50.394 48.7537 47.7893 50.8167 102.83

148.6014 10.47339 2.071165 8.410715 2.033693 3.003726 18.66224

567.9917 53.22792 50.9375 47.11958 47.30833 51.0625 100.3483

66.67307 8.119759 1.981614 5.983222 1.98032 2.267696 13.85999

2.619 N.S. N.S. N.S. N.S. N.S. N.S.

CR ML (g/cm2) FFS (cm2) FFL (%) RFS (cm2) RFL (%) L (%) TS (cm2)

779.9471 46.19118 49.35294 43.26412 48.61765 51.46471 89.45706

186.206 8.97327 2.85331 7.92672 2.80206 3.28499 16.3208

771.661 42.1079 49.8761 41.9732 47.8747 50.7673 84.0723

149.7735 8.953978 5.767664 9.873456 7.937654 6.297656 15.59077

N.S 2.978 N.S. N.S. N.S. N.S. 2.185

2

P

0.010

0.003

0.030

REST Z mandibular rest position; VTC Z maximal intercuspal position; CR Z cotton rolls; ML Z mean load pressures; FFL Z forefoot surface; RFS Z backfoot surface; FFL Z forefoot load; RFL Z backfoot load; L Z limb load, percentage of body weight placed on each ; TS Z total surface.

weight in the feet (Yoshino et al., 2003), to changes in the upper cervical spine (C1eC3) and sacroiliac joints (Fink et al., 2003) and to postural distortions in the sagittal and frontal planes of the trunk of the body (Nicolakis et al., 2000). A positive correlation was found between craniofacial morphology and pelvic inclinations (Lippold et al., 2006). These studies are examples of descending postural distortion patterns. That is the reason why it is very important to examine the stomatognathic system (SS) dysfunctions, in cases of resistant foot-ankle disorders. The relationships between SS and posture can be explained by the existence of musculoskeletal and neuroanatomical influences. Some authors have hypothesized the existence of a functional connection between muscular groups with the same motor action (chaıˆnes musculaires) (Souchard, 1993; Busquet, 1995). Myers (2001) and Stecco (2004) have described models explaining myofascial trains and sequences comprising myofascial connections crossing the entire body, linking the head to the toes and the centre to the periphery. Both these authors have postulated that these trains, or sequences, are directly involved in the organization of movement as well as muscular force transmission. The fascial system is connected so that changes occur due to these multiple connections: an anterior cruciate ligament injury can generate changes in the masseter, anterior temporalis, posterior cervicals, upper and lower

trapezius and sternocleidomastoid muscles (Tecco et al., 2006); Dvorak and Dvorak (1990), injected a hydro-saline solution into the transverse processes of C7 and using electromyography, observed muscle contraction in zones distal from the spinal metamer where the injection was made; an increase was observed in active mouth opening, and a decrease in TrP sensitivity in the masseter muscle, in response to the stretch of the hamstring muscles, assuming a functional relationship between the masticatory and hamstring muscles (Ferna ´ndez-de-las-Pen ˜as et al., 2006). The stomatognathic system is integrated with the brainstem centers via the sensorimotor system, including body balance and coordination control systems (Yin et al., 2007). Studies have revealed connections (in humans and in cats) between motor, mesencephalic, main and spinal nuclei of the trigeminus and vestibular and oculomotor nuclei (Pinganaud et al., 1999), dorsal and ventral horn of the cervical spinal cord (C1eC5) (Buisseret-Delmas and Buisseret, 1990), prepositus nucleus of the hypoglossus, cerebellum (Pinganaud et al., 1999), superior colliculus and many brainstem nuclei (nucleus of the solitary tract, dorsal reticular formation, cuneate nucleus) (Marfurt and Rajchert, 1991; Pompeiarto et al., 1992; Dauvergne et al., 2004). All the anatomical connections mentioned above suggest that portions of the trigeminal system strongly influence the coordination of posture.

PREVENTION & REHABILITATION e ORIGINAL RESEARCH

Right plantar surface (mean values)

248

A.M. Cuccia

Table 5

Mean values (S.D.) for baropodometric parameters of subjects with and without TMD.

Left plantar surface (mean values

Subjects with TMD

Subjects without TMD

Mean

D.S.

