Advances in Physical Therapy

Transcription

1 August 2013 Issue no. 01 Advances in Physical Therapy J o u r n a l <Original Articles> The McKenzie Method of Mechanical Diagnosis and Therapy Is the evidence taking us in the right direction?...p7 Aquatic fitness, Reeduction and the American Experience...P19 Enuresis, Dysuria, Encopresis.Could the pelvic floor be the link?...p31 <OPTL Annual Conference Abstracts> Effects of a 5-Week Intensive & Multidisciplinary Spine-Specific Functional Restoration Program in Chronic Low Back Pain Patients with or without Surgery...P42 Bimanual coordination in stroke: How do coupling and symmetry-breaking matter for upper-limb Rehabilition...P45

2 P. 2 Take your Career to a New Level Do you wish to become an Internationally Certified, Clinical Research Professional?? ClinAcademy Paris - Beirut bd@clinacademy.fr

3 P. 3 Ancient Phoenician Galley- 16th Century < Original Articles > The McKenzie Method of Mechanical Diagnosis and Therapy Is the evidence taking us in the right direction?...p7 Aquatic fitness, Reeduction and the American Experience...P19 Enuresis, Dysuria, Encopresis.Could the pelvic floor be the link?...p31 < OPTL Annual Conference Abstracts > Effects of a 5-Week Intensive & Multidisciplinary Spine-Specific Functional Restoration Program in Chronic Low Back Pain Patients with or without Surgery...P42 Bimanual coordination in stroke: How do coupling and symmetry-breaking matter for upper-limb Rehabilition...P45

4 P. 4 Advances in Physical Therapy Journal Editor-in-chief Ahmad Rifai Sarraj, Lebanon Editorial Board Alice AIKEN, Canada Claude Maroun, Lebanon Emma Stokes, Ireland Julie Fritz, USA Raphael Massarelli, France Scott Ward, USA Scope of the Journal Advances in Physical Therapy (APTJ) is a peer-reviewed journal dedicated to the advancement of the physical therapy profession Worldwide. Although, the journal is aimed at physical therapy practitioners, all medical and health professionals can participate to its educational, practical and informational activities. Why writing to the Journal Writing for APTJ will be interesting to you, researchers, practitioners, professors, clinicians, health professionals and managers with an allied health background. The APTJ is the scientific journal and the main publication of the Order of Physiotherapists in Lebanon and addressed to all Arab and Foreign Countries.

5 P. 5 E d i t o r i a l We further strive to make it our way of life! It is my distinct pleasure to a nounce the launching of the Lebanese peer-reviewed physical therapy journal Advances in Physical Therapy. This landmark event is part of the vision set for the advancement of the profession in the Order of Physiotherapists in Lebanon. The scope of the journal encompasses advances in all medical and healthcare professions. We believe that advances reflect our professional growth while evolving with other disciplines with which we collaborate. The main purpose of this collaboration is to improve quality, provide cost effective care and enhance diversity in the management of a patient s condition. 1- Improving Quality requires an integrated system that involves patients, healthcare professionals, and the environment of care. The fast changes that are occurring in the medical arena, create a challenge to keep up with the requirements of these three intertwined elements, while striving to evolve. n addition to people, change takes time and support, and requires modifying our mind set and our processes, as well as embracing transparency in behavior and communication. The constant challenge for quality interprofessional collaboration. Hence, knowledge-based translational interventions that lead to increasing evidence-based practice by a single professional group, may fail to take into account, difficulties in interprofessional relations. On the other hand, interprofessional education as well as collaborative interventions is a step ahead in improving interprofessional relations. Consequently, the effect of knowledge translation and the implementation of evidence-based practice will be facilitated. 2- Cost-effectiveness lies in the implementation of multidisciplinary/ multi-professional clinical practice guidelines. Guidelines describe the treatment pathway and recommend the most effective diagnostic and therapeutic processes for each profession. Clinical Practice Guidelines may act as an interprofessional education tool, meaning that implementation of change in the practice of one profession rarely occurs without accommodation by other professions. Interprofessional collaboration also materializes through the use of the International Claude E Maroun, PT, MPH President of the Order of Physiotherapists in Lebanon Director of Physical Therapy Department at the American University of Beirut Medical Center Classification of Functioning Disability and Health (ICF) as requested by the World Health Organization. ICF is used as a common language among the medical and healthcare professions to facilitate communication, ease understanding and improve clinical practice. 3- The third point is the diversity of patient management. The word Diversity is associated with Difference, and Different. Indeed, diversity is perceived similarly with the words diverge, divert and most importantly, divide. In the vast field of physical therapy, diversity means both difference and richness; this is due to the fact that physical therapy covers almost all pathologies spanning the diseases related to specific age groups to those related to different systems, such as neurological and musculoskeletal systems. As for patient management, diversity relies on the collaboration of different healthcare professionals, each of which plays a specific role, and simultaneously they complement each other. This constitutes unity that is essential and necessary for the best patient outcome. Physical Therapy is a unique profession in molding diversity and diminishing interprofessional differences. The pillars of this amalgam are professionalism, quality improvement, efficiency and effectiveness, all embedded in our service provision. In this era of fast change, this amalgam constitutes paradoxically the stability and the sustainability of the advancement of medical and healthcare professions. The above stressed points place high value on the involvement of medical and healthcare professionals, patients and their families to work collaboratively, and identify challenges for continuous growth. We at the Order of physical therapists in Lebanon have adapted our mindset to incorporate an innovative culture of professional interaction based on scientific discourse. We further strive to make it our way of life!

6 P. 6 The McKenzie Method of Mechanical Diagnosis and Therapy Is the evidence taking us in the right direction? Stephen May, Corresponding author PhD, Faculty of Health and Wellbeing, Sheffield Hallam University Sheffield, UK, s.may@shu.ac.uk Grant Watson, Dip Phys, Adv Dip Phys (MT), Dip MDT, MCSP Connect Physical Health, Newcastle upon Tyne, UK wattie@ts.co.nz This article presents a summary of the developments that have occurred in the McKenzie system of Mechanical Diagnosis and Therapy since its inception nearly 50 years ago. Abstract Robin McKenzie first observed the centralisation phenomenon in his clinic more than 50 years ago, and it is now welldocumented that referred or radiating spinal pain will frequently centralise in individuals who demonstrate a directional preference, and that this is associated with a good prognosis. This article discusses the key components of the McKenzie Method of Mechanical Diagnosis and Therapy (MDT), and explores the evidence supporting the concept with particular reference to the centralisation phenomenon and directional preference. Centralisation and directional preference are clinical findings that can be reliably evaluated and identified, and have been well-validated as predictors of superior outcomes when treatment is guided by these examination findings. Randomised clinical trials, in which patients who demonstrated one or both of these clinical findings, report much better outcomes when treated with matching directional exercises and posture modifications than when treated with an alternative intervention. Other studies linking these two clinical findings to dynamic changes within the disc give a biological rationale for these concepts, and further add to their validity. The presence or absence of centralisation and directional preference has also been demonstrated to be a greater influence on prognosis than many of the widely reported and publicised psychosocial issues. However, centralisation and directional preference continue to be largely ignored in international low back pain clinical guidelines. This is despite the fact that this literature is more extensive, compared to the support for the reliability and validity for most commonly used clinical findings and orthopaedic tests. At best, centralisation is occasionally mentioned as part of a discussion of M Kenzie exercises in the exercise treatment section of a guideline. It will be argued that these two clinical findings could become the most prominent features within the patient assessment section of future low back and cervical clinical guidelines as the extensive literature validating their importance continues to grow and be better understood. Introduction In 1958, in a chance occurrence in a Wellington, New Zealand physiotherapy clinic, a patient with leg symptoms inadvertently lay prone in significant lumbar extension for about ten minutes after which he reported to the astounded clinician (McKenzie) that his leg had not felt this good for weeks. Impressed by the event and this pain improvement, McKenzie began experimenting with the effect of sustained positions and repeated movements of the lumbar spine to end-range to observe

7 P. 7 the influence on spinal symptoms. During many years of experimentation, patterns of pain response emerged as did a system of classification and management for most spinal pain problems, which has become the McKenzie Method of Mechanical Diagnosis and Therapy (MDT) (McKenzie 1981, McKenzie 1990, McKenzie and May 2000, 2003, 2006). During the development of the system two terms were introduced: centralisation and directional preference. The phenomenon of centralisation refers to the sequential and lasting abolition of all distal referred symptoms and subsequent abolition of any remaining spinal pain. Directional preference refers to that single direction of lumbar test movements and sustained postures that cause symptoms to centralise, decrease, or even abolish while the individual s limited range of spinal movement simultaneously returns to normal. Finding more than one direction that elicits these improvements is unusual. Meanwhile, postures or movements performed in the opposite direction often cause symptoms and signs to worsen. Perhaps McKenzie s greatest contribution to musculoskeletal medicine is his demonstration of the great value in having patients perform repeated lumbar movements and sustained postures, both to end-range, whilst monitoring symptomatic and mechanical responses. It was this form of testing that enabled the discovery and characterization of the centralisation phenomenon and the development of one of the first classification systems for spinal pain. Most clinicians have their patients move only once into flexion and then once into extension. This often increases pain, causing the clinician to conclude that this is a harmful movement and even a sign of some specific pathology. However the value and true effect of any single direction of movement frequently is not apparent until it is repeated a number of times to end-range, often with this initially painful movement becoming easier and easier, with progressively greater movement range, less pain intensity, centralisation of referred symptoms, and, importantly, with these beneficial changes persisting after the movements cease. These responses indicate that an appropriate and beneficial movement direction (the patient s directional preference) has been identified, and would never have been appreciated with only a single test movement. The other key aspect of the system is the use of mechanical subtypes or subgroups, which are determined during the standardised MDT evaluation. The findings of the verbal assessment and physical examination enable the clinician to make a provisional classification of the patient s condition, which then directs the subsequent management, and is typically confirmed at a subsequent session. Patients may be classified into one of three mechanical syndromes: derangement, dysfunction, or postural syndrome. These syndromes are identified by the patient s history and response to the repeated movement examination, eliciting three distinctly different pain responses characteristic of the three syndromes (see box for operational definitions). Since its first written description for clinicians, over 30 years ago, there have been a number of developments within the system, and considerable documentary evidence published relating to a number of aspects of MDT. The aim of this article is to summarise some of these changes, and to highlight key aspects of the relevant literature base. It is not appropriate to present this material as a systematic review as the evidence-base is too wide and varied.

8 P. 8 Development Within MDT The much expanded second editions of the text books updated the system in various ways (McKenzie and May 2003, 2006). Clear operational definitions were given for the mechanical syndromes, and for other categories, the system was contextualised within the evidence-base for back and neck pain in general, and the system of numbering derangement syndromes was removed. Another major development was the extension of the system to include extremity musculoskeletal problems, with the same use of repeated movements and mechanical syndromes (McKenzie and May 2000), which lead to the need to distinguish between articular and contractile dysfunctions within the classification system. There is a growing body of literature relating to the use of MDT in the extremities, but the emphasis in this article will be on the lumbar spine. The Evidence Base for MDT Research into the MDT system began in 1990 when the first reliability study (Kilby, Stigant, Roberts 1990), randomised controlled trial (Stankovic and Johnell 1990) and study of centralisation (Donelson, Murphy, Silva 1990) were all published. Since then, the wealth of literature relating to MDT has expanded every year; not only including RCTs investigating the efficacy of the system, but also studies into the reliability of the assessment and classification methods and the prognostic validity of both centralisation and the concept of directional preference. The literature will be considered in the light of the Assessment-Diagnosis-Treatment- Outcome (ADTO) Model (Spratt 2002), in which it was proposed that for any system to have statistical relevance it must contain all four components. Furthermore the validity of any one aspect of the model requires that all previous links have been validated. This means, for instance that before a treatment effect is evaluated in a randomized controlled trial the methods of assessment and classification or diagnosis are validated in reliability and prognostic validity studies. Attempting to prove the efficacy of an intervention before first establishing the reliability of the system between clinicians, and then establishing the prognostic validity of its assessment findings, would be putting the cart before the horse(s) (Spratt 2002). There is considerable research that relates to these other important aspects of evaluation and management, some of which is summarised in two key systematic reviews (Aina, May, Clare 2004; May, Littlewood, Bishop 2006). Assessment MDT is first and most importantly a system of assessment and classification from which patient-specific treatments or management decisions emerge for all patients. An early decision, based on questions in the history taking, is identification of red flags that are indicators of possible serious spinal pathology, not suitable for mechanical evaluation. In such instances, prompt referral for further investigations is of course advised (McKenzie and May 2003).

9 P. 9 Reliability Studies To have clinical utility in physical examination, it is imperative that clinical findings in reliability studies are interpreted by different clinicians with high reliability correlation coefficients (kappa values). Alternatively, in the presence of poor intertester reliability, management decisions are potentially based on unsound judgements. Although several systematic reviews of reliability studies have been published recently, only one attempted to differentiate basic methods of physical examination, such as palpation, observation, pain response or classification (May et al. 2006). Regarding identifying and interpreting pain responses to repeated movements such as centralisation or directional preference, there is moderate evidence for reliability in multiple studies. There would appear at first to be conflicting evidence regarding reliability of the McKenzie classification system from three high quality and one other study. Of the high quality studies, two reported high reliability with kappa greater than 0.85 (Razmjou, Kramer, Yamda 2000; Clare, Adams, Maher 2005), but the third reported low reliability (kappa 0.26) (Riddle and Rothstein 1993). However, clinicians involved in this latter study had little or no previous experience with MDT and many of the errors resulted from basic flaws in their understanding of the classification system. In contrast, the first two used trained and experienced MDT clinicians to classify and sub-classify patients according to the MDT system, producing quite high kappa values of 0.7 / 0.96 (Razmjou et al. 2000), and 1.00 / 0.89 (Clare et al. 2005). A fourth study that also used trained MDT clinicians likewise showed moderately high kappa values of 0.6 / 0.7 (Kilpikoski et al. 2002).

