Journal of Bodywork and Movement Therapies Volume 14 2010

Journal of Bodywork & Movement Therapies (2010) 14, 99e101 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt PREVENTION & REHABILITATIONdSELF-MANAGEMENT: PATIENT SECTION SELFeMANAGEMENT: PATIENT SECTION The missing link in protecting against back pain Craig Liebenson* L.A. Sports & Spine, 10474 Santa Monica Blvd # 304, Los Angeles, CA 90025, USA Accepted 14 October 2009 Whether you suffer from lower back pain or merely wish to  Kneel on your hands on knees improve your fitness odds are you have been told to build up  Hands directly under your shoulders and knees directly your abdominals. While the abdominals are important, studies have shown that the often ignored spinal extensors under your hips (your back muscles) are at least as important (Biering-  Round your back up and then let your spine relax down Sorensen, 1984; Luoto et al., 1995). Yet, most people do not know how to train these vitally important muscles. to the floor into a natural slightly arched position (see Figure 1) Think for a second about your upright posture e or lack  Hold this slightly arched down position and ‘‘brace’’ thereof! It is easy to become slouched, stooped, or slum- your back by slightly tensing the muscles in 360 around ped. After all, we tend to sit way too much. The most your back to stiffen your spine popular abdominal exercise is the sit-up which actually  Hold this ‘‘braced’’ position while breathing normally makes us bend forward even more. Scientific investigations (this takes a little practice!) have discovered that normally our back muscles have one- third more endurance than our abdominals. But, in back Technique: pain patients this endurance is equal to the abdominals. So  Keep your spine ‘‘braced’’ and reach with 1 arm all the the message from the latest scientific evidence is clear e to way in front of you while simultaneously reaching with protect your back strengthen it! your opposite leg all the way behind you  Push with your support hand down into the floor so that Besides helping low back pain, spine extensor training is your head/neck and upper back push off the floor an ideal way to build up bone density in the spinal column slightly (see Figure 2) of pre-menopausal women. In fact, whereas sit-ups have  Hold this position for a few seconds been shown to be dangerous for osteoporotic women, back  Then return to the start position extensor exercises have been shown to be safe.  Alternate arms and legs Here are a few excellent trunk extensor exercises that Avoid: you can perform with a gymnastic ball.  Poking your chin out  Letting your shoulder blade stick out (see Figure 3) Bird Dog  Flattening or rounding your back  Dropping your pelvis on one side Start:  Holding your breath * Tel.: þ1 31047 02909; fax: þ1 31047 03286. E-mail address: cldc@flash.net 1360-8592/$ - see front matter ª 2009 Published by Elsevier Ltd. doi:10.1016/j.jbmt.2009.10.002

PREVENTION & REHABILITATIONdSELF-MANAGEMENT: PATIENT SECTION 100 C. Liebenson Figure 1 Start Position on All 4’s. Figure 5 Quad Leg Reach. Figure 2 Bird Dog. Figure 6 (a) start position (b) final position Figure 3 Incorrect and Correct Shoulder Blade Position. Sets/reps/frequency:  Perform 1 set  8e12 repetitions  1e2Â/day Troubleshooting:  If the Bird Dog is hard to control then perform the easier Quad Arm Reach and progress to the Quad Leg Reach (see Figures 4 and 5) Figure 4 Quad Arm Reach. Superman Start:  Kneel on the floor with your feet against a wall  Pull a gymnastic ball in tight against your thighs and place your abdomen over the ball  Arch your back slightly so that you are sticking your buttocks out  Raise your arms so your hands are next to your hips (see Figure 6a)

The missing link in protecting against back pain 101  Turn your palms so they are facing down and spread Sets/reps/frequency: your fingers apart  Perform 1 set  8e12 repetitions Technique:  1e2Â/day  Push off the wall until your body straightens up  Balance on the ball until you are on the tips of your toes References PREVENTION & REHABILITATIONdSELF-MANAGEMENT: PATIENT SECTION (see Figure 6b)  Hold this position for a few seconds Biering-Sorensen, F., 1984. Physical measurements as risk indi-  Then return to the start position cators for low-back trouble over a one-year period. Spine 9, 106e119. Avoid:  Slouching over the ball Luoto, S., Heliovaara, M., Hurri, H., Alaranta, H., 1995. Static  Poking your chin out back endurance and the risk of low-back pain. Clin Biomech  Arching up so much you are creating a sway back 10, 323e324.

Official journal of the: Journal of ® Association of Bodywork Neuromuscular Therapists, and Movement Ireland Therapies ® Australian Pilates Method Association ® National Association of Myofascial Trigger Point Therapists, USA ® Pilates Foundation, UK Volume 14 Issue 2 2010 EDITOR-IN-CHIEF Leon Chaitow ND, DO c/o School of Integrated Health, 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 John Hannon DC Dimitrios Kostopoulos PhD, DSc, PT San Luis Obispo, CA, USA ( [email protected]) Hands-on Physical Therapy, New York, NY, USA ([email protected]) Glenn M. Hymel EdD, LMT Craig Liebenson DC Department of Psychology, Loyola University, New Orleans, LA, Los Angeles, CA, USA ([email protected]) USA ([email protected]) ASSOCIATE EDITORS: PREVENTION & REHABILITATION Warrick McNeill MCSP Matt Wallden MSc, Ost, Med, DO, ND London, UK ([email protected]) London, UK ([email protected]) International Advisory Board D. Beales MD (Cirencester, UK) S. Fritz LMT (Lapeer, MI, USA) J. M. McPartland DO (Middleburg, VT, USA) G. Bove DC, PhD (Kennebunkport, ME, USA) G. Fryer PhD. BSc., (Osteopath), ND C. Moyer PhD (Menomonie, WI, USA) C. Bron PT (Groningen, The Netherlands) D. R. Murphy DC (Providence, RI, USA) I. Burman LMT (Miami, FL, USA) (Melbourne City, Australia) T. Myers (Walpole, ME, USA) J. Carleton PhD (New York, USA) C. Gilbert PhD (San Francisco, USA) C. Norris MSc CBA MCSP SRP (Sale, UK) F. P. Carpes PhD (Uruguaiana, RS, Brazil) C. H. Goldsmith PhD (Hamilton, ON, Canada) N. Osborne BSc DC FCC (Orth.), FRSH, ILTM Z. Comeaux DO FAAO (Lewisburg, WV, USA) S. Goossen BALMT CMTPT (Jacksonville, FL, USA) P. Davies PhD (London, UK) S. Gracovetsky PhD (Ocracoke, NC, USA) (Bournemouth, UK) J. P. (Walker) DeLany LMT (St Petersburg, FL, M. Hernandez-Reif PhD (Tuscaloosa, AL, USA) B. O’Neill MD (North Wales, PA, USA) P. Hodges BPhty, PhD, MedDr (Brisbane, Australia) J. L. Oschman PhD (Dover, NH, USA) USA) B. Ingram-Rice OTRLMT (Sarasota, FL, USA) D. Peters MB CHB DO (London, UK) M. Diego PhD (Florida, USA) J. Kahn PhD (Burlington, VT, USA) M. M. Reinold PT, DPT, ATC, CSCS (Boston, MA, J. Dommerholt PT, MS, DPT, DAAPM (Bethesda, R. Lardner PT (Chicago, IL, USA) P. J. M. Latey APMA (Sydney, Australia) MD, USA) MD, USA) E. Lederman DO PhD (London, UK) G. Rich PhD (Juneau, AK, USA) J. Downes DC (Marietta, GA, USA) D. Lee BSR, FCAMT, CGIMS (Canada) C. Rosenholtz MA, NCTMB (Boulder, CO, USA) C. Fernandez de las Peñas PT, DO, PhD (Madrid, D. Lewis ND (Seattle, WA, USA) R. Schleip MA, PT (Munich, Germany) W. W. Lowe LMT (Bend, OR, USA) J. Sharkey MSc, NMT (Dublin, Ireland) Spain) J. McEvoy PT MSC DPT MISCP MCSP (Limerick, D. G. Simons MD (Covington, GA, USA) T. M. Field PhD (Miami, FL, USA) D. Thompson LMP (Seattle, WA, USA) P. Finch PhD (Toronto, ON, Canada) Ireland) E. Wilson BA MCSP SRP (York, UK) T. Findley MD, PhD (New Jersey, USA) L. McLaughlin DSc PT (Ontario, Canada) A. Vleeming PhD (Rotterdam, D. D. FitzGerald DIP ENG, MISCP, MCSP (Dublin, C. McMakin MA DC (Portland, OR, USA) The Netherlands) Ireland) Visit the journal website at http://www.elsevier.com/jbmt Available online at www.sciencedirect.com Amsterdam • Boston • London • New York • Oxford • Paris • Philadelphia • San Diego • St. Louis Printed by Polestar Wheatons Ltd, Exeter, UK

Journal of Bodywork & Movement Therapies (2010) 14, 103e105 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt EDITORIAL Thoughts on the Amsterdam Fascia Congress: October 2009 In this and subsequent issues of JBMT during 2010, papers will knowledge presented and the off-conference conversations be published that have emerged from the 2nd Congress of have given me more knowledge regarding my own clinical Fascia Research, held at the Free University, Amsterdam, practice and the use of connective tissue manipulation. My during the last week of October 2009. For those wishing to ‘wow’ may be an overall insight into research I naively did share in the rich experience, a comprehensive immersion is not know existed. For starters, I was completely unaware possible through several invaluable resources, in the form of that people even studied fascia on a basic science level. Proceedings books, as well as DVDs, from the 2007 and the Michael Hicks’ presentation taught me external loading on 2009 Congresses. These are available from: http://www. the fascia acts on fibroblasts e and his lecture discussed the fasciacongress.org/2009/dvd-book-purchase-pub.htm differentiation of myoblasts for repair. I had not thought about the impact of our work on a cellular level e perhaps One major change from the first Congress, was the ever e and as a writer, lecturer, teacher and clinician I inclusion of two 90 minute plenary sessions, in which should have. Helen Langevin pointed out the difference experts presented briefly on an assortment of manual (high between ‘areolar connective tissue’ and ‘loose connective velocity manipulation, connective tissue manipulation, tissue’. I also became aware of Rolfing literature. and in neurodynamics, positional release techniques, structural general, I am pleased to see fascia and therapies studied at integration, and manually induced oscillation) and tool- cellular levels to help explain our clinical research assisted modalities (acupuncture, functional fascial taping, findings.’’ Fulford percussion/vibration, Graston technique, dry needling) e with the intention of informing scientists, and Zachery Comeaux DO other practitioners/therapists, about the methods used, and the theories that underpin them e and most impor- ‘‘I recognized the high calibre of the conference and tantly the presumed fascial connections. Three eminent appreciated knowing what experts were paying attention researchers/scientists were invited to comment on both to, and not paying attention to. I appreciated the inter- demonstrations/presentations. For the manual therapy disciplinary mix of participants both in informal conversa- session these were Professors Moshe Solomonow, Michael tion, and during the clinical demonstration. From the Kuchera and Walter Herzog. content point of view, I was most impressed by Dr. van der Waal’s anatomical presentation including the potential role For the Tool-assisted presentation the scientific panel of the connective tissue matrix, including mechanoreceptor comprised Professors Helene Langevin, Andry Vleeming and function, in coordination of regional motion. Aside from Siegfried Mense. The topics and presenters of the manual that I felt that the primary research was still largely demonstration session are shown in Figure 1. directed toward the mechanical properties rather than responsiveness of the connective tissue matrix. The next Impressions of Fascia 2 generation of research, I hope, will be more in tune with clinical practice, by defining hypotheses more along the Stephanie Prendergast MPT lines of natural process development, injury and thera- peutic intervention with the living system in mind. I was ‘‘This meeting was truly multi-disciplinary, both in the excited and surprised to find a communality of ideas with presentations, ranging from basic science through clinical the work of Luiz Fernando Bertolucci (Muscle Reposition- practice, and in the audience. This made interactions ing), in the Saturday workshops. His thoughts were able to on and off stage valuable. I had the opportunity to meet professionals I would not have met otherwise. The 1360-8592/$36 ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.01.001

104 Editorial Figure 1 Left to right: Leon Chaitow ND DO, Geoffrey Bove Figure 3 Area of ‘densification’ being treated, during Fascial PhD DC, Zachary Comeaux DO, Michel Coppieters PhD PT, Manipulationª workshop. Stephanie Prendergast MPT, Robert Schleip PhD. relates to the dynamic reconfiguration potential of the add both new considerations and new moves in my collagen network. This virtually instantaneous reconfi- approach to manipulation.’’ guration e occurring within seconds e suggests that the effect of manual therapy can be immediate and Geoff Bove PhD DC significant. ‘‘This work is a serious challenge to the classical representation and modelling of biomechan- ‘‘Overall there seems to be a schism between clinicians and ical systems’’ (Gracovetsky, in press, Guimberteau, scientists, this is not necessarily what it is typically thought 2007). to be. Many clinicians were thinking that scientists were  Helene Langevin (2009) provided elegant evidence trying to prove or disprove that what they do has an effect, or regarding the speed of change in behaviour of loose not. This is far from the truth. In fact what emerged is that (areolar) connective tissue (a matter of seconds e see scientists are interested in HOW the methods work, since above) when load is reduced following light static most of them seem to work, at least to some degree. Finding stretching. ‘‘Loose connective tissue fibroblasts are the common denominators will be very helpful. Specifically I dynamically responsive to tissue stretch ex vivo and in was very interested in the concept of using massage methods vivo.’’ to ameliorate lymphedema post-mastectomy, and found  Some of clinical relevance of this new understanding of Willem Fourie’s presentation illuminating.’’ (See Figure 2). connective tissue behaviour came from South African physiotherapist, Willie Fourie, who gave an insightful JBMT’s editor’s high points therapist’s view of the management of surgical (mainly post-mastectomy) scar problems. and of the dramatic  Probably the most dramatic new information that has effect of regularly applied, brief, mild stretching emerged from the two Fascia Research congresses, Figure 2 Willie Fourie PT. Figure 4 Julie Ann Day PT and Carla Stecco MD during Fascial Manipulationª workshop.

Editorial 105 methods e on Transforming Growth Factor b1 (TGF-b1) with some clarity possibly emerging in time for the 3rd Fascia production and collagen deposition (see Figure 2). Research Congress, which will take place in Vancouver, in  Jaap van der Wal offered a terminology lesson e 2012. The hosts for the 3rd congress are the Massage Ther- virtually instructing the delegates that ‘‘ligaments apists’ Association of British Columbia (MTABC) http:// don’t exist’’ because they are so enmeshed with www.massagetherapy.bc.ca/. connective tissue that the pictures we see in anatomy texts are science fiction. His preferred term, (that may The theme in 2012 will be the Practical Application of not catch on, I fear, despite his sound argument), is Research to Practice. ‘dynament’, to replace ligament.  Carla Stecco’s rich presentation offered many insights, JBMT will carry advance notice of the event, and will including how connective tissue resists traction/elon- once again be publishing papers from key presenters. gation, but allows itself to be lifted relatively easily, i.e. to be separated from ‘underlying/parallel structures’. References  A further Stecco illumination related to the ample pres- ence of intra-fascial nerves, oriented perpendicularly, Gracovetsky, S. The coupled motion of the spine Bipedalism versus therefore more likely to be stimulated by collagen stretch. human gait. JBMT, in press.  The Fascial Manipulationª workshop (Julie Ann Day and Carla Stecco) was fascinating and instructive. (See Guimberteau, J.C., October 2007. Strolling Under the Skin. In: Figures 3 and 4) Space does not allow for a full Video Presented at the First Fascia Congress. Harvard Medical description e suffice to say that the explanations School, Boston. offered, based on years of dissection and research, at the University of Padua, were impressive. Langevin, H.M., 2009. Fibroblast Cytoskeletal Remodeling Contributes to Viscoelastic Response of Areolar Connective The clinical implications of the evidence in relation to Tissue Under Uniaxial Tension. In: Fascia Research, vol. II. stretch and compression, as well the previously mentioned Elsevier, Munich. revelations regarding fascia’s responsiveness to adaptation demands, as provided by Langevin, Stecco. Schleip, Fourie Leon Chaitow, ND DO, Editor-in-Chief, and others, will require many months of personal processing, 144 Harley Street, London W1 G 7LE, UK E-mail address: [email protected] 4 January 2010

Journal of Bodywork & Movement Therapies (2010) 14, 106e107 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt EDITORIAL 2nd International Fascia Research Congress, Amsterdam, October 27e30 2009 - a Clinicians Review. Peter Wu¨hrl* Osteopathic Center Martinistrasse, Martinistrasse 11, 20251 Hamburg, FRG Accepted 2 February 2010 Having heard so much about the success of the first Fascia connected through a cable, the cable is important (until we Research Congress, at Harvard (October 2007) attending all use cellular phones) but the message is created some- the second Congress in Amsterdam involved feelings of where else and the fascia only transmits a message others curiosity and expectation. These feelings were fully created. Fascia re-acts, but as a clinician I want to know realised. who acts. On the other hand, the research presented at the conference clearly showed that restrictions in fascia play There was no resisting the atmosphere and the feeling of a key role in loss of function and pain; if the cable is not excitement that filled the conference hall. Researchers and able to slide smoothly on adjacent tissues transmission is clinicians from all continents came to the Free University in compromised. Amsterdam and joined together to discuss new ideas as well as to rediscover and appreciate old ones. Compliance 550 people attended the congress. Just observing the The palpable enthusiasm, for the subject of fascia, of those wide range of topics discussed in the halls, and on the floor, attending and presenting from such diverse backgrounds left no room for doubt: something has happened in the field engendered in this observer a sense of compliance. of fascia research and practice. The conference days started with keynote presentations The organizers presented a 325-page manual to help on the basic scientific research on fascia: cytology, delegates navigate through the different layers of the anatomy, biomechanics, innervation, pathology and connective tissue of this five-day event. The conference surgery. brought together researchers, clinicians, old time fans of fascia, recent converts and sceptics (like myself). Just listening to the concise questions asked of the speakers showed how well informed and prepared the Resistance audience was. One of the most impressive presentations was by Jaap van der Wal (University of Maastricht). He is As a clinician (Osteopath) I have an idea about the impor- interested in gross anatomy and calls himself a ‘‘dinosaur’’ tance and limitations of fascia in the body. I also had some in a world that is all about cytoskeleton, fibroblasts and resistance and felt the role of fascia is sometimes over- molecular biology. Van der Wals’ research led him to talk stated in Osteopathy. For example, if two phones are about the proprioceptive function of connective tissue architecture, a statement that resonates with movement * Tel.: þ49 (0)170 34 14 742. therapist and bodyworkers. Van der Wal and his colleagues E-mail address: [email protected] in Maastricht have developed a special form of dissection 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.02.002

Editorial 107 that conserves the connective tissue. In traditional dissec- Clinicians offered competing perspectives as to which tions the fascia is cut away, creating disconnected struc- group had been responsible for reigniting interest in the tures as objects of anatomy; one of the reasons, is topic. Fascia used to be a contentious issue. Historically the suggested, that fascia has been relatively neglected in interest in fascia research was kept alive by hands-on research until now. practitioners and fringe researchers. Critique Helene Langevin, another conference highlight, explained that in the Seventies even a Conference on The afternoons were filled with presentations of research Rheumatology no longer had special panels on connective papers: sometimes boring, sometimes exciting, sometimes tissue. Everything was dominated by immunology and hard to understand, and sometimes bordering on being molecular biology. sales pitches. This was, for this reviewer, the least inspiring aspect of the conference. Osteopaths and other characters In contrast the most enjoyable sessions were those in Of particular interest to this reviewer were the views of which researchers commented on the presentation of osteopathic presenters, especially how they made the split clinical application (Rolfing, osteopathic manipulation, between lab research and clinical application. Some Positional-Release-Technique). seemed to be quite comfortable in bridging the gap as Leon Chaitow did. Others defended eloquently the clinical The researchers were frank in their criticism and well experience as paramount to the lab. focused. Walter Herzog from the Human Performance Lab at the University of Calgary, pointed to the disconnect The conference involved some outstanding characters, between doing and explaining. Most clinicians show who provided both humour and depth in their observa- mechanics, but talk neurology. They act mechanically in tions, including Moshe Solomonow (University of Colo- their hands-on approach, but if it comes to talking about rado). He spoke with the voice of a grandfather telling the effects of the technique, they refer to neurological fairy tales. An embodiment of the fluidity and softness of relationships. connective tissue, he was never afraid to challenge the consensus with his well-thought-of and sceptical remarks. Friction At the end of the conference it was his job to remind everyone that we should not forget that life is beautiful The panel encounters between researchers and clinicians outside the lab. provided a valuable challenge during the conference. For the most part they treated each other with respect and It was also a pleasure to hear Helene Langevin (Univer- a curiosity to learn from each other. A healthy friction sity of Vermont) present and engage in a discussion that seemed to dominate. provided delegates with the vision that the complexity of the connective tissues might in time be understood. Sometimes it was a bewildered question by a non- researcher that added excitement to the discussion: why e Another outstanding presenter was fellow-German Rob- for example e are most experiments done with stretching ert Schleip. Schleip runs the Fascia Research Project at the fascia, and not with compression? Department for Applied Physiology, University of Ulm. From within his height and lankiness, his forward leaning Most research focused on fibers and fibroblasts and not demeanor and positive attitude, he can talk about the so much on the fluid volume of connective tissue. Both most complicated research with an uplifting voice filled compression and stretch impact the fluid compartment. For with joy, e a symbol of the way ahead in fascia research. a manual approach, working with the three-dimensional expression of forces, the mechanical properties of the fluid Finally the two Dutch organizers, Peter Hollander and compartment of fascia are as important as the mechanical Peter Huijing, both with a bone-dry sense of humor. properties of fibers. The closing panel acknowledged this bias and promised to put more emphasis on it next time Peter Hollander, the grey eminence of the conference, (Vancouver 2011). never in the spotlight always present backstage, without him nothing would have worked. Peter Huijing, always one- Refreshingly for this reviewer, most presenters were step ahead, never short of new ideas and a joke. Those two researchers, a fact some people complained about, and all the others put an amazing program together, that resulted in a rekindled excitement for fascia.

