Saturday, August 17, 2013

To Roll or Not to Roll

Foam rolling or also called self myofascial release is getting popular in fitness, exercise therapy and manual therapies. It is claimed to be an effective complement to massage, trigger point treatments, and also for stretching & increasing ROM. As many would then say "More research is needed to know its effects."
There are several skeptics website that mentioned foam roller is a waste of time (no research to prove it works). Well, in effect foam roller is not much different from applying pressure to the muscles. The following is a discussion by Robert Schleip on Foam Rolling.

How does it work?
Robert Schleip said "I don't think anybody 'knows' at this time. All people do is speculate based on their personal experience plus on more or less wild interpretations. "

Some people do not think foam rolling is useful, mostly stated that ITB cannot be stretched and quoting Robert Schleip's 2003 article on Fascial plasticity published in JBMT which mentioned that it is not possible for a therapist to generate force to 'melt' or deform the ITB. A paper by Threlkeld showed that the ITB can withstand longitudinal strain up to approx. 600 N (60 kg) without long lasting deformations. Based on this Robert raised questions, on whether the elbow power of a Rolfer would be sufficient for a purely mechanical plastic deformation effect in such dense collagenous structures.

However, many therapists claim they get beneficial effects from deep tissue massage on the ITB and similar dense fascial structures. In Schelip's 2003 article article, he then developed the hypothetical model, that at least some of deep tissue effects may be due to the stimulation of sensory nerve endings in fascia, which then can trigger changes in nearby skeletal muscle fibres (for the ITB maybe the vastus lateralis directly under the band, or the gluteus max or tensor fascia lata) or changes in the autonomic nervous system which can result in an altered fluid hydration of the fascial structure. Robert believed that this is one of the most likely/valid explanations for the often observed tissue release effects in hands-on myofascial work.

Applying self myofascial release by foam rolling can create similar force or effects as a hands-on (or elbow) stroke from a manual therapist.A newer and more intriguing explanation for the effects of myofascial work is that we may be squeezing water out of the tissue areas directly under our hands, and that these areas subsequently fill with new water molecules. See e.g.

At the last Fascia Congress keynote lecturer Gerald Pollack also emphasized his assumption, that the newly sucked in water molecules will associate more in a 'bound water' state with the proteoglycans in the tissue and will behave more like a liquid crysal, as compared to the higher content of unbound bulk water which often characterizes stagnant water zones in the body or tissues in a pathological condition.

Therefore Schleip suggested that most of the beneficial effects of foam roller self treatments in addition to sponge squeezing & rehydration effects are:
  • increasing pain tolerance, i.e. activating descending inhibitory cortical pathways
  • stimulation of sensory receptors on fascia (Ruffini, Golgi, FNE) with resultant downstream effects, such as decrease of related skeletal myofibre tonus, increased proprioception, increase of vasodilation & plasma extrusion.
  • stimulation of fibroblasts, which can lead to increased production of antiinflammatory and anti-fibrotic cytokines (in super-slow rolling speeds) or to increased collagen production (in rapid & forceful stimulations).
For effective application, it is helpful that the treated person pays detailed mental attention (state of mindfulness, curiosity for tiny details, etc.). The proprioceptive input can also be used to support specific changes in cortical body mapping (body schema, body image). If this aspect is important and included, then one can orchestrate the direction of the last tissue strokes such, that they support a specific body perception change (e.g. working in a distal direction for more 'grounding', or proximally for more lightness, etc.).

For the second, it is helpful if multiple directions of tissue squeezing are applied (analogy with cleaning a dirty towel in water, etc.) and also if the squeezing movement is done as slowly as possible in order to reach the tiny micro-vacuoles within the tissue.

The studies from Healey and Mac Donald (see below) seem to also describe stress related recovery effects in foam rolling. The study by Ohkamoto showed the increased expression of plasmic nitrous oxide is usually seen as beneficial. However it also is a well known response to mechanical tissue stress. The increased ROM in McDonald's paper does not necessarily mean that there was softening effect on joint capsules or related connective tissues. I would suspect that it was rather due to an increase of the perceived 'comfort zone' of the patient which was used for the measurement of this parameter.

How much Force?

The amount of pressure one can take can be different, one person to another can vary up to 5000% (i.e. factor of 50). It is best to choose a roller firmness that allows you to play around the edges of your subjective pain tolerance (often one will increase in roller firmness after a few weeks/months of application).

It is possible that some people overdo the self-torture effect of foam rolling and create bruises and minor vascular tears.

But even then the question can be asked: how much micro-injury (at what intensity and what time interval) is appropriate for possibly inducing a long term beneficial recovery response in terms of an ultimately increased physiological and/or biomechanical tissue resilience? E.g. the new and expensive 'cryogenic chamber therapy' or Gua Sha seems to work by creating irritation, stress and inflammatory reactions in the tissues close to the skin, which – if calibrated appropriately – stimulates the body to activate some pain modulating, anti-inflammatory and matrix remodeling cytokine responses during the subsequent hours and days.

However, similar to cryotherapy, Kneipp cures and other stress-imposing interventions, this therapy can also be overdone and then will not result in an increased tolerance to the same irritation but rather induce a longterm decrease of tolerance. In my limited clinical experience, I would think if the increased sensitivity (and resultant decrease in tolerance) lasts no longer than 1 or 2 days, it may still induce a tolerance-increasing long term effect afterwards. However if the perceived 'soreness' lasts 3 days or longer, then I am more doubtful about any long term benefits. Usually in those cases it then takes 1 or several weeks until the tissue returns to its previous resilience (if at all; while a subsequent super-compensation recovery effect towards an increased tolerance is very rare). An important exception to this 2 day rule of thumb are fibromyalgia patients: in some of them the immediate soreness period and resultant recovery period – even if ultimately beneficial – may take much longer than that.

How fast?
Robert recommended 1-2mm per breath – for softening scars and other tight and stiff collagenous tissues - seems to be too idealistic for most people. In my own teaching I have had good responses when replacing that with "slowest possible continuous rolling movement" and the added remark that a super slow speed of 1/2 to 1/4 inch per breath could be a great start.


Acute injury, acure inflammatory conditions (for forceful rolling applications), lack of embodiment and grim determination of the user. Otherwise I don't think there is a wrong way of doing it. Variation is usually better for fascial stimulation than repetition of the same exact 'correct' loading styles.

Direction of Rolling

Some people believed that (similar to one of the myths in massage) is that rolling should be distal to proximal (following blood circulation). However as in manual therapy, the direction of manipulation has a more notional and neural effect.

Robert commented: "I don't think it is very likely that we can push a piece of fascial tissue from A to B and that it will stay there during the following work day. What we do with directional rolling is the same as when gently brushing one's skin in a particular direction: we propose to the brain a suggested movement gesture. Like when stroking down several times with a soft brush on the right leg and upwards on the left one, the patients then tend to feel' longer' on their right leg afterwards and shorter on their left one. Same for rolling the upper ITB band in an anterior direction, which may invite the brain towards a more pigeon-toed stance or gait afterwards (for a few steps only). This 'gestural' effect probably involves short term changes in the cortical body schema and it can be beautifully tailored towards the specific needs of each client. For me it makes most sense to include such individually tailored 'directional rolling' at the very end of the therapeutic session, in order to increase a higher likelihood of transfer into their daily living habit formation. "

Here are Some Studies on Foam Roller

Acute Effects of Self-Myofascial Release Using a Foam Roller on Arterial Function

Authors: Takanobu Okamoto, Mitsuhiko Masuhara, Komei Ikuta

Flexibility is associated with arterial distensibility. individuals who practice yoga have significantly less arterial stiffness that those who are sedentary. Thus, flexibility exercises such as stretching or yoga might reduce arterial stiffness. Many individuals involved in sport, exercise and/or fitness perform self-myofascial release (SMR) using a foam roller, which restores muscles, tendons, ligaments, fascia and/or soft-tissue extensibility. However, the effect of SMR on arterial stiffness and vascular endothelial function using a foam roller is unknown.