10 P. 10 Diagnosis-Subgroup Classification Syndrome Prevalence For any classification system to be clinical relevant, it must have wide application in the population of interest. In the reliability studies mentioned above, the proportion of patients who could be classified in one of the mechanical syndromes has been generally high, with a mean of 87% across five studies (Kilpikoski et al. 2002; Kilby et al. 1990; Razmjou et al 2000; Riddle and Rothstein 1993; Clare et al. 2005). In 607 spinal pain patients, 55% of whom were deemed to be chronic, 83% were classified into one of the three mechanical syndromes by 50 international McKenzie clinicians, with the majority (78%) classified as derangement (May 2006). Likewise of over 300 patients with predominantly lumbar, but also cervical and thoracic pain, assessed by 34 MDT therapists about 75% were classified as derangement, and about 6% with dysfunction (Hefford 2007). There are two salient points: the consistency of the prevalence rates, and the high prevalence rate in spinal pain patients of derangement when assessed by MDT clinicians. This is clearly a common syndrome and easily recognised. A discussion of the anatomic means by which these rapid pain changes might occur is beyond the scope of this article but is addressed at some length in another review article (Wetzel and Donelson 2003). Prognostic Indicators Next, a classification or sub-grouping process is only valuable if it identifies useful prognostic indicators or management strategies (Spratt 2002). Multiple studies have consistently identified the positive prognostic value of centralisation (Aina et al. 2004) and conversely, have begun to identify that non-centralisation is associated with a poor behavioural response to back pain (Werneke and Hart 2001; 2005; George, Bialosky, Donald 2005). Each sub-group has different treatment needs. Many studies have been published about centralisation and DP; with numerous studies focusing on the excellent prognosis for centralizers if treatment is directed by patients directional preference (Donelson et al. 1990; Wernerke, Hart, Cook 1999; Long 1995; Karas, McIntosh, Hall, Wilson, Melles 1997; Sufka et al. 1998; Werneke and Hart 2001). A systematic review of centralisation identified that centralisation had been reported in 70% of 731 sub-acute back patients, and in 52% of 325 chronic back patients across nine studies (Aina et al. 2004). The review concluded that centralisation is not only a common clinical occurrence, but, with proper training, it is reliably detected and has important prognostic and management implications. The review also concluded that centralisation should be routinely monitored during spinal assessment and be used to guide treatment strategies. Directional preference has been elicited in 74% of subjects in a randomised controlled trial of which 53% had symptom duration greater than 7 weeks (Long, Donelson, Fung 2004). A more recent review about the prognostic value of symptom responses, which included 22 articles, concluded that only changes in pain location or pain intensity in response to repeated movements or mobilisations were useful predictors of outcome (Chorti, Chortis, Strimpakos, McCarthy, Lamb 2009). Centralisation is clearly one of the few physical examination findings that can give the clinician some indication of prognosis. A lot of recent literature has focussed on the importance of psychosocial factors as prognostic indicators; most of these studies have not included centralisation in the

11 P. 11 analysis. In fact these two documented outcome predictors have rarely been compared as to their relative strengths in predicting chronic LBP. However a number of studies have done so and demonstrated that centralisation is a more important outcome predictor than are fear-avoidance and work-related issues in terms of long-term pain, disability and a range of other health related outcomes (Werneke and Hart 2001; George et al. 2005; Long, May, Fung 2008). Indeed, failure to change the pain location during the baseline assessment, that is noncentralisation, has been shown to be a strong predictor of a poor outcome as well as a predictor of a poor behavioural response to spine pain (Werneke and Hart 2001). When non-centralisation was found, for example, the patient was 9-times more likely to have non-organic signs, 13-times more likely to have overt pain behaviours, 3-times more likely to have fear of work and 2-times more likely to have somatisation (Werneke and Hart 2005). Given these findings, in an effort to prevent the development of chronic LBP, the presence of noncentralisation during a baseline McKenzie assessment in more acute patients suggests that additional psychosocial screening for this small subgroup would be useful. If after a number of sessions, maximum five, but dependent on clinician experience and patient presentation, a patient cannot be classified in one of the mechanical syndromes then one of the other categories is considered. These are mostly types of specific back pain, with clear operational definitions (McKenzie and May 2003), such as trauma, postsurgery, chronic pain state, spinal stenosis, or sacro-iliac joint problems. These generally are not amenable to MDT management styles, but obviously may respond to other physical therapy interventions. This evidence indicates that a mechanical evaluation in the hands of an experienced clinician is a very powerful tool to determine the large subset of patients with chronic back pain who will respond in a straightforward manner using self-treatment methods, and conversely, the smaller group who will not respond and therefore are in need of either further investigations or a more involved psychosocial intervention. Treatment & Efficacy If a condition is very common, persistent and resistant to easy remedy, it is time that the patient is fully empowered to deal with these problems in an optimal and realistic fashion. As clinicians we should be offering this empowerment to our patients. (McKenzie and May 2003, page 29). Description of Treatment Procedures Such distinctly different syndromes as described previously require distinctly different treatment principles. For derangement, the treatment aim is to rapidly centralize and abolish all symptoms and restore all lumbar movement. Furthermore, treatment includes three important phases: demonstrating and educating patients about the beneficial effects of positions and end-range movements on their symptoms as well as the aggravating effects of the opposite movements and postures, educating them in how to maintain the reduction and abolition of their symptoms, and then how to restore full function to the lumbar spine without symptom recurrence. For dysfunction, eliminating the symptoms requires treatment aimed at intentionally reproducing the symptoms at end-range as an indicator that the short, painful structure is being adequately stretched so it can remodel, and become pain-free over time. For postural syndrome, the pain is eliminated simply by improving posture in order to avoid prolonged tensile stress on normal structures. This is done through educating

12 P. 12 the patient in posture correction while (s)he experiences the beneficial effect on their pain. Furthermore, within each syndrome, additional assessment findings dictate further treatment considerations. For example, two patients might both be classified as derangement, but one centralises and abolishes symptoms with extension exercises and the other with flexion exercises. Their treatment directions for their respective derangements are obviously opposite in terms of their exercises and posture strategies. This point is very important in light of the frequency with which McKenzie care has mistakenly been equated with extension exercises, certainly related to the fact that the subset in need of extension is so large (Hefford 2007). Fortunately, such misunderstanding is becoming less common as the assessment and classification portion of McKenzie care is more widely recognized. Fundamentally, the treatment strategy and direction of exercise is individually determined for each patient based on the assessment findings. So it is important to note that there is no generic prescription of standardised exercises within the McKenzie paradigm. The overall objective of McKenzie care is patient self-management. In most cases, treatment is based on patients performing their own distinct pain-eliminating exercises and posture strategies. The clinician s role is primarily as the assessor, classifier, and educator. With the clinician s guidance and through each patient s own experiential education, patients quickly and easily become empowered in how to first eliminate their own pain and then to become proactive with these same strategies to prevent its return. There is evidence that prone extension exercises, when performed prophylactically, are capable of preventing the recurrence of back pain in those who have had back pain in the past (Larsen, Weidick, Lebooeuf-Yde 2002). The Use of Manual Force For a minority of patients, fully centralizing and eliminating their pain requires greater end-range force than they are able to generate themselves. In these cases, MDT clinicians can assist by providing endrange over-pressures and even progress to mobilization and manipulation in the patient s direction of symptom preference. However, the majority of patients can selfmanage using end-range exercises under the clinicians guidance and education, with no further need for clinician-generated forces. Based on these findings, and the emphasis on promoting patient-centred care, books for patients to assist with self-managing their own pain (McKenzie 1980, 1983) have been used worldwide for the past 25 years. Outcomes Clinical Guidelines International and national guidelines for the management of back pain are now widespread; unfortunately very few of them refer to the assessment and diagnosis process referred to earlier, in which the MDT process has such strength. The MDT assessment, with all its reliability and predictive validity studies have been overlooked by most clinical guidelines. However one guideline has recognized MDT as a diagnostic tool and prognostic indicator and recommended it with what they determined to be Level B evidence (DIHTA 1999). McKenzie treatment methods have been mentioned in several clinical guidelines, but it should be noted that most guidelines, like most systematic reviews, incorrectly limit McKenzie care to just treatment and specifically then equate it with the performance of extension exercises. Therefore, most guideline attention given to McKenzie

13 P. 13 treatment is both deficient and flawed. However as a treatment method for chronic back pain, MDT has been recommended by a number of guidelines (DIHTA 1999; Philadelphia Panel 2001; CLIP 2006; Mercer et al. 2006; Bach and Holten 2009). Systematic Reviews Two systematic reviews have specifically investigated the efficacy of MDT (Clare, Adams, Maher 2004; Machado, de Souza, Ferreira, Ferreira 2006). Conclusions were similar, that there was some evidence to support shortterm effect in acute back pain, but there was limited evidence relating to chronic low back pain. However other systematic reviews exist that have considered classification-based treatment, using symptom response methods, which include mostly trials investigating MDT (Cook, Hegedus, Ramey 2005; Slade and Keating 2007; Fersum, Dankaerts, O Sullivan 2009). Two included five studies; in one all articles scored 6 or more by PEDro rating (suggesting high quality), and four out of five found that a directed exercise program implemented according to patient response was significantly better than control or comparison groups (Cook et al. 2005). In another a met-analysis showed a clear favour in terms of classification-based treatment over control in affecting pain (p=0.004) and disability (p=0.0005) (Fersum et al. 2009). Randomized Control Trials (RCTs) This section will just consider some of the relevant RCTs. One compared the McKenzie method with strengthening exercises where 85% of subjects had symptoms greater than 3 months (Petersen, Kryger, Ekdahl, Olsen, Jacobsen 2002). Miller, Schenk, Karnes, Rouselle (2005) compared McKenzie with stabilisation exercises, with a mean symptom duration of 26 months. Long et al. (2004) had a mixed population, mostly sub-acute and chronic, with 53% having symptoms longer than 7 weeks, but all of whom displayed directional preference. Another study recruited just centralisers and peripheralisers and randomised them to MDT or manipulation (Petersen et al. 2011). Results clearly favoured McKenzie short-term in one study (Long et al. 2004), showed a tendency to favour McKenzie in another (Petersen et al. 2002), the two treatments were equal in another (Miller et al. 2005), and MDT treatment was superior in another (Petersen et al. 2011). Future Research Recommendations Ideally, future low back pain RCTs need to shift away from studying patients with socalled non-specific low back pain (Spratt 2002). This move is clearly supported by early indicators that classification-based treatment is more effective than current one-size-fits-all evidence-based guideline treatment (Long et al. 2004, 2008; Fritz, Delitto, Erhard 2003) and other non-specific approaches (Brennan et al. 2006; Hicks, Fritz, Delitto, McGill 2005; Childs et al. 2004). With minimal differences found in nearly all RCTs of non-specific LBP to date, such trials need to be abandoned in favour of either randomizing reliably identifiable subgroups (Long et al. 2004, 2008; Spratt 2002; Brennan et al. 2006) or using validated clinical prediction rules to identify responding sub-groups (Brennan et al. 2006; Hicks et al. 2005; Childs et al. 2004). In light of all these positive research findings in studies targeting the sub-classification of the back pain population, the future should include greater attempts to define and refine the sub-classification process and determine the most suitable interventions for different sub-groups. Such trials need to be preceded by reliability studies to support the reproducibility of assessment systems, and then prognostic validity of assessment findings, in order to justify the time and expense of conducting a subgroup-focused RCT. Within this hierarchy of evidence, non-rct reliability and predictive

14 P. 14 studies have for too long been ignored in the rush to embrace the gold-standard RCT. The statistical significance possibly found in an RCT is based on the difference between mean scores between groups; by its very nature this type of testing does not identify individuals who respond best to a certain intervention. It is the latter that the clinician on the ground needs to know. It is commonly stated that psychosocial issues dominate the evolution from acute to chronic back pain and that consequently these issues must be addressed in treatment. Several recent studies have sought to test this theory, but many of these have failed to demonstrate clear superiority of a cognitivebehavioral approach to a physical treatment, such as exercise or manual therapy (Hay et al. 2005; Kaapa, Frantsi, Sarna, Malmivaara 2006; Storheim, Brox, Holm, Koller, Bo 2003; Smeet et al. 2006; Jellema et al. 2005) or to usual GP care (Koes, van Tulder, Thomas 2006). Furthermore, there is no evidence that evaluating, sub-classifying, or treating psychosocial factors in any way improves outcomes (Jellema et al. 2005; Koes et al. 2006). Alternatively in fact, successfully addressing patient s pain has been shown to resolve most accompanying psychosocial issues (Werneke and Hart 2001; Long et al. 2004; George et al. 2005) even with the use of physical treatment (Long et al. 2004, 2008; Storheim et al. 2003). This evidence suggests that the dominant role that many assign to the psychosocial element in chronic back pain and its management has not been entirely appropriate. More effort needs to be made in determining which sub-group of patients with persistent pain actually need a non-specific psychosocial approach. As discussed previously, the finding of non-centralisation has been reported as a strong predictor of poor prognosis (Werneke and Hart 2001). Further research to assist in dealing with this chronic subgroup should include the comparative prognostic validity of these different clinical findings, the degree to which psychosocial features are relevant to treatment decisions, and identifying reliable methods of evaluating and classifying sub-groups in whom these features may be dominant. Ongoing Studies There are multiple planned and ongoing studies related to MDT. These include, but are not limited to: subgroup determination in acute and chronic LBP, RCTs of McKenzie treatment in MDT subgroups versus placebo; centralisation in the cervical spine; comparative prognostic validity studies of centralisation and clinical prediction rules; centralisation and psychosocial factors; anatomic studies to define the mechanism of pain centralisation and directional preference; and reliability studies in determining the three McKenzie mechanical syndromes in extremity problems. Conclusion MDT has an important role to play in all patients with back pain in terms of reliably classifying them into distinct, validated subgroups with distinctly different treatment needs. The reliability and prognostic validity of the assessment findings are welldocumented across multiple studies, along with more recent subgroup-specific RCTs showing the efficacy of classifying patients in this way. Sub-group classification of back pain and subgroup-specific management strategies appear to be a highly successful and objective way to improve the care of patients with acute, subacute and chronic back pain, compared to the nonspecific, one-size-fits-all recommendations of most international guidelines to date.