Journal of Bodywork & Movement Therapies (2010) 14, 108e118 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt SPECIAL REPORT: MODIFYING THE EFFECTS OF CEREBRAL PALSY Modifying the effects of cerebral palsy: The Gregg Mozgala story Leon Chaitow, ND DO a,*, Tamar Rogoff, Choreographer b, Gregg Mozgala, Actor, Dancer c, Stefan Chmelik, MSc, Physician of Traditional Chinese Medicine d, Zachary Comeaux, DO, Professor of Osteopathic Principles and Practice e, John Hannon, DC, Associate Editor JBMT f, Eyal Lederman, PhD, DO, Professor g, Tom Myers, LMT, Anatomist, Rolfer h a University of Westminster, UK b Tamar Rogoff Performance Projects, 170 Avenue C, #19G New York, NY 10009 c No Affiliation d New Medicine Group, London, UK e West Virginia School of Osteopathic Medicine, USA f 1141 Pacific Suite B, San Luis Obispo, CA 93401, USA g Centre for Professional Development in Osteopathy and Manual Therapy, UK h Kinesis, 318 Clarks Cove Rd, Walpole, ME 04573, USA KEYWORDS Summary In response to a news report of the rehabilitation of a New York-based dancer/ Rehabilitation; actor with cerebral palsy, to the point where a ballet performance was scheduled, it was Movement therapy; determined that a report based on the individuals involved would be commissioned. The re- Dance; sulting reports from the choreographer responsible for the rehabilitation exercises, and the Cerebral palsy dancer, were circulated to an interdisciplinary selection of physical medicine experts, for commentary as to what clinicians might learn from the case, and what mechanisms might be involved. ª 2010 Elsevier Ltd. All rights reserved. * Corresponding author. In early 2008, a young actor with cerebral palsy, Gregg E-mail addresses: [email protected] (L. Chaitow), Mozgala, was appearing as Romeo in a Theater Breaking Through Barriers’ production in New York, which involved [email protected] (T. Rogoff), [email protected] a mix of actors, some with disabilities and some without. In (G. Mozgala), [email protected] (Z. Chmelik), the audience was choreographer Tamar Rogoff e who [email protected] (J. Comeaux), feldenkrais@ decided that she would explore the idea of producing digitalputty.com (J. Hannon), [email protected] (E. Lederman), a performance, with this same young man dancing e despite [email protected] (T. Myers). 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.02.001

The Gregg Mozgala story 109 This is followed by commentaries from experts who were selected from a variety of disciplines. Tamar Rogoff Figure 1 Tamar Rogoff during rehabilitation of dancer, Gregg ‘‘I began the work in order to prepare Gregg to dance the Mozgala ª2009-2010 by LORI GRINKER. role of the Faun in a new work I was choreographing. I first saw him as an actor and his body energy called out to me as the fact that he was totally untrained, and could not walk it was interestingdstrong and active and responsive to the without exceptional distortion and effort. text. I liked how his passion ignited and was in direct contradiction to his physical condition. He seemed to act Mozgala has described his walking style at that time as his way out of his c.p. leaving me unaware while watching looking like ‘‘a human velociraptor.’’ He walked on his toes, him do Romeo and Juliet that he had it and I knew he could with his lower extremities turned in, wobbling from side to dance his way beyond it as well. side to maintain balance. I used a lifetime of body learningdeverything from Genzlinger (2009), writing in the New York Times report decades of dance techniques (Ballet-Graham-Bharata on the Mozgala/Rogoff story, quotes him as saying: Natyam) to bodywork. My bodywork teachers were Allan Wayne and Monica and Harmon Hathaway both of whom ‘‘My knees were going in, my hips were totally rotated taught me ultimately never to listen to them but find my inward. Gravity was just taking me down. So my upper own way. I’ve never studied Feldenkrais or Trager or body d arms and chest d overcompensated, curling Alexander or Yoga. For the last 26 years I have given back and up.’’ a laboratory class at PS 122 and now at La Mama in New York. Many students have been with me for all these Some 9 months later, from December 3rd to 20th, Mozgala yearsdthey are mostly actors and they agree to being appeared in New York, in a production (Diagnosis of a Faun) there while I investigate whatever interests me move- choreographed by Rogoff, at the La Mama Experimental ment-wisedthis is an experiential anatomy approach Theater Club. How was Mozgala able to go from his previous where I can spend a year behind the sternum or the rib dysfunctional walk, to be able to appear on stage as a dancer? cage, for exampledthen include any landmarks in the body that interest medbones-joints muscles-spaces The early press reports offered only a few clues. It seems between thingsdthe class speaks my idiosyncratic that Tamar Rogoff possesses other skills e that do not language dalignment issuesdmine and theirs often spark involve formal training in health care, but which she has investigation. In my class at New York University’s Exper- acquired over the years of training and directing dancers. imental Theater Wing I add how this investigation can be The particular methods and approaches that she used with the origin of a choreographic vocabulary and how it can Gregg Mozgala, are described below. enliven actingdthis is not at all academic, as I haven’t studied the body in an organized course but have picked In the text that follows, Tamar Rogoff and Gregg Mozgala up information everywhere. I tend to start where I am or describe aspects of the process in their own words. from what I see and let the class follow where the body takes usda class can’t ever be replicated. The first order of business with Gregg was to steady him enough so he could transcend his main concern which was balance and introduce him to new ways other than his set in stone movement vocabulary which seemed designed to compensate for the inward rotation of his legs and hips He was locked in to a very specific body vise and felt at the mercy of the signals from his brain which were telling him to tense updwe sat on chairs and stamped the feetdI offered imagerydthe horse shoe heeldwe opened the kneesdtucked him into the foetal position which rounded the lumbar spine and changed the curves he needed for balance once standingdintroduced opposition walking rather than the seesaw side to side lurch which was the way he got around, and after a few weeks I taught him the shaking technique. Shakingdwe started lying down on the back e legs bent feet on the floordarms outstretched to the sidesdpalms upeopening and closing the legs (knees) waiting until involuntary shaking and trembling took overdit took several sessions and ended up starting in thumps of the chest against the floor, the head doing an uncomfortable looking lifting and noddingdall very violent and not where I

110 L. Chaitow et al. was expecting it to come fromdeach time he lay down the Figure 2 Gregg Mozgala dancing in ‘‘Diagnosis of a Faun’’. body took off in this same way until it ran its coursedany Gregg Dancing ª2009 Julie Lemberger. time I put my hand on Gregg’s chest I could elucidate a thumpingdlater came other lightning bolts of zigzag IdentitydGregg evolved his personhood ebody and mind energydmonth by month we worked out pattern after to fit into his C.P. bodydthru that body he felt every patterndmy finger under his lips could cause enormous emotion and in that body was stored all memories pleasur- gaggingdhis arms pounded the matsdhis hands clapped able and painfuldhis body rhythms ewalking and running together until they hurt and I had to put something were the sound score to his lifedthe drag of his footdhis between themdat some point what you might call shaking particular toe walkdas his alignment changeddhis patterns beganda bit quieter but still intensedthru the thighs and changed and he became a stranger to himself and in fact to sacrumdthen a vibrato took hold of his bellydhis stomach medit was the original walk that housed the person I was muscles had never served him as the way his upper body interested indthe new neutral was exciting because it met his lower was disconnected from the body’s original proved that change was possible but a bit blah and devoid of design e then came more pounding, now thru the lumbar- any personalitydI often noticed when Gregg was drunk, or dall this we followed as the body led us through. I selected stoned, that his happiness reverted into the old home base a position from which to start sometimes lying on the back of his original alignmentdhe reports that when he is being and sometimes on the belly or sitting in a chairdI selected an actor the same happens. a movement to begin getting us to the involuntary part and then we dedicated an hour or two to follow its courseewe Going forward the questions are: were in a gym so we had mats and blocks and everything  How will his new body house him? you might use for yogadI built him structures to get his  What parts of the changes he’s elicited in his body will pelvis up off of the floor so his legs could be tossed over his chest and his hamstrings could stretch and he could access remain with him irrespective of his actively being his stomach musclesdnow that his body had experienced conscious of them? the shaking it constantly went to that mode in any stretch.  What amount of consciousness will be necessary to keep a healthier alignment? Standing and hanging over fingers near toesdwe used this to stretch out and access the lumbar and open it updhere we got seizing up and a great deal of feardI bypassed the fear many a time by using my body against hisdalmost like lending him my nervous systemdmy sense of flowdthroughout I used my body to teach hisdhe could relax onto me in different waysdthe little Reiki I know I used to quiet him as well e my hands sent messages and new patternsdnow one sweep of my hand can elicit a 20 min reaction and instil a new or even a permanent understandingdmore and more he asks me to move aside as his body is telling him something directly and he must be left alone to follow his internal clues. Walkingdfrom the beginning he walked at every session and I gave him a small message often connected to an image to take on the street with himdwe had to watch his exiting on to the street as he tended to revert to a prior more protective ehistorically more familiar modedmostly I just watched his walk and saw where energy didn’t flowdwhere the body was uneven or where the foot didn’t touch the floordas his abilities grew he could feel when his sacrum was rigid or not. Attitudes e Gregg is now addicted to the way feelings and information come through his bodydhe’s in awe when he feels space in the hip sockets or connections from one place or anotherdor when he can just slow downethis is a reversal of his former attitude which was a slave to his condition ealways taking orders from the Bully (Oliver Sacks’ term for the lesion on the brain in C.P.)ealways using tons of fast frenetic energy to muscle him through everything from walking to sexdhis mind which functioned in a more nuanced way was at odds with the pace and lack of modulation in his body. What he thought in his mind- dwas not do-able in his bodyetherefore immense frustra- tion as his hyper-vigilance governed the resonance of his body making known its limitations.

The Gregg Mozgala story 111  For how long and how much will he have to continue the very emotional to the point of tears. Tamar and I never stop bodywork process? or get bogged down with the psychological or emotional ramifications of this. This would kill our progress. We  We are planning a phase two of this project which will soldier on through. Both of us realize that what’s happening include bringing another person with C.P. on board so when this occurs is that my body is opening up areas that Gregg can both watch me teach and teach this person have been previously unavailable or inaccessible for over himself. Will teaching the work keep him involved and thirty years. It is what it is, and this too shall pass. help preserve his new patterns? I’d like to digress for a moment here and talk a little bit  How far will we be able to go towards a permanent about my body’s relationship with fear. Tamar has said that positive alignment? my hyper-vigilance is due to my body being in a constant state of emergency. I have come to understand this as  How will Greggs’ personality e emotional balance e a constant fear of falling. During some of our most recent identity and world view evolve to meet his new needs in studio sessions as I experience release in my lower body, his changing body? specifically in the leg below the knee, I’ve noticed that my arms- shoulders, forearms, wrists and hands get extremely Gregg Mozgala: with cerebral palsy tense. I believe this is a compensation that my body does automatically as a protective measure. As I move my pelvis, ‘‘I’m sitting on a stool. Tamar is in front of me and has her hips, legs and feet into proper alignment- into an alignment hands on my feet. She’s placing them into proper alignment that my body has never felt- my body tenses. This is because I and pressing my pinkie toes, forever raised like the true believe IT believes I’m going to fall down. This is a new and aristocrats they are, into the ground. They were caught fascinating concept to me. I first became aware of my body’s unawares by the revolution and need to learn what it means fear response during the rehearsal period. The first day I was to do an honest day’s work. Tamar instructs me on how to working on the set piece we affectionately refer to as, ‘‘The get my feet into proper alignment. She uses her hands at Rock,’’ I couldn’t even sit on it without waves of physical first to show me the path my foot should travel up and terror coursing through me. I was flanked by Tamar on my left down. She lists all the joints in the foot: heel/talus/ankle/ and Sharon, our stage manager, on my right. As I moved ball/etc. and encourages me to think of the foot in its around on it and eventually tried to stand up, I held on to many pieces as opposed to a heavy, single slab. I ask her to them for balance and support. Initially I couldn’t stand up on let me try the motion on my own and input the suggestion it without their help. My body would tense so much that it of the feet as a mutli-faceted unit. There’s an increase in would literally drop me to my knees for a more supported sensation almost immediately. My body is in conflict with base. If they let go of me the waves of terror would return itself. It wants to discover these new routes, new ways of and I would simply ask- or scream or cry out- for one of them moving, which is actually the way it was originally designed to touch me. This simple action both comforted and groun- to move, but it takes time and effort to release it from it’s ded me. During our opening week of performance I was old modes of behavior. I’m working on my right foot alone. experiencing so much pain as a result of tension in my hip As I focus to raise and lower my foot, I can feel my left leg flexors that I was convinced it was only a matter of time grabbing in the hip flexor, the knee wanting to turn in, the before I was going to injure myself. Tamar stressed the heel coming off the ground. I stop. I ask Tamar for a yoga importance of a focused warm-up. As I increased my warm up block. With my left foot on the block and supported the and internal focus the pain first moved from my left side to ‘‘bully reflex’’ is interrupted and I can put all my attention my right and then disappeared completely. By the end of the and focus into my right foot. The simple action of raising first week of shows it was gone. It didn’t return for the and lowering my foot takes an incredible amount of focus remainder of the run. As we work in the studio, I’ve realized and is physically strenuous. After a few minutes I am that I can actually counter this fear response by slowing shaking. Not just in my legs, but my entire pelvis starts down and convincing my body that it’s okay- that it’s not in undulating. All this movement, termed ‘‘shaking’’ is purely a state of emergency. The grip we call, ‘‘The bully reflex’’ is involuntary. As my body discovers the correct pathways and the grip of fear. If I stay focused and connected to my body as what I assume are new neural connections as a result of I move into proper alignment, using my mind, I can show my positive alignment, my body learns that it can utilize these body that there’s an alternative to falling that’s better, new pathways and release the old mechanism that had safer, more productive. I’m still working on developing this previously allowed for standing, hind-limb ambulation, theory but could this be me willing my body to change? running, jumping and general mobility with the effective, but less efficient, C.P. alignment. What the shaking does is We work on my right side for a good forty-five minutes to an soften my otherwise tense or spastic musculature to hour. I’m shaking. I’m gagging. I’m nauseous. I feel great. It’s receive basic instructions such as; point your sternum time for me to stand up and walk around to see how my body down, tuck your tailbone under, close the front ribs/open has integrated these latest changes with movement. Tamar the back ribs, etc. What’s more, as my right leg and entire slowly removes my left foot from the block, being careful to right side begins to learn proper alignment my resting leg place it down on the ground in the proper alignment. I ask to begins to respond similarly. Not nearly with the same try and replicate what I have just done on my right foot with intensity, but it’s as if one side is teaching the other- like my left for a few times before I stand up. Tamar acquiesces. a game of ‘‘Follow the Leader.’’ As my body reroutes I often My left foot is considerably more rigid and less responsive then times also experience a physiologicaleemotional response. my right foot in general. It’s harder to lift and place down In this case, I experienced waves of nausea and became properly but I manage to do it about half a dozen times before Tamar assists me with standing up. With the first few steps it’s

112 L. Chaitow et al. as if my brain has caught fire. My feet are on the floor like network is created that seems able to compensate for the never before. I have a roll to my walk that involves the entire dysfunctional messages due to the brain lesions. foot that I’ve never utilized until this very moment. It’s incredible. I walk for a bit. I allow my body to integrate all the Zachary Comeaux new information we have just fed it. I try to let my new walk walk me. I listen to my body. Before we know it our work has This is exciting but not surprising. Couple bravery with come to an end for the day. determination and insightful intuition, and good things can happen. Neither of us had this planned when we arrived at the studio this morning. We never have an agenda. It just Many years ago at the Institute for the Achievement of happened. This progress with the feet however, would not Human Potential, Glen Doman and others formulated have been possible if we had not been working so intensively a program called patterning, for working with children with over the last eight to ten months. Tamar and I continue to talk cerebral palsy and other congenital conditions disrupting as we change clothes and prepare to reenter the world at the development of normal locomotion. By passively large. I have to head to the West Village to rehearse for putting the child through a series of positions replicating a reading I am doing later that evening. Before we exit the the sequence of stages involved in evolving locomotor studio Tamar gives me a few basic directions to carry with me skills, the children progressed. The process described here throughout the day. I listen. I try and put them into practice as reminds me of such treatment. we climb the studio steps and exit out onto the street. Tamar returns the keys to Teddy at the gym. I cross the street and More recently, with the instrumentation of Functional MRI enter my building. As I enter my apartment and hit the stairs I we have gained an increased appreciation for the role of remind my body of the work we have just done and take each certain brain centers into the coordination of motion, and its step slowly and deliberately, careful to make sure I am landing association with cognitive processes, including expectations, half-toe/heel/with the outside of my heel pressing down. As I body image. In other words, the divide between physical and walk up the steps I think for the first time ever, ‘‘I love walking ‘‘psychosomatic’’ aspects of human behavior is narrowing. up stairs,’’ as I fight back the urge to throw up in my mouth.’’ Additionally, we have learned that this psychomotor system is plastic, changeable, and that learning is a physical as well Invited commentaries as behavioral event. Stefan Chmelik The case of Rogoff and Mozgala is interesting to me, not simply as an accomplishment, but as a process. Most The description of the interaction and partnership between bodywork disciplines rely heavily on a conceptual base and Tamar and Gregg is a fascinating insight into the nature of prescribed routines. Ms Rogoff and her client have the body-mind. In Traditional Chinese Medicine (TCM) approached the challenge of optimizing locomotor function mind, body (and spirit) are regarded as linked and from a phenomenological point of view. It is my long held inseparable. belief that this is a valid dimension to any bodywork, and is maximized according to the perceptive capacity of the This is reflected in the association between structure, patient and therapist. physiology and emotion, often in a circular, non-linear event pattern: in which anything affecting the body will An admonition of Dr. Still, the founder of osteopathy, affect the mind, and vice versa. was to ‘‘find the unnatural and return it to the natural.’’ Certainly there are standardized criteria for assessing and CP is a profound neurological developmental or trauma- guiding treatment. But, especially with experience, clear related condition. In TCM this level of pathology is almost observation, empathic communication, the will to succeed always associated with the ‘Water element’ and the can serve to replace or complement conceptual analysis ‘Kidney’ viscera, as well as the Wood element and the and decision making. Liver. This requires some interpretation for the Western- trained mind. I salute Rogoff and Mozgala, and expect they should share credit for the accomplishment. I would also expect The ‘Kidneys’ have several important areas of associa- readers to be motivated to broaden their perspective on tion, including foetal development, DNA expression, the dealing with limitations of physical mobility, regardless of spine, the bone marrow and brain. The emotional associa- practice discipline. Creativity, flexibility and openness to tion is fear and shock. Gregg Mozgala discusses his fear dealing with problems in an existential, rather than simply response ‘‘Tamar has said that my hyper-vigilance is due to mechanical and prescriptive way, is legitimate and often my body being in a constant state of emergency. I have fruitful. come to understand this as a constant fear of falling.’’ Tom Myers, Author of Anatomy Trains (2nd edition, The ‘Liver’ is associated with the tendons and sinews Elsevier, 2010) and the free flow of energy (‘Qi’) and blood throughout the body as well as ‘Wind’ (Feng), the idea of either uncon- When this story appeared in the papers, I was very inter- trolled movement or lack or movement:‘ All this move- ested in the method employed, so I am glad to have this ment, termed ‘‘shaking’’ is purely involuntary.’ ‘What the level of detail from both teacher and recipient. How shaking does is soften my otherwise tense or spastic wonderful that the method has no name! It reminds us that musculature to receive basic instructions.’. the path of healing is not restricted by specific approaches, but wends its way upward in switchbacks. It reminds us that Neurons that fire together, wire together, and by allowing the Qi and Blood to circulate through shaking, a new neural

The Gregg Mozgala story 113 our ‘name brands’ in bodywork e dear to us if they are our Eyal Lederman own, or raising our interest or suspicion (or both) if they seem to run counter to our beliefs - are but signposts along Rehabilitation and re-abilitation this path, and not the path itself. Movement rehabilitation and motor normalization following central nervous system or musculoskeletal injury occurs Secondly, I was impressed with the emphasis on what naturally in varying degrees for most individuals. Following Gregg can do. So much of medical rehabilitation starts with injury most humans will take physical actions that will what the patient cannot do, striving to make the currently support their spontaneous and unaided recovery. This impossible possible again. It was Emilie Conrad (of Continuum would happen without any special knowledge or under- fame), herself a dancer originally, who first introduced me to standing of the underlying physiological principles under- the very liberating concept of: Start with what they can do. pinning their recovery. This recovery behaviour is the basis Explore that, and the novelty will arise, and then explore of functional neuromuscular rehabilitation. In this form of that, which leads on to more novel movements. Emphasis on rehabilitation the individual is attempting to, partially or the problem, difficulty, lack, and inability e even with fully, execute the movement that has been lost. As in a ‘helpful’ attitude e can leave a patient frustrated and Gregg’s process, attempting to walk becomes the rehabil- depressed. itation for the person who lost the ability to walk. The focus in this form of movement recovery is on the overall skill of Tamar’s method seems to owe much to the dancer’s performing the particular movement (skill rehabilitation). sure knowledge that everyone has limitations, and yet The therapist’s role (or Tamar’s in this situation) is to everyone has a world within his body. Gregg’s Bully had provide feedback/guidance about the ‘‘correctness’’ of the limited his movement range, and then he himself had movement, e.g. the placement of the foot on the ground or limited it further by adopting and constantly reverting to overall posture in movement. his CP stance, his rolling gait, his locked-in legs. By exploring an unrelated but possible movement within his However, this approach does not always lead to the range, he was led naturally up the switchbacks rather then intended results. Individuals who have motor losses may going for the straight line uphill e which can be an develop movement patterns that circumvent their losses. effective path for the simple injury rehab, but not for As in Greggs’ condition he presented with walking diffi- a complex and enduring ‘condition’ such as Gregg pre- culties due to losses in the control of balance and coordi- sented. Seeing the situation as an opportunity instead of nation (as well as other factors). Using the skill a problem is the artist’s prerogative, and one that more rehabilitation principle, one would imagine that by therapists would do well to adopt. encouraging the individual to increase their walking, ‘‘walking would train balance and coordination during Thirdly, we can note that everyone of these conditions walking’’. However, what may happen is that the individual has a somatoemotional component, very much evident in will get better at using their compensatory pattern as were Gregg’s self-disclosing comments e he loves this and he’s Gregg’s pre-training walking patterns. He tended to have about to gag; he’s standing and crying out in his fear of slower walking speed or use shorter steps, rather than truly failure (falling). Those who undertake these deep struc- improving his control of balance and coordination during tural healing processes should be prepared for cognitive walking. dissonance, for not believing everything you think, for contrary emotions that occupy brain and belly together, for Balance and coordination are part of several control deep swoops and giddy highs that follow each other. Gregg building blocks that make up skilled movement. These clearly had the strength for such a journey and not building blocks are called sensory-motor abilities (Figure 3). everyone is willing. A therapeutic approach that targets the various motor abil- ities is called ‘‘Re-Abilitation’’. At this level of rehabilitation The shaking is an essential part of such releases, when the aim is to recover control losses associated with particular the ‘accelerator/brake’ (combined excitatory and inhibi- abilities. Hence, in Gregg’s case Tamar focused on chal- tory signals, autonomic and somatic) lets go its grip and lenging balance and coordination in dynamic and upright neuromuscular patterns (in my experience) let go, shake for postures during the training. some time, and then normalise. From the sounds of it, there was a ‘whole lotta shakin’ goin’ on’, indicative of As we see in this case-study, skill rehabilitation and re- both how deep Gregg’s patterns ran, but also how deep he abilitation are both therapeutically important and are was prepared to go to free them. often used in combination. However there may be a shift of focus towards one of these particular approaches depend- Finally, we must note how much time and attention it ing on the individual’s condition and their phase of took to stage Diagnosis of a Faun e and to complete even recovery. This is seen in Tamar’s and Gregg’s journey. this stage of healing. There is no indication of how many hours the two spent together in the nine months, but on the The code for neuromuscular adaptation basis of my own experience with similar journeys, I can Neuromuscular rehabilitation is a straightforward process e easily believe that both were engaged pretty full-time on anyone can do it. Indeed, we all do it all the time. Every day this project. How lucky for Gregg to have such a dedicated we take actions that result in movement and behaviour teacher! How lucky for Tamara to have such a willing changes; we can self-modify our motor control. Further- student! Most professionals in the healing trade cannot set more, the neuromuscular system has the capacity for self- aside so much time for one person. But it is in these jour- recovery and to reorganize. It means that within our neys that the possibilities of healing a revealed, which are behaviour there are certain elements that facilitate the later refined and fitted into protocols by others who follow. recovery of movement control. Thank you Tamara, and thank you Gregg for the glimpse into deep and path-breaking healing via the arts.

114 L. Chaitow et al. Skill Rehabilitation could help to reduce the overall duration of the treatment/ Composite abilities Re- Abilitation training programme. Synergetic abilities Further reading: Lederman, E., 2010. Neuromuscular Rehabilitation in Parametric abilities Manual and Physical Therapy. Elsevier, Edinburgh. Figure 3 Rehabilitation of movement control can be at skill or Internet resources: ability level. Skill-level rehabilitation aim to recover movement http://www.cpdo.net/shop/lederman_neuromuscular_ losses by practicing the movement affected. Ability-level reha- rehabilitation_ch01.pdf bilitation (re-abilitation) focuses on challenging underlying http://www.cpdo.net/shop/lederman_neuromuscular_ motor ability changes/losses. (from: Lederman E 2010 Neuro- rehabilitation_ch14.pdf muscular rehabilitation in manual and physical therapy. Elsevier). John Hannon In functional rehabilitation we identify five such elements The artists that optimize neuromuscular adaptation: cognition, being She: a choreographer who found the young actor interesting active, feedback, repetition and similarity (Figure 4). Hence and knew he could dance beyond cerebral palsy with his body in order to learn a new task, modify our behaviour or help energy that was active, strong and responsive (and, she felt, our system recover we need to be aware of what we are in direct contradiction to his hampered movements). doing (cognition) and we have to actively perform the action that we aim to recover (being active). In order to correct our He: the actor both articulate and willing to learn (and to movement we rely on internal information from our senses endure the intensity of learning and not knowing). He or depend on guidance by someone (feedback) and we have describes his constant fear of falling (strong enough at times to practice the task many times (repetition). Furthermore, to provoke tears and severe nausea). He finds himself in the the practice has to closely resemble the movement we aim grip of the ‘‘bully reflex’’ that perpetuates his damaged to recover (similarity). movement patterns. These principles are evident throughout Tamar’s Together, they find a way to transform these movements description of her work with Gregg. She is intuitively facili- into capable and expressive ones; this process is emotional tating Greggs movement control by introducing these adap- and arduous in large part because, as he puts it, he invol- tive code element into the training/dance programme. This untary tenses when placed in better alignment because he approach will promote a functional recovery that is more believes the Bully reflex believes he must fall. likely to benefit the individual in their daily activities. The results are more likely to be maintained in the long term and Putting aside the enormous willingness of both parties to be vulnerable and honest. Putting aside the vast resources of creativity and intelligence both applied to these day-to- day challenges. What draws admiration is the pleasure they take in persistence. Tamar Rogoff in her persistence in a lifetime of body learning (and the courage to move past her teachers and find her own way). Gregg Mozgala in his moment-by-moment anguish as he painfully transcends his fear of falling to access his untapped capacity for balancing upon strong bones, intact nerves and a sharp intelligence. Together, they per- sisted and moved past the illusions, the delusions and the coarse muscle habits. Cognition Being active Feedback Repetition Similarity Figure 4 Experiences that contain the five code elements are more like to promote adaptive changes within the neuromuscular system resulting in movement and behavioural changes. (from: Lederman E 2010 Neuromuscular rehabilitation in manual and physical therapy. Elsevier).

The Gregg Mozgala story 115 What are some of the things we can learn and be inspired importance of ‘‘distinguishing between how we perceive by their actions? For one, there are our own illusions and our body to be, and how we remember or believe that it delusions; another is to not let our training hamper our work. is.5’’ They note this challenge is all the more poignant when we realize there is no equivalent to a GPS satellite signal in Current illusions the body that telling us where our body parts are in space. William James (1890) questioned the then-current percep- tion of the human body as ‘‘the same old body always Parallel touch systems there.’’ Since then, more nuanced views of the body have Myers (1998) points out that the English words ‘blind’ and arisen but the reliability and validity of palpatory findings ‘invisible’ define the incapacity of seeing and of being seen; continues to be a worrisome reminder that much remains to and, although ‘numb’ describes the inability to feel, there be learned. There are interesting pilot studies of the is no word for not being able to be felt. This inadequacy of vagaries of touch perception and the potential for illusion. our common language for mapping what Lea (2009) calls Even though this seems but a dry wasteland when compared ‘‘the messy corporeal geographies of learning a skill’’ make to the marvellous (and fluid) duet of learning/moving as it all the more important study how people learn to move presented in Diagnosis of a Faun, here are some intriguing well. This marvellous exploration of the possible as seen in items. Diagnosis of a Faun is in sharp contrast to what Lewit (2010) describes as the plight of modern medicine deftly using Rock and Victor (1964) presented people with objects complicated equipment while neglecting communication whose visual shape was vastly distorted experimentally and the evidence of our eyes and our hands. from their tactile shape. They found that, after simulta- neously grasping and viewing these objects, the subjects Longo et al. (2010) note evidence of two parallel touch were strongly biased in favour of the visual sense and systems. In addition to the myelinated afferents serving the unaware of any conflict between the senses.1 This idea that skin, they note the unmyelinated tactile C-fibres form visual assessments take precedence over tactile findings a parallel system also serving the skin. This they describe as suggests that therapist training must include methods of a system for ‘affective touch.’’ Serino and Haggard (2010) recognizing (and extinguishing) visual bias. This is particu- also discuss the dual nature of touch. They note that touch larly relevant when bridging the gap between anatomical is a crucial agent in the construction of our self-conscious- book-knowledge2 and that of the moving, breathing and ness6 and that tactile perception may vary depending on the utterly responsive clients we care for. mental representation of the involved body part. In other studies,3 the subjects often ‘know’ their body is McGlone et al. (2007) continue to study the C-tactile different than their illusory perceptions; they are not in afferents which they hypothesize drive the ‘‘emotional delusion4 but they find the illusion inescapable. Longo somatic system’’. They regret that although most acknowl- et al. (2010) quote Lhermitte (1942) as noting the edge somatic sensation drives the subjective experience of pain, it is not often appreciated it also provides the 1 Carter et al. (2009) extended this exploration of visual versus emotional pleasure of touch. tactile dominance; their findings suggest the presence of tactile ambiguity. By using a grid of discrete stimulators, they found Tremblay and Elliott (2003) also discuss dual sensory a tactile equivalent of the visual apparent motion illusion where processing. They describe two distinct visual streams; the the subject was unable to decode a solitary stimulation pattern. ventral stream functioning for form perception and object This implies the possibility for palpatory touch, at times, to lead recognition and the dorsal stream associated with action- treatment astray. based perceptual judgments. To explore this further, they studied visualevestibular illusions; interestingly, they 2 Huijing (2009) regrets the lack of detail in current texts in the explain the kinesthetic system as also being stimulated by descriptions of the ‘‘rapport’’ between adjacent muscles found in motor involvement and frame of reference orientation. many French anatomy texts of the 19th century. This disappear- ance of detail pales when compared to the lack of consideration in Another dual sensory system proposed by Mittelstaedt kinesiology texts of the nuanced movements championed by (1996) discusses postural perception as being affected by dancers, mimes, gymnasts, circus acrobats, martial artists, musi- previously unknown graviceptors located in the trunk. The cians and athletes in general. first input enters the spinal cord at the 11th thoracic level. He hypothesizes the second follows either the phrenic or 3 For instance, Longo et al. (2010), describe the Pinocchio illusion vagus nerves yielding gravity information through sensing where the experimenter vibrates the subject’s arm that is holding changes in inertia of the blood contained within the great the subject’s nose. (Vibration of the muscle tendons triggers the vessels. Vaitl et al. (2002) corroborated these findings with brain to consider the muscles as lengthening.) Thus a perceptual additional evidence that afferent inputs from the cardio- dilemma; the hand is perceived to be moving yet it is in continuous vascular system are significant in postural perception. contact with the nose. Many subjects experience their noses as growing longer from this illusion while remaining perfectly aware Decety and Gre`zes (2006) note yet another relevant dual their noses are not changing. system: that of a person perceiving the actions of another. They cite studies that suggest when individuals perceive 4 As compared to patients with certain brain lesions; there are the actions and the emotions produced by others, they use people that experience ’numbsense’ (similar to blindsight) where the same neural mechanisms as when they produce the they can localize touches that they are unable to detect. 6 This resonates with Seitz (2000) who believes there is a bodily 5 Sacks (1995) states that it is not enough to apprehend some- system of thought: ‘‘we do not simply inhabit our bodies; we thing. The mind must be able to accommodate and retain literally use them to think with.’’ a discovery and its possible connections. It is this second process that would benefit from careful study of the Rogoff:Mozgala process.

116 L. Chaitow et al. actions and emotions themselves. Moreover, a number of Taken together, these suggest we should look at how neuroimaging studies have shown that similar brain areas Rogoff arranged Mozgala; how she used stamping and are activated while imagining one’s own actions or those of shaking. Perhaps part of their success is based upon her another. seeing not only his movement but seeing where he could better ‘‘root’’ (with the help of gravity) his stance and his It may be possible to yoke in our minds these multiple actions. Metaphorically, if we imagine a joint or muscle as sensory systems and cobble together some speculations a ‘‘tree’’ and the whole body’s action as a ‘‘forest’’ perhaps about the magic and mystery of Rogoff:Mozgala. For we can simultaneously see not only the forest and the trees instance, it is striking how emotional concerns are por- but also the roots. And, lastly, perhaps we can formulate trayed in the excerpts from both Mozgala and Rogoff. If we answers to the question of how quickly is it possible for acknowledge the existence of multiple perceptual path- improvement to happen? And how to make gravity trust- ways, perhaps we will find additional ways of using them in worthy and taking the terror out of the distance between ourselves as we help those we serve. ourselves and the ground? Further considerations Consider a well-designed study of the quality of postural Cordo and Gurfinkel (2004) examined the sit-up. They used balance: Tsang et al. (2004),9 found elders practicing Tai Chi this action to illustrate that complex movements have improved stance control under reduced or conflicting sensory associated movements not consciously controlled but conditions with better balance than non-Tai Chi elders similar essential for successful function. They state that since in age and gender. They also found the elder Tai Chi practi- complex movements typically require a great deal of tioners behaved similar to the young healthy subjects in terms mobility (which makes instability likely), anticipatory of controlling body sway in their experimental design. postural adjustments (APA) are used to regulate posture. This implies for us to understand the capacity for humans to Questions abound. How fast can a person learn movement move, particularly those with impairments, we must track excellence? Does it take more than a year to achieve balance? both APAs and associated movements as well as make Just what is the quality of movement of healthy students? Let judgments regarding their quality and appropriateness. In us use the experience of Rogff & Mozgala; let us choose to fact, we may have to map apprehensive APAs as well. believe there is much more possible in the fields of movement quality and motor control than current studies suggest. Horstmann and Dietz (1990) suggested that in upright posture, a gravity-dependent mechanoreceptor system was What then can we learn from bodyworkers and move- needed (in addition to visual, vestibular and muscle ment therapists? From the wealth of published wisdom proprioceptive systems) to signal the position of the body’s there is only room to consider a few wise examples: centre of gravity relative to the feet. They further sug- gested that these force-dependent receptors are pressure Maitland (2002) describes treatments as being of three receptors within the joints and the vertebral column. kinds: relaxation; obtaining correction or, thirdly, inte- grating the subject as a whole. Browne (2006) notes three Pozzo et al. (1998), while studying subjects both characteristics of what he calls qualitative exercise. weightless and in normal gravity, found that gravity either initiates or brakes arm movements indicating that gravity 1. Self-awareness (‘‘know what you’re doing to do what may be represented in the planning of motor commands. you want.’’). Carson et al. (2009) devised a robotic system to reverse the effect of gravity upon the arms of participants.7 They found 2. Make the exercise look like the behavior you want. that in normal gravity, movements made on the downbeat 3. Link the exercise to real-life movements. were more stable than those on the upbeat; they also found this relationship was reversed when gravity was neutral- Rywerant (2003) recommended a continuous, creative ized. They concluded that the ubiquitous tendency for series of evaluative responses to what the teacher saw and downward movement on a musical beat arises ‘‘not from felt in his or her pupil. He states: ‘‘The outcome of the the perception of gravity but as a result of the economy of process may be considered to be an answer to a question or action that derives from its exploitation.8’’ problem concerning the subject. In some instances, a question may be proposed uniquely for the purpose of 7 Carson et al. had noted (while we find our arms being moved by having it answered, as in the case, consciously or uncon- music) that ‘‘invariably we will coordinate our movements so that sciously, with most creations of art’’. the end of the downward phase of our gesture coincides with the beat of the movement.’’ Blackburn and Price (2007) suggest being present with the client. Instead of ‘‘spacing out’’ where both therapist 8 This echoes Massion (1994) who noted that after training the and client drift in their own separate worlds, they present postural control system, the goal is to be as economical as possible ways for the therapist to stay present as well as ways for in terms of energy consumption. This is accomplished by using the therapist to encourage the quality of presence in the passive forces (such as gravity) when possible. He noted that the client. In this they agree with Rywerant (2003) who notes ‘‘overall picture of postural organization that emerges from recent that when the pupil is excessively alert to a possible investigations is a long way off the picture of classical postural infringement on its security, start by lessening this concern. reflexes presented by the Sherrington School. While the old description of these reflexes is still valid and their analysis is still 9 Tsang et al. used computerized dynamic posturography to study a useful means of experimentation and neurological evaluation, (in groups of about twenty) (1) young healthy students na¨ıve to Tai the emphasis is now on the flexibility of postural control and its Chi, (2) elderly Tai Chi practitioners (training at least 3 times adaptability to different contexts.’’ weekly for at least a year) and (3) healthy elders without Tai Chi experience.