The present study investigates the acute effect of SMR using a foam roller on arterial stiffness and vascular endothelial function. Ten healthy young adults performed SMR and control (CON) trials on separate days in a randomized controlled crossover fashion. Brachial-ankle pulse wave velocity, blood pressure, heart rate and plasma nitric oxide concentration were measured before and 30 min after both SMR and CON trials. The participants performed SMR of the adductor, hamstrings, quadriceps, iliotibial band and trapezius. Pressure was self-adjusted during myofascial release by applying body weight to the roller and using the hands and feet to offset weight as required. The roller was placed under the target tissue area and the body was moved back and forth across the roller. In the CON trial, SMR was not performed.

Results showed that the brachial-ankle pulse wave velocity significantly decreased (from 1202 ± 105 to 1074 ± 110 cm/s) and the plasma nitric oxide (NO) concentration significantly increased (from 20.4 ± 6.9 to 34.4 ± 17.2 μmol/L) after SMR using a foam roller, but neither significantly differed after CON trials. These results indicate that SMR using a foam roller reduces arterial stiffness and improves vascular endothelial function.

Journal of Strength and Conditioning Research Publish Ahead of Print. DOI: 10.1519/JSC.0b013e31829480f5

The Effects of Myofascial Release with Foam Rolling on Performance.

Authors: Healey KC, Hatfield DL, Blanpied P, Dorfman LR, Riebe D.

The purpose of this study was to determine whether the use of myofascial rollers before athletic tests can enhance performance.

Twenty-six (13 men and 13 women) healthy college aged individuals (21.56±2.04 years, 23.97±3.98 body mass index (BMI), 20.57±12.21 percent body fat) were recruited. The study design was a randomized, crossover design in which subject performed a series of planking exercises or foam rolling exercises then performed a series of athletic performance tests (vertical jump height and power, isometric force, and agility.) Fatigue, soreness, and exertion were also measured.

A 2 x 2 (Trial x Gender) ANOVA with repeated measures and appropriate post-hoc was used to analyze the data. There were no significant differences between foam rolling and planking for all four of the athletic tests. However, there was a significant difference between genders on all of the athletic tests .

As expected there were significant increases from pre to post during both trials for fatigue, soreness, and exertion. Post-exercise fatigue after foam rolling was significantly less than after the subjects performed planking (p ≤ 0.05). The reduced feeling of fatigue may allow participants to extend acute workout time and volume, which can lead to chronic performance enhancements. However, foam rolling had no affect on performance.

J Strength Cond Res. 2013 Apr 12. The Effects of Myofascial Release with Foam Rolling on Performance.

An acute bout of self-myofascial release increases range of motion without a subsequent decrease in muscle activation or force.

Authors: MacDonald GZ, Penney MD, Mullaley ME, Cuconato AL, Drake CD, Behm DG, Button DC.

The objective of the study was to determine the effect of self-myofascial release (SMR) via foam roller application on knee extensor force and activation and knee joint ROM. Eleven healthy male (height 178.9 ± 3.5 cm, mass 86.3 ± 7.4 kg, age 22.3 ± 3.8 years) subjects who were physically active participated. Subjects' quadriceps maximum voluntary contraction force, evoked force and activation, and knee joint ROM were measured before, 2 minutes, and 10 minutes after 2 conditions: (a) 2, 1-minute trials of SMR of the quadriceps via a foam roller and (b) no SMR (Control). A 2-way analysis of variance (condition × time) with repeated measures was performed on all dependent variables recorded in the precondition and postcondition tests.

There were no significant differences between conditions for any of the neuromuscular dependent variables. However, after foam rolling, subjects' ROM significantly increased by 10° and 8° at 2 and 10 minutes, respectively. There was a significant negative correlation between subjects' force and ROM before foam rolling, which no longer existed after foam rolling.

In conclusion, an acute bout of SMR of the quadriceps was an effective treatment to acutely enhance knee joint ROM without a concomitant deficit in muscle performance.

J Strength Cond Res. 2013 Mar;27(3):812-21. doi: 10.1519/JSC.0b013e31825c2bc1.

Roller-massager application to the hamstrings increases sit-and-reach range of motion within five to ten seconds without performance impairments.

Authors: Sullivan KM, Silvey DB, Button DC, Behm DG.

BACKGROUND: Foam rollers are used to mimic myofascial release techniques and have been used by therapists, athletes, and the general public alike to increase range of motion (ROM) and alleviate pressure points. The roller-massager was designed to serve a similar purpose but is a more portable device that uses the upper body rather than body mass to provide the rolling force.

OBJECTIVES/PURPOSE: A roller massager was used in this study to examine the acute effects on lower extremity ROM and subsequent muscle length performance.

METHODS: Seven male and ten female volunteers took part in 4 trials of hamstrings roller-massager rolling (1 set - 5 seconds, 1 set - 10 seconds, 2 sets - 5 seconds, and 2 sets - 10 seconds) at a constant pressure (13 kgs) and a constant rate (120 bpm). A group of 9 participants (three male, six female) also performed a control testing session with no rolling intervention. A sit and reach test for ROM, along with a maximal voluntary contraction (MVC) force and muscle activation of the hamstrings were measured before and after each session of rolling.

RESULTS: A main effect for testing time illustrated that the use of the roller-massager resulted in a 4.3% increase in ROM. There was a trend for 10s of rolling duration to increase ROM more than 5s rolling duration. There were no significant changes in MVC force or MVC EMG activity after the rolling intervention.

CONCLUSIONS: The use of the roller-massager had no significant effect on muscle strength, and can provide statistically significant increases in ROM, particularly when used for a longer duration.

Int J Sports Phys Ther. 2013 Jun;8(3):228-36.

A Comparasion between static stretch and self-myofascial release in order to improve the range of motion in the hamstrings: A five-week intervention study

Author: Lindström & Persson, Helena & Karolina (Halmstad University, School of Business and Engineering (SET))

Purpose: To determine whether static stretch or SMR, using The Grid (foam roller), were most effective to improve range of motion in the hamstrings.

Participants: Fourteen healthy men and women (26.5±8 years).

Methods: Participants were divided into two groups, performed either static stretch or SMR during five weeks. The participants performed five trials per week, one compulsory with the test leaders and remaining trials by themselves. All subjects were tested (One Leg Raise-test) before and after the study period. Pre-test were performed two separate times, with one day in between. Three tests were measured per leg and day, the average value of the six measurements on each leg were calculated and used as pre-test result. Same procedure during post-test and the average results were compared and analysed.

Results: Both groups showed an improvement in range of motion (ROM) over five weeks intervention, however this improvement was only significant in the stretch group . There was no significant difference in mean difference of improvement between the two groups.

