S po r ts In ju r ie s S u s t a in e d at t h e S ix t h A l l A f r ic a G a m e s : T h e P h y s io t h e r a p y P e r s p e c t iv e JENNIFER JELSMA* (BSc Physiotherapy) HEATHER DAWSON* (BAppSc Physiotherapy) GRAHAM SMITH** (Grad Dip MCSP) TAMBU MASAYA*** (BSc Hons Physiotherapy) DORCAS MADZIVIRE* (MSc) A B S T R A C T : The Sixth A ll A frica G am es were held in Zim babw e in Septem ber 1995. A voluntary ph ysioth erapy service w as p ro v id e d to gu est athletes. D a ta w as gathered relating to onset, mechanism, region and m anagem ent o f injuries. D uring the 10-day p e r io d o f the gam es, 541 treatm ents were p erfo rm ed on 2 5 8 gu est athletes. The onset o f injury in 35.3% o f cases w as p r io r to the sta rt o f the gam es. O veruse w as the m ost common mechanism o f injury an d 24% o f injuries were in the chronic stage. The low er limb w as the site o f 49.5% o f injuries with strains and sprains contributing 75% o f the injuries in this study. A ll togeth er 16 treatm ent m odalities w ere used, the m ost frequently used being ice com bined with com pression. Sixty-two p e r cent o f athletes atten ded f o r a single treatment. The m echanisms, distribution an d types o f injuries w ere sim ilar to those d esc rib e d by other authors. O f relevance is the num ber o f athletes who were carrying the injury a t the com m encem ent o f the gam es an d that the main m echa­ nism o f injury w as overuse. This has im plications f o r training an d treatment. The n eed to p ro vid e a com prehensive f ir s t treatm ent with ad vice regarding ongoing s e lf m anagem ent w as essential as the m ajority atten ded only once. K E Y W O R D S : M U L T I-S P O R T , E P ID E M IO L O G Y O F S P O R T S IN JU R IE S , P H Y S IO T H E R A P Y * D ep a rtm en t o f R ehabilitation, U niversity o f Z im babw e, B o x A 1 7 8 , A vondale, H arare, Zim babwe. Tel: 263 4 791631 X 175 (W ); 263 4 302 4 0 6 (H). ** PhysioTech, G lasgow, Scotland. *** H arare C entral H ospital. Correspondence to fir s t author. INTRODUCTION In recent years there has been a gro w ­ in g aw areness o f the need to prom ote safe and successful com petition by d o c­ um enting the epidem iology o f injuries sustained at large m ulti-sport ev e n ts.1 T he injury experiences from a m edical perspective have b een recorded for sev­ eral sporting ev e n ts1214 bu t there is a paucity o f literature to g uide p h y sio th er­ apists in the preparation and planning o f specific physiotherapy services at such events. E xceptions include p h y sio th era­ py specific articles on the patterns o f injury and treatm ent m odalities at the 1991 W orld S tu d en t G am e s in Sheffield56 and the X II C o m m onw ealth G am es held in B risbane. The A ll A frica G am es (A A G ) is the third largest m ulti-sport event after the O lym pic G am es and the C om m onw ealth G am es. T he Sixth A A G w as h eld in Z im b a b w e in S e p te m b e r 1995 an d involved 3 188 com petitors, 2 232 m ale and 956 fem ale, from fifty countries participating in 21 sports. A voluntary ph y sio th erap y service w as provided to both local team s and g u est athletes by 40 o f the 120 m em bers o f the Z im babw e P h y s io th e ra p y A sso c ia tio n . E ach Z im b a b w e a n team w as a llo c a te d a p h y sio th erap ist and guest athletes w ere catered fo r both at the venues and at the G am es V illage F acilities in the tw o cities that w ere host to the A A G. T his paper serves to docum ent the m o st com m on injuries encountered and the m ethods o f in te rv e n tio n e m p lo y e d b y th e h o st p h ysiotherapists w ho p ro v id ed treatm ent to the guest athletes. It is intended that such inform ation w ill prove useful for any p h y siotherapy b ody th at undertakes to pro v id e treatm ent as a h o st nation to guest athletes. P h y sio th erap y services p rovided to the Z