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An analysis of injuries & illnesses at the 2011 IAAF World Championships 

7/30/2013

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Study Title: Determination of future prevention strategies in elite track and field: analysis of Daegu 2011 IAAF Championships injuries and illnesses surveillance
Authors: J-M Alonso, P Edouard, G Fischetto et al.
Journal: British Journal of Sports Medicine
Date: 2012
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Summary:
  • There's no question that any attempt at implementing injury prevention strategies in sport must first be preceded by the identification and exploration of such injuries. This epidemiological study was a summary of the results from the injury and illness surveillance program implemented at the 2011 IAAF World Championships in Daegu. Modified and improved from the previous two programs in 2007 and 2009, the aim of this program was to identify the incidence and characteristics of injuries and illnesses sustained at the event with the intention of gaining insight into future prevention strategies.
  • In addition to injury report forms, the study's authors also joined forces with volunteers from the local organizing staff to conduct daily interviews of participating team physicians to ensure data quality. Countries with more than 15 registered athletes participated in this study, totalling 1512 (81.7% of athletes). The number of injuries reported by national teams was significantly higher than that reported by organizing committee physicians, and this was no surprise as athletes injured are often looked after by their own staff, especially if they are relatively minor. 249 injuries in total were reported with the lower extremity affected in 74.3% of cases. Again, no surprise. Interestingly, the hamstring was the most frequent body part injured (23% of all injuries), followed by strains and muscle cramps (I do wonder though, if any of these cramps were from the hamstring). Most of the injuries were "sustained" during competition and half of which during the finals. Although it was concluded that injury risk was therefore significantly higher in the finals than qualifying rounds, I think this can be somewhat misleading as I don't think "the finals" itself as an independent variable are concrete predictors. To me, "the finals" are just the straw that broke the camel's back. Males and athletes greater than 30 years of age sustained more injuries than their counterparts, and combined-events and distance athletes had higher rates as well. 
  • An incidence of 39.5 illnesses per 1000 athlete participations (126 illnesses in total) were reported with greater than a third of illnesses affected by the upper respiratory tract. Infection was also commonly reported. As stated in the discussion, I believe the combined stress and intensity of competition played a significant role in this. Only two episodes of heat exhaustion and no episodes of cardiovascular-system collapses were reported.
  • As mentioned above, the aim of this study was to use surveillance in order to identify, and subsequently prevent, injuries. Overuse injuries dominated the classification of injury, as did combined-events and distance events. Although the volume of competition that athletes in these events participate in is greater - from an epidemiological viewpoint - I personally would like to see more "high definition" in injury-density such as injuries per minute of competition. I know this would be quite a challenge to implement, but my concern is that those not familiar with track and field may fail to recognize the importance of surveillance and prevention in the jumps and sprints.
  • It was interesting to see hamstring strains being most prevalent not because this was a surprise to me, but more so because there is still plenty of room for investigative research. We still have more theories than answers in this subject matter and frankly, I believe research in this area should be increased to at least to being on par with the common jogging/treadmill-based research that's prevalent today. Note: if anyone reading this is interested in this subject matter, I'd be happy to chat with you.
  • Finally, it was stated that more than 75% of hamstring strains were overuse injuries. It was also stated that "this rate is unexpectedly high for this pathology which is most often reported as acute". In my opinion, no hamstring injury is acute. Sure, the diagnosis of a "strain" may be acute, but if the concept and thought process of muscle injury terminology is combined with the concept and thought processes of performance engineering and a guided framework, then I think we would be better positioned to improve injury prevention. 
  • Ultimately, preventing injury is next to impossible. And I both like and appreciate the implemented surveillance at these World Championships. Now it's up to us on the front lines and those doing research to do our job to help try and get the rates down even further.