Conclusion: There was no significant different between the methods in improving ROMs in the hamstrings after five weeks intervention.

Thesis, Halmstad University, School of Business and Engineering (SET)

Friday, June 28, 2013

Practical Massage and Corrective Exercises

Erik Dalton recently pointed out a 1916 book by a Norwegian Masseur Hartvig Nissen who was as an instructor for the Harvard University Summer School, teaching massage therapy and Swedish Gymnastics.

Hartvig may as well be the Father of Swedish Massage as he was probably the one who introduced The "Swedish Movement" in the US. In the History section of his book, he described the Ling's school as:

The principal studies for graduation are : Anatomy, Physiology, Pathology, Chemistry, Hygiene, Diagnosis, Principles of the Movement Treatment, and the use of exercises for general and local development. 

It was not, however, until after the middle of the nineteenth century that massage became really known and was considered by the medical profession as a scientific and valuable remedy in the treatment of diseases. 

In the United States massage was hardly known when I arrived here in the early eighties.

I opened an institute, "The Swedish Health Institute for the Treatment of Chronic Diseases by Swedish Movements and Massage," in Washington, where the foreign diplomats assembled for treatment well known to them, and they soon brought scores of the great men and women of the United States to the institute, and gradually the physicians of the city came to inquire into the mode of treatment and send their patients there. 

In March, 1888, I read a paper before the Clinical Society of Maryland, on "Swedish Movement and Massage Treatment," which appeared in several medical journals, resulting in numerous letters from medical men who wanted to know more about it, and urging me to write a manual and also give instructions on the subject, and in 1889 my book, "Swedish Movement and Massage Treatment," was published.

Swedish movements and massage are based on plain physiological laws, and have nothing in common with " magnetism," nor is it " regular gymnastics," nor " rubbing"

I think most of the current massage myths still come from the 19th century, as he wrote:

For instance, in a case of synovitis or glandular enlargement or sprains, etc., the manipulations should always be directed centripetally — toward the heart ; but in case of insomnia, or very painful neuralgia, the manipulation should be directed downward, from the shoulder toward the fingers, ...

Certainly current Swedish massage has other influences, as the movement he described is all in English such as centripetal stroking, kneading, and circular friction. The term petrissage, effluerage, tapotement are not found in his manuals.

It is a delightful reading, he also has written a few other similar books (Hartvig is the Leon Chaitow of 19th century):

Here are some other  interesting books:

  • Complete Course in Massage, Swedish Movement and Mechanical Therapeutics. With a subtitle based on the teachings of Peter Henrik Ling, founder of the Royal Central Gymnastic Institute, Stockholm, Sweden and supplemented by original discoveries and teachings. A practical course in manual treatment as applicable to surgery and medicine. Written by James Gwalia, published in Canada in 1911. In this book, the usual terms petrissage, effluerage, tapotement can be found under kinds of movement (page 6)

The nomenclature adopted in the description of the manipulations is that which isgenerally recognised both in Europe and America ; and although the use of foreignwords may be open to objection, still, it seems preferable to retain them, as they constitute a kind of volapuk among practitioners of the method throughout theworld, 

Effleurage, petrissage, tapotement, vibration, and massage a friction are the names given to these manipulations,

Digital kneading, instead of petrissage

Palmar stroking, instead of effluerage

Ulnar percussion, instead of tapotement

Homo elasticus: The catapult effect of throwing

Humans are the only species that are able to throw objects incredibly fast and with great accuracy. Darwin noted that the unique throwing abilities of humans, which were made possible when bipedalism emancipated the arms, enabled foragers to hunt effectively using projectiles.

Researchers from George Washington University and Harvard University, led by Neil Roach investigated when, how and why humans evolved the ability to generate high-speed throws. Their study was published in the June edition of Nature.

Using experimental studies of humans throwing projectiles the authors showed that our throwing capabilities largely result from several derived anatomical features that enable the storing and releasing energy in the tendons and ligaments crossing the shoulder. This energy is used to catapult the arm forward, creating the fastest motion the human body can produce, and resulting in very rapid throws.

The authors showed that this ability to store energy in the shoulder is made possible by three critical changes in our upper bodies that occurred during human evolution:
 1. the expansion of the waist,
 2. a lower positioning of the shoulders on the torso, and
 3. the twisting of the humerus.

 All of these key evolutionary changes first appear together approximately 2 million years ago in the species Homo erectus.

Roach, N.T., Venkadesan, M., Rainbow, M.J., Lieberman, D.E. 2013. Elastic energy storage in the shoulder and the evolution of high-speed throwing in Homo. Nature.

Friday, June 21, 2013

Massage and Body Image

Body image or the conscious sense of our body, is our perception of and beliefs about our own body’s appearance. Or simply the feeling we have of our own body. Constructed by the brain from past experience and present sensations, the body image is a mental representation of our physical appearance, and is a fundamental aspect of self-awareness and self-identity. Body image depends on our internal ‘body maps’ that are modulated by somatic and proprioceptive input.

The term “body image” was introduced in 1935 by Paul Schilder, an Austrian American neurologist, which refers to the mental pictures we have of our bodies or the way our bodies appear to us. It is the set of beliefs we hold about ourselves. The topic of body image is covered extensively in recent popular books: The Body has A Mind of Its Own by Sandra and Matthew Blakeslee and The Brain that Changes Itself by Norman Doidge. Distorted body image Body image can be disrupted in people with pain disorders, and the disruption can have profound physical and psychological effects. For example, body image distortion is implicated in people with eating disorders (such as anorexia nervosa). Anorexics experience their bodies as fat even when they are on the edge of starvation.

Body image can be distorted in people suffering from chronic pain, as complex regional pain syndrome, phantom limb pain, and back pain. Pain is commonly experienced as projected into the body. People say “My back is killing me!”, but not “My pain is killing me.” However people having phantom limb pain show that we don't need a body part or even pain receptors to feel pain. The only factor that controls this pain is our body image. Physician VS Ramachandran said that pain is an opinion on the organism's state of health rather than a mere reflexive response to injury. The brain gathers evidence from many sources before triggering pain. Pain, like the body image, is a construct of our brain. Therefore he successfully used a mirror box to modify a body image and eliminate the phantom and its pain.

Dr. Lorimer Mosely, a scientist from Australia, have demonstrated visual distortions of the body image in patients suffering from chronic pain can significantly affect their perception of painful sensations. People with CRPS and phantom limb pain, were shown to have decreased tactile acuity and distorted body image for the affected limb. CRPS and phantom limb pain patients tend to perceive the painful or phantom limb as being bigger than it really is. Lorimer also tested to use the mirror box to make chronic pain in a real limb disappear. He asked his patients to simply imagine moving their painful limbs, without executing the movements, in order to activate brain networks for movement. The patients also looked at pictures of hands, to determine whether they were the left or right, until they could identify them quickly and accurately. They were shown hands in various positions and asked to imagine them for fifteen minutes, three times a day. After practicing the visualization exercises they did the mirror therapy, and with twelve weeks of therapy, pain had diminished in some and had disappeared in half. Lorimer also demonstrated that people with chronic back pain has disrupted body image. The patients were unable to clearly delineate the outline of their trunk and stated that they could not ‘‘find it”. This finding raises the possibility that training body image or tactile acuity may help patients in chronic spinal pain.

