Hannah Beard. Clinical Case Report Competition. Utopia Academy. First Place Winner. Summer 2011

Transcription

1 Massage Therapists Association of British Columbia Clinical Case Report Competition Utopia Academy Summer 2011 First Place Winner Hannah Beard Increasing range of motion through a comprehensive massage therapy treatment to increase the speed of the golf swing P: F: research@massagetherapy.bc.ca massagetherapy.bc.ca MTABC 2011

2 2 ACKNOWLEDGMENTS A special thank you to my case advisor Rosanna Durante for guiding me through this new and exciting accomplishment also thank you Ben Ngui for supplying me with text books to help with my research, lastly thank you to my significant other for being my subject in this case report. ABSTRACT Objective: This study explored the effectiveness of a comprehensive massage therapy treatment to increase swing force in the golf swing, by increasing range of motion of the trunk. Methods: A protocol of ten 60 minute treatments over a month period was conducted. Techniques applied included Myofascial release, Swedish massage, Trigger Point Therapy, Joint Mobilizations and Passive Stretching. Home care which was given included strengthening, stretching and postural education. Techniques and home care focused on the structures of the trunk only. Results: The participant s range of motion improved in all directions, creating less restriction on his back swing. An improved range of motion proved to be effective in producing more velocity behind his swing speed, ball speed and distance of his drive. Conclusion: The results obtained from this study not only support the idea of increasing the trunk range of motion for a better swing, it supports the effectiveness of massage therapy in uninjured tissues. Golf and massage therapy; golf rehabilitation; golf related pain; golf therapies.

3 3 INTRODUCTION An accurate and long drive is known to reduce a golfer s handicap; to successfully achieve this, one must have proper biomechanics along with flexibility and strength. The purpose of this study was to measure the correlation between the range of motion of the trunk and the distance that a golf ball will fly by using a series of comprehensive massage therapy treatments. Understanding the purpose and motion of each phase of the golf swing will help explain where the power of the swing comes from. According to The Mechanics of Sports by Gerry Carr, there are four phases of the golf swing: Preparatory Movement phase, Backswing phase, Force-producing (or transitional) phase and the Downswing / Follow Through phase. The Preparatory Movement Phase is when the golfer takes up a stance and addresses the ball, this phase is important in finding his/her balance, correct footing and grip while maintaining a perpendicular line to the target line. The Backswing Phase is intended to help generate speed and power prior to striking the ball. The backswing is initiated by simultaneous rotation of the upper torso and upper extremities followed by a slight degree of pelvic rotation. Shoulder rotation should be 90 degrees from the target line and the torso rotation 45 degrees from target line for the optimal end position. The Force-Producing or Transitional phase is the specific actions the golfer uses to generate force; according to The Mechanics of Sports, this usually

4 4 begins at the feet. To get accuracy and strength it is important to transfer the weight from the right foot to the left foot for right-handed people and opposite for left-handed people. The Downswing / Follow Through phase requires perfect technique and power to generate club head speed and controlled trunk rotation. It is initiated by rotation of the hips and trunk along with extension, while the shoulders, arms and wrists follow with the summation of forces. It is important to note that the golfer should accelerate through ball impact to improve accuracy and decrease the risk of injury. According to sportsmed.org, a 2004 study suggests that, increasing the range of motion of lumbar spine along with extension and rotation of the lead hip (left hip in right-handed golfers) may decrease the incidence of low back pain. Greg Norman the Australian professional golfer states on his website, trunk muscle activity is high and constant during the down swing and demonstrates these muscles to be an important factor to a golfers entire performance enhancement, preventative and rehabilitative regime. Improving a golfer s range of motion will not only serve in preventing injuries but possibly helping them with the length of their drive. According to the Journal of Sports Sciences, teaching professionals seek to maximize torso rotation during the back swing while minimizing pelvic rotation in their students to increase the amount of stored energy, which is released in the down swing. This 2007 study demonstrated through a three-dimensional motion analysis system, a correlation between the

