PILATES

German born Joseph Pilates was living in England, working as a circus performer and boxer, when he was placed in forced internment in England at the outbreak of WWI. While in the internment camp, he began to develop the floor exercises that evolved into what we now know as the Pilates mat work.

As time went by, Joseph Pilates began to work with rehabilitating detainees who were suffering from diseases and injuries. It was invention born of necessity that inspired him to utilize items that were available to him, like bed springs and beer keg rings, to create resistance exercise equipment for his patients. These were the unlikely beginnings of the equipment we use today, like the reformer and the magic circle.

Joseph Pilates developed his work from a strong personal experience in fitness. Unhealthy as a child, Joseph Pilates studied many kinds of self-improvement systems. He drew from Eastern practices and Zen Buddhism, and was inspired by the ancient Greek ideal of man perfected in development of body, mind and spirit. On his way to developing the Pilates Method, Joseph Pilates studied anatomy and developed himself as a body builder, a wrestler, gymnast, boxer, skier and diver.

After WWI, Joseph Pilates briefly returned to Germany where his reputation as a physical trainer/healer preceded him. In Germany, he worked briefly for the Hamburg Military Police in self-defense and physical training. In 1925, he was asked to train the German army. Instead, he packed his bags and took a boat to New York City. On the boat to America, Joseph met Clara, a nurse, who would become his wife. He went on to establish his studio in New York and Clara worked with him as he evolved the Pilates method of exercise, invented the Pilates exercise equipment, and of course, trained students.

Joseph Pilates taught in New York from 1926 to 1966. During that time, he trained a number of students who not only applied his work to their own lives but became teachers of the Pilates method themselves. This first generation of teachers who trained directly with Joseph Pilates is often referred to as the Pilates Elders. Some committed themselves to passing along Joseph Pilates work exactly as he taught it. This approach is called “classical style” Pilates. Other students went on to integrate what they learned with their own research in anatomy and exercise sciences.

Joseph Pilates' New York studio put him in close proximity to a number of dance studios, which led to his “discovery” by the dance community. Many dancers and well-known persons of New York depended on Pilates method training for the strength and grace it developed in the practitioner, as well as for its rehabilitative effects. Until exercise science caught up with the Pilates exercise principles in the 1980s and the surge of interest in Pilates that we have today got underway, it was chiefly dancers and elite athletes who kept Joseph Pilates' work alive.

Joseph Pilates passed away in 1967. He had maintained a fit physique throughout his life, and many photos show that he was in remarkable physical condition in his older years. He is also said to have had a flamboyant personality. He smoked cigars, liked to party, and wore his exercise briefs wherever he wanted (even on the streets of New York). It is said that he was an intimidating, though deeply committed, instructor. Clara Pilates continued to teach and run the studio for another 10 years after Joseph Pilates death. Today,Joseph Pilates legacy is carried on by the Pilates Elders, and by a large group ofcontemporary teachers.

There are far more than 10 reasons to do Pilates. For example, better sleep and better sex aren't even on this list, but they could be. I'm starting with 10 because I want to inspire you and give you the opportunity to follow-up on the aspects of Pilates training that interest you. My personal list of the benefits of Pilates could reach way past 20 items. But start here and see what you think. Is Pilates right for you?

If you already do Pilates, read the list and see if your favorite reason to do Pilates is here. If not, visit the Pilates forum and tell us about it. You can also take the poll: Why Do You Do Pilates?

1.  Pilates is Whole-Body Fitness

Unlike some forms of exercise, Pilates does not over-develop some parts of the body and neglect others. While Pilates training focuses on core strength, it trains the body as an integrated whole. Pilates workouts promote strength and balanced muscle development as well as flexibility and increased range of motion for the joints.

Attention to core support and full-body fitness -- including the breath and the mind -- provide a level of integrative fitness that is hard to find elsewhere. It is also the reason that Pilates is so popular in rehab scenarios, as well as with athletes who find that Pilates is a great foundation for any kind of movement they do.

2.  Adaptable to Many Fitness Levels and Needs

Whether you are a senior just starting to exercise, an elite athlete or somewhere in between, the foundations of Pilates movement apply to you. Building from core strength, focusing on proper alignment, and a body/mind integrative approach make Pilates accessible to all. With thousands of possible exercises and modifications, Pilates workouts can be tailored to individual needs.

3.  Creates Strength Without Bulk

Long, lean muscles are the name of the game here. In Pilates, we are not looking to build muscles for show. We are building toned muscles that work perfectly within the context of the body as a whole, and the functional fitness needs of a person as they move through life. 

One of the ways that Pilates creates long, strong muscles is by taking advantage of a type of muscle contraction called an eccentric contraction.

4.  Increases Flexibility

In Pilates, we work toward a safe increase in length and stretch of the muscles and range of motion within the joints. You won't find quite as much "pretzel logic" in Pilates as you might in yoga, but a body that can stretch and bend to meet the flow of life is a very realistic goal.

5.  Develops Core Strength

The core muscles of the body are the deep muscles of the back, abdomen, and pelvic floor. These are the muscles we rely on to support a strong, supple back, good posture, and efficient movement patterns. When the core is strong, the frame of the body is supported. This means the neck and shoulders can relax, and the rest of the muscles and joints are freed to do their jobs -- and not more. A nice side benefit is that the core training promotes the flat abs that we all covet.

6.  Improves Posture

Good posture is a reflection good alignment supported by a strong core. It is a position from which one can move freely. Starting with Pilates movement fundamentals and moving through mat and equipment exercises, Pilates trains the body to express itself with strength and harmony. You can see this in the beautiful posture of those who practice Pilates.

7.  Increases Energy

It might seem like a paradox, but the more you exercise, the more energy you have and the more you feel like doing (to a point, of course). Pilates gets the breath and circulation moving, stimulates the spine and muscles, and floods the body with the good feelings one gets from exercising the whole body.

8.  Promotes Weight Loss and Long, Lean Appearance

If you practice Pilates regularly, it will change your body. Known for creating long, strong muscles and a leaner look; Pilates improves muscle tone, balances musculature, supports beautiful posture, and teaches you to move with ease and grace. All of these things will make you look and feel very fit.

If you want to lose weight, the formula for weight loss remains the same: Burn more calories than you take in. As a full-body fitness method, Pilates help will help you do that. Combined with aerobic activity, Pilates becomes a prime weight loss and body toning tool.

