physiotherapy, November 1986, vol 42 no 4 125 The E ffectiven ess o f P h ysio th era p y During the Comrades Ultramarathon LINDA EXELBV SUMMARY Physiotherapy stations along the Com rades Marathon route provided treatment for m uscu­ loskeletal problems. Common muscular condi­ tions encountered were fatigue, cramp and strains. These were treated with ice massage, conventional massage or a combination of the two. Every runner was also encouraged to t stretch the affected muscles. Joint related injuries were strapped. Questionnaires were sent to runners to assess the effectiveness of the treatment received. Most runners reported that the treatments helped. In spite of the limited treatment time available nearly half of those treated gained lasting relief. OPSOM M ING Fisioterapie punte langs die Comrades M ara­ thon roete het behandeling aan muskulo-skele- tale probleme verskaf. Die mees algemene spiertoestande wat voor- | gekom het, was uitputting, krampe en ooreising. i Laasgenoemde toestande is met ysmassering, algemene masseringstegnieke of ’n kombinasie van die twee behandel. Elke deelnemer is ook aangemoedig om die beseerde spiere te strek. Beserings van gewrigsoorsprong is verbind. Vraelyste is aan die deelnemers gestuur om die effektiwiteit van die behandeling wat ont- vang is, te bepaal. Die meeste deelnemers het geantwoord dat hulle baie baat daarby gevind het. Ten spyte van die beperkte beskikbare behandeling ontvang, het amper die helfte bly- wende verligting ondervind. IN T R O D U C T IO N O ne o f N a ta l’s m ain an n u al events, fo r b o th spectators an d ru n n e rs is th e C o m ra d e s M a r a th o n — a 90 k ilo ­ m etre race ru n o v er hilly te rra in . T h e leaders spend a p p ro x im a te ly 5 ‘/2 h o u rs o n th e ro a d w hile th o s e at th e b a c k o f th e field sp en d u p to 11 h o u rs c o v erin g th e sam e distance. T h e c lim atic c o n d itio n s are n o t fa v o u ra b le d u rin g y th e race, th e m a jo rity o f ru n n in g being d o n e in the heat o f th e d ay w hich is seldom below 20° C en tig rad e. It w as 2 8 °C in 1986. A s N o a k e s 1 p o in ts o u t te m p e ra tu re s such as these are a sso ciate d w ith a high risk o f h eat fatig u e especially in less tra in e d subjects. C o u p led w ith this is the high incidence o f d e h y d ra tio n 2 w hich occurs d u rin g th e race. T h e d e m a n d s o f this race cause new ru n n in g injuries a n d / o r a g g rav ate p rev io u s tra in in g injuries. D u rin g th e L o n d o n m a r a th o n , p h y sio th e ra p ists were s ta tio n e d h alf-w ay an d a t th e end o f th e race. M a c ­ D o n a ld 3 sta te d th a t p h y sio th e ra p ists w ere an essential L inda Exelby, B.Sc. Physiotherapy Form erly in private practice, but not currently working p a r t o f th e m edical team a t th e m a ra th o n . T he m ajo rity o f tr e a tm e n ts a p p e a r to have been d o n e a fte r th e finish o f th e race o r o n ru n n e rs w ho were u n a b le to c o n tin u e b ecau se o f in ju ry . T h e C o m ra d e s M a r a th o n , w ith its c u t-o ff tim e o f m o re th a n tw ice th a t o f a sta n d a rd m a r a th o n , differs in th a t m o re sta tio n s have to be situ a te d a lo n g th e course. T h is m eans th a t tre a tm e n t d u ra tio n is lim ited to the p erio d d u rin g w hich the ru n n e r is p rep ared to stop — usually less th a n 5 m inutes. T h e m a jo r p ro b le m s en c o u n te re d by ru n n ers were id en tified d u rin g