Tuesday, September 30, 2008

Structural Integration/Rolfing


Structural Integration is a type of
Alternative medicine which aims to align the human body in the gravitational field. The claimed benefit is that the increased use of balance at finer levels of the neuro-fascial-musculo-skeletal system allows for increased general well-being and physical adaptability and resilience as well as reduced pain from biomechanically caused pain.
Structural Integration practitioners are trained in the application of functional biomechanical and kinesiological analysis and in effective ways of changing a client's structure. Often connective tissue, in the form of fascia, is manipulated to allow body segments to shift to a more balanced position. Re-education of the clients movement patterns and other modalities are commonly used to achieve or support the goal of improved alignment.
First developed as a separate field by Dr.
Ida P. Rolf, Structural Integration, from the 1930s, evolved out of a number of sources including osteopathy, (including cranial osteopathy), yoga, Alexander Technique, and Feldenkrais.
By the 1950s Rolf was teaching Postural Release. In the 1960s this work was named Structural Integration and then "
Rolfing". Other schools teaching Structural Integration have since formed from the 1960s such as Kinesis Myofascial Integration".
Structural Integration is now taught by a number of individual schools. (see below) Techniques originally developed in Structural Integration are now found in deep tissue massage, myo-fascial massage and soft tissue work and other forms of bodywork, massage and physical therapy.
In an effort to preserve the essential elements of Structural Integration in its teaching and practice, practitioners from a variety of schools formed the International Association of Structural Integrators in 2002.
What to expect from a session?
Structural Integration is typically done over a series of sessions with a beginning middle and end. This is known as the "series" and is usually between 10 and 12 separate and progressive sessions. Before the first session begins a detailed history is taken, realistic goals are made and a postural assessment is done to determine any imbalances.
Most structural integration sessions are done in underwear or a bathing suit. Your comfort is paramount, but we need to get directly to the tissues that are restricting the free flow of movement. Much of the session work is done on a treatment table, though some moves are done on a stool or even standing.
The goal of the treatment is to free old restrictions and encouraging the tissues back to a freer place called for by your body's inherent design. This is done by contacting the tissue and asking for movement, thus you and your practitioner can work out how deep or how gentle you want the progression to be.
The sessions progress through the body as following:
Typically the first four(4) sessions are generally more superficial, freeing the tissues on the front, back, and sides of the body and freeing the shoulders and arms from any binding to the trunk. The middle four(4) sessions address the "core" of you body, working into the central stabilization muscles closer to the spine. The last four(4) sessions integrate "core" and "sleeve" into your habitual movement (and address specific problems you bring to the table). If issues are myo-fascial in nature, structural integration will be highly effective aiding their resolution.
Places where it is taught (you can contact them to study or do a short term course)
The International School of Structural Integration
Core Institiute
Guild for Structural Integration
Guild for Therapeutic Bodywork, Inc.
Hellerwork, International
Institut fur Strukturelle Korpertherapie
Institute for Structural Integration
Institute of Structural Medicine
Kinesis Myofascial Integration
Mana Integrative Therapies
Northwest Center for Structural Integration
Professional School of Bodywork (IPSB0)
Rolf Institute
The School of Integrative Therapies
Structural Integration for Horses
Professional Organizations

International Association of Structural Integrators


Neck pain is a frequently reported complaint of the musculoskeletal system which can be disabling and costly to society. Mechanical traction, Exercise therapy, Electrotherapy, Manipulation and mobilization and Medicinal therapies and injections is often used as therapies in outpatient rehabilitation.

The effectiveness of above said commonly recommended treatments for neck pain are yet controversial and question persists over their effectiveness.

Having this in mind, I tried to Cochrane Data base to find out the evidence of their effectiveness. I went through a series of reviews. The conclusion of their reviews I have presented in article. The reviews are in the following order:

1. Mechanical traction on MND
2. Exercises on MND
3. Electrotherapy on MND
4. Manipulation & Mobilization on MND
5. Medicinal & injection therapies on MND

1. Mechanical traction for neck pain with or without radiculopathy.
Graham N et al reviewed the effects of mechanical traction for neck disorders.

They found:

1. The current literature does not support or refute the efficacy or effectiveness of continuous or intermittent traction for pain reduction, improved function or global perceived effect when compared to placebo traction, tablet or heat or other conservative treatments in patients with chronic neck disorders.

2. They suggested; large, well conducted RCTs are needed to first determine the efficacy of traction, then the effectiveness, for individuals with neck disorders with radicular symptoms.

2. Exercises for mechanical neck disorders.
Kay TM et al reviewed the effectiveness of exercise therapy to relieve pain, or improve function, disability, patient satisfaction, and global perceived effect in adults with mechanical neck disorders (MND).

They found:

1. Specific exercises may be effective for the treatment of acute and chronic MND, with or without headache.

2. To be of benefit, a stretching and strengthening exercise program should concentrate on the musculature of the cervical, shoulder-thoracic area, or both.

3. A multimodal care approach of exercise, combined with mobilisation or manipulation for subacute and chronic MND with or without headache, reduced pain, improved function, and global perceived effect in the short and long term.

4. They suggested; relative benefit of other treatments (such as physical modalities) compared with exercise or between different exercise programs needs to be explored.

5. They also suggested, quality of future trials should improve through more effective 'blinding' procedures and better control of compliance and co-intervention. Furthermore, Phase II trials would help identify the most effective treatment characteristics and dosages.

3. Electrotherapy for neck disorders.
Kroeling P et al assessed whether electrotherapy, either alone or in combination with other treatments, relieves pain, or improves function/disability, patient satisfaction, and global perceived effect in adults with mechanical neck disorders (MND).
They found:
1. Basing on current literature no there is no definitive statements on electrotherapy for MND.

2. The current evidence on Galvanic current (direct or pulsed), iontophoresis, TENS, EMS, PEMF and permanent magnets is either lacking, limited, or conflicting.

3. They suggested, Possible new trials on these interventions should have larger patient samples and include more precise standardization and description of all treatment characteristics.

4. Manipulation and mobilisation for mechanical neck disorders.
Gross AR et al assessed whether manipulation and mobilisation, either alone or in combination with other treatments, relieve pain or improve function/disability, patient satisfaction, and global perceived effect in adults with mechanical neck disorders (MND).

They found:
1. Multimodal care has short-term and long-term maintained benefits for subacute/chronic MND with or without headache.

2. The common elements in this care strategy were mobilisation and/or manipulation plus exercise.

3. The evidence did not favour manipulation and/or mobilisation done alone or in combination with various other physical medicine agents; when compared to one another, neither was superior.