The Gregg Mozgala story 117 Speculative conclusions References The very existence of the splendid collaboration of Mozgala & Rogoff inspires us to move beyond scientific experiments. Blackburn, J., Price, C., 2007. Implications of presence in manual Their success suggests the need to revamp our own self- therapy. Journal of Bodywork and Movement Therapies 11, 68e training in observation, palpation and motivation. We can 77. re-learn how to listen, how to touch, how to feel and how to move. We need to be aware of the possible illusions that Browne, G., 2006. A Manual Therapist’s Guide to Movement: face us when we reach out and touch someone. Teaching Motor Skills to the Orthopedic Patient. Churchill Liv- ingstone Elsevier, Edinburgh. p.20. Perhaps we also need to find an inner well of somatic empathy to internalize a more accurate representation of Carson, R.G., Oytam, Y., Riek, S., 2009. Artificial gravity reveals what our clients/pupils/patients are feeling and how they that economy of action determines the stability of sensorimotor are moving. This means a three-dimensional living anatomy coordination. PLoS ONE 4 (4), e5248. constructed of volumes rather than a lifeless sheaf of plane images. Also note these volumes must move to be repre- Carter, O., Konkle, T., Wang, Q., Hayward, V., Moore, C., 2009. sentative. This movement includes the sloshing of liquids Tactile rivalry demonstrated with an ambiguous apparent- such as synovial fluid, lymph, blood and inflammation. motion quartet. Current Biology 18 (14), 1050e1054. Somehow we must sense the spring of bone and cartilage. Somehow we must tell the difference between resting Cordo, P.J., Gurfinkel, V.S., 2004. Motor coordination can be fully muscle’s heft and drape versus the stiffness and solidity of understood only by studying complex movements. Progress in a tightened/shortened/contracted muscle. We need to Brain Research 143, 29e38. sense layers; we need to identify those places that do not compress or elongate or glide well. Decety, J., Gre`zes, J., 2006. The power of simulation: imagining one’s own and other’s behavior. Brain Research 1079, 4e14. We need to learn to think for ourselves. Margaret Mead10 is reputed to have said ‘‘that the ways to get insight are to Genzlinger, N., 2009. Learning his body, learning to dance. New study infants; to study animals; to study primitive people; York Times November 24 2009. to be psychoanalysed; to have a religious experience and to get over it; to have a psychotic episode and get over it. .’’ Huijing, P.A., 2009. Epimuscular myofascial force transmission: Let us get exposed to the many wonderful ways of seeing a historical review and implications for new research. Interna- and treating people. Let us reach basic competencies in tional Society of Biomechanics Muybridge award lecture, Taipei, a formal method of bodywork or movement therapy and 2007. Journal of Biomechanics 42, 9e21. then ‘get over it’. Learn another way and get over that one as well. Once we have confidence in our own competence, Horstmann, G.A., Dietz, V., 1990. A basic posture control mecha- perhaps then we may think for ourselves. nism: the stabilization of the centre of gravity. Electroen- cephalography and Clinical Neurophysiology 76, 165e176. We need to debate our methods and our rationales. We need to translate the research in related fields to our own James, W., 1890. Principles of Psychology, vol. I. Henry Holt, New purposes and then we need to debate our rationales. We York, p. 242(1918 copyright edition viewed at Google Books: need to welcome temperate yet incisive criticism from our 1.26.10). colleagues and develop a common language in what could be termed ‘‘spatial medicine’’. Lea, J., 2009. Becoming skilled: the cultural and corporeal geog- raphies of teaching and learning Thai Yoga massage. Geoforum For instance, we benefit from learning of altered move- 40, 465e474. ment patterns appearing before the onset of pain as observed by Szeto et al. (2005).11 We further learn after Lhermitte, J., 1942. De l’image corporelle. Revue Neurologique 74, observing if we find similar findings in our own practices. We 20e38. vastly learn more when we share our findings. Longo, M.R., Azan˜o´n, E., Haggard, P., 2010. More than skin deep: Towards this end, we would do well to learn from those body representation beyond primary somatosensory cortex. who seek movement excellence, whether teachers or Neuropsychologia 48 (3), 655e668. artists. We need to learn from the best. There is a place for dual sensory streams and tactile illusions but let us not Lewit, K., 2010. Manipulative Therapy: Musculoskeletal Medicine. allow the dusty academics to spoil the view of the possible. Elsevier, p. 380. Let us harness the body’s capacity to exploit multiple sensory channels in ways utterly novel to scientists and McGlone, F., Vallbo, A.B., Olausson, H., Loken, L., Wessberg, J., clinicians alike. With eyes freshened by seeing the 2007. Discriminative touch and emotional touch. Canadian Rogoff:Mozgala transformation, let us develop confidence Journal of Experimental Psychology 61 (3), 173e183. in methods of our own. Maitland, J., 2002. Cultivating the vertical: the Rolf method of 10 Margaret Mead quote (viewed 1.26.10) at http://www. structural integration. In: Coughlin, P., Micozzi, M.S. (Eds.), goodreads.com/quotes/show/170824. Principles and Practice of Manual Therapeutics, pp. 88e99. 11 Szeto et al. (in a pilot study of 23 office workers) found that Massion, J., 1994. Postural control system Current Opinion in altered muscle recruitment patterns were observed in symptom- Neurobiology 4 (6), 877e887. atic subjects before the task became uncomfortable. Mittelstaedt, H., 1996. Somatic graviception. Biological Psychology 42 (1e2), 53e74. Myers, T., 1998. Kinesthetic dystonia: what bodywork can offer a new physical education. Journal of Bodywork and Movement Therapies 2 (2), 101e114. Pozzo, T., Papaxanthis, C., Stapley, P., Berthoz, A., 1998. The sensorimotor and cognitive integration of gravity. Brain Research. Brain Research Reviews 28 (1e2), 92e101. Rock, I., Victor, J., 1964. Vision and touch: an experimentally created conflict between the two senses. Science 143, 594e596. Rywerant, Y., 2003. The Feldenkrais Method: Teaching by Handling. Basic Health Publications, Laguna Beach, p. 81, 210. Sacks, O., 1995. Scotoma: forgetting and neglect in science. In: Silvers, R.B. (Ed.), Hidden Histories of Science. New York Review Book, New York, p. 159. Seitz, J.A., 2000. The bodily basis of thought. New Ideas in Psychology 18, 23e40.

118 L. Chaitow et al. Serino, A., Haggard, P., 2010. Touch and the body. Neuroscience Tsang, W.W., Wong, V.S., Fu, S.N., Hui-Chan, C.W., 2004. Tai Chi and Biobehavioral Reviews 34, 224e236. improves standing balance control under reduced or conflicting sensory conditions. Archives of Physical Medicine and Rehabili- Szeto, G.P.Y., Straker, L.M., O’Sullivan, P.B., 2005. A comparison of tation 85, 129e137. symptomatic and asymptomatic office workers performing monotonous keyboard workd1: neck and shoulder muscle Vaitl, D., Mittelstaedt, H., Saborowski, R., Stark, R., Baisch, F., recruitment patterns. Manual Therapy 10, 270e280. 2002. Shifts in blood volume alter the perception of posture: further evidence for somatic graviception. International Journal Tremblay, L., Elliott, D., 2003. Contribution of action to perception of Psychophysiology 44 (1), 1e11. of self-orientation in humans. Neuroscience Letters 349, 99e102.

Journal of Bodywork & Movement Therapies (2010) 14, 119e126 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt SPINAL REHABILITATION Preliminary investigation into a seated unloading movement strategy for the lumbar spine: A pilot study Jerome Fryer, BSc DC (Hons)*, William Zhang, MA, MSc University of Northern British Columbia, Prince George, BC, Canada V2N 4Z9 Received 28 February 2008; received in revised form 14 June 2008; accepted 16 June 2008 KEYWORDS Summary This study was a preliminary investigation into a seated unloading movement Lumbar; strategy for the lumbar spine using the upper extremities. With the economic burden of LBP Hydraulic; estimated in the billions worldwide, and also with a trend towards more jobs related to sitting, Nutrition; a simple distraction exercise coined chair-care is presented. An attempt to objectify using sta- Sitting; diometry was used to measure standing height changes after 15 min of sitting and after the Unload; exercise. The results showed significant standing height gains post-exercise when compared Posture to post-sitting and initial standing (2.4 and 2.7 mm, respectively). No significant standing height changes were seen after 15 min of sitting. It is therefore likely that this simple seated exercise creates standing height gains of the spine. Proposed mechanisms are discussed with an emphasis on spinal hydraulics and intervertebral disc nutrition. Reproducible studies are required. ª 2008 Elsevier Ltd. All rights reserved. Introduction narrowing. A common theme in these findings is a compartmental disturbance of water: dessication and/or In the description of low back pain (LBP), many have displacement. Whether it is lack or severe displacement as suspected the intervertebral disc as a probable source in herniated forms, water (with its solutes) plays an integral (Podichetty, 2007) with its degenerative cycle curiously role on the mechanobiology of the intervertebral discs intertwined in the etiology. Typical degeneration findings (Fortuniak et al., 2005). The fundamental role of the disc is include: radial fissures, prolapse, endplate damage, to resist compression (Adams and Roughley, 2006) and annular protrusion, internal disc disruption, and disc space maintain vertebral spacing in spinal motion. And when water is properly contained and directed, it critically * Corresponding author. #2-1551 Estevan Road, Nanaimo, BC, supports the disc structurally and nutritionally. Canada V9S 3Y3. Tel.: þ1 250 753 5351; fax: þ1 250 714 0162. Prolonged sitting has been shown by some as deleterious E-mail address: [email protected] (J. Fryer). to the low back (Beach et al., 2005) especially when combined with awkward postures (Lis et al., 2007). With the 1360-8592/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2008.06.008

120 J. Fryer, W. Zhang rapid development of modern technology, sitting is now the industrial grade carpet glued down without underlay. most common posture in today’s workplace (Li and Hasle- Informed written consent was obtained for all subjects. grave, 1999). Investigative tools like that of positional MRI has shown that sitting induces flexion in the lumbar spine as Measuring procedure well as posterior nuclear migration (Alexander et al., 2007) and dural sac swelling (Hirasawa et al., 2007). Others using Each subject approached the stadiometer with their backs this technology have found a positive correlation to the level facing the wall. To ensure the specific feet position of the of degeneration and anterior and middle disc height loss in subject for a standing height measure, the examiner placed sitting (Karadimas et al., 2006). Many LBP syndromes appear his or her index fingers on the border of a piece of tape that to be curiously related to prolonged sitting with a common was securely fastened 4.6 cm from the bottom of the wall clinical reporting of stiffness or pain during and/or after the on the carpet. Each subject was asked to bring their feet act. But under what mechanism is still unresolved. In 2005, in together (with shoes removed) and slowly shuffle each foot vitro static flexion disc loading showed greater movement of back to the point where symmetrical pressure was felt by vertebrae when compared to cyclic loading (Little and the examiner’s fingers in contact with the heels of each Khalsa, 2005). Obviously, sitting without shifting is a constant subject. Subjects rested their back on the vertical plex- gravitational load on spinal discs and correspondingly, it is iglass plate of the stadiometer. Subjects head position was speculated here that the efflux of water from discs determined as follows: if the subject was able to rest the predominates over the influx in sustained sitting. head against the wall comfortably, then resting the head on the vertical column of the stadiometer was preferably With the worldwide economic burden of LBP estimated in chosen as a standard measuring position for that subject. If the billions (Maniadakis and Gray, 2000; Luo et al., 2004), the subject had significant kyphosis and was not able to rest interest remains high in discovering successful therapeutic the head easily back onto the stadiometer, the subject was interventions. In many scientific treatment circles, decom- asked to look straight ahead. Examiners were trained in pression or unloading of the discs is a common theme in this standardized measurement procedures. Three examiners pursuit. These interventions range from conservative to were used in this study with one performing all measure- surgical treatments with outcomes of varying success. ments within each subject. Minimal pressure was induced Recently, potential evidence supporting the role of distraction on the top of the stadiometer head unit when measures in disc regeneration and hydration (through improving disc were obtained with an attempt for consistency within each nutrition via the endplates) has been published (Guehring examiner. Each measurement was recorded in 5e10 s upon et al., 2006; Crock and Yoshizawa, 1976) suggesting that rising from the chair. distraction seems to make the most probable sense from a therapeutic standpoint (Schnake et al., 2006). With newer Three standing height measurements were taken on all understandings of disc physics relating to endplate pressures subjects: an initial standing, a post-sitting, and a post- (Huber et al., 2007), fluid-flow (Van der Veen et al., 2005) and exercise measurement (see Figure 1). After the initial static versus dynamic loads (Huang and Gu, 2008), this measurement, the subject was asked to sit for 15 min and preliminary paper looks at a seated decompression/recom- instructed not to shift or use the armrests. The chair used pression strategy utilizing the upper extremities in the treat- was a standard office chair and was located approximately ment and prevention of LBP related to intervertebral discs. 1.2 m from the standing measuring site. A timer with an audible chime was utilized to identify the 15 min duration. In 1998, this movement strategy was conceived and At the 12e14 min mark of sitting, the participant was coined chair-care by the author. It was then prescribed in explained the exercise both procedurally and verbally by private practice to those with LBP and dysfunction related to way of demonstration by the examiner (see Figure 2a and b) sitting during the periods of 2000e2008. The outcomes have with subjects only watching the examiner. demonstrated consistent patterns of varying improvement. Here, an introduction to the movement strategy is pre- After 15 min of sitting, subjects got up (without using the sented, together with an attempt to objectify results seen in armrests) and approached the stadiometer for the post- private practice. sitting measurement. Materials/methods Immediately following this (post-sitting) measurement, the subject returned to the same chair and performed the This study included 49 subjects acquired primarily from exercise. After four repetitions of 5 s with a return to visiting patients to a chiropractic/naturopathic clinic in relative neutral for 1e3 s between each repetition Nanaimo, BC, Canada. Subjects were asked if they wanted to (Figure 2a), the subject stood up and the third (post-exer- participate in a study evaluating a newly designed exercise cise) standing measurement was taken. Measurements for LBP. Additional participants were recruited by way of were recorded within 5e10 s after the last distraction a posting in the local paper. Participants were of ages ranging component of chair-care. This was the conclusion of the from 12 to 85 (mean age of 54.9 years). Forty-nine percent of study for that participant. the participant were females (24/49) and 51% were males (25/49). Height measurements were taken using a 235 The outcome measures of interest were the height Heightronicä digital stadiometer (accuracy to 0.01 cm) using differences between each of the three standing heights a capacitive incremental encoding system by accurate within each subject. The descriptive statistics were evalu- technology. The stadiometer was installed on a stable inte- ated with stem and leaf analysis with QQ in determining rior wall in the waiting room of a clinical office. The surface normal distribution (see Table 1). Paired t-test was performed under the stadiometer was leveled concrete with an on each pair of standing height differences (initialepost- sitting, initialepost-exercise, post-sittingepost-exercise). The influence of age and gender was also investigated with

Investigation into a seated unloading movement strategy for the lumbar spine 121 Figure 1 Study flow. several ANOVA models, including General Linear Model (GLM) three measurements as repeated measurements, patient as with repeated measurements and age and sex as factors, and subject, gender as a fixed factor and age as a covariate was ANOVA model with the height change as response/dependent performed. The SAS code is variable. Here, only the GLM with repeated measurements will be discussed, which is further refined with age removed. proc glm dataZtest.Data; class sex; Results model start postchcar postsitZsex age/nouni; Stem and leaf plot and QQ plot did not find sufficient repeated Time 3 contrast(1); evidence against the assumption that the data follows normal distribution, therefore, paired t-tests for each pair run; of standing height differences (initialepost-sitting, initiale post-exercise, post-sittingepost-exercise) were performed. In the above SAS code, the repeated measurements form The post-exercise standing height measurements differed the factor ‘‘time’’. The results of the tests of hypotheses significantly (p<.001) from both post-sitting and initial for between subjects effects are shown in Table 3. The standing heights (Table 2) with mean height increases seen p-value for sex is .0006, indicating the average of three (2.4 and 2.7 mm, respectively). Significant changes were height measurements is significantly different between not seen comparing standing heights before and after man and woman, while the average of three height sitting. measurements does not change due to age changing. The same conclusions were found when the data were The results of hypotheses test for within subjects effects evaluated, stratified by gender. A general linear model with are shown in Table 4. As the age and timeÂage are both Figure 2 (a) Chair-care. (b) A seated anti-axial creep movement strategy, chair-care. Instructions: press into the seat cushion with your hands and relax the lower back while creating a distraction moment in the lumbar spine. The majority (approximately 60e80%) of your full weight should be supported by the shoulder girdles. Be sure to keep the chin retracted and arms externally rotated. Hold for 5 s. Most people feel a stretching in the lower back while performing. Gently return to neutral sitting posture for 1e3 s allowing the full weight to be resupported by the spine. Repeat four times.

122 J. Fryer, W. Zhang Table 1 Descriptive statistics for three standing measurements in the study cohort. Initial Gender N Minimum Maximum Mean S.D. Female 25 142.76 177.75 164.00 7.49 196.10 173.73 10.32 Male 24 150.27 196.10 168.77 10.16 Whole group 49 142.76 164.04 7.58 173.76 10.39 Post-sitting Female 25 142.01 178.15 168.80 10.22 196.15 Male 24 150.34 196.15 164.29 7.52 173.99 10.36 Whole group 49 142.01 169.04 10.18 Post-exercise Female 25 142.85 178.30 196.38 Male 24 150.40 196.38 Whole group 49 142.85 insignificant, the covariate age is taken out and the model were measured (both in this and Althoff’s study) which was is refined as not discussed in detail in the research of Althoff et al. Heel pad swelling was considered but intrasynovial swelling in  model start postchcar postsitZsex/nouni; other joints were not considered and assumptions were made with the influence on stature considered negligible. Following is the result of the tests of hypotheses for We disagree and believe the influence from the lower within subject effects (see Table 5). synovial joints is not negligible. They found that the act of supported sitting contributed to greater statural heights The result indicates that time is significant (p<.0001), but this was looked at with 30 min of sitting versus our study i.e., the mean of the heights are different between three of 15 min of sitting therefore, it is difficult to compare. measures. It also confirms that gender has no impact on Swelling within other joints in the lower extremities may how heights/measurements are changed across different have occurred to a greater extent with 15 more minutes of measuring time, i.e., the interaction between time and sex unloading. For example, the meniscus in knees has been is insignificant (pZ.9746). found to be involved significantly in load-bearing MRI studies in the calculation of JSW (Hunter et al., 2006). The results for the tests of contrast specified in the Obviously, when someone sits, the spine continues to be refined model are listed in Table 6. It indicated the same under load while the lower extremities are relieved of the conclusion about the two pairs (post-exercise height large axial forces of gravity. Height gains may have measurements versus the initial height, the height after occurred between epiphyseal plates/hyaline cartilage/ sitting versus the initial height) as the paired t-test in meniscus within joints in the lower extremities during Table 6 did. sitting in conjunction of height loss in the spine when standing heights were measured after 15 min of sitting. Discussion Deformation of all biological tissues, not only heel pad swelling, in lower extremity changes during sitting must be In the first part of this study, standing heights were accounted for when standing heights are of interest to help measured before and after 15 min of sitting without assess tissues involved in standing measures. Therefore, in significant changes seen. We expected to see standing future spinal studies of events related to height changes, it measures decrease after 15 min of sitting. Other is suggested that measuring sitting heights would help researchers have found height increases in standing height eliminate the lower extremity influence on data as has postures after a period of 30 min of sitting (Althoff et al., been done by Magnusson et al. (1990). If height increase of 1992) with greater attention to subject positioning intervertebral discs are related to a period of unloading compared to this pilot study. It is unknown whether we (Kourtis et al., 2004), then could it be possible that this would have seen the same, as our protocols were different. occurs in other cartilaginous structures, like that of the hip, We believe that a measure of increased joint space width knee and ankle? Could the common experienced relief in (JSW) occurs in the hips, knees and ankles likely resulting in height gains in the lower extremity when standing heights Table 2 Paired t-test for each pair of the three measurements: initial, post-sitting and post-exercise. Paired differences t-test d.f. Significance (two-tailed) Mean S.D. 95% confidence interval of the difference <.0001 .24367 .27836 <.0001 .27633 .31780 Lower Upper .03265 .29784 .447 Pair 1: Post-exerciseepost-sitting .16372 .32363 6.128 48 Pair 2: Post-exerciseeinitial .18504 .36761 6.086 48 Pair 3: Post-sittingeinitial À.05290 .11820 48 .767