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17 P. 17 Aquatic fitness, Reeducation and the American Experience Author: Thierry Terret, CRIS, University Lyon 1 terret@univ-lyon1.fr Abstract Aquatic fitness was born in the USA in the late 1960s and early 1970s. It defined its space, became institutionalized, and rationalized its content between 1985 and 1992 without making a radical break with its medical ties. The success of the practice was celebrated by several processes of legitimization, professionalization, and expansion, mainly ruled by an American organization: the Aquatic Exercise Association. The paper explores the conditions of both the birth and first diffusion of aquatic fitness within the USA and questions how the field could be recognized within the fitness sector, keeping links with the therapeutic and neohygienic issues of its origins. Based on a set of interviews conducted in the USA with some of the pioneers of the activity and archives of the Aquatic Exercise Association, it shows how a convergence of demographic/social, institutional, and technological/economic factors could explain its spread and success. Introduction & Methodology Aquatic fitness can be defined as physical exercises practiced in water, usually in a vertical position, for recreational, neohygienic, or therapeutic reasons (Terret and Humbert, 2002). Practices that correspond to this definition only appeared in the USA towards the end of the 1960s and progressively conquered the world. Considering more generally the extension of the fitness phenomenon over the last 50 years, it is clear that in most of the countries concerned, political factors were closely linked to an economic and industrial situation. Karin A.E.Volkstein (2000, 83) described the fitness movement from a sociological point of view as a phenomenon initiated by a group of people from the middle- to upperclass categories and where gender, age, and ethnic factors also play a non-negligible role. However, in order to explore the birth and early diffusion of aquatic Fitness I considered an interdisciplinary approach (Terret, 2004), because studying the diffusion process for a practice often boils down to bringing together and opposing historical, sociological, and geographical theories (Bale & Maguire, 1994). I have opted for a standard analysis of available written and videotaped sources, completed by a series of interviews with aquafitness pioneers (n = 10) and a survey taken in 2001 by the Aquatic Exercise Association (the world leading body in this field) among aquafitness instructors who subscribe to The Akwâ Letter. Internet was also an essential tool, both for accessing certain sources and for communicating with some of the players in aquafitness history - though using it involved taking a few methodological precautions (Cox & Salter, 1998).

18 P. 18 The invention of aquatic fitness (mid-1960s to 1985) In the United States, the development of fitness as a national preoccupation appears to have been less of a factor in the early manifestations of aquafitness in the late sixties and early seventies than were the itineraries of specific individuals who had not only a long experience with the aquatic environment, but also a heightened sensitivity to the problems of the handicapped. Aquatic fitness pioneers were all young North American women between thirty and forty years of age with a relatively good experience of water practices acquired in a personal or a professional capacity, and an interest in using aquatic exercise to develop the health and/or well being of participants. Besides their professional experience as swimming instructors or lifeguards, some of these women had a more than average interest in handicapped groups, which led them early on to develop original programs that were far removed from traditional teaching and training courses. All interviews illustrate the role played by the presence of such specific populations with needs that were more medical, preventive, or recreational than truly sports-oriented, making it necessary to depart from the types of aquatic exercise that dominated swimming pools and search for new methods. 1- The Role of the YMCA) In terms of institutional opportunities, the YMCA appears to have facilitated innovation in the field a number of times. Given its long experience with swimming practices, it is not surprising that the YMCA started developing aquatic practices as part of its reeducation programs for the handicapped as early as 1960 (Reynold and Dedrick, 1960) and continued to increase its involvement in that area (YMCA, 1973, 1987). By 1982, the YMCA was ready to launch its National Physical Fitness through Water Exercise Program (Sanders, 2000, 9). Although the initial choices were more swimmingoriented, the program gave rise to a variety of innovative proposals, some of which were oriented towards aquatic exercise. The first experiences occurred in a variety of places and types of institutions: recreation departments, paramedical institutions, schools, clubs, and marinas. Even the military establishment provided an opportunity. During the second half of the 1970s, however, aquatic exercise programs spread from such institutions to traditional fitness centers, where aquafitness classes became more or less firmly established. This was due to a threefold movement: 1) Aquafitness pioneers were seeking to develop their ideas for non-specific target groups, sometimes in the same city they were working in, sometimes following a move to a different area where the local fitness centers provided financially acceptable opportunities. 2) Owners of fitness centers were beginning to perceive the first signs of a saturation and dissatisfaction on the part of aerobics fans, either because the population was aging and were less able - physically or psychologically - to support the frenzied rhythms that were imposed, or because the physical fitness requirements of American women had changed. Knowledge of aquatic exercise classes for special groups led some of these owners to add that type of class to their land-based programs, letting their instructors learn on the job. 3) From about 1975 on, other second generation pioneers threw themselves into the adventure after observing a class or reading a book on the subject. These new players were less systematically integrated into the reeducation environment than the first generation. They were also all women, although their backgrounds were not just in swimming, but also aerobics, or even yoga or dance. Whether the project originated out of dance,

19 P. 19 swimming, therapy, or aerobics, most of the first and second-generation pioneers turned to the task of capturing the budding market. There was enormous demand. Supply was slow at first, since aquafitness instructors were mostly self-taught, but it didn t take very long to catch up. Given these conditions, the classes that were proposed were generally very successful. In the mid- 1970s, classes that started with ten to fifteen participants often doubled rapidly, with the result that new classes were started. Within a few years, it even became necessary to train new instructors in order to meet the demand for classes. Based on our interviews, we can consider that classes started to become saturated during the period 1980 to 1983, which reinforced the emergence of new training strategies within the institutions themselves. In a few cases, an instructor who had developed an original program would leave the area, forcing the owner of a land-based aerobics center to recruit or give on-the-job training to a new instructor. But generally what happened in the first few years was that the first generation of selftaught instructors organized training for new instructors in forms that varied all the way from simple advice to intensive workshops. This system was mostly informal, so exchange appears to have remained at the local level and progress was made by dint of individual experimentation. The absence of an organized network and the lack of available studies further reinforced such limitations. Indeed, because of the lack of specific organization and the limited diffusion of works on the subject, early exchanges often took place at aerobics or swimming conferences. These were largely informal meetings that were held at the occasion of other events organized by various institutions such as the Aerobics and Fitness Association of America (AFAA) or the old American Alliance for Health, Physical Education, Recreation and Dance (AAHPERD). 2- Early Exercisers: From Problem-Solving to Complementary Activities Before the institutional break when aquafitness literally exploded in all its forms, the first instructors already had hopes of opening the activity up to a wider public. This was not necessarily easy - in fact, it turned out to be a two-stage process that involved a shift in therapeutic modalities towards new locations, but not necessarily accompanied by a change in instructors, participants, or programs. In the early 1970s, participants were generally adults - mostly women, but not exclusively - who were seeking exercise of the physical or psychological reeducation type. When these methods shifted to traditional fitness centers, however, the public rapidly became even more feminine. Aquafitness methods at the time were largely inspired by land-based aerobics, which was getting a new start in the United States (low-impact exercise hadn t yet arrived to offer an alternative). However, the pace was slower and the water made the effort more tolerable for the untrained body, so the aquafitness classes in these centers began to attract often overweight or physically unfit women in their 30s to 50s who were unable to support the fast rhythms of landbased aerobics, or who were embarrassed to show their bodies. Fashion was beginning to be over-mediatized, and those who didn t conform to the norms it imposed were made to feel guilty. Besides that, immersing the body in water (not to mention the symbolic disappearance of the body in the water!) definitely had a psychological impact on women with a fragile self-image and who were sensitive to the opinion of others. In the early 1980s, a third movement occurred and took several orientations. The first was in the direction of another category in the same age range (25-50) as the two previous types of participants: women

20 P. 20 without specific problems but with a long experience in taking care of their bodies. These started to appear in great numbers. Many of them were babyboomers born in the forties and fifties who had always been neohygienic consumers of physical fitness activities, especially jogging, dancing, and aerobics (Heargreaves, 1987; Grover, 1989). This well-trained group was now in search of complementary or alternative activities. Many were taking two or three aerobics classes per week and because they were bored with the relatively repetitive nature of the classes or with the lack of inventiveness in the sector, sought to keep up their fitness by substituting other practices. Others, usually the older ones, wanted to maintain their level of activity by adopting practices that were easier on the body than aerobics. Aquafitness satisfied these expectations, and exercisers made the transfer from one activity to another even more easily because the movements and routines developed in aquatic fitness programs were partly inspired by those used in land aerobics. And there was finally an opening to a male public, a slight one, to be sure, but one that boded well for future change. The first decade of aquafitness rhymed with moderation and was subject to a more traditional vision of health. Men were afraid of being discredited in the eyes of women, and rejected the apparent passivity of the sessions compared to the traditional sports activities they considered to be worthwhile. Only when women started to demand more energetic forms of aquatic practice did men accept to join the aquafitness movement. That was in the early 1980s, and there was a lot of resistance for a long time after that. Men came often to the classes at the urging of their wives, to accompany them, or perhaps to warm up before going off to swim laps (Table 1). 3- Influencing Concepts) During the 1970s, aquafitness classes for most exercisers generally took place in swimming pools, in relatively shallow water, and at agreeable temperatures. It would have been inconceivable to place people in even more difficulty because of potentially anxietyproducing environmental conditions, when they were already uncomfortable with their bodies for health, weight, or fitness reasons. A prudent use of deep water appeared a bit later and became an integral part of programs by the late 70s, as technology for staying afloat evolved and user profiles gradually changed. The transition was due in large part to the possibility for jogging in deep water with floats, a reeducational strategy that was being used more and more for athletes as post-operative training, for example, but which broke free of its medical constraints by the end of the decade to be proposed as a fitness technique. In spite of the above, the pioneers had to create their initial programs intuitively and without explicit references. The pioneers that I interviewed drew mostly on their experience as swimmers to search for relevant movements and to justify their use. A few drew ample inspiration from dance or from aerobic movements at first, either because their swimming expertise was more limited, or out of personal choice. In general, instructors who transferred aerobics programs to the water had to reduce the speed and frequency of movements compared to the land model, which led to either abandoning the musical support altogether or using new background music that was dissociated from the movements themselves. The search for music that was better adapted in rhythm and tempo became more frequent, if not systematic, after 1975 and even generated new programs and routines (Table 2). Seeking out motivations was a dominant recurring theme for all. Some used music to that end, if only to create a mood; others gradually resorted to the use of equipment

21 P. 21 to stave off boredom and to experiment with new programs. The problem that the pioneers ran into immediately was the unsuitability of the equipment available in the land-based aerobics and physical fitness industry. The mats, balls, weights, bars, and bodywork equipment were clearly not intended for use in the aquatic environment. Large companies such as Speedo had not yet taken cognizance of the developing situation, so were not pursuing that commercial sector. The same was true for smaller businesses, which usually have a reputation for being more responsive to cultural change. In the meantime, instructors had to make do with traditional swimming equipment in order to influence posture, reinforce positions, and vary the exercises, but without really changing the types of resistance solicited. Instead, they compensated by using their imagination and creativity, and didn t hesitate to use objects that apparently had no relation to the activity. One pioneer interviewed confessed: We started out with gloves, but also bamboo sticks and plastic bottles; anything made out of plastic was good, or anything that floated or could be filled up. Milk jugs were immensely popular at the time. Some instructors observed swimming paddles and thought up webbed gloves, or duck feet, that they made themselves for their own use. There was obviously a bit of intellectual tinkering involved with all of these proposals. By the end of the 70s, some of the pioneers were trying to analyze the effects of aquatic exercise on physiological factors in a more scientific way (Sanders, 2000) and even they could not escape a little guesswork. Consequently, these programs were rebuilt into systems that possessed their own internal logic and coherence, and quickly found a position midstream between the commercial and the associative sectors. Until the end of the 1970s, they were still rarely used to support aggressive strategies that required approval from the medical or athletic community, market studies, sponsoring, or any other standard market promotional approach. The different aquatic fitness concepts that co-existed during the 1970s contributed to make a new field of recreational activity flourish throughout the early 1980s and up to 1985, when a number of determining factors came together to change the system more radically and opened up the way for qualitative as well as quantitative changes. The institutionalization of an idea ( ) In the USA, the mid-1980s was marked by three major changes in terms of physical activity and recreation. 1) A revived preoccupation with health dominated daily life, turning physical activity into a genuine lifestyle. The active living concept made fitness a factor of normality (Fitness, 1988). 2) Babyboomers started to age, resulting in greater demand for activities more adapted for older people; at the same time, new specializations were emerging (handicapped, athletes). 3) Opinions about exercise were changing: exercise in the North America of the early 1980s was subject to a physiological concept of the biological system s needs that viewed fitness in terms of measuring cardiorespiratory factors, according to guidelines established by the American College of Sport Medicine (1975, 1978). Ten years later, these views had changed. Cardiorespiratory capacity was no longer considered to be the only valid criterion, and other psychological and social factors began to be taken into consideration. These factors affected aquafitness, of course. They contributed to enhance its appeal and reinforced the search for diversification. However, the overall context wasn t enough to explain why the years from 1985 to 1992 constituted a definite break with the past - other more specific factors also played a role. During this short period, the aquafitness industry entered a stage of activity that may have contributed to establish its identity. Through their efforts to formalize, rationalize, restructure, institutionalize, and obtain recognition, the more directly involved actors started to trace out a territory and define an objective, almost without knowing it.

