Pilates method in personal autonomy, static balance and quality of life 199 Figure 8 Footwork for toes and heels. C10M, LPDV, and LCLC variables and in IG score; whereas in the Figure 10 Gluteus and trunk raises. PREVENTION & REHABILITATIONeQUALITY OF LIFE RESEARCH CG the only heterogeneously distributed variable was VTC. QVG  DOM6 (r Z 0.614); DOM2  DOM6 (r Z 0.387); DOM3 Graph 2 shows absolute D values of the PG and CG in  DOM4 (r Z 0.029); DOM6  DOM3 (r Z 0.501); DOM3 relation to IG. In the intergroup comparison the baseline  VTC (r Z 0.399) and DOM6  VTC (r Z 0.434). equivalence was observed and the post-PG  post-CG significant differences were observed in all tests, namely: The b error calculated in this paper was of 0.18. This C10m (p Z 0.0103); LPS (p Z 0.0164); LPDV (p Z 0.0001); result corresponds to a power experiment of 82%, remaining VTC (p Z 0.0401); LCLC (p Z 0.0011) e IG (p Z 0.0003). above the minimum acceptable that is 80% to control the type II error. Table 3 shows the descriptive and inferential Shapiroe Wilk analysis of quality of life (WHOQOL-OLD). PG has Discussion a heterogeneous data distribution (p < 0.05) in the following domains: DOM1, DOM4, DOM6 and QVG; whereas The maintenance of physical, psychic and social indepen- CG shows heterogeneous data distribution only in domain dence, often impacted by aging, is important in the DOM6. preservation of personal autonomy and quality of life for elderly people. This preservation, according to studies, can Graph 3 shows absolute D values of QVG for PG and CG. be obtained by regularly practicing physical activity, which The Wilcoxon test showed significant improvement in QVG functions as an important factor for maintaining motor of PG (p Z 0.0411). In the intergroup comparison, Student-t skills, preventing falls and improving quality of life for test showed a baseline difference in DOM5 (p Z 0.0483) and geriatric populations (Rogatto and Gobbi, 2001; Reeves DOM6 (p Z 0.0108). The ManneWhitney test showed et al., 2004), as has been observed in this research. significant post-test improvement in the PG following domains: DOM4 (p Z 0.0428), DOM5 (p Z 0.0349) and DOM6 The Pilates method is a mode of physical activity that (p Z 0.0286); and Student-t test in QVG (p Z 0.0378). offers resistance work, either using the subject’s own body weight or the springs that are applied in the method, According to Sigmound (1964), the Pearson correlation supported by a philosophy of body consciousness that coefficient (r) was significant in: Tinetti  C10m searches for harmony between body and mind. The prin- (r Z À0.384); Tinetti  DOM2 (r Z 0.428); IG  LPS ciples of the Pilates methods include: centralization, (r Z 0.679); IG  LCLC (r Z 0.676); IG  LPDV (r Z 0.579); control, concentration, fluidity of movement, precision and IG  VTC (r Z 0.854); IG  DOM3 (r Z 0.396); VTC  LPS breathing (Anderson and Spector, 2000), offering its (r Z 0.481); VTC  LPDV (r Z 0.459); LCLC  VTC (r Z practitioner a global practice in stability and flexibility. As 0.382); DOM5  LPS (r Z À0.438); QVG  DOM2 (r Z 0.566); QVG  DOM3 (r Z 0.566); QVG  DOM4 (r Z 0.614); Table 1 Descriptive and inferential analysis using Sha- piroeWilk tests of PG and CG for static balance, in pre- and post-test conditions. Average Æ SD SE Median SW p-value PG Pre 23.85 Æ 1.49 0.29 24 0.009 Post 24.88 Æ 1.07 0.21 25 0.084 0.58 23 CG Pre 22.04 Æ 2.89 0.53 22 Post 22.36 Æ 2.63 Figure 9 Sit ups. PG: Pilates group; CG: Control group; SW: ShapiroeWilk; SE: standard error; SD: standard deviation; the unit of measure was: score (Tinetti).
200 B.G.de Siqueira Rodrigues et al. PREVENTION & REHABILITATIONeQUALITY OF LIFE RESEARCH Graph 1 Comparative analysis of absolute D of PG’s and CG’s Graph 2 Comparative analysis of absolute D of PG’s and CG’s static balance. * p < 0.05 (PG-post  CG-post). IG. *p < 0.0001 (PG-post  CG-post). a result of its known benefits such as improved muscle stimulation and postural stability to analyze the effects of strength and flexibility, Pilates has come to be studied as the method in relation to static balance as indicated by this a physical activity method for older adults. study. This research indicated that the Pilates method can Personal autonomy was evaluated using the GDLAM offer positive benefits in relation to static balance in the protocol, which was developed especially for elderly elderly, since the group that practiced the method people and is composed of measures of activities of daily showed post-test results that were more significant than living such as walking, standing up, and getting dressed CG results. These results can be explained by diverse (Dantas et al., 2004). Although previous studies have not factors. It is known that loss of balance is related to many used this protocol for evaluating Pilates practice, the factors, including reduced speed of muscular responsive- results of this research show that through this method it ness (Orr et al., 2006), of strength (Heathcote, 2000) was possible to see significant differences in levels of and proprioceptive information (Westlake et al., 2007), personal autonomy of the elderly participants, whereas the characteristic of aging. In previous studies it was control group did not present significant results. demonstrated that Pilates method promotes increased strength (Schroeder et al., 2002), improves resistance According to previously performed studies, personal (Kloubec, 2005), and that with respect to principles such autonomy is dependent on variables such as strength, as concentration, precision and control, it supplies flexibility, coordination, balance, interpretation of senso- constant proprioceptive stimulation during practice rial stimulations, and cognitive capacity. The preservation (Lange et al., 2000). or improvement of autonomy demands work that incorpo- rates these variables. It was also demonstrated that phys- Moreover, studies such as Kaesler’s (2007) indicate that ical activities can improve strength (Sekendiz et al., 2007), the effect in relation to static balance can be a conse- resistance (Kloubec, 2005), flexibility (Vale et al., 2005), quence of postural stability, reached by the harmony of balance and motor abilities Lange et al., 2000, (Silva et al., opposing muscle groups. In this way, the effects related to 2008) since they improve neural function, and strengthen muscles can be associated with the proprioceptive the muscles of posture and the interpretation of sensory stimuli (Orr et al., 2006). Table 2 Descriptive and inferential analysis using ShapiroeWilk test of the functional autonomy of PG and CG in pre- and post- test conditions. Average Æ SD SE Median SW p-value PG CG PG CG PG CG PG CG C10M Pre 7.60 Æ 1.68 7.56 Æ 1.12 1.68 1.12 7.22 7.29 0.001 0.042 Post 6.89 Æ 1.60 7.59 Æ 1.21 1.60 1.21 6.49 7.29 LPS Pre 10.47 Æ 2.22 10.70 Æ 1.95 2.22 1.95 10.71 10.19 0.198 0.209 Post 9.23 Æ 2.27 10.58 Æ 2.19 2.27 2.19 9.12 10.47 LPDV Pre 4.20 Æ 0.93 4.44 Æ 0.96 0.93 0.96 4.07 4.47 0.001 0.080 Post 3.11 Æ 0.80 4.59 Æ 1.10 0.80 1.10 3.02 4.85 VTC Pre 14.30 Æ 3.31 12.95 Æ 1.78 3.32 1.78 14.04 13.09 0.056 0.175 Post 12.31 Æ 2.57 13.21 Æ 1.89 2.57 1.89 12.18 13.26 LCLC Pre 34.99 Æ 4.99 36.65 Æ 4.70 4.99 4.70 35.69 37.34 0.070 0.438 Post 31.07 Æ 6.01 36.69 Æ 4.89 6.01 4.89 29.8 36.59 IG Pre 27.21 Æ 3.85 26.96 Æ 3.37 3.85 3.37 26.66 26.91 0.035 0.125 Post 23.58 Æ 3.96 27.19 Æ 3.58 3.96 3.58 22.47 27.05 C10m: walked of 10 m; LPS: to rise from a seated position; LPDV: to rise from a ventral decubitus position; VTC: to put on and to take off a shirt; LCLC: to rise out of a chair and to move freely through the house; IG: Index GDLAM; PG: Pilates group; CG: Control group; SW: ShapiroeWilk; SE: error standard; SD: standard deviation.
Pilates method in personal autonomy, static balance and quality of life 201 Table 3 Descriptive and inferential analysis of quality of life of PG and CG in pre- and post-test conditions using the Shapiroe Wilk test. Average Æ SD SE MEDIANA SW p-value PG CG PG CG PG CG PG CG DOM1 Pre 04.23 Æ 2.87 13.44 Æ 4.34 0.56 0.87 15 13 0.001 0.225 Post 14.69 Æ 2.43 13.24 Æ 4.85 0.78 0.97 15 14 DOM2 Pre 13.74 Æ 2.82 13.88 Æ 2.49 0.54 0.50 14 14 0.466 0.293 Post 14.18 Æ 3.21 13.64 Æ 2.81 0.62 0.56 15 13 DOM3 Pre 15.70 Æ 1.61 15.00 Æ 2.52 0.31 0.50 16 15 0.026 0.272 Post 15.85 Æ 2.82 15.00 Æ 2.35 0.54 0.47 16 15 DOM4 Pre 15.88 Æ 1.77 14.52 Æ 3.51 0.35 0.70 16 14 0.009 0.277 Post 16.35 Æ 2.17 14.20 Æ 3.90 0.42 0.78 16 15 DOM5 Pre 12.92 Æ 4.06 10.84 Æ 4.81 0.78 0.96 12 10 0.254 0.224 Post 12.96 Æ 3.49 10.88 Æ 4.90 0.67 0.98 12 10 DOM6 Pre 15.18 Æ 2.99 17.16 Æ 2.32 0.57 0.46 15 17 0.070 0.044 PREVENTION & REHABILITATIONeQUALITY OF LIFE RESEARCH Post 14.96 Æ 3.80 17.16 Æ 2.52 0.73 0.50 15 17 QVG Pre 88.23 Æ 6.19 84.84 Æ 10.6 1.21 2.11 89 85 0.010 0.910 Post 89.35 Æ 9.38 84.16 Æ 11.0 1.84 2.20 89 86 PG: Pilates group; CG: Control group; SW: ShapiroeWilk; SE: standard error; SD:standard deviation; DOM1: sensorial abilities; DOM2: autonomy; DOM3: past, present and future activities; DOM4: social participation; DOM5: death and dying; DOM6: privacy; QVG: quality of life index. The Pilates method has already had proven results related Relevance of findings of this study. to variables such as strength (Sekendiz et al., 2007), flexi- bility (Segal et al., 2004), balance (Johnson et al., 2007) and The aging of the world’s population suggests there is postural stability (Kaesler et al., 2007). So, the positive a need to reduce the functional limitations arising results found in this research, from the improvement in daily from the degeneration of the systems of older people, activities to the improvement of measured variables as in order to attempt to preserve physical, psychological a whole, can be attributed to the Pilates method, which is and social independence. Therefore, any scientifically important for the development of necessary motor control. validated techniques and procedures, that positively influence the lives of elderly people, have undeniable Concerning quality of life, we observed that there was relevance. The results of this study offer reliable data a meaningful improvement in ratings of quality of life in the suggesting that Pilates exercise can be used to Pilates group but no meaningful difference in the control promote an improvement in functional capacity, group, which comprises the evaluation of this variable. offering a positive influence on static balance and, Several factors could explain this result. One issue is that consequently, an improved quality of life for elderly quality of life is a subjective concept that is not exclusively females. These results reflect the scientific evidence associated with physical performance, but also associated that Pilates improves the motor performance of aging with emotional and social conditions, although these are not people, reducing the time required to perform activ- essential objectives in the practice of Pilates. Moreover, it is ities of daily living and, therefore, suggests a resource possible to find correlations between the evaluation instru- that can improve function and quality of life for older ments, the short period of time for re-evaluation, the eval- individuals. uation modality and objectives of exercises, as well as the participant’s self-esteem (Velchia et al., 2005). Conclusion Based on this study it is possible to conclude that the practice of the Pilates method can improve the functional autonomy and static balance of elderly individuals. However, in rela- tion to quality of life, we suggest that further studies be carried out using a more representative sample, and a longer period of intervention, to more precisely evaluate the results of the method with respect to this variable. Graph 3 Comparative analysis of absolute D in PG’s and CG’s Conflict of interest QGV index. *p < 0.0001 (PG-post  CG-post). The authors have no conflict of interest.
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Journal of Bodywork & Movement Therapies (2010) 14, 203e205 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt PREVENTION & REHABILITATIONeSELF-MANAGEMENT: PATIENT SECTION SELF-MANAGEMENT: PATIENT SECTION Postural exercises on the foam roll Craig Liebenson L.A. Sports & Spine, 10474 Santa Monica Blvd., # 304, Los Angeles, CA 90025, USA Accepted 14 December 2009 Upright posture is a challenge to maintain. Chairs, desks, Vertical Foam Roll and computers all conspire with gravity to round our back Start Position (see Figure 1) and shoulders forward. Stress also is often felt as a ‘‘weight - Start on your back of the world’’ on our shoulders. For all these reasons and - Hands at your sides and palms up more, upright posture is hard to maintain. - Breathe in and out from your abdomen - Reps: 2e3 breaths Our upright posture develops gradually from the fetal - What you should feel: position in the womb. By 1 month of life an infant can raise B Feel your abdomen moving in with each exhalation, the head to look straight ahead. By 3 months, an infant arches and out with each inhalation the low back into extension away from the fetal, slumped B Feel your shoulders falling back towards the floor forward posture. By the end of the first year, supported upright walking is possible and by 4 years old most young Figure 1 Vertical Foam Roll e Start Position. children can stand upright like an adult and balance on 1 leg. Arms Overhead (see Figure 2) Unfortunately, excessive sitting at desks in our schools, - Raise your arms overhead and slouching on soft chairs and couches at home in front of - Be sure the back of your hands are on the floor the television poison this innate upright posture that we - If not, then lower your arms achieve. Slumping, slouching and stooping become a pro- - Reps: Hold for 1e2 breaths grammed habit. The effects of poor posture are seen - What you should feel: everywhere, and include loss of energy, headaches, neck or B Feel your abdomen moving in with each exhalation, back pain, pinched nerves, etc. and out with each inhalation This self-care hand-out will show you how to utilize a foam B Feel your chest and shoulders stretching roll to gain better conscious awareness of good posture so that - Note: If you feel excessive or persistent pain in the this will again become a subconscious habit in all your daily front of your shoulder(s) then lower your arms until activities. These exercises are designed to help you compen- you don’t feel discomfort sate for the environmental pollution of prolonged sitting and sedentarism. They act like a computer anti-virus program! Basics of Exercise Exercise is generally safe Mild discomfort is alright If you feel more pain, stop the exercise Perform slowly, with good form Breathe normally Frequency: Twice/day E-mail address: [email protected] 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.02.003
PREVENTION & REHABILITATIONeSELF-MANAGEMENT: PATIENT SECTION 204 C. Liebenson Horizontal Foam Roll (see Figure 5) Figure 2 Vertical Foam Roll e Arms Overhead. - Extend your back over the foam roll Chest Presses (see Figure 3) - Keep your chin tucked in - Stretch and roll - Hold a medicine ball in your hands - Reps: Roll back and 8e10 times - Press the ball all the way up to the ceiling - What you should feel: - Keep your neck relaxed on the foam roll - Reps: Perform 5e6 repetitions B Feel your upper back stretching backwards - What you should feel: B Feel your chest and arm muscles working Figure 5 Horizontal Foam Roll. - Common mistake to avoid: B Not arching back far enough B Poking your chin out (see Figure 6) Figure 6 Horizontal Foam Roll e Common Mistake e poking chin and not extending spine. Upper Back Cat (See Figure 7) Figure 3 a,b e Vertical Foam Roll e Chest Presses. - Common mistake to avoid: B Pressing up part way (see Figure 4) Figure 4 Vertical Foam Roll e Chest Press e Common Mistake Figure 7 a,b e Upper Back Cat e failing to reach up all the way.
Postural exercises on the foam roll 205 - Place your wrists on the foam roll PREVENTION & REHABILITATIONeSELF-MANAGEMENT: PATIENT SECTION - Round your back up (letting your head hang relaxed) and breathe in - Let your chest drop down and breathe out. Hold this position for another breath in and out - Reps: Perform 5e6 repetitions - What you should feel: B Focus on feeling your upper back and chest stretching down towards the floor B Feel the front of your shoulders stretching - Common mistake to avoid: B Shrugging your shoulders up towards your ears (see Figure 8) - Note: If you feel excessive or persistent pain in the front of your shoulder(s) when you drop your chest down, then discontinue this stretch Figure 8 a,b e Upper Back Cat e Common Mistake e shrugging the shoulders.
