ISSUE 1 8 OCT 2008
promoting
best practice in
HIGHLIGHTS
sports care ■ INTEGRATING STRESS REDUCTION STRATEGIES INTO CLINICAL PRACTICE
■ EVIDENCE-BASED PRACTICE AND HOW TO APPLY IT
■ MODERN MYOFASCIAL RELEASE ■ SOFT TISSUE TREATMENT OF HAMSTRINGS
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CONTENTS OCTOBER 2008 ISSUE 18 Publisher TOR DAVIES BSc (Hons) tor@sportex.net Editor BOB BRAMAH MSMA, MCSP bob@sportex.net Art editor DEBBIE ASHER debbie@sportex.net Advertising manager PAUL HARRIS paul@sportex.net 020 8144 3391 Sales and marketing LISA NAJI lisa@sportex.net 0845 652 1906 Subscriptions SANDRA GREATOREX subs@sportex.net 0845 652 1906 TECHNICAL ADVISORS
Bert Appleton Steve Aspinall Paula Clayton Steven Cluney Dr Marco Cardinale Dave Clark Stuart Hinds Brad Hiskins Ian Jeffrey
Michael Nichol Joan Watt Dr Greg Whyte
MSMA BSc (BASRaT), MSc MSMA, MCSP MSMA PhD, MSc, BSc
MSc, BSc (Med Hons), BPE Dip SST BSc, Dip SST BA (Hons), MSc, PGCE, CSCS BSc (BASRaT) MCSP, MSMA PhD, BSc (Hons)
is published by Centor Publishing Ltd 88 Nelson Road Wimbledon, SW19 1HX
Welcome
Welcome to the autumn edition of sportEX dynamics. I’m a founder member of the Sports Massage Association and practitioners often ask me. “Why should I join the SMA? What will I get out of it?” My answer is that I can’t tell them why they should join. I can only tell them why I’m a member. 1. I’m passionate about what I do. 2. I’m passionate about the use of massage and soft tissue techniques to help athletes reach their goals. 3. I want to be in an organisation of like minded people. For me the SMA fits the bill. Does it do everything I want it to? No. Does it do what it does quickly enough? No. Can it get better at what it does? Yes. My answer applies not just to the SMA but to BASRAT, the Campaign for Real Ale or any other special interest group you can think off. None of them are perfect. They are small, generally run by amateurs and need their members to contribute. They are not big enough to be everything to everybody but one day with the members support they might be. To paraphrase President Kennedy, “Ask not what your group can do for you but what you can do for your group”. Bob Bramah, MSMA, MCSP bob@sportex.net
Tel: 0845 652 1906 Fax: 0845 652 1907 www.sportex.net
OTHER TITLES IN THE SPORTEX RANGE sportEX medicine - ISSN 1471-8138. Written specifically for professionals working in the field of soft-tissue injury and rehabilitation - personal annual subscription £35, practice subscription £99 sportEX health formerly known as healthEX specialist - ISSN 1471-8154. For people working in the physical activity health promotion sector, health and fitness industry as well as in primary care and occupational health annual subscription £35 for individuals, £60 for departments
CONTENTS
4 Journal watch 7 Stress reduction programme 10 Evidence-based practice 14 Modern myofascial release A look at some of the latest research
How stress-reduction strategies can benefit clients
What is evidence-based practice and why should we apply it? A new less is more approach.
17 Travelling with teams tissue treatment for the AFL hamstring condition 20 Soft Effective and successful team travel
An overview of all aspects of this condition within this sport
trials and tribulations of teaching sports therapy 24 The
A personal account of the transition from clinician to teacher
DISCLAIMER While every effort has been made to ensure that all information and data in this magazine is correct and compatible with national standards generally accepted at the time of publication, this magazine and any articles published in it are intended as general guidance and information for use by healthcare professionals only, and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. To the extent permissible by law, the publisher, editors and contributors to this magazine accept no liability to any person for any loss, injury or damage howsoever incurred (including by negligence) as a consequence, whether directly or indirectly, of the use by any person of any of the contents of the magazine. Copyright subsists in all material in the publication. Centor Publishing Limited consents to certain features contained in this magazine marked (*) being copied for personal use or information only (including distribution to appropriate patients) provided a full reference to the source is shown. No other unauthorised reproduction, transmission or storage in any electronic retrieval system is permitted of any material contained in this publication in any form. The publishers give no endorsement for and accept no liability (howsoever arising) in connection with the supply or use of any goods or services purchased as a result of any advertisement appearing in this magazine.
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COMPARISON OF A TARGETED AND GENERAL MASSAGE PROTOCOL ON STRENGTH, FUNCTION, AND SYMPTOMS ASSOCIATED WITH CARPAL TUNNEL SYNDROME: A RANDOMIZED PILOT STUDY. Moraska A, Chandler C, et al. Journal of Alternative and Complementary Medicine 2008;14:259–267 Twenty-seven subjects with a clinical diagnosis of carpal tunnel syndrome (CTS) were randomly assigned to receive six weeks of twice-weekly massage consisting of either a general massage treatment programme (GM) or a CTS-targeted massage treatment programme (TM). Outcome measures included hand-grip and key-pinch dynamometers, Levine symptom and function evaluations, and the grooved pegboard test. Evaluations were conducted twice during baseline, two days after each of the seventh and eleventh massages, and
at a follow-up visit four weeks after the twelfth massage treatment. Results: A main effect of time was noted on all outcome measures across the study. Timeframe improvements persist at least four weeks post-treatment. Comparatively, TM resulted in greater gains in grip strength than GM, with a 17.3% increase over baseline but only a 4.8% gain for the GM group. Significant improvement in grip strength was observed following the seventh massage. No other comparisons between treatment groups attained statistical significance.
THE COMBINED ACUTE EFFECTS OF MASSAGE, REST PERIODS, AND BODY PART ELEVATION ON RESISTANCE EXERCISE PERFORMANCE. Caruso JF, Coday MA. Journal of Strength and Conditioning Research 2008;22:575–582 Although massage administered between workouts has been suggested to improve recovery and subsequent performance, its application between bouts of repetitive supramaximal anaerobic efforts within a given workout has received little attention. Thirty subjects performed three workouts that were identical in terms of the exercises (45o leg press, prone leg curl, seated shoulder press, standing barbell curl), the number of sets and the resistance employed. For each workout, subjects received one of the following treatments between sets: 1 minute of rest as they stood upright, 30 seconds of rest as they stood upright, or 30 seconds of concurrent massage and body part elevation (MBPE), which entailed petrissage of the exercised limbs in a raised and supported position in an attempt to abate fatigue and enhance recovery from the previous set. Subjects were instructed to perform as many repetitions as possible for each set. For each exercise, two dependent variables were calculated: a total work/elapsed time ratio and the cumulative number of repetitions performed. Results: We can imply that rest period duration exerts more influence than MBPE on resistance exercise performance.
sportEX comment People who seek improved resistance exercise performance should pay particular attention to rest period durations. There is a lot more work to be done here, such as changing the rest intervals and varying the massage routines. This is a good prospect for budding researchers.
sportEX comment More good stuff from Dr Moraska. Again, we are getting evidence of the efficacy of massage, suggesting that it may be a practical conservative intervention for compression neuropathies, such as CTS.
THE EFFECT OF DEEP-TISSUE MASSAGES THERAPY ON BLOOD PRESSURE AND HEART RATE. Kaye AD, Kaye AJ, Swinford J, Baluch A, et al. Journal of Alternative and Complementary Medicine 2008;14:125–128. This study involved 263 volunteers (12% males, 88% females), with an average age of 48.5 years. Overall muscle spasm/muscle strain was described as either moderate or severe for each patient. Baseline blood pressure and heart rate were measured via an automatic blood pressure cuff. Twenty-one different soothing CDs played in the background during the deep tissue massage. Results: An average systolic blood pressure reduction of 10.4mmHg, a diastolic blood pressure reduction of 5.3mmHg, a mean arterial pressure reduction of 7.0mmHg and an average heart rate reduction of 10.8 beats per minute were noted.
sportEX comment These are positive results, but still massage is described as “deep tissue”, which is not specific enough for the study to be repeated with accuracy. There is also a question about another variable: what is causing the reduction in blood pressure – is it the massage or the soothing CD playing in the background?
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JOURNAL WATCH
Journal Watch MASSAGE REDUCES PAIN PERCEPTION AND HYPERALGESIA IN EXPERIMENTAL MUSCLE PAIN: A RANDOMIZED, CONTROLLED TRIAL. Frey Law LA, Evans S, Knudtson J, Nus S, et al. Journal of Pain 2008;9:714–21 The purpose of this study was to perform a double-blinded, randomised controlled trial of the effects of massage on hyperalgesia (mechanical pressure pain thresholds, PPT) and perceived pain using delayed-onset muscle soreness (DOMS) as an endogenous model of myalgia. (Myalgia is defined as pain in a muscle or pain in multiple muscles.) Participants were randomly assigned to a no-treatment control, a superficial touch group or a deep-tissue massage group. Eccentric wrist extension exercises were performed at visit one to induce DOMS 48 hours later at visit two. Pain (assessed using visual analogue scales) and PPTs were measured at baseline, after exercise, before
treatment and after treatment. Results: Deep massage decreased pain (48.4% DOMS reversal) during muscle stretch. PPT was reduced (27.5% reversal) in both the deep massage and the superficial touch groups relative to control. Resting pain did not vary between treatment groups.
sportEX comment All soft tissue practitioners know the value of massage, but proving its efficacy by good clinical evidence is difficult. We should take any positives we can – and this study shows positive results. The study also highlights the difficulties facing researchers. The correlation between myalgia and DOMS is questionable.
Are DOMS signs and symptoms similar to those of myalgia? Previous studies tend to suggest that massage makes no difference to DOMS. The type of massage is rarely defined in these studies; in this study, however, the massage is described as “deep tissue massage”, which, although a bit more specific than in some studies, still leaves room for interpretation. The authors note the difficulties in choosing an assessment method. In many previous studies involving massage and DOMS, the result is quantified by performance factors rather than clinical findings such as pain on stretch, flexibility or power output; therefore, it becomes difficult to compare studies.
PHYSIOLOGICAL ADJUSTMENTS TO STRESS MEASURES FOLLOWING MASSAGE THERAPY: A REVIEW OF THE LITERATURE. Moraska A, Pollini RA, Boulanger K, Brooks MZ, Teitlebaum L. Evidence-based Complementary and Alternative Medicine. eCAM Advance Access published online on May 7, 2008 Online databases were searched for articles relevant to both massage therapy and stress. Articles were included in this review if (i) the massage therapy account consisted of manipulation of soft tissues and was conducted by a trained therapist, and (ii) a dependent measure to evaluate physiological stress was reported. Hormonal and physical parameters are reviewed. A total of 25 studies met all inclusion criteria. A majority of studies employed a 20to 30-minute massage administered twice a week over five weeks with evaluations conducted before and after an individual session (single treatment) or following a series of sessions (multiple treatments). Results: Single treatment reductions in salivary cortisol and heart rate were consistently noted. A sustained reduction for these measures was not supported in the literature, although the single-treatment effect was repeatable within a study. To date, there are insufficient research data to make definitive statements regarding the multiple treatment effect of massage therapy on urinary cortisol or catecholamines, but some evidence for a positive effect on diastolic blood pressure has been documented. Although significant improvement has been demonstrated following massage therapy, the general research body on this topic lacks the necessary scientific rigour necessary to provide a definitive understanding of the effect of massage therapy on many physiological variables associated with stress.
sportEX comment Moraska has a good track record, having previously produced an excellent review of sports massage literature. Like many reviews of the effects of manual therapy, this one criticises the standard of research methodology; the important thing to note here, however, is that the search criteria stipulated the use of trained therapists who should know what they are doing (some studies use nurses or students, who have received minimal training) and that, given the reported positive outcomes, bit by bit we are building up evidence that massage does have physiological effects.