9.  Increases Awareness - Body/Mind Connection

Joseph Pilates was adamant that Pilates, or contrology as he called it, was about "the complete coordination of body, mind, and spirit." This is one of the secrets of Pilates exercise: we practice each movement with total attention. When we exercise in this way, the body and mind unite to bring forth the most benefit possible from each exercise. The Pilates principles -- centering, concentration, control, precision, breath, and flow -- are key concepts that we use to integrate body and mind.

10.  There are Many Ways to Learn Pilates

Pilates instruction is easy to come by these days. The ever-growing popularity of Pilates has put it on the map all over the world. This is good because when you start Pilates training, it is important to start with live Pilates instruction at a studio or gym, and preferably from a certified instructor. But there are lots of ways to supplement your learning once you get going. You can practice at home and you don't need one bit of fancyequipment, just comfy clothes and a mat.

Pilates

Pilates

Definition

Pilates or Physical Mind method, is a series of non-impact exercises designed by Joseph Pilates to develop strength, flexibility, balance, and inner awareness.

Origins

Joseph Pilates (pronounced pie-LAH-tes), the founder of the Pilates method (also simply referred to as "the method") was born in Germany in 1880. As a frail child with rickets, asthma , and rheumatic fever , he was determined to become stronger. He dedicated himself to building both his body and his mind through practices which included yoga , zen, and ancient Roman and Greek exercises. His conditioning regime worked and he became an accomplished gymnast, skier, boxer, and diver.

While interned in England during World War I for being a German citizen, Pilates became a nurse. During this time, he designed a unique system of hooking springs and straps to a hospital bed in order to help his disabled and immobilized patients regain strength and movement. It was through these experiments that he recognized the importance of training the core abdominal and back muscles to stabilize the torso and allow the entire body to move freely. This experimentation provided the foundation for his style of conditioning and the specialized exercise equipment associated with the Pilates method.

Pilates emigrated to the United States in 1926 after the German government invited him to use his conditioning methods to train the army. That same year he opened the first Pilates studio in New York City. Over the years, dancers, actors, and athletes flocked to his studio to heal, condition, and align their bodies.

Joseph Pilates died at age 87 in a fire at his studio. Although his strength enabled him to escape the flames by hanging from the rafters for over an hour, he died from smoke inhalation. He believed that ideal fitness is "the attainment and maintenance of a uniformly developed body with a sound mind fully capable of naturally, easily, and satisfactorily preforming our many and varied daily tasks with spontaneous zest and pleasure."

Benefits

Pilates is a form of strength and flexibility training that can be done by someone at any level of fitness. The exercises can also be adapted for people who have limited movement or who use wheel chairs. It is an engaging exercise program that people want to do. Pilates promotes a feeling of physical and mental well-being and also develops inner physical awareness. Since this method strengthens and lengthens the muscles without creating bulk, it is particularly beneficial for dancers and actors. Pilates is also helpful in preventing and rehabilitating from injuries, improving posture, and increasing flexibility, circulation, and balance. Pregnant women who do these exercises can develop body alignment, improve concentration, and develop body shape and tone after pregnancy . According to Joseph Pilates, "You will feel better in 10 sessions, look better in 20 sessions and have a completely new body in 30 sessions."

Although Pilates is often associated with dancers, athletes, and younger people in general who are interested in improving their physical strength and flexibility, a simplified version of some Pilates exercises is also being used as of 2003 to lower the risk of hospital-related deconditioning in older adults. A Canadian study of hospitalized patients over the age of 70 found that those who were given a set of Pilates exercises that could be performed in bed recovered more rapidly than a control group given a set of passive range-of-motion exercises.

Description

During the initial meeting, an instructor will analyze the client's posture and movement and design a specific training program. Once the program has been created, the sessions usually follow a basic pattern. A session generally begins with mat work and passive and active stretching. In passive stretching, the instructor moves and presses the client's body to stretch and elongate the muscles. During the active stretching period, the client preforms the stretches while the instructor watches their form and breathing. These exercises warm up the muscles in preparation for the machine work. The machines help the client to maintain the correct positioning required for each exercise.

There are over 500 exercises that were developed by Joseph Pilates. "Classical" exercises, according to the Pilates Studio in New York involve several principles. These include concentration, centering, flowing movement, and breath. Some instructors teach only the classical exercises originally taught by Joseph Pilates. Others design new exercises that are variations upon these classical forms in order to make the exercises more accessible for a specific person.

There are two primary exercise machines used for Pilates, the Universal Reformer and the Cadillac, and several smaller pieces of equipment. The Reformer resembles a single bed frame and is equipped with a carriage

that slides back and forth and adjustable springs that are used to regulate tension and resistance. Cables, bars, straps, and pulleys allow the exercises to be done from a variety of positions. Instructors usually work with their clients on the machines for 20-45 minutes. During this time, they are observing and giving feedback about alignment, breathing, and precision of movement. The exercises are done slowly and carefully so that the movements are smooth and flowing. This requires focused concentration and muscle control. The session ends with light stretching and a cool-down period.

Once the basics are learned from an instructor, from either one-on-one lessons or in a class, it is possible to train at home using videos. Exercise equipment for use at home is also available and many exercises can be performed on a mat.

A private session costs between $45–$75, depending on the part of the country one is in. This method is not specifically covered by insurance although it may be covered when the instructor is a licensed physical therapist.

Precautions

The Pilates method is not a substitute for good physical therapy, although it has been increasingly used and recommended by physical therapists since the mid-1980s. People with chronic injuries are advised to see a physician.

Research & general acceptance

As of early 2004, several physical therapists and gerontologists have done research studies on the Pilates method, although much more work needs to be done in this area. The appeal of the Pilates method to a wide population, coupled with a new interest in it on the part of rehabilitation therapists, suggests that further studies may soon be underway. Dancers and actors originally embraced the Pilates method as a form of strength training that did not create muscle bulk. Professional and amateur athletes also use these exercises to prevent reinjury. Sedentary people find Pilates to be a gentle, non-impact approach to conditioning. Pilates equipment and classes can be found in hospitals, health clubs, spas, and gyms.

Training & certification

There are two main centers for training and certification. The Pilates Studio in New York City certifies teachers in the "classical" exercises of "The Pilates Method." The teacher training program of The Pilates Studio involves seminar training and 600 apprenticeship hours. Perspective teachers need a strong background in Pilates. There is an extensive application and examination process. Classes are available throughout the United States and in 20 international locations.