Massage is well known to make people feel more relaxed and better about themselves. While there are many evidences that suggest positive effects of massage on psychological health, several studies now showed the positive effects of massage on body image. Researchers have started to investigate massage as a way of improving body image. Thomas Pruzinsky in his book Body Image: A Handbook of Theory, Research, and Clinical Practice, writes that massage therapy is a somatic approach that is helpful in positively affecting body image “by helping the client reconnect to the body in a very concrete manner.” Dr. Marcia Hutchinson, author of the book Transforming Body Image, suggested that since body image is a product of the imagination, it can also be changed using the imagination. Hutchinson describes an exercise called “imaginal massage” in which you visualize a massage occurring allowing the hands of the massage therapist to transfer healing to your bodymind allowing acceptance of your body.

A study conducted by the Department of Nursing, Wonkwang Health Science College in South Korea evaluated the effect of massage on abdominal fat, waist circumference and body image of post-menopausal women. The participants received a full body massage once a week and massaged their own abdomens twice a day during a six week experiment. Half the group received massages with grapeseed oil. The other half received an aromatherapy massage with a blend of essential oils. Both groups felt better and improved body image after the treatment, but the group receiving aromatherapy massage showed significant changes across all areas – body image, waist circumference and abdominal fat.

An  in-depth interviews study conducted by Mary Bredin in UK explored the experiences of breast loss in mastectomy with particular focus on body image issues in three women. A pilot study also investigated a massage intervention as a means of helping them adjust to living with their changed body image. The study showed that the availability of a body-centered therapy such as massage might help with certain aspects of life adjustment.

The Touch Research Institute in Miami studied the effect of massage on people with eating disorders including bulimia (overeating and vomiting) and anorexia. Body image dissatisfaction contributes to the development and maintenance of  these eating disorders. Adolescents with bulimia who received one month of twice weekly massages plus their standard daily group therapy treatment (versus adolescents with bulimia who only received the standard group therapy) had  fewer symptoms of depression,  lower anxiety levels, and lower stress hormone levels (urinary cortisol levels). Their eating habits also improved, and their 
body image was less distorted. In another study on adolescents with anorexia at the same hospital the mas- 
saged women (versus the standard group therapy control women) reported lower anxiety levels and had lower  stress hormone levels.Over the five-week treatment period, they also reported decreases in body dissatisfaction on the Eating Disorder Inventory and showed increased dopamine and norepinephrine levels.  

Massage may improve body image by decreasing negative body image and increasing positive body image. A positive body image accepts the body and respects it by attending to its needs and engaging in healthy behaviours. In a qualitative study, many college women with a positive body image indicated that they regularly received massages to take care of, appreciate, and pamper their body, showing that they view massage as pleasurable. Massage treatment could function as a positive feedback cycle, by not only lessening negative feelings about the body through increasing body acceptance, but also by associating emergent positive feelings with the body and partaking in a behaviour that honours and relaxes the body. Massage could also improve body image by reducing women’s objectification of their body. A woman with a negative body image often views her body as an object to be evaluated. Women in western cultures learn to survey their bodies through the eyes of their culture to avoid negative judgment. A woman can feel that her body brings unhappiness and shame because it is perceived as not measuring up to society’s ideals. A woman who receives a massage, can let her body becomes a vehicle for the experience of pleasure. Women who hold a negative body image may avoid massage due to shame or embarrassment.

A study conducted by scientists from Bridgewater State University, MA, USA looked at the effect of massage on state body image. The study recruited forty-nine female university students; they were randomly assigned to either a massage condition or a control condition. It was hypothesized that participants in the massage condition would report improved state body image following the intervention when compared to participants in the control condition. As predicted, participants in the massage condition reported a more favourable state body image than participants in the control condition post-manipulation. Certain body image evaluations were moderately associated with views that massage is pleasurable, with the link between Body Areas Satisfaction and viewing massage as pleasurable reaching significance.

In this study, it is conclusive that the female university students reported feeling better about themselves and their bodies after having massage. Meanwhile the control group, who did not receive massage, showed no change in their attitudes. A woman’s negative view of her body can make the body seem untouchable and grotesque. Massage can be a vehicle to have a positive experience the body could potentially break through these negative body image attitudes. Nevertheless, a woman who holds negative thoughts about her body may be less apt to seek out massage therapy. This attitude will need to be addressed for massage to be a viable therapeutic option. In addition to relaxation and a shift in focus from the body as an object, regular massage could help change negative thoughts about the body as the body becomes associated with the good feelings that it brings through the massage experience.


Bredin M. Mastectomy, body image and therapeutic massage: a qualitative study of women's experience. J Adv Nurs. 1999 May;29(5):1113-20.

Cash TF, Pruzinsky T. Body Image: A Handbook of Theory, Research, and Clinical Practice. Guilford Press, 2004.

Dunigan BJ, King TK, Morse BJ.A preliminary examination of the effect of massage on state body image. Body Image . 2011 8(4):411-4.

Field T, Schanberg S, Kuhn C, Field T, Fierro K, Henteleff T, Mueller C, Yando R, Shaw S, Burman I. Bulimic adolescents benefit from massage therapy. Adolescence. 1998 Fall;33(131):555-63.

Hart S, Field T, Hernandez-Reif M, Nearing G, Shaw S, Schanberg S, Kuhn C. Anorexia nervosa symptoms are reduced by massage therapy.Eat Disord. 2001 Winter;9(4):289-99.

Hutchinson MG. Transforming Body Image: Learning to Love the Body You Have. The Crossing Press, 1985.

Kim HJ. Effect of aromatherapy massage on abdominal fat and body image in post-menopausal women. Taehan Kanho Hakhoe Chi. 2007 Jun;37(4):603-12. [Article in Korean] 

Lotze M, Moseley GL. Role of distorted body image in pain. Curr Rheumatol Rep. 2007 Dec;9(6):488-96.

Moseley GL. I can't find it! Distorted body image and tactile dysfunction in patients with chronic back pain. Pain. 2008 Nov 15;140(1):239-43.

Wood-Barcalow, N. L., Tylka, T. L., & Augustus- Horvath, C. L. (2010). ’But I like my body’: Positive body image characteristics and a holistic model for young-adult women. Body Image, 7, 106–116.

Wednesday, June 12, 2013

A Journey in Fascia Wonderland

This article is based on Robert Schlep’s talk at the 3rd World Fascia Congress in Vancouver 2012 titled: Alice in Wonderland- Getting curioser and curioser.

The scientific world and the clinician world rarely meet, and the fascia congress is one of the important events that tried to make scientists and manual therapists meet and started to talk to each other. Most manual therapists or bodyworkers choose to be in the complementary and alternative groups. The field is usually dominated by different schools, where the teachers or charismatic founders are regarded as the ‘knowledge’ authority. (Whitney Lowe called this The Sage on the Stage). The teachers are quite skilful but sometimes the concepts they proposed stretch a bit beyond from the scientific reality. For example Dr. Andrew Taylor Still, the founder of Osteopathy, and Dr. Ida Rolf, the founder of Rolfing. They have very profound clinical knowledge, and they tried to explain what they are doing based on their knowledge at that time. Myofascial release was thought to be able to change the state of the ground substance from gel to sol, or able to loosen the cross links of the collagen fibre. But most of these theories or hypotheses came from their own intuition without solid scientific proof.