Official journal of the: Journal of ® Association of Bodywork Neuromuscular Therapists, and Movement Ireland Therapies ® Australian Pilates Method Association ® National Association of Myofascial Trigger Point Therapists, USA ® Pilates Foundation, UK Volume 14 Issue 3 2010 EDITOR-IN-CHIEF Leon Chaitow ND, DO c/o School of Integrated Health, University of Westminster, 115 New Cavendish Street, London W1M 8JS, UK Preferred mailing address: P.O.Box 41, Corfu, Greece 49100 ([email protected]) ASSOCIATE EDITORS John Hannon DC Dimitrios Kostopoulos PhD, DSc, PT San Luis Obispo, CA, USA ( [email protected]) Hands-on Physical Therapy, New York, NY, USA ([email protected]) Glenn M. Hymel EdD, LMT Craig Liebenson DC Department of Psychology, Loyola University, New Orleans, LA, Los Angeles, CA, USA ([email protected]) USA ([email protected]) ASSOCIATE EDITORS: PREVENTION & REHABILITATION Warrick McNeill MCSP Matt Wallden MSc, Ost, Med, DO, ND London, UK ([email protected]) London, UK ([email protected]) International Advisory Board D. Beales MD (Cirencester, UK) S. Fritz LMT (Lapeer, MI, USA) J. M. McPartland DO (Middleburg, VT, USA) G. Bove DC, PhD (Kennebunkport, ME, USA) G. Fryer PhD. BSc., (Osteopath), ND C. Moyer PhD (Menomonie, WI, USA) C. Bron PT (Groningen, The Netherlands) D. R. Murphy DC (Providence, RI, USA) I. Burman LMT (Miami, FL, USA) (Melbourne City, Australia) T. Myers (Walpole, ME, USA) J. Carleton PhD (New York, USA) C. Gilbert PhD (San Francisco, USA) C. Norris MSc CBA MCSP SRP (Sale, UK) F. P. Carpes PhD (Uruguaiana, RS, Brazil) C. H. Goldsmith PhD (Hamilton, ON, Canada) N. Osborne BSc DC FCC (Orth.), FRSH, ILTM Z. Comeaux DO FAAO (Lewisburg, WV, USA) S. Goossen BA LMT CMTPT (Jacksonville, FL, USA) P. Davies PhD (London, UK) S. Gracovetsky PhD (Ocracoke, NC, USA) (Bournemouth, UK) J. P. (Walker) DeLany LMT (St Petersburg, FL, M. Hernandez-Reif PhD (Tuscaloosa, AL, USA) B. O’Neill MD (North Wales, PA, USA) P. Hodges BPhty, PhD, MedDr (Brisbane, Australia) J. L. Oschman PhD (Dover, NH, USA) USA) B. Ingram-Rice OTRLMT (Sarasota, FL, USA) D. Peters MB CHB DO (London, UK) M. Diego PhD (Florida, USA) J. Kahn PhD (Burlington, VT, USA) M. M. Reinold PT, DPT, ATC, CSCS (Boston, MA, J. Dommerholt PT, MS, DPT, DAAPM (Bethesda, R. Lardner PT (Chicago, IL, USA) P. J. M. Latey APMA (Sydney, Australia) MD, USA) MD, USA) E. Lederman DO PhD (London, UK) G. Rich PhD (Juneau, AK, USA) J. Downes DC (Marietta, GA, USA) D. Lee BSR, FCAMT, CGIMS (Canada) C. Rosenholtz MA, RMT (Boulder, CO, USA) C. Fernandez de las Peñas PT, DO, PhD (Madrid, D. Lewis ND (Seattle, WA, USA) R. Schleip MA, PT (Munich, Germany) W. W. Lowe LMT (Bend, OR, USA) J. Sharkey MSc, NMT (Dublin, Ireland) Spain) J. McEvoy PT MSC DPT MISCP MCSP (Limerick, D. G. Simons MD (Covington, GA, USA) T. M. Field PhD (Miami, FL, USA) D. Thompson LMP (Seattle, WA, USA) P. Finch PhD (Toronto, ON, Canada) Ireland) C. Traole MCSP, SRP, MAACP (London, UK) T. Findley MD, PhD (New Jersey, USA) L. McLaughlin DSc PT (Ontario, Canada) E. Wilson BA MCSP SRP (York, UK) D. D. FitzGerald DIP ENG, MISCP, MCSP (Dublin, C. McMakin MA DC (Portland, OR, USA) A. Vleeming PhD (Rotterdam, The Netherlands) Ireland) Visit the journal website at http://www.elsevier.com/jbmt Available online at www.sciencedirect.com Amsterdam • Boston • London • New York • Oxford • Paris • Philadelphia • San Diego • St. Louis Printed by Polestar Wheatons Ltd, Exeter, UK
Journal of Bodywork & Movement Therapies (2010) 14, 207e208 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt EDITORIAL Clinical prediction rules A trend in manual therapy has been the development of Discogenic and sacroiliac joint pain: fair to good Clinical Prediction Rules (CPR). CPRs are derived statisti- Segmental dysfunction/facet pain: poor cally e literally “translated” from research evidence e with Clinical lumbar instability: poor to good the aim of identifying the combinations of clinical exami- Clinical central or lateral stenosis: no reliable clinical nation findings that can predict a condition or outcome. (Fritz et al., 2003; Fritz, 2009; Cook, 2008) tests, however a self-reported history questionnaire has been shown to be a useful diagnostic tool for lumbar Falk and Fahey (2009) summarise the key element of spinal stenosis CPR as follows: “Clinical prediction rules quantify the contribution of symptoms, clinical signs, and available A further obvious question is whether or not classifica- diagnostic tests, and stratify patients according to the tion of different types of low-back pain actually improves probability of having a target disorder. The outcome of clinical outcomes? interest can be diverse and be anywhere along the diag- nostic, prognostic, and therapeutic spectrum”. In a study involving over 2000 patients with ‘mechanical low-back pain’, in which there was no direct reference to In manual and movement therapies, this might translate anatomic site, or pathological process, Hall et al. (2009) into a focus on particular problems, such as nonspecific observed that: “The identification of clinical syndromes low-back pain (LBP), as well as those patients enduring this directed treatment; there was no reference to specific condition. This would allow a degree of categorization e so pathology. This approach had a strong positive effect on predicting which forms of treatment would be most likely outcomes for pain relief, reduced medication use, to be of benefit to LBP in general, and/or which specific improved function, and shortened length of treatment”. subgroups of patients with LBP should be targeted with particular therapeutic approaches. Lee and Lee (in press), caution that while useful as part of decision making CPRs should not replace clinical judge- What though is the reliability of such prediction? ment e and should be seen as complementary to that And what is the reliability of the tests involved in process e which needs to involve experience, clinical producing categorization? opinion, intuition as well as research evidence. Paatelma et al. (2009) examined Inter-tester reliability in classifying sub-acute low-back-pain patients, comparing It is important to acknowledge that while statistical specialist and non-specialist examiners. They observed that: evidence tells us about the average response of a group, “Although a number of LBP classification systems have been defined by the characteristics used in design of the study, in proposed, such as a pathoanatomical/pathophysiological practice, individual symptoms and circumstances may be classification system, the McKenzie classification, treat- identified to a greater or lesser degree than such averages ment-based classification, and the movement-impairment suggest would be the case e or might even present quite classification, what is still unclear is which clinical tests differently. between two assessing clinicians are sufficiently reliable to allow subgroup categorization. The reliability and validity Most experienced clinicians are well aware of patients of the overall classification systems has been tested and has they have seen who display symptoms and characteristics been reported as moderate or good”. that are not the same as those suggested by data from Not surprisingly, the better trained the individual prac- clinical trials e and that these individual cases may indeed titioners, the more accurate the findings. offer insights that can lead to research questions being As to the reliability of tests used for placing types of generated. low-back pain, into separate groupings, the evidence is variable. Paatelma et al. (2009) summarise the current It is also useful to acknowledge that information deriving situation as follows: from research may at times be subject to bias during the process of interpretation as conclusions are drawn. It is a truism to state that a lack of evidence does not invalidate a technique, or an approach that has been shown by 1360-8592/$36 ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.04.005
208 Editorial experience to have clinical value, even if it does not quite Hall, H., McIntosh, G., Boyle, C., 2009. Effectiveness of a low back fit with clinical prediction rules. pain classification system. The Spine Journal 9, 648e657. References Lee, D., Lee, L.-J. Differential diagnosis and management of chronic pelvic pain. In: Chaitow, L., Lovegrove, R. (Eds.), Cook, C., 2008. Potential pitfalls of clinical prediction rules. Chronic Pelvic Pain & Dysfunction, Churchill-Livingstone, Edin- Journal of Manual & Manipulative Therapy 16 (2), 69. burgh, in press. Falk, G., Fahey, T., 2009. Clinical prediction rules. British Medical Paatelma, M., Karvqnen, E., Heinqnen, A., 2009. Inter-tester reli- Journal 339, b2899. ability in classifying acute and subacute low back pain patients into clinical subgroups: a comparison of specialists and non- Fritz, J.M., Delitto, A., Erhard, R., 2003. Comparison of a classifi- specialists. Journal of Manual & Manipulative Therapy 17 (4), cation-based approach to physical therapy and therapy based 221e229. on clinical practice guidelines for patients with acute low back pain: a randomized clinical trial. Spine 28, 1363e1372. Leon Chaitow, ND DO, Editor-in-Chief, University of Westminster, Fritz, J.M., 2009. Clinical prediction rules in physical therapy: London, UK coming of age? JOSPT 39 (3), 159. E-mail address: [email protected]
Journal of Bodywork & Movement Therapies (2010) 14, 209e218 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt DANCE: PSYCHO-PHYSICAL EFFECTS Greek traditional dances and quality of old people’s life Fotios H. Mavrovouniotis*, Eirini A. Argiriadou, Christina S. Papaioannou Sports Medicine Laboratory, Department of Physical Education & Sport Science, Aristotle University, Str. Makrigianni 20, Thessaloniki 54635, Greece Received 14 June 2008; received in revised form 16 September 2008; accepted 11 November 2008 KEYWORDS Summary The aim of the present study was to examine the effect of Greek traditional dances on Elderly; the improvement of old people’s quality of life. A hundred and eleven subjects (75 women and 36 Aerobic exercise; men) 60e91 years old, were divided into an experimental group (n Z 76) which participated in Greek Psychosomatic traditional dances and a control group (n Z 35) which was discussing and watching television, both responses; for 1 h. The Subjective Exercise Experiences Scale [McAuley, E., Courneya, K., 1994. The Subjective Mood state; Exercise Experiences Scale (SEES): development and preliminary validation. Journal of Sport and State anxiety Exercise Psychology 16, 163e177] was used to measure positive well-being, psychological distress, and fatigue and the State-Trait Anxiety Inventory [Spielberger, C.D., Gorsuch, R., Lushene, R., 1970. Manual for the State-trait Anxiety Inventory. Consulting Psychologists, Palo Alto] to measure state and trait anxiety respectively. Correlational analyses, between the various measures taken postdance, showed that the overall set of relations between the SEES subscales and the SAI-Y1 subscale supports the criterion-related validity of this measure of exercise-induced psychological responses. The independent groups t-tests showed that the control group in comparison to experi- mental group, at rest as well as on the second measurement, has significantly higher levels of state anxiety (t Z À4.45, p < 0.001 & t Z À6.56, p < 0.001), psychological distress (t Z À4.30, p < 0.001 & t Z À5.46, p < 0.001), and fatigue (t Z À3.16, p < 0.01 & t Z À3.46, p < 0.001), while it has significantly lower levels of positive well-being (t Z 4.23, p < 0.001 & t Z 6.90, p < 0.001). After dancing approximately 63% of maximum heart rate of experimental group was activated, while from paired t-tests significant decreases in state anxiety (t Z 5.02, p < 0.001) and psychological distress (t Z 3.14, p < 0.01) were observed, as well as significant increases in positive well-being (t Z À4.44, p < 0.001) and fatigue (t Z À2.15, p < 0.05). On the other hand, no significant difference in control group was observed. Consequently, Greek traditional dances may be used as a functional psycho- physical activity, to produce both physical and mental benefits for elderly individuals. ª 2008 Elsevier Ltd. All rights reserved. * Corresponding author. Tel.: þ30 32310707410/32310992184/32310992187, 6947521795 (mobile); fax: þ30 32310992183/32310707410. E-mail address: [email protected] (F.H. Mavrovouniotis). 1360-8592/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2008.11.005
210 F.H. Mavrovouniotis et al. Introduction Koinonikes-ypiresies/koinonika/kaph.htm). As far as the choices of exercise forms are concerned, there is fortu- Lifestyle modulates health state and blunts the changes nately a variety of training options for the elderly partici- that derive as a result of old age. However, most old people pating in exercise programs. These include group or acquire the habit of sedentary life, which is characterized individual walking programs, aerobic-exercise classes, by intense lack of any form of physical activity (Berger and chair-seated exercises, personal training, balance training, Hecht, 1989; Berger and McInman, 1993; Duda and Tappe, aquatics, relaxation classes, and active hobbies such as 1988; Smith and Serfass, 1981). Thus, the functional ability gardening or square dancing, or simply integrating more low level, that is observed in many old people, is not the physical activity into the daily routine of the elderly result of old age, but the result of their lifestyle (Vuori, (American Council on Exercise, 1998). Similar exercise 1995), and certainly of sedentary life. programs in Greece offer aerobic activities and traditional dance learning (Alexandris et al., 2007). However, in fact Physical activity, on the other hand, is necessary for the only few old people take part in these activities in Greece maintenance of physical health and psychological well- (Harahousou, 1999). The statistics of Eurobarometer being (Berger, 1996; Blair, 1995). The body should move (http://www.ec.europa.eu) indicate that older Greek and, an active lifestyle that leads to adaptations allows individuals’ (more than 65 years old) participation rates in individuals to move comfortably (Theodorakis, 1990). physical activities are on the average of the European Union Today, more and more people learn and understand the members, with around 50% of them reporting no partici- importance of regular physical exercise in their life, pation in any form of moderate physical activity in the particularly the importance of remaining physically active contexts of work, home, and leisure. However, the throughout their life span. The participation in physical percentage of physical inactivity during leisure time for activities constitutes an important factor that contributes older people in Greece is among the highest in the Euro- to psychological balance, promotes psychological state pean Union. Less than 9% of the individuals reported regular (Berger et al., 1993, 1998; Craft, 2005; Dimeo et al., 2001; participation in leisure time physical activities/recreation. International Society of Sport Psychology, 1992; Landers and Arent, 2001; Lawlor and Hopker, 2001; Morgan and In this direction, the C.O.P.O.P., these important O’Connor, 1988) and is the best preventive means for capitularies give a chance to the elderly and via social care, chronic diseases such as arteriosclerosis, hypertension, to make their free time productive, cultivate their inter- cardiovascular diseases, mellitus diabetes type II, osteoar- ests, participate in the life of the community and maintain thritis, osteoporosis, obesity, some forms of cancer, active living (Kostaridou-Efklides, 1999). The C.O.P.O.P. disturbances in the peptic system, as well as for premature provide leisure and recreation opportunities and a variety mortality, functional limitations, and disability (Antona- of activities for middle-aged and old individuals. The koudis and Antonakoudis, 2003; Nelson et al., 2007; Paf- members can choose from a variety of activities, such as fenbarger, 1996). social gatherings, seminars, leisure trips, exercise programs and programs of Greek traditional dances (Alexandris et al., Consequently, regular, moderate physical activity 2007). Dancing plays an important role for the old people contributes positively to the maintenance not only of because they have the chance to enjoy, as they used to physical, but, also, of mental and psychological health of when they were young (Atchley, 1993). Additionally, children and adults, as well as that of middle-aged and dancing has been their basic social activity from their elderly people (Berger and Hecht, 1989; Berger and McIn- adolescence to their aging (Cooper and Thomas, 2002). man, 1993; Ekkekakis et al., 2000; Duda and Tappe, 1988; Since Greek traditional dancing is an integral part of Greek Ostrow, 1989; Smith and Serfass, 1981; Tucker, 1990). More culture. Moreover, it is one of the most indicative charac- specifically, the old people who participate in kinetic and teristics of temperament, history and cultural identity of not competitive activities have higher levels of mood state, Greeks because it is connected with the same spontaneous, mental alertness and physical improvement, are satisfied instinctive expression of human mind and body. Greek with their life, rejoice bigger intervals of independence and traditional dance, music and singing are not just social life autonomy, and generally live more happily (Mahon and expressions and depictions, but also organic and integral Searle, 1994). In addition the physical well-being feeling elements of social life (Filias, 1999). At the same time, the that exercise ensures also results in psychological balance, Greek traditional dance is a familiar and popular activity leading to relaxation, absence of unnecessary anxiety and with elderly Greek people. to a feeling of completion (Spantideas, 2003). Therefore, it is imperative for a healthy person to remain active and vivid In relation to exercise intensity, for safety reasons, low- throughout his life and especially after his 60s in order for impact rather than high-impact modes of aerobic activity him/her to delay the loss of his/her organ function (Avlo- are recommended for older-adult participants, so that nitou, 2002). possible orthopedic problems and cardiovascular implica- tions are avoided (Pollock et al., 1991). An intensity level of Consequently, with a view to promoting health and well- 30%e75% VO2max (with a Rate of Perceived Exertion of 12e being, such programs have been implemented in the 14 on the Borg 6-to-20 Perceived Exertion Scale) sustained Centres of Old People’s Open Protection (C.O.P.O.P.) and for 30e60 min is recommended for older adults (American health care centres in the U.S.A. as well as in Europe College of Sports Medicine, 1995; Pollock et al., 1994). In (Kerr and Van den Wollenderg, 1997). The purpose of these fact, lower-intensity but longer-duration aerobic exercise is centres is to prevent old people’s physical, psychological much more beneficial compared to higher-intensity but and social problems, in order for them to remain shorter-duration exercise (American College of Sports independent and active (http://www.thessalonikicity.gr/ Medicine, 1991; Swart et al., 1996).
Greek traditional dances and quality 211 Dancing is a recreational activity and leads to a calorie Finally, a hundred and eleven (111) healthy members of loss that amounts to 300e360 kcal/h, when dancing in a low the five different C.O.P.O.P. (75 women and 36 men) intensity pace. On the contrary, when dancing in a more participated in the research. The subjects ranged from 60 intensive way we may burn from 420 to 480 kcal/h (Byrne, to 91 years of age (M Z 69.79, SD Z 7.18). They were, then, 1991; Klissouras, 2004; Papanikolaou, 1993). Moreover, it is divided into an experimental (Group A) (n Z 76) and a fact that dancing in the form of a physical activity of a control group (Group B) (n Z 35), according to the moderate intensity, of approximately 3e5 METs, contrib- following criteria: a) the subjects who were visiting the utes to the improvement of physical fitness (Balady and C.O.P.O.P. in order to socialize with other members, watch Weiner, 1987; Klissouras, 2004). It appears, therefore, that television, have fun and enjoy themselves, as well as dancing is advisable as an appropriate form of physical participating in one group dancing program for learning and activity in the application of programs for the elderly. performing Greek traditional dances to the C.O.P.O.P. and no other dancing or exercise program, constitute Group A, However, although the effects of aerobic exercise on b) the subjects who didn’t participate in any program of people’s psychological state have been studied adequately dancing or exercise, but were visiting the C.O.P.O.P. only in (Colussi, 2002; Ekkekakis and Petruzzello, 1999; Maroulakis order to socialize with other members, watch television, and Zervas, 1993; Ritter and Low, 1996), the effects of have fun and enjoy themselves, constitute Group B. Chat- dance, and more specifically the acute effects of Greek ting and watching TV are the main activities for the traditional dances, have not been studied sufficiently, yet members of a C.O.P.O.P. especially with reference to old people’s psychological state. Consequently, the two different groups were in all respects identical, and the control group was a group Concluding, the purpose of this study is to address this matched with the experimental group, except for the issue to old people’s psychological state, by examining the participation in the dancing program for learning and per- pre- and post-dancing levels of mood and anxiety. More- forming Greek traditional dances, which however is the over, the present study examines the effects of Greek factor who have been willing to investigate. It should, also, traditional dances on old people’s physical state by be noted that the subjects of the experimental group on measuring the heart rate not only pre- and post- the the time of the research conducted have managed to dancing session, but also in the middle of it. complete almost a 10-week traditional dancing course. Method Procedure Sample An approval for the conduct of the research was given from the committee of each C.O.P.O.P., after the aim and the Elderly people from five different C.O.P.O.P. from the city design of the research were described. Procedures were in of Thessaloniki, were used. We randomly selected 50 agreement with ethical standards of the Declaration of people from each centre who fulfilled all the inclusion Helsinki of the World Medical Association (2000). criteria such as participating only in a dancing program for learning and performing Greek traditional dances at the Before the beginning of the research, a description of C.O.P.O.P. or/and visiting the C.O.P.O.P. in order for them general requirements was given and, still, the aim of the to socialize and discuss with other members, watch tele- research was described to the participants without any vision, have fun and enjoy themselves. A communication/ briefing relative to previous research findings. The invitation to each chosen member, with regard to the psychological instruments were also presented and the research was made. After the above, a total of a hundred instructions were explained for each one of them. The need and twenty-five (125) members volunteered to participate for absolute honesty and precision was particularly in the research. emphasized. Moreover, the subjects of the experimental group received one-hour preparatory session, on methods A written informed consent for the participation in the of heart rate (HR) measurement and procedural details research was obtained from each subject. All the subjects, (Zervas et al., 1993). During this session, the subjects were prior to the beginning of the research, underwent medical trained to self-measure their HR using the palpation control so that it could be certified that they do not suffer method, the most popular and practical method of HR from any cardiovascular or other disease and, also, that measurement. The palpation method is appropriate for the they do not take any medication. Additionally, they HR measurement at rest and also after exercise, as in answered a questionnaire about their personal medical healthy individuals HR and pulse are exactly similar sizes history and any health problem, while a research assistant (Corbin et al., 2001; McArdle et al., 2001). The wrist loca- was present in order to give any essential clarifications if he tion (radial artery) was chosen, instead of the neck (carotid was asked to. Fourteen subjects who were found to fulfil artery), because if a subject (especially if older than 65) the exclusion criteria, that is health problems, such as press too hard on the carotid artery may become light- recent complicated myocardial infarction, unstable angina, headed and fall. The subjects learned to place their index serious dysrhythmias, acute pericarditis or myocarditis, and middle fingers, not the thumb, together on the wrist of endocarditis, severe aortic or mitral stenosis or other forms the other hand, about ½ inch on the inside of the joint, in of acute cardiopulmonary illness, etc. (American College of line with the index finger, so they could feel the pulse Sports Medicine, 1995; Hanson, 1984) or/and medication (Corbin et al., 2001; Nagashio et al., 2003). After the that could affect the results, or/and extra participation in subjects practiced taking HR, the accuracy of their HR exercise programs, were excluded from the research. measurement was checked by pre-trained assistants.
