ACTIVE RELEASE TECHNIQUE FOR ILIOTIBIAL BAND

ACTIVE RELEASE TECHNIQUE FOR ILIOTIBIAL BAND SYNDROME 1 ACTIVE RELEASE TECHNIQUE
FOR ILIOTIBIAL BAND SYNDROME: A CASE REPORT
A Case Report
Presented to
The Faculty of the College of Health Professions and Social Work
Florida Gulf Coast University
In Partial Fulfillment
of the Requirements for the Degree of
Doctor of Science in Physical Therapy in the College of Health Professions
By
Taylor Moore
2014
ACTIVE RELEASE TECHNIQUE FOR ILIOTIBIAL BAND SYNDROME APPROVAL SHEET
This case report is submitted in partial fulfillment of
the requirements for the degree of
Doctor of Physical Therapy
______________________________
Taylor Moore, CSCS
Approved: May 2014
______________________________
Stephen Black, DSc, PT, ATC, CSCS
Committee Chair
______________________________
Eric Shamus, PhD, DPT, CSCS
The final copy of this case report has been examined by the signatories, and we find that
both the content and the form meet acceptable presentation standards of scholarly work
in the above mentioned discipline.
ACTIVE RELEASE TECHNIQUE FOR ILIOTIBIAL BAND SYNDROME 3 Table of Contents
Title Page
1
Approval Page
2
Table of Contents
3
Abstract
4
Background and Purpose
5
Case Description: Patient History and Systems Review
9
Clinical Impression #1
9
Examination
10
Clinical Impression #2
11
Intervention
12
Outcomes
16
Discussion
16
Appendix A: Cumulative Injury Cycle
19
Appendix C: Table of Activities
20
References
21
ACTIVE RELEASE TECHNIQUE FOR ILIOTIBIAL BAND SYNDROME 4 Abstract
Title: ACTIVE RELEASE TECHNIQUE FOR ILIOTIBIAL BAND SYNDROME
Background and Purpose: ITBS is one form of presentation of repetitive strain injury
(RSI). There is a gap in evidence based treatment methods for RSI; however ART is one
method of treatment with emerging evidence. The focus of this case report is to describe
the various mechanisms of injury to the iliotibial band (ITB) and theory behind ART as a
successful treatment method. There is a need for additional research on the effectiveness
of ART and additional treatment methods for RSI.
Case Description: A 24-year old female triathlete with severe pain (10/10) associated
with ITBS and unsuccessful past treatment with corticosteroid injection.
Outcomes: Subjective outcome measures included pain ratings; while objective outcomes
measures included the Ober test and range of motion. No changes were made to the case
patient’s training load.
Discussion: A patient with ITB syndrome reported decreased pain and demonstrated
increased function after a 6-week treatment plan utilizing ART one time per week and a
foam roller two times a day.
ACTIVE RELEASE TECHNIQUE FOR ILIOTIBIAL BAND SYNDROME 5 Background and Purpose
The term repetitive strain injury (RSI) includes multiple dysfunctions such as
cumulative trauma disorder, repetitive motion injury, occupational overuse syndrome,
work related musculoskeletal disorder, and many others.1 A RSI is caused by a repetitive
movement that results in cumulative damage to soft tissue structures.2 Causative factors
include vibration, extreme temperatures, poor posture, incorrect ergonomics, or
inadequate rest.3 An acute injury4 causes an RSI and leads to a cycling of events resulting
in progressively worsening symptoms. After injury, scar tissue formation causes muscle
tightness and leads to decreased muscle length. 2, 5 The accumulation of scar tissue, which
causes reduced space and increased pressure near blood vessels, results in cellular
hypoxia and swelling from decreased circulation. The affected muscle weakens making
it more susceptible to injury and the cycle continues until the repetitive, injury-causing
action is discontinued or an intervention is performed.5 The law of repetitive motion
(Appendix B) demonstrates the impact of repetitive motion on tissues. It takes the
number, force, amplitude, and relaxation time between each repetition into
consideration.4 A combination of high repetitions and force or low amplitude and
relaxation results in high insult to the tissues and can be detailed by the cumulative injury
cycle.4 The cumulative injury cycle consists of a cyclical pattern of weak and tight
muscles; increased friction, pressure, and tension; decreased circulation and edema; and
adhesions and fibrosis between fascial compartments.4
The iliotibial band (ITB) is composed of dense connective tissue that originates at
the lateral iliac crest, tensor fascia latae, gluteus maximus, and gluteus medius muscles
and inserts at the lateral epicondyle and the Gerdy tubercle.6 The lateral epicondyle
ACTIVE RELEASE TECHNIQUE FOR ILIOTIBIAL BAND SYNDROME 6 insertion acts as a tendon and has a layer of adipose tissue underneath the attachment.