The first fascia congress held in Boston, in 2007, and covered by the prestigious Science magazine with an article titled “Cell Biology Meets Rolfing”. The article described the opportunity but also the challenges of how scientists and clinician can meet and talk to each other. The two groups reach out to each other, with a hope to provide fruitful exchanges of ideas and experiences. Clinicians such as Schleip have travelled from the ‘alternative world’ to the scientific world by doing a PhD degree in fascia biology. Meanwhile scientists such as Tom Findley, a medical researcher, travelled to the clinician world by studying Rolfing for several years. Robert compared himself as Alice in Wonderland, he has travelled in the Scientific Wonderland, and came back telling stories about strange scientists he met to his fellow clinicians.

Robert gave three specific examples of what he as a clinician had been able to learn from the scientific world. 

(1) Fluid dynamics
Water constitutes around 68% of the fascial tissuesvolume . Fascia regulates the flow of fluid in the extracellular matrix, and fluid flow can causes fascial remodelling. A study conducted by Schleip and co-workers at the University of Ulm (Figure 1) showed that, in an in vitro study using fascia from animal, that during the tissue loading (fascia stretch) water is extruded from the tissue and this tends to contribute to a temporary decrease in tissue stiffness (i.e. tissue softening) immediately after the stretch. The findings also found that that after the stretch, the stiffness of the tissue increases and it also regains a gradual rehydration. This phenomenon is due to the behaviour of the ground substance in the extracellular matrix which prevented from absorbing fluid by tension that fibroblast cells put on extracellular matrix fibres. When this tension is relaxed, the extracellular matrix can absorb fluid rapidly.

The implication is that when Robert applied pressure through his elbow to the thoracolumbar fascia, he now paid more attention to the fluid dynamics, rather than only trying to melt the tissue or breaking up the fibrous tissues, or stimulating the mechanoreceptors. Now Robert works more gently and more slowly. We should now thinking not only about stimulating the mechanoreceptors or golgi tendon organ, but be aware of how the fluid moves.

Another research by Melody Swartz (from Lausanne, Switzerland) described how subtle change in fluid shear on cell culture has a profound change in the fibroblasts. Fibroblasts are most responsive to the detection of fluid shear - i.e. to the slow motions of the water around them - as sensed through their antenna-like cilia (soft tentacle). It is indicated that a large portion of the impact of collagen stretch is less due to the direct effect of transmission of that stretch to the cell membrane, but rather to the sensation of the fluid shear which is induced by the collagen fibre reorientation which is then sensed by the hair-like cilia.

This idea can be illustrated as follow: imagine how much the hairy tip of a painter's brush would bend if you move it at a steady speed through a fluid medium. Or imagine moving a finger through yoghurt. Both the speed as well as the viscosity of the fluid medium will influence the amount of shear. The clinical implication is that if you move very slowly at a constant speed through a dense tissue area (e.g. with the therapist's knuckle or a foam roll), then the tiny cilia of the fibroblasts will be bent only very gently by the resulting fluid shear, and this seems to stimulate them to produce an enzyme (MMP-1) which starts to break down excessive collagen in the next few hours.

(2) A tool for evaluating the stiffness of tissue
Most palpation that we do is subjective, and therapists cannot remember how ‘stiff’ is the tissue before and after treatment (or even a week after treatment). Therapists should have a more objective tool to measure the therapeutic response. Robert suggested Myoton Pro, a tool recently developed to measure the tissue stiffness. The quantitative digital measurement provided by this ‘myometer’ proved to be reliable and useful for assessing biomechanical properties of myofascial tissues. This tool works by creating a constant pre-load of the soft tissue via a movable indentation probe, which is then rapidly released and the tissue response (damping oscillation) of the tissue is measured. This kind of tool could provide a more objective measurement on the effectiveness of our treatment.

(3) Innervations of the lumbar fascia
Prof. Siegfried Mense, in his lab. in Heidelberg, Germany, showed that the thoracolumbar fascia is densely innervated. Another recent study also from Heidelberg led by Jonas Tesarz et al. (2011), and published in Neuroscience journal, quantified the amount of innervation of the thoracolumbar fascia (TLF). Using calcitonin gene-related peptide (CGRP) and substance P (SP)-containing free nerve endings, they quantified the amount of nerve endings in the TLF of rat. They showed that the TLF is a densely innervated tissue with marked differences in the distribution of the nerve endings over the fascial layers (Figure 2). 
Figure 2. The distribution of CGRP and Substance P (SP)-immunoreactive nerve fibers in the Thoracolumbar Fascia (redrawn from Tesarz et al., 2011).
(a) Mean nerve fibre length of CGRP and SP. Almost all fibres were found in the outer layer of the fascia and the subcutaneous tissue. The middle layer was free of SP-positive fibres.
(b) Distribution of CGRP and SP-containing receptive free nerve endings expressed as percent of the total number of CGRP- or SP-containing fibres in each fascia layer. SP-containing free nerve endings were restricted to the outer layer of the thoracolumbar fascia and the subcutaneous connective tissue while CGRP-containing free nerve endings were also found in the inner layer of the thoracolumbar fascia.

They distinguished three layers:
(1) outer layer (transversely oriented collagen fibers adjacent to the subcutaneous tissue),
(2) middle layer (massive collagen fiber bundles oriented obliquely to the animal's long axis), and
(3) inner layer (loose connective tissue covering the paraspinal muscles).
It is the subcutaneous tissue and the outer layer that showed a particularly dense innervation with sensory fibres. SP-positive free nerve endings-which are assumed to be nociceptive-were exclusively found in these layers.
Because of its dense sensory innervation, including nociceptive fibres, the TLF may play an important role in lower back pain. Most of the myofascial pain may come from the superficial layer. This suggests that it may be most effective to work more superficially, stimulating proprioceptive nerve endings and reaching to the nociceptor. For many years Robert taught his students to work deeper for more profound change, but now based on this new finding, he often works more superficially to be more effective. 

In addition, Robert also suggested three areas of consideration that scientists can learn from therapists:

(1) The influence of sympathetic activation on and fascial tonicity
Vladimir Janda, suggested a close relationship between the autonomic nervous system (ANS) and fascial tonicity, implying that sympathetic activation may lead to an increased cellular contraction within fascial tissues. However it was not until recent findings that suggests that sympathetic activation induces an increased TGF-β1 expression; and- since this cytokine is known as the most potent stimulator of myofibroblasts contraction- that this may also lead towards an increased fascial contractility.
Figure 3 illustrates a possible two-way interaction between ANS activation and fascial tonicity. Besides the influence of the ANS on cellular contractility in fascia, this diagram also emphasizes the potential influence of therapeutic fascial stimulation on ANS tuning. Stimulation of non-nociceptive mechanosensory free nerve endings can influence ANS tuning. In addition, stimulation of Ruffini corpuscles- which are reportedly particularly sensitive to slow shear application - tends to inhibit sympathetic activation.

Figure 3. Proposed interaction between the autonomic nervous system and fascial tonicity. Sympathetic activation tends to activate TGF-β1 expression (as well as probably other cytokines) in the body, which has a stimulatory effect on myofibroblast contraction, thereby leading to an increase of fascial stiffness. In addition, shifts in the autonomic nervous system state can induce changes in pH, which affects myofibroblast contraction as well. Skilful therapeutic stimulation of mechanoreceptors in fascia - particularly of Ruffini or free nerve endings - can induce changes in the autonomic nervous system. Redrawn from Schleip et al. (2012).