th e 1985 race. T hese w ere m u scu lar fatig u e, c ra m p an d th e u su al lo n g d istan ce te n d o n and jo i n t injuries. T o estab lish th e m o st effective tre a tm e n t, th e type, severity an d e x te n t o f p ro b lem s e n c o u n te re d , needed to be identified. In a d d itio n feed b ack fro m th e c o m p e ti­ to r s w as n eed ed to e v a lu a te th e effectiveness o f o u r tre a tm e n ts. M E T H O D 1. S ix p h y sio th e ra p y s ta tio n s w ere estab lish ed along th e C o m ra d e s ro u te a p p ro x im a te ly every 10 km s, fro m the 30 k m m ark on w ard s. 2. T he tre a tm e n t techniques ch o sen fo r m u scu lar c o n d i­ tio n s ( th a t is fa tig u e , c ra m p an d stra in s ) w ere ice 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. ) 126 Fisioterapie, November 1986, deel 42 no 4 m assag e, c o n v e n tio n a l m assage o r a c o m b in a tio n o f th e tw o. S u sta in e d stre tc h in g w as e n c o u ra g e d , e ith er d u rin g o r a fte r th e tre a tm e n t. 2.1 Ice m assag e w as ap p lied to th e w hole m uscle u sin g a c irc u la r m o tio n . W a te r fro zen in p o ly ­ sty ren e c u p s w as fo u n d to be th e m o st p ra c tic a l a n d c o n v e n ie n t w ay o f p ro v id in g co o lin g .4,5 N o t o n ly is ice less expensive th a n eth y l ch lo rid e b u t it is safer as it c a n n o t reduce skin te m p e ra tu re s to d a n g e ro u s levels. T h is fo rm o f tr e a tm e n t was c h o se n , as stu d ies h av e show n th a t th a t skin an d su p e rfic ia l m uscle tissue te m p e ra tu re s can be decreased w ith in 2 to 5 m in u tes in this w ay.6 2.2 T h e c o n v e n tio n a l m assage te c h n iq u e used was p a lm a r k n e a d in g to the w hole m uscle. D e ep er fin g e r m assag e w as a p p lie d to a re a s o f local sp asm , w ith o u t c au sin g p ain . N o p ro p rie ta ry lo tio n s o f th e w in terg reen ty p e w ere used as a co o lin g effect w as desired. 2.3 S u sta in e d stre tc h in g , rep eated th re e tim es fo r te n se co n d s each , w ith o u t p ro d u c in g p a in was e n co u rag ed . T his h as show n to h av e a p ro lo n g ed p o sitiv e effect on m uscle re la x a tio n an d flexi­ b ility .7’8'9 3. T h e second m a jo r g ro u p o f c o n d itio n s was jo in t related injuries. T hese were stra p p e d w ith th e consent o f th e ru n n e r . K nee a n d an k le stra p p in g s w ere s ta n ­ d a rd iz e d .10 T h e s tra p p in g m a te ria l w as E la sto p la s t elastic ad h esiv e b an d a g e , as reco m m en d ed by m a n u ­ factu rers. 4. O th e r in ju ries e n c o u n te re d w ere tre a te d a t th e p h y ­ s io th e ra p is ts ’ d is c re tio n , u sin g an y o f th e ab o v e m e n tio n e d m o d alities. In a d d itio n a su p p ly o f a n ti­ in fla m m a to ry cre a m w as p ro v id ed . 5. T o en su re th a t tre a tm e n ts w ere c a rrie d o u t in as u n ifo rm a m a n n e r as po ssib le, tw o w o rk sh o p s w ere held p rio r to th e race, w here all th e ab o v e m e th o d s w ere p ractise d . 6. A t ea c h s ta tio n th e ru n n e r’s race n u m b e r, his injury a n d tr e a tm e n t w ere reco rd ed . 7. 