4. There was insufficient evidence available to draw conclusions for neck disorder with radicular findings.

5. The added benefit of exercise needs to be further explored.

6. They suggested, factorial design would help determine the active treatment agent(s) within a treatment mix and further phase II trials would help identify the most effective treatment characteristics and dosages. Greater attention to methodological quality is needed.

5. Medicinal and injection therapies for mechanical neck disorders.

Peloso P et al determined the effect of medicines and injections on pain, function/disability, patient satisfaction and range of motion in participants with mechanical neck disorders (MND).

They found:
1. Intra-muscular injection of lidocaine for chronic MND and intravenous injection of methylprednisolone for acute whiplash were effective treatments.

2. There was limited evidence of effectiveness of epidural injection of methylprednisolone and lidocaine for chronic MND with radicular findings.

3. Oral psychotropic agents had mixed results.

4. There was moderate evidence that Botox A intramuscular injections for chronic MND were no better than saline.

5. Other medications, including NSAIDs, had contradictory or limited evidence of effectiveness.

The above said article is based on review works of
Graham N et al (1), Kay TM et al (2), Kroeling P et al (3), Gross AR et al (4), Gross AR et al (5), Peloso P et al (6)

Monday, September 29, 2008




  • Myofascial Release is a form of soft tissue therapy which includes, but is not limited to, structural assessments and manual massage techniques for stretching the fascia and releasing bonds between fascia, integument, muscles, and bones are applied with the goal of eliminating pain, increasing range of motion and balancing the body. The fascia is manipulated, directly or indirectly, which allows the connective tissue fibers to reorganize themselves in a more flexible, functional fashion. In addition, Myofascial release (note the lower case r) may be considered a general manual massage technique any 'lay person' can use to eliminate general fascial restrictions on a living mammalian body.
    Fascia is a seamless web of
    connective tissue that covers and connects the muscles, organs, and skeletal structures in our body, which is located between the skin and the underlying structure of muscle and bone. Muscle and fascia form the myofascia system.
    Injuries, stress, inflammation, trauma, and poor posture can cause restriction to fascia. Since fascia is an interconnected web, the restriction or tightness to fascia at a place, with time can spread to other places in the body like a pull in a sweater. The goal of myofascial release is to release fascia restriction and restore its tissue health.
    In medical literature, the term myofascial was used by
    Janet G. Travell M.D. in the 1940s referring to musculoskeletal pain syndromes and trigger points. In 1976 Dr. Travell began using the term "Myofascial Trigger Point" and in 1983 published the famous reference "Myofascial Pain & Dysfunction: The Trigger Point Manual". Some practitioners use the term "Myofascial Therapy" or "Myofascial Trigger Point Therapy" referring to the treatment of trigger points, this is usually in medical-clinical sense.
    Here the term Myofascial Release refers to soft tissue manipulation techniques. It has been loosely used for different
    manual therapy, soft tissue manipulation work (connective tissue massage, soft tissue mobilization, Structural Integration, strain-counterstrain etc). There are two main schools of myofascial release: the direct and indirect method.
    Direct myofascial release
    The direct Myofascial Release method works on the restricted fascia. The practitioners use knuckles, elbows, or other tools to slowly stretch the restricted fascia by applying a few
    kilograms-force or tens of newtons. This is sometimes referred to as deep tissue work. Direct Myofascial Release seeks for changes in the myofascial structures by stretching, elongation of fascia, or mobilising adhesive tissues. The practitioner moves slowly through the layers of the fascia until the deep tissues are reached.
    Robert Ward suggested that the direct method came from the osteopathy school in the 1920s by William Neidner, at which point it was called Fascial Twist. German physiotherapist Elizabeth Dicke developed Connective Tissue Massage (
    Bindegewebbsmassage) in the 1920s, which involved superficial stretching of the myofascia. Dr. Ida Rolf developed Structural Integration, in the 1950s, a holistic system of soft tissue manipulation and movement education that with the goal of balancing the body. She discovered that she could change the body posture and structure by manipulating the myofascial system. Rolfing is the nickname that many clients and practitioners gave this work. Since her death in 1979, various Structural Integration schools arose which have adapted her original idea to their own needs and uses.
    Until the 1990s, instruction in direct myofascial release was rarely available outside of
    Structural Integration or Physical Therapy training programs. Currently, however, texts and courses are offered to general bodyworkers from a Physical Therapy background, and from a Structural Integration background.
    Michael Stanborough has summarised his style of Direct Myofascial Release technique as:
    Land on the surface of the body with the appropriate 'tool' (knuckles, or forearm etc).
    Sink into the soft tissue.
    Contact the first barrier/restricted layer.
    Put in a 'line of tension'.
    Engage the fascia by taking up the slack in the tissue.
    Finally, move or drag the fascia across the surface while staying in touch with the underlying layers.
    Exit gracefully.
    As Dr. Rolf said, "Put the tissue where it should be and then ask for movement."
    Indirect myofascial release
    The indirect method involves a gentle stretch, with only a few grams of pressure, which allows the fascia to 'unwind' itself. The gentle traction applied to the restricted fascia will result in heat and increased blood flow in the area. This allows the body's inherent ability for self correction to return, thus eliminating pain and restoring the optimum performance of the body. This concept was suggested, by Paul Svacina, to be analogous to pulling apart a chicken carcass- when it is pulled apart slowly, the layers peel off intact- too fast, and it shreds.
    The indirect technique originated in osteopathy schools and is also popular in physical therapy. According to Robert C. Ward, myofascial release originated from the concept by
    Andrew Taylor Still, the founder of osteopathic medicine in the late 19th century. The concepts and techniques were subsequently developed by his successor. Robert Ward further suggested that the term Myofascial Release as a technique was coined in 1981 when it was used as a course title in Michigan State University. It was popularized and taught to physical therapists, massage therapists, occupational therapists and physicians by John F.Barnes PT through his Myofascial release seminar series.
    Carol Manheim summarised the principles of Myofascial Release:
    Fascia covers all organs of the body, muscle and fascia cannot be separated.
    All muscle stretching is myofascial stretching.
    Myofascial stretching in one area of the body can be felt in and will affect the other body areas.
    Release of myofascial restrictions can affect other body organs through a release of tension in the whole fascia system.
    Myofascial release techniques work even though the exact mechanism is not yet fully understood.
    The indirect myofascial release technique, according to John Barnes, is as follows:
    Lightly contact the fascia with relaxed hands.
    Slowly stretch the fascia until reaching a barrier/restriction.
    Maintain a light pressure to stretch the barrier for approximately 3-5 minutes.
    Prior to release, the therapist will feel a therapeutic pulse (e.g. heat).
    As the barrier releases, the hand will feel the motion and softening of the tissue.
    The key is sustained pressure over time.

