Journal of Bodywork and Movement Therapies Volume 14 2010

The experiences of basic body awareness therapy 249 without political involvement I mean, and to be sometimes it stops and becomes quiet and that feels elevated, to be more satisfied with life, I think, as in very good, I feel clear in my head (6). ‘‘I’ve got enough, I don’t have to fight for it’’. A King doesn’t have to do that. They know that they will get it Another informant said: if they just ask for it. . It’s a kind of relaxation (3). Well, what shall I say . the possibility of hearing voices One informant who thought he had a better postural decreases when I.when I’ve been to physiotherapy. I stability, spontaneously reflected on the mental conse- feel clearer in my head . so it feels very good (5). quences of this: The informant who suffered from tiredness said that her I think it is that I feel much calmer and more stable. It is thoughts did not become calmer: as if I’ve got better self-esteem (4). Instead, when I get more alert it affects how I feel in my Effects described in a social context head. My thoughts become maybe a little bit more alive, it feels like my level of thinking gets ‘‘more vital’’ or Most of the informants received their treatment in small how shall I put it (8). groups and described several advantages of this. In addition to the effects of the group treatment itself, six Discussion informants described effects in a social context that they thought could be attributed to the effects of BBAT. The Discussion of methods effects were better ‘‘coping’’, increased feelings of integrity and ability to be in contact with others. Some This study is a qualitative approach describing the treat- informants carried out BBAT exercises before socializing ment effects of BBAT, as told by patients with schizo- with friends. phrenia. The number of informants was small, only eight patients were interviewed about their experiences. The One informant, who had struggled with her feelings of main purpose was, however, to get patient-based sugges- shame, described her benefits from the exercise: tions of variables, that could be examined further in a planned randomized controlled study, and in such studies I think when you have felt so insecure, and ashamed, it’s there are limited possibilities for following up all the very important to get your self-esteem back and if you effects that were experienced, except for the main ones. dare to look people in their eyes, then they look down if The decision to end the data collection after eight inter- you hold your gaze still. Sometimes it’s very hard but I views was based partly on the fact that the same treatment try. And I try to straighten myself up, sometimes I don’t experiences were reported several times and no new manage, but I try to think about it and not look down, themes were conveyed in the last interviews and partly on but straight ahead instead (6). the first author’s 20 year experience of working with BBAT and patients with schizophrenia providing a certain pre- The informants reported that they were more relaxed understanding of treatment effects. However, there may when socializing with other people, due to better aware- be some bias regarding this decision. ness and acceptance of their true selves: The informants had a positive attitude, showed interest Today I allow myself to be quiet. Before I forced myself and made efforts to be understood by the interviewer. As to be more talkative, I couldn’t accept that I was quiet, I a group, patients with schizophrenia are considered to be felt like a failure. So it was. So I forced myself to talk in difficult to motivate to participate in studies, in part due to situations where I didn’t want to, which hurts you in the their negative symptoms. Therefore, patients with less long run (8). positive experiences of BBAT probably did not participate in this study. Instead, the patients who participated in this Another aspect of recovery is the need to be and behave study can be considered to be well motivated. This may be like ‘‘normal’’ people. One informant described the due to positive treatment responses or other reasons, for importance of the erect posture in a social context: example, a desire to tell their personal story once more. Another possibility could be that a positive therapeutic It’s important to me, to be like other people mentally, encounter had been established between them and their psychologically and socially, to be like others. That is physiotherapist. The patients included in the study were one of my main goals as a psychiatric patient, so to offered the opportunity to participate by their own phys- speak (3). iotherapist. This also may have influenced the selection of participants, resulting in a positive sample of patients. Effects on the ability to think In order to increase the internal validity, three methods Five informants reported an increased ability to concen- for validity check were used (Farmer et al., 2006). First the trate, and an experience of a ‘‘calmer activity level’’ in the transcriptions were returned to the informants, with pre- brain, clearer thoughts or having the feeling of being stamped envelopes. There were no comments on the mentally awake. When doing sitting BBAT exercises one transcriptions, but three informants replied with personal informant experienced the following: comments about their ongoing progress. I look down and focus my eyes there and experience Another check of validity was the use of ‘‘triangulation a stillness, sometimes there’s a lot of babble, but by researcher’’ (Farmer et al., 2006). Three other persons were engaged in the sorting of meaning units, and two of

250 L. Hedlund, A.L. Gyllensten them had a different professional background. In this struggle with a lack of interest and motivation. Without comparison, there was a high level of agreement. Then, a basic vitality and feelings of interest, the ability to make when categorizing the meaning units to a higher abstrac- changes in life is limited. tion, a comparison was made between the first author and another qualified physiotherapist. The level of agreement Patients with schizophrenia are known to have symp- was very high. Finally, the first author used different toms such as blunted affects, and difficulties in how to theoretical frameworks, such as physiotherapeutic, discriminate and communicate them (McGorry, 2005; psychological and neurocognitive, when discussing the Brune, 2005). In this study the patients could describe results. This broadened the discussion and decreased the different affects/emotions. Whether this was also the case use of narrow-minded interpretation (Farmer et al., 2006). from the beginning of the treatment cannot be answered in the present study, but the informants described that their Most of the informants also met other caregivers at the emotional state changed when using BBAT. Some infor- same time. Many of the described effects are therefore mants had even learned how to use the exercises to regu- probably a result of the influence of several therapists. late their affects/emotions outside the treatment sessions. Different kinds of psychotherapy and medication can make They noticed that the more stressful feelings decreased it possible for other interventions to work and vice versa. with continued BBAT. It gave them a feeling of control and However, some effects are described by the informants security and helped them to protect their integrity. themselves as a direct result of BBAT, related in time and connected to different exercises. This is true for most of Within the research field of affects and emotions, there the experienced treatment effects, categorized under is an interest in the developmental aspects of affect ‘‘affect regulation, effects on the ability to think, body regulation, as a normal and pathological process. The function and self-esteem’’. When it comes to the effects connection between attachment and affect regulation is described in a social context and an increased activity described in an article by Mikulincer et al. (2003). The level, these effects are not experienced close to the BBAT authors present a theory of the child’s normal development session and therefore more likely to be influenced by of affect regulation, as an intimate process, linked to an a number of different factors. After a psychotic episode, emotionally present object. This ‘‘object’’ teaches the there are normally different recovery phases that also child how to regulate its affects, mostly in a subtle, influence the remission Andersen et al., 2003. On the other unconscious way. In order for this to be true, certain hand, there are several studies within different areas conditions must prevail; a safe attachment to a successfully concerning the effects of BBAT that have shown similar affect regulated object, stimulates the child to discover effects, irrespective of diagnosis (Mattsson et al., 1997; itself, actively deal with displeasure and to make use of the Grahn et al., 1998; Gyllensten et al., 2003a). This increases motivating force of pleasure. This leads to an increased the possibility of these results being related to the effects ability to solve different emotional problems. The child’s of BBAT. self-image expands and the self-esteem increases due to the incorporation of the parents’ successful strategies to Discussion of results regulate affects and their own experiences of successful regulations. The child eventually develops a feeling of According to the content analysis, certain experienced control, of being an agent with the capability to deal with effects of the BBAT treatment were reported frequently, emotions (Mikulincer et al., 2003). In comparison with this by most of the informants. This indicates that the expe- description, BBAT offers several similar components in the rienced treatment effects might be rather general and treatment process. One ambition is to encourage the common experiences, shared by many. Recovery from patients to be curious about their bodily experiences and schizophrenia is a complex and truly individual process reactions. The physiotherapist is to be emotionally present (Sells et al., 2004). Today there is a widening interest in and responsible for the intensity in experiences not over- the recovery process, what hinders and what initiates/ whelming the patient. The regulation techniques, used in stimulates recovery (Onken et al., 2002). According to the BBAT, arise both from theory and from the physiotherapist’s philosophy of BBAT, little attention is paid to different self-experienced knowledge about different ways to phys- symptoms and difficulties. Instead the therapist looks at ically increase or decrease affective reactions, as well as the patients’ own view of their problems, the status of the the importance of verbalizing the experiences and mentally body functions and individual strengths and resources accepting different affects and body reactions. The phys- (Gyllensten et al., 2003a). Therefore, in the long run, it is iotherapist also involves the patient in the decision-making especially interesting to find out if BBAT offers the concerning their own experiences so that the patients patients increased recovery potentials by matching their themselves learn to deal with their emotions. This is individual needs. especially important when distressing and painful experi- ences occur. Low tolerance for stress and stimuli is Affect regulation a common symptom within patients with schizophrenia (McGorry, 2005) and in this study all eight informants All of the eight informants reported changes of different reported experiences in BBAT that were unpleasant. affects and emotions from BBAT. They experienced them- However, they mostly understood the benefits of being selves as vitalized, with increased feelings of interest (five exposed to the unpleasant feelings. Therapeutically, it is of eight). Those changes must be considered as very important to emphasize the normality in unpleasant expe- important for patients with negative symptoms who riences, not to be afraid of it but at the same time encourage the patients own integrity and respect the need for avoidance. When given these opportunities, the

The experiences of basic body awareness therapy 251 tolerance often increases naturally and, if not, the phys- explained as a part of a more depressive symptomatology iotherapist guides the patients to a more acceptable which often includes lack of vitality, anxiety, feelings of experience. hopelessness, worthlessness and loss of meaningfulness. The informants in the present study described increased Body awareness and self-esteem alertness and strength, increased interest, decreased anxiety, better self-esteem and a better ability to ‘‘think’’. Body function, as described within the BBAT, includes the Moreover, BBAT contains soft exercises that allow the ability to have a stable and relaxed posture, to be groun- informant to adapt to physical activity at their own pace ded, to be able to coordinate movement with integrated and this contributes finally to a change of behaviour. All breathing, to be well-defined in movements and interper- these effects may explain the increased activity level which sonal relations and finally, to be mentally present or must be considered as an important change within the mindful (Gyllensten et al., 2003a; Hofman and Asmundson schizophrenia symptomatology. 2008). These body functions are systematically trained for better functioning. Seven of eight informants reported Effects described in a social context improvements concerning body functions, as experienced in having better balance and posture, more flexibility in Patients with schizophrenia are known to have difficulties movement and more in contact with their bodies and in social contexts, such as withdrawal and passivity (Brune, surroundings. Moreover, the reports of better balance and 2005; McGorry, 2005) In addition to the cognitive dysfunc- posture are linked to security and better self-esteem. The tions, a concurrent existence of social anxiety, low toler- intimate connection between self-awareness, self-esteem ance of stress and low self-esteem, with easily aroused and the ability to feel secure in our bodies is clearly shown feelings of shame, contributes to the need for withdrawal. by these statements and also described by Dropsy (1999). In this study, six informants described experiences that He postulates that when the person is ‘‘rooted’’ to the included increased opportunities for participation in social ground, with a better balance between the two forces, activities. They talked about shame, integrity, acceptance gravity and the postural reflexes, there is a better ability to of the self and the need to be like others. One important relax, feel calm and be mentally present and alert. The aspect of social interaction is the ability to separate your- increased contact with body functions is often followed by self from others, to filter the impressions of others and be a deeper feeling of existence and a better contact with the able to defend your integrity when needed. The exercises true self and agency. Dropsy declares that many people of the body function ‘‘delimitation of movement’’ leads to have a threefold contact problem, with the body, with the the experience of limits with the need to accept and physical reality (the room, spatial orientation and time) respect limitations, but also to ‘‘be safe’’ within the limits. and with other people. If there is a problem with one of the This is a ‘‘basic level schemata’’, generally self-explana- contact domains, it also has an effect on the other domains tory, and of great importance to later social functioning and vice versa. ‘‘Opening up’’ in one domain leads also to (Roth and Lawless, 2002). improvement in the other two (Dropsy, 1999; Gyllensten, 2004). Furthermore, five informants described moments in Effects on the ability to think BBAT that had led them to reflect on their own behaviour. They have ‘‘become aware of, observed and noticed’’ Five of the eight informants described experiences of different aspects of movement. The ability to reflect is a better ability to ‘‘think’’ after treatment sessions. The a very fundamental function of the ‘‘observing self’’ that is ability to concentrate increased, thoughts became calmer essential for self-regulation, to take good care of yourself and the feeling of clarity of the mind increased. Attention and the ability to change (de Vigemont and Fourneret, difficulties are common in patients with schizophrenia 2004). (Helldin et al., 2006). The treatment process with BBAT constantly appeals to the awareness of surroundings, the For one informant, his erect posture was important so body and bodily sensations and emphasizes the efforts to that he could look like ‘‘normal’’ people do. Patients with make voluntary movements that emanate from the body schizophrenia often make odd gestures and have restricted functions and this stimulates attention in a very direct, body movements and facial expressions, due to both the concrete and personal manner. The feeling of having illness and the side effects of medication, such as tardive greater clarity of thought might also be a result of greater dyskinesia (McGorry, 2005). This probably contributes to alertness. A specific cognitive function is ‘‘vigilance’’, the process of stigma. By normalizing the posture, move- important for the ability to sustain the attention over time ments and gestures, you can to some extent protect your and is partly regulated by the reticular formation, integrity and minimize the risk of being exposed to restraining the ‘‘wakefulness’’ in the central nervous discrimination. The importance of better body control, in system (Helldin et al., 2006). The exercise with BBAT may this context, is also presented by another qualitative study, have a specific influence on this function, resulting in also concerning patients with schizophrenia (Gyllensten clearer thoughts as well as increased ability to be mentally et al., 2003b). present and in better contact with the body etc. As defined in ‘‘embodied cognition’’, this is one of the ‘‘basic Six informants had increased their level of activity. elements of cognitive functioning’’ that is intimately linked Passivity is one of the major negative symptoms of schizo- to the body and its function (Roth and Lawless, 2002). phrenia and there is a strong association with cognitive Furthermore, another explanation for ‘‘clearer thoughts’’ dysfunction (McGorry, 2005; Helldin et al., 2006). However, there are probably several reasons for passivity. It could be

252 L. Hedlund, A.L. Gyllensten might be that BBAT regulates muscular tension and anxiety with a group where the student also writes a report on the and thereby decreases the disturbance on the cognitive dynamics in the BBAT group processes and the role of the processes. Consequently, there are at least three different therapist in BBAT. The student also reads about 2000 pages mechanisms that may explain the better ‘‘ability to think’’ of relevant literature that are processed and critically which might be stimulated or activated with BBAT. evaluated from a clinical perspective. This is done in two literature reports. All reports are evaluated by a teacher Conclusion who approves and gives feedback. The fifth level consists of a written project paper of clinical interest. This qualitative study focused on possible treatments effects of Basic Body Awareness Therapy, as they were Education in BBAT is offered both as private education at experienced by eight patients with schizophrenia. Four the Institute for Basic Body Awareness Therapy in Sweden main categories were identified; Affect regulation, body or public education e.g. examination in BBAT methodology awareness and self-esteem, effects described in a social at the University College of Bergen, Norway (60 EC credits). context and effects on the ability to think. These results should be targeted in future randomized controlled studies. After this students become certified BBAT therapists. The full education is available only for registered physio- Conflict of interest statement therapists. Other professionals are accepted for steps one and two. There are no conflicts of interest in this study. A typical therapist’s training consists of 30 weeks during Acknowledgements 4e5 years. Today, there are around 150 certified BBAT therapists in Europe (Sweden, Norway, Denmark, Finland, This study was funded by the Swedish Council for Working Island, Switzerland, UK and Spain). In this study, the life and Social Research (FAS) and the County Council of experts in BBAT were certified BBAT therapists, teachers at Scania, Sweden. the private institute, educating therapists with more than 20 years of clinical practice within psychiatric Appendix A. Interview guide physiotherapy. (1) Tell me if and how the treatment with BBAT has helped The methodology of BBAT you in any way? - In the short term History - In your every day life BBAT is inspired by Western movement practice, like Fel- - In the long term denkrais, Alexander technique and the European move- ment tradition (Gindler and Selver), the expressive arts, (2) What feels good about doing the BBAT exercise? like dance (Graham and Laban) and theatre (Stanislavski). (3) Are there exercises that feel bad or are difficult to do? Body-oriented psychotherapy (Reich and Lowen) also (4) Tell me more about your experiences of working with influences BBAT. From the East, Zen meditation and Tai-chi Chuan (Tai Chi), are important sources of inspiration. BBAT BBAT. was developed to be starting exercises for Tai Chi and tends to follow the same principles. A French psychotherapist and Appendix B. Description of body awareness actor, J. Dropsy, synthesized the aforementioned traditions therapy and published two books describing the method (Gyllens- ten, 2004). A Swedish physiotherapist used the method in Therapists’ education the treatment of patients with schizophrenia and published the results in a thesis at the medical faculty of Gothenburg Basic Body Awareness Therapy is a physiotherapeutic University, 1985 (Roxendal, 1985). Since then, the meth- treatment, developed in Scandinavia. The education to be odology has been used within physiotherapy mainly in a certified body awareness therapist requires a five step psychiatric physiotherapy, but also in the rehabilitation of educational programme. The programme consists of theo- prolonged pain. Today, there are 12 theses using BBAT or retical, practical and clinical training, with considerable the Body Awareness Scale (BAS). Eleven of them have been emphasis on one’s own treatment experience and process. written by physiotherapists and one by a medical doctor The students have homework to do between the four 1- (http://www.ibk.nu). week training sessions. The first two levels focus on developing body awareness and an understanding of the Methodology process from an inside perspective. The theoretical In BBAT one uses movement, breathing, massage/hands-on framework and history of body awareness, as well as how to guiding and awareness to try to restore balance, freedom verbalize goals and motivational aspects in patients work, and the unity of body and mind. BBAT is described as are also focused on. In the third level, students work with resource-oriented which in this case means working with and write a report on the individual process with a patient the resources of the body as a whole. Turning attention going through BBAT. The fourth level focuses on treatment both to the doing and to what is experienced in the movements is central and stimulates awareness and movement performance. BBAT differs from Tai Chi in the way that movements are quite simple, focused on the experience of stability, ease and intension (Gyllensten,

The experiences of basic body awareness therapy 253 2004). The therapist encourages the patients to move in References ways more optimal for postural control, balance, free breathing and coordination. The relation to the ground, Andersen, R., Oades, L., Caputi, P., 2003. The experience of vertical balance in the centre line, centring of movements recovery from schizophrenia: toward an empirically validated and coordination from the trunk and the solar plexus area, stage model. Australian and New Zealand Journal of psychiatry breathing, flow and awareness are seen as important 37, 586e594. aspects of the body-ego, trained in BBAT (Gyllensten, 2004). BBAT can be executed both individually and in Brune, M., 2005. ‘‘Theory of mind’’ in schizophrenia: a review of a group. It is performed lying, sitting, standing, walking and the literature. Schizophrenia Bulletin 31, 21e42. running. BBAT also includes partner work, in structured massage or push-hand exercises from Tai Chi. 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254 L. Hedlund, A.L. Gyllensten Recovery Facilitating System Performance Indicators. National Roxendal G, 1985. Body awareness therapy and the body awareness Technical Assistance Centre. scale, treatment and evaluation in psychiatric physiotherapy. Pallanti, S., Quercioli, L., Hollander, E., 2004. Social anxiety in Gothenburg Thesis. outpatients with schizophrenia: a relevant cause of disability. The American Journal of Psychiatry 161, 53e58. Sells, D., Stayner, D.A., Davidson, L., 2004. Recovering the self in Priebe, S., Ro¨hricht, F., 2001. Specific body image pathology in schizophrenia: an integrative review of qualitative studies. acute schizophrenia. Psychiatry Research 101, 289e301. Psychiatric Quarterly 75, 87e97. Roth, W., Lawless, D.V., 2002. How does the body get into the mind? Human Studies 25, 333e358. Van Dongen, C., 1998. Self-esteem among persons with severe mental illness. Issues in Mental Health Nursing 19, 29e40.