The layer of adipose tissue, which is highly vascularized and contains pacinian
corpuscles, may be the source of pain and inflammation experienced with ITBS.7 The
Gerdy tubercle insertion acts as a ligament in both structure and function; it is on tension
during internal rotation of the tibia during the loading phase of the gait cycle.8 This may
explain the connection between toeing in and ITBS. In addition, the ITB has other distal
attachments such as the biceps femoris, vastus lateralis, lateral patellar retinaculum,
patella (via the epicondylopatellar ligament and patellar retinaculm) and patellar tendon
to provide anterolateral support to the knee.8 The two theories behind ITBS are
compression of adipose tissue at the lateral epicondyle or a friction syndrome8;
inflammation is the main concern despite the etiology. In a literature review (quality
score > 60%), ITBS was the most common injury to the lateral side of the knee with an
incidence between 5 to 14%9 and in cyclists ITBS accounted for 15 to 24% of overuse
injuries.10 The etiology of ITBS in runners is unclear and may be due to a variety of
factors including hip abductor weakness, hip and knee kinematics, repetition, or lack of
knowledge about running shoes and surfaces. Other studies have suggested that ITBS is
related to a greater hip adduction angle and greater knee internal rotation angle; these
studies also found that females with ITBS presented greater femoral external rotation,
which led to respectively increased knee internal rotation.11, 12 In addition, 55% of
individuals with ITBS presented with mild to severe knee varus.8 With normal single leg
stance, the ground reaction force is directed medial to the knee and produces a varus
force; with increased hip adduction, the ground reaction force is directed more medially
with a greater perpendicular moment arm to the knee which results in increased varus
ACTIVE RELEASE TECHNIQUE FOR ILIOTIBIAL BAND SYNDROME 7 torque and the elongation of lateral hip musculature; with knee valgus combined with
increased hip adduction, the ground reaction force is directed lateral to the knee which
results in a compensated trendelenburg sign.8 Other intrinsic factors related to ITBS
include excessive calcaneal eversion, tibial internal rotation, or a leg length discrepancy
which results in ITBS on the longer leg.13 In cyclists with a leg length discrepancy, ITBS
typically presents on the shorter leg because the lateral side is overstretched when
attached to the pedal.14 Excessive hip adduction and knee varus or valgus can be related
to muscle imbalances.8 The tensor fascia latae is a postural muscle and can become
shortened and strong, while the gluteus medius and maximus are phasic muscles that are
more likely to become lengthened and weak. This imbalance can create a postural
pattern, trendelenburg or compensated trendelenburg sign, excessive hip adduction, knee
varus, or knee valgus during gait due to poor control.15
Some factors that contribute to ITBS are modifiable. These factors include rapid
mileage increases, hill training, and slow running, and shoe design.8 Downhill and slow
running lead to increased time spent in the impingement zone, which occurs during
repetitions at approximately 30 degrees of knee flexion.8 Excessive friction results in
inflammation during repeated knee flexion as the ITB moves over the lateral femoral
condyle.9, 16, 17
Rehabilitation phases have been recommended for the acute, subacute, and
recovery strengthening phase18 of ITBS. The acute rehabilitation phase consists of
limiting running, cycling, and swimming; use of ice, phonophoresis, or iontophoresis;
oral NSAIDs; and corticosteroid injection. The subacute phase includes ITB stretching
and soft tissue mobilization to reduce myofascial adhesions; the recovery-strengthening
ACTIVE RELEASE TECHNIQUE FOR ILIOTIBIAL BAND SYNDROME 8 phase includes strengthening exercises for the gluteus medius and gluteus maximus.