Alonso, J-M et al. Determination of future prevention strategies in elite track and field: analysis of Daegu 2011 IAAF Championships injuries and illnesses surveillance. British Journal of Sports Medicine, 2012; 46: 505-514
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Post-Game Recovery, Perception and Performance

2/22/2013

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Study Title: Association between post-game recovery protocols, physical and perceived recovery, and performance in elite Australian Football League players
Authors: A. Bahnert, K. Norton & P. Lock
Journal: Journal of Science and Medicine in Sport
Date: 2013
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Summary:
  • Similar to my recent post on perception of recovery and performance, this study looked specifically at the associations between post-game recovery interventions chosen by players and their subsequent physical and perceptual recovery, and game performances. But in contrast to the last paper, which described a short 3-week study, the authors of this paper undertook a season long project with members (n=44) of an  Australian Football team. Allowing these elite players to be their own controls, the players participated in mandatory post-game (within 10-20 min) recovery sessions whereby the given intervention was self-chosen. The modalities included: floor stretching, pool stretching, bike active recovery, pool active recovery, cold water immersion, contrast therapy, and compression garments. Again, the athletes were permitted to utilize any of the above (plus other modalities) on each given week. Their vertical jump (5 repeated countermovement jumps) was tested weekly to assess recovery, and the athletes reported their perceptions of recovery regularly. Asked of them was their daily rating (1-5 scale) of recovery, fatigue, muscle soreness, stress levels, sleep quality and 'hardness' of the previous session/game. Perceptions of recovery were combined to form a single Recovery Index score. Also collected regularly was a coaching-staff assessment of individual player game performance on a 0-4 scale.
  • Results of this study demonstrated that floor stretching, cold water immersion, and compression garments were the most utilized (preferred and self-chosen) forms of interventions while active recovery (bike or pool) were least utilized.  Additionally, those players who chose CWI, floor stretching and/or no active recovery demonstrated an increased probability of reporting greater perceptual recovery the following week. Interestingly, no association was found between the indicator of performance (vertical jump tests) and any of the recovery interventions.
  • To me, this paper sheds even more light to the importance of the cognitive component of "physical preparation". Again, far too often we think of the body as a machine, yet these results show that "the mental" is what may matter most in elite sport. We all know the old adage, yet millions of dollars are still spent on technology.  This is not to say that other modalities are not important, because I do administer my MARC-PRO quite regularly, but coaching and "performance engineering" are dynamic processes, so we really should be listening to our athletes better and engaging them in the decision making process.
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Bahnert, A., Norton, K. & Lock, P. (2013). Association between post-game recovery protocols, physical and perceived recovery, and performance in elite Australian Football League players. Journal of Science and Medicine in Sport, Vol. 16; 151-156.
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Perception of Recovery and Performance

2/21/2013

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Study Title: Individual perception of recovery is related to subsequent sprint performance
Authors: C. Cook & C. Beaven
Journal: British Journal of Sports Medicine
Date: 2013
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Summary:
  • With a great deal of "performance therapy" occurring between competitions, it is not uncommon for sport medicine staff and coaches to be asked which modality is best for the purposes of enhancing the rate of physiological recovery. In this study, 12 male semiprofessional rugby players were used to look at not only the relationship between immediate post-game induced changes in core body temperature and repeated sprint performance (RSP), but also between the athletes' perception of the recovery strategies and RSP. Only a 3-week study, the players were asked to perform one of three recovery interventions (15 min. cold water immersion - 14 deg; 15 min. warm water immersion - 30 deg; and a 15 min. passive control of sitting on a chair) immediately following a high-intensity conditioning session. Immediately following each intervention, the players were asked to rate each recovery modality on a 1-5 Likert scale to combine a subjective measure of perception of recovery with the physiological changes. Orally ingested sensors were used to measure core temperature and 5x40m repeated maximal running sprints were used to assess performance.
  • Not surprisingly, CWI induced the greatest immediate changes in core body temperature although temperatures returned to normal within 24 hours. Additionally, both the CWI and WWI interventions were preferred over the passive control intervention. And while the initial sprint performance was faster following the WWI than the control, the fifth sprint performances were faster following the CWI intervention than the WWI. Therefore, the most significant and pertinent result of this study was the correlation of the combined index of athlete perception and body temperature decrease with subsequent sprint performance. However, it must be strongly noted that the correlation between combined positive perception of recovery and WWI with subsequent sprint performance was strong as well.
  • I really enjoyed this short paper as it clearly demonstrates the important blend between art and science in coaching and sport medicine. Far too often we rely solely on "the science", yet many individuals forget to give credence to the psychological aspects of performance. To me, it is simple. Respect and understand the science but do understand that how an athlete perceives their recovery intervention at that given moment is just as important as the intervention itself.
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Cook, C. & Beaven, C. (2013) Individual perception of recovery is related to subsequent sprint performance. British Journal of Sports Medicine