Journal of Bodywork & Movement Therapies (2010) 14, 255e261 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt FASCIA RESEARCH: VISCERAL ADHESIONS Notes on visceral adhesions as fascial pathology Gil Hedley Received 25 April 2009; received in revised form 13 October 2009; accepted 19 October 2009 Summary Fascia is introduced as an organizing anatomical category for visceral mesothelia. Normal tissue relations are discussed in order to frame the presentation of abnormal visceral adhesions as fascial pathology, 4 types of which are identified. Laboratory dissections of fixed and unembalmed human cadavers provide the basis for insights into these pathologies as regards self-care and therapeutic technique. ª 2010 Elsevier Ltd. All rights reserved. Intent perceive these same differences when palpating the living is left to the skilled teachers of visceral manipulation. This Many clinicians assess and treat perceived limitations of paper simply reports what has been found in the laboratory visceral mobility which are attributed, among other things, by the present author. to visceral adhesions. This article notes some of the lines between normal and pathological adhesions of various Conventional anatomical literature and study is founded types. The intent is to illuminate this inner world of visceral on a regional approach. Because of this focus on particular adhesions considered as fascial pathology, in the hope of regions as distinct subjects of study from other regions of providing useful information for those who carefully the body, generalizations regarding common tissue textures consider the same in their therapeutic practices. and analogous functions sometimes escape the regional method. The author has developed and subscribes to Anatomical background a method of study which he calls ‘‘integral anatomy.’’ While these notes do not permit a full explication of the It is hard to overstate the value of undertaking many gross object and methods of integral anatomy, suffice it to say human dissections for establishing a baseline understanding that the approach places particular emphasis on the whole of normal tissue relations. Such experience enables one to person while emphasizing the textural layers of the body in differentiate more readily between a normal presentation, their continuities and relationships across purported a healthy but anomalous presentation, and a pathological regional boundaries. This having been said, the author presentation of visceral relationships. Exactly how to synthesizes the disparate information regarding the anatomical structures of the visceral regions by introducing URL: http://www.gilhedley.com the general and commonly recognized category of ‘‘fascia’’ as an organizing principle referent. The membranes and fibrous layers which surround the organs of the body do in fact represent various specialized types of the more 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.10.005

256 G. Hedley general category of ‘‘fascia,’’ the general properties and Photo #1 Above, we see the entire parietal peritoneum anatomy of which this author gives a more thorough presenting after the more superficial transversalis fascia has accounting elsewhere (Hedley, 2005a,b, 2006, 2009). In been differentiated and reflected superiorly. The visibly that prior resource is introduced the notion of ‘‘visceral yellowish midline tissues represent the normal locus of higher fasciae.’’ According to this account, the notion of ‘‘visceral degrees of normal fibrous fixation to the overlying transversalis fasciae’’ is observed to include, in a manner that repeats fascia. Image Copyright Gil Hedley, 2006. Used with permission. across regions, a fibrous outermost layer, a parietal serous layer, and a visceral serous layer. Careful and considerate typology. For the sake of anatomical accuracy then, it attention to these tissues is given by Barral in his several should be said that the rectum, uterus and bladder are all volumes of work, upon which the present author relies, invested/covered superiorly by parietal rather than visceral especially in so far as they provided foci of interest for peritoneum (Photo 2). more direct explorations in the laboratory. (Barral and Mercier, 1988; Barral, 1989,1991,1993) In order simply to Proceeding from the deep aspect of the visceral layer of convey from an integral perspective the various structures, the serous membrane, there are fibers that are continuous already known and identified in a disparate manner through with the connective tissue matrix of the underlying tissues. the conventional regional approach, the author developed Therefore the ‘‘skin’’ of an organ, despite its obvious Table 1. (Hedley, Vol. 3, 2006.) In Table 1, a schematization continuity as a fascial ‘‘wrap,’’ cannot be very readily of the various structures by region is offered, including the ‘‘peeled’’ from the enveloped organ itself, with which it membranes of the CNS for the sake of analogical exists in perfect continuity. The visceral serous membranes completeness, in a manner that organizes them according rather shred when an attempt is made to differentiate to analogous tissue textures. them, much as the periosteum does, when the deeper connections are severed and the thin fabric of the surfacing Normal adhesion of the parietal layer to the layer recoils upon itself. In this manner then, the degree of fibrous layer normal ‘‘adhesion’’ of the visceral serous membrane to the organ exceeds the tenacity of the relationship of the fibrous It is the author’s experience that it is normal for the pari- outermost layer and the parietal serous layer, whether etal, or ‘‘wall’’ layer, to be adherent to the outermost pleural, pericardial or peritoneal. fibrous layer. The parietal serous membranes are relatively well fixed to the fibrous layer in normal tissue presentations, The pia mater of the central nervous system is the least though they can be manually ‘‘peeled’’ apart and thus substantial as compared to its visceral membranous fascial differentiated in gross dissection in a manner which clearly analogues. It does not manifest enough depth in itself, or demonstrates the distinctness of the two layers. The degree enough fibrous matter, being only a two or three cell-deep to which the parietal layer is fixed is somewhat predictable covering over the brain, even to ‘‘shred’’ in the fashion of based on region. The parietal peritoneum, for instance, is the visceral pleura, for instance. It is soft enough to easily considerably more firmly fixed with fibers at the anterior push a finger through, which is not the case for the visceral midline to the transversalis fascia than it is more lateral to layer of the serous membranes in general. The pia simply this line. The two layers can be peeled apart manually along cannot be differentiated as a layer except histologically. most of their shared surface, but at the midline a scalpel is required to differentiate them (Photo 1). Normal adhesion of the visceral layer to the viscera It is also the author’s experience that it is normal for the visceral layer of serous membrane to be adherent to the underlying parenchymal tissues of the given organ which it covers. Because of their complete adherence to the tissue of the organs they cover, this author refers to the visceral serous membrane as the ‘‘skin’’ of the organ. The pelvic ‘‘space’’ is technically sub-peritoneal and outside of this Table 1 Schematization of cranial and visceral fasciae. Visceral Spaces Fibrous outermost layers Parietal serous layers Visceral serous layers Intracranial Dura mater Arachnoid Pia Thoracic Endothoracic fascia Parietal pleura Visceral pleura Cardiac Fibrous pericardium Parietal pericardium Visceral pericardium Abdominal Transversalis fascia Parietal peritoneum Visceral peritoneum Table 1 is taken from The Integral Anatomy Series, Vol. 3: Cranial and Visceral Fasciae, Copyright Gil Hedley, 2006, on DVD. Used with permission.

Fascia research: Visceral adhesions 257 Adhesion distinguished from ligamentous distortion Photo #2 Above we see the visceral peritoneum covering the An adhesion is distinguished by the author for the purposes hepatic flexure of the colon. Image Copyright Gil Hedley, 2009. of these notes from the phenomena of distortions of Used with permission. visceral ligaments. ‘‘Ligaments’’ in anatomical nomencla- ture most generally indicate literally a form of ‘‘tying’’ of Normal relations of parietal and visceral layers one structure to another. (from Latin, ligare, to bind or tie) to each other Ligaments ‘‘tie’’ bone to bone, but they also ‘‘tie’’ organ to organ, and so on. Visceral ‘‘ties,’’ or ligaments, most often The parietal and visceral layers of the various serous consist of various reflections, folds and spannings of the membranes form a continuity of tissue: the fascia is serous membranes (mesothelia) as they envelop the continuous, but it reflects off of the organs and then complex but interrelated forms of the viscera themselves doubles-back around them to form an enveloping and the convolutions of the spaces wherein the viscera ‘‘balloon’’ around them as well. (Gray, pp. 459, 901, 970, move. In the author’s experience, the serous membranes 1901/1977) Within the parietal layer, then, the viscera, are found to be highly elastic, which property is demon- themselves covered in their ‘‘skins,’’ ideally slide one strable not only in unfixed but also in fixed tissue samples, against another in perpetual motion in their ranges of evidenced insofar as they recoil in various degrees when normal mobility. They also slide against the parietal layer incised. The elastic property derives anatomically from the which surrounds them and with which they have varying ample presence of both simply elastic as well as actively degrees of contact throughout their range of motion. contractile fibers within the membranes. (Schleip, 2006, Further, in certain areas, the parietal layer is in sliding p.3) The causes of tissue shortening are various and beyond contact with itself. the scope of the present article. It is sufficient for now to simply distinguish for conversation’s sake between adhe- Normal sliding surfaces sions, where normal sliding surfaces are stuck to one another, and ligamentous distortion, where abnormal So normal sliding surfaces can be said to include visceral shortening or lengthening of the relationships of organs serous membranes against one another, parietal serous through their various ‘‘tyings’’ represent a different kind of membranes against themselves, and finally visceral serous fascial pathology of the viscera. membranes against parietal serous membranes. A few examples of these three categories of sliding surfaces are Types of pathological adhesion by cause schematized in Table 2. Table 2, therefore, can serve equally well to outline Definition of pathological adhesion potential loci of adhesions, because any normal sliding surface contacts also have the potential to become stuck: that is, to adhere, to one another. It is the author’s observation of clinical evidence in the laboratory that the circumstances which give rise to the adhesion of normally sliding surfaces are multiple. They include, but are not exhausted by, the following causes: 1) inflammation from infections or other types of disease processes 2) inflammation and scarring as the sequelae of surgical intervention 3) the sequelae of prior limitations upon movement cycles 4) intentional therapeutic adhesion A pathological adhesion, for the purposes of this conver- Inflammation from infections or other types of sation, is defined as a fixed connection between tissues disease processes which would normally slide relative to each other. Such adhesions are ‘‘pathological’’ to the extent that the normal Serous membranes, like other tissues of the body, being range of motion of the tissues is inhibited by the abnormal highly vascular and innervated, are subject to inflammation relations of the visceral fascia. The normal motion of the from a variety of causes. Any ‘‘-itis’’ in the region of the organs in their own right, as well as in their relationships viscera could potentially, though not necessarily, result in an with one another, are an essential aspect of the proper adhesion. For instance, a lung infection could result in one or physiological functioning of the organs. Therefore the more points of fibrous connection of varying degrees of disruption of normal motion via fascial pathology in the density between the visceral and parietal pleura. Pericar- form of adhesions is potentially disruptive of highest organ ditis may result in a broad fixation of the visceral and parietal function (Photo 3).

258 G. Hedley Table 2 Examples of normal sliding surfaces. Visceral layers against each other Parietal layers against themselves Visceral layers against parietal layers Stomach to liver Diaphragmatic aspect of parietal pleura Visceral pleura to parietal to costal aspect of parietal pleura pleura Loops of small intestine to Diaphragmatic aspect of parietal pleura to Visceral pericardium to parietal themselves mediastinal aspect of parietal pleura pericardium Uterus to rectum Visceral peritoneum to parietal Ovaries to loops of small peritoneum intestines Table 2 Copyright Gil Hedley, 2009. Used with permission. pericardium. The normally free border of a cystic ovary may direct observation, as aggregations of fibrous matter that become adherent to the adjacent parietal peritoneum of the result when surgical incisions or other types of wounds heal, posterior abdominal wall (Monk et al., 1994). The author leaving tissue layers (skin, superficial fascia, deep fascia, regularly dissects these types of ovarian adhesions as they and membranes) pinned to each other with reduced play and appear commonly in cadaver specimens (Photo 4). elasticity. This author has also observed how the fiber direction of scars so defined is usually plaited in a multi- This author has directly observed in the laboratory how direction manner, distorting the normal vectors of elasticity other disease processes can result in adhesions beyond those and tension native to the tissue. Scars can also be evident deriving from straightforward inflammatory processes. Cysts within the visceral spaces wherever incisions have been and tumors can have the effect of binding two organs or two made, and in these cases they sometimes have as sequelae sliding surfaces together with the aberrant growth serving as the adhesion of local tissues. (Zong et al., 2004) For instance, the focal point of adhesion between the membranes. Ulcers, this author has directly observed how open heart surgeries cancerous metastases and pancreatitis exemplify more will often result in major adhesions of the left lung to the extreme types of inflammation where strong adhesions may chest wall, i.e., the visceral to the parietal pleura, as well as result from the disruption of the local tissues (Troitskii, 1968). considerable adhesion of the visceral to the parietal peri- cardium. Because the incisions of surgery necessarily cause Inflammation and scarring as the sequelae of inflammation of the local tissues, in combination with scar- surgical intervention ring this can result in the formation of a seemingly progres- sive adhesion of visceral fasciae (Liakakos et al., 2001) Surgery offers so many advantages that we are prone to (Photos 5 and 6). forgive some of the problems that it can cause, among which can be counted visceral adhesions, and scarring. Where The sequelae of prior limitations upon there are surgical scars observed on the outside of a human movement cycles form, one can almost unerringly predict some manifestation of adhesions and scarring within the form. Scarring is defined Visceral ligaments and the spatial relationship of the organs by this author, for the sake of this discussion and based on to one another define the normal range of motion of the Photo #3 Arrow identify the adhesion of the visceral peri- Photo #4 Above the arrows indicate the whole inferior toneum of the small intestine to the parietal peritoneum of the margin of the liver adherent to the greater omentum as the ascending colon: these normally have a sliding relationship likely sequela of inflammatory processes. Image Copyright Gil with each other. Image Copyright Gil Hedley, 2009. Used with Hedley, 2009. Used with permission. permission.

Fascia research: Visceral adhesions 259 subsequent irritation of the membranes will initiate the formation of adhesions between the membranes which when fully progressed will have the effect of mitigating further collapse: the adherent membranes serve to sustain the inflation of the lung. (Montes et al., 2006) The loss of the sliding surface between the visceral and parietal pleura is the price willingly paid for the higher good of the lung’s permanent inflation. This author has directly observed how surgeons will suture tissues together in a manner demanding fixed relationships of tissues which might otherwise prolapse or spread apart. Thus sometimes tissues are adherent because it is demanded of them to be so (Wong and King, 2004). Photo #5 Adhesions of visceral to parietal pericardium Varying impact of adhesions following upon open heart surgery. Image Copyright Gil Hedley, 2006. Used with permission. The adhesion of normally sliding surfaces in any of the manners described range on a continuum of impact upon viscera as they respond to the breath cycle. A scar or initial normal organ function from inconsequential to debilitating. adhesion represents an abnormal limit cycle upon the Where the abdominal organs are reduced to a virtually solid phases of movement characteristic within the visceral and immobilized mass as a result of repeated major surgical spaces. It is this limitation of movement which is at the interventions, the physiology of the organs are necessarily heart of the type of progressive adhesion noted above. affected by their lack of mobility over time. On the other Adhesions beget adhesions, as the initial limitation of hand, a minor and singular adhesion of a fatty epiploic normal motion extends like a growing cloud of stillness in apendage of the descending colon to the adjacent parietal the immediate tissues. This type of progressive adhesion peritoneum is unlikely to have any particularly untoward will form as a diffused and general fixed relationship of the effect, given the normally relatively fixed position of the tissues across a broad surface, rather than as a cluster of colon along the posterior wall of the abdomen by the single-pointed fibrous linkages. In dissection, one ‘‘peels’’ parietal peritoneum (Photo 9). these adhesions apart, as opposed to cutting or ‘‘popping’’ them at individual points of relationship. The author has Palpating for adhesions dissected many human forms where numerous precedent abdominal surgeries have resulted in virtually the entire Part of the process of careful dissection of the viscera visceral contents becoming adhered into a single common involves visually observing and manually palpating the mass (Photos 7 and 8). tissues. This inspection process often reveals a variety of adhesions in the mostly elderly forms which donor programs Intentional therapeutic adhesion provide. Often it is possible to deduce or infer the causes of the adhesions based on the evidence at hand, and given In the instance of a repeatedly collapsing lung, talc may be a lack of explicit medical history, these inferences are all introduced between the visceral and parietal pleura. The Photo #6 After the removal of the adhesions of the visceral Photo #7 Above is a specific fibrous adhesion of the visceral and the parietal pericardium shown above. Image Copyright Gil pleura of the right lung at its most inferior tip, to the parietal Hedley, 2006 used with permission. pleura in its mediastinal aspect. Image Copyright Gil Hedley, 2009. Used with permission.

260 G. Hedley Photo #8 Above a progressive adhesion of the entire visceral adhesions can simply be directly pulled apart manually in surface of the lung to the mediastinal pleura is being manually dissection. The author has often imagined that the same peeled apart in dissection: the arrows indicate the still undif- could probably have been accomplished manually in vivo as ferentiated adhesions at the margins of the lung. Image well, given the appropriate leveraging of the tissues in Copyright Gil Hedley, 2009. Used with permission. question. However, though this type of direct technique seems possible, it does not, upon careful consideration, there is to go by. Many of the adhesions discovered, when appear to be the most advisable approach. Fibrous adhe- not obviously associated with evident disease processes or sions when broken abruptly can result in small wounds to surgical interventions, would likely have escaped the the tissues related by them, which wounds themselves knowledge of the donors and their doctors. Nonetheless, would be likely sources of inflammation. So a cycle of they may have been subtly affecting optimal visceral adhesion could easily be re-introduced with such a strategy, motion and health. The question then remains open as to creating little progress, or even exacerbating the problem. how a therapist trained in visceral manipulation might A more indirect technique for releasing adhesions in vivo facilitate the visceral motion in the living in a manner that would appear to be desirable. By manually facilitating might relieve some of the adhesions revealed in the movement towards the normal range of motion of the fixed dissection process. tissues with gentle traction, timed with several fulsome breath cycles on the part of the client, the expanding range Direct vs indirect approaches to releasing of motion may itself induce the dissolution of the adhe- adhesions sions, not necessarily in the moment, but over time. In the same way that restrictions upon movement from adhesions In the process of differentiating the viscera it becomes may progress into greater levels of adhesion over time, necessary to release adhesions as they are found. Many enhancements of movement may progress into greater levels of movement and the restoration of normal sliding relationships of tissues. Hypothetical examples of indirect release of adhesions in vivo These examples are hypothetical and are not meant to serve as medical advice. They could serve as sample protocols for researching the impact of interventions with respect to post surgical adhesions. Self-care example An individual might help themselves to release adhesions from progressing after thoracic surgery with a practice of simple variations on thoracic twists. For instance, with hands grasping on a pull-up bar positioned at a height within easy reach, an individual could introduce gentle torques into their thorax, accompanied by several deep breath cycles at each position explored. Such could be a daily practice for a few minutes a day post-surgery. The external torsion accompanying the internal breath could literally stretch and mobilize fixed but normally sliding tissues of the thorax. The reiteration of larger cycles of motion thus introduced could have the effect over time of gently dissolving adhesions, slowing the progression of further adhesion, or at least increasing the elasticity and range of motion of the individual’s visceral relationships, both normal and pathological. Practitioner-supported example Photo #9 Epiploic appendage of descending colon adhering In instances where the support of a practitioner is war- to parietal peritoneum. Image Copyright 2009 Gil Hedley. Used ranted, taking the same example as above, a trained with permission. bodywork practitioner could gently introduce torsions into the patients thorax while coaching their position and breath cycles, with an intent on varying the presenting

Fascia research: Visceral adhesions 261 motion patterns which may be reflecting underlying adhe- Hedley, G,, 2009. The Integral Anatomy Series, on DVD Viscera and sions. By increasing the factors which thus increase demand their Fasciae. for the gliding of sliding surfaces which may be fixed, greater movement cycles may reiterate and accrue to the Liakakos, T., Thomakos, N., Fine, P.M., Dervenis, C., Young, R.L., advantage of the client in the manner described above. 2001. Peritoneal adhesions: etiology, pathophysiology, and clinical Significance. Dig. Surg. 18, 260e273. PMID 11528133. References Monk, Bradley J, Berman, Michael L, Montz, F.J., 1994 May. Barral, J.-P., Mercier, P., 1988. Visceral Manipulation. Eastland Adhesions after extensive gynecologic surgery: clinical signifi- Press, Seattle. cance, etiology, and prevention. Am. J. Obstet. Gynecol. 170 (5), 1396e1403. Barral, J.-P., 1989. Visceral Manipulation II. Eastland Press, Seattle. Barral, J.-P., 1991. The Thorax. Eastland Press, Seattle. Montes, J.F., Garc´ıa-Valero, J., Ferrer, J., 2006 Sept. Evidence of Barral, J.-P., 1993. Urogenital Manipulation. Eastland Press, Seattle. innervation in talc-induced pleural adhesions. Chest 130 (3), Gray, Henry, 1901/1977. Anatomy, Descriptive and Surgical. 702e709. PMID: 16963666. Gramercy Books, New Jersey. Schleip, R., 2006, Active Fascial Contractility. Implications for Muscu- Hedley, G., 2005a. The Integral Anatomy Series, on DVD. In: Skin loskeletal Mechanics, Dissertation, Ulm University, Ulm, Germany. and Superficial Fascia, vol. 1. Troitskii, R.A., 1968 April. Abdominal adhesions and tumor growth. Hedley, G., 2005b. The Integral Anatomy Series, on DVD. In: Deep Bull. Exp. Biol. Med. 65 (4), 441e443. Fascia and Muscle, vol. 2. Wong, S.W., King, D., 2004 Aug. Sutureless intestinal plication. ANZ Hedley, G., 2006. The Integral Anatomy Series, on DVD. In: Cranial J. Surg. 74 (8), 681e683. and Visceral Fasciae, vol. 3. Zong, Xinhua, et al., 2004. Prevention of Postsurgery-induced abdominal adhesions by electrospun bioabsorbable nanofibrous poly(lactide-co-glycolide)-based membranes. Ann. Surg. 240 (5), 910e915. 2004 Nov.PMID: PMC1356499.