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JOURNAL WATCH
HUMOUR AND LAUGHTER MAY INFLUENCE HEALTH: III. LAUGHTER AND HEALTH OUTCOMES. Bennett MP, Lengacher C. Evidencebased Complementary and Alternative Medicine 2008;5:37–40 A review of how humour influences physiological and psychological wellbeing and its influence on health outcomes, including muscle tension, cardiorespiratory functioning and various stress physiology measures.
sportEX comment A DISTINCT PATTERN OF MYOFASCIAL FINDINGS IN PATIENTS AFTER WHIPLASH INJURY. Ettlin T, Schuster C, Stoffel R, Brüderlin A, Kischka U. Archives of Physical Medicine and Rehabilitation 2008;89:1290–1293 The purpose of this study was to identify objective clinical examinations for the diagnosis of whiplash syndrome; it focused on trigger points. A total of 124 patients and 24 healthy subjects participated in the study. Among the patient group were people with whiplashassociated disorders (n=47), fibromyalgia (n=21), non-traumatic chronic cervical syndrome (n=17) and endogenous depression (n=15). Each patient and control subject had a manual examination for trigger points of the semispinalis capitis, trapezius pars descendens, levator scapulae, scalenus medius, sternocleidomastoideus and masseter muscles bilaterally. Results: Forty (85.1%) of the patients with whiplash had positive trigger points in the semispinalis capitis muscle. The patients with whiplash had a significantly higher prevalence of positive trigger points in the semispinalis capitis muscle than any of the control groups. For the other examined muscles, the prevalence of trigger points in the patients with whiplash did not differ significantly from the patients with fibromyalgia or non-traumatic chronic cervical syndrome, but it did differ from the patients with endogenous depression and the healthy controls.
sportEX comment This is a significant mapping of post-neck-trauma trigger-point patterns of distribution and should give a focus for therapists seeking resolution of muscular problems. The semispinalis capitis muscle in particular is a target.
ACUTE EFFECTS OF SELF-SELECTED REGIMEN OF RAPID BODY MASS LOSS IN COMBAT SPORTS ATHLETES. Timpmann S, Ööpik V, Pääsuke M, Medijainen L, Ereline J. 2008;7:210–217 The purpose of the study was to assess the acute effects of the self-selected regimen of rapid body mass loss (RBML) on muscle performance and metabolic response to exercise in combat sports athletes. Seventeen male athletes reduced their body mass by 5.1±1.1% within three days. The RBML was achieved by a gradual reduction of energy and fluid intake and mild sauna procedures. A battery of tests was performed before (test one) and immediately after (test two) RBML. The authors included the measurement of the peak torque of knee extensors for three different speeds, assessment of total work (Wtot) performed during a three-minute intermittent intensity knee extension exercise and measurements of blood metabolites (ammonia, lactate, glucose, urea). Absolute peak torque was lower in test two compared with test one The peak torque in relation to body mass remained unchanged. Absolute Wtot was lower in test two compared with test one, as was Wtot in relation to body mass. Plasma urea concentration increased the concentration of ammonia in test two, while the plasma lactate and glucose responses to exercise were similar in tests one and two.
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Compiling Journal Watch is not always a satisfying activity but discovering this paper has opened up a new dimension in our search for performance research. The study of humour is a serious subject – even Sigmund Freud wrote a book about jokes (Jokes and Their Relation to the Unconscious 1905). The reference lists of these papers cite some heavyweight psychology and nursing journals and include such gems as “The effect of mirthful laughter on stress and natural killer cell activity”, “Mirth and oxygen saturation levels of peripheral blood” and our favourite “A chuckle a day keeps the doctor away”. The paper has a discussion on laughter as exercise and its effects on muscle tone. The evidence suggests muscle relaxation occurs for 45 minutes after laughter. The implications of this are that banter in the treatment room may actually have a beneficial effect.
sportEX comment Those of you who followed the Olympic Games in the summer may recall that a British boxing medal hope was sent home by his coach before competition because he struggled to make the weight. The coach maintained that it would have been dangerous to allow the boxer to complete following the necessary rapid weight loss. The authors conclude that the self-selected regimen of RBML impairs muscle performance in three-minute intermittent intensity exercise, and so it seems that the coach was right to protect his athlete – a tough decision but good for him.
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CAREERS STRESS REDUCTION
STRESS REDUCTION PROGRAMME BY STUART ROBERTSON, MCSP
‘WHERE IS THE LIFE WE HAVE LOST IN LIVING?’ – TS ELLIOT Life in the fast lane isn’t the preserve of the rich and famous. It is an ever-increasing reality for many people in today’s hectic global lifestyle. Trying to meet and balance the demands of family, work and social life can be one long juggling act. Many people are stressed out simply by trying to keep their head above water; they do not have time to reflect on how their life could be lived differently. Take me, for example: I was once a carefree young man, free to do as he pleased, time to do with as he pleased – the odd exam here and there to pass, but in general life was a breeze. This same young man one day found himself at work; this brought certain time constraints, but he still managed to get in everything he needed to do. He then matured into an adult (although this may be disputed by his mother!) who “needed” to make a success of his career. Indeed, he suddenly had no time for many of the things he loved doing, as he was far too busy. This adult matured into a father in his early forties; then not only did he have to think of the needs of his career and his wife, but also he had to consider the needs of his young children – and all this on a diet of junk food (due to lack of time and energy to prepare more wholesome food) and a lack of sleep. The very things that he had found nourishing were now a distant memory. Ring any bells, or am I the only one this has ever happened to?
This article offers a proactive perspective on health and how massage and manual therapists can integrate stress-reduction strategies into clinical practice in order to benefit their clients.
MAN CANNOT DISCOVER NEW OCEANS UNTIL HE HAS THE COURAGE TO LOSE SIGHT OF THE SHORE anon
‘THE MAIN THING IS TO KEEP THE MAIN THING THE MAIN THING’ – STEPHEN R. COVEY What is it you cherish most in life? Try to keep that at the top of your priority list. Below is a list of different aspects of our lives. Try ranking these aspects in terms of priority. Mark the most important to you as number one, and the least important as number six: ■ Family relationships ■ Financial situation ■ Work ■ Community and friends ■ Health ■ Fun and recreation Now rank the same aspects in terms of the time you devote to them: ■ Family relationships ■ Financial situation ■ Work ■ Community and friends ■ Health ■ Fun and recreation If the rankings match up – for example, you have your career as your top priority in life and you also rank it at number one in terms of most time devoted – then you are probably motoring along nicely. On the other hand, if you
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have a mismatch – for example, your family relationships are your number-one priority, but you can rank these only fourth in terms of time devoted because you are always away with work – then you may be experiencing elements of stress. Now think of a time when everything was going really well in your life. If you can’t think of one, try to remember a time when all was going well in one particular aspect of your life. How would your priorities have matched up then? There are certain things that we all have to do, such as eat and drink, but there are also things that we do not have to do – it’s just that we or other people tell us that we have to do them. Despite these things being matters of choice, once we have told ourselves that we have to do them they become self-fulfilling prophecies. They become habitual – and, once habitual, we often do not question them but just do them. As our lives become increasingly full, we have more habits to feed and less time to fit them all in. By prioritising what is important to us, and by rediscovering a sense of purpose and direction, we can prune away the paraphernalia and dead wood and create time for what truly nourishes us.
‘TWO ROADS DIVERGED IN A WOOD, I TOOK THE ONE LESS TRAVELLED, AND THAT HAS MADE ALL THE DIFFERENCE’ – ROBERT FROST Stress, health, immune function and ultimately wellbeing are linked intimately to how we think, feel and behave. As humans we receive information through our senses, which, together with past experiences (memories), leads us to take certain actions or behaviours. Similarly, each cell in our body experiences the internal environment through its receptors, which are akin to our senses. Information is gathered, and then the cell takes a certain course of action or behaviour. The cell either opens itself up to certain aspects of its environment or it closes down. The cell accepts certain incoming information and blocks other information. It forms certain relationships with other cells that nourish its existence and avoids other groups of cells that damage, or threaten to damage, its existence. The nervous system has overall responsibility for monitoring environmental signals and their interpretation, and for organising the appropriate response to external threat or danger. This system is called the hypothalamus–pituitary– adrenal (HPA) axis. The hypothalamus, which sits deep in the brain, receives and recognises environmental information; this can be likened to the body’s internal sense. The pituitary gland is responsible for setting into action the necessary behaviour – the “fight or flight” response. The immune system is the second mechanism employed to gear up for
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impending threat. The HPA axis, with the release of “stress hormones”, represses and inhibits the action of the immune system. The HPA axis was not designed with continuous activation in mind. In primitive terms its purpose was to alert us to the lion creeping up behind us in the bush. In today’s stressful world, however, we can be overwhelmed by constant worry, anxiety and fear, which has our HPA axis operating continuously in order to fall in line with our 24/7 lifestyle. The impact of this is not only to potentially compromise the effectiveness of the immune system, but also to reduce our ability to think straight. We are flooded with adrenaline, ready to react at any moment in time. We become so used to being stressed that it feels normal.
‘HABITS ARE LIKE A CABLE. WE WEAVE A STRAND OF IT EVERY DAY AND SOON IT CANNOT BE BROKEN’ – HORACE MANN Stress is a part of most people’s lives. Equally, many people are becoming more aware that how we think, feel and behave can have implications for our health. Bruce Lipton reports that ‘almost every major illness that people acquire has been linked to chronic stress’. Simply exposing people to this information, however, does not necessarily lead to change. Most smokers know that their habit is undermining their health – but still they don’t give up smoking. To give up smoking requires a desire to fundamentally change, and this requires considerable energy at times. On many occasions our good intentions fade and we return to our habitual ways of being. Many people see the need for change but remain stuck in a rut. As a simple exercise to demonstrate that we habitually do things the same way, fold your arms across your chest. How does that feel? Now unfold your arms and fold them the other way. What does that feel like? I suspect that the last way of folding your arms didn’t feel “right”. There is no right or wrong way to fold your arms, and you probably weren’t even aware that you always folded your arms in the same way. But you are now aware that there is a different way of doing it. Without thinking, however, the next time you fold your arms, you will probably use the old habitual pattern. Without conscious awareness, how we think, move and behave just “happens”, in the same way that our heart beats and our stomach digests.