    Source: From Wikipedia.
    Self Myofascial Release Exercises
    For these exercises you will need a foam roll (which is very inexpensive). You can get them from anywhere that sell sports medicine or physical therapy supplies.
    Adductor Self Myofascial Release
  • 1. Extend the thigh and place foam roll in the groin region with body prone (face down) on the floor. 2. Be cautious when rolling near the adductor complex origins at the pelvis. 3. If a “tender point” is located, stop rolling, and rest on the tender point until pain decreases by 75%.
    Hamstring Self Myofascial Release
  • 1. Place hamstrings on the roll with hips unsupported.2. Feet can be crossed so that only leg at a time is one the foam roll. 3. Roll from knee toward posterior hip. 4. If a “tender point” is located, stop rolling, and rest on the tender point until pain decreases by 75%.
  • Quadriceps Slef Myofascial Release
  • 1. Body is positioned prone (face down) with quadriceps on foam roll2. It is very important to maintain proper core control (abdominal drawn-in position & tight gluteus) to prevent low back compensations 3. Roll from pelvic bone to knee, emphasizing the lateral (outside) thigh 4. If a “tender point” is located, stop rolling, and rest on the tender point until pain decreases by 75%.
  • Iliotibial Band Self Myofascial Release
  • 1. Position yourself on your side lying on foam roll.2. Bottom leg is raised slightly off floor. 3. Maintain head in “neutral” position with ears aligned with shoulders. 4. This may be PAINFUL for many, and should be done in moderation.5. Roll just below hip joint down the outside thigh to the knee. 6. If a “tender point” is located, stop rolling, and rest on the tender point until pain decreases by 75%.
  • Upper Back Self Myofascial Release
  • 1. Place hands behind head or wrap arms around chest to clear the shoulder blades across the thoracic wall.2. Raise hips until unsupported.4. Stabilize the head in a “neutral” position. 5. Roll mid-back area on the foam roll. 6. If a “tender point” is located, stop rolling, and rest on the tender point until pain decreases by 75%.
    General Guidelines
    1. Spend 1-2 minutes per self myofascial release technique and on each each side (when applicable).
    2. When a trigger point is found (painful area) hold for 30-45 seconds.
    3. Keep the abdominal muscles tight which provides stability to the lumbo-pelvic-hip complex during rolling.
    4. Remember to breathe slowly as this will help to reduce any tense reflexes caused by discomfort.
    5. Complete the self myofascial release exercises 1-2 x daily.
    Source: http://www.sport-fitness-advisor.com/self-myofascial-release.html

Fascia & Trigger Points

Fascia is a specialized connective tissue layer surrounding muscles, bones and joints and gives support and protection to the body. It consists of three layers - the superficial fascia, the deep fascia and the subserous fascia. Fascia is one of the 3 types of dense connective tissue (the others being ligaments and tendons) and it extends without interruption from the top of the head to the tip of the toes.
Fascia is usually seen as having a passive role in the body, transmitting mechanical tension, which is generated by muscle activity or external forces. Recently, however some evidence suggests that fascia may be able to actively contract in a smooth muscle-like manner and consequently influence musculoskeletal dynamics.
Obviously, if this is verified by future research, any changes in the tone or structure of the fascia could have significant implications for athletic movements and performance. This research notwithstanding, the occurrence of trigger points within dense connective tissue sheets is thought to be correlated with subsequent injury.
Trigger points have been defined as areas of muscle that are painful to palpation and are characterized by the presence of taut bands. Tissue can become thick, tough and knoted. They can occur in muscle, the muscle-tendon junctions, bursa, or fat pad. Sometimes, trigger points can be accompanied by inflammation and if they remain long enough, what was once healthy fascia is replaced with inelastic scar tissue.
It has been speculated that trigger points may lead to a variety of sports injuries - from camps to more serious muscle and tendon tears. The theory, which seems plausible, is that trigger points compromise the tissue structure in which they are located, placing a greater strain on other tissues that must compensate for its weakness. These in turn can break down and so the spiral continues.
According to many therapists, trigger points in the fascia can restrict or alter the motion about a joint resulting in a change of normal neural feedback to the central nervous system. Eventually, the neuromuscular system becomes less efficient, leading to premature fatigue, chronic pain and injury and less efficient motor skill performance. An athlete's worst nightmare!
What causes a trigger point to form?
The list of proposed causes includes acute physical trauma, poor posture or movement mechanics, over training, inadequate rest between training sessions and possibly even nutritional factors.
Self myofascial release is a relatively simple technique that athletes can use to alleviate trigger points. Studies have shown myofascial release to be an effective treatment modality for myofascial pain syndrome although most studies have focused on therapist-based rather than self-based treatment.
Source: http://www.sport-fitness-advisor.com/self-myofascial-release.html
1. Approximately 80 percent of the main trigger point sites lie on points located on the meridian maps (Wall & Melzack 1990). Indeed, many experts believe that trigger points and acupuncture points are the same phenomenon (Kawakita et. al. 2002).
2. Dr. Langevin and her research colleagues have shown that acupuncture points, and many of acupuncture localized "points" lie directly over areas where there is a fascial cleavage, where sheets of fascia diverge to separate, surround and support different muscle bundles (Langevin et. al. 2001).
3. It seems that the traditional Chinese meridians may, in fact, be fascial pathways.
4. A QUESTION THAT THE RESEARCHERS ARE TRYING TO ANSWAR: This is not too surprising, since we know the fascial network represents one continuum from the internal cranial reciprocal tension membranes to the plantar fascia of the feet.
We know acupuncture points (and it seems the majority of trigger points) are structurally situated in connective tissue, but how does application of a needle or pressure in one part of the fascia translate to distant sites? How does the fascia communicate with other parts of the body?
Researchers from University of Vermont have also shown that connective tissue is a sophisticated communication system, of as yet unknown potential.
Loose' connective tissue forms a network extending throughout the body including subcutaneous and interstitial connective tissues. The existence of a cellular network of fibroblasts within loose connective tissue may have considerable significance as it may support yet unknown body-wide cellular signaling systems. ...
According to Langevin et al’s (2004) findings; Soft tissue fibroblasts form an extensively interconnected cellular network, suggesting they may have important, and so far unsuspected integrative functions at the level of the whole body.


