sportEX Medicine Journal Issue 57 - July 2013 by Co-Kinetic

ISSUE 57 july 2013 ISSN 1471-8138

promoting

excellence in

sports

highlights n functional screening of a semi-professional footballer

n the brain: movement & pain

medicine n preDictors in pfps

n physiotherapy anD pilates for Dressage riDers n sleep wake techniques for elite athletes n research analysis

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contents july 2013 Issue 57

Welcome

Publisher/editor Tor Davies Bsc tor@sportex.net Art editor DeBBie asher debbie@sportex.net sub-editor alison sleigh journal watch BoB BraMah subscriptions & Advertising support@sportex.net +44 (0) 845 652 1906 Technical aDvisors steve aspinall lynn Booth Joanne elphinston helen Millson Dr Dylan Morrisey Prof graham smith Joan Watt Dr nick Webborn Prof greg Whyte Paula clayton

july 2013

We’re just back from the 2013 coPa Practice growth conference, which took place over two days in london’s excel. it’s always great to network and catch up with people at industry conferences, but what was especially interesting here was the space it provided to talk to a range of practitioners about how they go about growing their businesses. From clinical up-skilling to developing marketing strategies to thinking through more innovative approaches, it was a fascinating mix.

Bsc (BasraT), Msc McsP, Msc BPhty Ma, McsP McsP, McsP, Msc PhD FcsP, srP McsP, srP MrcgP, Dip sports Med, Msc PhD, Bsc (hons) Msc, MsMa

is published by Centor Publishing ltd 88 Nelson Road Wimbledon, sW19 1HX Tel: +44 (0)845 652 1906 Fax: +44 (0)845 652 1907 www.sportex.net

stepping back from the clinical and ‘immediate’ to take a longer strategic view about organisational development or business growth is always beneficial. it’s even more useful to hear such a broad range of approaches, and to gain understanding on the depth of thought people put into this. We’ve blogged about one aspect of this – the decision-making processes practitioners go through before investing in new technology or equipment – and would be interested in hearing your views on this issue at the link below. Decisions related to investing in new kit are particularly significant for smaller practices or sole traders. Taking anything off the immediate bottom line can be daunting in the current climate, so decisions which push into the hundreds, if not thousands, of pounds can seem massive, or potentially risky, as the clinical or financial returns will be unknown. That, of course, is counterbalanced by the need to stay relevant and – often – in touch with what competitors are offering. To read the blog, hear what others have to say and add your comments on this issue, visit http://spxj.nl/ToBuyornot Tor Davies, publisher and founder tor@sportex.net

oTHeR TITles IN THe sPoRTeX RANge sporteX dynamics prom ing best ot - issn 1744-9383 prac sports tice Written specifically for care professionals working with a wide variety of athletes and sports people to help them get the most out of their athletic performance - personal annual subscription from £54, practice subscription from £94 in

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CoNTeNTs 4 journal watch 7 Functional screening 12 The brain and pain 18 Patellofemoral pain The latest key research

a case study following the treament of a semi-professional footballer The link between movement and pain What can be predicted with PFPs?

Physiotherapy and Pilates for 23 the dressage rider how musculoskeletal issues for the riders can be treated

wake techniques 27 sleep for elite athletes

an overview of the key elelments essential to a sleep recovery programme

32 Research reviews

Two pieces of research analysed

To FINd ouT MoRe AbouT sPoRTeX VIsIT

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H HIppOCAmpAL STRuCTuRE ANd HumAN COGNITION: COGNITION KEy ROLE Of SpATIAL pROCESSING ANd EvIdENCE SuppORTING THE p EffICIENCy HypOTHESIS IN fEmALES. Coloma R, Stein JL. Intelligence 2013;41(2):129–140 This study is a comparison between 59 women and 45 men aged 18–27. They completed twenty one tasks measuring abstract, verbal, and spatial intelligence, along with working memory, executive control, attention, and processing speed. Their brains were scanned and the relative sizes of their hippocampus compared and correlated with the test results. Generally, women’s brains are 8% smaller than men’s. Significant relationships were found for spatial intelligence, spatial working memory, and spatial executive control. Interactions with sex revealed significant relationships with the general factor of intelligence along with abstract and spatial intelligence. These correlations were mainly positive for males but negative for females, which might support the efficiency hypothesis in women. Verbal intelligence, attention, and processing speed were not related to hippocampal structural differences.

sportEX comment This simply confirms what many of our readers already know. Despite being smaller, women’s brains are more efficient. They need less energy and fewer neurons to complete a task. So, gentlemen, size isn’t everything.

Eff EffICACy Of THRuST ANd NON-THRuST mANIpuLATION ANd EExERCISE wITH OR wITHOuT THE AddITION Of myOfASCIAL THERA THERApy fOR THE mANAGEmENT Of ACuTE INvERSION ANKLE SpRAIN: A RANdOmIzEd CLINICAL TRIAL. domínguez ST, Salom-moreno J, et al. Journal of Orthopaedics & Sports Salomphysical Therapy 2013;43(5):300–309 Fifty patients (37 men and 13 women; mean ± SD age, 33 ± 10 years) post-acute inversion ankle sprain were randomly assigned to 2 groups: a comparison group that received a thrust and non-thrust manipulation and exercise intervention, and an experimental group that received the same protocol plus myofascial release to the lower limb. The primary outcomes were ankle pain at rest and functional ability. Additionally, ankle mobility and pressure pain threshold over the ankle were assessed by a clinician who was blinded to the treatment allocation. Data was captured at baseline, immediately after the treatment period, and at a 1-month follow-up. The myofascial group experienced a greater improvement in pain, function and ankle mobility than the other group. Non-thrust means mobilisation, basically Maitland grades 3–4 applied anteriorposterior (AP) to the subtalar joint, a lateral glide and an AP the distal tibiofibular joint for 20 to 30 seconds. Thrusts were grade 5 manipulations: a talocrural joint distraction and to the proximal tibiofibular joint technique.

sportEX comment Another controversial subject. How much of the effect of a manipulation is attributable to the effect on synovial fluid and is it a simple stretch of soft tissue around the joint? Whichever, it seems that the myofascial release enhances the treatment.

GLENOH GLENOHumERAL ROTATIONAL RANGE Of mOTION dIffERENCES BETwEEN ffAST BOwLERS ANd SpIN BOwLERS IN ELITE CRICKET. Sundaram B, Skn B, Karuppannan S. The International Journal of Sports physical Therapy. 2012;7(6):576–585 Thirty-five fast bowlers and 31 spin bowlers from an elite group were measured for glenohumeral passive internal and external rotational differences between dominant and non-dominant shoulders using a standardised mechanical inclinometer. There was a statistically significant difference for external rotational difference between fast and spin bowlers and no such difference for internal rotational difference.

sportEX comment Shoulder injuries are more common in spin bowlers than fast bowlers. Whether the difference in rotational ability is a cause or an effect is a subject for more research but in the meantime work on those external rotators to minimise injury.

sportEX medicine 2013;57(July):4-6

JOURNAL WATCH

Journal watch dOSE–RESpONSE dOSE EEffECTS Of mEdICAL ExERCISE THERApy E IN pATIENTS wITH pATELLOfEmORAL pAIN SyNdROmE: A RANdOmISEd CONTROLLEd CLINICAL TRIAL. Østerås B, Østerås H, et al. physiotherapy 2013;99(2):126–131 Forty-two patients with patella femoral pain syndrome were assigned at random to an experimental group or a control group. Both groups received three treatments per week for 12 weeks. The experimental group received high-dose, high-repetition medical exercise therapy, and the control group received low-dose, low-repetition exercise therapy. The groups differed in terms of number of exercises, number of repetitions and sets, and time spent performing aerobic/global exercises. Outcome parameters were pain (measured using a visual analogue scale) and function (measured using the stepdown test and the modified Functional Index Questionnaire (FIQ)). At baseline, there were no differences between the groups. After the interventions, there were statistically significant and clinically important differences between the groups for all outcome parameters, all in favour of the experimental group.

sportEX comment The previous study shows that we are not sure how to diagnose PFPS, but treat whatever it is aggressively and it gets better.

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AN fmRI-BASEd NEuROLOGIC SIGNATuRE Of pHySICAL pAIN. wager Td, Atlas L, et al. The New England Journal of medicine 2013;368:1388–1397 During the course of 4 studies this research group have developed a functional magnetic resonance imaging (fMRI) based measure of pain. In study 1 they used machine-learning analyses to identify a pattern of fMRI activity, across brain regions, that was associated with heat-induced pain. They called this a neurological signature. The pattern included the thalamus, the posterior and anterior insulae, the secondary somatosensory cortex, the anterior cingulate cortex, the periaqueductal grey matter, and other regions. It showed a 94% chance of discriminating painful heat from non-painful warmth, pain anticipation, and pain recall. In study 2, the signature discriminated between painful heat and nonpainful warmth with 93% sensitivity and specificity. In study 3, they assessed specificity relative to social pain, which activates many of the same brain regions as physical pain (85% sensitivity, 73% specificity). In study 4, they assessed the responsiveness of the measure to the analgesic agent remifentanil. The signature response was substantially reduced.

sportEX comment A machine that ‘sees’ pain. Could this be the end of pain as a subjective measure? No more VAS scales and lots of, “I told you it hurt”. Now all we need is a functional MRI scanner in every clinic. S SHOuLdER fuNCTIONALITy AfTER mANuAL THERApy IN SuBJECTS S wITH SHOuLdER ImpINGEmENT SyNdROmE: A CASE SERIES. Heredia-Rizo Am, López-Hervás A, et al. Journal of Bodywork and movement Therapies 2013;17(2):212–218 Twenty two subjects (aged 58 ± 10.86) were divided into two groups. The conventionalgroup (n = 11) received mobilisations of the shoulder and the experimental-group (n = 11) was treated with soft tissue techniques in the cervical and upper thoracic regions. Both groups received electrotherapy and postural advice over a 2-week period (15 daily sessions of 1½ hours). Outcomes were active and

passive range of motion (ROM) and self-perceived functionality of the upper limb (DASH questionnaire). Both were measured. The experimental group showed a significant improvement in the DASH scores and both groups improved mobility in the intra-group comparison pre-intervention versus post-intervention, but no statistically significant differences were found in the between-group comparison.

sportEX comment One-and-a-half-hour sessions! They don’t work for NHS England do they?! Both mobilisations and soft tissue therapy worked, but judging by the self-perceived questionnaire the soft tissue group felt better about it. There is a moral in that tale. 5

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INJuRy OR ACTIvITy-RELATEd pAIN SuSTAINEd By A pOpuLATION Of AT-RISK wOmEN duRING A 6-mONTH ExERCISE pROGRAm. Billecke SS, marcovitz pA, et al. The physician and Sportsmedicine volume 2013;41(2): doi: 10.3810/ psm.2013.05.2007 This was a study of 117 women on an exercise programme. At baseline their averages were 57.3 years; weight, 203lb; body mass index, 34.8kg/m2; and waist circumference, 39.9 inches. Measurements taken were cardiovascular efficiency (via standardised submaximal treadmill testing), and questionnairebased assessments of functional capacity (Duke activity status index (DASI)), daytime sleepiness (Epworth sleepiness scale), and depression (9-item patient health questionnaire). During the study period 27 (23%) experienced an injury or activity-related musculoskeletal pain (injured group). Characteristics did not differ significantly between the injured and non-injured groups for baseline demographics but obesity incidence (body mass index≥≥30kg/m2) was more prevalent in the injured group. The 9-item patient health questionnaire depression scores were higher for injured participants (5.6 v. 4.1) and DASI activity scores were significantly lower for injured participants (31.3 v. 41.0) despite there being no significant difference in baseline exercise capacity, expressed as metabolic equivalents (8.1 v. 7.5) between groups.

sportEX comment If you are starting an exercise programme it is useful to be able to predict those participants who are more likely to injure themselves and take steps to prevent it. The key factors here were those who were more obese, depressed, and reported lower functional capacity were more likely to be injured. Are they not also the group most needing the exercise programme? There is great scope for further research here. Would the results be the same for other age groups? Are they depressed because they are obese? What are their psychosocial issues? Can someone get us those answers, please.

uLTRASOuNd EvALuATION Of ACHILLES TENdON THICKNESS IN ASympTOmATICS: A RELIABILITy STudy. Kharate p, Chance-Larsen K. International Journal of physiotherapy and Rehabilitation 2012;Nov 16 The Achilles tendon thickness of 25 healthy participants was taken on two occasions, approximately 30 minutes apart; by the same rater, under the same testing conditions. The reliability was found to be excellent.

sportEX comment Excellent! See a picture, stop the guesswork. This shows that ultrasound can be used by physiotherapists with minimal training as a clinical tool for prevention, assessment and monitoring of athletes. Now all we need is the machines to come down in price.