A PROACTIVE HEALTH ROLE FOR MASSAGE AND MANUAL THERAPISTS Many therapists within the sporting community are already actively involved in “prehab”, preventing injuries and using sports psychology to optimise athletes’ performance. Why
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CAREERS STRESS REDUCTION be just as damaging as the real thing, as Mark Twain alludes to: ‘I have known many troubles in my life, and most of them never happened.’ As you tune your client back into their body, they will become more aware of their physical tensions. This process will enable your client to feel how their negative thoughts and internal dialogue impact on their body and hence their wellbeing. Appreciating this provides a platform for change. Our mind and body do not exist in a vacuum. They are married or single, working or not working, in jobs they like or dislike. They are embedded in our environment, which by and large has usually been created by us. That environment can either support our wellbeing or undermine it. By examining how we have created our own unique environment in which we live, it is possible to identify those areas in our life that really work for us and others that are holding us back. The concentric ring model in figure 1 demonstrates how the body, mind and external environment are inextricably linked. At the centre of the stress-reduction programme is the client’s body, which is influenced by their state of mind, which in turn is influenced by the client’s environment. It is easy for people to identify stress in others, but it is not always as easy to identify stress in ourselves. Through working with the core skills of soft tissue palpation and release, the massage and manual therapist can develop client awareness, adding a new dimension to their practice. Empowering clients to recognise and work with their stress levels is extremely rewarding – this is working “with” the client rather than “on” the client.
not take this concept of targeting proactive and optimal health into working with non-sporting clients? The techniques employed to gain sporting success can easily transfer to successful living. Manual and massage therapists are ideally placed to implement such programmes with their clients by helping their clients tune into their body. A stressed person holds tension in their body. Some people are aware of this stress, but others remain blissfully unaware of the areas of their body where they hold physical tension. As massage and manual therapists, we can help our clients. Many people take their body for granted until something goes wrong. Our cultural premise is that, if your body goes wrong, you “book it in” with a doctor, just as you would take your car to a mechanic to fix it. Until recently, we have viewed health very passively. The cards that we have been dealt are our cards for life, and we have taken a fatalistic approach. But things are changing: people are beginning to take more interest in their health. In my clinical experience, when we engage clients in the treatment process, they become inspired to work proactively towards better health.
‘PEOPLE TRAVEL TO WONDER AT THE HEIGHT OF THE MOUNTAINS, AT THE HUGE WAVES OF THE SEA, AT THE LONG COURSE OF RIVERS, AT THE VAST COMPASS OF THE OCEAN, AT THE CIRCULAR MOTION OF THE STARS; AND THEY PASS BY THEMSELVES WITHOUT WONDERING’ – ST AUGUSTINE Through developing sensitive palpatory skills, simple physical sensory exercises, mental imagery and effective release techniques, we as therapists are able to tune the client back into their body, enabling them to develop greater awareness of areas of physical tension. The purpose of bringing awareness into how the client’s body feels will bear fruit in three ways: ■ The client will become aware of where they hold physical tension in their body ■ The client will become aware of what state of mind increases or releases this tension ■ The client will become aware of what areas of their life are and are not in harmony.
Figure 1: The link between body, mind and external environment
e Ext
ctors, eg. w rnal fa ork
Mind
Body
Anyone who has experienced a nightmare will recognise how their body responds to the state of their mind. The sleeper awakens sweating, muscles tight, out of breath, heart pounding. In the nightmare, the body responds, even though the events are not real. Perceived threats and stresses can
THE AUTHOR Stuart Robertson graduated as a physiotherapist and completed an MSc in physiotherapy in 1996. He teaches both nationally and internationally on the fascial system, and he has a clinical practice in Somerset. He has broad clinical experience, having worked with both international sportspeople and patients with chronic pain. For further information see www.dmbem.com or email stuart.robertson@dmbem.com.
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THE QUALITY ISSUE: THE NEED FOR SYSTEMATIC SEARCH STRATEGIES, CRITICAL APPRAISAL AND HIERARCHY LEVELS OF EVIDENCE BY NICK DINSDALE, BSc
INTRODUCTION Few of us would argue with the importance of evidence-based practice (EBP) in sports medicine, but to develop such a culture we must have goodquality research literature (1). Research is simply a way of solving problems. Questions are raised, and methods are devised in an attempt to answer them (2). Research enables us to convert theory into practice in order to solve clinical problems. Research in medicine and the sciences has developed within a framework of thinking known as the “scientific method”. This framework has become the predominant model for rigorous research investigation. Unfortunately, owing to the vast quantities of research material now available, searching and locating relevant literature can be difficult and is often very time-consuming. Furthermore, the quality of research evidence cannot always be relied upon for EBP. This article attempts to identify some of the typical pitfalls and discusses the research skills required for EBP.
SYSTEMATIC SEARCH STRATEGIES The ability to conduct a literature search is an important skill (3) because the underpinning of EBP now relies on new skills – those of searching for research evidence, and those involved in critical appraisal of evidence (4). Efficient search strategies offer the opportunity to source relevant research, of potentially high quality, in the most time-efficient manner. There are several strategies for conducting a literature search, including searching with the help of a computer, cross-checking references lists, and hand-searching personal files (4). Caution should be exhibited when 10
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Evidence-based practice is an important aspect of sports medicine, but such practice requires good-quality research literature. The vast quantities of research material available make searching and locating relevant literature difficult and time-consuming. In addition, not all research evidence is of a high quality, and therefore cannot be relied upon for use in evidence-based practice. In this article we identify some of the typical pitfalls of research and discuss the research skills required in order to practise in an evidence-based manner.
using general Internet search engines such as Google or Yahoo!, particularly when gathering evidence on medical care issues. Although these search engines are attractive and easy to use, they often retrieve non-scientific, lowquality information (5). Internet search engines suffer from a lack of overall quality control, and the information continued therein is often incomplete because authors and publishers are reluctant to give away information free of charge. For most topics, computerised searches of medical scholarly databases such as MEDLINE, EMBASE, CINAHL, and SportDiscus offer the greatest potential yield, convenience and effective use of time. For randomised controlled trials and systematic reviews in physiotherapy,
the PEDro database and the Cochrane Library Database of Systematic Reviews and Controlled Trials Register are useful (6). Databases of primary research are staggeringly large: in 2005 there were more than 12 million citations in MEDLINE and 7 million in EMBASE. Simply searching using free text can give the impression that searching in the medical literature databases is easy. However, this is wrong; we still have to know how to formulate systematic search strategies in each particular database in order to identify reliable research (7). Identifying keywords forms part of a search strategy (8) but often results in a large number of false hits. Most scholarly databases offer the option of searching sportEX dynamics 2008;18(Oct):10-13
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RESEARCH SKILLS EBP by subject heading. Subject headings are sets of controlled vocabulary that give a standardised term to a concept. When a search retrieves nothing worthwhile, is it because no literature exists, or is it because the person looking has not found it (9)? In summary, knowing how to formulate a good search strategy makes searching more methodical, relevant, thorough, complete and timeefficient.
RESEARCH TYPES AND DATA For many years scientists have recognised two different types of research: primary and secondary (Table 1). Both types of research can involve either qualitative or quantitative research data. Qualitative data are depicted as rich and deep; the research methods generally include field observations, case studies, ethnography and narrative reports. Qualitative research seeks to understand the meaning of an experience to the subjects in a specific setting and how the components mesh to form a whole (2). The most fundamental characteristic of qualitative research is its express commitment to viewing, for example, events, action, norms and values from the perspective of the participants. In contrast, quantitative data are depicted as hard, rigorous and reliable (10). Quantitative research tends to focus on analysis; its strength lies in its reliability (repeatability), which is the extent to which a test or procedure produces similar results under constant conditions on all occasions (11). In summary, generally quantitative research is objective, whereas qualitative tends to be more subjective.
THE QUALITY ISSUE Evidence-based practice is a process of turning clinical problems into questions, and then systematically locating, critically appraising and using robust contemporary research evidence as the basis for clinical decisions (12). It is widely accepted that the reading of peer-reviewed research articles is essential for EBP and vital to continuing professional development (CPD) (4,13,14). Journal-reading enables the therapist to keep up to date with current thinking (15). However, research evidence should never be accepted www.sportEX.net
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TABLE 1. DEFINITIONS AND COMPARISON BETWEEN PRIMARY AND SECONDARY RESEARCH Primary
Primary research (also called field research) involves the collection of data that do not already exist. Primary research comprises original studies based on observation or experimentation on subjects designed to unearth original data. In order to do this, an original research plan must be devised, which encompasses methodology, data collection, data input, and the production and analysis of the subsequent results. Due to the sometimes lengthy duration of this research, it may be expensive to conduct. Because the research is original, however, the results gathered will be more relevant to the needs of the researcher and eventually the clinician.
Secondary
Secondary research is the use of information that other people have gathered through primary research. Secondary research involves reviews of published research, drawing together the findings of two or more primary studies. These secondary sources normally involve journal articles but may also include previous research reports, newspapers and magazines. A key advantage of secondary research is the full citation of original sources, usually in the form of a complete reference listing. Secondary research is generally easier to perform than primary research. Systematic reviews are classified as secondary research.
blindly and certainly should not be taken at face value (16). Therefore, research needs to be critically evaluated for both quality (validity) and relevance (17) in order to help the clinician make better use of the evidence (18) to inform clinical decisions and practice. In 1996, Rothstein realised that the survival of his profession (physical therapy) depended not on the quantity of dubious research but on the quality of focused and meaningful research (19). Rosenberg and Donald said: “we are confronted by a growing body of information, much of it invalid or irrelevant to clinical practice” (12). Many authors share this view; for example, Marshall reminds us of the need to read literature with a critical mind – even literature published in peer-reviewed journals (16). More drastically, Greenhalgh suggests that most published articles belong in the bin and should certainly not be used to inform practice (20). According to Del Mar, most research papers are written as communications from scientists to scientists and relatively few have immediate clinical relevance – most of the remainder are not rigorous enough to warrant applying clinically (9). Consequently, the proportion of useful
information is very small. Greenhalgh reported that many papers published in medical journals have potentially serious methodological flaws (20); therefore, if you are deciding whether a paper is worth reading, you should do so on the design of the methods section. In support of Greenhalgh,
IT IS WIDELY ACCEPTED THE READING OF PEER REVIEWED RESEARCH ARTICLES IS ESSENTIAL FOR EBP AND VITAL TO CONTINUING PROFESSIONAL DEVELOPMENT 11
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TABLE 2. HIERARCHY OF RESEARCH EVIDENCE Rank
Methodology
Description
Example
1
Systematic review, meta-analysis
Systematic review: review of a body of data that uses explicit methods to locate primary studies, and explicit criteria to assess their quality. Meta-analysis: systematic review that uses statistical methods to combine data, and analyse and summarise the results of the studies included.
Cochrane Collaboration
2
Randomised controlled trials (RCT)
Experiment in which individuals are randomly allocated to either a control group or a group that receives a specific intervention. Randomisation reduces the likelihood of bias. The strength of evidence is considerably boosted by the presence of at least one properly designed RCT of appropriate size.
3
Cohort study
Evidence from well-designed trials without randomisation. Cohort study: observational study in which a defined group of people (the cohort) is followed over time. The people are selected on the basis of their exposure to a particular agent and followed up later for specific outcomes.
4
Case-control studies
Evidence from well designed trials without randomisation. Case–control study: study that compares people in two groups with and without a specific condition or disease, all taken from the same population. Usually analysed retrospectively.
5
Cross-sectional survey
Survey or interview of a sample of the population to measure the distribution of interest at a particular point in time.
6
Case-report
A report based on a single patient or subject.
7
Expert opinion
Consensus of experience and opinions from respected authorities, based on clinical evidence, descriptive studies or reports from committees.