5 5 golfers with more pelvic-torso separation and a higher ball velocity. This can be explained through understanding the nature of elasticity and recoilablity of muscle tissue with Ellen Kreighbaaum and Katharine M. Barthels in a text booked called Biomechanics: A Qualitative Approach for Studying Human Movement, the elastic elements in muscle tissue lay beside the contractile muscle tissue; when a muscle contracts the elastic elements are passively stretched and transmit the force of the muscle contraction smoothly to the bone. Elasticity is the tension and recoilability for being an important contributor to the total force to move a body part. Imagine a golfer s backswing, the farther he goes back the more elastic force is being stored, as he goes into this down swing the elastic force will uncoil producing more torque though the body, into the club and onto the ball. CASE HISTORY The participant in this case study is a 28 year old male. He is a nonsmoker with good dietary habits and a healthy lifestyle. His exercise regime in the past three years has consisted of weight lifting and cardiovascular training along with recent core training applied two times a week. He has been playing golf for three years and within the past year his handicap has improved from 15 down to 5. His handicap has been consistent for 6 months prior to this treatment. He believes his previous weaknesses in golf have been the inability to make a full

6 6 turn on the back swing, lack of power in driving distance and general stability throughout the swing. His main physical complaint is feeling restrictions in his swing and not having a full back swing. In the three years he has been playing golf there has been an instance of tendonitis in his right bicep and a subluxed rib on his right side and has experienced delayed onset muscle soreness (DOMS). These injuries were treated and no longer affect his golf swing. He has no history of previous illnesses or surgeries that would affect his posture or functional movement. ASSESSMENT Thorough assessment of torso range of motion was consistently taken before and after each treatment while swing speed, ball speed and distance of the golf ball were measured periodically throughout the study. The complete range of motion assessments were recorded before and after the first, sixth and tenth treatments, they included trunk flexion, extension, side flexion and rotation. To ensure valid and reliable testing of ROM, each measurement was taken at approximately the same time every day while the same landmarks and tape measure were used every time by the same therapist. To measure the effects of trunk motion on the golf swing three numbers were recorded: the swing speed, ball speed and carry. Swing speed was recorded to

7 7 measure the strength behind the club. Ball speed was recorded to help account for the distance of the drive. The carry number indicates how many yards the ball was in the air until it hit ground; this number will help support the thesis. Fifteen shots were recorded within a 25 yard difference from the target line (center). These shots were recorded before the first treatment, after the sixth treatment and after the tenth treatment. To ensure there was validity and reliability these numbers were recorded by the same computer in a simulator at Golf Town. These measurements were taken indoors which also takes out variables such as the wind and weather. Pictures were taken to record visual evidence of shoulder and trunk rotation in the backswing before and after the first, sixth and tenth treatments. Postural assessment was performed before every treatment to observe imbalances in the client s stance. The palpation of tissues was performed during the postural assessment to observe the degree of tonicity while in the standing position. Two other tests were applied throughout the study: Gillets test and Apleys scratch test. The Gillets test indicates the range of motion of the sacroiliac joint and Apley s scratch test indicates the range of motion of the shoulders. METHOD The client was scheduled for two treatments per week for five consecutive weeks. Each treatment session was conducted at 10:00pm. Treatments were 75

8 8 minutes long which included 15 minutes in total of assessment at the beginning and end of each treatment. Thirty minutes were spent on the posterior trunk while the other thirty minutes were spent on the anterior trunk. The treatment goal of each session was to release adhesions in the muscles and structures that attached to the spine, ribs, sternum and pelvis to increase the range of motion of the trunk. Treatment was provided to the back, abdomen and chest. Each treatment began with full body compressions in the prone position, ten compressions were applied bilaterally. Myofascial release was applied to the Thoracolumbar Fascia, Erectorspinae muscle group and abdomen; this was performed in the same directions while waiting for three releases each time. Swedish massage was applied to Erectorspinae and Transversospinalis muscle groups, Latissimus Dorsi and External and Internal Abdominal Oblique while following the principle of massage. Joint mobilizations were applied to the thoracic and lumbar spine. The torso is an extensive area to treat, because of this treatments one through five were focused on releasing structures of the lumbar spine and lower thoracic spine. Trigger point therapy was used on Quadratus Lumborum, Psoas Major and Erectorspinae, each trigger point was held until the client reported 0 out of 5 on the pain scale. Passive stretches applied by the therapist were held for 30 seconds to the Erectorspinae Group, Quadratus Lumborum and Psoas Major. Treatments 6 through 10 focused on releasing the structures of the upper thoracic spine and chest. Myofascial Release was applied over the sternum and clavicle for three