How do pain and function vary with compartmental distribution and severity of radiographic knee osteoarthritis?
In OA affected knee identified by positive X-ray picture, how does radiographic severity and pattern of compartmental involvement influence symptoms? In a Population-based study of 819 adults aged >/=50 yrs with knee pain, Duncan R et al tried to find the answers.
He found:
1. It is the severity of radiographic disease within a compartment, rather than the distribution of radiographic disease between compartments that is associated with symptoms.
2. Positive X-ray in the PF joint is associated with symptoms, emphasizing the importance of radiographic changes in his joint.
How we must target physiotherapy for patellofemoral joint osteoarthritis?

The patellofemoral joint (PFJ) is one compartment of the knee that is frequently affected by osteoarthritis (OA) and is a potent source of OA symptoms. However, there is a dearth of evidence for compartment-specific treatments for PFJ OA.
Crossley KM et al evaluated whether a physiotherapy treatment, targeted to the PFJ, results in greater improvements in pain and physical function than a physiotherapy education intervention in people with symptomatic and radiographic PFJ OA.
A protocol suggested by
Crossley KM et al for PFJ OA is as follows:
(i) Quadriceps muscle retraining; (ii) Quadriceps and hip muscle strengthening; (iii) Patellar taping; (iv) Manual PFJ and soft tissue mobilisation; and (v) OA education.
NB: Resistance and dosage of exercises will be tailored to the participant's functional level and clinical state.

Sunday, September 28, 2008


I have often found that when a subject confuses me, or when I have partial knowledge of an area of my work, the best way of really getting to grips with the problem is to write a book about it - a process that virtually guarantees sufficient research and study to really understand it by the time the book is finished!
Leon Chaitow, DO

Saturday, September 27, 2008

Extracorporeal shockwave therapy (ESWT)

During the past decade application of extracorporal shock waves became an established procedure for the treatment of various musculoskeletal diseases in Germany. Extracorporeal shockwave therapy (ESWT) has been in use for the treatment of tendinopathies since the early 1990s.
Mechanism of working:
The exact mechanism by which ESWT relieves tendon-associated pain is not known; however, there is an increasing body of literature that suggests that it can be an effective therapy for patients who have had repeated non-surgical treatment failures.
Controversies surrounding ESWT:
There is still much debate over several issues surrounding ESWT that have not been adequately addressed by the literature: high- versus low-energy ESWT, shockwave dosage and number of sessions required for a therapeutic effect.
Further research is needed to ascertain the most beneficial protocol for patient care.
ESWT is employed in following conditions with high degree of success by physios even in fairly resistant cases.
According to a meta-analysis by Heller KD et al The advantages of ESWT are non-invasiveness and low rate of complications. Primary aim should be to evaluate adequate energy density levels and impulse rates for specific groups of indications using high quality studies according to evidence-based-medicine. Long term results need to be awaited to be able to compare ESWT with established methods. Recent inflationary use of ESWT especially in outpatient departments has no scientific indication in numerous cases as conservative methods are not used consequently.
However, ESWT is commonly used in following areas:
1. planter fascitis
2. common extensor tendinosis
3. insertional tendinopathy of achilles tendon.
4. Peyronie’s disease
5. supraspinatus tendonitis
6. patellar tendonitis
7. calcifying tendonitis of rotator cuff.
ESWT also has been experimentally used in
1. pseudoarthrosis
2. non-union
Possible complications and side effects using extracorporeal shock waves for orthopaedic diseases COULD BE AVOIDED if we know the side & adverse effects and contraindications.
Few cases may react to ESWT as follows:
1. Small superficial hematomas
2. Hyperventilations with blood pressure elevation over 200 mmHg (without other clinical symptoms & mostly transitory nature during therapy- abates within 3 hours of the therapy).
1. Application of shockwaves in the thoracic region or lung, coagulopathies or anticoagulant medicine, pregnancy and the use at nerval or vascular structures represent an absolute contraindication.
2. When using extracorporeal shock waves for bone lithotripsy, bone tumors, bone infection or infected pseudarthrosis and the application at growth plates in children and young adults represent an absolute contraindication.


Many studies show that; given a more proximal root compression (for example root compression at cervical transverse foramina) less involvement of the median nerve across the carpal tunnel was required to produce symptoms of CTS (carpal tunnel syndrome).
The surgical outcome of carpal tunnel release in this double crush group is poorer than in that group with isolated carpal tunnel involvement. It is important to preoperatively identify those patients who may have double crush lesions and thus anticipate a less than optimal result from surgical release of the peripheral nerve.

So let us review what a double crush syndrome means?
The double-crush syndrome was initially described by Upton and McComas in 1973. Multilevel lesions along a peripheral nerve trunk do occur. In the double crush syndrome as postulated by Upton and McComas, the presence of a more proximal lesion does seem to render the more distal nerve trunk more vulnerable to compression.
Concrete support of existence of double crush syndromes from MRI studies:
Pierre-Jerome C et al assessed the coexistence of narrowed cervical foramens and cervical canal stenosis in patients with carpal tunnel syndrome (CTS) through MRI studies.
Study of MRI of 120 wrists and 480 foramens in 60 age and sex matched subjects (30 patients with CTS and 30 controls) revealed that; there was no difference in the size of the cervical canal. The higher incidence of narrowed cervical foramens in the patients and its concordance with affected nerve roots on the same side as the CTS symptoms support the hypothesis of a double-crush phenomenon.
While the exact pathophysiologic mechanism of this interaction is not yet elucidated, it most likely relates to disturbances in axonal flow kinetics and the disruption of the neurofilament architecture.
MacKinnon and Dellon have expanded the description of this syndrome to include
a) Multiple anatomic regions along a peripheral nerve
b) Multiple anatomic structures across a peripheral nerve within an anatomic region
c) Superimposed on a neuropathy, and
d) Combinations of the above.
e) Further Zahir KS et al has reported an unusual case of symptomatic nerve compression caused by two non-anatomic structures within an anatomic region.
According to the hypothesis of Upton and McComas:
1. Non-symptomatic impairment of axoplasmic flow at more than one site along a nerve might summate to cause a symptomatic neuropathy. This was suggested by their clinical observation that the majority of their patients had a median or ulnar neuropathy associated with evidence of cervicothoracic root lesions.
Other researchers have since reported series of patients supporting the frequent association of a proximal and distal nerve compression syndrome, including carpal tunnel syndrome associated with cervical radiculopathy, brachial plexus compression, and diabetic neuropathy.
2. They also hypothesized that one of the constraints on axoplasmic flow could be a metabolic neuropathy, and this is supported by the high association of diabetes and carpal tunnel syndrome.
Presentation of a unique case study by
Putters JL:
Bilateral thoracic outlet syndrome with bilateral radial tunnel syndrome: a double-crush phenomenon.
A case of bilateral thoracic outlet syndrome combined with bilateral radial tunnel syndrome is reported. Persisting complaints in the upper extremities after bilateral first-rib resection and scalenotomy were due to radial nerve entrapment in the radial tunnel. Although this bilateral double-crush phenomenon is extremely rare, and has not been reported previously, persistence of symptoms after initial treatment of a nerve entrapment is an indication to search for another site of compression.
NB: This review is based on articles by
Osterman AL, Zahir KS et al, Pierre-Jerome C et al and Putters JL in pubmed.