800 o f th e ru n n e rs w ho received tr e a tm e n t a t o u r p h y sio th e ra p y sta tio n s w ere sent a q u e stio n n a ire w ith in a w eek o f ru n n in g th e race. 34 p e r cen t o f q u e stio n n a ire s were re tu rn e d an d an aly sed to e sta b ­ lish th e effectiveness o f th e tre a tm e n ts used. R E S U L T S 1010 ru n n e rs sto p p e d a t o u r sta tio n s. T hey re p re ­ sen ted 10 p e r cen t o f all ru n n e rs registered as sta rtin g th e race. 21 p e r cen t o f these ru n n e rs w ere tre a te d m ore th a n once. In a d d itio n to th e six p h y sio th e ra p y sta tio n s a lm o st every w aterin g s ta tio n h a d p eo p le a d m in iste rin g w in te rg re e n b ased lo tio n s . T h ese tr e a tm e n ts are n o t in clu d ed in th e figures q u o te d above. T h e m a jo rity (76 p e r cen t) o f ru n n e rs tr e a te d a t o u r sta tio n s to o k lo n g er th a n n in e h o u rs to c o m p le te th e race o r did n o t finish (10 p e r cent). H a lf o f these ru n n e rs w ere novices. 38 p e r cen t o f ru n n e rs sta rte d th e race w ith injuries, h o w ev er m in o r. O f these th e m o re c o m m o n injuries were: ru n n e rs kn ee, p a in localized a ro u n d th e low er b o rd e r o f th e p a te lla (12 p e r cen t), ilio tib ia l b an d sy n d ro m e (11 p e r cen t) an d m u s c u la r in ju ries (10 p e r cent). M o st sta tio n s tre a te d 200 ru n n e rs, w ith 2 s ta tio n s each tre a tin g over 300 people. F o r th is re a s o n th e c o n d itio n s th a t w ere tr e a te d co u ld o n ly be reco rd ed in to b ro a d cate g o ries o f m u sc u la r an d jo in t p ro b lem s. B ecause s tra p p in g w as ap p lied to th e ilio tib ia l b a n d sy n d ro m e a n d ru n n e r ’s knee, these hav e been classed as jo i n t p ro b le m s. In all, 1000 m u sc u la r tre a tm e n ts were p e rfo rm e d an d 243 jo in t p ro b le m s a tte n d e d to (T ab le 1). Table 1. M uscular Treatments Total N um ber I 000 Incidence % Calf 40,2 H am string 34,5 Q uadriceps 23,4 G roin 1,9 Joints Strapped Total N um ber 243 Incidence % Left knee 56,4 R ight knee 29,6 Ankles 7,8 O ther 6,2 Table 2. Muscular conditions % % % N ot Effective Effective Total No. o f Effective 0 - 1 0 mins. m ore than 15 mins. respondents Ice Massage 9 50 41 46 Massage 12 43 45 140 Ice Massage & Massage 5 47 48 98 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. ) physiotherapy, November 1986, vol 42 no 4 127 Table 3. Joint conditions Total No. o f 0 - 1 5 m i n s l 5 - 3 0 m i n s 3 0 - 6 0 m in s 1 - 3 hours Longer respondents L asting relief % 17,5 14 14 24,5 30 57 H av in g cate g o rised th e c o n d itio n s w hich occu rred d u rin g th e race th e effectiveness o f tr e a tm e n t was assessed fro m th e q u e stio n n a ire responses. M u scu lar co n d itio n s in th e q u estio n n aire were divided in to fatig u e a n d c ra m p . T h e resu lts sh o w ed th a t all th re e tr e a tm e n t o p tio n s gave sim ila r effectiveness. 91 p e r cen t o f th e ru n n e rs perceived th e tr e a tm e n t given to be effective. R u n n e rs w ere also asked fo r h o w lo n g th e tre a tm e n t w as effective (T ab le 2). F o r jo in t c o n d itio n s , 90 p e r cent o f resp o n d en ts p erceived s tra p p in g to be effective. M o s t (89 p e r cent) o f th e s tra p p in g w as d o n e to th e knee. O f th is figure 71 )per cen t h ad h a d k n ee related injuries a t som e tim e d u rin g th eir train in g . A high percentage o f these ru n n ers sta rte d th e race in ju red as d etailed ab o v e. 54 p e r cent o f ru n n e rs fo u n d s tra p p in g to be effective fo r lo n g er th a n one h o u r. S o m e restrap p in g was how ever necessary. T h e effectiveness o f the s tra p p in g is set o u t in T ab le 3. D IS C U S S IO