Mean

D.S.

t

ML (g/cm ) FFS (cm2) FFL (%) RFS (cm2) RFL (%) L (%) TS (cm2)

650.521 51.5093 50.7167 46.9169 47.3464 49.15 98.4276

179.984 11.9369 2.75309 9.2658 2.79291 2.8437 20.8187

621.35 48.2754 49.9333 45.4342 48.0167 48.9875 93.7113

106.55 9.9883 2.59693 6.34391 2.2738 3.04849 16.0468

N.S. N.S. N.S. N.S. N.S. N.S. N.S.

VTC ML (g/cm2) FFS (cm2) FFL (%) RFS (cm2) RFL (%) L (%) TS (cm2)

636.461 52.4265 50.3217 47.6523 47.7639 49.1602 100.08

159.7988 11. 20759 2.535458 8.904446 2.462033 3.014475 19.82342

562.9583 52.99417 50.60417 47.205 47.49583 48.9375 100.2

72.21199 8.763289 2.356947 7.087694 2.14425 2.267696 15.5888

3.844 N.S. N.S. N.S. N.S. N.S. N.S.

CR ML (g/cm2) FFS (cm2) FFL (%) RFS (cm2) RFL (%) L (%) TS (cm2)

791.541 44.1035 48.9941 42.3912 48.8647 48.5353 86.4959

169.7432 8.753276 3.76704 7.346517 3.53464 3.284993 15.59077

739.921 41.0965 49.9654 40.9342 48.8557 50.8983 82.1563

138.8735 9.994568 7.794565 9.8987676 6.922234 6.987656 11.99977

N.S. 2.156 N.S. N.S N.S. N.S. 2.022

2

PREVENTION & REHABILITATION e ORIGINAL RESEARCH

REST

P

0.000

0.033

0.045

REST Z mandibular rest position; VTC Z maximal intercuspal position; CRZ cotton rolls; ML Z mean load pressures; FFL Z forefoot surface; RFS Z backfoot surface; FFL Z forefoot load; RFL Z backfoot load; L Z limb load, percentage of body weight placed on each ; TS Z total surface.

The periodontal receptors respond to forces applied to the teeth. There are two types of receptors in the periodontal ligament: the receptors with their cell bodies in the mesencephalic nucleus of the trigeminus located in the middle of the fulcrum-apex (mainly Ruffini-like, spindle and expanded nerve endings), and principally stimulated during clenching, whereas the receptors whose cell bodies are situated in the trigeminal ganglion are distributed throughout the entire periodontal space (Tu ¨rker, 2002). Important sensory-motor functions are lost or impaired when these receptors are removed during the extraction of teeth (Trulsson, 2006). The mesencephalic nucleus of the trigeminus, which extends itself from the dorsal portion of the spinal trigeminal nucleus to the caudal part of the superior colliculus, is a sensory nucleus with unique characteristics. The cells of this nucleus are not central neurons, but protoneurons with the function of ganglionic cells. Kandel et al. (1991) showed that this nucleus can be considered the equivalent of a sensitive peripheral ganglion. They are pseudounipolar neurons that send the axon externally to the CNS, while the other connections establish intra-axial contacts with oculomotor nuclei, cerebellum, reticular formation vestibular nuclei. This may explain the sensitivity of SS to different descending stimuli (stress, anxiety, etc.) or ascending stimuli (proprioceptive inputs from spine, feet, legs). The functional near-infrared spectroscopy, used to determine oxygenated hemoglobin level, suggested that

the activity of the premotor area significantly increased as the clenching strengthened at 20%, 50% and 80% of maximum VTC (Takeda et al., 2010). Miyahara et al. (1996) showed that VTC can exert a strong influence on the motor activity of other parts of the body through actions at both a cortical and a spinal level. The spinal effect may be due to a reduction of presynaptic inhibition, whereas the cortical effect may be due to a temporal unmasking of lateral excitatory projections by afferent inputs during VTC (Schneider et al., 2000). Probably the correlation between teeth clenching and an increase in plantar surface area with a decrease in plantar loading, can be due to facilitation of the soleus Hoffman (H-) reflex. The soleus, together with the gastrocnemius, are the main plantar flexors of the ankle. The soleus H-reflex is modulated by influences descending from the cerebral cortex, as well as by peripheral afferent impulses deriving from the upper limbs or facial muscles (Miyahara et al., 1996). During human walking the soleus H-reflex increases progressively during the stance phase nearly in parallel with the soleus electromyographic activity reaching its maximum amplitude late in the stance phase, when it would be helpful in lifting the body off the ground. The same reflex is absent during the swing phase when it would oppose ankle dorsiflexion and while the tibialis anterior is active (Schneider et al., 2000).