Journal of Bodywork & Movement Therapies (2010) 14, 262e271 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt CLINICAL INFLUENCES Extensor coxae brevis: Treatment strategies for the deep lateral rotators in pelvic tilt Thomas Myers 318 Clarks Cove Rd, Walpole, ME 04573, USA Received 5 December 2008; received in revised form 26 November 2009; accepted 8 December 2009 KEYWORDS Summary The group of myofascial units known as the deep lateral rotators are considered in Myofascial; light of their role as postural hip extensors, resulting functional and palpatory assessments of Pelvic neutral; pelvic neutral are presented, and treatment strategies for anterior and posterior pelvic tilt are Hip joint; discussed. Postural assessment; ª 2009 Elsevier Ltd. All rights reserved. Piriformis Our Uniquely Human Hip substantially flexed, usually at 90 or more to the angle of the sacrum (Fig. 2). The differing roles of five small but important myofascial units e the gluteus medius, piriformis, obturator internus, Bring the leg of any cat or dog into such full extension; obturator externus and quadratus femoris e within the and one is likely to get an unmistakable non-verbal unified fascia of the posterior hip are here examined. This response before reaching the angle required for human group of muscles, commonly named as ‘deep lateral rota- standing. Even our closest relatives, the chimpanzee and tors of the hip’, can be seen alternatively as postural gorilla, who can achieve fuller extension when necessary, extensors of the coxofemoral (hip) joint. Within this seem to drop gratefully (in this author’s observation) back perspective, we propose informal assessments and treat- toward hip flexion, whereas humans routinely spend the ment strategies for these structures in anterior and poste- day standing ‘naturally’ in what would be for most other rior pelvic tilt (Fig. 1). primates or quadrupeds the more extreme end of the flexioneextension range. One of the many unique features of human plantigrade carriage is that our femur in standing posture is in general One can say ‘extreme’ even in the human, given that coronal alignment with the spine. Comparatively, few other there is very little additional extension left for the femur in quadrupeds or even primates are accustomed to such hip most of us, due to the twisting of the coxofemoral ligament extension; their mid-range positions for the femur are complex, specifically the pubofemoral ligament under (or blended with, in our limited but repeated dissection E-mail address: [email protected] observation) the iliopsoas tendon. Even the minor hyper- extension required for our gait can be observed at a certain point to incur lumbar hyperextension rather than further extension of the femur relative to the hip (Fig. 3). The 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.12.003

Extensor coxae brevis 263 Figure 1 The ‘extensor coxae brevis’ group. Art courtesy of Figure 3 In human standing the hip bone must make John Hull Grundy, used with permission.. a powerful movement around the femur to approximate the ischial tuberosity to the femur and lift the spine (After posturally lazy can thus shift the pelvis forward over Molliere). the feet to ‘lean’ against these ligaments, whereas the yogically or acrobatically trained, or those with a naturally hip. A relaxed body out of gravity will assume the ‘dead loose ligamentous bed, can achieve greater than normal man’s float’ position, with the hips flexed into a more coxofemoral hyperextension before the movement is quadrupedal position. transferred from hip to spine. The primary hip extensors are usually considered to be Attaining and maintaining our upright posture in either the hamstrings, pulling directly inferior from the posterior phylogenetic or ontogenetic terms requires approximating surface of the IT, with fascial extensions onto the sacrum. the ischial tuberosity (IT) to the femur. Hip extension can These muscles are also fascially continuous with both the involve either extending the femur away from the front of erectors and the triceps surae (fellow travelers in the the pelvis and spine, as we just did with our cat, or bringing Superficial Back Line (Myers, 2009) e Fig. 4). While the role the posterior aspect of the pelvis closer to the shaft of the of these ischiocrural muscles as hip extensors is unassail- femur. Human standing requires the latter: swinging the able, they have two disadvantages in performing the pelvis posteriorly around the stationary head of the nearly postural1 part of this uniquely human hip extension: vertical femur, as in Fig. 3. Coupled with the erector spinae above and the soleus below in keeping the body upright, 1) All three hamstrings are two-joint muscles, flexing the the author contends that the hip extensors are the muscles knee as well as extending the hip. This author’s clinical that must shorten, over evolutionary time, to extend the finding is that the body’s brain primarily uses the deeper, single-joint muscles to maintain posture whenever possible, leaving the more superficial multi- joint muscles to modulate and coordinate movement.1 How do the hamstrings mediate between their pivotal postural and dual movement roles? I.e.: how do the hamstrings maintain hip extension without also flexing the knees? Having this tendency constantly opposed by the quadriceps would be energetically inefficient. 2) All the hamstrings are very long. Because of the linear alignment of myosin and actin elements, maintaining posture via such long muscles (despite the extensive membranes and tendon arrangements within them) is mechanically and physiologically disadvantageous (Fig. 5). Figure 2 Human standing involves a uniquely extended hip 1 We can avoid the controversy concerning whether muscle joint where the femur is generally aligned with the axis of the activity is or should be involved in human standing posture by spine, compared to other mammals, even primates, where the positing that a) human standing involves constant low-amplitude coxofemoral relation is 90 or less. shifting and resulting tonic muscle activity, and b) muscle activity in hip extensors would be necessary to prevent hip flexion during loading, i.e. when carrying a child on the front of the trunk or it’s postural equivalent such as a pot belly.

264 T. Myers Figure 4 A dissection of the Superficial Back Line laid over superior and inferior, obturator internus, and quadratus a classroom skeleton. The hamstrings e part of this myofascial femoris (see Fig. 1). continuity e pull down on the ischial tuberosity. Photo cour- tesy of the author and the Laboratories for Anatomical This list constitutes the posterior portion of what can be Enlightenment. seen as a ‘fan’ of muscles, or a set of myofascial ‘spokes’ around the ‘hub’ of the greater trochanter (Myers, 2004a). Which are single-joint muscles whose tonus might The tensor fasciae latae, and anterior portions of gluteus maintain human hip extension against the force of gravity, medius and minimus constitute the anterior e and thus hip any myofascial tension in the numerous hip flexors, or any flexor as well as abductor and medial rotator e part of this fan. recoil of the pubofemoral ligaments? The fact that the muscles named above are commonly In answer, we find the long portion of the adductor named the ‘deep lateral rotators’ (of the femur) demon- magnus e a single-joint extensor of the hip just deep to the strates that their role as extensors of the hip has been hamstrings e and the deep lateral rotators. (Fig. 6) In fact, under-appreciated in our consideration of hip biomechanics. every one of the muscles behind the coronal midline of the The ‘lateral rotator’ designation implies that the pelvis is femur can help extend the hip: in addition to the posterior the stable origin and the greater trochanter of the femur fibers of adductor magnus, we can include portions of the is the moveable insertion. For the remainder of this article, gluteus medius and gluteus minimus, piriformis, gemellus we will be reversing the emphasis, taking the femur of the standing leg (or both legs) as origin and the posterior aspects of the os coxae and sacrum as the insertion e hence extensor coxae brevis. Any of the hamstrings, save the short head of biceps femoris, would thus be ‘extensor coxae longus’. Both groups, we are hypothesizing, share the workload of extending the hip and preventing unwanted hip/trunk flexion Though the two tasks of lateral femoral rotation and hip extension are related (think of the push-off phase of roller- blading or ice-skating as extensions of similar smaller movements in walking), their role as lateral rotators is subordinate, in this writer’s opinion, to their postural role in keeping the hip extended.2 If we concur with that role, these muscles become crucial to any strategy for dealing with an anterior or posterior pelvic tilt, as these postural positions could be alternatively described as hip flexion and extension respectively. In hip flexion/anterior pelvic tilt, these muscles will tend to be eccentrically loaded (neuromyofascially ‘locked long’); in hip extension/posterior tilt, they will tend to be concentri- cally loaded (‘locked short’) e though the precise parame- ters of such designations are yet to be defined. The extremes of both anterior and posterior pelvic tilt may involve a functional weakness in terms of these surrounding muscles’ ability to generate forceful contraction on any attachment or across the hip joint itself. Eccentrically loaded muscles have less overlap between the myosin and actin proteins, and thus cannot generate a strong contraction. Concentrically loaded muscles have plenty of overlap (so it is more difficult to generate relaxation in them), but are so near the end of the ‘ratchets’ that they cannot generate significant further contraction.3 Even though there is a certain amount of adjustability in tonal length within the muscles, neither of these ‘out of 2 This is an assumption not universally shared: No less an authority than Serge Gracovetsky says: ‘‘As a rule of thumb, the muscles must be considered as ‘‘gas guzzlers’’ and, to execute any tasks with minimum energy consumption or minimum stress in all joints, the musculoskeletal system will always attempt to use its ligaments first, and fire a muscle as a last resort.’’ (Gracovetsky, 1986). 3 Again, this is a presumption based on clinical palpation only. Hoyle found most striated muscle to be heterogeneous (Hoyle, 1967).

Extensor coxae brevis 265 Figure 6 The adductor magnus assists the hamstrings and the deep lateral rotators in maintaining hip extension. Art courtesy of John Hull Grundy, used with permission. Figure 5 Given that they are very long two-joint muscles, constitutes a ‘neutral pelvis’. Ida Rolf suggests that when the the hamstrings are ill-equipped to be postural muscles. superior surface of the pubic bone and the tip of the coccyx are in horizontal alignment, the pelvis is in a proper neutral neutral’ positions would seem to provide efficient and strong (Rolf, 1977). Hiramoto and Kendall and McCreary posit that muscle contraction in functional movement. If so, we spec- pelvic neutral is when the ASIS and the front surface of the ulate that those clients whose characteristic postural posi- pubic bone are in the same coronal plane (Hiramoto, 2000; tion tends toward one or the other of these extremes have Kendall and McCreary, 1983). Others suggest an ideal angle neither a strong and adjustable initiator for leg movement, between the ASIS and PSIS (Shamberger, 2002). nor a stable but responsive foundation for spinal movement. This author finds such markers objectionably geometric Assessing pelvic tilt and fixed, as they fail to account for individuated dynamic relations between the femur and the lumbar spine through If the treatment option employed varies with pelvic tilt, how the pelvis. A more complete goniometric method might yield shall we define pelvic neutral? Opinions abound as to what more convincing and less cut-and-dried measures with further research (Sprigle et al., 2003). We have been using a more individually responsive test, which has its own prob- lems, but produces, in our opinion, a truer overall result than these simple geometric visual measures. Again, more research with such measuring devices as a laser or balance beam might be possible to introduce objectivity and

266 T. Myers eliminate ideomotor bias from the following subjective (but muscle is a distinct slip running on the oblique line between nonetheless interesting and sensitive) assessment method. the posterior superior iliac spine (PSIS) and the superior aspect of the greater trochanter. By strumming across this With the subject in relaxed standing, place your hand line, the trailing edge of this muscle and its fascia can usually ever so gently on their head, with a cranial touch e no more be distinctly felt as if it were a separate muscle. than a nickel’s worth of pressure. Resting in the hair will suffice to feel what you are looking for. From whatever Piriformis pelvic position is ‘normal’ for this person, have them tilt the pelvis a bit anteriorly. Does the head rise into or shrink The only two-joint muscle of this group, as it also crosses away from your hand? If they increase the forward tilting of the sacroiliac joint, passes from the top of the greater the pelvis toward their end-range of hip flexion, at some trochanter through the greater sciatic foramen to attach to point the body will shorten away form your hand. Have the anterior aspect of the middle three segments of the them return to their normal. Now have them tilt the pelvis sacrum (Fig. 7). The piriformis is thus the sole axial- posteriorly a little. Same question: does the head bloom appendicular muscle of this group, with the ability to into your hand or shrink away? Again, if they continue into create ‘force closure’ on the sacroiliac joint during gait more extreme posterior tilt toward the end-range of hip (Vleeming et al., 2007). This function combines with its extension, the spine will eventually shorten. contribution to stabilizing the sacrum at the bottom of the spinal ‘lever’ in lateral tilts, bends, and rotations of the Have the subject slowly oscillate through the top of the spine, as well as the more familiar one of laterally rotating movement until you are sure where the ‘highest’ point in the femur (or preventing medial rotation), or teaming up the cycle occurs. In this model, pelvic neutral e the with the pectineus to create pelvic rotation e stretching postural ideal e is when the head is at its highest, indi- the poor piriformis among multiple roles (Myers, 2004b). cating that the spine is at its longest. The operating presumption for this test is that the pelvis should rest in the This muscle can be most easily palpated (though some- position where the spine is ‘living its full length’. times it is not easily palpated at all) in the center of a triangle made from the top and bottom of the sacrum Repeat the exercise in each direction a few times to make along the midline and the posterior aspect of the greater sure you are reading the results correctly. This test is more trochanter. Strumming up and down over the center of this accurate the more differentiated the client’s pelvic move- triangle will often (but not always) reveal the small but ment can be, such that they can isolate the movement of the potent piriformis. Whether it can be distinctly felt or not, pelvis from compensatory movement in the rib cage, legs and this is where piriformis is most easily touched manually lumbars. In individuals who are challenged with excessive (given that we are not entering the body cavities). Proximal stiffness, injury, or surgery, the test will be less effective, as to this point, it disappears deep to the sacrum, and distal to the spine will shorten due the forward or backward this point the tendon can be lost in the general ‘glom’ of displacement of the head or rib cage. In most cases, however, connective tissue around the trochanter. Of course pir- the anterior or posterior tilt of the pelvis reveals that ‘highest iformis can be ‘reached’ using the femur as a lever to point’, often only a few degrees from where they habitually rest, and that is where you should aim for having the patient rest in normal. This angle of the pelvis where the spine lives its fullest length, for the purposes of this paper, is defined as their particular ‘pelvic neutral’. Periodically retest over time, as the results can shift a little as greater balance is achieved. Please note that we are not suggesting that you should instruct your clients to ‘put’ themselves in this normal; if you do good work, the subject will arrive naturally and without effort at his own ‘personal best’ normal. Anatomy A brief review of the anatomy will be helpful before discussing treatment options. Precise palpation directions are offered as all of these muscles lie deep to the large and thick gluteus maximus, which can make easy palpation challenging. All but a small portion of this muscle (deep and parallel to the quadratus femoris, according to Janda) is quiescent in standing, so its role in hip extension is limited to running and stair-climbing, and not, like the rest of this list, in relaxed standing (Janda, 1986). We proceed from superior to inferior. Gluteus medius, posterior portion Figure 7 The unique piriformis performs multiple roles, and should be considered from both sides, as one myofascial The posterior portion of the gluteus medius is a combination continuity, as suggested in this art from John Hull Grundy. Used of a hip extensor and abductor. The posterior edge of this with permission.

Extensor coxae brevis 267 induce a general stretch, though this author finds far more specificity for each of the three slips by means of the direct To find the obturator internus (OI), locate the ischial manual approach. tuberosity (IT) from below on your prone client. ‘Walk’ Gemellus superior your fingers up the ‘mountain’ of the ischial bone toward the head until you find a soft ‘meadow’ of muscle e this is This small muscle passes from the lateral end of the sac- the OI, which can usually be felt as a distinct muscle if you rospinous ligament to the trochanteric fossa, and may thus strum up and down. From here go directly lateral to find provide muscular reinforcement to the ligament in its role the distal tendinous portion of this muscle, which may of stabilizing the side-to-side movement of the sacrum. In blend with one or both gemelli to produce a single large this way, this muscle is, in effect, a two-joint muscle as tendon, or may remain palpable as two or three distinct well, helping to reinforce the sacroiliac joint via the sac- tendons. rospinous ligament. Palpate this muscle, if it can be distinguished, along a line just superior to obturator Following Humphry4 we could see the obturator and internus. the gemelli as a single five-stem ‘bouquet’ of muscles Obturator internus arising from the trochanteric fossa, with the two gemelli forming the upper and lower (and shorter) portions over This fascinating muscle also inserts into the trochanteric to the upper and lower ischium, while the obturator fossa, but it passes behind the ischium to take a 90 turn internus rounds the tuberosity to divide into three over a bursa, fanning out to cover the whole inside of the portions e one reaching up toward the iliac portion near lower flange of the hip bone within the true pelvis, the anterior sacroiliac joint, one reaching straight across completely covering the medial side of the obturator the obturator membrane for the suprapubic ramus, and membrane. This muscle is thus much larger and stronger one reaching downward toward the ischioubic ramus than it appears from a posterior view of the hip. It also (Humphry, 1872). provides an attachment for the iliococcygeus of the pelvic floor. Take these two muscles together on both sides, and To find this larger, internal, and more muscular proximal one can see a fascial ‘hammock’, strung from trochanter to part of OI requires courage and a willing client e and even trochanter (Fig. 8). This author agrees with Grundy’s view then you are limited to the lower two of the three parts in Fig. 8: this complex can provide a resilient ‘spring’ for just described. Place three fingertips just inside the IT, the forces transferring from the spine to the legs, sparing using the sacrotuberous ligament as a guide for the index the full force from the coxofemoral joint itself (Grundy, finger. Slide in the direction of the navel, lateral to the 1982). anal verge and parallel to the ischium. Your fingerpads will feel the IT/ischial ramus at first, but as you pass into the Figure 8 The obturator internus, again considered from both ischiorectal fossa, you will encounter a softer area that is sides, and when coupled with the pelvic floor (not pictured), forms a sling to cushion the shock of the upper body’s weight 4 Humphry, 1872, p. 34 ‘The three flattened, closely adjusted on the hip joint. Art courtesy of John Hull Grundy, used with tendons which the obturator internus presents as it passes over the permission. smooth surface of the ischium, have often attracted attention. They are the result of a division of the muscle within the pelvis into three flat fan-shaped portions. Of these, one, lying internal to the others (in a superficial plane when dissected from the inner side), arises from the inner surface of the angle formed by the horizontal and the descending portions of the os pubis. It is situated internally to the obturator vessels and nerve, and the arch of fascia which covers them, and therefore away from the obturator foramen. The tendon proceeding from this is the middle tendon of the three. The second division of the muscle, from which the lowest tendon proceeds, arises from the ossa pubis and ischii bounding the lower half of the obturator hole, and from the surface of the obturator ligament. The third division arises from the upper half of the obturator ligament, and from the ossa pubis and ilii above the obturator hole and beneath the brim of the pelvis. It extends upon the ilium nearly to the sacroiliac synchondrosis. This tendon is the upper of the three. It occupies a groove commonly seen just below the spine of the ischium; and it sometimes presents a division into two for a short distance, giving the appearance of four tendons upon the internal surface of the muscle. The two last-mentioned divisions, which may be called respectively ‘‘pubischiatic’’ and ‘‘pubiliac’’, approach one another upon the obturator ligament beneath the first-mentioned, which may be called the ‘‘pubic’’ division. Having passed over the ischium, the tendons unite into one, the edges of which are joined above and below by the gemelli. If traced backwards from the trochanter, the tendon of the obtu- rator gives off, first, in a penniform manner, the fibers of the gemelli; then, in like manner, those of the ‘‘pubiliac’’ and ‘‘pubischiatic’’ portions; and lastly, in like manner, the fibers of the pubic portion’.

268 T. Myers comprised of the lower fibers of OI. You will be stopped in your upward and forward progress by the pelvic floor/ilio- coccygeus, which crosses over from the midline to attach to the OI fascia at the arcuate line. Have the client contract the pelvic floor and you will be able to assess its relative strength from the contraction against your fingertips. Gemellus inferior This small muscle reinforces the obturator internus from Figure 9 Obturator externus is included in the deep lateral below, extending from the distal end of the sacrotuberous rotator group, but not in our extensor coxae brevis group, as it ligament on the ischial tuberosity to blend in its attachment is a weak hip flexor. Hard to reach and difficult to treat, it is with the tendon of the obturator internus. Though this nevertheless a major stabilizer of the pelvis on the leg. Art muscle shares with all the others in this list the roles of hip courtesy of John Hull Grundy, used with permission. extensor and lateral rotator of the femur, any additional role e such as possibly providing an adjustable reinforce- The two obturator tendons arise from the same area of the ment to the sacrotuberous ligament complex e is as yet trochanteric fossa, and can, in this author’s limited dissec- unclear (Van der Wal, 2009). tion observation and Humphrey’s more extensive documen- tation, blend at their distal end (Humphry, 1872). Together, Quadratus femoris the two muscles could be seen to reach out from the femur like two hands holding the inner and outer aspects of the The last but not least of our group extends from the lateral lower flange of the pelvis in a close but adjustable grip. aspect of the IT laterally to the posterior trochanter. This muscle is a powerful postural extensor of the hip (or, more This is one of the more obscure muscles of the pelvic accurately, a powerful resistor to hip flexion as well as area to palpate, but it can be felt by the knowledgeable medial femoral rotation), given its ability to approximate practitioner on a willing client by entering the femoral the IT to the posterior aspect of the femur, and will be triangle of the client lying supine with the knees up. Find short and bunched in most clients with a pronounced the small fascial ‘window’ between the medial edge of the posterior tilt. pectineus origin and the lateral edge of the adductor longus tendon and press in superiorly and posteriorly with finger- Because the muscle is quadrate, it rarely presents as tips or your thumb pad. The tough and generally sensitive a twangy bit of myofascia, but more often as a graduated tissue beyond these two muscles is the OE, running from the mound of tissue. Quadratus can be found and assessed lateral surface of the ischium and obturator membrane above a line running lateral to the lower end of the IT e back and under the neck of the femur to the trochanteric frequently just above the line of the superficial gluteal fossa. Only a small portion of this muscle can be directly fold. Do not confuse this with the similar mound more palpated. distally located on the femur, below the gluteal fold, which is the fleshy attachment of the gluteus maximus. Treatment Obturator externus (OE) Having come this far, treatment options abound. The one sentence pre´cis is that in cases of a chronic postural set of This muscle is usually included in the deep lateral rotator anterior pelvic tilt/hip flexion the fascia of this muscle group, but is not an ‘extensor coxae brevis’ because it acts e group needs to be taken inferiorly individually and as alone in this group e as a hip flexor. This rogue muscle is hard a whole, while in cases of posterior pelvic tilt these myo- to palpate and difficult to treat in its entirety. Originating fascial units need to be neuro-muscularly and fascially from the lateral surface of the lower flange of the hip bone, released and allowed to lengthen and hopefully reset at covering the outer surface of the obturator membrane, the lower standing tension. OE passes under the neck of the femur from anterior to posterior to attach into the trochanteric fossa deep to the In anterior tilt, these muscles will be eccentrically quadratus femoris. loaded, so any or all of them present in our clinic as twangy, tight, and sore with active trigger points. In posterior tilt, Obturator externus counterbalances the OI in hip flexion they often present as bunched, often seemingly tied and extension, though both combine to resist the medial together, with primarily passive trigger points. rotation of the femur (Fig. 9). In running closely under the neck of the femur, it also offers a muscular reinforcement to the neck when it is under extra strain (in landing after a jump, for instance). It is probably not a powerful hip flexor, given the competition it finds in the more advanta- geously positioned iliacus, pectineus, and rectus femoris, etc., but chronic shortness in its myofascia could conceiv- ably prevent the ischial ramus from moving forward and thus the pubic bone from lifting.

Extensor coxae brevis 269 Figure 10 Treatment of these muscles in posterior tilt piriformis often reverts over a short time until the body generally involves lengthening the myofascial units, and reaches sufficient balance in all these forces for the pir- usually from pelvic origin to femoral insertion. Art courtesy of iformis to retain any new tonal ‘set point’.5) John Hull Grundy, used with permission. Gemellus superior and inferior are usually addressed Posterior tilt with the obturator internus rather than individually, again working along the muscles from the lateral side of the In posterior tilt, a variety of treatment options may be used upper ischial tuberosity laterally toward the fossa at the to ease standing tension, including neuromuscular therapy back of the greater trochanter. Work deeply and slowly for techniques, active isolated stretching, strain-counterstrain, best results. or proprioceptive neuromuscular facilitation. In terms of more commonly-used fascial release techniques, working For the intrepid practitioner and the willing client, the slowly along each individual muscle from pelvic origin larger portion of OI can be reached by sliding the fingertips toward the femoral insertion, using the guidelines for spec- up into the ischiorectal fossa in the direction of the navel, ificity outlined above, will usually result in lengthened fascia using the sacrotuberous ligament as a guide, as detailed and lower standing tone (Fig. 10). above. Once well onto the muscular fibers of the OI proper, hook the myofascia and bring the issue inferiorly and The posterior edge of the gluteus medius is easily posteriorly (bring your hand back the same way it went in, located between the superior trochanter and the PSIS. but with the fingertips hooked into the fascia), as the Beneath this muscle, the harder-to-feel but equally potent client medially rotates the femur. This one technique can gluteus minimus can be contacted (usually to the client’s result in a substantial reorientation of the pelvis in the initial horror) by passively abducting the side-lying client’s direction of an anterior tilt (as well as easing the overly- thigh with one hand or forearm, while working deeply into tight pelvic floor, in our experience), helping to restore the posterior hip tissue with the other elbow. a neutral lumbar lordosis when the client stands after treatment. The piriformis is harder to locate on some clients, but following the direction to the center of the triangle The quadratus femoris is a tough square of myofascia described above will guarantee that you are on the pir- that can be worked quite strongly and needs to be worked iformis whether it can be detected or not. Work laterally quite thoroughly in these cases, mostly along the posterior and inferiorly toward the insertion to lengthen this muscle side of the trochanter superior to the gluteal fold. If you (at least temporarily e modulating pelvic tilt is only one of are working this muscle with the client prone, ask them to piriformis’s many roles, which include antagonizing the arch their lumbar spine slowly into a lordosis as you work, lower psoas over the sacroiliac joint (Myers 2004b), rein- thus adding an active release component into your tech- forcing the sacrospinous ligament, and preventing excess nique. Release of this muscle e again along the grain of the movement in the sacroiliac joint due to forces descending fibers, deeply and slowly e often results in the ability to from spinal movements above, not to mention force closure more properly fold the hip joint into flexion without of the SI joint in walking e therefore treatment of the binding. Anterior tilt For anterior tilt, this entire set of myofascial units needs to be pulled caudad. One fascial portion of this treatment can be accomplished most easily behind the greater trochanter, where they all terminate. With your client prone and the hip relaxed as possible, hook the fascia at the top of the trochanter with an elbow and bring it down along the back of the trochanter (Fig. 11). Several passes and significant weight are often required to effect a change, as you are working with the tendons of all these muscles in the fascial fabric behind the trochanter. Similar work can be done nearer the origin of these muscles by hooking tissue slowly along the posterior iliac crest, just lateral to the PSIS, and along the lateral lower sacrum and ischial tuberosity. Cross-fiber work across each of these individual muscles seems to be helpful in unlocking the eccentric loading in the fibers of these muscles, helping to create (but not guaranteeing) a shorter standing tonus.6 Work slowly back 5 Resetting the standing tonus of muscles is an elusive concept in 6 This could be a useful area for future ultrasound research: what research. As a clinician, we ‘know what we feel’, but the science is is the architecture of fascia, particularly the endomysium, in an not yet fully in agreement here (Mori et al., 1982; Asanoma et al., eccentrically loaded muscle? And what is the effect of cross-fiber 1998; Bouret and Sara, 2005). work on this ‘locked long’ myofascial architecture? See Van der Wal, 2009; Purslow 2002; Passerieux et al., 2006 and Huijing 2007.

270 T. Myers Figure 11 Treatment in anterior tilt generally involves a dormant ‘sensori-motor amnesia’, and will benefit from pulling the fascial plane caudally while stimulating the muscles the kinds of muscle-activation techniques such as MET and to shorten via cross-fiber work. Art courtesy of John Hull PNF mentioned above. Grundy, used with permission. In cases where the two innominates are in a different angle, the two sides will require different degrees of treat- ment to ease locked nutation or counter-nutation of the sacroiliac joint. In general however, the inclusion of these ‘extensori coxae brevi’ in your treatment plans for excessive anterior or posterior pelvic tilt will be rewarded. In considering the postural balance of the pelvis on the femur, the hip flexors get a lot of attention and for very good reason: 1) they are large and strong muscles, 2) which must lengthen significantly for full maturational develop- ment, and 3) which can be subject (in our observation) to increased tension in common fear or post-traumatic situa- tions, as well as in chronic torsion or rotational patterns not addressed by this article. Here we have made the case that the ‘deep lateral rotators’ may act as postural antagonists to these hip flexors, not leaving the entire job to the long, bi-articular, and often over-worked hamstrings. We offered a test for determining the client’s personal ‘pelvic neutral’, and suggested techniques for this ‘extensor coxae brevis’ group to help move the client toward their functional norm. and forth across the muscle you wish to focus on, slowly References enough not to ‘twang’ the muscle, but to soften and differentiate the myofascia without allowing it to jump Asanoma, et al., March 1998. Augmentation of postural tone beneath your applicator (fingers, knuckles, or elbow). induced by the stimulation of the descending fibers in the midline area of the cerebellar white matter in the acute Of course, this work needs to be accompanied by the decerebrate cat. Neurosci. Res. 30 (3), 257e269. release of the hip flexors and spinal extensors for best results. Including the OE, the renegade of our group, can be Bouret, S., Sara, S., 2005. Network reset: a simplified overarching helpful in this regard. Again, this requires a willing client theory of locus coeruleus noradrenaline function. Trends Neu- and a certain skill by the practitioner. rosci. 28 (11), 574e582. 1 November 2005. With your client supine and the knees up, sit next to Gracovetsky, S., 1986. Determination of safe load. Br. J. Indust her hip and cup her knee in your axilla. Find the obvious Med. 43, 120e133. adductor longus tendon in the groin and place your thumb just anterolateral to its junction with the pubic Grundy, J., 1982. Human Structure and Shape. Noble Books, Chil- bone. Insinuate your thumb between the adductor longus bolton UK. and the pectineus. OE lies deep to these two, and is usually distinctly harder than the pectineus, and deeper Hiramoto, Y., 2000. Morpho-metrical features of the pelvis in than the adductor longus or brevis. Contacting it will standing posture. Kaibogaku Zasshi 75 (2), 223e230. often elicit a surprised reaction from the client, but with sensitive communication, you can get a release from the Hoyle, J., 1967. Diversity of striated muscle. Am. Zool. 7 (3), 435e portion of the muscle you can touch, which is by no 449. doi:10.1093/icb/7.3.435. means all of it. Huijing, P., 2007. Epimuscular myofascial force transmission This is only one access point to a fairly large attachment, between antagonistic and synergistic muscles can explain but by changing the angle of the thumbprint slightly from movement limitation in spastic paresis. J. Biomech. 17 (6), directly superior to inferior and medial against the pubic 708e724. bone, or superior and lateral, and calling for a slow pelvic rock, more of the muscle belly can be contacted. Most Humphry, G.M., 1872. Lectures on human myology. Br. Med. J. 2 clients with a fixed anterior tilt will find more freedom (602), 33e35. after this release, which can be repeated as often as time (and the client) allow. Janda, V.,1986. ‘‘Muscle weakness and inhibition (pseudoparesis) in back pain syndromes’’ in ‘‘Modern Manual Therapy of the Continuing our journey caudad from here, we would Vertebral Column’’ edited by GP Grieve, New York, Churchill- encounter the adductor minimus, which due to its posi- Livingston, p. 197e201. tioning and innervation is probably, like the OE a hip flexor. The remaining portions of the large adductor magnus Kendall, F., McCreary, E., 1983. Muscles, Testing and Function, running from the more posterior ischial ramus to the linea third ed.. Williams & Wilkins, Baltimore, p. 25. aspera and medial femoral epicondyle do appear to participate in hip extension, but are often stuck in Mori, et al., 1982. Setting and resetting of level of postural muscle tone in decerebrate cat. J. Neurophysiol. 48, 737e748. Myers, T., 2009. Anatomy Trains, second ed.. Churchill Livingstone, Edinburgh. Myers, T., 2004a. Fans of the hip joint. originally published in Massage Magazine 1998, self published 2004 as ‘Body3’. Avail- able from: www.anatomytrains.com. Myers, T., 2004b. Psoas-piriformis balance. originally published in Massage Magazine 1999, self published 2004 as ‘Body3’. Avail- able from: www.anatomytrains.com.

Extensor coxae brevis 271 Passerieux, et al., 2006. Structural organization of the perimy- Sprigle, S., Flinn, N., et al., June 2003. Development and testing of sium in bovine skeletal muscle: junctional plates and a pelvic goniometer designed to measure pelvic tilt and hip associated intercellular domains. J. Struct. Biol. 154 (2), flexion. Clin. Biomech. 18 (5), 462e465. 206e216. Van der Wal J 2009 The Architecture of the Connective Tissues in Purslow, P., 2002. The structural and functional significance of the Musculoskeletal System e based on a doctoral thesis ‘‘The variations of connective tissue within muscle. Comp. Biochem. Organization of the Substrate of Proprioception in the Elbow Phys. 133 (4), 947e966. Region of a Rat’’ published in 1988, reprinted in Journal of Bodywork and Movement Therapies, 2009 (2), 4. Rolf, I., 1977. Rolfing. Healing Arts Press, Rochester, VT, p. 87. Shamberger, W., 2002. The Malalignment Syndrome. Churchill Vleeming, A., Mooney, V., Stoeckart, R., 2007. Movement, Stability & Lumbopelvic Pain: Integration of research and therapy. Livingstone, Edinburgh.

Journal of Bodywork & Movement Therapies (2010) 14, 272e279 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt MICROCURRENT ELECTROTHERAPY The efficacy of frequency specific microcurrent therapy on delayed onset muscle soreness Denise Curtis, MSc, NMT a,*, Stephen Fallows, PhD a, Michael Morris, MSc a, Carolyn McMakin, MA DC b a Centre for Exercise & Nutrition Science, University of Chester, Parkgate Road, Chester CH1 4BJ, England, UK b Fibromyalgia and Myofascial Pain Clinic of Portland, 69 SW Hampton Street, Portland, OR 97223, USA Received 6 October 2008; received in revised form 11 January 2010; accepted 24 January 2010 KEYWORDS Summary This study compared the effects of frequency specific microcurrent (FSM) therapy Frequency specific versus sham therapy in delayed onset muscle soreness (DOMS) in order to determine whether microcurrent therapy; specific frequencies on two channels would produce better results than single channel single Delayed onset muscle frequency microcurrent therapy which has been shown to be ineffective as compared to sham soreness; treatment in DOMS. 18 male and 17 female healthy participants (mean age 32 Æ 4.2 years) were Eccentric; recruited. Following a 15-min treadmill warm-up and 5 sub-maximal eccentric muscle contrac- VAS tions, participants performed 5 sets of 15 maximal voluntary eccentric muscle contractions, with a 1-min rest between sets, on a seated leg curl machine. Post-exercise, participants had one of their legs assigned to a treatment (T) regime (20 min of frequency specific microcurrent stimula- tion), while the participant’s other leg acted as control (NT). Soreness was rated for each leg at baseline and at 24, 48 and 72 h post-exercise on a visual analogue scale (VAS), which ranged from 0 (no pain) to 10 (worst pain ever). No significant difference was noted at baseline p Z 1.00. Post- exercise there was a significant difference at 24 h (T Z 1.3 Æ 1.0, NT Z 5.2 Æ 1.3, p Z 0.0005), at 48 h (T Z 1.2 Æ 1.1, NT Z 7.0 Æ 1.1, p Z 0.0005) and at 72 h (T Z 0.7 Æ 0.6, NT Z 4.0 Æ 1.6, p Z 0.0005). FSM therapy provided significant protection from DOMS at all time points tested. ª 2010 Elsevier Ltd. All rights reserved. Introduction a secondary inflammatory condition (Gleeson et al., 1995; Wilmore and Costill, 2004; Connolly et al., 2003) resulting Delayed onset of muscle soreness (DOMS) has been described from unaccustomed eccentric contractions (Taleg, 1973; as damaged muscle tissue membranes combined with Newman et al., 1983a,b; Armstrong, 1984; Denegar and Perrin, 1992) and maximal isometric contractions (Clarkson * Corresponding author. Tel.: þ353 46 9059095. E-mail address: [email protected] (D. Curtis). 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.01.009

The efficacy of FSM therapy on DOMS 273 et al., 1986). Although many variables are reported in the single frequency microamperage current using 30 Hz at quantification of muscle damage, the typical symptoms 200 mA for 10 min and 0.3 Hz at 100 mA for 10 min was not associated with DOMS are loss of strength, pain, muscle effective in reducing pain or increasing range of motion 24, tenderness, stiffness, swelling and elevated levels of the 48 and 72 h after DOMS induction in the biceps muscle in enzyme creatine kinase (McHugh et al., 1999). Symptoms a group of 18 subjects (3 males, 18 females). The sham can vary from mild muscle tenderness to severe debilitating group in the Allen paper received treatment from a unit pain (Cheung et al., 2003). that had been disabled by the manufacturer to provide no electrical stimulation and both the subjects and experi- DOMS is a well researched phenomenon and the menter were blinded. In the present study the sham morphological injury to the muscle has been well treatment was provided by a unit that was not turned on described, however the mechanism underlying the injury and only the subjects were blinded. To the authors’ remains poorly understood. For many years, DOMS was knowledge, no controlled studies to date have examined attributed to an accumulation of the metabolic end prod- the effects of FSM therapy on DOMS. ucts of exercise resulting in elevated muscle lactate. This assumption is now understood to be unconnected to DOMS. History of frequency specific microcurrent It is now proposed that the soreness may be the result of, (FSM) therapy amongst others, mechanical (Newman et al., 1983a,b; Armstrong, 1984; Stauber et al., 1990) or biochemical Microcurrent electrical neuromuscular stimulation (MENS) (Armstrong, 1984; McIntyre et al., 1995) factors. was developed in the 1970s as a battery operated physical therapy modality delivering current in the microampere Research suggests that the soreness typically appears range. An ampere (amp) is a measure of the strength of between 8 and 24 h post-exercise, peaks at 24e48 h and electric current and measures the rate of flow of charge in can last for up to 7 days (Cleak and Eston, 1992; Howell a conducting medium. One micro amp (mA) equals 1/1000th et al., 1993). of a milliamp (mA). By comparison, interferential, TENS, and high-volt pulsed galvanic stimulators deliver currents in Although the precise details of muscle damage following the milliamp range causing muscle contraction, pulsing and eccentric exercise remains unknown, it appears that even tingling sensations. TENS applies an electrical force that a single bout of eccentric muscle contractions can offer stimulates pain suppressing A-beta afferent fibers which significant protection against muscle soreness in subsequent compete against A-delta and C fibers that transmit pain performances of the same exercise. This phenomenon, which signals. Most TENS units deliver current around the 60 mA has been known to last for several months, was termed the range (Kirsch and Lerner, 1998). Although microcurrent ‘‘repeated bout effect’’ by Nosaka and Clarkson (1995). devices are approved in the category of TENS for regulatory convenience, in practical use they are in no way similar and DOMS is a universal symptom familiar to most athletes cannot be compared to TENS in their effect. that usually occurs after an extended layoff from exercise or unfamiliar, predominantly eccentric exercise. Athletic With microcurrent the patient cannot feel the current performance is typically impaired when an athlete is sore. since there is not enough current to stimulate sensory nerve Research by Proske et al. (2003) implied that muscle sore- fibers (Mercola and Kirsch, 1995). Traditionally, micro- ness, following a bout of unaccustomed eccentric exercise, current therapy has been used to increase the rate of may also contribute to muscle weakness, possibly as healing in injured athletes, to treat and manage muscle a result of reduced excitability of the motor cortex. Thus, pain and dysfunction and to increase the rate of fracture any practice or therapy that limits soreness and restores repair (Rowley et al., 1974; Bertolucci and Grey, 1995; the maximal function of the muscles as quickly as possible Kirsch, 1996, 1997; Lambert et al., 2002). would be of interest and practical value to the athlete. Current in the range of 10 up to 500 mA was observed to Numerous treatment strategies, both prophylactic and increase ATP production, amino acid transport, protein rehabilitative, have been introduced to help relieve the synthesis, and waste product removal in rat skin whereas severity of DOMS. Some of the proposed treatments include ATP production leveled off between 500 and 1000 mA and pre- and post-exercise static stretching (Herbert and decreased when the current was above 1000 mA (Cheng, Gabriel, 2002; Cornwell et al., 2002; Yamaguichi and Ishii, 1982). TENS devices provide up to 60 times higher current 2005), pharmacological treatments using non-steroidal levels than that seen to decrease ATP production which anti-inflammatory drugs (NSAIDs) (Grossman et al., 1995; may explain why TENS units have not been found to be O’Grady et al., 2000; Sayers et al., 2001; Connolly et al., effective in treatment of DOMS (Craig et al., 1996). Typical 2003; Lanier, 2003), nutritional supplements (Kaminski and microcurrent applications use only low and simple one Boal, 1992; Warren et al., 1992; Jakeman and Maxwell, channel frequencies such as 0.3 Hz, 3 Hz, 10 Hz, 30 Hz, and 1993), massage therapy (Tiidus and Shoemaker, 1995; 300 Hz (Manley, 1994; Allen et al., 1999). Lightfoot et al., 1997), continuous compression (Kraemer et al., 2001) and ice-water immersion (Sellwood et al., The therapeutic use of frequencies and electrotherapy 2007). However, little scientific evidence exists to support began in the early 1900s in the United States and England the effectiveness of any of these therapeutic interventions. with thousands of medical physicians using a number of devices to treat a wide range of conditions from arthritis The following study compared the effects of FSM therapy and tuberculosis to pneumonia (Kirsch and Lerner, 1998). versus sham therapy on DOMS in order to determine if the The Electromedical Society and the journal Electromedical use of certain specific frequencies would produce better Digest served as a forum for physicians to share their results than simple single frequency microcurrent therapy which had been shown by Allen et al. (1999) to be inef- fective when compared to sham treatment in DOMS. Allen et al. (1999) determined that 20 min of single channel,