The PhysicalMind Institute in Santa Fe, New Mexico, offers a 275-hour basic certification program in "The Method." Prerequisites include a 15-hour course, knowledge of functional anatomy, and 10 hours of private sessions. After completing an apprenticeship, students must pass a written and practical final exam. Advanced training is also offered. Students at this center receive training in the original exercises of Joseph Pilates, as well as the concepts of body mechanics. Understanding the concepts behind the exercises enables teachers to create appropriate variations for their clients. Classes are available throughout the United States and Canada.

Osteopathy

Osteopathy

Definition

Osteopathy is a "whole person" philosophy of medicine, where doctors of osteopathic medicine (DOs) endorse an approach that treats the entire person, rather than a specific complaint. Attention is given to prevention, wellness, and helping the body to heal itself. Because the body is viewed as a single organism or unit, special focus is given to understanding body mechanics and the interrelationship of the body's organs and systems. A particular emphasis is placed on the musculoskeletal system. Dos may utilize physical manipulation of muscles and bones in conjunction with, or as an alternative to, conventional treatments, drug therapies, and surgery to provide complete health care.

Origins

Dr. Andrew Still developed the osteopathic approach to medicine. Still, whose father was a Methodist minister and physician, was himself a medical doctor who served as a Union surgeon during the Civil War. After the war, personal tragedy struck the Still household when three of his children died from spinal meningitis . This event angered and disillusioned him. He became dissatisfied with the state of medical knowledge and treatments available at that time. Consequently, he began an intense study of the human body to find underlying causes and cures for ailments.

Still gave great attention to anatomy. He recognized the importance of the musculoskeletal system, the body's ability for self-healing, and focused on prevention and the concept of "wellness." In an era when drug treatment was frequently dangerous and overused, and surgery often fatal, Still was able to develop alternative treatments. For example, by manipulating the ribs and spine, Still provided treatments for pneumonia . He gave attention to the lymphatic system (which filters foreign matter and removes excess fluids, proteins, and waste products from the tissues and transports them to the blood to be circulated and eliminated) and manipulating the fascia (connective tissue that is tough, but thin and elastic; it forms an uninterrupted three-dimensional network from head to foot, sheathing every muscle, bone, nerve, gland, organ, and blood vessel), allowing him to address a range of other ailments.

Still's sons learned his philosophies and techniques, but demand overwhelmed their ability to supply care. In 1892, Still founded the first college of osteopathic medicine, the American School of Osteopathy, in Kirksville, Missouri. When he died in 1917, there were more than 5,000 practicing osteopaths in the United States. Today, osteopaths are the fastest growing segment of the total population of physicians and surgeons in the United States. In 2002, there were more than 49,000 doctors of osteopathy. Osteopathy has spread outside of the United States and is now practiced in countries throughout the world.

Benefits

The osteopathic focus on prevention and wellness may help individuals to avoid illness by teaching healthy behaviors and encouraging health-promoting lifestyle changes. In addition to conventional treatments, drugs, and surgeries, DOs may offer manipulative therapies not available from their allopathic counterparts MDs). Many people seek care from an osteopath for back or neck pains, joint pains, or injuries. However, DOs may use manipulative therapies to treat a variety of ailments and conditions including arthritis, allergies, asthma, dizziness, carpal tunnel syndrome , menstrual pain , migraine headaches, sciatica , sinusitis, tinnitus(ringing in the ears), and problems in the jaw joints. Manipulative therapies may be incorporated into the treatment plan to speed recovery from various conditions, such as heart attack or disc surgery, and to address pediatric concerns, such as otitis media (ear infection ) and birth traumas. Various manipulative therapies may also be appropriate in alleviating discomforts associated with pregnancy , for example, back pain or digestive problems. Some osteopaths even feel that regular osteopathic treatments may help minimize the effects of aging on the spine and joints. Also, as noted by the American Osteopathic Association (AOA), the field of sports medicine has found particular benefit in osteopathic practitioners because of their emphasis on "the musculoskeletal system, manipulation, diet, exercise , and fitness. Many professional sports team physicians, Olympic physicians, and personal sports medicine physicians are DOs."

Description

Osteopathic medicine considers the human body to be a complex unit of interrelated parts, a unified organism. Organs and systems do not function independently and should not be treated as such. A disturbance in one part of the body affects the entire body. Illness is also impacted by many variables, such as emotions, stress , lifestyle, and environment. Therefore, illness must be addressed by taking a whole person approach to treatment. Because the body is seen as self-regulating and self-healing, the osteopath gives special attention to illness prevention and helping the body maintain or re-establish wellness.

The nervous and circulatory systems play crucial roles in maintaining the functioning of the body's organs and systems; negative body-wide effects may occur when these two major systems are not functioning optimally. Relieving blocked blood flow or nerve impulses will help the body to heal itself by promoting blood flow through affected tissues. The blood supply will be better able to deliver vital nutrients and boost the immune system, the nerve supply to the area will be improved, and systemic balance can be restored.

The musculoskeletal system is key in this effort to achieve and maintain systemic balance and health. The musculoskeletal system is comprised of the bones, tendons, muscles, tissues, nerves, and spinal column. As the body's largest system, it encompasses over 60% of body mass and can suffer mechanical disorders or amplify illness processes anywhere in the body. Therefore, structural evaluation and attention to the musculoskeletal system is central to osteopathy.

In addition to conventional care such as drug therapies and surgery, osteopaths may use a variety of manipulative procedures to help the body systems function at peak levels. These techniques are commonly referred to as Osteopathic Manipulative Treatment (OMT). OMT is a form of noninvasive, "hands-on" care used for prevention, diagnosis, and treatment to reduce pain and restore motion, as well as help the body heal itself. OMT may be used to facilitate the movement of body fluids and normal tissue functioning, and release painful joints or dysfunctional areas. These therapies take different forms depending on patient needs.

In addition to easing the pain of physical disorders, OMT appears to be helpful in some psychiatric conditions as well. A recent study performed at the College of Osteopathic Medicine in Downers Grove, IL, found that OMT as an adjunct to psychotherapy alleviated the symptoms of depression in women, as measured by the Zung Depression Scale, a standard diagnostic instrument.