(2) The Rhythmic oscillations of fascial tissues
When connective tissue cells were put together in a cell culture medium with a collagen grid, they tend to show periodic oscillations. In particular, it has been shown that they expressed rhythmic calcium oscillations which were accompanied by contractions of the cells. A study by Follonier et al. (2010) demonstrated that myofibroblasts tend to oscillate in such an environment in synchronicity, when they were in close contact with each other (Fig. 4). The observed oscillations had a mean period length of 100 second. It is an intriguing question whether this very slow rhythm observed in these cell cultures - with one cycle taking more than one and a half minutes- could be related to the so-called “long tide” oscillations in biodynamic craniosacral therapy. The so-called “breath of life” has a deep and slow rhythmic impulse expressed about once every 100 seconds. This needs to be tested in real-world, whether myofibroblasts can express this behaviour, and related to the "breath of life". Or this is just a palpatory illusion of the therapist.

Figure 4. Myofibroblasts expressed rhythmic calcium oscillations. The graph on the left showed recording of fluorescence activity of five individual cells, which were previously stained with Flura-2. The analysis revealed a common peak around 99 ± 32 seconds of the cells, as well as asecond maximumof 221 ± 21 s. Graphics based on Follonier et al. (201 0).

(3) Fascia research networking
Finally, scientists should collaborate more following the network properties of the connective tissues. Competition in the scientific world is very strong (sometimes can be ruthless), researchers compete to publish first, therefore they usually never share their findings or data. This is also instigated by competition for funding. Scientists should be more open to their work and collaborate more, without the fear of other people trying to steal their ideas. They should imitate the network tissues they are working on by forming a network of exchange of information.


Follonier, C.L., Buscemi, L.,Godbout, C., et al., 20 I 0.A new lock step mechanism of matrix remodeling based on subcellular contractile events. J. Cell Sci. 123, 1751-1760.

Schleip R, Duerselen L, Vleeming A, Naylor IL, Lehmann-Horn F, Zorn A, Jaeger H, Klingler W. Strain hardening of fascia: static stretching of dense fibrous connective tissues can induce a temporary stiffness increase accompanied by enhanced matrix hydration. J Bodyw Mov Ther. 2012 Jan;16(1):94-100. doi: 10.1016/j.jbmt.2011.09.003.

Tesarz J, Hoheisel U, Wiedenhöfer B, Mense S. Sensory innervation of the thoracolumbar fascia in rats and humans. Neuroscience. 2011 Oct 27;194:302-8. doi: 10.1016/j.neuroscience.

Schleip, R., Jager, H., Klinger, W. 2012. Fascia is Alive. In: Fascia: The Tensional Network of the Human Body. Churchill Livingstone.

Originally published in Terra Rosa E-magazine No. 12, June 2013. 

Watch Robert Schleip's lecture 

Pseudoscience and Pseudoskeptic

Early knowledge on massage therapy has been mostly based on what therapists observed or experienced. As with other health disciplines, early therapists present their hypothesis based on what they believed is happening. Nothing scientific, but some become myths that are still being passed on. For example, massage can expel toxins out of the body. It turns out some of these myths are completely wrong.

Some of massage teachers then become the ‘authorities’ and start to develop their own modalities and schools, and frequently used pseudoscience to describe what they are doing. Pseudoscience is a claim, belief, or practice which is presented as scientific, but does not adhere to a valid scientific method. It lacks supporting evidence or plausibility, cannot be reliably tested, or otherwise lacks scientific status ( 

A typical example is linking a modality with quantum physics, the authority would quote something about the efficacy of the technique is due to the reduction in entropy, engaging fractal structure, based on relativity, uncertainty principle, and so on that all sound scientific but got no scientific grounds at all. Pseudoscience holds back the progress in massage therapy.

However many great researchers have contributed to the better understanding of what is happening with massage. Much research has been conducted for the past 20 years to show the efficacy of massage through clinical trials and also trying to figure out the mechanisms on what’s happening. For example, in the field of fascia research there has been tremendous research on the basic understanding on the anatomy and physiology of fascia.

But, there are another group of people who claimed they understand science and started to discredit massage therapy research. E.g. massage has no benefit at all except for relaxation, most research studies on the efficacy were flawed, fascia research is overrated and of no use, stretching is no use, palpation is just an illusion, etc. 
Unfortunately many therapists buy into those arguments, some believed they liked to be challenged, and encouraged critical thinking as they dare to disagree. However most of this ‘critical thinking’ is just another presentation of a biased view.

What seems to be a skeptic turn out to be pseudoskeptic, which usually made negative claims without bearing the burden of proof of those claims. Pseudoskepticism (or pseudoscepticism) refers to arguments which use scientific-sounding language to disparage or refute given beliefs, theories, or claims, but which in fact fail to follow the precepts of conventional scientific principles. What you can see directly is that pseudoskepticism usually involves "negative hypotheses" - theoretical assertions that some belief, theory, or claim is factually wrong - without satisfying the burden of proof that such negative theoretical assertions would require. Some of the characteristics include double standards in the application of criticism, tendency to discredit, rather than investigate, and suggesting that unconvincing evidence is grounds for completely dismissing a claim. (

Pseudoskepticism is related to pseudoscience as both advocate poor scientific reasoning. They are impediment to growth and progress. Some like to be challenged, however one should also understand that doesn’t mean it follows any scientific principle. 

Critical thinking? All they do is just criticize and offer nothingI appreciate much more researchers who are doing actual research and trying to figure out what's happening rather.

Just as much of it needs science, massage is more as an art as well. Joe Muscolino said “Be open-minded, but don‘t be so open that your brains fall out”.

A quote from Zhiangzu illustrates this:
Life is finite, but knowledge is infinite. To pursue the infinite with the finite, how dangerous that is! To believe that one truly knows, how extremely more dangerous that is

Originally published in Terra Rosa E-magazine No. 12, June 2013. 

Fascia and Reflexology

Fascia, as we all now know, is a seamless web of connective tissue that covers, connects, and holds the muscles, organs, and skeletal structures in our body. Fascia envelopes every structure in the body, each nerve, bone, muscle, organ of the body is surrounded by fascia.  Fascia can be found superficially and deep within our body. Superficially, a layer of fascia can be found just under the skin sandwiched between two layers of a honeycomb-like structure that contains fat tissue (See Figure 1). Deeper within the body, fascial planes wrap around the muscles (Muscolino, 2012).

Figure 1. Cross-section from the skin to musculature, showing fascial membranes and rtetinacula cutis fibres. Illustration by Giovanni Rimasti, modelled from an illustration by Luigi Stecco. (From Muscolino, 2012, Used with permission).

Generally fascia is distinguished into superficial and deep fascia. The superficial fascia is located just underneath the skin. According to the Stecco studies, the superficial fascia is a bilaminar membranous layer rich in elastic fibres lying within two layers of what is called the “retinacula cutis”. The superficial fascia together with the superficial and deep retinacula cutis layers is commonly known as the hypodermis.  Deep fascia is a tough dense connective tissue below the superficial fascia, and it envelops the underlying muscles that are deep to the skin or envelops periosteum of the bone in regions. For a more thorough explanation on the different layers of fascia, read Joe Muscolino’s article Fascial Structure (originally published in the Massage Therapy Journal of the American Massage Therapy Association).