im babw ean team w ere analysed separately and w ill be p resen t­ ed elsew here. S im ilarly no d ata is p re­ sented on athletes from the team s o f countries w ho h ad th eir ow n p h y sio ­ therapists. SUBJECTS AND METHODOLOGY Ph y sio th erap y w as provided free o f charge w ithin the G am es V illages from 7h00 to 19h00. T he p resen ce o f the physiotherapists w as w ell advertised and the venues w ere easily accessible. The v ast m ajority o f cases w ere self­ referred and each athlete w ho presented fo r p h y siotherapy w as assessed and the findings and treatm ent docum ented. A separate sports m assage service w as p ro ­ vided b u t as clients w ho used this ser­ vice w ere not injured, their data is not included in this analysis. A sum m ary o f the findings and in terv en tio n w as then recorded on a separate spreadsheet. This qu estio n n aire (Figure 5,6) w as d ev el­ oped specifically to reco rd p h y sio th era­ py data and w as b ased on the general m edical data co llectio n form s used d u r­ ing the 1994 C o m m o n w ealth G am es in V ictoria, C anada and the W orld P olice and F ire G am es h eld in M elbourne in 1995. In form ation w as g ath ered reg ard ­ in g d em o g ra p h ic d eta ils, sp o rt type, position, h isto ry o f injury, region and structure injured, p resenting problem s, p h y siotherapy intervention and advice given regarding return to sport. T h e h is­ tory o f injury in clu d ed tim e o f onset, m echanism and classification regarding stage o f injury, i.e. acute (less than 36 SA J o u r n a l o f Ph y s io t h e r a p y 1997 V o l 53 No 3 17 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) hours), subacute o r chronic/overuse. O n com p letio n o f the gam es, the data w as analysed using d escriptive statistics by the SPS S-PC statistical package. RESULTS D u rin g th e te n -d a y p e rio d o f the gam es, 1 141 treatm ents w ere carried out on 52 0 a th letes by th e V illag e, Z im babw e Team and Venue p h y sio th era­ pists. A total o f 541 treatm ents was p ro ­ vided for 258 guest athletes (213 in the V illage facilities and 45 at the Venues). T here w ere 201 m ales and 57 fem ales (a ratio o f 78:22 co m pared to 70:30 o f all p articip atin g athletes). T he m edian age w as 24 years and the range w as 14 to 58 years. A t-test suggested a significant difference (p.=0.01) betw een the ages of the m ales (m ea n = 2 5 .6 S D = 6 .8 ) and fem ales (m ean= 23.4, SD =4.6). A thletes from 38 different countries w ere seen w ith 6 6 .6 % d eriv in g fro m non- A ng lo p h o n e countries. F ig u re 1 d ep icts th e n u m b e rs o f injured athletes w ho p articip ated in the different sports grouped according to gender. T w elve clients w ho p resen ted for treatm en t w ere noncom petitors. T rack a th letics h ad the h ig h e st n u m b e r o f injuries for both m ales (51) and fem ales (16). T rack athletes rep resen ted 22% o f all com petitors in the A A G and 28.7% o f injured athletes w ere draw n from these events. M ale m artial arts participants sim ilarly accounted for a higher pro p o r­ tion o f injured clients (19% ) than p ro ­ p o rtio n o f registrants for the G am es (13% ). C om petitors in these disciplines m artial arts, w hich in clu d ed ju d o , karate and Tae K w on D o, co m p rised the next largest group o f m ale clients (39) seek ­ in g p h y sio th e ra p y atten tio n . H o ck e y players accounted fo r the largest fem ale group (12). O ther sports that accounted for ten o r m ore injuries in m ales w ere handball, w eightlifting, w restling, v o l­ leyball and sw im m ing and diving. N in ety -o n e athletes (35% ) reported the on set o f injury as being p rio r to the start o f the G am es, 38 (14.7% ) w ere injured in training and 88 (34% ) w ere injured during the rounds and finals o f com petition. T he rem ain d er w ere injured in n onsport situations