8
Anecdotal
Informal account of evidence in the form of an anecdote or hearsay, eg. “My granny says the best treatment is to rub it with onions”. The term “anecdotal evidence” is often used in contrast to “scientific evidence”. Anecdotal evidence focuses on experience rather than more formal scientific evidence.
Articles published in peer-reviewed research journals
Source of informal verbal communication
Adapted from: Greenhalgh (20), Sackett et al. (26), and Cochrane (30)
Sheldon and colleagues suggest that, when designing studies, investigators should consider how and by whom their results will be used (21). The design should be sufficiently robust, the setting sufficiently similar to that in which the results are likely to be implemented, the outcomes relevant, and the study size large enough for the results to convince decision makers of their importance. Although textbooks play an important role in providing basic information to learners, the drawback with all books is that they are not current (4). Some concepts described in textbooks can lag behind the empirical evidence by as much as 10 years. This lag is in part attributable to the more prolonged publication cycle for textbooks than for journal articles. In summary, treatment interventions should be chosen from the most relevant, scientifically sound and rigorous evidence currently available. Fortunately, the use of hierarchies of evidence can assist clinicians in this process.
THE HIERARCHY OF RESEARCH EVIDENCE Research evidence comes in many forms and varies considerably in quality. The widespread use of hierarchies of evidence that grade 12
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research studies according to their quality has helped to raise awareness that some forms of evidence are more trustworthy than others (4). In biomedical science, there is general agreement over the advantages of having a hierarchy of evidence, based on validity, essentially designed to reduce the likelihood of errors. The higher up a methodology is ranked in the hierarchy, the more robust and closer to objective truth it is assumed to be. This is clearly desirable for practising clinicians when considering the effectiveness of evidence. Within the hierarchy ranking, systematic reviews of rigorous studies are generally accepted to provide the best evidence on the effectiveness of different strategies to promote the implementation of research findings to support clinical practice (22,23). Systematic reviews use scientific strategies to identify, select and critically appraise relevant research within a particular field, and to collect, analyse and quantify data. A meta-analysis is a systematic review that uses statistical methods to combine data and analyse and summarise the results of the studies included. Traditionally, the randomised controlled trial (RCT) has been regarded as the most objective method of removing bias and producing comparable groups. The RCT is most likely to sportEX dynamics 2008;18(Oct):10-13
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RESEARCH SKILLS EBP attribute effects to causes (1), allows for meta-analysis (24) and is often regarded as the gold standard (25,26). Rigorous RCTs greatly reduce systematic errors (bias) by ensuring that the groups being compared are similar, achieved mainly through randomisation (27,28). Care is required, however, as Juni and colleagues report that there is ample evidence that many controlled trials are methodologically weak and increasing evidence that deficiencies translate into biased findings of systematic reviews (29). Therefore, the influence of the quality of included studies should be examined routinely. The hierarchy is not fixed in tablets of stone; the rankings may change, and there is debate over the relative positions of systematic reviews and large RCTs. Furthermore, there is much controversy over the kind of evidence that is actually most relevant to clinical practice. Despite this, the hierarchy of evidence is still recognised as probably one of the most reliable and simplest ways of classifying research quality. Table 2 represents a compilation derived from various sources, including Greenhalgh (20) and Sackett and colleagues (26). The table represents a fair consensus of current thinking with respect to the grading of evidence.
CONCLUSION The need for effective highquality research evidence has arisen from EBP, fundamentally driven by patients’ expectations and their ever-increasing demands – and rightly so. Indirectly, the need has arisen from increasingly stringent legislation and the looming threat of civil action resulting from negligence and malpractice. Regardless of the driving forces involved, it remains abundantly clear to all concerned that high-quality evidence is a necessity now and will remain so in the future. Notwithstanding these reasons, the development of research skills remains a key issue and constitutes suitable components for future professional development. Understanding the concept of, and www.sportEX.net
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the components within, the hierarchy of evidence would represent a good starting point. References 1. Bleakley C, MacAuley D. The quality of research in sports journals. British Journal of Sports Medicine 2002;36:124—125 2. Thomas JR, Nelson JK. Research methods in physical activity, 4th edition. Human Kinetics 2001. ISBN 0736030050 3. Fine EV, Bliss DZ. Searching the literature: understanding and using structured electronic databases. Journal of Wound, Ostomy and Continence Nurses Society 2006;33:594–605 4. Bury TJ, Mead JM. Evidence-based healthcare: a practical guide for therapists. Butterworth Heinemann 1998. ISBN 0750637838 5. Steves R, Hootman JM. Evidence-based medicine: what is it and how does it apply to athletic training? Journal of Athletic Training 2004;39:83–87 6. Herbert RD, Maher CG, Moseley AM, Sherrington C. Effective physiotherapy. British Medical Journal 2001;323:788–790 7. Glasziou P, Vandenbroucke J, Chalmers I. Assessing the quality of research. British Medical Journal 2001;328;39–41 8. Hendry C, Farley A. Reviewing the literature: a guide for students. Nursing Standard 1998;12:46–48 9. Del Mar C. Clever searching for evidence. British Medical Journal 2005;330:1162–1163. 10. Bryman A. Quantity and quality in social research. Unwin Hyman 1988. ISBN 0415078989 11. Bell J. Doing your research project, 4th edition. Open University Press 2005. ISBN 0335215041 12. Rosenberg W, Donald A. Evidence based medicine: an approach to clinical problem-solving British Medical Journal 1995;310:1122–1126 13. Turner PA, Whitfield ATW. Physiotherapists’ reasons for selection of treatment techniques: a cross-national survey Physiotherapy Theory and Practice 1999;15:235–246 14. Turner PA. Evidence-based practice and
physiotherapy in the 1990s. Physiotherapy Theory and Practice 2001;17:107–121. 15. Alsop A. Evidence-based practice and continuing professional development British Journal of Occupational Therapy 1997;60:503–550 16. Marshall G. Critiquing a research article. Radiography 2005;11:55–59 17. Straus SE, Sackett DL. Using research findings in clinical practice. British Medical Journal 1998;317:339–342 18. Cape J. Clinical effectiveness in the UK: definitions, history and policy trends. Journal of Mental Health 2000;9:237–246 19. Rothstein JM. Outcomes and survival. Physical Therapy 1996;76:126–127 20. Greenhalgh T. How to read a paper: getting your bearings (deciding what the paper is about). British Medical Journal 1997;315:243–246 21. Sheldon TA, Guyatt GH, Haines A. When to act on the evidence. British Medical Journal 1998;317:139–142 22. Bero LS, Grilli R, Grimshaw JM, Harvey E, et al. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. British Medical Journal 1998;317:465–468 23. Coopey M, Nix MP, Clancy CM. Translating research into evidencebased nursing practice and evaluating effectiveness. Journal Nurse Care Quality 2006;21:195–202 24. Greenhalgh T. How to read a paper: assessing the methodological quality of published papers. British Medical Journal 1997;315:305–308 25. Merrick MA. “I can’t believe we don’t know that!” Journal of Athletic Training 2006;41;231–232 26. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, et al. Evidence based medicine: what it is and what it isn’t. British Medical Journal 1996;312:71–72 27. Ennos R. Statistical and data handling skills in biology. Prentice Hall 2000. ISBN 0582312787 28. Sackett DL, Wennberg JE. Choosing the best research design for each question. British Medical Journal 1997;315:1636 29. Juni P, Altman DG, Egger M. Assessing the quality of controlled clinical trials. British Medical Journal 2001;323:42–46 30. Cochrane Collaboration. Glossary of Cochrane Collaboration and research terms, version 4.2.5. Cochrane Collaboration 2005. www.cochrane.org/resources/ glossary.htm
THE AUTHOR Nick Dinsdale originally trained as a sports masseur and later qualified as an osteopath before completing a BSc (Hons) in sports therapy, gaining a first class degree. Over the years Nick has worked as team masseur to the GB and England cycling teams, covering both domestic and overseas events. Nick has been a keen athlete, competing in running and cycling events at all levels, culminating in winning the national cyclo-cross series. Nick is a part-time tutor at the Northern Institute of Massage (NIM). Specialist workshops include: i) Electrotherapy, ii) Lower limb biomechanics and orthotic prescription. Nick is a visiting lecturer at Teesside University and has carried out consultancy work for the University of Central Lancashire.
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BY RUTH DUNCAN
INTRODUCTION “Fascia” seems to have become quite a buzz word. Fascia, connective tissue, soft tissue, elastin, collagen, myofascial dysfunction and myofascial pain syndrome... the list goes on. So what is this fascination with fascia, and why?
RESEARCH BASE Fascial work is far from new, but recent research into the soft tissue of the body has highlighted some amazing facts that are slowly changing the way traditional healthcare views the anatomical structure. This has liberated therapists from the confines of oil and fluffy towels into actually having scientific backup that soft tissue harbours injury, inflammation and dysfunction and, with the use of fascial techniques, is ‘mouldable’ back to health and balance. More importantly, this research proves that fascial dysfunction has a physical and emotional history. A patient’s presenting symptom can now be traced back to a seemingly unrelated trauma several years ago that has slowly affected the overall fascial tensegrity, posture and balance, creating the present symptom. Ervin Laszlo’s Science and the Akashic Field, Lynne McTaggart’s The Field and James Oschman’s Energy Medicine in Therapeutics and Human Performance each discuss the nature of the human body, the body’s electromagnetic qualities, and the concept of the body acting as a whole rather than as separate parts (1–3). Laszlo states that the living organism is not a mere biochemical machine but a living organism, dynamic and fluid with all components in instant and continuous communication. Could he be describing the fascial network (boxes 1 and 2)? When we use the term “myofascial pain”, we are not simply talking about trigger points, myofascial meridians or lines. We are describing a dysfunction that affects the entire tensile network. Fascial scarring from an old injury to the coccyx can create a twist and pull throughout the entire network right up into the jaw, creating a temporomandibular joint (TMJ) problem that a dentist may try to resolve with jaw splints – but this is treating the symptom, not the cause. The constant groin strain will not be resolved unless 14
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MODERN MYOFASCIAL RELEASE Fascial work is not new, but current research changes the way we view the anatomical structure and stresses the importance of the fascial network in musculoskeletal dysfunction. In the modern form of myofascial release, less is more. The therapist treats in a threedimensional manner, which allows the fascia to release naturally, breaking habitual holding and bracing patterns and permitting a reintegration of awareness with physical function. BOX 1: FASCIAL FACTS ■ Fascia is a continuous three-dimension tensile web or network reaching from head to toe ■ Fascia is a microscopic tubular network made predominantly of collagen, elastin and a gel-like fluid called “ground substance” ■ Ground substance acts as a shock absorber ■ Fascia interweaves, supports and protects every other living cell of the body ■ Fascia is fluid in nature and provides cushioning and form to the body ■ Fascia supports the skeleton and visceral organs ■ The fascial network dissolves soon after death, leaving adhesions as the only visible sign of its existence ■ Fascia responds to pressure but is not compressible ■ Fascia resists force proportionally against the force of velocity applied to it ■ Fascia is affected by trauma, inflammation, overuse, underuse and poor posture.