Eff EffECT Of AIRLINE TRAvEL ON pERfORmANCE: A REvIEw Of THE LITERATuRE. Leatherwood w wE, dragoo JL. British Journal of Sports medicine 2013;47:561–567 The PubMed and Scopus databases were searched between December 2011 and February 2012 using the search terms that included travel, performance, sport, circadian rhythm, jet lag, altitude, nutrition and sleep loss related to long distance flights which here was taken to be crossing three or more time zones. They found 106 papers. They then discuss the studies under the headings of the effects of circadian rhythm and performance including the effects of light, melatonin and drugs to counter the effects, direction of travel around the globe and subsequent jet lag, sleep deprivation, altitude (average cabin pressures are 5000– 6000ft) including its effect on oxygen saturation levels and nutrition, especially the quantity and timings of consumption. (No comment is made about the standard of airline food). The conclusions are that no one of these individually can be linked to performance, and indeed in this context performance is a vague concept because performance, good or bad, can be attributed to multiple variables not least of which is the home advantage of the opposition. 6

sportEX comment Anyone travelling abroad with an athlete or team should read this and consider a strategy covering as many of the variables mentioned because together they most certainly do have an effect. Travel is hard work, and remember that it’s not just the athletes who have to perform – the support staff have to do a job as well. Note: See p28 for our article on Sleep and Performance. sportEX medicine 2013;57(July):4-6

Case study

by Dan amin mSc, GSR, QTLS

The naTuRe of The SpoRTinG acTiviTy The patient was a 30-year-old male, semi-professional, central-midfield footballer, who played approximately 55 games (and a similar amount of training sessions) within a 35-week season. During the early stages of this season, he had been diagnosed with meniscal damage to the right knee; however, due to financial constraints of both club and player, an immediate operation did not take place and he played on intermittently when pain was not a limiting factor. he underwent meniscal repair shortly after this investigation took place. in recent years, there have been several epidemiological studies of injuries in professional football. hawkins and Fuller (1) undertook a prospective, epidemiological study in 4 english clubs from November 1994 to may 1997 and identified strains (40%), sprains (20%) and contusions (20%) as the most common types of injury, with the thigh (23%), ankle (17%) and knee (14%) being the major locations. Their findings concurred with previous research (2,3) and were also similar to those of hawkins et al. (4) who undertook a more substantial epidemiological study in 91 english professional football clubs from July 1997 to may 1999. This study again found strains (37%), sprains (19%) and contusions (7%) as the most common types of injury, with the thigh (23%), ankle (17%) and knee (17%) again being the major locations. both hawkins and Fuller (1) and hawkins et al. (4) highlighted hamstring strains as the most common injury (11.9% and 12%, respectively). A more recent, though less extensive, prospective study was undertaken during the 2001/02 UeFA champions league and, once again, highlighted hamstring strains as the most common injury (10.7%) (5). They identified strains (26%), sprains (21%) and contusions (16%) as the most common types of injury, with the thigh (23%), knee (20%) and ankle (14%) being the major locations. so it can be seen that although hamstring strains are the primary injury in football, sprains to the ankle and knee www.sportEX.net

FunCtional sCreening oF a semi-proFessional Footballer A cAse AnAlysis

This article highlights that a simple approach, in terms of combining a literature-based analysis with practical assessment methods, could determine a subject’s physical status in terms of susceptibility to injury in their given sport. After such an analysis, the pre-participation physical examination can be refined greatly in order to highlight any injury risk factors associated with an athlete, which helps to limit the potential time required to assess an entire team. are also of major concern (1,3–5). These studies have also highlighted several consistent mechanisms of injuries. Player-to-player contact, in particular tackling or being tackled, has accounted for 38–41% of injuries (1,4,6). This type of mechanism was the causative factor for 59.4% of sprains, 61.9% of ankle injuries and 56.8% of knee injuries (6). The lower extremities are often injured during tackling as players cannot respond quickly enough to avoid such rapid and unpredictable movement (7). Non-contact injuries, however, accounted for a greater proportion of total injuries than player to player contact (47%–52%) (1,4) with running, pivoting and turning, and kicking highlighted as the key contributors (1,4,6,8). These types of activities contributed to 72.1% of strains and 71.3% of thigh injuries (6) and also 31–39% of ankle sprains (9,10). During pivoting and turning, the main causes of injury are inferior playing surfaces and inappropriate footwear. Uneven playing surfaces may result in more loading on the ligaments and muscles, whereas incorrect footwear, if generating too

much frictional force, will produce large torque when twisting and turning, which may also lead to injury (7). Running has been highlighted as the primary causative factor for hamstring strains, being most vulnerable during the end of the swing phase when they have to rapidly change from acting eccentrically to acting concentrically (11). Fatigue (central and peripheral) has been identified as a predisposing factor for both contact and non-contact injuries (4,12) and concurs with the observation that the two 15-minute periods at the end of each half have a significantly higher incidence of injury when compared with other 15-minute periods of match play (4). Through the simulation of the physiological demands of football, Gleeson et al. (13) identified

AN eviDeNce-bAseD ANAlysis oF The Risk FAcToRs iN sPoRT cAN ReFiNe ANy sUbseqUeNT PhysicAl AssessmeNT PRocess 7

that knee ligamentous injury risk is increased due to fatigue-induced increases in electromechanical delay of knee flexion and extension, and anterior tibiofemoral laxity. Another study which simulated the physiological demands of football (14) observed that peak eccentric hamstrings torque decreased as fatigue set in, in particular when required to sprint. looking specifically at the patient’s current injury history, injuries to a healthy meniscus are usually produced by coupled compressive and rotational tibiofemoral joint forces, which normally occur during sudden turning or pivoting (15,16). Although meniscal tears can be traumatic or degenerative in their nature, they do not tend to be associated with contact or collision with the knee (16).

pRimaRy TeST SeLecTion The following primary, functional screening tests were administered to the patient: singleleg squat; single-leg hop; hurdle step; and drop jump. current literature was used to inform the administration of the test; however, often there was little conjecture amongst the research regarding a standardised approach. The tests were administered after four bilateral practice attempts in an effort to allow for any learning effects to take place, making for a more valid test (17). slow-motion video analysis was then undertaken from both frontal and sagittal plane views, using the quintic® biomechanics 9.03 v14 software package.

Single-leg squat The single-leg squat (sls) involves the subject unilaterally attempting to achieve ‘squat position’ (60° knee flexion) (18) and, although no standardised method of performing the sls has been described, and no relationship documented to determine what the sls test is assess¬ing, it is a commonly used method of evaluating

lower-limb function (balance, dysfunction affecting the kinetic chain, and eccentric and concentric loading predominantly through the sagittal plane) (18–20). The sls, therefore, has good potential as a functional test as it involves dynamic movement requiring motor control, strength and balance and many athletic activities involve this component, for example, running, turning and jumping (21). it also has high to moderate specificity when identifying frontal-plane displacement (hip adduction >10°) (18). measures can be put in place in order to progress the test to identify where failure occurs, for instance, undertaking the test with additional weight; on a wobble-cushion; or undertaking with a reduced visual input.

dynamic stability during a stepping motion. There is limited literature associated with the test; however, it forms part of Gray cook and lee burton’s ‘Functional movement screen’. The hs mimics some of the functional aspects of football, for instance running, turning and, in particular, kicking. it focuses not only on the control of the stance leg, but also the ability to extend the open-kinetic chain that is the step leg. This may highlight any contributing factors to a hamstring strain, if dynamic knee extension during hip flexion is compromised. in order to progress this test to elicit a fail, the subject could be made to step over a higher hurdle; or undertake the test with stance leg on a wobble cushion or at an increased height.

Single-leg hop

Drop jump

The single-leg hop (slh) consists of the subject attempting a maximal horizontal distance with one-hop, while fixing the landing (22–24). it is a highly reliable test (r=0.96) (25) that calls for muscular power; strength; balance; dynamic stability through the hip, knee and ankle; and confidence in the knee (26). The test has been suggested as an appropriate predictive tool for identifying subjects who may have future problems as a result of knee injury or pathology (27). however, the slh is somewhat lacking in external validity as it does not involve any need to predict or react to external changes or perturbations such as dodging a defender or coming into contact with an opponent (28). As such, it has been suggested to include more of a twisting and cutting component in order mimic the demands of dynamic knee stability during sporting activities with variations including the single-leg crossover hop and single-leg vertical jump (29). The test can be progressed through the administration of any of the variations mentioned; or administration of the slh post-fatiguing exercises, whereby adaptive hip-extension tends to occur (22).

The drop jump (DJ) test involves the subject stepping off from a set height of approximately 30cm (30,31) and has been used as an identification tool for predicting non-contact anterior cruciate ligament (Acl) injuries in athletes; control of centre of mass (com); and sagittal plane stability – functions which are essential in football when turning, pivoting and landing (30). it is potentially an important functional test as it has been stated that no clinical system was in place for accurate and practical screening of athletic individuals who may be at risk for Acl injury (32). A limitation to the DJ in assessing for potential injury is that it involves a near vertical drop, whereas many Acl injuries involve significant forward momentum, in combination with complex movements (33,34). The test can be progressed by increasing the height of the drop; unilateral landing; or landing when fatigued.

hurdle step The hurdle step (hs) assesses coordination and stability between the hips and torso and single-leg stance

oFTeN, The Time coNsTRAiNTs AssociATeD wiTh AssessiNG whole TeAms meAN ThAT A ReFiNeD PRoTocol is esseNTiAl 8

movemenT fauLTS anD SeconDaRy TeST SeLecTion The left-leg squat would be graded as good (17) as the only issues were that hip flexion tended to initiate before knee flexion, allowing for some anterior translation of the patient’s com (Fig.1). The right leg would be classified as fair (17) as there was poor control and noticeable (>10°) adduction and hip external rotation at the end range of flexion prior to commencing the sportEX medicine 2013;57(July):7-11

Case study

concentric aspect of sls (Fig. 2). There was also a seeming difficulty in taking load through the quadriceps as the knee dropped into flexion at first. A limitation was the omission of any analysis from a posterior view as this could have hopefully highlighted any obvious pelvic rotation (more conspicuous rotation of ‘hanging’ leg). Although the patient performed better on the left-leg slh, there was still slight valgus and hip internal rotation on landing and there may also be some issues with force acceptance as the knee seemed to jerk when acting eccentrically, prior to generating concentric force. There were some major concerns when hopping on the right leg, as the patient barely left the floor throughout the protocol (Fig. 3). As with the left leg, there are problems with eccentric loading; however, the varus (on landing) and valgus (on take-off) present is more prominent (Fig. 4). Another issue was the inability of the patient to maintain any control over the repeated hop landing sites. The major limitation when undertaking slh was that no clear single-leg hop test was actually administered from which to compare results. The patient performed repeated vertical hops, without attempting to reach a maximal height, which invalidates any attempt to grade it based on vertical slh test scores (28). The hs was the best performed test that the patient undertook. when using the left leg as stance leg, the case-study showed fairly smooth control throughout each step without resorting to any compensatory pelvic deviation to counter the unilateral movement (grade 3). when the right leg was the stance, there was a little more knee deviation present and, also, at one point the case-study’s heel touched the floor due to a slow step over and reluctance to extend the left knee when doing so (grade 2). As such, there was an increased need for stability and control in the right leg, however, it was difficult to see whether it was the stance or step leg that allowed the heel to drop. The limited literature associated with this test suggests the use of a pole placed in the front- or back-swat position, however, this was omitted from the test. The client was requested to manoeuvre their heel as close to the www.sportEX.net

surface as possible without placing it down when stepping over; this was for the purpose of further assessing their control during the test, but may have affected reliability as a heel height was not set. The 17-item landing error scoring system (less) (35) was used to assess DJ and has shown good to excellent inter-tester and intra-tester reliability when tester is trained in evaluation (31,34). The left leg scored 7 points (poor). key points of failure were: foot position, toe out (> 30°; Fig. 5); and knee flexion displacement (>45° from initial contact to maximal knee flexion). The right leg scored 9 points (poor). key points of failure noted were: asymmetrical foot contact (Fig. 6); narrow foot stance (Fig. 7); and knee flexion angle at initial contact (<30°). it must be taken into consideration that the video quality and tester proficiency could affect the less score greatly and, as such, a subjective analysis is equally as pertinent. For instance, it was noted that when initial landing contact was made with the right leg there was a distinct anterior translation of com on which then needed correction (Fig. 8). based on the findings from the primary tests, it seemed as though the client has a diminished confidence in the right leg when bearing weight, which would seem consistent with a meniscal injury (16). The time to undertake each test was longer than when the test was undertaken using the left leg (where applicable) and slh height was markedly lower in the right leg as it seemed as though the case-study was reluctant to leave the ground. however, it was interesting to note that during DJ, there was a considerable asymmetry in foot landing contact time when the right foot made initial contact. These findings and others may actually suggest that there are several underlying strength issues. in particular, eccentric loading of the right quadriceps was markedly poor – the initial lowering aspect of the sls was not controlled, as the knee seemed to drop into flexion; when initial ground contact is made with the right leg during DJ, their com noticeably shifted anteriorly; and, despite the limited height gained during the vertical hop, upon landing the knee jerked forward before the quadriceps

Figures 1–4: Functional deficiencies when undertaking SLS (1 & 2) and SLH (3 & 4). Images were taken using Quintic Biomechanics v14 video software and reproduced with permission.