RSI account for a large portion of injuries in the athletic and occupational setting,
comprising up to 67% of reported injuries2, 19 and costing the United States 6.5 billion in
worker’s compensation each year.19 Other sources report the total cost of RSIs totals 110
billion dollars per year when accounting for medical coasts, lost wages, and decreased
productivity.2 The National Institute for Occupational Safety and Health concluded that
only 44% of repetitive strain injuries were reported; therefore, the prevalence of these
injuries could be 130% greater than suspected.2 RSI result in chronic tissue
inflammation, scarring, pain, fatigue, muscle spasm, and postural imbalance2; they
generally operate in a cyclical pattern known as the cumulative injury cycle. An overused
muscle contracts to limit movement and protect the muscle, subsequent scar tissue and
muscle shortening occur, and circulation decreases.20 Despite the significant effects of a
RSI, little research has been conducted to determine the most effective intervention
strategy and common interventions include rest, ice, and anti-inflammatories.2, 18 Other
conservative treatment methods for RSI are available and include corticosteroid injection,
dry needling, muscle energy technique (MET), Graston technique (GT), manual
neuromuscular therapy (MNT), myofascial release (MR), Active Release Technique
(ART), and muscle activation technique (MAT). There is limited evidence in the form of
randomized controlled studies that indicate the effectiveness of the aforementioned
treatment options and rationale for the use of these techniques is mainly anecdotal. The
purpose of this case study is to describe the characteristics of a RSI so proper diagnosis
and treatment can be initiated, discuss the concept behind ART as a treatment method,
and elaborate on the mechanism behind the effectiveness of ART.
ACTIVE RELEASE TECHNIQUE FOR ILIOTIBIAL BAND SYNDROME 9 Case Description: Patient History and Systems Review
The patient is a 24-year-old female triathlete and graduate student with ITBS. The
patient began triathlon specific training in July 2012 and primarily competes in sprint
distances triathlons. She has also completed two Half Ironman distance triathlons, with
one of those being the 2013 Half Ironman Age Group World Championship in Las
Vegas, Nevada. The patient reports a history of ITBS of greater than two years and
received a corticosteroid injection at Gerdy's tubercle in April 2012. This injection
provided limited pain relief for 2 months; but, caused skin discoloration, which is why
the patient did not return for follow-up treatment. The patient has been self-managing the
pain with foam rolling, stretching, and occasional rest when the pain prevents her from
running.
Clinical Impression #1
A physician previously diagnosed the patient with ITBS; but additional tests and
measures were conducted to rule out any other differential diagnosis. These tests and
measures included subjective pain, true leg length test, Noble compression test, palpation,
Ober test, and running gait analysis. The patient is a good candidate for ART as her ITBS
pain can be classified as a RSI that did not improve to corticosteroid injection. The
patient's ITBS is a chronic injury as it has persisted greater than six weeks. The patient
reports 10/10 pain with running and is unable to complete the prescribed training for her
triathlon. The patient is unable to miss additional training for her upcoming world
championship race; therefore, treatment options other than rest and ice are necessary.
ACTIVE RELEASE TECHNIQUE FOR ILIOTIBIAL BAND SYNDROME 10 Examination
Examination data collected included the following that will be described below:
subjective pain, history, true leg length test, Noble compression test, palpation, Ober test,
and running gait analysis. Subjective pain measures were taken with a 0-10 scale, with 0
being the least amount of pain and 10 being the worst amount of pain. Pain ratings were
taken orally each week prior to performing the intervention. Patients reported pain
measures varied depending on the training volume prescribed and competitions
prescribed for each week; however, reported pain measures decreased over time. Prior to
treatment, the patient reported 10/10 pain at the distal portion and insertion of the ITB. In
the history portion of the examination, the patient reported that she experiences the worst
pain when walking down stairs or sitting for extended periods of time. A true leg length
test was conducted to rule out structural causes for the reported pain. The patient was
instructed to lie supine in a hook position. The patient was asked to bridge up at the hips
to reset the pelvis. True leg length was measured using a tape measure from the ASIS to
the medial malleolus and from the umbilicus to the medial malleolus. The patient
presented with leg-length difference of 1 cm, which is insignificant. The Noble
compression test was done to rule in the ITB as the cause of the patient’s pain. The
patient was instructed to lie supine with the knee bent to 90 degrees. Compression was
applied over the lateral femoral condyle while the patient actively extended the hip and
knee. The patient described a reproduction of symptoms between the range of 90 and 30
degrees of knee extension; therefore indicating a positive test and ruling in the ITB as a
cause of the pain. Palpation was performed along the length of the ITB and surrounding
structures to identify any other contributions toward the patient’s pain. The patient
ACTIVE RELEASE TECHNIQUE FOR ILIOTIBIAL BAND SYNDROME 11 described tenderness when the examiner was palpating along the lateral epicondyle of the
femur and Gerdy's tubercle. The examiner also identified areas of restriction and
adhesion between the ITB and the vastus lateralis musculature. The Ober test was
performed to measure ITB length. The patient was instructed to lie in side-lying position
with the pelvis stabilized and affected leg up and passively flexed 90 degrees. The
examiner abducts and extends the hip until it is aligned with the trunk before allowing the
leg to adduct. The patient’s leg did not reach horizontal during the adduction portion of
the Ober test; this represents maximal shortening of the ITB. A running gait analysis and
training history questionnaire was administered to identify potential causes for the ITB
pain. During the running gait analysis, no significant differences were identified between
the patient’s painful and non-painful leg and the patient was wearing neutral footwear
with no gait pattern deviations. The training history questionnaire confirmed that the
patient had not increased training volume too quickly and was training on a variety of
surfaces. The patient was unable to rest as she has her last triathlon of the season in 6
weeks. In addition, the patient has an extremely busy schedule with graduate level course
work, training, and teaching; therefore, ART treatment protocols will be used once per
week for 6 weeks leading up to her final triathlon of the season.
