Co-Kinetic Journal Issue 69 - July 2016

ISSUE 69 JULY 2016

ISSN 2397-138X

Formerly published as....

medicine & dynamics

C0-KINETIC JOURNAL WELCOME

JULY 2016 ISSUE 69 ISSN 2397-138X

editorial

Welcome to the Summer edition of the Co-Kinetic journal. With the publication of this issue comes the launch of our brand new business growth and development module which we’ve named The LEAN Therapist (more information can be found on p46).

The purpose of the LEAN Therapist is to give you time-saving, practical, step by step guides on areas that can help you grow your business, save you time, increase your profits, and make you a happier practitioner.

We will be publishing many of the downloadable resources, worksheets, email and letter templates, video tutorials and screenshot guides on our website but will summarise the highlights in the print journal. We’re starting with four articles which will be published during July, including: How to Grow Your Therapy Business: Moving from Surviving to Thriving; 10 Simple Strategies for Increasing Word of Mouth Referrals; Critical Elements Every Website Homepage Must Have And How to Measure Whether Changes You Make Are Working; and How to Build a Website for Less than £100 in Under 8 Hours. For more information visit the following link: http://spxj.nl/1TzoUQq. We’re also excited to feature three articles to coincide with the British Fascia Symposium 2016 which took place in June and have a published a dedicated online module entitled Biotensegrity: Concepts and Practical Applications for the Manual Therapist.

More information can be found at this link http://spxj.nl/27ywC6E.

contents 4 Physical therapy journal watch 11 Manual therapy journal watch 12 Is this biotensegrity’s tipping point?

New concepts in movement science and manual therapies 16 Tensegrity and biotensegrity: The next ‘big thing’ in our understanding of functional anatomy and the interconnectedness of body structures?

22 Does biotensegrity represent a paradigm shift in our understanding of anatomy?

25 Considerations to reduce injury rates in the professional football setting: Injury surveillance and screening 31 Multidisciplinary rehabilitation: A case study of a proximal biceps tendon rupture 39 Research reviews 42 Manual Therapy Student Handbook: Assessment and treatment of the hip 46 Are you a LEAN therapist?

49 Social watch – a round-up of some of the best resources on social media

Enjoy the journal and have a great Summer.

Tor Davies, physio-turned publisher Publisher/editor TOR DAVIES tor@sportex.net Marketing and sales SHEENA MOUNTFORD sheena@sportex.net Art editor DEBBIE ASHER Sub-editor ALISON SLEIGH PHD Journal Watch BOB BRAMAH Subscriptions & Advertising support@sportex.net +44 (0) 845 652 1906

COMMISSIONING EDITORS AND TECHNICAL ADVISORS Tim Beames - MSc, BSc, MCSP Dr Joseph Brence, D PT, COMT, DAC Simon Lack - MSc, MCSP Dr Markus W Laupheimer MD, MBA, MSc in SEM, MFSEM (UK), M.ECOSEP Dr Dylan Morrissey - PhD, MCSP Dr Sarah Morton - MBBS Brad Neal - MSc, MCSP Dr Nicki Phillips - PhD, MSc, FCSP

ISSUE 69 JULY 2016

ISSN 2397-138X

Formerly published as....

medicine & dynamics 69SPX01FrontCover.indd 1

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DISCLAIMER While every effort has been made to ensure that all information and data in this magazine is correct and compatible with national standards generally accepted at the time of publication, this magazine and any articles published in it are intended as general guidance and information for use by healthcare professionals only, and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. To the extent permissible by law, the publisher, editors and contributors to this magazine accept no liability to any person for any loss, injury or damage howsoever incurred (including by negligence) as a consequence, whether directly or indirectly, of the use by any person of any of the contents of the magazine.

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CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

INCIDENCE AND AETIOLOGY OF ACUTE INJURIES DURING COMPETITIVE ROAD CYCLING. Mathieu Decock M, De Wilde L, et al.

British Journal of Sports Medicine 2016;50(11):669–672 All acute injuries that occurred during competition road racing in Flanders in 2002 and 2012 were analysed. The incidence, injury rate, diagnosis, circumstances and level of performance were evaluated.

Six different levels of performance were evaluated: riders from the U15, U17, U19 and U23 categories, elites without a contract, and women. A total of 3,331 road cyclists in 2002 and 4,487 road cyclists in 2012 from these different categories were registered. The Flanders Cycling Federation organised 1,728 road races for the evaluated levels of performance during cycling season 2002 and 1,382 races during cycling season 2012. Fractures, cartilage injuries, tendon ruptures, ligamentous

Co-Kinetic comment There may well have been a greater incidence of minor injury. The injured road cyclists had to pay an exemption of €25 to the insurance company before they could receive a refund and, thus, were included in the company’s database so it is highly likely that many minor injuries were not reported. It also makes you wonder if competitive cyclists should be wearing more protective equipment than a helmet.

A SYSTEMATIC SUMMARY OF SYSTEMATIC REVIEWS ON THE TOPIC OF THE ANTERIOR CRUCIATE LIGAMENT. Anderson MJ, Browning WM III, et al. Orthopaedic Journal of Sports Medicine 2016;4(3): doi:10.1177/2325967116634074

LIVER INJURY FROM NONSTEROIDAL ANTIINFLAMMATORY DRUGS IN THE UNITED STATES. Schmeltzer PA, Kosinski AS, et al. Liver International 2016;36(4):603–609

information on each of those topics to reproduce here but the rehabilitation highlights are that there is substantial evidence in the rehabilitation literature supporting the notions that there is no added benefit from knee brace or continuous passive motion (CPM), accelerated rehabilitation and open-chain exercises may be beneficial, cryotherapy is safe and effective, and resistance and proprioceptive training can be beneficial after surgery.

The aim of this paper was to report the features and outcomes of the subjects with severe drug-induced liver injury from non-steroidal anti-inflammatory drugs (NSAIDs).

Of 1,221 Drug Induced Liver Injury Network cases that were adjudicated, 30 cases were attributed to eight different NSAIDs. The mean age was 52 years old, 24 (80%) were women, and 21 (70%) were Caucasian. The mean latency was 67 days. Common signs and symptoms at presentation were nausea (73%), jaundice (67%) and dark urine (67%).

The most common pattern of injury was hepatocellular (70%) and autoantibodies were detected in 33% of cases.

Diclofenac was the most frequently implicated NSAID (16/30 cases), and characterised by hepatocellular injury.

Seventeen cases resulted in hospitalisation or prolongation of hospitalisation and one patient died from complications of Stevens–Johnson syndrome because of diclofenac.

This is a review of all anterior cruciate ligament (ACL)-related systematic reviews and meta-analyses published between January 2004 and September 2014 that were found following a search using PubMed, MEDLINE, and the Cochrane Database, which found a total of 1031 articles, of which 240 met the inclusion criteria. Included articles were summarised and divided into 17 topics: anatomy, epidemiology, prevention, associated injuries, diagnosis, operative versus non-operative management, graft choice, surgical technique, fixation methods, computerassisted surgery, platelet-rich plasma, rehabilitation, return to play, outcomes assessment, arthritis, complications, and miscellaneous. There is too much 4

injuries and dislocations were classified as ‘severe’ injuries.

A total of 777 documented reports of accidents (1,230 injuries) were retrieved. There was no significant difference between incidence and injury rate between 2002 and 2012. There was a strong significant difference in the incidence between the different levels of performance in both seasons.

Severe injuries were seen in 29.5% in 2002 and in 30.1% in 2012. The most common location of a severe injury was the hand. The most common lesion was abrasion. Collision with another rider was the most common cause of injury but almost one in three riders had a severe injury. Of the male riders, U17 riders had the highest injury rate during both seasons. U15 riders had least injuries.

Co-Kinetic comment This is the sort of study we like: a massive amount of up-to-date knowledge in one place. A must read for anyone likely to come into contact with an ACL injury.

Co-Kinetic comment This one slipped through last year’s net but it is well worth consideration given that some sports people eat NSAIDs like Smarties. They should stick to Smarties because “Smartie people are happy people, they smile all the time because they’re feeling fine”.

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Journal Watch INTERDISCIPLINARY ASSESSMENT CRITERIA FOR REHABILITATION AFTER INJURIES OF THE LOWER EXTREMITY: A FUNCTION-BASED RETURN TO ACTIVITY ALGORITHM. Keller M, Kurz E, et al. Sportverletzung Sportschaden 2016;30(1):38–49

This suggests that a paradigm shift is taking place: time-dependent concepts are increasingly being replaced by function-based concepts. Here a function-based ‘return-to-activity’ algorithm is presented, which contains a level classification (I–IV). Qualitative and subsequent quantitative tests are assigned to every level. Within each level, the respective qualitative test has to be passed before patients are allowed to perform the corresponding quantitative test. Criteria for success are qualitative and quantitative comparisons with the unaffected side.

Before entering the next level, both tests have to be successfully passed.

The levels are ordered according to increasing demands on the locomotor system. These demands are adequate

stability without impact interaction in the sagittal plane for level I, a Y balance test, followed by dynamic stability demands for level II (a singleleg hop test). Impacts in the frontal plane are added for level III (a side hop test), and finally multidirectional impacts have to be compensated at level IV (a square hop test). The time expenditure per level is no more than 5min. Here the example of a professional soccer player doing post-ACL surgery rehab is given. The results were that the athlete was able to successfully pass each level and finished his rehabilitation 203 days post-injury. He returned to the team training 221 days post-injury.

At 247 days post-injury, the athlete completed his first game.

Co-Kinetic comment What goes around comes around. These used to be called rehabilitation ladders and now they are called algorithms. They amount to the same thing and are really the basis of all rehabilitation. When your player can do this test without pain or adverse effects you can move on to the next level. This particular paper is only available in German but there is a poster-style presentation with details of the tests levels at http://www.osinstitut. de/download/cms/22/58.pdf and an earlier version of the study: Keller M., Schmidtlein O, Kurz E. Reporting on ACL deficient patients: a function-based return-to-activity algorithm.

British Journal of Sports Medicine 2013;47(10):e3.

MANAGEMENT OF LUMBAR SPINAL STENOSIS. Lurie J, Tomkins-Lane C. BMJ 2016;352:h6234 Lumbar spinal stenosis is the most common reason for spinal surgery in patients over 65 years. It is a clinical syndrome of pain in the buttocks or lower extremities, with or without back pain. It is associated with reduced space available for the neural and vascular elements of the lumbar spine.

The condition is often exacerbated by standing, walking, or lumbar extension and relieved by forward flexion, sitting or recumbency. Clinical care and research into lumbar spinal stenosis is complicated by the heterogeneity of the condition, the lack of standard criteria for diagnosis and inclusion in studies, and high rates of anatomic stenosis on imaging studies in older people who are completely asymptomatic. The options for non-surgical management include drugs, physiotherapy, spinal injections, lifestyle modification,

Co-Kinetic.com

and multidisciplinary rehabilitation.

Physiotherapy treatments include exercise (aerobic, strength, flexibility), muscle coordination and balance training, pain relieving treatments (heat, ice, electrical stimulation, massage), ultrasound, spinal manipulation and postural instruction.

However, few high-quality randomised trials have looked at conservative management. A systematic review concluded that there is insufficient evidence to recommend any specific type of non-surgical treatment. Several different surgical procedures are used to treat patients who do not improve with non-operative therapies. Given that rapid deterioration is rare and that symptoms often wax and wane or gradually improve, surgery is almost always elective and considered only if sufficiently

bothersome symptoms persist despite trials of less invasive interventions.

Outcomes (leg pain and disability) seem to be better for surgery than for non-operative treatment, but the evidence is heterogeneous and often of limited quality.

Co-Kinetic comment We always feel we should put in a rider when including studies that mainly affect older populations but, according to the UK Office of National Statistics, 14% of over 70s in the UK participate in physical activity and, of course, we have an aging population so studies such as this one are in.

Unfortunately the findings seem to be that the jury is out on anything but surgery. This paper, however, does give a wealth of information about the condition.

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KNEE LAXITY VARIATIONS IN THE MENSTRUAL CYCLE IN FEMALE ATHLETES REFERRED TO THE ORTHOPEDIC CLINIC. Shafiei SE, Peyvandi S, et al. Asian Journal of Sports Medicine 2016;doi:10.5812/asjsm.30199 Anterior cruciate ligament (ACL) injuries in female athletes are 2–8 times more common than male athletes in similar sport injuries so this study set out to examine one of the theories as to why.

Forty female athletes were referred to the orthopaedic clinic of the Imam Khomeini hospital in the north of Iran.

Hormone levels, such as estrogen and progesterone were assessed by one laboratory in three phases of the menstrual cycle. The Lachman test and anterior drawer test for knee laxity rate. The results showed that there is no significant difference in ACL laxity in female athletes in the three phases of the menstrual cycle; namely menstruation time, ovulation time and mid-luteal phase.

Co-Kinetic comment One theory for the higher incidence of ACL injuries in women bites the dust.

ECCENTRIC OR CONCENTRIC EXERCISES FOR THE TREATMENT OF TENDINOPATHIES. Couppé C, Svensson RB, et al. Journal of Orthopaedic & Sports Physical Therapy 2015;45:853–863 In this clinical commentary, the relevant evidence for different exercise regimes in tendinopathy rehabilitation is reviewed with particular focus on the applied loads that are experienced by the tendon and how the exercise regime may affect these applied loads. There is no convincing clinical evidence to demonstrate that isolated eccentric loading exercise improves clinical outcomes more than other loading therapies. However, the great variation and sometimes insufficient reporting of the details of treatment protocols may hamper the interpretation of what may be the optimal exercise regime with respect to parameters, such as load magnitude, speed of movement, and recovery period between exercise sessions.

Co-Kinetic comment We have all been doing eccentric exercise for tendon problems for some time and now there are seeds of doubt. This commentary is just one article for a special edition of the Journal of Orthopaedic & Sports Physical Therapy that concentrates on tendons. Well worth a look.

THE EFFECTIVENESS OF MULTIMODAL CARE FOR THE MANAGEMENT OF SOFT TISSUE INJURIES OF THE SHOULDER: A SYSTEMATIC REVIEW BY THE ONTARIO PROTOCOL FOR TRAFFIC INJURY MANAGEMENT (OPTIMA) COLLABORATION. Goldgrub R, Côté P, et al. Journal of Manipulative and Physiological Therapeutics 2016;39(2):121–139 Apparently each year, 30.3% of adults in industrialised nations will experience shoulder pain. In primary care clinics, patients with shoulder pain are primarily managed with multimodal care, which means a combination of multiple interventions including passive physical modalities, exercise, manual therapy, acupuncture, education, psychological interventions, soft tissue therapies or other conservative interventions [ie. nonsteroidal anti-inflammatory drugs (NSAIDs)].

The objective of this systematic review was to determine the effectiveness of multimodal care compared with other interventions, placebo/sham interventions, or no intervention in improving self-rated recovery, functional recovery, clinical outcomes, and/or administrative outcomes for the management of adults and/or children with soft

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tissue injuries of the shoulder. These included grade I–II sprains/strains, non-specific musculoskeletal shoulder pain, bursitis, subacromial impingement syndrome, shoulder tendinitis, tendinosis, tendinopathy and other soft tissue injuries.

What all this amounted to was that the evidence challenges the use of traditional multimodal care for subacromial impingement syndrome, rotator cuff tendonitis and non-specific shoulder pain.

Co-Kinetic comment If you are looking for help in dealing with your shoulder patients this paper isn’t for you. It just adds to the evidenced confusion. For example no evidence was found that multimodal care programmes are more effective than sham ultrasound, radial extracorporeal shockwave therapy, or surgery followed with exercises.

They found promising evidence that

a multimodal programme of care that combines dietary advice and acupuncture may be effective for the management of rotator cuff tendinitis of variable duration. Sham ultrasound!

Dietary advice! Hands up if you would think of either of those when a patient walked in. Their clinical conclusion is that patients with variable-duration shoulder pain should be managed with supervised strengthening or homebased strengthening and stretching, which probably isn’t much help to the patient in pain. There is a similar piece in the same publication dealing with lower limb injury in which they go as far as to state that apart from its use for plantar heel pain clinicians should not use multimodal care to manage soft tissue injuries of the lower extremity as there is currently no evidence to support its use. It makes you wonder how anyone’s problems get resolved.

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THE EFFECTS OF HYPERBARIC OXYGEN THERAPY ON POSTTRAINING RECOVERY IN JIU-JITSU ATHLETES. Branco BHM, Fukuda DH, et al. PLoS One 2016;11(3):e0150517 Eleven experienced Brazilian jiu-jitsu athletes were investigated during and following two training sessions of 1h 30min. They were randomly assigned to passive recovery for 2h or to hyperbaric oxygen therapy (OHB) for the same duration. After a 7-day period, the interventions were reversed. Before, immediately after, post-2h and post-24h, blood samples were collected to examine hormone concentrations (cortisol and total testosterone) and cellular damage markers (creatine kinase (CK)), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and lactate dehydrogenase (LDH). The rating of perceived exertion (RPE) and recovery (RPR) scales were applied. Final lactate values were not significantly different following the training sessions. There was no difference between any time points for blood lactate and RPE in the two experimental conditions. There was no effect of experimental conditions on cortisol, total testosterone, CK, AST, ALT or LDH. However, there was a difference between the two experimental conditions in RPR with higher values at post-2h and -24h in OHB when compared to the control condition.

Co-Kinetic comment So you are not really recovering better in the oxygen chamber. You just think you are.

MINIMALLY INVASIVE SEMITENDINOSUS TENDON HARVESTING FROM THE POPLITEAL FOSSA VERSUS CONVENTIONAL HAMSTRING TENDON HARVESTING FOR ACL RECONSTRUCTION: A PROSPECTIVE, RANDOMISED CONTROLLED TRIAL IN 100 PATIENTS. Franz W, Baumann A. The Knee 2016;23(1):106–110 One hundred patients who underwent anterior cruciate ligament (ACL) reconstruction were randomised to either have their tendon graft harvested from posteromedial (group 1) or via an anteromedial approach (group 2). Time for tendon harvest, length of skin incision and duration of tendon harvest were recorded as well as complications and sensory disturbances in the lower leg. Pain scores were documented on the visual analogue scale. The time for tendon harvesting averaged 1min 23s in group 1 versus 5min 20s in group 2.

The skin incision measured 21mm (group 1) versus 49mm in group 2. The length of the harvested tendon averaged 272mm (group 1) and 292mm in group 2. There was one superficial wound infection in group 2 and none in group 1.

Postoperative pain scores were similar in both groups. None of the patients in group 1 reported sensory disturbance in the lower leg, whereas seven patients in group 2 were found to have reduced sensation in the distribution of the saphenous nerve postoperatively.

Co-Kinetic comment Three–one to the postero. It’s quicker, results in a shorter scar and reduces the risk of injury to branches of the saphenous nerve but it results in a shorter tendon graft than the anterio.

PAPER TAPE PREVENTS FOOT BLISTERS: A RANDOMIZED PREVENTION TRIAL ASSESSING PAPER TAPE IN ENDURANCE DISTANCES II (PRETAPED II). Lipman GS, Sharp LJ, et al. Clinical Journal of Sport Medicine 2016;doi:10.1097/JSM.0000000000000319 [Epub ahead of print] Paper tape was applied to a randomly selected foot of 128 participants taking part in the 2014 250km (155mile) 6-stage ‘Racing The Planet’ ultramarathons in Jordan, Gobi, Madagascar and Atacama Deserts. The mean age was 39.3 years (range 22–63) and body mass index was 24.2kg/m2 (17.4–35.1), with 31 (22.5%) females.

The runners could choose between either a blister-prone area or randomly selected location if there was no blister history, with untaped areas of the same foot used as the control.

One hundred six (83%) participants developed 117 blisters, with treatment success in 98 (77%) runners. Paper tape reduced blisters by 40%. Most of the study participants had one blister (78%), with most common locations on the toes (n = 58, 50%) and heel (n = 27, 23%), with 94 (80%) blisters occurring by the end of stage 2.

Treatment success was associated with earlier stages and time spent running.

Co-Kinetic comment Paper tape was found to prevent both the incidence and frequency of foot blisters in runners.

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BILATERAL PRESENTATION OF TENSOR FASCIA SURALIS MUSCLE IN A MALE CADAVER. Gandhi KR, Wabale RN, Farooqui MS. International Journal of Anatomy and Research 2015;3(4):1745–1748 The tensor fascia suralis muscle is an anomalous muscle located in the popliteal fossa. The muscle may arise from any of the hamstring muscles and is inserted into the crural fascia or tendocalcaneus. The authors found the tensor fascia suralis muscle in a male cadaver originating from the medial side of the tendon of the biceps femoris muscle. The tendinous origin was then transformed into a well-defined fusiform belly in the roof of the popliteal fossa.

After traversing downwards and medially the muscle again became tendinous to get inserted into the deep fascia of leg. Bilateral presentation of the anomalous muscle is not yet documented in literature. The anatomical relation of the muscle explains its great clinical importance. The tendinous origin was anteriorly related to the sciatic nerve and the muscle belly to the tibial nerve. The sural nerve and short saphenous vein were in lateral relation to the muscle. Contraction of the muscle in the roof of popliteal fossa may lead to sciatic, tibial or sural nerve neuropathy.

A physician can confuse the muscle for a soft tissue mass or an aberrant vessel.

Co-Kinetic comment Not many people have one of these but clearly some do. There are also people that have a third head of the gastrocnemius so the patient presenting with posterior knee pain that also has a palatable mass may be perfectly ‘normal’. It was first reported in 1813 and a few authors since have mentioned it but not enough for it to get into the mainstream anatomy texts.

MANAGEMENT OF ATHLETIC TURF TOE USING BIOLOGICS. Mares AV, Schreiter R, et al. Operative Techniques in Orthopaedics 2016; doi:http://dx.doi.org/10.1053/j.oto.2015.12.006

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CALF INJURIES IN PROFESSIONAL FOOTBALL: TREAT THE PATIENT OR THE SCAN? A CASE STUDY. Barreira P, Kassarjian A, et al.

Physical Therapy in Sport 2016;doi:10.1016/j.ptsp.2016.01.004

A professional football player (35 years old, 1.90m, 88kg) male, African, striker, playing in the Professional Arabian Gulf League complained of pain in the region of the proximal tendon of the medial head of the left gastrocnemius muscle. There was no history of trauma during training or sudden pain episodes. Symptoms presented with a gradual onset. Standing ankle dorsiflexion lunge with knee flexion and knee straight was symmetric compared with the contralateral side with minimum discomfort at the end range. Resisted tests (such as singleleg heel raises with knee straight and bent, and repetitive hopping), were symmetric in power and repetitions to fatigue, with minor complaints arising from the left proximal medial gastrocnemius head. The medial head of the left gastrocnemius head was

tender on palpation proximally, with no further areas of pain. A week later after training and a competitive game the player added visible swelling in his left calf to his other presentations.