Figures 5–8: Functional deficiencies when undertaking the drop jump. Images were taken using Quintic Biomechanics v14 video software and reproduced with permission.

had time to act concentrically to generate the subsequent hop – this may also highlight a deficiency in the stretch-reflex and may actually contribute to the poor ability to generate height in the first instance. eccentric strength of the quadriceps muscles can either be assessed using more accurate and expensive isokinetic dynamometers or hand-held isometric dynamometers, where the tester will push against the subject’s flexed knee while the subject attempts to resist. Another strength concern may be associated with the issue of external rotation at the hip. The problem seemed more pronounced on the right side, however, external hip rotation and varus kinematics at the knee were present during the downward motion of the sls (right leg only) and slh (bilateral); and upon landing during the DJ test (right leg only), This could suggest either eccentrically weak internal rotators or tight external rotators. once again, isokinetic/isometric dynamometry of hip internal rotation under eccentric load could be assessed, as could the true length of the external rotators whereby the client lays prone on the couch, with neutral spine and knee flexed to 90°, the sacrum fixed in place and the hip actively externally rotated – external rotation could then be measured with a pair of goniometers. Finally, during slh, the patient struggled with landing in a similar spot, suggesting diminished proprioceptive feedback. This may be at the ankle, knee or hip, so secondary tests can either focus on each individual joint or the lower-limb kinetic chain as a whole. methods include joint position sense, where a joint actively reproduces a given position (36); kinaesthesia, which measures a subject’s ability to detect passive motion of a limb segment (36); and stabilometry, which uses a force plate to assess a subject’s postural control during one-legged stance (25).

concLuSionS Although there seemed to be no major issues, there were several consistent minor issues with the patient that may be contributing to their present knee pathology or may develop into further injury. however, it seems that the client is not, perhaps, at risk of developing 10

an Acl injury due to the lack of knee valgus during the functional tests. Despite the fact that the casestudy clearly favours the uninjured left leg over the right, that side of the lower body is not without its faults and may now be equally at risk of injury. it could also be claimed that these faults were a predisposing factor to the injury in the right side; however, this can only be conjecture from such a snap-shot study. only four primary tests were administered and it is felt that this protocol was exhaustive enough given the subject’s sport and recent injury history, although, time permitting, it may have been beneficial to screen for hamstring insufficiency too, because of the ubiquity of the injury in football. The primary tests themselves, importantly, still need to be standardised in order for meaningful results to be drawn from them in terms of functional ability and, therefore, for relevant interventions to be put into place. References 1. hawkins R, Fuller c. A prospective epidemiological study of injuries in four english professional football clubs. british Journal of sports medicine 1999;33:196–203 2. Nielsen A, yde J. epidemiology and traumatology of injuries in soccer. american Journal of sports medicine 1989;17:803– 807 3. mcGregor J, Rae A. A review of injuries to professional footballers in a Premier league football team (1990–1993). scottish medical Journal 1995;40:16–18 4. hawkins R, hulse m, et al. The Association Football medical Research Programme: an audit of injuries in professional football. british Journal of sports medicine 2001;35:43–47 5. waldén m, hägglund m, ekstrand J. UeFA champions league study: a prospective study of injuries in professional football during the 2001–2002 season. british Journal of sports medicine 2005;39:542–546 6. Drawer s, Fuller c. evaluating the level of injury in english professional football using a risk based assessment process. british Journal of sports medicine 2002;36:446– 451 7. wong P, hong y. soccer injuries in the lower extremities. british Journal of sports medicine 2005;39:473–482 8. ekstrand J, Gillquist J. soccer injuries and their mechanisms: a prospective study. medicine and science in sports in exercise 1983;15:267–270 9. Árnason A, Gudmunsson A, et al. soccer injuries in iceland. scandanavian Journal of medicine and science in sports 1996;6:40–45 10. woods c, hawkins R, et al. The Football

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Case study

Association medical Research Programme: an audit of injuries in professional football: an analysis of ankle sprains. british Journal of sports medicine 2003;37:233–238 11. verall G, slavotinek J, et al. clinical risk factors for hamstring muscle strain injury: a prospective study with correlation of injury by magnetic resonance imaging. british Journal of sports medicine 2001;35:435–440 12. Davis J, bailey s. Possible mechanisms of central nervous system fatigue during exercise. medicine and science in sports and exercise 1996;29:45–57 13. Gleeson N, Reilly T, et al. influence of acute endurance activity on leg neuromuscular and musculoskeletal performance. medicine and science in sports and exercise 1998;30:596–608 14. Greig m, siegler J. soccer-specific fatigue and eccentric hamstrings muscle strength. Journal of athletic training 2009;44:180– 184 15. wheatley w, krome J, martin D. Rehabilitation programmes following arthroscopic meniscectomy in athletes. sports medicine 1996;21:447–456 16. lento P, Akuthoka v. meniscal injuries: a critical review. Journal of back and musculoskeletal rehabilitation 2000;15:55– 62 17. livengood A, Dimattia m, Uhl T. “Dynamic Trendelenburg”: single-leg-squat test for gluteus medius strength. athletic therapy today 2004;9:24–25 18. Dimattia m, livengood A, et al. what are the validity of the single-leg-squat test and its relationship to hip-abduction strength? Journal of sport rehabilitation 2005;14:108–123 19. beutler A, cooper k, et al. electromyographic analysis of single-leg, closed chain exercises: implications for rehabilitation after anterior cruciate ligament reconstruction. Journal of athletic training 2002;37:13–18 20. liebenson c. Functional exercises. Journal of bodywork and movement therapy, 2002;6:108–116 21. Zeller b, mccrory J, et al. Differences in kinematics and electromyographic activity between men and women during the singlelegged squat. american Journal of sports medicine 2003;31:449–456 22. Augustsson J, Thomee R, et al. single-leg hop testing following fatiguing exercise: reliability and biomechanical analysis. scandinavian

Journal of medicine and science in sports 2006;16:111–120 23. björklund k, sköld c, et al. Reliability of a criterion-based test of athletes with knee injuries; where the physiotherapist and patient independently and simultaneously assess the patient’s performance. Knee surgery, sports traumatology, arthroscopy 2006;14:165– 175 24. Reid A, birmingham T, et al. hop testing provides a reliable and valid outcome measure during rehabilitation after anterior cruciate ligament reconstruction. physical therapy 2007;87:337–349 25. Ageberg e, Zatterstrom R, moritz U. stabilometry and one-leg hop test have high test-retest reliability. scandinavian Journal of medicine and science in sports 1998;8:198–202 26. bremander A, Dahl l, Roos e. validity and reliability of functional performance tests in meniscectomized patients with or without knee osteoarthritis. scandinavian Journal of medicine and science in sports 2007;17:120–127 27. Fitzgerald G, Axe m, snyder-mackler l. A decision-making scheme for returning patients to high-level activity with nonoperative treatment after cruciate ligament rupture. Knee surgery, sports truamatology, arthroscopy 2000;8:76–82 28. Drouin J, Riemann b. lower extremity functional performance testing, part 2. athletic therapy today 2004;9:49–51 28. Drouin J, Reimann b. lower extremity functional-performance testing, part 1. athletic therapy today 2004;9:46–49 30. Noyes F, barber-westin s, et al. The dropjump screening test: difference in lower limb control by gender and effect of neuromuscular training in female athletes. the american Journal of sports medicine 2005;33:197– 207 31. onate J, cortes N, et al. expert versus novice interrater reliability and criterion validity of the landing error scoring system. Journal of sport Rehabilitation 2010;19:41–56 32. Ford k, myer G, hewett T. valgus knee motion during landing in high school female and male basketball players. medicine and science in sports and exercise 2003;35:1745–1750 33. olsen o, myklebust G, et al. injury mechanisms for anterior cruciate ligament

injuries in team handball: a systematic video analysis. american Journal of sports medicine 2004;32:1002–1012 34. Padua D, marshall s, et al. The landing error scoring system (less) is a valid and reliable clinical assessment tool of jumplanding biomechanics. the american Journal of sports medicine 2009;37:1996–2002 35. boling m, Thigpen c, et al. item specific reliability analyses of the landing error scoring system (less). medicine and science in sports and exercise 2005;37:s124 36. wikstrom e, Tillman m, et al. measurement and evaluation of dynamic joint stability of the knee and ankle after injury. sports medicine 2006;36:393–410.

Th AuThor ThE Dan Amin is a lecturer on the BSc ((hons) programme in Sport, Fitness and Exercise Science at The university Centre, Doncaster. he graduated in Sports rehabilitation and h Injury Prevention from Middlesex university in 2007 and recently completed an MSc with distinction in Sport Injury rehabilitation at The university of Salford. Dan has presented work on balance assessment and functional screening at conferences in Belgium and romania and is due to present at the European College of Sport Science congress in Barcelona in June 2013. In addition to his lecturing role, Dan worked as the rehabilitator for Ilkeston Town Football Club from 2007–2009.

n in terms of a needs analysis, other than information pertaining to common injuries and injury DISCUSSIONS mechanisms, what other information would be essential? n what other primary tests would you have considered with this case study? n often in the semi-professional environment, you have no access to specialist equipment and minimal time for team conditioning. Given the needs analysis presented here, what exercise programme would you consider with the team if you only had 1 hour per week with them for conditioning?

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The brain, movemenT and pain Movement is a highly variable and contextual activity. The specific movement reaction will be according to the brain interpretation of a given situation and the perceived risk or threat to the body’s tissues. By appreciating this context based reaction we can create assessment, treatment and rehab processes that enable us to understand and then change specific movement reactions that maybe causing pain or limitations thus leading to more applicable treatment methods. This may be the missing link between finding a cause and merely treating a symptom.

by ben CormaCk FaFS

he aim of this article is to highlight the brain’s role in our movement and pain. It aims to provide a model of operation that highlights the need for both context in a movement situation and a function based approach that allows the brain to utilise its memory–prediction model. The brain may alter its motor control responses at a joint to different movement situations. These alterations are based on previous experiences and environmental factors, such as forces acting on the body, and are used to control perceived movement threats and maintain a predictable sphere of movement. This can lead to altered movements within the entire kinetic chain and contribute to pain in multiple associated areas within a movement pattern.

The memory–prediCTion model One of the underpinning concepts behind how the brain works is that the brain is a pattern recogniser. It works on a system of memory and prediction. It auto-associates stored neural patterns within the brain with the patterns of sensory input it experiences constantly during our interactions with the world. These neural patterns are a collection of neurons that fire when we see certain things, move in certain ways or even feel emotions. These neural patterns form the basis of who we are and what we do based on what we have experienced previously. These stored patterns allow us to subconsciously perform the everyday tasks that make up our routines or sit up and take notice when encountering new and novel patterns that are out of our stored or expected experience. Information ascends up the cortical hierarchy until it reaches areas of the brain that either recognise and respond to the pattern or become consciously aware of a change in the expected prediction (1). An example would be reaching out to pick up a cup: we only become conscious if the cup is not there where we expected it to be. The position of the cup is stored in our memory and we make a prediction that it will be there. We assign a motor pattern to carry out that prediction based on stored patterns of movement from memory. This includes the correct stiffness, speed, trajectory and strength level for the task. These are all variables that the brain can choose to adapt given the required task or position. This makes our movement responses unique. They are individual responses to the interpretation of a situation. These responses relate to our previous personal experiences that can both be positive or negative and therefore elicit a positive or negative reaction in terms of movement. Why does the brain use a memory–prediction model? The brain is much slower than a computer – computers can carry out millions of calculations per second compared to the brain’s 200 per second (1). It may take millions of calculations to perform a task if we were to calculate all the variables all the time. Instead of this the brain is able to auto-associate a stored pattern from memory, stored over years of experiences

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and practice, to perform a task. The memory–prediction model enables us to perform our daily actions quickly and efficiently. We build a vocabulary of movement from childhood through our movement experiences and repetition. Much like our verbal vocabulary, our movement is made up from smaller movement components that we piece together to make more complex movements that are then stored and recalled. This evolution of a pattern through countless repetition does not necessarily mean that this will be a positive for the body, but will result in an individual response to a stored pattern used to carry out the intended prediction. In a sporting environment this may help us respond to situations that can be beyond the calculation and reaction times of the motor system such as returning a tennis serve or hitting a ball bowled by a fast bowler. We are able to predict the speed and trajectory of the ball based on previous experiences. Stored mental representations are the key to generating superior performance through prediction, planning and reasoning alternative actions (2). Understanding the memory–prediction model of the brain (1) becomes important when we see the body’s movement as brain based rather than simply biomechanical. The biomechanical model sees the body as a predictable set of pulleys and levers that varies little from one individual to the next apart from minor changes in structure or tissue. When we factor in a brain-based model we can see that movement is a set of stored patterns constantly evolving in a neural structure that is also constantly plastically reorganising (3,4). Our movement is influenced by our previous stored movement experiences that we will auto-associate with from memory. What does this all mean on a practical level? If you want to assess the brain and body’s reaction to a particular pattern then you have to in some way feed into the auto-associated pattern involved. On a movement level are you assessing or treating similar patterns of movement that may cause a triggering of the neurons involved in a patient’s specific movement interactions, and possibly pain? Are you asking the right question of the individual to get the right answer? (See Box 1.)

movemenT iS an individual experienCe Ronald Melzack coined the phrase ‘the neuromatrix’ to describe the spatial distribution and synaptic connections neuroplastically shaped by sensory input during our lifetime (5,6). Melzack discusses a ‘neurosignature’ that is imparted on all nerve impulse patterns that flow through our particular neuromatrix. Much like a physical signature, this neurosignature is highly individual. As movement is a product of neural activity so will our response to movement tasks be a highly individual action based on our unique neuromatrix. The neuromatrix takes input from many parts of the body and brain to shape its output to a given situation. Some examples of input would be our previous learning, personal variables, sensory cutaneous input, visceral input, visual, vestibular and sensory input, immune system and the limbic system (involved in endocrine responses) (6).

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box 1: FunCTional movemenT prinCipleS By including some or all of these criteria into our movement assessment or treatment we can get a more complete picture of a patients functional movement capabilities. n n n n n

Upright Dynamic and active Integrated multi-joint movement Three dimensional (joint motion and space) Force acting on the body.

Our movement is highly contextual and based on our perception of the current situation. We do this by recalling stored neural patterns that will include patterns for (amongst others) the visual, proprioceptive, emotional, vestibular and threat assessment parts of our brain. The power of context for rehabilitation is underused (7). Balance, vision, place, emotion, stress, pain and threat level all have a bearing on our motor programmes and the set of neurons that may be involved within and affect the movement being performed (7). How our anatomy performs within one context may be very different from how it performs in another context. Hence the need for an assessment process that involves some context or functionality that relates to the patient standing in front of you and the movements and environmental factors that we would auto-associate with to achieve a movement task.

an ankle example An example could be an injured ankle. In an open-chain environment the muscular stiffness of the joint may be set low efferently from the brain based on low threat on sensory feedback and low threat perception. If we stand the patient up and subject them to dorsiflexion and compression forces this stiffness level may change to protect the injured tissue or to protect against a perceived threat to the tissue. This stiffness level may change again if we move them into eversion, inversion, adduction or abduction depending on positional threat recognition, as would be seen with an increase in ground reaction forces. The physical response or answer to the assessment will change depending on the level of demand and positional context of the question being asked. Increasing movement confidence is a huge part of resolving chronic injury (8). By finding less threatening positions involving the painful body part we can help build movement confidence. Altering biomechanical positions through limb or body position, movement angle or gravitational influences could do this. A good understanding of how to control and influence movement as a practitioner is as invaluable as manual therapy skills. All of our sensory systems send back information

THe BRAIn MAy AlTeR ITS MOTOR cOnTROl ReSpOnSeS TO DIFFeRenT MOveMenT SITUATIOnS 13

box 2: eFFeCTS oF uprighT and dynamiC aSSeSSmenT on joinT proprioCepTorS Being upright and dynamic will create changes in the input to the brain from the proprioceptive system. This then alters the specific and contextrelated motor control output. These changes include: n Angle and velocity of joint motion n Gravitational compression and torque n effects of mass and momentum n Active muscle and connective tissue length and tension changes.

box 3: movemenT demand TaSk This task is designed to highlight movement differences between the left and right sides of the body, specifically in this example internal rotation at the hip. It is also designed to highlight the change in range of movement as the stability of the system is challenged through the addition of a single leg demand. See video 1 ‘Functional hip assessment’ for more detailed instructions. n put one leg forward on the floor. n Keeping an equidistance circle rotate foot around the standing leg making sure the pelvis is rotating. n When you lose stability or reach comfortable end range stop. n check distance round on imaginary compass, eg. 45°. Record data. n Repeat on other side and compare data. Repeat task on both legs but this time stand on one leg with hip flexed to 90° (this bends knee to 90° also). compare data from balanced assessment to see if the range decreased significantly when the assessment demand increased. Is there are large disparity between balanced and less balanced range? It is the author’s personal belief that this difference between available and controllable ranges maybe a factor in movement problems and subsequent pain. This change in range would be down to a change in stiffness modulated by the motor control system as a response to the increase in movement challenge.

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afferently via the spinal column to the brain for processing. This is an essential component of fluid motor control (9). On a joint level our proprioceptive system will send information based on joint compression and pressure, direction of capsular stretch, changes in amplitude and velocity, tension and length, and rate of change of length within myofascial components (10) to the spinal cord and cortex (11,12). All this is within a full spectrum of sensitivity including both low and high threshold receptors. As soon as we become upright and under forces such as gravity and ground reaction, the neural information and associated stored pattern, and therefore the prediction and associated motor pattern involved in the outcome, will change. As the movement demand changes so again will our response it. The triggering of higher threshold receptors may create a response from the motor system to control the joint’s motion and keep it within a perceived safe range based on previous sensory and motor experiences. The role of the afferents in a joint’s stability has been hypothesised to provide reflexive activation of alpha motor neurons (9,13), which could be to reduce movement variability. We look at the possible reasons for this activation in the section ‘The effect of previous injury and pain on future movement’ (Box 2).

FunCTional movemenT aSSeSSmenT Functional joint stability is much more complex than the simple input–output motor control mechanisms available from the lower level motor control system. This must involve supraspinal components to provide dynamic stability, through motor adaptations, to both proximal and distal segments involved in the entire motor control of the body during an integrated movement (9). Hence the need for assessment based on the performance of the entire kinetic chain in a movement task (Box 3; video 1), a joint’s performance individually and its impact on other joints within the chain of an integrated movement task. each specific movement will have associated peripheral input and a neural pattern for a specific motor response. Assessments close to this specific input pattern for central processing may give us a closer picture of movement capability away from a clinical environment. Many motor responses are about controlling our movement within threedimensional space rather than a clinically based joint action in a single plane. For example, during gait the proximal pelvis moving away from our distal femur causes abduction of the hip. A common treatment strategy for ‘weak abductors’ is to move the distal femur away from the proximal pelvis in a side-lying position. Based on our understanding of the memory–prediction model of the brain and sensory-motor system, will this have the desired crossover to function? A recent study (14) showed that improvements in hip flexibility do not transfer to mobility during functional movement patterns. The specificity of a movement pattern is vital to storage and then auto-recognition for future use in the memory–prediction model. passive range seems to have little bearing on functional range of movement during the

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performance of active tasks. Functional range is more likely to be associated with stored movement patterns within the brain and less on a localised structural level. We may also be able to use the reverse methodology as a treatment option. If the brain recognises a specific movement as threatening to the tissue (15) can we use another variation of movement sequencing (another of the 5 movement options at the same joint for the same joint action – see Box 4) to provide a less threatening version of movement using the same body part (8) coupled with a graded level of exposure. This would also indicate if the pain was a perception of threat or actual tissue damage as the joint motion would be the same, but the response in terms of pain would be different.

The eFFeCT oF previouS injury and pain on FuTure movemenT Our motor control is not a set and unchanging ability; like all areas of our brain it is subject to neuroplastic change according to the activities we perform (3,4,16). Many things affect our movement mechanisms from the quality of our sensory feedback and associated brain areas as well as our previous movement ability and injuries. All of our movement is based on the nervous system, however, more emphasis is placed on the biomechanical or structural aspects during the patient assessment process. Our ability to perform movement tasks is highly dependent on the context and the associated motor ability. Our thought processes should shift towards the patient’s performance of active movement tasks in addition to more traditional, practitioner-led, passive joint assessment. pain has been shown to create motor adaptations (17–19) that create changes in our voluntary movement. The importance in these changes is to protect us from threat or perceived threat (17) to the injured tissue. This can involve reduced displacement or force (17) and segmental stiffening (20) to avoid unwanted movement or changes in load distribution on the injured segment (21).

box 4: FunCTional joinT moTion There are 5 ways to move a joint to create the same joint action, eg. hip abduction from the variations below. This highlights the functional variability in movement available for assessment and treatment. n proximal fixed, distal moving n Distal fixed, proximal moving n proximal and distal moving in opposite directions (towards or away from each other) n proximal and distal moving in the same direction – distal faster n proximal and distal moving in the same direction – proximal faster.

either professionally or in our leisure time. An example would be picking up a limp after spraining an ankle. Subconsciously we protect the damaged tissue through an alteration in our movement patterns, such as walking. Over time this movement, unless restored to the previous motor pattern, may remain in some element as part of our future movement. Is a patient’s movement ability generally assessed postinjury after pain has subsided to ascertain movement ability, or is the reduction in pain the overriding goal of the practitioner? Another issue is that the reduced movement at an injured joint may then have an effect on another joint, especially when involved in an integrated function-related movement. These movement adaptations will inevitably increase load on other structures involved within a kinetic chain (21). Reduced loading of the ankle has been shown to alter kinematics at more proximal joints (22). long-term persistence of these movement adaptations can have many problematic effects elsewhere in the body (22). A decrease in movement variability is also another issue involved with pain’s effect on our motor ability. This can affect us on a structural level through repetitive loading of joint surface, muscles and connective tissue (23). Reduced variation in joint movement has also been shown to be involved with lower-

ShorT-Term beneFiT verSuS long-Term impaCT The effect of the short-term benefit of tissue protection on our future movement ability is underestimated. Although the short-term adaptations are beneficial to reduce impact on injured segments, often the long-term implications can be problematic. What is the stimulus to return to the pre-injury movement capabilities or pattern once the injury has been resolved? (21). We pick up a large number of injuries, both major and minor, in our lifetimes that contribute to our unique movement potential, especially if we are involved within sports

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box 5: aSSeSSmenT viTalS These are key parts to a well-rounded assessment process, especially when dealing with longer-term problems. 1. Detailed injury history spanning 5 years minor and 10 years major 2. Active dynamic patient driven movement 3. Function related (to patient) movement 4. non-symptomatic assessment of associated joints within a kinetic chain. limb pathologies and gait variabilities (23). pain’s reorganising effect on the somatosensory cortex, used by the motor areas to plan our movement (24), has also been well documented (25–27). As these changes occur it would be reasonable to hypothesise that our motor control would also be changed or compromised. Again this may lead to increased stress on joints elsewhere in the body when integrated into multi-joint movement. It is not just current and previous pain that may cause changes in our motor ability. Our general ranges of movement are dictated by our daily activities such as working postures and movements and sports and hobbies. Areas of the body or movements that are used less may also be subject to reduced motor control through decreased somatosensory output to the brain (21,24) and create a greater load on other areas of the body. changes in sensory function have been identified with painful injuries (19,28,29). Reduced motor ability will also reduce sensory input to the sensory areas of the brain through decreased peripheral proprioceptive information, these areas are closely linked (24,30). What we sense and feel dictates how we move. This means our body will not move us into positions that it has marked as problematic or painful, hence adaptive motor patterns such as limps. A painful stimulus projects to many areas of the brain such as the anterior cingulate cortex and the insular cortex as well as the somatosensory cortex (S1) and secondary somatosensory cortex (S2) (30). Studies of the parietal cortex, specifically the posterior section, where the sensory areas are located, are now being viewed as important for sensory-motor integration with regards to movement planning (31). Smudging or blurring of the somatosensory representations of our body parts has also been linked with chronic pain (24, 32). This smudging may come from decreased movement input after pain or even through reduced movement through limited or repetitive daily activity. So in theory poor movement at a joint in itself could lead to a pain state.

praCTiCal impliCaTionS So what does this all mean to the practitioner? First of all it shows us that although a part of the body is not in pain, its limited movement can still have an effect on other parts of the body. This may drive other body segments to be overloaded in terms of force or repetitively loaded through decreased movement variability. pain is a complex subject involving many mechanisms and is not simply a case of nociceptive input. pain is a poor

marker for actual tissue damage or severity of that damage (33); in fact Ramachandran describes pain as an ‘opinion’ rather than simply reflective of the occurring tissue damage. It could be that reduced movement at a joint could provide a potential ‘threat’ to tissue when moving outside of a perceived safe range or trigger a potential ‘threat’ (15) response at another joint involved within a kinetic chain that maybe at risk of increased or repetitive load. We can put that into practice by starting to assess the body as a whole rather than just an injured segment, a non-symptomatic assessment. Multiple studies have shown a change in kinematics at one joint can affect others within a chain. A detailed injury history may give some clues of where to look for reduced movement. By putting patients in functionally authentic positions we can also see which areas of the body may not be contributing to the movement as a whole and forcing other areas to increase their movement contribution to completing the given task. It could be that even long forgotten injuries still have a bearing on our current motor patterns impacting on movement and pain in multiple parts of our bodies. previous injury has long been known to be a risk factor for future injury (34); the question now is about the time frame of the effect. It is important also to start to assess our patient’s movement actively through movement tasks rather than just passively moving them through a range at a joint (Box 5). Would the body have the same protective response when in a low threshold or low threat environment such as when lying down, seated or being passively moved? A good assessment should involve both passive local assessment and a more dynamic, upright and global-function related assessment. Often it can be the disparity between the ranges of movement in a passive situation compared to an active one that can be a good indication of a protective motor response. By putting the body in a moving context and having to control its mass against gravity, ground reaction and momentum acting on it may give an entirely different brain and nervous system response in terms of protecting the tissue. It will respond to protect a pattern that it feels may be threatening to a tissue by increasing stiffness of the efferently controlled tissue around a joint to reduce range of movement. To elicit that protective response we may have to put it in the right context or scenario, eg. upright, dynamic and under force. To make this even more specific for the brain and body’s pattern recognition we could put the patient in a functionspecific position or function-related movement task. The authentic biomechanical movements will create the authentic afferent proprioceptive information for the brain to assess and to make a context-specific motor control response. It could be that there is a specific threshold, in terms of range, speed or plane, at which a protective response becomes apparent. references r 1. Hawkins J, Blakeslee S. On intelligence. Times books 2004. ISBn 0805074562 (£9.95). Buy from Amazon http://spxj.nl/yWfFkk

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state of the art and implications for clinical practice. presented at the Third international Conference on movement dysfunction 2009, edinburgh, UK 27. Flor H. cortical reorganization and chronic pain: Implications for rehabilitation. Journal of rehabilitation medicine 2003;Suppl. 41:66–72 28. Garn Sn, newton RA. Kinesthetic awareness in subjects with multiple ankle sprains. physical Therapy 1988;68(11):1667–1671 29. Warner JJ, lephart S, Fu FH. Role of proprioception in pathoetiology of shoulder instability. Clinical orthopaedics and related research 1996;330:35–39 30. Hofbauer K, et al. cortical representation of the sensory dimension of pain. Journal of neurophysiology 2001;86:402-411 31. Anderson SJ, yamagishi n, Karavia v. Attentional processes link perception and action. proceedings of the royal Society of London Series b: biological Science 2002;269:1225–1232 32. Butler D. The sensitive nervous system. opTp 2006. ISBn 0975091026 (£65.00). Buy from Amazon http://spxj.nl/12IppAU 33. Ramachandran vS, Blakeslee S. phantoms in the brain. William Morrow paperbacks 1999. ISBn 0688172172. Buy from Amazon http://spxj.nl/190vl5w 34. Hagglund M. previous injury as a risk factor for injury in elite football: A prospective study over two consecutive seasons. british Journal of Sports medicine 2006;40(9):767–772.

FurTher reSourCeS The Gray Institute (www.grayinstitute.com) cor-Kinetic blog (http://bencormackpt.wordpress.com/) neuro Orthopaedic Institute (http://www.noigroup.com/) Butler D. The sensitive nervous system. OpTp 2006. ISBn 0975091026 (£65.00). Buy from Amazon http://spxj.nl/12IppAU Blakeslee S, Blakeslee M. The body has a mind of its own: How body maps in your brain help you do (almost) everything better. Random House 2009. ISBn 0812975278 (£7.58). Buy from Amazon http://spxj.nl/12S3nsp ThE AuThor Th Ben is a movement and exercise specialist based in London. he is a fellow of Applied Functional Science (FAFS) having studied at the Gray Institute in the uS and is currently undertaking a medical neuroscience course with Duke university, North Carolina, uS. Ben is the founder of Cor Kinetic (www.cor-kinetic.com) which is a continued professional development (CPD) provider based around understanding the body in its functional context and the associated mechanics and neuroscience, especially functional movement’s impact on both pain and performance. Cor Kinetic have worked with staff from many of the top teams in both premiership rugby and football both in house and on the CPD courses they run that also include physios and osteopaths from private practice and NhS.

DISCUSSIONS

n Does a static or passive assessment tell us how the body will actively perform in movement? n Does an isolated joint-by-joint treatment approach carry over into functional integrated activities? n How much is the brain involved in movement? n What are the implications of long-term injury and does how long ago matter?

What can be predicted When it comes to patellofemoral pain? by Simon Lack mSc mcSP

introduction Patellofemoral pain (PFP) is reported to be one of the most common presentations within both recreationally active and sporting populations. In one particular study of 2002 running injuries, 16.5% (331 patients) were diagnosed with PFP (1). A 2012 consensus statement of leading clinicians and researchers in the field of PFP further highlighted its high prevalence, particularly among younger persons who are physically active (2). Despite its high prevalence and positive short-term treatment outcomes, the fact that 80% of individuals who complete a rehabilitation programme for PFP still report pain, and 74% report a reduction in physical activity at 5-year follow-up, highlights the need for greater understanding of the condition, and more effective long-term management plans to be identified. With the aetiology of PFP widely accepted to be multifactorial in nature, these poor long-term outcomes may well represent a failure to address the key biopsychosocial factors that are contributing to its presence and persistence. A more tailored 18

Patellofemoral pain is widely considered to be a condition that is multifactorial in nature, and that requires a multimodal approach to its successful management. Using an evidence-based approach to understanding the key predicators of its onset, the key determinants of its presence, and the key characteristics that predict a successful treatment outcome empowers the clinician to make better clinical decisions regarding it management. intervention approach, therefore, may well offer a more effective means of addressing the problem.

ÂŠ2013 Primal Pictures

Femur

Patellofemoral joint (behind patella)

the knee Local, distal and proximal biomechanical factors have all been extensively investigated to determine the relative contributions of these variables to the development and maintenance of PFP. Locally, patellofemoral mal-alignment and maltracking (pathomechanics) is theorised to overload the subchondral bone and thus lead to the development of pain (Fig. 1). Further theories including shortened lateral retinaculum, secondary nerve changes and a loss of tissue homeostasis (3) have also been proposed, however, the evidence for these is limited. Increased subchondral

tibiofemoral joint

menisci Fibula tibia

Figure 1: Anatomy of the knee.

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literature revieW

metabolic activity was reported in 44% of 109 participants experiencing PFP, supporting this potential mechanism for pain, but is clearly far from conclusive (4). With pain being subjective, the influence of psychological factors must not be underestimated, and may offer explanation for the variance in local structural changes and perceived pain levels that have been reported within the literature.

the foot Theoretical paradigms have linked the biomechanics of the foot (Fig. 2) to that of the knee and hip. Tiberio reported the mechanism through which delayed subtalar joint re-supination during gait can subsequently lead to increased tibial internal rotation, and resultant compensatory increased femoral internal rotation (5). Consequently, alterations in femoral rotation could lead to an increased dynamic knee valgus and subsequent increased patellofemoral joint (PFJ) stress. Further research has supported this relationship, with peak rearfoot eversion positively correlating with peak tibial internal rotation in PFP populations (6). Static measures of foot posture, however, have been reported to correlate poorly with dynamic foot function, and have shown not to correlate with PFP development. In contrast, dynamic measures of foot mobility have been shown to predict the success of specific distal interventions (7). ©2013 Primal Pictures

the hip Deficits in hip abductor and external rotator muscle strength (Fig. 3) have been consistently observed within PFP populations (8,9). Additionally, altered neuromuscular activity has been reported within PFPS populations, with the systematic review by Barton et al. demonstrating moderate evidence for the delayed and shorter duration of gluteus medius (GMed) muscle activity during functional tasks (10). It is proposed that these deficits indicate an impaired ability to control frontal and transverse plane hip motion, commonly seen within PFP populations. The question as to whether these deficits represent cause or effect will be discussed later in this article. With retrospective biomechanical deficits having been identified within PFPS populations, and the population consistently being identified to be heterogeneous in nature, a more tailored intervention approach is likely to result in better clinical outcomes. To achieve this, however, clinical markers that are able to predict the onset, presence and those likely to respond favourably to specific interventions are required.

cLinicaL PredictorS oF PFP deveLoPment Identification of clinical measures that are predictive of the onset of PFP requires a prospective study design. Clinical variables are assessed within ankle joint – dorsi- and plantarflexion

a pain-free population, commonly prior to commencing a sporting season, or training programme, and the population is then monitored throughout the period to identify any injuries that have been sustained. Both Lankhorst et al. and Pappas et al. have recently produced systematic reviews that collate this research (11,12). Both identified seven papers that met their inclusion criteria, with Lankhorst et al. reporting a total of 135 variables that were examined within the included studies. It is advised that in order to achieve sufficient power for this type of predictive study, ten participants for each variable being examined should be obtained. It was reported that within all of the studies, within both reviews, this level of statistical power was not reached. The findings of the reviews, however, did produce interesting and clinically relevant results. No anthropometric measures, including height, body weight, body mass index, age, or body fat percentage were predictive of PFP development. Results could not be pooled, but some individual studies identified measures of fitness that were predictive of PFP development. These included participating in fewer hours of physical activity (13), being able to complete a greater number of press-ups(!) (14), and achieving a lower vertical jump compared to those who did not go on to develop symptoms (15). Eleven psychological measures were reported in one study identifying those who

Other major hip abductor, gluteus medius not shown, but lies over the top of gluteus minimus.

articulations of the subtalar joint – inversion, eversion, supination, pronation

Gluteus minimus Pectineus internal obturator Superior gemellus inferior gemellus obturator externus Quadratus femoris

Figure 2: Ankle and subtalar joints.

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Figure 3: Hip rotators and abductors.

80% OF INDIvIDUALS WHO COMPLETE A REHABILITATION PROGRAMME FOR PFP STILL REPORT PAIN, AND 74% REPORT A REDUCTION IN PHySICAL ACTIvITy AT 5-yEAR FOLLOW-UP box 1: key PointS For PredictinG the deveLoPment oF PFP Positive predictors n Knee extensor strength deficits n Greater Navicular Drop negative predictors n Static Q angle n Peak knee valgus angles during landing. sought less social support and had difficulty relaxing when confronted with a problem were statistically more likely to develop PFP (15). Muscle strength measures reported in both reviews showed pooled data demonstrated weakness within the knee extensors to be predictive of future PFP (11,12). Hip muscle strength was not shown to be predictive of future pain. Lower measures of knee extension concentric peak torque at both fast (240Â°/s) and slower (60Â°/s) speeds significantly predicted future PFP development (11). Measures of concentric knee flexion peak torque did not show the same significant findings. In one study, reported reduced flexibility of the gastrocnemius and quadriceps, and greater joint laxity measures of knee extension, thumb to wrist and elbow extension were predictive of future PFP (15). Q angle was the only measure of lower limb alignment that could be pooled, and was not significantly different between controls and those who developed PFP. Foot posture index was found by Thijs et al. (16) to not predict future PFP, however, greater navicular drop measures were reported

box 2: key PointS identiFyinG characteriSticS aSSociated with PFP n 170 significant variables associated with PFP n Larger Q angle, larger sulcus angle, larger patellar tilt angle, lower peak knee extension torque, lower hip abduction and external rotation strength variables with strongest evidence n Gluteal EMG activity is altered within PFP populations.

as a significant predictor variable by Boling et al. (17). Pooled measures of biomechanical variables showed that peak knee valgus angles during droplanding tasks did not predict PFP. The advantage of this information is twofold. Firstly, we can aim to identify characteristics that increase the risk of developing PFP, intervene appropriately, and consequently prevent its onset. This, however, is very rarely applicable to the normal clinical environment. It is only really within the elite sporting community where there is an opportunity to intervene in this way. Secondly, it allows us to determine which characteristics (movement patterns, strengths, tissue lengths etc) are causative of developing PFP, or are an effect of having the condition. It enables us, to some extent, to identify features that are pertinent to the pathology compared with those that represent the normal variance seen between individuals.

FactorS aSSociated with PateLLoFemoraL Pain In order to tie this story neatly together, Lankhorst et al. (18) have reviewed the literature that has looked retrospectively at factors that are associated with patellofemoral pain. This enables further inferences regarding cause and effect to be made. Within this review, 47 studies were included, 523 variables assessed but only 8 pooled. Of which 170 variables were reported to be significantly different within PFP populations compared with controls. Of the 8 variables that could be pooled, significantly larger Q angle, larger sulcus angle, larger patellar tilt angle, lower peak torque knee extension, lower hip abduction strength and lower hip external rotation strength were observed within PFP patients compared to controls. No difference was found for arch height index of the foot or congruence angle of the patella (18). Immediately we are witness to a clinical factor (Q angle) that is

associated with PFP, but that is not seen prospectively to be a risk factor for its development. With reduced hip abduction and external rotation strength also being reported retrospectively, it may well be these deficits that result in increased Q angles. Furthermore, these weaknesses around the hip were not observed prospectively, and thus similarly to Q angle, represent changes that are more likely an effect of the condition and not the cause. Knee extension strength, however, represents a clinical measure that sits on both sides of the fence. It has been shown in pooled results to be reduced within prospective PFP populations and retrospective ones. Historically weakness in this muscle group in patients has been attributable to pain, and the resultant inhibition that this causes. However, in these reviews, it highlights the potential protective role that stronger knee extensors have to the PFJ. The intricacies of patella position were not well investigated prospectively; however, the one study that looked at patella position (15) found no significance between groups. Both measures shown retrospectively to be greater in PFP patients (larger sulcus and patellar tilt angle) may represent a link with the changes in femoral biomechanics resulting from altered Q angle and hip muscle activity reported earlier. Altered gluteal activity has been extensively investigated within both intervention and case-control studies. The systematic review completed by our group at Queen Mary University London, exploring gluteal activity and PFP, identified consistent themes linking altered gluteal muscle activity within PFP populations. The results showed GMed to be delayed and of shorter duration during stair negotiation and running in PFP groups compared with controls. This may well represent a mechanism for the alterations in sagittal plane motion commonly observed within this group of patients.

outcome PredictorS oF conServative manaGement Maximising the clinical relevance of this article, we move on from identifying the characteristics that the literature sportEX medicine 2013;57(July):18-22

Literature review

box 3: key PointS demonStratinG outcome PredictorS oF conServative manaGement For PFP n Larger Q angle, greater usual pain and reduced LPA angle predictive taping success n Higher FIQ and greater forefoot valgus predictive orthoses success n Shorter symptoms duration and faster vMO reflex times predictive exercise success. suggests can cause PFP, and the factors that are associated with PFP, to establishing which clinical features can become ‘outcome predictors of conservative management’. We have been writing a systematic review (currently under review) that has sought to address this question. As with the previous reviews a great number of predictors have been investigated (205 in total from within 13 studies). Ten outcome predictors could be pooled. One demonstrated greater Q angle significantly predicted knee taping success, and two demonstrated a trend towards less usual pain and worse pain predicting orthoses intervention success. All other pooled results were insignificant or conflicting. Consequently, the conclusions made were that there is: “moderate evidence for greater Q angle to predict taping success, very limited evidence identifying higher FIQ (functional index questionnaire) scores and greater forefoot valgus significantly predict orthoses intervention success. Limited evidence demonstrates shorter symptom duration and faster vastus medius oblique (vMO) reflex times predict exercise success, and greater usual pain and reduced lateral patellofemoral angles (LPA) predict taping success. The predictive capacity of the remaining variables was inconsistent, possibly owing to variability in study design or the lack of these variables clinical relevance to the specific intervention modality received”. Inevitably the studies included within this review had limitations. In particular, 8 of the 13 studies failed to meet the pre-determined requirement of 10 participants per variable assessed. Additionally, only one study reported a follow-up period of 12 months or more, with 7 studies only investigating the www.sportEX.net

immediate effects of the intervention. This limited follow-up period seen across the included studies prevents strong clinically meaningful conclusions being made regarding the treatments effectiveness in long term management of this persistent pain complaint. With top-level evidence demonstrating that in the short-term physiotherapy interventions are effective, but with growing literature suggesting longerterm success is not being achieved, future research focusing on long-term outcomes is required.

concLuSionS PFP remains widely accepted as one of the most common musculoskeletal presentations, with aetiology that is multifactorial in nature. Despite shortterm treatment interventions showing good effects, longer-term outcomes are less promising. It could be argued that this failure to achieve good longterm results demonstrates a lack of tailored intervention that is specific to the individual, or a failure to sufficiently modify the true cause of the condition. Improved understanding of the cause and effects within PFP populations and successful identification of characteristics that guide a tailored intervention approach may therefore increase treatment effectiveness. Using these clinical measures to assign individuals with PFP into particular subgroups is worthy of future research. references 1. Taunton JE, Ryan MB, et al. A retrospective case-control analysis of 2002 running injuries. british Journal of sports medicine 2002;36:95–101 2. Powers CM, Bolgla LA, et al. Patellofemoral

pain: proximal, distal, and local factors, 2nd International Research Retreat. Journal of orthopaedic & sports physical therapy 2012;42:a1–54 3. Dye SF. The pathophysiology of patellofemoral pain: A tissue homeostasis perspective. clinical orthopaedics and related research 2005;436:100–110 Sheehan FT, Borotikar BS, et al. Alterations in in vivo knee joint kinematics following a femoral nerve branch block of the vastus medialis: Implications for patellofemoral pain syndrome. clinical biomechanics 2012;27:525–531 5. Tiberio D. The effect of excessive subtalar joint pronation on patellofemoral mechanics: a theoretical model. Journal of orthopaedic & sports physical therapy 1987;9:160–165 6. Barton CJ, Levinger P, et al. The relationship between rearfoot, tibial and hip kinematics in individuals with patellofemoral pain syndrome. clinical biomechanics 2012;27:702–705 7. Mills K, Blanch P, et al. A randomised control trial of short term efficacy of in-shoe foot orthoses compared with a wait and see policy for anterior knee pain and the role of foot mobility. british Journal of sports medicine 2012;46:247–252 8. Prins MR, van Der Wurff P. Females with patellofemoral pain syndrome have weak hip muscles: a systematic review. australian Journal of physiotherapy 2009;55:9–15 Bolgla LA, Malone TR, et al. Comparison of hip and knee strength and neuromuscular activity in subjects with and without patellofemoral pain syndrome. international Journal of sports physical therapy 2011;6:285–296 10. Barton CJ, Lack S, et al. Gluteal muscle activity and patellofemoral pain syndrome: a systematic review. british Journal of sports medicine 2013;47:207–214 11. Lankhorst NE, Bierma-Zeinstra SM, van Middelkoop M. Risk factors for patellofemoral pain syndrome: a systematic review. Journal of orthopaedic & sports physical therapy 2012;42:81–94 12. Pappas E, Wong-Tom WM. Prospective predictors of patellofemoral pain syndrome: A systematic review with meta-analysis. sports health 2012;4:115–120 13. Duvigneaud N, Matton L, et al. Relationship of obesity with physical activity, aerobic fitness and muscle strength in Flemish adults. the 21