ANDREW TAYLOR STILL 1828–1917

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Andrew Taylor Still, the father of osteopathy, was born on August 6, 1828, in Virginia to Abram and Martha Still. Growing up on the frontier lands of Tennessee and Missouri provided the impetus for his first studies of the musculoskeletal system. Skinning squirrels and deer, Still became familiar with the relationship between bones, muscles, nerves, and veins long before he picked up an anatomy book. He later studied medicine under his doctor-preacher father and served as a Union surgeon during the Civil War.

Following the war, his distrust of traditional medicine grew when three of his children died of cerebrospinalmeningitis . Still decided that the medications of his day were useless and that there had to be another way.

Still studied the attributes of good health so he could understand disease. He saw the body as a complex machine that, when working properly, stayed free of disease. He turned to a drugless, manipulative therapy believing disease was caused by a failure of the human machinery to carry the fluids necessary to maintain health. He called his holistic approach osteopathy for the Greek words osteon, meaning bone, and pathos, to suffer.

Still gained a following working as an itinerant healer, and in October 1892, he opened the American School of Osteopathy in Kirksville, Missouri. Still welcomed women even as other medical schools denied them access.

As of 2000, there were 16 osteopathic medicine colleges in the United States and 35,000 practicing doctors of osteopathy. The Kirksville College of Osteopathic Medicine remains open.

Manipulative procedures may be categorized and discussed in a variety of ways. According to the American Association of Colleges of Osteopathic Medicine, the following groupings encompass some of the most commonly used procedures. Descriptions are compiled from the American Academy of Osteopathy, Leon Chaitow, N.D., DO, and others.

• Articulatory techniques. Procedures that move joints through their range of motion (articulating the joints) may be used to restore normal functioning.
• Counterstrain. This type of therapy is used to alleviate trigger points localized areas of hyperirritability in the muscles). The procedure involves first finding a body position that relieves the patient's pain. Through a process in which the patient and practitioner repeatedly use coordinated techniques of pushing (or compression), relaxing, and changing position, the trigger point is eased.
• Cranial treatment. Cranial treatments focus on the craniosacral system which consists of the brain, spinal cord, cerebrospinal fluid, dura (the membrane covering the brain and spinal cord), cranial bones, and the sacrum (triangular bone comprised of five fused vertebrae, and forming posterior section of the pelvis). Craniosacral release is a gentle technique that focuses on normalizing imbalances in the natural rhythms of this system. A light touch is used to detect and release restrictions in the system and encourage the body's own healing processes. Craniosacral therapies arose from the work of Dr. William Sutherland, a DO who developed and explored the concept that the bones of the skull allowed movement and could be manipulated to improve the system's rhythmic movements. Some DOs choose to specialize in cranial osteopathy.Craniosacral therapy is also practiced by a wide variety of health care professionals. As listed by the Upledger Institute, these practitioners include MDs, chiropractors, doctors of Oriental medicine, naturopaths, nurses, psychiatric specialists, psychologists, dentists, physical therapists, occupational therapists, acupuncturists, massage therapists, and other professional bodyworkers.
• Myofascial release treatment. Various direct or indirect treatments are applied to release fascia tissues.
• Lymphatic techniques. These techniques focus on improving lymphatic circulation, improving the ability of the lymphatic system to do its job of waste removal.
• Soft tissue techniques. Applied to tissue other than bone, these techniques use varying pressure and may stretch, roll, or knead, resulting in the relaxation or release of tissues.
• Thrust techniques. A quick, sharp thrust (which is often described as high velocity/low amplitude) to the area requiring treatment is used to force a correction, restoring normal joint function and movement. This is similar to chiropractic adjustment.

Precautions

DOs use the full range of conventional diagnostic techniques, drug therapies, treatments, and surgical interventions available to MDs. If deemed appropriate by the DO, OMT may be employed in addition to these conventional diagnoses, and treatments or may serve as an alternative to drug therapies. During the course of treatment, manipulative therapies may be interrupted or stopped if complications occur—for example, a rise in blood pressure. In some situations, the osteopath may determine that no further benefit will be gained from continuing manipulative treatment. Manipulation should not be applied in several medical conditions. As listed by Chris Belshaw, these conditions are mainly "acute infections ; fractures ; bone disease; cancer ; gross structural deformities; such severe general medical conditions as gross high blood pressure or heart attack; vascular disease, for example, thrombosis; neurological conditions with nerve damage; spinal cord damage; and severe prolapse of an intervertebral disc." Additionally, as in any area of medicine, there is the possibility of mistaken diagnosis. Patients should always discuss all medical conditions, treatments, questions, and concerns with their physicians.

Side effects

Some patients, as noted by Belshaw, may experience mild headaches following neck treatments or discomfort after back manipulation. Some flushing and bruising may appear on those with sensitive skin. These reactions may last for several hours. Such symptoms may recur as treatment continues. Symptoms may return if treatment is stopped too soon.

Research & general acceptance

Research has shown the benefits of osteopathic care in a range of ailments and through improved recovery times. In addition to many of the conditions discussed above, the American Osteopathic Healthcare Association reports ongoing research on patient recovery times, length of hospital stays, chronic pain,chlamydia infection in women, reduction of deep vein thrombosis, and fall prevention for the elderly. Osteopathic colleges have increased their attention to biomedical research opportunities for students and those who desire to pursue research careers. The AOA Board of Research encourages and supports development of scientific research in the osteopathic medical profession. The AOA has also conducted several campaigns to educate the public on osteopathy. In 2000, the AOA started a Women's Health Initiative, a three-year campaign to promote women's healthcare among osteopathic physicians and the public.

Training & certification

Training and certification for DOs exceed those of chiropractors and physical therapists, two groups to which their manipulative techniques are sometimes compared. Chiropractic training focuses on spinal manipulation only. Chiropractors typically have fewer years and types of required postgraduate training, and are more limited legally in their practice. DOs also have training and licensing well beyond that of physical therapists.

Osteopathic physicians, like their allopathic physician counterparts, are complete physicians. This means they are trained and licensed to prescribe medication and perform surgery, and qualified to render complete healthcare. DOs are fully licensed in all 50 states and the District of Columbia, to serve in the military medical corps, Veterans Administration, and Public Health Service, and are recognized by the American Medical Association as physicians. They hold the same practice rights as MDs, have passed the same or similar state licensing examinations, and practice in fully accredited hospitals. DOs can practice in all branches of medicine and surgery, and can specialize in any area, but the majority are primary care physicians.