o r p o stco m p eti­ tion. M ost o f the injuries, 106 (41% ), w ere treated in the acute stage, follow ed by 63 (24% ) in the chronic stage. T he m echanism s o f injury and on set o f injury are show n in F igure 2. T h e m o st co m ­ m on m echanism was overuse as reported in 58 (22.5% ) cases. C ontact w ith a per- S P O R T T Y P E A T H L E T IC S T R A C K JU D O /M A R T IA L A R T S H A N DB A LL V O L L E Y BA LL S W IM M IN G /D IV IN G W R E S T L IN G W E IG H T L IF T IN G FO O TBA LL CYCLIN G BO XIN G T E N N IS TABLE T E N N IS B A S K E T B A L L /N E T B A L L A T H L E T IC S F IE L D S H O T T IS T S G Y M N A S T IC S H O C K E Y N O N -A T H L E T E S FIGURE 1: The number o f injured athletes per sport, grouped according to gender. N=258. 201 males, 57 females. MECHANISM c o n t a c t O V E R U S E ST R E T C H T O RSIO N SURFACE W T LIF T IN G C R A M P 4 C O M P ET IT IO N -7 5 H I T RA IN IN G -3 3 H PRIO R-77 0 10 20 30 40 50 60 O N S E T FIGURE 2: Mechanisms o f injury grouped according to time o f onset o f injury. Contact includes contact with a person or a tool. N=185. Non-sport injuries and missing data account fo r a fu rth er 73 cases. 18 SA J o u r n a l o f Ph y s io t h e r a p y 1997 V o l 53 No 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 10 2 0 3 0 4 0 S O 6 0 7 0 8 0 INJURED STRUCTURE FIGURE 3: Injured regions and structures. N=327 injured structures in 258 athletes. Lig.=ligament. M O D A LIT Y ICE M A S S A G E /T R IG G E R PT. U L T R A -SO U N D C O M P R E S S IO N E L E C T R O T H E R A P Y JO IN T M O BILISA TIO N HEAT S O F T T IS S U E ST R E T C H S T R A P P IN G R E F E R R A L F R IC T IO N S ELEVATION E X E R C IS E S AC U P U N C T U R E 166 O T H ER -25 JO IN T INJURY-10 E H F RA C TU R E-8 ^ H A E M A T O M A /G R A ZE S-1 6 H S T R A IN S /S P R A IN S -1 8 6 100 IN JU R Y 150 200 FIGURE 4: Modalities o f treatment. N=745 applications o f modalities in 246 athletes. Data on 12 cases were missing. Joint injury included dislocation, subluxation and effusion. Others included cramp, nerve compression, vascular damage, retropatellar pain and “shin splints”. son was cited as the m echanism o f injury in 48 (18.6% ) and stretch in 38 (14.7% ) cases. T he 258 athletes presented w ith a total o f 310 injured regions o f the body and 341 injured structures (Figure 3). T he low er lim b was the site o f 153 (49.5% o f regions) injuries w ith the m o st freq u en t­ ly injured regions being the knee (14.5% o f cases) and thigh (17.1% ). In the upper lim b the shoulder was m o st often injured accounting for 10% o f cases. T he stru c­ ture m o st com m only injured was m uscle (41% o f 155 injured structures), fo l­ low ed by jo in ts that accounted fo r 74 (21.7% ). P ain was the p red o m in an t p re­ senting sym ptom in 250 (96.8% ) o f the a th letes. O th er sy m p to m s in c lu d ed sw elling (oedem a or synovitis) in 50 (19.3% ) and reduced range o f m ovem ent in 47 (18.2% ) o f athletes. Sprains and strains accounted fo r 187 (72.4% ), with no o th er injury (eg. haem atom a, frac­ tures, subluxations) co n trib u tin g m ore than 5% to the total. T here w ere 745 applications o f treat­ m ent m odalities on the injuries sustained (Figure 4). Ice w as the m o st frequently used m odality fo llo w ed by therapeutic and trig g er p o in t m assage and u ltra­ sound. T h e m ean n u m b er o f m odalities p er athlete w as 2.7. T h irty -tw o cases (12.4% ) w ere referred to m edical ser­ vices fo r X -rays or m edical treatm ent req u irin g m edication. T h e total n um ber o f treatm ents given w as 520 and the m ean n u m b e r p er c lie n t w as 2.27. F em ales attended m ore frequently (m ean = 2 .8 5 , S D = 2 .3 9 ) th an m ales (m ean= 2.08, SD =2.04) (p.