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videos: Further information on how to assess some clinical measures that are shown to predict conservative management outcomes in PFP. video 1: navicular drop http://spxj. nl/114mJyW

Journal of sports medicine and physical fitness 2008;48(2):201– 210 14. Milgrom C, Finestone A, et al. Patellofemoral pain caused by overactivity. A prospective study of risk factors in infantry recruits. the Journal of bone & Joint surgery (american volume) 1991;73(7):1041–1043 15. Witvrouw E, Lysens R, et al. Intrinsic risk factors for the development of anterior knee pain in an athletic population. A two-year prospective study. american Journal of sports medicine 2000;28(4):480–489 16. Thijs y, van Tiggelen D, et al. A prospective study on gait-related intrinsic risk factors for patellofemoral pain. clinical Journal of sports medicine 2007;17(6):437–445 17. Boling MC, Padua DA, et al. A prospective investigation of biomechanical risk factors for patellofemoral pain syndrome: the Joint Undertaking to Monitor and Prevent ACL Injury (JUMP-ACL) cohort. american Journal of sports medicine 2009;37(11):2108–2116 18. Lankhorst NE, Bierma-Zeinstra SM, van Middelkoop M. Factors associated with patellofemoral pain syndrome: a systematic review. british Journal of sports medicine 2013;47:193–206.

Further reSourceS rehabrunning: iPhone app to help people back to running after injury (http://spxj.nl/12s5Euc) video 2: measuring lateral patellofemoral angle http://spxj. nl/15lcvrc

video 3: measuring forefoot valgus http://spxj. nl/1aDq32x

ThE AuThor Th Simon Lack is a PhD student at Queen Mary University London (QMUL), studying the interaction of hip and foot biomechanics in the presentation and management of patellofemoral pain. He graduated from Brunel University in 2005 with a degree in physiotherapy, and has gone on to study an MSc in Sports and Exercise Medicine at QMUL in 2010. Simon works as a physiotherapist in two London-based private clinics, having previously worked in New Zealand with professional golfers, local rugby and football teams.

n Which other features, not mentioned in this article, do you think are potentially predictive of DISCUSSIONS PFP and why? n Discuss the theories of PFP aetiology, and relate these to the predictors that have been reported. n Discuss the mechanism through which greater Q angle or increased forefoot valgus might predict taping success.

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EvidEncE informEd practicE

physiothErapy and pilatEs for thE drEssagE ridEr This article demonstrates the benefit of both physiotherapy and Pilates to the dressage rider in a sport where the rider’s position can dramatically affect the outcome of how the horse performs. It emphasises the demands on both horse and rider and how important it is that they work in synergy. The article highlights some important common musculoskeletal issues that dressage riders demonstrate as well as physiotherapy techniques and Pilates exercises that help in rider body awareness and correct body position in the saddle. by AnnA nelson MCsP

IntroduCtIon The Olympic Games of London 2012 brought the sport of dressage into the public eye after team GB scooped a host of medals. Although most still believe it is all about the horse ‘dancing’, dressage is a complex sport that is poorly recognised and understood. This is despite ‘classical riding’, which is still considered the basis of modern competitive dressage, being described since the Renaissance period (1). Dressage is a discipline within the equestrian world that is defined by the International Equestrian Federation as “the highest expression of horse training, where horse and rider are expected to perform from memory a

being rigid as this will be series of predetermined transferred through the movements”(2). seat to the horse, which This discipline is about in turn will become tense. asking the horse to work Horses are flight animals its muscles correctly and tension will engage and in balance so that a flight response, not it can perform certain something required in the movements effortlessly. effortless and relaxed The rider controls Figure 1: Good rider discipline of dressage! movement through their position in dressage. Schooling a horse seat and small movements Photograph reproduced with kind permission from properly is like giving it of the leg and rein contact. Becky Moody (2013). a Pilates workout. It too It is all about softness and engages its deep core suppleness of both horse muscles so that it can perform required and rider. movements in a controlled and relaxed It is of upmost importance that manner. Horse and rider have now the rider has core and general body formed a unique synergy. awareness to allow the horse to move The dressage rider must sit freely through its back under the equally on both ischial tuberosities as saddle. The rider should be able to any unevenness will be transmitted engage the core when needed without through to the horse. The rider’s leg should be relaxed and long. A common misconception is that riders become tight in their adductors. However, if they are sitting properly these muscles are relaxed. If they are overactive it can restrict the movement of the horse underneath them. The pelvis is in a neutral position as is the scapula, and

THE RIDER cOnTROLS mOvEmEnT THROuGH THEIR SEAT AnD SmALL mOvEmEnTS OF THE LEG AnD REIn cOnTAcT. IT IS ALL ABOuT SOFTnESS AnD SuPPLEnESS OF BOTH HORSE AnD RIDER www.sportEX.net

DRESSAGE IS A cOmPLEx SPORT THAT IS POORLy REcOGnISED AnD unDERSTOOD

box 1: CoMMon rIder Issues Feeling of uneven seat bones. This can be due to collapsing of the torso, side gliding or shift of the pelvis. Quadratus lumborum are often short and overactive in the dressage rider due to the rider ‘fixing’ their trunk in the saddle if they have poor stability muscles. It is also common to find an imbalance from side to side as both rider and horse may have a dominant rein. This is described as the rein that both horse and rider find easier to work on. Just as humans have a ‘dominant’ side, so do horses. If rider or horse or both find certain movements difficult, particularly laterally then the rider may fix the trunk by using the quadratus, which in turn will lead to a shortening of the trunk on that side and may even lead to a pelvic shift or glide. Elongation of the torso is important so that the torso is in line with the horse’s body. elevated shoulder girdle. Due to a lack of scapulothoracic/glenohumeral scapula control. upper trapezius muscles are often overactive as the rider tries to fix the shoulder girdle to gain control down the rein. correct activation of shoulder girdle stabilisers is important, as shoulder girdle stability is the key to quiet hands. If the shoulder girdle is elevated the arms and hands will be tense. This in turn will lead to the loss of dissociation between seat and hand. Without a central core the rider will tend to balance on their hands and overuse the upper body. This leads to tension down the rein. Serratus anterior, latissimus dorsi and mid and lower trapezius muscles are required to keep a low activation of a neutral shoulder girdle. Headaches. Due to tight suboccipitals. The suboccipital muscles are connected to eye movements and contain many stretch receptors. The fibres lead to the brain, which then orders the rest of the spinal muscles. Therefore, how you use your eyes and neck sets the tonus pattern for the rest of the back/pelvic muscles (3). This is important when riding as the rider should keep their head and eyes forward, looking directly between the horse’s ears. If the head is tilted to one side this will set an abnormal tonus pattern down that side of the body and be transmitted through to the horse via the saddle. uneven leg length. This is an issue that often is addressed through the treatment of the lumbo-pelvic region. Once core awareness and correct activation of it is achieved dissociation of the lower limbs follows. stiff thoracic spine. The ideal dressage position has already been described. Some riders try to achieve this posture by sitting tall with shoulders back. This however encourages the rider to go into thoracic extension with sternal lift, elevation of the shoulder girdle, overactive rhomboids and an increased lumbar lordosis which subsequently leads to a rigid and tense lower back. Poor core stability. This leads to poor dissociation of lower and upper limbs from the trunk (4). Dissociation of the peripheries from the trunk is important to the dressage rider as, when using the legs or arms, a soft supple seat must remain. Apical breathing. This leads to overactive accessory muscles of breathing which in turn can affect the shoulder girdle and therefore rein contact. Hip clicking/pain. Weakness in posterior gluteus medius, overactive piriformis and particularly in the dressage rider, femoroacetabular impingement (FAI) (5), needs to be addressed if the rider complains of painful clicking hips.

the cervical spine is in a degree of retraction. The elbows are held into the sides at 90° with an ‘elastic’ feel from hand to rein (Fig. 1). Dressage saddles are very different to other saddle styles. They are cut to allow greater movement of the horses’ shoulders and to keep the rider sitting deep and relaxed. However, the rider is positioned with a long leg that is in abduction, medial rotation and slight flexion at the hip joint. Therefore specialist knowledge of the hip region is of utmost importance when dealing with the dressage rider.

CoMMon rIder Issues A number of complaints are commonly presented by riders (Box 1). These rider issues can be due to a host of pathologies or muscle imbalances but all of them lead to an asymmetry when riding, which in turn can lead to an asymmetry of the horse. When assessing a dressage rider for such problems it is also important to question whether it is the rider leading to horse imbalances or vice versa. It is a bit of a chicken and egg scenario. Therefore, when treating a rider it is important that all aspects of horse management are addressed. Horses also have physiotherapists, sports massage, chiropractors and even dentists!!!

AssessMent oF tHe rIder swiss ball The Swiss ball is a useful aid in assessing how the rider may sit on their horse. A series of pelvic movements are completed to assess the presence of any faulty movement patterns. The movements performed are pelvic tilt, pelvic side glide and a figure of eight in both directions. These movements allow the assessor to watch for any faulty body actions. These may include the torso collapsing to one side and an uneven weight transference through the ischial tuberosities. The rider may be unable sportEX dynamics 2013;37(July):23-26

EvidEncE informEd practicE

to achieve thoracolumbar dissociation, which will lead to either a rigid lumbar or rigid thoracic region and with movement the shoulder girdle may become fixed and elevated. It is also necessary to check that the rider is not fixing through their upper limb and scapula, and that this is dissociated from the pelvis. It is then useful to perform the above movements with the rider’s arms elevated above their head. This will allow the assessor to see if any movement restrictions are present.

Wooden horse The wooden horse allows the rider’s saddle to be placed on it and then the rider can mount. This enables the assessor to see how the rider sits in their own saddle. Obviously no movement occurs so faulty movement patterns cannot be detected. However, it is a useful tool in exercise prescription for the rider. correct placement of shoulder girdle and thoracic spine can be demonstrated and a neutral spine achieved. Activation of transversus abdominis and serratus anterior can be taught and correct abdominal breathing practised. Abdominal breathing on the wooden horse is a useful exercise, as the rider feels how their seat relaxes and softens into the saddle. By placing the wooden horse in front of a mirror, the rider can be made aware of the body as segments. These segments need to be stacked on top of each other as shown below (Fig. 2). Through dissociation work the rider can learn how to move each segment individually without losing control of the one above or below. I describe to my riders the analogy of a chocolate orange! If one segment is out of place then this can disrupt the congruency of the shape. From assessing the rider on both the Swiss ball and wooden horse any faulty movement patterns can be used as corrective home exercises. Prior to assessing the rider on the Swiss ball and wooden horse, I carry out a thorough musculoskeletal assessment to test all joints and movement patterns. Any joint, muscle and neurological issues are highlighted and underlying pathologies detected. For the purpose of this article only the Swiss ball and wooden horse are considered.

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performs. Assessment on horseback is undertaken while the rider is under instruction from their coach as per insurance regulations. The additional benefit is then liaison with the riding instructor so that the rider receives a team approach to their individual issues.

HeAd tHorACIC sPIne

PelvIs

PHysIotHerAPy teCHnIques

Figure 2: The rider can be made aware of the body as segments that need to be stacked on top of each other, which the rider can learn how to move individually without losing control of the one above or below.

joInt MobIlIsAtIons

soFt tIssue releAse

sPIkey bAll

PHysIotHerAPy teCHnIques

A number of physiotherapy techniques can be used to treat the rider (Fig.3).

IMPortAnCe oF PIlAtes Figure 4 shows a series of goals that the dressage rider should be aiming for (first column) along with the physiology involved (second column). The third column provides examples of exercises that the rider can perform in order to reach these targets. The exercises discussed in Figure 4 are only a ‘taster’. There are many levels of exercises and exercise progressions depending on what has been found during assessment.