An MRI identified a large (5 × 4 × 1.6cm) complex fluid collection most consistent with haemorrhage between the superficial fascia and the mid and lower thirds of the medial margin of the medial gastrocnemius muscle, with no actual fibre disruption plus myofascial scarring proximally in the medial gastrocnemius muscle, which may have predisposed to shearing stress along the myofascial muscle surface, potentially leading to the current injury presentation. No signs of acute muscle belly injury were noted. An attempt was made to grade the injury according to the criteria set out by Munich consensus statement

Turf toe is a common injury especially in athletes involved in contact sports played on rigid surfaces. It is caused by a hyperextension injury to the hallux metatarsophalangeal (MTP) joint resulting in attenuation or tearing of the plantar capsular ligamentous complex. Treatment generally consists of non-operative measures such as rest, ice, non-steroidal anti-inflammatory drugs, taping, a stiff-sole shoe, walking boot, or casting. The athlete will usually present with sudden onset of pain, stiffness and swelling at the MTP joint, as well as the inability to push off and reduced agility. Turf toe can be graded as grade I: a sprain of the plantar plate, grade II: a partial tear of the plantar

plate, or grade III: a complete tear of the plantar plate. Biologics are genetically engineered proteins derived from human genes. Platelet concentrates for topical use are blood extracts obtained after processing of a whole blood sample by centrifugation. They are designed to inhibit specific components of the immune system that play pivotal roles in fuelling inflammation. They contain and release several different growth factors and other cytokines that are thought to aid in healing of bone and soft tissue.

This study reports on two cases of turf toe treated with a combination of Toradol® (a non-steroidal antiinflammatory drug) and autologous conditioned plasma (ACP). Both cases

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maybe we shouldn’t get too bogged down with any of them. The one referred to is: Functional muscle disorders 1: overexertion-related 2: neuromuscular muscle disorders describing disorders without macroscopic evidence of fibre tear and structural muscle injuries Structural muscle disorders 3: partial tears 4: total tears/tendinous avulsions with macroscopic evidence of fibre tear, that is, structural damage.

(Mueller-Wohlfahrt, et al., 2013). Injury symptoms and clinical signs suggested a 2a whereas location and imaging suggested a 3a. Because the player did not present with a lack of significant inhibition of contractions they settled on Grade 1.

Initial treatment was ice and compression but after 8 days an ultrasound-guided aspiration removed 6ml of red fluid suggestive of haemorrhage. This was repeated after 21 and 38 days. The player continued playing.

Co-Kinetic comment The first point to be made is that professionals play through injuries and it is the job of medical staff at that level to nurse them though training and games. The second is that no grading system can fit all circumstances and

involved American Football players. The first was initially treated conservatively followed by a cortisone injection and at 2 weeks post-injury he was given an intra-articular injection of ACP in combination with 10mg of Toradol.

In case two, the player was given the same treatment 48h after initial presentation. Both recovered fully and completed the season. A review of the literature for the treatment reveals that several studies have shown good results for specific conditions such as rotator cuff tears, ulnar collateral ligament injuries and lateral epicondylitis.

Co-Kinetic comment Toradol® is a trade name for

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All of the grades have sub groups.

And the final point is that although there appears to be a difference between significant imaging findings and a rather innocuous clinical presentation in reality they are complimentary. Remember point 1, professionals play with injury and the fact that the player refers himself to the medical staff suggests this injury is bothering him even though he can complete the clinical tests and continue training and playing. Without the identification of the fluid and its aspiration, the task of getting him through the season may have been much more challenging. Please can we have more case studies like this.

They are thought-provoking and share clinical experience.

Ketorolac, which in the UK is used for the short-term relief of moderate to severe pain following surgical operations. The study states that effectiveness of NSAIDs on soft tissue injuries is controversial. Most clinical studies demonstrate improvements in pain and earlier return to play although the improvements are usually small. Animal studies regarding ligaments show both positive and negative results. Apparently 90% of National Football League (NFL) medical staff have used intramuscular Toradol® in a pre-game setting and average of 15 players per team receive an injection up to once a week.

CAN WE PREDICT THE RESPONSE TO AEROBIC EXERCISE TRAINING? Bouchard C. Proceedings of The Physiological Society 2016;35:SA08 This is a report to the Physiological Society. It starts with the common assumption that cardiorespiratory fitness (CRF), as measured by VO2max, and cardiometabolomic risk factors such as weight to height ratio or waist circumference improve following aerobic exercise programmes. It goes on to report that in a series of studies in which the exercise prescription was rigorously standardised, it was consistently observed that there are young, middle-aged and older adults who experienced little to no increase in CRF or in the risk factor profile. Studies into exercise training performed in pairs of monozygotic twins and a cohort of about 200 nuclear families have revealed that CRF trainability was characterised by a heritable component in the order of 45%. In contrast, the heritability of the risk-factor trait responses is heterogeneous and ranges from 20% to 50%. What this suggests is that it may not be feasible to generate powerful predictive algorithms based on DNA sequence variants alone.

There are studies where a combination of single nucleotide polymorphisms and skeletal muscle gene expression profiling have been reported and have led to diagnostic improvements but many of these studies have been hindered by low statistical power and lack of adequate replication material. Diagnostics aimed at predicting the level of responsiveness to regular exercise must meet stringent sensitivity and specificity standards and achieve a high level of predictive power in order to be of sufficient quality for applications in a personalised exercise medicine context. This is unlikely to be attained without a comprehensive approach to diagnostic development that incorporates information on personal characteristics, morphological and physiological traits, genomics, epigenomics, transcriptomics and metabolomics.

Co-Kinetic comment This is basically a plea for further research funding and it is to be hoped that they get it because it may explain why there are some people who can put in the work and don’t seem to change.

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MANAGING ANKLE LIGAMENT SPRAINS AND TEARS: CURRENT OPINION. McGovern RP, RobRoy LM. Journal of Sports Medicine 2016;7:33 The purpose of this paper is to present a current review of patho-anatomical features, differential diagnosis, objective assessment, intervention and clinical course associated with managing lateral ankle ligament sprains. Proper diagnosis and identification of affected structures should be obtained through history and objective assessment.

From this information, an individualised evidence-based intervention plan can be developed to enable recovery while decreasing the risk of reinjury. An appropriate evaluation is needed not only to determine the correct diagnosis but also to allow for grading and determining the prognosis of the injury in those with an acute lateral ankle sprain. Examination should include an assessment of impairments as well as a measure of activity and participation. Evidence-based interventions for those with an acute lateral ankle sprain should include weight-bearing with bracing, manual therapy, progressive therapeutic exercises and cryotherapy. Early weight-bearing and movement are beneficial. Decreasing swelling around the ankle using manual lymphatic drainage techniques can increase the athlete’s proprioceptive awareness as well as decrease the risk of ankle stiffness. For those with chronic ankle instability (CAI), interventions should include manual therapy and a comprehensive rehabilitation programme. It is essential to understand the normal clinical course for athletes who sustain a lateral ankle sprain as well as risk factors for an acute injury and CAI. Risk factors for both an acute lateral ankle sprain and CAI include not using an external support and not participating in an appropriate exercise programme. Incorporating the latest evidencebased rehabilitation techniques provides the best course of treatment for athletes with an acute ankle sprain or CAI.

Co-Kinetic comment Another ‘all you need to know’ paper. There seem to be a lot of them at the moment and that should be applauded. This one has the added bonus of being an open access journal.

ANATOMIC STUDY SUGGESTS THAT THE MORPHOLOGY OF THE PLANTARIS TENDON MAY BE RELATED TO ACHILLES TENDONITIS. Olewnik L, Wysiadecki G, et al. Surgical and Radiologic Anatomy 2016;7:1–7 Many patients frequently experience pain on the medial side of the calcaneal tendon, between 2 and 7cm above the calcaneal tuberosity. This may suggest that the plantaris tendon is involved.

The tests were carried out on 50 randomised lower limbs (23 left and 27 right) fixed in 10% formalin solution.

Five insertion types of the plantaris tendon were identified in relation to the calcaneal tendon: four with their insertion on the calcaneal tuberosity (Types 1, 2, 3, 5), while the fifth (Type 4) had its insertion in the crural fascia.

In addition, two variants of the course of the plantaris tendon were identified, the most common being termed Variant A, in which the tendon crosses

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the space between the gastrocnemius and the soleus muscles, thus reaching the medial crural region, and is located on the medial side of the calcaneal tendon (84% cases). The course of the Variant B is similar to the course of the Variant A, but upon leaving the space located between the gastrocnemius and soleus muscle, it turned to the medial crural region and ran directly anterior to the calcaneal tendon (12%).

The plantaris muscle was found to be absent in two lower limbs (4%). The most frequent insertion type of the plantaris tendon into the calcaneal tuberosity is fan-shaped, occurring on the medial side of the Achilles tendon (Type 1, 44% of cases).

Co-Kinetic comment When you look, and palpate, the distal area of the posterior lower limb in live subjects it is easy to think it is one structure in which the tendons of gastrocnemius, soleus and plantaris are indistinguishably blended but when you look at the cadaver pictures that illustrate this study the plantaris tendon is clearly separate. The bottom line here is that not everyone looks like the pictures in the anatomy books and some of those Achilles tendinopathies might be plantaris tendinopathies.

Co-Kinetic journal 2016;69(July):4-11

MANUAL THERAPY RESEARCH INTO PRACTICE

Journal Watch MYOFASCIAL TECHNIQUES: WHAT ARE THEIR EFFECTS ON JOINT RANGE OF MOTION AND PAIN? A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMISED CONTROLLED TRIALS. Webb TR, Rajendran D. Journal of Bodywork and Movement Therapies 2016;doi:10.1016/j.jbmt.2016.02.013

MOBILIZATION AND MANIPULATION OF THE CERVICAL SPINE IN PATIENTS WITH CERVICOGENIC HEADACHE: ANY SCIENTIFIC EVIDENCE? Garcia JD, Arnold S, et al. Frontiers in Neurology 2016;7:40 A total of 66 relevant studies were originally identified through a review of the literature, and the 25 most suitable articles were fully evaluated via a careful review of the text. Ultimately, 10 studies met the inclusion criteria, which were that it was a randomised controlled trial (RCT) or open RCT; the study contained at least two separate groups of subjects that were randomly assigned either to a cervical spine mobilisation or manipulation or a group that served as a comparison; subjects must have had a diagnosis of cervicogenic headache (CEH); the treatment group received either spinal

mobilisation or spinal manipulation, while the control group received another physical therapy intervention or placebo control; and the study included headache pain and frequency as outcome measurements.

Seven of the ten studies had statistically significant findings that subjects who received mobilisation or manipulation interventions experienced improved outcomes or reported fewer symptoms than control subjects.

Co-Kinetic comment Manual therapy works.

That’s all you need to know really.

A structured literature search located 22 randomised controlled trials.

These were analysed with respect to performance effects and various characteristics of the study design.

Five studies used techniques of automated massage, while the other 17 used classic manual massage.

A tendency was found for shorter massage (5–12min) to have larger effects than massage lasting more than 12min. The effects were larger for short-term recovery of up to 10min than for recovery periods of more than 20min. Although after high-intensity mixed exercise, massage yielded

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This systematic review aimed to determine the evidence for the effect of a single manually applied myofascial technique (MFT) on joint range of motion (JROM) and pain in non-pathological symptomatic subjects. The usual data bases were searched from 2003 to 2015. All randomised controlled trials (RCTs) that used JROM as an outcome measure were identified. RCT quality was independently evaluated using PEDro and Cochrane Risk of Bias tools and all reported outcome data were independently abstracted and presented. If post-intervention central tendencies and variance were reported, these were assessed for heterogeneity with a view to performing a meta-analysis. Nine RCTs (n = 534) were systematically reviewed and outcome data presented; all trials concluded that MFT increased JROM and reduced pain levels in symptomatic patients. Two RCTs (n = 161) were judged ‘moderately’ heterogeneous and meta-analysis using a fixed effects model suggested a ‘moderate’ effect size of MFTs on jaw opening.

Co-Kinetic comment The reason that they only confirmed the jaw opening studies were that the rest suffered from various methodological deficiencies. Come on researchers get your act together. You can access the same evaluation tools as everybody else so why do so many studies fail to pass muster. If you want your research to be taken seriously you have to play by the rules whether you agree with them or not.

MASSAGE AND PERFORMANCE RECOVERY: A META-ANALYTICAL REVIEW. Poppendieck W, Wegmann M, et al. Sports Medicine 2016;46(2):183–204 medium positive effects, the effects after strength exercise and endurance exercise were smaller. Moreover, a tendency was found for untrained subjects to benefit more from massage than trained athletes.

Co-Kinetic comment There is a lot of information to be picked over, such as the questions about the duration of the massage.

There are also recommendations to researchers to try to standardise some

of the variables. The authors conclude with the statement that “it remains questionable if the limited effects justify the widespread use of massage as a recovery intervention in competitive athletes”. The trouble with that statement is that the majority of the reported studies are experimental. In ‘real’ situations there is a combination of physiological and psychological factors.

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IS THIS BIOTENSEGRITY’S TIPPING POINT?

The objective of our Co-Kinetic module on biotensegrity http://spxj.nl/27ywC6E is to help you as a therapist understand how to integrate biotensegrity principles into physical activity programmes and manual therapies. If we can achieve this, all signs point towards a recipe for fewer injuries, better rehabilitation, improved natural function in motion, greater happiness and by virtue of all the above, greater success as a therapist. I am sure that most of us will agree that when we, or our clients, move injury-free everyone is at their happiest. Pain and injury bring misery. Read this online http://spxj.nl/1TVzq6C FASCIA | 16-07-COKINETIC FORMATS WEB MOBILE PRINT

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BY JOHN SHARKEY BSC MSC, BACA BASES

INTRODUCTION A tipping point is defined as the point at which a series of small changes or incidents becomes significant enough to cause a larger, more important change.

The concept of biotensegrity has been around for a few years now, but to some people it will seem as if it has become a sudden overnight success.

Over the last 12–18 months, it has shot out of the shadows and is not only enjoying a global acceptance but is also now being heralded as ‘the model that binds’ all bioscience disciplines.

Movement science and manual medicine are no exceptions to this rule.

One of the goals of the 2016 British Fascia Symposium Biotensegrity Pre-conference day organised by the National Training Centre is to provide an insight into biotensegrity in movement science and manual therapy and to discuss the concept of the full body kinetic chain (FBKC) principle. The current multidisciplinary focus on fascia is having a positive impact on the work of clinicians and manual and movement therapists worldwide. Many of the

improvements seen in our patients and clients are related to a better understanding of the role of the fascial matrix within the human body.

Biotensegrity as an analogy for living architecture moves us away from more widely accepted linear approaches and this is a welcomed development. Human dissection provides the strongest evidence that everything in the human body is continuous. Words are vitally important in this regard. Medical anatomy textbooks inform us that muscles attach, or are connected, to bone. ‘Attach’ means to join or fasten something to something else.

‘Connect’ means to bring together or into contact so that a real or notional link is established. Similar words such as attach, join, fix, bind, tether or fetter fail to impart the fact that in human or living anatomy nothing is attached to anything but, rather, everything is continuous. Everything self evolved.

The world’s first biotensegrity-focused human dissection course in 2015 at the University of Dundee, Scotland, Co-Kinetic journal 2016;69(July):12-15

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demonstrated that this notion is incorrect (Fig. 1). Biotensegrity provides a rich language and vocabulary for the movement and manual therapist and most importantly provides answers to questions that we have all had over our careers.

DILEMMAS IN BIOMECHANICS Human beings are not assembled in a factory with employees responsible for super-gluing a head to the spine or a limb to the mainframe using screws and bolts. Although it may look like the spine is a block-on-block structure similar to a pillar, it is not.

Such a construct would result in axial loading and crush both the vertebral bodies and the inter-vertebral discs.

At this point I need to point out that mathematical equations used to explain human movement have always come up short. It is simply not possible to explain how we carry our weekly shopping from the supermarket to the car using Newtonian-based biomechanics.

It may surprise some people but this has been an ongoing dilemma in biomechanics. Some experts thought the problem was solved in 1957 by a researcher named Bartelink who introduced the concept of intraabdominal pressure. This model incorporated the widely held opinion that the erector spinae muscles were not capable of dealing with the forces generated by the lower limb musculature due to their inadequate size. This being the case, Bartelink put forward the hypothesis that intraabdominal pressure, making up the deficit in mathematical equations, would allow the trunk to resist loads placed on it. This model has prevailed to the present day even when it does not stand up to scientific scrutiny. Of course a lot has changed since 1957 and in the meantime leading researchers including Serge Gracovetsky have pointed out some problems with these mathematical lever-based equations. According to Gracovetsky an individual’s intraabdominal pressure would have to increase by 20 times more than their blood pressure, enough for them to explode, to allow a 250kg lift.

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Gracovetsky further informs us that the maximum load the erector spinae musculature could possibly support is no more than 50kg approximately.

To support the need for a new mathematical model for movement science Dr Steve Levin, similar to the example provided by Gracovetsky, explains that a 2kg fish hanging at the end of a 3m fly rod would exert a compressive load of 120kg, at least, on the lumbosacral junction. If the weight of the rod, torso, arms and head were included the calculated load on the spine would far exceed the critical load resulting in fracture of the lumbar vertebrae of the average mature male.

Humorously, Levin suggests this would make fly fishing an exceedingly dangerous activity. Dr Levin has put forward a model for human movement that he calls ‘biotensegrity’, strongly influenced by the pioneering work of Buckminster Fuller and Robert Snelson.

In this model there are no joints in the body. Joints become points of force transfer, and loads acting on the body are distributed throughout the tensegrity. This has ramifications for the manual therapies, as pain experienced in one part of the body may not represent the true source of the problem. In a tensegrity structure it is the weakest link that most likely results in pain and, of course, the squeaky wheel gets the oil. A tensegrity is often described as having two members. One member is continuous and provides tension (this would be the connective tissues including the fascia and ligaments) and the second member is a discontinuous strut providing compression (this would be the harder tissues or skeletal system). Of course both members are connected to and are continuous with each other. They are one. As an anatomist I break that relationship or connection with my scalpel. I create parts. I separate what has been united for a lifetime.

The human body is not constrained by the rules of classical mechanics, and biotensegrity is now a more up-to-date way of looking at functional anatomy.

It is a structural design principle that is founded on the basic rules of physics first and from which everything else is derived; a vision of human form and function that greatly expands our

BARTELINK’S MODEL OF INTRA-ABDOMINAL PRESSURE DOES NOT STAND UP TO SCIENTIFIC SCRUTINY knowledge and has been received to great acclaim.

Biotensegrity represents a paradigm shift in the way that we think about the human body and our varied approaches to treatment. It is a developing concept that describes the relationship between every ‘part’ of the body and the mechanical system that integrates them into a unified whole. Biotensegrity has the power to positively impact the success of all our therapeutic interventions regardless of the clinician’s stripe.

THE TENSEGRITY MODEL Tensegrity configurations (Fig. 2) are similar to biological structures in that they are strong, light in weight and resilient to the effects of damaging forces, yet can change shape with the minimum of effort and return automatically to the same position of stable equilibrium. Their structural mechanics operate the same in any position irrespective of the direction of gravity. They show how each part can be constructed from smaller ones (which are themselves made from Muscle tendons are continuous with the harder skeletal system and must be cut to separate the continuity, which reflects specialisation along a continuum. In this image the tendons of the fibularis longus and brevis become the bones of the foot (tibialis anterior has been removed by cutting). The calcaneal tendon is visible and has been cut. Note its continuity with the heel bone and plantar tissues.

Figure 1: Muscle tendons are continuous with the harder skeletal system (J. Sharkey, 2015)

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Figure 2: A tensegrity structure: Kenneth Snelson’s Needle Tower, Washington DC, USA (Photo credit: S. Levin, www.biotensegrity.com)

BIOTENSEGRITY EXPLAINS HOW ‘JOINTS’ CAN REMAIN COMPLETELY STABLE WITHOUT OVERSTRESSING THE SOFT TISSUES SURROUNDING THEM

even smaller ones) within a hierarchy, where each one is mechanically related to all the others and integrated into a complete functioning unit.

The recognition of biotensegrity as a unifying structural principle in living organisms began in the mid 1970s with Stephen Levin (b. 1932), an orthopaedic surgeon, who observed things at the operating table that could not be explained through orthodox biomechanical theory. He found that tightening up certain ligaments in the knee, etc, caused the bones to move apart, and that normal bones always had a slight spacing between them, but there was no known mechanism that could make this space possible; it was as if the bones were ‘floating’ within the soft tissues. Further investigations then uncovered a relatively little-known structural principle called ‘tensegrity’ and a likely explanation for these findings.

The term ‘tensegrity’ is a combination of the words tension and integrity, and this structural system was first recognised in 1948 by Kenneth Snelson (b. 1927), a young sculptor who continues to produce impressive works that he describes as “…unveil[ing] the exquisite beauty of structure itself”. Tensegrity structures are particularly interesting because the compressional elements remain isolated from each other and are suspended within the tension network.

The architect Buckminster Fuller (1895–1983) recognised them as part of his theory of synergetics, the study of nature’s coordinate system that considers that all natural structures are inherent displays of the forces within them; and Donald Ingber, a cell biologist, has described the structural lattice (cytoskeleton) within cells as a tensegrity structure that regulates cell function. Mechanical engineers also appreciate the distinctive properties of tensegrity structures and are producing robots for use in the exploration of space, etc.

BIOTENSEGRITY Both biologists and engineers now recognise that the simple principles of tensegrity can be applied to understanding the behaviour of more complex structures; but 14

because certain aspects are not transferable between these disciplines, Stephen Levin introduced the term ‘biotensegrity’ to distinguish between the two fields.

Biotensegrity models emulate biology in ways that were inconceivable in the past but it has taken some time for the concept to become widely accepted because of its challenges to generally accepted wisdom. Biotensegrity explains how ‘joints’ can remain completely stable without overstressing the soft tissues surrounding them, and demonstrates that the spine is essentially a tensioned structure that can function the same in any position, as well as how movement is controlled by the very structure itself. It is attracting the attention of biologists, therapists and clinicians because it provides a better means to visualise the mechanics of the living body in the light of new understandings about functional anatomy.

A biotensegrity view of life sweeps away the man-made constraints of classical mechanics and re-establishes biology at its very core. It is based on the laws of physics first rather than the artificially contrived ones that have dominated biomechanics for centuries, and recognises that the structure and behaviour of each molecule, cell, tissue and organism must result from those very same rules. Both simple molecules and complex structures result from the interactions of pure energy (forces), and although particular configurations dominate, they are not especially chosen by nature but because their simplicity, efficiency and stability favours them.