=,017). One hundred and fifty -n in e athletes (61.9% ) attended a single session o f physiotherapy an d 8 3.7% a tte n d e d le ss th an th ree tim es. S e v e n ty -six a th le te s (2 9 .5 % ) w ere ju d g e d to h av e su sta in e d an in ju ry severe enough to w arrant advice eith er to rest fro m sporting activity and not com pete (regarded as a severe injury) or to m odify training (m oderately severe injury). A thletes ad v ised to return to full activity w ere regarded as having m inor injuries. DISCUSSION A s in the other stu d ies57 it w as difficult to collect data fro m team s that had their ow n p h ysiotherapists and the in fo rm a­ tion presented relates pred o m in an tly to guest athletes fro m the sm aller national team s. T hose team s acco m p an ied by th e ir o w n p h y sio th e ra p is t, (su ch as K enya and S outh A frica) scarcely used the V illage services. T h e d ata presented here is consequently not n ecessarily rep ­ resen tativ e o f the injuries sustained by all the participants, bu t the results are o f relevance, for any h o st country planning to p rovide p h y siotherapy services for g u est athletes. A s 66.6% o f the clients cam e from n on -A n g lo p h o n e co u n tries, co m m u n ica­ tio n w ith clients w as lim ited and m ade history taking and treatm en t interaction difficult. A ccessib ility to p ro fessio n al interpreters is essen tial to facilitate safe and effec tiv e treatm en t. T he sm aller n um ber o f injured fem ale patients was expected but the fact that the proportion w as sm a lle r th an th e p ro p o rtio n o f fem ale athletes registered for the A A G m ig h t reflect th a t fem ale events give rise to few er injuries. F em ale athletes w ere significantly y o unger and attended m ore SA J o u r n a l o f Ph y s io t h e r a p y 1997 V o l 53 No 3 19 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) treatm en t sessions. It is u n clear if the increased n u m b er o f attendances reflect­ ed g reater severity o f injury or other fa c ­ tors. T he m ost striking featu re o f the fin d ­ ings on m echanism s, d istributions and types o f injuries is the sim ilarity to those pub lish ed reg ard in g other m ajo r m u lti­ sp o rt e v e n ts .137 T h is is o f in te re st because m o st o f A A G p articip an ts seen in this stu d y w ere fro m d ev e lo p in g countries w here training and m edical resources m ay be less than o ptim al. T he percentage o f injured track athletes p re ­ senting to the V illage F acilities w as both ab so lu tely and p ro p o rtio n ate ly (w hen co m pared to total A A G registrants for these events) m uch larg er than from any other sport. T he larg er rep resen tatio n o f these events is sim ilar to oth er stu d ies.13 8 M artial arts also accounted for a higher p roportion o f injuries than the p ro p o r­ tio n registered and clients fro m these disciplines required the g reatest num ber o f referrals to m edical services. T his w ould lend support to the suggestion o f M artin et al 1985 suggestion th at m ed ­ ical care resources should be sp ecifical­ ly allocated to these disciplines. It is notew o rth y that 35.3% o f the ath ­ letes w ere carrying the injury at the o p ening o f the A A G . T he o n going nature o f the injuries w as rein fo rced by the findings that 24% o f the injuries w ere in the chronic stage and that the cause o f in ju ry w as id e n tifie d as o v e ru se in 22.5% o f the athletes. T his high rate o f p re-ex istin g injury is alm ost u niversally reported in the literature. H annay et al 1993 found 40% o f injuries h ad started b efo re the W orld S tu d en t G am es in S heffield, Jull and C upit (1984) report that 50% o f injuries seen at the X II C om m onw ealth G am es w ere n o t acute b u t “m o re lo n g te rm in ju rie s ” and M artin et al (1985) found that 26% injuries w ere sustained p rio r to the 1985 Ju n io r O lym pics. Several other factors m ay co n trib u te to the high rate o f p re­ e x istin g an d tra in in g in