As of spring 2002, the AOA lists 20 AOA-accredited colleges of osteopathic medicine. Training for DOs and MDs parallel in many ways. Osteopathic colleges, like medical schools, offer a basic, comprehensive four-year medical education. Added to this curriculum are the osteopathic philosophies and a holistic care emphasis on prevention and community care. In addition to stressing the inter-relatedness of body organs and systems, students of osteopathy are taught to consider the whole person, including lifestyle, emotional factors, and environmental factors. Training also focuses on the musculoskeletal system and manual medicine. Manipulative therapies are taught for prevention, diagnosis, and treatment, and the osteopathic principle of helping the body toward good health.

After graduation from the four-year curriculum, DOs complete a one-year rotating internship, followed by several years in a residency program, if a specialty is desired. The areas covered during the internship period ensure that each DO is first trained as a primary care physician. Over half of all DOs are primary care physicians. Conversely, MDs are more likely to be specialists.

After the formal education process, the AOA requires members to earn continuing medical education (CME) credits every three years. To further enhance postgraduate medical education, the AOA has implemented the concept of Osteopathic Postdoctoral Training Institutions (OPTIs), which reflect the osteopathic emphasis on community care. These OPTIs are community-based consortia that include at least one hospital and college of osteopathic medicine. The intention of these is to promote institutional collaboration and enhance training opportunities that reflect the settings in which many osteopaths will practice. In early 2002, a new Osteopathic Research Center opened at the University of North Texas Health Science Center inFort Worth. The new Research Center is the result of collaboration among the American Colleges of Osteopathic Medicine, the American Osteopathic Foundation, and the American Osteopathic Association.

Many aspects of traditional osteopathic philosophy, such as advice about diet and smoking , have entered mainstream medicine to the point that the lines between DOs and MDs are blurring. In addition, the dedication of osteopaths to holistic medicine and primary care has been a great benefit to rural areas of the United States that are often underserved by mainstream practitioners.

Chiropractic treatment approaches for spinal musculoskeletal conditions: a cross-sectional survey

Mattijs Clijsters¹, Francesco Fronzoni¹ and Hazel Jenkins^2*

Abstract

Background

There are several chiropractic spinal manipulative technique systems. However, there is limited research differentiating the efficacy of these techniques. Additionally, chiropractors may also use ancillary procedures in the treatment of musculoskeletal pain, a variable that also needs to be considered when measuring the efficacy of chiropractic therapy. No data is currently available regarding the frequency of usage of chiropractic technique systems or ancillary procedures for the treatment of specific musculoskeletal conditions. Knowing which technique systems and ancillary procedures are used most frequently may help to direct future research. The aim of this research was to provide insight into which treatment approaches are used most frequently by Australian chiropractors to treat spinal musculoskeletal conditions.

Methods

Cross-sectional survey design. The survey was sent online to the members of the two main Australian chiropractic associations between 30^th June 2013 and 7^th August 2013. The participants were asked to provide information on treatment choices for specific spinal musculoskeletal conditions.

Results

280 respondents. Diversified manipulative technique was the first choice of treatment for most of the included conditions. Diversified was used significantly less in 4 conditions; cervical disc syndrome with radiculopathy and cervical central stenosis were more likely to be treated with Activator; flexion distraction technique was used almost as much as Diversified in the treatment of lumbar disc syndrome with radiculopathy and lumbar central stenosis. More experienced Australian chiropractors use more Activator and soft tissue therapy and less Diversified technique compared to their less experienced peers. The majority of responding chiropractors used ancillary procedures such as soft tissue techniques and exercise prescription in the treatment of spinal musculoskeletal conditions.

Conclusion

This survey provides information on commonly used treatment choices to the chiropractic profession. Treatment choices changed based on the region of disorder and whether neurological symptoms were present rather than with specific diagnoses. Diversified technique was the most commonly used spinal manipulative therapy, however, ancillary procedures such as soft tissue techniques and exercise prescription were also commonly utilised. This information may help direct future studies into the efficacy of chiropractic treatment for spinal musculoskeletal disorders.

Keywords: 

Chiropractic; Technique systems; Manipulation; Manual therapy; Musculoskeletal; Treatment; Prevalence

Background

One of the main tools chiropractors use to treat patients is the chiropractic manipulation, which can be manually applied or instrument-assisted. In the chiropractic profession there are several technique systems with regard to spinal manipulative therapy [1]. Curiously, in studies that examine the effect of spinal manipulation the technique system used is often not described, or a variety of techniques are applied in the intervention [2],[3]. As different chiropractic techniques might cause distinct effects, the results of such intervention studies do not reveal information of the effectiveness of a single technique system. Furthermore, a particular system might be more or less effective depending on the musculoskeletal condition it is used for. In chiropractic research studies the targeted musculoskeletal condition is often not specified. General symptomatic areas such as neck pain are researched instead of more defined conditions such as cervical facet syndrome or cervical disc syndrome. In medicine, the condition to be treated and the exact drug are specifically described and tested. For example ¿the efficacy of ¿acyclovir¿in the treatment of post-herpetic pain¿ [4]. By doing this they know the exact effectiveness of the drug for that specific condition. If future chiropractic studies could administer manipulations from only one chiropractic technique system targeted to a specific musculoskeletal condition, it would enhance the study¿s clinical relevancy.

There are several commonly used chiropractic technique systems [1] and many different spinal musculoskeletal conditions, therefore a myriad of specific intervention studies would have to be executed to cover all clinical situations. To aid in this process our survey aims to explore which techniques graduate chiropractors most frequently use to treat common musculoskeletal conditions. Frequency of use of a certain technique system in the treatment of a particular condition is not evidence of its effectiveness. However, it indicates that further research needs to be prioritised to these techniques to produce resultant data that will be relevant to a large group of chiropractors. As chiropractors do not only use manipulation in their treatment approaches [5]-[12], this study will also explore the usage of ancillary treatment techniques such as soft tissue therapy and exercise prescription.

Previous published studies have already explored the frequency of usage of chiropractic technique systems in general in clinical practice [5],[13],[14]. Our study will explore the frequency of usage of these technique systems in particular musculoskeletal conditions. With regards to the specific conditions we surveyed there is only limited positive evidence available in the literature for manipulative treatment (in isolation or as part of the therapy) of cervicogenic headache [15], myofascial pain syndrome [10], cervical radiculopathy [16], lumbar disc syndrome [2], lumbar stenosis [17], lumbar disc herniation [18],[19] and sacroiliac dysfunction [20]. However, the evidence is weak due to lack of randomised controlled trials. Most studies included in the referenced reviews did not include any specification of the used technique system for manipulation.