A significant layer of fat in the superficial fascia is distinctive to human, compensating for the lack of thick body hair, and plays an important role in heat insulation. The superficial fascia also conveys blood, lymphatic vessels and nerves to and from the skin and often promotes movement (gliding) between the skin and underlying structures.  It will be mostly affected by light touch techniques (e.g. lymphatic drainage therapy, Bowen therapy, myofascial release). By contrast, the deep fasciae in the limbs and back are typically dense connective tissue sheets that have large numbers of closely packed collagen fibres (Benjamin, 2009). The deep fascia in contrast to the superficial fascia has a robust, multilayer collagen fibre structure and relatively fewer elastic fibres. The deep fascia is responsible for mechanical function of force transmission and a possible proprioceptive role which is due to the large numbers of embedded mechanoreceptors. It is more probable that this layer can be affected by deep massage techniques, such as deep tissue work or friction concentrated in limited areas.

In most parts of the body, the superficial fascia is an elastic connective tissue layer surrounded above and below by adipose tissue. However at the palm and sole of the foot, the skin is tightly bound to the underlying tissues to prevent or restrict movement (Figure 2) . If movements were allowed to occur here within fascial planes, then the hands or feet would not been able to have a firm grip. The retinacula of the retinacula cutis layers in the palms and soles are much thicker. They bind the superficial fascia to the deep fascia and adipose tissue is sparse beneath the skin. It is even absent at the finger creases on the palmar sides of the interphalangeal joints, so that the skin immediately covers fascial tendon sheaths (Benjamin, 2009). See also Figure 2 and Figure 3 of Mike Benjamin’s article The fascia of the limbs and back . (The article also provides a thorough anatomical view of the fascia of the hands and feet) Pavan et al. (2011) studied the mechanical properties of the plantar aponeurosis.

Figure 2. A dissection view of the plantar aponeurosis  (Photo by Carla Stecco, Used with permission).

According to Julie Day, a physiotherapist working with the Stecco group in Italy: “The fact that the superficial fascia and the deep fascia almost fuse together in the soles of the feet and the palms of the hand could be an explanation for why working deeply in these areas, as in reflexology, can affect areas that are distant from the area we work on.” Julie who presented Fascial Manipulation at the AAMT conference said that she had often used plantar reflexology in the past and but, at that time, had not found any plausible anatomical explanations for its effectiveness. Reflexology is a relatively easy technique to learn and it can either be incorporated within a massage session or as a specific session apart.

The general belief in reflexology is that each part of the body is interconnected through the nervous system to the hands and feet. Stimulating specific reflex points in the feet is believed to be able to bring relieve to poorly functioning areas of the body. However there is no evidence of such connections between certain parts of the feet and hands and the various organs in the body.

According to Dr. Ida Rolf in “Rolfing and Physical Reality”: "The meridian points and reflex points in the feet are most likely end-points of myofascial strain, the result of imbalance which transmits its difficulty in compensating pattern through the body to the surface. Fascial planes may be the route of mechanical transmission of pain." She also mentioned "Foot reflexes are peaks of strains. They are nothing mystical; they are where strain goes in the foot. If you are relieving strain above the reflex points (for example in the ankle and shin) you will relieve those points of strain in the sole of the foot. When a weight goes down and dies in some place, it becomes a reflex point." And "I think that many if not all reflex points in the foot are simply points where gravitational strain inserts and comes together. They are the end of the line we call balance"

So next time we work on reflexology think of the connective tissue!

Mike Benjamin. The fascia of the limbs and back – a review. J Anat. 2009 January; 214(1): 1–18. doi:  10.1111/j.1469-7580.2008.01011.x
Julie Day. What’s New in Fascial Anatomy. Terra Rosa E-magazine No. 8, July 2011.
Joe Muscolino. Fascial Structure. Massage Therapy Journal, Spring 2012.
Pavan PG, Stecco C, Darwish S, Natali AN, De Caro R.  Investigation of the mechanical properties of the plantar aponeurosis. Surg Radiol Anat. 2011 Dec;33(10):905-11. doi: 10.1007/s00276-011-0873-z. 
Ida Rolf. Rolfing and Physical Reality. Edited by Rosemary Feitis. Healing Arts  Press, 1978, 1990.

Originally published in Terra Rosa E-magazine No. 12, June 2013. 

Friday, February 8, 2013

Brief psychosocial education reduced the incidence of low back pain?

Can a brief psychosocial education reduce the incidence of low back pain?
By Terra Rosa

A paper published in BMC Medicine in 2011 "Brief psychosocial education, not core stabilization, reduced incidence of low back pain: results from the Prevention of Low Back Pain in the Military (POLM) cluster randomized trial" has made a bit of headline and controversy among manual therapists. This paper is an open access manuscript, and can be read here

The title of the paper suggests that core stabilization doesn't work, but a brief one-off 'psychosocial' education session can lower the incidence of low back pain (LBP). People then start to jump into a big conclusion, and make claims that specialized core training is a waste of time, is no better than traditional exercise, but one session of 45 mins of ‘psychosocial’ education can reduce the incidence of low back pain by up to 5%!

Is that really that powerful? You sit in a seminar room and got lectured for 45 mins about low back pain, its anatomy, its evidence-based treatment and how to avoid it. Then somehow this 'psychosocial' education 'stayed' in your brain and even after two years it can reduce the incidence of low back pain.

Seems too good to be true, but from my statistical re-analysis of the data, the results are really not that great. (I have the statistical background to do this analysis, see below for more details or  read this document LBP data analysis)

My analysis suggested that the differences in LBP incidence between all 4 treatments are small (traditional lumbar exercise (TEP), traditional lumbar exercise with psychosocial education (TEP+PSEP), core stabilization exercise (CSE), or core stabilization with psychosocial education),  and not statistically different.

My view is that the authors have stretched the results a bit far and made a bold conclusion that a brief psychological education can lower the incidence of LBP. Let's be serious if you are briefed in a 45 mins session on the evidence-based treatment of LBP, will you still remember it after a month?

There are various limitations in this study, as it was carried out on a military population, and the results' differences are not huge. Scientists nowadays like to made a bold controversial statement, sometimes stretching the results a bit further. I once read a suggestion that a bold statement ...can add a little spark to your paper.

Details of Statistical analysis

From the paper, the clinical method was described as follows:

"The Prevention of Low Back Pain in the Military study was a cluster randomized clinical study with four intervention arms and a two-year follow-up. Participants were recruited from a military training setting from 2007 to 2008. Soldiers in 20 consecutive companies were considered for eligibility (n = 7,616). Of those, 1,741 were ineligible and 1,550 were eligible but refused participation.

For the 4,325 Soldiers enrolled with no previous history of LBP average age was 22.0 years (SD = 4.2) and there were 3,082 males (71.3%).

Companies were randomly assigned to receive

  • traditional lumbar exercise (TEP), 
  • traditional lumbar exercise with psychosocial education (TEP+PSEP),
  • core stabilization exercise (CSE), or
  • core stabilization with psychosocial education,

The psychosocial education session occurred during one session and the exercise programs were done daily for 5 minutes over 12 weeks.The primary outcome for this trial was incidence of low back pain resulting in the seeking of health care.

And here are the Results:

"There were no adverse events reported.

