Proper body mechanics from an engineering perspective 149 Table (continued) Hours worked Time off-work Day of week Body part affected 10%, <1 h 10%, 2 days 14% Monday 0%, 1e2 h 15%, 3e5 days 14% Tuesday 35% Upr. extremities 10%, 2e4 h 15%, 6e10 days 18% Wednesday 19% Wrist 10%, 4e6 h 20%, 11e20 days 23% Thursday 16% Trunk 15%, 6e8 h 15%, 21e30 days 14% Friday 10% Lwr. extremities 55%, Not reported 25%, >31 days 18% Saturday 6% Hand 6% Shoulder 6% Back n Z 220 Incidence rate of nonfatal occupational injuries and illnesses involving days away from work. Injuries per 10,000 workers Injury Event or exposure Injury source Body part affected 44.8 Strain/sprain 21.3 Overexertion 50.2 Worker motion/position 25.9 Wrist 17.3 Soreness, pain 21.0 Repetitive motion 10.1 Patient 13.4 Lwr. extremities 8.2 Carpal tunnel 7.7 Contact with object 7.1 Ground, floor surfaces 11.0 Upr. extremities 8.4 Other 30.9 Other 22.9 Other 10.0 Hand 8.3 Back 7.2 Shoulder 4.5 Trunk In 2006, there were 1.2 million cases requiring days away from work in private industry. The 2006 rate for all industries was 128 per 10,000 workers. The 2006 rate for massage therapists was 93.8 per 10,000 workers. Rates ranged from 11 (computer and mathematical) to 301 (transportation and material moving). Appendix B Joint capability data from University of Michigan 3D Static Strength Prediction Programä (3DSSPPä), used by permission 1) 3DSSPPä analysis summary Figure B1b Proper method. 2) Low back analysis e sagital plane Figure B1a Improper method. Figure B2a Improper method.
150 E.G. Mohr 4) Fatigue analysis Figure B2b Proper method. 3) Strength capabilities Figure B4a Improper method. Figure B3a Improper method. Figure B4b Proper method. Figure B3b Proper method. Appendix C Computer software 3D Static Strength Prediction Programä, version 5.0.8, copyrightª 2007, The Regents of the University of Michigan 2007, used with permission. Equipment Ergo-FET digital palm force gauge, Hoggan Health Industries. Serial #22153 e Patent #5090421. 150# maximum capacity. New unit, calibrated 4 months prior by manufacturer. References American Massage Therapy Association (AMTA), 2008. Massage Industry Research Report. AMTA.
Proper body mechanics from an engineering perspective 151 Chaffin, D., Andersson, G., Martin, B., 2006. Occupational Biome- Konz, S., 1995. Work Design, Industrial Ergonomics, fourth ed. chanics, fourth ed. Wiley-Interscience. Publishing Horizons. Ernst, E., Fialka, V., 1994. The clinical effectiveness of massage. Rich, G.J., 2002. Massage Therapy: The Evidence for Practice. Forsch Komplementarmed 1, 226e232. Mosby, Edinburgh. Fritz, S., 2009a. Essential Sciences of Therapeutic Massage, fourth Sanders, M., McCormick, E., 1993. Human Factors in Engineering ed. Mosby. and Design, seventh ed. McGraw-Hill. Fritz, S., 2009b. Fundamentals of Therapeutic Massage, fourth ed. Stobbe, T., 1982. The Development of a Practical Strength Testing Mosby. Program for Industry. Unpublished doctoral dissertation, The University of Michigan. Greene, L., 1995. Save Your Hands: Injury prevention for Massage Therapists. Gilded Age Press, Coconut Creek, Florida. U.S. Department of Labor, 2006. Occupational Injuries and Illnesses Report Involving Days Away From Work. Bureau of Labor Kodak Ergonomics Group, 1987. Ergonomic Design for People at Statistics. Work, vol. 2. Van Nostrand Reinhold.
Journal of Bodywork & Movement Therapies (2010) 14, 152e161 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt CLINICAL REVIEW Paradigm for assessment and treatment of SIJ mechanical dysfunction Manuel F. Cusi* School of Medicine, Sydney University of Notre Dame, 160 Oxford Street, Darlinghurst, NSW, 2010, Australia Received 4 October 2009; received in revised form 15 December 2009; accepted 16 December 2009 KEYWORDS Summary The sacroiliac joint (SIJ) is an integral part of both the lumbar spine and the pelvic Sacro-iliac joint; girdle. It is frequently the source of low back pain and pelvic girdle pain. Recent research has Mechanical assessment; permitted a deeper understanding of its function and assessment. The mechanical assessment SPECT/CT; of the SIJ as a transmitter of load between trunk and lower limbs, and as a means to absorb Self-bracing torsion stresses of the pelvis absorber of torsion is examined; history, clinical examination mechanism; and imaging modalities are explored and the role of exercise and some interventional thera- Prolotherapy; pies are described in general terms. Non-specific low back ª 2009 Elsevier Ltd. All rights reserved. pain Introduction Lumbar spinal pain has been defined (Merskey and Bog- duk, 1994) as pain perceived within a region bounded later- SIJ and Pelvic Girdle Pain in the context of ‘‘non ally by the lateral borders of the erector spinae, superiorly by specific low back pain’’ an imaginary line through the T12 spinous process, and inferiorly by a line through the S1 spinous process. Sacral pain Low Back Pain (LBP) has been described as an epidemic of is defined as perceived pain within a region overlying the the 20th century, and the trend continues in the 21st sacrum, bounded laterally by imaginary vertical lines century. In Australia up to 80% of the population will expe- through the posterior superior and posterior inferior iliac rience back pain in their lives, and 10% will experience spines, superiorly by a line through the S1 spinous process, significant disability as a result (Briggs and Buchbinder, and inferiorly by a transverse line through the posterior 2009). The causes are not well understood, and therapies sacrococcygeal joints. LBP is therefore pain arising from frequently fail. The very use of the term Low Back Pain as anywhere within the two areas described, independently of a ‘‘quasi diagnosis’’ e when pain is a symptom, not a disease radiation to other areas of the body. It does not indicate at all e reflects a general lack of knowledge. the origin or cause of the pain. * 15 Vernon Street, Strathfield, NSW 2135, Australia. The ability to make a specific diagnosis in patients with E-mail address: [email protected] LBP is the subject of debate. Often the diagnosis depends on the professional background of the diagnostician. Some authors consider that definite pathology can only be 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.12.004
Assessment and treatment of SIJ mechanical dysfunction 153 diagnosed in 15% of patients with LBP (Waddell, 1998). Structures that attach to it directly and indirectly span as Research on LBP has focused for a long time on anatomical far as the shoulder and the proximal humerus via latissimus structures with a nerve supply that could explain the origin dorsi, and to the lower limbs as far as the foot through of pain. The study of pain generators has yielded objective a combination of muscles (gluteus maximus, hamstrings, findings. Nerve block procedures have identified a structure peronei) and fascia (thoraco-lumbo-dorsal). responsible for the pain in over 50% of cases (Mc Gill, 2002) Pelvic girdle pain (PGP) is a specific form of low back The sacroiliac joint was first suggested as a source of lower pain that can occur separately or in conjunction with LBP back pain in 1905 by Goldthwaite and Osgood (1905) but (Vleeming et al., 2008). There is evidence that pelvic girdle largely ignored as the intervertebral disc became labelled as pain in pregnancy was recognised in the ancient world. the major cause of back pain by Mixter and Barr in 1934. The Hippocrates (circa 400 B.C.) mentioned symphysis pubis sacro-iliac joint is a source of pain in the lower back and dysfunction in his theory of ‘‘disjunctio pelvica’’. PGP has buttocks in up to 15e21% of the population (Dreyfuss et al., been described by various authors in the past 20 years in 1996). There is evidence that dysfunction of this joint could, the Scandinavian countries, United States, the Netherlands, similar to a herniated lumbar disc, produce pain along the South Africa, Israel, Australia and Nigeria. It generally ari- same distribution as the sciatic nerve (Fortin et al., 1994aec, ses in relation to pregnancy, trauma, osteoarthrosis and 2003). Using anaesthetic blocks of the sacro-iliac joint, arthritis. Pain is experienced between the posterior iliac Schwarzer (Schwarzer et al., 1995b) investigated the contri- crest and the gluteal fold, particularly in the vicinity of the bution of the SIJ in a low back pain population. They found that sacro-iliac joints (SIJ). It may radiate to the posterior thigh 18.5% were considered to have pain from the SIJ. As injections and can also occur with/or separately in the symphysis. The were given into the synovial part of the joint and did not endurance capacity for standing, walking, and sitting is involve the posterior ligaments, it is possible that the SIJ is diminished. The diagnosis of PGP can be reached after responsible for LBP in a higher proportion of subjects. exclusion of lumbar causes. The pain or functional distur- bances in relation to PGP must be reproducible by specific Identifying the anatomical source of pain does not auto- clinical tests (Vleeming et al., 2008; Laslett et al., 2005). matically explain why a particular structure is painful. A Three high quality prospective studies (Ostgaard et al., functional diagnosis (understanding why tissues are painful) 1991; Larsen et al., 1999; Albert et al., 2000) report on requires a different approach and a different model, with incidence and point prevalence of PGP in pregnancy, in a focus on functional kinematic relations and the integration large cohorts totaling close to 2000 patients. The results of structural constructs -bones, joints and ligaments- with indicate that around 20% of pregnant women suffer movement generators and control systems -muscles, neural from PGP. regulation- (Willard, 2007; Panjabi, 1992a, b; Lee, 2004). Willard (2007) provided the following description: The situation is different in non-pregnant patients. A large retrospective study by Bernard and Kirkaldy-Willis ‘‘The lumbosacral spinal column performs a key role in found a 22.5% prevalence rate in 1293 adult patients pre- the transfer of weight from the torso and upper body into senting with LBP. Diagnoses in this series were based the lower extremities, both in static positions and during predominantly on physical examination (Bernard and Kir- movement. The primary bone structures involved in this kaldy-Willis, 1987). There is a growing body of evidence force transduction are: five lumbar vertebrae, a sacrum, that points to the SIJ as an important source of PGP. The two innominate bones and the two femoral heads. Critical prevalence of sacroiliac joint pain would appear to be at to the stability of these bony components is a complex least 13% and perhaps as high as 30% (Schwarzer et al., arrangement of dense connective tissue. Although typically 1995a; Maigne et al., 1996). In our own small case series of described as separate entities in most textbooks of 25 patients treated with prolotherapy for ligamentous anatomy, these fibrous, soft-tissue structures actually form failure of the SIJ (Cusi et al., 2008), the clinical history a continuous ligamentous stocking, in which the lumbar suggests that two thirds of patients are post pregnancy, and vertebrae and sacrum are positioned. The major muscles the remaining third are post injury, usually falls or direct representing the prime movers in this region e such as the trauma to the buttock area. multifidus, gluteus maximus and biceps femoris e have various attachments to this elongated ligamentous The clinical diagnosis of pelvic girdle pain of SIJ origin is stocking. The muscular and ligamentous relationships difficult, given the variety of clinical tests and the absence composing the lumbosacral connection are of extreme of a gold standard. Maigne claims that double anaesthetic importance in stabilising the lumbar vertebrae and blocks of the SIJ are the gold standard, but they are only arrangement has been termed a ‘self-bracing mechanism’ effective to diagnose intra-articular pathology and do not (Snijders et al., 1993a, b) and, as such, its dysfunction is cover the ligamentous apparatus that surrounds the joint, critical to the failure of the lower back’’. an important source of pain (Laslett et al., 2005). Mur- akami’s study (Murakami et al., 2007) confirmed Laslett’s The pelvic girdle is a closed osteo-articular ring opinion: following a pain provocation test, an intraarticular composed of six or seven bones and the joints between injection of local anesthetic (2% lidocaine) was performed them. Acting as a unit it supports the abdomen as well as on the first 25 consecutive patients with SIJ pain and the pelvic organs. It also provides a dynamic link between a periarticular injection on another 25. The periarticular the spine and the lower limbs (Lee, 2004). injections were given to one or more sections of the posterior periarticular area of the SIJ and to another Acknowledging the position of the pelvic girdle as the section in the extraarticular portion. The periarticular link between trunk and lower limbs can be the key to injection was effective in all patients, but the intraarticular a better understanding of its function and the role of the one was effective in only 9 of 25 patients. structures that attach to it. The pelvis is part of both the trunk and as such of the spine and of the lower limbs.
154 M.F. Cusi The sacro-iliac joint undertaken. Different strategies are required to provide varying degrees of pressure across the joint surfaces. Anatomical and functional considerations Excessive, or insufficient, pressure across the SIJ can be identified as causes of deficient function and provide diag- A brief consideration of some anatomical functional and nostic clues (Vleeming et al., 1990b; Pool-Goudzwaard biomechanical aspects of the SIJ (Maigne et al., 1996; Van et al., 1998; Mens et al., 1999; Hungerford et al., 2003; Der Wurff et al., 2000) will underpin the tests proposed for O’Sullivan and Beales, 2007; Willard, 2007). the clinical assessment of the SIJ, and recent developments in imaging studies. Flat surfaces have been found to be best suited for transmission of large forces, but they are also less resistant The long dorsal sacroiliac ligament can be palpated to shear (Snijders et al., 1993a, b). Two mechanisms directly distal to the posterior superior iliac spine and inner contribute to prevent shear. The cartilage is thicker and lip of the iliac crest as a thick band that attaches distally and changes in the sacral surface are more prominent in women. medially to the lateral sacral crest of S3 and S4. It lies This may be related to childbearing and to a different posi- posterior to the interosseous ligament and is covered by the tion of the centre of gravity in relation to the sacro-iliac fascia of the gluteus maximus muscle. The fibre tension joint. The ‘‘keystone-like’’ bony architecture of the sacrum, varies with the movement of the sacrum. It is slack during wedged between the two ilia, wider anteriorly and cranially nutation (from the Latin nutare -to nod-) and becomes taut in than posteriorly and caudally, would be a second factor. counternutation; localised pain within the boundaries of the Finally, Vleeming proposed the concepts of form and force long ligament could indicate a spinal condition with sus- closure of the sacro-iliac joint (Vleeming et al., 1990a, b). tained counternutation of the SIJ (Vleeming et al., 1996). Shear is prevented by a combination of the specific anatomical features (form closure) and the compression Nutation of the sacrum increases the tension of the major generated by muscles and ligaments (force closure) that can ligaments of the SIJ. In normal subjects it occurs in load-bearing accommodate to specific loading situations. Force closure situations (sitting, standing, walking, etc). Counternutation (Figure 1) has been defined as the effect of changing joint slackens them when the SIJ is minimally loaded (supine). reaction forces generated by tension in ligaments, fasciae, and muscles and ground reaction forces. The structure of the sacro-iliac joint and its purpose have been controversial for a long time. The small range of In the ideal situation, force closure provides compres- movement (Jacob and Kissling, 1995; Sturesson et al., 1989, sion in a perpendicular plane to the sacro-iliac joint to 1999), the absence muscles that execute active movements overcome the forces of gravity. This has been termed a self- of the joint and its position in the pelvic ring suggest that its bracing mechanism (Snijders et al., 1993a, b). In the pelvis function is one of stress relief for torsional forces across the the self-bracing mechanism relies on the nutation of the pelvis (Bogduk, 2005), such as rotation during the gait sacrum. This movement is an anticipation for joint loading. sequence. In addition, it must be strong and stable to Hodges et al use the terminology ‘‘preparatory motion’’ for transmit forces from the vertebral column to the lower the same phenomenon in the lumbar spine (Hodges and limbs and vice versa. This is possible with a combination of Richardson, 1996). Nutation tightens most of the SIJ liga- complementary fitting surfaces and strong ligaments. ments, among them the interosseous and short dorsal sacro-iliac ligaments. The posterior parts of the iliac bones Pressure across the joint surfaces (compression) provides are then pressed together, thus increasing compression the stability that permits such load transfer. The amount of across the joint (Vleeming et al., 2008). pressure required varies according to the functional activity Force closure mechanism Form closure mechanism Self-bracing mechanism Figure 1 Diagrammatic representation of force closure, form closure and the self bracing mechanism of the SIJ.
Assessment and treatment of SIJ mechanical dysfunction 155 Joint stability is the effective accommodation of the joints and twisting, without any substantial lifting involved. The to each specific load through an adequately tailored joint initial episode can be either during or soon after pregnancy, compression, as a function of gravity, coordinated muscle and or traumatic such as a fall, head on motor vehicle collision, ligament forces, to produce effective joint reaction forces ‘hard braking’ whilst driving a car or a transverse ‘crushing’ under changing conditions. Non optimal stability may be mechanism which compresses the pelvis. Pain is worse when caused by altered laxity/stiffness of the joint, which results in the SIJ is loaded (sitting, standing, walking and negotiating increased joint translations or exaggerated joint compression. stairs). Patients typically have difficulties turning in bed. Dyspareunia and changes in bladder habit are also common. Experienced clinicians can now confidently diagnose mechanical derangement of the sacro-iliac joint. The diag- B. Clinical examination nosis is based on the assessment of function, rather than the traditional medical model of anatomical pathology, which Historically mechanical tests for the sacroiliac joint can be has been impossible to demonstrate to date. The Integrated divided into two broad categories: pain provocation tests Model of Function (Figure 2) proposed by Lee and Vleeming and palpation tests (for assessment of position and move- (1998) is an elegant summary of present day thinking. It has ment) There appears to be no single mechanical test for the been expanded to include motor control and emotions, sacro-iliac joint that provides sufficient reliable informa- which have been known clinically to influence the transfer of tion. Studies have shown that if considered in ‘clusters’ load across the joint (Moseley et al., 2004). their reliability increases (Laslett et al., 2005; Van Der Wurff et al., 2006; Robinson et al., 2007). Mechanical assessment of the SIJ Manual tests attempt to identify structures and rela- Failure of load transfer through the SIJ (‘‘SIJ instability’’ or tionships that can give a clue to the cause of the pain. ‘‘SIJ dysfunction’’) can be diagnosed on the basis of history, Manual tests rely heavily on the palpation skills of the clinical examination and imaging studies. examiner, and are ultimately ‘‘operator dependent’’. A. History Other tests assess the onset timing of muscle activity patterns around a joint, which in turn reflect motion The typical presenting symptom is LBP (Vleeming et al., patterns. There is a parallel situation in the assessment of 2008; Merskey and Bogduk, 1994). Pain maps have identified patello-femoral joint as a cause of anterior knee pain the distribution of symptoms related to the sacro-iliac joint. (Cowan et al., 2001). For instance, transversus abdominis It is never above the level of L5, and includes the overlying (TA) activation precedes independent arm movement in area, buttock and posterior aspect of thigh and lower leg. normal subjects, but it lags behind in patients with low There is evidence that dysfunction of this joint could, similar back pain (Hodges and Richardson, 1996). to a herniated lumbar disc, produce pain along the same distribution as the sciatic nerve (Fortin et al., 1994a, b, The following tests have been proven to appropriately 2003). The presenting symptom is often described by the assess different aspects of the function of the sacro-iliac patient as ‘‘sciatica’’. Episodes of pain are typically recur- joint. rent, triggered sometimes by trivial actions such as bending 1. The posterior pelvic pain provocation test (also known as thigh thrust) has been identified as reliable in the Integrated Model of Function (Lee & Vleeming 1998) Form Closure Force closure Muscles, fasciae Bones, joints, ligaments FUNCTION Motor control Emotions Awareness Neural recruiting patterns Figure 2 The integrated model of function of the SIJ (Lee and Vleeming, 1998).