Interrelationships between dental occlusion and plantar arch

Conclusions The success of postural treatment depends on many factors. It appears particularly important to not treat symptoms without investigating the cause of the disorder. This approach suggests that the examination should locate, and the treatment include, the primary factor. The key is to find primary conditions early in the investigation, since their correction will usually favourably influence many other dysfunctioning areas. Since the stomatognathic system is so important in neurologic organization throughout the body, it should be evaluated whenever there is a postural deviation, such as recurrent

cervical dysfunctions or fixations, unlevel head, shoulders and pelvis, aberrant gait or even abnormal foot postures. The clinical examination, for instance a sensory receptor test that evaluate relationship between various receptors and the use of more or less complex muscular and postural monitoring systems, makes it possible to achieve a more accurate diagnosis and to begin appropriate treatment. The findings of this study may even explain the interrelationship between stomatognathic inputs and locomotion, both in healthy subjects and in subjects with TMD symptoms. By using stimuli of different intensity and duration, further studies should ascertain how the treatment of TMD affects posture, and enables the most suitable postural parameters to be identified for evaluation and consequently to recognize the descending influences from the SS on pedal disorders.

References Abrahams, V.C., Kori, A.A., Loeb, G.E., Richmond, F.J., Rose, P.K., Keirstead, S.A., 1993. Facial input to neck motoneurons: trigemino-cervical reflexes in the conscious and anaesthetised cat. Experimental Brain Research 97, 23e30. Alstermark, B., Pinter, M.J., Sasaki, S., Tantisira, B., 1992. Trigeminal excitation of dorsal neck motoneurones in the cat. Experimental Brain Research 92, 183e193. Busquet, L., 1995. Les Chaıˆnes Musculaires. Tome II.Frison Roche, Paris. Bracco, P., Deregibus, A., Piscetta, A., 2004. Effects of different jaw relations on postural stability in human subjects. Neuroscience Letters 356, 228e230. Bricot, B., 1998. La Riprogrammazione Posturale Globale. Statipro Edition, Marseille. Buisseret-Delmas, C., Buisseret, P., 1990. Central projections of extraocular muscle afferents in cat. Neuroscience Letters 109, 48e53. Chaitow, L., 2005. Cranial Manipulation: Theory and Practice, second ed. Churchill Livingstone/Elsevier, Philadelphia, PA. Cuccia, A.M., Caradonna, C., 2008. Binocular motility system and temporomandibular joint internal derangement: a study in adults. American Journal of Orthodontics & Dentofacial Orthopedics 133 (640), e15e20. Dauvergne, C., Ndiaye, A., Buisseret-Delmas, C., Buisseret, P., VanderWerf, F., Pinganaud, G., 2004. Projections from the superior colliculus to the trigeminal system and facial nucleus in the rat. The Journal of Comparative Neurology 18, 233e247. Dvorak, J., Dvorak, V., 1990. Manual Medicine: Diagnostics. Thieme Medical Publishers Inc, New York. Ferna ´ndez-de-las-Pen ˜as, C., Carratala ´-Tejada, M., LunaOliva, L., Miangolarra-Page, J.C., 2006. The immediate effect of hamstring muscle stretching in subjects’ trigger points in the masseter muscle. Journal of Musculoskeletal Pain 14, 27e35. Fischer, M.J., Riedlinger, K., Gutenbrunner, C., Bernateck, M., 2009. Influence of the temporomandibular joint on range of motion of the hip joint in patients with complex regional pain syndrome. Journal of Manipulative and Physiological Therapeutics 32, 364e371. Ferrario, V.F., Sforza, C., Schmitz, J.H., Taroni, A., 1996. Occlusion and centre of foot pressure variation: is there a relationship? The Journal of Prosthetic Dentistry 76, 302e308. Fink, M., Wahling, K., Stiesch-Scholz, M., Tschernitschek, H., 2003. The functional relationship between the craniomandibular system, cervical spine and sacroiliac joint: a preliminary study. The Journal of Craniomandibular Practice 21, 202e208.