BOX 2: DYSFUNCTIONAL FASCIA ■ Dysfunctional fascia does not show up on X-rays, magnetic resonance imaging (MRI), myelography, computed tomography (CT) or electromyography scans ■ Dysfunctional fascia sticks to its own fibres, creating a pull throughout its structure ■ Dysfunctional fascia pulls the skeleton out of balance and compresses organs, nerves, blood and lymph vessels ■ Dysfunctional fascia harbours toxins, and decreases cell elimination and water and nutrient exchange within the cells ■ Dysfunctional fascia can exert a pressure of up to 200lbs per square inch on to pain-sensitive structures, vital organs and cells ■ Dysfunctional fascia solidifies the ground substance, affecting body temperature, proprioception and movement ■ Dysfunctional fascia creates emotional and physical holding and bracing patterns.
we look at the symmetry, balance and function of the entire network. A unilateral rotated pelvis, a rotated thorax and an anteriorly rotated shoulder girdle create enough tension and fascial pull to harbour the pain felt in the groin. We must find the pain and look elsewhere for the cause. In fact, surgery can potentially create more fascial scarring and in turn cause more dysfunction.
USING MANUAL THERAPY TO RESOLVE INJURIES Manual therapy is not just about bones, nerves and muscles. It’s about the entire fascial network that supports and includes everything else. This is where myofascial release (MFR) has gained its reputation. There are two main approaches: the direct, or traditional, approach; and the non-direct, or modern, approach.
Direct approach Direct, or traditional, MFR is the approach that most therapists are aware of. There is limited or no use of lubricant. Moderate to firm pressure from the finger, thumb, hand or elbow is applied into the tissue, following the muscle length and meridian or fascial lines. The therapist moves or glides through the tissue in order to restore length and balance, sometimes using strumming, stripping and skin rolling. The direct approach can be protocoland structure-oriented, and it can be part of a series of treatments.
Non-direct approach The non-direct, or modern, MFR approach uses no lubricant. The sportEX dynamics 2008;18(Oct):14-16
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SOFT TISSUE MODERN MYOFASCIAL RELEASE therapist applies moderate to gentle hand and elbow pressure into the tissue. The approach addresses the cause and effect relationship: the therapist waits for the tissue to release, signified by a yielding or softening of the tissue, and follows the collagenous releases in the deep fascial layers. The patient’s feedback and visual and sensory responses are followed, thus allowing time for emotional and sensory reorganisation. This permits the body time to move through the restrictions in order to regain its own natural balance. The non-direct approach views the body as the container of the unconscious mind. I have trained in both approaches, but I choose to use the modern form of MFR in my practice; this is also the style that I teach and promote. I prefer the modern approach because I don’t overuse my fingers and thumbs or have to work so hard to make the client’s body more pliable. Modern MFR is easy to use because we don’t need to follow lines or know where every muscle begins and ends. The modern approach allows the fascia to release naturally, breaking habitual holding and bracing patterns and permitting a reintegration of awareness with physical function. With the modern approach, we don’t need to work fast. We get more done by taking our time with fewer techniques, allowing the pressure and heat of our hands to do the work for us. We don’t use strength: our body weight, the heat of our hands and simply taking time initiate the release in the tissue. The release feels like a melting or yielding sensation, and we follow this feeling of fluidity. This is the piezoelectric effect: a low-load pressure, over time, creates a physical and chemical reaction in the tissue, allowing it to return naturally to a normal resting length. The Arndt–Schultz law states that
heavy pressures inhibit physiological activity while light pressure enhances activity. With the modern form of MFR, less is more. The results that occur from doing barely anything will change the way you view musculoskeletal dysfunction and the way you treat your patients.
TECHNIQUE In our workshops we teach therapists to feel and stretch slowly into the fascial network. The word “collagen” means “glue producer”. We teach therapists to feel for this glue-like texture, which, when dense, thick or hard, defines a fascial restriction. The modern MFR technique is very different from massaging muscles, tendons and ligaments. We teach therapists to be patient, to wait for the release, to allow their hands to be fluid in applying the pressure, and to move slowly though each and every fascial restriction. The time element is a vital factor: fascia cannot be forced, as it will naturally meet that force in return. Hence, the MFR therapist provides a sustained gentle pressure for a minimum of 90–120 seconds, allowing the fascia to elongate naturally and to return to its normal resting length, so restoring health and providing results that are both measurable and functional. Since fascia is a three-dimensional structure, fascial restrictions are also three-dimensional and we must treat them in a three-dimensional manner. An area in the body that commonly becomes short or restricted is the anterior thigh. The rectus femoris attaches to the anterior inferior iliac spine (AIIS) and crosses the hip and knee. When this area becomes short, it pulls the AIIS forward and down. This creates an abnormal pull through the pelvic floor and sacroiliac and low lumbar joints and compresses nerves and blood vessels. This restriction is not isolated: there will be many counterbalances and compensations all
WITH A GREATER UNDERSTANDING OF THE HUMAN STRUCTURE AND THE FUNCTION OF FASCIA, WE MAY BE ABLE TO TREAT MANY PEOPLE EFFECTIVELY WITHOUT THE AID OF SURGERY AND MEDICATION www.sportEX.net
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Figure 2: The cross hand MFR technique
untwists and the solidified ground substance returns to a fluid state. This technique should take between three and eight minutes as you slowly and gently follow the releases, layer upon layer, allowing the tissue to release without force. The release of this area helps to de-rotate unilateral rotated ilia and to balance the sacroiliac joints, sacrum and pelvis in general.
EFFECTS Figure 1: Effects of fascia on counterbalances in the body
over the body (Fig 1). One of the most fundamental modern MFR techniques is the cross-hand technique. With this hand technique, we simply place our crossed hands on the body, with the heels of the hands close together and the fingers pointing in the direction in which we wish to facilitate the release. The hands are on the skin at all times. The therapist places one hand on the upper anterior thigh, fingers pointing cephalad, and the other hand just below it, fingers pointing caudad (Fig 2). Allow your hands to soften slowly into the tissue – and then wait. This is the first dimension. You may begin to feel a thick toffee-like substance under your hands. This is the deep collagenous layer of restriction. As this yields and allows you to soften inwards, maintain the inward pressure and gently take up the slack between your hands. This is the second dimension. Wait for the release and continue to take up the slack. The third dimension is when you feel the tissue yielding under your hands in a twisting or sidebending movement; we call this “local unwinding” – it occurs as the fascia 16
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I always find it amazing to see and hear the feedback from a patient receiving the modern form of MFR for the first time. The patient can feel exactly where the therapist’s hands are, but they can also feel the yielding and softening in a completely different part of the body. If fascia supports and
interweaves with bones and muscles, then confining your treatment to manual adjustments and soft tissue mobilisations on muscles is not enough. Fascia is a network: we must feel into this network – by doing so, we will feel the unique fascial restrictions pertinent to the patient. Like our fingerprints, each person’s fascial network is unique because it has the history of fascial restrictions from that person’s traumas, posture and inflammation. When we treat a patient with the modern form of MFR, we feel their unique bracing and holding patterns. When we release tension from this tensile structure, we allow other areas to release their hold too, and so patients often feel multiple releases in different areas of the body. To summarise, when one looks at the depth and influence that fascia can have on the function of the body, in my view it becomes clear that the ‘buzz’ over fascial work, is therefore very well justified. References 1. Laszlo E. Science and the akashic field: an integral theory of everything. Inner Traditions 2007. ISBN 9781594771811 2. McTaggart L. The field: the quest for the secret force of the universe. HarperCollins 2002. ISBN 006019300X 3. Oschman JL. Energy medicine in therapeutics and human performance. Butterworth Heinemann 2003. ISBN 0750654007.
THE AUTHOR Ruth Duncan has been involved in complementary therapies for a number of years. She graduated with honours as a clinical massage therapist in Florida, USA. Her training included therapeutic, remedial, soft tissue, trigger point and myofascial approaches. Her postgraduate study included sports injury rehabilitation and clinical hypnotherapy. She has furthered her soft tissue training with Tom Myers and John F. Barnes, who is the world’s leading authority on myofascial release. Ruth has assisted with the Barnes American MFR seminars and offers MFR workshops for healthcare professionals in the UK. For more information visit www.myofascialrelease.co.uk for dates, venues and costs or call 0845 602 6274.
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CAREERS TRAVELLING WITH TEAMS
INSIDE THE INNER CIRCLE: EFFECTIVE AND SUCCESSFUL TEAM TRAVEL BY ROB GRANTER, BSocSci, AssDipAppSci (MYOTHERAPY)
BEGINNINGS In 1988 I was invited to work with the Australian Institute of Sport swimming team at the Seoul Olympic trials in Sydney. Six months later I was contracted to work with the Australian Olympic swimming team in their final training camp before leaving for the Seoul Olympic Games. After working with this awesome group of athletes every day for a week, I remember seeing them board the airport bus, en route to the Olympic Games. They looked a million dollars in their Australian team uniforms and they had smiles a mile wide. I felt, for the first time in my life, that I was on the edge of the inner circle. This was a turning point in my career. My goal was to turn a dream into a practical, achievable, clear and exciting pathway that would lead me to the Olympic Games. I was committed to working hard and learning fast. My aim was to travel with an Australian Olympic team as a massage therapist and to be part of the inner circle. I returned to my Melbourne practice with more fire in my belly and a passion for knowledge. I made it to Barcelona in 1992, Atlanta in 1996 and the Sydney Olympic Games in 2000 as head of massage therapy services for the Australian team. To get there I needed to be successful in three key areas: skill, effectiveness and organisation.
SKILL We must be great at what we do. How do we achieve this? By practice and by being guided by someone who is www.sportEX.net
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Having experienced being on the edge of the “inner circle” of the Australian Olympic team at their training camp in 1988, Rob Granter set himself the goal of travelling with the team and being inside the circle. Through hard work and dedication, he achieved his aim. In this article he sets out the requirements for being part of the inner circle. These requirements fall into three key areas: skill, effectiveness and organisation. already doing what we want to do. These are some of the necessary skills required to be a great team therapist: ■ Well developed massage treatment skills – knowing what technique, depth and rate of application is appropriate to the context ■ Excellent knowledge of functional anatomy and human biomechanics ■ Excellent knowledge of surface anatomy ■ Excellent assessment skills, such as testing and palpation, and knowing when to treat and when to refer ■ The ability to concentrate and keep focused on the specific region being treated and the overall treatment plan ■ Knowledge of appropriate terminology of sports medicine
SUCCESSFUL TEAMWORK ALLOWS ORDINARY PEOPLE TO ACHIEVE EXTRAORDINARY RESULTS 17
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I know therapists who have been working in sport for 20 years but who are no better now than they were after two years of involvement. Never switch off! If you feel you are losing effectiveness, rekindle you passion by observing the work of another enthusiastic and effective therapist. Your dress, your behaviour with others, and your therapeutic actions should reflect effective purpose.
ORGANISATION Your working environment
■ Sensitivity to the needs and expectations of the athlete with regard to training and competition ■ Knowledge of the sport in which the athlete is involved ■ Basic knowledge of sports nutrition, physiology of exercise and massage ■ Physical fitness and, ideally, involvement in a sporting activity ■ Enthusiasm and energy.