N T h e p re d o m in a n t m u s c u la r c o n d itio n s w ere in the c a lf a n d h a m s trin g m uscle g ro u p s , sim ila r to th o se fo u n d by M a c D o n a ld 3 d u rin g th e L o n d o n M a ra th o n . In a race su ch as C o m ra d e s , w here th e d ista n c e is lo n g er, th e te r ra in hilly a n d clim atic c o n d itio n s m ore severe, these p ro b le m s w ere g reatly increased. T h e P ie te rm a ritz b u rg to D u r b a n race, th a t is th e d o w n h ill ru n h as a n u m b e r o f steep u p h ills in th e first h a lf o f th e race an d th e r e a fte r d o w n h ill ru n n in g p re ­ d o m in a te s . T h o se fin ish in g a fte r 9 h o u rs ten d to co v er th e last p a r t o f th e race by w alking u p h ill an d ru n n in g dow nhill. D o w n h ill ru n n in g is a n a g g ra v a tin g o r c a u sa ­ tive facto r in ru n n in g injuries especially w hen th e ru n n e r is fatig u ed . S tu d ie s have sh o w n th a t th e h am strin g s, ^ q u ad ricep s an d g lu teal m uscles in p a rtic u la r are affected in th ese cases. S te e p u p h ill ru n n in g is resp o n sib le fo r th e c a lf an d g ro in p ro b lem s. A high p e rc e n ta g e o f ru n n e rs fo u n d th e tre a tm e n t effective. T h e tr e a tm e n t tim e varied betw een 1 an d 3 m in u tes a n d it is d o u b tf u l th a t sim ply restin g fo r this p erio d w ould c o n tr ib u te to th e relief o f fatig u e. In a race s itu a tio n it is n o t p o ssib le to hav e a c o n tro l w ho rests only, so fo r th is reaso n we co n sid ered a m u sc u la r tr e a tm e n t to be effective if th e effects lasted m o re th a n 15 m in u tes an d in d eed n e a rly h a lf o f th e re s p o n d e n ts re p o rte d this to be th e case. I t is well estab lish ed th a t high te m p e ra tu re s reduce m uscle efficiency an d increase fatigue especially in u n a c ­ clim atized s u b je c ts .11' 12,13' 14 It w as ev id en t fro m th e q u e s tio n n a ire th a t m o st ru n n e rs fell in to th is category. S o m e 88 per cen t tra in e d in th e cool o f th e day. A c o m b in a tio n o f ice an d c o n v e n tio n a l m assage gave th e m o s t la s tin g relief by a s m a ll m a rg in , so p ro v in g to be th e m o st effective tre a tm e n t. W ith the s h o r t tr e a tm e n t d u r a tio n o f ice m assage the c o o lin g o f th e skin p re d o m in a te d o v er d eep m uscle co o lin g .6’15’1617,1819 D ecreasin g skin te m p e ra tu re allow s b lo o d w hich has p o o led in th e veins to re tu rn to the c ir c u la tio n .1 T h is cooled b lo o d b eco m es av ailab le to the w o rk in g m uscles an d in creases th e ir efficiency. M assag e is a well e stab lish ed tre a tm e n t w hich m o b i­ lizes m uscle tissu e, reduces sp a s m an d im p ro v es c irc u ­ la tio n to localized ischaem ic areas. W ith m assage one is a b le to id en tify th e p ro b le m a r e a by feel a n d so localize tr e a tm e n t to these areas. M uscle c ra m p in g is effectively tre a te d w ith gentle m assage a n d su sta in e d stre tc h in g .3 S tre tc h in g , ice an d c o n v e n tio n a l m assage each h as its ow n u n iq u e effect a n d o b v io u sly th e c o m b in a tio n o f all th re e m ake fo r a m ore effective tre a tm e n t. O f th e a b o v e resu lts discussed th e re is n o d o u b t o f th e im p o rta n c e o f ice in th e tr e a tm e n t o f in ju ry to m uscles, te n d o n s o r jo in ts . It is th erefo re a necessity at all lo n g d is ta n c