A biotensegrity understanding of the fascia explains how the simplest of movements can cause complex changes in other parts of the body and why local treatments can have such a widespread influence. It is part of the basic science that underpins what each therapist and clinician does.

Bibliography 1. Buckminster Fuller R. Synergetics: explorations in the geometry of thinking.

Macmillan 1976. ISBN 978-0025418707 Buy from Amazon http://amzn.to/27vc277 Co-Kinetic journal 2016;69(July):12-15

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2. Guimberteau JC, Armstrong C. Architecture of human living fascia: the extracellular matrix and cells revealed through endoscopy. Handspring Publishing 2016. ISBN 978-1909141117. Buy from Amazon http://amzn.to/27vcfYf 3. Heartney E. Kenneth Snelson: Forces made visible.

Hard Press Editions/Hudson Hills Press 2009. ISBN 978-1555952433. Buy from Amazon http://amzn.to/1TkEBhz 4. Ingber DE. The architecture of life.

Scientific American 1998;278(1):30–39 5. Jarmey C, Sharkey J. Concise book of muscles, 3rd edn. Lotus Publishing

2015. ISBN 978-1905367627. Buy from Amazon http://amzn.to/27vcliz 6. Levin SM. Biotensegrity: a new way of modeling biologic forms http://www.biotensegrity.com/ 7. Scarr G. Biotensegrity: The structural basis of life.

Handspring Publishing 2014. ISBN 978-1909141216.

Buy from Amazon http://amzn.to/1TkEXEU. 8. Sharkey J. The concise book of dry needling. practical applications for myofascial trigger point therapy. Lotus Publishing 2016.

ISBN 978-1905367672. Buy from Amazon http://amzn.to/27vc5A2.

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HERE ARE SOME SUGGESTIONS Tweet this: Patients benefit from a better understanding of the role of the fascial matrix within the body. http://spxj.nl/1TVzq6C Tweet this: In human anatomy nothing is attached to anything but, rather, everything is continuous. http://spxj.nl/1TVzq6C Tweet this: Mathematical equations used to explain human movement have always come up short. http://spxj.nl/1TVzq6C Tweet this: In biotensegrity, joints are points of force transfer that spread loads throughout the tensegrity. http://spxj.nl/1TVzq6C Tweet this: Biotensegrity has the power to positively impact the success of all our therapeutic interventions. http://spxj.nl/1TVzq6C Tweet this: The spine is essentially a tensioned structure that can function the same in any position. http://spxj.nl/1TVzq6C Tweet this: Biotensegrity explains why local treatments can have such a widespread affect. http://spxj.nl/1TVzq6C

KEY POINTS n I n human or living anatomy nothing is ‘attached’ to anything but, rather, everything is ‘continuous’. n The spine is not simply a block-on-block structure like a pillar. This would result in loads that would crush the vertebral bodies. n Mathematical equations used to explain human movement have always come up short. n According to the maths behind the intra-abdominal pressure model, weightlifting and fly fishing would be deadly activities. n The cytoskeleton (the structural lattice within cells) has been described as a tensegrity structure that regulates cell function. n In biotensegrity, joints transfer forces so that loads are distributed throughout the tensegrity (or whole body). n Biotensegrity explains how ‘joints’ can remain completely stable without overstressing the soft tissues surrounding them. n This new understanding of functional anatomy allows therapists and clinicians to better visualise the mechanics of the human body and so to provide better treatment.

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A BIOTENSEGRITY UNDERSTANDING OF THE FASCIA EXPLAINS HOW THE SIMPLEST OF MOVEMENTS CAN CAUSE COMPLEX CHANGES IN OTHER PARTS OF THE BODY AND WHY LOCAL TREATMENTS CAN HAVE SUCH A WIDESPREAD INFLUENCE THE AUTHOR John Sharkey BSc MSc, BACA BASES is a recognised author and authority on the topic of myofascial trigger points and the treatment of chronic pain. John holds master’s degrees in clinical anatomy (BACA), exercise physiology (BASES) and is the programme leader of the masters degree in Neuromuscular Therapy accredited by the University of Chester. John is a member of the Olympic Councils Medical and Science Team and runs a successful chronic pain clinic. An International presenter and keynote speaker, John has proven to be a popular figure at conferences, workshops and masterclasses worldwide. He is a member of the editorial team Journal of Bodywork and Movement Therapies (JBMT) and the BioTensegrity Interest Group (B.I.G) under the guidance of his mentor Dr Stephen Levin.

Email: john.sharkey@ntc.ie LinkedIn: ie.linkedin.com/in/johnsharkeyMSc web: www.johnsharkeyevents.com

DISCUSSIONS hy are the traditional ideas of W biomechanics inadequate?

Discuss what is meant by tensegrity and how is the body a ‘tensioned structure’?

How does the model of biotensegrity allow the body to cope with loads placed upon it and what implication does this have for manual therapy?

RELATED CONTENT o-Kinetic content relating to biotensegrity C http://spxj.nl/1WhVCvj ther Co-Kinetic content written by John Sharkey O http://spxj.nl/1VhPUZh iotensegrity: concepts and practical applications for B the manual therapist http://spxj.nl/27ywC6E

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Can tensegrity, or more specifically biotensegrity (‘tensegrity in living structures’), explain the interconnectedness of the body?

More importantly, will an understanding of biotensegrity change the way in which you work? At this moment in our evolutionary history, it seems very likely it can and will, which is why the concept has become an international hot topic and has provoked much discussion among a wide range of scientists and therapists. Simply defined, it provides a scientific (and plausible) explanation for something that we as therapists instinctively already know, that every structure in the body is in some way interconnected in a way in which the whole is greater than the sum of the parts. This article (along with its associated links to a series of animations) documents a fascinating insight into the ongoing debate between two leaders in their fields of research into the organisation of living matter and gives the reader the opportunity to understand the relevant concepts and compare the different points of view. It looks very much like this is the next step in our journey of discovery of functional anatomy.

Read this online http://spxj.nl/1rOKzNl FASCIA | 16-07-COKINETIC FORMATS WEB MOBILE PRINT

MEDIA CONTENTS Excellent video explaining the concept of biotensegrity created by Chiropractor Mathieu Spencer: Performance & prevention https://vimeo.com/71026826 Tensegrity sculpture self assemble https://www.youtube.com/ watch?v=lf933URMdEY video by Kenneth Snelson Scarr G. Biotensegrity: The structural basis of life. Handspring Publishing 2014. ISBN 978-1909141216. Buy from Amazon http://amzn.to/1TkmbO2 A series of fascinating animations http://kennethsnelson.net/ animations/ from Kenneth Snelson (accompanied by some dramatic music) A range of resources http://kennethsnelson.net/ from the American sculptor, Kenneth Snelson, a student of the ‘founder’ of tensegrity Buckminster Fuller Tensegrity in biology http://www.tensegrityinbiology.co.uk/ website

by Graham Scarr, author of Biotensegrity: The structural basis of life, has many additional resources Tensegrity http://tensegrity.wikispaces.com/ Wiki website.

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TENSEGRITY AND BIOTENSEGRITY: The next ‘big thing’ in our understanding of functional anatomy and the interconnectedness of body structure?

BY COLIN ARMSTRONG DO AND DR JEAN-CLAUDE GUIMBERTEAU MD, SOFCPRE

INTRODUCTION This article discusses how biotensegrity, as an architectural concept, is an excellent working model for understanding energy transmission and the way that the human body deals with gravity, but acknowledges that it needs to be developed and refined if it is to account for the complexity of the architecture and behaviour of the anatomical structure.

The article documents a fascinating insight into the ongoing debate between two leaders in their fields of research into the organisation of living matter, who have agreed to disagree on some of the finer points of the biotensegrity model as it stands. It allows you, the reader, to compare the different points of view and draw your own conclusions on one of the most significant developments in the understanding of anatomy this century.

INTRATISSULAR ENDOSCOPY Dr Jean-Claude Guimberteau is the first person to have filmed living human tissue through an endoscope in an attempt to understand the organisation of living matter. He has

opened a window into the largely unexplored world of living human anatomy, a strange world of fibrillar chaos and unpredictable behaviour. He has discovered that the entire body is structured by a vast unitary tensional network that is composed of billions of interconnected multidirectional fibres and fibrils. The fibres interweave and intertwine to create three-dimensional microvolumes that Dr Guimberteau has named microvacuoles – simple, but irregular, polygonal structures. These are either filled with cells with their own cytoskeletons, or with pressurised fluids, depending on where they are in the body.

Dr Guimberteau has developed his own concept of the multifibrillar architectural organisation of the body, of which the microvacuole is the basic functional unit. Microvacuoles act as structuring elements within living tissue. They self-assemble and gather together and play an important role in the creation of the shape and form of the entire body. He has studied their behaviour during movement as well as how they deal with specific functional demands in different areas of the body. The multimicrovacuolar network Co-Kinetic journal 2016;69(July):16-20

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constraint is removed.

This astonishing behaviour of the fibrils in the multifibrillar, microvacuolar network adds another dimension to the way in which living matter adapts to constraint. The multifibrillar network allows simultaneous mobility, absorption of forces, and sliding of separate anatomical structures while having no effect on surrounding tissues. Form is thus maintained during and after movement.

Dr Guimberteau’s research has sparked some interesting debate about the application of the tensegrity model to living matter.

TENSEGRITY

plays an essential role in movement in the sliding systems around tendons, between organs and other anatomical structures.

The fibres in this body-wide multifibrillar system are not inert.

They do not move spontaneously, but respond to all types of constraint in three dimensions and orientate themselves in the direction of an imposed constraint. Some fibrils move more than others and they do not all react with the same intensity.

Therefore, we do not see a global, linear shift of fibrils.

The fibrillar network exploits several intrinsic properties of its constituent fibres to adapt to constraint in three dimensions. These properties include the ability to stretch, lengthen, divide and slide along each other, and this is one important way in which the fibrillar network inside the living body differs from traditional tensegrity structures made of cables and struts with fixed nodal points (See Box 1 for definitions of the key terms, ‘Tensegrity’ and ‘Biotensegrity’, for the concepts discussed in this article). The intrinsic properties of the fibrils enable the network to disperse and reduce the force of the constraint. They enable the anatomical structures to return to their original resting positions once the Co-Kinetic.com

The concept of ‘tensegrity’ – a contraction of tensional integrity – was developed by Buckminster Fuller (1895–1983), an American architect and systems theorist. Man-made constructions had traditionally been solid structures that made use of the forces of gravity and the compression they are subjected to.

Buckminster Fuller introduced tension into construction, which was quite revolutionary because tensegrity structures are completely different to traditionally designed structures.

They consist of isolated components under compression within a web of continuous tension. They maintain their integrity because their architecture associates global tension with local compression.

From the architectural point of view, a tensegrity structure is a collection of stable struts and interconnected cables under tension, which rearrange themselves when subjected to external constraint, and then return to their initial form and equilibrium as soon as the constraint is removed. A tensegrity structure is a closed structural system of discontinuous elements of compression in a continuous web of tension. The mechanical stability of these structures allows the components to remain in tension/ compression as external constraint on the structure increases. Tensegrity is, therefore, very useful in helping us to understand our relationship with gravity.

The organisation of the interlinked elements that make up the structure enables it to diffuse and absorb the

THE MICROVACUOLE IS THE BASIC FUNCTIONAL UNIT OF THE MULTIFIBRILLAR ARCHITECTURAL ORGANISATION OF THE BODY forces of compression by dispersing them throughout its continuous tensional network. One of Buckminster Fuller’s students, Kenneth Snelson, an American sculptor is known for creating structures according to the principles of tensegrity. He uses the term ‘floating compression’ to describe the balance between the rigid struts and cables of his sculptures. He defines a tensegrity system as follows: ”Tensegrity describes a closed structural system composed of a set of three or more elongate compression struts within a network of tension tendons, the combined parts mutually supportive in such a way that the struts do not touch one another, but press outwardly against nodal points in the tension network to form a firm, triangulated, prestressed, tension and compression unit.” (1) Buckminster Fuller set out to create an energy-efficient structure that would require the least possible energy to

BOX 1: DEFINITIONS Tensegrity Tensegrity, tensional integrity or floating compression, is a structural principle based on the use of isolated components in compression inside a net of continuous tension, in such a way that the compressed members (usually bars or struts) do not touch each other and the prestressed tensioned members (usually cables or tendons) delineate the system spatially. Source Wikipedia (https://en.wikipedia.org/wiki/Tensegrity) Biotensegrity Biotensegrity is a term formulated by Dr Stephen Levin (http://www.biotensegrity.com/) to describe tensegrity in living structures. It can be applied to living organisms at all levels of organisation and at all scales.

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fulfil its purpose. He discovered that the tetrahedron meets these requirements.

The tetrahedron (a polyhedron composed of four triangular faces) has a high surface-area-to-volume ratio.

It combines a large surface area with a minimal volume. The advantage of this configuration is that it can shift from one form to another without requiring more space. This confers real stability during movement. A tensegrity structure provides a global response to a local mechanical stress and the result is a degree of independence from the force of gravity.

The concept of tensegrity is closely related to the principle of synergy and antagonism (negative synergy).

Synergy – derived from the Greek word Synergia, meaning ‘working together’ – is the interaction of multiple elements within a system to produce an effect greater or different from the sum of their individual effects. Buckminster Fuller studied the implications of synergy in great detail, and proposed a new term, Synergetics. This refers to the behaviour of dynamic systems in which combined action is favoured over the actions of individual components (2).

These phenomena are universal in biomechanics, and there are many examples of tensegrity in the natural world. In the microscopic domain, Donald Ingber applied the tensegrity concept to the intracellular cytoskeleton, which has strong links to the extracellular matrix (ECM) (3).

Dr Jean-Claude Guimberteau’s research bridges the gap between the macroscopic and microscopic domains and reveals what is happening in the fibrillar architecture between the cells in

“BIOTENSEGRITY EXTENDS THE CONCEPT OF TENSEGRITY INTO THE REALM OF BIOLOGY AND AIDS OUR UNDERSTANDING OF HOW LIVING STRUCTURES DEAL WITH STRESS AND MOVEMENT 18

the ECM. In the living body, the threedimensional microvolumes formed by the interconnecting fibres in the ECM are usually simple polyhedrons.

It is difficult not to draw a parallel between the icosahedron or tetrahedron and the microvacuole, which is polyhedral and under pre-existing constraint.

Forms that resemble those in Euclidean geometry are sometimes observed in the fibrillar network. There is, therefore, a relationship between the observable and indisputable existence of microvacuoles and the theory of tensegrity.

BIOTENSEGRITY Stephen Levin was the first person to apply the principles of tensegrity to living matter. He formulated the term ‘biotensegrity’ to describe tensegrity in living structures. It can be applied to biological organisms at all levels of organisation and at all scales (4,5) and represents a major advance in our understanding of the organisation of the anatomical structures within living matter. It is the first model to introduce the notion of tension and the concept of equilibrium between the anatomical structures in living matter.

The fibrillar network and its cellular content may constitute a tensegrity structure. However, tensegrity is an architectural concept. Biotensegrity extends this concept into the realm of biology and aids our understanding of how living structures deal with stress and movement. This concept, therefore, has huge implications for energy transmission within the living form, and for the body’s ability to deal with both intentional and unintentional stress and movement. The ability of a tensegrity structure to spread a load across the entire system, instead of responding only in the area close to the point of load, helps to explain the intricate movements of anatomical structures in the body.

As Donald Ingber has shown, this wide-scale communication of movement and force works not only at the macroscopic and mesoscopic levels, but also with and within the cell.

The effects of mechanotransduction in one location may thus be due to stimuli in a different area and at a distance from the cells concerned (6,7).

ADAPTING THE TENSEGRITY CONCEPT TO LIVING MATTER The biotensegrity model involves geometric shapes – similar to Plato’s icosahedrons – but these icosahedrons are idealised force transmitters, not actual physical structures that can be clearly visualised in the body. Tensegrity models made from wooden rods and rubber bands are only representations of dynamical forces within a constantly changing milieu. These forces are present concurrently at the macroscopic and microscopic scales – at the subcellular, cellular, regional and whole organism levels. They span the scales at which Newtonian principles operate and those at which quantum principles operate. However, biotensegrity is a theoretical model. It is a very useful attempt to provide an explanation of human architecture, but does not appear to be fully applicable to living matter as it stands. The underlying laws of biological systems add further levels of complexity to the equation. In this respect, the following points need further discussion.

1. The non-linear, irregular and apparently chaotic organisation of living matter The distribution and arrangement of the cells and fibres of the living matter that constitutes the human form does not display any apparent order, and is not in accordance with Euclidean geometry and linear mathematics. The fibres form three-dimensional microvolumes – basic architectural units that are both polyhedral and irregular. There appears to be a non-linear and chaotic, but efficient organisation. Chaos in the mathematical sense implies an underlying order, and efficiency is a feature of all complex systems.

2. There are no empty spaces in living matter The microvolumes between the fibres are filled either with cells, with their own cytoskeletons, or with pressurised fluids. The pressurised intravacuolar contents are localised areas of compression within the continuous tensional network of fibres. It is difficult not to draw a parallel between these pressurised microvolumes and Buckminster Fuller’s ‘islands of compression in a sea of Co-Kinetic journal 2016;69(July):16-20

MANUAL THERAPY CURRENT TRENDS

tension’ (1). The microvolumes confer a degree of adaptive capacity to the system through local variations in pressure. The dynamic behaviour of the fibrils combined with the pressurised microvolumes formed by the intertwining of fibrils enables the fibrillar architecture to adapt to applied constraint in three dimensions.

This is how Dr Levin describes the complex relationship between tension and compression: “I came to realise that tension begets compression, and vice versa.

They are interdependent and must mutually coexist. When dealing with the tension components we must recognise that we are, at the same time, engaging the compression components at both the macro and micro scales. We must always be aware of both.” (8)

3. Fibrils in the multifibrillar network possess the ability to distend, dissociate and divide Dr Guimberteau describes fibrillar dissociation as ‘Dynamic fractalisation’.

This allows an imposed constraint to be absorbed at all levels of living matter, which explains its ability to resist gravity or any other imposed constraint.

Dynamic fractalisation means that the microvacuoles can multiply at leisure, and this enables them to react instantly to whatever constraint is imposed on the system. The polyhedral frame of the microvacuole is never stable and is likely to change at any given moment. This involves nonlinear behaviour, with unpredictable as well as deterministic characteristics.

The system is, therefore, not only irregular, but also unpredictable.

This element of randomness (and unpredictability) is characteristic of microvacuolar movement. The shape of the intramicrovacuolar volume is never constant and the inherent potential of the microvacuole for changing shape is considerable.

4. The biotensegrity model does not account for the capacity of the fibrils to move along each other In the biotensegrity model movement takes place at the junction between cables and struts, but Dr Guimberteau’s observations show that the fibres in the multifibrillar network behave in many Co-Kinetic.com

different ways – they can lengthen, shorten, move along each other and divide. His films show that the fibrillar structures are not organised as tensed cables and rigid struts in the body.

Fibrillar junctions are not always fixed nodal points, and mobile junctions between two fibres are frequently observed.

5. The fibrillar framework is able to resist and adapt to increased tension by strengthening the fibrils with extra collagen An increase in the resistance of the fibrils in response to repetitive constraint is a frequent in vivo observation. This implies that the quality of the fibrils can change. The biotensegrity model does not account for differences in the quality of the fibrils. The quantity of the fibrils also increases in response to mechanical demand. However, much research is still required in this field.

Dr Levin’s contribution to the book Architecture of Human Living Fascia sheds further light on the difficulty of adapting the tensegrity concept to living matter (9).

What Dr Guimberteau describes in the constantly changing microvacuoles and microfibres is entirely consistent with the biotensegrity model and is occurring at every level of organisation, at every scale and across scales.

It may be difficult, even impossible, to ascertain the true structural organisation at any one scale, because we are usually stuck with being able to visualise only one scale at a time.

The tensegrity icosahedrons in biotensegrity are force diagrams, not actual physical structures that can be seen in the body. They define the structural and mechanical relationship within cells and between cells, organs, regions and, ultimately, the structural and mechanical integrity of the organism and how it responds to external forces. Biologic tensegrity icosahedrons represent forces within an instant of time and in a constantly changing milieu, simultaneously, at every organisational level, and they may cross several scales of organisation.

Consistent with Dr Guimberteau’s observations they are in a continuous flux, so that what applies at one instant does not exist in the next.

IN CONSTRUCTION, TENSEGRITY STRUCTURES MAINTAIN THEIR INTEGRITY BECAUSE THEIR ARCHITECTURE ASSOCIATES GLOBAL TENSION WITH LOCAL COMPRESSION I see nothing but tensegrities in Dr Guimberteau’s marvellous endoscopic demonstrations; he has breathed life into a theoretical model. The fibrillar network and the cells within it coalesce to form a structural continuum of continuous tension, discontinuous compression that defines a tensegrity (8).

SUMMARY Dr Guimberteau summarises his view of biotensegrity as follows. ”I do not know of any other biomechanical theory that provides such a clear and rational explanation for what I observe during my endoscopic explorations.

However, as we have seen, the fibrils slide along each other, sometimes dividing into 2, 3 or 4 sub-fibrils, thereby immediately spreading the constraint into newly formed spaces. The specific changes that take place in the microvacuoles and micro-fibres during fractalisation are constantly changing, rapidly shifting, and not entirely consistent with the biotensegrity model.” (10) Biotensegrity can, therefore, be considered as a very useful concept for understanding the organisation of the anatomical structures within living matter, provided that the reader does not think that the architecture of the body consists of neatly arranged hierarchies of icosahedrons! However, it introduces the notion of regularity into a completely irregular, chaotic world and must therefore be considered as a model that needs to be refined in the light of in vivo observations. It explains many of the phenomena that can be observed in living matter, especially the ability to resist gravity, but does not account for the full complexity 19

of organic structural and functional relationships in the living body. The complexity of the balance of tension and compression within the body is so great that it needs other biomechanical hypotheses to enhance this concept, but for the moment it remains the only model able to explain our capacity to resist the force of gravity.

References 1. Kenneth Snelson.net.