EFFECTIVENESS Be very clear about the team’s objectives. Instil the same objectives in you and your massage therapist colleagues. First and foremost, always focus on the job required of you. The role of any support person involved in sport is to remove obstacles from the path of an athlete in order to allow the athlete to perform at their optimal level. You must bring to the team or organisation something that’s needed – for example, to monitor the impact of training and playing on the soft tissue system by providing effective assessment and hands-on treatment skills to positively impact on these potentially adverse factors. To quantify this, we keep player records, which clearly outline assessment pre- and post-treatment, such as range of motion in the sports-critical joint regions. Objectives, organisation and good quality records are important for the following reasons: ■ To be able to prioritise which structures need treatment more urgently than others ■ To be able to feed back valuable information to other members of the support staff so that changes can be made to squad and individual training loads ■ To provide information that allows you to have meaningful conversations with other support staff and therefore to develop meaningful relationships ■ To provide data that substantiate your worth to the team. In order to maximise your effectiveness, always think about your purpose for performing a particular assessment and technique. Think: “If the team doctor were standing at my shoulder, could I explain fully what and why I’m doing what I’m doing?” 18
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Always arrange your work environment so that it looks effective and organised. Keep your working space clear and clean. If the head coach or chief executive officer of the team or club walks in, you want their impressions to be that your goals are aligned with those of the team. Keep the working environment at a temperature that is comfortable for your athletes first and for you second. Throughout my career I have worked and observed in a huge variety of working environments – the very good, the very bad and the very ugly. Some of the things I find particularly non-effective and ugly in a working environment including the following: ■ Practitioners lying on tables – if you are not busy, do something to help the team and the environment or get out of sight ■ Practitioners reading newspapers on treatment tables – nothing conveys unproductiveness to me more than this. If you want to read a paper, do so in your own time and in your own private space ■ Practitioners watching television with the volume excessively loud and getting too involved in the wrong activity – this tells me as an athlete, coach or administrator that the practitioner is easily distracted and bored with the job. You may well find yourself on a trip with athletes, coaches or administrators who do all of these things. The important thing is to maintain your own high standards at all times.
The linen supply One of the first things you may need to do when you arrive with your team at a new hotel, venue or event is to organise a reliable supply of clean linen. Over my years of travel, I have found that gifts of bottles of wine for the hotel cleaning staff work wonders. You can usually get what you want if you are respectful of, and courteous to, these members of staff. ■ Have a place for soiled linen and send it off for washing regularly ■ Keep the clean linen properly organised. I once worked at an international tournament in Hobart, Tasmania, providing on-field treatment. One particular day was very windy and some of the clean linen was exposed to the elements. Later that day, while I was working at the hotel, two athletes reacted adversely to the treatment, presenting with excessively itching skin. The condition settled quickly, but the cause seemed to be some pollen in the linen that arrived in the strong wind. This was a lesson well learned – and it never happened again.
The set-up Always set up in the most conspicuous location possible. If sportEX dynamics 2008;18(Oct):17-19
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CAREERS TRAVELLING WITH TEAMS The support staff
this is not possible, then use appropriate signage to steer athletes in the right direction. Look for potential areas that may create injury to athletes. At the 2006 Commonwealth Games in Melbourne, Australia, the medical facility used by all the treatment disciplines was a semi-permanent tent-like structure. It was very secure, and had heating and air-conditioning, but on close inspection it had some potential lethal projecting metal edges where the upright beams were anchored to the floor. Our first job was to tape up the edges in order to protect the athletes’ bare feet (Fig. 1). It is important to tape and pad all sharp or protruding edges – even protruding castors on treatment tables can be a hazard.
Figure 1a: An exposed hazard
Figure 1b:a potential disaster made safe
At the 1996 Atlanta Olympic Games, our allocated working space in the Olympic Village was used, pre-Games, as a computer data centre. We failed to see a subtle hazard. There was a data input plug slightly protruding from one of the upright supporting beams, which had a razor-sharp edge. One of our swimmers suffered a substantial deep cut as he got off a treatment table. This incident kept him out of the water for a number of days and almost ended his Olympic dream. It never happened again.
Yourself For you to function to your optimal level in this environment, you must look after yourself well: eat well, rest and sleep well and organise your day well.
The athletes Don’t try and win your athletes over by “talking yourself up”, being a joker or being overconfident. If you are new to a team, you need to realise that you may be entering a battle-hardened group of cohesive athletes with a strong established group dynamic. The team will welcome you into their circle when you have earned your spot in the team and got their trust by being excellent at what you do. Let your behaviour as an excellent therapist do the talking. Don’t force it – let it happen. The team will welcome you if you demonstrate genuine respect for them and their achievements and respect their model of the world. A person should never be judged or put down for not being up with current world political situations or other things that may be important to you. A particular athlete may appear to be inept in certain matters, but when they talk about the finer points of their sport, team tactics or training methods, you may be blown away by their depth of knowledge in other areas. www.sportEX.net
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It is important to know what others expect of you and to make sure that these expectations are realistic. For example, establish a policy for the hours you are available to work with the team manager, head coach, medical officer and other medical team providers. It is important to balance the real needs of the athletes with your ability to provide a consistently high-quality service. Depending on the number of support staff in the team, I suggest that you are available to provide hands-on treatment for eight hours per day. There is a feeling among some people that you should be available on an “as required” basis, but I do not support this system. I like to know exactly what I am required to do each day and I believe that most athletes are happy to accept a system that is open, clear, and fair to both the athletes and the practitioner. Working hours can be flexible in order to allow normal training to take place. For example, you may treat for four hours in the morning, then take a few hours off to rest, and then work late in the evening after training or competition has finished. The treatment booking sheet should be placed on the door of the treatment room with clear instructions or at a “reception desk”, which may be required if you are servicing a large team. I am not suggesting that you turn away athletes in need of treatment. Where possible, you should fit them in – but only if this fits in with your capabilities. Always involve the other practitioners in your team. Don’t fall into the trap of believing you are the only person capable of successfully treating a certain athlete. In relation to the optimal function of the off-field support team, consider your role as a mediator and do not contradict the instructions of other support staff in the team. If you have problems with advice given to athletes by others, go straight to the person who gave the advice and discuss the issue directly.
CONCLUSION Have an attitude of “What can I put into this situation?” rather than “What can I get out of this situation?”, and put the team outcomes ahead of your personal gains. I love the phase “Successful teamwork allows ordinary people to achieve extraordinary results” because, when I see groups working together effectively, I consistently see extraordinary results – whether it’s gold medals or the establishment of deep, supportive, lifelong friendships. Good luck with positively transforming yourself and your team working environment!
THE AUTHOR Rob is widely regarded as one of Australia’s most respected and experienced educators and practitioners of soft tissue therapy. Rob is co-founder of the Australasian College of Soft Tissue Therapy and was a contributor to the internationally successful, Brukner & Khan textbook “Clinical Sports Medicine” now in its 3rd edition. He was head of massage therapy for the Australian Olympic Team in 1996 and 2000 and the Australian Commonwealth Games team in 1998. Rob also co-ordinated massage therapy services and the athlete recovery centre for the Melbourne 2006 Commonwealth Games. Rob currently consults from his own private practice in Melbourne and is a teacher in the myotherapy department at RMIT University, Melbourne, Australia.
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SOFT TISSUE TREATMENT FOR THE HAMSTRING CONDITION BY STUART HINDS CERT RM, DIP RM
INTRODUCTION The objective of this article is to broaden the understanding of the potential influence that soft tissue therapy can have in the assessment and treatment of hamstring pain and dysfunction, particularly but not exclusively, in elite Australian Football League (AFL) players. Hamstring strains are the most common injury in the AFL, contributing to 13% of all missed playing time (1). The majority of hamstring injuries occur during the three months of the playing season (March, April, May), and there is a decline in frequency as the season progresses. The most common mechanism of injury is when the player accelerates rapidly. It has been documented that the position of lumbar flexion with a straight leg, as happens when a player attempts to pick up the ball while on the run, is the most common position for hamstring injury to occur. One reason for this is because it places an excessive tensional load on the hamstring whilst it is under an eccentric contraction thus creating an indirect overload injury of the musculoskeletal unit.
PREDICTORS OF HAMSTRING INJURY Screening protocols developed by Gabbe and colleagues for predictors of hamstring injury at the elite level of AFL, highlight a history of hamstring injury in the previous 12 months and increasing age as independent predictors of hamstring injury (2). In particular, players who reported sustaining a hamstring strain during the previous year, and players over 24 20
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The term “hamstring condition” refers to the possible injuries that can occur in the hamstring area. The mechanics of injury fall into one or more of the categories “biomechanical”, “referred” and “local”. In this article we look at hamstring problems in the Australian Football League. We provide an overview of the mechanism of injury for hamstring strains, stiffness, soreness and restriction, predictors of injury and treatment considerations. years of age, were four times more likely to experience a hamstring injury compared with other players. Players with restricted ankle dorsiflexion on the lunge test were also at an elevated risk of sustaining a hamstring injury.
semimembranosus internally rotate leg in knee flexion ■ Both heads of biceps femoris externally rotate the leg.
HAMSTRING ANATOMY
The hamstring condition can be classified into four categories: ■ Biomechanical ■ Referred ■ Local ■ All of the above.
As a starting point, it is worth revising the key points of hamstring anatomy.
Innervations The innervations are the branches from the tibial portion of the sciatic nerve, the fifth lumbar nerve and the first two sacral nerves.
CLASSIFICATION OF THE HAMSTRING CONDITION
Figure 1: Posterior muscles around the hip
Gluteus medius
Function Movement of the hip ■ Extends thigh at hip ■ Decelerates forward-moving limb at terminal swing ■ Semimembranosus and semitendinosus assist in internal rotation of hip only when hip is straight ■ Long head of biceps assists in external rotation with the hip in extension.
Piriformis Superior and inferior gemellus Semimembranosus
Quadratus femoris
Semitendinosus Biceps femoris
Movement of the knee ■ Short head of biceps femoris is a flexor at the knee ■ Semitendinosus and sportEX dynamics 2008;18(Oct):20-23
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SOFT TISSUE TREATMENT HAMSTRING INJURIES
BIOMECHANICAL HAMSTRING CONDITION
Iliosacral dysfunction includes two common variations: anterior superior with internal rotation (ASIR) and posterior inferior with external rotation (PIEX).
sacral and sacroiliac pain with referral into right buttock and posterior thigh Sitting is usually more comfortable than standing ■ Structural signs: Left iliac crest high Right iliac crest low Right positive standing flexion test (superior posterior superior iliac spine movement on trunk flexion) (Box 1) Right positive stork test (Box 2) Right hip external rotation restricted ■ Muscular signs: Right positive Thomas test restricted range of movement (Box 3) Right hip flexor (especially iliacus) shortened, tight and tender Right hip adductors shortened Right gluteal medius and minimus increase in tone/ sensitivity trigger point referral Right hamstring lengthened. Note that straight leg raise will need to be modified for true hamstring length. Due to shortened hip flexors, bring hips into flexion to counteract the increase in lordosis, before performing the straight leg raise ■ Palpation: Increase in tone/tension trigger point activity in gluteus medius, minimus and tensor fascia lata Right sacrotuberous ligament is lax (Box 4) Right Baer’s sacroiliac point is tender; this is a painful point on a line from the umbilicus to the anterior superior iliac spine (ASIS), two inches from the umbilicus; pain is related directly to the sacroiliac joint The hamstring will feel under a tensional load.