e events. T h e a re a o f a p p lic a tio n is sm all an d a 3 m in u te ice m assag e will effectively reduce th e activ ity o f p a in recep to rs a n d local in fla m m a tio n .18 T h e m o st s trik in g asp ect o f th e s tra p p e d c o n d itio n s w as th e high incidence o f left knees re q u irin g stra p p in g . S ix ty tw o p e r c e n t o f ru n n e rs re p o rte d th a t th e y had r u n in th e m id d le o r o n b o th sid es o f th e ro a d eq u ally d u rin g th e race. T h e re fo re it is d o u b tfu l th a t th e race itself w as th e m ain cau se o f th e high in cid en ce o f left knee injury. I t is c o m m o n f o r e n tr a n ts to tr a in f o r 12 w eeks o r m o re a t d is ta n c e s o f a 100 o r m o re km s a w eek. I t is d u rin g these lo n g d istan ces th a t m o st in ju ries occur. T h is is b o rn e o u t by th e q u e s tio n n a ire resu lts w hich show th a t 71 p e r cen t o f th o se knees stra p p e d sta rte d th e ra c e in ju re d o r h a d b e e n in ju re d d u r in g th e i r tra in in g . F o r safety reaso n s m o s t tra in in g is d o n e on th e rig h t h a n d side o f th e ro a d a n d th is is reflected by th e high incidence o f left kn ee injuries. T h is in ju ry g ro u p co n sisted o f m ainly ilio tib ia l b a n d sy n d ro m e and r u n n e r ’s knee. F u r th e r re se a rc h is needed to id en tify to w h a t e x te n t th e d eg ree o f c a m b e r o f th e ro a d causes injuries to o ccu r m o re in one kn ee th a n in th e o th er. M y b u r g h ’s20 w o rk has sh o w n s tra p p in g loosens so t h a t a fte r o n e h o u r it n o lo n g e r restricts n o rm a l jo in t m o v em en t. H o w ev er, it is p o ssib le th a t th e s tra p p in g ’s su p p o rtiv e an d p ro p rio c e p tiv e fu n c tio n s last longer. T a k in g this in to a c c o u n t an d th e difficulties w ith gettin g s tra p p in g to stic k o n sw eaty , h a iry legs o r th o s e co a te d w ith g reasy lo tio n s , we are satisfied w ith th e large n u m b e r o f ru n n e rs w ho said th e ir s tra p p in g lasted fo r 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. ) 128 Fisioterapie, November 1986, deel 42 no 4 lo n g e r th a n an h o u r. T h e in tro d u c tio n o f an a g e n t to rem ove greasy lo tio n s in s u b s e q u e n t C o m ra d e s m a r a ­ th o n s sh o u ld help to elim in ate one o f these pro b lem s. C O N C L U SIO N We w ere able to show th a t p h y sio th e ra p ists fo rm an essential p a r t o f th e m edical te a m d u rin g long distan ce races. T h e tre a tm e n ts offered w ere fo u n d to be effective fo r m ost m u scu lo sk eletal p ro b le m s especially w hen o n e co n sid ers th e s h o r t tim e av ailab le fo r tre a tm e n t. F ro m now on we p la n to give lectu res to th e o th e r F irst Aid sta tio n s a lo n g th e ro u te so th ey will be ab le to deal w ith m uscle fatig u e a n d c ra m p m ore effectively. In sp ite o f all th e m e d ia coverage o f ro a d ru n n in g an d its asso ciate d injuries th e large n u m b e r o f ru n n e rs tre a te d p ro v e th a t f u r th e r p rev en tiv e e d u c a tio n is needed. P h y sio th e ra p ists sh o u ld play a m ore active role in this facet o f preventive m edicine. L ectures an d clinics sh o u ld be held a t th e b eg in n in g o f the season. T h e S p o rts In te re s t G ro u p o f th e N a ta l C o a sta l B ranch offers this service to clubs. T h ere is co n sid erab le sco p e fo r o th e r p h y s