212 F.H. Mavrovouniotis et al. In continuity, the subjects of the experimental group Heart rate measurement participated in a group program of Greek traditional dances performance, at the C.O.P.O.P. where they were members. HR response to dancing was monitored for assessing Each session of Greek traditional dances was conducted by workout intensity. So, just before the dancing session the teachers of physical education with extensive practical subjects self-measured their baseline HR during two 10-s experience and was exactly the same in all C.O.P.O.P., with periods. On the 30th minute, the performance of the Greek regard to the dances, the number of dances, their duration traditional dances was interrupted for a period of no longer and the accompanying music, as well as the number and than 1:00e1:30 min, during which the subjects measured duration of breaks. The performed Greek traditional dances their HR. Moreover, the subjects self-measured their HR were from different areas of Greece. In order to begin to immediately after the end of the Greek traditional dances dance the subjects were holding each other from the session during two 10-speriods, too. The teachers of phys- hands, creating a hemi-cycle. The performed dances ical education and pre-trained assistants supervised the HR included a variety of simple kinetic patterns with music measurements after averaging the two HRs. The intensity accompaniment. The dances intensity ranged from low to of Greek traditional dances was estimated by comparing moderate, with frequent rhythm alternations, so that the individual HRpeaks to age-predicted HRmax according to subjects could keep dancing continuously throughout the Tanaka et al. (2001) formula. dance session. Essential breaks of approximately 10 s in between dances in order to change dance were made. The Data analysis duration of each dance was about 2.5e3 min. The session duration was 60 min in total. The subjects of the control For the statistical analysis the statistic packet SPSS/PC group, on the other hand, were asked to stay in a room all Version 15.0 for windows was used. Descriptive analysis was together, free to discuss with each other or watch televi- used. The non-parametric test KolmogoroveSmirnov was sion. The discussing and watching TV session duration was used to evaluate the normal distribution of the sample. In 60 min in total. addition, the paired t-test was used to evaluate significant differences between measurements, that is before and Scales of measurement after the Greek traditional dances, and before and after the discussing and TV watching session, while the inde- The Subjective Exercise Experiences Scale (SEES; McAuley pendent groups’ t-test was used to evaluate significant and Courneya, 1994), which constitutes a measurement of differences between groups. Moreover, correlational anal- global psychological responses, to the stimulus properties yses between the various measures taken postdance for of exercise, was used. The scale facility and brevity allows experimental group were conducted to determine the its fast and repeated use by the researchers even during degree to which such measures were or were not associ- exercise. The scale is composed of 12 items that represent ated, thereby providing an index of both convergent and three factors. Two of these factors, positive well-being and discriminant validity for the SEES and SAI-Y1. The level of psychological distress, correspond to the positive and significance was set to p < 0.05. negative poles associated with psychological health, whereas the third factor represents subjective indicants of Results Fatigue. The three-factor structure originally established by exploratory factor analysis using young adults was also In Table 1 the anthropomorphological characteristics and, supported in middle-aged exercising adults (McAuley and also, trait anxiety of the subjects of both groups are pre- Courneya, 1994), as well as in the present sample. Addi- sented. From SAI-Y2 elaboration, it was found out that tionally, SEES, in the present study, demonstrated accept- Group A had low trait anxiety, while Group B had more able internal consistency (a ranges from 0.73 to 0.90). SEES increased trait anxiety (see Table 1). was completed about 5 min before and after the Greek traditional dances performance and the discussing and In Figure 1 the minimum, maximum, and mean values of watching TV session. the HR of subjects of Group A at rest, as well as at 30 and 60 min of the Greek traditional dances bout, are presented. Moreover, State-Trait Anxiety Inventory (SAI; Spielberger With this way, the subjects’ HR alteration during Greek et al., 1970) was used, for the measurement of anxiety. All traditional dances bout is shown. As it is observed, while at subjects completed the 20-item trait anxiety subscale, SAI- Y2, for trait anxiety measurement once, just about 5 min Table 1 Sample’s characteristics. before the Greek traditional dances session and the dis- cussing and watching TV session, with score ranging from 20 Parameters Group A Group B to 80 degrees. The 20-item state anxiety subscale, SAI-Y1 (experimental) (control) was also completed about 5 min before and after the Greek Mean Æ SD Mean Æ SD traditional dances performance and the discussing and watching TV session, for state anxiety measurement, with Age (years) 67.62 Æ 6.29 74.51 Æ 6.78 score ranging from 20 to 80 degrees. SEES and SAI were Height (cm) 163.32 Æ 8.33 169.34 Æ 5.50 administered in a counterbalanced order, which was Weight (kg) reversed at the posttest and translated in Greek following Body Mass Index (kg/m2) 74.55 Æ 10.40 77.57 Æ 8.57 a standard procedure involving the discussion of multiple Trait anxiety (degrees) 28.03 Æ 3.94 27.04 Æ 2.79 alternative wordings by a group of five bilingual experts. 32.01 Æ 10.16 43.46 Æ 11.40
Greek traditional dances and quality 213 minimum mean maximum Before the dancing session After the dancing session 30 140 130 25 120 110bpm 20 100 degrees 15 90 80 10 70 60 30min 60min 5 rest Figure 1 HR alteration during Greek traditional dances bout 0 Pos. Psychol. Fatigue (Group A). State well-being distress Anxiety Figure 2 Alterations to SAI-Y1 and SEES factors for Group A. rest the subjects presented HR 75.6 bpm and reached at (6.28%), was, also, statistically significant (t Z À4.44, the end of the Greek traditional dances bout, that is after p < 0.001). 60 min, 103.92 bpm a HR that is within the range of training zone for the age of 70 (American College of Sports Medi- Descriptive statistics for each measure assessed prior to cine, 1991; Chase http://plu.edu/wchasega/main.htm). and following the discussing and TV watching session and This increase represents approximately 63% of HRmax (see the significance of any demonstrated change of Group B are Figure 1). shown in Figure 3 and Table 3. In regard to SEES, according to data processing, it was obvious that small changes were Descriptive statistics for each measure assessed prior to recorded in the positive factor positive well-being, the and following the dance bout and the significance of any negative factor psychological distress, the subjective indi- demonstrated change of Group A are shown in Figure 2 and cators of fatigue, as well as in the state anxiety score from Table 2. In regard to SEES, according to data processing, it the SAI-Y1, after the discussing and TV watching session was obvious that there was an increase in the positive (see Figure 3). factor positive well-being, while there was a decrease in the negative factor psychological distress. Furthermore, Additionally, paired t-tests between the various the subjective indicators of fatigue showed an increase, measures taken before and after the discussing and TV while the state anxiety score from the SAI-Y1 presented watching session were then conducted to determine a decrease, after the Greek traditional dances performance possible differences between the measurements. It was (see Figure 2). found out that all factors of the SEES, that is positive well- being (t Z 0.18, p > 0.05), psychological distress (t Z 0.14, Moreover, from paired t-tests it was found out that all p > 0.05), and fatigue (t Z À0.84, p > 0.05), as well as the factors of the SEES, as well as the state anxiety score from state anxiety score from the SAI-Y1 (t Z 1.03, p > 0.05), the SAI-Y1, were significantly influenced by the Greek were not significantly influenced by the discussing and TV traditional dances bout (see Table 2). As it can be seen, watching session, but they stayed quite unchangeable (see these changes that are observed after the performance of Table 3). the Greek traditional dances generally reflect increases in positive responses and fatigue and decreases in negative In Figure 4 the differences between the two groups are responses. Although all of these changes are relatively presented. As can be seen, there are differences in all the modest in magnitude, they are all statistically significant. studied variables, at rest as well as after the dancing and More specifically, the greatest influence on psychological the discussing and TV watching session. The independent responses noted to be evidenced in the psychological groups’ t-tests which used to evaluate significant differ- distress dimension (12.79% decrease, t Z 3.14, p < 0.01), ences between the two groups showed that the observed state anxiety (10.50% decrease, t Z 5.02, p < 0.001) and differences are significant differences both at the first fatigue (9.55% increase, t Z À2.15, p < 0.05). However, the measurement (rest) and at the second measurement (after increase in positive well-being, although relatively small the dancing and after the discussing and TV watching). Table 2 Descriptive data, and degree of change for SAI-Y1, and SEES for Group A, before and after the Greek traditional dances. Affect Measure Pretest Posttest Change tp M SD M SD M SD SAI-Y1 29.80 10.76 26.67 8.69 À3.13 5.44 5.02 <0.001 State anxiety SEES 24.49 4.70 26.03 3.79 1.54 3.02 À4.44 <0.001 Positive well-being 6.41 Psychological distress 8.17 4.08 5.59 3.43 À0.82 2.26 3.14 <0.01 Fatigue 5.99 8.94 5.38 0.78 3.15 À2.15 <0.05
214 F.H. Mavrovouniotis et al. Before the discussing and After the discussing and Table 3 Descriptive data, and degree of change for SAI- tv watching session tv watching session Y1, and SEES for Group B, before and after the discussing and TV watching session. 40 35 Affect Pretest Posttest Change t p 30 Measure M SD M SD M SD degrees 25 20 SAI-Y1 15 State anxiety 39.57 10.72 39.11 10.47 À0.46 2.61 1.03 NS 10 SEES 5 0 Positive 20.14 5.67 20.05 5.08 0.08 2.72 0.18 NS State Pos. Psychol. Fatigue well-being Anxiety well-being distress Psychological 10.37 5.33 10.25 5.50 À0.11 4.77 0.14 NS distress Figure 3 Alterations to SAI-Y1 and SEES factors for Group B. Fatigue 12.02 5.94 12.91 6.11 0.88 6.22 À0.84 NS More specifically, at rest there were observed statistically NS: p > 0.05. significant differences between the two groups in terms of trait anxiety (t Z À5.30, p < 0.001), state anxiety Discussion (t Z À4.45, p < 0.001), positive well-being (t Z 4.23, p < 0.001), psychological distress (t Z À4.30, p < 0.001), The primary objective of the present study was to examine and fatigue (t Z À3.16, p < 0.01). After the dancing and whether a Greek traditional dance session results in posi- the discussing and TV watching session there were observed tive effects on old people’s psychosomatic state. Moreover, statistically significant differences between the two groups the effectiveness of the Greek traditional dances session in terms of state anxiety (t Z À6.56, p < 0.001), positive was contrasted with that of a discussing and watching TV well-being (t Z 6.90, p < 0.001), psychological distress session. Thus, elderly people taking Greek dance classes (t Z À5.46, p < 0.001), and fatigue (t Z À3.46, p < 0.001). were compared to elderly people who only spent their time Besides, it is important to note that Group B in comparison chatting and watching TV. The results overall indicate that to Group A has higher levels of trait anxiety, state anxiety, Greek traditional dances possess properties improving old psychological distress and fatigue while it has lower levels people’s psychosomatic state, which are not comparable to of positive well-being at rest, a state that is recorded not those of a chatting and watching TV session. only unchangeable but, also, more intense on the second measurement. However, the state of Group A has been More specifically, in the present study was found out that recorded improved after the Greek traditional dances as Greek traditional dances increased well-being, as well as long as state anxiety and psychological distress were decreased stress, and anxiety of old participants. In agree- significantly decreased and positive well-being was signifi- ment, other authors suggest that dancing causes anxiety and cantly increased (see Figure 4). neuromuscular tension reduction, and, also, causes psycho- logical and physical calm (Garnet, 1974; Leste and Rust, Correlational analyses between the various measures 1984; Payne, 1992; Stanton-Jones, 1992; Steiner, 1992). taken postdance for Group A were then conducted to Thus, it can be said that via dancing the old people’s determine the degree to which such measures were or were psychological state is generally improved. It has, indeed, not associated, thereby providing an index of both ascertained that the participation in dancing programs, of convergent and discriminant validity for the SEES and SAI- 45 min duration, once a week, for five months, improved the Y1. These relationships are shown in Table 4. psychological state of old people who suffered from stroke, traumatic brain injury and cerebral vascular accidents (Ber- From the results in Table 4, it appears that statistically rol et al., 1997). It has been, also, found out that the elderly significant correlations exist between the studied variables. women with senility who participated in a program with In particular, positive well-being correlated negatively with social/traditional dances could reconstruct their remaining the measures of negative affect, such as psychological faculties and present with personal style their kinetic- distress (r Z À0.69, p < 0.01), state anxiety (r Z À0.61, dancing learning and experiences, communicate as a team p < 0.01), and fatigue (r Z À0.26, p < 0.05), while the and try positive sentiments (Palo-Bengtsson et al., 1998). psychological distress factor correlated positively with indicants of negative states, such as state anxiety Additionally, exercising in Greek traditional dances (r Z 0.48, p < 0.01), and fatigue (r Z À0.33, p < 0.01). increased old people’s HR from 75.6 bpm at rest to Moreover, statistically significant negative correlation was 96.4 bpm in 30 min, and to 103.92 bpm in 60 min, that is the observed between state anxiety and positive well-being end of Greek traditional dances bout. Thus, old people’s HR (r Z À0.61, p < 0.01), while statistically significant positive was increased significantly and approximately 63% of their correlations were observed between state anxiety and the HRmax was activated. This exercise intensity can develop other variables, that is psychological distress (r Z 0.48, and maintain older people’s cardiorespiratory fitness p < 0.01), and fatigue (r Z 0.33, p < 0.01). So, it can be (American College of Sports Medicine, 1991). In particular, said that the overall set of relations between the SEES the HR exercise benefit range (EBR) for people older than subscales and the SAI-Y1 subscale supports the criterion- 61 years old is fluctuated from 85 to 139 bpm (Chase related validity of this measure of exercise-induced http://www.plu.edu/wchasega/main.htm). Consequently, psychological responses (in this case dances). the physical load from the Greek traditional dances is found
Greek traditional dances and quality 215 Trait anxiety State anxiety before State anxiety after Positive well-being before Positive well-being after Psychological distress before Psychological distress after Fatigue before Fatigue after 45 40 35 30 degrees 25 20 15 10 5 0 Group B Group A Figure 4 Alterations to SAI-Y1 and SEES factors for Groups A and B. to be within the EBR for the specific age group. Therefore, (Cox, 2002). So, while exercising many systems of the body the Greek traditional dances as performed in the present as cognitive, skeletal-muscular or cardiovascular, interact study, could constitute a part of a regular exercise program in a somewhat general or holistic manner together with aiming at improvement in physical fitness, and thus physical positive and negative moods (Thayer et al., 1994). More- benefits for old people. over, McGowan et al. (1996) showed that changes in affect were correlated with average HR. Higher HR was associated Similarly state anxiety decrease, together with mood with reductions in negative affect and increases in positive state improvement was observed in young adults, after one affect. Moreover, this sense of psychological well-being is session of traditional Greek dance, lasting approximatelty connected with endorphin excretion that has a morphine- 1.5 hours. (Argiriadou and Mavrovouniotis, 2001, 2002). effect in the exercising individual. The general euphoria Likewise, Konstantinidou et al. (2000) studied the effects that endorphins produce reduces depression, anxiety, of a program of Greek traditional dances on old women’s confusion and different negative mood states levels (Cox, subjective perception for life satisfaction. The results of 2002; Dishman, 1989). the study showed a strengthening in satisfaction and a significant improvement in all the parameters that Besides, old people who are engaged as dancers feel the delimit the quality of life generally. In another study benefits in their health, in a more intense way, physically a program of practice with movements of traditional and mentally, feel a sense of achievement, and accom- Korean dances. More specifically, after the program moral plishment, define their health in positive terms and also, satisfaction, self-confidence and psychological state in old feel much better, compared to their age peers (Barkoukis women participants (Kim et al., 2002). Furthermore, Ber- et al., 1998; Konstantinidou et al., 1998; Ransford and ryman-Miller (1988) found out that the 8-month application Palisi, 1996). This happens, possibly, not only because they of a dancing program in individuals aged 55e85 years old, have higher expectations from this activity, but also affected self-esteem and well-being positively and led to because the involvement in dancing as a physical activity mood state improvement. A possible explanation for the reduces their feelings of vulnerability to illness. Therefore, relation between the improved mood state and dancing, as dancing as a physical activity may be especially beneficial a form of aerobic exercise, is that the improvement in to maintain and boost positive definitions of health (Pikoula mood state is related to the improvement in cardiovascular et al., 2005; Ransford and Palisi, 1996). Moreover, it has functioning and in physical fitness that occurs by exercising been found out that the old people who participate in Table 4 Correlations between SEES subscales and the state anxiety measures. State anxiety Positive well-being Psychological distress Fatigue SAI-Y1 1.00 À0.61** 0.48** 0.33** State anxiety À0.69** À0.26* SEES À0.61** 1.00 1.00 0.45** Positive well-being 0.48** À0.69** 0.45** 1.00 Psychological distress 0.33** À0.26* Fatigue *Correlation is significant at the 0.05 level; **Correlation is significant at the 0.01 level.