ASIR Anterior superior with internal rotation indicates that the ilium rotates anteriorly on the sacrum, with an inflare or internal rotation tendency creating a muscular tensional change. Signs and symptoms of right-sided ASIR include the following: ■ Pain: Diffuse right posterior lumbar-
PIEX Posterior inferior with external rotation (PIEX) indicates that the ilium rotates posteriorly on the sacrum, with an external rotation tendency creating a muscular tensional change. Signs and symptoms of right-sided PIEX include the following: ■ Pain: usually localised to the right sacroiliac joint and ipsilateral buttock. Pain may be described as “deep”,
A biomechanically-oriented hamstring condition can be described as a biomechanical anomaly relating to the lumbar-pelvic/thigh/leg region, creating an overloading of the muscle group. In this case the hamstring acts like a tensional barometer for the lumbar-pelvic region. A biomechanical hamstring condition usually includes pelvic anomalies such as iliosacral fixations, up-slips, sacral torsions and pelvic torsion, which are commonplace in the contact athlete. Soft tissue therapists deal with a large range of signs and symptoms when treating the hamstring component. It is important to note, therefore, that treatment can be of a structural nature, and so interaction with practitioners who focus heavily on structural restrictions is integral.
Pelvic anomalies Pelvic anomalies are common. Many players present with congenital postural types such as anterior pelvic tilts and posterior pelvic tilts, which respectively place the hamstrings in a state of tension or compressional tension. These common postural types should not be confused with unilateral iliosacral anomalies. For example, a player may present with a postural type of bilateral anterior pelvic tilt but also with a unilateral right-sided posterior inferior external rotation of the iliosacrum.
Iliosacral dysfunction
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“achy”, “sore”, “tight”, etc. Pain may be referred down to the posterior thigh but not below the knee as with neurological or radicular pain ■ Structural signs: Right iliac crest high Left iliac crest low Right positive standing flexion test (superior posterior superior iliac spine movement on trunk flexion) Right positive reverse stork test (see Box 3) Right medial malleolus is shorter than left Restricted right hamstring range of movement Restricted right hip internal rotation Posterior iliac rotations produce a shortened stride length on affected side ■ Muscular: Right hamstring shortened, hypertonic and tender Right piriformis/gluteus maximus shortened Right hip flexors lengthened Bilateral quadratus lumborum ■ Palpation: Right hip flexor/quadratus lumborum increased trigger point activity Right sacrotuberous ligament taut and tender (Box 4) Right Baer’s sacroiliac point tender.
Figure 2: Anterior muscles around the hip
Quadratus lumborum Psoas major Iliacus
Gluteus medius Gluteus minimus Conjoined muscle and tendon of psoas major and iliacus Pectineus Vastus intermedius Vastus medialis
Adductor brevis Adductor longus Gracilis
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REFERRED-ORIENTED HAMSTRING CONDITION A referred-oriented hamstring condition is described as pain or an increase in tension referred from the interface between the peripheral nerves and spinal cord with muscular structures in the lumbar or hip regions.
Gluteus medius and minimus Trigger points in these two muscles can be the cause of considerable lumbar, gluteal, sacral and posterior thigh pain (3). Trigger points in the gluteus medius tend to be found along its superior attachment. As well as pain, patients often have restricted abduction. There may also be a positive BOX 1: STANDING FLEXION TEST ■ Tests movement of the ilium on the sacrum ■ With patient standing, the left and right posterior superior iliac spine are palpated while the patient bends into forward flexion ■ Positive if one side moves higher than the other, indicating hypomobility on that side.
BOX 2: STORK TEST (GILLETS TEST) ■ With patient standing, palpate posterior superior iliac spine and sacrum at same level ■ Patient flexes hip and knee on palpated side while standing on the opposite leg ■ Test both sides ■ Positive if posterior superior iliac spine on the tested side does not move downwards in relation to the sacrum – indicates hypomobility. BOX 3: REVERSE STORK TEST (THOMAS TEST) Tests hip flexion contraction. The patient lies supine and hugs one knee to the chest. The positive sign is that the opposite leg lifts off the couch. The modified Thomas test requires the patient to sit on the edge of the couch and bring one knee to the chest. The patient then assumes the supine position and ensures a posterior pelvic tilt to flatten lordosis, allowing the testing leg to extend off the table. In addition to being an indication of hip flexion contracture, an extended knee may indicate rectus femoris shortening and an abducted leg and TFL tension. BOX 4: SACROTUBEROUS LIGAMENT ■ With patient supine, flex and adduct the hip by moving knee to opposite shoulder ■ Compare left and right ■ Perform only if no hip joint pathology and full range of movement.
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Trendelenburg sign because of inhibition of this muscle’s function. The gluteus minimus muscle has a similar anatomical configuration to the medius, but it is less extensive. It arises from the external surface of the iliac, also attaching to the greater trochanter. Its trigger points can be seen in either the anterior or posterior portion of the muscle. The pain that arises is deep buttock, posterior thigh and calf pain. In the case of the anterior trigger points, pain distribution includes the buttock, lateral thigh and leg regions. The significance of these muscles in the origins of sacral, buttock and leg pain is that they can mimic radicular sources of pain as well as sacroiliac joint dysfunction. In addition, trigger points in these muscles may be a result of radicular and sacroiliac joint dysfunction. Referred pain originally from a spinal structure can set up satellite trigger points in these muscles. The myofascial source of pain may well outlast the primary joint dysfunction. Pain from facet joints may overlap that of the gluteus minimus muscle. Tension generated by trigger points in the gluteus minimus may further block movement of the sacroiliac joint, particularly when involvement of this muscle is seen with piriformis. Activation of these trigger points can be caused by acute overload as a result of a fall, distortion of gait or sacroiliac joint dysfunction. Being located deep to the gluteus maximus and medius and tensor fasciae latae, it is difficult to palpate taut bands here.
Trigger point examination for gluteals Anterior trigger points Patient lies supine, with leg extended of fthe side of the couch in hip extension. The tensor fasciae latae is identified. Palpate the deep distal ASIS. Posterior trigger points Have the patient lying on their side, with the thigh slightly adducted and slightly flexed to identify the piriformis line. Gluteus minimus trigger points are found above this line between its midpoint and the junction of its middle and lateral thirds. Associated trigger points These are seen in conjunction with
piriformis, gluteus medius, vastus lateralis, peroneus longus, quadratus lumborum and gluteus maximus. Anterior gluteus minimus and tensor fasciae latae often develop trigger points together. Vastus lateralis trigger points can develop as satellites. Gluteus minimus may develop as satellites to quadratus lumborum. The connection is so strong that sometimes activation of quadratus lumborum activates gluteus minimus trigger points.
Piriformis syndrome This muscle arises from the inner surface of the sacrum and attaches to the greater trochanter of the femur. It is a stabiliser of the hip and lateral rotator of the thigh in extension and neutral. At 90 degrees flexion it abducts the thigh, producing a strong rotatory force on the sacrum. This tends to displace the base of the sacrum anteriorly while the apex is displaced posteriorly. Pain is referred over the lateral aspect of the buttock, down the posterior thigh and the sacroiliac joint. Neurogenic pain may accompany active trigger points, and this pain can be referred into the back of the leg and the sole of the foot. Symptoms Pain and paraesthesia may be felt in the low back, buttock, groin, perineum, hip, posterior thigh, leg, foot and rectum. Symptoms are aggravated by flexion, adduction and rotation. The patient may complain of painful swelling in the limb and sexual dysfunction. The reported incidence of piriformis syndrome is six times more common in females. Travell and Simons identify three components in piriformis syndrome (3): ■ Myofascial trigger point pain ■ Nerve and vascular entrapment ■ Dysfunction of the sacroiliac joints. As any muscle contracts, its girth increases. Anatomical variations such as a large muscle in a small greater sciatic foramen could lead to neurovascular compression. Therefore, active trigger points in the piriformis could cause displacement of the sacroiliac joint, which in turn could maintain piriformis shortening. Pain due to the myofascial trigger points targets the back, buttock, hip and thigh and is often aggravated by sitting. Compression of the superior sportEX dynamics 2008;18(Oct):20-23
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SOFT TISSUE TREATMENT HAMSTRING INJURIES Figure 3: Piriformis trigger points
■ Assess and treat soft tissue component ■ Bilateral lower rectus abdominis/ external obliques trigger point activity? Reassess. Treat. Reassess.
and inferior gluteal nerves and vessels could cause buttock pain; in extreme cases, atrophy may develop. Pain in the region of the sacroiliac joint could be due to local dysfunction of the joint. Pressure on the sciatic nerve or on the post-femoral nerve could augment thigh pain. Symptoms in the calf and foot and paraesthesiae could be similarly explained. The pudendal nerve could be involved, leading to sexual dysfunction and groin pain. This syndrome may be easily confused with radiculopathy. Activation Trauma resulting from a fall can precipitate trigger points in this muscle, as can forceful rotation with body weight on one leg or resisting forceful medial rotation of the thigh during running. Perpetuation comes about through immobility of the sacroiliac joint, driving for long periods of time, and osteoarthritis of the hip. Patient examination ■ Test hip adduction strength in 90 degrees flexion ■ Piriformis stretch position test.
Increased neural tension Symptoms of peripheral nerve entrapments of the posterior femoral cutaneous nerve are to the posterior thigh and do not extend below the knee. The posterior femoral nerve runs adjacent to the sciatic nerve and can be compressed by piriformis.
LOCALLY-ORIENTED HAMSTRING CONDITION A locally-oriented hamstring condition is described as a local pathology from www.sportEX.net
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an overloading of the hamstring by indirect overload, or direct injury from collision or from delayed-onset muscle soreness (DOMS). There may be a past history of injury. Common sites of strains include the mid-belly, semitendinosus and biceps femoris and the attachments at the ischial tuberosity. In hamstring syndrome, the sciatic nerve is constricted between two fibrotic bands of the hamstrings at the lateral proximal attachment to the ischial tuberosity. Trigger points in the hamstring muscles are responsible for tightening and shortening, which produces a posterior tilt of the pelvis, reducing normal lumbar lordosis, a secondary compensatory overload to quadratus lumborum, iliopsoas, thoracic paraspinals and rectus abdominus. Adductor magnus tightness of the posterior part blocks full hamstring lengthening, especially of the medial hamstrings. More obscure conditions such as snapping syndrome of the semitendinosus tendon, semimembranosus tenosynovitis, snapping bottom or bursitis of the biceps femoris superior bursa are rare but are to be kept in mind as possible considerations.
TREATMENT CONSIDERATIONS Check the following: ■ Standing/sitting iliac heights ■ Standing/sitting flexion tests/stork test ■ PIEX/ASIR innominate as above ■ If present correct innominate dysfunction (muscle energy technique)
Consider the following: ■ Lateral flexion of trunk: quadratus lumborum tension versus compression symptoms ■ Flexion of trunk: lumbar, buttock, hamstring or calf complex ■ Extension: tensional versus compression symptoms ■ Hip range of movement: look for adductor magnus or medial hamstring tightness on straight leg raise ■ Piriformis (myofascial dysfunction) ■ Slump test: treat restriction myofascially ■ Clear antagonist, quadriceps tension and range of movement ■ Due to the prevalence of reduced dorsiflexion range of movement as one of the key predictors in hamstring injuries, assessment and treatment of the anterior and posterior compartments of the leg are worthy of consideration. References 1. Orchard J, Seward H. Epidemiology of injuries in the Australian Football League, seasons 1997–2000. British Journal of Sports Medicine 2002;36:39-44. 2. Gabbe BJ, Finch CF, Bennell KL, Wajswelner H. Risk factors for hamstring injuries in community level Australian football. British Journal of Sports Medicine 2005;39:106–110. 3. Simons DG, Travell JG, Simons LS. Travell and Simons’ myofascial pain and dysfunction: the trigger point manual, 2nd edition. Williams & Wilkins 1999. ISBN 0683083635.