io th e ra p y b ran ch es to p ro v id e p re v e n ta tiv e e d u c a tio n e a rly in th e seaso n to th e large d ed icated follow ing this s p o r t co m m an d s. A C K N O W L E D G E M E N T S T he a u th o r w o u ld like to th a n k S m ith a n d N ephew w ith w h o m we w o rk closely. A lso th a n k s go to J. E xelby fo r his assistance an d J . M o rto n fo r help w ith co m p ilin g the q u e stio n n a ire . References 1. N oakes T. Lore o f R unning. O xford U niversity Press 1985: 15-75, 271-304, 325-380. 2. M aughan R J. T em perature regulation during m arathon com petition. Br J Sports M e d 1984; 18(4): 257-260. 3. M acD onald R. Physiotherapy m anagem ent of m arathon m usculo-skeletal casualties. Br J S ports M e d 1986; 18(4V 283-285. 4. M cM aster WC, Liddle S and W aught TR. L aboratory evaluation of various cold therapy modalities. A m J Sports M e d 1978; 6(5): 291-294. 5. Lowdon BJ and M oore R J. D eterm inants and nature of intram uscular tem perature changes during cold therapy A m J Phys M e d 1975; 54(5): 223-233. 6. W aylonis GW. T he physiologic effects of ice massage. A rch Phys M e d R ehabil 1967; 48: 37-42. 7. Prentice WE. An electrom yographic analysis of the effec­ tiveness of heat or cold and stretching for inducing relaxation in injured muscle. Jospt 1982; 3(3); 133-140. 8. Siff MC. Flexibility in sport. S A S ports M e d 1983; 19: 2-6. 9. De Vries H. Prevention of m uscular distress after exercise R es Q 1960; 32(2): 177-185. 10. Elastosport. A S trap in Time. Sm ith and Nephew. 11. Fink W J, Costill DL and Handel PJ. Leg muscle m etabo­ lism during exercise in the heat and cold. Europ J A p p l P hysiol 1975; 34: 183-190. 12. E dw ard R H T , H arris RC, H ultm an E et al. Effect of tem perature on muscle energy m etabolism and endurance during successive isom etric contractions, sustained to fatigue, of the Q uadriceps muscle in man. J P hysiol 1972- 220: 335-352. 13. C larke D H and Stelm ach GE. M uscular fatigue and recovery curve param eters at various tem peratures. R es Q 1965; 37(4): 468-479. 14. Petajan JH and Eagan CJ. Effect of tem perature, exercise and physical fitness on the triceps surae reflex. J A p p l P hysiol 1968; 25(1): 16-20. 15. Bierm an W and F ridlaner M. The penetrative effect of cold. A rch Phys M ed R ehabil 1940; 21: 585-592. 16. B arcroft H and E dholm OG. T he effect of tem perature on blood flow and deep tem p e ra tu re in the hum an forearm . J P hysiol 1943; 102: 5-20. 17. Kowal MA. Review of physiological effects of cryo­ therapy. J ospt 1983; 5(2): 66-73. 18. De Jesus PV, H ausm anova-Petrusew iez I and Barchi RL. The effect o f cold on nerve conduction of slow and fast nerve fibres. N eurol 1973; 23: 1182-1189. 19. Lee JM and W arren M P. C old Therapy in Rehabilitation. London: Bell and Hyman, 1978: 15-71. 20. M yburgh KH and Vaughn CL. Ankle guards and taping; do they really work? S A Sport M e d 1986; 22: 4-6. Bibliography 1. B arnes J o M. Presenting research in a scientific article. SA J o urnal o f P hysiotherapy 1986; 42(1): 10-15. 2. S ainsbury R. M edical experience of the G reat N orth run. Br J S ports M e d 1984; 18(4): 265-267. Try New Flotation Pads to keep Now “ NEW BONMAT” and “NEWPARAMAT” come up with better quality yet lower prices than conventional dotation pads t f m s ) Rand Medical Supplies Randburg Centre 449, Jan Smuts Ave., Blairgowrie, Randburg 2194 Box 7166, Johannesburg. Tel. 789-2203/789-2286 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. )