The purpose of this survey is to provide descriptive information to help inform researchers and chiropractors about the patterns of use of chiropractic techniques by Australian chiropractors in specific musculoskeletal conditions. In particular, this study aims to provide a starting point for future intervention studies.

Methods

The study, an online cross-sectional survey of Australian chiropractors, was approved by the Macquarie University Human Research Ethics Committee (Medical Sciences) (reference no.: 5201300295) prior to the commencement of the study.

Survey development

The research being undertaken has not been previously performed in the literature and as such a relevant validated survey could not be found. Therefore, the survey questions were developed for initial use in this study. A list of commonly treated musculoskeletal conditions and commonly used chiropractic modalities was created based on literature review and consultation with practicing chiropractors. This process resulted in a list of 18 common spinal musculoskeletal conditions and eight chiropractic technique systems or ancillary procedures.

The final survey included background demographic questions and questions regarding most commonly used treatment modalities. For each of the spinal musculoskeletal conditions the participants were asked to select their first, second and third most commonly used treatment modalities. Where less than three modalities were used for a particular condition, participants were instructed to leave the additional modalities blank. Participants were given the opportunity to select `other¿ as a treatment modality and any additional techniques used could be specified at the end of the survey. The survey questions used in this research can be found in Additional file 1.

The survey was pilot-tested in the Department of Chiropractic at Macquarie University. Eight staff members (graduate chiropractors involved in education) completed the online survey and provided feedback about the content and accessibility of the survey, with subsequent minor amendments made. The final version of the online survey was structured to allow participants to complete it within a five to ten minute time period.

Survey administration and data management

The online survey was emailed via the professional associations COCA and CAA to their members. They have approximately 1000 and 2700 members respectively [21],[22]. An initial email to the participants was followed by a reminder email after three weeks. The survey was open from the 30^th of June 2013 until the 7^th of August 2013. All potential participants were notified that participation was voluntary and that confidentiality would be maintained. No identifying information was requested.

The survey was designed and administered online using the Qualtrics software of the Qualtrics Research Suite (Qualtrics, Provo, UT) [23].

Survey response rates were calculated compared to the number of chiropractors in the professional associations and the number of chiropractors within Australia. Demographic data from survey respondents was compared to national demographic data from the Chiropractic Board of Australia. Descriptive statistics were used to describe the style of practice reported and the main techniques generally used by respondents. Descriptive statistics were also used to summarise the overall frequency of individual techniques used for each musculoskeletal condition and the most commonly used techniques as first choice of treatment. Finally responses were subdivided into those from practitioners with more than ten years¿ experience and those from practitioners with less than ten years¿ experience. Descriptive statistics were used to describe any differences in treatment techniques between these two groups.

Results

Response rates

Two hundred and eighty practitioners completed the online survey, giving a response rate of 7%. However, this is likely to be an underestimation of the true response rate. It is unknown how many chiropractors are members of both professional associations, therefore, the total number of chiropractors who received the email is likely to be less than 3700. In addition, it is unknown how many members successfully received and opened the email invitation to participate in the survey. The number of total practicing registered chiropractors in Australia is 4399 [24], the available data, therefore, represented 6% of the total number of chiropractors working in Australia.

Demographics and background data

As reported in Table 1, 58% of the respondents were under 40 years old and half of the respondents have been in practice for ten years or less. Fifty-seven percent of the participants received their education in New South Wales (NSW). Almost half of the respondents (47%) are practising in NSW, whereas only 16% are practising in Victoria. Only 3 respondents were from New Zealand.

Table 1. Demographic and background data

When compared to chiropractic registrant data from the Chiropractic Board of Australia [24], demographic distribution of the survey respondents is skewed towards younger practitioners and those practising in NSW; and away from those practising in Victoria. Chiropractic registrant data reports 34% of Australian chiropractors practicing in NSW, 27% in Victoria and 50% less than 40 years old. The percentages of respondents from other states are similar to reports from the Chiropractic Board of Australia [24].

Scope of practice and main technique used in practice

The survey also included a question on scope of practice. As seen in Table 2, 97% of respondents described their scope of practice to be based on treatment of musculoskeletal pain and/or dysfunction. Ninety-six percent of the respondents reported use of rehabilitation or exercise prescription in their treatments. Ninety-seven percent of the respondents declared they used an evidence informed approach in their daily practice.

Table 2. Scope of practice

Chiropractors were also asked about the main technique system they used in practice. The majority of them (67%) used Diversified, followed by instrument adjusting (5%), Gonstead technique (5%) and Thompson or table assisted drop piece technique (4%). Seventeen percent of respondents reported that they used `other¿ techniques. On analysis of their responses no clear technique systems were being repetitively used and a number of respondents had used the `other¿ response to account for using more than one of the technique systems listed in the survey.

Techniques used for specific musculoskeletal disorders

Table 3 summarises the overall frequency of use of each technique for the musculoskeletal conditions surveyed. Diversified technique, soft tissue therapy, instrument adjusting and exercise prescription are the most commonly used techniques throughout the cervical and thoracic spinal regions, regardless of condition. In the lumbar spine instrument adjusting is less commonly used and table assisted drop piece/Thompson technique and `other¿ techniques become more common. Flexion distraction also demonstrates increased usage in the lumbar spine, particularly with disorders associated with neurological change including lumbar disc syndrome (with radiculopathy), lumbar lateral canal stenosis and lumbar central canal stenosis.

Table 3. Overall frequency of use of each technique for specific musculoskeletal conditions*

Table 4 gives an overview of the techniques that were most commonly selected as the first treatment choice for each musculoskeletal disorder investigated. Diversified technique is the first choice of treatment modality for the majority of listed conditions. There were four conditions where there was a significant decrease in the use of Diversified as the first choice of treatment. Instrument adjusting was the first choice of treatment modality for cervical disc syndrome with radiculopathy and cervical central stenosis. Diversified technique was the preferred first treatment modality for lumbar disc syndrome with radiculopathy and lumbar central stenosis, however, flexion distraction was used with similar frequency. Soft tissue therapy and instrument adjusting were the most commonly chosen treatment modalities in combination with Diversified technique.