9 9 releases. Skin rolling superior to inferior to superior was applied over the sternum one time. Intermuscular release of Pectoralis Major was applied bilaterally, the release was held for two minutes. Intramuscular release of Serratus Anterior was applied bilaterally until release was felt. A 30 second passive stretch to Pectoralis Major was applied by the therapist. The client was asked to stop his normal exercise routine to help reduce variables during the study. Because of the client s enthusiasm to achieve a better golf swing, a home care plan was to be completed on his own time. The strengthening, stretching, balancing and postural education exercises were given after each treatment. Instructions were given to stretch and strengthen Internal and External Abdominal Obliques, stretch the Erectorspinae group and strengthen the hip stabilizers with a balancing exercise. Postural education was given to walk and play golf with a posterior pelvic tilt. After treatments one through five, stretches for Quadratus Lumborum and Psoas Major were given. After treatments six through ten stretches for Pectoralis Major and erector spinae were given were also given. Instructions for stretching included slow, non-balistic movements while breathing into the stretch. Each stretch was to be done two times a day, every day and held for one minute. The instructions for the strengthening exercises included two sets of 15 repetitions, two times a day, every day. RESULTS

10 10 The client exhibited an increase range of motion in all six directions from the time of the first assessment (pre-treatments) to the time of the last assessment (post treatments). During the pre-treatment assessment the range of motion from neutral to maximum range were recorded. After treatments one through six were completed the mid-treatment assessment recorded an increase in thoracic spine flexion and extension by 3.5 cm. Lumbar flexion was increased by 2 cm and lumbar extension was increased by 1 cm. Trunk rotation improved by 1.5 cm to the right and 2cm to the left, while side flexion to the right and left were both increased by 2 cm. After treatments seven through ten measurements again increased from the mid-treatment assessments. Thoracic spine flexion increased by 2 cm and extension increased by 1 cm. Lumbar flexion and extension increased by 1 cm. Rotation to the right increased by 0.5 cm and rotation to the left increased by 1 cm while side flexion remained the same. Over all after the commencement of the study, the participant gained 8.5 cm in combined flexion, 6.5 cm in combined extension, 2 cm in rotation to the right and 3 cm in rotation to the left while gaining 2 cm in side flexion to the right and left.

11 11 cm Range of Motion of the Spine T- spine Flexion T- spine Extension L- spine Flexion L- spine Extension Right Rotation Left rotation Pre- treatment Mid- treatment Post- treatment Right sideflexion Figure 1. Measurements include the differences from neutral position into the direction indicated. Pre-treatment assessment of the participants golf swing recorded a swing speed average of 97 mph, ball speed average of 135 mph and the average distance the ball was in the air for at 215 yards. An increase was seen in all three numbers from the pre-treatment assessment to the mid-treatment assessment. The average swing speed after treatments one through five was mph, the ball speed average was mph while the average distance carried was yards. A difference of 3.6 mph in the swing speed, 4.5 mph on ball speed and approximately 15 yards were seen between pre-treatment assessments and midtreatment assessments. Post-treatment assessment of the participants golf swing recorded an average swing speed of mph, ball speed average of mph and the average distance of carry at yards. The overall the difference of pretreatment to post-treatment assessments is an increased swing speed of 4.8 mph,

12 12 an increased ball speed of 7.5 mph and an increase of 18.2 yards. See figures 3 and 4 for comparison. (See appendix B for detailed information of individual drives recorded.) Pre-treatment Mid-treatment Post-treatment Figure 8. Comparison of back swing in participant After the commencement of the study the clients presenting posture had changed slightly. The client presented with a moderate head forward posture, hyperlordosis in the lumbar spine, elevated left shoulder and an anterior pelvic tilt. The client s moderate head forward posture and elevated shoulders resolved by the end of the tenth treatment, while his hyperlordosis and anterior pelvic tilt only slightly decreased. Upon palpation of his tissues a decreased tonicity was felt in the Erectorspinae and in Quadratus lumborum; overall tissue pliability increased over

13 13 the ten treatment sessions. By the end of the fifth treatment the Gillets test was negative and functional motion of the Sacroiliac joint was restored. Apley s scratch test indicated an increase in shoulder range of motion through treatments one through six. On the last treatment the client stated that he noticed improvements in three ways: (1) more stability in his stance, (2) a new found range of motion during the back swing, and (3) an increase in awareness to correct his posture during his swing. Figure 2. Comparison of swing speed and ball speed in miles per hour.