Investigation into a seated unloading movement strategy for the lumbar spine 123 Table 3 Tests of hypotheses for between subjects Table 5 The result of the tests of hypotheses for within effects. subject effects. Source d.f. Type III SS Mean square F-value Pr>F Source d.f. Type Mean F-value Pr>F III SS square Sex 1 3366.54954 3366.54954 13.50 0.0006 Age 1 11.49442 11.49442 0.05 0.8309 Time 2 2.23054469 1.11527234 24.54 <.0001 Error 46 11467.28381 249.28878 0.9746 TimeÂsex 2 0.00234333 0.00117166 0.03 Error (time) 94 4.27266756 0.04545391 the lower extremities when someone sits down after data with any significant weight. It was presumed that most a period of standing be related to JSW? The act of of the subjects had been up for at least 1 h before ‘‘standing-up’’ after a period of 15 min of sitting did not commencing the study which has been shown in previous demonstrate standing height gains in this study when studies to have the greatest height variances (Tyrrell et al., compared to the seated distraction technique looked at in 1985). Preloading histories of entering subjects were not part 2. This finding suggests that the commonly encouraged known on the day of testing and it is uncertain whether this action to get out of a seated position (McGill, 2002) may not would have interfered with the results. The 235 Heightronicä have the same spinal benefits as the spinal unloading stadiometer is reliable with very little calibration required technique looked at in this study. (Æ.01 cm over 200 clinical uses). It is therefore unlikely that the unit itself posed any significant error. The investigators In the second part of the study, initial and post-sitting taking the measurements with the stadiometer had extensive heights were compared to post-exercise heights. Post- training and experience with the unit but unfortunately were exercise heights were found to be significantly increased. not blinded. Pressures on the top of the stadiometer during This supported the hypothesis that height increases are recordings may have influenced the data even if care was associated with this exercise. taken. Additionally, no other known studies using this stadiometer with these protocols were done previously; There were many possible limitations in the study. therefore, it is difficult to compare this pilot study to others. Positioning of the subject may have influenced the data; In this study, the screws were loosened with only very however, standardized measurement procedures were used minimal friction of the sliding apparatus. It is suggested that to minimize this error although not tested rigorously for in future studies utilizing the 235 heightronic, that the reliability. Even though the subjects were blinded from adjustment screws be loosened completely so the weight of measures, positioning changes may have occurred, even if the stadiometer head be the only factor in pressure induced a subject’s intent was objective. Future studies using the on the top of a subject’s head. 235 Heightronicä stadiometre should consider the use of the spectalevel to help minimize cervical flexion/extension This study did not investigate the duration that the variances within subjects in future stadiometric studies. observed changes in height were retained. Interestingly, This device was simply created with an attached site level when the third measurement (post-exercise) was taken, it on the arm of a pair of universal glasses although not used was noticed that the numerical digital reading was in this study. descending, almost as though the subject’s height was ‘‘settling down’’. The quicker a measurement could be Some researchers have implicated heel pad swelling as acquired after the exercise, the greater the height was for a factor in stature measures (Foreman and Linge, 1989) that subject. This is why a 5e10 s restriction was reporting that 2 min of standing pressure on the heels were implemented after the last unloading repetition to record required for reliable standing height measures. But as the height. Utilizing this sensitive stadiometer revealed the individual differences were looked at with the same dynamic nature of standing posture (especially immediately amount of heel-time pressure before measures were after the exercise) that was otherwise unknown to the obtained (5e10 s) after a period of unloading, this was author. considered a relative constant; with the likelihood of seeing even greater significant height gains post-exercise if Other areas of possible error might be the chair-care subjects remained seated to allow the heel pads to swell procedure itself. How to perform the exercise (Figure 2a even more before the final measure was taken. and b) is explained and demonstrated to the subject at the 12e14 min mark during the sitting phase of the experiment Diurnal changes in height happen most quickly in the early but having subjects perform this exercise for the first time morning hours so the measurements recorded in a window of brought some queries. approximately 17 min within each individual between the hours of 10 a.m. and 5 p.m. should have not influenced the Table 4 Univariate tests of hypotheses for within subject Table 6 Analysis of variance of contrast variables. effects. Source d.f. Type Mean F-value Pr>F III SS square Source d.f. Type III SS Mean square F-value Pr>F Time 2 0.24529072 0.12264536 2.64 0.0765 Post-exercisee 1 3.73467516 3.73467516 36.24 <.0001 0.00168957 0.00084479 0.02 0.9820 initial 0.05205355 0.05205355 0.57 0.4522 TimeÂsex 2 0.00394495 0.00197248 0.04 0.9584 4.26872260 0.04639916 Post-sittinge 1 TimeÂage 2 initial Error (time) 92

124 J. Fryer, W. Zhang Figure 4 Chair-care proposed hydraulic model. down from the gleno-humeralescapular complexes. A comparison study of differing postural relief strategies would prove to be useful in the future. No known risks are associated with this movement strategy although it is speculated that minor cervical compression may occur. The optional use of fists, in chair- Figure 3 Chair-care with armrests. Press into the armrests with the elbows to unload the lumbar spine. This exercise requires some practice and it is expected Figure 5 Proposed decompression hydraulics. that greater height gains would have been seen with more experienced performers. A recent literature review in people with non-specific chronic LBP suggested that there was strong supportive evidence in improving pain and function when comparing unloading movement facilitation to no exercise (Slade and Keating, 2007). This chair-care exercise (both without and with armrests (see Figure 3)) is thought to incorporate components of several common unloading therapeutic strategies for LBP (Cox flexion distraction, intermittent traction/distraction, and the McKenzie protocols) into a simple-seated vertical unloading format in which most people should be able to perform. It is also similar (in some respects) to the popular orthopedic sign called minors, but with an extension moment instead of the flexed unloading position as it often demonstrates in discogenic related syndromes. Chair-care also appears to be similar in posture to Brugger’s relief position (Lewit, 1996) as the lumbar spine is repositioned into an erect (lordotic) posture. The critical difference chair-care offers is the added compo- nent of lower spinal unloading through the act of pressing

Investigation into a seated unloading movement strategy for the lumbar spine 125 Conclusion This was a pilot/preliminary investigation to objectify a simple seated exercise, coined chair-care, that has demonstrated varying degrees of clinical success in private practice. Individual standing height differences were not seen after 15 min of sitting but were seen after the performance of the exercise. Future stadiometric investi- gations should include the use of a spectalevel to help with the invasive nature of positioning error using the 235 Heightronicä. Were the changes seen due to the lumbar angle and/or disc heights or something else? Positional MRI should be used to anatomically investi- gate. The ease of application makes this exercise poten- tially useful for many with LBP related to sitting. Optimal loading and unloading rates still require investigation in defining the most favorable microenvironments of human lumbar intervertebral discs in sitting. Conflict of interest declaration Figure 6 Proposed compression hydraulics. No grants, technical support or corporate support have been requested or utilized in this study. There are no care, should help those with symptoms related to the conflicts of interest. carpal tunnel. Acknowledgments With the diurnal loading recovery cycle of these struc- tures suggested in the mechanobiology and degenerative The lead author would like to thank John A. Dufton, DC MSc paradigm (Johannessen et al., 2004), it is proposed here MD; Mitch Haas, DC MA; David Panzer DC; and James Carollo that this decompression/recompression exercise aids in the MS for the editing of this paper. I must also thank my dear drawing of water and essential solutes across endplates in wife, Nichole. and out of discs in an ebb and flow fashion (see Figures 4e 6). Some forms of mechanical loading have demonstrated References the ability to induce highly specific metabolic responses (Iatridis et al., 2006) and with a yet to be determined Adams, M.A., Roughley, P.J., 2006. What is intervertebral disc optimal loading/unloading rate, this exercise is thought to degeneration, and what causes it? Spine 31, 2151e2161. encourage metabolism through an active cyclic osmotic mechanism, providing a relief of the effects of axial load Alexander, L.A., Hancock, E., Agouris, I., Smith, F.W., over time while sitting. The height increase in this study is MacSween, A., 2007. The response of the nucleus pulposus of believed to be due to (in part) by increasing the exposure of the lumbar intervertebral discs to functionally loaded positions. the fixed negative charges of sulphated GAG chains (Mar- Spine 32, 1508e1512. oudas and Evans, 1974) in discs to the large dipole moments of influxing water. With a greater number of water bound Althoff, I., Brinkmann, P., Frobin, W., Sandover, J., Burton, K., aggrecans, this is expected to contribute towards a greater 1992. An improved method of stature measurement for quan- disc volume. titative determination of spinal loading. Application to sitting postures and whole body vibration. Spine 17, 682e693. These height gains seen after chair-care in this prelim- inary study must be reproduced. Improvements to minimize Beach, T., Parkinson, R., Stothart, P., Callaghan, J., 2005. Effects measurement error using the 235 heightronicä stadiometer of prolonged sitting on the passive flexion stiffness of the in vivo should be implemented to help with issues of measurement lumbar spine. The Spine Journal 5, 145e154. validity and reliability. Future studies might consider positional MRI to help discern why height increases were Crock, H.V., Yoshizawa, H., 1976. The blood supply of the lumbar seen with chair-care in this study. The continuing investi- vertebral column. Clinical Orthopaedics and Related Research gation of the compressive effects of weight on interverte- 115, 6e21. bral discs while sitting should help cast light on associated disc rheology and sitting. Optimal low back unloading and Foreman, T.K., Linge, K., 1989. The importance of heel compres- re-loading rates while sitting require attention in the sion in the measurement of diurnal stature variation. Applied scientific pursuit of corresponding optimal osmotic trans- Ergonomics 20, 299e300. portation to and from intervertebral discs. Water carries both nutrients and structure to these large avascular Fortuniak, J., Jaskolski, D., Tybor, K., Komunski, P., Zawirski, M., structures. 2005. Role of proteoglycans in the intervertebral disc degen- eration. Neurologia i Neurochirurgia Polska 39, 324e327. Guehring, T., Omlor, G.W., Lorenz, H., Engelleiter, K., Richter, W., Carstens, C., Kroeber, M., 2006. Disc distraction shows evidence of regenerative potential in degenerated intervertebral discs as evaluated by protein expression, magnetic resonance imaging, and messenger ribonucleic acid expression analysis. Spine 31, 1658e1665.

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Journal of Bodywork & Movement Therapies (2010) 14, 127e138 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt PERFORMING ARTS MEDICINE Performing arts medicine e Instrumentalist musicians: Part III e Case histories Jan Dommerholt, PT, DPT, MPS* Bethesda Physiocare, Inc./Myopain Seminars, LLC, 7830 Old Georgetown Road, Suite C-15, Bethesda, MD 20814-2440, USA Received 24 November 2008; received in revised form 11 February 2009; accepted 12 February 2009 KEYWORDS Summary In parts I and II of this article series, the basic principles of examining musicians in Case reports; a healthcare setting were reviewed [Dommerholt, J. Performing arts medicine e instrument Performing arts medi- alist musicians: part I: general considerations. J. Bodyw. Mov. Ther., in press-a; Dommerholt, cine; J. Performing arts medicine e instrumentalist musicians: part II: the examination. J. Bodyw. Physiotherapy; Mov. Ther., in press-b]. Part III describes three case reports of musicians with hand pain, inter- Musicians; fering with their ability to play their instruments. The musicians consulted with a performing Ergonomics; arts physiotherapist. Neither musician had a correct medical diagnosis if at all, when they first Trigger points contacted the physiotherapist. Each musician required an individualized approach not only to establish the correct diagnosis, but also to develop a specific treatment program. The treat- ment programs included ergonomic interventions, manual therapy, trigger point therapy, and patient education. All musicians returned to playing their instruments without any residual pain or dysfunction. ª 2009 Elsevier Ltd. All rights reserved. Introduction injuries are the most common disorder among musicians, it follows that physiotherapists would play an important role in Parts I of this article series outlined the basic principles of the the management and prevention of injuries (Dommerholt history and examination of musicians within the context of and Norris, 1997; Brandfonbrener, 2000). Yet, in a study healthcare (Dommerholt, in press-a, in press-b). While many commissioned by the International Conference of Symphony aspects of the examination and treatment outlined in this and Opera Musicians only 13% of 2212 musicians associated article are applicable to other professions as well, the focus with 48 major symphony orchestras in the United States had of this article is on the physiotherapy assessment and consulted with physiotherapists (Fishbein et al., 1988). In management. Readers are encouraged to place the case 1994, the American Physical Therapy Association established reports within their own discipline. Because musculoskeletal the Performing Arts Special Interest Group [PASIG], which aims to be ‘‘a leading authority in performing arts physical * Tel.: þ1 301 656 5613; fax: þ1 301 654 0333. therapy [.] through professional development and dissem- E-mail address: [email protected] ination of current information/trends, current practice, research initiatives and outreach programs with performing 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.02.005

128 J. Dommerholt artists and performing arts groups’’ [https://www.orthopt. Case histories org/sig_pa.php, accessed February 11, 2009]. In 2004, the PASIG published a practice analysis survey to initiate the This article documents the physiotherapy management of development of clinical guidelines, which showed that after three musicians with hand pain. Each case illustrates dancers, musicians are the second most common population different aspects of the physiotherapy evaluation process treated by performing arts physiotherapists (Gamboa et al., and physiotherapy management. Although the article is 2004). The PASIG includes dancers, instrumentalists and written from the perspective of a performing arts physio- vocal musicians, ice skaters, and gymnasts in its definition of therapist, the principles are applicable to other healthcare performing arts physiotherapy. In spite of the efforts of the providers as well. PASIG and other performing arts medical associations, rela- tively few articles have appeared in the physiotherapy The bassoonist literature about the specific physiotherapy management of musicians (Gamboa et al., 2004). The patient was a 19-year-old male college student who experienced disabling pain in the left index finger, but only Performance-related injuries are almost always when he played the bassoon. He was on a full music preventable (Wynn Parry, 2003; Fjellman-Wiklund and Che- scholarship and played in the university’s symphony sky, 2006). Physiotherapists can educate musicians, music orchestra and in other school ensembles. During his high students, teachers, and managers of performing arts orga- school years, he had switched from saxophone to bassoon nizations, which has been shown to be very effective (Dom- at the recommendation of his music teacher, who had merholt and Norris, 1997; Hildebrandt and Nubling, 2004). advised him that colleges have much difficulty in finding Most music teachers have not received any education on care high-level bassoon players and the likelihood of getting of the physical body of musicians (Redmond and Tiermman, music scholarships would be considerably greater for 2001). Musicians need to learn and accept that their physical bassoon players than for saxophonists. The patient had body is part of the instrument and deserves and requires the played the bassoon for only three years. In preparation of same level of attention and care (Dommerholt et al., 2000). his college auditions, he had increased his practice time Teachers familiar with injury mechanisms and prevention considerably and often would play 6e8 h daily. Since he had strategies are essential in instructing students accordingly been accepted to the school on a full scholarship, he (Hildebrandt and Nubling, 2004). practiced approximately 5 h daily in addition to orchestra rehearsals, private lessons, and other ensemble engage- Physiotherapists and other healthcare providers can ments. When asked about his practice habits, he admitted initiate prevention programs in music schools or orchestras. playing nearly continuously without regular breaks. He did Preventative exercise program or movement re-education not use any practice methods without playing the instru- classes have proven track records in reducing playing-related ment, such as shadow-playing or mental practice. musculoskeletal problems (Spaulding, 1988; Chong et al., 1989; Wakely, 1998; Ackermann et al., 2002; de Greef et al., During the period that he prepared for the auditions, he 2003). For example, a fifteen-week self-awareness program had experienced similar pain in his left index finger, but the to reduce injuries and improve musicians’ perceived physical pain was not constant and did not interfere with his ability competence demonstrated a significantly reduced injury to play. Upon entering college, he started studying with rate compared to a control group. Forty-five percent of the a new teacher, but with few significant changes in his decrease in injuries was a direct result of an increase in playing technique. After approximately six weeks in the physical competence (de Greef et al., 2003). An injury music school, he started experiencing frequent pain in his prevention program at a Norwegian conservatory was very left index finger. Two months later he consulted with effective (Spaulding, 1988). A Dutch symphony orchestra a performing arts physiotherapist. The onset of pain started contracted with a physiotherapist to conduct a weekly after approximately 5e10 min of playing the bassoon. The consultation clinic available to all members of the orchestra. pain would increase unless he stopped playing. Rest periods The program has been well received, and has been shown to did not seem to make much difference. When he would reduce the rate of musculoskeletal disorders (Wakely, 1998). start playing again, the pain would start again after Strength and especially endurance programs directed at 5e10 min. At its worst, he rated his pain as a ‘‘8’’ on music students reduced their perceived exertion of playing a visual analog scale ranging from 0 to 10, with ‘‘0’’ being (Ackermann et al., 2002). Musicians do not necessarily make equal to ‘‘no pain’’ and ‘‘10’’ the ‘‘worse level of pain he regular exercise part of their daily routine, which increases could imagine.’’ When he stopped playing, the pain would their risk of injury. Poor proximal strength, endurance, and subside within minutes. The musical repertoire did not have stability result in poor posture, increased stress on distal any impact on the onset of pain. Other activities of daily muscles, and overuse injuries. The combination of poor and living did not evoke the patient’s pain complaint. He did not constrained postures, flawed practice habits, repetitive experience any pain in his finger unless he played the movements, poor physical conditioning, stressful work bassoon. There were no other pertinent findings from the conditions, faulty ergonomics, and poor awareness are direct history (for a review of pertinent questions, see part I of causes of injury (Lowe, 1992; Quarrier, 1993; Dommerholt this series). and Norris, 1997; Dommerholt, 2000; Brandfonbrener, 2006). Shafer-Crane emphasized trunk stabilization, shoulder The patient was examined with and without the stabilization, upper quadrant strengthening, stretching, and bassoon. The examination without the bassoon revealed overall conditioning as the main components of a prevention normal muscle strength of the finger flexors, extensors, and program for musicians (Shafer-Crane, 2006). interossei using manual testing. Range of motion was

Performing arts medicine 129 significant for the finding of hypermobility of the meta- condition and usually corresponds to the medical diagnosis. carpophalangeal joints of all his fingers. Passive extension Impairments are the consequence of disease, pathological was measured at 80 degrees and was not painful. Palpation processes, or lesions, and are defined as ‘‘abnormalities of of the extensor digitorum muscle and the finger flexors did structure or function.’’ When impairments result in the not trigger the patient’s familiar pain. Local palpation of inability to perform a physical activity, task, or activity in the intrinsic hand muscles and the wrist and finger exten- an efficient, typically expected, or competent manner, sors did not reveal any discomfort either. He did not have physiotherapists formulate functional limitations. Disability systemic whole-body hypermobility. Hypermobility was according to the model is defined as ‘‘the inability or limited to the upper extremity. restricted ability to perform actions, tasks, and activities related to self care, home management, work (job/school/ Examination of the patient while playing the bassoon play), community, and leisure roles in the individual’s showed a mismatch between the patient’s hand size and sociocultural context and physical environments’’ (Amer- the size of the instrument. In order to wrap his fingers ican Physical Therapy Association, 2001). around the bassoon, he kept his hand and fingers tightly against the instrument, which caused excessive passive The patient did not present with a clear pathological or hyperextension of the metacarpophalangeal joints (see pathophysiological condition. He had not seen a physician Figure 1). At the same time, he held his left arm closely for this problem and did not have a medical diagnosis. The against his trunk in an adducted position of the shoulder. patient’s hypermobility of the metacarpophalangeal joint The patient did not present with any other obvious appeared to be causative of the pain he experienced during impairments, which would explain the onset of disabling playing the bassoon and as such, hypermobility was diag- pain. nosed as an impairment. Hypermobility was particularly problematic, because of a mismatch between the patient’s Discussion hand anthropometry and the size of the bassoon. As a result From a music medicine perspective, the patient’s status of the impairment, the patient was functionally limited as was rated as a grade 1 on the Functional Grading of Severity he was no longer able to play the bassoon without pain. of Injury scale (Fry, 1986). As mentioned in part I of this Because he could not overcome his functional limitation article series, the Functional Grading of Severity of Injury and was not able to play his instrument and meet the scale is commonly used to determine the impact of pain on expectations of his work as an orchestra musician in the playing musical instruments. In this case, the pain was college symphony orchestra, he was considered disabled. limited to one site and the onset of pain was brought on by playing the instrument. The pain did not persist away from Following the examination, physiotherapists categorize the instrument and did not persist on rest. each patient into specific practice patterns, which direct the management plan. The Guide identifies four categories From a US physiotherapy perspective, it is recommended of conditions: musculoskeletal, neuromuscular, cardiovas- to use the Guide to Physical Therapy Practice to classify cular/pulmonary, and integumentary. Each category and diagnose patients’ problems (American Physical consists of several sub categories (American Physical Therapy Association, 2001). The Guide is developed by the Therapy Association, 2001). The patient was categorized American Physical Therapy Association and is based on into musculoskeletal practice patterns B (Impaired Posture) Nagi’s disablement model (Nagi, 1965, 1969, 1991; Amer- and D (Impaired Joint Mobility, Motor Function, Muscle ican Physical Therapy Association, 2001). In this model, Performance, and Range of Motion Associated with four interrelated concepts are identified, including Connective Tissue Dysfunction). As hypermobility was pathology/pathophysiology, impairments, functional limi- thought to be the primary impairment, pattern D was the tations, and disability (American Physical Therapy Associ- primary musculoskeletal pattern. The Impaired Posture ation, 2001). Pathology refers to a disease, disorder, or during playing the instrument was considered a secondary pattern. Figure 1 Hyperextension of the metacarpophalangeal joint due to a mismatch between hand anthropometry and size of The therapeutic management of this patient posed the instrument (ª 2008 e Jan Dommerholt). several interesting challenges. The Guide distinguishes three intervention strategies: coordination, communica- tion, and documentation (American Physical Therapy Association, 2001). The patient had not consulted with other healthcare providers, which limited the coordination and communication to the physiotherapist and the patient. Patients who are being seen by other practitioners require a more comprehensive level of coordination and commu- nication. Because the patient did not present with distinct pathological findings, his treatment plan was mostly func- tionally oriented. Initially, the patient was instructed to position his left upper arm into scaption, which positioned his hand in a more relaxed position at the instrument. Unfortunately, with his arm in scaption, he was not able to maintain good contact with the instrument and he was not able to play at all. As the patient was full-grown and bassoons do not vary much in size, there were limited options of modifying the fit

130 J. Dommerholt between the patient’s hand and the instrument. We Figure 3 Correction of hyperextension and direct pressure considered modifying the keys and extend the keys toward using Silopad pressure sensitive dots (ª 2008 e Jan the player’s hand. As an alternative, we considered using Dommerholt). a so-called plateau key, which is a covered key with a pad for the third finger of the left hand. A plateau key replaces severe pain and limited range of motion of the left thumb. the traditional ring key and allows small hands to more During a hiking trip two-and-a-half years earlier, a back- comfortably close a finger hole. The patient was however, pack fell on his outstretched left thumb, causing immediate quite concerned about making modifications to his instru- pain. He reported that the thumb and the thenar promi- ment, and he preferred other less permanent modifica- nence were swollen for several days following the accident. tions, which is a common response of musicians faced with He did not seek medical attention for several weeks, but he modifying their instruments (Ostwald, 1992). did consult eventually with a physician who diagnosed him with having a muscle strain and prescribed non-steroidal Placement of a few layers of gauze in between the left anti-inflammatories. After two months, he continued to hand and the instrument did correct his hand and shoulder have severe pain with movement and limited range of positions reasonably well, but was not a permanent position motion of the left thumb, at which point he consulted with (see Figure 2). a hand surgeon. The hand surgeon made a diagnosis of ‘‘scar tissue’’ and referred him to a hand therapist. The After two months of searching for a suitable solution, patient reported that he did not see any obvious signs of the problem was finally corrected using Silopad pressure scar tissue, but the hand therapist confirmed the diagnosis sensitive dots. The dots feature an adhesive, which made it of scar tissue. He had several weeks of occupational possible to attach the dots directly to the instrument, therapy/hand therapy, but he did not gain much progress. without damaging the veneer of the bassoon. Silopad He was informed that due to the scar tissue, he would not pressure sensitive gel dots were originally designed for the be able to play the guitar anymore. He was not able to treatment of pressure or friction induced lesions, such as position his left thumb behind the neck of the guitar and blisters or calluses, but they proved ideal to correct the play the instrument. He discontinued hand therapy and patient’s hypermobility and to eliminate the direct pres- stopped playing guitar. Occasionally, he tried to play the sure of the hand on the instrument (see Figure 3). instrument, but his limited thumb range of motion pre- vented him from playing comfortably. The pain in the Prior to discharge from physiotherapy, the patient was thumb eventually subsided somewhat, but was always educated regarding proper practice habits. With the Silo- present especially with any use of his thumb. pad, he was able to return to playing the bassoon full-time without any pain or other restrictions. He received a small After reading a newspaper article about music medicine, supply of dots for future use. Three years after discharge, the patient consulted with a performing arts physiothera- the patient contacted the physiotherapist. He reported pist. He reported that he had been playing guitar since high that his pain had not returned. However, he had run out of school. He started taking private classical guitar lessons pressure sensitive dots and ordered an additional set. approximately 8 years before the accident. He had always studied with the same teacher. As he was unable to play In summary, the patient returned to playing the bassoon guitar at all, questions about his repertoire, playing, and on a full-time basis without any restrictions or residual practice habits were only relevant to gain a better under- pain. Although his music career was seriously threatened, standing of his pre-injury status and his potential return-to- the problem was corrected after only one physiotherapy play objectives. At the time of the initial evaluation, he examination and treatment. rated his pain as a ‘‘5’’ on a visual analog scale ranging from 0 to 10, with ‘‘0’’ being equal to ‘‘no pain’’ and ‘‘10’’ the The guitarist ‘‘worse level of pain he could imagine.’’ Any activity involving the thumb, including playing the guitar, increased The patient was a 30-year-old male amateur classical his pain levels immediately. He suffered from persistent guitarist, who had not been able to play the guitar due to movement-activated pain in the thumb region. The pain was located in the thenar prominence and in the thumb. He Figure 2 Correction of hyperextension at the meta- carpophalangeal joints using several layers of gauze (ª 2008 e Jan Dommerholt).

Performing arts medicine 131 characterized the pain as a deep, aching pain, but he was ‘‘hyperirritable spots in skeletal muscle that are associated unable to identify the location of the pain exactly. with hypersensitive palpable nodules in taut bands (Simons et al., 1999). An active trigger point is a symptom- Visual inspection of the left hand did not reveal any producing point, which can trigger local and referred pain abnormalities. The examination of his left hand revealed or other paresthesia. Active trigger points cause muscle significantly decreased active abduction and extension of weakness and decreased range of motion. A latent trigger the first carpometacarpal joint of no more than 15 degrees. point does not trigger pain without being stimulated, but Passive range of motion was 25 degrees for abduction and may alter muscle activation patterns and limit range of extension and painful in the patient’s end range. Pain was motion (Lucas et al., 2004; Lucas, 2008). Gentle palpation located over the thenar eminence. The right thumb had full of a trigger point can trigger a patient’s familiar pain, range of motion in all planes. Wrist range of motion was which indicates that trigger points contribute to peripheral within normal limits. Resisted abduction, circumduction, and central sensitization (Ferna´ndez-de-las-Pen˜as et al., adduction, flexion, and extension of the thumb were 2007). Normally, skeletal muscle nociceptors require high painful. Palpation of the thumb musculature revealed taut intensities of stimulation and they do not respond to bands with myofascial trigger points in the abductor pollicis moderate local pressure, contractions, or muscle stretches brevis, the opponens pollicis, the adductor pollicis, and the (Mense, 2003). Trigger points cause persistent noxious first dorsal interosseus muscles. Palpation of the trigger stimulation, which results in an increase of the number and points elicited a familiar pain to the patient. The patient size of the receptive fields to which a single dorsal horn did not bring his guitar to the initial physiotherapy nociceptive neuron responds, and the experience of spon- appointment. taneous pain and referred pain (Mense, 1994). Myofascial trigger points are identified through either a pincer palpa- Discussion tion technique, in which a muscle is palpated between the The patient’s status was rated as a grade 4 on the Func- clinician’s fingers, or a flat palpation technique, in which tional Grading of Severity of Injury scale (Fry, 1986). He had a clinician applies finger or thumb pressure to muscle persistent pain irrespective of playing the musical instru- against underlying bony tissue (Simons et al., 1999; Dom- ment. The pain increased with any use of the thumb, merholt et al., 2006a,b). Several recent studies have including activities of daily living. A grade 5 was consid- determined excellent intrarater and interrater reliability ered, because he was no longer able to play the instrument. for identifying myofascial trigger points (Gerwin et al., However, because he did still had functional use of his 1997; Sciotti et al., 2001; Al-Shenqiti and Oldham, 2005; hand, a grade 5 seemed inappropriate. Bron et al., 2007). Following the Guide to Physical Therapy guidelines, the Many studies have confirmed that myofascial trigger patient’s active myofascial trigger points were considered points are common not only in persons attending pain his pathology. His impairment was restricted range of management clinics, but also in internal medicine and motion. His functional limitation was not able to play guitar dentistry (Graff-Radford, 1984; Fricton et al., 1985; without pain, leading to disability. The patient was cate- Rosomoff et al., 1989a,b; Skootsky et al., 1989; Gerwin, gorized into musculoskeletal practice patterns C (Impaired 1995; Chaiamnuay et al., 1998). In fact, myofascial Muscle Performance) and D (Impaired Joint Mobility, Motor trigger points have been identified with nearly every Function, Muscle Performance, and Range of Motion Asso- musculoskeletal and other pain diagnoses (Dommerholt ciated with Connective Tissue Dysfunction) (American et al., 2006a). For example, a study of adults with Physical Therapy Association, 2001). frequent migraine headaches diagnosed according to the International Headache Society criteria showed that 94% Although myofascial pain has been reported as the most of the patients reported migraineous pain with manual common diagnosis responsible for chronic pain and disability stimulation of cervical and temporal trigger points, in other populations, few reports on musicians’ specific soft compared with only 29% of controls (Headache Classifi- tissue dysfunctions have considered myofascial pain in the cation Subcommittee of the International Headache differential diagnosis (Rosomoff et al., 1989a,b; Skootsky Society, 2004; Calandre et al., 2006). In 30% of the et al., 1989; Fricton, 1990; Hendler and Kozikowski, 1993; migraine group, palpation of trigger points elicited Rosen, 1993; Dommerholt and Norris, 1997; Davies, 2002; a ‘‘full-blown migraine attack which required abortive Dommerholt et al., 2006a,b; Gerwin and Dommerholt, 2006). treatment.’’ The researchers found a positive relation- A survey of physician members of the American Pain Society ship between the number of trigger points and the showed general agreement that myofascial pain and trigger frequency of migraine attacks and duration of the illness points exist as distinct clinical entities (Hendler and Kozi- (Calandre et al., 2006). In a study of 110 adults with low kowski, 1993; Harden et al., 2000). Yet, generally speaking, back pain, myofascial pain was the most common finding physiotherapists do not pay much attention to myofascial affecting 95.5% of patients (Weiner et al., 2006). pain. Very few articles about muscle dysfunction and trigger points have been published in the physiotherapy literature, There are no controlled studies of the incidence or and few physiotherapists have received training and educa- prevalence of myofascial pain among musicians. One tion in pain management strategies (Dommerholt, 2005; retroactive study reported that 73% of musicians diagnosed Dommerholt et al., 2006a,b). The term ‘‘myofascial pain’’ is with overuse syndrome had in fact myofascial pain, sometimes used without referring to trigger points and their however, this study did not include a control group (Moran, characteristic features, which can be confusing (Wee and 1992). Facial myofascial pain was most prevalent among Brandfonbrener, 2005). violists, violinists and brass players (Bryant, 1989; Taddey, 1992). Meador reported the treatment of a viola player with Myofascial trigger points are the hallmark characteristic of myofascial pain and have been described as

132 J. Dommerholt myofascial pain with trigger points in the latissimus dorsi Figure 4 Trigger point dry needling of the adductor pollicis and teres major muscles (Meador, 1989). muscle (ª 2008 e Jan Dommerholt). Back to the guitarist, the initial focus of the physio- The most striking finding of the instrument-specific therapy intervention was on inactivating myofascial trigger evaluation was that the neck of his guitar was much too points in the abductor pollicis brevis, the opponens pollicis, narrow for the size of his hands (see Figure 5). the adductor pollicis, and the first dorsal interosseus muscles. Trigger points can be inactivated manually with To position his hand around the neck, he had to use muscle energy techniques, trigger point compression or a forced pincer grip, requiring prolonged isometric muscle transverse frictions, with ultrasound or laser, or invasively contractions. This was interpreted as a significant risk using trigger point dry needling or injections (Majlesi and factor for future overuse injuries. The patient was advised Unalan, 2004; Ferna´ndez-de-las-Pen˜as et al., 2005, 2006; to replace his instrument if at all possible, or to at least Dommerholt et al., 2006a,b; Rickards, 2006; Srbely and limit playing and practice time to very brief episodes. The Dickey, 2007; Blikstad and Gemmell, 2008; Dearing and patient decided to replace his instrument and he commis- Hamilton, 2008; Gemmell et al., 2008; Srbely et al., 2008). sioned a guitar builder to construct a new instrument. Several recent studies, including a Cochrane review, have Physiotherapy was discontinued at that time. Once the confirmed that trigger point needling is an effective inter- instrument maker was ready to complete the neck of the vention (Hong, 1994; Furlan et al., 2005; Dommerholt instrument, the patient returned to physiotherapy to et al., 2006a,b; Ga et al., 2007a,b; Giamberardino et al., determine the ideal thickness of the neck for his hand 2007; Hsieh et al., 2007).1 As part of the physiotherapy anthropometry in close coordination with the instrument program, musicians can learn self-treatment strategies for myofascial trigger points (Davies, 2002). The reader is referred to two recent review articles on myofascial pain and dry needling (Dommerholt et al., 2006a,b). The patient consented to being treated with trigger point dry needling. Myofascial trigger points were inacti- vated with solid filament needles with a diameter of 0.16 mm and a length of 20 mm (see Figure 4). Multiple local twitch responses were elicited per trigger point. A local twitch response is an involuntary spinal cord reflex of the muscle fibers in a taut band following snapping palpation or needling procedures (Hong and Torigoe, 1994; Hong et al., 1995). Eliciting local twitch responses are essential when trigger points are inactivated with either dry needling or injections (Hong, 1994; Dommerholt et al., 2006a,b). They are unique to trigger points. The dry needling procedures were followed with manual trigger point therapy (Dommerholt and Issa, 2003; Dommerholt et al., 2006a,b). After three treatments, the patient had full, but still painful range of motion of the thumb in all directions. After five sessions, he was pain-free with all movements of his left thumb. He was seen for five more sessions spread out over several weeks, during which only manual techniques were used in combination with patient education. The patient had to learn that he could start playing guitar again, after having been convinced that playing would never be possible again. During that period, he was asked to bring in his instrument for an instrument- specific evaluation. 1 Trigger point dry needling is within the scope of physical Figure 5 Narrow neck of the guitar compared to the size of therapy in many countries, including Australia, Canada, Ireland, the player’s hand (ª 2008 e Jan Dommerholt). the Netherlands, New Zealand, Norway, South Africa, Spain, and the United Kingdom, among others. Currently, physical therapy boards of eleven US states have ruled that dry needling is within the scope of physical therapy practice, including Alabama, Colo- rado, Georgia, Kentucky, Maryland, New Hampshire, New Mexico, Ohio, South Carolina, Virginia, and Texas. A few state boards ruled that dry needling would not fall within the scope of physical therapy practice, including Hawaii, Nevada, New York, North Car- olina, and Tennessee. In most other states, it has not been deter- mined at this point in time (Dommerholt et al 2006).

Performing arts medicine 133 Figure 6 Ergonomically improved interface with a broader of the right wrist and thumb. The pain started approxi- neck of the guitar matching the size of the player’s hand (ª mately three months before her visit to a performing arts 2008 e Jan Dommerholt). physiotherapist. She was still able to play the organ and maker. After the instrument was completed, he returned piano, but had to stop playing the organ after less than for three additional physiotherapy sessions, during which 10 min and the piano after approximately 20 min, due to he was educated about gradually returning to playing the the onset of severe pain. The pain decreased away from the guitar. The new guitar fit his relatively large hand size (see instruments, but never resolved. The pain significantly Figures 6 and 7). He was discharged from physiotherapy impacted her ability to use her right hand with other after a total of thirteen sessions. Five years later, he was activities of daily living. She was no longer able to meet the still pain-free and continued playing guitar without any demands of her job as church organist, choir director, and restrictions. He even recorded a demo CD of his music. music teacher. The pain had started insidiously and she could not identify any precipitating event. Within two In summary, this patient had been erroneously diag- months following the onset of pain, she was no longer able nosed with ‘‘scar tissue’’. In spite of not having played at to play. As her career was seriously threatened, she con- all for a period of two-and-a-half years, he was able to sulted with three orthopedic surgeons, who were unani- resume playing the guitar once he was treated for myo- mous in their diagnosis of de Quervain’s syndrome. Two of fascial trigger points in combination with correcting the the three surgeons recommended immediate surgical repair ergonomic aspects of the playereinstrument interface. and informed her that delaying the surgery would jeopar- The organist dize her ability to ever play the organ again. The third The patient was a 26-year-old female professional organ orthopedic surgeon recommended a course of physio- player, who complained of severe pain in the radial aspect therapy combined with pharmacological management, but did not rule out surgical intervention if physiotherapy Figure 7 Comparison of the old and new guitar (ª would not resolve her pain. The patient was reluctant to 2008 e Jan Dommerholt). submit to surgery and consulted a performing arts physio- therapist for another non-surgical opinion. She reported that she started playing piano at the age of six. She switched to organ when she was fourteen. She had a variety of music teachers until she went to college, where she got a bachelor’s degree in organ. She planned to pursue graduate studies in organ, but the current pain levels had shattered that dream. More urgently, she was very con- cerned about not meeting the demands of her job as church organist. In that function, she was expected to not only play during church services, but she was also responsible for playing during any other church function, including funerals, weddings, and other special occasions. She was also the director of several church choruses and responsible for selecting the music repertoire for the church services and the choruses. Her job demanded her playing several hours daily. In addition, she was an organ and piano teacher with 15 weekly students. She played several organ recitals throughout the year. The patient received free housing from the church and she was afraid that she would be forced to move if she would not be able to perform the duties of her job. The patient reported that the repertoire made no difference in her pain. She did admit practicing several hours without regular breaks, but did not feel that her practice habits contributed to the onset of pain. The patient could easily identify the area of pain over the radial aspect of the right wrist and thumb. She rated her pain as an ‘‘8’’ on a visual analog scale ranging from 0 to 10, with ‘‘0’’ being equal to ‘‘no pain’’ and ‘‘10’’ the ‘‘worse level of pain he could imagine.’’ Visual inspection of the hand, thumb, wrist, arm, shoulders, and neck did not reveal any obvious deficiencies. There were no signs of swelling in the wrist and thumb, including the anatomical snuff box region. She did have relatively small hands considering that she was an organist. In spite of her smaller hand size, she had been able to meet the demands of the instrument. She did present with forward head posture, protracted shoulders, internal rotation of the upper extremities, and overall poor core stability (slouched

134 J. Dommerholt posture), but her posture did not seem to contribute to the strength (Fournier et al., 2006; Forget et al., 2008). Active sudden onset of pain. The patient presented with hyper- thumb range of motion was increased, while in persons with abduction and hyperextension of both thumbs. Measure- de Quervain’s syndrome, active range of motion is usually ments of strength of the thumb muscles in adduction, decreased (Forget et al., 2008). The increase in range of extension, flexion, abduction, and circumflexion were motion may be a functional adaptation, as sometimes is within normal limits and did not cause any additional pain. seen in musicians, but it is nevertheless inconsistent with a diagnosis of de Quervain’s syndrome (Ackermann and The patient tested positive for the Finkelstein test and Adams, 2003). she confirmed that the orthopedic surgeons had performed the same test. Surprisingly, when the Finkelstein test was In 1895, Swiss physician Fritz de Quervain first described performed with the elbow in extension, the test was the disorder, which later became known as de Quervain’s negative with the patient reporting having no pain in the syndrome (de Quervain, 1997; Ahuja and Chung, 2004). The wrist and thumb. She did complain of the familiar pain with syndrome is usually defined as pathology of the tendons of pronation of the forearm combined with ulnar deviation of the extensor pollicis brevis and the abductor pollicis longus the wrist. This suggested that the pain she experienced was muscles secondary to stenosis of the first dorsal compart- not due to stenosis of the first dorsal compartment or ment of the wrist. The Finkelstein test, during which the inflammation or irritation of the extensor pollicis brevis or clinician grasps the patient’s thumb and quickly deviates abductor pollicis longus. The position of the elbow and the hand and wrist ulnarly, is the classic diagnostic test for forearm has no mechanical effect on the first dorsal de Quervain’s disease. The Finkelstein test was first compartment. described by surgeon Harry Finkelstein in 1930 (Finkelstein, 1930). A few years earlier, Eichhoff described a similar test The patient was also examined for other possible causes for de Quervain’s syndrome in 1927 (Eichhoff, 1927). Many of pain in the thumb, including referred pain from myo- clinicians erroneously refer to Eichhoff’s recommendation fascial trigger points. She presented with latent myofascial to place the thumb within the hand and subsequently bring trigger points in the right infraspinatus, supraspinatus, the hand into ulnar abduction as the Finkelstein test. medial scalene, brachioradialis, supinator, and extensor Interestingly, recent biomechanical analysis has shown that carpi radialis longus muscles. It was not clear however, the Finkelstein test has a bias toward the extensor pollicis whether these trigger points contributed to the pain brevis tendon over the abductor pollicis longus, and it was complaint as she did not recognize the pain patterns asso- suggested that de Quervain’s syndrome may in fact be ciated with trigger point palpation, which is why these a pathology of the extensor pollicis brevis tendon and trigger points would be classified as latent trigger points subsheath (Kutsumi et al., 2005). Surgical releases of the (Dommerholt et al., 2006a). subsheath have resulted in complete relief of symptoms (Louis, 1987). Physiotherapy intervention following surgical Discussion intervention has been shown to be important and effective The patient’s status was rated as a grade 5 on the Func- (Robinson, 2003). tional Grading of Severity of Injury scale (Fry, 1986). She had persistent pain irrespective of playing the organ or The differential diagnoses for de Quervain’s syndrome piano. The pain increased with any use of the thumb and include a scaphoid fracture, osteoarthritis of the carpo- hand, including activities of daily living, and seriously metacarpal joint of the thumb, Kienbock disease, and threatened the patient’s musical career at the time of the Wartenberg’s syndrome. Kienbock disease is character- initial physiotherapy evaluation. The physiotherapy diag- ized by wrist pain, sclerosis and collapse of the lunate nosis was more challenging, as it appeared that the patient due to avascular necrosis. Wartenberg’s syndrome, did not have the correct medical diagnosis. sometimes referred to as cheiralgia paresthetica, is an entrapment of the sensory branch of the radial nerve Keyboard players with smaller hand sizes are at (Carlson and Logigian, 1999). The patient had no history increased risk for developing overuse syndromes and of falls or other trauma, which increased the likelihood occupational palsies, including de Quervain’s syndrome that she could have a superficial radial neuropathy or (Sakai et al., 2006). Small-handed keyboard players have to Wartenberg’s syndrome. The patient had increased pain play with a greater abduction angle of their thumbs, which with ulnar deviation and pronation of the forearm, which increases the risk of developing de Quervain’s syndrome supported the diagnosis of Wartenberg’s syndrome (Sakai et al., 2006). In a study of 200 Japanese pianists, 35% (Carlson and Logigian, 1999). of the players developed overuse problems. In 74% of all cases the pain was attributed to practicing octaves and Some authors have suggested that Wartenberg’s chords (Sakai, 1992, 1993, 2002). Brown identified a direct syndrome and de Quervain’s syndrome may be correlated correlation between awkward postures of pianists and wrist (Rask, 1978). Lanzetta and Foucher emphasized the impor- injuries (Brown, 2000). Paying much attention to postures tance of identifying Wartenberg’s syndrome before per- of musicians is critical (Lister-Sink, 1993, 1994). In keyboard forming a surgical release of the first dorsal compartment to playing excessive thumb abduction is often combined with avoid poor surgical outcome, aggravation of neuritis, and maximum radial deviation (Sakai et al., 2006). potential legal action against the surgeon (Lanzetta and Foucher, 1993). Rask maintained that superficial radial In spite of the patient being at increased risk, the neuritis may actually be the result of contiguous inflamma- diagnosis of de Quervain’s syndrome did not match the tion of de Quervain’s disease (Rask, 1978). Patients with physical findings of the physiotherapy examination. For superficial radial neuropathy or Wartenberg’s syndrome example, the patient’s thumb strength was well within often present with numbness or pain over de dorsolateral normal limits. Studies of strength measurements in de aspects of the hand, wrist and thumb, and the index, middle, Quervain’s syndrome have demonstrated significant loss of

Performing arts medicine 135 and ring fingers (Plancher et al., 1996; Fontes, 2004). Some though three orthopedic surgeons had made that diagnosis. patients experience a poorly localized burning or shooting She needed to understand that surgery of the first dorsal pain into the dorsum of the thumb, first web, or index finger compartment would most likely not resolve her pain and (Eaton and Lister, 1992). At the recommendation of the restore her function. Instead, physiotherapy consisted of physiotherapist, a neurologist confirmed the clinical diag- soft tissue mobilizations of the muscles around the elbow, nosis of Wartenberg’s syndrome. including the brachioradialis, supinator, and wrist extensor muscles. Myofascial trigger points were treated with To better direct the physiotherapy program, it seemed a combination of trigger point dry needling and manual important to investigate the cause or causes of the nerve trigger point therapy. She was instructed in gentle nerve entrapment. Superficial radial neuropathies can be caused gliding exercises for the radial nerve within a pain-free by nerve entrapment in the forearm, wrist, or in the distal range. After six sessions of physiotherapy twice per week, nerve branches in the hand. The site and nature of the patient started noticing a modest improvement. She entrapment determine the therapeutic intervention. Some was instructed to start playing piano again, but only during patients presenting with compression of the radial nerve 5e10 min per day. According to the patient, playing piano are relatively easy to treat, by removing the compressive was less involved than playing the organ. agent (Rask, 1979; Plancher et al., 1996). For example, when a tight wristband causes sensory radial nerve A friend of the patient took photographs while she was entrapment, the treatment would consist of removing the playing the piano and organ to allow the physiotherapist to band (Rask, 1979; Plancher et al., 1996). Entrapments in evaluate playing her playing postures. At that time, the the forearm are more challenging. One possible entrap- physiotherapy clinic did not yet have a piano at the pre- ment site is in between the two slips of a split brachior- mises. The photographs were reviewed with the patient. adialis tendon, which was observed in 5 out of 150 dissected She presented with poor posture at both instruments with arms in 4 out of 74 cadavers (Turkof et al., 1994). An in-vivo the same postural problems identified during the initial study of patients with Wartenberg’s syndrome found this evaluation. The organ is particularly challenging from kind of entrapment in 7 out of 143 patients (Turkof et al., a postural perspective. Organ players use their feet and 1995). Other entrapment sites at the elbow include their hands and balance their trunk on the bilateral ischial compression underneath an accessory brachioradialis tuberosities, which makes it difficult to keep the trunk muscle (Spinner and Spinner, 1996a), in between the aligned in a spine neutral position. The focus of the phys- tendons of the brachioradialis and extensor carpi radialis iotherapy program changed slowly from the pain manage- longus (Kleinert and Mehta, 1996), or as the result of ment phase to the conditioning phase with more emphasis surgical tendon transfers (Spinner and Spinner, 1996b). on proper posture, correction of forward head posture, Because the Finkelstein test was negative when performed core stabilization, and functional training to reduce with the patient’s elbow in extension, the possibility of disability. During the pain management phase, reduction in a nerve irritation secondary to stretch could not be pain is the main objective and physiotherapists may employ excluded. The role of the observed myofascial trigger manual therapy, dry needling (where legally allowed), points seemed relevant as well. Trigger points have been electro-therapeutic modalities, and emphasize the basics associated with nerve entrapments and it seemed of posture training and early improvement in physical conceivable that taut bands and trigger points in the bra- functioning. During the conditioning phase, the focus shifts chioradialis and extensor carpi radialis longus muscles to advanced exercises and training to further improve could potentially contribute to nerve compression (Dom- physical function and reduce disability (Dommerholt, merholt et al., 2006a,b). The referred pain patterns of 2005). Musicians must learn that successful rehabilitation trigger points in the right infraspinatus, supraspinatus, requires self-pacing during activities, for example when medial scalene, brachioradialis, supinator, and extensor the musician returns to playing the instrument, and setting carpi radialis longus muscles do include the area of the pain appropriate and achievable goals, including physical, complaint, even though the pain was not elicited with functional, and social goals (Norris and Dommerholt, 1995; palpation (Simons et al., 1999). The possible contributions Harding et al., 1998). The patient was instructed in proper of latent trigger points are still largely unknown (Lucas practice habits, emphasizing regular and frequent breaks, et al., 2004; Lucas, 2008). Although the exact location of shadow-playing, mental practice, relaxation, and visuali- the nerve entrapment could not be identified, a physio- zations of the music. therapy treatment plan was developed and implemented. Physiotherapy was continued for a total of four months Following the Guide to Physical Therapy guidelines, the at which point the patient was nearly pain-free. She rated patient’s sensory radial nerve entrapment was considered her pain as a ‘‘1’’ on a visual analog scale ranging from 0 to her primary pathology. Her impairment was pain. Her func- 10, with ‘‘0’’ being equal to ‘‘no pain’’ and ‘‘10’’ the tional limitation was not able to play organ or piano without ‘‘worse level of pain she could imagine.’’ She had no pain pain. The patient was clearly disabled as she was not able to with activities of daily living and was able to play the organ meet the demands of her job. The patient was categorized and piano. Several months after being discharged from into musculoskeletal practice patterns B (Impaired Posture), physiotherapy, the patient pursued her dream and started C (Impaired Muscle Performance), and neuromuscular her graduate studies in organ. Two years later, she gradu- pattern F (Impaired Peripheral Nerve Integrity and Muscle ated from the program with a master’s degree in organ. Performance Associated with Peripheral Nerve Injury) Since her graduation, she returned twice to physiotherapy (American Physical Therapy Association, 2001). for other non-related musculoskeletal problems. By her own report, she never experienced the pain in her wrist and The first step in treating this patient was explaining why thumb again. she could not possibly have de Quervain’s syndrome, even

136 J. Dommerholt In summary, this patient was diagnosed incorrectly with Ackermann, B., Adams, R., Marshall, E., 2002. Strength or endur- de Quervain’s syndrome. Instead, based on the physio- ance training for undergraduate music majors at a university? therapy examination she was eventually diagnosed with Med. Probl. Perform. Artists 17, 33e41. a sensory radial nerve entrapment. Even though the actual entrapment was not identified, the physiotherapy treat- Ahuja, N.K., Chung, K.C., 2004. Fritz de Quervain, MD ment regimen was very successful and returned the patient (1868e1940): stenosing tendovaginitis at the radial styloid to full function. Not only was she able to meet the demands process. J. Hand Surg. [Am.] 29 (6), 1164e1170. of her job, she was able to complete graduate studies in organ. Al-Shenqiti, A.M., Oldham, J.A., 2005. Testeretest reliability of myofascial trigger point detection in patients with rotator cuff Summary and conclusions tendonitis. Clin. Rehabil. 19 (5), 482e487. Physiotherapists are essential providers in the field of per- American Physical Therapy Association, 2001. Guide to physical forming arts medicine. As illustrated by the case reports, therapy practice, second edition. Phys. Ther. 81, 9e744. physiotherapists can play a substantial role in the preven- tion, diagnosis, and management of performance-related Blikstad, A., Gemmell, H., 2008. Immediate effect of activator musculoskeletal injuries of musicians. The case reports of trigger point therapy and myofascial band therapy on non- the guitarist and organist illustrate that patients may not specific neck pain in patients with upper trapezius trigger points always have the proper medical diagnosis. The guitarist compared to sham ultrasound: a randomized controlled trial. presented with myofascial pain and dysfunction, but was Clin. Chiropr. 11, 23e29. previously diagnosed with ‘‘scar tissue.’’ The organist was almost exposed to surgical correction of a presumed de Brandfonbrener, A.G., 2000. Epidemiology and risk factors. In: Quervain’s syndrome, which she did not have. The case Tubiana, R., Amadio, P. (Eds.), Medical Problems of the reports of the bassoonist and guitarist highlight particular Instrumentalist Musician. Martin Dunitz, London, pp. 171e194. ergonomic challenges. Through specific individualized instrument modifications both musicians were able to Brandfonbrener, A.G., 2006. Special issues in the medical assessment return to playing their instruments. of musicians. Phys. Med. Rehabil. Clin. N. Am. 17 (4), 747e753. v. Other ergonomic measures within the scope of physio- Bron, C., Franssen, J., Wensing, M., Oostendorp, R.A.B., 2007. therapy practice may include the evaluation of orchestra Interrater reliability of palpation of myofascial trigger points in chairs, which often are poorly designed and not suitable for three shoulder muscles. J. Man. Manip. Ther. 15 (4), 203e215. the task. Musicians often have musical instruments that do not match their anthropometry, as illustrated in the Brown, S., 2000. Promoting a healthy keyboard technique. In: guitarist and bassoonist’s case reports. Many string instru- Tubiana, R., Amadio, P. (Eds.), Medical Problems of the ments, including violins and guitars, are available in Instrumentalist Musicians. Martin Dunitz, London, pp. 559e571. different sizes, which should be considered as part of injury prevention and treatment programs (Kopfstein-Penk, Bryant, G.W., 1989. Myofascial pain dysfunction and viola playing. 1994). Familiarity with musicians’ backgrounds, musical Br. Dent. J. 166 (9), 335e336. instruments, and work conditions is helpful and clinicians who do not have a musical background may need to develop Calandre, E.P., Hidalgo, J., Garcia-Leiva, J.M., Rico- the necessary skills and knowledge (Wagner, 1995). Villademoros, F., 2006. Trigger point evaluation in migraine patients: an indication of peripheral sensitization linked to Few publications have documented the actual physio- migraine predisposition? Eur. J. Neurol. 13 (3), 244e249. therapy treatments of musicians (Warrington, 2003; Wins- pur, 2003). This article included three case reports, but Carlson, N., Logigian, E.L., 1999. Radial neuropathy. Neurol. Clin. more systematic research is needed to determine the 17 (3), 499e523. outcome of physiotherapy intervention in the treatment of musicians. Physiotherapists interested in treating musicians Chaiamnuay, P., Darmawan, J., Muirden, K.D., can start with expanding the history component of the Assawatanabodee, P., 1998. Epidemiology of rheumatic disease initial evaluation as outlined in part I of this article series. in rural Thailand: a WHOeILAR COPCORD study. Community By asking specific questions about the instrument, practice oriented programme for the control of rheumatic disease. J. habits, education, repertoire, and employment much Rheumatol. 25 (7), 1382e1387. pertinent information will direct the physiotherapist and musician toward a solution of otherwise career-threatening Chong, J., Lynden, M., Harvey, D., 1989. Occupational health injuries. In the end, attending concerts by former patients, problems of musicians. Can. Fam. Physician 35, 2341e2348. who at one time were convinced that their musical careers has ended due to injury, is one of the most gratifying Davies, C., 2002. 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Journal of Bodywork & Movement Therapies (2010) 14, 139e151 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt ERGONOMICS Proper body mechanics from an engineering perspective Edward G. Mohr, CPE, CSP, NCTM 1581 Oneida Trail, Lake Orion, MI 48362-1243, USA Received 27 June 2008; received in revised form 24 February 2009; accepted 5 March 2009 KEYWORDS Summary The economic viability of the manual therapy practitioner depends on the number Massage; of massages/treatments that can be given in a day or week. Fatigue or injuries can have Body mechanics; a major impact on the income potential and could ultimately reach the point which causes Ergonomics; the practitioner to quit the profession, and seek other, less physically demanding, employ- Computer modeling; ment. Injury risk; Strain Manual therapy practitioners in general, and massage therapists in particular, can utilize a large variety of body postures while giving treatment to a client. The hypothesis of this paper is that there is an optimal method for applying force to the client, which maximizes the benefit to the client, and at the same time minimizes the strain and effort required by the practi- tioner. Two methods were used to quantifiably determine the effect of using ‘‘poor’’ body mechanics (Improper method) and ‘‘best’’ body mechanics (Proper/correct method). The first approach uses computer modeling to compare the two methods. Both postures were modeled, such that the biomechanical effects on the practitioner’s elbow, shoulder, hip, knee and ankle joints could be calculated. The force applied to the client, along with the height and angle of application of the force, was held constant for the comparison. The second approach was a field study of massage practitioners (n Z 18) to determine their maximal force capability, again comparing methods using ‘‘Improper and Proper body mechanics’’. Five application methods were tested at three different application heights, using a digital palm force gauge. Results showed that there was a definite difference between the two methods, and that the use of correct body mechanics can have a large impact on the health and well being of the massage practitioner over both the short and long term. ª 2009 Elsevier Ltd. All rights reserved. E-mail address: [email protected] 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.03.001

140 E.G. Mohr Introduction generating components. In engineering terms, these components can be equated to levers, fulcrums, pulleys, Massage therapy is a profession that can bring much needed etc. Some massage therapy textbooks (Fritz, 2009a) make relief to clients suffering from a variety of soft tissue reference to these terms, but, to our knowledge, no one injuries and illnesses. From pain associated with tight has made an attempt to actually calculate the forces muscles, to joints that are dysfunctional due to physical involved with massage, to mathematically show the activities, massage is a modality that is pursued by many advantages of using proper body mechanics. people. The skilled massage therapist is the one who offers relief to such people’s pain and suffering (Ernst and Fialka, To understand the forces that occur at the joints of the 1994; Rich, 2002). human body, a brief description and example is necessary. The irony is that in providing relief to others, many The one main descriptor of any joint in the human body massage therapists cause injury to themselves. Sometimes is movement, more specifically rotational movement. A in their zeal to help their client, they put themselves in an ‘‘moment’’ is an engineering term used to defined rota- awkward posture and attempt to apply excessive degrees of tional movement around an axis. This term adequately force. Repetitive degrees of biomechanical load, commonly describes the forces that occur at a joint. For example, in associated with poor body use, appears to affect many order to hold a weight in one’s hand with the forearm massage therapists, resulting in them leaving the profession parallel to the ground, there are two forces trying to rotate (Greene, 1995). the arm in a downward motion, and simplistically speaking one counteracting force trying to rotate the forearm In all occupations, it is important to use ergonomic upward, thus keeping it steady. The two downward forces principles when designing jobs involving muscle strength are the weight of the forearm (including the hand) and the and movement (Kodak Ergonomics Group, 1987). The weight of the load being held. The upward, stabilizing purpose of this paper is to explore how the use of body force, comes from the muscles of the upper arm (biceps mechanics impacts the massage therapist, both physically brachii and brachialis). Figure 1 (Chaffin et al., 2006) shows and economically. The hypothesis is that proper body what happens at the elbow joint when this occurs. mechanics can lessen the chance of injury or illness, and the main approach will be to look at this issue from A moment is calculated by multiplying the force acting a scientific and an engineering perspective. on a rotational axis (in this case the pivot point of the elbow) with the distance that force is from the axis. Using The need the anthropometry for a 50th percentile female, the total distance from the elbow joint to the center of the hand is According to 2007 data from the American Massage Therapy 12.2 inches (w31 cm), and the center of mass (CM) of this Association, there are approximately 267,000 people in the arm/hand segment is 5.3 inches (w13.5 cm) from the United States who are involved in the massage therapy elbow. The weight of this body segment is 3.0 pounds profession. Based on their survey (n Z 838 therapists), 15% (1.35 kg). If a person were holding a load of 20 pounds are male and 85% are female, with an average of 6.5 years (w9 kg) in the hand, the downward moment created at the in the profession and an average age of 42. The average elbow would be: time actually performing (paid) massage is 15.1 h/week. There is an average turnover of 20% per year in the MðelbowÞ Z ð5:3 inch  3:0 lbÞ þ ð12:2 inch  20 lbÞ profession, and although more research is needed to ð13:5 cm  1:35 kgÞ þ ð31:0 cm  9:0 kgÞ determine the cause, 11% of respondents stated that avoiding personal injury was the top challenge facing MðelbowÞ Z 15:9 inch-lb þ 244:0 inch-lb massage therapists (AMTA, 2008). Since the majority of the 18:2 cm-kg þ 279:0 cm-kg massage population is female, data for the 50th percentile female will be utilized in all analyses using calculations or MðelbowÞ Z 259:9 inch-lb computer modeling. 297:2 cm-kg The U.S. Bureau of Labor Statistics and the National If the arm is stationary, then the counteracting moment Safety Council gather injury data from a variety of occu- of the muscle must also equal 259.9 inch-pounds (297.2 cm- pations. According to 2006 injury data for massage thera- kg). Knowing that the attachment point for the biceps pists (code 319010), 56% of the injuries were due to brachii and brachialis muscles is 1.97 inches (5.0 cm) from ‘‘sprains/strains’’, and 57% of the injury sources were from the rotational axis of the elbow, the muscle force required ‘‘worker motion/position’’. The upper extremities to hold this load can be calculated as follows: (including hand/wrist) accounted for 51% of the injuries, followed by the trunk at 16%. (See Appendix A for a break- FðmuscleÞ Z 259:9 inch-lb = 1:97 inch down of all the massage therapist injury statistics.) 297:2 cm-kg = 5:0 cm The human body as a system of levers and FðmuscleÞ Z 132 lb pulleys 59:4 kg The human body is composed of muscle, bone, tendons and Thus, in this example, it takes 132 pounds (59.4 kg) of ligaments, all of which make up its load bearing and force muscle force to hold a 20 pound (9.0 kg) object in the hand. This information can then be compared to research which was conducted to determine population muscle strength moments (Stobbe, 1982), in order to determine the percent of the given population that could withstand this rotational force on the elbow.

Proper body mechanics from an engineering perspective 141 Figure 1 Free body diagram of the forces acting on the elbow joint while holding a load in the hand. ME is the sum of the moments at the elbow, determined by the load in the hand (LH), weight of the forearm and hand (WF&H), the force of the muscle (FM), and the attachment distance of the muscle (m). (From Chaffin et al., 2006, p. 116, used by permission). As can be seen, even this most basic calculation can be the therapist how to use their body in a manner that will very complex. As one starts to work further through the reduce the chance of the therapist becoming fatigued body, all the forces acting on the elbow, in addition to and possibly injured over the long term. those acting on the upper arm, come into play to calculate the shoulder moments. Calculations for the hip, knee and Fritz (2009b) dedicates a chapter to the use of proper ankle become increasingly complex. Also, this example is body mechanics. Some of these concepts will be discussed two-dimensional, and all forces are acting at 90 degrees. In in order to understand, and ultimately compare the effects the real world, postures are three-dimensional and forces of body mechanics. act at varying angles, requiring a great deal of trigonometry to make the calculations. Whenever the body utilizes muscle force, energy must be expended. When a joint is stacked (in straight align- The above description is provided to show that it is ment), forces acting on the joint go straight through, and possible to determine the effect that a given posture and do not generate any rotational force that must be coun- forces can have on the human body. Fortunately, there is teracted by the muscle. The other key principle in massage human modeling software available that can make all of is that body weight and gravity are free. Making movements these calculations and compare the results to the strength in a downward direction, the weight of the body can be moment data for the population selected. However, it must used to increase the force (Konz, 1995). Normally, when- be noted that both the above calculations and the modeling ever the center of gravity of the body moves past the base software make assumptions about the human anatomy and of the feet, some muscles contract to counteract and function. All of the complex dynamics of human motion (such stabilize the body. However, when that force generated by as the affect of synergistic muscles) cannot be completely body weight can be transferred through the hand onto accounted for, but these models can provide a good another stationary object, this force transfer requires only approximation, especially for comparative purposes. This minimal muscle activity. Also, since the majority of the human modeling software will be utilized to make the force is generated through body weight, the force can be comparisons between proper and improper body mechanics applied for a longer time period without generating undue in a later section. fatigue. This can be achieved by ‘‘stacking’’ body segments in such a way that the rotational effects of moments at the Proper body mechanics e general concepts joints are minimized and the majority of force is applied through body weight (Figure 2). All massage therapists, to varying degrees, learn how to apply forces to their clients in order to affect some Proper body mechanics e computer modeling neurological, physiological or mechanical change. Some approach schools may also teach the therapist how to use their body in order to make the massage visually appealing by As was shown in the section on ‘‘The human body as giving it a certain flow. However, very few schools teach a system of levers and pulleys’’, the forces acting on the

142 E.G. Mohr Whereas 99% of the selected female population has the capability to generate the necessary strength moments at all of the joints using the ‘‘Proper’’ body mechanics posture, only 40% has the capability using the ‘‘Improper’’ posture, with the limiting factor being the ankle joint. (Note: because the ankle cannot be rotated in the 3D Program, small weight and balance adjustments that a person would use are difficult to model, thus the results for the ankle should be used with caution). The elbow was also a significant limiting joint, with only 60% having the required capability. In addition, the ‘‘Improper’’ posture put 13% more compressive force on the L5/S1 joint. Proper body mechanics e field study approach Figure 2 Diagram of stacked joints (from Fritz, 2009b, In addition to the 3D modeling discussed above, a strength test p. 224). protocol was developed to test three different applications of body mechanics. Eighteen (18) massage practitioners, with joints of the body can be mathematically calculated and varying levels of experience (normal distribution with median these calculations can by aided by existing computer soft- of 2e3 years e see Table 2), were asked to apply a compres- ware models. The University of Michigan 3D Static Strength sive force using what was hypothesized to be ‘‘Poor’’ Prediction Programä (3DSSPPä) was utilized to compare (standing arm push), ‘‘Good’’ (stacked joints but without what was hypothesized to be ‘‘Improper’’ versus ‘‘Proper’’ locking the back knee), and ‘‘Best’’ (stacked joints with body mechanics in a massage application. The following a locked back knee) body mechanics. Applications using photographs (Figure 3) show two contrasting methods for counterpressure were also recorded for the ‘‘Poor’’ and applying a compressive force to a client. ‘‘Best’’ positions. (Note: in this study, the ‘‘Poor’’ and ‘‘Best’’ postures, correspond to the ‘‘Improper’’ and ‘‘Proper’’ The ‘‘Improper’’ posture in Figure 3a, the massage postures used in the computer modeling section). practitioner is standing in a more upright posture and bending at the torso, at approximately 55 degrees. The left The subjects were outfitted with an Ergo-FET digital elbow is bent, thus requiring a majority of the force to be palm force gauge, which could record a maximum force of exerted using arm strength, and causing a rotational 150 pounds (w68 kg) (see Figure 6). Static strength movement (moment) at the elbow joint. In contrast, the assessments must be kept to less than 10 s to keep from ‘‘Proper’’ posture in Figure 3b, shows the massage practi- fatiguing the muscle, with the recommended duration tioner using ‘‘stacked joints’’ where the opposite leg, being between 4 and 6 s (Sanders and McCormick, 1993). All torso, neck and head are in alignment. The force gener- test durations were less than 10 s, with the majority being ating arm is also straight, transferring the force straight within the recommended range. through the elbow joint and thus not requiring any addi- tional muscle force to counteract a rotational movement. The subjects were tested applying compressive force at a 45 Instead of using arm strength as in the previous posture, the degree angle to the edge of massage tables, at vertical heights practitioner can lean on the client and thus use her body of 39.5 inch (100 cm), 34.5 inch (w87.5 cm), and 29.0 inch weight to assist in generating the majority of the force (w73.5 cm) (see Figure 7). The surfaces were wooden frames, applied to the client. covered with a thin layer of foam and a vinyl covering. The massage practitioner’s posture (body segment All subjects had been previously trained in the use of the angles) was loaded into the 3DSSPPä software, using the ‘‘Good’’ and ‘‘Best’’ postures. For the ‘‘Poor’’ posture anthropometry of the 50th percentile female and the (Figure 7a), the subjects were instructed to stand at applicable muscle strength moments. The computer a comfortable location from the table, and to apply maximal generated posture output is shown for both postures in pressure by pushing with their arm. The subjects were Figure 4 and the free body diagram of the joint segment intentionally not given more than this general instruction, so analysis in Figure 5. as to allow them to find their most natural position. There was a tendency to still lean in with the body to some degree, A load of 40 pounds (w18.2 kgm) was chosen as the thus pure arm strength forces would be generally even lower compressive force to be applied to the client, applied at than recorded. Five data points were collected at each of the a height of 33.3 inch (84.5 cm) and at a downward angle of three vertical heights. These data points were as follows. 45 degrees. Utilizing these two postures with the same magnitude and angle of force, capabilities were calculated (A) Standing arm push (Figure 7a) for the elbow, shoulder, hip, knee and ankle joints. The (B) Standing arm push with counterpressure actual computer results are shown in Appendix B, and are (C) Stacked joints, not locking the knee summarized here in Table 1. (D) Stacked joints, with locked knee (Figure 7b) (E) Stacked joints, with locked knee and counterpressure The raw data collected are shown in Table 2, with references AeE corresponding to the above postures.

Proper body mechanics from an engineering perspective 143 Figure 3 Photographs of two contrasting methods for applying compressive force to a client. (a) Improper method. (b) Proper method. Figure 4 Computer modeling of application methods (from University of Michigan 3DSSPPä, ver. 5.0.8, used by permission). (a) Improper method. (b) Proper method. Figure 5 Computer modeling of application methods (from University of Michigan 3DSSPPä, ver. 5.0.8, used by permission). (a) Improper method. (b) Proper method.

144 E.G. Mohr Table 1 Results from computer modeling analysis, comparing the Proper and Improper methods. Percent of Females Able to Apply the Compression Force Proper 91 lbs. on the L5/S1 Disk: Improper 103 lbs. 40 Pound Force – by Joint Location Summary of analysis results from 100 99 93 98 98 99 97 100 The University of Michigan 3D 86 Static Strength Prediction ProgramTM 75 60 50 40 25 Ankle Knee Hip Shoulder Elbow Proper Improper Comparisons were performed using the average forces locked posture averaged 49.0 pounds (w22 kg). By looking in generated at each of the three table heights (Table 3), and the table at the intersection of these two postures, it shows using the combined averages for all three tests (Table 4). The that this comparison generated 51% more force for the stacked results in both tables are interpreted as follows. A percentage and locked posture. figure in the table compares the description in the column on the left with the row description above. Using for example Table 3 compares the effects of the different test ‘‘standing arm push’’ (poor) versus ‘‘stacked and locked’’ heights. Test 1 (with H Z 39.5 inch (w100 cm)) has the (best) at a height of H Z 39.5 inch (w100 cm), the arm push largest percentage increases in all categories. By contrast posture averaged 32.5 pounds (w14.7 kg) and the stacked and Test 3 (with H Z 29.0 inch (w73.5 cm)) has the smallest percentage increases in all categories. Thus, while proper Table 2 Raw data showing subject’s years of massage experience (also see distribution below table), height, and weight. Data within the table are maximum applied forces recorded (in pounds) at the three test heights using the five application methods (AeE). The last three rows contain the average, minimum and maximum force for each column (n Z 18). Demographics Test 1: H Z 39.5 inch Test 2: H Z 34.5 inch Test 3: H Z 29.0 inch Years Height Weight (lb.) ABCDE AB CDE AB CDE (inches) (1 inch Z 2.54 cm; 1lb Z.45 kg) 2e3 62 145 25 48 26 32 63 36 56 31 40 72 58 67 44 51 72 2e3 63 130 31 47 35 41 58 53 55 48 59 68 63 68 68 70 73 0e1 63 170 17 26 18 28 28 18 35 25 31 40 33 41 39 42 49 >5 63 173 32 73 38 42 87 40 71 44 45 88 48 64 55 58 89 2e3 64 130 21 75 51 59 104 28 80 43 56 82 46 88 48 59 98 1e2 65 125 26 52 34 46 61 45 70 51 53 77 54 64 57 51 59 3e5 66 185 47 84 65 78 92 62 86 71 80 84 72 93 75 86 83 1e2 66 130 40 48 30 46 61 52 69 46 50 70 61 72 51 53 62 2e3 66 32 66 52 64 71 49 77 48 57 78 40 68 70 71 73 3e5 66 170 30 56 25 43 73 28 65 33 44 57 28 48 32 47 57 1e2 66 285 60 68 45 70 82 55 66 63 69 76 67 69 76 89 97 2e3 67 130 39 61 50 48 81 36 56 38 49 66 39 62 49 51 78 0e1 67 170 22 35 33 38 49 26 43 31 42 61 34 49 35 45 59 3e5 67 165 32 42 29 39 60 35 43 38 42 59 36 38 37 54 77 >5 67 205 32 34 34 43 67 29 40 32 41 69 48 60 46 58 71 2e3 72 150 42 82 52 56 97 47 79 58 69 95 57 87 59 66 95 2e3 69 165 24 69 35 50 71 35 57 40 51 74 32 48 33 40 51 2e3 68 140 33 55 39 59 96 34 62 52 62 98 49 76 59 75 110 Average 66 163 32.5 56.7 38.4 49.0 72.3 39.3 61.7 44.0 52.2 73.0 48.1 64.4 51.8 59.2 75.2 Minimum 62 125 17 26 18 28 28 18 35 25 31 40 28 38 32 40 49 Maximum 72 285 60 84 65 78 104 62 86 71 80 98 72 93 76 89 110 Years of massage experience 0e1 1e2 2e3 3e5 >5 Number of subjects 23832

Proper body mechanics from an engineering perspective 145 Proper body mechanics e general tips for massage therapists Although the main purpose of this paper is to validate the concept that proper body mechanics do indeed reduce stress on the massage practitioner, it would be remiss to leave the topic without providing some useful suggestions. Fritz (2009b) dedicates an entire chapter in her book explaining and demonstrating various techniques. The following is a very brief summary of some of the major concepts. Referring back to Figure 2, in addition to the photos in Figure 8, will assist in visualizing these concepts. Weight transfer Figure 6 Photo of Ergo-FET digital palm force gauge. Leveraging body weight, as opposed to utilizing muscle force, will significantly reduce the stress on the practi- body mechanics allow the subject to generate higher tioner. Pushing with upper body strength can cause neck forces in all cases, it has the most impact when the point and shoulder problems. Stand in an asymmetric stance with of application is higher off the floor. the back leg and torso in a straight line, keep the hips and shoulders aligned and facing the client, and lock the back Overall comparisons for the data are in Table 4, and knee to generate pressure coming from the back heel. Note can be summarized as follows. Tables are in Imperial how in Figure 8a, the table is too low causing the therapist measures: to convert to decimal use 2.54 cm Z 1 inch, and to rock back and bend at the waist. In Figure 8b, the higher 0.45 kg Z 1 pound/lb) table allows the therapist to leverage all of his body weight. Also, Figure 8e shows the therapist’s weight improperly on  Counterpressure increases forces for both methods the front foot, versus the proper posture in Figure 8g with (standing arm push increases by 53% and stacked and the pressure coming from the back heel. locked increases by 37%) Perpendicular application of force  Counterpressure is higher with proper body mechanics (by 21%) Align the client and practitioner such that force is applied at a 90 degree angle. This makes the force application more  Stacked and locked (best) body mechanics is better than efficient by directing 100% of the pressure into the client’s stacked not locked (good) body mechanics (by 20%) tissue (refer back to Figure 2).  Stacked not locked (good) and stacked and locked (best) are both better than standing arm push (poor) body mechanics (by 12% and 34%, respectively) Figure 7 Photo of test subject performing: (a) poor posture and (b) best posture at 34.5 inch test height.

146 E.G. Mohr Table 3 Comparison of force differentials at each test height, presented as a percentage (1 inch Z 2.54 cm; 1lb Z .45 kg). Standing SAP with Stacked Stacked S and L with arm push C/pressure not locked and locked C/pressure Test 1: H Z 39.5 inch Compression force (lbs.) 32.5 56.7 38.4 49.0 72.3 Standing arm push 75% 18% 51% SAP with C/pressure 27% Stacked not locked 28% Stacked and locked 48% Test 2: H Z 34.5 inch Compression force (lbs.) 39.3 61.7 44.0 52.2 73.0 Standing arm push 57% 12% 33% SAP with C/pressure 18% Stacked not locked 19% Stacked and locked 40% Test 3: H Z 29.0 inch Compression force (lbs.) 48.1 64.4 51.8 59.2 75.2 Standing arm push 34% 8% 23% SAP with C/pressure 17% Stacked not locked 14% Stacked and locked 27% Stacked joints structures of the carpal tunnel. The hand and fingers should be relaxed whenever possible, to keep from transferring As discussed previously, joints that are not stacked and stress to the forearm and shoulder. locked require additional muscle force to hold the joint steady and counteract rotational forces in the joint while Economic impact applying pressure (refer to Figure 8ceg). There is no current research which delves into why Core stability approximately 50,000 massage therapists leave the profession each year, in the USA (AMTA, 2008). As was Having good core stability is essential to eliminate fatigue stated earlier, the majority of the injuries which require and possible injury. If the core is not working, the psoas massage therapists to lose time from work are related to and rectus abdominis take over core responsibility. Also, ‘‘sprains and strains’’, and the most common cause is the body over breathes in order to cause the lumbar ‘‘worker motion or position’’. Also, 11% of therapists dorsal fascia to tighten, in an attempt to stabilize the surveyed cite ‘‘avoiding personal injury’’ as their top core. challenge in the profession. Since the use of proper body mechanics has been shown to reduce the strain on the Point of contact therapist’s body and improve their motions and positions, the data suggest that there is some number of therapists The practitioner must use caution to protect their hands who have left the profession due to injury, who would still and wrists. Whenever possible, force should be applied be working today if they had used proper body mechanics. using the forearm. If the hand is used, the wrist should remain in the mid-range of motion, avoiding any extreme The ramifications are personal injury and loss of income extension of the wrist which puts undue stress on the (especially since very few massage therapists have health benefits from their employers or are self-employed). The Table 4 Comparison of the average force differentials from all test heights, presented as a percentage. Composite averages at all heights (1 inch Z 2.54 cm; 1lb Z.45 kg) Standing arm SAP with Stacked Stacked S and L with push C/pressure not locked and locked C/pressure 73.5 Compression force (lbs.) 40.0 60.9 44.7 53.5 Standing arm push 53% 12% 34% 21% SAP with C/pressure Stacked not locked 20% 37% Stacked and locked

Proper body mechanics from an engineering perspective 147 Figure 8 Examples of correct vs. incorrect postures (from Fritz, 2009b, pp. 217e237). economic impact can also affect the profession in a more proper body mechanics can increase their daily output. subtle way. If strain and soreness from improper body Using an industry average of 15 paid massages per week (in mechanics is the limiting factor in the number of clients the USA), and an average wage of $39 per hour (AMTA, that a therapist can see on a daily basis, then the use of 2008), and assuming a therapist works 5 days per week

148 E.G. Mohr (equating to 3 massages per day) and 48 weeks per year, proper body mechanics being greatest at the highest point the therapist would theoretically make $28,080 per year. If of application. the therapist, by improving their body mechanics, could increase their workload by only 1 client per day, their However, one cannot use the actual dimensions used in annual income could increase by $9360 to a total of this study to set a table height. The practitioner must $37,440. If they could now physically perform 2 additional evaluate their own body type and massage style (majority massages per day the annual income would be $46,800, an hand or forearm work) and make adjustments accordingly. increase of $18,720. Key concepts Further research would be required to put an exact number on the injured therapists leaving the profession and Certain general concepts assist in the application of good the potential for increased client workload, as well as the body mechanics. A few of these concepts are as follows. impact that proper body mechanics would have. However, there is enough data here to suggest that a relationship  Leveraging body weight as opposed to using muscle does exist, and for the good of the profession it is one that force should be explored further.  Applying forces at 90 degree angles Summary  Stacking joints to avoid rotational forces in the joints  Locking the back knee and pushing from the heel to Poor body mechanics can affect both the client and the practitioner. If a certain amount of compressive force is generate more force required to deal with the client’s symptoms, and the massage  Application of force using the forearm wherever practitioner cannot deliver that force, then the client’s treatment will not be as effective as possible. If the practi- possible and keeping the hand and fingers relaxed tioner can deliver the required force, but they are working at  Keeping the wrist within the mid-range of motion when or near their maximum strength, then the practitioner may suffer either an acute or chronic injury. necessary to use the hand to apply force  Having a good breathing pattern and core stability. The physical effects of the massage on the massage  Although not proven, the data suggest that the reduced practitioner can be quantified. In the computer modeling comparison, use of the improper posture showed that only strain from proper body mechanics can have a positive 40% of the 50th percentile female population would have effect on the therapist’s economic well being, either the strength moment capability at the ankle, and only 60% from the ability to increase client workload, or from the would have the capability at the elbow. In contrast, using ability to avoid injury and stay in the profession. proper body mechanics, that same population would have  Setting the correct massage table height, and using 99% capability at the ankle and 100% capability at the proper body mechanics, will allow the massage/manual elbow. All other joints showed the same trend, but the therapy practitioner to generate higher compressive range of capability was less significant. forces, while at the same time using less force and strain on their own body. In the field study of massage practitioners (n Z 18), it was found that proper body mechanics correlated with an Appendix A overall 34% increase in applied maximal force, as compared with the improper posture. When counterpressure was used Injury data for massage therapists from the U.S. Depart- with both postures, the increase was 21%. This trend held ment of Labor (2006), Bureau of Labor Statistics (http:// true for all three test heights, with the impact of using www.bls.gov/iif/oshwc/osh/case/ostb1801.pdf) and the National Safety Council. Note: data reformatted by author. Number of nonfatal occupational injuries and illnesses involving days away from work. Source: National Safety Council, 2006 data for Massage Therapists, based on data from the U.S Department of Labor, Bureau of Labor Statistics (code 319010). Sex Age Race Length of service 32% Men 47%, 25e34 48% White 14%, <3 months 68% Women 32%, 35e44 14% Hispanic 14%, 3e11 months 21%, 45e54 38% Not reported 32%, 1e5 years 41%, >5 years Injury Event or exposure Injury source Time of day 56% Strain/sprain 26% Overexertion 57% Worker motion/position 19%, 8:00 ame12:00 pm 22% Soreness, pain 26% Repetitive motion 10% Ground, floor surfaces 19%, 12:00 pme4:00 pm 11% Carpal tunnel 11% Contact with object 10% Patient 14%, 4:00 pme8:00 pm 11% Other 37% Other 24% Other 48%, Not reported (continued on next page)