Frequently asked Questions http://www.kennethsnelson.net/faqs/faq.htm 2. Buckminster Fuller RB. Synergetics: explorations in the geometry of thinking. Macmillan 1976. ISBN 978-0025418707 Buy from Amazon http://amzn.to/1TFU3B8 3. Ingber DE. Cellular tensegrity: defining new rules of biological design that govern the cytoskeleton. Journal of Cell Science 1993; 104(3):613–627 4. Levin SM. Continuous tension, discontinuous compression: a model for biomechanical support of the body. Bulletin of Structural Integration 1982;8(1):31–33 5. Levin SM. The icosahedron as the three-

dimensional finite element in biomechanical support. In: Dillon JR (ed.) Proceedings of the Society of General Systems Research on Mental Images, Values and Reality. Society of General Systems Research 1986 6. Ingber DE. Cellular tensegrity: defining new rules of biological design that govern the cytoskeleton. Journal of Cell Science 1993;104(3):613–627 7. Ingber DE. Cellular mechanotransduction: putting all the pieces together again. FASEB Journal 2006;20:811–827 8. Guimberteau JC, Armstrong C. Architecture of human living fascia: the extracellular matrix and cells revealed through endoscopy, pp139,140. Handspring Publishing 2016. ISBN 978-1909141117. Buy from Amazon http://amzn.to/1TFU202 9. Guimberteau JC, Armstrong C. Architecture of human living fascia: the extracellular matrix and cells revealed through endoscopy. Handspring Publishing 2016. ISBN 978-1909141117. Buy from Amazon http://amzn.to/1TFU202 10. Guimberteau JC, Armstrong C. Architecture of human living fascia: the extracellular matrix and cells revealed through endoscopy, p129. Handspring Publishing 2016. ISBN 978-1909141117. Buy from Amazon http://amzn.to/1TFU202

KEY POINTS nA natomical research is traditionally carried out on cadavers. n Dr Guimberteau is the first person to investigate connective tissue in vivo. n Endoscopic investigation of living matter has provided much new information. n Connective tissue is traditionally removed during dissection and considered to be of little importance. n Biotensegrity is a useful model for helping us to understand how biological organisms deal with gravity and maintain their form. n Dr Guimberteau has discovered astonishing behaviour of fibrils in a body-wide multifibrillar network. n The rod and string tensegrity models are useful teaching aids, but they do not account for the full complexity of the architecture and behaviour of living matter. n Dr Guimberteau’s films reveal the chaotic, irregular and non-linear architecture and unpredictable behaviour of living matter. n In the light of Dr Guimberteau’s discoveries, it appears that the biotensegrity model needs to be developed and refined.

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THE AUTHORS Colin Armstrong DO is a British trained osteopath. He spent the first five years of his career in Zimbabwe and has been based in France for the past 30 years. Areas of special interest include pediatric osteopathy and osteopathic care during pregnancy. He is founder member of the French Academy of Osteopaths.

Email: arm.colin@gmail.com LinkedIn: http://spxj.nl/1WEb9p7 Dr Jean-Claude Guimberteau MD, SOFCPRE is co-founder and scientific director of the Institut Aquitain de la Main, and pastpresident 2011–2012 of the French Society for Plastic and Reconstructive Surgery (SOFCPRE). Dr Guimberteau trained in hand and plastic surgery at the University of Bordeaux, and has worked in microsurgery and transplantation. He has developed our knowledge of the structure and function of tendon physiology, as well as pioneering techniques for secondary flexor tendon repair. His innovative use of video-endoscopy to investigate the structure of the fascia in vivo has resulted in what is essentially a new concept of living tissue and a new ontology for human body architecture.

Through the company endovivo.com he has published many videos on living matter: ‘Strolling under the skin’, 2005; ‘Skin excursion’, 2008; ‘Muscle attitude’, 2009; ‘Interior architectures’, 2011; ‘Skin, scars and stiffness’, 2012; and ‘Destination tendon’, 2012. Dr Guimberteau is also a member of the French Hand Society (GEM), and of the French Academy of Surgery. He has been a member of the (French) Health Service High Authority 2007–2010.

Website: http://www.guimberteau-jc-md.com/en/

DISCUSSIONS ow is force transmitted within the living form H during movement?

Does the biotensegrity model fully explain and account for the complex balance of tensions and compressions within the human body?

How is this complex balance of tensions and compressions maintained at all times, at all levels of organisation, from macroscopic to microscopic, during movement and at rest?

RELATED CONTENT iotensegrity: concepts and practical applications for the B manual therapist - http://spxj.nl/27ywC6E iotensegrity Part 1: Introduction to biotensegrity B http://spxj.nl/1S42bOm iotensegrity Part 2: Considering the role of the fascia in B the science of body architecture - http://spxj.nl/1S427OL iotensegrity Part 3: Levers and pendulums B http://spxj.nl/1HNSNK6

Co-Kinetic journal 2016;69(July):16-20

BY JOHN SHARKEY BSC MSC, BACA BASES AND JO AVISON KMI, E-RYT500 Biotensegrity is becoming much more than an alternative ‘model’ to some of the more classical theories upon which biomechanics tends to be based. It is fast becoming the key foundation that may help explain many movement modalities, manual therapies and medical interventions.

Indeed, it provides a fundamental logic that sits behind human movement, whether in terms of rehabilitation or high performance programmes. At both ends of the scale, the logic it provides is compelling. Moreover, it is just as relevant to the gross movement of the larger tissues as it is to the internal motility at a cellular level.

Over recent years the research has grown regarding the significance of the fascia as an important, primary player in the suite of connective tissues in the body. However, we cannot make full sense of its essentially structural role, without a clear understanding of biotensegrity and its various applications in human, physical, living architecture (Fig. 1). That applies when the body is still or in motion, and to internal motility or injury that prevents natural motion and disorganises structure.

FASCIA | 16-07-COKINETIC | FORMATS WEB MOBILE

DOES BIOTENSEGRITY REPRESENT A PARADIGM SHIFT IN OUR UNDERSTANDING OF ANATOMY? This article is part of a special series published to coincide with the Biotensegrity Pre-Conference day which preceded the British Fascia Symposium 2016. It is part of a special module of articles which can be found at the following link: http://spxj.nl/27ywC6E. Other articles in this series include: ‘Biotensegrity Part 1: Introduction to biotensegrity’; ‘Biotensegrity Part 2: Considering the role of fascia in the science of body architecture’; ‘Biotensegrity Part 3: Levers and pendulums’; ‘Dissecting the anatomy experience: a valuable learning tool’; ‘Function, form and fascia: What lies beneath?’; and ‘A new anatomy for the 21st century’. Read this online http://spxj.nl/1Ow11wb. move around – or, as in Figure 2, hold ourselves relatively still?

Why does biotensegrity answer such fundamental questions; indeed – why are we asking them?

This is a tensegrity mast designed by Bruce Hamilton to represent tension–compression architecture. Biologic forms are neither rigid nor static; however, this provides a compelling 3D map of soft tissue organisation.

Figure 1: Tensegrity mast (Model, author’s own; designed by Bruce Hamilton www.tensegrity.com)

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MEDIA CONTENTS Tom Flemons, Intension Designs at http://www.intensiondesigns.com/, including images of models and several excellent articles including The Bones of Tensegrity, 2012 Bruce Hamilton, Tension Designs, models at http://www.tensiondesigns.com/ Kenneth Snelson http://kennethsnelson.net/ Leonid Blyum, Advanced Biomechanical Rehabilitation at http://abr-denmark.com/home/abr-therapy/blyum/ Graham Scarr, Tensegrity in Biology, models, book and articles at http://www.tensegrityinbiology.co.uk/ Stephen Levin, Biotensegrity, http://www.biotensegrity.com/ for many articles, videos and access to the Levin Archives.

Ingber I. The Architecture of Life. Scientific American 1998;278(1):48–57 Vytas Sunspiral http://www.magicalrobot.org/BeingHuman/

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FROM ‘CLASSICAL’ TO ‘CONTEMPORARY’ As a model, many will intellectualise over biotensegrity versus lever mechanics, as if they are opposing themes. Lever mechanics have to be modified to account for human movement and expand upon notions of ‘upright inverted pendulums’ to explain walking gait. Biotensegrity does not oppose that: rather it completely shifts paradigms and presents a clear explanation of how we move naturally; from the pointing of a finger, to the logic of carpal tunnel syndrome and the way in which we can run faster. It goes further to show that the macrocosm and the microcosm are the same; which begins to make sense of living biology at its most fundamental. What does it take for us to get up and

WHOLE COMPLETE STRUCTURES We begin as a conceptus; which is in itself whole, complete and approximately spherical. That wholeness itself, besides echoing the call of complementary practice as a holistic practice, implies a geometry of structure that is never incomplete, anywhere in the body at any point in its developmental process. Throughout the journey of development to whatever age is reached, these approximately spherical cells multiply and organise and differentiate to ‘form us into our form’ via the rules of structure that biologic forms abide by.

The human body is, according to John Sharkey, “a reflection of specialty along a spectrum of continuity resulting from the ubiquitous fascial matrix of connective tissues.”

The connective tissues, with which the body is self-assembled, govern and integrate all aspects of our structure, form and function. However, there are laws of organisation in this entire make-up, which do not support the notion of levers, upright inverted Co-Kinetic journal 2016;69(July):22-24

MANUAL THERAPY CURRENT TRENDS

LEVER MECHANICS HAVE TO BE MODIFIED TO ACCOUNT FOR HUMAN MOVEMENT

Every part of the dog’s whole body is engaged in the structural balance of drinking (from tongue tip to tail tip) and balancing over the water, even its very soft ears that are hanging down have to be brought into the equation that his soft tissue form naturally calibrates.

Figure 2: Puppy in balance (Credit: Shane McDermott, www. wildearthilluminations.com)

pendulums or many other mechanical explanations of biological motion, such as is assumed from many classical texts. It doesn’t matter how common the misunderstandings are; it doesn’t make them accurate. Fascia research has already changed many ideas of anatomy and physiology. To make sense of those shifts in biomechanics, we have to embrace biotensegrity.

Under living biologic conditions, biotensegrity becomes what clinical anatomist John Sharkey calls “the model that binds”. Indeed, they govern its spatial arrangement and its arrangement in space. This changes everything we have learned so far regarding classical ideas of levers, lines and pendulums. It suggests different ways of moving, different rules of posture and new explanations of how we express our structure in such individual ways. We are not robots and we do not follow the laws of linear non-biologic forms. We are non-linear biological forms and, in a phrase from Dr Stephen Levin (who coined the term ‘biotensegrity’), “there are no levers in biologic forms; anywhere, ever.”

BIOLOGIC FORMS ARE SOFT MATTER

This is a classical anatomical image of the ‘spinal or vertebral column’ represented as a series of stacked bones, based upon the notion of a column in hard-matter physics.

Figure 3: The spine as a column

Co-Kinetic.com

Many aspects of human motion are measured or assessed under the laws of hard-matter physics. This is readily exemplified in the classical naming of the spine as the ‘Spinal or Vertebral Column’ (Fig. 3).

Columns exist in hard-matter physics; they are compression structures that hold up buildings. Each block is stacked upon the one below and relies on its mass to support all the structures above it. The slightest shift in the ground upon which the compression structures are stacked will compromise the structural integrity of the whole column and the structures stacked upon it.

If the model in Figure 4 had a spinal column, such as the term implies, then this posture would be impossible. If the spine were a column, it would involve this body’s vertebral organisation being

If the spine were indeed a column, given that the bones do not touch each other, what would prevent the torso falling off the hips or the hands falling off at the wrists? Clearly this does not happen!

Figure 4: The spine is not a compression column (Image reproduced with kind permission from Katie Courts)

This model of a continuous spinal structure was created and designed

by Tom Flemons to demonstrate how a tension compression system, such as this tensegrity model, can be shown as a column-like structure, but organised in such a way as to more nearly represent soft tissue organisation and the requirements of force transmission.

Figure 5: The spine as a biotensegrity structure (Image reproduced with kind permission from Tom Flemons; www.intensiondesigns.com)

BIOTENSEGRITY PROVIDES A FUNDAMENTAL LOGIC THAT SITS BEHIND HUMAN MOVEMENT completely compromised by its parallel relationship to the ground. Moreover, if the model’s whole body relied on being stacked, or entirely on muscular power, how would the muscles of her one foot, hold her entire body weight in a horizontal position such as this?

Neither of the notions of a column or a super-strong foot hold up to scrutiny, if hard-matter physics is applied – or the model moves into a hand balance, for example. In a compression model, the 23

BIOTENSEGRITY SHIFTS PARADIGMS AND PRESENTS A CLEAR EXPLANATION OF HOW WE MOVE NATURALLY body would crumble, break or collapse and it clearly doesn’t do that.

PARADIGM SHIFT The paradigm shift taking place is in the recognition that this is a perfect example of how soft-matter physics expresses itself as a tension– compression network: a completely different model. This model, with no levers, pendulums, flat planes, straight lines or more than moderate muscle strength – allows for Katie (the yogini) to stand on her hands or her head

or (as here), on one foot, without threatening the structural integrity of her body’s connective tissue organisation: she can maintain her overall structural integrity and move it. The tissue remains continuous and retains its continuity throughout the practice (Fig. 5).

FURTHER RESOURCES For more information about the topics discussed in this article, please see the web links under the ‘Media contents’ panel.

KEY POINTS nB iotensegrity is key to explaining movement and manual therapies. n Fascia is a primary player in the suite of connective tissues in the body and its role becomes clear with a better understanding of biotensegrity. n Mechanical explanations involving levers and pendulums do not adequately explain biological motion. n Biotensegrity provides new explanations of how we move and is fundamental to rehabilitation and high performance. n Typical columns as assessed by the laws of hard-matter physics are compression structures. n The spine is not a column in the classic sense of block-on-block structure. n Biotensegrity allows us to understand how a person or animal can hold their own body weight in a horizontal position. n Soft-matter physics, describing the body as a tension–compression network, allows us to maintain the overall structural integrity of our bodies in different positions as well as moving them.

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DISCUSSIONS hy do classic biomechanical models of movement not stand up to W scrutiny?

What role does fascia play in the biotensegrity model?

Discuss the models of the spine as a column or a tensegrity structure.

Which works best and why?

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THE AUTHORS John Sharkey BSc MSc, BACA BASES is is a recognised author and authority on the topic of myofascial trigger points and the treatment of chronic pain. John holds master’s degrees in clinical anatomy (BACA), exercise physiology (BASES) and is the programme leader of the masters degree in Neuromuscular Therapy accredited by the University of Chester. John is a member of the Olympic Councils Medical and Science Team and runs a successful chronic pain clinic. An International presenter and keynote speaker John has proven to be a popular figure at conferences, workshops and masterclasses worldwide. He is a member of the editorial team Journal of Bodywork and Movement Therapies (JBMT) and the BioTensegrity Interest Group (B.I.G) under the guidance of his mentor Dr Stephen Levin.

Email: john.sharkey@ntc.ie LinkedIn: ie.linkedin.com/in/johnsharkeyMSc web: www.johnsharkeyevents.com Joanne Avison KMI, E-RYT500 is a CMED graduate, and has extensively studied human development and specialised in soft tissue and the links between archetypal behaviour and physiological patterns. Her studies also included Human Dissection and movement research in Fascial Fitness with Dr Robert Schleip. Joanne is a fully accredited Professional Structural Integrator (Kinesis Myofascial Integration School) and has taught at the KMI School of Structural Integration (Maine, USA) and also taught Anatomy Trains™ in the UK, pioneering its application to Movement Practitioners in Yoga, Pilates and professional sports, including English Premier League Soccer Clubs and golf professionals.

Jo is an experience trainer of yoga teachers, holding E-RYT500 status and is the co-founder and director of the accredited Art of Contemporary Yoga Teacher Training School (AOCY). Joanne’s book YOGA: Fascia, Anatomy and Movement, published in 2015, has been highly regarded in a variety of bodywork fields for its clear explanations of how understanding Fascia and the concept of Biotensegrity, can be applied to help us (and our clients) move better; whatever type of discipline we teach.

Joanne currently teaches regular workshops and webinars around the world: See www.joanneavison. com and www.trainings.co.uk for eHealth Learning programmes.

Email: jo@joanneavison.com Twitter: @joavison LinkedIn: https://uk.linkedin.com/in/joavison

RELATED CONTENT ll articles relating to biotensegrity can be found at the A following link – http://spxj.nl/27ywC6E

Co-Kinetic journal 2016;69(July):22-24

PHYSICAL THERAPY MSK DIAGNOSIS, TREATMENT, REHABILITATION

CONSIDERATIONS TO REDUCE INJURY RATES IN THE PROFESSIONAL FOOTBALL SETTING Injury surveillance and screening We all know injuries are bad news. Not only do they have an adverse affect on the player, causing a range of emotional responses that can then unmask other more serious mental health issues (see the ‘Related content’ box) but just as importantly, if the athlete is a team player, the consequences can and do escalate to affect the whole team and, even worse, its performance (1). Our job as physical therapists is to do our utmost to ensure injuries don’t happen on our watch and one of the most powerful tools we have in our armoury for achieving this is injury screening. This article reviews the evidence supporting the importance of surveillance and screening programmes, outlines some of the evidence-based screening tests, and offers some practical steps on constructing a programme, as well as enhancing or developing an existing one. And if you have ‘seniors’ who don’t yet appreciate the significance of this area of medical care, it will also arm you with some excellent research to help you support and justify your work.

Read this online http://spxj.nl/1TEyG2V FOOTBALL | 16-07-COKINETIC FORMATS WEB MOBILE PRINT

MEDIA CONTENTS Video demonstration of measuring external and rotation of the hip using a goniometer http://spxj.nl/1TKydMP (Credit YouTube user SCOFPTA2013) Video demonstration of knee-to-wall measurement http://spxj.nl/1VdceDj (Credit YouTube user Strength Physio) Video and information about the star excursion balance test http://spxj.nl/22hSG1u (Physiopedia) Video demonstration of the functional movement screen http://spxj.nl/1XE5zm2 (Credit YouTube user itrainwithscott)

How the functional movement screen works: Injuryproofing your body with the functional movement screen http://spxj.nl/1TiYcRg (Credit Linsay Way) Continuing education quiz This article also has a certificated eLearning assessment that can be found in the Media Contents box, or under the eLearning Assessment area in your Account area, on the Co-Kinetic website. The eLearning assessment(s) can be completed on all platforms including mobiles when accessed through the Co-Kinetic site; however, they are NOT accessible through the sportEX mobile app as you have to be logged into the actual website for the results to be recorded and the certificate to be generated. http://spxj.nl/1TEyG2V

Co-Kinetic.com

BY DAVID HARTLEY GSR

INTRODUCTION Research shows that injuries have an adverse effect on team performance in male professional football (1). This fact is, to a certain extent, common sense; when a team has their best players available they will tend to win more matches.

Over the last two decades, the financial reward for success in football has increased dramatically; clubs earn millions of pounds for qualifying for the Champions League group stages, and the English Premier League has recently announced a new TV deal worth billions.

Therapists already have an ethical commitment towards players’ health and wellbeing, but the financial rewards bring added pressure from owners, shareholders and coaches to keep players fit.

Injury prevention, therefore, plays an important role within the professional football setting. Current research advocates a multidisciplinary approach involving continuous athlete monitoring,

evidence-based interventions and objective outcome measurements.

This series will examine the research and outline how it can be applied in practice.

INJURY SURVEILLANCE Injury surveillance is a useful tool for monitoring injuries. It can highlight common patterns, locations and mechanisms of injury, which in turn can guide prevention strategies. If a team sustains a lot of knee injuries, for example, prevention strategies can be put in place to target the risk factors for these injuries.

Injury surveillance can also act as an outcome measure of injury prevention programmes. In short, are the prevention strategies working?

If a team still sustains a lot of knee injuries the following season, then the prevention programme would be deemed a failure. Likewise, if there was a significant reduction in knee injuries then it could be assumed that the prevention programme had

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the desired effect.

The UEFA Research Group outlined the methods by which to record injuries (2), which have been used in several longitudinal studies of injury rates in European football competition (3–5). The guidelines were designed for research purposes but by using the same methods, a therapist can make comparisons with published epidemiological data.

Details such as location of injury (Table 1) and injury classification (Table

INJURY SURVEILLANCE CAN ACT AS AN OUTCOME MEASURE OF INJURY PREVENTION PROGRAMMES. IN SHORT, ARE THE PREVENTION STRATEGIES WORKING TABLE 1: LOCATION OF INJURY (Orchard J. Orchard sports injury classification system (OSICS). Sport Health 1995;11:39–41) Region Total Head/face Neck/C-spine Shoulder/clavicle Upper arm

2) should be recorded (6), as should the mechanism of injury (traumatic versus overuse).

Non-contact and overuse injuries are generally considered to be ‘preventable injuries’, so these are the injuries that should be targeted by prevention programmes. If a player lands from a jump with hip internal rotation and knee valgus and ruptures their anterior cruciate ligament (ACL), there is probably an underlying biomechanical or neuromuscular deficiency to cause the injury. Similarly, a player could present with an Achilles tendinopathy following a heavy training schedule. In both scenarios, there are underlying issues that can be addressed by the therapist. However, there is nothing the therapist can do if a player sustains a fracture due to a dangerous tackle.

Training exposure and match exposure should be recorded on a daily basis. Injury rates can be calculated using the number of total injuries sustained in a season and the total exposure. Injury rate is expressed as number of injuries per 1,000 hours

TABLE 2: INJURY CLASSIFICATION (Orchard J. Orchard sports injury classification system (OSICS). Sport Health 1995;11:39–41) Injury type

Subtype

Fractures and bone stress

Fracture

Elbow Forearm Wrist

Hip and groin

Lower leg/Achilles Ankle Foot/toe

26

Sprain/ligament injury Lesion of meniscus or cartilage

Muscle and tendon

Tendon injury/rupture/tendinopathy/ bursitis

Contusion/laceration and skin lesions

Haematoma/contusion/bruise

Thigh Knee

Other bone injuries

Muscle rupture/tear/strain/cramps

Sternum/ribs/T-spine

L-spine/sacrum

Total

Dislocation/subluxation Joint (non-bone) and ligament

Hand/finger/thumb

Abdomen

of football (training and matches), as well as separately as injuries per 1,000 hours of training and injuries per 1,000 hours of matches. This enables the therapist to identify patterns of injuries.

If the majority of injuries are sustained in training, the therapist may examine the intensity or duration of the sessions in an attempt to reduce the injuries in this environment.

A detailed explanation of injury surveillance guidelines can be seen in the original consensus statement on injury data collection by Fuller et al. (2).

A study comprising seven consecutive seasons of professional football (4) identified the most common locations of injury as the thigh, knee, ankle and the hip and groin, whereas the most common injury classifications were muscle strains, ligament sprains and contusions. The fact that the common injuries are all of the lower limb is due to the nature of the sport and this will have implications in the screening protocol, as these are the locations that should be targeted.