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Muscle Injury Terminology & Classification

1/18/2013

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Study Title: Terminology and classification of muscle injuries in sport: a consensus statement
Authors: H-W Mueller-Wohlfahrt & colleagues
Journal: British Journal of Sports Medicine
Date: 2012
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Summary:
  • Rather than an actual "study" this paper is a consensus statement by world-renown German physician, Mueller-Wohlfahrt, and colleagues. The impetus for this statement was based on the lack of standardization with traditional clinical- and imaging-based grading schemes of muscle injury. Utilizing the assistance of several of the top scientific and medical experts in the field of sports medicine, Mueller-Wohlfaht and colleagues undertook a two-part project to create this consensus statement. Part one consisted of a questionnaire based on terminology sent out to sport medicine experts in an attempt to identify potential discrepancies in muscle injury terminology. Based on this questionnaire (completed by 19 individuals), it was revealed that much variability exists in key definitions of injury. Specifically, a lack of consensus exists in the descriptions of muscle strain, muscle tear, and structural vs functional injuries.
  • Part two of this project entailed a one-day gathering of various experts to create a consensus statement for improved classification and standardized definitions. A brief description of the consensus statement is as follows:
  • Functional Muscle Disorder: "acute indirect muscle disorder 'without macroscopic' evidence (i.e. on imaging) of muscular tear.
  • Structural Muscle Injury: "acute indirect muscle injury 'with macroscopic' evidence (i.e. on imaging) of muscle tear.
  • Interestingly, the authors highly recommended against the use of the term muscle strain due to it's "layman" nature and lack of standardization in definition (in comparison to the varying degree in injury).
  • Classification of Acute Muscle Disorders and Injuries:
  • Indirect Muscle Disorder/Injury
  • Functional muscle disorders subclassified as Type 1 (Overexertion-related muscle disorder: A - Fatigue-induced; B - Delayed-onset muscle soreness) and Type 2 (Neuromuscular muscle disorder: A - Spine-related neuromuscular Muscle disorder; B - Muscle-related neuromuscular Muscle disorder)
  • Structural muscle injury subclassified as Type 3 (Partial muscle tear: A - Minor partial muscle tear; B - Moderate partial muscle tear) and Type 4 ((Sub)total tear: Subtotal or Complete muscle tear; Tendinous avulsion)
  • Direct Muscle Injury - Contusion or laceration
  • I thought that this article was a nice step in the right direction, especially as a complement to understanding muscle injury healing phases. However, I do think it was somewhat bold to proclaim a "consensus statement", considering the fact that it has yet to be put through the rigours of scientific scrutiny. That said, such standardized terminology and classification will likely lead to improved diagnostics, management and return to play recommendations.
  • My more detailed review on this paper will likely come out on Research Review Service sometime in the next several weeks but in the meantime, Johannes, Hamilton and Best wrote a nice editorial piece as a follow up.

Mueller-Wohlfart, H-W et al. (2012). Terminology and classification of muscle injuries in sport: a consensus statement. BJSM; 0:1-9

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The Short-Foot Exercise and Dynamic Balance

