Journal of Bodywork and Movement Therapies Volume 14 2010

Journal of Bodywork & Movement Therapies (2010) 14, 299e301 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt PREVENTION & REHABILITATIONePOSTURAL PHYSIOLOGY POSTURAL PHYSIOLOGY The Pelvic Crossed Syndromes: A reflection of imbalanced function in the myofascial envelope; a further exploration of Janda’s work Josephine Key, MPAA, Musculoskeletal Physiotherapist* Edgecliff Physiotherapy Sports and Spinal Centre, Suite 505/180 Ocean Street, Edgecliff N.S.W. 2027, Australia Received 25 April 2009; received in revised form 14 January 2010; accepted 20 January 2010 KEYWORDS Summary Structurally, the sacrumecoccyx provides the dual roles of serving as the base of Back pain; the spinal column while also forming part of the pelvic ring. Physiological movement control of Pelvic pain; the pelvis and the spine are functionally interdependent. In particular, intra-pelvic control, Motor control; (that between the ilia and sacrum/coccyx in support and control of the forces and small move- Posturo-movement ments within the pelvic ring) is fundamental to controlling its spatial organization as a whole dysfunction; and its control on the femoral heads, all of which directly influence spinal alignment and Lumbo-pelvic-hip control mechanisms. This involves coordinated activity in the related neuro-myofascial movement control; systems in providing mechanisms of both intrinsic and extrinsic support and control. Therapeutic exercise; ª 2010 Elsevier Ltd. All rights reserved. Core stability; Clinical sub-group classification Janda proposed the concept of the Pelvic Crossed movement alignment and control. While certainly evident Syndrome as an underlying factor in the genesis and in back pain populations, for the observant clinician it is not perpetuation of many low back pain syndromes (Janda, a universal finding. 1987; Janda and Schmid, 1987; Janda et al., 2007). Here, imbalanced muscle activity e tightness and overactivity of Like Janda, our group has been interested in the validity the hip flexors and low back extensors and a coexistent of clinical pattern recognition which appears to also underactivity in the abdominals and glutei create a ‘crossed delineate another different, yet broad subgroup within the pattern’ of disturbed sagittal lumbopelvic posturo- back pain population who share in common similar features of changed postural alignment and control. This sub-group * Tel.: þ61 02 93261168; fax: þ61 02 93281695. displays a relative hyperactivity in the upper abdominal E-mail address: [email protected] wall and piriformis/hamstrings with underactivity in the lower abdominals, deep hip flexors and low back extensors. This also creates an altered ‘crossed pattern’ affecting 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.01.008

300 J. Key PREVENTION & REHABILITATIONePOSTURAL PHYSIOLOGY sagittal lumbopelvic alignment and control and has been support and stability and contributing to a structural and described by Key et al. (2008b). functional bridge between the lower torso and legs. It is suggested that these collective myofascial aggregations be It is clinically apparent that most patients presenting termed the ‘Lower Pelvic Unit’ (LPU). This includes the with low back and pelvic pain syndromes display at least obvious contractile elements for which there is accumu- some of the features attributable to either of these two lating evidence of deficient function in subjects with low primary pictures of altered pelvic function. In Janda’ s back and/or pelvic pain e the transversus abdominus originally proposed Pelvic Crossed Syndrome, the pelvis is (Hodges and Richardson, 1996, 1998, 1999) multifidus more posterior and this is associated with imbalanced (Hides et al., 1996) the diaphragm and pelvic floor muscles coactivation of the trunk muscles with more dominant (O’Sullivan et al., 2002; Hodges, 2006). Impressions from activity observed in the extensors. Key et al. (2008b) clinical practice suggest inclusion also of the obturators, proposed this syndrome be re-termed the Posterior Pelvic iliacus, psoas, and all their related and interconnecting Crossed Syndrome (Figure 1C). Conversely, in the other fascial sheaths. Sound activity within this myofascial ‘inner broad group, the pelvis is postured more anteriorly and this stocking’ sustains many functional roles: e providing deep is associated with a predominant tendency to more axial anterior support to the lower half of the spinal column; flexor activity e described by Key et al. (2008b) as the with the spinal intrinsics it contributes to lumbopelvic Anterior Pelvic Crossed Syndrome (Figure 1B). control (Hodges, 2004); while also contributing to the generation of IAP (Cresswell et al., 1994), continence and However, it is important for the clinician to also recog- respiration (Hodges and Gandevia 2000) (Figure 2). nise that underpinning both primary pictures of pelvic posturo-movement dysfunction there is usually a related, Importantly, it is further asserted that from a thera- common and clinically apparent fundamental deficit in the peutic perspective, co-operative activity within the LPU integrated and balanced control provided from the deep, allows the modulation of discrete yet clinically apparent, innermost myofascial sleeve which sub-serves the founda- fundamentally important intra-pelvic movements and tions of lumbopelvic support and control. spatial shifts. In helping to control our posturo-movements, it acts as the ‘collective internal agonist’ to balance the Key et al. (2008a) proposed that the muscles of the body actions and forces created by activity of the ‘outer antag- could for practical purposes be conceptually viewed as onists’. This balanced coactivation within the LPU and essentially consisting of two systems e a deep and between it and the large more superficial muscles provides a superficial systemic muscle system. They termed the control of the myo-mechanics and movement force couples deep system the Systemic Local Muscle System and necessary to allow the pelvis to be the initiator and driver proposed that this plays a critical role in underlying of functional posturo-movement control of the torso on the postural support and control. legs. Control initiated from the base of the spine through the pelvis, directed via the ischia and coccyx, is essential in It is hereby further proposed that in respect to healthy being able to effectively manage the delicate neuro- lumbopelvic function, an important part of this deep muscular balance involved in being upright against system is a continuous, largely internal three dimensional gravity. It also enables one to draw upon on an endless myofascial web, providing a scaffold of tensile inner array of options in the fluid control of movement including being able to create kinematically sound patterns of movement which support basic activities of daily living e bending over, lifting, reaching squatting, jumping and so on e all possible when the pelvis can act in its prime role as the centre of weight shift in the body. Balanced coac- tivation from the LPU provides internal stability to the pelvis as it swings and swivels on the femoral heads which is necessary in weight shift, load transfer and in controlling equilibrium. This is ‘core control’. Clinical relevance Figure 1 Altered control of pelvic position changes the The experienced clinician knows that seemingly subtle alignment and control mechanisms throughout the spine. changes and differences in pelvic posturo-movement Reproduced from ‘‘Back pain: A movement problem’’ by Key, control can mean a lot in the presenting symptom picture publishing early 2010. With permission from Elsevier. of those with spinal pain and related disorders. Apprecia- tion of the Pelvic Crossed Syndromes and the common associated dysfunction in the LPU helps the practitioner ‘to see’ and better understand what is driving the patients underlying problem and the likely needs in terms of retraining appropriate functional motor control. In the author’s clinical experience, this is best addressed in the patient initially relearning specific activation of deficient elements within the LPU, establishing the important fundamental patterns of intra-pelvic control and

The pelvic crossed syndromes: A reflection of imbalanced function in the myofascial envelope 301 Figure 2 Much of the LPU involves a prevertebral and intra-pelvic myofascial web of support. Reproduced from ‘‘Back pain: A PREVENTION & REHABILITATIONePOSTURAL PHYSIOLOGY movement problem’’ by Key, publishing early 2010. With permission from Elsevier. integrating these into basic functional patterns of move- Hodges, P.W., Richardson, C.A., 1999. Altered trunk muscle recruit- ment control initiated from the pelvis. This will better ment in people with low back pain with upper limb movements at ensure the likelihood of the patient achieving more func- different speeds. Arch. Phys. Med. Rehabil. 80 (9), 1005e1012. tionally appropriate and ‘real core control’. Hodges, P.W., Gandevia, S., 2000. Changes in intra-abdominal References pressure during postural and respiratory activation of the human diaphragm. J. Appl. Physiol. 2000 (89), 967e976. Cresswell, A.G., Oddsson, L., Thorstensson, A., 1994. The influence of sudden perturbations on trunk muscle activity and intra- Janda, V., 1987. Muscles and motor control in low back pain: abdominal pressure while standing. Exp. Brain Res. 98, 336e341. assessment and management. In: Twomey, L. (Ed.), Physical Therapy of the Low Back. Churchill Livingstone, New York. Hides, J.A., Richardson, C.A., Jull, G.A., 1996. Multifidus muscle recovery is not automatic following resolution of acute first Janda, V., Schmid, H.J.A., 1987. Muscles as a pathogenic factor in episode low back pain. Spine 21, 2763e2769. back pain. Proc. IFOMPT New Zealand 1980. Hodges, P., 2004. Abdominal mechanism and support of the lumbar Janda, V., Frank, C., Liebenson, C., 2007. Evaluation of muscular spine and pelvis. In: Richardson, C., Hodges, P., Hides, J. (Eds.), imbalance. In: Liebenson, C. (Ed.), Rehabilitation of the Spine: Therapeutic Exercise for Lumbopelvic Stabilisation: a Motor a Practitioner’s Manual, second ed. Lippincott Williams & Wil- Control Approach Foe the Treatment and Prevention of Low kins, Philadelphia. Back Pain, second ed. Churchill Livingstone, Edinburgh. Key, J., Clift, A., Condie, F., Harley, 2008a. A model of movement Hodges, P.W., 2006. Low back pain and the pelvic floor. In: dysfunction provides a classification system guiding diagnosis Carrie`re, B., Markel Feldt, C. (Eds.), The Pelvic Floor. Thieme, and therapeutic care in spinal pain and related musculoskeletal Stuttgart. syndromes: a paradigm shift e part 1. J. Bodyw. Mov. Ther. 12 (1), 7e21. Hodges, P.W., Richardson, C.A., 1996. Inefficient muscular stabi- lisation of the lumbar spine associated with low back pain: Key, J., Clift, A., Condie, F., Harley, C., 2008b. A model of move- a motor control evaluation of transversus abdominus. Spine 21 ment dysfunction provides a classification system guiding diag- (22), 2640e2650. nosis and therapeutic care in spinal pain and related musculoskeletal syndromes: a paradigm shift e part 2. J. Hodges, P.W., Richardson, C.A., 1998. Delayed postural contraction Bodyw. Mov. Ther. 12 (2), 105e120. of transversus abdominus in low back pain associated with movement of the lower limb. J. Spinal Disord. 11 (1), 46e56. O’Sullivan, P.B., Beales, D., Beetham, J., Cripps, J., Graf, F., Lin, I., Tucker, B., Avery, A., 2002. Altered motor control strategies in subjects with sacroiliac joint pain during active straight leg raise test. Spine 27 (1), E1eE8.

Journal of Bodywork & Movement Therapies (2010) 14, 302 available at www.sciencedirect.com PREVENTION & REHABILITATIONeSELF-MANAGEMENT: PATIENT SECTION journal homepage: www.elsevier.com/jbmt SELF-MANAGEMENT: PATIENT SECTION Improving trunk rotation D.C. Craig Liebenson* International Association for the Study of Pain, American Pain Society, Team Chiropractor, N.B.A. Los Angeles Clippers, L.A. Sports and Spine, 10474 Santa Monica Blvd., #304, Los Angeles, CA 90025, USA Received 5 April 2010; accepted 6 April 2010 Sports such as tennis, golf, baseball, and hockey each involve Figure 1 Kneeling trunk rotation (a) start position (b) final a tremendous amount of trunk rotation. It is not just striking position. sports, but also throwing, kicking, running, swimming, skiing, etc which all require your body to rotate through your core. In  Think about sticking your chest out order to transmit forces from your bigger, stronger leg  Hold this position for a few seconds muscles to your arms, trunk rotation is needed.  Then return to the start position Back injuries, oblique abdominal strains, rotator cuff Avoid problems, and even reduced performance can directly result from diminished mobility in trunk rotation. This self-  Staying slouched care article shows a very simple trunk rotation exercise that can be performed as a warm-up or part of a daily Troubleshooting stretching routine.  Use towel under forehead Another benefit of trunk rotation training is that it can  Use rolled up towel or ½ foam roll behind knees help improve to posture. A slouched posture with rounded  Be sure to stick chest out so that you are arching your back shoulders will quickly straighten up with these simple stretches. through your shoulder blades instead of from your lower back Kneeling trunk rotation (Fig. 1) Sets/reps/frequency Start  Perform 1 set  8e12 repetitions  Kneel on the floor  1e2x/day  Sit back on your heels  Place one hand behind your neck Technique  Lift your head & torso up while simultaneously twisting your upper body * Tel.: þ1 310 470 2909. E-mail address: [email protected] 1360-8592/$ - see front matter ª 2010 Published by Elsevier Ltd. doi:10.1016/j.jbmt.2010.04.002

Journal of Bodywork & Movement Therapies (2010) 14, 303 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt Obituary: David Simons (1922e2010) e the next adventure Jan Dommerholt, PT, DPT, MPS* Bethesda Physiocare/Myopain Seminars, 7830 Old Georgetown Road, Suite C-15, Bethesda, MD 20814-2440, USA On April 5, 2010, Dr. David and learn from Dr. Travell. Inspired by her teachings, he Simons, co-author of the became certified as a physiatrist and started examining and Trigger Point Manuals and treating patients with MTrPs. He continued to work with author of many innova- Dr. Travell, and in 1981, they published the first MTrP tive and thought- hypothesis. Eventually, Dr. Simons became the driving force provoking articles and behind writing the Trigger Point Manuals, which have been research studies on myo- translated into many foreign languages. fascial trigger points, started what he described Perhaps the words of Hugh Elliot offer a good characteriza- as “the next adventure”, tion of our mentor, friend, colleague and teacher Dave Simons: when he passed away at “I am not dying, not anymore than any of us are at any moment. the age of 87. We run, hopefully as fast as we can, and then everyone must Dave Simons was a pioneer not just in musculo-skeletal stop. We can only choose how we handle the race.” medicine, but also in aerospace explorations. After receiving his medical degree in 1946 from Jefferson Medical Throughout his life, Dave Simons ran as fast as he could, College in Philadelphia, PA, he served in the United States trying to accomplish as much as possible. At age 85, he Air Force, initially as a researcher and during the Korean started writing a book about global warming out of concern conflict as a flight surgeon. As project officer for balloon for the well-being and future of the world. When asked why flights at the Aeromedical Field Laboratory at Holloman Air he would take on such an endeavor, he replied that since Force Base in New Mexico, he was particularly interested in there are now enough clinicians and researchers in the world the effects of galactic cosmic radiation on living tissue. On carrying on MTrP research and clinical practice, he was no August 19, 1957, his career reached new heights, when he longer concerned that MTrPs soon would be forgotten. “I became the first man in outer space traveling 101,516 feet think I can serve the world better by explaining the real above the Earth in a pressurized gondola as part of the Man threat of global warming,” he explained. In 2009, he decided High Project. This 36-hour record-breaking high altitude not to publish the book after all, but the energy and fervor he balloon flight earned him a place on the cover of Life displayed was truly inspiring. Instead, he returned to work on magazine and the title of “Father of Radiobiology”. the next edition of the Trigger Point Manuals, which he When attending a two-day lecture and demonstration by continued until just a few days before his death. Dr. Janet Travell in 1963, he was immediately intrigued by the concept of myofascial trigger points (MTrPs) and described her Dave Simons will be remembered by doctors, physical lectures and demonstrations as “a revelation” and “awe- therapists, chiropractors, osteopaths, massage therapists, inspiring”. Following his 1965 retirement from the US Air body workers and many other healthcare providers worldwide. Force, Dr. Simons became coordinator of research at the His work has and will continue to inspire researchers and Veterans Administration and had the opportunity to meet with clinicians. Every day, thousands of clinicians treat even more thousands of patients based on the works by Travell and * Tel.: þ1 301 656 5613; fax: þ1 301 654 0333. Simons. It gave David great pleasure realizing that so much unnecessary suffering was relieved as a result of his endeavors. 1360-8592/$ - see front matter doi:10.1016/j.jbmt.2010.04.007 It seems likely that in his next adventure, David Simons will once again reach new heights and continue to amaze us.

Journal of Bodywork & Movement Therapies (2010) 14, 304e308 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt INTERVIEW Research and osteopathy: An interview with Dr Gary Fryer by Helge Franke Helge Franke* Received 19 August 2009; received in revised form 12 January 2010; accepted 16 January 2010 Dr Gary Fryer is a Senior Lecturer at Victoria University, electrical skin resistance) was groundbreaking in many ways Melbourne, and Research Associate Professor with the A.T. and appeared to support the osteopathic paradigm, but by Still Research Institute, Kirksville, Missouri. He graduated in today’s standards it falls short in terms of methodology and 1991 and practiced osteopathy in Melbourne, Brisbane and analysis. These studies are often cited as demonstrating rural Victoria. Dr Fryer has been extensively involved in objective evidence of somatic dysfunction and supporting osteopathic education and research. In 2007, he joined the the rationale of osteopathic manipulative treatment (OMT), A.T. Still Research Institute in Kirksville, Missouri, the but most of them did not directly investigate palpatory birthplace of osteopathy, where during a two-year period findings or the effect of manipulation, and their results have he conducted research with and taught osteopathic not been re-examined or verified by later studies. manipulative medicine as Adjunct Assistant Professor at Kirksville College of Osteopathic Medicine. Dr Fryer has I think it was unfortunate that there was little follow-up authored many articles in peer-reviewed journals, several to this work and that a research culture did not develop in book chapters, and has been an invited speaker at osteo- the osteopathic profession. We now see considerable pathic conferences in the United States, United Kingdom research in the wider field of manual medicine, but the and Europe. osteopathic profession cannot be considered at the cutting edge in many of these research areas. I have been inter- Question: The English osteopath Eyal ested in Denslow and Korr’s pioneering work at Kirksville, Lederman, said to me in an interview, that but the question of abnormal EMG activity associated with osteopathy lacks 50 years of research. Would tissue texture abnormality is still uncertain. At the A.T. Still you agree with that perception? Research Institute, we have been examining intramuscular EMG activity associated with palpatory findings, but e Yes, I agree. I think the profession became complacent unlike a previous study (Fryer et al., 2006) e have so far following the pioneering research of Denslow, Korr and been unable to verify any abnormal EMG activity that might colleagues in the 1940s and 1950s (Denslow and Clough, account for the abnormal texture at rest (Fryer et al., in 1941; Denslow and Hassett, 1942; Denslow et al., 1947; Korr press). Interestingly, years after the original EMG study, et al., 1962). The interpretation of these studies suited the Denslow reported that abnormal spontaneous activity was profession, and many believed the osteopathic paradigm was not consistently detected on further attempts to reproduce proven and further research was not a priority. This early his earlier findings (Denslow, 1975). My feeling is that these body of work (paraspinal electromyography [EMG] and tissues appear abnormal due to increases in tissue fluid either from tissue inflammation or secretion of pro- * Correspondence. inflammatory compounds. We have also been examining the E-mail address: [email protected] EMG response of deep paraspinal muscles from various manual interventions and are currently processing and analysing these results. 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.01.006

Research and osteopathy 305 Although evidence exists that supports the plausibility nociceptive pathways. The functional and structural of muscle dysfunction associated with minor trauma to the changes in the nervous system result in hyperalgesia and spinal segment (whether reflex contraction or inhibition, allodynia, the later being pain evoked by stimuli that would sensitized stretch reflexes, or more complex motor not normally be painful. The peripheral tissue injury may changes) (Fryer et al., 2004a,b), we still lack convincing resolve completely, but the neuroplastic changes e and the research demonstrating that what we palpate is clinically symptoms e remain as a source of pain generated entirely meaningful. In other words, as a result of palpation, do we by the nervous system, which appears to be the process find things that are related to pain and dysfunction, that underlying many cases of chronic pain. There may also be occur less frequently in people without pain or dysfunction, effects on the peripheral tissue site because the activated and that are reduced or eliminated by treatment? There is nociceptors may secrete pro-inflammatory peptides, also a need to continue to investigate whether OMT enhancing tissue inflammation. Additionally, these central produces relevant physiological and clinical outcomes. On processes may involve changes to motor strategies, acti- the positive side, I think the osteopathic profession vating and inhibiting different muscle groups. The osteo- understands the importance of research e both politically path typically works with the understanding that tissue and for improving patient care e and there are a growing tenderness and abnormal texture to touch or motion indi- number of small clinical trials examining osteopathic cate tissue pathology or dysfunction, but in some individ- management of a range of patient complaints and condi- uals these symptoms and clinical findings may be generated tions, somatic and non-somatic, and a small number of by the central nervous system (allodynia and neurogenic larger multicentre trials. inflammation), rather than the tissues. Add the importance of patient psychology to recovery and disability (bio- Question: Between A.T. Still and today are psychosocial approach), and the violations to the struc- more than 100 years of development in ture/function interrelation paradigm may be substantial. medicine. In view of new knowledge over this How we determine that the structure/function concept is time does it make sense to refer to A.T. Still relevant in certain instances but not in others is an area when asking therapeutic questions? that needs closer attention and exploration. Perhaps clin- ical experience is important for recognising patients who A.T. Still saw a connection between disturbed structure and may respond better to treatment, but e from a scientific altered function and through practical experience found perspective e this is yet to be determined. that he could influence his patients’ health using manual techniques. I think in many ways we have moved on from Question: You prefer the term ‘‘evidence- Still’s original beliefs, particularly in regard to the physio- informed therapy’’ in osteopathy instead of logical mechanisms underlying manipulative therapy. I see ‘‘evidence-based medicine’’. What is the relevance in recalling Still’s words for historical perspective difference? and to remind us to look at many aspects of the body (fascia, nerves, fluids, etc) and to not become too ortho- Due to the lack of high-quality research evidence in osteop- paedic or pharmaceutically based. However, I don’t count athy, we cannot ‘base’ practice on evidence, or we would myself among those who believe that scrutiny of Still’s end up doing very little. I suspect there will never be a time books will reveal hidden meanings or secrets from the past. when we can base every aspect of treatment on research literature because it is hard to imagine that there would ever Although the structure/function interrelation concept be high-quality evidence for every procedure that we use in has taken a beating from some quarters, I don’t think it patient consultation. Instead, we use existing evidence to should be dismissed entirely, but there are limits to its inform and guide our decisions in practice e hence, evidence- applicability. On one level, the connection is self-evident, informed practice e where we assess the relevance of the such as the relationship between poor posture and existing evidence with the needs of a given patient and make mechanical strain on tissues, where altered structure decisions by integrating this knowledge with our own expe- results in physiological changes like inflammation or noci- rience, with other forms of evidence (expert opinion, phys- ception. The possibility that mechanical strain on tissues iological rationale, etc), and with the patient’s own alters cell physiology is also becoming evident from the expectations and individual needs. In short, evidence- process known as mechanotransduction, where fibroblasts informed practice is using research evidence to make have been shown to respond to mechanical forces, changing informed decisions; evidence-based medicine (EBM), in the their physiological processes and even gene expression. strictest sense, disregards clinical judgment and is simply not This process raises potential new support for structure/ possible in view of the limited relevant evidence available. function interaction although the clinical implications of this research are still speculative. The original definition of EBM reads much more like evidence-informed medicine (‘the judicious use of current As a result of the increasing research and resulting best evidence by integrating individual clinical expertise knowledge of pain processing and pain pathophysiology, with the best available external clinical evidence from however, we have reason to further limit the general systematic research’ (Sackett et al., 1996)), but some EBM applicability of the structure/function interrelation purists appear to disregard the role of clinical judgment. concept. The process known as central sensitization may There is also a justifiable fear that EBM may be applied for occur in response to a bombardment of noxious input, economic reasons, rather than for best care. Evidence from resulting in neuroplastic changes in the dorsal horn and randomised controlled trials addresses average results from higher centres to produce long term sensitization of

306 H. Franke large groups and may not necessarily inform a practitioner measure) is also being limited. I actually think this is about individual patients. A treatment found to be effective reasonable and appropriate e why should the state (or for the majority of individuals with a similar complaint may anyone) pay for treatments that don’t work or have no not always be best for the individual for a variety of reasons, evidence of being effective? If we do not provide evidence of including the aetiology of their condition, and their past effectiveness, then third party payers will progressively experience (negative or positive) and expectations of withdraw funding. Lack of evidence of effectiveness is also treatment. Some approaches or techniques are likely to be a major hindrance for emerging osteopathic professions in more effective in the hands of particular practitioners, some countries, where clear evidence of effectiveness would related to their skill and experience. It is also likely that greatly assist their recognition and quest for state licensing. certain treatments will have much larger non-specific effects (placebo) for some patients, and these effects should not be This is not to say that we have no evidence of effec- dismissed lightly. Hence, there remains a need for balance tiveness. We have a moderate level of evidence for the and integration between external clinical evidence and effectiveness of OMT for low back pain (Licciardone et al., clinical experience, and this applies, not just to osteopaths, 2005) and have a growing number of small trials that but to all health practitioners. support the effectiveness of OMT for a variety of condi- tions, such as neck pain, pneumonia in the elderly, irritable Question: Evidence-based medicine means not bowel syndrome, and other conditions (Noll et al., 2000; only that we need evidence for decisions about Fryer et al., 2005; Hundscheid et al., 2007; Schwerla et al., treatment, but also transparency in the 2008; Lombardini et al., 2009). Many of these studies process of a decision, a trial or a position. In involve limited participant numbers and may be criticised short, it means we have to deal with on various methodological grounds; but it is heartening to information and decisions on treatment in see a renewed interest in research within the profession, a different way. Therapists have to explain and as the profession and its researchers mature, we will what they are doing. Do you agree with that see larger, more convincing studies. The growth in the side of view? number of osteopathic research studies, however, presents a problem with the compilation and accessibility of Absolutely. We have moved away (I hope) from past prac- evidence relevant to osteopathic management. It would be tices where patients were told to remain silent because helpful to have this research collated in a form that could they would be incapable or unqualified to ask an intelligent be easily accessible to practitioners, but I am not aware of question to practices where we actively engage the patient any such repository. I have often received requests from with the problem, explore the options with them, and practitioners asking what studies have been done for empower them to participate in the solution. I think one a particular condition or treatment. The collection of positive trend from the EBM movement is the availability of studies (not to mention the interpretation of them) can be information to empower patients in their treatment deci- a tedious process when no reviews exist on a subject. sion-making process. Therefore, we can discuss treatment management with a patient in an honest and intelligent Question: You said also, if a therapist knows way (with an encouraging and positive manner while without any doubt that a treatment will have addressing any inappropriate attitudes or pain behaviours), no success it’s better he does not treat in this the merits of best evidence, and the most effective treat- way. This sounds good and I think many ment in the experience of the practitioner. Although not osteopaths would agree with you. But what in every patient wants to be empowered or active in their osteopathy do we really know without any management, I think those who do are more likely to be doubt? compliant in their aftercare management and have a better chance of recovery. At this stage, there is not much that we can say without any doubt, but this is probably true of most health professions. Question: At the ‘‘Fifth International Rather, we make decisions as to what course of action is Symposium on Advances in Osteopathic reasonable and rational and may be supported by good Research’’ last year you said, that there is external evidence. Osteopathy is not alone in its struggle to a political imperative for osteopathy to be support practice with high-quality external evidence. Some effective. What do you mean by that? researchers have estimated that approximately 13% of medical treatments are based on evidence that supports We need to demonstrate that our approach is effective the beneficial effect of the intervention and that 46% of (assuming that it is). In Australia, we are seeing third party practice has unknown benefit (BMJ Evidence Centre, 2009). payers, such as our state-based Workcover and other health insurance agencies, begin to limit payments to manual I think I also said that we do not have quality evidence that therapists, justified on the basis of EBM. Payment for clearly helps us to select the most appropriate technique, ‘passive’ treatments that are not well supported by evidence but we are beginning to see some effort in this direction. is being limited, and payment for treatment without There is moderate evidence that some techniques produce demonstrated improvement in outcomes (using a validated measurable short-term changes (range of motion, pain thresholds) (Clements et al., 2001; Lenehan et al., 2003; Fryer and Ruszkowski, 2004; Cleland et al., 2005; Ferna´ndez- de-las-Pen˜as et al., 2008; Kanlayanaphotporn et al., 2009)

Research and osteopathy 307 and evidence that osteopathic management produces benefit in using manipulation to the lumbar spine in low improved outcomes for low back pain and certain conditions, back pain; the art may include the identification of lumbar although some of these studies are not easily generalizable to segments that appear restricted, the application of tech- all practice situations (Noll et al., 2000; Fryer et al., 2005; niques (such as soft tissue used firmly enough to produce Licciardone et al., 2005; Hundscheid et al., 2007; Schwerla a change in compliance of the muscle mass, but not enough et al., 2008; Lombardini et al., 2009). Most of this evidence to provoke pain and reactive guarding), and the patiente supports the rationale for the use of these techniques and the practitioner interaction that fosters trust and confidence in conditions or situations where the techniques may be bene- the treatment, dispels irrational fear and counterproduc- ficial. This is not to say that they produce benefit without any tive behaviours, and instils realistic optimism. doubt (nothing in the manual therapy armamentarium, or probably in mainstream medicine, could promise that), but Question: Is it more important to be free in the there is a rationale based on limited external evidence for therapeutic decision-making process or do the use of these techniques to achieve certain aims. I think osteopaths need more guidelines? this is the case for high velocity, muscle energy, and a few other techniques. There is also a good case for non-manual I don’t have any problem with clinical guidelines provided approaches, such as addressing inappropriate pain-related that they are used as guidelines and do not restrict practice behaviours, as per the bio-psychosocial model. There are options. Relevant evidence is there to inform and guide our many manual techniques that are currently being used that choices for the benefit of our patients. By working within have little or no supporting evidence or established efficacy, the recommendations of guidelines, our treatments are but I think it can be appropriate to continue using them more likely to be consistent with the best current research, (based on personal experience and anecdotal evidence) but there should always be the flexibility to use treatments provided they are combined with approaches that have some according to the judgment of the clinician (which may be research or guideline support. If a technique does not have based on previous experience, awareness of patient values a plausible physiological rationale e in addition to a lack of or preferences, etc). Guidelines can provide recommen- evidence of efficacy e then it is appropriate to question its dations about treatment approaches that have the best use. When there is clear evidence of no effectiveness or supporting evidence. Practitioners may use these guidelines evidence of harm, then these approaches should be aban- to add approaches and techniques to what they already use doned (of course, debate will ensue over what constitutes to ensure the best patient care, rather than removing clear evidence of ineffectiveness versus lack of evidence of treatments that may currently have only anecdotal or benefit); although, it is hard to cite an example because of theoretical rationale, but this depends on the individual the lack of research. The bottom line is that practitioners situation. So I think we can benefit from guidelines without should use common sense and be willing to change what they the removal of our clinical judgment or freedom to make do if there is good evidence to do so. decisions. Question: From your point of view: What is the Question: If you compare the development of essence of art in osteopathy? research in osteopathy in Europe, USA and Australia e what are the common points and This is a hard one. I change my answer every time I think what are the differences? about it. I think the art encompasses a range of skills. It includes the way we interact with the patient (listening Research began in the US, with early researchers, such as ability, empathy, support, encouragement, etc) and our Louisa Burns, F.P. Millard, and Wilbur Cole. It gained intuitive interpersonal responses. Then there is the art momentum with the Kirksville research team, which associated with palpation and manual treatment, and this included J.S. Denslow and Irvin Korr, in the 1940s and aspect may largely be intuitive (not supernatural, however 1950s. After the 1960s, the momentum appears to have not resulting from analytic conscious processes, but been lost e with the exception of a few researchers e and assimilated from experience and observational cues) and only in the past decade have we seen renewed interest and may complement the analytical approach. This is probably allocation of resources towards osteopathic research. I0m no different from the art associated with other manual and not aware of any substantial osteopathic research efforts in bodywork disciplines, except perhaps the philosophical the UK or Australia until relatively recently, and the same is emphasis on the ‘whole body’ approach in osteopathy may true of Europe and Canada (particularly given the emerging help promote intuitive leaps in a whole body context (in the state of the professions there). postural, ergonomic, or psychological spheres). But I admit when talking about art I0m completely out of my depth! Lack of access to funding is a common problem for osteopathic researchers outside the US (and probably Question: Are the art of the osteopathy and within the US). In the UK, the profession has a longer history the knowledge of science necessarily and is more established than in continental Europe, but few contradictory? researchers have access to Medical Research Council funds (the UK BEAM trial being an exception). Much of the current I would say complementary, rather than contradictory. The research consists of small-scale student projects that are ‘art’ is the manner in which the ‘science’ is applied. For limited by the funding and resources of private colleges and example, the science may tell us that there is short-term are complicated by an ever increasingly complex Ethics

308 H. Franke approval process. On the positive side, the establishment of in pressure pain thresholds over C5eC6 zygapophyseal joint the National Council for Osteopathic Research in 2003 after a cervicothoracic junction manipulation in healthy shows a commitment to research, with a number of subjects. J. Manipulative. Physiol. Ther. 31 (5), 332e337. projects on adverse events in progress. There are also Fryer, G., Alivizatos, J., Lamaro, J., 2005. The effect of osteo- a growing number of osteopathic PhDs and doctoral pathic treatment on people with chronic and sub-chronic neck students. The situation in Australia is similar, with small- pain: a pilot study. Int. J. Osteopath. Med. 8 (2), 41e48. scale projects conducted with limited funding from osteo- Fryer, G, Bird, M, Robbins, B, Johnson, J. Resting electromyo- pathic departments at state universities, but with few PhDs graphic activity of deep thoracic transversospinalis muscles within the profession. identified as abnormal with palpation. J. Am. Osteopath. Assoc., in press. The state of research in Europe and Canada shows great Fryer, G., Morris, T., Gibbons, P., 2004. Paraspinal muscles and potential. There has been extraordinary growth in smaller intervertebral dysfunction. Part 1. J. Manipulative. Physiol. clinic-based projects e often associated with the require- Ther. 27 (4), 267e274. ments of fulfilling a Master’s degree or similar e resulting in Fryer, G., Morris, T., Gibbons, P., 2004. Paraspinal muscles and innovative and quality research. I have noticed that intervertebral dysfunction. Part 2. J. Manipulative. Physiol. researchers in countries, such as Germany and Italy, often Ther. 27 (5), 348e357. investigate treatment (with an emphasis on visceral tech- Fryer, G., Morris, T., Gibbons, P., Briggs, A., 2006. The electro- niques) of non-musculoskeletal conditions, which is myographic activity of thoracic paraspinal muscles identified as a research area that is not as apparent in the UK or abnormal with palpation. J. Manipulative. Physiol. Ther. 29 (6), Australia. The main barriers to research in Europe are lack 437e447. of access to Ethics approval committees and limited Fryer, G., Ruszkowski, W., 2004. The influence of contraction resources and funding from private colleges, but because of duration in muscle energy technique applied to the atlanto- the post-graduate structure of osteopathic training in some axial joint. J. Osteopath. Med. 7 (2), 79e84. countries (such as Germany), research is being performed Hundscheid, H.W., Pepels, M.J., Engels, L.G., Loffeld, R.J., 2007. by osteopaths with established practices in their own Treatment of irritable bowel syndrome with osteopathy: results clinics, which does not occur in the UK and Australia of a randomized controlled pilot study. J. Gastroenterol. Hep- because students train in undergraduate programs. There is atol. 22 (9), 1394e1398. increasing professionalization taking place in Europe, with Kanlayanaphotporn, R., Chiradejnant, A., Vachalathiti, R., 2009. Master’s and doctoral programs in progress in several The immediate effects of mobilization technique on pain and countries. It looks very promising for the future. range of motion in patients presenting with unilateral neck pain: a randomized controlled trial. Arch. Phys. Med. Rehabil. References 90 (2), 187e192. Korr, I.M., Wright, H.M., Thomas, P.E., 1962. Effects of experi- BMJ Evidence Centre 2009 How much do we know? Retrieved mental myofascial insults on cutaneous patterns of sympathetic 14.01.2010, from http://clinicalevidence.bmj.com/ceweb/ activity in man. J. Neural. Transm. 23, 330e355. about/knowledge.jsp. Lenehan, K.L., Fryer, G., McLaughlin, P., 2003. The effect of muscle energy technique on gross trunk range of motion. J. Cleland, J.A., Childs, M.J.D., McRae, M., Palmer, J.A., Stowell, T., Osteopath. Med. 6 (1), 13e18. 2005. Immediate effects of thoracic manipulation in patients with Licciardone, J.C., Brimhall, A.K., King, L.N., 2005. Osteopathic neck pain: a randomized clinical trial. Man. Ther. 10 (2), 127e135. manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. BMC Mus- Clements, B., Gibbons, P., McLaughlin, P., 2001. The amelioration culoskelet. Disord. 6, 43. of atlanto-axial rotation asymmetry using high velocity low Lombardini, R., Marchesi, S., Collebrusco, L., et al., 2009. The use amplitude manipulation: is the direction of thrust important? J. of osteopathic manipulative treatment as adjuvant therapy in Osteopath. Med. 4 (1) 8e4. patients with peripheral arterial disease. Man. Ther. 14 (4), 439e443. Denslow, J.S., 1975. Pathophysiological evidence for the osteo- Noll, D.R., Shores, J.H., Gamber, R.G., Herron, K.M., Swift Jr., J., pathic lesion: the known, unknown and controversial. J. Am. 2000. Benefits of osteopathic manipulative treatment for Osteopath. Assoc. 75 (4), 415e421. hospitalized elderly patients with pneumonia. J. Am. Osteo- path. Assoc. 100 (12), 776e782. Denslow, J.S., Clough, G.H., 1941. Reflex activity in the spinal Sackett, D.L., Rosenberg, W.M., Gray, J.A., Haynes, R.B., extensors. J. Neurophysiol. 4, 430e437. Richardson, W.S., 1996. Evidence based medicine: what it is and what it isn’t. Br. Med. J. 312 (7023), 71e72. Denslow, J.S., Hassett, C.C., 1942. The central excitatory state Schwerla, F., Bischoff, A., Nurnberger, A., Genter, P., associated with postural abnormalities. J. Neurophysiol. 5, Guillaume, J., Resch, K., 2008. Osteopathic treatment of 393e402. patients with chronic non-specific neck pain: a randomised controlled trial of efficacy. Forsch Komplementmed 15, Denslow, J.S., Korr, I.M., Krems, A.D., 1947. Quantitative studies of 138e145. chronic facilitation in human motorneuron pools. Am. J. Phys- iol. 150 (2), 229e238. Ferna´ndez-de-las-Pen˜as, C., Alonso-Blanco, C., Cleland, J.A., Rodr´ıguez-Blanco, C., Alburquerque-Send´ın, F., 2008. Changes