22 P Local Restructuration and National Institutionalization In the mid-1980s, the structure crumbled under the weight of a twofold movement. Large clubs were maintaining land aerobics, dance, and aquacise components in their programs, but also were stepping up specialization. This soon led to the appearance of centers devoted entirely to aquatic fitness, even if it meant building small pools that would quickly break even. Also, most of the dynamics were provided by programs that were popping up all over the country wherever there were available swimming facilities and a desire for educational, financial, health, or recreational returns. In 1988, 45% of water exercise participants practiced in YMCA and YWCA pools, compared to 19% in school and university facilities, 16% in municipal pools (recreation departments), and only 12.6% in fitness club pools (Midtlyng and Nelson, Within a few years, this tremendous boost to the sector meant that supply finally was meeting demand. As local structures multiplied and became specialized, the number of genuine professionals increased proportionally, due to a combination of three major factors. The market played a role by guaranteeing the sustainability of the smaller businesses and the more selective programs. If participants themselves had not started to demand more qualified instructors, the existing market could even have gone on just supplying fitness centers. But according to a AEA study of 831 participants that was carried out in 1987, some of the people who had been practicing for ten or more years began to push for more expertise and improved material conditions (The Akwâ Letter, 1987). Exerciser profiles were also changing - which, added to growing competition in the sector, resulted in a race for technical and technological innovation that was not compatible with extremely multi-purpose centers where individual skills are not necessarily developed. From then on, a combination of economic and cultural conditions made it absolutely necessary to have qualified staff in the form of personal trainers or salaried instructors. By the mid-1980s, such staff did exist: a professional community was developing unawares. Within a few years, a need for a minimum of organization and exchange among instructors inevitably developed. Attempts by the YMCA to set up a training program did guarantee the system a certain legitimacy, but the situation couldn t be maintained as it was for much longer: a lack of harmonization in teaching content and coordination is scarcely tolerable even when only few people are involved. If the sector had fallen apart in theoretical and human terms, the very existence of aquafitness centers could have either been jeopardized or risked a reorientation towards solely paramedical use. Ruth Sova, an enterprising, charismatic, and dynamic young aquatic fitness instructor, took the initiative to create a national association just when it was becoming urgent to do so. By the mid-1980s, she already had about ten years of experience in aquatic fitness. She was very involved in the fitness industry and had presented her ideas on aquatic exercise any number of times at national conventions: With the surge in interest in aquatic exercise, classes have been growing by leaps and bounds. Not only are more people taking classes, but the variety of programs being offered has increased. What is everyone doing? What s working and what isn t? What s safe and what isn t? What research has been done that might give us guidelines for designing our programs? ( ) When I was lecturing across the nation, I found that people had no idea what other aquatic exercisers were doing. Many expressed a desire to learn from each other and share resources. The association was formed for that reason. (The Akwâ Letter, May 1987, 4). First the association had to be given a name. The word fitness perpetuated the confusion with what already existed; exercise seemed more neutral and widespread. The Aquatic Exercise Association officially came into being in Defining its objectives was no

23 P. 23 problem: the purpose of practicing aquatic exercise was to improve health and fitness through safe, effective aquatic exercise and to encourage a physically healthy lifestyle for all individuals. AEA is dedicated to networking a worldwide cooperative to advance the quality of the aquatic fitness industry as a whole. It didn t take long for the association to become known, in particular thanks to press coverage. Just a few months after it was created, the AEA already had several hundred members. 2- In Search of an Identity The AEA had to begin by establishing its identity as an organization; or, more precisely, defining what it meant by aquatic exercises and finding a position for them among activities that an uninitiated observer might have trouble differentiating. Aquatic fitness was neither simply land-based aerobics transferred into water, nor a marginal and underrated form of swimming - it needed to gain recognition as a legitimate form of exercise among others. In 1987, AEA Executive Director Vicki Chossek commented in the first issue of The Akwâ Letter (1987): While some exercisers prefer swimming their way to fitness, others are finding the pleasure of jogging, leaping, kicking, kneelifting and swinging their way through the water and on to better health ( ). Pools aren t just for swimming anymore. This last sentence even became a catchphrase for the last page of the magazine in several issues, with anymore underlined twice. Chossek went on to say: Aquatic exercise instructors need to know a lot more than how to swim. Fitness, insurance, music rights, motivation, pool safety, class format and program design are all important to the success of aquatic exercise programs. Science also played a part, for instance with research that measured the effects of aquatic exercise in the vertical and horizontal positions. But in general, it was less a question of proving something scientifically and more of taking a stand on the specificity of aquafitness and demanding recognition for it; in the end, the point of the exercise was to define the originality of aquatic fitness by emphasizing its differences with respect to swimming. As Ruth Sova (1987) puts it, the first thing aquatic exercisers need to do is ignore any study done strictly on swimmers. In the search for identity, they developed a reasoning that was different in form, but similar in substance with respect to traditional fitness practices. Some of the remarks sound like warnings and approval at the same time: Tiled cement floors and over-enthusiastic bouncing has taken its toll on aerobic dancers. People like the idea of dancing as an exercise form. They like the music and the movement, but they don t like the injuries that accompany it (The Akwâ Letter, May 1987). Even so, the national fitness associations were not at all hostile towards aquatic fitness, and were indeed rather interested in the institutional approach. So were the very large associations that were already involved in the sector, such as the YMCA and the YWCA. In 1988, the YMCA set up its own certification system. The identity issue appeared to be less of a problem with respect to fitness than to swimming, especially since some professionals were interested early on in a new orientation that broke completely with those prioritized until then. With the creation of the USWFA, they wanted to get the industry involved in competitive activity by making competition an objective for some of the aquafitness programs. By entering into a sports-oriented logic, excellence could be redefined in terms of performance instead of physical condition, which would lead to a much more complete redefinition of the entire activity. As Sandy Stoub expressed it when interviewed, AEA was closed to aerobics and vertical, USWFA was closed to swimming and horizontal. The incompatibility between swimming and aquatic exercise wasn t insurmountable, but fitness swimming was probably a more important element in the big picture than competitive swimming.

24 P. 24 Fitness swimming was just taking off in the United States during the 1980s. As early as 1988, the movement appeared to be irresistible for the AEA, which succeeded in setting the criteria for the specific nature of aquatic fitness and establishing itself on the basis of significance and validity. As the number of instructors increased, regional associations were even a possibility. The California Aquatic Association, created in 1989, is an early example. 3- Meeting and Persuading In the 1970s and early 80s, promoting aquatic fitness did not depend on standard mass media channels, or even specialized ones, but on more local campaigns. There were numerous scientific and medical publications on the advantages of aquatic exercise, but these addressed well-informed publics. Otherwise, the pickings were poor for aquatic activities, swimming, and other fitness activities. Articles on aquatic fitness itself were relatively rare in the specialized press, so the general public was not very informed about the budding industry. Near the mid-1980s, fitness magazines gradually started devoting columns to aquatic exercise and to AEA activity. Some magazines gave only rare reports of aquatic fitness programs, and these emphasized the original aspects that made them stand out. The index for the magazine American Fitness included only three articles on the subject between 1985 and After that, the frequency of articles increased more significantly, an indication that the industry had reached normality. The growth of the industry must have depended on other means of persuasion. Now, one AEA objective is precisely to serve as a tool for communication and the diffusion of ideas that addresses the general public as well as the community of aquatic exercise professionals. A good illustration of the mass communication aspect is the demonstration that Ruth Sova gave on ABC s Saturday Morning Health Show on October 3, 1987, and one of the best examples of the second aspect is The Akwâ Letter, a journal created by the AEA during an experiment with in-house communications. The first issue of the bimonthly journal was printed out in May The composition of the Board of Advisors for The Akwâ Letter is an indication of the seal of approval given by the scientific, medical, and educational communities, not to mention the world of swimming-pool management and marketing. Finally, in the mid-1980s, a new medium emerged in the form of videotaped programs. Books had rapidly reached the limits that concern any technical production The need for exchange and the identity search based on individual experience also resulted in the first independent AEA conference, which took place in May 1988 and gathered together 200 exercisers and hydrotherapists for 42 workshops and lectures. At first, the IAFC (International Aquatic Fitness Conference) attracted mainly land aerobics instructors, who came as much out of curiosity as out of interest, but it turned into a vast convention that was held once a year and quickly became an essential meeting place for aquafitness professionals. Smaller meetings emerged to fill the gaps in the national network. Conferences were organized in different states, providing the occasion to certify new instructors or ratify practicing ones. At the same time, aquafitness was becoming more integrated at several levels. It continued to be included in YMCA programs, and benefited from the development of specific programs and training projects. From 1986 to 1992, aquatic fitness also gradually became an essential component in the overall fitness sector, which now integrated it without challenging it. The America s Fitness Conference in October 1987 offered several aquatic exercise workshops and invited AEA members. In 1990, the IDEA Conference included a whole Aquatics section. Even universities had started to organize classes for students, although the demand was often much greater than local resources allowed.

25 P Establishing A Norm: Teaching and Certification The 1980s generation of instructors came from a wide variety of backgrounds. Those who sought out aquafitness generally had credentials in swimming, dance, or aerobics. In all cases, however, aquafitness was based on outside activities; very few instructors were directly attracted by the activity itself, but came to it following another experience. An AEA study confirms that 18% of instructors had never practiced aquafitness before teaching it, and more than half (53%) had no more than a year s experience. This type of professional itinerary explains why most aquatic fitness instructors have other activities on the side: 42% are also swimming teachers; 38% are also land-based aerobics instructors; and 38% also have responsibilities as program directors (AEA Member Survey, 1991). And we must not forget those whose main activity is further removed from the industry, such as therapists and other types of teachers, but who also contribute significantly to the system. From 1985 on, those who devoted part of their time to training instructors had to take the diversity of content and method into account. The idea of certification stemmed as much from this diversity as from the need to harmonize the level of the industry by pooling everyone s experience. One of the AEA s first initiatives was to organize a certification system that rapidly played a considerable role in the development of aquatic fitness. The existence of a qualification that was issued by a national organization, that bore its label of quality and guaranteed a certain level of expertise helped to promote the activity and gain acceptance for it from the participants themselves, of course, but also from the public authorities and the whole fitness industry. And, what is probably more important for our analysis, any system of certification also creates a system of standards for training content from the moment the qualification becomes established as the most legitimate in a given sector. This is exactly what happened with the AEA. Indeed, the AEA created its certificate in The principle was simple: training was to be organized within a variety of frameworks, with or without AEA support. AEA directors were not necessarily involved, except for evaluating skills. The training program guaranteed that instructors and employer would have a minimum of knowledge in anatomy, kinesiology, physiology, safety and injury prevention, basic emergency procedures, legislation, and the principal techniques used. The system included a Continuing Education Certification component that involved taking a fifteenhour training module every two years. A two year interval may seem relatively short, but was appropriate for the high rate of renewal in the industry in the area of equipment, programs, and to a lesser extent, specific skills. The choice may not have been devoid of financial considerations, but it especially was indicative of the preoccupations in an area of activity that was developing a bit haphazardly. Certification and ratification could be scheduled upon request and within a few months, the AEA was almost snowed under from the enormous demand for certification, due to the increase in the number of participants. The success of the certification programs was a measure not only of a concern with being recognized within the aquatic fitness community, but also of the steady growth of that community. The distribution curve for entry into the profession showed a more or less steady increase from 1975 to 1995, before turning sharply upwards. In 2000, the average amount of experience for American aquafitness instructors was eight years (Table 3). Over and above the experience-pooling objective mentioned earlier, the certification program followed the aquafitness movement and indirectly imposed an orientation. Therefore, we can consider that, although it had no particular ambitions for supremacy, the Aquatic Exercise Association found itself in a situation of cultural monopoly once

26 P. 26 the industry really started booming. After establishing the foundations of the activity on a relatively consensual basis, the AEA contributed to widen them by means of its conventions and certification programs population who wanted to maintain a regular activity while limiting the risks of injury. This had an effect on the programs which, while they gave priority to livelier tempos than during the seventies, were still less energetic 5- Young American Women and New Athletes According to a two surveys done by the AEA in 1988 and 1991, ninety percent of the concerned population were women. The results were evidence of the painfully slow integration of men into aquatic fitness over the decade, although their presence was stabilized or even slightly rising. Nevertheless, while aquatic fitness remained a predominantly feminine practice that was attractive to older people, there was more change in the age of participants than in gender during the second half of the 80s. The 1991 survey showed that more than 70% of exercisers were under forty, with a high concentration in the age group, speaking for an unquestionable rejuvenation of the sector. It also confirms a break. The success of aquatic fitness had been based for a number of years on the aging of an active than aerobic routines. These precautions were becoming less justifiable, and the demand for more open programs that included some energetic tempos could not be ignored. This is what attracted more men as their perception of the activity gradually changed. The fact that only 58.5% of exercisers had more than a year s experience at aquafitness shows that aquafitness was still very popular during those years, even though a number of exercisers dropped out for reasons linked to dissatisfaction with the first sessions, health problems, or transportation difficulties. Lastly, earlier skills did not appear to play a decisive role. Even not knowing how to swim or being a novice at it was not seen as an obstacle, since that was true of more than 30% of participants. Athletes were a case apart during those years, however. High-level athletes were already using water therapy for faster recovery from injury before There is less risk of trauma from non-weight-bearing exercise when it is

27 P. 27 done in the water. For fans of energetic types of practice, water exercise makes it possible to continue a basic minimum training. Joints may be mobilized sooner (after an operation, for example), guaranteeing that limbs will recover range of movement and coordination more rapidly. After 1985, however, trainers looking for new, less traumatic and more motivating methods for training their athletes started to use the aquatic environment as a support for a new form of training. Swimming doesn t provide the same benefits for athletes who aren t specifically swimmers; cross training, on the other hand, brings simple motor functions into play with the added benefit of being developed by aquatic exercise. So, except for relatively exceptional cases, the programs did not necessarily include movements that were related to techniques in the specific athlete s reference sport, insofar as the training component was complementary to the specific training for each discipline (running, football, tennis, etc.). In the early eighties, the cross-training model was reserved for the elite, but began to spread after Ordinary athletes adopted the new method very quickly - a measure perhaps of how much the zapping culture has permeated all areas of our society. Fitness centers were already offering more vigorous programs that satisfied the need for additional training, which brought in a