216 F.H. Mavrovouniotis et al. Greek traditional dances programs have a better picture participants to escape from their problems. Besides, plea- for their body limbs and functions, as well as bigger satis- sure (from exercise or any other activity) appears to be faction than their age peers that do not participate in a main factor in the improvement of psychological well- similar programs (Barkoukis et al., 1998; Konstantinidou, being and quality of life, which is closely related to the et al. 1998). concept of flow (Berger, 1993; Wankel, 1993). When a person is in the condition of flow, he/she concentrates on This fact was, also, proven in the preset study, where a limited field of stimuli, loses the sense of time, forgets the subjects of the control group, that didn’t participate in personal problems, makes a ‘‘time out’’ from the daily a dance or other exercise form program, had higher levels routine, feels capable and in control, and has a sense of of trait anxiety, state anxiety and fatigue, while they had harmony with the environment (Colussi, 2002; Csikszent- lower levels of positive well-being at rest. So it can be said mihalyi, 1991). These are, probably, some of the reasons that they taste greater levels of negative and smaller levels explaining the observations in the present study. of positive feelings, or else that subjects of the experi- mental group taste smaller levels of negative and greater In conclusion, Greek traditional dances of moderate levels of positive feelings. This state may have been intensity, with music accompaniment, could lead to a function of the dance context, as the subjects of the significant improvements in old people’s psychological and experimental group at the time of the measurements physical well-being. Consequently, Greek traditional dan- completed almost a 10-week participation in the Greek ces, as a form of aerobic activity, could produce not only traditional dances program, showing that the elevated physical but also mental benefits, and should constitute predance states may be reflective of anticipatory effect, a part of exercise programs that aim both to the improve- while the subjects of the control group didn’t participate in ment of old people’s psychological state and quality of life. any program. Nevertheless, further examination is essential Of course these observations about the value of Greek in order for us to ensure that these results have to do with traditional dances are preliminary. Besides, they concern the participation to the dance program. Moreover, after the the acute effects of a Greek traditional dances session and chatting and TV watching session the subjects’ state cannot be generalized to assess long-term participation in remained unchanged, while the state of the subjects of the a dance program, although there have been indications for experimental group improved significantly after dancing the positive effects. In order to support these observations Greek traditional dances, indicating the significant positive further validation research is necessary. effects of Greek traditional dances on old individuals’ psychological state. As a first systematic attempt to assess the effects of dancing Greek traditional dances on psychological and Consequently, it could be said that dancing is an effec- physical well-being, our study was limited to a sample old, tive factor of mood state improvement of old people, as it healthy and mostly physically active individuals. Despite contributes to the creation of a special stream state of the fact that the dancing intensity involved was moderate consciousness which is related to various ecstasy levels, or, and the results were indicating positive effects on our in other words, to a state of enthusiasm (Dimoulas and sample’s psychosomatic state, whether the findings repor- Karatolias, 1990; Schott-Billmann, 1997). Therefore, it ted here will generalize to other populations, such as the appears that dancing is not simply and only the means of sedentary, the overweight, or various patient and medically bodyespirit reconnection. It is a kinetic activity that can, vulnerable populations, remains unknown. Future research as the primitive, ritual dances, use brain properties in order could extend the investigation to such populations. to connect, via the conceiving rhythm, the internal and the external, that is the individual and the world, a funda- References mental element in psychotherapy (Schott-Billmann, 1997). Alexandris, K., Barkoukis, V., Tsormpatzoudis, Ch, 2007. Does the In addition, via dancing a safety and confidence climate theory of planned behavior elements mediate the relationship is created in which sentiment expression is attained via between perceived constraints and intention to participate in movement. An environment, absolutely adapted to old physical activities? A study among older individuals. European people’s faculties was offered and corresponded to their Review of Aging and Physical Activity 4, 39e48. real needs (Cooper and Thomas, 2002). 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Journal of Bodywork & Movement Therapies (2010) 14, 219e226 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt NEUROPHYSIOLOGY The use of surface electromyography for the study of auricular acupuncture* Fabiano Politti a,b,*, Cesar Ferreira Amorim c, Lilian Calili a, Adriano de Oliveira Andrade d, Evanisi T. Palomari a a Department of Anatomy, University of Campinas (Unicamp), Brazil b Department of Physical Therapy, Rehabilitation Sciences Biomechanics Lab, University of Vale do Sapucaı´(Univa´s), Brazil c Department of Mechanical Engineering, Sa˜o Paulo State University (UNESP - FEG), Guaratingueta´ - SP, Brazil d Biomedical Engineering Laboratory (BioLab), Federal University of Uberlandia, Brazil Received 13 June 2008; received in revised form 11 November 2008; accepted 22 November 2008 KEYWORDS Summary The advancement of knowledge in neurophysiology has demonstrated that Electromyography; acupuncture is a method of peripheral neural stimulation that promotes local and systemic Auricular acupuncture; reflexive responses. The purpose of this study was to determine if surface electromyography Neurophysiology can be used as a tool to study the action of auricular acupuncture on striated skeletal muscle. The electromyographic amplitudes of the anterior, middle and posterior deltoid muscle and the upper trapezium muscle with 20%, 40% and 60% of maximal voluntary contraction of 15 healthy volunteers, were analyzed after the individuals were submitted to the auricular acupuncture treatment. The non-parametric Friedman test was used to compare Root Mean Square values estimated by using a 200 ms moving window. Significant results were further analyzed using the Wilcoxon signed rank test. In this exploratory study, the level of significance of each comparison was set to p < 0.05. It was concluded in this study that a surface electro- myography can be used as a tool to investigate possible alterations of electrical activity in muscles after auricular acupuncture. However there is still a lack of adequate methodology for its use in this type of study, being that the method used to record the electromyographic signal can also influence the results. ª 2008 Elsevier Ltd. All rights reserved. * Work accomplished at the State University of CampinaseUNI- Introduction CAMP, Institute of Biology, Department of Anatomy. Acupuncture has recently been recognized by western * Correspondence to: Fabiano Politti, Universidade Estadual de science as a procedure that can be used supplementary to Campinas, UNICAMP, Depto of Anatomia, Instituto de Biologia, Cx medicine, especially in the treatment of chronic pain Postal 6109, CEP: 13084-971, Campinas - SP, Brazil. syndrome (NIH, 1998). Advances in the knowledge of E-mail address: [email protected] (F. Politti). 1360-8592/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2008.11.006
220 F. Politti et al. neurophysiology have made it possible to establish that this effects of acupuncture, because it is then possible to is a neural peripheral stimulation method that promotes investigate the amplitude and occurrence of electrical local and systemic reflexive responses, mediated by endo- activity in the muscle while a task is being performed crine and immune systems and by superior centers of (Robertson et al., 2004) central control (Mayer, 2000; Carlsson, 2002). The aim of the present study was to determine if surface A reflexive response is caused by a gauging stimulus electromyography can be utilized as a tool to study the located in the somatic nerve fibers, which is triggered by action of auricular acupuncture on striated skeletal insertion of a needle (Andersson and Lundeberg, 1995) in muscles. Additionally, the behavior of the electrical specific points of the skin and muscles, called acupoints activity was verified from anterior, middle and posterior (Li et al., 2004). These acupoints, found in greater deltoid muscles and upper trapezium muscle at different concentration in specific areas such as the ear, can be used levels of exertion in a single test position. in a combined fashion with points on the body (Ellis, 1994). Methods The most frequent use of acupuncture treatment is in muscular relaxation (Lewith and Kenyon, 1984); in the Subjects systemic regulation of motor dysfunctions (Ulett et al., 1998) and in the control of skeletal muscle pain, consid- The volunteers taking part in the study were selected by ering that its analgesic effects are mediated by central means of a blind draw from the population of undergrad- mechanisms that involve neural standards (Sim, 1997; uate and graduate students from the Anatomy Department Pomeranz, 2001). of the University of Campinas Biology Institute. Fifteen volunteers, between ages 20 and 28, were selected and of However, results are still questionable regarding those, eight were females (average 20.63 Æ 2.97) and seven acupuncture’s action in pain control. Studies carried out on were males (average 26.33 Æ 5.68). Included in the study the effects of chronic pain have indicated that individuals were healthy, non-obese, sedentary volunteers having no who received treatment with sham acupuncture, demon- history of previous shoulder pain. The volunteers were strated better results than the individuals receiving real examined by a physical therapist familiar with musculo- treatment (effective treatment of chronic pain), gener- skeletal disorders of the upper limbs and scapular waist and ating much criticism about the methodology applied in neck. All volunteers signed a Term of Consent as required these types of studies (Ezzo et al., 2000). by resolution 196/96 issued by the National Health Council and previously approved by the Ethical Committee in In general, the methodology utilized to demonstrate the Research from the State University of Campinas. Each effects of acupuncture has concerned several authors subject was informed of the purpose and potential risks of (Birch, 2003; Hopwood and Lewith, 2003), who rate many of the study before their written voluntary consent was these studies inconsistent, partial and likely to over- obtained. estimate the positive effects of the treatment (Moher et al., 1996; Jadad and Rennie, 1998; Ezzo et al., 2000). Equipment Due to the existence of different techniques for the Myoelectric signals were obtained using an 8-channel insertion of the needle, combined with different strategies module (EMG System do Brazil Ltda.â), consisting of a band for the localization of the insertion points and the existence pass filter of 20e500 Hz, an amplifier gain of 1000, and of several treatment methods for the same type of diseases a common rejection mode ratio >100 dB. All data were (Birch, 2003), it is essential for this type of study to acquired and processed using a 16-bit Analog to Digital consider the appropriate selection of a specific treatment converter (EMG System do Brazil Ltdaâ), with a sampling for each type of pathology, and the selection of the control frequency 1.33 kHz. The system was composed of active group, the choice of the participants and the choice of the bipolar electrodes displaying a pre-amplification gain of acupuncturists (Sherman and Cherkin, 2003). 20Â. A channel of the acquisition system was enabled for the utilization of the load cell (Alfa Instrumentsâ), having Recent review articles have concluded that acupuncture an output between 0 and 20 mV and a range up to 1 kN. still requires investigation. This is due to the fact that the neuromodulating mechanisms of nociception resulting from Procedure and data collection the stimulus caused by acupuncture, which happen at the three levels of the central nervous system (spinal, tron- In western culture, the use of the auricular microsystems coencephalic and diencephalic), needs greater clarification developed in France by neurologist and acupuncturist Paul (Moya, 2005), as do the methodological standards such as Nogier gave another perspective to the understanding of appropriate sample sizes, well-defined inclusion and some of the mechanisms by which acupuncture works. The exclusion criteria, and collection of data on safety and side concept of the technique is based upon the somatotopic effects (Sherman and Cherkin, 2003). An important note of organization of the external auricular pavilion and princi- observation about these revision articles is that, as of yet, pally on its direct relation to the central nervous system, there exists no standardized method for each area of which is hypothesized to function through the branches of investigation into acupuncture activity. pairs of cranial nerves innervating the whole auricular pavilion (Nogier, 1969, 1972, 1983). Since it is an acceptable method in the investigation of muscular function in various types of analysis such as in muscular biomechanics (Finley et al., 2005), muscular skeleton fatigue (Ebaugh et al., 2006), strength (Kami- bayashi and Muro, 2006), rehabilitation (Barak et al., 2006) and neuromuscular disorders (Hogrel, 2005), surface electromyography can be a reliable tool to validate the
The use of surface electromyography 221 Nogier’s original discovery led to the identification of electrodes, the skin was cleansed with 70% alcohol for the the body mapping on the auricle which presented remark- elimination of residual fat; cleansing was followed by able consistency with respect to anatomic and embryolog- exfoliation using a specific sand paper for skin (Bio-logic ical considerations. Thus, the ‘‘inverted fetus’’ presents Systems Corpâ) and a second cleaning with alcohol. The with the musculoskeletal (mesodermal) projections in the electrodes were affixed 2 cm laterally in reference to the upper aspect of the ear, including the anti-helix, scaphoid mid point of a line traced from the posterior lateral edge of fossa, and triangular fossa (Nogier, 1969). the acromion to the 7th cervical vertebra (Matthiassen et al., 1995) in the upper trapezium muscle. For the ante- According to the theory and body mapping proposed by rior, middle and posterior deltoid electrodes were Nogier, it is possible to conclude that the needle stimulus in positioned in the lower half of the distance from the the specific external auricular pavilion can influence in acromion to the deltoid tuberosity (Nannucci et al., 2002). a reflexive manner specific regions of the body. However, A reference rectangular electrode (3 cm  2 cm), was this hypothesis is yet to be tested in a blind, placebo- lubricated with electro-conductor gel (Pharmaceutical controlled clinical trial. In order to verify this hypothesized Innovationsâ) and fastened to the left wrist of the volun- reflexive action of auricular acupuncture on the musculo- teers. During the experiments, the individuals remained skeletal activity, we used the acupuncture point referring comfortably seated in the test chair. to the scapular waist and shoulder, as proposed by Nogier (Figure 1). Before beginning the recording of electromyographic signals, each individual subject was asked to carry out Consequently, the possible reflexive action of the scap- a series of three maximum force elevations of the shoulder ular waist and shoulder acupuncture point was verified ipsi-lateral to the auricular acupuncture treatment, with through activity from the upper trapezius and deltoid duration of 3 s each, against the resistance offered by the muscles respectively. load cell (Figure 2). A 2-min rest period was given between efforts. Verbal encouragement was given to the subject Muscle activity was recorded from the upper trapezius, especially during the task. selected because they are the primary muscles used to elevate the arm (Michels and Boden, 1992; Campos et al., The mean value from the three trials represented 1994) and because they are commonly related to tension a subject’s 100% maximum voluntary contractions (MVC) pain of the head and neck. The anterior, middle and force, and the 20%, 40% and 60% values of MVC were posterior deltoid muscles were chosen because they assist calculated from that number. Mean muscle output was used in the elevation and stabilization of the shoulder during this to determine MVC as it was believed to be a more accurate elevation (Hagberg, 1981; Kronberg et al., 1991; McCann representation of a subject’s strength than a single et al., 1993). contraction. The three sub-maximal contractions (20%, 40% and 60% MVC) were used in the analysis of the auricular Self-adhesive disposable surface electrodes (Ag/AgCl e acupuncture action on the shoulder muscle. Medical Traceâ) of 10 mm of diameter were used for the surface recording of electromyography with a center to center distance of 20 mm. Prior to the fixation of the Figure 1 Insertion points of the acupuncture needle in the Figure 2 Test position as the individual elevates the shoulder ear, corresponding to the shoulder (a) and the scapular waist ispi-lateral to the auricular acupuncture (A) against the resis- (b) used in the experimental group and the point located in the tance of the load cell (B). shell of the ear (c) used for the placebo group.
222 F. Politti et al. Due to the necessity of having an appropriate control waist (Nogier and Boucinhas, 2001). Asepsis by means of group for this type of study, the same volunteers served as alcohol was provided at the location of the acupuncture the control. Consequently, the experiment was run in two needle insertion. A physical therapist certified in the Nogier stages with a fixed, 7-day interval between the two tests. Method of Auricular Acupuncture by the Regional Physical The results obtained with the needles placed in the points Therapy Council (CREFITO-4) and having 5 years of clinical specific to the treatment of shoulder region problems were experience with the Nogier Method, performed the auric- assigned to the experimental group and the placebo group ular acupuncture treatment. served as the control. A blind draw determined the order of the individual subjects sampled. As suggested by Sherman Processing and analysis of the signals and Cherkin (2003), the real function of each acupuncture point was masked from the participants. Likewise, the For this study, the EMG signals obtained during the 20%, 40% participants were requested not to visualize the application and 60% sub-maximal MVC contractions under the condi- site of the needle. Communication with the patient was not tions ACP, ACP1 and ACP2, were normalized by the medium permitted during the experiment, and the acupuncturists values of the three repetitions at maximal effort with fixed were not aware of the specific purpose of the study. resistance for each muscle analyzed, as used by McLean Questions about the study were noted by one of the (2005). Each sample lasted 4 s with a rest interval of 2 min. authors, but were answered only at the conclusion of the The position and action of each muscle studied was thus: i) research, when all data had been collected. upper trapezium and medium deltoid: individual subject seated, performing static contraction of the limb in Electromyographic signals were recorded at three abduction of 90 and neutral rotation of the shoulder, distinct moments, the first, pre-acupuncture (ACP), served against the resistance of a strap positioned near the elbow as comparison to the signal obtained after the insertion of joint (McLean et al., 2003); ii) posterior deltoid: individual the acupuncture needle. Five minutes after the first subject seated, with a slight abduction, extension and sample (ACP), disposable sterile acupuncture needles medial rotation of the shoulder, performing extension of 0.25 Â 13 mm (Suchou Huanqiu Acupuncture Medical the limb with isometric contraction during the traction of Appliance Co. Ltd.â) were inserted at previously estab- a fixed strap attached near the elbow joint (Kendall et al., lished points of the outer ear and were maintained without 1993); iii) anterior deltoid: individual subject seated, with manipulation until the end of the experiment. After a 1-min slight abduction, flexion and lateral rotation of the interval, a second electromyographic signal sample was shoulder, performing flexion of the limb in isometric recorded with acupuncture (ACP1), and after 5 min, the contraction during the traction of a fixed strap attached third and last sample electromyographic signal (ACP2) was near the elbow joint (Kendall et al., 1993). recorded, followed by immediate removal of the needle. After data were normalized for each muscle the root The criteria for the recording of the electromyographic mean square (RMS) was calculated using a 200 ms moving signals were always the same for all stages of the experi- window technique. Electromyographic Analysis Software, ment. At each moment (ACP, ACP1 and ACP2), 20%, 40% and Version 1.01 (EMG System do Brasil, Ltda.â) was used. 60% sub-maximum MVC samples were collected and main- tained through visual feedback provided by a line drawn on Statistical analysis the computer screen. The duration of each electromyo- graphic signal sample was 5 s. In order to avoid a learning Data are presented as means and standard deviations (SD). effect, the order of the sample collection was also deter- The non-parametric Friedman test was used to compare mined by blind draw. Possible risks of bodily compensation intraclass results in root mean square amplitude (RMS). during the traction of the load cell and of patterning in the Significant results were further analyzed using the Wilcoxon whole experiment were prevented through training before signed rank test. In this exploratory study, the level of all the tests. Of greatest concern during the experiment significance of each comparison was set to p < 0.05. The was that the head and neck be always maintained in the entire analysis was conducted using the software SPSSâ same position, so as to avoid interference from the upper (Version 12.0). trapezius muscle in the activity. Results Needle insertion points on the ear The intraclass analysis (Friedman test) of anterior, middle In the experimental group, the needles were inserted on and posterior deltoid muscle (Table 1) did not present the ear at the points corresponding to the scapular waist, a statistically significant difference (p > 0.05) of the values located in the sixth of seven spaces contained between the of RMS amplitude, under pre-acupuncture conditions and posterior fold of the anti-tragus (in the region of its post-acupuncture, tested under each sub-maximum force junction with the anti-helix and the second depression level (20%, 40% and 60% of MVC). located on the anti-helix), and to the shoulder, located approximately 3 mm above the furrow which separates the The same analytical criteria were adopted for the anti-helix from the anti-tragus as indicated in Figure 1 upper trapezium muscle, which, in accordance with the (Nogier and Boucinhas, 2001). Friedman test displayed significant difference (p < 0.003) for values corresponding to 60% of the MVC in the In relation to the placebo group, the needles were experimental group. In the multiple comparisons, using inserted on the shell of the ear as placebo treatment the Wilcoxon test, a significant difference (p < 0.003), (Figure 1), being that this region does not present any somatotropic relationship to the shoulder and the scapular
The use of surface electromyography 223 Table 1 Mean and standard deviation (SD) of RMS (mV) from the anterior, middle and posterior deltoid muscle from experi- mental group and placebo group. ACP indicates the pre-acupuncture condition and ACP1 and ACP2 indicate the acupuncture condition tested under three levels of sub-maximum force (20%, 40% and 60% MVC). Muscles % MVC ACP ACP1 ACP2 *p value Mean (SD) Mean (SD) Mean (SD) Experimental Group 60% 0.29 (0.18) 0.28 (0.18) 0.32 (0.22) 0.76 Anterior Deltoid 40% 0.18 (0.12) 0.21 (0.12) 0.17 (0.14) 0.42 20% 0.14 (0.09) 0.14 (0.11) 0.15 (0.11) 0.54 Middle Deltoid 60% 0.83 (0.58) 0.80 (0.59) 0.86 (0.55) 0.81 40% 0.52 (0.49) 0.56 (0.42) 0.54 (0.42) 0.81 20% 0.47 (0.41) 0.46 (0.41) 0.48 (0.40) 0.62 Posterior Deltoid 60% 0.88 (0.56) 0.86 (0.68) 0.90 (0.69) 0.93 40% 0.58 (0.52) 0.49 (0.43) 0.52 (0.41) 0.12 20% 0.28 (0.16) 0.28 (0.19) 0.31 (0.19) 0.48 Placebo Group 60% 0.21 (0.06) 0.20 (0.10) 0.20 (0.06) 0.72 Anterior Deltoid 0.20 (0.19) 0.28 0.10 (0.03) 0.76 40% 0.17 (0.06) 0.21 (0.19) 0.67 (0.35) 0.62 20% 0.10 (0.03) 0.11 (0.04) 0.46 (0.21) 0.62 0.38 (0.19) 0.86 Middle Deltoid 60% 0.67 (0.39) 0.63 (0.36) 0.63 (0.41) 0.63 40% 0.42 (0.17) 0.47 (0.22) 0.43 (0.23) 0.21 0.28 (0.12) 0.70 20% 0.35 (0.15) 0. 39 (0.20) Posterior 2Deltoid 60% 0.71 (0.68) 0.62 (0.51) 40% 0.43 (0.23) 0.41 (0.28) 20% 0.27 (0.12) 0.26 (0.11) *A Friedman test did not show a significant difference (p > 0.05) in the intraclass comparison. was identified in the RMS values corresponding to the ACP Discussion and ACP2 (Figure 3). These results indicate an increase of the RMS amplitude in the upper trapezium muscle at 60% Based on the advances in neurophysiology, it is possible to MVC, after 5 min of the insertion of the acupuncture define acupuncture as a neural peripheral stimulation needle in the ear. For values regarding 20% and 40% MVC method aimed at promoting changes in the sensorial, in the experimental group, no significant differences were motor, hormonal and cerebral functions (Nishijo et al., found (Friedman test, p > 0.05). Under these same test 1997; Mayer, 2000). Such changes originate from the reflex conditions, no statistically significant differences were response caused by the afferent stimuli in the somatic found in the analysis of the trapezium muscle in the nerve fibers after the insertion of the needle (Andersson placebo group (Figure 3). and Lundeberg, 1995). Figure 3 Mean of the RMS (mV) value computed over 5 seg from the upper trapezium muscle. The intraclass tests accomplished in the placebo group, did not demonstrate significant statistical differences (Friedman test, p > 0.05) between the pre-acupuncture (ACP) and with acupuncture (ACP1 and ACP2) in each one of the tree tested levels of sub-maximum force (20%, 40% and 60% MVC). * Indicates a significant difference between ACP and ACP2 (Wilcoxon, p < 0.003).
224 F. Politti et al. Knowledge about the reflex response is concentrated in no way of proving this, each possibility of sub-maximum experimental studies carried out on the pathways of the contraction (20%, 40% and 60% MVC) having been deter- sensory nerve system responsible for the modulation and mined by the draw which preceded each of the samples. If inhibition of pain (Mayer, 2000; Carlsson, 2002) in the three this really occurred, the increased electromyographic levels of the central nervous system: spinal cord (Lewith signal amplitude could be related to the onset of fatigue and Kenyon, 1984; Cao, 2002), encephalic trunk (Cao, 2002) (Masuda et al., 1999), which can happen during a repetitive and cerebral cortex (Zhang et al., 2004). However, the or sustained activity (Mannion & Dolan, 1996), as was the action of auricular acupuncture on the motor apparatus is case during the experiment. This points to a possible fault not frequently discussed in scientific studies, which makes in the method used in this study. a difficult discussion of the results presented in this work. Thus, the duration of data collection and the number of With respect to the results obtained by means of the repetitions of the experiment also need to be well planned methodology used in this study, it is not possible to state to avoid alterations of the amplitude electromyographic that auricular acupuncture can influence the activity of the signal as a result of biological factors such as muscular muscles studied because, although a significant increase fatigue. (p < 0.05) in electromyographic activity of the upper trapezius muscle was observed in the experimental group During the development of this study, a constant source with 60% of MVC there was no alteration of the electro- of concern for the authors was the use of methodological myographic signal with 20% and 40% of MVC. rigor in the collection and treatment of data. This concern arose mainly after the literature review indicated potential The significant alteration observed only in the upper problems involving sample size, nature of the study, inad- trapezius muscle in the experimental group with 60% of equate control groups and absence of long-term responses MVC, requires extra care in its interpretation. To affirm (Mclellan et al., 1993; Moher et al., 1996; Ezzo et al., 2000; a possible effect of auricular acupuncture on the muscle Sherman and Cherkin, 2003; Moya, 2005). activity would be possible only if statistically significant alterations of the electromyographic signal with 20% and To ensure confidence in the results obtained, a blind 40% of MVC had been found. Factors such as type (Tarkka, clinical trial was carried out by means of a draw. The trial 1984) and time duration of contraction (DeVries et al., aim was to compare the action of the true points in the 1982; Tarkka, 1984) can also alter the muscle activity and treatment experimental group versus the action of the false should be considered in the analysis of the results obtained points in the placebo group, in random distribution, as in this study. suggested in the literature (Carroll et al., 1996; Filshie and White, 1998) and described in the methodology of the In general, during an isometric exercise at constant present study. The use of false points is possible due to the load, there is a time related increase of the electromyo- fact that points on the ear are highly specific and there are graphic signal (Tarkka, 1984) which could be related to differences between the stimuli effect from the real and changes in the recruiting pattern of motor units after the false points (Farber et al., 1995; Tavares et al., 1996). first seconds of contraction, as well as to the increase of the amplitude of the action potential and to the recruit- It is important to mention that is impossible to carry out ment of motor units or the firing of the motor neurons a double blind study in acupuncture since the acupuncturist (DeVries et al., 1982; Tarkka, 1984); however, this fact is cannot be blinded (Filshie and White, 1998; Carlsson, 2002). not enough to justify the increased amplitude of the elec- Consequently, the volunteers who participated in this tromyographic signal in the experimental group, since the study, as well as the author of the evaluations of the same experimental conditions were maintained for the two electromyographic signals, were not informed of the groups studied. specific function of the auricular acupuncture treatments adopted in the experiment, as suggested by Filshie and Another argument that would contradict this outcome is White (1998) and Carlsson et al. (2000). that acupuncture has as one of its more frequent clinical uses, muscular relaxation (Lewith and Kenyon, 1984) and, Even with all these cautionary measures, it was observed in this case, the electromyographic signal is reduced. that the methodology used for electromyographic signal recording of the deltoid muscle was not the most appro- All the consulted therapists using the Nogier method priate. Previous studies indicate that the action of the relate muscle relaxation and a reduction or an elimination three portions of the deltoid muscle is directly related to of pain as principle therapeutic effects. As such, the results the movements of abduction, flexing and the dislocation of of this study open to questioning the affirmation that the upper limb in different angular movements (Michels and auricular acupuncture has muscular relaxation as one of its Boden, 1992; Campos et al., 1994). Since this experiment effects. This contradiction indicates that the clinical was conducted without angular shoulder movement treatment results are not the same as those present in the (Figure 2), the electromyographic signal amplitude controlled study, suggesting that further investigation is obtained from the three portions of the deltoid muscle was necessary. very low and possibly not sufficient to show a possible influence of auricular acupuncture on this muscle. With One possible explanation for the appearance of the relation to the upper trapezius muscle, the position adop- significant difference found in the experimental group at ted for the tests (Figure 2) permitted that this muscle 60% of MVC could be related to the methodology employed performed its functions as a prime mover during elevation during the experiment. Since the collection sequence of and rotation of the scapula and as a stabilizer of the electromyographic signal was by blind draw, the data scapula during glenohumeral movements (Schenkman and referring to the sub-maximum contraction of 60% of MVC De Cartaya, 1987) and during glenohumeral torque could have randomly been the last to be collected under production (Mathiassen and Winkel, 1990). Consequently, it the ACP2 condition of the experimental group, but there is
The use of surface electromyography 225 is important to respect the muscular function because the transcutaneous electrical nerve stimulation in acute post- firing frequency of the motor units varies according to the operative pain. British Journal of Anaesthesia 77, 798e803. levels of force exerted during the isometric contraction DeVries, H.A., Moritani, T., Nagata, A., 1982. The relation between (Maton, 1981) and it is possible that the greater the motor critical power and neuromuscular fatigue as estimated from engagement, the greater the chance that alterations will electromyographic data. Ergonomics 25, 783e791. be observed in the pattern of the electromyographic signal. Ebaugh, D.D., McClure, P.W., Karduna, A.R., 2006. Effects of shoulder muscle fatigue caused by repetitive overhead activi- Conclusions ties on scapulothoracic and glenohumeral kinematics. Journal of Electromyography and Kinesiology 16, 224e235. Based on the results found, it is not yet possible to state Ellis, N., 1994. Acupuncture in Clinical Practice: a Guide for Health that auricular acupuncture can influence the electrical Professionals. Chapman & Hall, London. activity of the muscle. A suitable methodology needs to be Ezzo, J., Berman, B., Hadhazy, V.A., et al., 2000. Is acupuncture developed to allow the utilization of auricular acupuncture effective for the treatment of chronic pain? A systematic as a research tool in the investigation of the action of review. Pain 86, 217e225. auricular acupuncture on the electrical activity of the Farber, P.L., Neves, F.G., Tavares, A.G., et al., 1995. O aumento do muscle. Factors such as the duration of collection, main limiar da dor com acupuntura auricular na cervicobraquialgia action of the muscle and the number of test repetitions aguda: estudo placebo controlado. 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Journal of Bodywork & Movement Therapies (2010) 14, 227e233 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt REVIEW AND HYPOTHESIS Qi Gong exercises and Feldenkrais method from the perspective of Gestalt concept and humanistic psychology Dr. Paul Posadzki a,*, Dr. Andrea Sto¨ckl a,1, Dr. Dariusz Mucha b,2 a School of Medicine, Health Policy and Practice, University of East Anglia, Norwich NR4 7TJ, UK b Health and Physical Education Institute, Radom Polytechnic, 26-600 Radom, Poland Received 11 April 2008; received in revised form 15 December 2008; accepted 16 December 2008 KEYWORDS Summary This study describes two similar approaches to human movement: Qi Gong exer- Qi Gong; cises and the Feldenkrais method. These systems are investigated in terms of Gestalt concepts Feldenkrais; and humanistic psychology. Moshe Feldenkrais created the concept known as Awareness Gestalt concept; Through Movement. This concept assumes that by becoming more aware of one’s movements, Humanistic psychology one functions at a higher level. In similar ways to those using the Feldenkrais method, individ- uals may become more aware of their own movements by performing Qi Gong exercises: A therapeutic modality that facilitates mindebody integration. Qi Gong exercises commonly lead to increased personal awareness accompained by enhanced quality, fluency and smooth- ness of movement. These two methods of movement therapies are explored in terms of their relations with Gestalt concept and humanistic psychology. Crown Copyright ª 2008 Published by Elsevier Ltd. All rights reserved. Introduction ability to discover flexible and adaptable behaviour, which are, as he argued, self-organized (Buchanan and Ulrich, Feldenkrais is an educational system designed to use 2001). It could therefore be claimed that Feldenkrais’ movement and perception of one’s own self to foster methods are somatic education techniques designed to individualized improvement in function. Moshe Feldenkrais, establish a heightened awareness of movements (Jain its originator, believed his method enhanced people’s et al., 2004). Feldenkrais method also describes excellence in motor control and it provides encouragement towards * Corresponding author. Tel.: þ44 01603591223. developing awareness of body movements (Hannon, E-mail addresses: [email protected] (P. Posadzki), 2000a,b, 2001a,b). A self-awareness exploration principle is presented to help to deepen this understanding and to [email protected] (A. Sto¨ckl), [email protected] (D. Mucha). encourage a visceral comprehension of another principle: 1 Tel.: þ44 01603 591879. Control follows awareness (Hannon, 2000a,b). It is worth 2 Tel.: þ48 601 482 162. 1360-8592/$ - see front matter Crown Copyright ª 2008 Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2008.12.001
228 P. Posadzki et al. mentioning that the Feldenkrais approach has in common symptoms of depression (Kerr et al., 2002; Kolt and with phenomenology of bodyemind approaches a general McConville, 2000; Huntley and Ernst, 2000), and improving philosophy of enhancing natural processes system to self-esteem (Huntley and Ernst, 2000). It has been sug- improve function and decrease pain (Lusky and Devlin, gested that Feldenkrais method can facilitate voice 2001). Therefore, persons who seek out these practices and projection (Emerich, 2003) and therefore that it may be incorporate them into their daily lives and expressions of useful in various social interactions. These results suggest physical activity are often motivated to maintain or that this type of motor learning intervention can be establish an optimal state of well-being and function effective in improving a variety of physical and psycholog- (Schlinger, 2006). The author believes that Chinese Qi Gong ical parameters related to balance confidence and self- exercises and Feldenkrais method are based on similar efficacy (Stephens et al., 2001). principles: both approaches consist of conscious move- ments that are performed with precision and full concen- Clinical effectiveness of Feldenkrais tration: an effortless permission of flow (Levey and Levey, 2005). In addition, both Qi Gong exercises and Feldenkrais Studies suggest that Feldenkrais may be more effective method may have principles of Gestalt concept and than conventional treatment in patients with non-specific humanistic psychology in common, such as, firstly, a feeling musculoskeletal disorders (Malmgren-Olsson et al., 2001). It of presence in the reality that can be defined as a mental can be thought that this kind of therapy encourages indi- process-act in the present, embedded in the structure of viduals to explore various, more effective movement the actuality (Perls, 1951, p. 67); secondly, consciousness: patterns. For instance, fibromyalgia patients showed a place from which acceptance and committed action can improvement in balance and trends to better lower occur (Strosahl, 2002); and thirdly, self-development: the extremity muscle function after the Feldenkrais interven- tendency of the organism to move in the direction of tion (Kendal et al., 2001). It should be noted that Fel- maturation (Rogers, 1951, p. 488). They also share a similar denkrais therapy participants reported increased joint approach to describe the various processes that a person mobility of neck and shoulders in 97 female industrial with motivational progression towards ultimate self-actu- workers (Lundblad et al., 1999). Other studies reported alization develops: once the basic needs are completely that Feldenkrais participants improved significantly in gratified, step by step, the person moves onto the next measurements of flexibility (sit and reach test) as opposed higher one and eventually emerges into consciousness to their control group counterparts (Hopper et al., 1999). (Maslow, 1968, p. 32); 4). Self-realization brings a value of Likewise, Feldenkrais therapy patients stated decreased richness of existence that expands horizons and maximises perception of pain, both immediately after the program potential through movements. The aim of this study is to and in a one-year follow-up (Bearman and Shafarman, describe Qi Gong exercises and Feldenkrais method in the 1999). Results from analyses of variance showed that the context of humanistic and Gestalt concept and explore how Feldenkrais intervention was effective in reducing the patients and therapists can benefit from this fusion. affective dimension of pain for people experiencing chronic lower back problems (Smith et al., 2001). From a social Benefits of Feldenkrais therapy perspective, the Feldenkrais group showed significant decreases in complaints from neck and shoulders and in Psychological and social benefits of Feldenkrais disability during leisure time (Lundblad et al., 1999). From therapy physiological point of view, for example, an endurance score, and exertion capacity according to a dynamic Laumer et al. (1997) reported that participants of the Fel- endurance test of the shoulder flexors with simultaneous denkrais course showed increased contentment with regard surface EMG were improved (Lundblad et al., 1999). In their to problematic zones of their body and their own health as social survey Junker et al. (2004) sent 180 questionnaires to well as concerning acceptance and familiarity with their members of the German Dystonia Society. Functional Inte- own body. Other results showed open and self-confident gration (FI) and Awareness Through Movement (ATM) are behaviour, a decrease of feelings of helplessness, height- aspects of the Feldenkrais method that have been used ened sense of self-confidence, and a general process of successfully in the rehabilitation of these patients. Clinical maturation of the whole personality (Laumer et al., 1997). effectiveness of Feldenkrais has been confirmed among The participants in the group with well-developed body orthopedic patients (Stephens, 2000). Both FI and ATM can awareness described an enhanced attitude towards the influence various body spheres and dimensions and facili- body, and they gave clearer descriptions about their tate improved neuromuscular organization and coordina- experiences of emotions (Ryding et al., 2004). Additionally, tion, range of movement or soft tissue flexibility. Pain free the results showed significant positive changes over time in movements are possible with decreased muscle tension and all three treatment groups with regard to reduced joint stiffness, leading to less fatigue as a consequence. psychological distress, pain, and improved self-image Other outcomes suggest that ATM is beneficial for some (Malmgren-Olsson et al., 2001). Some analyses of variance people with multiple sclerosis (Stephens et al., 1999). for repeated measures revealed mood improvement Feldenkrais method includes approaches to motor learning following Feldenkrais method (Netz and Lidor, 2003) and that can be used to facilitate change and integration in a sense of well-being (Stephens et al., 1999). These findings postural and general musculoskeletal control (Stephens, can be interpreted as further support for the efficacy of the 2000; Stephens et al., 2001). In addition, it can be used in Feldenkrais method in reducing states of anxiety and postural education or reeducation in children’s ‘back school’. Seegert and Shapiro (1999) support this point of
Qi Gong exercises and Feldenkrais method 229 view as they described that only the exercise group of 25 the general population (Chow and Tsang, 2007). Mental well- college students showed statistically significant changes in being can be achieved due to Qi Gong movements as they quality and harmony of posture and simple movement such may reduce tensions, and regulate the body’s internal as postural sway after Feldenkrais intervention. Other balance (Ryu et al., 1996, 1997; Wu et al., 1999; Jones, outcomes show that two broad areas of improvement were 2001). From the perspective of Western science, physiolog- ease and steadiness of daily movements (Stephens et al., 1999). ical effects of Qi Gong may be taken into account such as changes in brain functioning, i.e. theta rhythm frequencies, Brief characteristics of Qi Gong level of concentration (Pan et al., 1994), and increase in blood flow velocity in the posterior cerebral artery (Litscher According to Chinese Medicine, Qi is the energy that et al., 2001). The respiratory movements can be improved simultaneously pervades the macro-cosmos e the Universe by changing the volume of oxygen consumed, the carbon and the micro-cosmos e the human body. Followers of Qi dioxide that is produced, and changes in the frequency of Gong believe that within the human body Qi energy flows in breath (Lim et al., 1993). The sympathetic nervous system channels called meridians. Gong may be translated as functions, such as heart rate, skin potential, skin tempera- a way of development, enhancement and improvement. As ture, stomach and intestine metabolism, endocrine and such, Qi Gong means augmentation of the body’s energy. Qi immunity systems can also be influenced positively (Xu, Gong are Chinese health exercises that have been used and 1994; Ryu et al., 1995; Jones, 2001). It can be assumed that developed for thousands of years to optimize energy within consequences of regular Qi Gong exercises are overall on the body, mind, and spirit (Litscher et al., 2001). Qi Gong is health and longevity. It seems to be a valuable and reliable a combination of meditation, controlled breathing and method to enhance the individual’s health awareness gentle, physical movements designed to control or mobilize (Mayer, 1999). the vital energy (Qi) of the body. It consequently may improve spiritual, physical and mental health (McCaffrey Gestalt concept and Fowler, 2003; Jones, 2001). Qi Gong exercises may either sedate or ‘speed up’ the functioning of the human Gestalt theory (GT) is the result of investigations in brain, depending on the Qi Gong methods practiced by psychology, logic, and epistemology and is a palpable different individuals (Zang et al., 1993). Qi Gong can be convergence of concepts ranging through the sciences, and seen as a usage of specific movements to direct mental various philosophic points of views of modern times (Ko¨hler, attention to specific areas of the body. The Qi Gong master 1940; Koffka, 1935; Wertheimer, 1944). Gestalt theory of frames it as a ‘mind-in-body’ practice rather than minde perception draws on existential and various Eastern body interaction (Kerr, 2002). Qi Gong practitioner may philosophies and aims to enable the individual to seek his or experience various body sensations due to enhanced Qi her own solutions to personal problems. Literally translated flow within the body (Xu, 1994). These sensations may as ‘form’, Gestalt focuses the individual to appreciate and include warmness in hands, state of relaxation, sense of experience the present (Jones, 1992). harmony with movements and universe simultaneously, chillness, and state of tranquility and serenity (Agishi, Gestalt Psychology (GP), founded by Max Wertheimer at 1998). Evidence shows that Qi Gong exercises may be the beginning of the 20th century, was to some extent beneficial for various ‘civilization’ diseases such as hyper- a rebellion against the paradigm of molecularism that was tension or diabetes (Iwao et al., 1999; Mayer, 1999). For in fashion at the time. In fact, the word Gestalt means example, Iwao et al. (1999) have, shown that both Qi Gong a unified or meaningful whole. GP focuses on understanding and conventional walking decreased plasma glucose levels of essentials of reality within ‘here and now’. Similarly to in comparison to control groups, however in the Qi Gong phenomenology, Gestalt theory penetrates the problem group no increase in pulse rate was observed. Longitudinal itself and therefore it can be regarded as ‘applied studies over 20 years have shown that Qi Gong exercises phenomenology’ (Koffka, 1935, pp. 9e10). promote longevity (Kuang et al., 1991; Wang et al., 1993). There is some encouraging evidence of Qi Gong for lowering Frederick Perls introduced the Gestalt concept into systolic blood pressure, nevertheless rigorously designed psychotherapy, and it was then developed by Paul Goodman trials are needed to confirm this (Lee et al., 2007). (Perls et al., 1951). As a psychotherapy method, Gestalt concept was used to facilitate an integration of life and to Qi Gong and health give the person a sense of balance in life through the restoration of awareness, which allows for increased choice Qi Gong exercises can affect many functions of the body and and flexibility in all aspects of living (Zahm and Gold, 2002, improve health in a beneficial manner (Sancier, 1996). From p. 863). Gestalt may also mean recognizing the communi- the perspective of a mind-body approach, the psycho-social cation between thoughts and feelings as they appear in our effect of Qi Gong was hypothesized by Tsang et al. (2002) as reality during the course of actions. Healthy functioning they argued that Qi Gong, as a form of Chinese therapeutics, requires self-regulation in which the person becomes aware has the effect of improving life quality and overall well- of needs which are contingent on a given situation. The being. Chow and Tsang (2007) have suggested that Qi Gong person expresses himself to satisfy those needs and to can be considered as an alternative therapy to help to meet ‘complete’ his or herself (Mosher, 1977). The perception of the increasing demand for non-pharmacologic modalities in self is widely used in Gestalt concept (Schnake Silva, 1981). achieving holistic health for those suffering from anxiety in The natural process of self-regulation cannot be inter- rupted by the self and further personal growth requires experimenting with new solutions for unsolved problems (Mosher, 1979a,b).
230 P. Posadzki et al. Gestalt practitioners believe that wholeness is it the phenomenal field, arguing that individual perception a complex system in which some parts are determined by of reality and its interpretation determines further behav- the behaviour of other parts (Zimbardo, 1999, p. 307), ioral patterns (Rogers, 1946). During the life span-devel- therefore it can be regarded as a unity of basic perception opment, an individual focuses on the role of external and experiences. In Gestalt concept, an encounter with relationships in the shaping and maintenance of self- the self may take place, when one realizes that a precious concept and personal identity that entails an integration of aspect of life can be created by concentrating on intro- self-acceptance and new positive and realistic self- ception and extraception simultaneously within the here perceptions (Rogers, 1961). Maslow (1968: p. 15) believed and now. A powerful source of life can occur and bring that the self-actualization drive of the organism’s potenti- change to an individual’s way of life, while being closer to alities towards a more effective basis for further growth experiences of living because of heightened awareness stands at the top of the hierarchy of individual’s needs and (Moreau, 1980). Some principal concepts are then is the most powerful impulse and internal motivation that elaborated more fully such as the cycle of awareness individuals possess. Self-actualization (SA) is a concept of (Corbeil and Poupard, 1978). Mosher (1979a,b) claims that the integrity of a person’s nature: the organism sponta- awareness is conceived to be selective, curative, neously reorganizes its capacities to actualize its potential a method, a prescription for ideal living, and a ground through whichever avenues are available (Maslow, 1971, p. for human existence. The same author presents more 168). SA could be seen as a final state of affairs and Gestalt awareness methods such as continuum of aware- a human’s goal and a dynamic process, active during ness, awareness questions, bio-behavioral feedback, a lifetime of ‘Being and Becoming’. It has also been argued directed awareness, concentration, present-centering, that a person will choose the right path of development and being more responsible for one’s own and others’ lives when she or he distinguishes and properly interprets the (Mosher, 1979a,b). Enhanced self-realization, self-devel- specific current development opportunities (Perls, 1948; opment, and self-acceptance, new ways of approaching Rogers, 1964). In addition to a personality’s integrity, and solving problems, coherence with self-awareness, and wholeness can be achieved via the drive to self-develop- unity with the Universe can be achieved by a sense of ment. Generally, humanistic psychology emphasizes the ‘grounding’ in the reality. Experimenting and trying to find individuals’ strengths and tries to find optimistic aspects of meaning via full awareness contribute to this sense of peoples’ nature, their positive self-esteem that allows grounding. In Qi Gong exercises and the Feldenkrais them to adjust to environmental demands (Rogers, 1964; session some Gestalt method principles could be applied: Maslow, 1971). Additionally, an individual should possess an the continuum of movements’ awareness, constant feed- increasing openness to experience, tendency to live fully in back from body as a whole, effortless concentration on each moment, trust in his or her organism as a means of movements, and the sense of grounding in the presence arriving at the most satisfying behaviour in each existential (reality). Equally, Feldenkrais stated that at any single situation and psychological freedom to move in any direc- moment the whole system achieves a kind of general tion (Rogers, 1961, p. 186). Similarly, Feldenkrais (1972: pp. integration that the body will express at that moment 16e18) pointed to different stages of development which when it acts (moves) (Feldenkrais, 1972, p. 38). The can be found in each individual and there is no limit to body’s position in space, positive thoughts and emotions, improvement and the boundaries of the possible should be as well as chemical and neuro-hormonal processes expanded in order to reach its fullest potential through combine to form a whole that cannot be separated out movements. The more an individual advances his develop- into its various parts during the movements. The nature ment through movements, the greater will be his ease of and essence of movements could be therefore ‘pene- action with harmonious self-organization. On the other trated’ and explored by the individual. Gestalt would be hand, through Qi Gong movements one can maximize his or similar to the explorations of Qi Gong and/or Feldenkrais her potential as a human being, freedom of expression and in the sense that unity of movements’ perception, its fulfillment of awareness. Finally, it can be suggested that experience and expression could be an open door to Qi Gong movements facilitate self-actualization and further enhanced self-realization and self-development. However, continuous personal growth. a discussion should be opened and further explorations may bring some insights into the relationships between Qi Psychological approach to Qi Gong exercises Gong exercises and Feldenkrais method in the light of and Feldenkrais method Gestalt concept. Chiropractors, osteopaths, naturopaths or physiotherapists may take inspiration from such Qi Gong practitioners and Feldenkrais patients could focus synthesis of these concepts for patients’ best benefits. their attention on more passive and calm introspection as Researchers can obtain valuable and additional arguments a sine qua non condition for having the sense of control, through such cross-fertilization of ideas across presented which is awareness of the body (Vollmer, 1998). Such studies that may be united by shared assumptions. attentive awareness of the body would allow them to focus on various kinds of body movements: quick and rapid, as Humanistic psychology well as slow, soft and relaxed ones. Vollmer (1999: pp. 34e35) also suggested that we do not have to try to find the Humanistic psychology emphasizes the functioning of the mental cause of the movements, but simply pointed to the holistic body (Zimbardo, 1999, p. 702). Carl Rogers fact that, since we move naturally, we know how to start to emphasized the world of individual experiences, and called move. He argued that this attempt consists of something
Qi Gong exercises and Feldenkrais method 231 we can do without trying because we never do more than knowledge of one’s own self and the structure of one’s move our bodies. Qi Gong exercises could be regarded as an consciousness (Zimbardo, 1999, p. 26). Additionally, Ryding aware intention to perform fluent movements combined et al. (2004) claim that body awareness has two dimen- with the of knowledge how to move our bodies in practical sions: one which is expressed in posture and movement and ways. Similarly to the Feldenkrais method, it can be sug- a second that pertains to the introspective dimension. Both gested that a constant development through movements in Qi Gong exercises and Feldenkrais practice introspective can be achieved following Qi Gong practice. Qi Gong and perceptive awareness should coalesce with each other exercises could mean to the practitioner a persistent self- in a unity of the present moment. It means that an indi- exploration in the direction of enhanced self-organization vidual should simultaneously be aware of both psycholog- at the level of personality characteristics. This could imply ical processes (attention, thoughts, feelings) and further changes in psychological well-being (positive mood, surrounding circumstances including his or her own body emotions and/or optimal self-esteem), social functioning and its movements in the current moment (Armstrong, (quality and quantity of interpersonal relationship) and 1989). Feldenkrais suggested that we have to learn to use spiritual growth beyond the self. Both Qi Gong and Fel- the parts of out bodies separately and the major difficulty is denkrais could be considered in broader conceptual field: differentiation of movement that includes all temporal and awareness mechanisms such as ‘communication’ between spatial changes in the state and configurations of the body thought and movement, emotions and movement, relaxa- and its parts (Feldenkrais, 1972, p. 32). Indeed, first of all tion of the whole body, and effortless concentration within Qi Gong practitioner should learn how to use the trunk, the here and now would facilitate personal growth, self- head, upper and lower extremities ‘separately’. Later on, actualization and self-realization. Such combination of one should consider the entire body full of consciousness, concepts could allow an individual to reach his or her fullest which allows for freedom and continuity of movements potential as a human being. During Qi Gong exercises and within here and now. From the exercise perspective it has Feldenkrais method the receptive mind should be tuned been suggested that Qi Gong exercises should be the into harmony with nature and life within reality. Likewise, ‘mixture’ of appropriate muscle usage in order to promote Qi Gong exercises and Feldenkrais classes are based on the the body’s balance, i.e. relaxation and tension, inter- assumption that the human body possesses positive changeably. Appropriate rhythm and adjustment in time resources which enable individuals to obtain maximum and space is equally important (Feldenkrais, 1972, p. 34). potential through movements so enhancing the body’s self- Such movement quality influences the nervous system regulatory processes. Jain et al. (2004) suggested that more positively. Body movements performed with full awareness, efficient movements are developed in the learning process state of unity within reality and self may be an optimal way and a person’s system can function better as a result. A for self-discovery, self-exploration and overall develop- person’s awareness is a valuable tool that can be used when ment. Rogers (1961: p. 173) wrote that the individual an trying to express his or her potential through Qi Gong should move towards living in an open, friendly, close movements or Feldenkrais method. However, being truly relationship to his own experience-movements. Therefore, aware and attentive to the subtleties of our movements the Gestalt concept and humanistic psychology can be requires effortless concentration, systematic and persis- major ‘modalities’ applicable to movement therapy. tent efforts via practice (Jain et al., 2004). Equally, Fel- denkrais suggests that once people mature their Conclusions movements, further function becomes automatic and does not require concentration and systematic and persistent The goal of Feldenkrais method and Qi Gong exercises is to effort. Nevertheless, Qi Gong movements could and should teach the individual to become more aware of his or her be constantly developed in order to achieve the perfection own movements in a functional and kinesthetic way. As of precision and personal growth through such ‘movements a result of these approaches, the improvement of posture of self-realization’. The conscious process of self-explora- or liberation of muscle tension may occur (Jain et al., tion and realization through movements might be and 2004). It is suggested that observation of our experience should be pleasant, fascinating and passionate. Similarly, indicates that consciousness is closely related to movement Maslow (1971: p. 43) proposed that people working on and the muscular sense. From concrete examples from the something which is very precious to them and which they Feldenkrais method and Qi Gong exercises, it can be shown love makes the work-joy dichotomy in their lives disappear. that changes in the organization of movement and func- Both Qi Gong and Feldenkrais can be regarded as potential tioning are intimately related (mind and the body are an methods or ways of aware self-development and self-real- inseparable whole during movements) and that one cannot ization through movements. Qi Gong and Feldenkrais change without conscious experience of the other (Gins- practitioners may potentially have ‘better’ perception of burg, 1999). Therefore, through exploration and association reality than non-practitioners due to movements performed of awareness and movements, functional patterns can be with full awareness and concentration on the ‘here and modified. Gestalt concept of presence and humanistic now’. Perfectly fluent movements can be obtained in Qi psychology approach to self-development opportunities Gong exercises through self-awareness and concentration. should therefore be incorporated into Qi Gong exercises Correspondingly, Feldenkrais method allows an individual and Feldenkrais practice. It can be suggested that such to increase or develop consciousness and improve percep- incorporation could enable a better understanding of both tion of reality through the perception of his or her own body Gestalt concept and humanistic psychology from the and body movements. Both Qi Gong exercises and Fel- perspective of a person’s movements and vice versa. Qi denkrais method can be regarded as a way of obtaining
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Journal of Bodywork & Movement Therapies (2010) 14, 234e238 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt COMPARATIVE STUDY Behavior analysis of electromyographic activity of the masseter muscle in sleep bruxers Ce´sar Ferreira Amorim a,*, Lilian Chrystiane Giannasi b, Luciano Maia Alves Ferreira c, M´arcio Magini b,1, Claudia S. Oliveira d, Luis Vicente Franco de Oliveira d, Tamotsu Hirata a, Fabiano Politti e a Department of Mechanical Engineering (FEG), Sa˜o Paulo State University - UNESP, Guaratingueta - SP, Brazil b Institute of Research and Development IP&D, University of Vale do Paraı´ba e UNIVAP, Sa˜o Jose´ dos Campos, SP, Brazil c Biomechanics of Movement Laboratory, University Center Claretiano e CEUCLAR, Batatais, SP, Brazil d Rehabilitation Sciences Master’s Program, Nove de Julho University e UNINOVE, Sa˜o Paulo, SP, Brazil e Department of Anatomy, University of Campinas (Unicamp), Brazil Received 18 February 2008; received in revised form 27 November 2008; accepted 28 December 2008 KEYWORDS Summary The effects of occlusal splint on the electric activity of masseter were studied in Electromyography; 15 women who presented sleep bruxism using surface electromyography. Sleep bruxism was Sleep bruxism; defined by its clinical characteristics. The signal acquisition was done during mandible occlu- Masseter muscle sion without clenching and maximum voluntary contraction in two situations. The first was after a workday without using the occlusal splint; and the second, after a sleeping night using occlusal splints. Evaluating masseter muscles during mandible occlusion without clenching, it could be observed that lower values were noticed after splint wearing in both sides. The same results were verified in maximum voluntary contraction (MVC). These results confirmed that the use of occlusal splints reduced the electromyographic activity of the right and left masse- ters, showing its myorelaxing effect. ª 2009 Elsevier Ltd. All rights reserved. Introduction sleep. It could be clinically observed by signs like abnormal tooth wear; orofacial pain; temporal headache; tooth The International Classification of Sleep Disorders defines hypersensibility to cold foods and drinks. Noises and hinge sleep bruxism (SB) as a disease characterized by tooth in the temporomandibular joints are also related to sleep clenching and grinding harmful movements during the bruxism (Tosun et al., 2003). * Corresponding author. Tel.: þ55 12 3942 4736. SB is considered an idiopathic disease since innumerous E-mail address: [email protected] (C.F. Amorim). physiological and pathological motor activities could involve the orofacial muscles during sleeping. The masti- 1 Current address: Universidade Camilo Castelo Branco, Nu´cleo catory activity consists of mimic, lips protrusion, and Parque Tecnolo´gico, Rodovia Presidente Dutra, Km 138, Eugeˆnio de tongue and swallow movements, which are completely Melo, Sa˜o Jose´ dos Campos, Sa˜o Paulo, Brazil, 12247-004. physiological during sleep (Kato et al., 2003). 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2008.12.002
Behavior analysis of electromyographic activity 235 Sleep bruxism is a controversial phenomenon regarding its Clinical diagnosis was made under world standards of etiology. Its diagnosis is described as a complex process diagnosis, based upon patient history and orofacial exami- composed by peripheral and central factors (Lobbezoo and nation. Tooth wear was evaluated with a dental mirror and Naeije, 2001). The peripheral factors, morphological, like adequate light. Upper and lower casts were made to occlusion and anatomical differences of the bone structures analyze the degree of tooth wear (Seligman and Pullinger, of orofacial region, were considered as being involved in 1995). Diagnosis of muscular hypertrophy was also consid- sleep bruxism etiology (Lobbezoo et al., 2006a; Lobbezoo ered bearing in mind the age of patients and dental/facial et al., 2006b). Other factors such as chronic alcohol use, drug morphology (Raadsheer et al., 1996). use, smoking, diseases and trauma could also be involved in sleep bruxism etiology, as well as pathological and psycho- All of those evaluated used flat and plane, myorelaxing logical factors which appear as central factors (Lobbezoo occlusal splints during sleep, to avoid tooth wear, and et al., 2006a,b). More specifically, disturbances in the central temporomandibular joint overload, for at least 30 days. dopaminergic system had been recently described as being involved in sleep bruxism etiology (Lobbezoo et al., 1997). Biological signals were obtained using an eight channel module (EMG System do Brasil LTDA), consisting of a signal The effects of SB are not limited to the temporoman- conditioner with a band pass filter with cut-off frequencies dibular joints, head or neck areas. It can also be related to at 20e500 Hz, an amplifier gain of 1000 and a common physiological and psychological health. Disturbances mode rejection ratio >120 dB. related to SB include insomnia, headaches, muscle stiffness in the morning, congestion of facial sinuses, cervicodynia, All data were processed using specific software for arthrosis and vertigo (Treacy, 1999). acquisition and analysis (Tool Box BR V1.0 by EMG System do Brasil LTDA) (Figure 1), a converting plate for In other study, the authors showed that SB was found in A/D 16 bits signal to convert analog to digital signals 8% of a sample of 846 subjects with clinical signs of tooth with a sampling frequency of anti-aliasing 2.0 kHz for wear, associated with rhythmical masticatory muscle each channel. The differential double electrodes used activity. Its consequences include tooth destruction, consisting of three rectangular parallel bars of Ag/AgCl mandibular pain and tooth grinding (Lavigne et al., 1998). (1 cm in length, 0.2 cm in width and separated by 1 cm) were used and were coupled to a rectangular acrylic Occlusal splint (OS) wear is considered an effective and resin capsule 2.2 cm in length, 1.9 cm in width and non-invasive treatment for many sleep bruxism patients 0.6 cm high with an internal amplifier in order to reduce and those with temporomandibular disorders. Several the effects of electromagnetic interference and other studies have been proposed to elucidate the splint action noise (Amorim et al., 2006). such as the modulation of neuromuscular function, relief of temporomandibular joints’ loads and psychological effects Electrodes were fastened to the skin where it was (Hiyama et al., 2003). previously cleaned with alcohol 70%, to reduce the impedance, and guided by bone prominences and the route Glaros and Rao (1977) suggested that some studies had of the muscle fibers (Dornelas de Andrade et al., 2005). This demonstrated changes in the masticatory muscular activity system obtained data, in root mean square (RMS), of each after the sear of OC wear in awaken patients. Those studies sample participant. Surface silver electrodes were posi- used systems of conventional electromyographic signs regis- tioned in the motor point, located in the muscular womb tration to monitor the electric activity of masticatory muscles. center, indicated by masseter muscle hypertrophy in contraction. SB was also studied using polissonographic methods, including surface electromyography of the mandibular In all procedures the capture and analysis of EMG signals muscles. The presence or absence of SB and its frequency was were carried out as recommended by the International determined using a match of EMG pattern and amplitude of Society Electrophysiology Kinesiology (ISEK) (Solomonow, the masseter and temporal muscles (Lavigne et al., 1996). 1995). The EMG evaluation occurred in the mandibular resting position, and after a maximal voluntary contraction Electromyography (EMG) has been widely used as an (MVC), isometric muscle contraction, biting a chewing gum auxiliary method on temporomandibular disorders diag- placed bilaterally. Chewing gum was used to eliminate the nosis. Its use allows evaluating the functional and biome- discomfort of tooth contact. chanical responses of masticatory muscles in rest, chewing and grinding (Michelotti et al., 2005). Patients were placed sitting safely on a comfortable chair, staring the computer screen, which was exhibiting The study of muscular function by EMG is defined by the the electromyographic signs. A clear and precise verbal analysis of electric signal produced during the muscular command was given to the patients concerned about contraction, and allows interpretations in pathological and muscles’ contractions and signs acquired. The utilization of normal conditions (De Luca, 1997). a computer screen, like a biofeedback, was used to control the intensity of maximum voluntary contraction, in order to The present study aims to analyze the electromyo- eliminate subjective muscular effort. graphic signs of masseter muscle in women who presented SB, after a working day, correlating stress factors, The data were collected twice per patient: after a work psychological and intellectual conditions, and after the OS period without occlusal splint wearing (before occlusal wearing during a sleeping night. splint wear) and after a night’s wearing the occlusal splint (after occlusal splint wear). Method The signal treatment was performed by complete wave The sample consisted of 15 (fifteen) women with average rectification, linear cover by Butterworth of fourth level, age of 26.5 Æ 3 years, who worked for 8 (eight) hours per with 5 Hz frequency of cut, normalized in time base and day, 40 hours per week. amplitude, where the amplitude was normalized by mean.
236 C.F. Amorim et al. Figure 1 Software acquisition and signal processing. The intensity variability of the EMG signs in the different masseter muscle in maximal volunteer contraction before muscular situations was made by ManneWhitney’s Test and and after occlusal splint wear. Wilcoxon’s Test based on the values of rectified signal of paired samples. The level of significance adopted was 0.05. Discussion Results Sleep bruxism is a parafunctional oral habit characterized by harmful tooth clenching and grinding movements Figure 2 shows the values concerning to electromyographic during sleep, which result in excessive tooth wear, peri- signs acquired on left and right masseter muscles in rest odontal disease and temporomandibular disturbances position. It could be observed that the comparative values (Xhonga, 1977). of EMG signs measured respectively on right and left masseter muscle in mandibular rest position. Both masseter Recently, the relationships between stress, muscular muscles show EMG signs verified after a work journey hyperactivity and painful symptoms have been studied before and after wearing occlusal splint. using EMG. The clinical use of EMG in orofacial pain, muscular hyperactivity and specific daily activities Figure 3 and Table 2 demonstrate the values concerning shows considerable variations among patients (Rugh and to electromyographic signs acquired on left and right Harlan, 1988). masseter muscles in maximal volunteer contraction (MVC), isometric muscle contraction. It shows the comparative EMG signs evaluated on the right masseter in rest values of EMG signs measured respectively on right and left (Figure 2) showed reduction of the electromyographic activity with a significant statistical difference in 15 of the Right Masseter Muscle Left Masseter Muscle Amplitude µV RMS8 8 Amplitude µV RMS7 7 6 6 5 2 5 2 4 4 3 After occlusal 3 After occlusal 2 splint 2 splint 1 1 0 0 1 1 Before occlusal Before occlusal splint splint Figure 2 Values of EMG signs of the masseter muscle in rest, with statistically significant difference to p < 0.05.
Behavior analysis of electromyographic activity 237 200 Right Masseter Muscle Left Masseter Muscle 200 180 Amplitude µV RMS 180 Amplitude µV RMS160 160 140 140 120 120 100 100 80 80 60 60 40 40 20 20 0 2 0 2 1 1 Before occlusal After occlusal Before occlusal After occlusal splint splint splint splint Figure 3 Values of EMG signs of the masseter muscles in MVC, with statistically significant difference to p < 0.05. subjects analyzed. The Average of the EMG sign obtained on are in accordance with scientific literature. Our results the left masseter at rest (Figure 2 and Table 1) also showed showed a significant statistical decrease of electromyo- a significant statistical difference in 15 subjects, with all 15 graphic activity for muscles of both sides. Only one subject presenting a reduction in the myoeletric activity. One of presented no significant result. the subjects tested presented no significant statistical difference on EMG signs measured on the right masseter but The efficacy of OS and placebo was compared during 6 showed significant differences on EMG values on the left. In weeks, and the authors found no statistical difference another patient it could be observed an inverse situation: between the 2 types of devices, but the findings showed significant differences on EMG signs on the right masseter that there was statistically significant reduction of the and no significant differences on EMG signs on the left masseter EMG activity immediately after the insertion of masseter. splints. However, there were no significant changes in 2, 4 and 6 weeks after the insertion of either splint (Baba This situation of different results found in masseter et al., 2000). muscles of the same individual can be explained by (Baba et al., 2000), which showed that inadequate force distri- The results of our study also are in agreement with those bution of the masticatory muscles and temporomandibular found by Landulpho et al. (2002), which showed a signifi- joints, can lead to occlusal asymmetry. cant reduction (p < 0.05) in the EMG activity of masseter during isometric muscle contraction in occlusal splint EMG signs obtained on the right masseter in maximum wearers, indicating decrease of electromyographic activity. voluntary contraction (MVC) showed that 2 subjects pre- sented no significant statistical differences between signs A randomized cross-over study using 10 patients, measured before and after occlusal splint use. compared the masseter EMG effects of two types of occlusal splint: a nociceptive trigeminal inhibitory splint EMG signs on the left masseter in maximum voluntary providing occlusion only on the front teeth and a standard contraction (MVC) (Figure 3) showed that 13 subjects pre- occlusal splint. Each patient received both splints and the sented significant statistical differences, with all 13 study lasted 7e8 weeks including the washout period. showing reduction of the sign values. Two subjects The authors concluded that the significant decrease of presented no statistical differences. EMG activity is not associated with a reduction in temporomandibular disorders’ signs or symptoms, once 5 Another study showed a significant difference in the of 10 patients perceived pain at baseline (Baad-Hansen distribution of masticatory forces on muscles and tempo- et al., 2007). romandibular joints. During tooth clenching, small jaw movements occur and it affects the temporomandibular Armijo-Olivo and Magee (2007) evaluated the electro- joints loading. In an experimental situation, the maximum myographic activity of the masticatory (masseter and level of force could differ depending on jaw movement, anterior temporalis) and cervical (upper trapezius and which affects the clenching force and the EMG activity. The splenis capitis) muscles during resisted jaw opening in results from this study indicate that the distribution of awake patients, and found that EMG activity of these 4 clenching forces in sleep bruxism could be influenced by muscles significantly increased during resisted jaw occlusal patterns of the subject (Baba et al., 1996). opening. Our findings related to electric potential produced by right and left masseter during occlusion, without clenching, Table 1 Average of EMG signs of the masseter muscles in Table 2 Average of EMG signs of the masseter muscles in rest, with statistically significant difference to p < 0.05. MVC, with statistically significant difference to p < 0.05. Before splint using After splint using Before splint using After splint using Right Left Right Left Right Left Right Left 178.90 170.60 120.40 129.37 Æ 7.6 mV Æ 6.6 mV Æ 6.5 mV Æ 5.3 mV 8.23 Æ 2.6 mV 7.40 Æ 1.6 mV 6.59 Æ 1.5 mV 5.82 Æ 1.3 mV
238 C.F. Amorim et al. Therefore, more investigative studies are necessary to Dornelas de Andrade, A., Silva, T.N., Vasconcelo Ket, A.L., 2005. verify the relationship among peripheral and central Inspiratory muscular activation during threshold therapy in factors, and sleep bruxism etiology. Different investigative elderly healthy and patients with COPD. J. Electromyogr. methods may also be tested, comparing the control and Kinesiol. 15 (6), 631e639. pathological groups after situations of induced stress or electroencephalographic exams correlating sensitive-motor Glaros, A.G., Rao, S.M., 1977. Bruxism: a critical review. Psychol. activities during the sleep. Bull. 84 (4), 767e781. Conclusion Hiyama, S., Ono, T., Ishiwata, Y., Kato, Y., Kuroda, T., 2003. First night effect of an interocclusal appliance on nocturnal masti- Occlusal splints wearing as a prevention or treatment of catory muscle activity. J. Oral Rehabil. 30 (2), 139e145. sleep bruxism should decrease electric activity of right and left masseter in situation of mandibular rest and maximal Kato, T., Dal-Fabbro, C., Lavigne, G.J., 2003. Current knowledge on isometric muscle contraction in women. awake and sleep bruxism: overview. Alpha Omegan 96 (2), 24e32. Stress factors during a work period can influence the Landulpho, A.B., e Silva, W.A., e Silva, F.A., Vitti, M., 2002. The increase of electric activity of masseter muscles in sleep effect of the occlusal splints on the treatment of temporo- bruxism bearers. mandibular disorders e a computerized electromyographic study of masseter and anterior temporalis muscles. Electro- Acknowledgments myogr. Clin. Neurophysiol. 42 (3), 187e191. The authors are grateful to Thiago R. Amorim for his help in Lavigne, G.J., Rompre´, P.H., Montplaisir, J., 1996. Sleep bruxism: developing the software of analysis. The amplifier system validity of clinical research diagnostic criteria in a controlled and the differential double electrodes, were made avail- polysonographic study. J. Dent. Res. 75 (1), 546e552. able by EMG System do Brasil, Sa˜o Jose´ dos Campos e Sa˜o Paulo, Brazil. This study was supported by FAPESP e Fun- Lavigne, G.J., Rompre´, P.H., Poirier, G., et al., 1998. Rhythmic da¸c˜ao de Amparo a Pesquisa do Estado de Sa˜o Paulo and masticatory muscle activity (RMMA or chewing-automatism) CNPq e Conselho Nacional de Desenvolvimento Cient´lfico e during sleep in normal controls. J. Sleep Res. 7, 229. Tecnolo´gic. Lobbezoo, F., Naeije, M., 2001. Bruxism is mainly regulated cen- References trally, not peripherally. J. Oral Rehabil. 28 (12), 1085e1091. Amorim, C.F., Amorim, L.J., et al., 2006. Electromyographic Lobbezoo, F., Van Der Zaag, J., Naeije, M., 2006a. Bruxism: its analysis of mouth’s orbicular muscle in individual class II. In: XVI multiple causes and its effects on dental implants e an updated Congress of The International Society of Electrophysiology and review. J. Oral Rehabil. 33 (4), 293e300. Kinesiology, vol. 52. Lobbezoo, F., Brouwers, J.E., Cune, M.S., Naeije, M., 2006b. Armijo-Olivo, S., Magee, D.J., 2007. Electromyographic activity of Dental implants in patients with bruxing habits. J. Oral Rehabil. the masticatory and cervical muscles during resisted jaw 32 (2), 152e159. opening movement. J. Oral Rehabil. 34 (3), 184e194. Lobbezoo, F., Soucy, J.P., Hartman, N.G., et al., 1997. Effects of Baad-Hansen, L., Jadidi, F., Castrillon, E., et al., 2007. Effect of the D2 receptor agonist bromocriptine on sleep bruxism: report a nociceptive trigeminal inhibitory splint on electromyographic of two single-patient clinical trials. J. Dent. Res. 76 (9), activity in jaw closing muscles during sleep. J. Oral Rehabil. 34 1610e1614. (2), 105e111. Michelotti, A., Farella, M., Gallo, L.M., et al., 2005. Effect of Baba, K., Ai, M., Mizutani, H., Enosawa, S., 1996. Influence of occlusal interference on habitual activity of human masseter. J. experimental occlusal discrepancy on masticatory muscle Dent. Res. 84 (7), 644e648. clenching. J. Oral Rehabil. 23 (1), 55e60. Raadsheer, M.C., Kiliaridis, S., Van Eijden, T.M., et al., 1996. Baba, K., Akishige, S., Yaka, T., Ai, M., 2000. Influence of alteration Masseter muscle thickness in growing individuals and its relation of occlusal relationship on activity of jaw closing muscles and to facial morphology. Arch. Oral Biol. 41 (4), 323e332. mandibular movement during submaximal clenching. J. Oral Rehabil. 27 (9), 793e801. Rugh, J.D., Harlan, J., 1988. Nocturnal bruxism and temporoman- dibular disorders. Adv. Neurol. 49, 329e341. De Luca, C.J., 1997. The use of surface electromyography in biomechanics. J. Appl. Biomech. 13 (2), 135e163. Seligman, D.A., Pullinger, A.G., 1995. The degree to which dental attrition in modern society is a function of age and of canine contact. J. Orofac. Pain 9 (3), 266e275. Solomonow, M.A., 1995. Practical Guide to Electromyography. International Society of Biomechanics Congress XV, Jvaskyla, Finland. 1995. Treacy, K., 1999. Awareness/relaxation training and trans- cutaneous electrical neural stimulation in the treatment of bruxism. J. Oral Rehabil. 26 (4), 280e287. Tosun, T., Karabuda, C., Cuhadaroglu, C., 2003. Evaluation of sleep bruxism by polysomnographic analysis in patients with dental implants. Int. J. Oral Maxillofac. Implants 18 (2), 286e292. Xhonga, F.A., 1977. Bruxism and its effect on the teeth. J. Oral Rehabil. 4 (1), 65e76.
Journal of Bodywork & Movement Therapies (2010) 14, 239e244 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt CLINICAL INFLUENCES Differences in practitioners’ proficiency affect the effectiveness of massage therapy on physical and psychological states Nozomi Donoyama a,*, Masanao Shibasaki b a Course of Acupuncture and Moxibustion, Department of Health, Faculty of Health Sciences, Tsukuba University of Technology, 4-12-7, Kasuga, Tsukuba 305-8521, Ibaraki, Japan b Allergy and Immunology, Department of Health, Faculty of Health Sciences, Tsukuba University of Technology, 4-12-7, Kasuga, Tsukuba 305-8521, Ibaraki, Japan Received 24 March 2008; received in revised form 16 January 2009; accepted 27 January 2009 KEYWORDS Summary Objective: An examination was made of how differences in the proficiency of Massage therapy; massage practitioners had different physical and psychological effects on clients. Proficiency; Method: Eight healthy 50-year-old females, suffering from chronic neck and shoulder stiffness, Practical training; were recruited and four interventions were conducted: three 40-minute massage therapy Muscle stiffness in the interventions, one each by a freshman and a sophomore student studying massage therapy, neck and shoulder; and one by their instructor, and one rest on the massage table. Visual analogue scale score Visual analogue scale for muscle stiffness in the neck and shoulder, state anxiety score, and salivary cortisol concen- (VAS); tration levels and secretory immunoglobulin A, were measured pre- and post- interventions. State anxiety; Results: Visual analogue scale of neck and shoulder stiffness after massage by the instructor Salivary cortisol; was significantly lower than that after the other interventions, and the score of state anxiety Secretory immunoglob- was lower than that after resting. ulin A (s-IgA) ª 2009 Elsevier Ltd. All rights reserved. Introduction therapy have rapidly increased, particularly because of its emphasis on stress reduction and increased physical and Recently, the use of complementary and alternative psychological relaxation (Lovas et al., 2002). In Japan, medicine (CAM) therapies has increased around the world, practitioners of massage therapy, including traditional and the prevalence of and expectations for massage Japanese massage called Anma therapy, foreign-style massage, and shiatsu, should undergo professional training * Corresponding author. Tel.: þ81 29 858 9631; fax: þ81 29 855 for at least three years after finishing high school, and then 1745. they should pass the national examination to obtain a national license for massage practitioner. In Japan, E-mail address: [email protected] (N. hands-on therapies, including those mentioned above, are Donoyama). often collectively called ‘‘massage’’ and are not properly 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.01.007
240 N. Donoyama, M. Shibasaki distinguished from each other. In this case, traditional laboratory. Requirements for participants’ gender, age, and Japanese Anma therapy is the most widely used form of physical condition were: (i) to be a female in the fifth ‘‘massage’’. Thus, in this manuscript, the term, ‘‘massage’’ decade of life; (ii) to feel chronic muscle stiffness around is used to refer to the traditional Japanese Anma therapy. the neck and shoulders;, (iii) to have no disease requiring (It is recommended that the previous study (Donoyama medical intervention; (iv) to desire massage therapy; and et al., 2010) be referred to for more detailed information especially to eliminate the influence of sexual hormones, as on the traditional Japanese Anma therapy.) suggested in the study by Kirschbaum et al. (1999) showing that salivary cortisol levels are affected by the menstrual Japanese law stipulates that students who are in schools cycle, (v) to be a few years post-menopause, and (vi) to for professional education for at least three years, have to feel no current symptoms of menopause. pass 77 units of coursework (one unit includes 15e30 lecture hours and 30e45 practical training hours), including Muscle stiffness in the neck and shoulders is defined by basic massage studies (e.g. anatomy, physiology, basic symptoms which produce a feeling of irritation, an kinesiology, pathology, hygiene and public health, general unpleasant sensation, strain, stiffness, ache and/or pain in clinical medicine, clinical medicine, rehabilitation medi- the Regio axillaris and/or Regio scapularis muscles (Hir- cine, medical systems overview), professional massage abayashi, 2002; Ishii and Hirasawa, 2002). All participants studies (e.g. oriental medicine, meridian and treatment gave their informed consent, were screened for conditions points, massage theory, clinical oriental medicine, clinic of chronic muscle stiffness in the neck and shoulders, and management), and practical training (e.g. basic practical the absence of medical disease was confirmed by a doctor. training, clinical training, clinical clerkship at massage They were asked to avoid strenuous exercise on the days clinics and medical settings). Special emphasis is placed on they were participating in the study and to avoid eating and 10 units that involve about 450 h of practical training and drinking within one hour of participating in the study. clinical clerkship (Japan Association of Massage and Acupuncture Teachers, 2003). Interventions In spite of this hard study and intensive practical All participants received four interventions, conducted on training, the public and the government seem to believe different days. Three 40-minute massage therapy sessions, that it is easy for anyone to treat physical symptoms, one each conducted by a freshman student (60-h practical relieve mental stress, and induce relaxation. As evidence of training, 6-month educated) and a sophomore student (240- that, it is easy in Japan for persons without a national h practical training, 15-month educated) who were major- license for massage therapy to practice illegally and almost ing in acupuncture and massage therapy at a university, one none of them have been punished by the government. It is session conducted by an instructor who taught them and thought to be dangerous for therapists who are not had more than 15 years of experience in massage therapy adequately familiar with human body structures and func- and its education, and one session consisting of a 40-minute tions, formation of diseases, and principles of massage rest on the massage table without massage therapy. therapy to treat clients. There is a review that has reported Student therapists (five freshmen and five sophomores) incidents of massage therapy practiced by unlicensed were recruited to conduct two interventions each. Partic- therapists and students that resulted in aggravation of ipants were randomly assigned to the students but in a way lower back pain, induction of pain in part or even all of the that would guarantee that each participant would receive body, infection through massage oil, and even rib fracture, one intervention by a freshman and one by a sophomore. among other adverse effects (Donoyama, 2002). They did not know the academic year of the students. The instructor treated all 10 participants. Interventions were Even given the occurrence of such harmful mistakes, is it conducted at one-week intervals. true that any practitioner can use massage therapy to treat clients? Massage therapy is composed of tactile, pressure, The massage procedure essentially consisted of basic and mechanical stimuli given from the surface of the body and clinical versions of traditional Japanese massage taught to muscles and other soft tissues. Can massage therapy at the university, Anma therapy, which is composed always have the same effect on clients, regardless of the primarily of massage techniques that are commonly used in proficiency or experience of the practitioner? In order to Japan. Anma therapy is usually administered through answer this question, the present study examined the clothing or using a piece of cloth; here, it was administered results of massage sessions conducted by practitioners with through clothing. Practitioners were given leeway with differing levels of experience and the different physical and their massage sessions in order to deal adequately with psychological effects these sessions had on clients, by individual participants’ symptoms of neck and shoulder measuring the visual analogue scale (VAS) of participants’ stiffness. However, all practitioners in this experiment symptom of the neck and shoulder stiffness, state anxiety, were required to use at least the following massage salivary cortisol, and secretory immunoglobulin A (s-IgA). procedure: have the participant lie down on one side and stroke, knead, and press her neck, shoulder, back, lower Materials and methods back, arm, hand, leg and foot. Next, have the participant lie down on the opposite side and repeat the same proce- Participants dure on the other side of her body. Finally, with the participant in a prone position for several minutes, stroke, Ten healthy females were recruited randomly from knead, and press her whole body except the head. This a volunteer list, in which about 150 persons are registered massage procedure was the same as in our previous study, as volunteers for the massage experiments in the
Practitioners’ proficiency and effectiveness of massage therapy on physical and psychological states 241 so please refer to our previous article for details (Donoyama To compare the immediate changes by interventions, et al., 2010). repeated measures analyses of variance (ANOVA) with Bonferroni correction were performed. Next, values before Procedure of the experiment interventions were converted into scores based on 100, values after interventions were calculated, and each Upon arrival at the laboratory, participants rinsed their intervention group was compared by repeated measures mouths out with water from a disposable paper cup and ANOVA with Bonferroni correction. All statistical analyses took a 15-minute rest. Then, a saliva sample was obtained, were performed by SPSS 15.0. Alpha was set equal to 0.05, and participants wrote self-assessments of their neck and thereby implying that any statistical outcome that had shoulder stiffness using the visual analogue scale and a p < 0.05 would indeed be statistically significant. feelings of anxiety using the State Trait Anxiety Inventory. A 40-minute intervention was then performed. After the Results session, assessments were made again. Each time, the experiments began at 3:00 p.m. in consideration of the The repeated measures ANOVA with Bonferroni correction circadian rhythms of cortisol and s-IgA in saliva (Walker were performed to clarify differences among massage et al., 1984; Dimitriou et al., 2002). therapy sessions by the freshman students, the sophomore students, and the instructor, and the rest (control), and This study was approved by the Medical Ethics Committee results are shown in Table 1. Post-intervention VAS scores of Tsukuba University of Technology and was performed were significantly lower than those obtained pre-interven- according to the ethical standards set forth in the Helsinki tion (F Z 38.2, p Z 0.0005). There were significant differ- Declaration of 1964 and its amendment of 2000. ences among the four interventions (F Z 9.7, p Z 0.017); the VAS scores were significantly lower after massage Measurements therapy sessions by the instructor than those by freshman students (p Z 0.041) and after the rest sessions (i) The visual analogue scale (VAS) was used to assess the (p Z 0.043). Post-intervention state anxiety scores were severity of the subjective symptoms, muscle stiffness in significantly lower than those obtained pre-intervention the neck and shoulders. A sheet of paper (width (F Z 16.7, p Z 0.005); however, there were no significant 100 mm  height 40 mm) was given to each subject and differences among the four interventions (F Z 0.7, it was explained that the left edge of the paper repre- p Z 0.448). For concentration levels of salivary cortisol, sented no symptom and the right edge represented the post-intervention values were significantly lower than those most serious symptom that the subjects could imagine. obtained pre-intervention (F Z 16.4, p Z 0.005); however, The subjects were then asked to indicate how serious there were no significant differences among the four the degree of their neck and shoulder stiffness was at interventions (F Z 1.5, p Z 0.264). Concentration levels of that time by ticking the corresponding location on the s-IgA post-intervention were increased significantly paper. The length from the left edge of the paper to the compared with those obtained pre-intervention (F Z 23.1, tick was measured and treated as the VAS score. p Z 0.002); however there were no significant differences (ii) The state anxiety score, which was measured by the among the four interventions (F Z 1.7, p Z 0.237). Japanese version of the State Trait Anxiety Inventory (STAI) by Spielberger et al. (Mizuguchi et al., 1991), was Second, values before interventions were converted into a self-report Likert scale consisting of 20 items to assess scores based on 100, values after interventions were the degree of anxiety being felt by participants at that calculated, and each intervention group was compared by time. The scores obtained ranged from 20 to 80, with repeated measures ANOVA with Bonferroni correction higher scores representing stronger states of anxiety. (Table 2). The VAS scores of neck and shoulder stiffness (iii) Saliva was collected pre- and post-interventions. were found to be significantly lower after massage therapy Each time, a swab was removed from a Salivetteâ (Sar- sessions by the instructor than after the other interventions stedt, Aktiengesellschatt & Co., Germany), chewed 60 (the instructor vs. the freshman students, p Z 0.017; the times gently for a minute in synch with a metronome, instructor vs. the sophomore students, p Z 0.049; the then returned to the Salivetteâ. It was sealed and frozen instructor vs. the rest, p Z 0.004), and the value of state immediately in a freezer on the night when the inter- anxiety was lower after massage therapy sessions by the vention was conducted. The next morning, the Saliv- instructor than after resting on the massage table ettesâ were delivered to the assay company (SRL Inc, (p Z 0.002). Tsukuba, Japan). Assays were conducted to determine the concentration of salivary cortisol and s-IgA in Discussion samples by g-cortisol and enzyme immunoassay (EIA) s- IgA test, respectively. In the post-massage therapy by all three kinds of practi- tioners, VAS scores were lower than the pre-massage Statistical analysis therapy VAS scores, whereas the rest-sessions did not reduce the scores. Despite their relatively brief period of In the present study, data for eight participants who could academic learning, the students could fractionally improve take part in all four of the interventions were analyzed; two the symptoms of muscle stiffness in the neck and shoulders. persons withdrew from one intervention due to family In previous studies on anesthetized rats (Cao et al., 1992; circumstances. Sato et al., 1996, 2002) tactile and pressure stimuli, from
242 N. Donoyama, M. Shibasaki Table 1 Comparison of temporal changes in values among four interventions (repeated measures analyses of variance ANOVA with Bonferroni corrections). Time Effect Pre Post Group Time Group  time Mean Æ SE (95% CI) Mean Æ SE (95% CI) Fp Fp Fp Visual analogue scale 9.7 0.017* 38.2 0.0005*** 7.8 0.027* 0.69 Freshmen 75.8 Æ 5.9 (62.6e86.9) 57.4 Æ 8.3 (40.5e74.3) 0.23 0.09 Sophomores 70.8 Æ 5.9 (58.6e82.9) 54.9 Æ 8.3 (38.0e71.8) p Z 0.041* Instructor 72.5 Æ 5.9 (60.3e84.7) 23.3 Æ 8.3 (6.3e40.2) p Z 0.043* Rest (control) 58.4 Æ 5.9 (46.2e70.5) 57.1 Æ 8.3 (40.2e74.0) State anxiety 0.7 0.45 16.7 0.005 ** 0.2 Freshmen 36.8 Æ 2.7 (21.1e42.4) 30.0 Æ 2.1 (25.8e34.2) Sophomores 37.5 Æ 2.7 (31.9e43.1) 28.4 Æ 2.1 (24.1e32.6) Instructor 36.4 Æ 2.7 (30.8e42.0) 26.8 Æ 2.1 (22.5e31.0) Rest (control) 34.1 Æ 2.7 (28.5e39.7) 30.3 Æ 2.1 (26.0e34.5) Cortisol (mg/dL) 1.5 0.26 16.4 0.005 ** 1.8 Freshmen 0.239 Æ 0.020 (0.198’e0.279) 0.219 Æ 0.019 (0.179e0.258) Sophomores 0.276 Æ 0.020 (0.236-0.317) 0.240 Æ 0.019 (0.209-0.279) Instructor 0.234 Æ 0.020 (0.202e0.283) 0.199 Æ 0.019 (0.159e0.238) Rest (control) 0.230 Æ 0.020 (0.190e0.270) 0.205 Æ 0.019 (0.166e0.244) s-IgA (mg/mL) 1.7 0.24 23.1 0.002 ** 3.8 Freshmen 417.8 Æ 54.1 (307.0e528.6) 819.6 Æ 142.7 (527.3e1111.8) Sophomores 355.7 Æ 54.1 (244.9e466.5) 813.5 Æ 142.7 (521.2e1105.7) Instructor 389.3 Æ 54.1 (278.5e500.1) 571.8 Æ 142.7 (279.5e864.1) Rest (control) 434.1 Æ 54.1 (323.2e544.9) 719.0 Æ 142.7 (426.7e1011.2) *p < 0.05; **p < 0.01; ***p < 0.001. the surface of the body affected the autonomic nervous massage table (Table 2). The results imply that massage system and induced reflexive motions, somato-visceral therapy by an experienced and skilled practitioner can reflexes, which are thought of as a massage therapeutic greatly improve not only the physical symptoms of the mechanism. In previous studies (Field, 2002a,b; Mori et al., muscle stiffness in the neck and shoulders but also 2004), it was found that manual mechanical stimuli by psychological conditions, and state anxiety. massage increase blood flow, remove metabolites and waste products. This suggests that massage stimuli by even Moreover, in the present study, salivary cortisol unskilled students may be able to induce autonomic nerve concentrations in the post-interventions were decreased reflexes and cause some alleviation of physical symptoms of significantly (Table 1). The significant decreases in salivary muscle stiffness in the neck and shoulders. Nevertheless, cortisol levels after massage sessions were the same as in the massage therapy by the instructor was significantly previous studies (Field, 1998, 2000; Field et al., 1992, 1997, different from that by freshman students and the resting 1998; Hart et al., 2001; Hernandez-Reif et al., 2000). session (Table 1). The comparison of values after inter- Cortisol is a major steroid hormone secreted by the adrenal ventions, when values before interventions were converted cortex via reactions in the hypothalamusepituitarye into scores based on 100 among the four interventions, adrenal axis and autonomic nervous system that is clearly indicates that VAS scores after the massage therapy commonly used as an index of stress (Fukuda and Morimoto, by the instructor were significantly lower than those by the 2001). This result suggests that stimulation from the other three types of interventions (Table 2). As a result, it surface of the body can affect the autonomic nervous was concluded that the massage therapy by the experi- system and help to release psychological stress through the enced and skilled practitioner was much more effective in hypothalamusepituitaryeadrenal axis. In our previous improving the physical subjective symptoms than that by study, in which saliva had been collected directly, rather the unskilled practitioners. than with Salivettesâ, salivary cortisol concentration levels after massage therapy by the same practitioner partici- The changes in the post-intervention state anxiety pating in the present study were not reduced significantly scores indicated that massage therapy by all three kinds of compared with those before the massage sessions practitioners and the resting session could reduce state (Donoyama et al., 2010). It is thought that the use of Sal- anxiety compared with before interventions, although the ivettesâ to obtain saliva without distress could increase the differences among the four interventions were not clear accuracy of measurements taken of cortisol concentration (Table 1). Next, a comparison of values after interventions, levels before and after massage therapy. However, there when values before interventions were converted into were no significant differences among the four interven- scores based on 100 among the four interventions, showed tions (Tables 1 and 2). that the score of state anxiety after massage therapy by the instructor was significantly lower than after resting on the S-IgA concentration levels were significantly increased after interventions, however, there were no significant
Practitioners’ proficiency and effectiveness of massage therapy on physical and psychological states 243 Table 2 Comparisons of values after interventions when values before interventions were converted into scores based on 100 (repeated measures analyses of variance ANOVA with Bonferroni corrections). differences among the four interventions (Tables 1 and 2). same experiences and the same skills, one instructor was Previous studies not only on massage therapy (Green and used across all eight subjects in the study. This was not the Green, 1987; Groer et al., 1994) but also on relaxation by case with the freshman and sophomore interventions. All watching a humorous movie (Dillon et al., 1985) and eight subjects should have been treated by each and every imagery (Jasnoski and Kugler, 1987) showed the same freshmen and sophomore. In the absence of this type of results, i.e. increase of s-IgA after interventions. These control, it is possible that variances across the five fresh- findings in previous studies suggested that increases in well- men and across the five sophomores might have been being (Dillon et al., 1985) and holistic benefits (Groer et al., a factor influencing the outcomes of the study. 1994) caused s-IgA to increase. The present study implies that all four kinds of interventions could enhance well- In the present study, repeated measures ANOVA was being and provide holistic benefits to participants and, in performed twice to clarify differences among the four the results, s-IgA concentrations were increased. This in interventions, as shown in Tables 1 and 2. The first anal- turn may enhance immunological functions and help yses using ANOVA were expected to reveal differences prevent illness. However, massage therapy is no more among the four interventions; however, they could not effective for increasing s-IgA than resting, watching clearly indicate significant differences among the inter- humorous movies, or viewing images. ventions. Therefore, values before interventions were converted into scores based on 100, values after inter- In conclusion, this study has verified that massage ventions were calculated, and each intervention group was therapy practiced by a competent experienced practitioner compared by repeated measures ANOVA with Bonferroni can greatly alleviate subjective symptoms of muscle stiff- correction. As a result, statistically significant differences ness in the neck and shoulders and state anxiety, and lower among the four interventions finally became clear. This salivary cortisol as an index of psychological stress. It is suggests that our sample size was too small to perform thought that the differences in effectiveness between an statistical analyses. It would thus be advisable to try the experienced practitioner and unskilled student depend on study again with a sufficiently large sample size to confirm the proficiency of the practitioner, which has been culti- the results. vated by experience. Massage instructors have the respon- sibility to educate students to become professionals who Acknowledgement can attend to clients’ needs. The results presented here strongly suggest that practical training and clinical clerkship The present study, No. 17653125, was supported by should be an integral part of massage therapy education. a science study program grant from the Education and Science Ministry of Japan, 2006. The limitations of this study should be noted. Since it was too difficult to recruit massage professionals with the
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Journal of Bodywork & Movement Therapies (2010) 14, 245e254 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt QUALITATIVE STUDY The experiences of basic body awareness therapy in patients with schizophrenia Lena Hedlund, RPT, MSc*, Amanda Lundvik Gyllensten, RPT, PhD Department of Health Sciences, Division of Physiotherapy, Faculty of Medicine at Lund University, PO Box 157, 221 00 Lund, Sweden Received 13 October 2008; received in revised form 3 March 2009; accepted 31 March 2009 KEYWORDS Summary Background: Basic Body Awareness Therapy (BBAT) is a physiotherapeutic treatment Physiotherapy; method that is commonly used in Scandinavian mental health services. However, for patients with Affect regulation; schizophrenia, there are few studies that verify the effectiveness of BBAT, or explain which Self-esteem; dysfunctions or disabilities BBAT has an effect on in this group of patients. The aim of the present Cognitive function; study was thus to describe patients’ experiences of BBAT, focusing on perceived main treatment Rehabilitation effects. The areas of perceived effects are to be investigated in future research. Method: In a qualitative study, eight patients with schizophrenia were interviewed. The interview transcriptions were analysed with content analysis methodology. Result: Patients with schizophrenia report positive treatment effects of physiotherapy with BBAT. Four main categories were identified: affect regulation, body awareness and self-esteem, effects described in a social context and effects on the ability to think. These should be targeted in a future randomized and controlled study. ª 2009 Elsevier Ltd. All rights reserved. Background and executive functions (Helldin et al., 2006). These negatively affect the daily life of the individual (McGorry, Schizophrenia is a severe mental disease which causes 2005) and the link between cognitive dysfunction and great suffering for the afflicted individual and renders negative symptoms is well supported (Helldin et al., large costs for society. It involves a variety of symptoms, 2006). including both negative symptoms (blunted affects, passivity and isolation) and positive symptoms (halluci- Blunted or flattening of affects is a common major nation) (McGorry, 2005) as well as cognitive dysfunctions symptom in schizophrenia and is associated with difficulties that include a broad variety of impairments concerning in engaging in social activities (McGorry, 2005; Brune, attention, memory, verbal fluency, psychomotor speed 2005). Alexithymia is a term reflecting the difficulties in verbalizing and apprehending your own and others’ * Corresponding author. Tel.: þ46 46 222 00 00. emotions and mental states and is more common among E-mail address: [email protected] (L. Hedlund). patients with different kinds of psychoses, especially those with schizophrenia (Maggini and Raballo, 2004a). 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.03.002
246 L. Hedlund, A.L. Gyllensten Another aspect of the disease concerns insecure iden- perceived main treatment effects. The areas of perceived tity, a lack of self-esteem, depression and anxiety (Van effects are to be investigated in future research. Dongen, 1998; Pallanti et al., 2004). Furthermore, many patients suffer from symptoms of disembodiment, body Method image disturbances and deficits in the feeling of being an agent in their own bodies and lives (Priebe and Ro¨hricht, Participants 2001; Maggini and Raballo, 2004b). Two physiotherapists, who were experts in the BBAT One theoretical ‘‘starting point’’ for almost all bodyemind method, nominated 10 physiotherapists who had experi- physiotherapeutic treatments is the psychomotor develop- ence of work with patients with schizophrenia or similar mental aspects of movement and cognition, mainly based on diseases for at least 2 years and had an adequate education Piaget’s theory of psychomotor development, focusing on the in BBAT, at level two or higher. child’s activity as a central aspect in development (Gebhardt et al., 2008). Lately researchers have focused on unconscious All the physiotherapists worked at community psychi- processes and the interplay between different areas in the atric clinics for patients with schizophrenia and other brain and the connection between the body and thought severe mental illnesses. They all agreed to participate in processes. From this perspective, our cognition is to a large the study, engaging at least one patient, a person who in extent dependent on acting and sensory motor experiences, writing declared that he or she was willing to participate in in relation to environmental and social contexts. Roth and an interview with one of the researchers. The inclusion Lawless describe this embodied form of cognition as ‘‘basic criteria for the patients were that they were diagnosed level schemata’’ and suggest that these are (a) generally self- with schizophrenia or similar diseases and had received explanatory and (b) basic elements of cognitive functioning BBAT for at least 1 year. Twelve patients agreed to partic- (Roth and Lawless, 2002). ipate in the study, one of whom later declined thus resulting in 11 available informants. One patient did not One main physiotherapeutic treatment, in the Scandi- appear for the interview. After eight interviews, no new navian mental heath services, is Basic Body Awareness information was communicated, with the same information Therapy (BBAT) with roots in the eastern tradition of body being received. The decision was thus made to end the data movement, Tai Chi Chuan (Gyllensten et al., 2003a). In the collection and consequently two of the 11 patients who had treatment process, the basic goals include establishing agreed to participate were not called for an interview. better contact with the living body, increasing the feeling of ‘‘ownership’’ of the body and increasing the tolerance The patients lived in three different towns in Sweden and for different sensory motor and affective sensations. The were diagnosed by their psychiatrists, in accordance with psychomotor interplay is trained through different body ICD-10, as having schizophrenia (three patients), unspecified functions; the ability to have a stable and relaxed posture, schizophrenia (two patients), undifferentiated schizophrenia to be grounded, to be able to coordinate movement with (two patients) and paranoid schizophrenia (one patient). All breathing, the ability to be well-defined in movements and of the patients received other treatments, pharmacological interpersonal relations and finally the ability to be mentally and various verbal therapy forms, mostly of a supportive present or mindful (Gyllensten et al., 2003a). The patients nature, over and above the BBAT. Four of the patients were take part in various exercises where they are asked to be male and four were female, the ages ranged from 29 to 56, mentally present and observe their own activities, reac- with an average of 45.5 years, median 48.5 years. Their tions and other experiences within or without the body duration of illness ranged from 4 to 30 years, averaging (Gyllensten et al., 2003a). For a further description of 16.3 years, median 16 years and had received BBAT for 2e BBAT, see Appendix B. 7 years, averaging 3.3 years, median 3 years. BBAT has been shown to be effective and relevant as part All patients were single and lived alone except for one of the treatment for several groups of patients with mental who lived with her parents. One patient had only received illness (Mattsson et al., 1997; Grahn et al., 1998; Eriksson BBAT individually, while the others had started individually et al., 2007; Gyllensten et al., 2003a), but there are few and then continued in small groups. studies concerning patients with schizophrenia or other severe psychoses. In a controlled prospective study, 17 Interview technique and interview process patients with schizophrenia who were treated with BBAT for 6 months were compared with nine patients with schizo- The study utilized a qualitative method with interviews as the phrenia who only received treatment as usual. The results source of information (Burnard, 1991). The first author used an revealed that patients, treated with BBAT, significantly interview guide focusing on the experienced effects of the improved their quality of movement, body image, gaze, BBAT treatment. The interview guide consisted of open ques- sexual interest and suffered less from anxiety compared with tions with follow-up questions (see Appendix A). The inter- the control group (Roxendal, 1985). In a qualitative study, views were characterized as only allowing short periods of focusing on the perceived and most important aspects of silence and not having the ambition of attaining higher levels of treatment, six patients with schizophrenia reported that abstraction due to the patients’ varying cognitive disabilities they experienced better own control and that this feeling and sensitivity to stress. was important for them (Gyllensten et al., 2003b). It is thus important to continue to evaluate the effects of BBAT and In seven cases, the interview took place at the patients’ a relevant first step is to describe the patients’ own experi- ordinary community psychiatric clinic, while one interview ences of the method. The aim of the present study was thus was carried out at the patient’s home. The interviews were to describe patient experiences of BBAT, focusing on recorded, transcribed and then sent back to the patients
The experiences of basic body awareness therapy 247 for an approval of the content, together with prepared increased the experience of vitality and interest, and also envelopes. None of the patients commented on the tran- the ability to accept and tolerate more unpleasant expe- scribed content of the interview, while three patients riences, such as discomfort and distress. wrote a letter about their treatment progress after the interview. They mostly felt stronger or more vigorous, alert and relaxed after the BBAT sessions. An informant who had The process of analysing the transcriptions suffered from a painful tiredness for many years explained: The main interest of the present study was the different Well, yes, often you feel a sense of well-being after- experiences of treatment effects. A cross-case analysis was wards, life feels easier and the well-being increases. thus performed, based on a manifest content analysis and Mostly I feel more alert afterwards, in fact, I don’t get triangulation in order to increase validity (Burnard, 1991; tired. Often when you feel more relaxed, you may feel Farmer et al., 2006). tired but that doesn’t happen so often to me. I usually get more alert (8). The total number of transcribed pages of text was 160, written with double line spacing. Manifest content analysis Another informant described how she found her strength is a qualitative method, which can include a quantitative when training her strength to protect her body boundaries strategy for organizing the transcribed text. The text is and integrity: systematically reduced into meaning units in distinction to latent analysis, where the underlying meaning of the text is . and when I say NO! Then I get the strength . I have interpreted and used (Graneheim and Lundman, 2003). A a living soul, I own my body and can say NO! (6). meaning unit is an existing word in the text that represents or is central to the meaning of the sentence, e.g. ‘‘I get When unpleasant feelings occurred, the patients were more strength after training with BBAT’’. The meaningful encouraged to deal with them. Five informants had expe- unit here is ‘‘strength’’. These meaning units are then rienced that the difficult moments had become easier and categorized in several stages and organized quantitatively easier when continuing with BBAT and three of them (Burnard, 1991). In the present study, four persons e one thought that it might be beneficial to specifically train psychiatrist, one psychiatric nurse, the first author and those moments that were difficult to deal with. As one another physiotherapist e read and identified the meaning informant said: units separately. In a comparison, the level of agreement between the four persons was good, except for a few cases . and I don’t want to escape the difficult moments that eventually resulted in either disqualification or because one of these moments may give you the greatest changes of the meaning unit. The first author and the benefits. No, it is rather that I suspect that it can be like physiotherapist, who is also trained in BBAT, then continued that, the fact that it hurts a little bit, or is strenuous shows the process of analysis by comparing their own separate that you are untrained and really need the training (8). categorization of transcriptions from three patient inter- views. The analysis revealed that the agreement was very The exercises offered the opportunity to get in contact good between the two physiotherapists. with oneself, which sometimes can be difficult. It addresses one of the main problems with having a false or low sense of Approval was granted by the Regional Ethical Committee self that is common in this group of patients. in Lund, Sweden, registration number 108/2008. Ehm, well, the fact that you are left alone with your own Result way of dealing with time . and there’s no other way. You didn’t have any tools to use, instead you had to just All informants reported some positive treatment effects, deal with the time. And the exercises were a little bit . both in the short as well as the long term. Their contribu- prickly for one’s psyche, quite simply (3). tions to the result, the number of meaning units, differed greatly, due to their varying capacity to verbalize their Six informants used the exercises in BBAT in order to be experiences in the interviews. For example, one informant able to feel better in their everyday lives, noted in the contributed 18 meaning units while another informant’s subgroup as better coping (see Table 1). Two of them transcribed text consisted of 150 units. described that they could deal more successfully with anxiety and were able to prevent it from developing into Four different main categories were identified; affect panic. Another informant described how she now deals with regulation, body awareness and self-esteem, effects her psychotic anxiety: described in a social context, and effects on the ability to think. Each of the main categories contained a number of I become aware of my breathing, my body and stretch in subgroups, shown in Table 1. situations where I otherwise would have felt that my body was disconnected (5). Affect regulation A further four informants said they suffered from All the informants described how the treatment resulted in generalized anxiety to a lesser extent, and that stress and a change of their emotional state towards more subjec- fears were reduced in the long run. Three of them felt tively pleasant feelings (see Table 1). The treatment calmer and in greater control by focusing on being mentally present and in contact with their bodies. One informant said that, by using the exercise and focusing on his centre of coordination in the solar plexus region, he was able to prevent himself from being overwhelmed.
248 L. Hedlund, A.L. Gyllensten Body awareness and self-esteem Six of the informants described an increased activity level, ranging from a minor change to a more thorough Seven of eight informants reported improvements in their change. When talking about BBAT and the standing exer- ability to be mentally present, to be in better contact with cise, one informant said: their bodies, to have increased awareness of their move- ment behaviour and changes in body posture, balance and Well, one change I’ve noticed is that, before, I used to movability (see Table 1). Increased ability to be more lie down on my sofa, when watching TV. Now I sit mentally present and in better contact with their bodies instead, in fact. Actually, I don’t know why. It has just were reported by six informants. They experienced an become like that (1). increased sensory awareness and were in better contact with the surroundings. After many years of disliking moving her body, one informant described that she nowadays liked to do it: One informant who used to be preoccupied by her illness said: Well, yes it is, and then another positive effect it has had is that I’ve started to be more interested in I was too focused on my own brain, my head, the voices becoming physically active. Actually, I did like to take and my illness, unaware of how I dressed myself, if it a walk even before but now I’ve started to train in a gym was warm or cold . I’ve opened up for a bigger room, and practice Yoga and Tai Chi. I’ve never been inter- with clothes and warmth and everything, And see the ested in that before (8). nature and trees and birds (6). The importance of good balance and posture is often The exercise made it possible for the informant to connected with increased self-esteem and feelings of experience a greater sense of being grounded in the self, security. This is described by five informants. One infor- and to meet the stillness inside. mant tries to explain what it meant to him, to get a better posture and also raise his head: Well, I think so, when we do this exercise, lying on the mattress, then I feel my breathing and that I am in my Well, symbolically you think of an emperor, a king in body and I feel this stillness within myself (6). China or something, or an old King from the North, Table 1 Main categories and subcategories in the order of how many informants reported a certain effect, with the frequency of the meaning units in the transcribed text and, in parentheses, the number of informants contributing to each category or subcategory (range and medians are also reported). Main categories and subcategories, total number of meaning units in Total number of Range (median) main category (number of informants) meaning units in each subcategory (number of informants) Affect regulation, 184 (8) 46 (8) 1e10 (4) Increased sense of well-being and a better mood 28 (8) 1e5 (4) Finding it difficult and disliking some parts of the treatment 20 (6) 1e9 (3) Calmer 23 (6) 1e7 (3) Better coping 21 (6) 1e6 (3) Relaxed and positively tired 26 (5) 3e9 (3,5) More alert and strengthened 13 (5) 1e5 (2) Increased interest 7 (4) 1e3 (1,5) Decreased anxiety, stress and fear Body awareness and self-esteem, 201 (7) 73(6) 1e18 (4) More mentally present and in better contact 17 (6) 2e4 (2,5) with the body and body sensations 60 (6) 2e20 (8,5) More active 18 (5) 1e6 (4) Better self-esteem 18 (4) 2e6 (5) Increased awareness of their own behaviour 15 (4) 1e6 (2) Better balance and posture Movability 17 (5) 1e6 (3) Effects described in a social context, 36 (6) More relaxed and natural in social situations, 12 (3) 2e8 (2) 7 (3) 1e4 (2) greater ability to have eye contact with others Greater integrity 28 (5) 4e9 (5) Less shame Effects on the ability to think, 28 (5) Better concentration and ’’calmer or clearer’’ thoughts
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