Official journal of the: Journal of ® A ssociation of Bodywork Neuromuscular Therapists, and Movement Ireland Therapies ® A ustralian Pilates Method Association ® N ational Association of Myofascial Trigger Point Therapists, USA ® P ilates Foundation, UK Volume 14 Number 4 2010 EDITOR-IN-CHIEF Leon Chaitow ND, DO c/o School of Integrated Health, University of Westminster, 115 New Cavendish Street, London W1M 8JS, UK Preferred mailing address: P.O.Box 41, Corfu, Greece 49100 ([email protected]) ASSOCIATE EDITORS John Hannon DC Dimitrios Kostopoulos PhD, DSc, PT San Luis Obispo, CA, USA ( [email protected]) Hands-on Physical Therapy, New York, NY, USA ([email protected]) Glenn M. Hymel EdD, LMT Craig Liebenson DC Department of Psychology, Loyola University, New Orleans, LA, Los Angeles, CA, USA ([email protected]) USA ([email protected]) ASSOCIATE EDITORS: PREVENTION & REHABILITATION Warrick McNeill MCSP Matt Wallden MSc, Ost, Med, DO, ND London, UK ([email protected]) London, UK ([email protected]) International Advisory Board D. Beales MD (Cirencester, UK) G. Fryer PhD. BSc., (Osteopath), ND D. R. Murphy DC (Providence, RI, USA) G. Bove DC, PhD (Kennebunkport, ME, USA) T. Myers (Walpole, ME, USA) C. Bron PT (Groningen, The Netherlands) (Melbourne City, Australia) C. Norris MSc CBA MCSP SRP (Sale, UK) I. Burman LMT (Miami, FL, USA) C. Gilbert PhD (San Francisco, USA) N. Osborne BSc DC FCC (Orth.), FRSH, ILTM J. Carleton PhD (New York, USA) C. H. Goldsmith PhD (Hamilton, ON, Canada) F. P. Carpes PhD (Uruguaiana, RS, Brazil) S. Goossen BA LMT CMTPT (Jacksonville, FL, USA) (Bournemouth, UK) Z. Comeaux DO FAAO (Lewisburg, WV, USA) S. Gracovetsky PhD (Ocracoke, NC, USA) B. O’Neill MD (North Wales, PA, USA) P. Davies PhD (London, UK) M. Hernandez-Reif PhD (Tuscaloosa, AL, USA) J. L. Oschman PhD (Dover, NH, USA) J. P. (Walker) DeLany LMT (St Petersburg, FL, USA) P. Hodges BPhty, PhD, MedDr (Brisbane, Australia) D. Peters MB CHB DO (London, UK) M. Diego PhD (Florida, USA) B. Ingram-Rice OTRLMT (Sarasota, FL, USA) M. M. Reinold PT, DPT, ATC, CSCS (Boston, MA, J. Dommerholt PT, MS, DPT, DAAPM (Bethesda, J. Kahn PhD (Burlington, VT, USA) R. Lardner PT (Chicago, IL, USA) MD, USA) MD, USA) P. J. M. Latey APMA (Sydney, Australia) G. Rich PhD (Juneau, AK, USA) J. Downes DC (Marietta, GA, USA) E. Lederman DO PhD (London, UK) C. Rosenholtz MA, RMT (Boulder, CO, USA) C. Fernandez de las Peñas PT, DO, PhD (Madrid, D. Lee BSR, FCAMT, CGIMS (Canada) R. Schleip MA, PT (Munich, Germany) D. Lewis ND (Seattle, WA, USA) J. Sharkey MSc, NMT (Dublin, Ireland) Spain) W. W. Lowe LMT (Bend, OR, USA) D. G. Simons MD (Covington, GA, USA) T. M. Field PhD (Miami, FL, USA) J. McEvoy PT MSC DPT MISCP MCSP (Limerick, Ireland) D. Thompson LMP (Seattle, WA, USA) P. Finch PhD (Toronto, ON, Canada) L. McLaughlin DSc PT (Ontario, Canada) C. Traole MCSP, SRP, MAACP (London, UK) T. Findley MD, PhD (New Jersey, USA) C. McMakin MA DC (Portland, OR, USA) P. W. Tunnell DC, DACRB (Ridgefield, D. D. FitzGerald DIP ENG, MISCP, MCSP (Dublin, J. M. McPartland DO (Middleburg, VT, USA) C. Moyer PhD (Menomonie, WI, USA) CT, USA) Ireland) E. Wilson BA MCSP SRP (York, UK) S. Fritz LMT (Lapeer, MI, USA) A. Vleeming PhD (Rotterdam, The Netherlands) Visit the journal website at http://www.elsevier.com/jbmt Available online at www.sciencedirect.com Amsterdam • Boston • London • New York • Oxford • Paris • Philadelphia • San Diego • St. Louis Printed by Polestar Wheatons Ltd, Exeter, UK

Journal of Bodywork & Movement Therapies (2010) 14, 309e311 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt EDITORIAL Italian osteopathy e An exciting European example Osteopathy in Europe e particularly in Italyeis evolving its Frymann DO, who continues her teaching and clinical work own professional shape e independent of the long-estab- as she approaches 90. Dr Frymann spoke about her work lished United Kingdom model (which is itself changing), and with infants and neonates, some of it collaboratively with different from osteopathy’s roots in the USA. Italian osteopaths. In the UK, since the initiation of state regulation, and Some of the projects reported on by Italian osteopaths the establishment of the profession’s regulating body, the (see selection of summaries below), involved only small General Osteopathic Council, there appears to have been number of patients e making it impossible to draw definitive an emerging trend towards a more biomechanical/muscu- conclusions e however what seems at least as important as loskeletal, evidence-based, focus for the profession. the results of such studies (and arguably far more important), Obvious conditions such as low back pain, and neck and is the fact that they are taking place at all. shoulder issues (as examples), seem to be what UK’s close to 4000 osteopaths treat, most of the time, encouraged by Dr Viola Frymann, Rome, June 2010 the GOC, and the BOA (British Osteopathic Association) the profession’s virtual ‘trade-union’. While those UK trained osteopaths who have had, as part of their training, a broader philosophical and practical exposure e for example where naturopathic subjects are part of the training, or where ‘classical osteopathy’ has been taught e still treat patients with general health conditions, this is not the direction either the GOC, BOA, or the colleges, are encouraging. In the USA the majority of DO0s no longer employ manip- ulation as part of their patient care; their work being almost indistinguishable from standard medical practice. Those DO0s who do use manual approaches in patient care are finding an ever more hostile environment in which, in many States, payment for time spent on such treatment is being denied, or drastically reduced, by health insurance providers. Participation in the 2nd Italian Congress of Osteopathic Medicine, in Rome, in June (June 17e20), demonstrated that an energetic and exciting osteopathic profession is alive and thriving in Italy (as it is in many other European countries e including Spain, France, Belgium, Austria, Germany and Russia). The conference, efficiently organised under the direc- tion of Paulo Tozzi DO, brought together many young (mainly) Italian osteopaths, who appear to have found ways of initiating and/or collaborating in a range of research projects, details of which were presented to an enthusi- astic conference audience of around 200. Two veteran American osteopaths were also presenting, Professor Michael Patterson e who in his address confirmed many of the trends discussed above e as well as Viola 1360-8592/$36 ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.07.005

310 Editorial A dynamic Italian osteopathic profession is emerging, from “assessment for joint dyskinesia, asymmetry of myo- with an enthusiastic desire to explore osteopathic efficacy fascial tonus and posture.” in many areas of health concern. One result is a cohort of osteopaths, whose research skills are being refined, In her presentation the collaborating surgeon, Anastasia offering new insights as to the mechanisms and methods Ussia MD, reported on one study, involving 4 patients, aged that osteopathic treatment can produce. between 20 and 40, who had demonstrated idiopathic infertility for over 2 years, accompanied by superficial A brief summary of selected research reports from the endometriosis. The osteopathically treated patients were Congress include: compared with those for whom a ‘wait and see’ approach, was adopted. Three one hour, osteopathic treatments were Osteopathy in neonatology clinical approach, given at fortnightly intervals. At six-month follow-up three treatment protocol, statistical study members of the infertile group were pregnant. Craighero Germano DO presented a report on 5 years of In a separate pilot study, five patients aged 20e45, who study of approximately 2000 neonates at Villa Salus had previously had surgery for serious endometriosis, and Hospital in Venice. A summary report was given involving who subsequently suffered persistent pain, “not attribut- 1000 infants who had been examined and treated e 772 able to gynaecological problems”, also received three one vaginal births and the remainder caesarean. hour, osteopathic treatments at fortnightly intervals. At 6 months follow-up, two patients were pain free, and two Based on assessments of these infants the following others showed significant reductions in pain. No conclusions summary of findings emerged: could be drawn due to the small numbers involved in these trials, however the researchers suggest that the encouraging Infants born vaginally most commonly demonstrated results highlight a need for further studies, with the objec- lateral cranial strains and occipital and cranial axis tive of developing a randomized controlled research project. compressions. Infants born by caesarean section demonstrated a greater head circumference with more Osteopathic manipulative treatment as adju- frequent injuries to the occiput. vant therapy in patients with peripheral arte- rial disease (PAD.) Based on his years of experience with neonates it was suggested that “osteopathic rebalancing” might prevent This study (Lombardini et al., 2009), conducted at the adverse structural and functional developmental effects of University of Perugia, evaluated and compared endothelial the observed cranial distortions. function and lifestyle modifications in 15 intermittent claudication patients who received both medical and Cancer related fatigue syndrome (CRFS) osteopathic treatment (OMT group) and 15 intermittent claudication patients, matched for age, sex and medical Members of the research team that investigated the effects treatment e the control group e who received standard of osteopathic care given to patients with CRFS, (Gugliemo medical attention. Compared to the control group, the OMT Donniaquio, Luca Brema, Marino Pietro, Patrizia Boero) group had a significant increase in brachial flow-mediated reported on a study conducted at San Paolo Day Hospital, vasodilation, ankle/brachial pressure index, treadmill Savona, Italy. The study was conducted by 6th (i.e. final) testing, and physical health component of life quality (all year osteopathic students from the European School of p < 0.05), assessed at 2 months and 3 months from the start Medical Osteopathy in Genoa, under the supervision of of the study. A report on this research initiative was pub- faculty. The aim was to evaluate whether osteopathic lished in Manual Therapy in August 2009. treatment could be helpful in producing objective and effective results in patients with CRFS. Each of the 50 Many other reports were delivered at the Rome cancer patients (male and female), aged between 40 and congress, on topics as varied as: 60, received 1 h of osteopathic treatment, every 3 months for 15 months. Treatment involved a cranial osteopathic  Possible correlations between performance and reba- protocol, as well as “‘multidimensional technique’ lancing of osteopathic pivots in athletes (Feliziani C involving craniosacral, visceral, somatic-structural and Moretti M) neurovegetative rebalancing methods”. The findings of improved CRFS-related symptoms, and life quality  Clinical and kinematic evaluation of osteopathy-vs- improvements, suggested that a larger study would be specific exercise in obese non-specific chronic low back justified. pain patients (Vismara L et al) Infertility, endometriosis and osteopathy  OMT and epicondylitis (Giacomo S et al)  The importance of deglutition in athletic performance Two small trials, initiated in a collaboration between surgeons and osteopaths, were reported on. The lead oste- (Desiro P) opath involved in the study, Alexandre Belloni DO, reported  Pain in patients with spinal injuries: OMT effects asso- that in both trials, osteopathic treatment involved “elonga- tion, manipulation, inhibition, stimulation” following on ciated with drug therapy (Arienti C et al)  Dynamic Ultrasound evaluation of sliding motion of organs related to fascia layers, before and after oste- opathic techniques are applied (Bongiorno D Tozzi P) These examples of research initiatives from Italy suggest a bright future for osteopathy in that country.

Editorial 311 Reference Leon Chaitow, ND DO 144 Harley Street, London W1G7LE, Lombardini, R., et al., 2009. The use of osteopathic manipulative treatment as adjuvant therapy in patients with peripheral United Kingdom arterial. Man. Ther. 14 (4), 439e443. E-mail address: [email protected]

Journal of Bodywork & Movement Therapies (2010) 14, 312e314 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt CONFERENCE REPORT Lessons from the conference: “Highlighting Massage Therapy in Complementary and Integrative Medicine” Geoffrey M. Bove, DC, PhD a,*, Susan L. Chapelle, RMT b,1 a University of New England College of Osteopathic Medicine, 208A Stella Maris Hall, 11 Hills Beach Road, Biddeford, ME 04005, United States b Squamish Therapeutic Massage, #108-41105 Tantalus Road, Squamish, BC V8B-0A8, Canada Received 4 June 2010; accepted 4 June 2010 A landmark conference, Highlighting Massage Therapy in pointed out that the majority of treatments provided by Complimentary and Integrative Medicine, was held in Seat- massage therapists are for conditions where the etiologies tle, Washington, on May 13the15th, 2010. The conference are unknown. While this is true for other providers as well, it was designed to address the status of research related to is a critical point, and is not usually discussed. If we do not massage therapy, as well as to have an open discussion know the etiologies of the problems we are treating, how can regarding attitudes towards research and professional we design treatments based on anything but experience? And issues. Leaders from diverse manual therapy professions if a treatment works, can we move backwards to the presented interesting and important data. The itinerary and etiology? Moreover, how can we look for mechanisms without summaries of the meeting can be found at http://www. etiologies? These are critical questions to think about and massagetherapyfoundation.org/researchconference2010. discuss. Dr. Langevin also discussed that while the histology html. In this brief report, rather than summarizing the of connective tissue is well understood, the physiology of it is presentations, we will share a combination of our observa- not. It is commonly held that connective tissues are passive. tions and impressions, as well as suggestions for the direc- She presented evidence that undifferentiated and pluripo- tion of massage therapy research. tent fibroblasts within connective tissue respond to stresses by migration to injured areas, where they transformation Diana Thompson, LMP, opened the conference by into contractile elements. More data presented showed that stressing the need for mutual respect and collaboration fascia is innervated with neuronal processes consistent with between clinicians and researchers, and pointed out the those that may mediate pain (such innervation is present in overarching need to determine possible mechanisms of virtually all other structures). Such neurons “police” the action of massage therapy. structures they are in and mediate inflammatory responses. Dr. Langevin concluded by showing that the thoracolumbar Helene Langevin, MD, re-emphasized the need for fascia in humans with back pain is thicker than in humans mechanistic understanding. Perhaps more importantly, she without back pain. While preliminary, these data in combi- nation document that fascia is not only responsive to * Corresponding author. Tel.: þ1 207 602 2921 (Lab); fax: þ1 207 stresses, but is more so in pathological states. These data 602 5931. have the potential to form a foundation for much future research into the mechanisms of back pain and its E-mail addresses: [email protected] (G.M. Bove), slchapelle@me. treatment. com (S.L. Chapelle). 1 Tel.: þ604 567 2666. 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.06.005

Lessons from highlighting massage therapy 313 Helene Langevin, MD clinical efforts. This particular area seems fertile for studying Dan Cherkin, PhD, shared data from his recent studies. the potential effects of manual therapy at a cellular level. In a study of acupuncture compared to massage, it was shown that massage therapy led to better outcomes. In The first panel discussion involved public health and another study, both “relaxation” and “structural” massage professional issues that are critical to massage therapy therapy improved function for back pain patients better research. It was presented that although there are many than normal care. These data constitute good evidence that thousands of massage practitioners, and that more than 8% massage therapy has significant effects for low back pain, of the US population uses their services, the educational and needs further research. Dr. Cherkin pointed out that standards and licensing of massage practitioners are critical issues such as provider type and training, dosage, diverse. The discussion also involved questions of whether technique, and patient type need to be addressed. massage therapy is a profession or a discipline. Should Willem Fourie, PT, discussed the use of manual therapy in massage therapy work towards integration into mainstream recovery from breast cancer, specifically post-surgical scarring healthcare, or should it remain largely separate? In many due to mastectomy, which very often leads to chronic pain and provinces in Canada, massage therapy has enjoyed the lymphedema. The current lack of understanding of the respect of being a registered health care profession. response of connective tissues to surgery became clearer, as Massage therapists in three provinces are governed by the did the potential role of manual therapists in post-surgical same rules and regulations as other health care providers, complications. Mr. Fourie included data from Antonio Stecco to and this allows for accountability within the system. In the stress the importance of inflammation in surgically disrupted USA, the licensing is inconsistent between states, and there connective tissue. Research into the physiology of post- remain a few states without licensing. The discussion sup- surgical complications and the effects of treatments directed ported the efforts of the associations and educators to to the scarring are necessary and seem to be of high priority. standardize education. Such efforts would be expected to This is an excellent example of where therapists could be and lead to uniform licensing, and would also increase the should be directly involved in all facets of both laboratory and possibility of developing more extensive and collaborative research efforts. Willem Fourie, PT The second panel discussion emphasized “translational research.” This phrase is now used along with “from bench to bedside” to describe the reciprocal need of sharing information between the clinic and the laboratory. For clinical science to advance most efficiently, clinicians will need to better inform scientists of their pressing questions, and the scientists will need to develop clinically relevant approaches to answer these questions. Such communica- tion is typically initiated during meetings such as this one. In the breakout sessions, science related to massage therapy was presented. Space does not allow coverage of each presentation. The diversity of the backgrounds of the presenters was striking, and consisted of professional researchers as well as practitioners giving their first presentations. We applaud the newcomers, who should inspire others to feel confident to make such an effort. In the first session, challenges in methodological designs were clearly presented, and this seemed to be somewhat of a revelation to the audience. The presentations accentu- ated that performing meaningful research is very difficult, time consuming, and expensive, and that a supportive, collaborative, and multidisciplinary environment is of utmost importance. A presentation by Laurel Finch, LMT, CNMT was more about the process than the data, and we found this most inspiring. She reminded us that the fore- most skills for performing research are tenacity and the belief that one can succeed. This research meeting for massage therapy can be considered a call to arms for the profession. However, many challenges need to be overcome. We see the two major challenges as being funding and formal education. Funding remains a primary problem for massage therapy research, as it is for all research. In the US, the National Institutes of Health has designed grant mechanisms specifically for manual therapy research. The funds go to the best appli- cations as judged by peer review and the program priorities of the institute. We do not know what resources are potentially available worldwide. Organizations like the

314 G.M. Bove, S.L. Chapelle Massage Therapy Foundation, as well as other smaller all modalities, animal models need to be developed that massage therapy associations, have made some funds resemble the conditions that massage therapists treat. The available for research, despite limited resources. profession needs to identify research priorities through consensus to ensure that the research proceeds in the most A general impediment to being awarded grants is that efficient manner possible, and with the most benefit to the advanced degrees are required. Until a cadre of therapists public health care system. Perhaps with more of an attain such degrees, the profession needs to develop more evidence base, massage therapy can enter the public partnerships with universities and laboratories interested in health system and ultimately be supported as a health care the effects of manual treatments as provided by massage modality for both prevention and treatment of soft tissue therapists. The profession is urged to identify and sponsor pathology. interested therapists to complete advanced training in research methods. Luata Bray, a shaman and massage therapist, gave a beautiful closing prayer. It is fitting to quote her: “May It is our belief that the massage therapy profession stones be lifted from your path more easily in the upcoming needs to develop a standardized education system, years. Let us continue to lead the way in offering our designed to give a deeper knowledge of anatomy and communities with solid and acceptable evidence that pathology as well as to promote critical thinking. Schools massage therapy is indeed a medical modality for all must seek degree-granting accreditation, necessary for people.” The road ahead is indeed rocky, but not academic advancement. Besides aiding research efforts, impassible. such changes will lead to deeper communication with and respect among health care professionals. Of course, all Acknowledgement such changes will positively impact patient care, which is the ultimate goal. Partial funding for GMB to attend the meeting was provided by Elsevier. As for the direction that massage therapy research might take, it is clear that clinical trials based on case studies need to identify treatment effects on larger cohorts. As for