ConClusIon The aim of this article was to MyoFAsCIAl provide the reader with insight into releAse the complex world of dressage and the treatment of the dressage rider through physiotherapy and Pilates. It PHysIotHerAPy is important that professionals who teCHnIques treat dressage riders are aware of the importance of position on the horse and how this can be affecting Figure 3: A number of physiotherapy techniques can be used to treat the rider. overall performance of both horse and rider. Assessment tools have been discussed so that faulty movement Assessment on horseback patterns can be detected both on I am often asked by horse riders if I use and off the horse and it has covered a mechanical horse for my assessments. a basic introduction to physiotherapy I personally feel that through the techniques and Pilates exercises combined use of the Swiss ball, wooden used. Truly effective assessment and horse, musculoskeletal assessment and treatment of the dressage rider needs assessment of the rider on their own a full understanding of the complexity horse, I can gain the most accurate of the sport, the rider and the horse. information. Horses can be of varying sizes and widths and move differently; references and this all affects how the rider sits and FoAM rollIng

THE RIDER’S POSITIOn cAn DRAmATIcALLy AFFEcT THE OuTcOmE OF HOW THE HORSE PERFORmS

1. Loch S. chapter 1: What is the classical art of riding? In: Dressage: The art of classical riding. trafalger square publishing 1990. p17. ISBn 0943955327 2: International Equestrian Federation. About dressage. doi 26/08/11, sourced 07/02/13 (http://spxj.nl/197emJZ) 3. myers T. chapter 3: The superficial back line. pp86–87. In: Anatomy trains, 2nd ed.

tHerAPeutIC AIMs

PHysIology

exerCIses

neutrAl sPIne

rest position,neutral with Awarenessthe of lumbo-pelvic hundreds, hip twist (6) activation of trans abdominals

the rest position, hundreds, hip twist (6)

sHoulder gIdle stAbIlIty

Activation of serratus anterior, latissimus dorsi and lower trapezius

dumb waiter, shoulder shrugs, shoulder protractions, double leg stretch (6)

breAtHIng

diaphramatic breathing

breathing control with resistance band around rib cage (6)

FlexIble HIP And leg

encouragement of a long relaxed leg

one leg stretch, side kick, bend and stretch (6)

body dIssoCIAtIon

segmental control

spinal twists, sternal lifts, shoulder bridge, roll up, hip twist (6)

CervICAl retrACtIon

relaxed sub-occipitals and lengthened cervical spine

Postural setting, the rest position, swim arms (6)

Figure 4: The first column shows a series of goals that the dressage rider could be working towards along with the physiology involved (second column). The third column provides examples of exercises that the rider can perform in order to reach these targets. c churchill Livingstone 2008. pp86– 87. ISB ISBn 044310283x (£29.48). Buy from Amazon http://spxj. nl/10O9Die 4. comerford m, mottram S. c chapter 3: Assessment and classification of uncontrolled movement. In: Kinetic control: The management of uncontrolled movement. churchill livingstone 2012. p46. ISBn 0729541673 (£77.99). Buy

from Amazon http://spxj.nl/13npe6S 5. myers SR, Eijer H, Ganz R. Anterior femoral acetabular impingement after periacetabular osteotomy. clinical orthopaedics & related research 1999;363:93–99 6. The Australian Physiotherapy and Pilates Institute (APPI). modified pilates rehabilitation program – pilates for horse riders. one-day course, london, 2009. (http://spxj.nl/16TQlkc).

THE RIDER cOnTROLS mOvEmEnT THROuGH THEIR SEAT AnD SmALL mOvEmEnTS OF THE LEG AnD REIn cOnTAcT. IT IS ALL ABOuT SOFTnESS AnD SuPPLEnESS OF BOTH HORSE AnD RIDER

DISCUSSIONS

n What are the key musculoskeletal areas that dressage riders may find problems with? n Why is apical breathing so detrimental to the dressage rider and diaphragmatic breathing so important? n Why is Pilates so beneficial to the dressage rider?

ThE AuThor Th Anna Nelson BSc ((hons), MCSP, oCPPP, AACP, Modern Pilates Trained. o Anna is joint partner of Physiocure (www.physiocure.org.uk) based in North Leeds, established in 2000. her involvement in treating dressage riders developed after completing her Kinetic Control courses in 2001 and when, through having her own horse, she began to see the link between a correct dressage seat and how the horse performs. Anna then went onto complete her Pilates training and in 2002 joined Gunthwaite Dressage which is a professional dressage training yard in the North of England. She attends the yard once a month to help the riders with their position and any musculoskeletal problems they may have. Anna is an accredited member of the AACP and has specialist post graduate training in muscle imbalance, muscle energy techniques, soft tissue massage, soft tissue release, myofascial release, trigger point release, Maitland, McKenzie and Cyriax mobilisations. She is also a guest lecturer at huddersfield university for third year Physiotherapy students. Anna can be contacted directly via annanelson@ physiocure.org.uk sportEX dynamics 2013;37(July):23-26

EvidEncE informEd practicE

its timE to rEdEfinE slEEp Applied sleep-wAke-routine techniques developed for elite olympic Athletes The focus of this article is to highlight the key elements essential to any sleep recovery programme. You will learn, through a simple 3-step approach, how to establish a practical, achievable and structured sleep wake routine (SWR) and apply it. This is the key to sleep recovery success, but something that very few apply. by Nick LittLehaLes

iNtroductioN Although we know how important sleeping is to function at our personal best every day it still remains a recovery process taken somewhat for granted. Although ongoing research clearly identifies the clear mental and physical benefits, the ongoing challenge for athletes is how to apply the varied, and sometimes complex and intrusive interventions (Box 1). For over 13 years I have been working with elite athletes and organisations across a varied range of sporting disciplines in the pursuit of

sleeping recovery excellence, including, Manchester United Football Club, the British Cycling and Para-cycling Teams London 2012, and the Sky Professional Cycling Team 2009/2013. Each year, as the demands and performance targets are raised, the need to adopt new (more productive) recovery techniques increases. The focus of this article is to highlight the key essential element to any sleep recovery programme: establishing a practical, achievable and structured sleep wake routine (SWR), how to create and then to apply it (Fig. 1). This is the key to sleep recovery success, but from my experience very

OPTIMAL SLEEP IS nECESSARY TO ATTAIn PEAk AThLETIC PERFORMAnCE box 1: rob swire, head physiotherapist, Msc Mcsp srp, MaNchester uNited FootbaLL cLub â&#x20AC;&#x153;in the ever more demanding world of professional football, coaches and players are constantly striving to gain the competitive advantage. encouragement to adopt new methods to improve that vital side of overall performance, rest and recovery, are essential to perform at the highest levels throughout a long, physically and mentally demanding season. with sleeping taking up the largest percentage of that recovery time, it is even more important, that the key staff and players, at all levels are able to establish the best techniques and practices to adopt a more professional approach to sleeping as individuals and as a team.â&#x20AC;?

www.sportEX.net

12.30 aM 11.00 pM

2.30 aM

9.30 pM

8.00 pM suprachiasmatic nucleus light

6.30 pM

glutam

6.30 aM

ate

5.00 pM

8.00 aM

3.30 pM

9.30 aM 2.00 pM

11.00 aM 12.30 aM

Figure 1: R90 Sleep wake routine

box 2: sir david braiLsFord, head oF british cycLiNg Sir Dave Brailsford’s ethos is based on the winning formula that was developed for the track teams. Brailsford’s buzz phrase is ‘the aggregation of marginal gains’, which means that if you can improve a tiny amount across 10 different areas, that adds up to a considerable improvement over the opposition. It means pulling apart everything and trying to identify best practice, from the smallest detail on a bike, to the pillows cyclists sleep with.

suprachiasmatic nucleus

light

glutam

Figure 2: Circadian harmony

ate

body’s principal supportive and restorative mechanisms. Whether it is sailing, soccer, dance, darts, swimming, the workplace or gardening sleep has a role for optimal performance for all age groups” dr chris idzikowski bsc phd cpsychol Fbpss (Fig. 2)(1). You may be somewhat surprised to learn that this extract was taken from the first ever sleep and sports performance conference 2012, bringing together some of the leading experts in sleep and sport (2).

how MaNy hours a day do we actuaLLy Need? “Probably a lot less than you think”, according to Professor Jim horne (3). It is clear that the 8-hour nocturnal period has become and will remain a benchmark for the healthy adult, but as each research project is completed it is also clear that shorter controlled periods of sleep have been and can be as beneficial. not surprising when you consider that we have three natural sleep periods, which, over the centuries, have been condensed into one nocturnal period. “People were becoming increasingly time-conscious and sensitive to efficiency, certainly before

the 19th Century,” says Roger Ekirch. “But the industrial revolution intensified that attitude by leaps and bounds.” In 2001, historian Roger Ekirch of Virginia Tech published a seminal paper, drawn from 16 years of research, revealing a wealth of historical evidence that humans used to sleep in two distinct chunks. his book At Day’s Close: Night in Times Past, published four years later, unearths more than 500 references to a segmented sleeping pattern (4,5).

doN’t waste vaLuabLe tiMe tryiNg to sLeep The majority of daily routines are driven by occupations and making the most of every social hour. Recovery (sleep) routines for most are based on simply what’s left when nothing else can be done. Again not that surprising when we consider that very little, if anything at all, is passed on through the formative, educational years creating a ‘sleep for granted’ population. Sleeping can be very individual: some identify with being able to sleep anywhere anytime, some not being able to sleep at all, with the majority somewhere in between. The concern today is that an increasing percentage of the population (some would say ‘most’) observe sleep disorders and insomniac characteristics principally driven by poor, counterproductive sleep hygiene routines (6). Two studies led by Cheri D. Mah, MS, researcher at the Stanford Sleep Disorders Clinic and Research Laboratory in Stanford, CA, concluded that optimal sleep is necessary to attain peak athletic performance and that extra sleep improves sports performance and mood. In one study, published in the July 2011 issue of the journal SLEEP, 11 healthy students on the Stanford University men’s varsity basketball team were asked to sleep a minimum of 10 hours a night for a period of 5 to 7 weeks. Their athletic performance was then measured after every practice (7,8).

key sLeep recovery perForMaNce iNdicators To create a structured SWR, which is sportEX medicine 2013;57(July):27-31

EvidEncE informEd practicE

In a full 90-minute sleep cycle, sleepers should experience all these stages. The key steps for establishing an SWR are: n Step 1. Establish a personal sleep profile – an in depth assessment of the current approach and routines which would identify an every day, consistent wake time. n Step 2. By applying cycles, rather than hours, to the constant wake time an ideal SWR can be established, which in turn creates optimal sleep times (Table 1). A common example would be the 5 cycle routine (ie. 5 × 90 min = 7.5 h): asleep at 11.00pm and awake at 6.30am. In this example the athlete has a target of 11.00pm to be in a prepared sleep state, but would also use 12.30am and 2.00am as shorter

periods (cycles) to adapt to the many outside influencers. n Step 3. The technique would then be used to forward plan a daily routine based on ideally 90-minute periods. For example; what activities are performed during the first 90 minutes after waking and in the final 90 minutes before the targeted sleep time (post- and pre-sleep routines)? For example, a good pre-sleep routine should trigger the ‘tech break’: planning download; final fuel and hydrate; light and dark therapy; and de-clutter mind and environment.

a structured swr creates sLeep targets how many sleep cycles (hours) will be (can be) planned into any year, quarter, month, week, day and or specific period? This should be a first priority for most, rather than an ‘I try to get 8 hours every night’ random approach. For example, for a 2013 SWR, a five-cycle routine for every day of the year would require up to 2,920 hours from the 8,760 hours available (240 hrs out of 720 hrs per month).

beiNg prepared to sLeep “Research has shown that high performance athletes need more sleep than others. however, sleep is often neglected when considering strategies for optimal training and competition”, says EIS Dr Cathy Speed (9). A structured SWR, once established, will unlock increased sleeping confidence, in particular during the final week(s) prior to a key event. The athlete can identify on what days the optimal SWR can be achieved, what days a shorter SWR is required, and therefore when a second or third controlled sleep recovery period

RESEARCh hAS ShOWn ThAT hIgh PERFORMAnCE AThLETES nEED MORE SLEEP ThAn OThERS. hOWEVER, SLEEP IS OFTEn nEgLECTED WhEn COnSIDERIng STRATEgIES FOR OPTIMAL TRAInIng AnD COMPETITIOn Dr Cathy Speed, EIS www.sportEX.net

Sleep cycle

awake REM

Asleep

one of the main key sleep recovery performance indicators (kSRPIs), think of sleep as a 90-minute cycle rather than an hour (Fig. 3). ninety minutes is a recognised measured period for the five sleep stages essential to normal body physiology to develop naturally: n Stage 1. A drowsy, relaxed state between being awake and sleeping – breathing slows, muscles relax, heart rate drops n Stage 2. A slightly deeper sleep – you may feel awake but may be asleep and not know it n Stage 3 and Stage 4. Deep sleep – it is very hard to wake or be woken in this stage because of the lowest amount of activity in your body n Stage 5. After stages 3 and 4 we may hop back to Stage 2 for a short period, and then a period of REM (rapid eye movement) referred to as the Dream state.

nREM nREM 2 nREM3 1

Time asleep (h) Figure 3: Sleep wake cycle rhythms

(CSRP) or nap needs to be applied to balance the overall sleep cycle target (Fig. 4). This controlled approach ensures the athlete is not trying to sleep when the circumstances dictate otherwise, trying to catch up on what is perceived to be lost hours, and/or wasting valuable time. Sleep restriction is a term used for the process of resetting our internal clocks.

discussioN Without structure to the SWR our ability to adapt and cope with the demands of our occupations, changes in lifestyles and unforeseen circumstances, increase levels of stress and anxieties. If not

tabLe 1: sLeep as 90-MiNute cycLes No. of 90 minute cycles

sleep times

sleep duration

2.00am – 6.30am

4.5 hours

12.30 am – 6.30 am

6.0 hours

11.00 pm – 6.30 am

7.5 hours

9.30 pm – 6.30 am

9.0 hours

Figure 4: Over tired – over doing it – burnout

EvidEncE informEd practicE

Sleep cycle

awake REM

Asleep

nREM nREM 2 nREM3 1

Time asleep (h) Figure 3: Sleep wake cycle rhythms

tabLe 1: sLeep as 90-MiNute cycLes No. of 90 minute cycles

sleep times

sleep duration

2.00am – 6.30am

4.5 hours

12.30 am – 6.30 am

6.0 hours

11.00 pm – 6.30 am

7.5 hours

9.30 pm – 6.30 am

9.0 hours

Figure 4: Over tired – over doing it – burnout

addressed quickly they will form routines that attempt to compensate for lost sleep which in turn makes it even more difficult to sleep. So if you’ve got a daunting intellectual or emotional task on a given day, knowing whether it’s more time sleeping or better quality sleep that’s best for your age group might help you the night before. But for overall health, we all need to go for both and treat sleep with the respect it deserves, according to sleep expert Jeanne Duffy (10). From my experience being able to cope and adapt to the varied lifestyle changes we all have to face, never mind those in elite sport, having a structured SWR provides a tool to adapt and reset routines with more confidence and purpose. One out of 6 (and rising rapidly) suffers from electronic insomnia. gamers, social networkers and virtual communicators create new routines based on poor sleep hygiene, excuses and increased use of stimulants to try to get by. According to a study by Eve Van Cauter, PhD. (11,12) the physiological effects of sleep deprivation on athletic performance are profound. They include an impairment of the athlete’s motor function. The inability of the athlete to control all aspects of muscular movement will result almost invariably in substandard sports performance. Another effect is an impairment of the athlete’s visual reaction time. In sports where the athlete must react to an object, such as a hockey goaltender or a cricket batsman, this impairment will mean the difference between success and failure (Fig. 5). references 1. Idzikowski C. sleep specialist (www.sleepspecialist.co.uk/) 2. The Royal Society of Medicine, sleep and sports performance conference 2012, london, UK. (www.rsm.ac.uk/academ/sld01. php) 3. horne J. how much sleep do you really need? Probably a lot less than you think, says an expert. the daily mail online 2008 (http://spxj.nl/12ie0d0) 4. Ekirch R. Sleep we have lost. commentary virginia tech (http://spxj.nl/15ihc58) 5. Ekirch R. At day’s close: night in times past. W. W. norton & company 2006. ISBn 0393329011 6. Mahowald M. Can’t sleep? What to know about insomnia. USA national Sleep Foundation (http://spxj.nl/1ayrIgA) 30

Figure 5: Sleep – the difference between success and failure?

A gOOD PRE-SLEEP ROUTInE ShOULD TRIggER ThE ‘TECh BREAk’: PLAnnIng DOWnLOAD; FInAL FUEL AnD hYDRATE; LIghTAnD DARk ThERAPY; AnD DE-CLUTTER MInD AnD EnVIROnMEnT 7. Brandt M. A slam dunk for sleep: Study shows benefits of slumber on athletic performance. Scope blog Standford University (http://spxj.nl/13YtoJc) 8. Mah CD, Mah kE, et al. The effects of sleep extension on the athletic performance of collegiate basketball players. sleep 2011;34(7):943–950 9. Speed C. In: Roberts R, Sleep key to performance and recovery. English Institute of Sport news http://spxj.nl/1bn8hue 10. Jeanne Duffy, MBA, PhD. Division of Sleep Medicine, harvard Medical School 11. Van Cauter E. In: Quinn E, Sleep deprivation can hinder sports performance. About.com Sports Medicine (http://spxj.nl/117ig8O) 12. Spiegel k, Leproult R, Van Cauter E. Impact of sleep debt on metabolic and endocrine function. lancet 1999;354:1435–1439.

Further resources 1. Why not try this quick-start sleep profiling tool? (http://spxj.nl/15i1EyX) 2. Sleeping Politics – could you last on 4 hours? de Castella T. Thatcher: Can people get by on four hours’ sleep? (www.bbc.co.uk/news/ magazine-22084671) 3. hegarty S. Segmented sleep: Ten strange [or not so strange] things people do at night: Real life

ThE AuThor Th Nick Littlehales is an International elite sports sleeping performance consultant and coach and regarded as the leading industry expert with over twenty five years experience in the world of sleep, sleeping and product design. As a former PGA golfer based at the famous Little Aston Golf Club, international sales and marketing director of the Slumberland Group, and chairman of the uK Sleep Council, Nick has conducted many practical and clinical research projects into the varied (and sometimes crazy) sleeping habits adopted by the modern day sleeper and athlete. In 2000 he became one of the first sleep experts to focus on sport advising Manchester united Football Club on mental and physical sleep recovery techniques. With now over a decade dedicated to elite athletes, in pursuit of sleeping recovery excellence, his unique, proven and passionate approach is recommended and endorsed by leading professionals in world sport and business. Clients include: the Sky Pro Cycling Team 2009/2013; the British Cycling & Para Cycling olympic Teams, London 2012; the Football Association & England squads; leading Premiership football clubs; the rPA; leading Premiership rugby union clubs; unilever Plc; the VA Museum; and the uK Sleep Council. Founder of www.sportsleepcoach.com r90 sleeptechnic™ products r90™ sleep coaching programmes. sportEX medicine 2013;57(July):27-31

research reviews

BY Joseph Brence dpT

inTroducTion patellofemoral pain syndrome (pfpS) is the most commonly diagnosed knee condition in patients less than 50 years old. the condition is often perceived as difficult to treat due to differing opinions of aetiology and risk factors. A recent systematic review (1) concluded that the only two risk factors that have a positive predictive value for the development of pfpS are being female and having weak knee extensor strength. other studies have concluded it may be a result of abnormal Q angles, delayed muscle firing patterns of the quadriceps, abnormal transverse and frontal plane movement of the knee, etc. All of this stated, one thing that appears to be consistent in the literature is that strengthening of the musculature of the knee and hip appears to be more effective than solely focusing on the knee. A recent article (2) supports this statement and examined the long-term effects of using this approach.

A rAndomised conTrolled clinicAl TriAl fukuda et al. (2) designed a randomised controlled trial to examine and compare fifty-four women’s response to either a protocol designed to focus on strengthening and flexibility of the knee (K) or the knee and hip (Kh). each group consisted of individuals who had unilateral symptoms and described their physical activity levels as sedentary (ie. not practising aerobic or strengthening exercises any day of the week for at least six months). the researchers excluded women with any other knee pathology, neurological disorder or injury to the lumbosacral area/hip/ankle. outcomes were measured on a numeric pain rating scale (nprS), the lower extremity functional scale (LefS), the anterior knee pain scale (AKpS) as well as a single-hop test. the treatment of the K group included the following interventions: n Stretching of the hamstrings, plantar flexors, quadriceps, and iliotibial band n Seated knee extension at 45 and 90° n Leg press from 0–45° n Squatting from 0–45° n Single-leg calf raises 32

Does your patient have patellofemoral pain? – Don’t forget the hip… n prone knee flexion the treatment of the Ke group included the exercises above plus the following interventions: n hip abduction in side-lying (with weight) n hip abduction standing (with elastic band) n hip lateral rotation in sitting (with elastic band) n hip extension (on machine). the participating subjects performed these activities for 12 treatment sessions in isolation of any other form of therapeutic intervention. following 12 sessions, the participants were followed for 1 year and outcome forms were administered at 3, 6 and 12 months.

The outcomes the following outcomes were found: n the Kh group experienced reduced pain and improved function at 3, 6 and 12 months compared to their baseline measures. n this included improved measures on the LefS, AKpS and nprS which exceeded the minimal clinically important difference for those scales. n the Kh group also demonstrate significant improvement in the singlehip test. n the K group only experienced reduced pain at 3 and 6 months.

What does this mean to clinical practice? this article further supports the importance of hip strengthening in individuals who present to us clinically with pfpS. this study does control rather tightly for internal validity (it excludes other commonly used therapeutic interventions such as manual therapy, modalities, taping, etc. which may have an effect on outcomes). i am not sure that this study completely represents what is done clinically but do believe it leads

us in the right direction for determining strengthening activities for our patients. references 1. Lankhorst ne, Bierma-Zeinstra SMA, Middelkoop MV. risk factors for patellofemoral pain syndrome: a systematic review. Journal of orthopedic and sports physical therapy 2012;42(2):81–95 2. fukuda tY, Melo Wp, et al. hip postlateral musculature strengthening in sedentary women with patellofemoral pain syndrome: A randomized controlled clinical trial with 1-year follow up. Journal of orthopaedic & sports physical therapy 2012;42:823–830 3. Distefano LJ, Blackburn tJ, et al. gluteal muscle activation during common therapeutic exercises. Journal of orthopaedic & sports physical therapy 2009;39(7):532–540.

AddiTionAl exercises Another article published in 2009 (3) examined the eMg activity of gluteal musculature during commonly performed exercises. the researchers in the study above performed some rather basic and commonly used activities. here are some additional exercises which have been shown to isolate and challenge gluteal musculature (the mean single amplitude levels are included which are expressed as a percent of minimum voluntary isometric contraction).

Gluteus medius Side-lying hip abduction (81 ± 42%) Subjects are positioned in side-lying with full knee extension and neutral hip position. Subjects slowly abduct the top leg while keeping the knee in extension. Single-limb squat (64 ± 24%) Subjects stand on one leg with their knee and hip flexed to 30°. they slowly lower themselves towards the ground, using their ankle, knee and hip joints until they can touch their contralateral hand to the outside of their stance foot and return to the starting position. Lateral band walk (61 ± 34%) An elastic band is tied around the subject’s ankles while they stand upright. the subjects maintain their hips and knees in 30° of flexion and sidestep laterally.

Gluteus maximus Single-limb squat (59 ± 27%) See above. Single-limb deadlift (59 ± 28%) Subjects stand on one leg with their knee and hip flexed to 30°. the subjects slowly flex their hip and trunk to touch their contralateral hand to their stance foot. they keep their knee flexed to 30° and slowly return to their starting position.

sportEX medicine 2013;57(July):32-34

research reviews

pain after surgery: BY Joseph Brence dpT

steoarthritis (oA) is the most commonly occurring joint disease, affecting millions of aging individuals across the globe. incidence rates have shown to be as high as 26 million in north America alone, and the progression is physiologically related to the degradation of cartilage, joint space narrowing, and bony changes. Clinically, individuals with oA present to us with painful joints which are stiff and swollen, often resulting in decreased mobility. Joint replacement procedures are often performed by orthopaedic surgeons when the disease results in disability. in 2010, there were over 71,000 total hip and 79,000 total knee procedures performed in the UK. in the United States, the number was much higher with 231,000 and 542,000 respectively (to put these numbers into perspective, the population of each country during this time was 63 million in the UK and 308 million in the United States). following the procedure, many individuals report improved mobility and decreased pain, but clinically, we all know that some do not get better. for many clinicians, this is puzzling, because the peripheral joint, which was perceived to be the contributing variable, is gone. Some research is beginning to answer this conundrum and is further examining why some patients do not get better. A recent systematic review of prospective analyses on individuals receiving joint replacement of the knee (tKA) and/or hip (thA) was published in BMJ open last year. the study aimed to focus on the proportion of patients who do not get better following each procedure and examined variables which appear to be present in those cases. from their search, the authors found 14 studies which met the established criteria for inclusion. the authors found within the data in which they analysed, 7–23% of patients have continued pain and disability following a thA and 10–34% following a tKA. this data, in my professional opinion, is quite staggering and alarming. in the most simplistic terms, the dysfunctional and degenerated tissue 34

WhY Do SoMe pAtientS StiLL hUrt?

has been removed, but the patients continue to have pain. So what gives? the authors believe this occurs due to a conglomerate of variables which are contributory to outcomes. they state: “Better general health, physical, emotional and social function, motivation and selfefficacy and lower levels of pain before surgery and during the rehabilitation period are associated with improved short- and medium-term outcomes”. the outcomes of this study are not surprising and correspond to what i, and colleagues, appear to be seeing clinically. So, prognostically, can there be better screening processes pre-surgically, to predict those who will not improve posttotal joint procedure? A 2011 article in pain highlighted the effects of pre-surgical expectancies and variables on postsurgical outcomes in individuals undergoing a total knee arthroplasty (tKA). the study prospectively followed 120 individuals over a 1-year period and measured: 1. pain and function: via the WoMAC index 2. Co-morbidities 3. pain-related fear of movement: via the tampa Scale for Kinesiophobia 4. Depressive symptoms: via the patient health Questionnaire 5. expectancies: via four questions: how likely is it that 1 month following surgery: n Your pain will have decreased? n Your sleep will return to normal? n You will have assumed your household responsibilities? n You will have resumed your social and recreational activities n pain catastrophising: via the pain catastrophising scale. the results of the study indicated that psychological factors appeared to have significant prognostic value in predicting post-operative pain severity and function

following a total knee arthroplasty. pre-surgical pain catastrophising predicts poorer recovery as well as pain-related fear of movement and depression. i suspect that we can improve outcomes in individuals with osteoarthritis if we approach care within a biopsychosocial model. pain is a multidimensional experience, and as research is demonstrating, simply replacing a peripheral structure does not guarantee the sensation will normalise.

Bibliography 1. felson Dt. An update on the pathogenesis and epidemiology of osteoarthritis. radiologic clinics of north america 2004;42:1–9, v 2. Kopec JA, rahman MM, et al. Descriptive epidemiology of osteoarthritis in British Columbia, Canada. the Journal of rheumatology 2007;34:386–393 3. Attur M, Krasnokutsky-Samuels S, et al. prognostic biomarkers in osteoarthritis. current opinion in rheumatology 2013;25:136–144 4. Beswick AD, Wylde V, et al. What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BmJ open 2012;2:1–12 5. Sullivan M, tanzar M, et al. the role of presurgical expectancies in predicting pain and function one year following total knee arthroplasty. pain 2011;152(10):2287–2293.

Th auThor ThE Joseph Brence is a doctor of physical therapy from Pennsylvania, uSa. he is currently a director of two facilities in Pittsburgh and takes a manual approach to patient care. he is also a contributor to www.physiotherapyinfo.com and www. theptproject.com and is currently working on multiple research projects which he will present to the sportEX community as they are published. To read Joseph’s monthly contributions, click the following link http://eepurl.com/brgmj

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