Clinical Impression #2
The patient is appropriate for the use of ART as she has a RSI. The patient
presents with fascial restrictions, determined via palpation,. The patient has tried other
intervention methods; including corticosteroid injection, rest, ice, and foam rolling; with
little long-term pain relief. She has her final triathlon of the season in 6 weeks and is
unwilling to rest before the event. With the use of ART as an intervention, the goal is to
ACTIVE RELEASE TECHNIQUE FOR ILIOTIBIAL BAND SYNDROME 12 reduce restrictions between the ITB and surrounding musculature, normalize tissue
length, which may reduce pressure placed on the ITB during training. Decreased patient
reported pain measures, reduced pain during Noble compression test, increased adduction
during Ober test, and elimination of adhesions would be indications of a successful
treatment method using ART.
Intervention
Active Release Technique (ART): ART was developed by Dr. Michael Leahy; he
correlated patient symptoms to changes occurring in the soft tissue after different soft
tissue manipulation techniques. ART consists of two basic steps: “shorten the tissue and
apply a contract tension to either lengthen the tissue or make it slide relative to the
adjacent tissue.”4, 21 ART consists of over 500 treatment protocols specific to multiple soft
tissue dysfunctions; case studies utilizing ART have shown improvements in function
and mobility, structural dysfunction, and pain measures..25-33 Despite the potential benefits
of ART, it is yet to be a widely utilized treatment option, possibly due to the lack of
research available. A detailed description of ART, the principles behind the approach,
and its efficacy is presented below.
ART is a form of tissue manipulation aimed at treating soft tissue injuries that
include, muscle weakness, tendonitis, and nerve entrapment.2,21 Overuse injuries cause
changes in the muscle that lead to an accumulation of scar tissue.42 Scar tissue exhibits
different properties than the surrounding structures; in both ligaments and tendons, scar
tissue contains more Type III, V, and VI collagen fibers with a decreased proportion of
Type I collagen fibers.22 Type III collagen fibers are arranged in a random pattern rather
than along the lines of tensile strength as seen in Type I fibers.23 The tensile strength of
ACTIVE RELEASE TECHNIQUE FOR ILIOTIBIAL BAND SYNDROME 13 the scar matrix can be up to 30% weaker than that of un-injured, healthy tissue24; this
makes areas with scar tissue more likely to become reinjured under normal stress loads.
There are a variety of case and pilot studies that imply the value of ART as a
treatment method for soft tissue injuries.25-32 ART was used to treat nerve entrapment,26
tendonopathy,27 muscle strain,28 snapping hip syndrome,29 lateral epicondylosis,30
impaired range of motion,31 overuse syndrome,32 and improve performance25 and
contributed to faster return to activity and decreased treatment time. Although these case
studies imply a benefit of ART, information regarding the mechanism of action, specific
ART treatment protocols, number of passes per treatment session, total treatment
sessions, and duration of intervention were lacking during my literature review. A few
studies hypothesized that the potential benefit of ART stems from the stimulation of golgi
receptors or ruffini organs.4 The cumulative injury cycle results in increased tissue
tension,33 leads to decreased circulation (chronic) or inflammation (acute), and causes
scar tissue, adhesions, and trigger points.4
Myofascial trigger points (MTrPs) commonly occur with chronic musculoskeletal
conditions caused by acute and repetitive microtraumas34 and can be palpated in
individuals with a RSI. The etiology of MTrPs is lacking in evidence; however, one
theory suggests a cyclical pattern correlating with the cumulative injury cycle. An
automatic nervous system response causes the abnormal acetylchoine (Ach) is released
into the synaptic cleft,35 muscle fiber tension increases, arterial blood flow is restricted,
metabolism is increased, and local hypoxia occurs. Glycolytic and aerobic energy supply
cause a reduction in ATP production and the release of bradykinin, 5 hydroxytryptamin,
prostaglandins, potassium, and protons.35 Prostaglandins contribute to inflammation and
ACTIVE RELEASE TECHNIQUE FOR ILIOTIBIAL BAND SYNDROME 14 protons create an acidic environment that activates muscle nocioceptors, induces the
release of a calcitonin gene-related peptide, and results in the additional release of ACh.38
ATP regulates the sarcoplasmic reticulum calcium pump; therefore, reduced ATP leads to
sarcoplasmic reticulum dysfunction and increased calcium.35 Increased calcium sustains
the muscle contraction which results in the contracture found at MTrPs.35 Sarcoplasmic
reticulum dysfunction and sensitizing substances are the primary source of
pain.36 Therefore, stretching the affected muscle could break the cyclical pattern because
the contractile strength of the sarcomere decreases when the actin and myosin are not in
contact.36 The basic concept of ART is to take the muscle from a shortened position to a
lengthened position and hold at the lengthened position.4, 18 Additional theories suggest
that abnormal depolarization occurs at presynaptic, synaptic, and postsynaptic junctions.37
Presynaptic junctions result in an excessive release of ACh, synaptic junctions release a
defective version of actychoinesterase; and post synaptic junctions up regulate nicotinic
ACh receptor activity.37 This results in a muscle spasm that impairs arterial blood flow
and restricts oxygen and calcium supply necessary for muscle relaxation.37 The relatively
similar effectiveness of lidocaine injection versus dry needling suggests that increased
blood flow and mechanical disruption of muscle fibers is necessary to deactivate
MTrPs.38 Manual therapy techniques (stretching muscle to normal range of motion,
ischemic compression, transverse friction massage) can be used to deactivate MTrPs and
cause short-term pain redutions.37 A treatment program consisting of ischemic
compression followed by sustained stretching produced greater decreases in pain than
active range of motion exercises alone;37 this technique is similar to ART as both involve
tissue contact (compression) and lengthening the tissue (stretching).4, 37 An alternate study
ACTIVE RELEASE TECHNIQUE FOR ILIOTIBIAL BAND SYNDROME 15 states that active rhythmic release, a modified version of peripheral neuromuscular
facilitation, can be used to deactivate MTrPs. It utilizes post-isometric relaxation by
stretching the muscle to initial discomfort, having the patient perform a submaximal
isometric contraction, and finally utilizing reciprocal inhibition by having the patient
actively contract the antagonist muscles during the release phase.36 Treatment of MTrPs
aims to reduce pain, eliminate adhesions, and regain normal range of motion.39
The ART protocol involves taking the tissue from a shortened to a lengthened position
while holding the soft tissues longitudinally in place.4 Case studies demonstrate success
with ART as a treatment method, but represent only a small sample; however, these
provide reasonable support for the use of ART as a treatment method.
The ART treatment protocols utilized in each session include 5 passes of the ITB
side-lying treatment protocol and the ITB with vastus lateralis treatment protocol (ART
protocol 62 and 63). Treatment sessions were conducted once per week due to the
patient’s busy schedule. To supplement ART, the patient was advised to continue her
foam rolling routine, which she had been doing since starting triathlon specific training..
Foam rolling is a form of self-myofascial release (SMF); individuals can self-treat areas
of restriction by using their body weight to apply pressure over an area of restriction onto
a mysofascial foam roller. 40 For an area of restriction in the ITB the patient was
instructed to lie on her side with the lateral portion of her leg resting on the myofascial
foam roller. The patient then supported her upper body with her hand or elbow while
using her body weight to apply pressure through her ITB and onto the myofascial foam
roller. The patient was advised to complete at least 60 seconds of myofascial foam rolling
on the ITB pre and post exercise each day.
ACTIVE RELEASE TECHNIQUE FOR ILIOTIBIAL BAND SYNDROME 16 Outcomes
After 6 weeks of treatment, subjective patient measures had improved with a
reported decrease in pain to 4/10 from 10/10 before initiating treatment. The patient
reported that she was able to maintain training volume throughout treatment with weekly
averages as follows: 15,000 yards swimming, 15 miles running, 40 miles biking, and 2-3
30 minute exercise videos. The patient reported a decrease in symptom replication during
the Noble compression test and with palpation of the lateral epicondyle and Gerdy's
tubercle. The Ober test confirmed minimal ITB shortening with adduction past
horizontal. All outcome measures revealed improvement; however, additional research is
needed regarding the specificity and the sensitivity of the Noble compression test and
Ober test.
Discussion
The use of ART was a successful intervention for ITBS and allowed the patient to
continue training while reducing subjective reported pain measures and improvement in
objective special tests. ART aims to break the RSI cycle described earlier and restore
normal length and motion in the treated muscle. Long-term beneficial outcomes have
been achieved using non-invasive conservative management without the risk of adverse
effects related to invasive treatment methods for RSI. Conservative treatment options are
non-invasive, relatively painless, safe, easy to administer, and cost effective in
comparison41 Individuals are able to achieve positive results while still performing the
repetitive motion as part of their work or fitness routine. Providers should consider this
before initiating non-conservative management of repetitive strain injuries.
Despite the reported benefits of ART in case studies, the literature is lacking
ACTIVE RELEASE TECHNIQUE FOR ILIOTIBIAL BAND SYNDROME 17 randomized controlled studies to support this intervention. Randomized controlled studies
are needed to support ART as an intervention technique supported by evidence-based
practice. Evidence based practice is not always attainable in manual therapy settings as it
fails to recognize the individual's response to specific treatment interventions.41
Therefore, evidence informed practice that integrates the research into a comprehensive
treatment program is recommended.
ACTIVE RELEASE TECHNIQUE FOR ILIOTIBIAL BAND SYNDROME 18 Appendix A: Cumulative Injury Cycle4
ACTIVE RELEASE TECHNIQUE FOR ILIOTIBIAL BAND SYNDROME 19 Appendix B: Law of Repetitive Motion4
I = NF/AR
I = insult to tissues
N = number of repetitions
F = force or tension of each repetition as a percent of maximum muscle strength
A = amplitude of each repetition
R = relaxation time between repetitions
ACTIVE RELEASE TECHNIQUE FOR ILIOTIBIAL BAND SYNDROME 20 Appendix C: Table of Activities
Activity
Request committee chair
Learning
Outcomes
Affective
Submit Written Proposal
Revised Written Proposal
Cognitive
Cognitive
Oral Defense
Cognitive
Affective
Psychomotor
Cognitive
Affective
Psychomotor
Cognitive
Affective
Psychomotor
Cognitive
Affective
Psychomotor
Cognitive
Affective
Psychomotor
Cognitive
Affective
Psychomotor
Cognitive
Affective
Psychomotor
Shadow an ART certified
PT (Dr. Black)
Build a research library.
Presentation to exercise
science and athletic
training students
Attend Lower Extremity
ART Certification course
in Orlando, FL
ART Network Provider
Ironman Florida
Present to 1st year PT
students and
undergraduates on ART
Technique
Renew APTA Membership
Submit scholarly paper
draft
Post Notice of Defense
Final Oral Defense
Submit Edited Final Paper
Submit material to print
poster
Print copies for FGCU
Enter competition section
of FGCU’s Research Day
Present at Research Day
Cognitive
Affective
Cognitive
Cognitive
Affective
Psychomotor
Cognitive
Evaluation
Assignment of Committee
chair
Returned copy.
Committee comments on
proposal and plan of study.
Committee approval.
Date
Completed
04-15-11
08-22-11
09-06-11
09-12-11
Feedback from PT.
Throughout
Inclusion of resource in
final paper.
Throughout
Feedback from class
evaluation. Presentation
material.
Inclusion of learned
material in final paper.
Seminar manual and DVD
Photographs
10-15-11
Feedback from class
evaluation. Presentation
materials.
May 1, 2012
Membership card and
inclusion of additional
resources in final paper.
Committee approval for
defense
Ongoing
Committee approval of
completion and edited
paper.
May 2013
November
2013
December 2013
March 2014
April 2014
February 2014
February 2014
February 2014
March 2014
Cognitive
Affective
Psychomotor
Research day attendance
04-18-14
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Scheumann D. The Balanced Body: A guide to deep tissue and neuromuscular
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Active Release Technique Web site.
http://www.activerelease.com/what_providers.asp.. Accessed April 30, 2014.
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Hildebrand KA, Frank CB. Scar formation and ligament healing. Canadian
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