Table 4. Techniques reported as first choice to treat specific musculoskeletal disorders

To explore the possible role of experience in choice of technique system a comparison was made between practitioners of 10 years or less in practice (n?=?133) and practitioners of more than ten years in practice (n?=?131) (Figure 1). Practitioners who have been in practice ten years or less use more Diversified technique in all the conditions except for sacroiliac joint dysfunction for which Diversified was used in equal amount between the two groups. The chiropractors that have been practicing for more than a decade, use more instrument adjusting and more soft tissue therapy across all of the 18 conditions, compared to their less experienced colleagues.

Figure 1. Differences in first choice of treatment (in %) between chiropractors in practice less than 10 years versus chiropractors in practice more than 10 years. Key: 1 Cervical myofascial pain syndrome, 2 Torticollis, 3 Cervical facet syndrome, 4 Cervical disc syndrome (without radiculopathy), 5 Cervical disc syndrome (with radiculopathy), 6 Cervical lateral stenosis, 7 Cervical central stenosis, 8 Cervical related headache, 9 Thoracic myofascial pain syndrome, 10 Thoracic facet syndrome, 11 Rib dysfunction, 12 Lumbar myofascial pain syndrome, 13 Lumbar facet syndrome, 14 Lumbar disc syndrome (without radiculopathy), 15 Lumbar disc syndrome (with radiculopathy), 16 Lumbar lateral stenosis, 17 Lumbar central stenosis, 18 Sacroiliac dysfunction.

Discussion

There are many different chiropractic technique systems that have been developed. To our knowledge there is no current information available regarding which technique systems are the most effective in the management of specific musculoskeletal conditions. Developing studies to evaluate the effect of every technique system on every specific condition is not feasible at this stage. This survey describes the techniques commonly used by chiropractors in the treatment of specific spinal musculoskeletal conditions with the aim to help researchers make clinically relevant choices for future research.

Scope of practice

The majority of respondents primarily focus their treatments on musculoskeletal conditions and apply an evidence informed approach to their clinical practice (Table 2). Therefore, the scope of practice reported by the respondents is consistent with the focus of the survey. The positive attitude of many Australian chiropractors towards evidence based practice was also found in a study from Walker et al., where 78% of the respondents agreed that the application of evidence based practice is necessary [25].

Diversified technique was reported to be the most commonly used technique system amongst Australian chiropractors. The high frequency of use of Diversified technique is in line with previous studies from Australia and overseas [4]-[6],[13],[26]. A Canadian study from 2009 found that Diversified was the main technique used in private practice, followed by Activator and Thompson technique [14]. In North America, Diversified technique is by far the most common (over 92%), followed by flexion distraction, Gonstead and Activator [5]. In 1994 a large chiropractic job analysis was done in Australia and New Zealand [13]. At that time Diversified was the most commonly used technique, followed by Activator, Gonstead, SOT, AK, Thompson and flexion distraction. In 2005, Walker et al. [26] conducted a telephone survey in Australia and New Zealand. In this study the most common technique system used by Australasian practitioners was Activator (49%), followed by Diversified (44%) and Gonstead (29%). However, additional categories of `manual adjustment¿ and `manipulation¿ were used in Walker¿s survey that may have skewed the results.

The survey results indicate that Australian chiropractors often include exercise prescription and soft tissue therapy in their treatments but rarely use electrophysical therapies. This is in contrast to chiropractic care in North America [5],[27] but similar to European studies [6],[28]. French et al.[29] performed an observation and analysis study of Australian chiropractors. They found a high use of manipulative technique, soft tissue techniques and exercise prescription consistent with the results of this survey.

Technique selection for specific musculoskeletal conditions

Manipulative therapy (Diversified technique), soft tissue techniques and exercise prescription were reported as the most commonly used treatment techniques in the management of spinal musculoskeletal disorders. Instrument adjusting (Activator or similar) was commonly used in the cervical spine, however, use decreased in the thoracic and lumbar spinal regions. Table assisted drop piece and flexion distraction techniques were more commonly used in the lumbar spine. Small changes were noted in the frequency of use of different techniques between specific musculoskeletal conditions, however, the predominant differences were region rather than condition specific.

Diversified manipulative technique is the most frequent initial treatment of choice for the majority of musculoskeletal conditions surveyed. In 16 of the listed 18 conditions, it was reported to be used as the most frequent first choice of treatment. Conditions with a neural component such as: cervical disc syndrome (with radiculopathy); cervical central stenosis; lumbar disc syndrome (with radiculopathy); and lumbar central stenosis were associated with less use of Diversified technique as the first treatment choice. In these conditions more practitioners reported the use of instrument adjusting in the cervical spine and flexion distraction in the lumbar spine. It is unknown whether the increased use of instrument adjustment and flexion distraction in these conditions may be related to safety concerns or belief of increased efficacy. Instrument adjusting and flexion distraction are viewed as lower force techniques, however, no clinical evidence exists indicating that the use of these techniques is safer than Diversified technique [30]. Further research to determine risk versus treatment benefit is important in these cases.

A higher use of instrument adjusting (Activator or similar) was reported for musculoskeletal conditions in the cervical spine compared to conditions in other spinal regions. Similar findings were reported in a British study where chiropractors reported cervical pain as the predominant reason for using Activator [31]. Our data suggests an increased use of flexion distraction in conditions such as lumbar disc syndrome with radiculopathy and lumbar central stenosis. A review by Gay et al. [32] also reported that lumbar dysfunction was the main indication for the use of flexion distraction. In light of these data, controlled studies are needed to determine if instrument adjusting is more effective or safer than other treatments for cervical conditions and if flexion distraction is more effective or safer than other treatments for lumbar conditions.

Table assisted drop piece technique was rarely used for cervical and thoracic conditions, but there was an increase in use for lumbar and sacroiliac conditions. To our knowledge, no randomised trials evaluating the effectiveness of table assisted drop piece technique are available and evaluation of this technique in the treatment of sacroiliac dysfunction may be indicated.

Factors influencing treatment choice

Chiropractors may choose to use a specific technique system in certain conditions for several different reasons. As a result of clinical experience and therapeutic trial and error in similar situations, practitioners may have developed an understanding of what techniques work better with specific presentations. Practitioners may find one technique system easier to apply than others because of their own physical characteristics or the complexity of the technique system. In addition, they may have been guided by their education and apply technique systems to a degree which they were taught in their chiropractic course.