Friday, September 26, 2008



Of late we have seen many INDIAN physios especially young ones are getting fascinated by Osteopathic manipulative treatments. Study 3 discussed below just gives us an idea where osteopaths employ spinal manipulations.
A few CPD/paid seminar providers though moderate in their cost; are currently providing module courses on the same. I doubt many young physios even know when they slip from a physiotheputic domain to Osteopathic domain. No doubt techniques such as myofascial releases, MET are quite helpful but what about different spinal manipulations? Do they have any current scientific evidence to induct them in our day to day clinical practice?
Osteopathic manipulative treatment (OMT) is a distinctive modality commonly used by osteopathic physicians to complement their conventional treatment of musculoskeletal disorders. Previous reviews and meta-analyses of spinal manipulation for low back pain have not specifically addressed OMT and generally have focused on spinal manipulation as an alternative to conventional treatment. The effectiveness of spinal manipulation as a treatment for back pain remains uncertain and controversial. This is because of methodological weakness in many of the published clinical trials and also because of markedly opposing interpretations of the primary data by different reviewers.

I have taken 6 recent reviews on this issue from PEDro & simplified them for the common physio readers. The last review is probably coinciding with my views.

Study1. HVLA spinal manipulation for symptomatic lumbar disk disease: a systematic review of the literature

Lisi AJ et al reviewed the evidence for high-velocity low-amplitude spinal manipulation (HVLASM) for symptomatic lumbar disk disease (SLDD). This review was published in Journal of Manipulative and Physiological Therapeutics 2005 Jul-Aug;28(6):429-442.

16 studies met the inclusion criteria, representing 203 total subjects. Of these, 172 subjects received HVLASM as active treatment, and 31 received other treatments as comparison subjects. Improvements in patient-based and physiological outcomes were reported among subjects receiving HVLASM

The conclusion of this study was:

1. There is limited evidence, and definitive conclusions on safety and effectiveness cannot be made.
2. HVLASM may be effective in the treatment of SLDD and does not support the hypothesis that HVLASM is inherently unsafe in SLDD cases.
3. However it was recommended that it is an area of research importance. More high-quality clinical trials are necessary.

Study 2: A systematic review of systematic reviews of spinal manipulation

Ernst E collated and evaluated the evidence from recent systematic reviews of clinical trials of spinal manipulation which was published in Journal of the Royal Society of Medicine 2006 Apr;99(4):192-196.

16 papers were included relating to the following conditions: back pain (n = 3), neck pain (n = 2), lower back pain and neck pain (n = 1), headache (n = 3), non-spinal pain (n = 1), primary and secondary dysmenorrhoea (n = 1), infantile colic (n = 1), asthma (n = 1), allergy (n = 1), cervicogenic dizziness (n = 1), and any medical problem (n = 1).

The conclusion of this study was:

1. These reviews were largely negative, except for back pain where spinal manipulation was considered superior to sham manipulation but not better than conventional treatments.
2. Collectively data do not demonstrate that spinal manipulation is an effective intervention for any condition.
3. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.
Study 3: Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials
Licciardone JC et al assessed the efficacy of OMT as a complementary treatment for low back pain published in BMC Musculoskeletal Disorders 2005 Aug 4;6(43):Epub.

6 trials, involving 8 OMT versus control treatment comparisons, were included because they were RCTs of OMT that involved blinded assessment of low back pain in ambulatory settings.

The conclusion of this study was:

1. Overall, OMT significantly reduced low back pain. There were significant pain reductions with OMT regardless of whether trials were performed in the United Kingdom or the United States.
2. Significant pain reductions were also observed during short-, intermediate-, and long-term follow-up.
3. However the authors suggested additional research is warranted to clarify mechanistically how OMT exerts its effects.

Study 4. Distraction manipulation of the lumbar spine: a review of the literature

Lumbar distraction manipulation is a non-thrust mechanically assisted manual medicine technique with characteristics of manipulation, mobilization, and traction. It is used for a variety of lumbar conditions and chronic pelvic pain. The primary rationale for its use is on the basis of the biomechanical effects of axial spinal distraction.

Little data are available describing the in vivo effect of distraction when used in combination with flexion or other motions. Gay RE reviewed the literature concerning distraction manipulation of the lumbar spine, particularly regarding physiological effects, clinical efficacy, and safety.

30 articles were identified; 3 were uncontrolled or pilot studies, 3 were basic science studies, and 6 were case series. Most were case reports.

This study concluded:
1. Despite widespread use, the efficacy of distraction manipulation is not well established.
2. Further research is needed to establish the efficacy and safety of distraction manipulation and to explore biomechanical, neurological, and biochemical events that may be altered by this treatment.
Study 5. Chiropractic spinal manipulation treatment for back pain? A systematic review of randomised clinical trials

Back pain is a common condition for which chiropractic treatment is often recommended. Ernst & Canter
did a study to evaluate critically the evidence for or against the effectiveness of chiropractic spinal manipulation for back pain which was published in Physical Therapy Reviews 2003 Jun;8(2):85-91.
Data sources ware only from RCTs of chiropractic spinal manipulation with patients suffering from back pain from 5 independent literature searches. The authors extracted data on trial design, methodological quality, sample size, patient characteristics, nature of intervention, outcome measures, follow-up and results.

The findings are as follows:

1. Twelve studies could be included. They related to all forms of back pain. Many trials had significant methodological shortcomings. Some degree of superiority of chiropractic spinal manipulation over control interventions was noted in 5 studies.
2. More recent trials and those with adequate follow-up periods tended to be negative.
3. So it was concluded that the effectiveness of chiropractic spinal manipulation is not supported by compelling evidence from the majority of randomised clinical trials.
A nail on the coffin: Sources of bias in reviews of spinal manipulation for back pain

Study 6:

Researchers have highly conflicting views whether spinal manipulation works or not. Canter PH et al have systematically assessed a representative sample of recent reviews on spinal manipulation for back pain. They have tried to find out “What are the sources of bias in reviews?”. Reviews were included in the analysis if they were published between 1993 and March 2004, were listed in PubMed with an abstract and categorised as a review or meta-analysis, and were written in English.

They found that:

1. 29 reviews met the inclusion criteria. 16 reached an overall positive conclusion, 7 a negative conclusion and 6 a neutral conclusion regarding therapeutic effectiveness.
2. This study indicated a strong association between authorship by osteopaths or chiropractors and low methodological quality and positive conclusion. (Overtly biased Osteopaths for their treatments)
3. It also concluded that, the outcomes of reviews of this subject are strongly influenced by both scientific rigor and profession of authors.
4. This study also suggested that effectiveness of spinal manipulation for back pain is less certain than many reviews suggest; most high quality reviews reach negative conclusions.
Full text may be available at: http://www.springerlink.com/openurl.asp?genre=journal&eissn=1613-7671

1. This review is not intended or targeted to any audience.
2. The opinion does not dissuade anybody to acquire the OMT skills.
3. This opinion certainly intends to reach those clinicians who invest time & labor to see smiles in his patients face.

Massage decreases aggression in preschool children: a long-term study.

In a study by von Knorring AL et al (2008) of Department of Neuroscience, Uppsala University, Sweden ( anne-liis.von_knorring@bupinst.uu.se) showed Daily touching by massage lasting for 5-10 min could be an easy and inexpensive way to decrease aggression among preschool children.

Thursday, September 25, 2008

Prognosticating the effectiveness of physiotherapeutic spinal mobilization with the centralization phenomenon of symptoms.

What is centralization?

Centralization refers to the abolition of distal pain emanating from the spine in response to therapeutic exercises.

According to a review article in Manual Therapy 2004 Aug;9(3):134-143; authored by Aina A et al focused on prognostic significance along with prevalence and reliability of assessment. The prevalence rate of pure or partial centralization was 70% in 731 sub-acute back patients, and 52% in 325 chronic back patients.

Points to remember:

1. It is a symptom response that can be reliably assessed during examination.

2. Centralization is consistently associated with a range of good outcomes, and failure to centralize with a poor outcome.

3. Centralization appears to identify a substantial sub-group of spinal patients; it is a clinical phenomenon that can be reliably detected, and is associated with a good prognosis.
4. It is recommended that centralization should be monitored in the examination and reexamination of spinalpatients.

Wednesday, September 24, 2008

Sports injuries and NSAID

NSAIDs are some of the most widely consumed medications in the world. Painful conditions i.e. mostly acute conditions of athletes are treated with non steroidal anti-inflammatory drugs (NSAID). While NSAIDs have become synonymous with the management of acute musculoskeletal injuries, their efficacy has yet to be proven. The major goal of clinicians when treating acute musculoskeletal injuries is to return athletes to their pre-injury level of function, ideally in the shortest time possible and without compromising tissue-level healing.
1. According to Fournier PE et al (2008), there is a lack of high-quality evidence to use NSAIDS.
2. According to
Fournier PE et al (2008), the adverse effects of NSAIDS medications include potential negative consequences on long-term healing process. According to Mehallo CJ et al NSAIDs are not recommended in the treatment of completed fractures, stress fractures at higher risk of nonunion, or in the setting of chronic muscle injury.
According to
Almekinders LC, Stretch-induced muscle injuries or strains, muscle contusions and delayed-onset muscle soreness (DOMS) are common muscle problems in athletes. Anti-inflammatory treatment is often used for the pain and disability associated with these injuries. The most recent studies on nonsteroidal anti-inflammatory drugs (NSAIDs) in strains and contusions suggest that the use of NSAIDs can result in a modest inhibition of the initial inflammatory response and its symptoms. However, this may be associated with some small negative effects later in the healing phase.
Baldwin examined the use of NSAIDs for attenuating exercise-induced muscle injuries (EIMI), with an emphasis on their safety and usefulness for improving muscle function and reducing soreness. However it is concluded that, there is a lack of agreement concerning NSAID effectiveness for this purpose. According to Fournier PE et al, Mehallo CJ et al and variour others, in all tentative cases, if used, length of NSAID treatment should always be kept as short as possible & must be for analgesic purposes only.
Effect of specific drugs:
1. Nonsteroidal anti-inflammatory drugs Vs analgesic drugs in the treatment of an acute muscle injury.
In a animal study
Rahusen FT, hypothesized that, the effects of nonsteroidal anti-inflammatory drugs are no different than the effects of an analgesic (acetaminophen) without anti-inflammatory action in an experimental, acute muscle contusion model. He concluded that, rofecoxib as a nonsteroidal anti-inflammatory drug and acetaminophen as a non-nonsteroidal anti-inflammatory drug analgesic have similar effects. The lack of differences in wet weights and histology suggests that the anti-inflammatory effects of rofecoxib are not an important feature of its action. He further suggested that, the routine use of nonsteroidal anti-inflammatory drugs in muscle injuries may need to be critically evaluated because low-cost and low-risk analgesics may be just as effective.
2. Cyclo-oxygenase-2 inhibitors: beneficial or detrimental for athletes with acute musculoskeletal injuries?
The following is a review of a paper by
Warden SJ reveal following important points:
The latest class of NSAIDs - selective cyclo-oxygenase-2 inhibitors or the COXIBs were developed to reduce the adverse gastrointestinal (GI) effects of traditional NSAIDs. There is currently no randomised, controlled trial evidence of the tissue-level effects of COXIBs on acute musculoskeletal injuries.
While they have beneficial anti-inflammatory and analgesic properties, and appear to facilitate earlier return to function following acute injury, the effect of COXIBs on tissue-level healing is currently unknown. In experimental animal models of acute injury, COXIBs have been shown to be detrimental to tissue-level repair. Specifically, they have been shown to impair mechanical strength return following acute injury to bone, ligament and tendon. Clinically, this may have implications for ongoing morbidity and future injury susceptibility. Extrapolation of animal studies to clinical setting may however find significant limitations.
More importantly recently studies showed link between one COXIB (rofecoxib) and an increased risk for adverse cardiovascular events. In comparison, traditional NSAIDs do carry the potential for greater adverse GI effects and their clinical effects on tissue-level healing remain relatively unknown but they do not appear to be associated with adverse cardiovascular effects, and they are effective pain relievers and cheaper alternatives.
Review of Topical NSAIDS applications for sports injuries & acute pain
One previous systematic review reported that topical NSAIDs were effective in relieving pain in acute conditions like sprains and strains, with differences between individual drugs for efficacy.
1. The empirical evidence supporting the use of topical NSAIDs in acute soft tissue injuries is weak. According to
Heyneman CA., patient ratings of improvement consistently favor NSAID treatment over placebo. Although it is very difficult to differentiate the placebo effect from the natural course of improvement in these patients, the overall impression given by these studies is that of superior efficacy of topical NSAIDs over placebo. The study by Akermark and Forsskahl suggests that indomethacin applied topically is as effective as therapeutic doses of oral indomethacin. Further studies need to be conducted to generalize this conclusion to other NSAIDs. Studies comparing the relative efficacy of topical NSAIDs with counterirritants available over-the-counter (e.g., menthol, camphor, methylsalicylate) also would be useful.
2. But according to a meta-analysis by,
Mason L, topical NSAIDs were effective and safe in treating acute painful conditions for one week. Similarly Moore RA reported, Topical non-steroidal anti-inflammatory drugs are effective both in relieving pain in acute and chronic conditions.
Russell AL compared Piroxicam 0.5% topical gel to placebo in the treatment of acute soft tissue injuries. He found that piroxicam 0.5% gel, administered as 5 mg q.i.d. is an effective treatment of musculoskeletal injuries (sprains and tendinitis), is significantly more effective than placebo, and is well tolerated.

Tuesday, September 23, 2008


Sharma KR (2001) studying on Median sensory nerve conduction velocity: found digit 1 to wrist is more sensitive than the median sensory nerve conduction velocity distoproximal ratio in the diagnosis of mild CTS. However, Electrodiagnostic studies have significant false-positive and false-negative rates in CTS, and therefore provocative tests remain important in its diagnosis. Tinel's (nerve-percussion test), Phalen's(wrist-flexion test,), Reverse Phalen's and carpal tunnel compression tests (tourniquet test) are more sensitive and very commonly employed for physical diagnosis of CTS. In a study consisting of 50 control subjects with electrodiagnostically proved carpal-tunnel syndrome found following:

The sensitivity and specificity of each test of the above were calculated. The wrist-flexion test was found to be the most sensitive while the nerve-percussion test, although least sensitive, was most specific. The tourniquet test was quite insensitive and not very specific, and should not be used as a routine screening test in the diagnosis of carpal tunnel syndrome.
DURKAN test of carpal tunnel compression is already mentioned above.
1. DURKAN JA (1991) suggested a new test, called the carpal compression test, consists of application of direct pressure on the carpal tunnel and the underlying median nerve. The results of the Tinel percussion test, the Phalen wrist-flexion test, and the new test were evaluated in thirty-one patients (forty-six hands) in whom the presence of carpal tunnel syndrome had been proved electrodiagnostically, as well as in a control group of fifty subjects.
DURKAN found, the carpal compression test was found to be more sensitive and specific than the Tinel and Phalen tests.
2. According to AHN DS (2001) Hand elevation can reproduce the symptoms of carpal tunnel syndrome. This phenomenon prompted the idea of developing a simple hand elevation test to diagnose carpal tunnel syndrome. AHN DS found the sensitivity and specificity of the elevation test were higher than those of Phalen's test and Tinel's test.

Sensitivity of a combined test:
In a study by TETRO AM et al (1998) to establish the value of median nerve compression with wrist flexion as a provocative test for carpal tunnel syndrome (CTS), they recorded results for the common provocative tests (Tinel's percussion test, Phalen's wrist flexion test and the carpal compression test) and the new test which combines wrist flexion with median nerve compression.
TETRO AM et al found that the optimal cut-off time for the wrist-flexion and median-nerve compression test was 20 s, giving a sensitivity of 82% and a specificity of 99%. They have also shown that wrist flexion combined with the median-nerve compression test at 20 s, is significantly better than the other methods, and may thus be clinically useful.
Possibility of a double crush:
Physios do not ever forget to test at least a transverse glide or CPA to Lower Cervical spine to rule out possibility of a double crush in all cases of suspected CTS.

What stops slipping of a vertebra in spondylolisthesis?

The shear is normally resisted by the annulus fibrosus, compression of the facets at the apophyseal joints, and by tension in the anterolateral layers of cortical bone in the pars interarticularis.
1. The failure strength and the anterior shear-strength of the disc, spinal ligaments are very high.
2. The ariculation of facet joints (Capacity of the pars for resisting tensile forces anteriorly at L4 and L5 has been reported at up to 2500 N)
3. In case of retrolysthesis; even the posterior displacement of the inferior facets reported to be 6.5 mm at failure.

Anterior displacement in spondylolisthesis is a slow process. The forces contributing to anterior shear arise from following things:
1. from vertical load on the spine above the lesion
2. from activity in the muscles of the spine and trunk
3. from the effects of movements.

Monday, September 22, 2008

What FABER test in Hip can tell you is; hip has pathology but CAN NOT specify what the EXACT DISORDER.

Many patients report to us with hip and groin pain (usually unilateral) with pain only on crossed sitting and less often with walking stairs, squatting or getting from squatting. FABER test for inguinal pain is positive & SLR is 80 degree suggests that there is no involvement of SI or lumbar spine. I am surprised that it does not match with any common or remote possible pathologies of hip. If FABER is the only sign what the therapist should do? Let us discuss.

The FABER test: Passively flex, abduct, and externally rotate the hip of the lower extremity that is to be tested while subjects is in a supine position, so that the lateral malleolus of the tested lower extremity rests just superior to their opposite extended knee. The test response for hip disorders is an inguinal pain. Similarly the test response for SI disorder is LBA or posterior sacral pain.

For physio researchers: Measurement can be done like the following way: the vertical distance between a fixed mark on the lateral border of the patella of the tested lower extremity and the treatment table can be measured.

Litareture review: According to an article in archives of physical medicine (2008) Strength and ROM testing of the hip in people with hip osteoarthritis can be performed with good to excellent reliability. For hip pain assessment FABER test, log roll test, and assessment of greater trochanteric tenderness were highly reliable and with confidence level (95%). How ever there is a low reliability for the flexion-internal rotation-adduction impingement test. In a study by Mitchell B et al of the 17 patients whose flexion, abduction, external rotation (FABER) test results were reported at the time of examination, 15 (88%) were positive, and 2 (12%) negative on arthroscopy for hip pathology.

Possible interpretations for FABER test:

1. A partial articular pattern; the test position stress the anterior-medial capsule.
2. Muscle tightness; tight flexors of hip, adductors etc.
NB: these structures must be differentiated in a manner suggested by J.Cyriax.

My suggestions: Arthrokinematic correction + muscle stretching.

Myofascial pain; points of an overview by Yap EC

1. Skeletal muscle is the largest organ in the human body. In modern society, myofascial pain is a major cause of morbidity.
2. Any of these muscles may develop pain and dysfunction. It may present as regional musculoskeletal pain, as neck or back pain mimicking radiculopathy. It may also present as shoulder pain with concomitant capsulitis, and hip or knee pain with concomitant osteoarthritis.
3. The condition is treatable. However, it is often under-diagnosed and hence undertreated. Traditional medical training and management of musculoskeletal pain have focused much attention on bones, joints and nerves.
4. During history taking and physical examination, precipitating and perpetuating factors, taut bands, trigger points, tender spots and sensitised spinal segments have to be accurately located for successful institution of treatment.
5. There is also a high recurrence rate unless appropriate exercises are prescribed, with active participation from the patient, to restore flexibility and balance to the muscles.
6. With rehabilitation, many patients do not have to continue to suffer unnecessary pain that affects their daily activities and quality of life. Early diagnosis and management may also help reduce psychosocial complications and financial burden of chronic pain syndrome.

How to assess physical activity? How to assess physical fitness?

How to assess physical activity? How to assess physical fitness? I have discussed this issue in detail my forthcoming book.
Regular aerobic physical activity (PA) increases exercise capacity and physical fitness (PF), which can lead to many health benefits. Accurate quantification of PA and PF becomes essential in terms of health outcome and effectiveness of intervention programmes.
Three types of PA assessment methods can be distinguished: criterion methods, objective methods and subjective methods.
1. Criterion methods like doubly labelled water, indirect calorimetry and direct observation are the most reliable and valid measurements against which all other PA assessments methods should be validated, but they also hold important drawbacks.
2. Objective PA assessment methods include activity monitors (pedometers and accelerometers) and heart rate monitoring.
3. Finally, questionnaires and activity diaries are considered subjective methods.
For the assessment of PF, we distinguish field tests and laboratory tests.
About a test battery called Eurofit:
1. The Eurofit for Adults is a test battery that is designed to assess health-related fitness of individuals, communities, sub-populations and populations.
2. It is mainly used for evaluating the morphological component, the muscular component, the motor component and the cardio-respiratory component.
Laboratory exercise testing:
1. In the laboratory, exercise capacity is preferentially assessed through maximal incremental exercise testing.
2. Cardio-pulmonary exercise testing is a well-established procedure that provides a wealth of clinically diagnostic and prognostic information.
3. The peak oxygen uptake is the gold standard in the assessment of exercise tolerance.
4. When maximal exercise is contraindicated or not achievable, the VAT or the submaximal slopes provide reasonable alternatives.

Saturday, September 20, 2008


JOASSIN R et al (2008) reported 3 cases.
They elaborated the diagnosis and treatment of adhesive capsulitis of the hip as follows:


1. Adhesive capsulitis of the hip is a supposedly rare but probably underestimated condition which predominantly affects middle-aged women.
2. Clinical assessment reveals a painful limitation of joint mobility. (may be capsular pattern)
3. The diagnosis is confirmed by arthrography, where the crucial factor is a joint capacity below 12ml.

1. Osteoarthritis and
2. complex regional pain syndrome type 1 are the two main differential diagnoses.

The treatment:
The first-line treatment consists of sustained-release corticosteroid intra-articular injections and physical therapy. Arthroscopy and manipulation under anaesthesia


ACL injury rehabilitation; conservatively or after reconstruction, is both difficult and time taking. It may take as long as a year before the athlete returns to competitive sports. For a athlete ACL injury is a shattering experience.

Anterior cruciate ligament (ACL) injuries are common in athletes participating in sports requiring jumping and pivoting maneuvers i.e. often during landing from a jump or making a lateral pivot while running where knee joint movement overcomes both the static and the dynamic constraint systems. 70% ACL injuries occur in non-contact situations. It is estimated that 80,000 anterior cruciate ligament (ACL) tears occur annually only in the United States. The highest occurrences are seen in the individuals 15 to 25 year age groups. Estimated treatment cost of treatment in ACL injuries of almost a billion dollars per year only in USA.

Few authorities have developed screening protocols for the identification of high-risk athletes. Potential risk factors such as Neuromuscular & biomechanical, hormonal, anatomic, and environmental factors have been extensively studied so that effective preventive strategies could be formulated. Studies on risk factors reveal that Interventions addressing neuromuscular factors appear particularly promising and further suggest that enhancing body control may decrease ACL injuries especially in women. Many clincians prefer dynamic neuromuscular analysis (DNA) based training as it is seen that Dynamic neuromuscular training has been shown to increase knee stability and decrease knee injury rates.

What is special about ACL injuries in females?

1. Numerous studies have found that female athletes who participate in jumping and pivoting sports are 4-6 times more likely to sustain ACL injury, than male athletes participating in the same sports.
2. Female athletes with increased dynamic valgus and high abduction loads are at increased risk of anterior cruciate ligament injury.

Neuromuscular & biomechanical aspects of ACL injuries:

1. Knee instability, due to ligament dominance (decreased medial-lateral neuromuscular control of the joint)
2. Quadriceps dominance (increased quadriceps recruitment and decreased hamstring recruitment and strength), and
3. Leg dominance (side-to-side differences in strength, flexibility, and coordination) are possible contributing factors to the increased incidence of knee injury in especially female athletes


Many studies conducted in USA recently results that balance and neuromuscular control play a central role in knee joint stability, protection and prevention of ACL injuries.
In a study on Croatian female athletes suggests:

Balance neuromuscular skills as measured by their balance index score using the Sport KAT 2000 testing system indicates a possible correlation between their balance index score and balance effectiveness. However training by this method may only help to develop simpler neuromuscular control.
But this method can monitor balance which can be used to estimate risk predictors in athletes who withdraw from sports due to injured or ruptured anterior cruciate ligament and to direct female athletes to more effective, targeted preventive interventions.

Formulating and executing the most reliable evidence based prophylactic training programs be introduced during athlete training, since the prevention of an initial injury will be more effective than prevention of injury recurrence. And further effort to reduce the risk of future injuries and thus prevent female athletes from withdrawing from sports prematurely.
Suggested resources:
1. Sports performance bulletin (to know the exact evidence based practical skill to prevent ACL injuries)