Evaluable patient analysis (4,147/4,325 provided data) indicated no differences in low back incidence resulting in the seeking of health care between those receiving the traditional exercise and core stabilization exercise programs.

However, brief psychosocial education prevented low back pain episodes regardless of the assigned exercise approach, resulting in a 3.3% (95% CI: 1.1 to 5.5%) decrease over two years (numbers needed to treat (NNT) = 30.3, 95% CI = 18.2 to 90.9)."

Now, here is when statistical analysis can be interpreted differently:

"Results from the generalized linear mixed model indicated that Soldiers in the combined exercise and psychosocial education groups (CSEP + PSEP and TEP + PSEP) were similar,
but experienced an average of 0.49 fewer months with incidence of LBP (95% CI: 0.003 to 0.983, P = 0.048) in comparison to those not receiving PSEP. "

I analysed the data from Table 3 of George et al. (2011). Since I do not have all other data, I did a simple linear mixed model:

Percent LBP incidence = Treatment (Fixed effect) + company (random effect)

The model said that the percent of LBP incidence is a function of the treatment (which we called fixed effect) and company (called random effect, because the company or group of people can behave differently). This document (LBP data analysis) shows the results of my statistical analysis.

The results of my statistical analysis: While the model says that TEP + PSEP will decrease the mean of incidence by 2% decrease , they are not statistically different from other treatments. All the parameter estimates from the linear model indicated that the coefficients are not statistically significant. Now we can do another statistical test to see if there are differences between treatments.

The first is the usual Student's t-test at the level of 0.05 (95 percent confidence interval, or 95% of the time it does not happen by random chance).

Although TEP+PSEP has a lower mean (14%), it is not statistically different from CSEP+PSEP. In addition, core stabilisation (CSEP), traditional exercise program (TEP), and (CSEP + PSEP) are not statistically different.

If we used another more rigorous statistical Tukey HSD test, which compares all the treatments, the result shows that the means for all treatments are similar, or not significantly different!

Since I do not have the raw data, I can only analyse what was given in the paper, the percentage of LBP incidence (after 2 years of trial). My analysis suggests that the differences in LBP incidence between all 4 treatments are small, and are not statistically different.

The authors then made another step in generalising the psychosocial education (PSEP), by collapsing the treatment into 2 groups! Having psychosocial education (yes or no) or core stabilization (yes or no). Really, there are 4 separate treatments in different groups of people, and you can't simply group them for 'more efficient communication of results'. This should make PSEP stands out, but even with this grouping, the difference between CSPE and PSEP is only 1.8% (CSEP mean incidence of LBP 16.7%), and psychosocial education (PSEP mean incidence 14.9%). Then the authors 'adjust' the baseline and suggested that PSEP was estimated as having 3% lower LBP incidence.

"The analyses of the four intervention groups suggested a pattern that allowed for more efficient communication of results by collapsing the intervention groups into those receiving any core stabilization (CSEP - yes or no) or any psychosocial education (PSEP - yes or no). There were no differences between the TEP + PSEP and CSEP + PSEP groups, but chi-square test indicated that receiving the PSEP program with any exercise program was protective of LBP incidence (Chi-square = 5.56, P = 0.018; and 5.05, P = 0.025 when adjusted for intracluster correlation) in comparison to those not receiving PSEP. Furthermore, after adjusting for demographic and baseline levels of clinical variables, the protective pooled effect of any PSEP was estimated at 3.3% (95% CI: 1.1 to 5.5%) decreased LBP incidence over two years (P = 0.007). This effect corresponds to numbers needed to treat (NNT) of 30 (95% CI = 18.2 to 90.9)."

Readers interested in the science and the process of an article review, should also read the comments by reviewer Dr. Raymond Ostelo who expressed a skepticism on the effect of a 1 session of education and questioning the "collapsing" intervention group:

I am not sure what to make out of this, but my view is that the authors have stretched the results a bit far and made a bold conclusion that a brief psychological education can lower the incidence of LBP. Let's be serious if you are briefed in a 45 mins session on the evidence-based treatment of LBP, will you still remember it after a month? The statistical difference is small and probably makes not much of a difference.

There are various limitations in this study, as it was carried out on a military population, and the results' differences are not huge. Scientists nowadays like to made a bold controversial statement, sometimes stretching the results a bit further. I once read a suggestion that a bold statement ...can add a little spark to your paper.

Also consider the conclusions other LBP studies conducted by the same group of authors (using the same military group). There are many other factors that influenced the results.
Effects of traditional sit-up training versus core stabilization exercises on short-term musculoskeletal injuries in US Army soldiers

"soldiers who completed the TEP and experienced a low back injury had more days of work restriction: 8.3 days (SD=14.5) for the TEP group and 4.2 days (SD=8.0) for the CSEP group."
Predictors of Occurrence and Severity of First Time Low Back Pain Episodes: Findings from a Military Inception Cohort

In this article, the authors said:
"Education level and physical fitness were consistent predictors of pain intensity, while gender, smoking status, and previous injury status were predictors of disability. Gender, smoking status, physical health scores, and beliefs of back pain were consistent predictors of psychological distress. "

OK, so is psychosocial education not important? I didn't say so, but the authors' suggested 3 references that deal with this issue. And what can be learnt is that additional psychosocial educational materials can be supplemented to manual therapy.

George SZ, Teyhen DS, Wu SS, Wright AC, Dugan JL, Yang G, Robinson ME, Childs JD:Psychosocial education improves low back pain beliefs: results from a cluster randomized clinical trial NCT00373009) in a primary prevention setting.
Eur Spine J 2009, 18:1050-1058. PubMed Abstract | PubMed Central Full Text

In this article, the same authors recruited companies of soldiers (n = 3,792), and cluster randomized to receive a PSEP or no education (control group, CG). A back beliefs questionnaire (BBQ) was given, which assesses inevitable consequences of and ability to cope with LBP. The BBQ was administered before randomization and 12 weeks later. The authors concluded that soldiers that received the PSEP had an improvement in their beliefs related to the inevitable consequences of and ability to cope with LBP.

George SZ, Fritz JM, Bialosky JE, Donald DA: The effect of a fear-avoidance-based physical therapy intervention for patients with acute low back pain: results of a randomized clinical trial.
Spine 2003, 28:2551-2560. PubMed Abstract

In this article, the authors concluded that "Patients with elevated fear-avoidance beliefs appeared to have less disability from fear-avoidance-based physical therapy when compared to those receiving standard care physical therapy. Patients with lower fear-avoidance beliefs appeared to have more disability from fear-avoidance-based physical therapy, when compared to those receiving standard care physical therapy. In addition, physical therapy supplemented with fear-avoidance-based principles contributed to a positive shift in fear-avoidance beliefs."

Coudeyre E, Tubach F, Rannou F, Baron G, Coriat F, Brin S, Revel M, Poiraudeau S: Effect of a simple information booklet on pain persistence after an acute episode of low back pain: a non-randomized trial in a primary care setting.
PLoS ONE 2007, 2:e706. PubMed Abstract | PubMed Central Full Text

In this article, the setting is in a primary care practice in France. Participants: 2752 patients with acute LBP. Intervention: An advice book on LBP (the "back book"). Main outcome measures: The main outcome measure was persistence of LBP three months after baseline evaluation. The conclusions: "The level of improvement of an information booklet is modest, but the cost and complexity of the intervention is minimal. Therefore, the implications and generalizability of this intervention are substantial."