PREVENTION & REHABILITATION e ORIGINAL RESEARCH

The stance phase of walking begins when the heel of the forward limb makes contact with the ground and ends when the toe of the same limb leaves the ground, while the swing phase begins when the foot is no longer in contact with the ground and the limb is free to move. Ankle flexors and extensors are activated alternately during stance and swing phases, respectively. During the stance phase, the ankle extensors contract and ankle flexors relax to extend the ankle joint for propulsion of the body mass. On the other hand, during the swing phase the ankle flexors contract and the extensors relax (Miyahara et al., 1996; Schneider et al., 2000). The effect of cotton rolls on body posture has been attributed to the convergence of afferents from the dental proprioceptors, the ganglion of Scarpa, and the muscular proprioceptors, on the same nuclei of the brainstem. Cotton rolls should facilitate the changes in the central pathways, determining various effects: they minimize occlusal interferences (Fischer et al., 2009), increase the vertical dimension of occlusion modifying the anteroposterior condylar position related to the glenoid fossa, creating an immediate change in the activity of the masticatory and neck muscles (Leiva et al., 2003), but also reducing proprioceptive periodontal information. This suggests that the reduction of occlusal contacts reduce the surface and increase the load in all subjects. Tecco et al. (2010) by positioning a cotton roll on the left or on the right side of dental arches showed a lower loading surface of the ipsilateral foot than in habitual occlusion. Since the load distribution between forefoot and backfoot showed significant changes only among TMD patients when two cotton rolls were bilaterally placed between the upper and the lower dental arches, a change of these parameters could be considered as possible indicators of a pathological condition of SS which could influence the posture, with a descending action. Studies have shown an absence of correlation between SS and posture (Fischer et al., 2009; Michelotti et al., 2006, 2007; Perinetti, 2006). Our findings, however, cannot be compared with those studies because they did not investigate patients during walking, but in static positions. In our opinion, the potential relationship between occlusion and posture has biological plausibility since in pathologic subjects (i.e., with parafunctional activities, atypical swallowing, abnormal occlusal contacts) the teeth get into contact for different time periods and with different intensity in comparison to healthy subjects, generating an imbalance of load distribution on feet during walking.

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PREVENTION & REHABILITATION e ORIGINAL RESEARCH

250 Fujimoto, M., Hayakawa, I., Hirano, S., Watanabe, I., 2001. Changes in gait stability induced by alteration of mandibular position. Journal of Medical and Dental Sciences 48, 131e136. Gangloff, P., Louisc, J.P., Perrin, P.P., 2000. Dental occlusion modifies gaze and posture stabilization in human subjects. Neuroscience Letters 293, 203e206. Ishijima, T., Hirai, T., Koshino, H., Konishi, Y., Yokoyama, Y., 1998. The relationship between occlusal support and physical exercise ability. Journal of Oral Rehabilitation 25, 468e471. Kandel, E.R., Schwartz, J.H., Jessell, T.M., 1991. Principles of Neural Science, third ed. Elsevier Science Publication Co, New York. Leiva, M., Miralles, R., Palazzi, C., Marulanda, H., Ormen ˜o, G., Valenzuela, S., Santander, H., 2003. Effects of laterotrusive occlusal scheme and body position on bilateral sternocleidomastoid EMG activity. The Journal of Craniomandibular Practice 21, 99e109. Lippold, C., Danesh, G., Schilgen, M., Derup, B., Hackenberg, L., 2006. Relationship between thoracic, lordotic, and pelvic inclination and craniofacial morphology in adults. The Angle Orthodontist 76, 779e785. Manni, E., Palmieri, G., Marini, R., Pettorossi, V.E., 1975. Trigeminal influences on extensor muscles of the neck. Experimental Neurology 47, 330e342. Marfurt, C.F., Rajchert, D.M., 1991. Trigeminal primary afferent projections to “non-trigeminal” areas of the rat central nervous system. The Journal of Comparative Neurology 303, 489e511. Michelotti, A., Buonocore, G., Farella, M., Pellegrino, G., Piergentili, C., Altobelli, S., Martina, R., 2006. Postural stability and unilateral crossbite: is there a relationship? Neuroscience Letters 392, 140e144. Michelotti, A., Farella, M., Buonocore, G., Pellegrino, G., Piergentili, C., Martina, R., 2007. Is unilateral posterior crossbite associated with leg length inequality? European Journal of Orthodontics 29, 622e626. Miyahara, T., Hagiya, N., Ohyama, T., Nakamura, Y., 1996. Modulation of human soleus H reflex in association with voluntary clenching of the teeth. Journal of Neurophysiology 76, 2033e2041. Myers, T.W., 2001. Anatomy Trains. Churchill Livingstone, Oxford. Nicolakis, P., Nicolakis, M., Piehslinger, E., Ebenbichler, G., Vachuda, M., Kirtley, C., Fialka-Moser, V., 2000. Relationship between craniomandibular disorders and poor posture. The Journal of Craniomandibular Practice 18, 106e112. ¨ berg, T., Karsznia, A., O ¨ berg, K., 1993. Basic gait parameters: O reference data for normal subjects 10-79 years of age. Journal of Rehabilitation Research and Development 30, 210e223. Okeson, J.P., 1993. Management of Temporomandibular Disorders and Occlusion, third ed. CV Mosby, St Louis, MO. Okubo, M., Fujinami, Y., Minakuchi, S., 2010. The effect of complete dentures on body balance during standing and walking in elderly people. Journal of Prosthodontic Research 54, 42e47. Perinetti, G., 2006. Dental occlusion and body posture: no detectable correlation. Gait & Posture 24, 165e168.

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SELF-MANAGEMENT: PATIENT SECTION

Hip muscle training D.C. Craig Liebenson* L.A. Sports & Spine, 10474 Santa Monica Blvd, #304, Los Angeles 90025, United States Received 29 December 2010; accepted 29 December 2010 Low back and knee pain often are due to poor function of the hip joint. The hip is a large, deep ball and socket joint located near your groin. The outer gluteal muscles e the gluteus medius in particular e control the alignment of your knee and your pelvis during movement such as walking. For instance, during 85% of walking you are balancing on one

leg, and the gluteus medius muscle, and one side and lateral trunk muscles (quadratus lumborum) on the opposite side, are controlling your posture. Isolated training of the gluteus medius muscle can be a first step in stabilizing a knee, hip, or back problem.

The clam shell
Lie on your side with knees bent;
Place one hand on your pelvis (Figure 1a);
Use a light band around your knees for resistance;

Figure 1

Clam shell.

* Tel.: þ1 31047 02909; fax: þ1 31047 03286. E-mail address: [email protected]. 1360-8592/$ - see front matter ª 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2011.01.003

Figure 2

Athletic position.

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252

D.C. Craig Liebenson

PREVENTION & REHABILITATION e SELF-MANAGEMENT: PATIENT SECTION

Functional clam shell
Place a band around your knees;
Stand in an athletic position (Figure 2);
Allow your knee to slowly move inwards slightly (Figure 3a);
Then, perform a functional clam shell by turning your knee out against the resistance of the band (Figure 3b);
Perform 8e10 repetitions.

The lateral band walk

Figure 3

Functional clam shell.


Raise your knee slowly while keeping your foot down (Figure. 1b);
Monitor with your hand that your pelvis & spine don’t rotate;
Perform 10e12 repetitions. Once the gluteus medius muscle is “turned on” then it’s activity should be integrated into functional activities.

Figure 4


Start in an athletic position with a band just above your knees (Figure 4a);
Balance on one leg (Figure 4b);
Step to the side and balance again on the same leg (Figure 4c);
Repeat for 5e6 steps;
Reverse directions;
Perform 2e3 repetitions;
Troubleshooting: be sure to feel the buttocks or outer hip muscles on the leg you are balancing on & pushing off with; B If you feel the front of your thigh then “peel back” to the clam shell to wake up the hip/buttock muscles; B If you are feeling the lead leg that you are pulling with, then balance for longer on the support/push leg, and possibly perform a few shallow single leg squats on that leg; B To progress this exercise you may add a 2nd band around the ankles.

Lateral band walk.

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CORRIGENDUM

Corrigendum to ‘‘Massage therapy and restless legs syndrome’’ [J Bodywork Movement Ther 11 (2007) 146e150] Meg Russell P.O. Box 26, Carthage, NC 28327, USA Please be advised that there was incomplete acknowledgement for Figure 1 e Functional Rating Index: a self-reporting index of symptom intensity. The Figure should include the following: ˆ ª 1999 Institute of Evidence-Based Chiropractic; www.chiroevidence.com. A

DOI of original article: 10.1016/j.jbmt.2006.12.001. E-mail address: [email protected] 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.10.006