274 D. Curtis et al. research and clinical findings. Copies of Electromedical The frequency specific protocols were developed clini- Digest were found in the rare book room of the National cally through trial and error by one of the authors after it College of Naturopathic Medicine in Portland containing was determined through clinical use on volunteers that the frequencies and protocols for the above conditions and use of a frequency combination that did not produce articles documenting clinical outcomes in every edition improvement also did no apparent harm. The descriptions available published between 1920 and 1951. In 1934, as of the frequencies from the list were taken at face value part of its effort to standardize medicine and medical and used speculatively for various chronic and acute education, the American Medical Association (AMA) conditions in clinical practice to determine if they would decreed that pharmaceutical medications and surgery were produce a change in symptoms and clinical improvement the legitimate tools of medicine and that electromagnetic (McMakin, 1998; McMakin, 2004; McMakin et al., 2005). therapies, homeopathy, herbs and other treatments were ‘‘unscientific’’ (Berliner, 1975, Barzansky and Gevitz, For example, the frequencies described on the list as 1992). The biophysics and medical research that would reversing ‘‘hemorrhage’’ in the ‘‘arteries’’ were used provide the mechanisms and science explaining electro- speculatively in acute injuries to reduce bruising ‘‘as if’’ it medicine would not be done until the 1980s (Becker and correctly represented the effect of the frequency. It was Seldon, 1985; Oschman, 2000). The use of electromag- subsequently observed not only to prevent bruising and netic therapies and frequencies declined, the research reduce pain but also coincidentally noted to stop bleeding being reported in Electromedical Digest ceased and the last for up to 12 h in patients who were menstruating at the edition of the journal available was published in 1951 time of treatment. No other frequency tried produced this (Electronic Medical Digest, 1951). The FDA made the orig- effect. This frequency had no effect on any other condi- inal devices illegal around the same time. tion. No formal research has been done to verify the effect of this frequency but it has been reproduced on numerous The frequencies used in this study were obtained in 1995 occasions by the authors and many of the 1200 clinicians from a retired British osteopath who bought a practice in using FSM worldwide including athletic trainers for the USA Vancouver, BC (Canada) in 1946 that came with a machine National Football League (NFA), surgeons and an obstetri- (manufacturer unknown) and a list of frequencies that were cian who use this frequency specifically to stop bleeding created in 1922 thought to address specific tissues and and bruising in medically appropriate settings. neutralize specific conditions. The list acquired from the osteopath included approximately 100 frequencies alleged The other frequencies used in FSM therapy were to neutralize certain pathologies or conditions and over 200 explored in the same way. 40 Hz was described on the frequencies thought to address certain tissues. The osteo- osteopath’s list and in Electromedical Digest as being useful path’s method of treatment included using a frequency on to ‘‘reduce inflammation’’. Use of this frequency in a clin- one channel to ‘‘remove a pathology’’ combined with ical setting suggested that it did only that and was not useful a frequency on the second channel to ‘‘address a specific to change any other condition. Use of 40 Hz on channel A tissue’’. The device used by the osteopath has long since and 10 Hz on channel B was found to reduce pain in fibro- disappeared and has never been available for inspection. myalgia patients and to reduce all of the inflammatory While it is thought to have plugged into the wall current cytokines as measured by micro-immunochromatography which may have been DC in 1922, it is not known what (McMakin et al., 2005). One control patient treated with current level it delivered and there is no reason to suspect a protocol that did not include 40 Hz had no change in that it delivered microamperage current which was not cytokines (McMakin et al., 2005). introduced until the early 1980s. Frequencies found on the back page of Electromedical Digest in a wall chart being Clinical response to the frequencies over the last 14 sold by Albert Abrams were identical to those that came years suggests that the conditions being treated and the with the osteopath’s machine where the two lists over- tissues being addressed are accurately represented by the lapped. The use of microcurrent and frequencies for the frequency descriptions although decades of research will treatment of nerve, muscle pain and injury repair was be required to confirm and clarify these effects. Until such developed clinically using the osteopath’s two channel, research is done no claims can be or are made by the condition and tissue treatment paradigm and has been authors for the specific effects of frequencies on biolog- taught as Frequency Specific Microcurrent (FSM) since 1997 ical tissues or conditions. Clinical research, such as this (McMakin, 1998; McMakin, 2004; McMakin et al., 2005). paper, may report the observed and reported effects in a research setting of certain frequency combinations The technique requires use of any microcurrent device that without making specific claims for the frequencies used. can provide a different frequency on each of two channels Fortunately, medicine is pragmatic and it is not uncommon using a ramped square wave and alternating pulsed direct for apparently effective medications, such as aspirin, to current. The devices used in this study are calibrated by the be used for many years before the mechanism is manufacturer (Precision Microcurrent, Newberg, Oregon, understood. USA) and the company standards require that the frequencies be accurate to within 0.5 Hz on both channels. Frequencies on Methods one channel are thought to be effective in neutralizing specific conditions such as hemorrhage, fibrosis, scar tissue, mineral Participants deposits, histamine, and acute and chronic inflammation. These frequencies are combined with frequencies on a second Following the posting of an advertisement on the student channel thought to be specific for muscles, fascia, tendons, notice board at the National Training Centre (NTC) in Dublin, nerves and arteries and other tissues (McMakin, 2004). Ireland, forty-four students volunteered to participate in the

The efficacy of FSM therapy on DOMS 275 study. 18 male and 17 female students (mean age 32 Æ 4.2 themselves with the equipment. Participants were then years) were selected from these volunteers to take part in instructed to perform five sets of 15 maximal eccentric the study. Each of the participants had one of their legs contractions, with a 1-min rest between each set. assigned to a treatment group, while the opposite leg was assigned to a control group. The nomination of the partici- Post-exercise, one of their legs, randomly chosen, pants’ leg (left or right) as treatment or control was underwent a 20-min FSM programme and the other leg was randomized by the toss of a coin. not treated. The frequencies delivered in the programme were chosen from a list provided by Frequency Specific Participants were required to meet the following inclu- Seminars, Inc. (Vancouver, Washington, USA) and are sion and exclusion criteria to be eligible for the study. thought to be specific for tissues and conditions. The channel A frequency values that were used in this study Inclusion were chosen because they were thought to be specific to Participants were: some of the main pathologies induced by DOMS, while the channel B frequency values that were used were chosen 1) aged between 20 and 40 years; because they were thought to be specific to some of the 2) healthy and recreationally active; main soft tissues that are affected by DOMS. 18 Hz on 3) required complete a health screening questionnaire channel A was combined with 62 Hz on channel B for 4 min. 124 Hz on channel A was combined with 62 Hz, 142 Hz and prior to the study; 191 Hz on channel B for 1 min each. 40 Hz on channel A was 4) required to give written consent. combined with 116 Hz on channel B for 4 min. 40 Hz on channel A was combined with 62 Hz, 142 Hz and 191 Hz on Exclusion channel B for 2 min each. 49 Hz on channel A was combined Potential participants were excluded if they were: with 62 Hz, 142 Hz and 191 Hz on channel B for 1 min each. The intensity was set at 200 mA and the waveslope was set 1) engaged in resistance training or eccentrically biased at 10 for the entire 20-min programme. exercises for the lower body three months prior to the study; Procedure for seated leg curl 2) suffering from unstable cardiovascular or pulmonary Participants were asked to sit into a Pulse Fitnessâ leg curl conditions or diseases; machine and align the knee joint with the axis of the machine. The seat was then set so that their backs made 3) suffering from any pain or injury in the legs or other full contact with the back rest and to ensure that the health problems; posterior aspect of the knee joint was positioned at the edge of the leg curl seat. Starting in full leg extension, 4) pregnant. their ankles were dorsi flexed and placed on the rollers with the feet no wider than hip distance apart. Subjects Participants received a participant information sheet were asked to hold the side handles for support. The two weeks before the study commenced and were given machine was set to allow for full range of movement three days to decide if they wanted to be involved in the (Figure 1). Subjects were instructed to curl the rollers research. The study was reviewed by the Ethics Committee downwards and backwards to full leg flexion (Figure 2) and of the School of Applied and Health Sciences, University of then slowly return the rollers to full leg extension. Male Chester, UK. A health screening questionnaire was participants began with a starting weight of 25 kg, completed by each of the participants on the day of the whereas female participants started with a weight of study to rule out any pathology that may have excluded 20 kg. Participants either performed 15 repetitions with them from taking part in the research. Participants were their starting weight or continuous repetitions until they asked not to massage, stretch or treat the hamstring could no longer push or resist the weight. When partici- muscles in any way and to refrain from NSAIDs or supple- pants could no longer push or resist the weight, the weight ments until the final set of data was completed. Massage, was reduced by 5 kg and the protocol continued either to stretching, NSAIDs and supplements are common practices fatigue or until the fifteen repetitions were completed. that exist for the treatment of DOMS and may therefore Participants were verbally encouraged to exert maximal have affected the final results. resistance in the upward (eccentric) phase of the move- ment. To ensure consistency, participants were instructed Once the students agreed to participate in the study and to control the lifting velocity of the rollers by counting had given written consent a phone call was made to each from one to five from the beginning to the end range of the participant to confirm times and dates and also reconfirm eccentric action. inclusion criteria. During this phone conversation partici- pants were verbally instructed to drink at least 2 l of water Procedure for FSM treatment in the 2 h prior to their allocated time for participation in the study. During the warm-up and training session, Post-exercise, participants were instructed to lie in the a 500 ml bottle of water was provided to each participant prone position on a massage table. Each of the participants’ to prevent dehydration. legs were attached to separate FSM machines (Precision Microcurrent, Newberg, Oregon, USA) that were placed on Design either side of the table in alignment with the hamstring Following a 15-min warm-up on an ascent Pulse Fitnessâ treadmill, at a speed of 6 km/h, participants were instructed to perform five sub-maximal eccentric contractions on a Pulse Fitnessâ seated leg curl machine to familiarize

276 D. Curtis et al. Figure 1 Eccentric end range on leg curl machine. Figure 3 Subject position for FSM treatment. muscles and positioned so that the patient could not see The VAS has been shown to be a valid and reliable the front panel of the device or determine which machine measurement for determining the intensity of human pain, was turned on (Figure 3). As DOMS was induced in only the it is minimally intrusive and is easily and quickly adminis- hamstring muscle group, the current was directed only tered (Lee and Kieckhefer, 1989; Mattacola et al., 1997). through the soft tissues in this muscle group. The positive leads from the device were attached to graphite gloves that Statistical analysis were wrapped in wet towels and placed on the upper portion of the participants’ thighs. The negative leads were As the VAS falls into the ratio level of measurement (Myles attached to graphite gloves that were wrapped in wet et al., 1999), parametric tests were conducted to investi- towels and placed below the participants’ knees. This gate significant differences within and between the groups. allowed the current to flow between the two leads through Changes in the VAS within the groups were analysed via the soft tissues of the treated leg. One of the machines was a One Way repeated measures ANOVA and post hoc analysis turned off providing the sham treatment and the volume on utilising multiple paired t-tests tests. Differences between the working machine was turned down. the groups were investigated using multiple Independent t-tests, one at each time point (baseline, 24, 48 and 72 h). Rated soreness and tenderness were evaluated at Normality was assessed and confirmed prior to each test via baseline and 24, 48 and 72 h post-exercise using a visual the Shapiro Wilk statistic and data are presented as analogue scale (VAS). The VAS consists of a 10 cm horizontal mean Æ standard deviation (SD). All data were analysed line with the two end points labeled 0 (no pain) to 10 (worst using SPSS for Windows (Version 14.0) and significance was soreness ever) (Huskinson, 1974; Joyce et al., 1975). set at the 0.05 level. A post hoc sample size calculation Participants were asked to make a vertical slash across the based on the data from this study revealed an effect size 10 cm line that corresponded to the level of pain intensity 0.08. Based on a significance level of 0.05, being a two between the limits of no pain felt (left end of line) and tailed test with 80%, power, this provided a sample size of worst soreness ever (right end of line). A blank scale was 26 participants in each group. used each time to avoid bias from previous measurements. Results Perceived muscle soreness Figure 2 Concentric end range on leg curl machine. The baseline values for perceived muscle soreness before exercise as assessed by the VAS (Table 1) for each group revealed no significant difference (p Z 1.000). This indi- cated that the groups had no prior muscle pain and understood how to use the scale correctly. Once each group had undergone the exercise regime to induce the muscle damage the ratings on the VAS signifi- cantly increased. This was observed in both groups with the non-treatment group increasing from zero at baseline to 5.2 Æ 1.3 at 24 h (p Z 0.0005) and the treatment group increasing from zero to 1.3 Æ 1.0 (p Z 0.0005). This signif- icant increase demonstrated that the exercise regime had worked at inducing muscle damage. It can also be seen that

The efficacy of FSM therapy on DOMS 277 Table 1 Perceived muscle soreness at baseline, 24, 48 20 min of FSM therapy compared to sham treatment. It was and 72 h for each treatment. hypothesized that FSM therapy would offer significant protection from post-exercise muscle soreness. Baseline 24 h 48 h 72 h The participants were blinded to which leg was being Treatment 0Æ0 1.3 Æ 1.0a 1.2 Æ 1.1a 0.7 Æ 0.6 treated because they could not see the machine and 5.2 Æ 1.3a 7.0 Æ 1.1a 4.0 Æ 1.6a because the current is subsensory. This reduced the possi- Non-treatment 0 Æ 0 bility of a placebo effect while the treatment was been 0.0005 0.0005 0.0005 given. However it should be acknowledged that by using the p Value (between 1.000 participant’s opposite leg as a control, it is likely that participants could have guessed quite quickly (probably groups) within hours of the treatment been given) which leg had been treated and which leg had not. As initial improve- N.B.: Results presented as mean Æ SD. ments in one leg may have had them guessing which leg had a Significant difference from baseline VAS score within each been treated, this would have meant that they were no longer blinded. group (p < 0.05). The use of graphite gloves wrapped in wet towels as the non-treatment group reported a significantly greater conductors was assumed to prevent the reduction in (p Z 0.0005) increase in perceived muscle soreness than voltage seen in Petrovsky’s measurements of graphite the treatment group. electrodes in TENS devices (Petrofsky et al., 2006). The use of wet towels also ensures that the current will remain A similar trend existed between 24 and 48 h with both subsensory since graphite electrodes against dry skin may groups demonstrating significant increases in perceived make even microamperage current sensible (Grimnes, muscle soreness (non-treatment p Z 0.0005; treatment 2008). group p Z 0.001). The perceived muscle soreness in the treatment group (1.2 Æ 1.1) was significantly less The method selected for inducing DOMS was deemed (p Z 0.0005) than in the non-treatment group (7.0 Æ 1.1). successful, as the data collected at 24, 48 and 72 h post- exercise differed significantly from the data collected at At 72 h the perceived muscle soreness in the treatment baseline. This pattern was similar to previous literature group had almost retuned to baseline levels (0.7 Æ 0.6) related to the time course and intensity of DOMS (Cleak and indicating an absence of any pain although the scores in the Eston, 1992; Howell et al., 1993; Nosaka and Clarkson, non-treatment group remained elevated (4.0 Æ 1.6) and 1996) and suggests that the methodology was appropriate significantly higher than baseline values (p Z 0.0005). to create DOMS. The VAS was selected as a measurement A summary of the results is presented in Figure 4. for perceived pain because it is patient friendly, low cost, easy to administer and not too time consuming. However, Discussion although the VAS is a well established, valid and reliable measurement for determining the intensity of pain, the The aim of this investigation was to compare the effects of authors acknowledge the possibility that variations may FSM therapy versus sham at 24, 48 and 72 h post-exercise. have occurred in participant responses during the data Allen et al. (1999) found that 20 min of single channel collection period. As participants were required to inde- microcurrent therapy that was not frequency specific pendently perceive their soreness at four different time compared to sham treatment was not effective in reducing points over a 72 h period, it should be noted that how they pain or increasing range of motion 24, 48 and 72 h after perceived their pain may have altered over the 72 h, DOMS induction in the biceps muscle. Clinical evidence depending on how they were being affected by their pain at suggested that dual channel microcurrent using different that specific moment. Also, individual tolerance for pain frequency combinations was very effective in reducing the can vary greatly from person to person. pain associated with muscle trauma and DOMS providing the motivation for conducting this study. This study was Acknowledgement is also given to the possibility that undertaken to provide a controlled trial evaluation of reciprocal facilitation may have had an effect on the overall findings. The FSM units were set up so that the Visual Analogue Scale (VAS) score 10 treated leg had current flowing between the positive and negative leads while the untreated leg had no current 9 Treatment Leg delivered as the machine on this leg was turned off. Non Treatment Leg Although there is no evidence in any electrical theory or practice that suggests that the current will migrate to other 8 areas outside the area between the two leads, because of the interconnectedness of the body there is no way of 7 knowing what effect, if any, the FSM treatment had on the control leg. 6 No attempt was made in the present study to control for 5 the effects of environmental electromagnetic influences (‘‘electronic smog’’) since such influences would have had 4 equivalent effects on both the treated and untreated leg. In future studies in which there is a sham control group 3 being treated at another time and setting than the 2 1 0 24hrs 48hrs 72hrs Baseline Time (hrs) Figure 4 VAS scores for TL and NTL over a period of 72 h. N.B.: Results expressed as mean Æ SD.

278 D. Curtis et al. treatment group consideration may need to be made for Clarkson, P.M., Byrnes, W.C., McCormack, K.M., Turcotte, L.P., the possible effects of extraneous electrical interference. White, J.S., 1986. Muscle soreness and serum creatine kinase activity following isometric, eccentric and concentric exercise. A possible limitation to the study was that only one International Journal of Sports Medicine 7, 152e155. marker, perceived muscle soreness, was used to assess muscle damage. Other markers such as maximal isometric Cleak, M.J., Eston, R., 1992. Muscle soreness, swelling, stiffness strength, range of motion, angle of peak torque, leg and strength loss after intense eccentric exercise. British circumference and plasma creatine kinase levels were not Journal of Sports Medicine 26, 267e272. assessed. Connolly, D.A.J., Sayers, S.P., McHugh, M.P., 2003. Treatment and A suggestion for future research would be to use prevention of delayed onset muscle soreness. Journal of multiple markers as an assessment for DOMS. Future Strength and Conditioning Research 17, 197e208. studies of FSM in DOMS or any condition may include a methodology that includes separate sham and active Cornwell, A., Nelson, A.G., Sidaway, B., 2002. Acute effects of treatment groups and will also allow for double blinding stretching on the neuromechanical properties of the triceps the subjects and the experimenters. Even though the surae muscle group. European Journal of Applied Physiology 86, patients turned in their pain scores without any further 428e434. contact with the un-blinded experimenter, the possibility of some experimental error due to lack of experimenter Craig, J.A., Cunningham, M.B., Walsh, D.M., Baxter, G.D., blinding cannot be excluded. To ensure double blinding it Allen, J.M., 1996. 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Journal of Bodywork & Movement Therapies (2010) 14, 280e286 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt INVITED REVIEW The biomechanics of spinal manipulation Walter Herzog, PhD* Faculty of Kinesiology, University of Calgary, Calgary, AB T2N 1N4, Canada Received 30 November 2009; received in revised form 19 March 2010; accepted 29 March 2010 KEYWORDS Summary Biomechanics is the science that deals with the external and internal forces acting Spinal biomechanics; on biological systems and the effects produced by these forces. Here, we describe the forces Chiropractic; exerted by chiropractors on patients during high-speed, low-amplitude manipulations of the Manipulative therapy; spine and the physiological responses produced by the treatments. The external forces were Vertebral artery; found to vary greatly among clinicians and locations of treatment on the spine. Spinal manip- Stroke; ulative treatments produced reflex responses far from the treatment site, caused movements Internal forces of vertebral bodies in the “para-physiological” zone, and were associated with cavitation of facet joints. Stresses and strains on the vertebral artery during chiropractic spinal manipula- tion of the neck were always much smaller than those produced during passive range of motion testing and diagnostic procedures. ª 2010 Elsevier Ltd. All rights reserved. Introduction Herzog et al., 1993c; Meal and Scott, 1986; Miereau et al., 1988; Reggars, 1996). Despite the acknowledged nature of Chiropractic spinal manipulations are mechanical events. mechanical force application as a treatment modality Clinicians exert a force of specific magnitude in (Triano, 2000), and the accepted idea that HVLA treat- a controlled direction to a target site, typically on the ments produce mechanical effects (e.g., Triano and spine. High-velocity, low-amplitude (HVLA) manipulations Schultz, 1997) at the treatment site, little is known about are more frequently used by chiropractors than other the biomechanics of spinal manipulation. treatment modalities, and they are of special interest, as force magnitudes and the rates of force application are Biomechanics is the science that deals with the external high. HVLA treatments cause deformations of the spine and and internal forces acting on biological systems and the surrounding soft tissues and often elicit a cracking sound associated effects produced by these forces. Here, I will that has been identified as cavitation of spinal facet joints attempt to briefly review what is known about the external (Cascioli et al., 2003; Conway et al., 1993; Haas, 1990; forces applied by chiropractors during HVLA manipulative treatments on patients, discuss selected effects of these * Tel.: þ1 403 220 8525; fax: þ1 403 220 2070. forces, and then focus specifically on an increasingly E-mail address: [email protected] important topic of internal force transmission: the stresses and strains experienced by the vertebral artery during HVLA neck manipulations. 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.03.004

The biomechanics of spinal manipulation 281 External forces applied by chiropractors during 2. The external forces applied during HVLA treatments HVLA spinal manipulations vary dramatically across clinicians Wood and Adams (1984) and Adams and Wood (1984) were the These results suggest that local mechanical conditions first to quantify the forces exerted by chiropractors during might affect the amount of force applied by clinicians. For spinal manipulation. Their work involved application of example, all clinicians apply substantially less force for a HVLA manipulative thrust to a treatment dummy. Although treatments of the cervical spine compared to the thoracic a classic piece, the limitation of their work was that treat- spine (Herzog et al., 1993a). The reasons for this observa- ments were not performed on human subjects, thereby tion are not clear, although it makes intuitive sense that bringing into question the validity of the results for a clinical a relatively mobile part of the spine (cervical spine) would setting. Hessel et al. (1990) were the first to directly measure be treated differently than a relatively stiff segment of the the forces applied by chiropractors on human subjects for spine (thoracic spine). The amount of force applied to a variety of different treatment modalities. They used a thin, patients by a given chiropractor varies dramatically as flexible pressure pad that was placed under the thrusting indicated above (Conway et al., 1993; Herzog, 1991; Herzog hand of the clinician to measure the forces applied to the et al., 1993a,b; Kawchuk et al., 1992; Triano, 2000). target site on patients. This pioneering work was followed by Clinicians, who tend to adjust with great force, do so a series of similar studies, all aimed at obtaining information consistently and clinicians who use little force do so on the force-time histories of HVLA spinal manipulations consistently as well. Some “soft” adjusting clinicians will (Conway et al., 1993; Herzog et al., 1993a,b; Kawchuk et al., not even reach the preload forces of some of the “hard” 1992; Kawchuk and Herzog, 1993; Triano and Schultz, 1997; adjusting clinicians, thus it is questionable whether force Triano, 2000; Triano and Schultz, 1990). magnitude is an important variable in the application of a HVLA chiropractic treatment. The thrust times (Figure 1) When combining the results of selected force parameters were approximately 100 ms for cervical and 150 ms for during HSLA treatments, the following results emerged: Peak thoracic and lumbar spine treatments. Since the peak force and Preload forces (Figure 1) varied dramatically depending magnitudes vary substantially and thrust times are similar on the location of treatment application (Herzog et al., across practitioners, it follows that the rate of force 1993a). Peak forces for neck manipulations (on average application varies substantially too (Table 1), and thus is about 100N) were substantially smaller than the peak forces likely not a relevant factor for the success of a chiropractic applied during thoracic and lumbar spine and sacroiliac joint treatment. In the absence of consistent force-time histories treatments ((all about 400N (Table 1)). Furthermore, the for chiropractic manipulations, one may conclude that the treatment forces varied dramatically between clinicians, detailed force magnitude might not be an important char- and in our laboratory we have measured peak forces ranging acteristic for the success of a treatment, while the thrust from 200N to 1600N (Herzog et al., 1993a), which is an eight- direction might be. Unfortunately, thrust force directions fold difference. Figure 2 shows a random sample of ten have not been studied systematically, thus this proposition female and ten male chiropractors performing treatments on must be considered a hypothesis at present. a small number of subjects (Forand et al., 2004). Interest- ingly, the average forces between males and females are Selected effects of HVLA spinal manipulative about the same ((Forand et al., 2004) (Figure 3)), and so are treatments the average forces between novice and experienced chiro- practors (results not shown). There are many scientific and clinical publications adver- tising the efficacy of HVLA spinal manipulation. However, From these direct measurements of the external forces the number of publications investigating mechanical, applied by clinicians on patients, the following conclusions physiological or neurological effects produced by such seem warranted: treatments is small, and a direct link between the treat- ment forces, the effects produced by these forces, and the 1. The external forces applied during HVLA treatments beneficial effects created are almost completely missing. vary dramatically depending on the treatment site Here, I would like to discuss just some selected effects of HSLA treatments that have been debated intensely. Peak force Δf Relative movements of the target segment in the para- physiological zone Preload One of the premises of HVLA spinal manipulative treat- force ments has been that the target joint (typically a spinal facet joint) is brought to its end range of motion by the Preload Thrust Resolution application of a directed and well described preload force phase phase phase ((Triano, 2000) (Figure 1)). Following application of the preload force, a force thrust is given that represents the time, Δt actual treatment, and the idea has been that this thrust force takes the (facet) joint beyond its regular end range of Figure 1 Definitions for the preload force, peak force and motion into the para-physiological movement zone. Of thrust time. course, when applying a thrust, every clinician can feel the

282 Cervical spine Thoracic spine Sacroiliac joint W. Herzog Table 1 27 139 88 Activator instrument 107 399 323 22 Preload forces (N) 150 41 Peak forces (N) 81 2660 32 Thrust times (ms) 1321 Rate of force application (n/s) 1281 Force [N] Forces on T4 by men Forces on T4 by women Time Force [N] 600 [ms] 900 Time 800 100 150 200 250 300 350 400 450 [ms] 800 700 700 600 600 500 500 400 400 300 300 200 200 100 100 0 0 0 100 200 300 400 500 0 50 Figure 2 Force-time histories of thoracic spinal manipulations performed by 10 male (left) and 10 female (right) chiropractors. Note the vast difference in force between clinicians. deformation of the spine under the thrusting hand, Reflex responses associated with HVLA spinal however, it was not possible to decide if part of this manipulative treatments movement arose from the target joint, or if the entire Spinal manipulative treatments, although aimed primarily at deformation was caused by joints neighbouring the target restoring joint (including facet joint) mobility and function, joint that were not brought to the end range of motion by had been thought to produce reflex responses in the muscles preload force application. In order to study this question in underlying the treatment area. In order to test this hypoth- detail, we inserted bone pins into three adjacent vertebral esis, we measured the surface electromyogram (EMG) of bodies of the thoracic spine in human cadavers, and then back muscles at the treatment site. Typically, EMG activity calculated the relative movements of the vertebral bodies was measured within 200e400 ms following the onset of the during the preload and the thrust phase of HVLA anterior to treatment thrust (Herzog et al., 1995). Muscle activity dis- posterior thrusts to the transverse process of a thoracic appeared following the treatment thrust, and was not vertebra (Ga´l et al., 1994, 1997a,b). There was substantial observed during preload application, suggesting that this was relative movement of the target and adjacent vertebrae indeed a reflex response, and that the reflex response was during the preload phase, and there was further relative associated with the speed of force application (Figure 5). movement of target and adjacent vertebrae during the thrust phase of the manipulative treatment (Figure 4). This P-A translation [mm] result illustrates that there is movement of the target 3 (facet) joint during thrust application beyond the move- ment achieved by the preload force (Ga´l et al., 1994, 0 1997a,b). -3 T10 Force [N] -6 Sag rotation[deg] start of T11 600 2 thrust T10 1 500 0 T11 1000 400 -1 250 500 750 Time [ms] 300 0 200 Figure 4 Posterier-Anterior translation and sagittal rotation of thoracic vertebrae T10 and T11 during the thrust phase of 100 a thoracic spinal manipulation. Note the approximate 2 degree difference in sagittal rotation during the treatment thrust 0 Time indicating vertebral movement in the “paraphysiological” 0 100 200 300 400 500 600 [ms] zone. Figure 3 Mean force-time histories of thoracic spinal manipulations across 10 male (dashed line) and 10 female (solid line) chiropractors.

The biomechanics of spinal manipulation 283 Figure 5 Force-time and EMG-time histories measured Figure 7 EMG-time history for patient with spastic activation during a thoracic spinal manipulation. Note the delayed onset of the back musculature. The arrow indicates the time of the of the EMG response suggesting a reflex activation of the treatment thrust. Note the release of spasticity and EMG muscles caused by the treatment thrust. activation following the treatment thrust. When applying a very short and precisely focused manipulative treatments elicit a reflex response that is not treatment force (using an activator instrument), a reflex necessarily localized, and affects locations that are remote response was elicited that had the visual shape of a single from the actual treatment site. motor unit action potential. Furthermore, its delay from the onset of force application (50e100 ms) was such that it Role of the audible release was suggested to be a muscle spindle reflex pathway The audible release, or cracking sound, is an indicator of (Herzog et al., 1995). Reflex responses produced by acti- a successful treatment for many chiropractors, so much so, vator application were always restricted to the vicinity of that when an audible release does not occur, many clini- treatment application. For HVLA spinal manipulations, the cians will immediately apply a second or even third treat- reflex responses were not restricted to the immediate ment thrust. The role of the audible release has been treatment area, but formed characteristic activation a matter of intense debate (Brodeur, 1995; Sandoz, 1969) patterns that depended on the site of force application and one of the roles associated with the audible release has ((Herzog et al., 1995, 1999) (Figure 6)). Finally, patients been the idea that it causes the reflex responses discussed presenting with spastic muscles showed EMG activity in the above. However, there are a variety of observations that do muscles of the treatment area. When subjected to a HVLA not fit that idea. For example, every HVLA treatment thrust treatment thrust, the muscles relaxed and EMG activity was we have recorded was associated with an electromyo- abolished in some but not all of the patients (Herzog, 2000) graphical response, but not all of these caused cavitation (Figure 7). It is not known why treatments produced a relief (Conway et al., 1993). That is, reflex responses were of muscle spasticity in some patients but not in others. We observed in the absence of cavitation. However, in order to conclude from these observations that HVLA spinal address this question directly, we asked chiropractors to apply treatment forces at the exact location and exact direction as they would for a normal manipulative thrust, Figure 6 EMG-time histories of 16 channels collected before and after spinal manipulation (left). The vertical line indicates the time of onset of the treatment thrust. Note the reflex activations elicited by the thrust for various EMG channels. Approximate placements of the EMG electrodes (open circles) and area of reflex response (enclosed areas 100% response, 80% response and 50% response for smallest, middle and largest area, respectively) for treatments of the left (left) and right (right) sacroiliac joint (filled circle).

284 W. Herzog Distance [mm] neutral head position 15.5 15 14.5 14 13.5 fully flexed head position 13 04 8 12 16 Time [s] Figure 8 Stretch-shortening time history for a vertebral artery segment during neck flexion. but to do so very slowly. With a slow force application, an Figure 10 Mean force-time histories of spinal manipulations audible release can be elicited, but this release is not of the neck averaged across 15 patients (normal) and 15 associated with a corresponding EMG response (Conway measurements from cadaveric specimens (cadaver). Note the et al., 1987), suggesting that the audible release is not force-time histories are virtually identical suggesting thrust responsible for the observed reflex responses during HVLA treatment forces given to patients and in our cadaver work are chiropractic spinal manipulations. very similar. Internal stresses and strains during HSLA have involved the vertebrobasilar system, specifically the manipulative treatments of the cervical spine cephalad/distal loop of the vertebral artery, as it exits the foramen transversarium of C1 (Haldeman et al., 1999). One major issue with the use of HVLA spinal manipulation is Because of the unique configuration of the vertebral artery, its safety, especially with respect to neck manipulation and it has been suggested that it experiences considerable the risk of stroke. Estimates of the risk of stroke vary from stretch and associated tissue stress during extension and 1:5000 to 1:10 million (Cote et al., 1996; Frisoni and Anzola, rotation of the neck which may lead to occlusion and 1991; Haldeman et al., 1999, 2002; Hurwitz et al., 1996; damage to the arterial walls (Terrett and Kleynhans, 1980). Lee et al., 1995). Although the proposed risk is extremely Consequently, it has been hypothesized that HVLA spinal small, the serious and irreversible nature of vascular acci- manipulation may also lead to stretch-induced vertebral dents makes this an important issue (Terrett and Kleynhans, artery damage, although our biomechanical evidence does 1980). The earliest documented reports of fatal vascular not support this view (Herzog and Symons, 2002; Symons accidents following spinal manipulation can be traced back et al., 2002). to the 1930s (Foster vs Thornton, 1934), and 1940s (Pratt- Thomas and Beyer, 1947). The majority of these cases Measurements of internal stresses of soft tissues caused by spinal manipulation are rare, and the only documented reports of such measurements on the verte- bral artery are those by Herzog and Symons (2002), and Length [mm] C2/C3 17 16 19.8 C3/C4 19.6 19.4 19.2 Time 0 10 20 30 40 50 [s] Figure 9 Stretch-shortening time history for a vertebral Figure 11 Stretch-shortening-time history for vertebral artery segment during a neck manipulative treatment. The artery segments C2/C3 (top) and C3/C4 (bottom) for a rota- onset and end of the thrust phase of the treatment is indicated tional range of motion test. Note that the two segments show by the arrows. opposite behaviour: C2/C3 is stretched during neck rotation (as one would expect based on the anatomy) while segment C3/C4 shortens.

The biomechanics of spinal manipulation 285 Force [N] forces applied by the chiropractors during spinal manip- 150 ulations were similar to those administered to patients, 100 thus we may assume that the external mechanics were 50 similar (Figure 10). The peak strain (elongation form 0 neutral) that was measured for any of the 176 treatments procedures was 2.1% while strains for diagnostic proce- Length [mm] dures were in excess of 10% (flexion 10.1%, rotation 13.0% 16.5 and Houle’s test 9.4%), suggesting, in agreement with our 16.4 previous studies, that strains during HVLA cervical spinal 16.3 manipulations were much smaller than those produced during diagnostic procedures. 21.4 21.2 In contrast to our previous work, however, the strains 21.0 measured in adjacent vertebral artery segments were not always intuitively apparent. For example, we found the 0123 repeatable (across multiple measurements and across Time [s] clinicians) result that for some diagnostic and treatment procedures, one vertebral artery segment shortened Figure 12 Stretch-shortening-time history for vertebral while the adjacent segment was stretched. For example, artery segments C2/C3 (top) and C3/C4 (bottom) for a chiro- in Figure 11, we show the right vertebral artery segments practic neck manipulation. Note that the two segments show C2/C3 and C3/C4 for a left rotation of the neck. Text- opposite behaviour: C2/C3 is stretched during neck rotation (as book anatomical considerations would suggest that the one would expect based on the anatomy) while segment C3/C4 vertebral artery segments should be stretched, which was shortens. observed for the C2/C3 segment, but not the C3/C4 segment which shortened consistently for both chiropractors and for Symons et al. (2002). In these studies, the strains of the all three repeat measurements. Similarly, these same vertebral artery were measured from the neutral length segments behaved opposite during a HVLA neck manipula- (head and neck in the neutral position) for a variety of tion (Figure 12). Again, this result was observed for all range of motion and diagnostic testing, as well as for three repeat measurements of and both clinicians. different HVLA cervical spine manipulations across all Combined, the results of this study suggest that spinal levels performed ipsi- and contralaterally to the target manipulative treatments produce stretches of the verte- vertebral artery (Figures 8 and 9). They then excised the bral artery that are much smaller than those that are vertebral arteries carefully from the cadaveric specimens produced during normal everyday movements, and thus used for these studies and measured the corresponding they appear harmless. However, textbook anatomical forces experienced by the vertebral arteries for the considerations do not necessarily allow prediction of the strains (elongations) measured during the diagnostic and direction of strain in different vertebral artery segments. clinical procedures. Some non-intuitive behaviour was observed that cannot be explained at present but might be related to the intricate Symons et al. (2002) and Herzog and Symons (2002) coupled motions of vertebral bodies and the complex found that stretches to the vertebral artery during neck fixation of the vertebral artery to the transverse foramen manipulative procedures (6% for the cephalad/distal of C1eC6. segment) were much smaller than the stretches produced during range of motion and diagnostic testing (13%). They In summary, there is little knowledge of the transmission also found that the elongations produced during HVLA of stresses and strains across hard and soft tissues during spinal manipulations did not produce any tensile forces in spinal manipulation. This is a vast field of investigation that the vertebral artery, suggesting that the vertebral arteries needs careful attention so that the detailed mechanics of were slack when the head and neck were in the neutral HVLA treatments can be understood and possible risks of position and that this slack was not fully taken up during these procedures may be identified. spinal manipulative treatments. Therefore, spinal manipu- lation did not cause any tensile stress in the vertebral Acknowledgements arteries during the treatment procedures. The Canadian Chiropractic Research Foundation, Canadian However, the studies by Symons et al. (2002) and Chiropractic Protective Association, The Alberta College Herzog and Symons (2002) had several limitations. Most and Association of Chiropractors. importantly, measurements were only made for two segments (cephalad to C1 and caudad to C6), forces References during the spinal manipulations were not measured and the vertebral arteries of the unembalmed cadavers were Adams, A.H., Wood, J., 1984. Comparison of forces used in devoid of fluid, thus possibly affecting their shape. In selected adjustments of the low back: A preliminary study. Res. order to overcome these limitations, we performed a pilot Forum 1, 5e9. study to measure the strains in the vertebral artery segments C1eC6 with the arteries filled with gel and Brodeur, R., 1995. The audible release associated with joint while measuring the forces applied by two chiropractors manipulation. Journal of Manipulative and Physiological Ther- during all diagnostic and treatment procedures. The apeutics 18, 155e164.

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Forces exerted during spinal manipulative therapy. sacral spinal manipulative therapy. Spine 22, 1955e1964. Spine 18, 1206e1212. Triano, J.J., 2000. The mechanics of spinal manipulation in Clinical Herzog, W., Conway, P.J.W., Zhang, Y.T., Ga´l, J., Guimaraes, A.C. Biomechanics of Spinal Manipulation. In: Herzog, W. (Ed.). S., 1995. Reflex responses associated with manipulative treat- Churchill-Livingstone, Philadelphia, PA, pp. 92e190. ments on the thoracic spine. Journal of Manipulative and Physiological Therapeutics 18, 233e236. Triano, J.J., Schultz, A.B., 1990. Cervical spine manipulation: applied loads, motions and myoelectric responses. Proc.14th Herzog, W., Kawchuk, G.N., Conway, P.J.W., 1993b. Relationship Mtg.Amer.Soc.Biomech. 14, 187e188. between preload and peak forces during spinal manipulative treatments. Journal of the Neuromusculoskeletal System 1 (2), Wood, J., Adams, A.H., 1984. Forces used in selected chiropractic 52e58. adjustments of the low back: A preliminary study. The Research Forum,. Palmer College of Chiropractic 1, 16e23.

Journal of Bodywork & Movement Therapies (2010) 14, 287e288 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt BOOK REVIEW arranged into a systematic approach that could be imple- mented immediately and used along with other clinical Frank C, Lardner R, Page P. The assessment and techniques.’’ treatment of muscular imbalance e The Janda Approach Hardback $64, Human Kinetics, Champlain, IL USA, An important concept presented well is the interplay ISBN-13:9780736074001 between injuries and muscle imbalance. Janda’s ‘‘muscle imbalance continuum’’ describes tissue damage, pain and Vladimir Janda, MD, DSc (1923e2002) influenced genera- altered gait as potential causes of imbalance, while tions of practitioners spanning many disciplines. This emphasizing that the reverse can also exist. evidence-based book is written by three physical thera- pists, all of whom worked with Janda. It emphasizes various The book’s wide range of topics associated with neuro- assessment and treatment procedures based on the exis- muscular function is as impressive as the therapeutic tence of muscle imbalance e the combination of abnormal options offered e from acupuncture and trigger point muscle inhibition (‘‘weakness’’) and hypertonic muscles therapy to the works of Florence and Henry Kendall, and (tightness). This would make a useful addition to every George Goodheart. All the topics are well researched with clinician’s library e especially physical therapists, chiro- 40 pages of references. practors, osteopaths and all those using hands-on therapies. Janda’s view of muscle imbalance is presented well e the combination of tight/short muscles and weak ones, The book is divided into four parts: mediated by the central nervous system with important stimuli from the peripheral nervous system (in particular, - The Scientific Basis of Muscle Imbalance includes proprioception from joints). While the book references chapters on the structural and functional approaches to Sherrington, Janda often deviated in his approach by muscle imbalance, and the ‘‘pathomechanics’’ of pain. treating the tightness as the primary muscle problem rather than the weakness. - Functional Evaluation of Muscle Imbalance discusses posture, gait, muscle length testing and soft tissue The book’s side-by-side comparison is made between assessment. Janda’s clinical approach to muscle imbalance and that of physical therapist Dr. Shirley Sahrmann. However, to help - Treatment of Muscle Imbalance Syndromes describes address the common debate among clinicians regarding the restoration of muscle balance and sensorimotor which side of muscle imbalance is primary, it might have training. been useful to also present the different perspectives adopted by physical therapist Diane Damiano (Damiano - Clinical Syndromes presents four common areas of et al., 1995; Wiley and Damiano, 1998) or George Good- musculoskeletal pain disorders: cervical, upper heart DC (Walther, 2000; Goodheart, 1964) whose clinical extremity, lumbar and lower extremity. work focused mainly on muscle weakness. The interpre- tation of Sherrington’s law of reciprocal inhibition Like many pioneers, Janda’s terminology and ideas appears to be the difference. The Janda Approach does evolved apart from the traditional clinical sciences. The recommend using muscle testing in certain cases, and author’s state: ‘‘There are several schools of thought suggests, at times, treating the weakness side of muscle regarding muscle imbalance. Each approach uses imbalance. a different paradigm as its basis. Vladimir Janda’s paradigm was based on his background as a neurologist and The Janda Approach describes a full spectrum of muscle physiotherapist.’’ imbalance e from relatively common problems associated with aches and pains, including chronic low back syndrome, The Janda Approach provides more than an introduction to the more serious mechanical distortions in brain and of his material for practitioners and students. In the spinal cord injured patients. An important tenet is worded preface the author’s state: ‘‘We wanted to write a text that well by the authors: ‘‘[Janda] based his approach on his both preserves and supports Janda’s teaching. This book is observations that patients with chronic low back pain only a tool for everyday practitioners; it is not meant to exhibit the same patterns of muscle tightness and weakness address all chronic pain syndromes or even all muscle that patients with upper motor neuron lesions such as imbalance syndromes. Instead, we wanted to provide cerebral palsy exhibit, albeit to a much smaller degree.’’ practical, relevant, and evidence-based information doi:10.1016/j.jbmt.2009.11.003

288 Book Review Janda believed that 80% of patient’s with low back pain help activate/retrain the motor system, improve postural could be shown to have minimal brain dysfunction. control and optimize gait. In our symptom-oriented healthcare world, it was The last part of the book contains four chapters, each refreshing to read Janda’s philosophy that the source of representing a common clinical syndrome by region: pain is rarely the cause. The book dedicates a chapter to cervical, upper extremity, lumbar and lower extremity. this concept of interactions between the skeleton, muscles Case histories offer good examples, but they don’t replace and nervous system, and the process of cause and effect. an effective assessment and the potential for a wide variety While the authors describe Janda’s many clinical models, of therapeutic options e many of these are offered by The clinicians are well aware that patients typically deviate Janda Approach. from these patterns, creating their own unique neuromus- cular patterns. Despite this reviewer’s many years of study of Janda’s work, this book provided much new information and ideas, Like many chapters, the one on posture, balance and largely because the authors present the material so well. gait is excellent. However, despite writing his first book on muscle testing, The Janda Approach describes only a few Dr. Maffetone can be reached through his website (www. manual muscle tests, instead relying more on posture, gait, PhilMaffetone.com): [email protected] muscle length assessment and basic movement patterns to evaluate muscle imbalance. References Because Janda felt that manual therapy was not suffi- Damiano, D., Kelly, L., Vaughan, C., 1995. Effects of quadriceps cient by itself to successfully treat the neuromuscular femoris muscle strengthening on crouch gait in children with system, the authors discuss his sensorimotor training as an spastic diplegia. Phys Ther 75, 658e671. important aspect of patient care. Rather than traditional strength training, Janda used sensorimotor training to Goodheart Jr. G, 1964. Applied Kinesiology. Detroit: Privately promote whole-body neuromuscular activity with emphasis Published. on incorporating certain areas of the brain. These include gently increasing proprioception from the sole of the foot, Walther, D., 2000. Applied Kinesiology Synopsis, second ed. deep cervical musculature and the sacroiliac joint, as well Systems DC, Pueblo, CO. as vestibular balance training. These physical activities Wiley, M., Damiano, D., 1998. Lower-extremity strength profiles in spastic cerebral palsy. Dev Med Child Neurol 40, 100e107. Philip Maffetone

Journal of Bodywork & Movement Therapies (2010) 14, 289e293 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt PREVENTION & REHABILITATIONdEDITOR: WARRICK MCNEILL PREVENTION & REHABILITATION: EDITORIAL About prevention Warrick McNeill, MCSP, Associate Editor* United Kingdom What is prevention? poster points out that it is a myth that Health and Safety rules stop classroom experiments. The cartoon shows a rather sad About 4500 years ago, according to Chinese tradition, and teacher and pupils wearing safety goggles watching paint dry Fletcher (1988), the Yellow Emperor, Huang-di, only paid on a card propped up in a safety-glass cabinet. his physician’s retainer when he was well and stopped paying when he was not. ‘The wise people (the sages) did As a Physiotherapist I use the UK Health and Safety not treat those who were already ill; they instructed those Regulations on Display Screen Equipment (1992) (based on who were not yet ill.’ Preventative measures (nourishment, the relevant EC directives) in the part of my practice which rest, exercise and sleep) consisted of 4 of the 5 modes of involves ergonomically assessing staff at their computer treatment espoused at that time. workstation, but even then, I’m a second tier external consultant e only brought in when the staff member is Serge Gracovetsky, reports in an interview published on already reporting pain, and has usually already been seen YouTube, that he once, while suffering back pain, went to by the in-house assessors. Is my role ‘preventative’? see seven different Orthopaedic or Neuro Surgeons but received seven different diagnoses. Gracovetsky appears to Prevention, as a concept of health management, have applied a similar principle and didn’t pay any of them appears to be wasted on the young. The hubris and inde- to proceed with their suggested treatments. Four recom- structibility of youth becomes more glaring as one ages and mended surgery, three did not. He decided that the best becomes more risk adverse. The young appear not to listen course of action was to do nothing, but go to the Library to to sound advice, they do not appear to learn by others find out what he could about back pain. mistakes rather they seem to want to sustain the injury to discover that they need to avoid injuring themselves in the Have we then come very far in the intervening four first place. Being an Injury Prevention specialist working millennia? with the young might not possibly score highly on a job satisfaction questionnaire, but how much ‘prevention’ On the safetylit.org website, an online source of injury work actually occurs prior to first episode injuries? prevention literature, they state: ‘Injuries have causes e they don’t simply befall us from fate or bad luck. To prevent When my Physiotherapy colleagues discuss prevention it injuries it is necessary to have information about the factors is usually about preventing recurrence of the injury, so it is that contribute to their occurrence. With this information we after the fact of the original insult, and becomes part of may understand the options for prevention. Effective injury rehabilitation. prevention requires a multifaceted, multidisciplinary approach.’ It is also a very broad remit. Too broad perhaps? Mark Ford, a Pilates/Gyrotonic/Franklin Method Health and Safety Directives seem to be impinging on society instructor in Australia says, ‘To me rehabilitation and and the workplace. Enough so as to encourage the UK’s Health prevention can not be separated. Rehab is not complete if and Safety Executive to produce ‘Myth of the Month’ posters the client doesn’t understand causes, actions and conse- debunking ‘Great health and safety myths.’ November 2009s quences.’ (Ford, 2010). * Tel.: þ44 7973 122996. Chaitow (2010) says eloquently in a personal communi- E-mail address: [email protected] cation, ‘I work with a model in which dysfunction emerges from a background of failed adaptation (to overuse, misuse, abuse and disuse). In such a model prevention is seen to involve modifying or eliminating those stressors that can be 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.04.001

PREVENTION & REHABILITATIONdEDITOR: WARRICK MCNEILL 290 W. McNeill identified e so reducing adaptation demands bodywide, or available evidence; to put research outcomes into the locally. In addition, prevention entails enhancing func- clinical context; and even question the clinical utility tionality (bodywide and/or locally) so enabling the system of some findings or area to better cope with adaptation demands. Rehabil- (b) The evidence is pointing more towards deficiencies in itation of existing dysfunction involves a similar model of motor control being associated with spinal pain disor- care e with specifically focussed interventions and strate- ders and so, more beneficial programs should focus gies, as well as generalised ones (better posture, breathing, upon the quality of our patterns of movement control nutrition, habits of use etc). Prevention therefore only rather than the ubiquitous ‘strengthening’ and differs from rehabilitation by virtue of the context and the ‘stretching’ objectives’. (c) The practitioner needs to be cognisant of the fact that seemingly subtle changes in posturo-movement control So it appears, in the context of therapy and therapists, that are usually apparent before the onset of pain. These prevention and rehabilitation treatments or strategies could changes can tell us a lot about the potential or actual possibly be the same thing, but just be a question of timing, problems the patient may be/is experiencing and so before or after an incident (or injury provoking behaviour), this can also serve a certain predictive role e important that may itself be an original insult, second or third. for prevention programming. (d) The practitioner needs to appreciate ‘‘what are the Chronic low back pain more likely patterns of dysfunctional response going to be’’? While evidence is giving us more answers in this Exciting advances made in motor control and pain research area, at this point in time we need to rely more on our means that there is a diagnosis and management shift from clinical pattern recognition and therapeutic skills to a pathological and anatomical viewpoint to a dynamic provide the substance of more meaningful prevention systems approach according to Key (2010a). In the opening program. chapters of her recently published book, ‘Back Pain: A (e) In essence, effective programs of care e therapeutic movement problem.’ Key neatly summarises Waddell who and preventative, depend upon a balance between states that: only about 15% of patients with back pain show artful clinical practice informed by the knowledge that definite structural pathology, the relationship between science can offer.’ imaging and symptoms is weak, and in the absence of a diagnosis Health professionals may look to psychological In summary Key said she ‘is trying to get the message out reasons for their pain, therefore, there is no surprise that there that clients most probably need to work smarter not the ‘biopsychosocial model’ has evolved. harder!’ While not discounting the biopsychosocial model readers We know that a marker for measuring the success of of the Journal of Bodywork and Movement Therapies may rehabilitation is in dropping recurrence rates, it is the too realise that hands-on or therapeutic exercise answers underlining and exclamation point a researcher has when may exist for their clients neuromusculo-skeletal problems. they publish their follow up study, see Hides et al. (2001) work on the deep multifidus. Key goes further and looks at classification systems for Chronic non-specific low back pain (CNLBP) or ‘ordinary’ The 3rd movement dysfunction conference back pain, quoting Riddle (1998) that current classification 2009 systems are confusing, looking at appropriate treatments, or prognoses, or pathology. She also quotes O’Sullivan During a dismally wet Edinburgh weekend Sahrmann (2005) who overviews 8 models, including the ‘Motor (2009a) presented her Keynote Lecture on Low back pain: control model’ in which O’Sullivan bases his own work. Key ‘Isolated or degenerative problem e what are the impli- suggests the ‘Functional movement model’ that combines cations?’. She stated that ‘90% of people are expected to many features of other CNLBP models including the bio- experience low back pain during their life’ with a high psychosocial (Key’s own bolding) and Motor control. She recurrence rate ‘between 30 and 80%’ These high incidence suggests that ‘altered function of the posturo-movement and recurrence rates, she says, ‘are consistent with low system is the primary problem largely responsible for the back pain being associated with the degenerative process’ development and perpetuation of most pain syndromes.’ and this process consists of ‘temporary dysfunction and 4 stages of hyper-mobility before the final stage of hypo- I asked Key (2010b) about how she considers prevention mobility and spinal stenosis. If the ‘‘acute episodes’’ are in the therapeutic context, she said, ‘I certainly consider part of the pattern of temporary dysfunction associated that prevention is an important aspect of comprehensive with segmental hyper-mobility then treatment should be therapeutic care e yet this aspect seems to have been directed toward control and prevention of the progressive largely usurped by the ‘fitness’ and related industries who hyper-mobility that at a minimum should slow the degen- have little ‘real rehabilitation’ training e hence who knows erative process.’ She challenges physical therapists to what they base their ‘‘prevention programs’’ on. I consider ‘monitor the pattern of movement of the low back, that if prevention strategies are to be meaningful and designing and appropriately instructing the patient in functionally useful, they need to be built upon a well corrective exercises and movement strategies rather than informed understanding around a number of related just providing episodic short-term treatment.’ Sahrmann aspects concerning movement control: reported that clinical examination is reliable, in trained (a) What is ‘more ideal’ posturo-movement function? Appreciating this also enables better application of the

About prevention 291 PREVENTION & REHABILITATIONdEDITOR: WARRICK MCNEILL people, in identifying movement faults and that there is which it occurs (low or high). Comerford terms this validity in identifying (movement) subgroups (Sahrmann, ‘uncontrolled movement.’ Sahrmann refers to the same 2009b). concept as the ‘direction susceptible to movement’, and O’Sullivan as a ‘control impairment.’ Comerford suggests it Fass (1996), ‘Exercises: which ones are worth trying, for is the threshold at which the failure occurs which dictates which patients, and when?’ found that more research on whether the specific exercises required to improve the ‘different types of exercising’ in patients with chronic back uncontrolled movement should be slow motor unit domi- pain was necessary. Sahrmann’s comments at the Move- nant (low threshold) thereby showing a Central Nervous ment Dysfunction conference suggests that there may System (CNS) led ‘recruitment’ failure of the muscles that eventually be a plethora of well reasoned, specific exer- should be providing the control, or a fast motor unit cises for specific movement faults, identified by pattern dominant (high threshold) ‘weakness’ e meaning the recognition and clinical testing, that probably make up the hyper-mobile area needs muscular strength to provide the 85% of CNLBP sufferers that do not have a structural control. This is the key differentiation between the FMS and pathology. Performance Matrix approaches. ‘Movement screening’ was highlighted at the confer- In the real world ence, first by Gray Cook who introduced his Functional Movement Screen (FMS). Cook (2009) identified that the Swart (2010), Physiotherapist for elite athletes in South strongest predictor of future injury is previous injury. The Africa reports that ‘in the area of symptoms we mostly find FMS, is a reliable (Minick et al., 2010) predictive system for uncontrolled movements with the low threshold tests those who do not have a known musculo-skeletal injury. It which makes sense due to the fact that pain affects slow assesses functional movement patterns looking for asym- motor unit recruitment. With the Performance matrix or metries and movement limitations, and therefore, he FMS we can determine risk factors for injury in other areas suggests, indicates what ‘to do’ with the client. of the body before they occur preventing further time out due to injury. It is less time consuming to prevent injuries The test movements are relatively simple and include: rather than treat the injuries, and athletes hate not being able to train. Once there is pathology it usually means the  a deep squat athlete has to rest for 6 weeks to allow for healing or at  a hurdle step least I change their exercise program to allow them to  an in-line lunge perform unloaded training in water. Athletes usually start  shoulder mobility too quickly and try to progress too fast leading to recur-  an active straight leg raise rences of injuries or injuries in other areas due to  a trunk stability push up, and compensation.’  a rotation stability test. Barr (2010), an Injury Prevention Specialist for the New Comerford (2009, 2004) in his presentation to confer- York Knicks Basketball Team, confirms the requirement for ence discussed that in sport (where improving performance interdisciplinary co-operation. Barr does not regard re- becomes a major goal of the support staff, as opposed to, in active injury prevention programs as injury prevention e the clinic where the major goal is reducing pain and this, he says, ‘is just an extension of injury rehab.’ Like the disablement) the significant ‘Recurrence of injury and pain’ Yellow Emperor before him Barr believes that, ‘optimal indicates that something is missing in our current screening nutrition, hydration and sleep quality are all essential and prevention strategies. aspects of injury prevention. If these obvious basics are not taken care of fully, then any other injury prevention Comerford pointed out that assessments and screening strategy employed will have a lesser effect.’ of athletes is standard across the board. Screenings primarily look at testing joint range, muscle strength Barr suggests the athlete needs to: (power and endurance) and muscle extensibility. Comer- ford was clear that these are all relatively unsuccessful at  be specifically conditioned to perform in their specific predicting risk of re-injury or recurrence of pain. Like Cook, sport, Comerford also identified that history of previous injury is the single most consistent and reliable predictor of high risk  after previous bouts of exercise be fully recovered to of re-injury. He identified that the isolationist testing of perform, joint range of motion or normal muscle strength is not an adequate rehabilitation end point to prevent recurrence.  be in a ready state to perform physically (warmed up) Comerford suggested it is the assessment of the control of and mentally (focused) and, ‘real’ function that is the missing piece of the screening puzzle. He defines ‘real’ function as the influence of the  have optimal neuromuscular control, stability, mobility multiple muscle interactions acting on multiple joints in and strength for the demands of their specific sport. functionally orientated tasks. To ensure all these considerations are taken care of Comerford advocates the Perfomance Matrix screen, reliable screening and testing methods need to be that he presented to the conference. I personally teach frequently performed. a version of this to the pilates community. At the centre of the screen is the assessment of the motion segment (or ‘My area of expertise,’ says Barr, ‘and what I believe to regional) ‘hyper-mobility’ referred to by Sahrmann earlier. be an essential part of the screening process, is the This may be directional (i.e. flexion, extension, rotation ‘‘analysis of the quality of movement.’’ In my experience etc) and, equally importantly, relates to the threshold at screening for ‘‘movement control’’ and ‘‘producing injury

PREVENTION & REHABILITATIONdEDITOR: WARRICK MCNEILL 292 W. McNeill prevention programs to improve the control of movement’’ a ‘cheat’ in which the cheat becomes perpetuated. Criti- have great success. Aside from traumatic injuries most cism of the disciplines of Pilates and Yoga (Key, 2010a) to other injuries can be related to ‘‘uncontrolled movement.’’ name but two disciplines is fair especially when poorly It is relating uncontrolled movement to the pathology that trained teachers, use exercise recipes and dogma instead allows you to understand how uncontrolled movement is an of individual assessment, critical thought and exercise injury risk and correcting uncontrolled movement is injury modification. prevention.’ In my personal opinion the nascent scientific research Crossover between pain and human looking at Pilates or Yoga often lets itself down by not performance defining within the research question what part of the discipline it is looking at. The disciplines have varied It is interesting to note that Cook and Comerford, system practices of the same activities yet a broad brush stroke developers, and Swart and Barr, users of a system of description of what is undertaken is often deemed assessing movement control, are physical (or physio) ther- enough. Describing every detail, especially modifications apists who originally trained to treat pain and injury but of exercises encouraged and cueing used, may help the have moved out from a narrow focus to look at human disciplines develop a scientific credibility that at present performance as well. They have the remit, via their appears to be unfortunately lacking. Careful thought as to professional training, to look at both patients (those in what exercises should be excluded from a particular study pain) and athletes (concentrating on those with perfor- might be more beneficial than performing all the available mance deficits). Not all who read the JBMT will be able to repertoire. The history of chronic low back pain research move easily between these two camps. Some movement over the last one or two decades, and recent thoughts on disciplines such as Pilates or Yoga are not widely regarded motor control and sub-grouping that are now developing, as ‘treatment’ and therefore their teachers should not could be applied to help accelerate research in Pilates or work without the co-operation of a suitably qualified health Yoga. professional or without clearance from a doctor who is knowledgeable (both about the patients condition and the Call to action discipline they are referring to). Yet many who present to Pilates or Yoga Teachers do so because they are in pain, As this is the Prevention and Rehabilitation section of the perhaps they do not identify themselves as having pain for Journal of Bodywork and Movement Therapies I would like fear of being excluded from the session or perhaps they do to put a call out for papers with a focus on injury prevention not see that it is important for the teacher to know about or the prevention of injury recurrence. If we accept that their pain. It is often the wording of the practitioners motor control deficiencies eventually lead to pain and insurance policy that defines who a Teacher can see, disability we want to know which movement strategies can however, it is becoming very clear that movement be used as motor control tests, or whether those motor dysfunctions are responsible for the internal environment control tests currently in use are good predictors of injury that leads to pain. Pain is probably just a late sequelae risk. of the same movement faults that Pilates and Yoga teachers see in every class that they teach. The Teachers Gracovetsky’s (2010) paper discussing ‘Range of have the tools to alter these movement faults by their Normality’ and injury prevention is an excellent example of interventions, cueing and handling, thereby ‘preventing’ the type of paper that improves our knowledge of injury the ‘pain’ that could have otherwise have been expected prevention. to follow. Feedback: core stability is a subset of motor It is the fact that exercise is often undertaken in group control classes so that a teacher should ideally: Lederman’s (2010) Myth of core stability paper provoked  keep the group size small, a muted response in reply to my editorial (McNeill 2010),  know the clients extremely well, though it is currently, at the time of writing, the most  have assistants, downloaded article from the JBMT, via ScienceDirect.  play to the lowest common physical denominator, or Comments made showed appreciation of a critical look at core stability, and reiterated that clinicians should be ‘sub-group’ their classes to fit those with similar prob- careful not to read too much into research that might not lems together, to keep the individual in a group as be there. ‘safe’ as possible. In relation to Core Strengthening, Marcus (2009) quoted Individual or ‘one to one’ sessions are a luxury that for ‘plus a change, plus c’est la mA´me chose’. (The more many clients is imperative if they are to progress with the things change, the more they stay the same). He identified least risk of recurrence from being given an inappropriate that in his time as a pain medicine MD that several exer- exercise or trying too hard too soon or simply not working cise approaches have come and gone, ‘they become hard enough. In an individual session a teacher is able to jargonized and thus useless. New is not necessarily discover the modifications that that client requires to zone better.’ Marcus et al. (2010) points out that he currently a specific exercise into something that is maximally uses the Kraus exercise program in his chronic pain beneficial in that instance as opposed to performing treatment protocol. This system (of what we might now regard as non-specific exercise) was developed in the

About prevention 293 PREVENTION & REHABILITATIONdEDITOR: WARRICK MCNEILL 1950s and reduced or eliminated back pain in 80% of those Hides, J.A., Jull, G.A., Richardson, C.A., 2001. Long term effects of undertaking them. specific stabilizing exercises for first episode low back pain. Spine 26 (11), 243e248. It seems that despite science and fashion appearing perhaps to be opposite fields of endeavour they both HSE Booklet L26 Display screen equipment work: Health and Safety appear influenced by seasons! (Display Screen Equipment) Regulations 1992: guidance on regulations. ISBN: 0-7176-2582-6. In this edition Key, J., 2010a. Back Pain: A Movement Problem. Churchill Living- In line with this editorials theme on prevention (and in this stone Elsevier. case ‘prevention of recurrence’), and with its prevalence in sports, Stephanie Panayi discusses the need for lumbar- Key, J., 2010b. Personal correspondence. pelvic assessment in chronic hamstring strain. Josephine Lederman, E., 2010. The myth of core stability. Journal of Body- Key, who has written before for the JBMT, elaborates further on Vladimir Janda’s ‘Pelvic crossed syndromes’ for work and Movement Therapies 14 (1), 84e98. this issue. Craig Liebenson’s popular self management: Marcus, N., 2009. Personal correspondence. patient section wraps up this editions Prevention and Marcus, N., Gracely, E., Keefe, K., 2010. A comprehensive protocol Rehabilitation section. to diagnose and treat pain of muscular origin may successfully As always, please feel free write to me in response to and reliably decrease or eliminate pain in a chronic pain pop- the Editorial, the papers, or the ongoing themes within the ulation. Pain Medicine 11 (1), 25e34. journal or affecting your own practice. McNeill, W., 2010. Core stability is a subset of motor control. Journal of Bodywork and Movement Therapies 14 (1), 80e83. References Minick, K.I., Kiesel, K.B., Burton, L., Taylor, A., Plisky, P., Butler, R.J., 2010. Interrater reliability of the functional Barr, A., 2010. Personal correspondence. movement screen. Journal of Strength Conditioning Research Chaitow, L., 2010. Personal correspondence. 24 (2), 479e486. Comerford, M.J., 2004. Core stability: priorities in rehab of the O’Sullivan, P., 2005. Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control athlete. SportEx Medicine 22, 15e22. impairments as an underlying mechanism. Manual Therapy 10, Comerford, M.J., 2009. Recurrence of injury and pain in sport e 242e255. Riddle, D.L., 1998. Classification and low back pain: a review of the what’s missing. Manual Therapy 14 (5), S1eS54. literature and critical analysis of selected systems. Physical Cook, G., 2009. What is our baseline for movement? The clinical Therapy 78 (7), 708e737. Sahrmann, S., 2009a. Low back pain: isolated or degenerative need for movement screening and assessment. Manual Therapy problem e what are the implications? Manual Therapy 14 (5), 14 (5), S1eS54. S1eS54. Fass, A., 1996. Exercises: which ones are worth trying, for which Swart, J., 2010. Personal correspondence. patients, and when? Spine 21 (24), 2874e2878. Fletcher, G.F., 1988. Exercise in the Practice of Medicine, second Web sources revised ed. Futura Publishing, Mount Kisco, New York. Ford, M., 2010. Personal correspondence. Science & Humour with Dr. Serge Gracovestsky e Part 1. http:// Gracovetsky, S., 2010. Range of normality versus range of motion: www.youtube.com/watch?vZqgh2C8M50Iw. a functional measure for the prevention and management of low back injury. Journal of Bodywork & Movement Therapies 14 http://www.safetylit.org. (1), 40e49. http://www.hse.gov.uk/myth/nov09.pdf. Sahrmann, S., 2009b. http://www.webducate.net/icmd_blog/? pZ53. www.functionalmovement.com. www.performance-stability.com.

Journal of Bodywork & Movement Therapies (2010) 14, 294e298 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt REVIEW The need for lumbarepelvic assessment in the resolution of chronic hamstring strain Stephanie Panayi* Shop 5/325 Centre Rd, Bentleigh, VIC 3204, Australia Received 24 June 2009; received in revised form 20 August 2009; accepted 23 August 2009 PREVENTION & REHABILITATIONdREVIEW KEYWORDS Summary A lumbarepelvic assessment and treatment model based on a review of clinical Hamstrings; and anatomical research is presented for consideration in the treatment of chronic hamstring Mobilisation; strain. The origin of the biceps femoris muscle attaches to the pelvis at the ischial tuberosity Sacroiliac joint; and to the sacrum via the sacrotuberous ligament. The biomechanics of the sacroiliac joint and Arthrokinetic reflex hip, along with lumbarepelvic stability, therefore play a significant role in hamstring function. Pelvic asymmetry and/or excessive anterior tilt can lead to increased tension at the biceps origin and increase functional demands on the hamstring group by inhibiting its synergists. Joint proprioceptive mechanisms may play a significant role in re-establishing balance between agonists and antagonists. An appreciation of neuromuscular connections as well as overall lumbarepelvic structural assessment is recommended in conjunction with lumbare pelvic strengthening exercises to help resolve chronic hamstring strain. ª 2009 Elsevier Ltd. All rights reserved. Introduction a valuable part in the successful resolution of chronic hamstring strain. One of Dr. Ida Rolf’s frequent mantras to her students was ‘Where the pain is, it ain’t!’ According to Dr. Rolf, first and Hamstring injuries are the most prevalent muscle injury foremost in any evaluation of chronic pain is global in sports involving rapid acceleration and sprinting (Hoskins assessment of structure. Localised evaluation is necessary and Pollard, 2005). At its simplest, treatment of hamstring for acute injury, however a global approach is often strain might include stretching and soft-tissue work to appropriate when addressing chronic musculoskeletal pain. increase flexibility and address scar tissue formation. While the etiology of hamstring strain is multifactorial and Research into the value of stretching for injury prevention sometimes difficult to define, this article proposes that (Herbert and Gabriel, 2002), and the value of massage to assessment of lumbarepelvic biomechanics may play effect muscle damage (Tiidus, 1997), does not however show significant effects of these interventions. Research * Tel.: þ61 434 919 487. suggests that lumbarepelvic alignment may play a signifi- E-mail address: [email protected] cant role in hamstring strain (Cibulka et al., 1986; Hen- nessey and Watson, 1993; Hoskins and Pollard, 2005). 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.08.004

The need for lumbarepelvic assessment 295 In the 1970s Dr Vladimir Janda (1978) developed a multi- faceted approach to musculoskeletal pain. His treatment protocol included restoring postural alignment, correcting the biomechanics of joints, increasing the proprioceptive input to the central nervous system, and exercise to increase muscular endurance (Janda, 1978). Using Janda’s conceptual framework, research relating to assessment and treatment of hamstring strain is presented under the following headings: Posture, Joint Influences, and Lumbare pelvic Stabilisation Exercises. Posture Lumbar hyperlordosis, anterior tilt of the pelvis, and Figure 1 When walking, as the right leg swings forward the PREVENTION & REHABILITATIONdREVIEW sacroiliac joint (SIJ) dysfunction have all been implicated in right ilium rotates backward in relation to the sacrum. Simul- chronic hamstring strain (Cibulka et al., 1986; Hennessey taneously, the sacrotuberous and interosseous ligamentous and Watson, 1993; Hoskins and Pollard, 2005). tension increases to brace the sacroiliac joint (SIJ) in prepa- ration for heel strike. Just before heel strike, the ipsilateral Lumbar hyperlordosis often correlates with anterior hamstrings are activated, thereby tightening the sacrotuberous pelvic tilt, placing strain on the origin of the hamstrings at ligament (into which they merge) to further stabilize the SI the ischial tuberosity, resulting in hamstring tissue joint. Figure. 1 is figure 5.15 from A Massage Therapist’s Guide pathology (Cibulka et al., 1986). When no tissue pathology to Low Back and Pelvic Pain Chaitow L., Fritz S. 2007 Elsevier/ is present in the hamstrings, it has also been linked to Churchill Livingstone, Edinburgh Redrawn from Vleeming et al. lumbarepelvic myofascial pain referral, mimicking 1997 Movement, Stability and low back pain. 1st Edition hamstring strain (Hoskins and Pollard, 2005). Van Wing- Churchill Livingstone, Edinburgh. erden et al. (1997) suggest that the high correlation between tight hamstrings and lower back pain might reflect produce anterioreinferior rotation force on the anterior a beneficial compensatory mechanism for people with superior iliac spine, while a tight biceps femoris muscle pelvic instability. They point out that, in low back pain could produce posterioreinferior rotational force at the patients, bending forward is often painful because of the ischial tuberosity (Schamberger, 2002). increase in spinal load during this movement. Increased hamstring tension prevents the pelvis from tilting forward, Cibulka et al. (1986) investigated the role of SIJ dysfunc- which diminishes the forward-bent position of the spine, tion in hamstring strain. Results showed a significant increase thereby reducing spinal load Van Wingerden et al. (1997). in hamstring strength immediately following SIJ mobi- lisation. The researchers had noted a high correlation SIJ dysfunction has been defined as pelvic asymmetry between hamstring muscle strains and an anterior tilt of the between the left and right innominates (Pool-Goudzwaard innominate bones, associated with sacroiliac dysfunctions. et al., 1998). The two innominates join anteriorly at the They concluded that mobilising the SIJ reduced the tilts of pubic symphysis, and posteriorly they border the sacrum. the innominates, releasing undue stress on the previously Joint play is movement within a synovial joint that is elongated biceps femoris. More recent research has also independent of, and cannot be introduced by, voluntary found SIJ mobilisation to increase hamstring flexibility (Fox, muscle contraction (Greenman, 1996). The amount of joint 2006). Hoskins and Pollard, (2005), found that improving play at the SIJ is less than 1/8 of an inch in any plane but lumbarepelvic biomechanics, including SIJ mobilisation, allows the innominates to rotate anteriorly and posteriorly played a role in treatment and prevention of hamstring injury during ambulation (Figure 1), causing side bending and in Australian Rules footballers. rotation in the sacrum (Greenman, 1996). These move- ments are essential for the normal pain-free, non- Apart from producing a static stretch of the biceps restricted movement of the joint and significant somatic femoris muscle, fixations of the SIJ can exacerbate pain dysfunction can occur if any of these movements are upon ambulation. Ideally, during hip flexion the innominate impeded (Greenman, 1996). on the same side rotates in a posterior and inferior Ideally, when standing or seated, the innominates do not differ in terms of anterior or posterior rotation. However, it is not uncommon for pelvic obliquity to develop, involving an anterior tilt on one side and a posterior tilt on the contralateral side. Rotation of the innominates and torsion of the sacrum can result from forces being transmitted to these bones from the spine, pelvic floor or lower extremi- ties (Schamberger, 2002). In athletes, training error, or overtraining with unilateral loading, as in kicking or throwing, can exaggerate the normal sacroiliac movements (Ross, 2000). Over time, unilateral muscle tightness or contracture can produce a rotational force on the innomi- nates. For example, a tight rectus femoris muscle could

296 S. Panayi direction (using the posterior superior iliac spine as the point of reference), moving the ischial tuberosity anteriorly and reducing hamstring strain. If however, the innominate is fixed in an anterior rotation, the ischium will not move anteriorly during hip flexion and this will increase stress at the origin of the hamstrings. This kind of stress is particu- larly relevant in sports involving rapid acceleration during running or sprinting (Gabbe et al., 2005). SIJ dysfunction has also been associated with piriformis spasm on the side of the posterioreinferior lateral angle, paravertebral spasm, iliopsoas spasm and gluteal and hamstring spasm (Dowling, 2004). SIJ dysfunction and muscle pathology e cause/ effect PREVENTION & REHABILITATIONdREVIEW A primary function of the pelvis is to transfer the loads Figure 2 Posterior oblique system: latissimus dorsi, gluteus generated during standing, walking, sitting and other maximus and the lumbodorsal fascia (which links them). When functional tasks (Lee, 2005). Effective load transfer latissimus and contralateral gluteus maximus contract there is requires optimal force and form closure of the SIJ. Form a force closure of the posterior aspect of the SIJ. Figure 2 is closure refers to the stable situation of the SIJ due to figure 5.11 from A Massage Therapist’s Guide to Low Back and closely fitting joint surfaces where no extra forces are Pelvic Pain Chaitow L., Fritz S. 2007 Elsevier/Churchill Living- needed to maintain stability (Pool-Goudzwaard et al., stone, Edinburgh Redrawn from Vleeming et al. 1997 Move- 1998). However, since the sacrum does not fit the pelvis ment, Stability and low back pain. 1st Edition Churchill with perfect form closure and some mobility is required Livingstone, Edinburgh. during ambulation, ligament and muscle-forces are needed to provide compression of the SIJ, especially during Joint influences unilaterally loading of the legs when shear forces increase (Pool-Goudzwaard et al., 1998). Force closure refers to the Mobilisation is commonly utilised to ease joint pain and stability of the SIJ produced by surrounding myofascia increase range of movement. Recent research also (Figure 2), particularly that with a fibre direction perpen- emphasises the role of joint mobilisation in reciprocal dicular to the SIJ, such as gluteus maximus (Pool-Goudz- inhibition (Liebler et al., 2001; Makofsky et al., 2007; Yerys waard et al., 1998). Weakness or underactivity of gluteus et al., 2002). maximus may therefore predispose the SI joints to injury (Elphington, 2008). Sherrington’s principle of reciprocal innervation states that during contraction of agonist muscles, the antagonists While contraction of the myofascia assists form closure do not behave passively, but are actively inhibited by of the SIJ, the question remains whether muscular central nervous mechanisms (Day et al., 1984). This contraction is able to influence the positioning of the mechanism, long thought to be based in afferents from sacrum and therefore have the potential for creating SIJ muscles or tendons, may also be mediated by the articular dysfunction. Based on research in which joint restrictions receptors; these can inhibit or facilitate muscle tone, and did not alter when myorelaxants were given to hypertonic failure to recognise the importance of these arthrokinetic muscles, Lewit (1985) defines the SIJ as one of three joints (AKR) circuits may explain the difficulty in neuromuscular in the body where joint restrictions are not the result of re-education and strengthening of muscle groups (Makofsky soft-tissue changes. However recent research suggests that et al., 2007). although the muscles crossing the SIJ are not described as prime movers of that joint, motion can occur at the SI joint In relation to chronic hamstring strain, a tightened as a result of their contraction (Schamberger, 2002; anterior hip capsule would facilitate the iliopsoas muscle Vleeming et al., 1989a; Vleeming et al., 1989b; Wingerden while inhibiting the gluteus maximus through the arthroki- et al., 2004). netic reflex (Yerys et al., 2002). Visible muscle wasting of the gluteal muscles is often seen when tightness is present In a dissection study of 12 cadavers, Vleeming et al. in the iliopsoas. Since gluteus maximus is a prime mover in (1989a) found that in all cases, gluteus maximus attached hip extension, its inhibition places undue loads on its to the sacrotuberous ligament, and in 50% of cases unilat- hamstring synergists (Elphington, 2008), making them more eral or bilateral fusion of the sacrotuberous ligament with prone to injury. Mobilisations performed on the anterior hip the tendon of the long head of biceps femoris was evident. capsule have been shown to significantly increase gluteus In some specimens, fusion was so complete that there was maximus strength (Yerys et al., 2002). Muscle weakness no connection of this muscle to the ischial tuberosity itself. may therefore be influenced by inhibition related to In a subsequent study, Vleeming et al. (1989b) found that capsular hypomobility of the underlying joint (the gluteus load to the sacrotuberous ligament, either directly or via continuation with the long head of biceps femoris, signifi- cantly diminished the forward rotation of the base of the sacrum (Figure 3).

The need for lumbarepelvic assessment 297 PREVENTION & REHABILITATIONdREVIEW Figure 3 Deep longitudinal system: erector spinae, deep When there are joint restrictions, mechanoreceptor laminae of the thoracodorsal fascia, sacrotuberous ligament inputs to the CNS can cause active weakening (or inhibition) and biceps femoris. When contraction occurs, biceps femoris of muscles whose action could take the joint beyond its influences compression of the SI joint and sacral nutation can restrictive barrier. Therefore, trying to strengthen a muscle be controlled. Figure. 3 is figure 5.12 from A Massage Ther- that is being inhibited before mobilising the joint may be apist’s Guide to Low Back and Pelvic Pain Chaitow L., Fritz S. counterproductive. Much in line with Janda (1978), Makof- 2007 Elsevier/Churchill Livingstone, Edinburgh Redrawn from sky et al., (2007) proposed a simple clinical rule of thumb: Lee D 1999 The Pelvic Girdle 2nd Edition Churchill Livingstone, ‘Stretch what’s tight and mobilise what’s stiff prior to Edinburgh. strengthening what’s weak.’ maximus is inhibited each time the hip extends against its restrictive barrier of motion). Joint mechanoreceptors can also be stimulated during tasks that maximise sensory input to the central nervous During mobilisation, the alteration in mechanoreceptor system and elicit subconscious and automatic responses in discharge theoretically removes the neurally driven inhibi- muscles. This is most effectively done by providing balance- tion of the gluteus maximus muscle whilst simultaneously challenging exercises which stimulate the sub-cortical inhibiting the iliopsoas muscle through reciprocal inhibition systems which regulate movement and balance (Janda (Yerys et al., 2002). Perhaps the therapeutic role of SIJ et al., 2006). Bullock-Saxton et al., (1993), found that mobilisation (Cibulka et al., 1986; Fox, 2006) extends gluteal muscles activated more affectively by stimulating beyond normalising an anterior rotation of the innominate, the proprioceptive mechanism during walking. Subjects to stimulating joint receptors involved in an AKR with the wore ‘balance shoes’, which acted as a labile surface, to hamstrings. facilitate cerebellovestibular circuits. This study showed significant increases in gluteal activity and faster contrac- The timing, pattern and amplitude of the muscular tions after one week of facilitation. Specific sensory motor contractions involved in force closure of the SIJ depend on tasks have been shown to be as effective for improving an appropriate response of both the central and peripheral strength as traditional strength training (Risberg et al., nervous systems which in turn rely on appropriate afferent 2007; Ihara and Nakayama, 1986), and lead to shorter input from the joints, ligaments, fascia and muscles (Lee, latency of contraction (Ihara and Nakayama, 1986). 2005). Unusual positioning of the SI joints can influence Because the sub-cortical regulatory systems do not rely on afferent output of the joint capsule and there may be conscious control, they are faster, and after time the sta- a causal relationship between different afferent output of bilising process can become ‘second nature’ (Norris, 1995). the joint capsule and changes in the motor programme of supporting myofascial tissue such as transversus abdominus Lumbar/pelvic stabilisation exercises and multifidus (Pool-Goudzwaard et al., 1998). Lumbarepelvic stabilisation exercises are important to promote normal lengthetension relationships across the pelvis, optimal arthrokinematics, dynamic stability, and efficient kinetic chain muscle activation patterns (Elphington, 2008). The main muscles of lumbarepelvic stabilisation are the multifidus, transversus abdominus and internal obliques (Elphington, 2008). The oblique abdomi- nals and transversus abdominus are particularly important in spinal stability due to their connections with the thor- acolumbar fascia and their role in enhancing intra-abdom- inal pressure (Norris, 1995). Gracovetsky (2008) has described the important relationship between the trans- versus abdominus and the thoracolumbar fascia in exten- sion of the spine, and how internal abdominal pressure, together with lordosis, controls the force transmission efficiency of the lumbodorsal fascia. The gluteal group is also an important contributor to dynamic pelvic stability and must activate effectively to produce the short foot contact times necessary for fast running (Elphington, 2008). In stability training, the client’s attention to the exer- cise is crucial. This is not only important so that the exer- cise is performed properly, but attention is likely to aid in the facilitation of muscles which have become relatively inactive. In a study by Day et al. (1984) conscious inhibition of the wrist flexor reflex was demonstrated with the radial nerve anaesthetised by injection of local anaesthetic at the elbow. Subjects were asked to try to contract the paralysed extensor muscles. Under this condition, attempted volun- tary wrist extension inhibited the flexor reflex even though

PREVENTION & REHABILITATIONdREVIEW 298 S. Panayi no extension occurred. Similar results were obtained by Duk Hennessey, L., Watson, A.W., 1993. Flexibility and posture Yang et al. (2005) showing that imagination of movement assessment in relation to hamstring injury. British Journal of facilitated motorneurons of the agonist muscle while having Sports Medicine 27, 243e246. an inhibitory effect on those of the antagonist muscle. This suggests that focussed attention to specific muscular Herbert, R., Gabriel, M., 2002. Effects of stretching before and contraction can play a significant role in muscle facilitation after exercising on muscle soreness and risk of injury: system- and reciprocal inhibition. atic review. British Medical Journal 325, 468e478. Summary Hoskins, W.T., Pollard, H.P., 2005. Successful management of hamstring injuries in Australian rules footballers: two case reports. The etiology of hamstring strain is multifactorial and often Chiropractic & Osteopathy 13 (4). doi:10.1186/1746-1340-13-4. difficult to define. There is, however, evidence to suggest that hamstring strain may sometimes be reflective of lum- Ihara, H., Nakayama, A., 1986. Dynamic joint control training for barepelvic imbalances. These imbalances increase the knee ligament injuries. American Journal of Sports Medicine 14 functional load on the hamstrings by defacilitating the (4), 309e331. gluteus maximus, and/or increasing the tensile stress on the biceps femoris origin. Apart from working to increase Janda, V., 1978. Muscles, central nervous motor regulation and hamstring flexibility and address scar tissue formation, back problems. In: Korr, I. (Ed.), The Neurobiological Mecha- successful resolution of hamstring strain may involve the nisms in Manipulative Therapy. 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