Practitioners might choose a certain technique system, based on their clinical experience in managing patients with a similar musculoskeletal condition. A trend was noted when chiropractic practitioners of more than ten years¿ of clinical experience were compared to those of less than ten years¿ experience. In general, the more experienced practitioners tended to use more instrument adjusting and soft tissue therapy, whereas, the less experienced practitioners tended to use more Diversified technique. Possible reasons may be that the more experienced chiropractors have found better results with these techniques or it may relate to the fact that these techniques are less physical demanding. Also, instrument adjusting is not taught in pre-professional courses in Australia, but can be learnt after graduation. Therefore, new graduate chiropractors may use instrument adjusting less frequently due to reduced exposure to this treatment modality.

Implications for further research

It is hard to determine which chiropractic techniques are most effective. To do this, randomised controlled trials (RCTs) have to be executed. Unfortunately, it is very difficult to provide a placebo treatment for a manipulation. RCTs comparing the clinical effectiveness of two different technique systems on specific musculoskeletal disorders may help to inform practitioners¿ treatment choices. However, reaching a conclusive musculoskeletal diagnosis in a clinical setting may limit the ability to perform this research. Subgrouping musculoskeletal disorders into those with and without neurological involvement would be more achievable in a clinical setting, and would capture the differences in preferred treatment technique found in this survey. As evidenced by our data and data from other studies [5]-[12], a chiropractor often uses a combination of manipulative techniques and ancillary treatment methods in the clinical setting. Although this does not provide evidence of efficacy of a single technique, RCTs investigating a combined approach would more closely mimic clinical practice.

The data from this study can be used to inform future studies and direct formulation of research questions. After analysing our data we suggest seven future research questions (see `Proposed future research questions for major RCTs¿ list below) that might directly influence decision making in clinical practice for Australian chiropractors. These seven research questions have been formulated based on the trends we described in the above sections.

Proposed future research questions for major RCTs

Clinical effectiveness of Diversified technique in the management of any of our listed musculoskeletal conditions.

Clinical effectiveness of instrument adjusting (Activator or similar) in the management of cervical disc syndrome with radiculopathy.

Clinical effectiveness of instrument adjusting (Activator or similar) in the management of cervical central stenosis.

Clinical effectiveness of the flexion distraction technique in the management of lumbar disc syndrome with radiculopathy.

Clinical effectiveness of the flexion distraction technique in the management of lumbar central stenosis.

Clinical effectiveness of table assisted drop piece technique in the management of sacroiliac joint dysfunction.

Clinical effectiveness of soft tissue therapy and/or exercise prescription in combination with Diversified technique in the management of any of our listed conditions

Limitations

The main limitation of this research is that of low response rate. Surveys were distributed through emails from the two main Australian chiropractic associations and it is impossible to know how many chiropractors actually received and read the emails. Therefore, true response rate, and assessment of potential non-response bias, cannot be determined. Non-response bias is of concern if only subjects interested in the subject complete the survey. The results of this survey were compared to demographic data from the chiropractic registration board and previous research to try and establish how reflective the respondents of this survey were to the chiropractic population as a whole. Demographic data was similar to survey respondents except for an increase in the number of respondents working in New South Wales with a decrease in those working in Victoria and an increase in the number of respondents from a younger age group. Scope of practice among survey respondents was heavily skewed to those treating muscular pain and dysfunction, possibly indicating respondant bias. However, previous research conducted by French et al. [29] also indicated that Australian chiropractic practice primarily focuses on the treatment of musculoskeletal pain. Therefore, this result may be reflective of the chiropractic population as a whole. There was also a high proportion of respondents who used Diversified as their primary therapeutic technique as opposed to other chiropractic techniques. However, similar trends are noted in previous studies done in Australia [13],[29] and the United States [5], indicating that our sample population responded fairly consistently with other, larger scaled, studies. Although we do have some similarities between the survey responses and previously published data we cannot eliminate the possiblity of non-response bias skewing the results of this survey. Therefore, the results of this survey should be interpreted with caution as they may not be reflective of the Australian chiropractic population as a whole.

Epidemiological data was to be used to help formulate the list of musculoskeletal conditions included in the survey. However, data regarding the prevalence of specific musculoskeletal conditions presenting to chiropractic practices is lacking. There is some data available regarding presenting symptomatic regions [7],[26],[33], but not related to specific musculoskeletal diagnoses. Therefore, selection of musculoskeletal conditions based on specific epidemiological data was not possible.

The survey instrument was not validated, however, it was based on questionnaires used in similar studies that focused on technique systems in general [5],[13],[14]. These questionnaires were reformed to suit our condition-specific questions. In addition, the survey was not exhaustive, with only five chiropractic technique systems included. Although the option was provided to select and specify any other technique system, the setup of the question may have influenced respondents to select one of the five listed technique systems. These five technique systems were chosen as previous research had shown them to be the main techniques used in Australia [13]. Reviewing comments from practitioners who specified ¿other techniques¿ in the survey failed to demonstrate any consistent trends in additional technique systems used.

Recall bias may also be a concern in this survey. Practitioners may over- or under-estimate the degree that they use certain techniques for specific conditions. Although we cannot rule out recall bias we feel that the general nature of the questions asked limit this as a particular concern. The survey questions asked for preferred first, second and third treatment techniques rather than the frequency of usage of those techniques to reduce the effect of recall bias.

Lastly, it may be possible that the musculoskeletal conditions listed in the survey were interpreted differently by different respondents. The aim of the survey was not to test diagnostic abilities in the practitioners, but rather to gain information about which chiropractic technique they would use to treat a specific textbook condition. Gradations in severity of the conditions were not provided, nor were many other variables that may change decision making.

Conclusion

This survey provides information on commonly used treatment choices to the chiropractic profession. Treatment choices changed based on the region of disorder and whether neurological symptoms were present rather than with specific diagnoses. Diversified technique was the most commonly used manipulative therapy, however, ancillary procedures such as soft tissue therapy and exercise prescription were also commonly utilised. This information may help direct future studies into the efficacy of chiropractic treatment for spinal musculoskeletal disorders.

Competing interests

The authors declared that they have no competing interests.

Authors¿ contributions

All authors contributed to the research design, survey design and administration. MC and FF performed the data analysis and initial drafting of the manuscript. HJ supervised the research and edited the final manuscript. All authors read and approved the final manuscript.

Additional file

Additional file 1:. Survey Questions: copy of the survey questions used in the research.

Format: PDF Size: 239KB Download file

This file can be viewed with: Adobe Acrobat Reader

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