28 P. 28 rush of new exercisers with a considerably different profile than the previous generation in terms of athletic experience, physical condition, and gender. In some classes there was a relative increase in the number of male participants. There was also a diversification in what was offered, not just as a function of the specific nature of the particular sport, but also as a function of the state of physical condition of the participant. The continuum that emerges is fundamental in that its extremes serve to delineate the boundaries of an identity for the sector. 6- The Importance of Therapy and Diversification of Tempos The change in demand may be understood only by relating it closely to changes in the supply. In the late eighties, the industry avoided making the mistake of limiting the objectives to a simple continuance of a therapeutic orientation that was retailored to accommodate a more diversified public. It fully assumed its ties to land fitness activities by varying the forms and tempos of programs as a function of the desired intensity and of the specific blend of choreography / cardiorespiratory development to be chosen along a continuum (in other words, somewhere between dance and aerobics). In a 1989 AEA survey, more than half of the people questioned said they often practiced: water jogging (66,9%); open water exercises (63,4%); stretching, bending and twisting exercises for warming up (60,2%) and cooling down (60,5%); wall exercises (59,2%); exercises routines (60,1%); and water jumping (57,6%). A look at the videocassettes from these years also confirms that the routines were organized mostly in reference to older reeducation, aerobics, and dance models, with a number of intermediate possibilities. There is no reason to be surprised by these changes, as they are consistent with what was happening in the whole fitness industry at the time. Aerobics, for example, was diversifying in two different directions: 1) towards adapting the energy levels of individual programs to the different publics (step, low impact aerobics, stretching, etc.), and 2) towards a hybridization with other types of activity (yoga, dance, martial arts, etc.) to produce new forms (Bessy, 1990). That aquafitness programs were on the rise was due as much to efforts to adapt the supply to the variety of demand as to efforts to obtain a better position in the fitness market. Certain requirements remained a constant, such as specificity, safety, and quality, thanks in part to the fact that these were included in AEA certification principles. At the end of the 1980s, the common requirements for specificity were illustrated by the way that workouts in the deep end of the pool were shunned, or by the heavy emphasis on exercising in a vertical position rather than in a horizontal position. The potential advantages of working otherwise were not exploited. The requirements for safety revolved around the depth of the water (here again, the shallow end), the number of people taking the class, systematic warmup and cooling down periods, health history, and fitness testing. Quality requirements were manifest in the care taken to offer complete programs that provided a certain measure of physical, mental, and emotional benefit. The modalities of aquafitness programs appear to have been better-identified than in the earlier decade in reference to three typical models that rarely coincided: training, reeducation, and fitness, even though a good many professionals moved easily from a cross-training perspective to a recreational or neo-hygienic perspective from one class to another. Therapy and cross-training are at opposite ends of a single continuum, and subtle specializations become established in the wake of each model, contributing to diversify the offering: cross-training subdivides as a function of the level of practice and the reference sport; reeducation appears in a variety of forms as a function of specific need (post-operative,

29 P. 29 pregnancy, obesity); and fitness activities are offered in various forms as a function of the public (seniors, children, etc.) and/ or the targeted changes (cardiorespiratory, functional, esthetic, social, etc.) (Table 4). factors explains the spread of the practice. Demographic and social factors were responsible for an explosion in demand for new practices, but the institutional role of the Aquatic Exercise Association was really Conclusion Aquafitness was born in the late 1960s. It defined its space, became institutionalized, and rationalized its content between 1985 and 1992 without making a radical break with its medical ties. The success of the practice was celebrated by the processes of legitimization, professionalization, and expansion. The practice became recognized within the fitness sector. A convergence of demographic/social, institutional, and technological/economic the determining factor in establishing an aquafitness community and building an identity that would soon be sanctioned by the scientific community. AEA activity did help to create a more stable identity around practices that were taking more and more different forms. It also set up a system for developing skills and certifying experts that turned out to have a significant effect on the development of the activity and its recognition in the United States and, later, abroad.

30 P. 30 References American College of Sports Medicine (1975). Guidelines for Graded Exercise Testing and Exercise Prescription, Philadelphian Lea & Febiger. American College of Sports Medicine (1978). The Recommended Quantity and Quality of Exercise for Developing and Maintaining Fitness in Healthy Adults, Medicine and Science in Sports, 10. Bale, J., Maguire, J. (1994). The Global Sports Arena: Athletic Talent and Migration in an Interdependent World, London, Franck Cass. Bessy, O., (1990). De nouveaux espaces pour le corps. Approche sociologique des salles de «mise en forme» et de leur public. Le marché parisien, diss., University of Paris V,. Chossek, V. (1987), The Akwâ Letter, 1, 1. Cox, R.W., Salter M.A. (1998). The IT Revolution and the Practice of Sport History: An Overview and Reflection on Internet Research and Teaching Resources, Journal of Sport History, 25, 2. Fitness Canada (1988). Fitness the Future, Ottawa, Fitness and Amateur Sport Canada. Grover, K. (ed.) (1989). Fitness in American Culture, Amherst, MA, University of Massachussetts Press. Heargreaves, J., (1987). The Body, Sport and Power Relations, in J. Horne, D. Jary, Tomlinson, A. (eds). Sport, Leisure and Social Relations, London, Routledge,. Midtlyng, J., Vanclaeve Nelson, C. (1989). National Survey of Water Exercise Participants, The Akwâ Letter, 2, 5. Reynold, G.D, Dedrick, E.M. (1960). YMCA Aquatic Manual for Special Populations, Washington, Longview. Sanders, M. (2000). YMCA Water Fitness for Health, YMCA, Human Kinetics. Sova, R. (1987). More on Weight Loss and Aquatic Exercise, The Akwâ Letter, 1, 3. Terret, T., Humbert, H. 2002, Histoire et diffusion de la gymnastique aquatique, Paris, L Harmattan. Terret, T. (2004). Une histoire de l aquatic fitness est-elle possible? Réflexion méthodologique, in Delaplace, J.M., Villaret, S. (eds), Sport and Nature in History, Sankt Augustin, Academia Verlag, Volkwein, K.A.E. (2000), Fitness as Cultural Phenomenon, in Tollener, J., Renson, R. (eds.), Old Borders, New Borders, No Borders. Sport and Physical Education in a Period of Change, Oxford, Meyer & Meyer Sport. YMCA (1973). A Swimming Program for the Handicapped, Champaign, YMCA. YMCA (1987). Aquatics for Special Populations, Champaign, YMCA.

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32 P. 32 Enuresis, Dysuria, Encopresis.Could the pelvic floor be the link? Els Bakker,PT, PhD, An Bael MD, PhD HE L de Vinci- IES Parnasse-Deux Alice Unité de Recherche - Bruxelles ZNA Paola Kinderziekenhuis - Antwerpen Abstract A child without problems has an efficient control on his urinary and bowel system, which means equilibrium between the two important phases of each system: storage and emptying. This implicates not only control of the pelvic floor muscles (contraction and relaxation) but also a correct interpretation of the sensorial information during both functional alternative phases leading to social acceptable responses by automatic and voluntary procedures. Both automatic and voluntary responses are part of a learning process. Key-words : overactive bladder, urgency, constipation, nocturnal enuresis Introduction An efficient control on urinary and bowel system in humans means equilibrium between the two important phases of each system: storage and emptying. This implicates integration of sphincter function and a correct interpretation of the sensorial information from the bladder and the bowel leading to social acceptable responses by automatic and voluntary procedures. The whole process requires perfect co-ordination of smooth- and striated muscles of the outflow region of the little pelvis, including the pelvic floor muscles (PFM), and is regulated by complex neural control systems at the different levels of our central nervous system. Since the last 10 years we find many publications on the activity of the brain in normal storage and emptying, and especially on the specific brain areas involved at each step in adults. [Fowler, Griffiths, de Groat. The neural control of micturition. Nat revue neuroscience 2008:9:453-66]. Unfortunately still very little has been published of this process in children, but it is well-known that this integration is part of a learning process in children. First the child has to learn a correct interpretation of bladder and bowel fullness, and then he has to control the moment of emptying at a social acceptable time. He will postpone bladder and bowel movements by contracting the PFM. A contraction of PFM will counteract bladder overactivity (OAB), increase urethral closure pressure, increase the ano-rectal angle and the tonus of the anal sphincter. It will therefore often be used by children to avoid leakages, or postpone toilet visit and can lead to nonrelaxing PFM. Relaxation at the other hand is necessary to allow normal emptying of the bladder and the bowel: non- or insufficient relaxing of the PFM will lead to a hypertonic PF, who in turn will lead to weak or intermittent urine flow, and incapacity to empty correctly the bladder or the bowel leading to post mictional residu and constipation. Whether PFM dysfunctions are leading to nonneurological bladder and bowel dysfunctions (NNBSD) or the inverse is until yet not clear but it is well accepted that NNBSD plays

33 P. 33 an important role in urological and bowel symptoms, leading to symptoms as urinary and/or faecal incontinence, frequency, urge or reduced autonomy for bowel movements and recurrent urinary infections. [Hoebeke 1996] The PFM can be activated by 3 distinct pathways: the somatic motor system (voluntary command and axial movements), the emotional motor system (anticipatory postural adjustments and behaviour) and by direct projections on the Nucleus of Onuff from the Pontine Micturitin Center. It is important during our therapy to realise that the incapacity to relax might be due to an automatic response of the PFM to 1. Postural perturbations (musculosqueletal dysfunctions of the thoracoabdomino-lombo-pelvic region, inad equate toilet-sitting,...) [Bakker 2008], 2. Changes in intra-abdominal pressure during the emptying phase (straining) 3. Activation through the Pontine Micturition Center, etc. We therefore need to have a global approach during our reeducation, and to consider not only the PFM of the child! Although the functional link between the urinary and ano-rectal systems is well established, which implicates the necessity to consider the two systems together, we will now for better understanding start to analyse each isolated item, keeping in mind that we have to restore the global function. Lower Urinary Tract Dysfunctions The infant bladder has for a long time been accepted to be overactive and to empty automatically at regular intervals through simple spinal reflexes and without any control of higher centres [Bauer et al. 1980, Hjalmas 1988]. Development was believed to be a maturational process, normally functional at the age of 4 years [Doleys 1982]. It was only in 1999 that several authors pointed out spinal micturition pathways which were influenced by behaviour and/or arousal and dyssynergic voiding patterns with incomplete emptying in infants. They concluded that voiding with incomplete coordination between detrusor contraction and sphincter relaxation could be normal [Sillén 1999]. This more complex mechanism has since been confirmed by other urodynamic studies [Gladh 2000], revealing the presence of a more complex mechanism during voiding than has generally been thought. Spinal micturition pathways, involving a complex integration of neural pathways at both peripheral and central levels, are influenced by behaviour and/or arousal: e.g. micturition never occurs during quiet sleep: there is a cortical arousal in response to full bladder even in newborn infants [Wille 1994, Neveus 1999]. Normal function of the LUT requires 1. bladder filling with little or no changes in pressure 2. desire to void, 3. postponement of the voiding, 4. initiation of the voiding by sphincter relaxation and reflex detrusor contraction, 5. continuous detrusor contraction that leads to complete bladder emptying within in a normal time span, and in absence of obstruction. Consequently functional pathophysiology can be divided into abnormalities during filling or during emptying phases, though dysfunction can occur during both simultaneously. Symptoms of these dysfunctions are urgency, incontinence, urinary tract infections, and can occur during day and/or nighttime.

34 P Bladder filling phase Detrusor overactivity The first descriptions of non-neurological detrusor dysfunctions in patients with severe disease date from 1915 [Beer]. He described disharmony between sphincter and detrusor and postulated it was caused by an occult neurological disorder. Further reports on this condition did not appear until 1973, when Hinman described a small group with uncoordinated micturition, and recurrent Urinary Tract Infection (UTI) without neurological or obstructive diseases. It was thought to be a behavioural disorder. Its reversal by biofeedback and hypnosis gave an argument in favour of the behavioural nature. Different terminology has since been used in the pathophysiology of filling: uninhibited bladder, infantile bladder, irritable bladder, spastic bladder, reflex bladder. In the ICS standardisation of the terminology of lower urinary tract dysfunction [1976,1977] the term detrusor instability, adopted as first used by Bates in 1970, was reserved for an involuntary phasic detrusor contraction of any pressure during the filling phase while the patient is trying to inhibit micturition. In patients with relevant neuropathy this was called detrusor hyperreflexia. In 2002 the ICS standardisation and terminology has introduced the term overactive bladder (OAB), defined as a urodynamic observation characterised by involuntarily detrusor contractions during the filling phase which may be spontaneous or provoked, and can be qualified according to the cause in neurogenic- or idiopathic detrusor overactivity. In 1980 Bauer defined abnormal filling patterns, based on urodynamic investigations in a large study of affected children. He grouped the disorders into: 1. primarily unstable bladders (small capacity, hypertonic bladders, detrusor hyperreflexia) 2. Infrequent voiding associated with large capacity hypo- or acontractile bladder. 3. Psychological non-neuropathic bladder Clinically OAB is characterised by urgency (formerly urge syndrome or urgency syndrome). Urgency defined as the complaint of a sudden compelling desire to pass urine, which is difficult or impossible to defer in absence of a proven infection or other obvious pathology [Abrams 2002]. This condition may lead to urgeincontinence, which is the complaint of involuntary leakage accompanied by or immediately preceded by urgency [van Gool 1989, van Gool and de Jonge 1989]. The overactive detrusor contractions are countered by PFM contractions to minimise wetting and to postpone imminent voiding. This will overtrain the PFM, who will cause functional outlet obstruction due to urethral and PFM overactivity (see dysfunctional voiding). The dysfunctional voiding will, in turn, maintain the filling phase dysfunction of the detrusor [Hoebeke 1996]. If children wet in spite of PFM contractions, they may even add external compression to the urethra, such as sitting on the point of a chair, pushing the heel against the urethra. [Vincent 1966]. The habit of countering every urge to void inevitably leads to postponement of defaecation (see associated symptoms). Urge incontinence usually peaks in the afternoon, and may have a nocturnal component, which may or may not wake the child. Night-time wetting in a child with urge is not categorised as enuresis but as incontinence: the wetting at night is caused by the same dysfunction as its daytime s counterpart. The exact causes of the development of OAB in children are yet unclear. It has been believed that the uninhibited bladder contractions are exclusively a consequence of a retardation of the maturation of the reticulospinal cords and the inhibition centres in the cerebral cortex. Studies in large populations of children show involuntary detrusor