156 M.F. Cusi diagnosis of pelvic girdle pain in pregnant women traditionally based on the diagnosis of sacroiliitis. Sacroi- (Ostgaard et al., 1994) liitis can be differentiated into ankylosing spondylitis, 2. Palpation of the long dorsal sacro-iliac ligament reactive arthritis, psoriatic arthritis, arthritis of chronic (Vleeming et al., 1996, 2002). It becomes taut e and bowel inflammatory disease and undifferentiated spondy- painful on palpation e when the sacrum is counter- loarthropathy (Braun et al., 2000). nutated; it provides information on inappropriate patterns of relative motion between sacrum and ilium. X-ray was historically the first modality used. Compu- 3. The Trendelenburg test in its different forms indicates poor terised Tomography (CT) scans are a superior modality to muscle activity of gluteals (Malanga and Nadler, 2006). identify normal and pathological features (Lawson et al., 4. The stork test (also known as Gillet test), assesses intra- 1982). However, degenerative changes are found some- pelvic motion (Hungerford et al., 2003, 2007; Cusi et al., times in younger age group healthy individuals (Cohen 2008). More importantly, it recognises changes in muscle et al., 1967). This questions whether normal development activation patterns in the action of weight transfer and of symmetrical grooves and ridges can be considered as elevation of the contra-lateral knee. In patients with osteoarthritic changes, or rather normal changes within sacro-iliac joint pain there is early activation of biceps the life span (Dijkstra et al., 1989; Vleeming et al., femoris and delayed contraction of internal oblique and 1992b). multifidus (the opposite of normal subjects). 5. The active straight leg raise (ASLR), tests the load Magnetic Resonance Imaging (MRI) scans provide further transfer through the sacro-iliac joint, and has been information that can be matched with scintigraphic uptake shown to be reliable and reproducible (Mens et al., (Hanly et al., 2000). Description of findings in normal and 1999, 2001, 2002, 1997; De Goot et al., 2008). pathological joints is available, and caution is required to 6. Patrick’s Fabere and Gaenslen’s test are also useful avoid existing pitfalls especially in the diagnosis of when used in clusters (Laslett et al., 2005). sacroiliitis. Other clinical manouvres have been used by a large Nuclear medicine investigation is also a useful tool to number of clinicians, and provide valuable information of assess the sacroiliac joint. Sacroiliitis, stress fractures and intraarticular motion, when compared from side to side, degenerative changes can be identified. Once again, particularly the SIJ glide test as described by Lee (Lee, caution is required because of the very low sensitivity and 2007). A number of these clinical manouvres have been high specificity of nuclear imaging in the evaluation of tested in pregnancy-related back and pelvic girdle pain ‘‘sacroiliac joint syndrome’’ (Slipman et al., 1996). (Albert et al., 2002) and confirmed that the joints of the pelvic ring can be examined reliably in a clinical setting. In summary, inflammatory processes, degenerative changes, fractures and stress fractures have been identified C. Imaging with sound use of the available imaging modalities, but it has not been possible to identify mechanical changes within The sacro-iliac joint can be assessed with a variety of the joint. Most research and clinical experience have imaging modalities. Imaging of the SIJ has been concentrated on the anterior -synovial- and to a certain extent cartilaginous portions of the joint. However the ligamentous apparatus of the joint -that plays an important role in its function as a load transmitter- has resisted accurate imaging to date. Figure 3 SPECT-CT of SIJ. Increased uptake in the left SIJ soft tissue region and the intense sclerosis of both sacral and ilial margins of the joint (arrows), indicative of mechanical stress. (Image courtesy of M Cusi & H can der Wall).
Assessment and treatment of SIJ mechanical dysfunction 157 The combination of Single Photon Emission Tomography particular muscle or set of muscles being trained and and CT scan (SPECT-CT, Figure 3) offers exciting possibili- develop both strength and endurance. Contractions are ties. Early preliminary work undertaken by the author and usually light (10% of a maximal voluntary contraction), as colleagues suggest that SPECT-CT of the sacro-iliac joint stabilising muscles will be active for long periods of time. can provide a specific set of images that matches the Each stage needs to be completed before the patient can clinical diagnosis of failure of load transfer. Those changes be progressed to the next stage in a safe and effective include increased uptake in the ligamentous (posterior) manner. The use of a sacro-iliac belt may assist some portion of the joint and attachment of the interosseous patients, especially in the early stages (Vleeming et al., ligament to the surface of the ilium and loss of the 1992a). ‘‘dumbell effect’’. The pattern of contrast uptake is quite different to the images of degenerative changes or Stage 1: isolation inflammatory disease of the sacro-iliac joint. Patients need to develop the ability to recruit the targeted group of muscles independently of other groups. The initial Improved understanding of the functional and biome- target is the so called ‘‘inner unit’’ and includes transversus chanical features of the sacroiliac joint provide the abdominis (TA), deep multifidus and pelvic floor. Neuro- framework for the diagnosis of failure of load transfer muscular training is often the first strategy as it is necessary through the sacroiliac joint, formerly termed ‘instability’. to change existing muscle recruitment pattern strategies In the author’s opinion both terms could be used concur- that compensate for the relative inactivity of the deep rently. Failure of load transfer is biomechanically more stabilisers. Common compensation patterns are the use of correct, but in a clinical setting the term instability refers internal and external obliques, hip adductors and to a constellation of signs and symptoms independent hamstrings. These and other global muscles need to be from the existing amount of movement within the joint, ‘‘downtrained’’ (Lee, 2004). Re-training motor control is which is known to be minimal in any case (Sturesson et al., difficult for some patients. Real time ultrasound is a good 1989). teaching tool that gives patients a useful visual cue. Once recruitment is achieved strength and endurance are Differential specific diagnosis developed gradually, to prevent fatigue and inappropriate compensating muscle recruitment patterns. In the daily clinical setting the diagnosis of failure of the SIJ to transfer load does not indicate whether the failure is of Stage 2: combination force closure (altered neural drive, deficient muscle In the second stage those muscles are recruited in various strength or dynamic ligamentous failure), or form closure combinations to develop endurance. This is usually ach- failure (joint surfaces, capsule and passive ligaments as ieved by adding ‘challenging’ elements to the contraction, passive structures). and incorporating progressively activation of the larger superficial ‘‘movement’’ muscles. Examples of this would The specific diagnosis can only be made by exclusion, be non weight bearing, weight bearing, closed chain and retrospectively. In cases where deficient stability of the open chain movements whilst maintaining controlled sacro-iliac joint has been established, clinical experience contraction of the deep muscles (TA, multifidus, pelvic suggests that exercise programs designed to increase floor) without unnecessary compensatory strategies such as appropriate compression have inconsistent results in terms isolating hip abduction from combined lateral trunk flexion of decreased pain and increased function. Exercise and hip abduction. Added movements should be slow and programs are successful when there is adequate ligamen- measured initially, and become faster as control and tous strength (Stuge et al., 2004, 2006). Patients who endurance improve. respond to a specific muscle strengthening program would qualify for the retrospective diagnosis of failure of force Stage 3: function closure of neuromuscular origin. Response time can vary, In the third stage the patient progresses to functional but it can take three months for such programs to yield activities; daily living, work or sport physical requirements. results (Stuge et al., 2004) (neuromuscular coordination, It requires tailoring the exercise programme to the timing and onset of muscle activation and strength patients’ needs and goals, whilst maintaining the guiding development). principles. It is always important to maintain good tech- nique to prevent falling back to compensatory strategies. Therapeutic alternatives At higher level some muscles will change their mode of contraction from tonic to phasic, in keeping with functional A. Exercise therapy. Assessment of levels, criteria demands (Saunders et al., 2005). for stage progression The specific exercises a patient does in each stage can Exercise therapy is considered the first therapeutic vary according to what ‘‘works for them’’ that also works strategy once the diagnosis of load transfer failure has for the treating therapist. It is more important to adhere to been made. A successful exercise programme needs to be the principles outlined above, and ensure that the patient specific, targeted and progressive (Hides et al., 2001; is not compensating in some way by using ‘the wrong Mooney et al., 2001; Prather, 2003; Zelle et al., 2005). It muscles’ to carry out the prescribed exercise. can be divided into three stages (Isolation, Combination, Function). In each stage the patient learns to recruit the In the author’s experience, failure to respond to an exercise programme carried out along these three stages
158 M.F. Cusi can be due to a variety of factors, intrinsic or extrinsic to randomised and non-randomised studies, but there is little the exercise programme. Intrinsic causes include: standardisation of protocols, and generally limited high- quality data supporting the use of prolotherapy in the - Poor design (exercises are not specific enough), treatment of musculoskeletal pain or sport related soft - Premature progression through the stages (neuromus- tissue injuries. cular patterns not established, insufficient endurance) Application to spinal pain - Poor compliance Prolotherapy is one of many interventional techniques - Inappropriate exercise technique (exercises not done applied to spinal pain. However, its published results have not been consistent (Klein et al., 1993; Yelland et al., 2004b; properly) Linetsky and Manchikanti, 2005). A Cochrane Collaboration report concluded that: ‘‘There was no evidence that prolo- The treating clinician needs to be aware of these pitfalls therapy injections alone were more effective than control to ensure that patients obtain benefit from the therapy. injections alone, but in the presence of co-interventions, prolotherapy injections were more effective than control Extrinsic causes are considered when a properly designed injections, more so when both injections and co-interven- and executed exercise program is not sufficient to solve the tions were controlled concurrently’’ (Yelland et al., 2004a). problem, and the patient cannot reach the desired level of A large prospective, well designed randomised controlled activity. It is reasonable to think that specific exercise trial of the injection of either normal saline or a mixture of programs fail when deficient ligament strength of the 20% Dextrose with 0.2% lignocaine found that all patients posterior elements of the sacro-iliac joint does not provide with non-specific low back pain improved, irrespective of a sufficiently stable base to permit an effective muscle the solution injected or concurrent use of exercises (Dhillon, recruiting strategy (Pool-Goudzwaard et al., 1998). A 1997; Yelland et al., 2004b). mechanism that increases the passive stiffness of the joint would improve dynamic stability of the pelvis (force closure). Most studies that involve the use of prolotherapy in the In these cases the increased ligamentous stiffness would treatment of spinal pain do not consider a specific clinical have the effect of providing a more stable anchor for specific diagnosis for patient selection. They instead take a ‘‘scatter- strengthening programs to produce the desired outcome. gun approach’’ to treating all forms of low back pain without Experimental work in rats indicates that prolotherapy may the initial establishment of a firm working diagnosis. Patient indeed be effective in building up collagen fibers and thus selection is based mainly on pain location, and the injections strengthening ligament (Dagenais et al., 2007a). are given in the painful sites. Injected volumes depend on the number of sites injected, and the number of injections B. Prolotherapy depends on symptom response. Prolotherapy is an injection therapy used to treat chronic A more functional approach has been used in a recently ligament, joint, capsule, fascial and tendon injuries. The published case series. The population studied was 25 goal of this treatment is to stimulate proliferation of patients with failure of load transfer through the SIJ, who collagen at the fibro-osseous junctions to promote non- had not improved with a specific exercise programme along surgical soft tissue repair and to relieve pain (Klein and the guidelines outlined above. Patients underwent three CT Eck, 1997). It has been defined by Hackett as ‘‘the reha- guided injections of a small volume (1 ml) of 20% Dextrose in bilitation of an incompetent structure (such as a ligament Bupivicaine 0.5% into the dorsal interosseous ligament. or tendon) by the induced proliferation of new cells’’ There was significant improvement both in the clinical (Hackett, 1956). It is also called ‘‘Regenerative Injection examination parameters and in the functional question- Therapy (RIT) (Reeves et al., 2008), ‘‘Reconstructive naires (Quebec Disability Scale, Roland Morris 24 and Roland Therapy’’, ‘‘Non-Surgical Tendon, Ligament, and Joint Morris 24 Multi-form Questionnaires) at 3, 12 and 24 months Reconstruction’’ and ‘‘Growth Factor Stimulation Injectio- (Cusi et al., 2008). This is a novel approach, as the indication n’’(Alderman, 2007). for treatment was loss of function and a specific clinical diagnosis, not pain alone. The time between injections (six The injection of various solutions aimed at producing weeks) was based on the assumption that the inflammatory a sclerosing effect to treat soft tissues injuries (e.g., reaction and formation of collagen takes up to seven or eight inguinal hernia) has been used in modern times since the weeks, and it is not necessary for the injections to follow 1930s, when Schultz described a treatment for subluxation each other closely. Three injections were considered suffi- of the temporomandibular joint (Schultz, 1937). cient to ensure a reasonable length of time for regeneration of collagen. This study suggests that Prolotherapy has been used extensively in the USA since the 1930s (over 450,000 patients) and in other countries (a) It is possible to make a clinical diagnosis of SIJ deficient around the world, but it is not a recognized ‘main-stream’ load transfer of ligamentous origin. therapy. Indeed the question has been raised: ‘‘Prolother- apy at the fringe of medical care, or is it at the frontier’’ (b) Treatment with CT guided prolotherapy injections in the (Mooney, 2003). The abundance of case series studies and dorsal interosseous ligament of the affected SIJ e in anecdotal evidence has not been supported by a large body combination with specific core stability training e can of randomised controlled trials (Yelland et al., 2004a; successfully correct the deficiency, reduce pain and Dagenais et al., 2007b). Two systematic reviews of the use improve function. of prolotherapy for chronic musculoskeletal pain (Rabago et al., 2005; Dagenais et al., 2005) have found a variety of
Assessment and treatment of SIJ mechanical dysfunction 159 Further research is required to confirm these results Physical Medicine and Rehabilitation 82 (2), 183e189, pp. 82, with randomised control studies that compare prolotherapy 183e189. to placebo injections. Cusi, M., Saunders, J., Hungerford, B., Wisbey-Roth, T., Lucas, P., Wilson, P., 2008. The use of prolotherapy in the sacro-iliac joint. C. Surgery British Journal of Sports Medicine. doi:10.1136/bjsm.2007.042044. Dagenais, S., Haldeman, S., Wooley, J., 2005. Intraligamentous Surgical stabilisation has been advocated in patients with injection of sclerosing solutions (prolotherapy) for spinal pain: SI joint pain unresponsive to more conservative measures. a critical review of the literature. The Spine Journal 5, Unfortunately, all published reports on SI joint fusion 310e328. have been small case series or retrospective studies. Dagenais, S., Mayer, J., Wooley, J., Haldeman, S., 2007a. Safety Whereas the primary indications for SI joint fixation are and toxicity of prolotherapy for back pain. In: Vleeming, A., either joint instability or fractures (Waisbrod et al., Mooney, V., Cusi, M. (Eds.), Sixth Interdisciplinary World 1987), successful arthrodesis has also been reported for Congress on Low Back & Pelvic Pain. Diagnosis and Treatment; degenerative joint disease. It can be done as an open the Balance between Research and the Clinic. ECO, Barcelona. technique or percutaneously, with CT guidance (Arand Dagenais, S., Mj, Yelland, Del Mar, C., Ml, S., 2007b. Prolotherapy et al., 2004). The success rate of SIJ arthrodesis is around injections for chronic low-back pain (Review). Cochrane Data- 70%, regardless of the underlying pathology. In the case of base of Systematic Reviews. instability it must be considered as a measure of last De Goot, M., Al, Pool-Goudzwaard, Cw, Spoor, Cj, S., 2008. 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Journal of Bodywork & Movement Therapies (2010) 14, 162e171 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt MANUAL MANIPULATION FIBROBLAST RESEARCH In vitro modeling of repetitive motion injury and myofascial release Kate R. Meltzer, M.S a, Thanh V. Cao, B.A a, Joseph F. Schad, M.S b, Hollis King, D.O, Ph.D. c, Scott T. Stoll, D.O, Ph.D. d, Paul R. Standley, Ph.D. a,* a Department of Basic Medical Sciences, University of Arizona, College of Medicine, Phoenix, AZ 85004, USA b Arizona College of Osteopathic Medicine, Midwestern University, Glendale, AZ 85308, USA c A.T. Still University, School of Osteopathic Medicine, Mesa, AZ, USA d University of North Texas Health Sciences Center, Texas College of Osteopathic Medicine, Fort Worth, TX 76107, USA Received 1 November 2009; received in revised form 12 November 2009; accepted 31 December 2009 KEYWORDS Summary Objective: In this study we modeled repetitive motion strain (RMS) and myofascial Cyclic strain; release (MFR) in vitro to investigate possible cellular and molecular mechanisms to potentially Human fibroblasts; explain the immediate clinical outcomes associated with RMS and MFR. Morphology; Method: Cultured human fibroblasts were strained with 8 h RMS, 60 s MFR and combined treat- Myofascial release; ment; RMS þ MFR. Fibroblasts were immediately sampled upon cessation of strain and evalu- Repetitive motion strain ated for cell morphology, cytokine secretions, proliferation, apoptosis, and potential changes to intracellular signaling molecules. Results: RMS-induced fibroblast elongation of lameopodia, cellular decentralization, reduction of cell to cell contact and significant decreases in cell area to perimeter ratios compared to all other experimental groups (p < 0.0001). Cellular proliferation indicated no change among any treat- ment group; however RMS resulted in a significant increase in apoptosis rate (p < 0.05) along with increases in death-associated protein kinase (DAPK) and focal adhesion kinase (FAK) phosphoryla- tion by 74% and 58% respectively, when compared to control. These responses were not observed in the MFR and RMS þ MFR group. Of the 20 cytokines measured there was a significant increase in GRO secretion in the RMS þ MFR group when compared to control and MFR alone. Conclusion: Our modeled injury (RMS) appropriately displayed enhanced apoptosis activity and loss of intercellular integrity that is consistent with pro-apoptotic dapk-2 and FAK signaling. Treat- ment with MFR following RMS resulted in normalization in apoptotic rate and cell morphology both consistent with changes observed in dapk-2. These in vitro studies build upon the cellular evidence * Corresponding author. University of Arizona, College of Medicine- Phoenix, ABC Building 1, Room 324, 425 N. 5th Street, Phoenix, AZ 85004-2157, USA. Tel.: þ1 602 827 2107/2132; fax: þ1 602 827 2127. E-mail address: [email protected] (P.R. Standley). 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.01.002
In vitro modeling of MFR 163 base needed to fully explain clinical efficacy of manual manipulative therapies. ª 2010 Elsevier Ltd. All rights reserved. Introduction reported for counterstrain (Meltzer and Standley, 2007), here we hypothesize that human fibroblasts secrete Myofascial release (MFR) is a widely employed direct inflammatory mediators in response to RMS, and that manual medicine treatment which utilizes specifically modeled MFR reduces such secretions. Further, we guided mechanical forces to manipulate and reduce myo- hypothesize that RMS acutely induces fibroplasias fascial restrictions of various somatic dysfunctions. MFR (increased fibroblast hyperplasia and hypertrophy), while when used in conjunction with conventional treatment, is MFR acutely reverses this effects. Importantly since clinical effective to provide immediate relief of pain and to reduce reports suggest that immediate pain relief is attained post- tissue tenderness (Hou et al., 2002; Fernandez de las Penas MFR (Hou et al., 2002; Fernandez de las Penas et al., 2005), et al., 2005). Additional post-treatment clinical outcomes we will test the immediate effects of RMS and MFR strain include attenuation of edema and inflammation, reduction paradigms on fibroblast cytokine secretion, morphology, of analgesic use, improved muscle recovery post trauma proliferation and hypertrophy. This study will build upon and increased range of motion in affected joints (Sucher, cellular and molecular evidence to explain mechanisms 1993; Andersson et al., 1999; Sucher et al., 2005). Despite underlying the immediate clinical outcomes associated these reports for clinical efficacy, no cellular or molecular with RMS and MFR. mechanisms conclusively have been shown to be responsible. Methods and material We previously reported that, in vitro, fibroblasts respond Human fibroblast cultures to repetitive mechanical strain with a delayed inflamma- tory response, upregulated nitric oxide secretions and Normal human dermal fibroblasts (NHDF) from Cambrex increased cell proliferation (Dodd et al., 2006; Eagan et al., Laboratories (East Rutherford, New Jersey) were used for 2007; Meltzer and Standley, 2007). This response was not all experiments. Cells were cultured in Fibroblast Basal observed in counterstrain treated fibroblasts. Importantly, Medium (FBM; Cambrex Laboratories) at 37 C, 5% CO2, and RMS-induced inflammatory responses were attenuated by 100% humidity. FBM was changed every other day and NHDF counterstrain (Meltzer and Standley, 2007). Therefore, we were passed at confluence (usually 7e14 days). Experi- focus here on the ability of fibroblasts to serve as ments utilized passage numbers 2e6. a mechanotransducer by which they respond acutely to modeled repetitive motion strain (RMS) and modeled MFR. In vitro strain apparatus Specifically we will model repetitive motion strain and MFR in vitro by using human fibroblast tissue constructs and The Flexercell FX-4000 Tension Plus System (Flexcell videomorphometric and palpometric data we have reported International Corp, Hillsborough, NC) is a computer-based previously (Meltzer et al., 2007). Similar to what we Text box 1. Clinical relevance of study Under normal conditions the fascia moves with fluidity and is unrestricted to provide stability and structural support. However, the functional roles of the fascia may become impaired as a result of repetitive motion injury, physical trauma and inflammation. Traumatized fascia disrupts normal biomechanics of the body, increasing tension exerted on the system and causing myofascial pain and reduced range of motion. Myofascial release (MFR) is clinically effective to provide immediate pain relief and to improve physiologic functions that have been altered by somatic dysfunctions. Despite clinical efficacies, our understanding of the underlying mechanisms responsible is minimal. Here, we inves- tigated the molecular and cellular effects of modeled repetitive motion strain (RMS) and MFR on human fibroblast constructs in vitro. Fibroblasts treated with modeled RMS responded with morphological changes as measured by cellular actin staining, reduction in area and perimeter ratios and increased focal adhesion kinase activity. Fibroblasts also displayed enhanced cellular apoptosis (programmed cell death), likely mediated by death-associated protein kinase. Fibroblasts strained by RMS followed by MFR displayed attenuation in these responses. Modification of these cellular properties may predispose to myofascial restrictions and tension and alleviation of symptoms with MFR noted in vivo. While clinical MFR directs force to fascial fibroblasts, indirect strains applied to nerves, blood vessels, lymphatic system, and muscles were not considered in this model. Despite the limitations of this in vitro modeling, these and other data from our laboratory suggest that fibroblasts, the primary cell type of the fascia, adapt specifically to mechanical loading in manners dependant upon strain magnitude, duration and frequency. This cellular strain model may prove useful to further investigate mechanisms and to build a cellular evidence base describing the positive outcomes of applied manual treatments in the clinical setting.
164 K.R. Meltzer et al. Text box 2. Description of clinical MFR methodology Several challenges exist in order to effectively model MFR in vitro including accurately modeling strain directions, durations, frequencies and magnitudes. In an attempt to improve our modeling techniques, we have analyzed digital video data of several osteopathic manual treatments (OMTs) performed by osteopathic clinicians. Fig. 1 shows two still frames of a video segment illustrating the procedure used to analyze MFR strain direction, frequencies and durations. Fig. 1A shows the neutral, pre-treatment positioning of the patient and clinician’s hands prior to MFR. A clear Plexiglas sheet was immobilized approximately 24 inches above the patient in a manner that did not interfere with MFR. On the sheet were placed a series of three black dots, representing the neutral position and two arrows representing the strain direction in which the treatment will be applied. On the patient, a series of three red dots were applied to indicate the change in position of the skin, relative to neutral pre-strain, when strain is applied. In this pre-treatment frame, the dark and light dots are superimposed upon one another. In Fig. 1B, the direct MFR is applied (in a manner with sufficient force to engage the deep fascia as determined by clinician palpation) as shown by displacement of the two series of dots. The displacement indicates superior, lateral, and clockwise strains imparted to the fascia and underlying muscle. Data from these frames and several additional MFR sessions were captured digitally (Scion Image software suite) to analyze the superior and lateral strain (by measuring the inter-dot distances in the superior/inferior and lateral/medial fields) and the clockwise rotational strain (i.e., torque; by measuring angle of deviation from the pre-treatment parallel relationship of the two series of dots).’’ From these data, we utilized the following to generate our in vitro strain profile: time to load, duration of static strain, and time to unload. Strain magnitude used in the current study was equivalent to those studied in published reports. Strain direction, although equiradial in the current study, often includes heterobiaxial, uniaxial and shear in clinical settings. system, which utilizes vacuum to strain cells adhered to Strain profiles flexible collagen-coated membranes arranged in a six-well per plate format. The deformation of the collagen causes NHDF were seeded (120,000 cells/well) onto collagen I- the attached fibroblasts to also deform. Strain profiles are coated Bioflex plates, six wells per treatment group. Once created by programming the magnitude, duration, direc- cells were approximately 50e60% confluent (approximately tion and frequency of the negative pressure to create the 24 h post-seeding), FBM was replaced with a reduced-serum desired profile. We have reported utilizing this apparatus medium (0.2% FBS) to induce quiescence. After 24 hours, to effectively model aortic pressure waveforms (Standley cells were subjected to mechanical strain profiles. Strain et al., 1999, 2001), injury (Meltzer and Standley, 2007), profiles were designed to simulate a repetitive motion injury and counterstrain (Eagan et al., 2007; Meltzer and Stand- (8 h of RMS; Fig. 2A) and a simulated myofascial release ley, 2007). (60 s of MFR; Fig. 2B) based upon videomorphometric Figure 1 Still images captured from video clips of a clinical MFR treatment. (A) Clinician’s hands and patient’s back before treatment, and (B) the same placements during a 90 s MFR. Note the simultaneous superior, lateral and clockwise strain directions.
In vitro modeling of MFR ~10% 165 A 1.6 s is used to denature cellular DNA with subsequent assess- ment of chromatin changes specific to apoptotic (and not Slope: necrotic) cells. The detection of denatured DNA was 33.3% / sec accomplished by using a monoclonal antibody to single- stranded DNA. B Slope: Slope: Intracellular signaling measurements 3%/s for 2s 1.5%/s for 4s Potential changes in intracellular signaling molecules were 6% assessed pair-wise for selected treatment groups. Each treatment group was composed of one to two pooled six- 60 s well plates. Cell lysates were obtained by treatment with ice-cold lysis buffer (5 ml lysis buffer, 15 ml pepstatin A, Figure 2 Strain paradigm specifics for repetitive motion 1 mg/ml DMSO, 25 mg of a protease inhibitor cocktail strain (RMS; A), and a complete 60 s cycle of modeled myo- (Roche Molecular Biochemicals, Indianapolis, IN) and fascial release (MFR; B). 0.77 mg DTT). Lysates were centrifuged at 15,000 rpm at 4 C for 30 min and the supernatant was aspirated and analysis of clinical MFR treatments (Meltzer et al., 2007). collected and frozen at À80 C. Samples were then sent on The following four strain regimens were tested: dry ice for microarray processing (Kinexus Bioinformatics Corporation, Vancouver, B.C. Canada). Expression levels 1. Control: cells were not subjected to any strain protocol and phosphorylation states of cell signaling proteins were for the duration of the experiments. assessed in duplicate. 2. RMS (Repetitive Motion Strain): cells were subjected to Cytokine secretion measurements the RMS profile (Fig. 2A) for 8 hours, and then sampled immediately upon cessation of RMS. Cytokine secretion was measured by testing the condi- tioned media on a quantifiable cytokine microarray 3. MFR (Myofascial Release): cells were subjected to the (RayBiotech, Inc., Norcross, GA). Briefly, glass slides MFR profile (Fig. 2B) for 60 seconds, and then sampled impregnated with antibodies of 20 cytokines in 16 repli- immediately upon cessation of MFR. cate microarrays were incubated with blocking buffer, a six-sample standard curve cytokine cocktail and 4. RMS þ MFR: cells were subjected to the 8 hours RMS conditioned media samples obtained from the four strain protocol followed three hours later by the 60 second groups described above. Slides were then incubated with MFR protocol and then sampled immediately after a detection antibody cocktail (Alexa Fluor 555-conju- cessation of MFR. gated streptavidin) and the signal was detected with an Agilent Scanner G2505B. Data were extracted from the Photomicrographs image via GenePix Pro 4.0 (Molecular Devices, Sunnyvale, CA), and then further analyzed with Q-Analyzer v3.5 Fibroblast tissue constructs were analyzed microscopically (RayBiotech, Inc., Norcross, GA;). All data were cor- for potential differences in cell morphology including rected for volume and cell number before statistical lamellopodia elongation and/or truncation, cell membrane analyses. blebbing and removal from the collagen matrix. NHDF were also immunohistochemically stained with rhodamine-tag- Statistical analysis ged phalloiden and subsequently observed for potential actin microfilament reorganization. Photomicrographs of Two to four experiments (with two to four replicates each) each treatment group were also analyzed for cell counts were completed to obtain the proliferation, cell count, per high powered field (HPF), cell area and cell perimeter protein, DNA, apoptosis and cytokine data presented. using Image J 1.40 g (National Institute of Health, USA; NHDF area and perimeter measurements were derived http://rsb.info.nih.gov/ij/) and Prism 4.03 (GraphPad from 42e48 random cells per experimental group. Intra- Software, Inc., San Diego, California). cellular protein measurements were derived from 6e12 pooled replicate wells and each array was completed in Cell viability and growth measurements duplicate. Cytokine results were then evaluated by Grubbs’ Test to determine significant outliers from data Cell viability was confirmed and proliferation was measured set and further analyzed by a two-way ANOVA Bonferroni using the CellTiter 96âAqueous One Solution cell prolifer- post-test. Additionally, all data were analyzed with a one- ation assay (Promega Corp.; Madison, WI). way ANOVA with post-hoc Tukey’s Multiple Comparison tests using Microsoft Excel (Microsoft Corporation) and Apoptosis measurements Prism 4.03 (GraphPad Software, Inc., San Diego, Cal- ifornia). Group means were considered significantly Apoptosis was measured using ssDNA Apoptosis ELISA kit different if p < 0.05. (Chemicon International; Billerica, MA) in which formamide
166 K.R. Meltzer et al. Figure 3 Representative photomicrographs of human fibroblast construct morphology, growth patterns and actin architecture of the four treatment groups: control, repetitive motion strain (RMS), myofascial release (MFR), and RMS þ MFR. Results Fibroblast proliferation does not appear to be strain regulated RMS-induced morphologic changes appear mediated when followed three hours later by MFR Cellular proliferation e as measured by cells per high powered field, the calorimetric proliferation assay, and Eight hours of RMS caused elongate lamellopodia, cellular DNA content e did not differ significantly among any of the decentralization, larger intercellular distances and reduced four treatment groups (Figs. 5 and 6). Differences in protein cell-cell contact area when compared to all other groups concentration among RMS, MFR or RMS þ MFR were found to (Fig. 3). Sixty seconds of MFR did not appear to cause these be insignificant. A ratio of protein to DNA (as a proxy of cell morphologic changes. When RMS is followed three hours hypertrophy) also showed no significant differences among later by MFR, the degree of lamellopodia presence/elon- any treatment groups (Fig. 6d). gation and cytoplasmic condensation was reduced while intercellular distances and cellecell contact area were RMS causes apoptosis in fibroblasts mostly restored. Eight hours of RMS caused a significant increase in apoptosis RMS causes NHDF area and perimeter changes compared to control, MFR and RMS þ MFR (One-way ANVOA p < 0.05; Tukey post-hoc; Fig. 7). There were no significant NHDF from all three strain groups displayed significantly differences in apoptosis rates among control, MFR and decreased cellular area when compared to control cells RMS þ MFR groups. (one-way ANOVA p < 0.0001; Tukey post-hoc; Fig. 4, top). RMS caused a significant increase in cell perimeter Intracellular signaling protein results suggest compared to all other treatment groups (one-way ANOVA support for morphologic and apoptotic changes p < 0.0001; Tukey post-hoc; Fig. 3, middle), while MFR resulted in significantly reduced cell perimeters vs. control Over 600 intracellular signaling proteins were identified and and RMS groups only. NHDF from the control group dis- compared by microarrays among the four treatment groups. played significantly greater area to perimeter ratios than While many displayed significant differences among the any other group, NHDF from the RMS group displayed strain groups (data not shown for brevity), we focused our significantly reduced area to perimeter ratios vs. any other analyses on those that might suggest potential mediators of group (One-way ANOVA p < 0.0001; Tukey post-hoc; Fig. 4, the observed cell morphology and apoptosis differences bottom). (Table 1). Our intracellular signaling results in the RMS
In vitro modeling of MFR 167 0.0175 A 120Proliferation Index (% of Control) 0.0150 110 RMS Area (mm2) 0.0125 BBB 100 MFR 0.0100 RMS+MFR 0.0075 90 10 0.0050 5 0.0025 0 0.0000 Control Figure 5 Proliferation indicies, as measured calorimetrically RMS with the CellTiter 96âaqueous one solution cell proliferation MFR assay, of the treatment groups as a percent of non-strain control; N Z 3e4 (p > 0.05). RMS+MFR of numerous genes (Shaywitz and Greenberg, 1999). NHDF 0.9 B subjected to RMS displayed a 159% increase in this phos- phorylated peptide when compared to control. NHDF Perimeter (mm) 0.8 A AC strained with the MFR protocol displayed an increase of C only 21% compared to control, and those treated with 0.7 RMS þ MFR displayed only a 6% upregulation compared to 0.6 the RMS group. 0.5 Analysis of cytokine secretion 0.4 NHDF secretions of 20 human cytokines were assessed immediately after cessation of the four strain treatments 0.3 (Table 2). Of the 20 cytokines measured, IL-6, IL-8, and VEGF were secreted from NHDF in concentrations in excess 0.2 of 100 pg/mL and GRO and MCP-1 secretion was greater than 1000 pg/mL as measured in conditioned media. All 0.1 other cytokines were measured to be minimal immediately after cessation of strain. There was a significant increase in 0.0 GRO secretion in the RMS þ MFR group when compared to control and MFR group. All other cytokine secretions Control measured were found to be non significant among the four RMS treatment groups. MFR Discussion RMS+MFR To our knowledge, this is the first study to model MFR in an 0.025 A in vitro human fibroblast culture. While reports have shown various repetitive strain-induced changes in fibroblast Area:Perimeter 0.020 C proliferation, growth factor secretions and cellular align- 0.015 C ment, ours is the first to show that several morphological 0.010 changes in fibroblasts seen post repetitive strain B are reversed if followed by modeled MFR. The lack of RMS-induced proliferation seen in this study may be masked 0.005 by DAPK-2 associated apoptosis, an effect not seen in MFR or RMS þ MFR groups. While we observed no differences 0.000 among a number of secreted inflammatory and growth promoting mediators with the strain paradigms tested, we Control can not rule out up- or downregulation of their receptors, RMS intracellular effectors or expression/secretion differences MFR in non-measured mediators. This in vitro strain model may be useful to further explore key cellular mechanisms that RMS+MFR may underlie positive outcome of clinical MFR. Figure 4 Cell area (top), perimeter (middle) and area:- Fascia is a tough connective tissue that contains elastic perimeter (bottom) assessed from photomicrographs via digital fibers and its elasticity contributes to its passive resistance image capturing. Different letters denote significant relation- ships among groups (one-way ANOVA with post-hoc Tukey Multiple Comparisons Test); p < 0.05; N Z 42e48 cells analyzed per treatment group. treatment group showed that tyrosine 576 phosphorylated focal adhesion kinase (FAKY576) is upregulated by 58% when compared to control nonstrained NHDF. We also observed a 55% upregulation of phosphorylated peptide in the RMS þ MFR group compared to RMS alone while there was only a 23% increase in the MFR group compared to control (averaged data from duplicate microarray spot analyses of 6e12 pooled lysate samples each). Death-associated protein kinase 2 (DAPK-2), a signaling protein that mediates apoptosis, is upregulated by 74% in the RMS group compared to control. The other two comparisons (MFR vs. Control and RMS vs. RMS þ MFR) revealed downregulation in this pro- apoptotic peptide of 12% and 10%, respectively. Serine 133 phosphorylated cyclic AMP response element binding protein (CREBS133) causes an upregulation in transcription
168 K.R. Meltzer et al. A Cell Count per HPF Proliferation Index [DNA]B 200 (% of Control) (% of Control) 200 100 150 100 0 50 0 RMS MFR RMS+MFR RMS MFR RMS+MFR C [Protien] [Protein]:[DNA] D 200 (% of Control) (% of Control) 200 150 100 100 50 0 0 RMS MFR RMS+MFR RMS MFR RMS+MFR Figure 6 Cell counts per high powered field (HPF; N Z 3e4 experiments), DNA, protein, and protein:DNA concentrations of treatment groups as a percent of control; N Z 2. to tensile forces. Under normal conditions the fascia tendsApoptosis Index discomfort, pain and reduced range of motion. Improve- to be fluid and move with minimal restrictions. However, ment in these sign and symptoms are often seen post-MFR injuries resulting from physical trauma, repetitive motion(% of positive control) treatment (Sucher, 1993; Andersson et al., 1999; Hou et al., strain and inflammation can decrease fascia tissue length 2002; Fernandez de las Penas et al., 2005; Sucher et al., and elasticity resulting in fascial restriction. Physical strainControl 2005). has also been shown to influence the density of fibroblasts,RMS connective tissue proteins such as collagen and fascialMFR In our in vitro RMS model, NHDF tissue constructs dis- myofibroblasts which may be capable of active fascial played fibrotic looking cells with elongate actin-containing contraction (Schleip et al., 2006). Injuries, such as repeti- RMS+MFR lamellopodia and general decentralization which are tive motion strain, result in abnormal changes to tissue apparent in the enclosed photomicrograph. Significant texture affecting passive and active resistance to motion decreases in area to perimeter ratio confirmed that which in turn leads to compromised joint articulation, substantial morphologic changes occurred in the RMS group that is indicative of cell elongation, increased intercellular *65 distances and decrease cell-cell attachment area. If similar tissue changes occur in vivo in response to RMS, these 60 findings may be characteristics of abnormal tissue texture 55 change which, in turn, may attribute to fascia restriction. 50 45 We have previously reported that acyclic strain causes 40 morphological changes in fibroblasts (Dodd et al., 2006; 35 Eagan et al., 2007) while others have found cyclic strain- 30 induced reorientation of fibroblasts (Jungbauer et al., 25 2008; Wen et al., 2009). Studies of fibroblast morphologic 20 changes due to cyclic strain are scarce. However, in other 15 cell types, cyclic stretching induced morphologic changes 10 of HUVEC cells from a normal polygonal shape to elongated spindle-like shapes (Naruse et al., 1998) and cyclic 5 stretching of vascular smooth muscle cells have been shown 0 to cause a variety of phenotypic changes including causing cell elongation (Riha et al., 2005). To our knowledge this is Figure 7 Apoptosis indices of treatment groups as a percent the first study to investigate fibroblast morphology changes of positive control. Significance determined via one-way that may be consistent with fascial restrictions evident ANOVA with post hoc Tukey Multiple Comparisons Test; after repetitive motion injuries. p < 0.05; N Z 2; *, significantly different from all other groups.
In vitro modeling of MFR 169 Table 1 Intracellular proteins of interest, their function, and percent change from control as assayed via Kinexä Antibody Microarray. Protein or Phosphorylation Site Function Control vs. RMS Control vs. MFR RMS vs. RMS þ MFR DAPK-2 Positively mediates apoptosis þ74% À12% À10% FAKY576 Maximizes FAK activation þ58% þ23% þ55% CREB1S133 Upregulates gene transcription þ159% þ21% þ6% In addition to observing morphological changes we found to pre-apoptotically stabilize stress fibers, but not investigated several intracellular proteins that may be maintain focal adhesions in quiescent murine embryonic involved in the morphologic responses seen in the RMS fibroblasts (Kuo et al., 2003). DAPK also triggers uncoupling group. We report upregulation of Focal Adhesion Kinase of the formation of stress fibers and focal adhesions, (FAK) phosphorylation at Tyrosine 576 by 58% in the RMS possibly predisposing cell to apoptosis which is found to group compared to the control group. Focal Adhesion occur after this uncoupling effect (Kuo et al., 2003). Kinase (FAK) is an important mediator of actin-extracellular Specifically, DAPK-2 is involved in apoptotic signaling matrix interaction and cell motility (Calalb et al., 1995; (Kawai et al., 1999), and its regulation influences overall Schlaepfer et al., 2004) and the phosphorylation of FAK at fibroblast growth rates and, consequently, fibroplasia and Tyrosine 576 maximizes FAK activation (Calalb et al., 1995). alterations in tissue texture. Compared to control, RMS Changes in physical morphology require modifications of strained cells had a significant 21% increase in apoptosis cell extracellular matrix interactions and our result of concomitant with an upregulation of dapk-2 by 74%. Cyclic increased FAK activity is consistent with our observed strain has been found to cause increases in apoptosis in morphology changes allowing structural stabilization during mesenchymal stem cells (Kearney et al., 2008), vascular actin-cytoskeleton remodeling. In a related study, cyclic endothelial cells (Kou et al., 2009), and periodontal liga- strain has been found to increase FAK tyrosine phosphory- ment cells (Zhong et al., 2008). Fibroblasts apoptosis in lation from minutes to hours and decrease in time frames response to cyclic strain has been mixed with increases greater than 24 h (Naruse et al., 1998; Molina et al., 2001; seen from minutes (Skutek et al., 2003) to days (Barkhausen Wang et al., 2001). We observe similar results and report et al., 2003), decreases (Danciu et al., 2004) and no change immediate response changes in FAK tyrosine phosphoryla- (Persoon-Rothert et al., 2002; Nishimura et al., 2007). tion immediately upon cessation of an 8 h cyclic strain. Thus, the rate of apoptosis appears to be highly dependant on sampling time. Barkhausen et al. (2003) found an upre- Another intracellular protein that was accessed was gulation of apoptosis after one day, consistent with our death-associated protein kinase (DAPK). DAPK has been Table 2 NHDF secretion of select cytokines and growth factors from the four treatment groups described. Cytokine Treatment groups Control RMS MFR RMS þ MFR Mean SEM Mean SEM Mean SEM Mean SEM IL-1a 0.4 0.3 28.9 17.6 18.8 10.2 0.9 0.2 IL-1b 0.6 0.2 0.3 0.0 0.3 0.0 0.3 0.0 IL-2 5.4 0.4 5.0 0.1 5.2 0.5 5.4 0.4 IL-4 21.3 10.5 4.3 0.4 4.5 4.9 1.0 IL-5 0.4 0.0 0.4 0.0 10.4 0.1 2.2 1.0 IL-6 107.7 82.9 5.8 0.5 92.0 37.2 IL-8 146.4 1.5 13.1 46.6 123.7 34.2 IL-10 11.3 5.1 226.3 71.6 84.1 5.9 9.8 4.7 IL-12 6.6 3.9 0.4 91.4 5.3 13.6 0.1 IL-13 1.5 0.6 9.2 0.1 13.1 0.1 5.3 1.5 GM-CSF 0.4 0.0 5.8 1.5 2.2 0.4 0.0 GRO 1897.0 297.9 4.1 0.5 0.7 0.1 3761.0* 2037.0 IFNg 11.3 9.5 1.3 4.6 59.53 12.6 MCP-1 1467.0 551.0 2595.0 921.5 0.3 127.8 2313.0 566.4 MIP-1a 8.3 4.7 27.2 13.6 1152.0 5.9 10.8 4.1 MIP-1b 1.6 1.0 1509.0 13.6 1.7 0.7 MMP-9 3.2 0.1 11.6 617.7 2225.0 952.0 3.2 0.1 RANTES 10.9 7.3 2.8 5.4 5.3 1.7 2.0 1.0 TNFa 7.2 1.1 3.2 2.0 3.8 1.5 133.5 59.5 VEGF 256.9 44.3 2.2 0.1 3.0 0.1 493.5 129.0 7.3 0.7 13.2 8.3 275.2 1.1 7.3 1.8 800.9 14.4 126.3 Group means and SEMs are calculated with the exclusion of significant outliers determined by Grubbs’ Test. All data are expressed in pg/ml (N Z 2e3). *, Significant differences compared to control and MFR.
170 K.R. Meltzer et al. findings, however, after two days apoptosis decreased. In this study we broadened the search of cytokines that Apoptotic response to strain may change over time as the may be involved in immediately post-treatment changes. cells adapt to modified environments as induced, for Of the twenty cytokines measured we only observed example, by additional injurious strains or by manually a significant increase in GRO secretion in the RMS þ MFR directed strain maneuvers such as MFR. group when compared to control and MFR. GRO has been classified as a neutrolphil chemotractant and although Furthermore, we also observed a 159% increase in CREB studies have shown that GRO is unresponsive to induce phosphorylation at serine 133 in the RMS test group. CREB proliferation in fibroblasts there is evidence to support its phosphorylation at serine 133 is essential for CREB-medi- effect on regulating fibroblast collagen expression ated transcription and studies have shown its involvement (Unemori et al., 1993). This suggests that GRO may play in key cellular processes that include proliferation, a potential role in fibroblast actin-extracellular matrix differentiation and adaptive response (Shaywitz and remodeling as observed here in this study. All other cyto- Greenberg, 1999). Upregulation in gene transcription may kines secretion investigated were found to be non signifi- be associated with apoptotic, morphologic genes or cell cant, however, we did observe an increasing trend in IL-1a surface receptor protein increasing NHDF sensitivity to in the RMS group compared to control which is consistent select cytokine and growth factors. For example, studies with our previous report (Meltzer and Standley, 2007). have shown that fibroblasts cyclically strained resulted in Interestingly, RMS-induced IL-1a expression was attenu- an increase in cell proliferation (Webb et al., 2006; Eagan ated with the addition of MFR following RMS. The et al., 2007) but here we report that there were no morphologic and apoptotic changes observed here appears significant changes in cell proliferation among the test to be independent of the cytokines we examined. groups. Cell proliferation was accessed by cell count per However, the possibility of mechanical strain altering high powered field and confirmed be quantifying dsDNA. NHDF sensitivity to select cytokines through upregulating In addition, we have also shown that RMS treated cells surface cell protein receptors is plausible. A 24 h post- resulted in an increase in apoptotic signaling. Significant treatment investigation of cytokines is out of the scope of increases in apoptosis should result in a decrease in total this study; however it may elucidate delayed cytokines cell number however, this was not the case. Together, secretion in response to the stimuli. Future studies will these data suggest that proliferation may have increased examine delayed secretion of cytokines and the immediate but the increase in apoptosis may have masked the mediators of the morphologic and apoptotic changes proliferation rate resulting in no net gains. These data observed in this study. Clinically, temporal delays from suggest that RMS in our NHDF tissue constructs bears hours to days in cytokine induction, inflammatory many resemblances to injurious strain profiles noted in processes, and pain after a repetitive motion strain type vivo. injury or a soft tissue trauma are well documented (Smith et al., 2000; MacIntyre et al., 2001; Hildebrand et al., In clinical application, manual manipulative therapy is 2005). However, in this study we focused only on potential effective in immediate response changes in tissue texture mediators of cellular changes that take place immediately and pain threshold with patients diagnosed with mechan- post-treatments. ical neck pain (Fernandez de las Penas et al., 2005). In a related report, MFR e when used with other treatment Funding sources and conflicts of interest modalities e showed immediate reduction in pain and improved range of motion in patients with cervical myo- Funding for these studies came from the National Institute fascial dysfunction (Hou et al., 2002). Our in vitro of Health e National Center for Complementary and RMS þ MFR model incorporated a three hour delay in Alternative Medicine, the American Osteopathic Associa- between treatment to reflect the delay associated with tion and the Arizona Biomedical Research Collaborative. No patient seeking treatment at times after initially authors declare any conflict of interest, financial or sustaining an injury. Although this delay may contribute to otherwise. cell recovery after RMS, clinically this delay might be insignificant. In vitro analysis of the NHDF immediate Acknowledgments proliferative response to a modeled MFR after injury showed a significant reduction in cellular apoptosis We thank Chris Gooden, Diana Petitti, Michael Hicks and accompanied with a 10% decrease in DAPK-2 activation. To Shande Chen for their technical assistance. maintain non-fluctuation in cell numbers, as we did not observe changes in net cell proliferation in comparison to References other treatment groups, the decrease in apoptosis may be correlated with a reduction in proliferation rate, as Andersson, G.B., Lucente, T., Davis, A.M., Kappler, R.E., opposed to RMS. Lipton, J.A., Leurgans, S., 1999. A comparison of osteopathic spinal manipulation with standard care for patients with low Morphological changes induced by RMS were not back pain. N. Engl. J. Med. 341 (19), 1426e1431. observed in the RMS þ MFR group. 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Journal of Bodywork & Movement Therapies (2010) 14, 172e178 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt MASSAGE THERAPY FOR HYPOCHONDROPLASIA Improving mobility in a client with hypochondroplasia (dwarfism): A case report* Amy Axt Hanson, LMP* 923 N. Lawrence St., Tacoma, WA 98406-5510, USA Received 18 August 2009; received in revised form 4 January 2010; accepted 5 January 2010 KEYWORDS Summary A client with hypochondroplasia dwarfism and a medical diagnosis of spinal Myofascial release; stenosis had found that her ability to walk had decreased over the past 7 years from easily Muscle fatigue; walking 6 miles (10 K) to now needing to rest every half block (171 ft/52 m) due to muscle Achondroplasia; fatigue. Such weakness is consistent with nerve impingement due to spinal stenosis, which Structural bodywork; would not be improved by massage. However, during a preliminary assessment, it was found Climbing stairs; that both lower legs had severe fascial adhesions, possibly compressing lower leg blood vessels Compartment syndrome and nerves. It was hoped that by using myofascial massage techniques to relieve the adhesions, her mobility would improve over the course of 8 sessions. Myofascial massage techniques showed positive results in reducing adhesions, improving circulation, and increasing the distance the client could walk before resting to 2 blocks (686 ft/209 m). Working with this client showed that Licensed Massage Practitioners (LMPs) can easily accommodate clients of very short height. ª 2010 Elsevier Ltd. All rights reserved. Introduction height. Although exact numbers of dwarfs are unknown, they are estimated to account for more than 200,000 Clients of very short height are a surprisingly large group, people in the US (Adelson, 2005a). That figure seems to be with a study done in 2003 by the advocacy group Little low even for a baseline: the same study found that roughly People of America finding that 1 in 277 US adults, or roughly 169,000 people in the US were 40600/137 cm or shorter, a million people, were 4 feet 10 inches/147 cm or shorter. a height likely tied to a medical cause (Adelson, 2005a). To Most were thought to simply have a family history of short be considered a dwarf, a client must be 401000 or shorter due to a medical condition that limits growth. Those medical * Winner of Massage Therapy Foundation’s 2009 Annual Student conditions identified to date include faulty mechanisms of Case Report Contest. cartilage and bone development, pituitary or thyroid hormone deficiencies, absent or incomplete chromosomes, * Tel.: þ1 253 222 3651. genetic syndromes, malnutrition, extreme emotional E-mail address: [email protected] neglect or abuse, and chronic diseases of the kidney, heart, URL: http://www.amyhansonmassage.com liver, or gastrointestinal tract (Adelson, 2005b). 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.01.003
Improving mobility in a client with hypochondroplasia 173 The client in this report was diagnosed with the bone groups yet holds them together (Smith, 2005a). In the lower growth disorder hypochondroplasia (literally ‘under carti- leg, deep fascia divides muscles into anterior, lateral, deep lage molding’), which produces defective conversion of posterior, and superficial posterior compartments, with cartilage into bone due to point mutations in the same major bundles of nerves, arteries, veins, and lymph vessels fibroblast receptor protein linked to achondroplasia (liter- running between compartments, within compartments, and ally ‘no cartilage molding’) (Francomano, 2005a; Hall, underneath the superficial fascial layer (see Figure 1). 2005). Hypochondroplasia is considered to be a less severe form of achondroplasia (Beighton, 1993; Francomano, These nerves, blood and lymph vessels can become 2005b; Greenfield, 1990a; Greenspan, 2000a). Achondro- compressed due to contraction of surrounding muscles, plasia is the most commonly diagnosed form of dwarfism, from inelasticity in the fascial wrapping, or from a gluing- appearing in 1 of every 15,000e40,000 live births, and is together of fascial septa on either side of the nerves and thought to account for half of all cases of dwarfism (Fran- vessels. Collagen fibers can lose elasticity and/or become comano, 2005c; Greenfield, 1990a). The prevalence of bonded to collagen fibers in adjacent fascial layers from hypochondroplasia is unknown but thought to be similar to disuse, dysfunctional use, aging, or injury (Smith, 2005b). achondroplasia, only less frequently diagnosed since body These adhesions, if severe enough, can produce muscle changes are milder and likely to be overlooked (Franco- fatigue and pain, and at the most extreme, produce mano, 2005c,d). compartment syndrome in which underlying muscle tissue degenerates (Travell and Simons, 1993). Typical presentation of hypochondroplasia and achon- droplasia includes normal trunk length but disproportion- In participating in this study, the client’s primary ately short arms and legs. Hands and feet are broad and interest was to see whether massage could increase the short (Francomano, 2005b,e; Spranger et al., 2002). Much is distance she could walk before the onset of muscle fatigue. known about hypochondroplasia and achondroplasia from She was unconcerned with the tingling in her feet, and had X-ray studies of skeletal features, with several issues being no expectation of any other changes. It was suspected that pertinent to discussions of mobility, including lumbar fascial adhesions or inelasticity could be compressing hyperlordosis, a squared, shortened ilia, a more horizon- nerves and blood vessels in her lower legs, creating or tally tilted sacrum, short femoral neck, mild genu varum exacerbating her symptoms, and a series of sessions were (bowed legs), and a reduced greater sciatic notch planned in which myofascial techniques would be used (Beighton, 1993; Bogumill and Schwamm, 1984; Franco- along with other massage techniques. It was not known mano, 2005c,e; Greenfield, 1990b; Greenspan, 2000b; whether there might be undiagnosed cardiovascular issues; Spranger et al., 2002). These clients tend to have shorter improvements could also be limited by spinal stenosis, than average pedicles, the bridges between vertebral a true neurological condition that produces pain and bodies and the arch holding the transverse and spinous weakness in the legs (Mayo Clinic, 2008). processes. With smaller than average vertebral and inter- vertebral foramina, any further narrowing due to injuries, Methods herniated disks, bone spurs, or cartilage aging can produce pain, numbness, and weakness in the extremities, partic- Profile of client ularly the legs (Beighton, 1993; Francomano, 2005c; Greenfield, 1990b; Greenspan, 2000c; Spranger et al., A 63-year-old librarian was, at 40400 (132 cm), the only 2002). According to orthopedic surgeon Dr. Steven E. member of her family with hypochondroplasia. Her ability to Kopits, who specialized in dwarfism, ‘With progression of walk had been normal until her 40s, allowing her to partic- the severity, the patients have to make obligatory stops at ipate in 10-km (6-mile) fundraising walks. She was diagnosed periodic distances during gait because of numbness, pain, with spinal stenosis 13 years ago and started experiencing and weakness of the lower limbs’ (Kopits, 1976a). This muscle weakness in her legs 7 years ago, which had pro- accurately describes the client in this study, who was gressed to where she could only walk half a block (171 ft/ limited in the distance she could walk before having to stop 52 m) before having to stop and rest for several minutes. and rest due to muscle weakness in her legs. In addition, Muscle weakness only occurred when walking, and was not she found climbing stairs difficult, and had to bring both associated with any pain or burning in her legs or lower back, feet to each step. After sitting at her desk for 4 or more although occasionally she felt tingling in her feet and toes at hours, and on waking in the morning, various areas of her this time. She was not able to link the fatigue to any specific feet and toes tingled, which could be relieved by dorsi- muscle or group of muscles. When she forced herself to keep flexing and plantar flexing her feet, or by walking. Deep posterior compartment Tibia Anterior compartment During assessment it was discovered that the client had Tibialis anterior severe fascial restrictions in both lower legs, and the skin of Tibialis posterior Extensor digitorum longus her lower legs and feet felt significantly cooler to the touch Flexor digitorum longus Extensor hallucis longus than her thighs or arms. Fascial adhesions are considered to Flexor hallucis longus be a potential cause of blood and nerve flow impingement (Archer, 2007a; Travell and Simons, 1993). Layers of fascial Superficial posterior Lateral compartment connective tissue are found most superficially as a body compartment Peroneus longus stocking under the dermis, and also more deeply wrapping Peroneus brevis groups of muscles (compartments), each named muscle, Gastrocnemius each inner bundle (fascicle) within a muscle, and each indi- Soleus Fibula vidual muscle cell (fiber). Fascia separates various functional Figure 1 Cross-section of the lower leg showing the major fascial divisions grouping muscles into the anterior, lateral, deep posterior, and superficial posterior compartments.
174 A.A. Hanson walking, her leg muscles no longer functioned and she fell. for assessment). The time between massages averaged 14 Use of a cane as a mobility aid did not improve her muscle days, ranging from 11 to 21 days. Two weeks after session 8, fatigue or distance, but helped her walk faster and feel more final information was gathered on walking distance. balanced. Session 1 used whole-body Swedish massage and deep Tingling in her toes and feet had become more tissue techniques (focused work on deeper muscles, both pronounced over the past 5 years, especially when she with-fiber and cross-fiber, with the intent to release long- woke up in the morning or sat at her desk at work for 4e5 h. standing adhesions) for assessment, palpation, and to She had not noticed a pattern to the tingling, which introduce the client to massage. occurred in her toes, heels, and various areas of her feet (lateral, medial, and superior sides). The tingling was Techniques in sessions 2e6 included prone broad-plane, relieved by dorsiflexing and plantar flexing her foot, or by linear shift, and horizontal-plane myofascial release tech- walking, and disappeared within 5 min. niques (Archer, 2007b) to the posterior compartment, plus Swedish and deep tissue techniques to posterior lower leg, The client had a positive attitude toward life, adapting hamstrings, iliotibial band, gluteals, and back. Supine tech- to her increasing limitations with good humor. She often niques included broad-plane, linear shift, and horizontal- used a cane when walking at work, home, and shopping, plane myofascial release to anterior and lateral lower leg, and for longer distances used a mobility scooter. She felt plus Swedish and deep tissue techniques to anterior lower that her mobility would be improved by losing weight, and leg and quadriceps. Sessions 7 and 8 used the more specifi- had been following a nationally franchised weight-reducing cally targeted, heavier-pressure techniques of structural program for 3 years, losing 38 pounds (17 kg) to bring her to bodywork using the finger chisel, dorsum of hand, and a current weight of 163 pounds (73 kg). octopus-hand strokes intended to produce myofascial release of heavy adhesions and deep structures (Smith, The client had never received massage of any kind. She 2005c). With the client standing and slowly flexing her received physical therapy for low back pain 13 years ago for knees, greater pressure was directed to the extensor reti- a term of 2 months. At that time, she had steroid injections naculum, anterior valley, and gastrocnemius/soleus. A small to relieve low back pain caused by spinal stenosis. She also structural ball was placed under each medial arch with knee performed stretching exercises for her legs and back, and flexion while the client was standing. With the client supine felt that it helped improve her mobility, but also felt that and dorsiflexing and plantar flexing her feet, greater pres- reduced pain from her steroid injections was more important sure was directed to the flexor retinaculum, anterior and in improving her mobility. At the outset of the study, she had lateral compartments. Muscle rolling was employed to help no pain in her legs or low back, but sometimes felt tightness release muscle group adhesions (Archer, 2007b). Session 8 down the posterior muscles of her leg, especially when also included horizontal-plane release just superior to and walking and climbing stairs. This tightness required her to inferior to each knee (supine and prone), and traction bring both feet up to each stair before tackling the next. release to each femur was employed in order to help release fascia of the ankle, knee, and hip joints (Archer, 2007c). On initial assessment, the client was found to have Side-lying contract-relax stretches of the iliopsoas were fascial tension in both lower legs to the extent that skin conducted in sessions 2, 4, 5, 6, 7; direct iliopsoas massage moved very little in any direction. Muscles of the anterior was performed in session 3 (Archer, 2007d). and lateral compartments felt tight. She had light to moderate range of motion (ROM) limitations in all planes of Hip and knee ROM were checked in sessions 2, 4, and 7; the hips, knees, and ankles, with no limitation in knee ankle ROM was checked at sessions 2, 4, 7, and 8. At the extension. Of note was a moderate-plus limitation in dor- start of each session, the client reported the distance she siflexion and plantarflextion of her ankles. Hip flexion had could walk before symptom onset during the intervening a firm active end point at 90 degrees, with no further gain two weeks. Results were encouraged to be average in ROM on passive movement. distances, not an unusual maximum for that time period. The client was assigned no stretching homework in order to The client stood with light lateral rotation of both monitor results from myofascial techniques alone. femurs, low medial arches, lumbar hyperlordosis, and no other significant postural deviations. On initial assessment, Results her lower legs, feet, and toes felt significantly cooler in temperature than her thighs. She had no significant tension Improved functional outcomes in the muscles of her lower leg posterior compartments, At the beginning of the series, the client’s feet and lower anterior thighs, or posterior thighs. legs felt significantly cooler in temperature than her thighs before massage; during and after massage sessions, her The client was very interested to see if massage could calves and feet felt noticeably warmer and often changed improve her ease of movement and flexibility to the extent color from uniformly pale to showing patches of pink. By that it might increase her walking distance from half session 8, her legs and feet felt significantly closer to thigh a block to two blocks between rest stops. She had no other and trunk temperature prior to massage. Similarly, fascial goals for this study, but the author was interested to see restrictions noted in session 1 that resisted skin movement whether easing the client’s myofascial restrictions might be in any direction were eased throughout the course of this accompanied by an increased ROM and reduction in the study so that by session 8, the skin on the client’s lower leg tingling of her toes and feet. moved well in all directions. Treatment plan During sessions 1 and 2, when the client lay prone, the tingling in her feet increased and became uncomfortable. Eight massage sessions were conducted over the course of 15 weeks, with each session lasting 1.5 h (plus additional time
Improving mobility in a client with hypochondroplasia 175 Semi-side-lying alleviated this. On session 3, the client Figure 3 An 8-inch standard bolster held the client’s lower found she could lie prone comfortably, which lasted for all legs in significant flexion. subsequent sessions. As a gauge of iliopsoas tension, the client had little After each session, the client reported a greater feeling femur extension beyond the frontal/coronal plane. This did of ease of movement in her lower legs, a feeling that she not change with side-lying iliopsoas contract-relax retained until the next session. At session 4, she reported stretches, or with direct iliopsoas massage. All other ROM that climbing stairs had become easier, as she could now limitations in her hips and knees were unchanged. ascend stairs with one foot per step. Previously, she had to bring both feet to each step before continuing. It is not known how much change in muscle tension was achieved in the anterior and lateral compartments of the During sessions 1e6, the client’s ROM in her ankles lower leg during the course of this study due to incomplete (dorsiflexion and plantar flexion) were limited to attention by the student LMP. a moderate-plus extent and did not change as a result of broad-plane myofascial techniques. After the more Discussion focused, deeper structural/myofascial work conducted during session 7, ankle dorsiflexion and plantar flexion Adhesions of the intramuscular and superficial fascia can improved significantly to only a light limitation. bring about decreases in circulation, leading in extreme cases to compartment syndromes and muscle necrosis Structural myofascial work done in session 8 raised the (Travell and Simons, 1993). It was hypothesized that the medial arches of her feet. client’s muscle weakness may have been due in part to fascial tension in her lower legs that was constricting nerve Walking distances before stopping were reported at the or blood flow to her calves and feet. As her fascial beginning of each massage session and are reported in restrictions were reduced, circulation improved as Figure 2. Blocks were converted to feet/meters after the observed by skin color change and a feeling of warmth to client walked with the author and pointed out where she the practitioner’s hand (Smith, 2005d). Concurrent with usually had to stop. Distances were measured with a 25- this, the client reported steady improvements in ease of foot carpenter’s measuring tape. At the study’s outset, the movement, stair-climbing ability, and walking distance. It is client could only walk half a block (171 ft/52 m) before reasonable to assume that these improvements were due to having to stop. Swedish techniques performed at session 1 the easing of fascial restrictions, but this can only be allowed the client to walk three-quarters of a block (257 ft/ inferred because massage practitioners have no methods to 78 m) before having to stop. No distance improvements quantitatively measure fascial restrictions. were noted in conjunction with the broad-plane myofascial techniques performed during sessions 2 through 4. Broad- Figure 4 A 4-inch bolster (in this case, a rolled-up yoga mat) plane myofascial work done at session 5 resulted in an reduced flexion in the client’s lower legs. improvement to 1 block (343 ft/104 m) before stopping; the same work done at session 6 resulted in her ability to walk 1.5 blocks (514 ft/157 m) before stopping. Structural bodywork techniques in sessions 7 and 8 improved the cli- ent’s ability to walk 2 blocks (686 ft/209 m) before having to stop (A year after the initial work, the client continues able to walk 2 blocks before having to stop.). Unchanged functional outcomes The tingling reported by the client in her toes and feet did not change during the course of this study, nor was there any change in the lateral rotation of her feet. 8 7 6 Numbered 5 massage 4 session 3 2 1 prior to study 0 100 200 300 400 500 600 700 Distance walked (feet) before resting Figure 2 The average distance the client could walk before needing to rest prior to the study and in the two-week period after each numbered massage.
176 A.A. Hanson It was hoped that ROM change would be seen at each feeling tightness down the back of her legs when climbing session as an indication of fascial easing, but this client’s stairs. It improved her quality of life in that she sometimes ROM remained unchanged until session 7, when significant had to climb a flight of stairs at work to reach certain gains in dorsiflexion and plantar flexion occurred as a result books. In addition, her home has stairs to the basement and of structural bodywork techniques. It is possible that these to the second floor, and she used a stepstool in the kitchen techniques are inherently more effective than lighter work, to reach the countertops. though it is also possible that the client responded well because her fascial restrictions had been released enough The tingling in the client’s toes remained an unresolved so that stronger work could be effective. The unchanged issue. It was hoped by the LMP that these symptoms could ROM limitations of her hips and legs may not have had be reduced, but such was not the case, and it is considered a fascial origin, as it was later discovered that her initial that these may be a symptom of spinal stenosis or undiag- assessment had been in comparison to LMP expectations nosed cardiovascular or neurologic issues. learned from average-height clients. It may be that her ‘‘limitations’’ were in fact entirely within the normal range Changes in our assumptions of normal of motion for bone configurations inherent to the legs and hips of clients with hypochondroplasia. As the study progressed, the author found it refreshing to work with a client who allowed a re-examination of various Measuring progress via the large-scale measurement of assumptions of normality. For example, it is entirely normal walking distance was also problematic because although for clients with hypochondroplasia and achondroplasia to there was a gain after the first massage, there seemed to be have bone configurations that produce lumbar hyper- no change for the following 3 massages, with improvements lordosis that no amount of bodywork could change. Lumbar only being seen in the 2-week period following session 5. nerve difficulties are common due to their commonly Future studies would be better served by having the client shortened lumbar pedicles, and work to relieve false walk in place or walk on a treadmill until the point of sciatica, while helpful, would not relieve symptoms of true muscle fatigue in order to more finely gauge progress. sciatica. The author found it an interesting challenge to Having the client self-report her average walking distances conduct the iliopsoas tension/length test (Thomas’ test). also adds uncertainty to the data in that city blocks are not Lack of tension in the iliopsoas is seen when the client’s standard units, and can vary widely. A measure of confi- knee rests below horizontal, but a shorter leg length results dence in the data was obtained by the fact that the client in smaller angles below horizontal and potentially a more trevelled the same route every day between home and difficult test interpretation. Interestingly, predicting work, making it possible for stopping locations to be muscle issues by watching a client walk is impossible for determined. There still remains the possibility that the client might have wanted to please the practitioner by reporting results greater than those actually obtained. The author would always ask about changes in mobility and symptoms, making the point of saying that ‘no change is totally fine, too.’ Since the client consistently reported no change in walking distance for many sessions, nor a reduc- tion in foot or toe tingling throughout the course of the study, the author is more confident with this data. The client’s greater ease of climbing stairs was an unexpected bonus to the work, and may be another indi- cation of fascial easing given the client’s initial reports of Figure 5 A set of folding steps can be used for clients to get up Figure 6 Stairs can be a challenge for even the most mobile onto a fixed-leg table. This version has steps 8 and 10 inches (20 dwarf clients, and a barrier to those in a wheelchair. and 25 cm) high, which is still a challenge. An electric or hydraulic table eliminates problems for both clients and LMPs.
Improving mobility in a client with hypochondroplasia 177 Figure 7 Dwarf clients do not span the massage table as Since short-height clients do not span the massage table fully as clients of average height. as fully as do average-height clients, LMP body mechanics clients with hypochondroplasia because normal posture and benefit by positioning them at the distal end of the table gait patterns have not been documented. Normal gait has when sessions include a substantial amount of lower been determined for achondroplasia, with data available as extremity work (see Figures 7 and 8). a master’s thesis (Knudsen, 1993); it has been broadly described elsewhere as a ‘characteristic waddling gait’ Finally, to paraphrase orthopedic surgeon and dwarfism (Greenspan, 2000d). Altered gait is expected due to specialist Dr. Stephen E. Kopits (1976b) the challenge to significant differences in bone structures, including lumbar LMPs is not to see the unusual bone structures of dwarfism hyperlordosis, mild genu varum short neck of the femur, as a problem. The only problem e and this is the case with and hip changes including a more horizontal tilt to the all clients e comes from their long-term use patterns of sacrum. these bones and muscles. Practical (office) considerations LMPs fortunate enough to work with this population will No matter what the cause of a client’s short height, LMPs will find that massage therapy offers the possibility of improving find they need to make only minimal changes in office range of motion and ease of movement in a supportive, equipment and routine to maximize client comfort. When non-clinical, and body-neutral environment. lying supine, this client’s lower legs were held in significant flexion by an 8-inch bolster or pillow; a 4-inch bolster (in this Acknowledgements case, a rolled-up yoga mat) worked best (see Figures 3 and 4). The author is grateful to the client for her participation in A low chair aided client comfort during intake and tests this study, to Dr. John E. Hanson for his support and tech- for true neurological conditions. Since this client was quite nical expertise, and to the teachers at Cortiva Institute- mobile, a footstool leading to an average-height chair Seattle School of Massage Therapy for their insights, helped her climb onto the table; later a set of folding stairs suggestions, encouragement, and education in medical was used (see Figure 5). massage therapy. Less-mobile clients may require an electric or hydraulic References table. Stairs are usually a challenge and/or a barrier, so massage space must be wheelchair accessible (see Adelson, B.M., 2005a. Dwarfism: Medical and Psychosocial Aspects Figure 6). of Profound Short Stature. The Johns Hopkins University Press, Baltimore, p. 22e23. Figure 8 For significant amounts of foot and leg work, the client should be positioned at the distal end of the table to Adelson, B.M., 2005b. Dwarfism: Medical and Psychosocial Aspects optimize LMP body mechanics. of Profound Short Stature. The Johns Hopkins University Press, Baltimore, p. 17e20 & 287e297. Archer, P., 2007a. Therapeutic Massage in Athletics. Lippincott Williams & Wilkins, Philadelphia, p. 232e234. Archer, P., 2007b. Therapeutic Massage in Athletics. Lippincott Williams & Wilkins, Philadelphia, p. 164e174. Archer, P., 2007c. Therapeutic Massage in Athletics. Lippincott Williams & Wilkins, Philadelphia, p. 171e172. Archer, P., 2007d. Therapeutic Massage in Athletics. Lippincott Williams & Wilkins, Philadelphia, p. 134. Beighton, P., 1993. McKusick’s Heritable Disorders of Connective Tissue. Mosby-Year Book Inc, St. Louis, p. 578. Bogumill, G.P., Schwamm, H.A., 1984. Orthopaedic Pathology: A Synopsis With Clinical and Radiographic Correlation. WB Saun- ders Co, Philadelphia, p. 43e49. Francomano, C.A., 2005a. Hypochondroplasia. GeneReviews Available from: http://www.ncbi.nlm.nih.gov/bookshelf/br. fcgi?bookZgene&partZhypochondroplasia, p. 4 [Internet] [cited 2008 August 4]. Francomano, C.A., 2005b. Hypochondroplasia. GeneReviews Available from: http://www.ncbi.nlm.nih.gov/bookshelf/br. fcgi?bookZgene&partZhypochondroplasia, p. 1 [Internet] [cited 2008 August 4]. Francomano, C.A., 2005c. Hypochondroplasia. GeneReviews Available from: http://www.ncbi.nlm.nih.gov/bookshelf/br. fcgi?bookZgene&partZhypochondroplasia, pp. 6e7 [Internet]. [cited 2008 August 4]. Francomano, C.A., 2005d. Hypochondroplasia. GeneReviews Available from: http://www.ncbi.nlm.nih.gov/bookshelf/br. fcgi?bookZgene&partZhypochondroplasia, pp. 6e7 [Internet] [cited 2008 August 4]. Francomano, C.A., 2005e. Hypochondroplasia. GeneReviews Available from: http://www.ncbi.nlm.nih.gov/bookshelf/br.
178 A.A. Hanson fcgi?bookZgene&partZhypochondroplasia, pp. 2e3 [Internet] Kopits, S.E., 1976a. Orthopedic complications of dwarfism. Clinical [cited 2008 August 4]. Orthopaedics and Related Research 114, 158. Greenfield, G.B., 1990a. Radiology of Bone Diseases. JB Lippincott Co, Philadelphia, p. 276. Kopits, S.E., 1976b. Orthopedic complications of dwarfism. Clinical Greenfield, G.B., 1990b. Radiology of Bone Diseases. JB Lippincott Orthopaedics and Related Research 114, 154. Co, Philadelphia, p. 272e276. Greenspan, A., 2000a. Orthopedic Radiology: A Practical Approach. Mayo Clinic, 2008. Spinal Stenosis. MayoClinic.com Available from: Lippincott Williams & Wilkins, Philadelphia, p. 910. http://www.mayoclinic.com/health/spinal-stenosis/DS00515 Greenspan, A., 2000b. Orthopedic Radiology: A Practical Approach. (accessed 11.03.08.). p. 1e2. [cited 2008 August 8]. Lippincott Williams & Wilkins, Philadelphia, p. 908e909. Greenspan, A., 2000c. Orthopedic Radiology: A Practical Approach. Smith, J., 2005a. Structural Bodywork. Elsevier, London, p. 58e62. Lippincott Williams & Wilkins, Philadelphia, p. 909e910. Smith, J., 2005b. Structural Bodywork. Elsevier, London, p. 73e74, Greenspan, A., 2000d. Orthopedic Radiology: A Practical Approach. Lippincott Williams & Wilkins, Philadelphia, p. 908. 84e89. Hall, B., 2005. Bones and Cartilage: Developmental and Evolutionary Smith, J., 2005c. Structural Bodywork. Elsevier, London, p. Skeletal Biology. Elsevier Academic Press, Amsterdam, p. 437. Knudsen, M., 1993. Range of motion and flexibility of adults with 135e141. achondroplasia [master’s thesis]. Denton (TX), Texas Woman’s Smith, J., 2005d. Structural Bodywork. Elsevier, London, p. 136. University. Spranger, J.W., Brill, P.W., Poznanski, A., 2002. Bone Dysplasias: An Atlas of Genetic Disorders of Skeletal Development. Oxford University Press, Oxford, p. 90. Travell, J.G., Simons, D.G., 1993. Myofascial Pain and Dysfunction, The Trigger Point Manual, The Lower Extremities. Lippincott Williams & Wilkins, Philadelphia, p. 361e362, 443e444.
Journal of Bodywork & Movement Therapies (2010) 14, 179e184 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt COMPARATIVE STUDY Osteopathic manual therapy versus conventional conservative therapy in the treatment of temporomandibular disorders: A randomized controlled trial A.M. Cuccia a,b,*, C. Caradonna a,b, V. Annunziata b, D. Caradonna a,b a Department of Dental Sciences ‘‘G. Messina’’, University of Palermo, Via del Vespro 129, 90128 Palermo, Italy b School of Specialization in Orthodontics, University of Palermo, Via del Vespro 129, 90128 Palermo, Italy Received 10 April 2009; received in revised form 1 August 2009; accepted 12 August 2009 KEYWORDS Summary Objective: Temporomandibular disorders (TMD) is a term reflecting chronic, pain- OMT; ful, craniofacial conditions usually of unclear etiology with impaired jaw function. The effect Physical therapy; of osteopathic manual therapy (OMT) in patients with TMD is largely unknown, and its use in Stomatognathic system; such patients is controversial. Nevertheless, empiric evidence suggests that OMT might be Occlusal splint; effective in alleviating symptoms. A randomized controlled clinical trial of efficacy was per- Masticatory muscle formed to test this hypothesis. Methods: We performed a randomized, controlled trial that involved adult patients who had TMD. Patients were randomly divided into two groups: an OMT group (25 patients, 12 males and 13 females, age 40.6 Æ 11.03) and a conventional conservative therapy (CCT) group (25 patients, 10 males and 15 females, age 38.4 Æ 15.33). At the first visit (T0), at the end of treatment (after six months, T1) and two months after the end of treatment (T2), all patients were subjected to clinical evaluation. Assessments were performed by subjective pain intensity (visual analogue pain scale, VAS), clinical evalu- ation (Temporomandibular index) and measurements of the range of maximal mouth opening and lateral movement of the head around its axis. Results: Patients in both groups improved during the six months. The OMT group required significantly less medication (non-steroidal medication and muscle relaxants) (P < 0.001). * Corresponding author at: Department of Oral Sciences, University of Palermo, Via del Vespro 129, 90128 Palermo, Italy. Tel.: þ39 091 6552296/6811287; fax: þ39 091 214637. E-mail address: [email protected] (A.M. Cuccia). 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.08.002
180 A.M. Cuccia et al. Conclusions: The two therapeutic modalities had similar clinical results in patients with TMD, even if the use of medication was greater in CCT group. Our findings suggest that OMT is a valid option for the treatment of TMD. ª 2009 Elsevier Ltd. All rights reserved. Introduction tissue quality, in order to maintain or restore the circula- tion of body fluids (Magoun, 1976). Temporomandibular disorders (TMD) are a collective term that includes disorders of the temporomandibular joint Osteopathic treatment is utilized by many practitioners (TMJ), of the masticatory muscles and their associated of neuromusculoskeletal medicine and osteopathic manip- structures in the absence of other visceral pathology (for ulative medicine in many countries, including the United example ear disorder, pharyngeal tumour, or dental States of America, Australia, South Africa and the United abscess). It is characterized by pain, joint sounds, and Kingdom. The evidence regarding treatments is from clin- restricted mandibular movement (De Bont et al., 1997). ical reports, patient outcomes and is largely anecdotal. The pathogenesis of the TMD, however, is unclear. Only a few studies evaluated the effect of osteopathic Physical (trauma, muscles spasms, chronic malocclusion, treatment in TMD (Larsen, 1976; Royder, 1981). Monaco bruxism causing grinding or clenching of teeth), biochem- et al., (2008) suggested that OMT can induce changes in the ical (vitamin inadequacy), and physiological factors stomatognathic dynamics, offering a valid support in the (anxiety, stress and depression) may all play a role (Levy clinical approach to TMD. and Gorlin, 1953; Haskin et al., 1995). Upledger (1987) stated that TMD may originate from sacral dysfunction The purpose of the current case-control study was to (Upledger, 1987). study the effects of OMT in adult subjects with TMD. Several types of treatment have been proposed in the Methods literature by dentists, orthodontists, psychologists, physical therapists, and physicians, although with highly disparate The subjects in this study were recruited from among the results among the published studies (Cascos-Romero et al., patients with TMD who attended the Department of 2009). Orthodontics and Gnathology, University of Palermo, Italy, during a six-month period from September 2008 to February non-invasive therapies should be attempted before 2009. A total of 50 consecutive patients, aged 18e50 years, pursuing invasive, semipermanent or permanent treat- diagnosed with TMD were selected for the study. The ments (such as orthodontics or surgery) that have the subjects were randomly assigned to the OMT group (25 potential to cause irreparable harm. patients, 12 males and 13 females, age 40.6 Æ 11.03) and a conventional conservative treatments (CCT group, 25 Non-invasive therapies may include pharmacological patients, 10 males and 15 females, age 38.4 Æ 15.33). treatment (non-steroidal anti-inflammatory drugs, muscle relaxants, antidepressants and corticosteroids), oral appli- A standardized TMD examination was executed in all ances, home care procedures, cognitive-behavioral informa- patients: joint pain, crepitation, uncoordinated movements tion program, acupuncture, and dry needling, chiropractic, of the head of the mandibular condyles during opening or physical therapy, osteopathy, relaxation and meditation closing the mouth were investigated by lateral and poste- (Carlson et al., 2001; DeBar et al., 2003; Alcantara et al., 2002; rior palpation of each TMJ with both index fingers. Buescher ,2007). Subjects were included if they had a temporomandibular Physical therapy is intended to relieve musculoskeletal index (TMI) reference value of !0.08 Æ 0.10, and pain, reduce inflammation, and restore oral motor func- a minimum pain intensity of 40 mm on a visual analogue tion. The American Academy of Craniomandibular Disorders scale (VAS). The TMI is a clinical measure used to determine and the Minnesota Dental Association have cited physical the severity of the disorder. It is composed of a total index therapy (electrophysical modalities, therapeutic exercises, (TMI) with three sub-indices: function index (FI), muscle manual therapy techniques) as an important treatment to index (MI) and joint index (JI). The FI includes 12 items relieve musculoskeletal pain, reduce inflammation and related to the range of motion of the mandible. The MI restore oral motor function (Sturdivant and Fricton, 1991). measures pain associated with bilateral digital palpation of selected masticatory muscles at a total 20 sites. The JI Numerous physical therapy interventions are potentially measures pain evoked by digital palpation of 2 sites for effective in managing TMD. These therapies include: elec- each TMJ and the incidence of noise in each TMJ. The FI, MI trophysical modalities (shortwave diathermy, ultrasound, and JI are calculated by dividing the sum of positive findings biofeedback, microwave, laser therapy and transcutaneous for each subindex by the total number of items examined electrical nerve stimulation), acupuncture, therapeutic (respectively 12 for FI, 20 for MI and 8 for JI). The scores of exercises for the masticatory or cervical muscles and all indices ranged from 0 to 1, with 1 being the highest manual therapy techniques. These interventions are score possible. The overall TMI score is the average of the commonly used to reduce pain and to improve mandibular scores for the FI, MI, and JI. (Pehling et al., 2002). range of motion (McNeely et al., 2006). The intensity of jaw pain was recorded on the visual Osteopathic treatment is a physical therapy interven- Analogue (VAS) pain scale of 1e10 with 1 indicating mild pain, tion, characterized by fine manipulative techniques, less 5 moderate pain and 10 unbearable pain (Huskisson, 1974). invasive than other interventions, individually adapted to
Osteopathic manual therapy versus conventional conservative therapy 181 In addition, assessment of the range of maximal mouth The CCT was provided by a gnathology specialist. Gna- opening (MOV) and lateral movement of the head around its thology is the study of the masticatory system, including its axis were examined (ROM). physiology, functional disturbances and treatment. Maximal mouth opening was measured using calibrated The treatment included use of an oral appliance, phys- caliper with a 1 mm accuracy, as the maximal inter-incisal ical therapy (gentle muscle stretching and relaxing exer- distance added to the vertical overlap of the incisors. cises), therapies such as hot or cold packs (or both), Patients were asked to open their mouth as wide as possible transcutaneous electrical nerve stimulation. to the point of pain, and were measured with their heads supported in a neutral position (Figure 1). Both groups could take a non-steroidal medication (anti- inflammatory medication and analgesics) and/or muscle The Cervical Range of Motion instrument (Performance relaxants, when prescribed by their medical practitioner. Attainment Associates, 958 Lydia Drive, Roseville, MN 55113) was used in order to measure the rotation of the The therapeutic protocol specified treatments at inter- cervical spine on the transverse plane. This instrument vals of two weeks in both groups. At 24 (T1) and 32 (T2) consists of an eyeglass-shaped plastic frame with incli- weeks, the patients were assessed by an evaluator who was nometers. For the rotation measures (degrees), the incli- blinded to the treatment assignments. nometer is magnetic and moves along the transversal plane (Neiva and Kirkwood, 2007). The Ethics Committee of the University Palermo approved the protocol. Written informed consent was The exclusion criteria were: history of adverse effects obtained from each subject after a full explanation of the with osteopathic treatment, being under orthodontic experiment. treatment or under treatment for TMD, previous treatment for TMD, making regular use of analgesic or anti-inflam- Statistical method matory drugs, use of dental prosthesis, presence of any other oro-facial pain condition, neurological or psychiatric Chi-square tests were used to compare the age and sex of disorders and systemic inflammatory disorder. OMT and CCT groups. Scores of TMI, FI, MI JI, and VAS, age and range of MOV and ROM (mm) were presented as the The OMT group received osteopathic manipulation by means Æ standard deviation (sd). a doctor of osteopathy (VA). Treatments lasted 15e25 min, and were gentle techniques such as myofascial release, The t of Student was applied to compare the data balanced membranous tension, muscle energy, myofascial between OMT patients and control group. release, joint articulation, high-velocity, low-amplitude thrust and cranial-sacral therapy (Greenman, 2003; The two-way mixed analysis of variance (ANOVA) with Magoun, 1976; Ge´hin, 2007; Winkel et al., 1997). Treatment the Tukey Post test was performed in order to verify was directed to the cervical and TMJ regions. whether the differences in the measurements of VAS, MOV, ROM and TMI at T0, T1, and T2 between OMT and CCT In particular, the specific manipulative procedures groups were statistically significant. performed by the osteopath were designed both to reduce the dysfunction (pain and restriction) of the ligaments of Data were analyzed using Primer of Biostatistics for the TMJ (stylo-mandibular and spheno-mandibular liga- Windows (version 4.02, McGraw-Hill Companies, New York) ments, lateral collateral ligament) and to retrain the (Glantz, 2002). Significance for all statistical tests was set involuntary neuromuscular, reflexive control of posture at P < 0.05. and balance. Results Figure 1 Clinical measurement of maximal active mouth The findings indicated that the OMT and CCT groups did not opening using calibrated caliper. demonstrate any significant difference. The use of medi- cation was greater in the CCT group than in the OMT group, with significant differences for non-steroidal anti-inflam- matory drugs (X2 Z 4.083, P < 0.001) and muscle relaxants (X2 Z 4.878, P < 0.001). Non-steroidal medication was prescribed to 14 patients of the CCT group vs 6 patients of the OMT group. In addition, a muscle relaxant was prescribed in 8 patients in the CCT group and to 1 patient in the OMT group (Table 1). There were no differences in the mean pre-test values of VAS, MOV and ROM between OMT and CCT groups. When the two groups were compared at T1 and T2, the best results were obtained in the OMT group: only the VAS value at T2 was not statistically significantly different between two groups (3.80 Æ 1.26 vs 4.40 Æ 1.75, P > 0.05) (Table 2). Improvement in values of VAS, MOV and ROM in both groups was observed at T1 and at T2 than at T0. A statistically significant difference was observed in the OMT group between T1 values and T2 values for the VAS (1.5 Æ 0.85 vs 3.8 Æ 1.26, F Z 184.44, P < 0.000) and MOV (46 Æ 4.78 vs 42.9 Æ 2.69, F Z 48.19, P < 0.000), and in CCT group for the VAS (2.6 Æ 0.7 vs 4.4 Æ 1.75, F Z 48.66,
182 A.M. Cuccia et al. Table 1 The ratio and number of distribution for sex, age fibromyalgia), but also in several pathologies such as and patients who took medication. recurrent acute otitis media, cerebral palsy, learning disorders, neurologic deficits, asthma, pneumonia, bron- Age y OMT CCT tP chiolitis, gastrointestinal disorders and headaches (Ander- sson et al., 1999; Mill et al., 2003; Duncan et al., 2004; Mean Æ SD 40.6 Æ 11.03 38.4 Æ 15.33 NS Frymann, 1966, 1976; Degenhardt and Kuchera, 2006). Range NS 30e63 29e62 It is likely that the benefits of osteopathic interventions in these conditions could extend to other pain conditions Age group (years), n (%) X2 P such as TMD. NS Women < 45 15 (60) 16 (64) NS Results of this study suggest that reduction in pain and 9 (36) improved range of motion were reported after six months, Men ! 45 10 (40) suggesting that OMT and CCT provide relief for TMD related conditions. However, in the OMT group it was observed that Sex 17 (68) 15 (60) X2 P the best values were for VAS, MOV and ROM at T1 and T2, Women 8 (32) 10 (40) NS and the reduction of FI and MI and the use of medications. Men NS Even if at T2 there was a mild worsening of MOV, ROM Medications n (%) X2 P and VAS than at T1, MOV and ROM values remained within 4.083 0.001 the normal range of motion, and the reduction of VAS was Non-steroidal 6 (24) 14 (56) noteworthy in that, and however there was an improve- 4.878 0.001 ment at T2 when compared to T0. medication 8(28) 13.718 0.000 22 (88) Numerous mechanisms have been considered as sources Muscle relaxants 1(4) of muscle and articular pain: local factors (microtrauma, local ischemia or hypoperfusion) can produce structural or Total number of 7 (28) functional consequences due to release of endogenous algesic substances (glutamate, histamine and others) from medications tissue cells and afferent nerve fibres leading to excitation or sensitization of nociceptors; central processes involving used neuroendocrine factors (endogenous and exogenous hormones) as well as neurophysiological mechanisms P < 0.000). These higher values at T2 indicate moderate (peripheral and central sensitization) also play a role in the worsening of symptoms and signs after 2 months (Table 3). pathophysiology of muscular pain (Sessle, 1999; Svensson Improvement in values of FI (F Z 3.72, P < 0.005) and MI and Graven-Nielsen, 2001). (F Z 4.43, P < 0.015) was observed at T1 compared to T0 in OMT group (Table 4). Researchers suggest that massage and manipulation trigger a release of neuropeptides in patients and have Discussion studied the relationship between OMT and the endo- cannabinoid system (Christian et al., 1988). The endo- Osteopathic treatment is a form of manual medicine first cannabinoid system, like the better-known endorphin applied by Still (1902). His principles and philosophy are system, consists of receptors in the brain, nervous system based on an appreciation of human beings’ triune unity and elsewhere (cannabinoid receptors) and their endoge- (body, mind, and spirit), the interrelationship between nous ligands (endocannabinoids). McPartland et al. (2005) structure and function, and the body’s ability to heal itself inferred that the endocannabinoid system may be elicited (Ward et al., 2003). Still hypothesized that manipulative by OMT, with sedative, anxiolytic, analgesic and hemody- treatment stimulated the production of endogenous namic effects (McPartland et al., 2005). compounds that promoted homeostasis and healing. A study by Licciardone et al. (2005) indicated that OMT significantly There is also low evidence from a single case study that reduces low back pain. The level of pain reduction was massage therapy and strain-counterstrain technique greater than expected from placebo effects alone and persisted for at least three months. OMT has been utilized not only in musculoskeletal disorders (e.g. low back pain, Table 2 Comparison of the VAS, MOV and ROM values between OMT and CCT groups (n Z 25) at T0, T1 and T2. OMT CCT t P T0 VASa 6.9 Æ0.88 6.40 Æ1.42 NS 0.000 0.000 MOVb 35.1 Æ4.36 34.9 Æ34.5 NS 0.000 0.001 ROMc 62.4 Æ10.67 64.5 Æ9.55 NS 0.000 T1 VASa 1.5 Æ0.85 2.6 Æ0.7 À4.995 MOVb 46.0 Æ4.78 41.3 Æ4.52 3.572 ROMc 81.9 Æ10.31 71.9 Æ9.05 3.654 T2 VASa 3.8 Æ1.26 4.4 Æ1.75 NS MOVb 42.9 Æ2.69 40.4 Æ2.41 3.461 ROMc 80.5 Æ5.44 72.4 Æ2.95 6.545 a The visual analogue pain scale was scored from 0 to 10. b Measure in millimeters. c Measure in degrees.
Osteopathic manual therapy versus conventional conservative therapy 183 Table 3 Average values and SD of the VAS, MOV and ROM values, ANOVA for repeated measures and Tukey Post test results. Group TO T1 T2 F P Tukey Post test Mean SD Mean SD Mean SD OMT 6.9 Æ0.88 1.5 Æ0.85 3.8 Æ1.26 184.88 0.000 TO vs T1, TO vs T2, T1 vs T2 VASa 35.1 Æ4.36 46.0 Æ4.78 42.9 Æ2.69 48.19 0.000 TO vs T1, TO vs T2, T1 vs T2 MOVb 62.4 Æ10.67 81.9 Æ10.31 80.5 Æ5.44 35.53 0.000 TO vs T1, TO vs T2, ROMc 6.40 Æ1.42 2.6 Æ0.7 4.4 Æ1.75 48.66 0.000 TO vs T1, TO vs T2, T1 vs T2 CCT 34.9 Æ34.5 41.3 Æ4.52 40.4 Æ2.41 23.6 0.000 TO vs T1, TO vs T2 VASa 64.5 71.9 Æ9.05 72.4 Æ2.95 0.000 TO vs T1, TO vs T2 MOVb Æ9.55 8.07 ROMc a The visual analogue pain scale was scored from 0 to 10. b Measure in millimeters. c Measure in degrees. The mean values of VAS, MOV and ROM at T0, T1, and T2 in the OMT and CCT. For each parameter the Post test results are reported. If P < 0.05, difference between treatment at T0, T1 and T2 is statistically significant. (positional release), stimulated parasympathetic activity, tone or diminished neuromuscular coordination may have and reduced neuromuscular activity. These activities would been associated with improvement of TMD in this study engage the relaxation response and, in turn, reduce stress (Schleip et al., 2005). and anxiety associated with TMD (Eisensmith, 2007). The favourable cost benefit ratio of physiotherapy over In the current study, the positive therapy effect on TMD other treatment modalities seems to indicate that physio- may be explained by neural plasticity which could have therapy, in general, can be regarded as a first choice been induced by these therapeutic interventions. Plasticity approach in selected TMD patients. OMT, in particular, had is a property of a self-organizing central nervous system a positive effect on physical symptoms of TMD, and it is (changes in network, synaptic or cell intrinsic properties) recommendable as an effective treatment in patients that is continually optimizing its own performance. suffering from TMD. Therapies targeting the masticatory system (occlusal Further studies need to be conducted to evaluate splints, physiotherapy, osteopathic manipulation and whether the findings are reproducible, and if positive long- others) may have significant neurologic implication via term outcomes can be achieved. If the findings of this study sensorimotor integration with the brainstem, subcortical are reinforced by future research, OMT would prove to be and cortical centers, cervical region, proprioception and a non-invasive solution for managing TMD, either alone or body posture. If therapeutic approaches induce appropriate together with other therapies and/or medication as part of neural plasticity, then it is possible that considerable an overall treatment plan. neurologic improvement of the patient may be achieved (Yin et al., 2007). In this regard, it would be desirable that in the management of disorders involving the TMJ and related It is also possible that manual therapies may influence musculoskeletal structures, dentist should work in close myofascial tone. Thus, increased or decreased myofascial collaboration with osteopaths and physical therapists. Table 4 Average values and SD of the temporomandibular index and the associated subindex in OMT group and the CCT group, ANOVA for repeated measures and Tukey Post test results. Group TO T1 T2 FP Tukey’s test Mean Mean Mean P < 0.05 SD SD SD OMT 0.45 (0.12) 0.34 (0.12) 0.39 (0.15) 0.45 (0.12) 0.34 (0.12) 0.39 (0.15) 3.72 0.005 TO vs T1 Function index 0.64 (0.23) 0.44 (0.27) 0.51 (0.22) 0.64 (0.23) 0.44 (0.27) 0.51 (0.22) 4.43 0.015 T0 vs T1 Muscle index 0.46 (0.28) 0.38 (0.24) 0.43 (0.17) 0.46 (0.28) 0.38 (0.24) 0.43 (0.17) Joint index 0.52 (0.21) 0.39 (0.21) 0.44 (0.18) 0.52 (0.21) 0.39 (0.21) 0.44 (0.18) NS Temporomandibular NS 0.47 (0.23) 0.35 (0.14) 0.40 (0.17) 0.47 (0.23) 0.35 (0.14) 0.40 (0.17) index 0.62 (0.41) 0.45 (0.19) 0.52 (0.18) 0.62 (0.41) 0.45 (0.19) 0.52 (0.18) NS CCT 0.47 (0.36) 0.41 (0.37) 0.44 (0.09) 0.47 (0.36) 0.41 (0.37) 0.44 (0.09) NS Function index 0.52 (0.33) 0.40 (0.23) 0.45 (0.15) 0.52 (0.33) 0.40 (0.23) 0.45 (0.15) NS Muscle index NS Joint index Temporomandibular index The mean values of FI, MI, JI and TMI at T0, T1, and T2 in the OMT and CCT. For each parameter the Post test results are reported. If P < 0.05, difference between treatment at T0, T1 and T2 is statistically significant.
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Journal of Bodywork & Movement Therapies (2010) 14, 185e194 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt PREVENTION & REHABILITATION: EDITORIAL Shifting paradigms Matt Wallden, MSc Ost Med, DO, ND, Associate Editor Received 6 January 2010; accepted 6 January 2010 PREVENTION & REHABILITATIONeEDITOR: MATT WALLDEN Often a fad may be described, perhaps falsely, as a para- product called Vibram Fivefingers. This product is one of digm shift. In the rehabilitation and prevention section of many on the market that claims to offer a functional the previous issue of JBMT, Lederman (2010) challenged benefit to users; fitting it into the emerging category of what many would consider a paradigm shift that has ‘‘functional footwear’’ alongside brands such as Masai occurred over the last decade or more as a result of the Barefoot Technology (MBT), FitFlop, Nike Free’s, Vivo focus by many bodywork and movement therapists on Barefoot and Newton running shoes, among others. ‘‘core stability’’. The sports medicine physician commented that since What Lederman’s (2010) article highlighted was the fact there was little research to back use of the Vibram Five- that, bodyworkers and movement educators have a number fingers; and that what research there was seemed to of tools in their tool-kit, and an important skill involves the suggest a dramatic change of the gait pattern, and the way ability to grow with the knowledge base, and not to the user runs (Squadrone and Gallozzi, 2009), they could be succumb to trends as ‘‘panaceas’’; nor to become too dangerous and might well cause as many injuries as might dogmatic regarding beliefs. This is easier said than done, of be prevented. This may, of course, be true. However, the course. Nevertheless, if such advances can be seen as fact that this new data correlated closely with barefoot emergent tools, which may, at some point, become usurped data, but was distinct from shod data, meant that it could by other more current techniques, this may be judged an be interpreted either as a dramatic change to what the appropriate evolution. Equally, it is important to not (shod) individual is used to; or a dramatic reversion to what become dogmatic in the way the tools used by others are the individual is designed for. judged; too narrow a focus usually results in collisions with unforeseen peripheral concepts and rationale. Evolving ideas One rationale Lederman has previously used was to ask Study of the foot offers an opportunity to consider factors how the human body should function by looking for an such as the possible benefits of barefoot walking. Data evolutionary advantage (Lederman, 2000). Clearly, there is searches suggest that there is an abundance of evidence in rarely a time when a primal human being would be found support of this. (Warburton, 2001; Wallden, 2008; Squad- doing a prone transversus abdominis activation exercise rone and Gallozzi, 2009). with a biofeedback cuff! Nevertheless, there may be rationale to explain how human physiology could embrace In recent years Masai Barefoot Technology shoes have ‘‘core stability’’ and other methods, as part of a primal gained ground in the market place as a new concept. At the environment (see Textbox 1). same time Nike, the largest producer of sports shoes (orig- inators of the concept of a ‘‘running shoe’’), recognized that In a recent discussion with a sports medicine physician, in order to enhance running performance, and decrease a ‘‘tool’’ that the author of this editorial has been involved running injuries, their top advisors were recommending that with for just over 2 years, was explained; a footwear athletes should frequently train barefoot (McDougall, 2009). E-mail address: [email protected] Objectively barefoot walking appears sensible, espe- cially when it is appreciated that supporting a structure (in 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.01.004
186 M. Wallden PREVENTION & REHABILITATIONeEDITOR: MATT WALLDEN Textbox 1: The Survival Reflex (taken from Wallden (2008) Rehabilitation and re-education (movement) approaches in Chaitow (Ed) Naturopathic Physical Medicine. Elsevier) Chek (2000, 2004) has described what he terms a survival reflex where the body will reflexively recruit all muscles it can, to avoid an actual, or a perceived, catastrophic event. Certainly these observations seem to have good founding both in the clinical environment, and in the neurophysiological literature. For example, Davidoff (1992) explains that the capacity of the segmental myotatic reflex system to compensate for changing loads is only modest. What the Swiss ball does not tend to do is to place the body under significant load (as would occur in some sports or in weight-lifting). Davidoff goes on to say that reflexive adjustments at the segmental level may be effective at compensating for perturbation when the errors of position are small and the stretch is rapid. This is exactly what we tend to find with Swiss ball use; a small rapid need to correct the posture. Nitz and Peck (1986) also observe that a characteristic of the deeper, inner unit musculature is that they have an increased concentration of spindle cells making them particularly important for (and reactive to) stability challenges. As Panjabi et al. (1989) discuss, the typically shorter length of the inner unit muscles, and their lower threshold to stimulus, allow them to react more quickly; hence their response to anything that induces a stability challenge, such as a Swiss ball, wobble boards, or balance shoes. Additionally, Janda (1999) comments that a classic way of combating low back pain utilized by the aboriginal Indians of North America was to run in dried out river-beds. Anyone who has tried to run on the soft sand of a beach will recognize that this probably posed something of a perturbation and/or balance challenge to help reactivate their inner unit. In contrast, Hides et al. (1996) showed that even 1 year after resolution of low back pain, the lumbar multifidus had not recovered its normal function. They proposed that this may be a mechanism for the onset of chronic back pain. What Hides and co-worker’s research implies is that if someone has a pain problem, they cannot properly recover from it unless they see a trained therapist to teach them to consciously activate multifidus/transversus abdominis and other inner unit muscles. However, this may be a somewhat simplified view. Indeed the implication would be that prior to Hides’ research in 1996 e which would include the whole of human evolution e a single bout of low back pain or a back injury would result in compromised inner unit function and therefore presumably, compromised ability to move, to hunt or to evade predators. In short, the prognosis after even one bout of back pain wouldn’t be too good. In their paper, Hides et al. do not state how many of their experimental subjects were actively engaged in sports, how many were entirely sedentary e or any shade in between. In an unpublished meta-analysis of the available high-quality literature available on core rehabilitation in 1998, the author concluded that, since there are so many potential methodological flaws with most exercise prescriptions at that time, it would seem that the best way to effectively rehabilitate function of the core musculature, would be to play sports that involved multiple movement patterns. Since then, knowledge has moved on, and effective core activation can be progressed from floor based to Swiss ball based, to standing functional exercises. But to play interactive sports is still a very reasonable piece of advice for core conditioning e assuming that the patient is able to activate their deep stability system when they play their sport. The primal pattern system of assessment described above can be utilized to see if, when and in which movement patterns (motor chunks) the patient is able to activate their core. This conclusion seemed to coincide somewhat with the concept of the ‘‘survival reflex’’ and with the nature of existence in the great outdoors. There is little doubt that in running as fast as the body can manage would allow the climbing of the nearest tree e even perhaps then swinging through the vines to escape a big cat, would be enough to activate both Chek’s ‘‘survival reflex’’ and the perturbations described by Davidoff e and show some parallels to Janda’s river-bed running. the same way one might support a broken arm in a cast) harder than concrete for at least 6 months of the year and, would ultimately result in weakening of the supporting significantly, where most of the major fossil finds of our musculature. To keep the feet strong, and the athlete hominid ancestors were in rocky environments such as the injury-free, Nike were being encouraged by their advisors Rift Valley, Olduvai Gorge or volcanic regions such as Lae- to consider a ‘‘barefoot’’ alternative, ultimately resulting toli. Indeed, the African palaeoecological record of the past in the birth of the ‘‘Nike Free’’. 2þ million years shows a proliferation of drought-tolerant trees, with moisture-loving trees being less prevalent for The evolutionary experiment the last 2þ million years than they are even today (Stringer and Andrews, 2005). All animals require sufficient func- The foot evolved around 270 million years ago (Haines, tional dexterity so that they can survive and thrive in the 1999). In contrast, shoes have been around for a few thou- environment in which they find themselves; which would sand years at most, making their congruence with optimal rarely be one single substrate, but a combination of hard, biomechanical function of the foot more questionable. soft, rugged, flat and inclined surfaces, and much more besides. The primary counter argument posed by those who hold strongly to the notion that shoe support, or cushioning, is Interestingly, Zipfel and Berger (2007) assessed lesions required, is that humans did not evolve on concrete roads found in the metatarsals of the three recently evolved human and paths (Downey, 2009). groups (Sotho, Zulu and European) and found that they generally appeared to have more severe pathologies than The best available evidence implies that humans evolved those found in groups of 35 pre-pastoral (9720 and 2000 years in Africa, where great swathes of the land were baked
Shifting paradigms 187 PREVENTION & REHABILITATIONeEDITOR: MATT WALLDEN before present) remains. They suggest that this result may Nike developed the Nike Free running shoe in 4 phases: support the hypothesis that pathological variation in the In Phase 1, they gathered information regarding barefoot metatarsus was affected by habitual behaviour e including function while running on grass; in Phase 2 they created the wearing of footwear e and exposure to modern substrates. a shoe to allow close mimicry of the barefoot kinematics observed in phase 1. For Phase 3, Nike decided to partner However, since both recent and ancient groups presented with Prof. Peter Brueggemann at the University of Koln to with similar patterns of pathological variation, but notable assess the potential benefits of warming up and walking differences in frequency, Zipfel and Berger (2007) interpret around with the Nike FREE shoes. Brueggemann conducted these changes as only, in part, a result of the environment, an unpublished study in which 100 athletes participated. and to a greater extent ton be a result of differences in Athletes were randomly divided into a control group and an habitual behaviour e primarily the wearing of shoes. experimental group. Following 12 weeks of warming up and walking around with the Nike FREE, rather than warming in When shod versus unshod populations are compared, their own sport shoes (Control group), Brueggemann found there is research confirming that unshod populations have that the Nike FREE group increased the flexibility and better arch development (Rao and Joseph, 1992; Mauche strength of their feet more than the control group (use of et al., 2008), and that there is a lower prevalence of many their own sport shoes). He also found that the Nike FREE of the most common running injuries in barefoot running group improved its balance score while standing on 1 foot populations, versus shod running populations including (Personal Communication, Mario Lafortune, Nike Inc, 2009). ankle sprain, shin splints, Achilles tendinopathy, plantar Breuggemann was twice contacted with a request for fasciitis, iliotibial band syndrome, peri-patella pain, back further detail of this research but no response has been pain (Warburton, 2001). received to date. From this recognition, a new phenomenon has arisen; Nike concluded that trainers, coaches and athletes they the emergence of a market for ‘‘functional footwear’’. were working with believed that this improvement in flex- ibility, strength and balance should lead to better perfor- Functional footwear mance and lower injury risk. Six current brands of so-called ‘‘Functional Footwear’’ are VivoBarefoot (Contributor: B. Le Vesconte, discussed below (the Nike Free, the MBT, the FitFlop, Viv- VivoBarefoot.) obarefoot, the Newtons, and the Vibram Fivefingers). It is acknowledged that this list is not fully comprehensive, and VivoBarefoot shoes are based on the simple principal, that that there are other products such as Beech Sandals, Earth being barefoot is the most natural and healthy way for our Shoes, Crocs, and many others besides, who claim (and may feet and bodies to be. Vivobarefoot shoes have an ultra well have) functional benefits, however, journal space and the thin, puncture resistant sole. ability to provide a fully exhaustive review in such a growth sector would always dictate the need for a cut-off point. In their marketing literature they explain that the human foot is a masterpiece complete with 200,000 nerve Conflict of interest endings, 28 bones, 19 major muscles, 33 joint centres and 17 ligaments. Six million years of evolution created the The author of this editorial is UK Distributor, Vibram Five- perfect foot, then we started wearing shoes. fingers, one of the six brands reviewed in this editorial. VivoBarefoot claim that their shoes protect the foot with Nike free (Contributor: M. Lafortune, Nike Inc.) an ultra-thin (3 mm) puncture resistant sole; that they strengthen the foot naturally by encouraging the muscles of Nike is closely connected with athletes and coaches at all the feet to work; that they stimulate every nerve ending in levels, from beginners to elite athletes. At the time of the the feet to enhance sensory perception; and that they Sydney Olympics, we started to hear more and more about realign posture. athletes either warming up for or cooling down from their runs, barefoot. These barefoot warm ups or cool downs Editor’s note: Whilst there is no citation of medical typically took place on nice pristine soccer/football fields. references for these claims, there are examples of this kind In the opinions of coaches and athletes, this leads to better of information in the medical literature that are easily performance and less injury. obtainable, for example, see Warburton, (2001). ‘‘ I can’t prove this, but I believe that athletes that have Of particular interest in this section is the last claim that been training barefoot run faster and have fewer injuries. the shoes may realign posture. The paper by Siqueira et al., It’s just common sense.’’ Vin Lananna, Track & Field, 2010. in this section of this issue of JBMT, looks at postural University of Oregon (McDougall, 2009; Lafortune, 2009) stability in those with knee hyperextension versus those with optimal knee alignment. Considering that only few athletes (beginners to elites) have access to well maintained and safe grassy surfaces due Firstly, such hyperextension of the knee, based on to locations or climatic conditions, Nike decided to create Siqueira et al’s work, may, theoretically, be tempered by a shoe that would allow athletes to run on pavement and wearing shoe with inbuilt lability (as with the MBT’s and have their feet function as they function when running FitFlops), and secondly, hyperextension at the knee is, barefoot on grass. according to Barker (2005), the most common result of having a heel on a shoe, something deliberately avoided by the VivoBarefoot, the Vibram Fivefingers, and minimized in the Newton’s and the Nike Free.
PREVENTION & REHABILITATIONeEDITOR: MATT WALLDEN 188 M. Wallden Linking this to Liebenson’s contribution to this section of Editor’s note: This presupposes sufficient mobility and JBMT on sagittal plane curvatures, the most common elasticity in these joints, especially pelvic and spinal joints, biomechanical result of knee hyperextension is a concomi- to accommodate such demands, otherwise adaptative tant increase in lumbar lordosis (Barker, 2005). As Janda stresses could evolve. has stated, an upper crossed syndrome is the ‘‘child’’ of a lower crossed syndrome (Chek, 1994). Any alteration in MBTs increase muscle activity in the lower limb which MBT spinal curvature will impact on spinal mechanics (Wallden, claim will reduce joint loading whilst increasing calories 2009), on the function of the spine as an engine in gait burned in standing walking and jogging (Vernon, 2004; Nigg, (Gracovetsky, 1997), and thereby reduce overall locomotor 2004, 2009; Romkes, 2006; Mueller, 2007; Hoppeler, 2008). efficiency and increase injury risk. It may be possible then, that shoes may be a causative factor in stooped posture, as Editors note: This seems counterintuitive, as increased discussed in Liebenson’s paper. muscle contraction will always increase joint loading. However, it may be that the lability of the surface the MBT Shoes translate loading toward the forefoot, which provides results in facilitation of the tonic musculature creates an excitatory response in the quadriceps group, or which, whilst designed to compress the joints, does so in a quad-dominant muscle firing pattern. If this occurs, the a relatively gentle (usually at just around 1e10% of maximal quadriceps are firing in a dominant fashion over and above voluntary contraction) and controlled manner (tonic moto- the gluteus maximus and the combination of these two neurons have a far fewer muscle fibres they communicate factors results in an increased anterior tilt of the innominate with, increasing their capacity for fine tuning) (Bompa, 1999) and subsequent lumbar hyperlordosis. (Sahrmann, 2002) MBT: Clinical benefit have been shown using MBTs for The potentially detrimental sequellae of this, range reduction in low back pain, reduction in neck pain, reduc- from increased hallux valgus due to aberrant load of the tion in knee pain secondary to osteoarthritis (Nigg et al., forefoot, increased stress to the anterior cruciate ligament 2006 a,b), improvement in chronic ankle instability (Ka¨lin, due to quadriceps dominance (Neumann, 2002a), unlocking 2008), reduction in heel pain and improvements in quality and relative instability of the sacroiliac joints due to of life measures for workers that stand at work. decreased form closure (Lee, 2005), and facet impinge- ment/irritation due to increased loading through the Editor’s note: MBT provide references for many of these posterior load-bearing columns (Wallden, 2009). claims, though most are unpublished. MBT suggest that the positive effect of their footwear is ‘‘based on the principle It has been observed that the fashion for high heels on of natural instability. An effect which can, in fact, be shoes in Europe historically correlates consistently with achieved without the benefit of high-tech footwear: by climactic events; mini-ice-ages (Lafferty, 2008) The only simply walking barefoot on soft, uneven, natural ground other rationale for having a heel on a shoe, historically is that such as sand or moss’’. it is the part of the shoe that wears out the quickest due to the increased impact at heel strike when walking so a thicker However, they claim, in today’s modern world such heel means a longer lasting shoe (Neumann, 2002b), and barefoot walking on soft ground is not always easy to do and perhaps a longer lasting shoe or being ‘‘well-heeled’’ was their footwear provides a solution. once perceived as equating with higher social status. MBT say ‘‘From hard, flat surfaces to soft, natural, uneven Masai Barefoot Technology (MBT) (Contributor: ground, MBTs activate and strengthen the small supporting J. Wies, Director MBT Academy UK.) muscles which are the body’s natural shock absorbers’’.This is another way of describing what’s been already stated The concept behind the MBT is that the foot is not designed to above, though the concept of shock absorbers is perhaps walk on flat hard ground and so, by building a soft spongy heel a little outdated; and exploitation of a specific energy niche component into the shoe ‘‘the MBT sensor’’, the heel sinks may be a more effective and accurate way of viewing these into the shoe (as it would do on sand or a soft forest floor) and muscles and their associated fascia. that the contour of the sole of the shoe; a convex arch, makes the foot ‘‘roll’’ from heel to toe, decreasing impact forces, According to MBT ‘‘The mid-sole, with its integrated spreading the load across the foot more evenly and mini- [convex] balancing area, requires an active and controlled mizing stresses higher up in the kinematic chain. rolling movement with every step.’’ This function of the MBT may be of use for those with functional hallux limitus; Editor’s note: Similar to the FitFlop concept discussed though it may equally inhibit the normal flexibility of the below, the MBT creates a labile base of support; particularly, 1st MTP in those with ‘‘normally functioning feet; and will in this instance, in the sagittal plane, which will excite the certainly curtail any benefits of the windlass1 mechanism tonic motoneurons (Davidoff, 1992) and hence the tonic or which is most active as the toe hyperextends to around 65. ‘‘inner unit’’/‘‘local system’’ musculature of the body. 1 Windlass mechanism Z classically, as the gait cycle moves from MBT: MBTs have been shown to change postural align- mid-stance to toe-off, the toes move into hyperextension, ideally ment to a more upright position by 10 due to equal changes reaching 65 degrees of extension, the plantar fascia is drawn tight occurring at the knees, hips, pelvis and lumbar spine; increasing the arch along the medial aspect of the foot creating probably because of this capacity to excite the tonic a spring like mechanism to push the person forward as they toe-off musculature or postural musculature of the body. This in (Neumann c) 2002). Less commonly described, but equally valid, turn may lead to more efficient postural muscle and joint the windlass mechanism occurs in the open chain extension of the function. (New & Pearce, 2006) The regular wearing of toes in the swing phase of gait prior to heel strike prepares the MBTs improve both static and dynamic balance (Nigg, 2005) medial longitudinal arch of the foot for loading; and may also be engaged further in runners who forefoot strike, thereby storing elastic energy in the plantar fascia.
Shifting paradigms 189 PREVENTION & REHABILITATIONeEDITOR: MATT WALLDEN It does of course also raise the point that if the arches of Greater shock absorption compared to leading brands. a bare foot are concave, why would a shoe that is convex be The Newton Active Membrane Technology (AMT) called ‘‘barefoot’’? MBT’s answer is that they have provides up to 80% greater displacement on impact, attempted to recreate the way a barefoot moves through resulting in dramatically increased energy absorption sand; not necessarily how it moves on harder surfaces, and (lower shock to the body.) Leading brands result in up so such kinematic analysis shows that the heel sinks to 100% high shock to the body (see Figure 1). somewhat, the midfoot pivots over the ridge created by the displaced sand, in a rocking style motion; and it is this Editor’s note: Newton also report other benefits less motion that MBT have attempted to recreate in their shoe related to this discussion such as increased energy return design. and increased forefoot support, compared to other leading running shoe brands. They also go on to say that MBT say that in conjunction with the Masai Sensor, the most people load the heel portion of their shoe at some body’s entire musculoskeletal system is activated and point during the gait cycle and, depending on their exercised, the muscles in the buttocks, stomach and back running style and shoe geometry, this loading may vary are strengthened, posture and gait are kept relaxed and from almost negligible to severe impact. Irrespective of upright and stress on the joints and back is relieved. this heel loading, significant midfoot forces are generated by all runners as their centre of mass moves anteriorly These points are all of relevance to the bodyworker and over the foot before push off. The standard heel-to-toe movement therapist. It might be noted that the claims of drop is just over 1 cm in most running shoes; meaning it is ‘‘increased muscle contraction’’ with ‘‘relaxed posture and difficult to avoid hitting the heel portion of a regular gait’’ would appear somewhat contradictory, though this running shoes. does depend on which muscles are being assessed; the larger outer unit muscles like the hamstrings and gluteals, Newton’s along with some of the other brands of or the smaller intrinsic muscles such as the deep multifidus, ‘‘functional footwear’’ in this discussion (VivoBarefoot, the gemelli, vastus medialis obliquus, if it is the latter, then Nike Free & Vibram Fivefingers) have decreased or nullified it makes more biomechanical and physiological sense and the heel-to-toe drop; both allowing more of a midfoot may not be contradictory. strike (as if running in a natural barefoot state) and reducing shock loads associated with heel strike, see Newton (Contributor: I. Adamson, Newton Figure 1. Running.) FitFlop (Contributor: D. James, co-designer Editors note: Newton running shoes don’t so much try to FitFlop.) mimic barefoot running as to encourage the wearer to run in a more ‘‘natural’’ running gait by promoting a forefoot The FitFlop was developed in 2006 with the brief to develop strike in running gait, as opposed to the more commonly a shoe-based technology and concept that was biome- seen ‘‘heel strike’’ in those wearing running shoes (Squad- chanically valid. Since the earlier Masai technology was rone and Gallozzi, 2009; De Wit et al., 2000). designed from a sagittal plane perspective it seemed intu- itive to approach development of a new shoe from Newton: Newton claim that their improved shoe geom- etries encourage a natural running gait, resulting in lower Figure 1 Forefoot strike versus Heel strike. The research impact to the body. Newton shoes have 4e5 mm heel lift conducted by Newton on the peak impact force when wearing compared to 12e13 mm for traditional running shoes their footwear versus other running shoe brands is congruent (10 mm for racing flats.) with other research (McDougall, 2009; Lieberman et al., 2010) suggesting that forefoot strike (which the Newton running Editor’s note: This, of course, correlates with one of the shoes mechanically engender) minimizes impact force. rationale described by VivoBarefoot in their shoe design (as well as the Nike Free’s and the Vibram Fivefingers). Newton: This allows users to run naturally by loading their leg when their centre of gravity passes over their foot and their joints are flexed. Traditional shoes with a 10e13 mm heel lift load the leg too early in the gait cycle when the joints are locked out and the foot strike is forward of the centre of gravity, resulting in high shock loads and braking. The small lift in Newton shoes allows runners to readjust the soft tissues in the back of their leg (stretch back to their natural length) without being too aggressive. Zero drop has proven too much of an adjust- ment for most runners. Biomechanical top plate (inside the shoe) enhances afferent feedback from the ground to the foot, facili- tating the runner’s ability to sense and react to the ground naturally. Traditional cushioning (foam, gel, air etc.) dampen afferent feedback, encouraging harder foot strikes.
PREVENTION & REHABILITATIONeEDITOR: MATT WALLDEN 190 M. Wallden a medial-lateral standpoint. The concept they developed (unpublished data). Such a finding might have postural was what they term ‘‘Micro’wobbleboard’’ technology, its benefits. We have performed acceleration measures goal, to enhance muscle activation patterns. recorded at the lower leg and found a 53% increase in low frequency power when compared to a control shoe The FitFlopä is constructed out of differing mid-sole (p Z 0.006; n Z 10; unpublished data). This power is densities in an innovative vertical arrangement. The indicative of active kinematic strategies, and such concept is to slightly destabilise the user during the adaptations have been noted in the literature in dealing weight-bearing phase of the gait cycle, in a way similar to with the forces associated with ground impact (De Wit a soft, uneven forest floor or other ‘‘natural’’ surface; thus et al., 2000). creating a more continuous tension in the supporting Reduce shock. Our research has demonstrated a 22% muscles in the foot and leg to correct this instability. decrease in impact-related shock (p Z 0.02; n Z 10) at the tibia compared to a control shoe using spectral Editor: This line of thought; an unstable surface creating analysis of the acceleration signal, see Figure 2 increased tensioning of the musculature of the lower limb is (unpublished data). consistent with the study presented in this section by Increase muscle activity. Peroneus Longus (PL) activity Sequeira et al. and also with Janda’s description of ‘‘river- consistently shows significantly increased muscle bed running’’, and the rocker shoes Janda promoted in the activity when tested against a control shoe. In our most rehabilitation setting for the last few decades (Janda recent study (n Z 17), RMS ratio was increased by 11% 2007). (see Textbox 1 above). (p Z 0.007) (unpublished data). Such a repeatable measure demonstrates the validity of ‘Micro-Wobble- FitFlopä claims to improve posture, to reduce shock, to boardä’ Technology. The PL acts as a stabilizer during increase muscle activity and to reduce foot pain. Research mid-stance to assist in the maintenance of an upright supporting these claims include: posture (Schunk, 1982), and is accentuated further as the foot passes over the soft-density medial section of Improve posture. An independent investigation repor- the mid-sole. ted the ground reaction force vector during loading response to be directed more centrally towards the trunk in the FitFlopä when compared to a control shoe Figure 2 Pressure distribution Fitflop versus control shoe during walking gait. Compare and contrast these with the pressure distributions in Figure 3 below.
Shifting paradigms 191 PREVENTION & REHABILITATIONeEDITOR: MATT WALLDEN Increased activation of Rectus Femoris (6%), Medial Significance: Barefoot running and running in Vibram Gastrocnemius (4%), and Tibialis Anterior (5%) has previously Fivefingers results in more of midfoot or forefoot strike, been reported whilst wearing the FitFlopä; however, these whereas running shod results in more of a heel strike. differences were not large enough to elicit a significant Barefoot running and running in Vibram Fivefingers effect (p > 0.05) when compared against a control shoe. increases the stiffness requirement of the lower limb; this may have significant effects on sports performance as Reduce foot pain ‘Microwobbleboardä’ Technology has stiffness is a factor in top flight running speed and in been shown to reduce the pressure distribution under effective load transfer. the plantar surface of the foot when compared to a control shoe, see Figure 2 (unpublished data). In Shod running is around 2e3% less efficient (in terms of particular, reductions have been demonstrated under oxygen consumption) compared to barefoot running the medial and lateral heel, and metatarsals (Figure 2). These observations support the efficacy of our tech- Running in Vibram Fivefingers is 0e1% more efficient (in nology along with the notable difference in centre of terms of oxygen consumption) compared to barefoot pressure trajectory. Interestingly pressure distribution running is greater under the phalanges. The implications of these findings are not clear until a clinical population is Significance: Running barefoot and in Vibram Five- tested; however, it appears that foot functionality is fingers is more energetically efficient than running shod. preserved in the FitFlopä. This has been known about running barefoot for a long time (Warburton, 2001) but has been assumed to be due to Editor’s note: Similar to the MBT, the FitFlop can be the weight of the shoe on the end of a long lever e the leg. seen to increase muscle activation in walking in, however, This finding, however, throws that interpretation into there are no claims that this increases gait efficiency; question. moreover that it stimulates greater muscle contraction in a way similar to walking over uneven ground (Vines, 2005). Shod running spreads loading more broadly across the foot compared to the natural condition (see Figure 3) Vibram Fivefingers (Contributor & Editor M. Wallden, UK Distributor, Vibram Fivefingers) Running in Vibram Fivefingers creates a pressure loading spike around the 2nd metatarsal head; almost In contradistinction to the other shoes in this range of identical to barefoot running. functional footwear, the Vibram Fivefingers were not developed with any biomechanical intent in mind. The Significance: Switching from running shod to barefoot history of Vibram as the world’s leading sole manufacturer running may result in increased loading (and potential meant that, at its core, Vibram’s reputation was to produce injury) of the 2nd metatarsal head; particularly if a period hard-wearing, sure-gripping soles. The remit of the of adaptation is not built into the transition. However, in designers at Vibram was to use this protective grip tech- order to generate forward power, loading against the nology to create a shoe that mimicked the sensation of being ground in toe off, where there is optimal leverage for barefoot on a sailing boat with the grip and reassurance of forward propulsion is required. This may explain the a Vibram sole. increased efficiency of barefoot and Vibram Fivefingers, versus shod, running. However, when Vibram’s Fivefingers were taken to the US Market in 2006, it soon became clear that they were A major difference between the Vibram Fivefingers attracting attention from fields far outside the anticipated footwear and the other shoes discussed are the separated sailing market. With strength and conditioning coaches, toe compartments. The theory behind this is to allow the running coaches, pilates instructors, yoga instructors, foot to function as nature intended; and in doing so, allow physical therapists and many podiatrists taking a keen the toes to act more proprioceptively, through their entire interest in the Fivefingers product, Vibram knew that they range of motion and to allow lateral spread; affording had to look at providing an evidence base for their rec- greater frontal plane stability. ommending customers to refer to. Discussion This first piece of research specifically detailing the biomechanical effect of wearing Fivefingers footwear was Some of the key discussion points in terms of the functional published in March 2009 (Squadrone and Gallozzi, 2009) footwear products discussed are: 1) Labile sole, versus non- comparing shod running, with barefoot running with ‘‘Five- labile; 2) Tactile sole versus non-tactile; 3) functional flex fingered running’’ and, in brief, concluded with the following points in the sole; 4) Sole modifications to create a soft points: landing, versus shoe modifications to minimize any protection on landing; 5) Minimal or no heel raise. Shod running creates significantly change in angles at ground contact, of the ankle, the knee and the hip 1) Labile versus non-labile: The function of a labile sole compared to the natural barefoot state (such as the MBT or Fitflop sole) may be of use in mini- mizing repetitive strain injuries, in facilitating the tonic Running in Vibram Fivefingers creates an almost iden- system of the body and in training the tilting reflex tical posturing of ankle, knee and hip compared to the (useful in most water sports or in any situation where the natural barefoot state surface you’re standing on moves under you e.g. riding
192 M. Wallden PREVENTION & REHABILITATIONeEDITOR: MATT WALLDEN Figure 3 Pressure distribution barefoot versus Vibram Fivefingers versus control running shoe during running gait. Note the pressure spike near the 2nd metatarsal head, this may be optimal for forward propulsion, but may equally lead to metatarsalgia if transition from shod to barefoot (or minimalist footwear) is too rapid to allow for adaptive change. a bus or an escalator). A non-labile sole, may be of more forefoot strike. This is considered the ‘‘natural’’ use in training for sports or activities in which the surface patterning as it is adopted almost instantaneously by does not move under you; most ball sports, running, subjects under biomechanical analysis; whereas it walking, dancing, climbing, activities of daily living; takes the same subjects as much as 4 min of running to anywhere you’re using a righting reflex profile. ‘‘acclimatise’’ and adjust their gait to suit the running 2) Tactile versus non-tactile: This function of the sole may shoe they may be wearing (De Wit et al., 2000) be of use in facilitating proprioceptive feedback and may 5) Minimal or no heel raise: As discussed above, the heels facilitate afferent neural pathways as well as optimizing on shoes, sports shoe notwithstanding, is a historical efferent muscle recruitment strategies; in an ‘‘infor- (or fashion) artefact which has no biomechanical benefit mation out can only be as good as information in’’ way. e and probably only a biomechanical detriment. 3) Functional flex points in the shoe: This function will allow a full range of motion at all 26 joints of the foot, To draw this back to the research presented in this rather than just the one or two of traditional supportive section of this issue of JBMT, by Siqueira et al. regarding sports shoes; maintaining functional range of motion flexing of the knees under perturbation; as well as the and biomechanical function. This may be of particular discussion by Liebenson of correcting the sagittal spinal significance with regard to the metatarsophalangeal curves, there is a further possible mechanism for the joints (esp 1st, 2nd and 3rd) which are so heavily changes in knee flexion we see in the research. De Wit et al. involved in the windlass mechanism. (2000) confirm that knee flexion and leg stiffness is 4) Sole modification to create a soft landing versus those increased when subjects run barefoot versus shod. Squad- that minimize protection: Research by Robbins and rone and Gallozzi (2009) agree that this knee flexion Waked (1997), as well as Divert et al. (2005) questions occurred in their barefoot runners and their runners the validity of creating a soft landing through provision wearing Vibram Fivefingers; while Siqueira et al. also find of ‘‘soft’’ sole materials as it appears that the nervous increased flexion in their subject under balance challenge. systems response to this is to ‘‘seek’’ for the stability of the ground through the soft sole; thereby increasing Hypotheses strike impact through the shoe to compensate for its softness. Minimalist soles (or going barefoot), on the It could be that flexion of the knee both brings the centre contrary, evoke a change in biomechanical strategy; of gravity lower as well as increasing stiffness of the a shortening of the stride, a quickening of the cadence lower limb due to the prerequisite muscle contraction. and an altered ground contact e usually a midfoot or
Shifting paradigms 193 And if this is the case, it might be that barefoot runners Free 3.0). The VivoBarefoot or Vibram Fivefinger would (or equivalent) drop their centre of gravity and flex probably be somewhere between 0.1 and 1.0 on this their knees more due to the fact that they have scale. Recommendation of a long term active rehabilita- a smaller base of support. tion/re-strengthening strategy by means of transition from support to no support, in daily increments, Additionally it is possible that MBT and FitFlop users do combined with a parallel corrective exercise program to the same, due to the labile nature of their footwear? rebuild the arch, would be clinically appropriate, whereas the use of an acute ‘‘passive crutch’’ which an anti- A question remains as to why stiffness increases, and it pronation device offers, is probably only a short term may be hypothesised that this is merely an artefact of solution. a flexed lower limb? Similarly, it would make little clinical-sense to place Another possible answer is that a cushioned sole and someone on a labile surface all day, when most rehabili- the increased loading through that sole requires less tation and conditioning specialists would advise against stiffness to achieve the appropriate raw energy pulse using a wobble board, or a Swiss ball, for lengthy periods; as from the ground reaction force, to drive the spinal the result would be fatigue in the tonic musculature, engine2, as described by Gracovestky (1997). leaving the user vulnerable to injury or faulty compensatory recruitment patterns. Summary ‘‘Functional footwear’’ is just one of many of the useful Conclusion PREVENTION & REHABILITATIONeEDITOR: MATT WALLDEN tools that are available both to the bodyworker and movement therapist; as well as to their patient base. Choice of functional footwear should not be dependent on products because of their appearance but should reflect To be able to advise on which of these tools may be most clinical and practical needs. appropriate for clients/patients, based on their needs, has relevance to the effectiveness and integrity of any Since the human form spent somewhere between 4 and 7 healthcare practice. million years in the making, and the foot a further 265 million years evolving, the recent model (40 years or so) of While it may be appropriate to recommend use of MBT to placing of feet on thick polyurethane soles (with various someone with hallux rigidus, the same recommendation to ingenious contours) between the plantar aspect of the foot, someone who needs to retain full ROM in their first MTP e or and the ground might be seen to be undesirable. The weight who has hallux limitus e may be inappropriate. of evidence appears to be tipping towards that perspective (Stacoff et al., 2000; Richards et al., 2009; Mauch et al., It may be inappropriate to recommend barefoot training, 2008; Anderson, 1996; Divert, 2008; Squadrone and Gallozzi, or minimalist shoes for someone with metatarsalgia, whereas 2009; Robbins and Waked 1997; Nigg et al., 1999; Wolf et al., a runner with a history of plantar fasciitis or Achilles ten- 2008; De Wit et al., 2000; Divert et al., 2005). dinopathy may benefit greatly from barefoot running, due to the lack of heel strike and lighter footfall. In much the same way that ‘‘core function’’ or motor control research can be seen to have correlates with the To recommend the wearing of shoes with inbuilt lability to path we trod to get here (Texbox 1); so too can emerging someone who uses a righting reflex profile for their sport or research on the functional foot. This understanding may activities of daily living (ie land-based activities) may be a less help us to select appropriate tools for intervention, based effective strategy than encouraging them to wear a shoe in on each individual patient’s physiological needs. which they can feel the ground. In contrast, someone engaged in a sport or activity in which the surface on which they stand References moves (a boat, a bus, a surfboard, a horse, or a skateboard), may benefit greatly from a shoe with inbuilt lability. Anderson, T., 1996 Aug. Biomechanics and Running Economy. Sports Med 22 (2), 76e89. Duration is another factor that requires consideration. For someone with a longstanding pronation pattern, to Barker, V., 2005. In: Posture Makes Perfect, third ed. Waiwera introduce a rapid transition to minimalist footwear, would International Limited. not be advisable. This is why Nike developed a sliding scale, moving from 10 being a standard fully supportive Bompa, T., 1999. Periodization training for sports. Human Kinetics, shoe to 0 being barefoot. The Nike Free currently 18e20. encompasses a ‘‘near full support’’ (the Free 7.0) to ‘‘half support’’ (the Free 5.0), to ‘‘minimal support’’ (the Chek, P., 1994. Scientific Back Training. Correspondence Course. CHEK Institue, Vista, CA. 2 The spinal engine theory, (briefly explained in Wallden, 2009) was developed in the 1980s by Serge Gracovetsky and published in Chek, P., 2000. How to activate ‘‘survival reflexes’’ for improved his book of the same name in 1988. The theory proposes that the strength. Published on. http://www.dragondoor.com/articler/ spine optimizes efficacy of motion in the gravitational field by using mode3/231/ Accessed 05.12.06. the spine to propel the legs forwards by capturing the ground reaction force to de-rotate the spinal segments with each step of Chek, P., 2004. 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Journal of Bodywork & Movement Therapies (2010) 14, 195e202 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt PREVENTION & REHABILITATIONeQUALITY OF LIFE RESEARCH QUALITY OF LIFE RESEARCH Pilates method in personal autonomy, static balance and quality of life of elderly females Brena Guedes de Siqueira Rodrigues, Esp., Prof. a,b,*, Samaria Ali Cader, Dra., Prof. b,c, Nat´ali Valim Oliver Bento Torres, MSc., Prof. d, Edile´a Monteiro de Oliveira, Esp., Prof. a,b, Este´lio Henrique Martin Dantas, Dr., Prof. a,b,e,f a PROCIMH e Universidade Castelo Branco, RJ, Brasil b LABIMH e UCB, RJ, Brazil c Universidade Nossa Senhora de Assun¸ca˜o e Paraguai d Universidade Federal do Para´ e UFPA, Bele´m-Pa, Brazil e Grupo de Desenvolvimento Latino-Americano para a Maturidade e GDLAM, Brazil f Bolsista de Produtividade em Pesquisa e CNPq, Brasil Received 26 August 2009; received in revised form 18 December 2009; accepted 20 December 2009 KEYWORDS Summary Objective: The aim of this study was to evaluate the effects of the Pilates method Pilates; on the personal autonomy, static balance and quality of life in healthy elderly females. Personal autonomy; Method: Fifty-two elderly females were selected and submitted to evaluation protocols to Balance; assess functional autonomy (GDLAM), static balance (Tinetti) and quality of life (WHOQOL- Quality of life OLD). The Pilates group (PG: n Z 27) participated in Pilates exercises twice weekly for eight weeks. Descriptive statistics were compiled using the ShapiroeWilk test. The level of signifi- cance was considered to be p 0.05. Results: The dependent Student-t test demonstrated significant post-test differences in the Pi- lates group in the following areas balance (D% Z 4.35%, p Z 0.0001) and General Index of GDLAM (D% Z À13.35%, p Z 0.0001); the Wilcoxon test demonstrated significant post-test differences in the quality of life Index (D% Z 1.26%, p Z 0.0411). Conclusion: The Pilates method can offer significant improvement in personal autonomy, static balance and quality of life. ª 2009 Elsevier Ltd. All rights reserved. * Corresponding author. Brena Guedes de Siqueira Rodrigues, Rua Mundurucus 984/402, Jurunas, Bele´m-Pa-Brazile 66025-660, Brazil. Tel.: þ55 91 8867 2002/3222 9946. E-mail addresses: [email protected] (B.G.de Siqueira Rodrigues), [email protected] (S. Ali Cader), natalivalim@ yahoo.com.br (N.V.O. Bento Torres), [email protected] (E.M.de Oliveira), [email protected] (E.H. Martin Dantas). 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.12.005
PREVENTION & REHABILITATIONeQUALITY OF LIFE RESEARCH 196 B.G.de Siqueira Rodrigues et al. Introduction Methods and procedures The aging process involves a series of degenerative, gradual Samples and irreversible alterations of body systems culminating in complete loss of function (Matsudo et al., 2000). These Fifty-two volunteer participants were selected by a simple alterations can cause losses of strength, flexibility, random sampling. They were randomly divided by lottery balance, coordination and memory, leading to considerable into two groups: twenty-five in the control group (CG) and losses of personal autonomy and quality of life for elderly twenty-seven in the age-matched Pilates group (PG). They people (Heathcote, 2000; Rogatto and Gobbi, 2000). were all women, aged 60e78 years (66 Æ 4 years), with a height average of 1.55 (Æ0.06), weight of 62 (Æ14.12) and Loss of balance represents a significant difficulty in the body mass index of 25.8 (Æ5.64), participants of an Occu- lives of elderly people characterized by reduced postural pational Therapy group (twice weekly), sedentary for at control in dynamic and static situations and increased risk least six months and none had been through a Pilates class of falls and injuries (Montes-Castillo, 2006). This deficit has before. direct consequences for personal and functional autonomy related to individual capacity to complete daily activities, All participants met the inclusion criteria, which control will and feelings and hide physical and/or mental included the following: capacity to carry out activities of limitations (Heathcote, 2000; Dantas et al., 2004). daily living without physical support, physical aptitude for the practice of Pilates exercises, and no practice of any Functional limitations due to age affect the capacity of other type of physical activity during the study period. They each individual to carry out their activities and present also failed to meet the following exclusion criteria: direct challenges to well-being and quality of life for pathologies that could cause physical limitations or that elderly people (Rebelatto et al., 2006; Siren and Hakamies- interfered with the functions of attention, understanding Blomqvist, 2009). Quality of life is a subjective concept, and cognition, and use of medication for the treatment of although it can be understood as a measure of perfect bone, muscle or joint injuries. All participants were physical, psychic and social well-being (Minayo et al., required to complete the entire intervention program. 2000). All subjects gave their written consent according to Several studies have been developed to examine the the Regulations Governing Research on Human Subjects of importance of health quality in old age. Many of them have (WMA, 2002), and this study was approved by the Institu- emphasized the importance of physical activity or mobility tional Ethics Committee under protocol number 0050/2008 as a way of improving organic conditions and slowing e UCB/VREPGE/COMEP/PROCIMH. This research does not physical degeneration. (May, 2003; Kura et al., 2004; pose physical or psychological risks to participants, and all Pieron, 2004). of the ethical rules of identity and image confidentiality were respected. Pilates consists of a physical exercise that uses resources such as gravity and the resistance of springs, either to resist Procedures or assist movement execution (Gagnon, 2005). It aims to prevent automatic movements, which are responsible for For the evaluations, the following equipment was used: unwanted muscle activity that can cause injuries (Petrofsky a mechanical adult scale with a capacity of 330.7 lb et al., 2005). (Instituto Sa˜o Paulo/SP), a stopwatch with 30-lap memory (SL210 Oregon), a shirt (Heringâ size X), two obstacles to According to Anderson and Spector (2000), Pilates turn and one chair without arms (50 cm height). encouraged the importance of proprioceptive stimulation for motor learning improvement using the powerhouse Both groups were submitted to a general evaluation of exercise (transversus abdominus, obliques, and multifidi personal autonomy, static balance and quality of life. muscles) and repetition of correct movement to achieve Personal autonomy was evaluated through the Latin the training standard, leading to a better motor perfor- American Development Group for Elderly (GDLAM) protocol mance and less risk of injuries. (GDLAM, 2004), which consists of tests including 10 m walks (C10 m) (Spila´ et al., 1996), standing up (LPS) (Guralnik Pilates practice can be divided in phases: assistive et al., 1994), putting on and to taking off a shirt (VTC) (Vale movement (to inhibit improper muscles actions), disasso- et al., 2006) rising from the prone position (LPDV) (Alex- ciation, stabilization, mobilization, dynamic stabilization ander et al., 1997) and rising to walk through the house and functional reeducation (Anderson and Spector, 2000). (LCLC) (Andreotti and Okuma, 1999). From the results of these tests, GDLAM (IG) is obtained, which represents the Pilates method has been studied in relation to its final test scores (Dantas et al., 2004). effects on personal autonomy (Johnson et al., 2007), posture (Blum, 2002; Kaesler et al., 2007), pain control Balance was evaluated by the Tinetti test (Tinetti, (Gladwell et al., 2006), improved muscle strength 1986), wherein a source of mobility guides test perfor- (Schroeder et al., 2002), flexibility (Segal et al., 2004) and mance that is specific for static balance. motor skills (Lange et al., 2000); its effects in these areas have been proven. Quality of life was evaluated by the WHOQOL-OLD, the version for the elderly of World Health Organization’s New research is needed on the Pilates method as quality of life questionnaire. It is comprised of twenty-four a mechanism for the prevention and treatment of geriatric questions, divided into six domains, as follows: DOM1, disorders. Thus, the aims of this study are to analyze the sensory abilities; DOM2, autonomy; DOM3, past, present effects of the Pilates method on the personal autonomy, static balance and quality of life of healthy elderly females.
Pilates method in personal autonomy, static balance and quality of life 197 and future activities; DOM4, social participation; DOM5, death and dying; and DOM6, intimacy (Fleck et al., 2006). Pilates intervention program After initial evaluation, the PG began the intervention, Figure 2 Mermaid. PREVENTION & REHABILITATIONeQUALITY OF LIFE RESEARCH which consisted of practicing the Pilates method using a Bobath ball and the Cadillac, Wall Unit, Combo Chair and 4. Arms by the side (Cadillac/Wall Unit): standing tall Reformer devices made by Metacorpus Pilates Studioâ (RJ/ position, pelvis neutral. Holding the spring handle, Brazil). They voluntarily performed Pilates practice in perform abduction and adduction of a shoulder a private clinic (Bele´m-Para´-Brazil). (Figure 4). The subjects were supervised by a physical therapist 5. Arms up and pull down (Cadillac/Wall Unit): supine certified as a qualified Pilates method instructor (Brazil). position, straight legs, pelvis neutral. Holding the bar, An explanation about Pilates and the apparatus was given perform flexion and extension of both elbows to the subjects, as well as a practical demonstration of (Figure 5). each exercise before they began their intervention. The same instructor taught all sessions, with the assistance of 6. Supine lower leg series (Cadillac/Wall Unit): with foot three volunteers at each session ensuring quality of caught in the handle, pelvis neutral, lift the leg up and supervision. down (flexion and extension of hip) (Figure 6). The session was divided into the following stages: initial 7. Leg series on side, up and down (Cadillac/Wall Unit): global stretching (10 min), a general conditioning (40 min) lying on side, pelvis neutral, under leg in hip and knee and relaxation (10 min), in accordance with protocols used flexion. With foot caught in the handle, lift the leg up in other studies (Lord et al., 1996; Barnett et al., 2003; and down (abduction and adduction of hip) (Figure 7). Kaesler et al., 2007). 8. Footwork toes and heels (Reformer): supine position, The initial global stretching included two exercises: pelvis neutral. Firstly toes in foot bar, than heels in foot bar. Perform knees flexion and extension (Figure 8). 1. Hamstring stretch (Combo Chair): standing tall position, feet apart, straight legs. Press through hands to push 9. Sit ups (Cadillac/Wall Unit): supine position, pelvis pedal down. Slowly control pedal return through trunk neutral, straight legs. Pull the Cadillac/Wall Unit tower extension (Figure 1). bar up and sitting using abdominal muscles (Figure 9). 2. Mermaid (Reformer): sit tall, legs on table, one hand on 10. Gluteus and trunk raises (Cadillac/Wall Unit): supine foot bar. Pull foot bar and perform an arm arc over position, neutral pelvis, arms besides body, legs above head (Figure 2). a Bobath Ball (55 cm). Perform gluteus and trunk raises from table (Figure 10). For exercise 1 two springs of 81 kilogram force/ meter (kgf/m) were used, and for exercise 2 one spring of For exercises 3, 4, 6 and 7 springs of 8.3 kgf/m were 24.4 kgf/m and one of 10 kgf/m were used. used; for exercise 5 two springs of 10 kgf/m were used; for The general conditioning phase included eight exercises: 3. Arms up and down (Reformer): supine position, pelvis neutral, hips flexed in 90 degrees. Holding the reformer handles, perform flexion and extension of both shoul- ders (Figure 3). Figure 1 Hamstring stretch. Figure 3 Arms up and down.
198 B.G.de Siqueira Rodrigues et al. PREVENTION & REHABILITATIONeQUALITY OF LIFE RESEARCH Figure 4 Arms by the side. Figure 6 Supine lower leg series. exercise 8 springs of 29.8 kgf/m were used; for exercise 9 the normal distribution analysis, the sample ShapiroeWilk and 10 only gravity was employed. test was used. The statistical comparison method for variables was the paired Student-t test or the Wilcoxon The springs used were the same for all the volunteers, test (intragroup) and ANOVA 2 Â 2 or KruskaleWallis however, to work on individual needs, adjustments were (intergroup), followed by the Post Hoc de Shefee´ or Manne made to the angle in which they were inserted in the Whitney tests, respectively. For all hypothesis tests, the apparatus, in order to provide greater or lesser resistance, alpha level for significance was 0.05 for rejection of the null according to the physical capacity of each subject. The hypothesis, as previously defined. Microsoft Excel 2007 and maximum angle chosen was the one that allowed the the BioEstat 5.0 statistical package (Ayres et al., 2008) subject to achieve total range of motion. were used to analyze data. The implementation of exercise followed the principles of Results Pilates. The subjects were taught by the instructor to inhale through their nose during relaxation and gently exhale through Table 1 presents the descriptive and inferential analysis of the mouth during the movement. Thus, the movements were the sample’s static balance (Tinetti) using ShapiroeWilk performed slowly, at the individual’s own pace. Each exercise test. Notably, the PG shows a heterogeneous distribution of was performed for a maximum of ten repetitions. data (p < 0.05). The intervention occurred during a period of eight The Graph 1 presents the absolute D values. The consecutive weeks, with frequency of two weekly and each Wilcoxon test demonstrated significant difference session lasted 1 h, according to the protocol used by Kaesler (p < 0.05) in the PG’s balance (p Z 0.0001). According to et al. (2007). ManneWhitney test in the intergroup comparison, a difference in baseline was found of p Z 0.0626. The PG After the intervention, all the participants (PG and CG) had significant improvement in post-test relation were re-evaluated and the tests were compared. The (p Z 0.0002). control group was not submitted to any kind of intervention. The descriptive and inferential ShapiroeWilk analysis of Statistical treatment the sample’s personal autonomy is displayed in Table 2. PG shows a heterogeneous data distribution (p < 0.05) in the The descriptive analysis was carried out by calculating mean, median, standard error and standard deviation. For Figure 5 Arms pull up and down. Figure 7 Leg series on side, up and down.
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