14 14 Figure 3. Comparison of the averages of ball flight in yards CONCLUSION The purpose of this study was to measure the relationship between torso motion and power of a golf swing. The treatment plan proved to be effective by increasing power behind the golf swing, creating a faster ball speed and a greater distance on the golf drive. Although the results were conclusive with the theory, the treatment did not take into consideration other biomechanical factors of the golf swing, for example shoulder, wrist and leg contributions. In support to the findings of this study a golf swing needs to be timed perfectly to get the accuracy of the shot, the client noted by creating a new length in his back swing the normal timing of his wrists were off. According to John Maddalozzo s study on the anatomical and biomechanical analysis of the full golf swing, wrists are an important factor in maintaining maximum club head velocity. Once the

15 15 participant gets adjusted to his new swing, the ball has the potential to fly farther than the results in this study. The results obtained from this study not only support the idea of increasing the trunk range of motion for a better swing, it supports the effectiveness of massage therapy in uninjured tissues. A comprehensive massage treatment involving more specific work to the spine such as muscle energy and mobilization of the ribs may be beneficial for a more flexible stroke. Completing this case report taught me to stay focused on one goal at a time and to believe that massage therapy is not only important for rehabilitation but improvement of the game.

16 16 APPENDIX A: Hannah :41 PM Deleted: Figure 6 Apley s Scratch Test used to test the range of motion of the Glenohumeral joint. Figure 7 Gillets Test, used to test the movement between the sacrum and iliums. Landmarks include PSIS and S1 of the sacrum Figure 4. Example of how thoracolumbar rotation was recorded. Land marks used were the jugular notch to L5 spinous process. Rotation occurs to opposite side of measuring tape.

17 17 Figure 5. Example of how side flexion was recorded. Landmarks used for side flexion include finger tips to Flexion and Extension of the trunk is not shown here. floor. Land marks used to measure Thoracic spine range of motion were the spinous processes of T1 and T12 and for the Lumbar spine L1 and L5 were used. Appendix B: Figure 9. Pre treatment results Figure 10. Mid-treatment results Figure 11 Posttreatment results

18 18 APPENDIX C: Home Care: Figure 12. Ilioposas Stretch Figure 13. Erectorspinae Stretch Figure 14. Abdominal/shoulder stretch Figure 15. Hip stabilization exercise Figure 16. Abdominal strengthening with a theraband.

19 19 The stretch for Quadratus lumborum is not shown, instructions given were to kneel on the ground with the trunk flexed and arms out in front while walking the hands to either side of the body. References: Web: Conon Elliot. (2010). How to Increase Your Golf Swing Speed. Retrieved July 26, 2011 from: Martin Hughes. (2010). Live Strong.com. Retrieved July 18, 2001 from: AOSSM. (2011). The American Orthopaedic Society for Sports Medicine. Retrieved July 20, 2011 from: es%2008.pdf Greg Norman. ( ). Shark, The official Site of Greg Norman. Retrieved July 13,2011 from: G.F. John Maddalozzo. (1987). An anatomical and biomechanical analysis of the full golf swing. Department of Physical Education and Leisure Studies. Retrieved June 27, 2011 from: Joseph Myers, Scott Lephart, Yung-shen Tsai, Timothy Sell, James Smoliga & John Jolly. (2008). The Role of upper torso and pelvis rotation in driving performance during the golf swing. Journal of Sports Sciences. Retrieved June 15, 2011 from: torso%20and%20pelvis%20during%20golf%20swing.pdf

20 20 Book: Ellen Kreighbaum, Katharine M Barthels. (1996). Biomechanics, A Qualitive Approach for Studying Human Movement.Needham Heights, MA: Allyn and Bacon. Gerry Carr. (1997). Mechanics of Sports.Champaign, IL: Human Kinetics David J Magee. (2008). Orthopedic Physical Assessment. St. Louis, Missouri: Saunders Elsevier Gerry Carr. (2004). Sport mechanics for Coaches.Champaign, IL: Human Kinetics Darlene Hertling, Randolph M Kessler. (2006). Management of Common Musculoskeletal Disorders. Philadelphia, Pennsylavania: Lippincott Williams & Wilkins. Fiona Rattray, Linda Ludwig. (2000). Clinical Massage Therapy. Elora, Ontario: Talus Incorporated. Pictures: All pictures are a copyright of Hannah Beard.