The same study found that the mean injury rate was 8 ± 3.4 injuries per

Central/peripheral nervous system Other

Abrasion Concussion (with or without loss of consciousness) Nerve injury Dental injury Other injury

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1,000 hours, with injury rates increasing during matches. Each player can be expected to sustain two injuries per season. Assuming a squad to have 25 players, a team can expect to sustain 50 injuries per season (4).

prevention strategies more effectively.

Some of the most well-documented modifiable risk factors include joint range of motion (ROM) (8), strength (9–11), motor control (12) and proprioception (13,14).

RISK FACTORS

SCREENING

Screening is used in the sports medicine environment to highlight players who are at risk of injury.

Before we start the screening process, however, we must determine what we are looking for. What makes athletes susceptible to injury? What are the risk factors?

Traditionally, risk factors are listed as either intrinsic (athlete-related) or extrinsic (environment-related) (7,8).

Some intrinsic risk factors of injury cannot be controlled, such as age, gender and previous injury (8), whereas many extrinsic risk factors of injury are beyond the scope of the medical team, such as playing surface and foul play.

For the purposes of injury prevention, it may be more appropriate to list risk factors as either modifiable or non-modifiable in order to target

In practice, this means that a screening protocol should incorporate validated tests for these risk factors.

Published normative data (15–18) is available (Table 3) and can be used to determine which players are at risk of injury; once we determine what is ‘normal’, we can determine what is ‘abnormal’, and any individual outside the normal parameters should receive prevention exercises.

There will occasionally be individuals with anatomical variants that are ‘normal’ for them. For example, a player may be hypermobile, with excessive joint laxity. Although there is little that the therapist can do to modify this condition, it is useful information to obtain – especially if the therapist is assessing the player at a later date and a joint has no end feel! The nine-

point Beighton score is a quick and simple test that can reliably identify hypermobile individuals (19).

Preseason screening will provide baseline measurements of the players, which is useful should a player undergo a period of rehabilitation later in the season. The findings will also highlight areas to focus on and this will guide the individualised preventative exercises that are prescribed to each player. Screening should be repeated regularly throughout the season to ensure that the preventative exercises are working.

THE TESTS Tests should be reliable and quick to perform, using measurement tools that have been validated for use.

The mechanisms by which these factors increase risk of injury, and the rationale behind the tests used, will be discussed in more detail.

Reduced hip ROM (goniometer testing) Reduced hip ROM is thought to precede chronic groin injury,

TABLE 3: DOCUMENTED RISK FACTORS OF INJURY, CLINICAL TESTS AND NORMATIVE DATA (D. HARTLEY, 2016) Risk factor for injury

Test

Normative data/threshold

Reference

Reduced hip ROM

Goniometer testing

Internal rotation 38° External rotation 41°

Kouyoumdjian et al. Orthop Traumatol Surg Res 2012;98:17

Weak adductors

Dynamometer testing

Adduction strength equal to contralateral side

Thorborg et al. Am J Sports Med 2011;39(1):121

Adduction : abduction ratio >90%

Whitaker et al. Br J Sports Med 2015;49:803

Side-to-side imbalance <10%

Gill. sportEX med 2014;62:19

Conventional H : Q ratio 0.6

Gill. sportEX med 2014;62:19; Croisier et al. Am J Sports Med 2008;36:1469; Coombs & Garbutt. J Sports Sci Med 2002;1:56

Functional H : Q ratio 0.75

Gill. sportEX med 2014;62:19

Weight-bearing lunge (knee-towall test)

11–14cm

Bennell et al. Aust J Physiother 1998;44(3):175 Hoch & McKeon. Man Ther 2011;16(5):516

9.5cm Equal bilaterally

Konor et al. Int J Sports Phys Ther 2012;7(3):279

Ankle instability

Star excursion balance test

Equal maximal reach bilaterally

Olmsted et al. J Athl Train 2002;37(4):501

Poor motor control

Functional movement screen

>14/21

Kerkhoffs et al. Br J Sports Med 2012;46:854 Olmsted et al. J Athl Train 2002;37(4):501 Gribble et al. J Athl Train 2012;47(3):339

Hamstring:quadriceps strength imbalance

Reduced ankle ROM

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Isokinetic testing

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adductor muscle strains and pubic bone stress injury (20–23); hip joint restriction is also evident in those with femoroacetabular impingement (24) and pathology of the lumbar spine (25).

Rotational sports such as football, in which players squat, cut and pivot, require appropriate amounts of hip mobility. A hip joint restriction will affect the kinetic chain (25), causing an overload of other structures, which will in turn result in injury. A study comparing football players and age-matched controls suggested that football players have significantly reduced hip ROM, which may be a sign of early degenerative changes (26).

A goniometer is commonly used to measure hip joint ROM, with no significant differences found when testing the patient in different positions (15). This is a relatively inexpensive piece of equipment. Normative data published in 2012 (15) suggested a mean internal rotation of 38° and mean external rotation of 41°. This study included participants aged 20–60, and the authors noted that hip ROM decreases with age.

Weak adductors (dynamometer testing) There is level 1 and 2 evidence that reduced adduction strength is a risk factor for groin injury (27). The demands of football require the player to repeatedly sprint, change direction at pace, jump and strike the ball (28).

This requires high forces and the player must be able to produce and control these forces repeatedly during a game.

Biomechanical and EMG studies have shown that the adductor muscle group is most vulnerable at the backswing

NORMATIVE DATA CAN BE USED TO DETERMINE WHICH PLAYERS ARE AT RISK OF INJURY; ONCE WE DETERMINE WHAT IS ‘NORMAL’, WE CAN DETERMINE WHAT IS ‘ABNORMAL’ 28

and leg cocking phase of kicking, when they are eccentrically contracting at high intensity (29,30). Weak muscles will not be able to tolerate these forces, resulting in injury.

Prospective studies have shown that low levels of adduction strength result in a significantly increased risk of groin injury; Tyler et al. state that athletes have a 17 times greater risk of sustaining an adductor muscle strain if adductor strength is <80% that of the abductors (31).

A handheld dynamometer (HHD) is a reliable method to quantify hip strength (32,33). Research on adduction strength has investigated isometric and eccentric testing using a HHD. Isometric testing is less stressful on musculoskeletal tissues, but eccentric testing will better reflect the maximal strength required during activity and will, therefore, provide a more reliable strength value (32).

The adduction : abduction strength ratio is a simple way to evaluate adduction strength. Adduction strength is considered adequate if it is equal to the contralateral side (34) and within 90% that of the ipsilateral abductors (35).

Weak hamstrings (isokinetic testing) Most hamstring strain injuries (HSIs) occur during sprinting, at terminal swing phase of the running cycle when the hamstrings contract eccentrically (36).

It is, therefore, reasonable to assume that an individual with weak hamstrings would have an increased risk of sustaining a hamstring injury.

A side-to-side isometric hamstring strength imbalance of greater than 10% is considered a risk factor for hamstring strain injury (37), and Croisier et al. state that individuals with a side-to-side imbalance have a 4.66 greater risk of sustaining a HSI (10).

There has been a wealth of investigation of the agonist-antagonist relationship between the hamstrings and quadriceps. Isokinetic testing has often used the conventional ratio (concentric hamstrings : concentric quadriceps) to identify those at risk of a HSI. A conventional ratio of 0.6 is widely accepted as a threshold to

modify the risk of HSI; a conventional ratio of less than 0.6 would be considered at risk of injury (37–39).

The functional ratio (eccentric hamstrings : concentric quadriceps) has more recently been proposed as a more valid measure of hamstring strength. The functional ratio considers the action of the hamstrings during the most common mechanism of injury, so it is a better measure of the hamstrings’ ability to control the eccentric forces placed upon it during sprinting. A functional ratio of 0.75 is widely accepted as a threshold to modify the risk of HSI; a functional ratio of less than 0.75 would be considered at risk of injury (37).

Knee-to-wall test The weight-bearing lunge – or kneeto-wall test – is a measure of ankle dorsiflexion. Dorsiflexion is essential in most functional movements, such as walking, running or squatting. Limited closed-kinetic-chain dorsiflexion will result in compensations elsewhere in the kinetic chain; Cook et al. found that the most common limitation of squatting is due to reduced dorsiflexion (40). A reduction in ankle dorsiflexion has also been shown to increase the incidence of patella tendinopathy (41), and is associated with a greater risk of ACL injury (42).

The knee-to-wall test is quick and simple to perform, requiring only a tape measure. The subject performs a weight-bearing lunge so that their knee touches the wall with their foot remaining flat on the ground. The foot is moved further from the wall until the subject’s heel lifts. The therapist lightly touches the heel to assess for any movement while also visually assessing the subject’s foot position. Verbal cues may be required to ensure the subject does not pronate to achieve a higher score, as this could skew the results.

The score recorded is the furthest distance from the wall when the foot remains flat on the ground (18).

Bennell et al. and Konor et al. found the test to have high inter and intratester reliability (17,18). One centimetre of distance is thought to correspond to 3.6° of dorsiflexion,

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SUBJECT AREA LINK WHOLE REFERENCE TO ARTICLE PHYSICAL THERAPY MSK DIAGNOSIS, TREATMENT, REHABILITATION

although there is some debate as to what constitutes a normative value.

Some studies (17,43) state that individuals should have 11–14cm of ankle dorsiflexion, whereas Konor et al. found that 9.5cm is considered normal (18). In the author’s clinical experience, there is a high degree of variability amongst individuals. A better way of judging dorsiflexion is a side-to-side comparison. That is, if a subject’s dorsiflexion is equal bilaterally, it is probably ‘normal’, whether or not the values are within published normative data.

Star excursion balance test Functional ankle instability, whereby proprioceptive and neuromuscular deficits cause recurrent ankle instability, is thought to contribute to the sensation of joint instability. Mechanical instability refers to ligament laxity following an ankle sprain (14).

Functional and mechanical instability are both thought to contribute to chronic ankle instability (repetitive bouts of ankle instability, causing numerous ankle sprains), which causes significant time loss from sport. Exercises to prevent lateral ankle sprains (LAS) are only effective in those who have previously sustained an LAS (44). It is, therefore, important to identify those with ankle instability, in order to reduce the risk of sustaining recurrent LAS. Traditionally, single-leg stance has been the clinical assessment of choice; the examiner would subjectively analyse the subject’s postural control.

An individual with chronic ankle instability would demonstrate significant postural sway, and this method has been validated by numerous studies (14). It may be that static assessment of postural control does not provide sufficient challenge to consistently detect functional deficits in subjects after LAS (45), as functional instability is likely to be a combination of proprioception, neuromuscular and strength deficits (44), as well as postural control deficiencies.

The star excursion balance test (SEBT) is a test of dynamic stability that offers a more accurate assessment of lower limb function

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than single-leg stance. The subject is required to adopt single-leg stance and perform a maximal reach in eight directions with their opposite leg.

This is repeated with the other leg.

The length of the subject’s reach is recorded and both sides are compared.

The advantage of this test is that it provides a quantitative value to lower limb function, which is arguably more reliable than a subjective assessment of single-leg stance. Individuals with chronic ankle stability have significantly less reach on the affected stance leg, suggesting impaired function (45).

The test was traditionally designed to detect those with chronic ankle stability. However, successful performance of this test requires ankle dorsiflexion, knee flexion and hip flexion, extension, abduction and adduction, as well as proprioception, neuromuscular control, balance and strength; it is a true lower limb functional performance test. It can also be used to predict lower limb injury (46) and as an outcome measure of ACL rehabilitation (47).

Functional movement screen Research has shown that the central nervous system (CNS) – and more specifically the motor cortex – changes in the presence of pain, which results in altered muscle recruitment (48,49). Cholewicki et al. demonstrated that this change does not reverse following clinical recovery from injury (50). Individuals will display aberrant muscle recruitment patterns and abnormal motor control, even when asymptomatic, resulting in compensation. Training with these altered biomechanics will increase injury risk. This may partly explain why previous injury is the most influential risk factor for subsequent injury.

Identifying individuals with suboptimal motor control is an important component of a screening process. It is difficult to quantify movement, however, and even more so to define thresholds at which poor motor control becomes a risk factor for injury.

The functional movement screen (FMS) is a reliable, validated system for

THE FACT THAT THE COMMON INJURIES ARE ALL OF THE LOWER LIMB WILL HAVE IMPLICATIONS IN THE SCREENING PROTOCOL, AS THESE ARE THE LOCATIONS THAT SHOULD BE TARGETED predicting injury risk (50). It consists of movement challenges requiring various degrees of mobility and stability – tests are performed in symmetrical stance, split stance and single-leg stance. Each of the seven tests is scored out of three for quality of movement, providing a maximum score of 21. Prospective studies in several populations suggest that a score of less than 14/21 is a predictor of injury risk (51–53), but a score greater than this does not reduce injury risk.

A recent systematic review on injury risk factors and screening tests in professional football (54) included no studies on the FMS because they did not meet the eligibility criteria.

This is because studies including only professional male football players were included, whereas the majority of the research on the FMS has taken place on American football players. This resulted in a graded recommendation of D, indicating there was insufficient evidence to make a recommendation for the use of FMS.

Other documented risk factors of injury A screening programme should also include a postural analysis to identify any deficits that could predispose an athlete to injury. Excessive anterior pelvic tilt (55) has been implicated in HSIs, for example, and navicular drop (56) is considered a risk factor for medial tibial stress syndrome.

Evidence for flexibility as a risk factor is inconclusive. Some studies suggest a correlation between flexibility and injury risk (57), whereas other

29

studies demonstrate no relationship between the two (58).

CONCLUSION Injury surveillance can highlight common patterns and mechanisms of injury, which can in turn be addressed by the medical team.

Injury rates can be compared to epidemiological studies and determine the effectiveness of injury prevention strategies.

Joint mobility, muscle strength, proprioception and motor control have been identified as risk factors of injury and this article discusses validated clinical tests of these risk factors that are quick and simple to perform.

These tests can highlight athletes at risk of injury, enables the medical team to intervene and modify the risk. Tests can provide a baseline measurement in preseason, and can be repeated regularly throughout the season.

Interventions to modify risk factors of injury will be discussed in the next article in this series.

References Owing to space limitations in the print version, the references that accompany this article are available at the following link and are also appended to the end of the article in the web and mobile versions. Click here to access the references http://spxj.nl/1TtZ7fM

THE AUTHOR David Hartley GSR studied Sports Rehabilitation at the University of Salford and has worked in professional football since graduating in 2011. In that time he has worked closely with youth team, first team and international-level players, in both domestic and European competition. He is qualified to undertake the functional movement screen. He is a certified Matwork Pilates instructor with the Australian Physiotherapy & Pilates Institute. He has a special interest in injury prevention and the role it can play in enhancing and prolonging an athlete’s career. He will be beginning a Masters degree in Strength & Conditioning at the University of Salford in 2016.

Email: dhartley@live.co.uk Twitter: @davidbobhartley

DISCUSSIONS he epidemiological studies used to compare T injury rates are based on clubs competing in European competition. Is it possible to generalise these findings to clubs competing at other levels of the game?

Mobility, strength, proprioception and motor control are all validated risk factors for injury.

Do you think any of the risk factors has a more significant impact on an individual’s overall risk of injury than others?

Research to validate the FMS was undertaken on American Football players and military recruits.

A recent systematic review on injury prevention strategies in professional football concluded that there was insufficient evidence to recommend its use in football. Does the FMS have a place in a screening programme in the professional football setting?

A battery of clinical tests is useful to identify athletes at risk of injury. Some of the tests are more strenuous than others. What is the best order in which to undertake the tests?

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KEY POINTS n I njury surveillance can be used to find patterns and common mechanisms of injury. n Non-contact and overuse injuries are considered preventable injuries. n Risk factors of injury include joint mobility, strength, proprioception and motor control. n A battery of clinical tests can be used to test for risk factors of injury. n Some individuals have anatomical variants outwith normative data, which are ‘normal for them’. n Screening results can be compared with normative data to highlight those most at risk of injury. n Results will dictate the preventative exercises prescribed to each player. n Screening can be repeated regularly throughout a season to ensure prevention exercises are workings.

RELATED CONTENT Reintegration of a player back into the team after injury (Psychological and Physical factors). Fisic Conference presentation 2015 – http://spxj.nl/1ZRDnMa Reaching out for a helping hand: The role of social support in sports injury rehabilitation – http://spxj.nl/1cSm3DL It’s all in the mind: Psychosocial interventions to improve recovery – http://spxj.nl/1HdmLFz Risk, response and recovery: Psychology of sports injury – http://spxj.nl/1cSkzcK More psychology related content at this link – http://spxj.nl/1qy7z1T More football related content at this link – http://spxj.nl/1Tj08sM

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2002;1:56–62 40. Cook G, Burton L, Hoogenboom B. Pre-participation screening: The use of fundamental movements as an assessment of function – part 1. North American Journal of Sports Physical Therapy 2006;1(2):62–72 41. Malliaras P, Cook J, Kent P. Reduced ankle dorsiflexion range may increase the risk of patellar tendon injury among volleyball players. Journal of Science and Medicine in Sport 2006;9(4):304–309 42. Fong C-M, Blackburn JT, et al. Ankle dorsiflexion range of motion and landing biomechanics. Journal of Athletic Training 2001;46(1):5–10 43. Hoch MC, McKeon PO. Normative range of weight- bearing lunge test performance asymmetry in healthy adults. Manual Therapy 2011;16(5):516–519 44. Kerkhoffs GM, van den Bekerom M, et al.

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British Journal of Sports Medicine 2012;46:854–860 45. Olmsted LC, Carcia CR, et al. Efficacy of the star excursion balance tests in detecting reach deficits in subjects with chronic ankle instability. Journal of Athletic Training 2002;37(4):501–506 46. Gribble PA, Hertel J, Plisky P. Using the star excursion balance test to assess dynamic postural-control deficits and outcomes in lower extremity injury: a literature and systematic review. Journal of Athletic Training 2012;47(3):339–357 47. Clagg S, Paterno MV, et al. Performance on the star excursion balance test at the time of return to sport following anterior cruciate ligament reconstruction. Journal of Orthopaedic & Sports Physical Therapy 2015;45(6):444–452 48. Hodges PW, Moseley GL. Pain and motor control of the lumbopelvic region: effect and possible mechanisms. Journal of Electromyography and Kinesiology 2003;13:361–370 49. Tsao H, Galea MP, Hodges PW. Reorganisation of the motor cortex is associated with postural control deficits in recurrent low back pain. Brain 2008;131:2161–2171

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50. Cholewicki J, Greene HS, et al.

Neuromuscular function in athletes following recovery from a recent acute low back injury. Journal of Orthopaedic & Sports Physical Therapy 2002;32(11):568–575 51. Kiesel K, Plisky PJ, Voight ML. Can serious injury in professional football be predicted by a pre-season functional movement screen? North American Journal of Sports Physical Therapy 2007;2(3):147–158 52. Chorba RS, Chorba DJ, et al. Use of a functional movement screening tool to determine injury risk in female collegiate athletes. North American Journal of Sports Physical Therapy 2010;5(2):47–54 53. O’Connor FG, Deuster PA, et al.

Functional Movement Screening: predicting injuries in officer candidates. Medicine & Science in Sports & Exercise 2011;43(12):2224–2230 54. McCall A, Carling C, et al. Injury risk factors, screening tests and preventative strategies: systematic review of the evidence that underpins the perceptions and practices of 44 football (soccer) teams from various premier leagues. British Journal of Sports Medicine 2015;49;9:583–589 55. Brukner P, Nealon A, et al. Recurrent hamstring muscle injury: applying the limited evidence in the professional football setting with a seven-point programme.

British Journal of Sports Medicine 2014;48(11):929–938 56. Hamstra-Wright KL, Bliven KCH, Bay C. Risk factors for medial tibial stress syndrome in physically active individuals such as runners and military personnel: a systematic review and meta-analysis.

British Journal of Sports Medicine 2015;49:362–369 57. Barton CJ, Lack S, et al. The ‘best practice guide to conservative management of patellofemoral pain’: incorporating level 1 evidence with expert clinical reasoning.

British Journal of Sports Medicine 2015;49(14):923–934 58. O’Sullivan K, McAuliffe S, Lehman G. Injury prevention and management among athletic populations: to stretch or not to stretch? Aspetar Sports Medicine Journal 2014;3(3 Dec):624–628.

Co-Kinetic journal 2016;69(July):25-30

PHYSICAL THERAPY MSK DIAGNOSIS, TREATMENT, REHABILITATION

MULTIDISCIPLINARY REHABILITATION A case study of a proximal biceps tendon rupture

Working in a multidisciplinary team can be frustrating and difficult at times.

Creating a team requires a clear strategy with objectives and boundaries and good communication. To ensure a functioning and useful team, members must be constantly aware of their working relationships with each other and the impact they have on the player and their teammates. This case study involves an elite football player in a Premier League team with a complex hamstring injury and shows how a criteria-driven rehabilitation model is a practical approach to coordinating a multidisciplinary team and helping an athlete solve problems that are limiting their rehabilitation. The article is packed with practical tables covering most elements of the rehabilitation protocol and clearly demonstrates the effectiveness of using objective markers and criteria for progression within the rehabilitation process.

Read this online http://spxj.nl/1rOJQf9 FOOTBALL | LOWER-LIMB | 16-07-CO-KINETIC FORMATS WEB MOBILE PRINT

BY MATTHEW BRAMHALL MSC, ASCC, TOM SMITH BSC, MCSP HCPC AND DR BENJAMIN ROSENBLATT PHD, ASCC

INTRODUCTION It is widely acknowledged that rehabilitation from sports injury to returning to competition should be criteria-driven and hierarchical in nature (1). Athletes competing in professional and elite sport have a wide variety of sports science, medical and coaching practitioners at their disposal in order to help them achieve the highest level of sports performance possible. Indeed, a multidisciplinary rather than an individual-discipline focused approach to rehabilitation provides preferential outcomes in stroke and lower back rehabilitation (2,3). Within each phase of rehabilitation, athletes present with complex problems that limit their progression through each stage of rehabilitation.

This article demonstrates how a criteria-driven, multidisciplinary, problem-solving approach, was used to rehabilitate a professional footballerâ&#x20AC;&#x2122;s complex hamstring injury.

By adopting a problem-solving approach, the sometimes complex nature of injury rehabilitation can be simplified by identifying which physical parameters need to change and how best to achieve this change.

Furthermore, by using a problemsolving approach, specific rehabilitation objectives can be targeted and achieved, thus reducing the chances of fundamental elements being overlooked due to focusing only on the injury itself. The article presents several examples of using evidencebased practice and practice-based evidence to achieve a successful rehabilitation outcome, while highlighting the importance of early involvement of the multidisciplinary team when planning rehabilitation programmes.

The following case study of a

VARIED PRACTICE CAN ENHANCE SKILL PERFORMANCE BETTER THAN PRACTICE WITH LITTLE VARIETY Co-Kinetic.com

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professional football player outlines a complex individual case history, the constraints and considerations of the rehabilitation process and the problemsolving approach used in order to return the player to competitive match play. The case study also provides an insight into the value of a collaborative

approach to player rehabilitation between a physiotherapist, strength and conditioning coach, nutritionist and members of the technical coaching staff.

CONTEXT Understanding an athlete’s full case

history is important as it may help to determine some of the multifaceted causes behind the most recent issues that an athlete faces.

This particular athlete was a 19-year-old male professional footballer, contracted to an English Premier League club. He has represented his

TABLE 1: PLAYER’S INJURY HISTORY (M. Bramhall, T. Smith, B. Rosenblatt, 2016) Date

Injury history

Notes

2008

Fused right 1st metatarsophalangeal joint (non-surgical)

2012

Left RF proximal reattachment following partial rupture

RTP at 166 days

2014a

5×5mm oedema of long head of right BF at MT junction, no architectural disruption

RTP within 12 days

2014b

150mm longitudinal area of oedema of long head of right BF associated with partial fibre disruption at MT junction

During maximal velocity sprint RTP within 45 days

2014c

10×10mm oedema of long head of right BF at MT junction, no architectural disruption

During sprint acceleration RTP within 23 days

2014d Right BF and ST tendon insertion partial tear

During high-speed running Two platelet-rich plasma injections.

RTP within 102 days

2014 Functionally complete, acute tear of the intramuscular (current portion of the conjoined tendon of the BF and ST, injury) 72mm distal to the origin

Surgical repair 7 days post-injury.

RTP 157 days post-surgery

BF, biceps femoris; MT, musculotendinous; RF, rectus femoris; RTP, return to play; ST, semitendinosus

Figure 1: Transverse image of the macerated conjoined tendon tear (M. Bramhall, T. Smith, B. Rosenblatt, 2016) Figure 3: Sagittal image of the intramuscular tear (M. Bramhall, T. Smith, B. Rosenblatt, 2016)

Figure 2: Coronal image of the intramuscular conjoined tendon tear with margin laxity (M. Bramhall, T. Smith, B. Rosenblatt, 2016)

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Figure 4: Minor partial tearing of the proximal musculotendinous junction of semitendinosus and associated peri-sciatic haemorrhage (M. Bramhall, T. Smith, B. Rosenblatt, 2016)

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PHYSICAL THERAPY SUBJECT MSK AREA DIAGNOSIS, LINK WHOLE TREATMENT, REFERENCE REHABILITATION TO ARTICLE

KNOWLEDGE OF AN ATHLETE’S FULL CASE HISTORY IS IMPORTANT FOR UNDERSTANDING THE MULTIFACETED CAUSES BEHIND THEIR CURRENT PROBLEMS TABLE 2: PHASES OF REHABILITATION: OBJECTIVES AND PROGRESSION CRITERIA (M. Bramhall, T. Smith, B. Rosenblatt, 2016) Phase 1

2

3

4

5

Entry criteria

Objective

Immediately post- Tissue healing and restoration of joint operation range

10 Weeks postsurgery, full weight-bearing and full range of motion

Global and local muscle work capacity

Assessment

Rationale

Exit criteria

Straight leg raise (Passive: weeks 1–4) (Active: week 4+)

Biarticular muscles being lengthened across two joints, neural structures also under tension

Full weight-bearing and range of motion

Active knee extension (Hip 90° flexed) (From week 4)

Starting with hip already flexed, extension of the knee will demonstrate the limitation of soft tissue structures without incorporating neural tension

Isometric single-leg hamstring bridge.

Risk of hamstring injury due to sport-specific neural deconditioning, relative muscle weakness and fatigability (Elliot et al., 2011)

120s hold without any technical deviations

Isometric trunk hold (McGill, 2010)

Trunk conditioning is required to reduce stress going through pelvis (McGill, 2010)

120s hold without any technical deviations

50% Improvement in hamstring and trunk capacity

Hamstrings force production & stiffness

Isokinetic concentric knee flexion (60/240)

Capacity to produce high force and velocity contractions

Isokinetic eccentric knee flexion (60/240)

Capacity to tolerate high strain at high forces and velocities

90s Single-leg bridge

Football-specific conditioning

Completion of progressive sprint and change of direction drills

Develop a capacity for football-specific ‘match-based’ training

Symptom free completion of technical drills with no changes in clinical markers

Consistent exposure to high-speed running and sprinting

Develop a tolerance for high-speed running and sprinting

Between 75–85% of maximum match high-intensity distance per session over a period of 3–4 weeks

120s Single-leg bridge

<10% difference

Return to competition

Elliot, et al. Am J Sports Med. 2011;39:843 McGill. Strength Cond J. 2010;32:33

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Stage 1

Figure 5: L4/5 disc protrusion (M. Bramhall, T. Smith, B. Rosenblatt, 2016)

Time (s)

Hamstring capacity (s) 140 120 100 80 60 40 20 0

14 weeks

left right

17 weeks 20 weeks 25 weeks Assessment date (post-surgery)

31 weeks

Figure 6: Progression of hamstring muscle capacity (M. Bramhall, T. Smith, B. Rosenblatt, 2016

country at U19 level. His injury history is described in Table 1. Figures 1–4 show the extent of the injury using MRI.

CRITERIA-DRIVEN APPROACH TO RETURN TO COMPETITION A criteria-driven rehabilitation model was selected as a practical approach for coordinating the multidisciplinary team and ensuring that the player had the biomechanical and physiological capability of completing the increased activity demand before engaging with that work. The full criteria-driven returnto-competition model is detailed in Table 2.

TABLE 3: ROM RESTRICTIONS AND WEIGHT-BEARING STATUS, WEEKS 1–6 POSTOPERATION (M. Bramhall, T. Smith, B. Rosenblatt, 2016) Week Knee flexion

ROM 1

90° to full

Hip flexion ROM

WB status

Not beyond 60°

NWB

Stage 2 Following the return to an appropriate functional joint ROM, the player entered the second stage of the rehabilitation

process. The aim for this stage was not only to develop and increase the work capacity of the hamstring muscle group, but to increase the players overall tolerance to physical work: both physiologically and muscularly.

Individuals who have high capacities and tolerance for work are more robust and they also recover more quickly, both during exercise and between exercise exposures (ie. matches) (4). To determine the capacity of the hamstring muscle group, a single-leg bridge test was used. The single-leg bridge (SLB) test was similar to the one previously described by Hallet (5); however, the measure used in the current case study was an isometric position held for time as opposed to repetition number, as used by Hallet. The target threshold used was 120 seconds as this has been shown to provide an appropriate base of fatigue resistance from which to build other physical qualities such as force production and power.

Furthermore, it has been suggested that following periods of time away from match play, players may be at risk of hamstring injury due to sport-specific

TABLE 4: EXERCISE SELECTION TO IMPROVE HAMSTRING CAPACITY AND RATIONALE (M. Bramhall, T. Smith, B. Rosenblatt, 2016) Exercise

Rationale

Single-leg gym ball curl Loading of proximal hamstring to maintain hip

extension, while controlling knee flexion and extension Bridge walkouts Dominance of hip extension required more

proximal loading of hamstring with eccentric lengthening Single-leg bridge marching

Loading of proximal hamstring to maintain hip extension, while maintaining a fixed knee angle

Single-leg box bridge with opposite leg swing

Dominance of hip extension required more proximal loading of hamstring

TABLE 5: PERIODISATION OF HAMSTRING CIRCUIT LOADING IN ORDER TO FACILITATE CHRONIC ADAPTIVE RESPONSE

2

90° to full

Not beyond 60°

NWB

3

60° to full

Up to 90° with KF

NWB

4

60° to full

Up to 90° with KF

NWB

Week (post-surgery)

Load

5

30° to full

Beyond 90° with KF

NWB

14–17

3 rounds,

10 seconds on each exercise

Combined HF/KE as comfortable

Partial

18–20

3 rounds,

15 seconds on each exercise

6 0° to full

HF, hip flexion; KE, knee extension; KF, knee flexion; NWB, non-weight-bearing; WB, weight-bearing

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The key objectives of the initial stage of rehabilitation were to promote tissue healing, neural mobilisation and maintain muscle activity and blood flow, while minimising the formation of adhesions to the sciatic nerve, the collection of oedema and avoiding wound infection.

This all had to be delivered within the surgeon’s constraints of knee and hip flexion range of motion (ROM) and weight-bearing status (Table 3).

Weeks 7–10 were focused on retraining a normal gait pattern after weaning from crutches, while regaining normal joint ROM at the hip and knee by addressing the soft tissue tightness through specific, progressive mobilisation. Alongside this, early isometric strengthening work progressed to closed-chain concentric exercises, hydrotherapy was used for rehabilitation and conditioning, and trunk stability training was increased.

(M. Bramhall, T. Smith, B. Rosenblatt, 2016)

21–25 3 rounds,

20 seconds on each exercise (weeks 21 & 22) 25 seconds (weeks 23–25)

26–31

30 seconds on each exercise

3 rounds,

Co-Kinetic journal 2016;69(July):31-38

PHYSICAL THERAPY MSK DIAGNOSIS, TREATMENT, REHABILITATION

neural deconditioning, relative muscle weakness and fatigability (6), further highlighting the need for a sound base of localised muscular conditioning.

In addition to hamstring muscle capacity, the capacity of the anterior and lateral trunk musculature was also deemed to be important for the player, particularly in light of his previous contralateral injuries. The ability of the trunk to absorb and control rotational and shear forces has been linked to injury, as an inability to do this transfers forces to other structures, therefore putting them at risk of injury (7). As with the hamstrings, the ability of the trunk muscles to resist fatigue is crucial if an individual is to develop a tolerance for work and progress to develop an ability to tolerate high-force movements and actions. The anterior trunk was assessed by using a supine isometric leg hold, whereas the lateral trunk was assessed using lateral isometric hold on a weight-room bench.

work done and how that work relates to actual performance.

As the player had a history of injuring his hamstring muscles while sprinting, we felt it important that we gave him regular exposure to sprinting in order to condition his neuromuscular system to the specific biomechanical demand.

PROBLEM-SOLVING APPROACH TO REHABILITATION This section describes some of the problems that arose during the different stages of rehabilitation and how they were resolved by the multidisciplinary team. No rehabilitation is linear or straightforward and the key to successful and sustained return to competition is being able to identify the problems, apply critical thinking to identify a strategy or intervention and then put a measurement in place to ensure that the issue has been resolved.

Stage 3 As with any rehabilitation, the final phase of returning an individual to full training and competition can often be the most difficult to manage and measure the appropriate amount of loading required to prepare them for a full return to play.

In this case, the initial stages of the final phase included the reintroduction of basic movement skill rehearsal characterised by multiple submaximal repetitions, progressing onto maximal unopposed efforts over a number of weeks. However, this type of work is difficult to quantify in relation to actual

Stage 1 At approximately 10 weeks post-surgery, the player complained of a constant background, nagging low backache which was difficult to localise. The complaint of back pain was respected, and a lumbar spine MRI arranged to investigate its possible involvement. The scan showed an L4/5 disc protrusion, with discogenic abutment of the right L5 nerve (Fig. 5). Epidural steroid injection has been found to alleviate symptoms and allowed the return to high-level sport of 89% of American football (NFL)

TABLE 61: EXERCISE SELECTION TO IMPROVE TRUNK CAPACITY AND RATIONALE (M. Bramhall, T. Smith, B. Rosenblatt, 2016)

players with lumbar disc herniation (8).

As a consequence, a spinal specialist was consulted who recommended the epidural steroid injection. Within 10 days of the procedure, the player’s back pain settled and he was able to fully engage within his rehabilitation.

During the rehabilitation planning process, this lumbar spine pathology had to be considered carefully, as appropriate strengthening programmes for the biarticular hamstrings group had to be designed, avoiding any loading of a flexed or rotated lumbar spine, as well as the avoidance of unnecessary compressive axial loading.

Stage 2 Capacity assessments were undertaken approximately every 4–5 weeks throughout the rehabilitation process.

Upon initial assessment the player showed poor levels of muscle capacity in both hamstrings and a large left-toright imbalance (Fig. 6).

There is emerging evidence that muscle hypertrophy can be achieved using low loads and high training durations (9). This is due to the large muscle activity required to sustain contractions in the presence of fatigue (10). Additionally, varied practice can enhance skill performance compared to practice with little variety (11). As a consequence, a circuit of multiple exercises was developed to challenge the athlete’s capability to stabilise the pelvis with the trunk and gluteals, and extend the hip and flex the knee with the hamstrings (Table 4). The volume of work was periodised over a 4–5 week period before reassessment to ensure that the hamstrings were always receiving the necessary stimulus to facilitate an adaptive response (Table 5).

The progression of hamstring muscle capacity is shown in Figure 6.

Exercise

Rationale

Gym ball pot stir

Development of trunk capacity while reducing compressive forces on the spine and resisting rotation, flexion and extension

Side planks

Isometric strength development to resist lateral flexion of the trunk

TABLE 7: ANTERIOR AND LATERAL TRUNK ASSESSMENT SCORES POST-SURGERY (IN SECONDS) (M. Bramhall, T. Smith, B. Rosenblatt, 2016)

Double leg lower

Eccentric loading of the hip flexors while maintaining a neutral spine position

Assessment

14 Weeks

31 Weeks

Anterior trunk

104s

180s

Lateral trunk: left

85s

99s

Lateral trunk: right

90s

120s

Front planks

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Development of trunk capacity while reducing compressive forces on the spine and resisting rotation, flexion and extension

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Trunk capacity was developed using a variety exercises, some of which have been previously described by McGill (7), and the same circuit-based method as for the hamstring muscle group (Table 6). Target thresholds of 180 seconds and 120 seconds were required for the anterior and lateral trunk respectively.

Table 7 shows initial and most recent assessment values.

Following the development of appropriate levels of muscular capacity, the player was then able to focus on developing his force production and muscle stiffness qualities, and be reintroduced to pitch-based conditioning work.

Stage 3 At 15 weeks following surgery, the athlete demonstrated a similar deficit in peak torque regardless of contraction mode or velocity (with the exception of high-speed eccentric) (Fig. 7).

This indicated that regardless of the mechanism, the neuromuscular system was unable to produce similar amounts of force on both legs. As the player also had very low muscular capacity (Fig. 6), the conditioning circuits were used to address this imbalance.

Following 5 weeks of training, peak torque had increased across all isokinetic testing modalities (Fig. 7). As a consequence, more focus was placed upon reducing the asymmetry and placing greater strain loads through the tissue using exercises which replicated the mechanism of injury.

Extensive research has been conducted trying to identify the most appropriate exercises that can be used to rehabilitate injured hamstrings. Askling et al. (12) reported that rehabilitation exercises that focused on muscle lengthening were more effective than conventional exercises that shortened muscles. Given that the player in this case study sustained his injury during an action that resulted in extreme muscle lengthening, it was decided, in conjunction with the strong supporting research evidence, that exercises involving muscle lengthening would be the most appropriate type of exercise to form the majority of the rehabilitation programme. The programme included a

36

number of ‘traditional’ eccentric-based exercises, such as the Nordic hamstring; however, it also included exercises such as ‘the diver’ and ‘the glider’, both of which were used and found to be effective by Askling et al. (12).

It was felt that these exercises were appropriate for the player in question as they allowed eccentric loading of the hamstrings while maintaining a neutral lumbar spine. The exercises outlined also avoided any axial loading of the spine. The reason for lengthening exercises being so effective for this type of hamstring injury is due to the maximal dynamic loading of the hamstring involving movements at the hip and the knee (12). Table 8 describes the rationale for exercise selection in

order to resolve the specific issues that the player faced.

Stage 4 Upon returning to squad training, daily meetings with the technical coaches were held to discuss the player’s involvement in each session to manage his reintegration appropriately. Upon returning to training, the player was not receiving the planned stimulus of sprint and high-intensity distance (Table 3), due to the nature of a session or his role within the session (Fig. 8). In order to maintain specific conditioning of his hamstrings, the player was given top-up sessions of straight-line running in order to provide a conditioning stimulus. The volume and intensity of

15 Weeks

Left hamstring

Right hamstring

20 Weeks Left hamstring

Right hamstring

Concentric Deficit Eccentric Deficit (Nm) (%) (Nm) (%) 108

19 87

15 Weeks

Left hamstring

Right hamstring

20 Weeks Left hamstring

Right hamstring

132 75

43

118

144 24 7 110 110

240°/sec

60°/sec

Concentric Deficit Eccentric Deficit (Nm) (%) (Nm) (%) 134 204 22 27 105 148 176

24 133

226 163

28

Figure 7: Isokinetic peak torque at 240°/sec and 60°/sec, measured at 3 and 4 months post-surgery (M. Bramhall, T. Smith, B. Rosenblatt, 2016)

TABLE 8: HIGH-FORCE HAMSTRING EXERCISES AND RATIONALE FOR SELECTION (M. Bramhall, T. Smith, B. Rosenblatt, 2016) Exercise

Rationale

Nordic lowers

Development of eccentric strength while maintaining hip extension

The glider

Developing eccentric strength while maintaining a fixed-knee angle and neutral lumbar spine

The diver

Eccentric loading of the hamstring with hip flexion and neutral lumbar spine

Glute Ham Developer hip Isometric hamstring strength allowing for hip extension (bilateral flexion to extension without spinal loading progressed to unilateral, progressed with perturbations)

Co-Kinetic journal 2016;69(July):31-38

PHYSICAL THERAPY SUBJECT MSK AREA DIAGNOSIS, LINK WHOLE TREATMENT, REFERENCE REHABILITATION TO ARTICLE

work was determined by identifying the ‘shortfall’ between sprint distance performed in the session that had just been completed and the average sprint distance obtained from previous match data. The shortfall was then broken down into set distances to be achieved during a set time, for example 5 × 50m sprints, each to be completed in 10 seconds with a walk recovery.

Only by having access to this data were we able to prescribe top-up sprint work to be done each week so that he received an appropriate level of sprint stimulus each week.

CONCLUSION The purpose of this article is to demonstrate how a multidisciplinary team can solve the problems that an athlete faces in rehabilitating a complex injury. By identifying strict entrance and exit criteria to the progressive stages of rehabilitation, a problem-solving framework was established to help the athlete progress through the stages. In this example, the multidisciplinary team planned the exit and entrance criteria and used the data and clinical information that they collected at each stage in order to identify the most appropriate strategy to progress the athlete.

In conclusion, a criteria-driven rehabilitation model is a practical approach to coordinating a multidisciplinary team and helping an athlete solve the problems that are limiting their rehabilitation.

References 1. Myer GD, Paterno MV, et al. Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sport phase. Journal of Orthopaedic Sports Physical Therapy 2006;36(6):385–402 2. Yagura H, Miyai I, et al. Benefit of inpatient multidisciplinary rehabilitation up to 1 year after stroke. Archives of Physical Medicine and Rehabilitation 2003;84:1687–1691 3. Henchoz Y, de Goumnoëns P, et al.

Functional multidisciplinary rehabilitation versus outpatient physiotherapy for non-specific low back pain: randomised controlled trial. Swiss Medical Weekly 2010;140:w13133 4. Johnston RD, Gabbett TJ, et al. Influence of physical qualities on post-match fatigue in rugby league players. Journal of Science

Co-Kinetic.com

Figure 8: GPS data from pitch-based sessions for high-intensity distance and sprint distance. Pink, percent of match maximum; red, percent of match average.

(M. Bramhall, T. Smith, B. Rosenblatt, 2016 and Medicine in Sport 2015;18(2):209– 213 5. Hallet P. A reliability study examining the inter- and intra-observer reliability of the muscle capacity tests included in the ECB musculoskeletal screening protocol.

Masters thesis, University of Nottingham 2010 6. Elliott MC CW, Zarins B, et al. Hamstring muscle strains in professional football players. The American Journal of Sports Medicine 2011;39:843–850 7. McGill S. Core training: evidence translating to better performance and injury prevention. Strength and Conditioning Journal 2010;32:33-46 8. Krych AJ, Richman D, et al. Epidural steroid injections for lumbar disc herniation in NFL athletes. Medicine & Science in Sport & Exercise 2012; 44:193–198 9. Burd NA, West DW, et al. Low-load high volume resistance exercise stimulates muscle protein synthesis more than highload low volume resistance exercise in young men. PLoS One 2010;5(8):e12033 10. Tanimoto M, Ishii N. Effects of lowintensity resistance exercise with slow movement and tonic force generation on muscular function in young men. Journal of Applied Physiology 2006;100:1150–1157 11. Schmidt RA, Bjork RA. New conceptualizations of practice: common principles in three paradigms suggest new concepts for training. Psychological Science 1992;3(4):207–217 12. Askling CM, Tengvar M, et al. Acute hamstring injuries in Swedish elite sprinters and jumpers: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. British Journal of Sports Medicine 2014;48:532–539.

KEY POINTS nR ehabilitation of a complex hamstring injury was successful because of a close collaborative relationship between the S&C coach and physiotherapist. nT he successful outcome could also be accounted for by taking a problem-solving approach rather than a model of linear progression. nT he criteria-driven approach was important as it provided the practitioners with a framework to progress the athlete. nU sing objective markers provided clear evidence of progression and directed future programme content. nT he criteria-driven approach was important as it helped to manage expectations and returnto-play time frames for both the player and coaching staff. nT he use of GPS technology during the late return-to-play phase can ensure that the appropriate level of pitch-based training has been achieved before a return to full training and competitive match play. nT he complex nature of this hamstring injury required the appropriate selection of rehabilitation exercises related to the mechanism of injury while acknowledging other physical constraints and limitations. nB y using a constraint-led, criteria-driven approach, the rehabilitation team was able to focus on rehabilitating the needs of the individual rather than the sole focus being on the specific injury.

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THE AUTHORS Matt Bramhall MSc, ASCC is head of strength and conditioning at a leading Premier League club academy where he works as part of an innovative, dynamic and highly experienced multidisciplinary support team. He previously spent 7½ years at the English Institute of Sport (EIS) predominantly working with the Great Britain and England Hockey squads, including supporting the London 2012 Olympic bronze medal and 2013 European silver medal winning women’s squads. Prior to his role with GB and England Hockey, Matt was the lead S&C coach for Paralympics GB in the build-up to and during the 2008 Paralympic games in Beijing. In 2014 he completed his MSc in strength and conditioning, with his thesis focusing on hormonal responses to different training stimuli, and has been a qualified soft tissue therapist since 2010. During his 10 years of coaching experience Matt has worked with a wide range of sports and organisations ranging from The Football Association to England Golf and British Swimming, supporting numerous squads and individuals.

Twitter: @matbram Tom Smith BSc, MCSP HCPC is a chartered physiotherapist who trained at the University of Hertfordshire. He began his career working in the NHS and private practice, and has since gone on to enjoy an illustrious career to date working at various levels in professional football.

After working with a club in Singapore, Tom went on to work as an academy physiotherapist back in the UK for 2 years. The following 4 years saw him working as a first team physiotherapist for a Premier League Football Club, including a period involved in European competition. Since 2012, Tom has been in his current position of head of Elite Performance and Sports Medicine at a leading category 1 football academy, where he manages people involved

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HERE ARE SOME SUGGESTIONS Tweet this: A problem-solving approach allows specific rehab objectives to be achieved http://spxj.nl/1rOJQf9 Tweet this: Early involvement of the multidisciplinary team is important when planning injury rehab http://spxj.nl/1rOJQf9 Tweet this: Muscle hypertrophy can be achieved using low loads and high training durations http://spxj.nl/1rOJQf9 Tweet this: Varied practice can enhance skill performance better than practice with little variety http://spxj.nl/1rOJQf9

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in an array of disciplines (such as sports scientists, strength and conditioning coaches, physiotherapists, doctors, psychologists and nutritionists), while practising as a physiotherapist to the leading talented players hoping to progress their careers as Premier League footballers.

LinkedIn: https://uk.linkedin.com/in/tom-smith-1a032b56 Dr Benjamin Rosenblatt PhD, ASCC is passionate about working with coaches and athletes to help them find the most effective training approaches to help them win matches, tournaments and competitions.

He is a senior strength and conditioning coach at the English Institute of Sport. He leads the physical preparation programme for the GB Women’s Hockey team in the build up to the Rio Olympic Games. Ben is also the S&C coach for several international judo fighters who have won Olympic, Commonwealth and World Cup medals and is a physical performance and rehabilitation consultant for the English Cricket Board. Ben completed his PhD in a biomechanical analysis of the principles of training in 2014. Prior to his work with GB Hockey, Ben was the senior rehabilitation scientist of the British Olympic Association’s Intensive Rehabilitation Unit. Within this role he worked in a multidisciplinary team to develop innovative training methods to accelerate the rehabilitation of injured athletes. Ben took on this role after leading the Sports Science and Conditioning department of Birmingham City FC for two seasons. Ben is a consultant for football clubs, rugby clubs and national governing bodies of sport, and has written book chapters and presented at international conferences on rehabilitation and training.

Twitter: http://twitter.com/ben_rosenblatt

DISCUSSIONS hat are the advantages of multidisciplinary W rehabilitation?

What value did the S&C coach add to the rehabilitation?

Was there value in using a problem-solving approach?

Given the same scenario, what would you do?

RELATED CONTENT Sprint-related hamstring injuries: The current state of play http://spxj.nl/1HdmmTJ Hamstring injuries in football part 1: assessment, diagnosis and prognosis http://spxj.nl/1cSkNRk Hamstring injuries in football part 2: prevention http://spxj.nl/1Hdnbfg More football-related content http://spxj.nl/1Tj08sM

Co-Kinetic journal 2016;69(July):31-38

PHYSICAL THERAPY RESEARCH LITERATURE INTO PRACTICE REVIEW

Our regular research reviewer, physical therapist Joseph Brence, reviews research looking into how good communication skills and a careful subjective examination of the patient are at the base of creating the therapeutic alliance and caring for the patient.

Read this online http://spxj.nl/1iIUEau

THE IMPORTANCE OF A SUBJECTIVE EXAMINATION TO DRIVE PATIENT-CENTRED CARE

W

16-07-COKINETIC FORMATS WEB MOBILE PRINT

hile attending the annual American Academy of Orthopedic Manual Physical Therapists’ conference in October 2013, I was introduced to a very insightful researcher, Dr Ali Rushton.

Dr Rushton gave a very charismatic lecture which discussed the value of a focused subjective examination. Within the talk, she stated: “The subjective examination data is essential to clinical reasoning processes and its theoretical support is strong. You should understand why you ask every question. Every question should serve a purpose in your clinical practice.”

She highlighted the importance of distinguishing the biological, psychological and social factors which impact practice and the importance of gathering hypotheses while proceeding through the subjective examination.

She stated, ‘experts’ spend more time with their patients and develop more hypotheses [12] during the subjective exam as compared to novices [9].”

Following her talk, I thought about how important her topic is to everyday

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BY JOSEPH BRENCE DPT, FAAOMPT, COMT, DAC patient care. The subjective examination ultimately helps us construct the ‘therapeutic alliance’, which likely has a large impact on outcomes. The subjective examination involves a significant amount of clinical reasoning to know ‘what questions to ask and why’ as well as the ability to develop and test hypotheses.

In 2012, Pinto et al. performed a systematic review to determine which communication factors correlate with the constructs of forming a positive therapeutic alliance with our patients. The authors found interaction styles that are patient facilitating, patient involving and patient supporting are associated with constructs of this alliance (1). The authors found that listening more to what patients had to say, asking questions and showing sensitivity to emotional concerns helped to facilitate this relationship. These factors help drive ’patient-centred’ care and ultimately, outcomes.

Communication styles and the ability to deliver ‘patient-centred’ care differs between novices and experts. During her talk, Rushton stated, “Expertise is not just based upon duration of time, but the quality of work performed during that time.” This quote is supported by the work of Jensen et al. who describe the concept of expertise as a continuous process, not a single state of being (2). It is a constant development that incorporates change; accumulation of experience does not equal expertise.

We learn through our interactions with others and the ability to clinically reason is based on cognitive and metacognitive processes as well as the development of knowledge.

The concept of ‘patient-centred’ care is derived from the selfdetermination theory (SDT) (3). The SDT states that humans have basic psychological needs for autonomy, perceived competence and relatedness (feeling safe and cared for in one’s personal relationships). When a patient feels these needs are being met, their participation in treatment will be more autonomous and willing. Often, the opposite occurs in healthcare, where controlled motivation involves the patient engaging in treatment secondary to external pressure, coercion, and/or feelings of guilt. As clinicians, we ultimately want to limit our abilities to be ‘operators’ and instead become ‘interactors’.

Overall, we must understand that we have a complex being in front of us that needs to interact on multiple levels. It’s ultimately not about us; it’s about them. Understanding this is the foundation of the subjective exam.

References 1. Pinto RZ, Ferreira ML, et al. Patientcentred communication is associated with positive therapeutic alliance: a systematic review. Journal of Physiotherapy 2012;58:77–87 2. Jensen GM, Gwyer J, et al.

Expertise in physical therapy practice, 2nd edn. Saunders 2006. ISBN 978-1416002147. Buy from Amazon http://amzn.to/1s4vpUd. 3. Deci EL, Ryan RM. Overview of self-determination theory: An organismic dialectical perspective.

In: Deci EL, Ryan RM (eds) Handbook of self-determination research. University of Rochester Press 2013. ISBN 9781580461566. Buy from Amazon http://amzn.to/1s4v2Jr.

39

BROUGHT TO YOU BY

Nxt Gen Institute of Physical Therapy

THE ROLE OF THE PLACEBO IN PATIENT CARE A Our regular research reviewer, physical therapist Joseph Brence, reviews s we reflect on our clinical interactions, we can all describe instances in which some of our patients got better (this is what we attempt to do, right?). Although we would like to attribute these results to the interventions we employed, we cannot ignore the fact that they may at least be partially attributed to contextual or non-specific factors, known as the placebo effect. In 2011, Bialosky et al. (1) attempted to give some weight to this concept by stating, “The mechanisms through which manual therapy inhibits musculoskeletal pain are likely multifaceted and related to the interaction between the intervention, the patient, the practitioner, and the environment. Placebo is traditionally considered an inert intervention; however, the pain research literature suggests that placebo is an active hypoalgesic agent.” The idea of reconceptualising the placebo has been assessed in multiple recent articles. In this literature review, I took a look at a recent article published in Pain (2) that set forth to understand patients’ acceptability of placebo through using a patient-centred survey.

THE STUDY The researchers of this study sought to examine: (1) the individual’s knowledge of placebos, (2) the role of medical contextual factors in appraising a placebo’s acceptability, and (3) the role of deception and treatment effectiveness in attitudes towards using a placebo as an analgesic. They designed the study around an online patientcentred questionnaire, which was administered to subjects that had a history of chronic musculoskeletal pain, existing for at least 3 months.

Fifty-seven participants (40 female, 17 male; mean age of 45.12 years) were recruited from two university outpatient medical clinics, as well as community advertisements, to take part in the study.

40

BY JOSEPH BRENCE DPT, FAAOMPT, COMT, DAC

research looking into evidence that suggests that the placebo effect can be useful in treating chronic pain conditions.

Read this online http://spxj.nl/1iIUIHl THE QUESTIONNAIRE’S THREE MEASURES This 30-minute online questionnaire set out to further examine three concepts: 1. Placebo knowledge, conceptualisation and efficacy Participants used a visual analogue scale (VAS) and were asked to rate their perceived knowledge of placebo analgesia, conceptualisation of placebo, perceived effectiveness of placebo for reducing pain, and placebo analgesia treatment accountability.

2. Placebo acceptability Participants used a VAS to answer six questions: i. How acceptable would it be if a physician overtly administered a placebo treatment for pain? ii. How acceptable would it be if a physician covertly administered a placebo treatment for pain? iii. How acceptable would it be if a physician used a placebo as a treatment enhancer of an adjunct treatment? iv. I s it acceptable for a medical provider to treat pain with a placebo for a condition for which there are other established treatments? v. Is it acceptable for a medical provider to treat pain with a placebo for a condition for which there are no other established treatments? vi. Is it acceptable for a medical provider to use a placebo to determine whether a patient’s complaints are ‘real’?

3. Deception, trust and negative mood Participants were presented with six hypothetical scenarios and they had to determine if the individual in each scenario was receiving a placebo intervention. They used a VAS to rate: i. The deceptiveness of the

hypothetical clinical encounter/ placebo intervention ii. Their level of trust in the prescribing physician iii. The amount of negative mood they would experience if they had received the placebo treatment for their pain.

16-07-COKINETIC FORMATS WEB MOBILE PRINT

THE RESULTS The researchers found that individuals suffering with chronic musculoskeletal pain had little knowledge of the placebo effect and its efficacy for reducing pain.

This stated, it was found that receiving a placebo analgesic response appeared to reduce negative mood and improve trust in a provider. Acceptability of this was found to be dependent on the context in which the placebo was used.

OUR INTERPRETATION So although there is much more that needs to be understood about the placebo effect, it does appear that individuals suffering from chronic pain may benefit from the addition of a placebo during treatment. This study found that placebo interventions were most acceptable when used to complement established pain treatments to improve overall efficacy.

References 1. Bialosky JE, Bishop MD, et al. Placebo response to manual therapy: something out of nothing? The Journal of Manual & Manipulative Therapy 2011;19(1):11–19 2. Kisaalita N, Staud R, et al. Placebo use in pain management: The role of medical context, treatment efficacy, and deception in determining placebo acceptability. Pain 2014;155(12):2638–2645.

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Co-Kinetic journal 2016;69(July):39-41

PHYSICAL THERAPY RESEARCH INTO PRACTICE

L

ow back pain (LBP) is a complex diagnosis that affects millions of individuals per year. Epidemiological studies indicate the 1-year incidence of people who will experience LBP ranges from 1.5 to 36% and estimates of the re-occurrence of this pain at 1-year, ranges from 24–80% (1). It is suspected that the prevalence of chronic LBP is on the rise with certain geographical rates rising from 3.9% in 1992 to 10.2% in 2006 (2). The costs associated with the treatment of chronic LBP are astronomical and our ability to screen and predict chronicity has been inherently difficult.

A recently developed screening tool, the ‘subgroups for targeted treatment’ (STarT) back screening tool, may be an important resource in helping guide our initial determination of treatment for those with LBP (and ultimately reduce the development of chronic issues).

This article is to further help clinicians understand the potential implications of the STarT tool.

In 2011, an article in the Lancet compared the clinical effectiveness and cost-effectiveness of stratified primary care with current non-stratified practice (3). To do this, investigators used a 2:1 randomisation to divide 851 individuals who presented with back pain, into either an intervention or control group, respectively. All participants (both groups) completed the STarT questionnaire before the study to determine risk classification.

Individuals randomised into the control group were assessed and the treatment decision was simply based upon a physiotherapists judgement. Those in the intervention group were treated based upon their STarT scores, which determined a level of risk: n Low risk: 3 or less on total STarT score. Patients had a 30-minute assessment and initial treatment with advice focusing on promotion of appropriate levels of activity, including return to work, as well as given a pamphlet highlighting local exercise venues and self-help groups. In addition, these individuals were shown a video, Get Back Active, and given the Back Book. n Medium risk: 4 or more on total

Co-Kinetic.com

THE STarT BACK SCREENING TOOL: A PLAUSIBLE TOOL FOR STRATIFICATION

BY JOSEPH BRENCE DPT, FAAOMPT, COMT, DAC

Our regular research reviewer, physical therapist Joseph Brence, reviews research looking into the benefit of grading low back pain using the ‘subgroups for targeted treatment’ (STarT) back screening tool from Keele University. Read this online http://spxj.nl/1UOcVj2 STarT, with 3 or less on questions 5–9. Patients were also given the same initial session and then referred for standardised physiotherapy to address symptoms and function. n High risk: 4 or more on total STarT, with 4 or more on questions 5–9. Patients were also given the same initial session but referred for psychologically informed physiotherapy to address physical symptoms and function, while also addressing psychosocial obstacles.

Primary clinical outcomes were assessed on a Roland and Morris Disability Questionnaire at baseline, 4 and 12 months. Multiple secondary outcome tools were also assessed which looked at variables such as catastrophising, kinesiophobia, anxiety and depression, etc.

Overall, the results of this study indicated that stratified management of patients with LBP leads to improved efficiency of care, better outcomes and reduced costs. Significant improvements in secondary measures were also noted. Use of this method of stratification, using a prognostic-risk screening to match referral needs, appears to be more effective than simply treating based upon clinical judgement. Additional research needs to be conducted to assess the abilities of this tool, but at face value, the tool makes sense and its prognostic abilities appear plausible.

The STarT back screening tool, and further information about it, is available from Keel University STarT Back http://www.keele.ac.uk/sbst/ website.

References 1. Hoy D, Brooks P, et al. The

epidemiology of low back pain. Best Practice and Research Clinical Rheumatology 2010;24(6):769–781 2. Freburger JK, Holmes GM, et al. The rising prevelance of chronic low back pain. JAMA 2009;169(3):251–258 3. Hill JC, Whitehurst DGT, et al.

Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011;378:1560–1571.

UPPER BODY | LOW BACK PAIN | 16-07-COKINETIC FORMATS WEB MOBILE PRINT

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THE AUTHOR Joseph Brence DPT, FAAOMPT, COMT, DAC is a physical therapist and clinical researcher from Pittsburgh, PA, USA. He is also a fellowship candidate with Sports Medicine of Atlanta, GA, USA. Joseph’s primary clinical interests involve a better understanding of the neuromatrix and determining how it applies to physical therapy practice. He is currently involved in a wide range of clinical research projects investigating topics such as the effects of verbalising pain, the effects of mobilising versus manipulating the spine on body image perception and validation of an instrument which will assess medical practitioners’ understanding of pain. Clinically, Joseph treats a wide range of painful conditions in multiple settings including complex regional pain syndrome, fibromyalgia and chronic fatigue syndrome. Joseph also runs the Forward Thinking PT blog http://forwardthinkingpt.com/.

Email: joebrence9@hotmail.com

41

MANUAL THERAPY STUDENT HANDBOOK: Assessment and treatment of the hip This article is the fifth in a series from our Manual Therapy Student Handbook (see the ‘Contents panel’ for further details) and it describes how to assess and treat common hip complaints. As well as listing a comprehensive assessment procedure, the treatments are described in full and have accompanying videos, which provides a great practical resource for the clinician. Read this online http://spxj.nl/1QhBT6P FUNCTIONAL ANATOMY A sound knowledge of anatomy is a necessary skill for the competent manual therapist. As a result, the functional anatomy of the region should be revised before continuing with assessment and treatment techniques.

Video 1 shows surface marking of the anatomical area and will help you with the key structures encountered in this article.

Assessment of the hip For a full assessment of the hip, the therapist must be familiar with the anatomy of the area and perform the observations and examinations detailed in Table 1 and Video 2.

Treatment around the hip CAPSULAR PATTERN The capsular pattern of movement limitation at the hip is defined by: n Most loss of medial rotation n Equal loss of abduction and flexion n Least loss of extension.

CAUSES OF CAPSULAR PATTERN Typical causes of capsular pattern movement limitation at the hip are shown in Table 2.

HIP | 16-07-COKINETIC FORMATS WEB MOBILE

BY JULIAN HATCHER GRAD DIP PHYS MPHIL, MCSP FOM Treatment choice n Mobilisations of the hip.

Flexion mobilisation (Video 3) Directions: 1. Stride standing with lower leg supported on inside arm.

2. Support thigh or pelvis with outside hand below.

3. Take leg into flexion (depending on grade).

4. It may be helpful to place patient’s foot on your inner shoulder so you can utilise your own body weight in making the manoeuvre easier to control.

Medial rotation mobilisation (Video 4) Directions: 1. Similar position to above with lower leg supported on inner arm.

2. Again, support thigh or pelvis with outside hand below.

3. Use inner arm to take lower leg laterally causing the femur to rotate medially.

4. Again, grade according to clinical assessment.

Video 1: Surface marking of the hip region (Video with captions but no sound; J. Hatcher, 2013)

Caudad longitudinal mobilisation in flexion and extension (Video 5) Directions: 1. Stride standing with lower leg supported on inside arm.

2. Support thigh or pelvis with both hands low on the thigh.

3. Use body weight through firm hands to pull the upper end of the femur in a caudad direction.

4. Grade accordingly.

Lateral glide mobilisation (Video 6) Directions: 1. Similar position to longitudinal mobilisation.

2. Support thigh or pelvis with both hands low on the medial side of the thigh.

3. Use body weight through firm hands to pull the upper end of the femur in a lateral direction.

4. Again, grade accordingly.

NON-CAPSULAR PATTERN Patterns of movement limitation that do not fit the capsular pattern are therefore described as non-capsular.

Video 2: Assessment of the hip (Video with captions but no sound; J. Hatcher, 2013)

PRINT

MEDIA CONTENTS Video: Hip rehabilitation exercises J. Hatcher, 2013

42

Co-Kinetic journal 2016;69(July):42-45

MANUAL THERAPY STUDENT HANDBOOK

TABLE 1: ASSESSMENT OF THE HIP (J. Hatcher, 2013)

TABLE 2: CAUSES OF CAPSULAR PATTERN AT THE HIP (J. Hatcher, 2013)

OBSERVATION/ EXAMINATION DETAILS

CAUSE Osteoarthritis (OA)

TYPICAL FEATURES nW ear and tear to the joint, may be primary, or possibly secondary to previous lesion. n Mild capsulitis, possible crepitus.

Rheumatoid arthritis (RA) and other systemic arthropathies

n Refer to GP for nS ystemic autoimmune Rheumatology opinion. disease, causing degeneration and possible n If not in acute flareup, may use Grade A joint disruption.

(Maitland Grade I and n Often severe capsulitis, II) mobilisations and may lead to joint laxity progress to Grade B (III and deformity. and IV).

1. Anatomy

n Joint derived from L3 segment nD ermatomes L1,2,3: front S2: back n Myotomes L1,2,3: flexors L2,3,4: adductors L5: abductors S1: extensors

2. Initial observation n Face and posture and gait 3. History n Age and occupation

n Site and spread

n Onset and duration

n Behaviour and symptoms

n Past medical history (P.M.H.) 4. Inspection

n n n n

Bony deformity Colour changes Wasting Swelling

5. Objective n Observe/examine state at examination rest and eliminate lumbar spine and sacroiliac joint 6. Supine

n F ive passive tests: flexion medial rotation lateral rotation abduction adduction

n F our resisted tests: flexion extension abduction adduction

7. Prone

n Two passive tests: extension medial rotation (again)

n F our resisted tests: medial rotation lateral rotation knee flexion (hamstrings) knee extension (rectus femoris)

8. Additional specific tests

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Traumatic arthritis (TA)

n Unusual in the hip joint.

CAUSES OF NONCAPSULAR PATTERN A common cause of non-capsular movement limitation at the hip is the presence of a loose body.

Loose body The key clinical features are: n Intermittent twinges of pain nM ay have sense of locking, or more likely giving way nM ay have springy end-feel to movements nM ay have mild capsular pattern if degeneration involved.

Treatment choice n L oose body manoeuvre.

Video 3: Mobilisation of the hip: flexion (Video with captions but no sound; J. Hatcher, 2013)

TREATMENT n Warm the capsule using appropriate electrotherapy and use Grade B (Maitland Grade III and IV) mobilisation and self-help exercises to end of range.

nM ay require mobilisation as pain allows, Grade A–B (I–IV).

Loose body manoeuvre to the hip joint (Video 7) Directions: 1. Stand on end of bed facing direction you wish to rotate the leg (medial or lateral rotation).

2. Grasp lower leg above ankle, cephalad hand below, caudad hand above.

3. Take caudad leg away from bed and lean away from patient (causing traction).

4. Slowly step off the bed (keeping traction on) and take leg through small range of extension while simultaneously ‘flicking’ leg into rotation (medial or lateral). Aim for 3 good flicks through small range of extension.

Video 4: Mobilisation of the hip: medial rotation (Video with captions but no sound; J. Hatcher, 2013)

Don’t forget to perform any special tests and complete the examination with palpation of the region.

43

VIDEOS OF INDIVIDUAL EXERCISES:

RECOMMENDED READING

CONTRACTILE LESIONS

FURTHER RESOURCES

A common contractile lesion of the hip is adductor longus strain.

n Often traumatic lesion, either repetitive or single strain n Trauma may not be remembered, often stubborn to treat n Pain on resisted adduction of hip n Pain on passive abduction.

1. Diduch D, Brunt LM. Sports hernia and athletic pubalgia: diagnosis and treatment. Springer Publications 2014. ISBN 9781489974204.

Buy from Amazon http://amzn. to/1Xrt9Cb 2. Karageanes SA. Principles of manual sports medicine. Lippincott Williams & Wilkins 2005. ISBN 9780781741897. Buy from Amazon http://amzn.to/1XrtaWR

1. Anderson MK, Parr GP. Fundamentals of Sports Injury Management. Lippincott, Williams & Wilkins 2011. ISBN 9781451109764. Buy from Amazon http://amzn.to/20pUR1v 2. Cyriax J. Textbook of orthopaedic medicine, vol.

1: diagnosis of soft tissue lesions, 8th ed. Balliere Tindall 1982. ISBN 978-0702009358 Buy from Amazon http://amzn.to/20pV4ld 3. Boyling J, Jull G. Grieve’s modern manual therapy: the vertebral column, 3rd ed.

Churchill Livingstone 2005. ISBN 978-0443071553. Buy from Amazon http://amzn.to/20pVckX 4. Higgs J, Jones A, et al.

Clinical reasoning in the health professions, 3rd ed.

Butterworth-Heinemann 2008.

ISBN 978-0750688857. Buy from Amazon http://amzn.to/20pVND2 5. Abrahams PH, McMinn RMH. McMinn and Abrahams’ Clinical atlas of human anatomy, 7th ed. Mosby 2013. ISBN 9780723436973. Buy from Amazon http://amzn.to/20pVjNk 6. Magee DJ. Orthopaedic physical assessment, 6th ed.

Saunders 2014. ISBN 9781455709779. Buy from http://amzn.to/20pVM1S 7. Hengeveld E, Banks K. Maitland’s Vertebral Manipulation: management of neuromusculoskeletal disorders – volume 1, 8th ed. Churchill Livingstone 2013. ISBN 978-

Video 5: Mobilisation of the hip: longitudinal in extension (Video with captions but no sound; J. Hatcher, 2013)

Video 6: Mobilisation of the hip: lateral glide in flexion (Video with captions but no sound; J. Hatcher, 2013)

Video 7: Manipulation of the hip: loose body manoeuvre (Video with captions but no sound; J. Hatcher, 2013)

Individual videos available on Co-Kinetic.com (J. Hatcher, 2013) Video 1. Surface marking of the hip region Video 2. Assessment of the hip Video 3. Mobilisation of the hip: flexion Video 4. Mobilisation of the hip: medial rotation Video 5. Mobilisation of the hip: longitudinal in extension Video 6. Mobilisation of the hip: lateral glide in flexion Video 7. Manipulation of the hip: loose body manoeuvre Video 8. Deep transverse frictional massage to adductor longus Video 9. D eep transverse frictional massage to upper attachment of hamstrings

Adductor longus strain The key clinical features are:

44

Treatment choice n Deep transverse frictions.

Deep transverse frictions to the adductor longus (Video 8) Directions: 1. Have patient’s flexed knee resting against your stomach.

2. Place tip of middle finger directly over site of lesion (usually tenoosseous junction of adductor longus).

3. Reinforce with index finger and apply transverse frictional massage.

Deep transverse frictions to hamstrings origin (Video 9) Directions: 1. Have patient with flexed knee and hip, lying prone at edge of bed.

Support leg on additional chair.

2. Place thumb of outmost hand directly over site of lesion (tenoosseous junction of biceps femoris).

3. Have bed in relatively low position to allow you to ‘dominate the patient’ using your body weight.

4. Reinforce with heel of other hand and apply transverse frictional massage.

Co-Kinetic journal 2016;69(July):42-45

MANUAL THERAPY STUDENT HANDBOOK

0702040665. Buy from Amazon http://amzn.to/1s4p8YS 8. Hengeveld E, Banks K. Maitland’s Peripheral manipulation: management of neuromusculoskeletal disorders – volume 2, 5th ed. Churchill Livingstone 2013. ISBN 978-

0702040672. Buy from http://amzn.to/20pVrMR) 9. Kapandji IA. The physiology of the joints, volume 3: the spinal column, pelvic girdle and head.

Churchill Livingstone 2008.

ISBN 978-0702029592. Buy from Amazon http://amzn.to/1s4pwXj.

DISCUSSIONS hy is medial rotation performed twice during W assessment of the hip?

Why is it important to address loss of hip flexion?

Why are accessory glides performed as mobilisations at the hip?

Why is the adductor longus often injured in groin injuries?

KEY POINTS nT he therapist must be familiar with the anatomy of the area in order to perform a full assessment. n The capsular pattern of movement limitation at the hip is defined by: most loss of medial rotation; equal loss of abduction and flexion; and least loss of extension. n Causes of capsular pattern at the hip are often osteoarthritis, rheumatoid arthritis and other systemic arthropathies. n Treatment for capsular pattern is mobilisations of the hip. n The main cause of non-capsular movement limitation in the hip are loose bodies and the treatment is the loose body manoeuvre. n A common contractile lesion of the hip is adductor longus strain and treatment is deep transverse frictions to the adductor longus and the hamstrings origin.

RELATED CONTENT

CONTENTS PANEL ARTICLES IN THIS SERIES ON MANUAL THERAPY INCLUDE: 1. Introduction to manual therapy 2. Definitions: mobilisation, manipulation and massage 3. Musculoskeletal assessment 4. Musculoskeletal diagnosis 5. Assessment and treatment of the hip 6. Assessment and treatment of the knee 7. Assessment and treatment of the ankle and foot 8. Assessment and treatment of the shoulder 9. Assessment and treatment of the elbow 10. Assessment and treatment of the wrist and hand 11. Assessment and treatment of the cervical spine 12. Assessment and treatment of the lumbar spine 13. Assessment and treatment of the thoracic spine

Other articles in the Manual Therapy Student Handbook - http://spxj.nl/1ivbIR5 Other Co-Kinetic content for students - http://spxj.nl/1QXQkOx

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Co-Kinetic.com

Video 9: Deep transverse frictional massage to upper attachment of hamstrings (Video with captions but no sound; J. Hatcher, 2013

THE AUTHOR Julian Hatcher Grad Dip Phys MPhil, MCSP FOM is a senior lecturer at the University of Salford and the programme leader for BSc Hons Sport Rehabilitation programme, having created it 1997. Previously he was senior physiotherapist in Orthopaedic Medicine at Warrington Hospital Trust from 1987–1997. He also worked in Rugby League (including Great Britain BARLA Rugby League) for 7 years as well running his own Sports Injuries Clinic in Warrington up until 1997.

Julian became a Fellow of Orthopaedic Medicine (FOM) in 2000, and Certified Strength & Conditioning Specialist in 2005. After starting with a Graduate Diploma in Physiotherapy (Grad Dip Phys), he gained his Master of Philosophy (MPhil) from the University of Salford in 2007 and has several publications around the knee particularly concerning topics such as ‘ACL deficiency: detection, diagnosis and proprioceptive acuity’ and ‘Osteoarthritis long-term outcomes’. Julian is also an Honorary Member of British Association of Sport Rehabilitators and Trainers (BASRaT).

Email: J.Hatcher@salford.ac.uk Website: Julian Hatcher, University of Salford, UK http://www.seek.salford.ac.uk/profiles/JHATCHER.jsp

45

ARE YOU A

LEAN

THERAPIST?

OVERVIEW The goal of our new business growth section, which we’ve called The LEAN Therapist, is to give you advice and resources to help you either start your own business (or self-employed career), or turn your existing business into a fighting-fit example of best practice. Through our content we’ll give you practical tools to help you build and run an efficient and effective business, guided by the principle of ‘less is more’, informed by structured analysis of data, and wherever possible automated, so that once you’ve set up your processes, only minor amounts of input will be needed. Read this online http://spxj.nl/1s5o5aP BUSINESS | 16-07-COKINETIC FORMATS WEB MOBILE PRINT

BY TOR DAVIES, PUBLISHER The content will be divided into two sections: ‘Business in training’ for the therapists who are either currently training or are in the start-up phase of business and ‘Business in play’ for those self-employed practitioners or existing business owners, like myself, who have gone through the start-up phase but want to achieve more.

And of course as you’d expect from anything that is created by Co-Kinetic, we’ll focus on practical application. Wherever possible we’ll be giving you checklists, workflows, templates of emails and letters, worksheets and any other resources we can think of that will help you apply our information quickly and efficiently.

WHY HAVE WE CALLED IT THE LEAN THERAPIST? I’ve called it The LEAN Therapist for a couple of reasons, firstly I love the the philosophy and thinking behind The Lean Startup (http://theleanstartup. com/ model devised by Eric Reis. The 46

book of case studies called The Lean Entrepreneur http://amzn.to/1OpgU23 is one of my favourites.

They are both focused on: n increasing efficiency n reducing waste n eliminating risk n building strong customer relationships n and being transparent.

All things we believe very strongly in at Co-Kinetic.

Secondly the feedback I’ve had from many existing Co-Kinetic subscribers, is that most of us would love to run a lean business but often feel overwhelmed by lack of time.

The Lean Enterprise Institute defines lean as the following: Lean means creating more value for customers with fewer resources.

A lean organisation understands customer value and focuses its key processes to continuously increase

it. The ultimate goal is to provide perfect value to the customer through a perfect value creation process that has zero waste.

And lean management “seeks to eliminate any waste of time, effort or money by identifying each step in a business process and then revising or cutting out steps that do not create value.”

Lastly I created an acronym out of LEAN which I think works well for what I hope we can achieve through this content.

L – Less is more E – Efficient, effective, enterprising and enabled A – Analyse and automate N – Nivarna

L – Less is more Most of you will have heard of Pareto’s principle, often also referred to as the 80–20 rule or law. Examples are: 80% of your profits are likely to come from 20% of your customers; 80% of your complaints probably come from 20% of your customers; 20% of people experience 80% of the suffering; in the US, 20% of the patients use 80% of the healthcare and the list goes on – just Google ‘real life examples of 80–20 rule’ or click this link http://spxj.nl/1U6XK2w, it’s fascinating).

It’s actually uncanny how frequently and in how many settings this rule proves to be true. If you’re intrigued (and it is a truly intriguing topic if you’re a bit of nerd like me!) then read Richard Koch’s highly practical and at times jaw-dropping book, The 80/20 Principle: The Secret to Achieving More with Less http://amzn.to/24NPDj9. I can guarantee that within just a couple of chapters you’ll have identified a number of areas in your life that you can apply the 80–20 rule to, in order to achieve more with less.

The relevance of the 80–20 rule is that we can use it as a way of ‘working clever’. We can use it to eliminate (or at least reduce) wastage, focus on the areas of business and the clients that bring you most benefit (and that doesn’t have to mean money) and to inform your marketing strategy, and in most cases, achieving this is Co-Kinetic journal 2016;69(July):46-48

PHYSICAL THERAPY PAIN, BRAIN AND SPORTS THE LEAN PERFORMANCE THERAPIST

too distant past we were producing 12 journals a year between 1 .5 of us (me full time, my designer part time).

Yes, that involved crazy working hours but it could only be achieved using automation. In fact I could possibly be accused of being automationobsessed. Once my processes had been streamlined, it was the only way I could buy myself more time so I think I’ve got pretty good at it, admittedly through sheer desperation at times.

During the course of creating this business content I’ll be interviewing as many practitioners and therapists as I can to find out your favourite automations or to look at your processes and see if I can come up with some automations that could help save you time. If you have an existing automation that you’d like to share, then please email me directly (tor@ sportex.net) and give me a few details.

I really look forward to exploring this area with you.

N – Nirvana There are a few different definitions of Nirvana but the one that I’d like to use for our purposes “is a place of perfect peace and happiness. In Hinduism and Buddhism, nirvana is the highest state just a matter of following some basic steps and taking the time to think, act, measure and adapt.

In a nutshell it’s about working ‘clever’ and through our articles we’ll give you as much practical information we physically can to enable you to do this simply, easily and quickly.

E – Efficient, effective, enterprising and enabled I couldn’t decide which E was most important so I’ve used them all. They’re all key and I think they speak for themselves.

Efficient = a system achieving maximum productivity with minimum wasted effort or expense, or a person working in a well-organised and competent way.

Effective = someone who is successful in producing a desired or intended result.

Enterprising = having or showing initiative and resourcefulness.

Enabled = give (someone) the means Co-Kinetic.com

to do something or make it possible for.

A – Analyse and automate Again both these aspects are key. I know data can be perceived as dull if you don’t have the kind of brain that likes numbers but analysis is key to refining your processes and making them more intelligent. It’s essential to the less is more approach. Remember – think, act, measure and adapt. If we’re not measuring, we can’t adapt and if we don’t adapt, there’s a risk our business will die or certainly won’t thrive.

Don’t worry, we’ll lead you through screen-by-screen guidance or videos showing you how to extract the information you need in Google Analytics [assuming you have your site hooked up to Google Analytics (and if not, we’ll give you links that show you how)].

Once we know what works, then we can automate. I’m a big personal fan of automation. At one point in the not

THINK

ACT

MEASURE

ADAPT

Figure 1: The cycle of continuous improvement (Credit: Co-Kinetic, 2016)

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that someone can attain, a state of enlightenment.”

The specific goal of the content under this section is to take away as many of your stresses as we can. We’re going to do this by giving you ways of relieving the pressure on your time, helping reduce or maybe even eliminate the feeling of being overwhelmed by things you don’t like or understand such as social media or Google Analytics, but feel you should be doing something with, wondering what you could be doing better, worrying about paying salaries and bills, and feeling like you’re not completely in control and as a result, and most importantly, missing quality time with the people you love.

Through our content we will show you ways to save time by having a laser focus on what matters, increasing the results you want and reducing the ones you don’t want, improving your processes to eliminate wasted time, identifying non-productive activities, and giving you peace of mind through the knowledge that you’ve covered all the important bases and you’ve done it efficiently and effectively.

More importantly we’ll do this in a thorough and practical way giving you step by step instructions and resources, along with links to information you need in order to achieve the goal of each particular exercise. Our focus will be on things that matter – saving you time, finding you more clients (if desired), improving your profit margins and turning your existing clients and patients into your greatest advocates.

So let’s go and make our businesses LEAN!

THE LEAN THERAPIST AT 2016 At Therapy Expo 2016 we will be coordinating 4 x 40 minute sessions under the Business and Innovation section of the exhibition. The topics will include:

L E A N

n L ess is More: How to identify the key areas of your business that will lead to increased profit with the least effort n E fficient, Effective and Enterprising: Free tools and resources you can use to save time and simplify your working life nA nalysis Can Be Fun: 15 simple things you can track using Google Analytics that will give you powerful insights into your business n ‘ New’ Technology: Using social media to identify and attract the right kind of customers

For more information about Therapy Expo or to book tickets visit http://www.therapyexpo.co.uk/

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THE LEAN THERAPIST YOUR PHYSICAL Growing THERAPY BUSINESS:

MOVING FROM SURVIVING TO THRIVING

Are you a clinic owner or a self-employed physical or massage therapist that’s surviving in business but feel that you should and could be doing better? Do you feel that there’s never enough time in the day and that you can’t quite find a way to tip that balance from surviving to thriving? This three step article will help you regain focus on what’s important to you, understand how to integrate that passion into a business strategy and finally how to put that strategy into practice. The end result will be that you are not only doing more of what you like, but you become more profitable and more sought-after in the process. Registered users can read and follow all the steps in the article. Full access includes more practical detail, specific guidance and downloadable worksheets.

SIMPLE STRATEGIES FOR INCREASING WORD OF MOUTH REFERRALS

10

Everybody knows it’s at least 5 times harder and more costly to acquire a new customer than it is to keep or up-sell to an existing one. This article outlines 10 ways in which you can build customer loyalty, increase word of mouth referrals and up-sell additional services while building greater trust with your current clients. Registered users can read the full strategy, full article access through a subscription provides email templates and links to further resources.

ELEMENTS EVERY HOMEPAGE MUST HAVE CriticYouralhomeWEBSITE page is your internet shop window. You can send all the traffic in the world to it and it still may not be achieving your goals. We outline what every homepage should feature AND show you ways in which you can measure whether the changes you’re making are having the desired impact. Registered users can read the full article, subscription access provides additional checklists and downloadable resources.

HOW TO BUILD A WEBSITE FOR LESS THAN £100 IN UNDER

8 hours

For many of us, the last thing we want to do is spend time building a website. In fact most of us probably wouldn’t know where to start so we engage the services of web designers and the costs start piling up. In this article we outline some free options and some low cost options along with pros and cons of each. We’ll also give you links to some free and low cost royalty-free stock photography options that will help you get a professional looking website up and running with less than a few hours work. Using this guide along with our “Critical Elements Every Website Homepage Must Have” checklist, we guarantee you’ll be up and running in less than 8 hours. Registered users can read the full article, subscription access provides step by step instructions, screenshots, video tutorials and more detailed guidance.

Co-Kinetic journal 2016;69(July):46-48

SOCIAL WATCH

SOCIAL

WATCH

There are some great resources on social media sites.

Here are some of the best ones published most recently.

’S HIGHLIGHTS THIS QUARTER

We’ve highlighted the resources below because they are promoting useful, practical resources across a range of physical and manual therapy topics.

CHECK OUT ON FACEBOOK

CHECK OUT ON YOUTUBE

l Trust me, I’m a “Physiotherapist” http://spxj.nl/1TEkzNW l Physio-Therapy - http://spxj.nl/1WiXqEj l Physio Research - http://spxj.nl/1UdyF96 l Physiotherapy Evidence Database http://spxj.nl/1TzQ0GR l Physio Guy - http://spxj.nl/1XUDmHW

l Anatomy Zone - http://spxj.nl/1sQ08VX l M edical Education - Anatomy Playlist http://spxj.nl/27SwkYD l Massage Nerd - http://spxj.nl/1Vihg1h l Susan Findlay from the NLSSM http://spxj.nl/20BMXlN

@Scienceofsport

Thanks Asker, really flattered and I appreciate it.

Thanks for helping get the message out! http://spxj.nl/1WSSaYB

@shereebekker

Too much information? Blog post for my paper on the problematic proliferation of guidelines http://spxj.nl/1sPC85i

TWEETS

2,775

FOLLOWING

1,063

FOLLOWERS

4,757

@knowpainmike

@mikereinold

How to Assess Shoulder Capsular Mobility http://spxj.nl/1YYUWJd

Pain is complex. Education is complex. Practice is complex. Daunted? We all are! Embrace the challenge. #knowpain http://spxj.nl/1OWo5Ew

@Peter_Gettings

@docsarahb

First article audio recordings now launched @sportexjournals: ‘The Hidden Influence of Metaphor Within Pain’ http://spxj.nl/1s9wha8

Co-Kinetic.com

Join in!

@BJSM_BMJ

Nice set of 4 materials. 3 of them OPEN! Podcast here: http://spxj.nl/1VhWHC7

@DrMarwanAl_D @LinearProbe @UTC_imaging @sportsdocjb There was a really nice UTC summary by @JarrodAntflick recently in @sportexjournals http://spxj.nl/1TzmeSR

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’S HIGHLIGHTS THIS QUARTER CHECK OUT ON INSTAGRAM l Massage Nerd - http://spxj.nl/1YZD8xt l M assage Media - http://spxj.nl/22paRT2 l #injury— http://spxj.nl/1TKPhWU (Warning - some gruesome injury pictures but useful for presentations!)

SOME OF OUR TWITTER FAVOURITES l l l l

M ike Reinold - http://spxj.nl/1TzQRr5 M ike Stewart - http://spxj.nl/1Xx1kZm A chilles Tendons - http://spxj.nl/1TElePl A ndy Franklyn-Miller - http://spxj.nl/1qJw5NB

@Brad_Neal_07

My man @rwilly2003 is cranking out some quality work at present ! http://spxj.nl/25lxoFw

@gleds13

Nice little poster #coaching #athletes #talent http://spxj.nl/1VhXTW6

@JonWhittingham

Thoughts? @DrJamieBarker @DrMattSlater @DrMJTurner - Guest blog by Rebecca Symes: sport psychology in action… http://spxj.nl/27Sgjlj @MSSEonline

Most Popular: Hamstring Strength and Morphology Progression after Return to Sport from Injury: Purpose: Hamst… http://spxj.nl/25lwtoL

@WhichUK

So, it now seems that we can eat fat and not get fat? That’s what the headlines seem to be telling us anyway http://spxj.nl/1OMVNH0

@GoogleUKBiz

Want to improve your online skills? Get free digital training from Google http://spxj.nl/1OWofeX

@OpenAccess_Top

@hjluks

Are we letting our athletes with hamstring injuries return to sports too quickly? http://spxj.nl/1Widc2d

CO-KINETIC ON SOCIAL MEDIA

Imaging and treatment strategies of the spine, including disc pathology and spondylolysis a… http://spxj.nl/1YYTZ3A

https://www.facebook.com/sportEX.net/ https://twitter.com/sportexjournals https://www.linkedin.com/groups/4048152 https://pinterest.com/co_kinetic https://www.instagram.com/co_kinetic/ 50

@KineticRev

Simple Glute Medius Exercise for Runners http://spxj.nl/1WSQajc

Co-Kinetic journal 2016;69(July):49-50

The Sports Massage Association

Annual Conference

23rd November 2016 Taking place at Birminghamâ&#x20AC;&#x2122;s NEC on the 23rd November. This is simply unmissable for Sports Massage Therapists, with two days of the latest insight, education, networking and training.

Combining the Annual Conference with full access to Therapy Expo 2016, the SMA conference programme includes dedicated sessions, hands on training sessions, covering the assessment and treatment of Sacroiliac Joint (SIJ) Dysfunction.

The SMA AGM will take place Wednesday 23rd November 17:00pm - 18:00pm. Only registered SMA members will be able to access the AGM. Further details and the AGM agenda will be made available later in the year.

Purchase your SMA member ticket for just ÂŁ79 +VAT at http://www.therapyexpo. co.uk/sma-annual-conference.

SMA Conference Programme Highlights 13:30pm - 14:15pm: Assessment of the SIJ (Room 1) 13:30pm - 14:15pm: Introduction to treatment of SIJ dysfunction: (Room 2) 15:15pm - 16:00pm: Assessment of the SIJ (Room 1) 15:15pm - 16:00pm: Introduction to treatment of SIJ dysfunction (Room 2) 17:00pm - 18:00pm: Sports Massage Association AGM and Awards (Room 1) 18:00pm - 18:30pm: Drinks Reception

http://www.therapyexpo.co.uk/sma-annual-conference Website: http://www.thesma.org/ Facebook: https://www.facebook.com/The-Sports-Massage-Association-107952845937063/ Twitter: https://twitter.com/SportsMassUK LinkedIn: https://www.linkedin.com/groups/4289333/profile

LEAFLET CLEARANCE SALE

25 75p LEAFLETS

eX2mI U 1 l/ n j. x p s : http:// it is v S T E L N LEAF O I T A T I L I B VERY LIMITED STOCKS REHA EXERCISE IS MEDICINE visit: http://spxj.nl/1qL033W

WHEN THEY’RE GONE – THEY’RE GONE! PLEASE PURCHASE ONLINE AT WWW.SPORTEX.NET (not Co-Kinetic)