ju ry fo u n d . A th letes m ay den y injury in o rd er to com pete. T here m ay be ex cessiv e p res­ sure on athletes to com pete and rep re­ sent their countries. T he intensive train ­ ing in prep aratio n fo r high profile events m ay ex acerb ate p re-existing conditions and p recip itate new injuries. H ealth p ro ­ fessionals and coaches need to be aw are o f these facto rs and adopt suitable strate­ gies to allow for p h y siotherapy in v o lv e­ m en t during p re-ev en t training. T here is an o bvious need for im proved screening b efo re p a rtic ip a tio n in in te rn a tio n a l events so the health pro fessio n s and coaches are aw are o f these problem s and can adopt suitable strategies. T he need fo r both im proved training m ethods and ongoing inv o lv em en t o f physio th erap ists is underscored. A s in prev io u s studies, m o st o f the injuries w ere to the low er lim b and soft tis s u e stru c tu re s (m u sc le s an d lig a ­ m e n ts).13 T he k n ee and thigh are co n sis­ tently reported as the m o st v ulnerable sites o f injury.7 In this study, as in other studies, sprains and strains w ere the m o st com m on cause o f injury.13 8 T he p articip atio n o f physiotherapists at the A A G and at the X II C o m m o n ­ w ealth G am es is reflected by the greater variety o f m odalities used at these events (17 and 16 resp ectiv ely ) co m p ared to m o s t o th e r stu d ie s. Ice a p p lic a tio n rem ain ed the m ain stay o f treatm ent and w as applied to 65.5% o f clients. U sually the ice w as applied through the m edium o f C ryocuff® w hich com bines cold and com pression. T his fig u re is com parable to those rep o rted at the 1995 Ju n io r O ly m p ics (60% ) but co n sid erab ly m ore than the 32.5% usage o f ice reported d u ring the X II C o m m o n w ealth G am es. M o d ified trig g er p o in t m assage, i.e. the ap p licatio n o f sustained and gradually in creasin g pressu re o v er pain fu l sites o f localised m uscle spasm as d escrib ed by COJA-Z 1995 PHYSIOTHERAPY DATA F igure 5 TI z (Z Venue: Physiotherapist: ID number: Name (optional): Age: Sex: Country: Language Time o f assessment: Sport type: [H Athletics Track EH Football CD M artial Arts □ Volleyball Position/Event: CD Forward dSOO-IOOOOm CD Swim:200-800m □ Wtlift: < 7 0kg CD Athletics Field CD Gymnastics CD Netball CD Weightlifting CD Midfielder CD Throwing CD Shoot: smallbore □ Wtlift: >70 kg 1 1 Basketball CD Handball CH Swimming/diving CD Rugby CD Back CD Jumping CD Shoot: claypigeon CD Other CD Boxing CD Hockey CD Table Tennis CD Goalkeeper CD D iving CD Gym-rhythmic CD Cycling CD Judo CD Tennis C \l0 0 -4 0 0 m CD Swim:50-200m CD Gymnastics Onset o f symptoms: C lassification: Time o f day o f injury: □ Prior 13th Sept. CD Compel, -rounds CD Acute/<36hrs □ 06h00-12h00 □ 12h00-18h00 £ 1 1 Training CD Compet. -finals CD Sub-acute \Z \l8h00-24h00 □ 24h00-06h00 1 1 Non-sport related EH Post-compet. CD Chronic/Overuse M echanism o f injury: £ CD Contact/Person LD Contact/Tool CD Cont. s u r f ace/Frict. CD Stretch H r t a OM/ CD Overuse CD Torsion/Twist CD Weightlifting CD Environment □ Other X Relevant history: CD No previous inj. CD Sim ilar inj. <2wks 0 Sim ilar inj. >2wks 1_1 Previous surgery to sam e site CD Other inj same CD Other injury opp. CD Other surgery CD Other (specify) limb < 4 wks limb within 4 wks Region: □ l CDr CD Dominant CD N on-dom inant □ Head CD Face CD N eck CD Spine CD T runk U i Shoulder CD Upper arm 1_1 Elbow CD Forearm □ Wrist c \^ \H a n d CD Finger EH Pelvis CD Groin C3 Hip £ V n Thigh {J Knee CD Lower leg 1_1 Fool \ j T o e Cfflj V V CD Vital organs □ iSystemic CH Ankle CD Other < Primary injured structure: 1_1 Bone CD Joint □ Muscle CD Ligam ent CD Tendon CD Nerve □ Organ EH Vascular [ H s w « CD Nails CD Ear l_J Eye □ Other 20 SA J o u r n a l o f P hysiothera py 1997 V o l 53 No 