11/20/2012

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Study Title: Differences in Static and Dynamic Balance Task Performance After 4 Weeks of Intrinsic Foot Muscle Training: The Short-Foot Exercise Versus the Towel-Curl Exercise
Authors: S. Lynn, R. Padilla & K. Tsang
Journal: Journal of Sport Rehabilitation
Date: 2012
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Summary:
  • This study, from Cal State-Fullerton, compared the effects of towel curls and the short-foot exercise on static and dynamic single-leg balance tasks. Towel curls have traditionally been used for foot muscle strengthening however, such exercises theoretically may actually recruit more of the extrinsic foot musculature rather than the intrinsics.
  • A RCT was used in this study whereby 30 healthy university students (24 completed the study) were assigned to either the short-foot exercise group, the towel-curl exercise group or a control group. The dependent variables of the study were range of mediolateral movement of the center of pressure during static and dynamic balance tests and standing navicular height. The center of pressure was measured via forceplate while performing a modified Y-balance test (without the test device).
  • The participants performing the short foot exercise were instructed to raise the medial longitudinal arch by drawing in the metatarsal heads toward the calcaneus without flexing the toes and holding this position for 5 seconds each repetition. The participants performing the towel curl exercise were instructed to drag a towel (placed on a slick surface) under their foot via toe flexion to generate a strong grip for 5 seconds per repetition. Each group performed 100 repetitions daily for 4 weeks, progressing from seated to standing positions.
  • During the static tasks, no differences were found. During the dynamic balance test, both intervention groups demonstrated a significant decrease in movement of the COP of both the dominant and non-dominant limbs however, the short foot group demonstrated much greater improvement (an average decrease by 9.3 mm). This was a large effect size.
  • To me, this paper wasn't very impressive. It seemed like a mountain was made out of a molehill with their results. I do prefer the short foot exercise over the towel curl exercise but I generally use an integrated approach as demonstrated in this post. I do understand that variables need to be isolated for the purposes of research, but a static hold and dynamic contractions to me are quite different.
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Lynn, SK., Padilla, RA., & Tsang, KW. (2012). Differences in static- and dynamic-balance task performance after 4 weeks of intrinsic-foot-muscle training: The short-foot exercise versus the towel-curl exercise. Journal of Sport Rehabilitation, vol 21; 327-333

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An Update to Hegedus' Systematic Review on Orthopaedic Tests for the Shoulder

10/19/2012

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Study Title: Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests
Authors: E. Hegedus
Journal: British Journal of Sports Medicine
Date: October 2012
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Summary:
  • Although high quality open access journal articles aren't common - yet - they still do occur. This systematic review with meta-analysis by Hegedus is one such paper for example, and is one that is essentially an updated version of his 2008 review. With a surplus of orthopaedic tests for the shoulder and an equally great number of review papers investigating such tests, it can be very simple for clinicians who a) take a less than adequate history and b) are unfamiliar with the accuracy of the arsenal of tests to fall into the trap of utilizing inappropriate tests for given clinical presentations.
  • Hegedus' review provides us with an update of his original article, based on the fact that since his original article was published, not only have new studies been published, but also the methodologies behind systematic reviews and meta-analyses have been updated as well.
  • Without going into great detail, the protocol used in this review was that of the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). The original paper examined studies from 1966-October, 2006 while this paper confined it's Medline and CINAHL search to November, 2006-February, 2012. Additionally, EMBASE and the Cochrane Library were added as databases as well. 2x2 tables were used for meta-analysis and quality was assesed via the QUADAS-2 tool.
  • In total, 32 new studies addressing diagnostic accuracy were revealed in this new time frame with 12 of these studies added 13 new tests to the literature. And the majority of these tests pertained to the diagnosis of SLAP tears. What this updated paper adds to the literature include the following:
  • Biceps Load II seems to be less diagnostic for SLAP lesions
  • The belly-off and modified belly press tests may add to subscapularis tendinopathy diagnosis
  • The olecranon-manubrium percussion test may be useful in traumatic cases for requiring imaging
  • The passive compression test may be helpful in diagnosing a SLAP lesion
  • The modified dynamic labral shear test may be helpful for SLAP lesions
  • The lateral Jobe test for diagnosing rotator cuff tears
  • The passive distraction test may assis in ruling in a SLAP tear if possible
  • With the information provided above, it is still very reasonable to assume that rather than clarifying the application of orthopaedic testing for the shoulder, we may be no further from a practicality standpoint. I, myself, firmly believe that although there are numerous tests for the shoulder, a detailed clinical history combined with a good understanding of the mechanisms behind shoulder pathologies hold more value than the testing itself. Essentially, orthopaedic tests should confirm or deny your differentials but your differentials will always be based on your investigative and listening skills, as well as your understanding of the body (and mind).
  • So with that said, I want to leave you with a snippet of an email discussion I had several months back with a colleague of mine who is an orthopaedic surgeon that specializes in the upper extremity.

"Sorry, but I won't be much help with the biceps/slap debate.  My own personal view is that all the tests are pretty useless and I've not found much predictive value with any of them.  Most of them put the arm in significant flexion or adduction and these are essentially the impingement or AC compression testing positions, so I feel they overlap siginificantly with eliciting the much more common cuff and AC pathology.  I also refuse to do multiple tests to evaluate the same structure, I pick the one that is the best (even if it's the best of a bunch of bad tests).  So for superior labrum I do the crank test, because it is past the painful arc and mimics the peel back meneuvre that we do intra-operatively to visualize an unstable II slap if it's there.  

Combine that diagnostic dilema with the fact that most slap repairs either don't heal or cause significant stiffness and essentially I only repair slaps in combination with a pan labral injury during instability surgery.  Final caveat though is that I definitely don't have a very young sportsy practice, so maybe others are seeing the real deal, for me it's all hocus pocus."
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Hegedus, E. (2012). Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. British Journal of Sports Medicine, vol 46; 964-978
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Neuroscience and Chronic Pain in Athletes - a more comprehensive approach

3/29/2012

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Study Title: A Neuroscience Approach to Managing Athletes with Low Back Pain
Authors: E. Puentedura & A Louw
Journal: Physical Therapy in Sport
Date: 2012
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Summary:
  • I have written previously on the importance of respecting neuroscience with managing athletes suffering from pain. While many injuries are acute in nature, especially in collision sports, chronic pain and injuries are certainly very prevalent in the athletic population. This particular paper (not an actual study) provides an excellent review and summary of the rationale for utilizing a "neuroscience approach" when managing athletes suffering from pain, especially of the chronic variety.
  • Puentedura and Louw suggest a complete biopsychosocial approach to management that, in addition to anatomy, biomechanics and tissue pathology, incorporates the integration of pain mechanisms in interactive care. In my opinion, this is probably the most concise paper I have read to date that explains the rationale and one that is an appropriate introduction for those unfamiliar with this paradigm.
  • Among the explanations described for using such an approach, the authors describe the contributions of environmental (situational) influence, sensitization mechanisms, and the role of cognitive states. They also explain the role of representation maps in the brain as well as triggers for "neurotag" activation. Many images were provided to enhance the readers understanding of this approach and the parallel relationship as "outputs of the brain" between pain and sports performance were discussed.
  • Finally, suggestions were made for appropriate treatment of athletes with chronic pain utilizing this neuroscience approach, although it is my opinion that such an approach may also be taken when managing athletes who suffer from acute injuries as well.
  • Overall, I really enjoyed this paper not only because it was all encompassing in nature, but also because it can be of great benefit to those who may be novel to the idea that pain and injuries may not solely be of the tissue variety.
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Puentedura, EJ & Louw, A. (2012). A neuroscience approach to managing athletes with low back pain. Physical Therapy in Sport.
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SMT, Meds and Exercise for Neck Pain

1/4/2012

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Study Title: Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial
Authors: G. Bronfort, R. Evans, A. Anderson, K. Svendson, Y. Bracha, R. Grimm
Journal: Annals of Internal Medicine
Date: 2012
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My thoughts
  • First of all, seeing this study capture the attention of many manual and rehabilitation therapists through the power of the internet reminded me of the old "Start the Car" ikea commercial.
  • As a chiropractor that highly values exercise and rehabilitation, most would assume that I too would take this paper, "start the car", and run away with it. Unfortunately, I wanted to read the actual paper and see what all the hype was about beyond the good publicity from the New York Times.
  • There's no question that I strongly believe manipulation and exercise may be better alternatives to medication in some if not many "pain" presentations, however, overtime I have learned to become more attached to patient-specific care more than anything else. Patient-specific care may indeed call for meds, manipulation and exercise - but patient-specific care may also call for reassurance, education, and / or soft tissue therapy.
  • Now having read the actual study, the authors did do a relatively good job to prescribe individually based exercises but I do think they could have been more thorough. Gentle stretching and scapular retraction exercises, as well as neck and possibly (although not convincing in this paper) thoracic manipulations don't cut it when it comes to sending a message that SMT and exercise are better than meds. I understand that this is a research paper so I will accept some limitations in the study.
  • While there was significant difference in follow up at 6 months, no significant differences were found at the 1 year mark of follow up when compared to baseline. To me, this likely indicates symptomatic relief or treating the DP (which I think is ok)...but what about the root cause? And what about integrated care? Because how often do you just manipulate or just rehab? I know quite well many of you who read this blog also combine the two. But you probably combine other therapeutic approaches as well. What I don't want to see is manipulating people's necks for the simple reason that this paper said it was more beneficial. If it is indicated, and the patient consents, then by all means. But if not, don't "start the car". We need to be more precise and we need to be accountable.
  • Again, it is a research study and I get that we can't control for everything in research but I do think we can be a little more responsible when drinking the kool-aid. And responsibility means taking an objective, rather than emotional opinion...especially on social media. So please feel free to advocate that SMT and Exercise may sometimes be better a alternative than medication for neck pain (and that meds are often unnecessary), but please also recognize that generalizing the study's results to all of your patients is an act that is no different than advocating for meds alone.