Journal of Bodywork & Movement Therapies (2010) 14, 315e317 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt CONFERENCE REPORT Highlighting Massage Therapy in CIM Conference: A massage therapist’s perspective Michael Hamm, LMP CCST Cortiva Institute e Seattle, 425 Pontius Ave North, Seattle, WA 98109, USA Introduction Major themes In May of 2010, the second Highlighting Massage Therapy in Like any good conference, it was impossible to witness every CIM Research Conference took place in Seattle, WA. The worthwhile presentation. A brief scan of the daily agenda conference attracted 350 attendees, including massage revealed an array of compelling subjects and thoughtful therapists, allied healthcare practitioners, researchers, and speakers. The following are four major themes that emerged: public health administrators. 291 attendees traveled from within the United States, 46 came from Canada, and Science as a social enterprise a handful arrived from Australia, New Zealand, Italy, Greece, To the newly initiated bodyworker, it is easy to conceive of South Africa, and the United Kingdom (C. Leeders, personal science as a monolithic entity, churning out its judgments communication, June 14, 2010). This article is a brief without outside input. Conversely, a scientific investigator synopsis from the perspective of one attendee. Major themes may imagine manual therapists as uninterested in his/her are highlighted and implications discussed, but a compre- work and incapable of constructive discourse. Outgoing MTF hensive overview is not intended in this report. President Diana Thompson addressed these misconceptions in her conference-opening talk by encouraging both prac- Purpose/Intent of the Conference titioners and researchers to recognize the creative poten- tial in both domains. She cautioned against the use of In organizing the conference, the Massage Therapy Foun- insular terminology, described the passion that underlies dation (MTF) had four primary goals. First was the dissem- both kinds of work, and set a tone of mutual curiosity that ination of new research to attendees, which included carried through the conference. During a breakout session clinical trials, basic mechanistic studies, educational on the next day, Menard & Weeks (2010) presented quali- research, case reports, and high-level reviews. Second, the tative interview findings on what factors give rise to MTF hoped to encourage translational research e that is, successful collaborations between CIM providers and empowering both scientist and massage practitioner with research institutions. (These include diligent preparation, knowledge from the other’s field. Third (and perhaps most personal initiative, and the persistent cultivation of funders interestingly), the conference was to incorporate live and institutional allies.) Overall, the impression given was demonstrations of technique and thus foster more creative that a healthy massage research community includes active research design. Fourth was to facilitate productive exchange between researchers and practitioners, and that collaborations between manual therapists and CIM each group must strive to be accessible to the other. researchers through focused breakout sessions and theme lunches. (Massage Therapy Foundation, 2009) Clinical findings The bulk of the content presented was focused on the effects E-mail address: [email protected] of manual therapy in practice, and did not attempt to establish new physiological models or to redefine the 1360-8592/$ - see front matter doi:10.1016/j.jbmt.2010.07.002

316 M. Hamm Translational research and the future of massage science bodywork field. These clinical presentations spanned the If the 2005 Highlighting conference was organized around range of evidence, including case reports, pilot studies, promoting research literacy and participation, this second clinical trials, and high-level reviews. Haraldsson (2010) installment sought to make emerging research more effec- updated a 2006 Cochrane Review on massage for mechanical tive. How swiftly can a published finding make its way into neck disorders, finding that positive evidence remains a typical massage practice? What makes for sound clinical modest at best, and that studies must be strategically craf- reasoning? How do the various hunches of bodyworkers ted to determine risk, placebo effects, optimum dosage, etc. become testable hypotheses? Several speakers attempted to Moyer (2010) presented a comprehensive quantitative address these questions. Julie Ann Day (2010) discussed the review on cortisol reduction in massage therapy, concluding work of Italian physiotherapist Luigi Stecco, who developed that cortisol reduction is mostly insignificant (with the major a fascial manipulation technique through the painstaking exception being children receiving multiple massage treat- extrapolation of a central hypothesis. He proposed that the ments), and that other mechanisms should be proposed for myofasciae have a proprioceptive function, and that this effects on anxiety, depression, and pain. On the other end of function is divided into discrete segments throughout the the evidence spectrum, a survey of recent case reports body. As more complex movements are assembled, the body highlighted some creative approaches to examining massage uses retinacula and septa between antagonists to coordinate in practice. This included an innovative body diagram for action. Stecco’s assertions are similar to those of later concisely describing massage techniques (Larson, 2010) and (contemporary) fascial theorists, but the specificity of his the use of pupil position for the accurate measurement of concepts allowed for meaningful histological study to be postural change in photographs (Goral and Burkett, 2010). conducted. Day’s presentation was an urgent appeal to innovative clinicians to hone their treatment models into Better measures lead to clearer mechanisms testable hypotheses. The basic science of bodywork can be hard to conduct with appropriate rigor. The multivariate nature of human Equally urgent was the call for research that is designed contact e combined with a relative paucity of scientists with clinical relevance in mind. In a panel discussion on who are also trained in manual therapy e make for an translational research, Leon Chaitow (2010) listed examples anemic literature on physiological mechanisms (Langevin 2010a). Large-scale clinical trials of massage therapy are Figure 1 Diane Thompson LMT and Julie Ann Day PT. being conducted without knowledge of how effects are produced. The result is studies whose conclusions are not Figure 2 Geoff Bove PhD DC. useful to clinicians. Dr. Helene Langevin summarized this state of affairs with her usual clarity, portraying basic research and clinical trials as two interdependent pursuits. She specifically called for developing better biomarkers in clinical trials (Can we devise more measures that are clin- ically relevant, non-invasive, and predictive of therapeutic response?)(Langevin 2010b). Willem Fourie, a physiothera- pist from South Africa, gave an illuminating talk on the use of ultrasound in measuring the success of manual therapy for scar tissue mobilization (Fourie 2010). In a patient recovering from shoulder surgery, Fourie showed a series of ultrasound scans taken at different times in the course of manual therapy treatment. In the early slides, Fourie pointed out a thick adhesion between superficial and deep layers, and then showed the adhesion dissipate in later scans, until it had mostly normalized. The obvious conclu- sion was that manual therapy was successful. “Do you agree with me?,” Fourie asked his audience, and after receiving approval from the friendly crowd, pro- ceeded to dismantle his own prior argument. Despite the exciting findings, there were major weaknesses in his methods and the ensuing implications. The scans were taken by multiple people with varying styles of application, the scans themselves were not positioned precisely, and the visual plane of each scan varied somewhat between readings. All of these inconsistencies may have accounted for the apparent reduction in scar, and thus they severely limited the conclusions to be drawn from Fourie’s investi- gation. Such studies are all too common in the manual therapy field, and too often the clinicians reading those studies fail to recognize the methodological limitations. In offering his own work as a cautionary tale, Fourie exposed some of the pitfalls of incomplete outcomes measures.

Highlighting massage therapy in CIM conference 317 of scientific studies that fail to translate into practice. These References include studies that e for practical reasons e are conducted on asymptomatic patients and/or normal tissues. In other Day, J.A., 2010. First the hypothesis: How a biomechanical model studies, conclusions are muddled with too many variables or can influence fascial anatomy research description. Conference with clumsy research questions. Dr. Chaitow lamented the lost Presentation: Highlighting Massage Therapy in CIM Research. opportunity in such endeavors. Panelists Geoffrey Bove (2010) Seattle, WA. and Dan Cherkin (2010) both described their experiences in conducting research with a translational goal. Dr. Bove Bove, G., 2010. Translational research panel. Conference Presenta- reported on the effects of mechanical stress on nerve tissue, tion: Highlighting Massage Therapy in CIM Research. Seattle, WA. and delineated three types of peripheral pain (nociceptive, ectopic nociceptive, and neuropathic). It became clear during Chaitow, L., 2010. Translational research panel. Conference Bove’s talk that our understanding of pain is undergoing rapid Presentation: Highlighting Massage Therapy in CIM Research. revision, and that the treatment models used in manual Seattle, WA. therapy must be updated accordingly. Dr. Cherkin, a researcher of low back pain, spoke of the importance of Fourie, W., 2010. Translational research panel. Conference collaborative relationships during the design phase of a clin- Presentation: Highlighting Massage Therapy in CIM Research. ical trial, and offered a fresh perspective on placebo effects: Seattle, WA. “Placebo is a reflection of healing. We need to learn how to capitalize on it, and not [merely] control for its effects.” Cherkin, D., 2010. Translational research panel. Conference Presentation: Highlighting Massage Therapy in CIM Research. Once concrete findings have been published, it is Seattle, WA. important to incorporate them into practice. Whitney Lowe (2010) gave the last keynote address, summarizing the Goral, K., Burkett, M., 2010,). Massage-induced postural change as concepts from several other presentations into an insightful a mechanism of effect for reduction of anxiety: related discussion of “knowledge translation”. The bodywork procedures and findings from two case studies. Conference profession has a number of obstacles e educational, insti- Presentation: Highlighting Massage Therapy in CIM Research. tutional, and cultural e to overcome if it will make full use Seattle, WA of the evidence available to it. Lowe offered practical advice on how to manage information overload, how to Haraldsson, B.G., 2010. Massage for mechanical neck disorders: A read articles critically, and how to reform the continuing systematic review e 2009 update. Conference Presentation: education model that currently prevails. Highlighting Massage Therapy in CIM Research. Seattle, WA. At the core of the conference was an excitement about Langevin, H.M., 2010a. Connective tissue physiology and its rele- the possibility that bodyworkers can find a wider audience, vance to manual therapies. Conference Presentation: High- build effective research collaborations, and relieve more lighting Massage Therapy in CIM Research. Seattle, WA. suffering within integrative healthcare settings. Along with that excitement came a growing maturity about the role of Langevin, H.M., 2010b. Translational research panel. Conference research in clinical practice. Bodywork remains an art form, Presentation: Highlighting Massage Therapy in CIM Research. and manual therapists make frequent use of compassion Seattle, WA. and improvisation in their work. In years past, there was a suspicion among some therapists that scientific investi- Larson, E., 2010. Massage therapy effects in a long-term prosthetic gation would undermine the intuitive nature of bodywork. user with fibular hemimelia. Conference Presentation: High- The overall impression from the 2010 Highlighting confer- lighting Massage Therapy in CIM Research. Seattle, WA. ence was that science and artistry cannot only coexist, but will thrive in each other’s presence. Lowe, W., 2010. Knowledge translation: Key skills for highly successful clinicians. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA Massage Therapy Foundation. 2009. R13 Conference grant proposal to NCCAM, section 5: Conference plan. (PHS 398 Research Plan). Evanston, IL. Menard, M. and Weeks, J., 2010. Developing research collabora- tions: A “how-to” guide for CAM schools. Conference Presenta- tion: Highlighting Massage Therapy in CIM Research. Seattle, WA. Moyer, C.A., 2010. Cortisol reductions in response to massage therapy: A comprehensive quantitative review. Conference Presentation: Highlighting Massage Therapy in CIM Research. Seattle, WA.

Journal of Bodywork & Movement Therapies (2010) 14, 318e325 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt FASCIA RESEARCH How much time is required to modify a fascial fibrosis? Borgini Ercole, MD a, Stecco Antonio, MD b, Day Julie Ann, PT c, Carla Stecco, MD d,* a Borgini Medical Center, Cesenatico, Italy b Physical Medicine and Rehabilitation Clinic, University of Padova, Italy c Centro Socio Sanitario dei Colli, Physiotherapy, Azienda Ulss 16, Padova, Italy d Department of Human Anatomy and Physiology, University of Padova, Via A Gabelli 65, 35127 Padova, Italy Received 9 October 2009; received in revised form 18 January 2010; accepted 10 April 2010 KEYWORDS Summary The perception of what appears to be connective tissue fibrosis, and its conse- Connective tissue; quent modification during therapy, is a daily experience for most manual therapists. The Fascia; aim of this study was to evaluate the time required to modify a palpatory sensation of fibrosis Manipulation; of the fascia in correlation with changes in levels of patient discomfort in 40 subjects with low Plasticity; back pain utilizing the Fascial Manipulation technique. This study evidenced, for the first time, Low back pain; that the time required to modify an apparent fascial density differs in accordance with differ- Manual therapy ences in characteristics of the subjects and of the symptoms. In particular, the mean time to halve the pain was 3.24 min; however, in those subjects with symptoms present from less than 3 months (sub-acute) the mean time was lesser (2.58 min) with respect to the chronic patients (3.29 min). Statistically relevant (p < 0.05) differences were also evidenced between the specific points treated. ª 2010 Elsevier Ltd. All rights reserved. Introduction suggest that trauma or overuse syndromes can alter the connective tissue and that, in particular, it could become Many authors (Myers, 2001; Schleip, 2003; Stecco, 2004; tighter, altering its histological, physiological and biome- Hammer, 2007; Chaitow, 2008; Masi and Hannon, 2008) chanical characteristics. The process that induces patho- logical modification of myofascial tissue is still not clear. * Corresponding author. Tel.: þ39 049 8272327; fax: þ39 049 Some authors (De Deyne et al., 2000; Matsumoto et al., 8272319. 2002) suggest it could be due to an alteration of the collagen fibre composition. Others (Schleip et al., 2005, E-mail address: [email protected] (C. Stecco). 2006; Chiquet et al., 2007; Grinnell, 2008) evidence the 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.04.006

How much time is required to modify a fascial fibrosis? 319 alteration of the fibroblasts with their transformation into required to produce a pain relief during application of this myofibroblasts, while others (Whatmore and Kholi, 1974; massage varied from 0.4 to 5.1 min, with a mean time of Staubesand and Fischer, 1980; Scott, 2003; Hammer, 2 min. Carreck (1994) evaluated the effect of a light 2007; Stecco and Stecco, 2009) suggest an alteration in stroking massage, applied for a total of 15 min in 20 healthy the ground substance due to neurophysiological influences subjects, and demonstrated that this manoeuvre increased and changes in biochemical fluid relationships could be pain threshold levels, elicited by transcutaneous electrical involved. There is some agreement that when fascia loses stimulation. Kelly (1945, 1946) applied deep transverse its pliability and becomes restricted, it could be a source of massage for 5 min in 46 volunteers using a minimal amount body misalignment and that, over time, this can potentially of pressure that did not cause any pain and demonstrated lead to poor muscular biomechanics (Barker et al., 2006), that this particular modality did not produce a significant altered structural alignment, and decreased strength and modification in the pain perception. motor coordination (Stecco, 2004; Fourie, 2008). Subse- quently, patients may experience pain and functional The aim of this study is to evaluate the time required to deficit. modify the palpatory sensation of fibrosis of the fascia in correlation with changes in levels of patient discomfort in It is also theorized that different manual and physical 40 subjects with low back pain utilizing the Fascial Manip- techniques could restore the normal physiological state of ulation technique. We selected low back pain because it is the fascia, but there is very little scientific evidence about a leading cause of disability with a significant economic the mode of action of manual therapies in general. The impact, not only on lost productivity but also on healthcare Cyriax method (1980) of deep transverse massage and expenditures, approximately a fifth of patients will see similar manual therapies, such as the Graston Technique multiple physicians in their quest for relief of low back pain (Hammer, 2003, 2004) and Rolf (1963), propose modifica- (Jerymyn, 2001) and most manual therapies present tion of connective tissue mobility using the force of cross specific treatment of this pathology. Furthermore, the fibre friction. According to the Myofascial Release tech- fascial planes of the thoracolumbar fascia have been nique (Barnes, 1990), a sustained pressure applied into hypothesised to play a role in the pathogenesis of low back a restricted tissue barrier will cause this tissue to undergo pain (LBP) (Langevin and Sherman, 2007; Schleip et al., histological length changes, and after 90e120 s, a sensation 2007) and there is some initial evidence of correlations of perceivable release is noted and the tissue softens and between altered connective tissue structures and LBP becomes more pliable. Other authors claim that restoration (Langevin et al., 2009), as well as preliminary studies of length and health to the myofascial tissue could relieve indicating possible differences in motion between fascial pressure on pain sensitive structures such as nerves layers in the thoracolumbar fascia in subjects with LBP as (Sucher, 1993) and blood vessels (Quere´ et al., 2009), as compared to a no-LBP groups (Fox et al., 2009). well as restoring alignment and mobility to the joints (Day et al., 2009). The Fascial Manipulation technique (Stecco, Three small areas over the thoracolumbar fascia that, 2004; Stecco and Stecco, 2009) proposes to restore according to Fascial Manipulation theory (Stecco and impeded gliding of collagen and elastic fibres within the Stecco, 2009), are primarily involved in LBP mechanisms ground substance by exploiting heat generated from the have been selected for treatment: friction of deep manipulation. According to the law of Van t’Hoff (Haynie, 2001), which describes the relationship - The area located at the level of the first lumbar between temperature and the velocity of chemical reac- vertebra, approximately 3 cm laterally to the spinous tions, this process could be established only if friction is process of L1 for the paravertebral muscles. Note: in applied where rigidity of the fascial tissue is perceived. By Table 1 this point is indicated with the abbreviation re- applying localized friction in an area of palpable rigidity, lu (retro-lumbi), which is an abbreviation used in the the therapist creates local heat and this may increase Fascial Manipulation technique to indicate this specific certain chemical reactions such as the attenuation of the area (Stecco, 2004). secretion of inflammatory cytokines (Standley and Meltzer, 2008). When connective tissue is heated, it stretches more - The area located at the level of the third lumbar easily (Lehmann et al., 1970). However, no definitive vertebra at approximately 5 cm laterally to the spinous explanation for the biomechanical bases of these trans- process of L3 for the quadratus lomborum. Note: this formations exists. point is indicated with the abbreviation la-lu (latero- lumbi). While manual therapists often report perceptions of altered segmental tissue texture and its modification during - The area immediately below the twelfth rib is for the therapy (Evanko, 2009), and correlations between changes latissimus dorsi, posterior inferior serrati and external in pain thresholds and perceived changes in tissue consis- oblique muscles. Note: this point is indicated with the tencies are at the basis of different therapies (Cyriax, 1980; abbreviation er-lu (extra-lumbi). Typaldos, 2002; Chaitow, 2003; Hammer, 2007; Stecco and Stecco, 2009) little direct evidence for these correlations Materials and method exists (Fryer et al., 2004). Furthermore, a calculation of the mean time required for such changes to occur and the Three operators (B.E., S.A., D.J.A.), each one with more correlation between different patient subgroups with than five years of experience in this method, analysed the different degrees of altered fascial tissue is still lacking. De time required to reduce the pain provoked during the Bruijn (1984) described the application of deep transverse application of this technique by half. Prior to this study, the massage to soft tissue pain in 13 subjects. The time 3 operators evaluated the three points considered for this study in 10 patients with low back pain and compared

320 B. Ercole et al. Table 1 The main characteristics of the treated subjects and the initial and final pain, evaluated with the Verbal Numeric Scale, are reported. aThese patients were treated only on one side because in the opposite side no fascial alteration was detected during comparative palpation.

How much time is required to modify a fascial fibrosis? 321 fibrosis evaluation after each patient until 95% level of left elbows according to the side of the body treated. The agreement was reached (Bland and Altman, 1986). Forty direction of the therapeutic manoeuvres varies according to subjects suffering from acute or chronic mechanical low the underlying structure: in a longitudinal direction with back pain were selected for this study. respect to the muscular fibres of the erector spinae (Fig. 1b); in a transverse direction for the quadratus lumborum The research was conducted on 17 males and 23 females (Fig. 1c); and in an oblique direction for the muscles below with ages ranging from 15 to 67 years (mean age 39.1 years the 12th rib (Fig. 1a). old, SD Æ 13.85). All of the subjects were evaluated with radiography and MRI prior to participation in this study in All subjects were instructed how to report any experi- order to satisfy the inclusion/exclusion criteria for the enced pain correctly, and were asked to inform the study. Subjects who showed evidence of clinical neurolog- operator about the progression of pain provoked during ical deficit, disc herniation, lumbar spine canal stenosis, treatment utilizing a verbal numeric scale (VNS). The systemic inflammatory disease such as rheumatoid arthritis, verbal numeric scale (VNS) is a simple scale for the eval- or had suffered either direct trauma or surgery to the back uation of pain, quite similar to the VAS (Visual Analogical were excluded to avoid the possibility that excessive Scale), with which it has a moderate correlation (Fosnocht adherence between subcutaneous planes could influence et al., 2005). Subjects easily understand the VNS, as they the results of this study. are requested to choose a number from 0 to 10 that represents the level of their pain: zero corresponds to the Symptoms of mechanical low back pain were present for absence of pain and ten corresponds to the most intense a period ranging from several months (m) to several years pain imaginable. This scale was chosen for this study (y) and, in general, pain was discontinuous with recurrent because immediate and progressive reporting of pain exacerbating episodes being common (Table 1). levels was required and the verbal aspect was more functional than the VAS scale. Subjects were also In order to quantify the time required to halve the pain instructed that they could ask for brief rest periods of perceived during the application of this technique, the a maximum of 10 s during manipulation to avoid extended fasciae of three muscular groups often implicated in low interruptions that may have influenced results. back pain were chosen for treatment. These three groups include the paravertebral muscles, the quadratus A chronometer, which was activated at the beginning of lumborum muscles, and the muscles that insert onto the each manipulation, was used to evaluate the time required inferior border of the twelfth rib. Within each of these to halve the pain according to pain levels reported by the muscle groups, a small area of the fascia of approximately subject. Prior to commencing treatment, the subjects were two square centimetres, known as the Centre of Coordi- asked to report the exact moment in when either a minimal nation,1 was identified and evaluated. decrease or an important reduction in pain occurred. Subjects were also encouraged to report pain levels regu- According to Fascial Manipulation methodology (Stecco, larly (approximately every 30 s) and to indicate when the 2004; Stecco and Stecco, 2009), comparative palpation was pain became less than 50% of the initial pain. All these then applied to examine all these small areas. This process variations in the pain/time curve were noted and reported involves operator skills in palpation and detection of altered in the Table 1. fascial tissue, while simultaneously questioning the subject about perceived pain or discomfort. By means of continuous The time within which the therapist perceived a consis- verbal feedback, the patient’s perception of pain and the tent change in sliding between the tissue layers was also palpatory sensation of fibrosis by the therapist were corre- noted. lated and the most altered small area among the three evaluated points was selected. Treatment was bilateral in The mean value of the VNS scale measurements at the most cases, however, in some subjects, only a unilateral beginning and at the end of the treatment was calculated. alteration of the fascia was noted. Consequently, in these The analysis of the differences in pain resolution among cases, treatment was applied unilaterally to the altered or different subgroup of patients and among the three different fibrotic Centre of Coordination. On each point selected for evaluated points were compared with nonparamentric tests: treatment, the operator exercised the minimal amount of KruskaleWallis test and Dunn’s multiple comparison test and pressure necessary to create friction against the fasciae of ManneWhitney test for double comparisons. the abovementioned muscle groups. According to a previous study (Pedrelli et al., 2009), a mean force of 73.5 N over the Results CC of re-lu was required to produce a piercing pain sensation; in the CC of la-lu a mean force of 61.9 N and over the CC of er- At the beginning of treatment, the mean measurement of lu a mean force of 35.8 N. The operators all used pressure pain as reported by subjects was 7.9 on the most altered applied with the olecranon process and upper part of the ulna side and 6.7 on the contralateral side, while at the end of to perform the treatments, alternating between right and treatment it was of 3.2 and 3.0 respectively. 1 A Centre of Coordination (CC) is a small area on the deep The mean time necessary to reduce the referred level of muscular fascia where force exerted by the muscular fibres of pain to 50% was 3.24 min (ÆSD 1.3), but specific differences a specific region converge. The resultant myofascial forces appear could be evidenced among the different patients. In the to be transmitted to the surface of the deep fascia via its conti- subjects with sub-acute pathologies (<3 months), the mean nuity with the endomysium, perimysium and epimysium. The CC time to halve the pain (ÆSD) is 2.20 min (Æ1.1), while in the has the role of coordinating the motor units that are located within chronic subjects this time increases (3.29 min Æ 1.3). In this region. a few cases (16%), the reduction in pain occurred slowly (>5 min), while in 36%, the reduction occurred more quickly (<2.5 min). In 54% of cases the pain diminished

322 B. Ercole et al. progressively (Fig. 2), while in 46% one distinctive phase females, in particular in males, the mean time to half the was noted (Fig. 3), with pain passing in less than 30 s from pain was 3 min, in the females 2.45 min. a high score (8 or 9) to a sensation of mere pressure (approximately 3). No specific correlation between Discussion a sudden or a slow reduction in pain was noted in any particular area. This study evidenced, for the first time, that the time required to modify an apparent fascial fibrosis differs in The therapists noted a marked increase in tissue accordance with the site and the differences in charac- mobility more or less at the same time the patients teristics of the subjects and of the symptoms. In particular, perceived a reduction in pain. the difference in the time to halve the pain level between sub-acute and chronic patients, and the differences Differences among the evaluated areas are also evident. between the specific small areas that were treated, was In the CC of the fascia of the serratus posterior inferior statistically significant (p Z 0.006). muscle (er-lu), the mean time is 2.56 min (Æ0.9); in the CC of the fascia over the quadratus lumborum muscle (la-lu) The therapists noted a marked increase in tissue the mean time is 3.73 min (Æ1.3), and in the CC corre- mobility more or less at the same time the patients sponding to the fascia over the muscular mass of the lumbar perceived a reduction in pain. It is hypothesised that pain erector spinae (re-lu) the mean time is 2.91 min (Æ1.1). reduction and increase in sliding of the tissue layers coin- The mean time to halve the pain is different between the cides with a sufficient increase in temperature that permits dominant and the opposite side, but this difference is not the transformation of the ground substance from its significant (p Z 0.355). densified state (gel) to fluid (sol), as discussed in Introduction. It could be that an increased fluidity of the The time to halve pain at the 75 percentile is in younger extracellular matrix permits the nerve endings within the subjects (<25 years old) 3.3 min (SD Æ 1.2 min), in adults fascia to adapt to the pressure exercised by the therapist, (26e55 years) 3.8 min (SD Æ 1.4 min) whereas in older resulting in a reduction in perceived pain. subjects (>55 years) 3.4 min (SD Æ 1.2 min). The statistical analysis with KruskaleWallis test does not show significant Both the right-sided (re-lu, la-lu, er-lu) and the left- differences between younger and adult (p Z 0.833), sided area were often (87.5%) palpably altered in the same between adult and older (p Z 0.91) and between younger subject, even though the time for the pain to be halved in and older (p Z 0.767). Also the mean time to half the pain is not statistically different (p Z 0.123) between males and Figure 1 A: Centre of Coordination of ER-LU, localized over the inferior border of the twelfth rib, where the fasciae of latissimus dorsi, posterior inferior serrati and external oblique muscles join together. B: Centre of Coordination of RE-LU, located over the fascia of the paravertebral muscles at the level of the first lumbar vertebra, approximately 3 cm laterally to the spinous process of L1. C: Centre of Coordination of LA-LU, located over the fascia of the quadratus lumborum muscle, at the level of the third lumbar vertebra, approximately 5 cm laterally to the spinous process of L3. D: schematic representation of the localization of the three Centres of Coordination considered in this study.

How much time is required to modify a fascial fibrosis? 323 Figure 2 Pain level vs time graph, overlaid for each of the subjects that had a slow decrease of the pain. the two areas was not always the same. While this differ- There are not statistically significant differences in the ence is not statistically significant (p Z 0.355) it could duration of the treatment between young, adult and old nevertheless signify that the fasciae, on the two sides of patients and between males and females. the body, may not always be altered in the same manner. These differences could cause postural imbalances, deter- Different studies have highlighted the atrophy of para- mining involvement of different muscle groups. Tensional spinal, quadratus lumborum, psoas and, most prominently, anomalies caused by fascial alterations do not usually cause multifidus muscles in chronic low back pain (Kamaz et al., pain within the muscular fascia itself but could alter joint 2007; Hides et al., 2008a,b), although the paraspinal movements, causing pain at this level. Pain associated with component is arguable (Kalichman et al., 2009). Other mechanical low back dysfunction is often felt in the studies show evidence of atrophy of multifidus in chronic lumbosacral region, which is an important pivot zone for neck pain (Ferna´ndez-de-las-Pen˜as et al., 2008) as well as the lumbar muscles, however, according to the biome- a reduced capacity to perform voluntary isometric contrac- chanical model adopted in Fascial Manipulation, the areas tions in some of these muscles (Wallwork et al., 2009). This of the fascia that require treatment are generally located does appear to be a localized phenomenon and asymmetry at a distance from the site of pain. between sides in chronic LBP patients presenting with a unilateral pain distribution has been evidenced (Hides Figure 3 Pain level vs time graph, overlaid for each of the subjects that had a sudden decrease of the pain.

324 B. Ercole et al. et al., 2008a,b). Therefore, it is probable that on palpation Chaitow, L., 2008. Biochemistry and bodywork. Journal of Body- the muscular structure of these sub-groups is very different. work and Movement Therapies 12, 95. While motor control impairment is an important aspect in chronic low back pain, this study has focused on the overlying Chiquet, M., Tun¸c-Civelek, V., Sarasa-Renedo, A., 2007. Gene fascia, and its response to localized pressure. Apart from regulation by mechanotransduction in fibroblasts. Applied Langevin et al.’s study (2009), which focused on an area 2 cm Physiology, Nutrition, and Metabolism 32, 967e973. lateral to the midpoint of the L2-3 interspinous ligament, in literature, specific studies analysing eventual variations of Cyriax, J.H., 1980. Textbook of Orthopaedic Medicine. In: Treat- the fasciae, for example in thickness or resistance, among ment by Manipulation, Massage and Injection, tenth ed, vol. II. different groups and subgroups are still lacking. Ballie`re Tindall, London. Our present study highlighted the differences in time as Day, J.A., Stecco, C., Stecco, A., 2009. Application of fascial indicated by Cyriax (Stasinopoulos and Johnson, 2004) for manipulation technique in chronic shoulder pain e anatomical the mobilisation of tendons (about 15 min), as compared to basis and clinical implications. Journal of Bodywork and Move- the time required to halve the pain and to apparently ment Therapies 13, 128e135. produce a palpable difference in the connective tissue by acting specifically on altered fascia (3 min). According to De Bruijn, R., 1984. Deep transverse friction: its analgesic effect. the Fascial Manipulation technique (Stecco, 2004; Stecco International Journal of Sports Medicine 5, 35e36. and Stecco, 2009), a tendinous irritation or inflammation is often a consequence of poorly coordinated muscle fibre De Deyne, P.G., Meyer, R., Paley, D., Herzenberg, J.E., 2000. The recruitment, and emphasis is given to identifying small adaptation of perimuscular connective tissue during distraction areas of altered fascia as the possible cause. In general, osteogenesis. Clinical Orthopaedics and Related Research 379, a connective tissue alteration is not an isolated phenom- 259e269. enon but distributes along muscle chains or myofascial sequences. Therefore, where necessary, it is important to Evanko, S., 2009. Extracellular matrix and the manipulation of act along the different points of a dysfunctional chain in Cells and Tissues. IASI Yearbook, 61e68. the same treatment session. If therapists are able to re-create a global balancing of connective tissue mobility, Ferna´ndez-de-las-Pen˜as, C., Albert-Sanch´ıs, J.C., Buil, M., then it is possible to have interesting results with a single Benitez, J.C., Alburquerque-Send´ın, F., 2008. 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Considering wider myofascial involvement as exercising a focused pressure and respecting the individual a possible contributor to upper extremity dysfunction following levels of pain tolerance and general health condition, the treatment for primary breast cancer. Journal of Bodywork and benefits from this type of treatment often outweigh the Movement Therapies 12, 349e355. disadvantages of the discomfort experienced. Fox, J., Stevens-Tuttle, D., Langevin, H., 2009. Quantification of The role of psychological distress in these patients was Thoracolumbar Fascia Shear Plane Motion During Passive Flexion not evaluated. Further studies are necessary to evaluate if in Human Subjects with Chronic Low Back Pain. Fascia Research an alteration in central nervous system processing (such as II, Basic Science and Implications for Conventional and somatisation, anxiety, depression), often evident particu- Complementary Health Care. 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Journal of Bodywork & Movement Therapies (2010) 14, 326e333 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt CLINICAL METHODS The effects of manual treatment on rounded- shoulder posture, and associated muscle strength* Christopher Kevin Wong, PT, PhD, OCS a,*, Denise Coleman, PT, DPT b, Vincent diPersia, PT, DPT c, Judi Song, PT, DPT d, Dennis Wright, PT, DPT, ATC/L e a Columbia University, 710 West 168th Street, NI8, New York, NY 10032, USA b New York Presbyterian Hospital, New York, NY, USA c Palisades Rehabilitation Center, Cresskill, NJ, USA d New York City Department of Education, New York, NY, USA e One-On-One Physical Therapy & Sports Rehabilitation, Brooklyn, NY, USA Received 9 January 2009; received in revised form 30 April 2009; accepted 3 May 2009 KEYWORDS Summary A relationship between pectoralis minor muscle tightness and rounded shoulder Posture; posture (RSP) has been suggested, but evidence demonstrating that treatment aimed at the Strength; pectoralis minor affects posture or muscle function such as lower trapezius strength (LTS) Pectoralis minor; remains lacking. In this randomized, blinded, controlled study of the 56 shoulders of 28 healthy Soft tissue mobilization participants, the experimental treatment consisting of pectoralis minor soft tissue mobiliza- tion (STM) and self-stretching significantly reduced RSP compared to the pre-treatment base- line (Friedman test, p < .001) and the control treatment of placebo touch and pectoralis major self-stretching (ManneWhitney U-test, p < .01). RSP remained significantly reduced 2 weeks after the single treatment. Both control and experimental treatments resulted in increased LTS (Friedman test, p < .01) with no significant difference in LTS noted between treatments (p > .05). This study demonstrated that STM and self-stretching of the pectoralis minor can significantly reduce RSP. ª 2009 Elsevier Ltd. All rights reserved. * This study was completed at: Touro College, 27-33 West 23rd Introduction Street, New York, NY 10010, USA. The habitual slouched postural common in everyday tasks * Corresponding author. Tel.: þ1 212 305 0683; fax: þ1 212 305 can be brought on by, or lead to, rounded shoulder posture 4569. E-mail address: [email protected] (C.K. Wong). 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.05.001

The effects of manual treatment on RSP, and associated muscle strength 327 Possible clinical relevance: RSP and lower trapezius strength (LTS) compared to passive placebo touch and self-stretch of the pectoralis major  Soft tissue mobilization and stretching of the muscle. pectoralis minor muscle can reduce rounded shoulder posture. Methods  Soft tissue mobilization and stretching of the Design pectoralis minor muscle is no more effective than passive touch and pectoralis major stretching in Individual shoulders of each participant were considered increasing lower trapezius muscle strength. separately and randomly assigned to the control or exper- imental group, using a random number table. Participants  The 2.5 cm threshold for the supine measure of attended three sessions with 1e7 days between the first rounded shoulder posture may not detect and second session, and 2 weeks between the second and dysfunction. third or follow-up session. The first session included completion of a questionnaire and an assessment for RSP (RSP) (Magee, 1992; Chansirinukor et al., 2001). Charac- and LTS of each shoulder. On the second session, the terized by protracted, downwardly rotated, and anteriorly following were applied to each shoulder: (1) RSP and LTS tipped scapula position with increased cervical lordosis and measurements; (2) the experimental or control treatment; upper thoracic kyphosis, RSP has been identified as a pre- and (3) repeated RSP and LTS measurements. The follow-up disposing factor leading to upper quarter pain (Greenfield, outcome measures of RSP and LTS were reassessed on the 2001; Greenfield et al., 1995; Sahrman, 2002; Wang et al., third session 2 weeks later. 1999; Lukasiewicz et al., 1999). The cause of RSP is multi- factorial. One factor that can contribute to RSP is tightness One investigator provided all manual interventions and of the pectoralis minor muscle (Wang et al., 1999; Sahrman, additional investigators provided self-stretch instruction 2002; Lukasiewicz et al., 1999; Borstad and Ludewig, 2005), and supervision. Investigators providing treatment did not which can occur with decreased scapular posterior tilt, perform assessments; investigators performing assessments retraction, and upward rotation during arm raising (Luka- were blinded to group assignment. Separate investigators siewicz et al., 1999). assessed RSP and LTS without knowledge of each other’s Treatment for a tight pectoralis minor is an important findings and all investigators were blinded to past results. In component in the rehabilitation of those with shoulder addition, participants were blinded to the assignment of pathology and RSP (Sahrman, 2002; Kisner and Colby, 1990). their shoulders to the control or experimental group. A Treatments suggested for RSP include stretching (Lukasie- research coordinator kept the confidentiality of all data wicz et al., 1999; Wang et al., 1999; Kisner and Colby, 2002) and maintained the blinded environment by guiding and soft tissue mobilization (STM) to restore pectoralis participants to and from separate treatment rooms. minor length (Cantu and Grodin, 2001; Andrade and Clif- ford, 2001). Strengthening of the lower trapezius and ser- Study sample ratus anterior muscles have also been used to actively counteract the strength and movement loss associated with Volunteer participants of either gender between the ages RSP (Ekstrom et al., 2003; Ludewig et al., 2004; Hall, 2005; of 20 and 40 years old were recruited from a college Smith et al., 2002). However, the effect on RSP of campus by announcement for this study. Participants were stretching, strengthening, or STM directed to the pectoralis included if they exhibited RSP, as indicated by a distance minor muscle remains unknown. !2.5 cm from the posterior aspect of the acromion to the table in supine (Sahrman, 2002). Participants were The scapular position related to RSP has been measured excluded if they had shoulder pain, pathology, or history of using x-rays (Greenfield et al., 1995) and with two- and shoulder surgery; neurologic or cardiac symptoms; or three-dimensional video analysis (Plafcan et al., 1997; prescriptions for any medication that altered muscle Johnson et al., 2001). Clinicians, however, need a reliable function. All participants gave informed consent before physical assessment method to utilize in a clinical setting. A participating in this study, approved by the Institutional supine method has been described using the distance of the Review Board of the Touro College School of Health acromion to the supporting table as a simple measurement Sciences in New York, and participated without expectation for RSP (Kendall et al., 1993; Magee, 2002; Sahrman, 2002). of compensation or credit. While questioned as a measure of pectoralis minor muscle length (Borstad, 2005; Lewis and Valentine, 2007), use of In total, the study sample included 28 healthy partici- the supine measure as an assessment of scapular position pants with 56 shoulders. Individual shoulders were treated related to RSP has been demonstrated to have good reli- as independent entities and randomized to experimental or ability (ICC > 0.90) in both symptomatic and non-symp- control groups. As a result, six participants had both tomatic shoulders (Lewis and Valentine, 2007). The supine shoulders assigned to the experimental condition, three RSP measure has also been shown to be comparable to had both shoulders assigned to the control condition, and a seated method of scapular posture assessment (Wang, 19 had one shoulder in each condition. Sagital plane scap- 2006), but should be performed in a consistent degree of ular position has been demonstrated to vary between humeral rotation position for consistency (Borstad, 2006). asymptomatic and symptomatic subjects with a difference between mean seated RSP of 7 Æ 2.5e3.2 mm respectively The purpose of this study was to determine the effects (Lewis et al., 2005). Scapular position has been shown to of STM and self-stretch of the pectoralis minor muscle on

328 C.K. Wong et al. influence isometric shoulder strength in healthy volunteers recorded the LTS measurement after the participant measured in kilograms with mean differences of 2.6e3.3 kg pressed against the digital muscle tester for 3 s for each with standard deviations of 3.3e4.0 kg between the neutral shoulder with 10 s rest between two repetitions. The and protracted or retracted positions (Smith et al., 2002). highest value was recorded as the peak strength. One study For the purposes of power analysis, expected mean changes that reported LTS measure intra-rater reliability of and standard deviations based on these studies were used ICC2,1 Z .89, also demonstrated significant construct val- with a two-tailed power analysis with power set at 80%, idity with significantly greater lower trapezius muscle a Z .05, and common standard deviation of 5 kg/mm, activity observed in the LTS test position compared to the revealing that 25 shoulders were needed for each group to upper and middle trapezius muscle testing positions demonstrate a significant difference for a potential treat- (Michener et al., 2005). ment effect size of 4 kg LTS strength or 4 mm RSP. The sample size of 56 shoulders was considered sufficient with Reliability 25 shoulders assigned to the control and 31 to the experi- The reliability of pre-treatment RSP and LTS measurements mental groups. from separate days of this study for all shoulders were analyzed using intraclass correlation coefficients (ICC) for Measures absolute agreement of single measures with 95% confidence intervals using SPSS version 16.0. Portney and Watkins have The demographic, anthropometric, and activity related suggested that ICC values above .75 indicate good reliability information of each participant was collected by (Portney and Watkins, 1993, p. 514). Thus, the inter-day questionnaire. intra-rater reliability of the supine RSP measure in this study (ICC2,1 Z .80, 95% CI Z .68e.88) was considered good, Rounded shoulder posture (RSP) although less than that of two studies (ICC3,1 Z .88e.93) that With the participant lying at rest in supine on an unpadded used the same RSP measure (Wang et al., 2006; Lewis and examination table, scapular position related to RSP was Valentine, 2007). Inter-day intra-rater reliability of the LTS measured with the shoulder positioned in neutral to avoid measure (ICC2,1 Z .87, 95% CI Z .79e.92) was also consid- measurement variations due to humeral rotation (Borstad, ered good and comparable to previously reported intra-rater 2006). The investigator palpated and marked the height from reliability (ICC Z .80e.95) for other shoulder muscle the examining table to the posterior aspect of the lateral strength measurements using digital muscle testers (Phillips acromion process on an unmarked plastic right angle posi- et al., 2000; Magnusson et al., 1990; May et al., 1997; tioned perpendicular to the table surface as described by Bohannon, 1990). others (Kendall et al., 1993; Lewis and Valentine, 2007; Magee, 1992; Sahrman, 2002). The distance was then Treatments measured using a separate straight ruler and recorded in millimeters. It has been noted that the supine RSP measure The experimental group received STM and performed does not correlate well with an index of pectoralis minor stretching to the pectoralis minor muscle. The control length (Borstad, 2006) nor is the RSP measure an effective group received passive light manual placebo touch and diagnostic predictor of shoulder symptoms (Lewis and Valen- performed stretching to the pectoralis major muscle. All tine, 2007). The current study, however, used the supine RSP manual procedures were performed by a single licensed measure as a measure of scapular position not of pectoralis physical therapist certified as an orthopedic clinical minor length. In a study that assessed the concurrent validity specialist by the American Board of Physical Therapy of the supine RSP measure and a seated assessment of scapular Specialties. Self-stretch exercises were instructed and posture, no significant difference between the measures of supervised by separate investigators. RSP was observed (Wang et al., 2006). Experimental treatment Lower trapezius strength (LTS) For the STM portion of the experimental treatment, the To assess LTS, the participant was positioned in supine with participant was positioned in supine, anterior shoulder hips and knees flexed to approximately 45 and 90 degrees and chest exposed, and arm at the side. The STM proce- respectively, the chest strapped to the table through the dure consisted of strumming perpendicular to the pec- lowest anterior ribs, the shoulder positioned in 160 degrees toralis minor muscle with the physical therapist’s fingers flexion and abduction using a standard goniometer, the allowed to rebound across the muscle belly in a constant elbow extended, and the distal forearm just proximal to rhythm (Johnson, 2001, p. 597), producing muscle play or the posterior wrist placed in contact with the padded movement from side to side (Godges et al., 2003; Cantu digital muscle tester (Liebler et al., 2001). The MicroFET2 and Grodin, 2001). Pectoralis minor STM was performed Muscle Tester (Kom Kare Company, Middletown, OH), which for 3 min with a force sufficient to move the muscle from is reported to be accurate with a Æ2% error for up to 150- side to side to the tolerance of the participant (see pound loads (http://www.rehaboutlet.com/manual_ Figure 1). muscle_test.htm, accessed 12/21/2008) was securely mounted on an adjustable platform that allowed the The STM was followed by a variation of supine pectoralis described arm position. A practice trial was performed to minor self-stretching described by others (Hall, 2005; Bor- familiarize the participants to the testing method, followed stad and Ludewig, 2006) that incorporated spine extension/ by a 1 min rest. A different investigator then used the ipsi-rotation/contra-sidebending with related rib motion. In standard verbal directions ‘‘press as hard as you can’’ and the supine position with knees bent, the legs were rotated to the floor in the opposite direction of the arm to be

The effects of manual treatment on RSP, and associated muscle strength 329 Figure 1 Hand position and depth for strumming soft tissue Figure 3 Hand position for the passive manual placebo touch mobilization of the pectoralis minor. of the control treatment. stretched placing a stabilizing distal tension on the ribs Statistical analysis (Sahrman, 2002). The subject then slowly brought the arm in a circular motion overhead pausing at points of tightness, The limited number of shoulders included in the sample and maintaining close contact to the mat (see Figure 2). Over- the finding that both initial LTS and RSP were skewed head arm motion facilitated scapular posterior tipping, upward and tended to differ from a normal distribution elevation, and retraction needed to stretch the pectoralis (ShapiroeWilk p < .01 and p Z .06 for LTS and RSP, minor (Hall, 2005; Sahrman, 2002). The stretch was held for respectively), led to the use of non-parametric statistics in 30 s and repeated for a total of 3 min. this studyda conservative choice since non-parametric tests are less sensitive than parametric tests with small Control treatment samples (Portney and Watkins, 1993, p. 420). Statistical The control treatment consisted of passive placement of the therapist’s fingers on the anterior shoulder over the lateral aspect of the pectoralis major muscle. Placebo touch was held for 3 min without applying tension or inducing movement (see Figure 3). After the passive placebo touch, participants performed a modified ‘door stretch’. With elbow extended, participants placed one hand on the door at waist level and leaned gently through the door, in a stretch intended to affect primarily the clavicular head of the pectoralis major (Kisner and Colby, 2002) (see Figure 4). Figure 2 The pectoralis minor self-stretch of the experi- Figure 4 The pectoralis major self-stretch or modified ‘‘door mental treatment. stretch’’ of the control treatment.

330 C.K. Wong et al. analysis was performed, using SPSS version 16.0 (SPSS-UK pre-treatment baseline. Immediately after treatment, Ltd, St. Andrews House, West Street, Woking, Surrey, GU21 experimental group RSP was significantly less than before 6EB, UK). Pre-treatment group comparisons were analyzed treatment and the average post-treatment RSP was signif- using ManneWhitney U-tests. To determine within-group icantly less than the pre-treatment baseline. At the 2 week treatment effects on the outcome measures through the follow-up, RSP had increased from the immediate post- post-treatment period, Friedman tests with statistical treatment RSP. Although the average RSP at follow-up was significance set at p < .05 and minimum significant differ- significant less than the pre-treatment baseline (Friedman, ences (MSD) calculated with f Z .05 were performed. p < .001, f < .05), a significant difference in RSP could not Comparisons of the between group treatment effects be assumed with 95% confidence given that the confidence through the post-treatment period were performed using interval included zero (Sims and Reid, 1999). No within- ManneWhitney U-tests (p < .05). group change in RSP was observed for the control group (see Table 2). Results For both groups, within-group LTS increased significantly Descriptive data from pre-treatment to the initial post-treatment session and subsequently from initial post-treatment to follow-up Descriptive statistics are presented in Table 1. No signifi- session (Friedman, p < .001, f < .05). The average imme- cant difference was found between the control and diate post-treatment effect in the control group had a 95% experimental shoulder groups prior to treatment. Pre- confidence interval that included zero, however, and the treatment LTS and RSP measures revealed no significant chance that no difference occurred for any individual could difference between groups; means, standard deviations, not be excluded until follow-up (Sims and Reid, 1999). No and ranges for both groups were comparable. No significant significant difference in LTS increases existed between the change in RSP or LTS occurred in either group between the groups (see Table 2). first and second pre-treatment measures (Friedman, p > .05). Overall, the control and experimental group Discussion shoulders were considered statistically equivalent prior to treatment (see Table 1). Treatment directed to the pectoralis minor muscle con- sisting of STM and self-stretching significantly reduced RSP Treatment effects compared to the control group treatment consisting of Experimental group RSP decreased significantly compared passive placebo touch and a self-stretch of the clavicular to the control group immediately after treatment, at the head of the pectoralis major. While the control group RSP follow-up measure, and when average post-treatment did not change from the pre-treatment baseline, experi- measures were compared (ManneWhitney U-test: mental group RSP decreased significantly (p < .05) p Z .001, Z.015, <.001 respectively). The experimental compared to the pre-treatment experimental group group also demonstrated a significant within-group baseline period during which no intervention took place. decrease in RSP (Friedman, p < .001, f < .05) compared to The experimental shoulder group demonstrated a signifi- cant decrease in RSP immediately after treatment after Table 1 Group comparison. Variable Category/unit Control Experimental p* Gender Men 15 17 e Race Women 10 14 e White Am 19 23 Shoulder African Am 2 4 e Daily sitting time Asian Am 1 1 .459 Native Am 0 2 Age Other 3 1 .377 Height Dominant 15 14 .607 Weight Non-dominant 10 17 .608 Pre-treatment LTS 1e4 h 4 10 .792 Pre-treatment RSP 5e8 h 13 11 .902 9e12 h 8 10 years Æ SD 24.8 Æ 5.1 26.2 Æ 5.6 cm Æ SD 171.7 Æ 7.9 172.5 Æ 7.4 kg Æ SD 72.6 Æ 15.7 74.8 Æ 17.4 kg Æ SD (range) 18.9 Æ 8.2 (8.9e46.1) 18.2 Æ 7.5 (7.6e39.8) cm Æ SD (range) 4.9 Æ 1.6 (2.8e8.3) 4.8 Æ 1.4 (2.6e9.3) Abbreviations: RSP, rounded shoulder posture; LTS, lower trapezius muscle strength; SD, standard deviation; cm, centimeter; kg, kilogram; h, hours. * denotes results of ManneWhitney U-tests.

The effects of manual treatment on RSP, and associated muscle strength 331 Table 2 Treatment effects on rounded shoulder posture (RSP) and lower trapezius strength (LTS). Experimental group RSP (cm) Post-treatment Mean change Æ SD Median 95% CI Follow-up Average post-treatment À.65 Æ .78*,y À.60 À.37: À.94 À.19 Æ .83*,y À.50 À.49: .11 À.42 Æ .68*,y À.55 À.67: À.17 Control group RSP (cm) Post-treatment À.02 Æ .75 À.15 À.33: .29 Follow-up .17 Æ .60 .25 À.07: .42 Average post-treatment .09 Æ .50 .00 À.13: .29 Experimental group LTS (kg) Post-treatment 1.2 Æ 3.1* 1.3 .03: 2.3 Follow-up 3.9 Æ 4.4* 3.5 2.3: 5.5 Average post-treatment 2.5 Æ 3.1* 2.3 1.4: 3.7 Control group LTS (kg) Post-treatment 1.2 Æ 3.8* 1.5 À.33: 2.8 Follow-up 4.3 Æ 4.0* 3.5 2.7: 6.0 Average post-treatment 2.8 Æ 3.3* 3.3 1.4: 4.2 Abbreviations: CI, confidence interval; SD, standard deviation; cm, centimeter; kg, kilogram. * Denotes significant within-group change from pre-treatment with Friedman tests (p < .05) and minimum significant differences calculated (a Z .05). y Denotes significant difference between groups with ManneWhitney U-tests (p < .05). pectoralis minor STM and self-stretching and the average The value of the supine RSP measure may be as an post-treatment RSP during the 2 week follow-up period outcome measure that can demonstrate within subject remained improved compared to the baseline RSP change. The average difference in post-treatment reduc- measure, suggesting that the single experimental treat- tion in RSP between the control and experimental groups ment produced a benefit beyond no treatment at all (see was .51 cm, which was more than 10% of the pre-treatment Table 2). RSP and double the SEM (SEM Z .12 cm). Because participants were not monitored during the The results of this study suggest that the control treat- follow-up period, it is not known whether they continued to ment had no effect on RSP while the combination of STM stretch on their own, avoid slouched postures, or engage in and a pectoralis minor self-stretch reduced RSP to both other activity that affected RSP. Regression towards the a statistically and clinically significant degree. mean was observed in the experimental group at the follow-up, however, suggesting that more than one treat- While treatment directed to the pectoralis minor ment may be necessary to maintain the decreased RSP for reduced RSP in this study after intervention directed to the periods longer than 2 weeks. pectoralis minor, the supine RSP measure may not measure or predict pectoralis minor muscle length (Borstad, 2006). Although experimental group RSP was reduced after Supine RSP did not correlate strongly with a pectoralis treatment directed to the pectoralis minor, more than 95% minor index based on a seated pectoralis minor length of the experimental shoulders in this study of healthy measured from the coracoid process to the fourth rib participants still had RSP greater than 2.5 cm. In a study adjacent to the sternum (Borstad, 2006), perhaps because that did not involve treatment of 135 subjects with and of different test positions and the typically more lateral without symptoms, Lewis and Valentine found that none pectoralis minor attachment to the ribs. In the current had a RSP less than 2.5 cm using the supine measure (Lewis study, RSP was used as a measure of scapular position not and Valentine, 2007). The results of the current study pectoralis minor length and the experimental treatment support Lewis and Valentine’s notion that the 2.5 cm was directed to the pectoralis minor but may have affected threshold for the supine RSP measure is not a sensitive other factors in RSP in addition to the pectoralis minor. predictor of dysfunction, since mean and median values are While the placebo touch received by the control group well above the 2.5 cm threshold (Lewis and Valentine, could be isolated to the superficial pectoralis major, the 2007). Future research may indicate a more useful pectoralis minor STM received by the experimental group threshold. Rounded shoulder posture is a multifactorial may have affected the overlying pectoralis major. In addi- finding that may reasonably vary with hypomobility of any tion, the self-stretch used in the experimental group segment of the spine, rib articulation, or joint of the incorporates spine and rib motion and does not isolate the shoulder girdle including the acromioclavicular, sternocla- pectoralis minor. Thus pre- and post-measures of RSP vicular, and glenohumeral joints; tightness of the muscles reflect the total affect of the experimental treatment not related to any segment of the spine, ribcage, and shoulder change in pectoralis minor length. girdle; as well as patient weight, height, position, and physical girth. A diagnostic choice for the treatment of an The average post-treatment measures of LTS after the individual patient based on their RSP value as compared to experimental and control treatments both increased the average RSP of people with mixed characteristics would significantly by comparable amounts (control 2.8 kg or be a questionable approach for a measure such as the 14.8%; experimental 2.5 kg or 13.7%), with no apparent supine RSP measure in this study. differences between groups ‘see Table 2’. Friedman tests with MSD set at a Z .05 comparing the pre-treatment,

332 C.K. Wong et al. post-treatment, and follow-up LTS values revealed in the control group (Friedman p < .05, MSD f < .05). a significant increase (p < .001) between all three repeated Though the small number of participants prevents firm measures suggesting that LTS increased immediately after conclusions, it is possible that one shoulder may have treatment and increased further 2 weeks later in both affected the other undermining the assumption that indi- groups. It is noted, however, that the post-treatment vidual shoulders are independent entities. Future studies change in strength of the control group could not be should assign individual people, not shoulders, to groups. assumed to be positive with 95% confidence (Sims and Reid, 1999) until the 2 week follow-up. The increase in the LTS of Second, this study used a small healthy sample of both groups throughout the study may have resulted from convenience derived from a single college campus increased familiarity with the testing method or repetitive precluding generalization of the results beyond the sample maximal voluntary testing, although no change was noted population. in the two pre-treatment baseline measurements (p > .05). It is possible that the placebo touch and self-stretch of the Lastly, the control and experimental treatments both pectoralis major had an effect on LTS equivalent to the combined a manual touch or technique with a self-stretch experimental treatment through the positive influence of procedure, thus results should not be interpreted as human contact (Cheing and Cheung, 2002; Keller and resulting from an individual procedure. While limiting the Bzdek, 1986) or increased neuromuscular recruitment treatments to a single procedure may have demonstrated similar to that observed in an initial exercise program the outcome of a specific technique, the procedures were (Moritani and deVries, 1979). combined in this study to replicate a realistic clinical approach to excessive RSP. The use of passive placebo A variety of placebo treatments have been shown to touch in the placebo-controlled design, while complicating affect 30% of patients (Winemiller et al., 2005; Lappin the research design and introducing its own potential et al., 2003; Hoffman et al., 2005) with benefits in objec- effect, remains vital to research involving manual therapy tive measures, such as blood flow (Martel et al., 2002) or to differentiate manual therapy from simple human touch tumor reduction, of less than 7% in a comprehensive meta- (Cheing and Cheung, 2002). analysis of the use of placebos in oncology research (Chvetzoff and Tannock, 2003). This degree of change is Conclusion comparable to the 6.3 and 6.6% changes in LTS observed in the present study immediately after treatment in both This study has shown that a single session of STM paired groups: control and experimental, respectively ‘see Table with self-stretching to the pectoralis minor muscle reduced 2’. It is noted, however, that the control treatment, which RSP for up to 2 weeks compared to passive manual touch included passive placebo touch, had no effect on RSP. and a pectoralis major self-stretch. Overall, the results of this study support the notion that treatment aimed at the Study limitations pectoralis minor can benefit shoulder posture and muscle function and may be an important component of shoulder The results of the present study must be considered in the rehabilitation (Sahrman, 2002; Lukasiewicz et al., 1999; context of several limitations. First, the practice of using Borstad and Ludewig, 2005; Wang et al., 1999; Kisner and the shoulders of each participant as independent entities Colby, 1990). raised two potentially problematic possibilities: that the 19 participants who received different treatments could have Acknowledgements distinguished between the control and experimental treatments and responded differently based on group The authors wish to acknowledge the contributions of assignment; and that outcomes of one shoulder may have Limone Paljevic who coordinated this research. affected the other. Disclosure statement For the 19 participants who had a shoulder in each group, ManneWhitney U-tests were conducted to deter- The authors have no conflict of interest to disclose. mine whether there was a difference in shoulder performance. References There was no significant difference between the control Andrade, C., Clifford, P., 2001. Outcome Based Massage. 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Journal of Bodywork & Movement Therapies (2010) 14, 334e335 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt FASCIA CONGRESS ABSTRACT Neurocognitive enhancement for the treatment of chronic pain Peter Przekop, DO, PhD a,b,*, Allison Przekop, DO b, Mark G. Haviland, PhD a, Matt L. Riggs, PhD c a Department of Psychiatry, Loma Linda University Medical School, 11374 Mountain View Avenue, Loma Linda, California 92354, United States b Department of Pediatrics, Loma Linda University Medical School, Coleman Pavilion, Room A1109 Loma Linda, California 92350, United States c Department of Psychology, California State University, San Bernardino, California 92407, United States Received 12 July 2009; received in revised form 11 October 2009; accepted 19 October 2009 Abstract dependent Z 8 years) with various chronic pain complaints (post laminectomy syndrome, post cancer pain, fibro- Chronic pain remains at epidemic levels in the United myalgia, chronic headache, osteoarthritis; average time in States, affecting approximately 20% of the population pain Z 9 years) were enrolled in a 12-month comprehensive (Breivik et al., 2006). At present, treatments generally pain management program designed to enhance brain areas target symptom relief and seldom address improvements in affected by pain. Treatments included group process, quality of life and overall healing. Recent insights in mindfulness exercises, movement exercises (Tai Chi, Qi neurobiology have demonstrated that chronic pain is Gong, and Yoga), manual treatments (Qi Gong and Neuro- a degenerative disease of cortical and sub-cortical struc- fascial release), and the establishment of a treatment tures (Tracy, 2008). Thus, treatments can be designed to community. Patients met weekly for group process that enhance specific areas of the brain affected by chronic pain addressed emotional and cognitive decision-making strate- and, thereby, improve patients’ cognitive and emotional gies, cognitive change, and movement. Patients received abilities. For example, specific treatments can be designed monthly manual treatments that consisted of Qi Gong and that normalize function of frontal lobe areas negatively Neuro-fascial release. All chronic pain patients received the affected by the effects of chronic pain. same management program. All were assessed at intake and at months 3, 6, 9, and 12, with a visual analogue pain scale, Method the Beck Depression Inventory, the McGill Pain Scale (short form), and the Perceived Stress Scale. 21 patients who had been detoxified from opiate therapy (13 women and 8 men; average age Z 48.5; average time opiate Results * Corresponding author. Department of Psychiatry, Loma Linda By month 12, patients’ scores declined dramatically on all University Medical Center, 11374 Mountain View Avenue, Loma tests (growth curve analysis), and these improvements were Linda, California 92354, United States. Tel.: þ1 909 558 4505; fax: statistically significant (p < .01); (p < .01, dependent t tests). þ1 909 558 6090. Mean reductions: visual analogue (7.0 / 2.3), depression (26.4 / 4.6), McGill-somatic (22.7 / 5.4), McGill-affective E-mail address: [email protected] (P. Przekop). (7.7 / 1.5), and perceived stress (26.5 / 12.8). 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.10.003

Neurocognitive enhancement treatment for chronic pain 335 Discussion References Targeted treatments appear effective in restoring several Breivik, H., Collett, B., Ventafridda, V., Cohen, R., Gallacher, D., aspects of chronic pain patients’ lives. Future studies could 2006. Survey of chronic pain in Europe: prevalence, impact on be designed to address specific pain complaints or test daily life, and treatment. European Journal of Pain 10, 287e333. larger populations. Tracy, I., 2008. Imaging pain. British Journal of Anaethesia 101 (1), 32e39.

Journal of Bodywork & Movement Therapies (2010) 14, 336e345 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt CASE REPORT Rhythmic exercises in rehabilitation of TBI patients: A case report Yigal Goldshtrom, MS*, Gregory Knorr, PT, Iris Goldshtrom, PT, DPT Pillar of Light, Physical Therapy, Address 37-03 Berdan Ave, Fair Lawn, NJ 07410, USA Received 12 January 2009; received in revised form 20 May 2009; accepted 5 June 2009 KEYWORDS Summary Patients who have sustained traumatic brain injury (TBI) often present with Traumatic brain injury; a multiplicity of dysfunctions making rehabilitation challenging. Patients who have taken part Rehabilitation; in studies of rehabilitation exercises that incorporated monotonous timed auditory cues (using Rhythm; a metronome) following cerebrovascular events demonstrated improvement in gait and motor Exercise; functions. The purpose of this case report is to describe the efficacy of Rhythmic Exercises with Cognitive; Auditory Cues (REAC) to improve functions in a patient, years after their traumatic brain Motor; injury. Neuroplasticity Methods: A single case report of a 24-year-old female patient, nine years post hemispherect- omy following TBI that resulted in right hemiparesis. The patient was taught to perform REAC exercises at home. These exercises were designed to activate the body while Alternating hands and feet Bilaterally with Cross-midline movements for a short Duration while synchronizing the movements with a metronome as a Rhythm regulator. Outcome measurements included gait and functional assessment and cognitive and psychological instrument scores that were compared pre and post treatment. Clinical improvement was observed in the patient’s gait pattern with reduced hip hiking motion and increased cadence. There was a decrease in spasticity in the right arm and leg with some isolated volitional movements of the hand and fingers returning. She also regained sensa- tion in her right arm and leg. Cognitive improvement was demonstrated by increased IQ scores from 78 to 94. Published by Elsevier Ltd. * Corresponding author. Tel.: þ1 201 797 8028. Introduction E-mail address: [email protected] (Y. Goldshtrom). Traumatic Brain Injury (TBI) is a disorder of major personal 1360-8592/$ - see front matter Published by Elsevier Ltd. and public health significance. A study in the United States doi:10.1016/j.jbmt.2009.06.002 has reported that among hospitalized TBI survivors in 2003, forty-three percent remained in long-term disability

Rhythmic exercises in rehabilitation 337 (Selassie et al., 2008). Since 2001 there has been sharp the primary sensorimotor (S1M1) and the secondary motor increase in the number of TBI as result of the deployment of areas in the remaining hemisphere. These results were 1.5 million military personnel to Iraq or Afghanistan. TBI noted following intense gait training using Body Weight- since the start of military operations have become an Supported Treadmill Training (BWSTT) on a treadmill with important source of morbidity in the Iraq and Afghanistan rhythmic passive/active activation for two weeksd60 h wars (Warden, 2006). A recent study of a U.S Army brigade total training (de Bode et al., 2007). Evidence of brain had found that as many as 4.9% of the U.S. military personnel reorganization under functional MRI (fMRI), specifically reported injuries with loss of consciousness (Hoge et al., ipsilateral to the affected limb, have also been reported in 2008). Historically, motor recovery is not expected beyond several studies with chronic stroke patients (Calautti and 6e12 months after injury (DeLisa et al., 1999), leaving TBI Baron, 2003; Gerloff et al., 2006) with patients recovering patients with a wide range of limitations, including cognitive from motor deficit after stroke using traditional rehabili- deficits, motor disabilities, emotional and social dysfunc- tation methods (Dong et al., 2007; Green, 2003; Jang et al., tions, personality changes, and changes in appearance 2007). (Chesnut et al., 1999). Patients with neuromuscular involvement have difficulty in executing motor actions Multiple studies revealed under fMRI and positron because of the reduction in movement capabilities and emission tomography (PET) scans that hemispheric adap- sensations of the paretic limbs, which results in non- tation occurs naturally when movement is combined with rhythmic and asymmetrical sensorimotor control feedback rhythm. When fingers of one hand are tapped, the activity that limits recovery and function (Sibley et al., 2008). Some will be detected in the contralateral hemisphere. However, injuries require craniotomy (removal of part or the entire multiple studies have shown that when finger tapping is hemisphere) with result in loss of motor and sensory combined with an external auditory rhythmic beat the awareness in the affected limbs. Loss of sensory awareness activity had been detected in the ipsilateral hemisphere such as tactile discrimination is an indication of damage to (Del Olmo et al., 2007; Horenstein et al., 2009; Thaut, brain area corresponding to the affected body part. 2003). Using PET, increased blood flow to the brain was Increased tactile discrimination after brain injury corre- visualized during rhythmic tapping, like tapping one finger, sponds with brain plasticity (brain reorganization) in primary which activates parietothalamic and premotor activity, sensory and motor cortices as result of an enlargement of the predominantly ipsilateral to the finger that is tapping representations of the trained body parts (Hodzic et al., (Thaut, 2003). These studies demonstrated that simple 2004). rhythmic finger movement has the effect of developing awareness bilaterally (Horenstein et al., 2009), which is Brain plasticity precursor to re-learning motor and cognitive function deficits after brain injury. Brain plasticity refers to adaptations of the neural network or a restructuring of the network both functionally and Rhythmic exercises with auditory cues hemisphericaly (Doidge, 2007). Functional restructuring (REAC) in rehabilitation happens when a cortical area that has a known function assumes additional function, while hemispherical restruc- The effect of rhythmic activation of the extremities during ture is the adaptation of the function into the opposite exercises with resultant brain plasticity and recovery have hemisphere. The hemispheres exhibit unique and bilateral been proposed in multiple studies; some were studying functions. The right hemisphere, for example, generally movement patterns while others have used fMRI to study process the nonverbal elements of communications like how the brain is activated in response to timed movements. reading facial expressions, while the left hemisphere This case report describes a rehabilitation process with process the verbal-linguistic elements of communication rhythmic exercise program called Rhythmex, a REAC like speech (Doidge, 2007). Many functions in the brain program using exercises with a metronome. Each exercise is occur bilaterally like motor, sight, sound and tactile guided by five principles labled ABCD & R: sensations, and some of those functions, like motor func- tions occur in the contralateral hemisphere (on the oppo- A. Alternating hands and feet in movements site side) of the affected limb. TBI can result in loss of B. Bilateral activation of the body and extremities motor function contralateral to the injured hemisphere; C. Cross-midline movements while many areas of the brain can be involved in TBI we are D. Duration of exercise limiting the discussion here to the cerebral cortex. R. Rhythmic auditory cues (via metronome) Regaining motor function depends on neuroplastic processes that can re-establish the function in the opposite The following studies demonstrate these principles: hemisphere, ipsilateral of to the paretic limb, which is known as function lateralization. The recent use of brain  Bilateral alternating hand and feet exercises foster scanning technologies offer direct evidence of significant bilateral cortical activation which generates multisen- neuroplastic restructuring in the cortical motor area of the sory crossmodal spatial mapping of vision and touch brain for patients receiving rehabilitation after stroke or (Gray and Tan, 2002). The expected result is greater cerebral hemispherectomy (Richards et al., 2008). For awareness unilateral of the affected limb as a precursor example, studies of children after cerebral hemi- for functional lateralization. spherectomy reported increased cortical activation both contralaterally and ipsilaterally post hemispherectomy in  Bilateral or bimanual movement training as a single modality or in combination with other modalities has

338 Y. Goldshtrom et al. been found to be effective in stroke rehabilitation two levers in a push/pull uniform motion regulated by protocols during the sub-acute and chronic phases of a metronome. This approach has since been replicated recovery (Cauraugh et al., 2009; Cauraugh and elsewhere (Luft et al., 2004; Stinear and Byblow, 2004; Summers, 2005; Stewart et al., 2006). Bilateral training Waller and Whitall, 2004). Even a short period of rhythmic has been found to improve motor coordination in the walking among patients with incomplete spinal cord affected limb in patients with central or peripheral injuries has demonstrated improvements in the gait impairments (Cauraugh and Summers, 2005; Luft et al., parameters of cadence, velocity, and stride length (de 2004; Mudie and Matyas, 2000; Whitall et al., 2000). l’Etoile, 2008). However, when a bilateral training exercise Some studies did not find bilateral movement training was used with stroke patients but without auditory cues, it alone to be effective with stroke patients (Desrosiers did not result in better outcomes compared to the regular et al., 2005). Bilateral Arm Training With Rhythmic exercise protocol (Desrosiers et al., 2005). Auditory Cueing (BATRAC), a repetitive bilateral arm movement exercise has been found to be effective for The purpose of this paper is to report the effect of upper extremity rehabilitation after stroke (Waller and rhythmic exercises, and in particular on Rhythmex REAC Whitall, 2008; Whitall et al., 2000) protocol with a single patient with TBI who has improved  Walking exercises with Rhythmic Auditory Stimulation significantly nine years post hemispherectomy (partial (RAS) have been shown to improve gait with Parkinson’s removal of her left hemisphere) for 12 months of Rhythmex patients (Ellis et al., 2008; Password, 2007; Thaut exercises. Studies that use REAC protocol have been et al., 2007, 1997, 1996), and another study with Par- limited by the extremity they activate; upper extremities kinson’s patients used spatial and temporal rhythmic in BATRAC and APBT, and lower extremities in RAS and visual cues to change and improve the patients’ walking BWSTT, and the devices they use for these activities. speed on a treadmill (van Wegen et al., 2006). Another Rhythmex is a natural all body movement exercise with the study using RAS protocol with children diagnosed with goal of restoring functional movement patterns using Cerebral Palsy reportedly improved their gait perfor- rhythmic motions, however small in amplitude, and is mance (Kwak, 2007). adaptable to many dysfunctions, their severity, and exer-  Active-Passive Bimanual Therapy (APBT) using passive cise settings. rhythmical flexion-extension repetitions has been proposed for upper extremities among stroke patients Method (Stinear et al., 2008)  Body Weight-Supported Treadmill Training (BWSTT) Profile of the patient with rhythmic cues has been proposed for lower extremity rehabilitation among children after hemi- Jill (assumed name) is a 24-year-old female who is pre- spherectomy (de Bode et al., 2007). sented with Traumatic Brain Injury (TBI) as result of  Cross-midline movement activation creates dynamic a sledding accident at age 15. She suffered an intracranial multisensory crossmodal integration that can restore hemorrhage, brain contusion, and left open depressed skull body-part perception, improve motor action execution, fracture that required hemispherectomy twice. Post-oper- and body-part self-awareness (Maravita et al., 2003). atively, she experienced increased intracranial pressure Body-part awareness and motion activation occur con- with hydrocephalus and excess Cerebral Spinal Fluid tralaterally in each hemisphere, where sensory infor- collection that required shunting on two occasions. Her mation (vision, tactile and audio data) integrates into recovery was complicated by seizures. She presented with a dynamic baseline spatial map which then develops into refractory seizures that were moderate in intensity and was sensory, movement, and overall self-awareness. Studies taking anti seizure medications, to reduce the number of of cross-limb actions have revealed cross-cortical episodes. cooperation in remapping of visual space that occurs while tracking the hand’s positions as it crosses midline Motor control (Macaluso and Driver, 2005; Spence et al., 2001). As in most cases of patients with TBI and stroke with  Brain exercises are learning activities, as the brain damage to the motor control centers, her gait demon- learns a new task from a novice state to improved strated a combination of deviationsdincluding hip hiking performance, different areas of the brain become and circumduction, and lack of active dorsiflexion that active. As the neural networks switch from controlled required a correction by Ankle Foot Orthotics. Her right activation into automatic activation a reduction in the upper extremity had strong flexor spasticity; no volitional general neural activities occurs (Grill-Spector et al., motion below the elbow, and her right hand was fisted and 2006). The ‘‘learned’’ movement is distinguished from therefore she had to wear a splint. During walking the a novice conscious movement by its being automatic, flexor spasticity in the right upper extremity increased with rapid, and stereotyped (Thach, 1996). Learning (i.e. the elbow gradually flexing to 100 degrees. movement) for more than 15 min switches the activi- ties in the cortex to an automatic process that prohibits Dorsiflexion of the affected ankle was minus two degrees new learning (Raichle et al., 1994). when passively ranged, and she had strong clonus when the ankle was forcibly dorsiflexed. She was unable to negotiate The use of rhythmic auditory cues in rehabilitation was stairs functionally and she also had poor balance standing first proposed in a study among stroke patients (Whitall and walking, even with the use of a cane. Her hip joint on et al., 2000) which facilitated bilateral arm training using the affected side was moderately retracted, as was the shoulder.

Rhythmic exercises in rehabilitation 339 Sensory awareness generated by the patient and actively executed, regardless Jill displayed deficit in her tactile awareness of the of the amplitude of the motion. For example, at the affected limbs. She had a complete loss of her sensation to beginning of Jill’s rehabilitation the movement of the touch from the elbow to the fingers in the right arm and affected right arm was limited to the shoulder joint at from the knee to the toes in the right foot. a range of 10e15 degrees flexion with horizontal adduction and strong elbow flexion to 100 degrees, while the left arm She also had right hemianopsia (blindness in one half of had a normal swing. the visual field), and expressive aphasia, with resultant difficulty reading, and impaired comprehension and The rhythm’s tempo was determined by the patient. speech. Once the activity started the clinician observes the actual tempo the patient was able to perform and sets the Rehabilitation history metronome accordingly. There was no goal tempo or course In the first two years after the accident, Jill received of progression goals for the tempo. The auditory cue serves intensive inpatient physical therapy, and thereafter weekly as an attention grabber and the tempo should be set physical therapy in residential programs. According to her comfortably for the patient’s ability. physical therapy reports she received passive and active stretching and gait training. She was discharged from Exercise duration was limited to allow the patient to be physical therapy completely in 2005 two years before she active but not fatigued, to prevent the brain switching from came to our clinic. control activation to automatic activitation. The duration of each exercise for this case varied between exercises in She also received occupational therapy, and had the range of 30e90 s following 30e60 s resting and about 10 participated in a cognitive program to improve her reading repetitions for each set. ability. The Rhythmex exercises Currently, Jill lives in a supervised residential commu- When we began with the Rhythmex exercises, we modified nity for individuals with chronic TBI. She sought services in the principles of alternating upper and lower extremities to our clinic looking for improvement in her gait, spasticity address Jill’s limitations due to her tightness and increased and functioning of her right hand. spasticity. Jill was presented with exercises that activated upper extremities only and separately exercises that acti- The treatment plan vate the lower extremities. The goal was to synchronize upper and lower extremities. The guidelines in choosing an effective treatment modality for Jill were governed by several factors. One, the chronic The following are examples from Jill’s exercise regimen stage of her dysfunction nine years post trauma, second, in the last six months of the rehabilitation including 4 the history of her rehabilitation in the past including exercises targeting her pelvic area and right shoulder passive range of motion, muscle strength, and gait training, spasticity, 2 of them performed lying on an exercise mat to and third, the significance of the existing limitations of the avoid abnormal gait activation and loss of rhythm, one involved extremities; the high level of spasticity and low exercise was performed while standing in place, and one level of mobility and functionality. These limitations while in the quadruped position. preclude the use of techniques like Constraint-Induced (CI) movement therapy for her upper extremities (Taub et al., Wag-the-tail 2006) due to lack of function in her right hand, BATRAC was The exercise was performed in quadruped position offering excluded due to the spasticity in the shoulder, RAS and distal stability while activating the core muscles. Jill was similar techniques because of spasticity in the right leg. instructed to side bend the pelvis from left to right with the metronomed40 beats/min for 1 min followed by a rest Rhythmex exercises were chosen because they can be with 10 repetitions. utilized and beneficial even with minimal range of motion. Upside down bicycle Treatment guidelines and procedures The patient was lying on her back with her feet off the mat, Treatment guidelines followed the ABCD&R principles of and hips and knees flexed 90 degrees. This position allowed the Rhythmex method. stability of the torso and mobility of the legs. She simulated riding a bicycle, with one leg extending while the other was A. Alternating upper and lower extremities (like in flexing, with the metronome set ond42 beats/min for 90 s, walking; left leg movement is synchronized with right with a brief 30 s rest the sequence repeated 10 times arm movement and vice versa) (Fig. 1). B. Bilateral activation of both sides of the body in Cross-over bicycle a reciprocal movement The patient was lying on her back with the feet on the floor, alternately bending each knee and touching it with the C. Cross midline, hands should cross the midline in opposite hand (Figs. 2 and 3). In this position she benefited movement from the stability of the trunk and the resting foot. The goal was to achieve 2e5 min of continuous activity per day with D. Duration, each exercise was executed 30e90 s before the metronomed40 beats/min for 90 s, with a brief 30 s a break rest repeating the sequence 10 times. This exercise R. Rhythmic auditory cue with the metronome Each session starts with an assessment of current limi- tations, matching the limitations with an appropriate exercise. During each exercise movements must be self

340 Y. Goldshtrom et al. Figure 1 Upside down bicycle. Figure 3 Right-hand (paretic) touches left knee. accomplished all the ABCD&R principles; Alternating arms Results and legs, bilateral activation, crossing midline, sustaining the duration and keeping up with the rhythmic beat. This case report documents a year in Jill’s rehabilitation using Rhythmex, a rhythmic exercises program. Over that When Jill began the exercise, she could not bring the period, Jill came to the office every 2e3 weeks and most of right (paretic) hand to touch the left leg, but over time her arm became more functional to the point where she now stretches her hand to touch the knee. Dancing Starting position is standing with hips and knees slightly bent. The instructions were to shift the weight to the right leg maintaining the hip and knee in flexion while rotating the torso to the left and at the same time allowing the arms to cross midline (Fig. 4). The same movement is then repeated to the opposite side, shifting the weight to the left foot and rotating to the right (as in a dancing motion) keeping the beat with the rotation. Metronome was set to 30 beats/min for 90 s, with a brief 30 s rest and the sequence repeated 10 times. Initially, Jill was not able to shift her weight sideways and rotate her upper body. We began with gentle weight shift, rocking the pelvis side to side to the metronome, within the range allowed by her spasticity. Gradually the spasticity in her hips decreased and Jill gained control over the lateral weight shift. As she progressed in the activity, she gained control over the upper body rotation and with it the ability to cross midline with her arms. Figure 2 Cross-over bicycledleft-hand touches right knee. Figure 4 Jill shifting her weight to the left rotating her upper body to the right and crossing midline with her left arm e dancing.

Rhythmic exercises in rehabilitation 341 her workout was done as a home program by herself. During the office visit, she performed all of her exercises while the team modified her exercises (i.e., changing target range of motion, or beat rate) based on her progress and the specific functional goals (see Appendix A). She reportedly spends 20e30 min a day (not counting set up time and rests) 4e5 days a week for 12 months practicing Rhythmex exercises. During that time Jill has shown gradual improvements in several key areas including gait and independent mobility, functional use of the right paretic arm, cognition, and psychological factors. Gait and independent mobility Jill’s primary goals were to improve her gait and indepen- Figure 5 The spasticity in her fingers decreased and the fist dent mobility. Gait was assessed by her walking pattern and began to open spontaneously at rest. cadence (number of steps per minute), while independent mobility was assessed by balance reactions and coordina- 2003 her Full Scale rose by merely 2 points to 78 (7th tion of the upper and lower extremities and the trunk. percentile) with Verbal IQ of 78 and Performance IQ of 83. In repeated evaluations in 2005 her WAIS-III Full Scale IQ Jill has improved her balance and coordination while in scores did not change. In April 2008, a few months into the motion as result of reduced spasm in the pelvic area and rhythmic exercises, Jill requested to be tested again as increase of pelvic stability and isolated hip function, part of the application for accommodations during GED resulting in less hip hiking of the right hip during the swing testing, because of her difficulty in reading due to the phase of gait. The improved coordination carried through to hemianopsia. This time, all of her scores rose markedly: her gait pattern, with improvement in cadence, from about Full Scale rose to 94 (34th percentile) with Verbal IQ of 89 4 steps per 10 s with foot brace (0.4 m/s), to 12 steps per and Performance IQ of 100 (VIQ and PIQ difference of 10 s without a brace and 14 steps with a brace (1.4 m/s). 32.4%). According to the Speed-Based Classification System, Jill’s walking speed has improved from the lowest category of Levels of agitation ‘‘household’’ speed to the highest category of ‘‘commu- nity’’ speed (Bowden et al., 2008). An additional parameter One of the instruments available for measuring the severity of improvement of the leg was the return of sensation to of the brain injury is agitation; and the level of engagement touch that was impaired from the knee to the toes since the in TBI patients is the Agitation Behavioral Scale injury. (Corrigan, 1989; Lequerica et al., 2007). An instrument with Hand function and ADL Jill’s goals for her right hand were to reduce the spasm and need of the splint, and to gain function. When treatment began Jill wore a hand splint stabilizing her right wrist in approximately 10 degrees of extension. With the splint removed the strong flexor spasticity dominated her posture with wrist flexion and tight fisted fingers. At the present time Jill no longer wears a splint, the hand is held in a relaxed posture (see Fig. 5) and there is reduced tone in the finger and wrist flexors. Jill began gaining isolated function of the hand and fingers (see Fig. 6), being able to pick up a small object between the thumb and index fingers of the right hand. Jill has been using her right hand in ADL activities such as washing dishes and fastening her seat belt. In addition, when initially seen, Jill had no sensation in her right hand from the elbow to fingers. Over the year she experienced sporadic returns of sensation to touch with the ability to discriminate the location. At present she has regained full sensation to touch from the elbow to the fingers. Cognitive skills Jill has been given several neuropsychological evaluations Figure 6 Picking up an object with relaxed fingers. since her accident in 1999. Her WAIS-III Full Scale IQ eval- uation in 2000 was measured at 76 (5th percentile) and in

342 Y. Goldshtrom et al. three subscales: Disinhibition, Aggression, and Lability functional improvement since she was released from (adaptability to change). A comparison between her state a rehabilitation program at a university hospital two years of agitation as measured by the Agitation Behavioral Scale, after the accident and was sent to live in community resi- completed by her parent to reflect Jill’s behavior at the dency. When she arrived in our clinic in 2007 she was nine beginning of our treatment in 2007 with a second obser- years post TBI. Two years earlier she had been released from vation after a year in the program have showed improve- all out patient physical therapy services, yet she still showed ments in all of its subscales (See Fig. 7). multiple impairments. The specific disabilities Jill presented in 2007 excluded her as a candidate for rehabilitation Discussion methods such as Constrained Induces therapy or any of the REAC (rhythmic) based methods such as BATRAC or RAS This case report describes the use of Rhythmex, a rhythmic because walking was labored for her and she had minimal exercise program with auditory cues (REAC) protocol in range of motion in the paretic arm. Rhythmex was suggested treating a TBI patient nine years post craniotomy. Several because of its flexibility and versatility. For example, after studies in the last decade have showed the benefit of REAC in analyzing her level of spasticity and her movement restric- rehabilitation of patients after stroke and Parkinson’s tions, it was decided that the best beginning posture for her is disease, and with children with Cerebral Palsy. Rhythmex in supine (lying on the back) which allows her the highest promotes five exercise principles labeled: ABCD & R to inspire degree of control over her movement, and although her trunk spontaneous brain reorganization and re-learning of functions was supported she could freely move her extremities. that have been impaired or lost due to brain injury. Exercises Rhythmex allows any small movement to inspire brain reor- must activate the body extremities in an Alternating fashion ganization if the motion is active and the individual coordi- Bilaterally, while the movements should Cross midline, and nates the movement with a metronome. with each exercise Duration should only last 30e90 s before resting. The individual exercising must synchronize the Jill started her rehabilitation in our clinic in 2007, her movement to a constant Rhythm (such as a metronome). goals were to gain independent mobility and improve the function of her right hand. During the year Jill practiced Brain training exercises are learning modalities and Rhythmex exercises and regained independent mobility and unlike muscle training, learning occurs in small windows function (see Appendix A). Her progress covered gross (the ‘‘novice’’ phase) and intends to bring diminishing motor functions, sensory awareness, cognitive and results with increase in the length of practice, as the brain psychological functions. switches from control to an automatic activation. Rhyth- mex training adapts to the ‘‘novice’’ windows in two ways. Motor improvement included decreased spasticity of the First it limits the practice to 20 min a day while breaking right hand with improved spontaneous movement that down each exercise to 30e90 s units, and second by allowed the use of the hand to assist in ADL. Spasticity adapting the exercises as their novelty wears off. Options decreased at the right pelvis and hip improving Jill’s gate for changing the exercise include increasing the tempo or pattern and cadence. Jill’s balance reactions had improved changing one or all of the movement parameters (i.e., and she is able to perform activities like walking without her direction, distance, position, etc.). cane, climbing stairs independently and walking backwards. Jill regained her sensation to touch on the right arm and leg. Rehabilitation with rhythmic exercises Her cognitive function as measured on standardized IQ When Jill arrived in the clinic she complained she had tests has improved raising from the 7th percentile to an reached a plateau in her progress toward function using average level of 34th percentile and opening her possibili- traditional rehabilitation programs. She demonstrated no ties in education. She passed the GED exam and is currently in courses to improve her reading ability in preparation to ABS Subscale Scores enroll in college. There has been improvement in her stress level as evident by lowering the agitation level as measured 25 Disinhibition by the ABS scores. Aggression Jill is now looking to leave the community residency, Lability find an apartment and planning to get a job. She feels 20 confident taking a train or a bus to a major city or to school by herself, and she enjoys going out with friends. 15 We find that some of the physiological and cognitive 10 improvements in the past year can be attributed to the rhythmic exercises. We recognize that rehabilitation 5 through rhythm has the potential to facilitate changes in brain organization even in patients who have plateaued. 0 2008 The use of rhythmic exercises in this case has correlated 2007 with improved motor and cognitive functions bilaterally, regaining movement patterns that were lost or impaired Figure 7 Agitation behavioral subscales scores. due to the severe brain injury, suggesting that brain reor- ganization was still able to occur, even this long after her injury. Furthermore, this case shows that rhythmic exer- cises carried out as home program with sporadic follow up sessions every 2e3 weeks, can be effective in bringing about significant improvements in a multitude of functions

Rhythmic exercises in rehabilitation 343 that include: physiological, psychological, and cognitive, References even in a patient nine years post injury. More studies of rhythmic exercises are needed to explore and confirm the Bowden, M.G., Balasubramanian, C.K., Behrman, A.L., Kautz, S.A., effect of rhythmic movement under REAC protocol on brain 2008. Validation of a speed-based classification system using reorganization and function lateralization. quantitative measures of walking performance poststroke. Neurorehabil. Neural. Repair 22 (6), 672e675. Appendix A Assessment of outcomes summary Calautti, C., Baron, J.-C., 2003. Functional neuroimaging studies of motor recovery after stroke in adults: a review. Stroke 34 (6), 1553e1566. Observation/test Pre intervention evaluation 2007 Post intervention evaluation 2008 Gross Motor Upper Extremities Goal: Functional ADL Spasticity of fingers has Paretic right hand Right upper extremity under decreased and the fist has the influence of a strong begun to open spontaneously. Lower Extremities flexor spasticity; no volitional Climbing stairs motion below the elbow Right arm used more in ADL Ambulation Right hand splinted in 10 degrees functions like washing dishes extension and strapping the safety belt Cadence in the car. Hip hiking Goal: Independent Mobility Sensory Awareness/Fine Motors Unable to climb stairs without Can climb stairs without Tactile discrimination holding the rail or using a cane assistance, holding the rail, or a cane Cognitive Difficulty in ambulating and often Ambulating freely without WAIS-III Full Scale IQ evaluations use of a cane any assistance Unable to ambulate backwards Able to ambulate backwards Psychological without assistance at least 60 feet Agitation Behavioral 4 per 10 s with ankle foot orthotics 12 per 10 s without a brace and (0.4 m/s) e ‘‘household’’ speed 14 with a brace (1.4 m/s) Scale (ABS) - An instrument e ‘‘community’’ speed with three subscales: Marked hiking of the right hip Increased pelvic stability and Disinhibition, Aggression, during the swing phase of gait isolated hip flexion resolving and Lability. hip hiking No discrimination to superficial finger touching in right arm from Consistent awareness to superficial the shoulder to fingers finger touching of right arm between the shoulders and wrist No discrimination to superficial Consistent awareness to superficial finger poking touch in the right finger poking touch in the right leg leg from knee to toes from knee and ankle Partial awareness to touch in Jill’s WAIS-III Full Scale IQ evaluation fingers and toes in 2000 was measured at 76 (5th percentile), repeated tests in 2003 and 2005 show that In 2008 her Full Scale rose to 94 her Full Scale rose by merely 2 points to (34th percentile) with Verbal IQ of 78 (7th percentile) with Verbal IQ of 78 89 and Performance IQ of 100 and Performance IQ of 83. (VIQ and PIQ difference of 32.4%). 2007 ABS scores e Disinhibition (22.55), 2008 ABS scores e Disinhibition (17.5), Aggression (17.5), and Lability (18.6) Aggression (14), and Lability (14) e lower agitation level.

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Journal of Bodywork & Movement Therapies (2010) 14, 346e351 available at www.sciencedirect.com journal homepage: www.elsevier.com/jbmt PHYSIOLOGY Maximal clenching effort influence on the electromyographic activity of the trapezius muscle in healthy subjects* Fabiano Politti a,b,*, Cesar Ferreira Amorim d, Luis Henrique Sales Oliveira b,c, Fl´avia Dare´ Guerra a, Ivan Luis Souza Pieres a, Evanisi T. Palomari a a Departments of Anatomy, Cell Biology and Physiology and Biophysics, State University of Campinas (Unicamp) Brazil b Department of Physical Therapy, Rehabilitation Sciences Biomechanics Lab, University of Vale do Sapuca´ı (Univa´s), Brazil c Department of Plastic Surgery, Federal University of Sa˜o Paulo (UNIFESP), Brazil d Department of Mechanical Engineering, State University of Sa˜o Paulo (Unesp-FEG), Brazil Received 28 January 2009; received in revised form 29 May 2009; accepted 5 June 2009 KEYWORDS Summary Alteration of the occlusion and the position of the jaw can affect the muscles of Electromyography; the neck, due to a relationship between the masticatory and cervical systems. Thus, the objec- Masticatory apparatus; tive of this study was to verify whether the bite in maximal clenching effort, in centric occlu- Clenching; sion, in individuals with clinically normal occlusion, and without a history of dysfunction in the Trapezius muscle masticatory system, influences the electromyographic activity of the upper trapezius muscle. A total of 19 normal individuals participated in the study, 14 of which were women (average age of 25.4 Æ 4.14 years), and 5 were men (average age of 24.11 Æ 3.28 years). The root mean square (RMS) amplitude and median frequency (MF) of the upper trapezium muscle with 40% and 60% of maximal voluntary contraction were analyzed under pre- and post-maximal clench- ing effort conditions in centric occlusion. The electromyographic signal was collected with a sampling frequency of 2 kHz and the value in RMS was obtained by a moving window of 200 ms. The paired Student’s t-test was used to compare RMS amplitude and MF under pre- and post-maximal clenching effort conditions. The level of significance for each comparison * Work accomplished at the University of Vale do Sapuca´ı e UNIVA´S, Department of Physical Therapy, Rehabilitation Sciences Biomechanics Laboratory. * Corresponding author. Universidade Estadual de Campinas, UNICAMP, Depto de Anatomia, Instituto de Biologia, Cx Postal 6109, CEP 13084-971, Campinas e SP, Brazil. E-mail address: [email protected] (F. Politti). 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.06.001

Maximal clenching effort 347 was set to p < 0.05. This study concluded that in individuals without a history of dysfunction of the masticatory system, maximum clenching effort in centric occlusion does not alter the elec- tromyographic signal of the upper trapezius. ª 2009 Elsevier Ltd. All rights reserved. The trigeminal system is composed of neurons with Material and methods peripheral extensions that connect to the neuromuscular shafts of the masticatory musculature, to receptors in the Subjects temporomandibular joint and to the teeth. These periph- eral extensions have the function of informing the position The subjects of this study are 19 volunteers, 14 of whom of the jaw and the bite force through the synapses with the were women (average age of 25.4 Æ 4.14 years), and 5 were neurons of the motor nucleus of the trigeminal nerve, thus men (average age of 24.11 Æ 3.28 years), all were under- forming the simple myotactic reflex arches, also called graduate and graduate students in the University of Vale do mandibular reflex (Costacurta, 1979). Sapuca´ı e UNIVA´S, Minas Gerais State, Brazil. Eligible subjects were screened for TMD according to Axis I of the The existing reflex arch in the trigeminal system allows Research and Diagnostic Criteria e RDC/TMJ (Dworkin and the afferent relationship of the trigeminal nerve with LeResche, 1992). To be included in the study, the subject proprioception of the dental occlusion, vision and standard had to meet the following criteria: (a) adult age (>18 corporal posture (Gangloff and Perrin, 2002). Furthermore, years); (b) pain-free active mouth opening >40 mm it also has an important functional relationship with the (including overbite), pain-free active protrusion and later- cervical system, through the inhibition and reciprocal co- otrusion >7 mm; (c) difference between active and passive activation of the mandible, neck and shoulder during the opening 62 mm; (d) positive overjet and overbite between performance of upper limb positioning, as verified in 0 and 4 mm; (e) willingness to participate in the study and specific tests (Ferrario et al., 2003; Ciuffolo et al., 2005). to sign a written informed consent. Exclusion criteria were: (a) any TMD diagnosis; (b) chronic pain conditions (>3 Dysfunctions in the masticatory system can induce in the month duration) in other parts of the body; (c) current trapezius muscle a condition of hyper-contraction in orofacial inflammatory conditions; periodontal diseases; (d) response to the nociceptive signal in the acting area of the removable dental prostheses; (e) absence of any teeth trigeminal nerve (Gola et al., 1995). This muscle is recruited (except third molars); (f) neurological and movement systematically to produce stability at the neck and disorders; and (g) habitual intake of drugs influencing the frequently it can be activated by pain reflexes as a protec- activity of the central nervous system. tive mechanism. This increased recruitment of the trapezius muscle may change its ability to sustain prolonged Shoulder and cervical spine normality of was determined contractions in patients with temporomandibular joint by these specific tests: (a) Neer’s Test (Neer, 1983): the test disorders (TMD), which may lead to significant changes in is performed by placing the arm in forced flexion with the body posture. A relationship between increased muscle EMG arm fully pronated. The scapula should be stabilized during activity in the neck muscles and myofascial pain has been the maneuver to prevent scapulothoracic motion. Pain with observed in subjects with TMD (Pallegama et al., 2004; this maneuver is a sign of subacromial impingement; (b) Tecco et al., 2008). This myofascial pain might not be Hawkins’ Test (Hawkins and Kennedy, 1980): it is performed limited just to these neck and masticatory muscles, but by elevating the patient’s arm forward to 90 while forcibly might spread out to several body parts, for example to the internally rotating the shoulder. Pain with this maneuver shoulder region (Pedroni et al., 2006; Munhoz et al., 2004). suggests subacromial impingement or rotator cuff tendon- itis; (c) Instability Testing (Harryman et al., 1990, 1992): These findings, associated with the complex anatomical the tests described in this section are useful in evaluating and biomechanical interaction between the stomatognathic for glenohumeral joint stability. Because the shoulder is system and the head and neck regions, have led many normally the most unstable joint in the body, it can scientists to discuss these relationships (Mannheimer and demonstrate significant glenohumeral translation (motion). Rosenthal, 1991; Darling et al., 1994). Again, the uninvolved extremity should be examined for comparison with the affected side; (d) Posterior Appre- As demonstrated by many studies, regardless of the hension and Instability (O’Driscoll, 1991): with the patient known relationships between the masticatory system, the supine or sitting, the examiner pushes posteriorly on the neck muscles and the scapular waist, it is hypothesized that humeral head with the patient’s arm in 90 of abduction the activity of these muscles is altered only in cases of and the elbow in 90 of flexion; (e) Spurling’s Test (Palmer dysfunction of the masticatory system (Pedroni et al., 2006; and Epler, 1998): the patient’s cervical spine is placed in Ciuffolo et al., 2005; Munhoz et al., 2004; Ferrario et al., extension and the head rotated toward the affected 2003; Gola et al., 1995). shoulder. An axial load is then placed on the spine. Reproduction of the patient’s shoulder or arm pain indi- Thus, the objective of this study was to verify whether cates possible cervical nerve root compression and the bite, in maximal clenching effort, in centric occlusion, in individuals with clinically normal occlusion and without a history of dysfunction in the masticatory system, influ- ences the electromyographic activity of the upper trapezius muscle, as happens in individuals with disturbances in the masticatory apparatus mentioned by the literature.