35 P. 35 contractions during provocative cystometry, being one of the most common elements of NNBSD. [Mayo 1990, Breugelmans 1992]. In 1989 Goldraich however noticed that the balance between bladder and sphincter is very vulnerable as long as the child has not acquired the ability to suppress the detrusor contractions. Hellström suggested considering dysfunctional voiding as normal with a risk of NNBSD developing during the transition to bladder control [Hellström 2000]. This concept might explain the success reported with training and behavioural programmes for dysfunctional voiding associated with recurrent UTI and/or daytime wetting. [Hoebeke 1996, De Paepe 1998] Abnormal bladder sensation Bladder sensation may be increased (an early desire to void at low volume), reduced (diminished sensation during bladder filling) or absent. Bladder sensation is difficult to evaluate in children, and can only be used in toilet trained cooperative children. It can be judged by three defined points noted during cystometry and evaluated in relation to bladder volume at that moment, but no differences between two groups with and without MNE could be established [Wyndaele 1993] Incompetent urethral closing mechanism Very exceptional in children without neurological diseases, and therefore not discussed in this paper 1.2. Bladder emptying phase Dysfunctional voiding Overactivity of the PFM and the external urethral sphincte (EUS) used continuously as emergency brake to prevent leakage s, leads to hypertonic PFM. In consequence the most important problem in these children is their inability to relax PFM during the mictions, leading to dysfunctional voiding. Different patterns of dysfunctional voiding have been described, all with PFM overactivity during voiding as common denominator. The patterns range from staccato voiding, to fractionated voiding to hypo- or acontractile bladder (formerly lazy bladder) with incomplete pathogenesis of these disorders easy to understand [van Gool 1996]. Staccato voiding occurs in case the urethral sphincter no longer relaxes completely. During voiding a staccato pattern may be observed. This rhythmic voiding pattern is caused by periodic bursts of pelvic floor activity during voiding; resulting in dips in the urine flow rate coinciding with high detrusor pressure. The PFM contractions are triggered by a flow rate above a certain threshold. As soon as this contraction has reduced the flow rate, the pelvic floor relaxes again and the flow rate regains the threshold. Flow time is prolonged and emptying may not be complete, increasing the child s risk for developing UTI. Fractionated voiding is characterised by incomplete and infrequent voiding, with micturition in several separate fractions, due to voluntary or automatically induced contractions of the PFM, and possibly caused by augmented pressure of the abdomen Detrusor underactivity Detrusor underactivity, the hypo- or acontractile bladder is defined as a contraction of reduced strength and/or duration, resulting in prolonged bladder emptying and/or failure to achieve complete bladder emptying. The most extreme form is an acontractile detrusor. This pattern in children was recognised in 1962 by Luca. A comprehensible mechanism of this would be the voluntary, repeated postponement of the voiding, which can also lead to chronic overactivity of the pelvic floor, with

36 P. 36 overdistension of the bladder and loss of perception of bladder filling. Gradually the bladder will lose its capacity to contract and these children will have incomplete voiding on abdominal pressure, raise in IAP triggering automatic PFM contractions. The voiding consists of several detrusor contractions, each with his own flow. Abdominal pressure is often used to shorten the flow time. Wetting in these cases is usually secondary to overflow incontinence. However, the fact that children with hypo- or acontactile bladders usually tend to be younger than those with OAB and/or dysfunctional voiding defavorizes this hypothesis. BedWetting Nighttime wetting is a very bothersome condition for children and parents. A study in 4332 children aged from years showed clearly that night-time wetting is the most important reason to ask for professional help, where daytime wetting tends to be kept in the dark [Bakker et al] In most of the cases nighttime wetting (no turanal enuresis (NE) is associated with functional problems and will then be referred to as non-monosymptomatic NE. Only Monosymptomatic NE (MNE) is defined as nighttime wetting without any functional disorder, and concerns a minority of all bedwetting children [Bakker 2002]. Is seems logical to restore first the normal bladder and bowel function during daytime, before trying to solve the nighttime symptoms [Kalo and Bella 1996]. Bowel Dysfunctions Functional constipation, with or without soiling represents a common problem in children with urge syndrome. The high pelvic floor tone present in urge syndrome and in dysfunctional voiding, as a result of defence against urine-loss, might contribute to the occurrence of constipation [Dohil 1994, Wan 1995, Blethyn 1995,, Loening-Baucke 1997, De Paepe 2000]. Whether constipation or OAB come first is not clear until yet. Soiling is defined as the involuntary seepage of loose stool resulting in staining of underwear. Encopresis is the involuntary loss of formed, semi-formed or liquid stool into the child s underwear in the presence of idiopathic (functional) constipation in a child after the age of 4 years, occurring on a regular basis without any organic cause. The difference between encopresis and soiling is the amount of faeces lost [Loening-Baucke 1991] For a variety of reasons the toilet training process itself can be a primary cause of stoolwithholding behaviour and constipation: for e.g. children using regular toilets with dangling legs rather than a potty [Issenman 1999, Christophersen 1991]. Additionally the toddler in training may withhold stools as response to excessive parental pressure. Institutionalised day care settings may also lead to constipation and primary encopresis by inadequate information between caregivers and parents: both parties may incorrectly assume that the child defecates only at home or only at the centre [Brazelton 1999]. It is highly significant that a majority of children who do not attain social bowel continence have a history of constipation beginning at toilet training age [Issenman 1999]. Another hypothesis for the development of constipation is the habit to counter

37 P. 37 every urge to void with voluntary pelvic floor contractions leading to inappropriate postponement of defaecation, leading to constipation and soiling [Renson 2000]. This explains the link between constipation, OAB and UTI described as by O Regan in 1985 [O Regan 1985, 1986], and confirmed by Romanczuk and Korczawski in 1993, who revealed a high percentage of LUT-problems in hospitalised children for chronic constipation. Koff proposed in 1998 the concept of dysfunctional eliminating syndrome, covering both urinary and bowel dysfunction. 2.1.Bowel filling phase : Abnormal sensation The overtraining of pelvic floor muscles to withhold stool, causes faecal impaction, causing pain during the defaecation, leading to a paradoxal contraction of the sphincter and incomplete emptying of the bowel [Loening-Baucke 1982]. This leads to chronic distension, decreased ano-rectal sensibility, more faecal impaction, more pain and finally involuntary stool loss. Indeed, infants and toddlers with constipation usually have a history of infrequent, hard and painful bowel movements, often accompanied by screaming and stoolholding manoeuvres [Loening-Baucke 1987]. to delay of eliminating stool. Another reason for triggering automatic PFM might be a bad toilet position, creating disequilibria with postural perturbation, triggering automatic contractions of the PFM [Smith 2008]. Therapy Although medication with anticholinergics for OAB, antibiotics for treatment or prophylaxis for UTI or laxatives for treatment of concomitant constipation are still very popular, pelvic floor therapy has gained a lot of attention during the last years. This therapy, used in the rehabilitation of dysfunctional bladder and bowel, is a combination of cognitive, behavioural and physical therapy methods. The programs are based on careful evaluation of bladder and bowel function. The aim of this training is to normalise the whole voiding and defecation pattern and prevent further functional disturbances. Function should be viewed as an integrated concept, from the filling to the emptying phase. In the table beyond you will find a proposition for a systematic approach for urinary (left colomn) and faecal (right colomn) dysfunctions. 2.2.Bowel emptying phase High tension of the PFM can cause a paradoxal contraction of the muscles, which is defined as the contraction of the puborectalis muscle or/and the external anal sphincter (EAS) during defecation [Wasserman 1964, Wald 1986, Keren 1988]. Indeed high PF tone creates 3 functional obstacles, situated at either the recto-rectal angle, and/or the ano-rectal angle an/or EAS. This reflex contraction of the PFM can also be in answer to anal pain, or fear for pain, caused by hard stools or anal injuries. This may lead to postponement of the next defecation and thus

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41 P. 41 Conclusion The association between bladder and bowel dysfunction has been described in many reports, but the exact pathophysiology remains unclear, although the anatomical proximity of bladder and bowel, and the identical innervations of the urethra and the anal sphincter, make it tempting to conceptualise that dysfunction can occur in both systems simultaneously. Until yet the exact starting point of the dysfunctions is not established, probably it can start from different stations at the time. It therefore is very important to consider global storage and emptying functions of the small pelvis and to treat both at the time. Many authors report resolution of urinary symptoms in treating constipation, and vice versa [Neumann 1973, O Reagan 1986, De Paepe 2000]. Actually the tendency is to first treat bowel problems, before the urinary symptoms. Standardisation and definitions are used in this article as approved by the International Children s Continence Society (ICCS) in 1998, adapted to the new terminology 2002 of the ICS (International Continence Society).

42 P. 42 References (1976) [Standardisation of the terminology of function of the lower urinary tract. Incontinence, cystometry, ureteral profile, units of measurement (author s transl)] J Urol Nephrol (Paris); 82: Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, van Kerrebroeck P, Victor A and Wein A. (2002) The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society Neurourol Urodyn; 21: Bakker E, van Sprundel M, Van Der Auwera J, van Gool J and Wyndaele JJ. (2002) Voiding habits and wetting in a population of 4332 Belgian schoolchildren aged between 10 and 14 years. Scand J Urol Nephrol; accepted for publication. Bakker E, van Gool J, van Sprundel M, Van Der Auwera J and Wyndaele JJ. (2002). Risk factors for urinary tract infection in a population of 4332 Belgian schoolchildren aged between years. Eur J Paediatr 2004:163:234-8 Bakker E, Fayt C. (2008). Intérêt de la prosynergie abdominopelvienne dans le cadre de la rééducation pelvienne pour l IUE. KS 492:7-9 Bates CP, Whiteside CG and Turner-Warwick R. (1970) Synchronous cine-pressure-flow-cysto-urethrography with special reference to stress and urge incontinence Br J Urol; 42: Bauer SB, Retik AB, Colodny AH, Hallett M, Khoshbin S and Dyro FM. (1980) The unstable bladder in childhood Urol Clin North Am; 7: Beer E. (1915) Chronic retention of urine in children JAMA; 65: 1709 Blethyn AJ, Jenkins HR, Roberts R and Verrier Jones K. (1995) Radiological evidence of constipation in urinary tract infection Arch Dis Child; 73: Brazelton TB, Christophersen ER, Frauman AC, Gorski PA, Poole JM, Stadtler AC and Wright CL. (1999) Instruction, timeliness, and medical influences affecting toilet training Pediatrics; 103: Breugelmans AL and Wyndaele JJ. (1992) Urodynamic findings in patients below 12 years old with different clinical types of enuresis Acta Urol Belg; 60: Capitanucci ML, Camanni D, Demelas F, et al. Long-term efficacy of percutaneous tibial nerve stimulation for different types of lower urinary tract dysfunction in children. J Urol 2009; 182:2056. Christophersen ER. (1991) Toileting problems in children Pediatr Ann; 20: Combs AJ, Glassberg AD, Gerdes D and Horowitz M. (1998) Biofeedback therapy for children with dysfunctional voiding Urology; 52: De Paepe H, Hoebeke P, Renson C, Van Laecke E, Raes A, Van Hoecke E, Van Daele J and Vande Walle J. (1998) Pelvic-floor therapy in girls with recurrent urinary tract infections and dysfunctional voiding Br J Urol; 81 Suppl 3: De Paepe H, Renson C, Van Laecke E, Raes A, Vande Walle J and Hoebeke P. (2000) Pelvic-floor therapy and toilet training in young children with dysfunctional voiding and obstipation BJU Int; 85: Dohil R, Roberts E, Jones KV and Jenkins HR. (1994) Constipation and reversible urinary tract abnormalities Arch Dis Child; 70: De Jong TP, Klijn AJ, Vijverberg M, de Kort, Van Empelen, Schoenmakers MA. (2007) Effect of BF training on paradoxical PF movement in children with dysfunctional voiding. Uology 70:790-3 Doleys DM and Dolce JJ. (1982) Toilet training and enuresis Pediatr Clin North Am; 29: Fowler, Griffiths, de Groat. The neural control of micturition. Nat revue neuroscience 2008:9: Gladh G, Persson D, Mattsson S and Lindstrom S. (2000) Voiding pattern in healthy newborns Neurourol Urodyn; 19: Goldraich NP, Ramos OL and Goldraich IH. (1989) Urography versus DMSA scan in children with vesicoureteric reflux Pediatr Nephrol; 3: 1-5. Hellstrom AL, Hjalmas K and Jodal U. (1987) Rehabilitation of the dysfunctional bladder in children: method and 3- year followup J Urol; 138: Hellstrom AL. (1992) Urotherapy in children with dysfunctional bladder Scand J Urol Nephrol Suppl; 141: Hellstrom AL. (2000) Influence of potty training habits on dysfunctional bladder in children Lancet; 356: Herndon CD, Decambre M and McKenna PH. (2001) Interactive computer games for treatment of pelvic floor dysfunction J Urol; 166: Hinman F and Baumann FW. (1973) Vesical and ureteral damage from voiding dyfunction in boys without neurologic or obstructive disease J Urol; 109: Hjalmas K. (1988) Urodynamics in normal infants and children Scand J Urol Nephrol Suppl; 114: 20-7 Hoebeke P, Vande Walle J, Theunis M, De Paepe H, Oosterlinck W and Renson C. (1996) Outpatient pelvic-floor therapy in girls with daytime incontinence and dysfunctional voiding Urology; 48: Hoebeke P, Renson C, De Schrijver M et L, Leenaerts E, Schoenaers A et al. (2011). Prospective evaluation of clinical voiding reeducation or voiding school of LUT conditions in children. J Urol 186: Hoebeke P, Van Laecke E, Everaert K, et al. Transcutaneous neuromodulation for the urge syndrome in children: a pilot study. J Urol 2001; 166:2416. Issenman RM, Filmer RB and Gorski PA. (1999) A review of bowel and bladder control development in children: how gastrointestinal and urologic conditions relate to problems in toilet training Pediatrics; 103: Jerkins CR, Noe HN, Vaughn WR, Robert E. (1987) Biofeedback training for children with bladder-sphincter incoordination. J Urol; 138: Kalo BB and Bella H. (1996) Enuresis: prevalence and associated factors among primary school children in Saudi Arabia Acta Paediatr; 85: Khen Dunlop N, Van Egroo A, Boutellier C. (2006) Biofeedback treatment in the treatment of bladder overactivity, VUR and UTI. J Pediatr Urol 2: Keren S, Wagner Y, Heldenberg D and Golan M. (1988) Studies of manometric abnormalities of the rectoanal region during defaecation in constipated and soiling children: Modification through biofeedback therapy. Am J Gastroenterol; 83: Kjolseth D, Knudsen LM, Madsen B, Norgaard JP and Djurhuus JC. (1993) Urodynamic biofeedback training for children with bladdersphincter dyscoordination during voiding Neurourol Urodyn; 12: Koff SA, Wagner TT and Jayanthi VR. (1998) The relationship among dysfunctional elimination syndromes, primary vesicoureteral reflux and urinary tract infections in children J Urol; 160: Loening-Baucke VA. (1987) Factors responsible for persistence of childhood constipation J Pediatr Gastroenterol Nutr; 6: Loening-Baucke VA and Younoszai MK. (1982) Abnormal and sphincter response in chronically constipated children J Pediatr; 100: Loening-Baucke V. (1991) Persistence of chronic constipation in children after biofeedback treatment Dig Dis Sci; 36: Loening-Baucke V. (1997) Urinary incontinence and urinary tract infection and their resolution with treatment of constipation in childhood Pediatrics; 100: Luca FG, Swenson O, Fisher JH, Louffi AH. (1962) The dysfunctional lazy bladder syndrome in children. Arch Dis Child; 37:117. Malm-Buatsi E, Nepple KG, Boyt MA, et al. Efficacy of transcutaneous electrical nerve stimulation in children with overactive bladder refractory to pharmacotherapy. Urology 2007; 70:980. McKeith R. (1973) How children become dry Child Dev Med; 48/49: 3-32 McKenna PH, Herndon CD, Connery S and Ferrer FA. (1999) Pelvic floor muscle retraining for pediatric voiding dysfunction using interactive computer games J Urol; 162: ; discussion Neumann PZ, DeDomenico IJ and Nogrady MB. (1973) Constipation and urinary tract infection Pediatrics; 52: Neveus T, Hetta J, Cnattingius S, Tuvemo T, Lackgren G, Olsson U and Stenberg A. (1999) Depth of sleep and sleep habits among enuretic and incontinent children Acta Paediatr; 88: O Regan S, Yazbeck S and Schick E. (1985) Constipation, bladder instability, urinary tract infection syndrome Clin Nephrol; 23: O Regan S, Schick E, Hamburger B and Yazbeck S. (1986) Constipation associated with vesicoureteral reflux Urology; 28: Romanczuk W and Korczawski R. (1993) Chronic constipation: a cause of recurrent urinary tract infections Turk J Pediatr; 35: Schurch B, Corcos J. Botulinum toxin injections for paediatric incontinence. Curr Opin Urol 2005; 15:264. Hagstroem S, Mahler B, Madsen B, et al. Transcutaneous electrical nerve stimulation for refractory daytime urinary urge incontinence. J Urol 2009; 182:2072. Sillen U, Hellstrom AL, Holmdahl G and Solsnes E. (1999) The voiding pattern in infants with dilating reflux BJU Int; 83: 83-7 Smith MD et al.(2007) Postural response of the PF and abdominal muscles in women w<ith stress urinary incontinence. Neurourol and Urodyn 26: van Gool J. (1996) Non-neuropathic bladder-sphincter dysfunction: a complex of bladder/sphincter dysfunction, urinary tract infection and vesico-ureteral reflux Acta Urol Belg; 63: Van Gool JD, Van Wijk AA and de Jong TP. (1989) The urge syndrome in children Acta Urol Belg; 57: van Gool J and de Jonge G. (1989) All children referred with recurrent UTI and clinically manifest NNBSD Arch Dis Child; 64: van Gool JD and de Jonge GA. (1989) Urge syndrome and urge incontinence Arch Dis Child; 64: van Gool JD, Vijverberg MA, Messer AP, Elzinga-Plomp A and de Jong TP. (1992) Functional daytime incontinence: nonpharmacological treatment Scand J Urol Nephrol Suppl; 141: Van Laecke et all. Treatment of daytime incontinence. ICCS Standardisation document. J. Urol 2012, submitted Vijverberg MA, Elzinga-Plomp A, Messer AP, van Gool JD and de Jong TP. (1997) Bladder rehabilitation, the effect of a cognitive training programme on urge incontinence Eur Urol; 31: Vincent S. (1966) Postural control of urinary incontinence-the curteys sign Lancet; ii: 631 Wald A, Chandra M, Chiponis D and Gabel S. (1987) Anorectal function and continence mechanisms in childhood encopresis. J Pediatr Gastroenterol Nutr; 6: Wasserman I. (1964) Puborectalis syndrome Dis Colon Rectum; 7: Wennergren HM, Oberg BE and Sandstedt P. (1991) The importance of leg support for relaxation of the pelvic floor muscles. A surface electromyograph study in healthy girls Scand J Urol Nephrol; 25: Wille S. (1994) Nocturnal enuresis: sleep disturbance and behavioural patterns Acta Paediatr; 83: Wyndaele JJ. (1993) Studie over het blaasgevoel bij bedwateren. In JJ Wyndaele Evaluatie van twee methoden toegepast in de urologische kliniek bij het onderzoek naar gevoel in de lagere urinewegen. Proefschrift Universiteit Gent

43 P. 43 Effects of a 5-Week Intensive & Multidisciplinary Spine-Specific Functional Restoration Program in Chronic Low Back Pain Patients with or without Surgery CABY Isabelle 1, VANVELCENAHER Jacques 2, LETOMBE Axel 2, PELAYO Patrick 3 1- EA 4488, Activité Physique Muscle et Santé, Faculté des Sciences du Sport et de l EP (FSSEP), Univ Lille Nord de France, F Lille & Faculté des Sports et de l Education Physique, Univ Artois, F Liévin, France 2- Centre de rééducation et de réadaptation fonctionnelles spécialisées, L Espoir, Lille-Hellemmes, France 3- EA 4488, Activité Physique Muscle et Santé, FSSEP, Univ Lille Nord de France, F Lille, France i.caby@wanadoo.fr; jacques.vanvelcenaher@centre-espoir.com; a.letombe@orcet-helios.org; patrick.pelayo@univ-lille2.fr Abstract 144 subjects with chronic low back pain included in the retrospective study and divided into two groups: patients who had spine surgery (GI, n: 81) and patients who did not have surgery (GC, n: 37). The two groups followed the same functional restoration program (175 hours). All the subjects were evaluated before (T0) and after (T5wks) rehabilitation care based on physical, functional, psychological and professionals parameters. All outcome measures were significantly improved for all subjects at the end of the study, regardless of the group. 81% of patients returned to work. The surgery group obtained better results at the end of the program for pain and back muscle isometric endurance measures. The effects of the intensive program were validated; nevertheless spine surgery seems to have a positive impact on some physical parameters of this spine-specific functional restoration program. Introduction Programs for chronic low back pain have been developed during the past two decades. They include multidisciplinary interventions and aim to get people back to work and resume their leisure activities. A spine-specific functional restoration program (FRP) was first introduced in France at the end of the 20th century. In this context, the aim of this study was to analyze the shortterm efficacy of a spine-specific FPR and to compare the answers to the FRP between the group of patients who had spine surgery and the group of patient who did not. Materials & Methods Population 144 chronic low back pain patients (73 men, 71 women) with a mean age of 41.5 years ± 8.6 were included in a spine-specific FRP after receiving a physical evaluation upon inclusion. All subjects were volunteers and referred by their primary physician. They were divided into two groups: one group of chronic low back pain patients who had spine surgery (GI, n = 37), one group of patients who did not have any surgery (GC, n= 81).

44 P. 44 Experimental Protocol Our study was retrospective, not-randomized and conducted in a rehabilitation center. In order to observe the adaptations and responses to the program, two evaluations were planned. The first one (T0) took place on the first day of admission before starting the reconditioning training program, the second (T5wks) happened at the end of the 5-week FRP. Measured Parameters Demographic and clinical data, quality of life, pain, flexibility (Finger to Floor Distance: FTF), muscular capacity (flexors and extensors Trunk strength) and load lifting (the American progressive isoinertial lifting evaluation: PILE)were measured for all patients. Statistical Analysis The results were expressed as means and standard deviations. Student-t test for paired population data and Student-t test were used to achieve the statistical analysis to refine the interpretation of the studied parameters the significance threshold was set at 5%. Results & Discussions Results at T 0 The results at T0 for the entire population of patients with chronic low back pain reported moderate pain, reduced functional load lifting capacities and decreased muscle endurances. The psychological impact of chronic low back pain on quality of life was significant for activities of daily life (ADL), work and leisure activities, and anxiety and depression. Before FRP only lumbar-pelvic mobility was significantly better for the no surgery group (GC) than for the surgery group (GI): 93 ± 22 vs. 83 ± 26 (table I). Besides this difference in mobility, physical, functional and psychological parameters were identical. Results at T 5 Weeks The short-term efficacy of the program, after 5 weeks of rehabilitation care, was significant for the entire population. Pain (VAS) decreased by 46%, flexibility, load lifting capacities and isokinetic performances of trunk extensors progressed respectively by 146%, 76 % and 57 %. After the program, the inversion of the F/E ratio at slow and high speed validated greater muscle strength for trunk extensors. Isometric muscle endurance (Sorensen test) progressed significantly by 80%. On a work level, 81% of subjects went back to work. After the 5-week training program GI had significantly better results than GC for pain: 20 ± 20 vs. 31 ± 22mm; for isometric muscle endurance: 129 ± 50 vs. 92 ± 38. Nevertheless, GC had a significantly better F/E ratio at 120 s than GI: 1.02 ±0.3 vs ± Lumbar-pelvic mobility became similar in both group, furthermore functional and psychological parameters were not affected by spine surgery either before or after the training program. Besides these differences, most physical, functional and psychological parameters progressed positively and in a similar manner before and after treatment for both groups. The results seem to be similar even though the therapeutic endings are different. The European recommendations (COST B13) in terms of prevention and nonspecific low back pain therapeutic care validate that invasive surgery is not more efficient than protecting treatments such as FRP. Conclusion Subjects who had surgery had more muscle stiffness before the program than subjects who did not have surgery yet they had greater improvement on pain and muscle endurance. Herniated disc surgery is not the solution for chronic low back pain but the major benefits of FRP in chronic patients even after disc surgery should be considered.

45 P. 45 Table I. Pre and post treatment comparison for the groups with (GI) and without (GC) spinal surgery FTF: finger to floor; VAS: visual analog scale; PILE: progressive iso-inertial lifting evaluation; DPQ: dallas pain questionnaire; Ratio F/E: ratio flexors/extensors; level of significance for the groups comparison at T0 and T5Wks: * p<0.05 ; ** p<0.01 ; *** p<0.001; ns: nonsignificant (p>0.05). References I. Caby, J. Vanvelcenaher, A. Letombe, P. Pelayo. Effects of a 5-week intensive and multidisciplinary spinespecific functional restoration program in chronic low back pain patients with or without surgery, Annals of Physical and Rehabilitation Medicine 53, 2010: , for the congress of OPTL, Editor OPTL, 2011.

46 P. 46 Bimanual coordination in stroke: How do coupling and symmetry-breaking matter for upper-limb rehabilitation Rita SLEIMEN-MALKOUN 1, Jean-Jacques TEMPRADO 1 1- Institute of Human Movement Sciences E.J. Marey, UMR 6233 CNRS & University of the Mediterranean Aix-Marseille II, Marseille, France rita.sleimen-malkoun@univmed.fr Abstract Despite the lack of evidence of how stroke alter (or not) bimanual control, many of the recently developed upper-limb rehabilitation protocols are based on the use of bimanual training. Simultaneous training is thought to facilitate the control of the paretic limb. However, in order to properly explore, re-establish and exploit bimanual synergies following stroke, researchers and therapists need to move beyond the classical characterization of each limb performance in a separate and isolated fashion. The preliminary step consists in exploring coupling and symmetrybreaking mechanisms in both the undamaged and stroke-lesioned neuro-behavioral system. These two fundamental principles governing bimanual behavior provide: (1) a better understanding of stroke-related alterations of bimanual synergies, (2) conceptual guidelines for experimental and clinical studies, and (3) theoretically founded recommendations for rehabilitation. Background Recently, bimanual movement training has been introduced as a promising approach to improve upper-limb recovery following stroke (see [1] for a recent review). Bimanual training protocols mainly aim to exploit interlimb coupling in order to improve the paretic limb performance. Such rationale is based on the assumption that when both limbs are used simultaneously, the non-impaired limb would entrain the impaired one which should result in a faster, smoother and more precise movement of the paretic limb. In healthy subjects, inter-limb coupling is well identified and has been studied for a long time in the framework of the dynamical systems approach to coordination patterns (e.g. [2]). However, in stroke patients, and in spite of the large amount of studies exploring the outcome of bimanual training on upper-limb function, there is still no final evidence on the persistence of bimanual coupling following CVA, or on its benefits for the recovery of the paretic arm. The lack of evidence regarding who can take advantage from bimanual therapy, and how it should be used as a part of a complete rehabilitation protocol, could be explained by the fact that the fundamental principles governing bimanual behavior have been largely under-explored in stroke literature [3].