THE AUTHOR Stuart Hinds is a lecturer in remedial soft tissue techniques at Victoria and RMIT Univeristy, Australia. Stuart has been involved with elite cycling (national and international) and a range of athletes from all professional levels of sport. Stuart was a part of the International Olympic Committee’s massage services for the 2000 Sydney Olympic Games/and soft tissue services for the Australian Olympic Team for the 2004 Athens’ Olympic games. He is also soft tissue therapist for the Geelong Football Club and has just returned from the Beijing Olympics.
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THE TRIALS AND TRIBULATIONS OF TEACHING SPORTS THERAPY BY AMY BELL, BSC
INTRODUCTION This article is for clinicians who are thinking of entering the ever-challenging world of teaching. After graduating from Salford University in 2006 with a bachelor’s degree in sports rehabilitation, I worked for a year as a self-employed fulltime practising member of the British Association of Sports Rehabilitators and Trainers (BASRaT). Although I enjoyed this immensely, I found that I really missed studying. Treating clients and athletes requires a lot of thought, but my brain yearned for something different. A past lecturer pointed me in the direction of teaching when he heard of a position to teach sports therapy for a fitness training provider. Despite being just 22 at the time, and not long out of full-time education myself, I decided to go for it.
In this article the author offers a personal reflection on teaching sports therapy. It begins with an insight into the interview process and the first steps in the transition from practising clinician to teacher. It looks briefly at learning styles, deciding what depth to go into and the importance of self-analysis as a teacher. Voluntary work is touched upon, as is the necessity of clinical practice for students.
FIRST STEPS I got through the rather rigorous first interview, which consisted of a 40-minute presentation on shoulder anatomy and physiology, numerous questions on my suitability for the job and my ability to deal with difficult learners, and finally some information about the background of the company. I was extremely nervous and started off at high speed, but my confidence grew. I must have delivered a good presentation, for I was given a second and final interview. This time I had to produce a lesson plan on common soft tissue conditions and then carry out practical treatment of a fictitious injury. It was the first time I had ever done a lesson plan, but I managed to get through it and I was offered the job. It seemed that taking all the best bits from my past lecturers paid off! And so, a little over a year ago, my teaching journey began. It was a daunting experience in the beginning. Knowing how to massage a leg or reel off the origins and insertions of every muscle is one thing, but passing on my knowledge to others is entirely different.
IT IS VITAL TO PROVIDE THE STUDENTS WITH THE SKILLS THEY NEED NOT ONLY TO PASS THEIR EXAMS BUT ULTIMATELY TO BE GOOD SPORTS THERAPISTS 24
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Teachers not only need to know their subject in detail but also have to be able to explain why things happen. Teachers must have opinions, but they must also be open-minded to those of others, thus providing their students with the opportunity to make informed decisions for themselves. Most importantly, teachers must be passionate about what they teach. How can a teacher expect their students to enjoy learning if the teacher does not appear to be enjoying it? One of my greatest compliments was on an end-ofcourse evaluation sheet. A student of mine wrote that I had ‘a contagious passion and energy for the subject that was impossible not to catch’. If you are enthusiastic about your subject, then you are halfway to being able to teach it.
LEARNING STYLES I try to be as creative as I can and get the students doing as much for themselves as possible. All learners are different, but I have found that adults do not just want to be talked at while being expected to listen and take everything in. We must cater for all learning styles, but generally I find that sports therapy students tend to lean more towards kinaesthetic and visual styles rather than auditory styles. Sports therapy students have chosen to do a practical course to enable them to work in a practical profession, so why sit them down and work through hours of theory every day? Of course we must learn some theory, and certainly computer presentations have their uses, but students learn much more if they are actively learning. Students must know the origins and insertions of over 60 muscles, but what good is this if they cannot point to the location of the anterior superior iliac spine, or the coracoid process, or the ischial tuberosity? My point is not to undermine the importance of theory – of course underpinning knowledge is essential – but it is vital to provide the students with the skills they need not only to pass their exams but ultimately to be good sports therapists. sportEX dynamics 2008;18(Oct):24-26
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TEACHING SPORTS THERAPY Sports therapy students may not all be aspiring actors or artists, but I find that drawing and role-playing are great methods when teaching sports therapy. I get my students to draw the muscles on huge flipchart paper, which we then stick on the walls so they can learn the muscle origins and insertions while they are massaging. Going one step further, I ask my students to draw the muscles on to each other – after making sure they haven’t picked up my permanent markers! This allows them to see the muscles in a much more realistic, three-dimensional way, which unfortunately books often fail to do. I recently took my students to the Body Worlds exhibition in Manchester. It is a shame that this is not a permanent event, as my students found it so beneficial – just as I did when I saw cadavers when I was studying. I bought the Body Worlds book and I plan to show it to all my students so they can see what a real body looks like on the inside and notice the countless subtle anatomical variations between us all. Role-playing and simulation is another effective way of covering information. As communication and listening skills are vital to being a good therapist, students must be given the time to develop these skills. I use various role-play scenarios where one student is the client and the other is the therapist. I ask the students to carry out a subjective assessment under different circumstances; for example, the role-playing client may be deaf in one ear, may speak limited English or may be incapable of giving more than oneword answers. This may sound ridiculous, but all clinicians encounter challenging clients at times. Doing exercises like these can be fun, but more importantly they develop the students’ skills in gathering information and extracting the important parts in order to form their subjective assessment.
TEACHERS NOT ONLY NEED TO KNOW THEIR SUBJECT IN DETAIL BUT ALSO HAVE TO BE ABLE TO EXPLAIN WHY THINGS HAPPEN BOX 1: TOP TEN TIPS FOR THE BUDDING TEACHER 1. Know your subject inside-out. 2. Be passionate, enthusiastic and motivational. 3. Meticulous preparation is vital and planning is essential, but you must be flexible and able to adapt. Every group is different. 4. Keep up to date with clinical knowledge and practice. 5. Always cater for different learning styles. Ideally each lesson should incorporate something for everyone. You can never be too creative: always give things a try and then reflect on their effectiveness. 6. Don’t be afraid to admit you don’t know the answer to a question. Rather than give a vague answer, tell the student you will get back to them with a response. 7. Relate theory to practical and real life whenever possible. Students learn much better if information is put into context and they can see why it is relevant. 8. Don’t be afraid of silences: they are great for allowing students to take in information and reflect. 9. Remember that students of all ages respond well to praise and constructive feedback. 10. Learn from your mistakes! Teaching is a learning process for both the student and the teacher.
SELF-ANALYSIS When I started teaching sports massage techniques, I had to be very critical of myself to make sure I was practising what I was going to preach. I was more than capable of delivering an effective treatment session, but I had picked up some bad habits along the way. My posture wasn’t perfect and neither was my hand positioning. I had to study again so that I didn’t pass my bad habits on to my students. I liken this to driving: many of us, if asked to take our driving tests again, would
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TEACHERS MUST HAVE OPINIONS, BUT THEY MUST ALSO BE OPENMINDED TO THOSE OF OTHERS, THUS PROVIDING THEIR STUDENTS WITH THE OPPORTUNITY TO MAKE INFORMED DECISIONS FOR THEMSELVES not do as well as we like to think we would. And if we taught others to drive, we would probably pass on what driving examiners consider to be our less favourable driving habits. Of course nobody has ‘perfect’ sports massage posture or technique, but this is what I must strive for – and strive for my students to achieve – while emphasising that each person will favour certain techniques and have their own individual style.
KNOWING WHAT LEVEL TO TEACH In some subject areas, such as neuromuscular techniques and muscle energy techniques, it can be difficult to work out how much detail to go into. To a certain degree the level is determined by the learning objectives and the course syllabus, but some subject areas have week-, month- or even year-long courses dedicated solely to them. It then becomes difficult to teach just the basics, as there are always some students who want to know more. However, by giving these students extra information, other students inevitably get left behind – especially if the subject is one that will not be examined. To get around this, I direct students towards areas of interest for continual professional development (CPD). Continuing professional development is not only a requirement for professional insurance and memberships but also vital for the personal development of any aspiring sports therapist. Some students expect to do a single sports therapy course or degree and then to know everything there is to know about sports therapy. This is not possible, however. The health and fitness industry is always changing, and we must do our best to keep up to date with recent developments in our field, continuing to enhance our skills and techniques. Similarly, we must encourage our students to do the same.
CLINICAL PRACTICE Clinical practice is essential before a student commences work. If you reflect on the first paying client you treated on your own, you may remember it as a scary experience – even if you had treated many real, but non-paying, clients before. The more hours the student puts in, and the more clients they treat before starting work, the better prepared they will be for their paying clients. Role-playing is useful, but there is no substitute for the real thing. Having a variety of clients is also important – the same student should not be treating the same clients every week. There are some advantages to treating the same clients – the student knows the client’s background and can progress their treatments and rehabilitation programmes accordingly – but it is more beneficial for each student to treat as many different bodies as possible. 26
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I also know from my own experience that it is important for students to treat professional athletes and to enable students to work alongside medical professionals. One of my final-year placements at university was with Bolton Wanderers FC. I was fortunate enough to work with the club’s first team, shadowing their highly experienced physiotherapists, masseurs and sports therapists. In my two months at the club, I learnt an incredible amount – including that treating elite athletes differs greatly from treating nonathlete clients. It is important for students to have treated as wide a range of patients as possible under supervision so that they will be better equipped when they qualify. In the north-west of England, where I live, the company I work for has developed a great relationship with some Super League clubs. This has provided invaluable hands-on experience for my students, and I would encourage all teachers to establish similar contacts.
PAID VERSUS VOLUNTARY WORK Students should be encouraged to do voluntary work and get as much experience as possible. Whether the student should continue to work on a voluntary basis after they have qualified is another matter and a personal decision that each of us has to make. I know that the voluntary work I did soon after graduating led on to clinical work and many other professional opportunities, but there comes a time when, as qualified professionals, we should demand at least some recompense for our services; some clubs and employers may offer to subsidise CPD courses, for example.
CONCLUSION If you have been considering following the teaching route, I would urge you to go for it. Although the idea can be quite daunting in the beginning, teaching sports therapy is unbelievably enjoyable, and it is rewarding to pass on to others what you already know. Every group of students brings new challenges, and every day and every lesson is different. I feel that teaching has made me a much better graduate sports rehabilitator. Teaching has made me analyse everything I do, and my teaching has contributed to the process of self-reflection. I expect high standards of my students so I must deliver them myself, 100% of the time, as indeed any clinician should. I would like to finish by acknowledging my colleagues for all I have learnt from them. Each trainer has taught me something different. I would also like to thank my lecturers who taught me so much during my time at Salford University – not just about what I was learning, but about how to teach with passion, creativity and, above all, a relentless commitment to students. THE AUTHOR Amy Bell was awarded a BSc (Hons) in sports rehabilitation from the University of Salford in 2006. She went on to work for rugby and football clubs and in various sports injury clinics. She joined Premier Training International in 2007 after deciding to follow the teaching route. She is close to completing her teacher training and is about to embark on a master’s degree in exercise and sports injury at Manchester Metropolitan University. Amy is a keen athlete, having played football and netball internationally for Northern Ireland up to the under 21 level.
sportEX dynamics 2008;18(Oct):24-26
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