Bronfort, G et al. (2012). Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial. Annals of Internal Medicine, vol 156; 1-10....
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MSK Myths

12/19/2011

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Title: Musculoskeletal Myths
Author: C. Liebenson
Journal: Journal of Bodywork and Movement Therapies
Date: December 2011
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Summary:
  • A must read for all professionals in the health care and fitness industries. In this review, Craig Liebenson not only utilizes the current state of the literature to debunk 10 widely common myths in low back health, but also provides us with evidence-informed alternatives and explanations. From the role of diagnostic imaging in low back pain to spine stability and pain science, Liebenson does an eloquent job in stressing the importance of a science-based approach to patient management and the value in active care. Some of the myths discussed are: "the cause of musculoskeletal pain can be found on an x-ray or MRI"; "let pain be your guide"; "the deep intrinsic muscles...are the keys to stability"; and "we should breathe out with exertion-right?".
  • In addition to the exposure of these myths, Liebenson also introduces the reader to a new paradigm of care that is grounded in the functional assessment.  It has been highly stressed that we, as clinicians, should be focusing more on the source - rather than the site - of pain, and Liebenson provides us with a clear rationale for this approach. He further provides specific evidence via regional interdependence of this paradigm shift.
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"This new paradigm requires a reevaluation of a number of current tenets of care. If this happens a more patient-centered approach which is designed to help patients safely return to activities which are important to them will result".

Liebenson, C. (2011). Musculoskeletal Myths. Journal of Bodywork and Movement Therapies. doi:10.1016/j.jbmt.2011.11.003.
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Vojta / Dynamic Neuromuscular Stabilization in a Migraine Sufferer

10/10/2011

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Study Title: A Case Study Utilizing Vojta/Dynamic Neuromuscular Stabilization Therapy to Control Symptoms of a Chronic Migraine Sufferer
Authors: DD. Juehring & MR. Barber
Journal: Journal of Bodywork and Movement Therapies
Date: October 2011

  • A relatively low level of evidence but a good read nonetheless. This recent case study published in the Journal of Bodywork and Movement Therapies described the use of the Vojta/Dynamic Neuromuscular Stabilization treatment strategy for chronic migraine symptoms in a 49-year old female. Hypothesized to be triggered via neural mechanisms, this type of headache has been described to be modulated supraspinally and often has been elusive to conventional treatment strategies. The specific treatment strategy reported was described (although not directly stated) to be via reflex stimulation of the breast zone in the first phase of reflex turning. For those of you who are unaware, the breast zone is located at the widest intercostal space between ribs 5-8, nearby the mamillary line. Subjective improvement was reported over the 12-week course of therapy via the Headache Disability Index and VAS pain scale measures, although there was no mention of any cognitive approach to care. Several other unsuccessful treatment strategies previously undertaken over the span of 20 years were mentioned, however, unfortunately no statements pertaining to follow up of this particular strategy could be found. Overall, I thought this was a good start to getting the efficacy of DNS in the English published literature, but I do recognize its limitations and that we still have a long way to go. In particular, I would like to see more advanced forms of DNS utilized in the literature, especially utilized in athletic populations, as well as published research with higher levels of evidence. That said, I myself have utilized this treatment approach in a variety of patients (athletic injuries, neurological pathologies, chronic pain, etc) often with very successful results, so I have no doubt of its positive effect on this 49-year old woman.

Juehring DD & Barber MR. (2011). A case study utilizing Vojta/Dynamic Neuromuscular Stabilization therapy to control symptoms of a chronic migraine sufferer. Journal of Bodywork and Movement Therapies, 15; 538-541
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