47 P. 47 Discussion Bimanual coordination dynamics in healthy neuromusculo-skeletal system Research on interlimb coordination has shown that spontaneous coordination patterns emerge as the result of neurally-mediated cross-talks that occur at different levels of the CNS facing internal (proper to the system) and external (environmental) constraints. In the dynamical systems approach, bimanual behavior is thought to be a task-specific functional synergy where the upper-limbs act as a single unit (i.e. bimanual behavior is more than a simple addition of two unimanual ones). In this specific framework, the abstract notion of coupling captures the occurrence of spontaneous interactions between the limbs s kinematics in bimanual tasks. Behavioral signatures of coupling are more obvious when the tasks assigned to the limbs are different (e.g. drawing simultaneously a circle and a line, or aiming simultaneously at two different targets as in [4]). Correspondingly, bimanual coupling represents the tendency of the limbs to cooperate and realize the same behavior at the same time. Conversely, symmetry breaking mechanism represents the opposite tendency i.e. of the limbs to maintain their proper behavior (maintenance tendency). Bimanual behavior is thus considered as the result of the competition between coupling and symmetry-breaking mechanisms. Whereas coupling is supported by the neural connectivity scheme (ensuring the commands exchange), symmetry-breaking is favored by the degree of intrinsic or extrinsic asymmetries between the limbs. Intrinsic asymmetries reflect the differences in neuro-mechanical properties of the limbs (as in coordinating different limbs) and the extrinsic ones represent the asymmetry between the external constraints imposed to the limbs (as in achieving different tasks). Accordingly, changes in inter-hemispheric cross-talks (due to a neural lesion) or in inter-limb asymmetries (reflecting changes in the limbs properties or task constraints) shape the dynamics and stability of bimanual coordination. Application of coordination dynamics principles to strokelesioned system Reviewing the theoretical foundations of bimanual movement training protocols, in the light of the knowledge provided by the research on bimanual coordination, offers evidencebased answers to the remaining uncertainties in upper-limb rehabilitation literature [5]. One of the major obstacles facing clinicians and researchers when trying to analyze and generalize the experimental results from different studies is the absence of a strict correspondence between the neural characteristics of the cerebral lesion and its behavioral consequences. This barrier justifies the use of behavioral signatures/variables to group patients and to characterize their deficits. Additionally, acknowledging the specificity of bimanual control, along with taking into consideration the constant competition between coupling and symmetry-breaking mechanisms, leads to more appropriate bimanual interventions and more precise interpretations of the observed results. Actually, in a CVA-lesioned system, inter-hemispheric connectivity might be perturbed which results in a weaker coupling (or even a total loss of coupling). More importantly, depending on the lesion severity, the neuro-mechanical properties of the paretic limb are more or less severely altered, which might significantly increase the internal asymmetry between the limbs. The resulting degree of imbalance between coupling and symmetry breaking respective

48 P. 48 strength would change the dynamics and stability of bimanual coordination. Consequently, in order to counter-balance the lesion-induced dysfunctions and favor the expression of spontaneous synergies, external constraints should be adequately adapted. In other words, if the environmental and task constraints were not properly adjusted, stroke-induced symmetry breaking might mask coupling signatures and results in a loss of entrainment between the limbs, which goes against prescribing simultaneous uppelimb training for stroke patients. Following the same aforementioned reasoning, in order to facilitate the expression of neuro-behavioral coupling and make use of it in rehabilitation, it is necessary to adapt bimanual protocols to patient baseline characteristics. The experimental observations we made with stroke patients suffering from different degrees of impairments show that recoupling could be achieved by modulating task constraints applied to the nonparetic limb during bimanual movements. In an on-going research program, at the Institute of Human Movement Sciences (Marseille, France) in collaboration with the functional rehabilitation unit of the Laveran Military Hospital (Marseille, France), we are currently investigating the outcome of a constraint- led bimanual rehabilitation approach. Preliminary results seem to be promising. Conclusion Since bimanual control deficits have scarcely been systematically investigated in the context of stroke, many uncertainties remain on the adequate prescription and the true value of bimanual rehabilitation. Clearly, researchers and clinicians should pay a lot more interest to bimanual coordination assessment and rehabilitation. In the quest for evidence and guidelines concerning the appropriate use and settings of bimanual protocols, coupling and symmetry-breaking are very promising concepts to guide researchers and therapists to conceive and adapt their intervention protocols. To sum up, the two key messages for clinicians are: 1) For a given bimanual task, scaling of external constraints may preclude or, conversely, facilitate the production of an adaptive coordinated behavior. 2) Bimanual training is beneficial for the paretic limb only when bimanual coupling is unimpaired and interlimb asymmetry is rather small (i.e. surmountable or partially compensated). References [1] J. H. Cauraugh, N. Lodha, S. K. Naik,and J. J. Summers. Bilateral movement training and stroke motor recovery progress: a structured review and meta-analysis Hum Mov Sci, 29(5): , [2] J. Kelso. Dynamic patterns: The self-organization of brain and behavior Cambridge, MA:MIT Press, [3] R. Sleimen-Malkoun, J. J. Temprado, L. Thefenne and E. Berton. Bimanual training in stroke: How do coupling and symmetrybreaking matter? BMC Neurol 11:11, [4] J. Kelso, D. Southard, D. Goodman. On the coordination of two-handed movements J Exp Psychol Hum Percept Perform, 5(2):229-38, [5] R. Sleimen-Malkoun, J. J. Temprado, V. K. Jirsa and E. Berton. New directions offered by the dynamical systems approach to bimanual coordination for therapeutic intervention and research in stroke. Nonlinear Dynamics Psychol Life Sci 14(4): , 2010.

49 P. 49 Instructions for Authors Advances in Physical Therapy (APT) is a peer-reviewed journal dedicated to the advancement of the physical therapy profession Worldwide. Although, the journal is aimed at physical therapy practitioners, all medical and health professionals can participate to its educational, practical and informational activities. Writing for APT will be interesting to you, researchers, practitioners, professors, clinicians, health professionals and managers with an allied health background. The APT is the scientific journal and the main publication of the Order of Physiotherapists in Lebanon and addressed to all Arab and Foreign Countries. The instructions for authors include information about preparing a manuscript for submission to APT Journal, criteria for publication and the online submission process Submission process Manuscripts must be submitted by one of the authors of the manuscript, and should not be submitted by anyone on their behalf. The submitting author takes responsibility for the article during submission and peer review. Please note that Advances in Physical Therapy does not request any article-processing charge on all accepted Research articles and Reviews articles Files in the requested format must be submitted by to the editor-in-chief at the following address ahmadrifai@optl.org During submission you will be asked to provide a cover letter. Use this to explain why your manuscript should be published in the journal, and to declare any potential competing interests. You will be also asked to provide the contact details (including addresses) of potential peer reviewers for your manuscript. These should be experts in their field, who will be able to provide an objective assessment of the manuscript. Any suggested peer reviewers should not have published with any of the authors of the manuscript within the past five years, should not be current collaborators, and should not be members of the same research institution Types of paper accepted - Full Research articles reporting results of original fundamental research in any branch in the physical therapy practice (maximum length allowed will be 4000 words). - Short Communications reporting on research, which has progressed, to the stage when it is considered that the results should be made known quickly to other colleagues in the field. The maximum length allowed will be 1500 words or equivalent space in tables and illustrations. - Reviews of developments in the fields covered by the scope of the journal (maximum length allowed will be 6000 words) File formats Microsoft Word office format with the extension (doc. or docx.) is strictly requested. Rich text format (RTF) is also accepted. Users of other word processing packages should save or convert their files to RTF before submission. Many free tools are available which ease this process. Figures must be submitted as separate image files, not as part of the submitted manuscript file and must be in a good resolution.

50 P. 50 Tables must be submitted also as separate word document files and must have a legend placed below it Preparation of the manuscript General guidelines of the journal style and language are provided below Manuscript organization Manuscripts for Research articles submitted to the Journal of Advances in Physical Therapy should be divided into the following sections (in this order): Title page Abstract Keywords Introduction Methods Results Discussion and Conclusion Competing interests Acknowledgements References Illustrations and figures (if any) Tables and captions Title page The title page must designate one corresponding author and the full names, institutional addresses and addresses for all authors. The title page should explain why the manuscript would be of interest to the Journal s readers. Please indicate briefly what is important or unique about the submission that has not been previously published in the medical literature Abstract The abstract should not exceed 350 words and must be adapted to the article design. Please do not cite references in the abstract and minimize the use of abbreviations Keywords Three to five keywords must be included on the line after the end of the abstract. Use appropriate MeSH subject headings as listed by the National Library of Medicine. For more information visit Introduction The introduction should provide only the necessary background information, rather than a comprehensive review of the specific field. It should not contain subheadings and should be accessible to researchers even without specialist knowledge Methods The methods section should include all experimental procedures. Eligibility of experimental subjects, details about randomization, blinding of observations, intervention complications and numbers of observations must be discussed in this section Conclusions Conclusion must be clear and summarize all the dimensions of the article. This should not contain abbreviations or citations of references. It should clearly state the importance of the article and its relevance to its objectives Competing interests Any personal or financial factors related to people or organizations that can influence your interpretation of data or presentation must be mentioned in this section. Authors must disclose any financial competing interests; they should also reveal any non-

51 P. 51 financial competing interests that may cause them embarrassment were they to become public after the publication of the manuscript. Authors are required to complete a declaration of competing interests. All competing interests that are declared will be listed at the end of published articles. Where an author gives no competing interests, the listing will read The author(s) declare that they have no competing interests Acknowledgements Authors often wish to thank anyone who contributed to the success of the research project by assisting the authors in preparing, designing, analyzing or interpretation of the data or other part of the submission process. People who will be acknowledged in the article should not be authors or anyone who contribute or may contribute to the review of the article and especially members of the editorial board References References should be listed in alphabetic order and must be double-spaced. References format should follow the current APA style. Examples of the APA style can be seen in the end of this document. Abbreviate the names of journals according to the format given in Index Medicus. References cited separately as footnotes in tables or figure legends should be numbered in accordance with a sequence established by the first identification of the particular table or figure in the text Preparing illustrations and figures Illustrations should be provided as separate files, not embedded in the text file. Each figure should include a single illustration and should fit in a single page in portrait format. If a figure consists of separate parts, it is important that a single composite illustration file be submitted which contains all parts of the figure. There is no charge for the use of color figures that will be published online only. EPS, TIFF, PNG, JPEG and BMP Figure legends The legends should be included in the main manuscript text file at the end of the document, rather than being a part of the figure file. For each figure, the following information should be provided: Figure number (in sequence, using Arabic numerals - i.e. Figure 1, 2, 3 etc); short title of figure (maximum 15 words); detailed legend, up to 300 words. Author(s) must obtain permission from the copyright holder to reproduce figures or tables that have previously been published elsewhere Preparing tables Tables must be included separately in separate files. Each table should be numbered and cited in sequence using Arabic numerals (i.e. Table 1, 2, 3 etc.). Tables should also have a title (above the table) that summarizes the whole table; it should be no longer than 15 words. Detailed legends may then follow, but they should be concise. Tables should always be cited in text in consecutive numerical order.

52 P Style and language General Currently, Advances in Physical Therapy can only accept manuscripts written in English. There is no explicit limit on the length of articles submitted, but authors are encouraged to be concise. There is also no restriction on the number of figures, tables or additional files that can be included with each article online. Figures and tables should be numbered in the order in which they are referred to in the text. Adequate writing of English language is required. Assistance, if needed, should be sought with native English educated persons, as well as in standard dictionaries and handbooks of composition Abbreviations Abbreviations should not be used unless they are defined when first used and a list of abbreviations can be provided following the main manuscript text Typography Please use double line spacing. Type the text unjustified, without hyphenating words at line breaks. Use hard returns only to end headings and paragraphs, not to rearrange lines. Capitalize only the first word, and proper nouns, in the title. All pages should be numbered. Neither Footnotes nor endnotes can be allowed in the text. Please do not format the text in multiple columns. Greek and other special characters may be included. If you are unable to reproduce a particular special character, please type out the name of the symbol in full. Please ensure that all special characters used are embedded in the text, otherwise they will be lost during conversion to PDF Units International System of Units (SI) should be used throughout (liter and molar are permitted, however). APPENDIX 1 REFERENCES CITATION GUIDELINES IN THE JOURNAL OF ADVANCES IN PHYSICAL THERAPY APA STYLE 1. REFERENCE ARTICLE: ENCYCLOPEDIA, DICTIONARY Merriam-Webster s collegiate dictionary (10th ed.). (1993). Springfield, MA.: Merriam- Webster. 2. BOOKS 2.1 One Author: Hemingway, E. (1964). A moveable feast. New York: Scribner s. Chase, J. A. (1979). Advertising: The hits and myths. New York: Doubleday. 2.2 Two Authors: Cone, J. D., & Foster, S. L. (1993). Dissertations and theses from start to finish: Psychology and related fields. Washington, DC: American Psychological Association.

53 P PERIODICAL ARTICLES: JOURNALS, MAGAZINES AND NEWSPAPERS Martin, J. (1997). Inventing sincerity, refashioning prudence: The discovery of the individual in Renaissance Europe. American Historical Review, 102, DISSERTATIONS Doctoral Dissertation Beilke, D. (1997). Cracking up the south: Humor and identity in southern Renaissance fiction. Doctoral dissertation, University of Wisconsin, Madison. 8. ELECTRONIC RESOURCES Wisconsin Department of Natural Resources. (2001). Glacial habitat restoration areas. Retrieved September 18, 2001, from land/wildlife/hunt/hra.htm 9. PARENTHETICAL (IN-TEXT) CITATIONS: Within the text you need to identify the sources briefly so that readers can tie them to more complete information in the reference list at the end of the article. In APA style you provide the last name of the author, the year of publication and the page number(s) if particular part of the source is being cited or if a direct quotation is used. Format of the parenthetical citations 1. One author: EXAMPLE: Issac (2001) indicated in his research In a recent study, research indicates (Isaac, 2001) 2. Two authors: Multiple authors are cited with both last names if there are only two. You can use either of these formats: EXAMPLE: Frank and Jones (2001) stressed that schools need all-day kindergarten. The study (Frank & Jones, 2001) stressed More than two authors: Cite all authors the first time the reference occurs. EXAMPLE: Guerin, Labor, Morgan, Reesman, and Willingham (2005) found In later citations, include only the surname of the first author followed by et al. (not italicized and with a period after al ) and the year EXAMPLE: Guerin et al. (2005) found 4. Six or more authors: EXAMPLE: As Williams et a!. (1999) demonstrated, the Internet holds the potential to open consumer markets in new and unexpected ways.

54 P. 54 We Deliver Quality from Paris to the Middle East & AFRICA Quality Healthcare Consultancy company, for accreditation, auditing and coaching, with a mission to provide the highest quality services and solutions to achieve full continuous compliance with top International and Local accreditation standards and requirements related to all health care sectors. Quality Systems International Hazmieh, Lebanon bd@qsysi.com Advances in Physical Therapy Journal