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) M anheim and L av ett (1989), w as fre­ quently co m bined w ith oth er m assage techniques. E lectro th erap y m o d alities, w h ich in c lu d e d u ltra -s o u n d th erap y , interferential, laser and T E N S, rep re­ sented 20% o f m odalities applied, a fig ­ ure that is low er than that rep o rted by Ju ll and C u p it (1 9 8 4 ) at the X II C om m onw ealth G am es. A decision was taken to lim it the use o f electrotherapy m odalities to clients w ith w hom ad e­ q uate com m u n icatio n w as possible. N o other article has d o cu m en ted the m ean n um ber o f treatm ent sessions per athlete and in this study it w as found to be rela tiv e ly low (2.27) w ith 61.9% attending only once. Several hypotheses are postu lated to explain this p h en o m e­ non. As the severity o f injury p revented or lim ited p articip atio n in only one third o f cases, it is p o ssib le that o th e r athletes d id n o t feel th at th eir in ju ries w ere severe en o u g h to w arran t co n tin u in g treatm ent. M any athletes attended ju st p rior to p articipation and it is likely that they w ere seeking reassurance as to their fitness to com pete. T hey then defau lted on failing to q ualify or on co n clu sio n o f com petition. T h e low attendance rate w as sim ilar at both V illage facilities. T h e results p resen ted in this article are intended to p rovide guidelines to p h y sio ­ therapists in a h o st country as to the type o f injuries sustained by visiting athletes th at are likely to n eed m anagem ent. P atterns o f injury w ere sim ilar to those prev io u sly docum ented, desp ite the d if­ ference in the p articip atin g population. As ice, the C ryocuff® and ultra-sound w ere freq u en tly used, it is suggested that this eq u ip m en t be m ade available to p h y sio th erap ists called upon to provide se rv ic e s at m u lti-sp o rt ev e n ts. It is strongly reco m m en d ed that the co llec­ tion o f ep id em io lo g ical data be stan d ard ­ ised at m u lti-sp o rt events to allow for co m p ariso n betw een these events. ACKNOWLEDGEMENTS C O JA -Z , the o rganising co m m ittee o f the A A G ; C letus S atum ba for assistance w ith d ata collection. REFERENCES 1. Martin RK, Yesalis CE, Foster D and Albright JP. Sports injuries at the 1985 Junior Olympics: A n epidem iological analysis. Am J Sports M ed 1987; 15: 603- 608. 2. Peres-Perdomo R, M orell-Rivera CA, M ayor-Becerra AM, Serrano-R odriguez RA and Frontera WR. Description o f m or­ bidity notified to the epidemiologic surveil­ lance system o f the XVII Central American and Caribbean Games, Puerto Rico 1993. Puerto Rico Health Sciences Journal 1994; 13: 267-272. 3. Laskowski ER, Najarian MM, Smith AM, Stuart MJ and Friend LJ. Medical coverage for multi-event sports com peti­ tion: A comprehensive analysis o f injuries in the 1994 Star of the North Summer Games. Mayo Clin Proc 1995; 70: 549- 555. 4. Ahuja A and Ghosh AK. Pre-Asiad '82 injuries in elite Indian athletes. Br J Sports M ed 1985; 19: 24-26 5. Hannay DR, English BK, Usherwood TP and Platts M. The provision and use of medical services during the 1991 World Student G am es in Sheffield. J Public Health M ed 1993; 15: 229-234. 6. Thompson S and Ratcliffe A. World Student G am es, 1991-Sheffield. Experiences o f student physiotherapists. Physiotherapy 1991; 77: 820. 7. Jull GA and Cupit RN. Physiotherapy at the X II C om m onw ealth Games: Organisation and utilisation o f services. Aust J Physiotherapy 1984; 30: 3-14_ 8. Watson AWS. Incidence and nature of sports injuries in Ireland. A m J Sports M ed 1993; 21: 137-143. 9. M anheim CJ and L avett D. The M iofascial Release Manual. Canada: Slack Incorporated, 1989. F igure 6 Z im b a b w e P h y s io th e r a p y A s s o c ia tio n SA J o u r n a l o f Ph y s io t h e r a p y 1997 V o l 53 No 3 21 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )