Co-Kinetic Journal Issue 70 - October 2016 by Co-Kinetic

PRACTICAL RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

journal ISSUE 70 OCTOBER 2016 ISSN 2397-138X

Formerly published as....

medicine & dynamics

n o i s s e f o r P OUR n o i s s a P R U O o p x E Y P A R E OUR TH

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C0-KINETIC JOURNAL WELCOME

OCTOBER 2016 ISSUE 70 ISSN 2397-138X

editorial

contents

Although the Rio 2016 Paralympics haven’t yet taken place (at the time of writing), I hope that it is able to build on the magic that began in London four years ago. The London 2012 Paralympics did more to normalise disability than any other single international event to date and that’s sport at its best, a unifier. London became a flag bearer for what can be achieved by a nation which, for the most part, respects and embraces diversity (despite the sentiments of the naysayers). According to the official Olympic site: “The goal of the Olympic Movement is to contribute to building a peaceful and better world by educating youth through sport practiced without discrimination of any kind and in the Olympic spirit, which requires mutual understanding with a spirit of friendship, solidarity and fair play.” The inclusion of the Refugee Olympic Team was an important part of putting this philosophy into practice at Rio 2016. At a time when the Olympics has become such a huge international commercial brand, it would serve us well to remember that this is its modern philosophy, if not those of its origins! Rio 2016 Olympics - WOW what is there to say but amazing? My highlight was the Women’s Hockey Final but so many amazing moments. Thank you to all those of you who contributed to building such an amazing Team GB :-) Lastly welcome to our new Entrepreneur Therapy section - lots more of this to come if feedback is good - so please talk to me! Email is tor@co-kinetic.com or start a chat on our site. Enjoy!

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Physical Therapy Journal Watch Manual Therapy Journal Watch The Role of Vision in Rehabilitation Medical Screening in Physical Therapy: Understanding Neurodynamics Low Back Pain Assessment: The 10 Minute Consultation Low Back Pain During Pregnancy: Physiological versus Pathological Back Pain 5 Evidence-based Exercise Prevention Strategies for Reducing Injury Rates in Professional Football Manual Therapy Student Handbook: Assessment and Treatment of the Knee New Content on the Co-Kinetic Site 10 Website Home Page Essentials for Winning New Clients Financial Health Check-up for the Self-employed Therapist Social Watch – a Round-up of the Best Resources on Social Media

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Tor Davies, physio-turned publisher Publisher/editor TOR DAVIES tor@co-kinetic.com Marketing and sales SHEENA MOUNTFORD sheena@co-kinetic.com Art editor DEBBIE ASHER Sub-editor ALISON SLEIGH PHD Journal Watch BOB BRAMAH Subscriptions & Advertising info@co-kinetic.com +44 (0) 203 012 1906

COMMISSIONING EDITORS AND TECHNICAL ADVISORS Tim Beames - MSc, BSc, MCSP Dr Joseph Brence, DPT, 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

PRACTICAL RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

journal ISSUE 70 OCTOBER 2016 ISSN 2397-138X

is published by Centor Publishing Ltd 88 Nelson Road Wimbledon, SW19 1HX, UK Tel: +44 (0) 203 012 1906 https://co-kinetic.com

Formerly published as....

medicine & dynamics

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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. Copyright subsists in all material in the publication. Centor Publishing Limited consents to certain features contained in this magazine marked (*) being copied for personal use or information only (including distribution to appropriate patients) provided a full reference to the source is shown. No other unauthorised reproduction, transmission or storage in any electronic retrieval system is permitted of any material contained in this publication in any form. The publishers give no endorsement for and accept no liability (howsoever arising) in connection with the supply or use of any goods or services purchased as a result of any advertisement appearing in this magazine.

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

The usual databases were searched to find papers relating to the effectiveness of physical therapy on pain, function and range of motion in individuals with subacromial pain syndrome (SAPS). The results were that 64 highquality RCTs were included. Exercise therapy provided high evidence of being as effective as surgery intervention and better than no treatment or placebo treatment to improve pain, function and range of motion in the short, mid and long terms. The combination of mobilisation and exercises provided high evidence to decrease pain and improve function in the short term. There is limited evidence for improvements on the outcomes

EFFECTIVENESS OF PHYSICAL THERAPY TREATMENT OF CLEARLY DEFINED SUBACROMIAL PAIN: A SYSTEMATIC REVIEW OF RANDOMISED CONTROLLED TRIALS. Haik MN, Alburquerque-Sendín F, et al. British Journal of Sports Medicine 2016;doi:10.1136/bjsports-2015-095771 [Epub ahead of print] with the isolated application of manual therapy. High level of evidence was synthesised regarding the lack of beneficial effects of physical resources such as low-level laser, ultrasound and pulsed electromagnetic field (PEMF) on pain, function or range of motion in the treatment of SAPS. There is limited evidence for microwave diathermy and transcutaneous electrical nerve stimulation. There is moderate evidence for no benefits with taping in the short term. Effects of diacutaneous fibrolysis and acupuncture are not well established yet.

Co-Kinetic comment Put aside for the moment the use of the term ‘subacromial pain syndrome’ because it is nonsense. There is no such thing as ‘SAPS’. There is pain caused by an underlying cause. As far as treatment is concerned find the cause and treat it. Unfortunately that is not always possible without expensive investigations, so as with all soft tissue injury get pain-free movement early on and then build on that. This excellent piece of work proves it.

ULTRASOUND AND MRI CORRELATION OF ROTATOR CUFF INJURIES. Patil KK, Seth NDN, Joshi P. Indian Journal of Applied Research 2016;6(4):101–105 Fifty patients with clinically suspected rotator cuff pathology underwent X-ray, ultrasonography and MRI of the affected shoulder. Ultrasound findings were compared with gold-standard MRI. The results were that the accuracy in detection of a full thickness tear was 72% and 76% for ultrasonography and MRI respectively.

Co-Kinetic comment We made a comment some years ago in this publication that diagnostic ultrasound should be standard training in MSK therapy schools and that the kit should be in every clinic. Hopefully this work will help push the powers that be in that direction. Ultrasound is almost as good as an MRI scan, a fraction of the cost and without the noise and the claustrophobia.

TOPICAL NSAIDs SIGNIFICANTLY REDUCES PAIN IN ADULTS WITH ACUTE MUSCULOSKELETAL INJURIES. Vuurberg G, Kerkhoffs GMMJ. Evidence-Based Medicine 2016;doi:10.1136/ebmed-2016-110406 This review was an update of a previous study. It included double-blinded randomised controlled trials comparing topical non-steroidal anti-inflammatory drugs (NSAIDs) with placebo or another form of active treatment for acute pain. Injuries treated were mainly from strains, sprains or sports injuries. The primary outcome consisted of ‘clinical success’, defined as 50% pain reduction. Twenty new studies were identified, of which 14 met the inclusion criteria and were added to

the data from 47 previously identified studies. In total, this update includes 61 studies, involving 8,386 participants. Diclofenac was the main subject of the newly added studies. Most effective in pain reduction were the diclofenac gel, ibuprofen gel, and ketoprofen gel. Reported adverse events were only local and consisted of redness and itching.

Co-Kinetic comment They may reduce pain in the short term but so will rubbing the

area without the actual NSAIDs. What they don’t do is assist in healing in any way. The authors do note that most included studies were industry sponsored, with possible influence on results and also on disclosing data. About 5,400 participants, from studies registered in the clinical trial registry, short reports from meetings and ongoing studies, were not included as full details from these could not be obtained, which may influence the results.

Co-Kinetic Journal 2016;70(October):4-7

PHYSICAL THERAPY RESEARCH INTO PRACTICE

Journal Watch ROLE OF PSYCHOLOGICAL FACTORS IN MANAGEMENT OF SPORT INJURIES: AN OVERVIEW. Yadava V, Awasthi P. Purushartha: A Journal of Management Ethics and Spirituality 2016;9(1):111–117 This article starts from the premise that in order to understand the process of injury occurrence, recovery and management, physiological and psychological factors should be considered by the practitioners. Injury is part of sport and therefore how athletes react and psychological factors that influence this is something that needs attention. It adds that medical literature has ‘de-emphasised’ this. These factors are described in four broad areas: 1. Psychological variables as predictors of injury occurrence. 2. The athlete’s psychological response to injury. 3. Psychological aspects of the rehabilitation process. 4. Psychological readiness to return to competition.

Co-Kinetic comment There is a great statistic in this paper. Every year, 10 million people suffer a sports injury. It comes from a referenced work which is well worth finding if you are involved with sporty kids. (Shanmugam C, Maffulli N. 2008. Sports injuries in children. British Medical Bulletin 2008;86(1):33–57). As to this paper if you are new to the concept of sports psychology it is a good introduction.

COMMON INJURIES AMONGST INDIAN ELITE ARCHERS: A PROSPECTIVE STUDY. Adkitte RG, Shah S, et al. Saudi Journal of Sports Medicine [Epub ahead of print] This was a survey of 138 Indian archers (compound bow archers, 63; recurve bow archers, 56; and Indian bow archers, 19). The most common injuries were the draw-arm shoulder (19.79%), followed by blisters on fingers (17.01%) and then injuries by the string touch (15.97%).

Co-Kinetic comment There are 1,100 clubs and 40,000 registered archers in the UK according to the governing body of the Grand National Archery Society, and in the USA according to the archery trade association 18.9 million people participate in the sport. That is a lot of potential injuries. Recurve bows were historically used by horsemen, and modern versions of the bow are the ones used in Olympic events. In Rio, the South Koreans won both the men’s and the women’s event. They got a clean sweep in the women’s with Silver and Bronze as well and for good measure they won both team events. Apparently they identify talented kids at primary school, have a lot of top-class coaches and the government picks up 30% of their budget. Other sports take note.

BRINGING GOLF INJURY PREVENTION TO THE FORE. Catlow S, Doggart L. International Therapist 2016;116:32–35 This is an article in the journal of the Federation of Holistic Therapists. Basically it highlights areas of potential golf injury which include the workload of an 18-hole match including the number and intensity of the shots and for some golfers the fact that they may be carrying a 20kg+ bag of gear. Other factors include techniques of grip and swing, the environment of the course, age and skill level, frequency of play and practice sessions. Assessment will include looking at posture, wrist and elbow rotation and

Co-Kinetic.com

flexibility, balance, shoulder mobility, thoracic spine range of motion, gluteal strength, core strength, hip mobility and hip flexor/hamstring/calf flexibility. The rehabilitation process should be dynamic and golf specific in order to mimic the joint and muscle actions produced in the game.

Co-Kinetic comment If you don’t know anything about golf and its potential for injury when playing it this is a short, simple, easy to read introduction.

PATELLOFEMORAL PAIN. Crossley KM, Callaghan MJ, van Linschoten R. BMJ 2015;351:h3939

pain, usually unrelated to trauma, but associated with an increased frequency or duration of patellofemoral loaded activities (squatting, climbing stairs, hiking, running). There is no definitive clinical test to diagnose patellofemoral pain. The best available test is anterior knee pain elicited during a squatting manoeuvre: patellofemoral pain is evident in 80% of people who are positive on this test. Biomechanics of the hip, knee, and foot, the alignment of the kneecap in the femoral groove and the strength of muscles will affect the load on your kneecap and can result in pain. Most people have noticeable improvement 6–12 weeks after starting physiotherapy. However, people who have had pain for longer may need additional time to respond. Patients who adhere to the instructions have a better response to treatment. In addition to supervised exercise consider foot orthotics, patellar taping or kneecap mobilisation.

SCAPULAR MUSCLE ACTIVITY IN A VARIETY OF PLYOMETRIC EXERCISES. Maenhout A, Benzoor M, et al Journal of Electromyography and Kinesiology 2016;27:39–45

This paper gets its information from a literature review of recent systematic reviews, updated to June 2014. Its findings are that patellofemoral pain refers to pain behind or around the patella. It is also known as patellofemoral pain syndrome, anterior knee pain, runner’s knee and, formerly, chondromalacia patellae. It is a common condition accounting for 11–17% of all knee pain presentations to general practice in the UK. It typically occurs in physically active people aged <40 years but it can occur in people of all ages. Patellofemoral pain commonly presents as gradual onset of knee pain (behind or around the patella) associated with patellofemoral loaded activities (squatting, climbing stairs, hiking, running). Imaging is rarely indicated. Conservative therapies (especially physiotherapist-led exercise, targeted exercises based on the clinical findings, foot orthoses) are effective. Accurate diagnosis and explanation of the condition and rationale for the rehabilitation programme, with some indication of timeline for prognosis, improves the likelihood of a successful outcome. Patients commonly describe a gradual onset of anterior knee

This is another of the type of papers we love. Lots of background, a touch of anatomy and lots of tips for assessment and rehabilitation. Keep them coming please.

Plyometric shoulder exercises are commonly used to progress from slow analytical strength training to more demanding high-speed power training in the return-to-play phase after shoulder injury. This paper is really useful for anyone using or thinking of using plyometrics. The 10 exercises are well described and there are photos.

Novice runners (n = 129, 18–60 years old, <2 years recent running experience) were randomised to one of three groups: a ‘resistance’ strength training group, a ‘functional’ strength training group, or a stretching ‘control’ group. The primary outcome was running related injury. The number of participants with complaints and the injury rate were quantified for each intervention group. For the first 8 weeks, participants were instructed to complete their training intervention three to five times

a week. The remaining 4 months was a maintenance period. A total of 52 of the 129 (40%) novice runners experienced at least one running related injury: 21 in the functional strength training programme, 16 in the resistance strength training programme and 15 in the control stretching programme. Injury rates did not differ between study groups. Although this was a pilot assessment, home-based strength training did not appear to alter injury rates compared to stretching.

RUNNING INJURIES IN NOVICE RUNNERS ENROLLED IN DIFFERENT TRAINING INTERVENTIONS: A PILOT RANDOMIZED CONTROLLED TRIAL. Baltich J, Emery CA, et al. Scandinavian Journal of Medicine & Science in Sports 2016;doi:10.1111/sms.12743 [Epub ahead of print]

Co-Kinetic comment

Thirty-two healthy subjects performed 10 plyometric exercises while surface EMG activity of the scapular muscles [upper (UT), middle (MT) and lower trapezius (LT) and serratus anterior (SA)] was registered. A high-speed camera tracked start and end of the back and forth movement. The mean scapular EMG activity during the 10 exercises ranged from 14.50% to 76.26% maximum voluntary contraction (MVC) for UT, from 15.19% to 96.55% MVC for MT, from 13.18% to 94.35% MVC for LT and from 13.50% to 98.50% MVC for SA. Plyometric shoulder exercises require moderate (31–60% MVC) to high (>60%MVC) scapular muscle activity. There were significant differences in scapular muscle activity between exercises and between the back and forth movement within exercises. Highest MT/LT activity was present in prone plyometric external rotation and flexion. Highest SA activity was found in plyometric external rotation and flexion with XCO (XCO-Trainer® is a tube filled with granulate) and plyometric push-up on a Bosu Ball (an inflated rubber hemisphere attached to a rigid platform). Specific exercises can be selected that recruit minimal levels of UT activity (<15%): side lying plyometric external rotation and horizontal abduction or plyometric push-up on the Bosu.

Co-Kinetic comment

Co-Kinetic comment In another paper we have included in this edition (Yadava V, Awasthi P. Role of psychological factors in management of sport injuries: an overview) it says that injury is part of sport but you have to ask what is going on if 40% of the novice runners report an injury.

Co-Kinetic Journal 2016;70(October):4-7

PHYSICAL THERAPY RESEARCH INTO PRACTICE

MANAGEMENT OF PLANTAR FASCIITIS IN THE OUTPATIENT SETTING. Lim AT, How CH, Tan B. Singapore Medical Journal 2016;57(4):168–171 Plantar fasciitis is the most common cause of plantar heel pain, with an incidence of one million patient visits per year in the United States of America. Current thinking is that it is secondary to myxoid degeneration, microtears within the plantar fascia, collagen necrosis and angiofibroblastic hyperplasia of the plantar aponeurosis, and not due to an inflammatory process. The patient usually presents with gradual onset of pain over the medial side of the plantar heel that is most noticeable when taking the first few steps in the morning. The pain may get better after a short period of walking, but returns when performing activities that involve prolonged weight-bearing, such as The background to this paper is the idea that partial meniscectomy does not consistently produce the desired positive outcomes intended for meniscal tear lesions so there is a search for alternatives. The ‘squeeze’ technique was applied in five cases of clinically diagnosed meniscal tears in a physically active population. A numeric pain rating scale (NRS), the patient specific functional scale (PSFS), the disability in the physically active (DPA) scale, and the knee injury and osteoarthritis outcomes score (KOOS) were used to assess participant pain level and function. Statistically significant improvements were found on all outcomes. Most importantly

standing, walking or running. Heel spurs may be present in 50% of patients but the relationship to subcalcaneal pain has not been established. Heel spurs are now thought to be a result of traction forces on the plantar fascia origin rather than the cause of plantar fasciitis. Ultrasonography is a very useful and reliable tool in diagnosing plantar fasciitis. Treatment is largely nonoperative, with 90–95% of patients experiencing resolution of symptoms within 12–18 months. Modification of activities should be advised, especially stopping repetitive impact, such as running. A gradual return to activity may be allowed after the patient is asymptomatic for 4–6 weeks and no

longer has localised tenderness over the plantar fascia. Plantar fascia stretch and ice massage, night splints, orthotics have a place. In the short term, steroid and platelet-rich plasma injections show promise but interestingly the latter is not approved for use in Singapore where this paper was published. For chronic conditions, focal extracorporeal shockwave therapy is described as efficacious and if all else fails surgery is a possibility.

Co-Kinetic comment Yet another ‘all you need to know’ paper and yet another publication coming out of the East and Far East that is easy to read and informative. Nice to know they are copying us!

AN ALTERNATIVE APPROACH TO THE TREATMENT OF MENISCAL PATHOLOGIES: A CASE SERIES ANALYSIS OF THE MULLIGAN CONCEPT “SQUEEZE” TECHNIQUE. Hudson R, Richmond A, et al. International Journal of Sports Physical Therapy 2016;11(4):564–574 each of the participants continued to engage in sport activity as tolerated unless otherwise required during the treatment period. The treatment is basically putting the patient’s knee into either 90° flexion or the maximum that pain will allow. The therapist then places a supported thumb across the most painful part of the joint line and squeezes while the patient actively extends the knee to its maximal pain-free range. Pressure on the joint line is eased as the joint line closes as full extension is reached and reapplied as the patient takes the

knee back into flexion. At the active flexion end point the clinician continues to hold the pressure at the joint line for two seconds as the participant applies overpressure by pulling the tibia with both hands to add range to the knee flexion. This repeated for 3 sets of 10 reps. All participants were discharged within six treatments.

Co-Kinetic comment This is worth a go as an alternative to or while waiting for surgery. If it doesn’t work the surgery option is still there.

FROM ENDURANCE TO POWER ATHLETES: THE CHANGING SHAPE OF SUCCESSFUL MALE PROFESSIONAL TENNIS PLAYERS. Gale-Watts AS, Nevill AM. European Journal of Sport Science 2016;16(8):948–954 The height and body mass of the players qualifying for the first round in all four Grand Slam tennis tournaments during the period 1982–2011 was obtained. Successful players were defined as those reaching the third round. Body mass index (BMI) and the reciprocal ponderal index (RPI) were used as our measures of body shape. The results suggest that the body shape of elite tennis players has changed over time, reflecting greater muscle mass rather than greater adiposity. A more ectomorphic body shape is a less important factor in terms of success. These results suggest that elite male tennis players are becoming more power-trained athletes as opposed to endurance athletes, with greater muscle mass being an important factor associated with Co-Kinetic.com

success in all Grand Slam tournaments.

Co-Kinetic comment We know you are going to ask: the ‘corpulence index’ or ‘ponderal index’ is a measure of leanness calculated as a relationship between mass and height. It was first proposed in 1921 by F. Rohrer so it is also known as Rohrer’s Index. It is similar to the BMI but the weight is divided by the height cubed rather than squared. It is thought to be more accurate than the BMI with very tall or very short people. 7

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

Forty-six women between the ages of 18 to 30 years with thoracic kyphosis diagnosed by flexicurve ruler were randomly assigned to either an exercise therapy or a manual therapy group. The exercise therapy programme focused on stretching and strengthening exercises in 15 sessions over 5 weeks. The manual therapy group received 15 sessions of manual techniques including massage,

mobilisation, muscle energy and myofascial release. Kyphosis angle and back extensor muscle strength were measured with a motion analysis system and a dynamometer at the baseline and after treatment. After treatment, the angle of thoracic kyphosis was smaller and back extensor muscle strength was significantly greater in both the exercise and manual therapy groups with no significant differences between

MYOFASCIAL RELEASE THERAPY IN THE TREATMENT OF OCCUPATIONAL MECHANICAL NECK PAIN: A RANDOMIZED PARALLEL GROUP STUDY. Rodríguez-Fuentes I, De Toro FJ, et al. American Journal of Physical Medicine & Rehabilitation 2016;95(7):507–515 A group of 59 patients aged between 18 and 65 years old were split into two groups. All had mechanical neck pain with or without symptoms that radiated to the head and/or upper limbs, and who scored 0% or higher on the neck disability index or 2 points or more on the visual analogue scale of pain at initial evaluation. Both groups received

Sixty patients with mechanical neck pain were randomly allocated to either the muscle energy technique (MET) group or control group. The former group received MET, (post-isometric relaxation technique was applied to upper trapezius and levator scapulae muscles for five repetitions using 20% of maximal isometric contraction. The stretch was held beyond resistance barrier for 20 seconds. The latter group received passive static stretching to upper trapezius and levator scapulae muscles for five repetitions with 20-second hold. Both groups received conventional therapy described as

analgesic therapy of 15 minutes under an infrared lamp and TENS. They received 10 treatment sessions over 4 weeks of either manual therapy (n = 29; 18F/11M; mean age, 38.24 years) or myofascial release (15F/15M; mean age, 38.20 years). The former included: (1) anterior-posterior and side-shift of the cervical spine; (2) muscle energy technique involving side bending of cervical spine; (3) neuromuscular technique for restricted C1/C2 rotation; (4) inhibitive occipital distraction; and (5) cervical stretching: post-isometric relaxation for the upper trapezius, scalene and sternocleidomastoid muscles. The myofascial release included: (1) cranial base release,

COMPARISON OF MANUAL THERAPY AND EXERCISE THERAPY FOR POSTURAL HYPERKYPHOSIS: A RANDOMIZED CLINICAL TRIAL. Kamali F, Shirazi SA, et al. Physiotherapy Theory and Practice 2016;32(2):92–97 groups in the changes in kyphosis angle or muscle strength after treatment.

Co-Kinetic comment So both work. Now let’s try the two together. adjusting the relation of the rectus capitis posterior muscles to the dura mater; (2) gross release of the sternocleidomastoid muscle; (3) release of the suprahyoid and infrahyoid muscles; and (4) release of the retrohyoid fascia. The treatment of occupational mechanical neck pain by myofascial release therapy seems to be more effective than manual therapy for correcting the advanced position of the head, recovering range of motion in side bending and rotation, and improving quality of life.

Co-Kinetic comment This is a complicated study. There is a mixture of treatment techniques and there are lots of outcome measures, but the bottom line is that overall both approaches work and the myofascial release is slightly better. They had enough people in the study so it is a pity that they didn’t have a third group that mixed up the myofascial and manual therapy.

EFFECT OF MUSCLE ENERGY TECHNIQUE AND STATIC STRETCHING ON PAIN AND FUNCTIONAL DISABILITY IN PATIENTS WITH MECHANICAL NECK PAIN: A RANDOMIZED CONTROLLED TRIAL Phadke A, Bedekar N, et al. Hong Kong Physiotherapy Journal 2016;35:5–11 strengthening exercises for deep neck flexors, rhomboids, lower trapezius and serratus anterior because they are weak muscles in upper crossed syndrome (2 sets of 10 repetitions once a day) and stretching exercises for pectoralis muscles (20-second hold, 5 repetitions). Treatment was given once a day for 6 days. A visual analogue scale (VAS) was used to measure the intensity of pain, and functional disability was assessed using the neck disability index (NDI) immediately before treatment and again on the 6th day.

The VAS and NDI scores showed a significant improvement in both MET and stretching groups on the 6th day postintervention. However, both VAS and NDI scores showed better improvement in the MET group as compared to the stretching group.

Co-Kinetic comment The official conclusion here is that MET was better than stretching in improving pain and functional disability in people with mechanical neck pain. However, the treatment in both groups and the extra ‘conventional’ therapy was so similar that the only conclusion you can really make is that it all works.

Co-Kinetic Journal 2016;70(October):8-11

MANUAL THERAPY RESEARCH INTO PRACTICE

Journal Watch STRESS AND MASSAGE. Deekshitulu B. Innovare Journal of Health Sciences 2016;4(2):9–1

Hands up if you can honestly say that either you are not stressed or you are not dealing with stressed people. An injured athlete is a stressed athlete. This paper gives some de-stressing solutions including massaging your own ears because it releases endorphins in your brain and makes you feel good. Anyone that has been taught facial massage will know that this is a powerful relaxation technique. Others include face painting (it’s not just for kids) and decluttering your living space (just dump stuff). Try a laughing yoga class. Google them – they do exist. Be brutally honest, instead of bottling things up inside you, which causes stress and tensions, why not let it go through the power of honest speech. Express your emotions and tell people how you really feel without being rude or obnoxious. Be loud and bold. Dance in the rain. It’s only water. Next time it rains, have a little fun, get wet and do a little dance. Singing in the rain is optional. Enjoy a ‘staycation’. Forget the hassle of travelling somewhere on a holiday, stay at home. To make it an adventure, get a map of some nearby hiking trails and plan some

day hikes. If you are in a colder climate, consider cross-country skiing or snow-shoeing. Try a new activity such as outdoor photography. Visit some local cafes that you have never been to before. Hey, have you ever been to your local museum or art gallery? Finally and on a more serious note the paper lists 14 different research papers that show that massage reduces anxiety, depression, pain, blood pressure and mood disturbance.

Co-Kinetic comment Lighten up people! Have a bit of fun. This paper provides a great definition of massage in a healthcare context, “Massage therapy is soft tissue manipulation for healing purposes”. If you are stressed you are killing yourself and you need “healing”. It also contains our favourite piece of advice ever, which is to make a list of things to do and then do not do it. Call it your procrastination list. Genius.

WHAT IS STUPID? PEOPLE’S CONCEPTION OF UNINTELLIGENT BEHAVIOUR. Aczel B, Palfi B, Kekecs Z. Intelligence 2015;53:51–58 To study these questions the authors analysed reallife examples, ie. where people called an action stupid. A collection of such stories was categorised by raters along a list of psychological concepts to explore what the causes are that people attribute to the stupid actions observed. They found that people use the label stupid for three separate types of situation: (1) violations of maintaining a balance between Co-Kinetic.com

confidence and abilities; (2) failures of attention; and (3) lack of control. The level of observed stupidity was always amplified by higher responsibility being attributed to the actor and by the severity of the consequences of the action. These results bring us closer to understanding people’s conception of unintelligent behaviour while emphasising the broader psychological perspectives of studying the attribute of stupid in everyday life.

THE IMPACT OF MASSAGE THERAPY ON FUNCTION IN PAIN POPULATIONS—A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS: PART I, PATIENTS EXPERIENCING PAIN IN THE GENERAL POPULATION. Crawford C, Boyd C, et al. Pain Medicine 2016;17(7):1353–1375

Key databases were searched from inception through to February 2014. Meta-analysis was applied at the outcome level. Sixty high-quality and seven low-quality studies were included in the review. The results demonstrate that massage therapy effectively treats pain compared to sham, no treatment, and active comparators. Compared to active comparators, massage therapy was also beneficial for treating anxiety and health-related quality of life.

Co-Kinetic comment Can we please put to bed forever the idea that there is no evidence for the use of massage. There is, and lots of it. There is a part two to this paper which concentrates on cancer pain and has similar results: Boyd C, Crawford C, et al. Impact of massage therapy on function in pain populations—a systematic review and meta-analysis of randomized controlled trials: part II, cancer pain populations. Pain Medicine 2016;17(8):1553–1568.

Co-Kinetic comment We couldn’t resist putting this in. Go on admit it, you have thought that someone or something was stupid today. Be comforted by the fact that not only are you not alone, but academics are studying why you have the thought. 9

PREVALENCE AND RISK FACTORS OF THUMB PAIN IN ITALIAN MANUAL THERAPISTS: AN OBSERVATIONAL CROSS-SECTIONAL STUDY. Rossettini G, Rondoni A, et al. Work 2016;54(1):159–169 A self-administered questionnaire was sent to 523 manual therapists, 219 replied. Of these 49.3% experienced thumb pain at least once in the previous 12 months and 70.8% at least once in their lifetime. Statistically significant associations suggest that manual therapists with more than 5 years of experience are less likely to report thumb pain, whereas those who perform trigger point pressure release, trigger point ischemic compression and fascial neuro-connective manipulation are more likely to experience it. In terms of lifetime prevalence, female manual therapists and those who perform trigger point ischemic compression are more likely to suffer from thumb pain.

Co-Kinetic comment Thumbs are lonely, they should never be used on their own. Look after them if you want a pain free career.

One hundred and five subjects were divided into two groups and received either manipulation and massage or massage only. Four treatment sessions were applied over four weeks. The massage was described as 10 minutes of gentle rubbing and kneading concentrating on the cervical and sub-occipital muscles. The manipulation was described as occiput-atlas-axis manipulation to restore mobility. Both groups demonstrated a large improvement on headache disability inventory scores. Those that received manipulation reported a medium-sized reduction in headache frequency across all data points compared to the massage group. Both groups showed a large within-subject effect for upper cervical extension, a medium-sized effect for 10

STRATEGIES TO OVERCOME SIZE AND MECHANICAL DISADVANTAGES IN MANUAL THERAPY. Hazle Jr CR, Lee M. Journal of Manual & Manipulative Therapy 2016;24(3):120–127 The clue is in the title ‘manual’. It’s hard physical work made harder if you have large patients and small practitioners. The purpose of this paper is to examine ways in which techniques can be modified using simple principles so that they require less exertion. The bottom line is that the way you were taught or the pictures in the text books are not the only way of doing things. Some of the strategies include: 1. Pre-positioning. Pre-position the patient or complete the technique using smaller body segments of the patient. Additionally, the patient may be able to participate in the pre-positioning process. 2. Gravity assistance. a. Patient or practitioner. Position the patient and practitioner to allow the practitioner’s upper body weight to be more directly superior in space to the target area of the technique to maximise the effect of gravity. b. Table or treatment surface. Change the table or treatment surface (height, angle, etc.) to allow the practitioner’s body

mass to be more directly superior in space to the target area of the technique. 3. Mechanical advantage. a. Tools. The technique can be altered using tools to improve the practitioner’s mechanical advantage or augment the therapist’s force for more efficient delivery to the patient. b. Shorter lever arms. Use alternate methods that do not require moving as large a portion of the patient’s body.

Co-Kinetic comment What a great idea. The lifetime prevalence of MSK disorders among physical therapists has been reported to be as high as 91%, so very little helps as they say. Tissue thinks everything you do is great and responds accordingly. It doesn’t care how you do it. This paper should be standard issue at every therapy training school. In addition to the general principles it gives a few examples of specific techniques. Not too sure about the politically correct ‘size disadvantaged practitioner’. ‘Little’ will do.

THE EFFECT OF MANIPULATION PLUS MASSAGE THERAPY VERSUS MASSAGE THERAPY ALONE IN PEOPLE WITH TENSION-TYPE HEADACHE. A RANDOMIZED CONTROLLED CLINICAL TRIAL. EspiLopez GV, Zurriaga-Llorens R, et al. European Journal of Physical and Rehabilitation Medicine 2016; PMID:26989818 [Epub ahead of print] cervical extension, and large effects for upper cervical and cervical flexion. The addition of manipulation resulted in larger gains of upper cervical flexion range of motion, and this difference remained stable at the follow-up.

mechanical neck pain: a randomized parallel group study” (http://spxj.nl/2bi10LC) that we have reported. It shows that the massage treatment works but that it works even better when combined with cervical manipulation.

Co-Kinetic commenta This is almost a companion piece to the Rodriguez-Fuentez paper, “Myofascial release therapy in the treatment of occupational Co-Kinetic Journal 2016;70(October):8-11

MANUAL THERAPY RESEARCH INTO PRACTICE

TREATMENT OF THE SCAR AFTER ARTHROSCOPIC SURGERY ON A KNEE: A CASE STUDY. Alvira-Lechuz J, Roca Espiau M, Alvira-Lechuz E. Journal of Bodywork and Movement Therapies 2016;doi:http://dx.doi.org/10.1016/j. jbmt.2016.07.013 [Article in press] This case study is about treating scars based on percutaneous traction. Which, in simple terms, means fascial manipulation. Movements are performed against the barriers detected in different planes. The stages of this technique are described in detail along with the results after applying it to a post-arthroscopic scar on a knee. The active and passive mobility of femoro-tibial and femoro-patellar articulations improved substantially after the treatment, as verified by signs such as pain relief, greater flexibility,

Twenty-two subjects were randomised into a MWM group (n = 6), SMWM group (n = 8) or a control group (n = 8). The primary outcome measures included the functional internal rotation test (FIRT) for the hip and the passive seated internal rotation test (SIRT) for the hip. Outcomes were captured at baseline and immediately after one treatment. The subject was set up in four-pointkneeling on a plinth. To ensure the subject’s hips stayed in 90° of flexion

Twenty healthy participants (10 males and 10 females, aged 21.6 ± 1.6) performed a glute bridge at three hip abduction angles: 0°, 15°, and 30°. Surface electromyography (EMG) signals were recorded from the erector spinae (ES) and gluteus maximus (GM). Simultaneously their anterior pelvic tilt angle was measured using Image J software. The EMG amplitude of the GM muscle and the GM/ES EMG ratio were greatest at 30° hip abduction, followed by 15° and then 0° hip abduction. In contrast, the ES EMG amplitude at 30° hip abduction was significantly less than that at 0° and 15° abduction. Additionally, the anterior pelvic tilt angle was significantly lower at 30° hip

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disappearance of inflammation and a major recovery of tissue elasticity. A sonoelastography study of the portals and patellar tendon was carried out before and after therapy, showing semi-quantitatively the recovery of the viscoelastic properties of the tissue.

Co-Kinetic comment Excellent stuff – a paper describing what any therapist with a knowledge of fascia knows. Surgery scars, even the little ones at arthroscopy sites, can restrict range of

motion. It is worth getting hold of this paper for the reference list alone. Lots and lots of information on the importance of fascia and how and why we need to work with it.

THE EFFECTS OF CAUDAL MOBILISATION WITH MOVEMENT (MWM) AND CAUDAL SELFMOBILISATION WITH MOVEMENT (SMWM) IN RELATION TO RESTRICTED INTERNAL ROTATION IN THE HIP: A RANDOMISED CONTROL PILOT STUDY. Walsh R, Kinsella S. Manual Therapy 2016;22:9–15 the tester positioned their hands on the subject’s greater trochanters. All MWMs were administered by a single undergraduate with 1 year of clinical experience. The MWM was performed with a caudal glide to the femur applied with a Mulligan® mobilisation belt.

Co-Kinetic comment On the positive side this is an example of manual therapy that works. The downside is that the description of the movement and the accompanying photo don’t really look like a caudal glide, it’s more posterior, but hey it works so who cares?

MODIFYING THE HIP ABDUCTION ANGLE DURING BRIDGING EXERCISE CAN FACILITATE GLUTEUS MAXIMUS ACTIVITY. Kang S-Y, Choung S-D, Jeon H-S. Manual therapy 2016;22:211–215 abduction than at 0° or 15°.

Co-Kinetic comment So decide what you want to achieve with a glute bridge exercise,

activation of GM and/or the back muscles, because you can change the emphasis depending on how you set up the hip position.

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Our regular research review summarises research looking into how the act of observing an action can help prepare the patient for executing the action. It is possible that using this activity as a first stage in the rehabilitation process might result in higher quality movements and faster recovery. Read this online http://spxj.nl/1UOcEMZ

THE ROLE OF VISION IN REHABILITATION 16-10-COKINETIC FORMATS WEB MOBILE PRINT

he role of vision and observation in physical therapy practice is potentially an underused variable that may significantly impact outcomes (influencing how one moves). Common conditions treated by physical therapists include: low back pain, fibromyalgia and Parkinson’s disease (1–3). Although each of these conditions present with different signs and symptoms, patients with these conditions often present with altered motor control (3-5). When one has altered motor control, it has been speculated that ‘seeing’ may result in ‘mirroring’, thus altering how one may potentially move (6). This is thought to occur through a complex neural network of preparing and planning within the brain, resulting in a different formulated plan of executed movement. The objectives of this literature review are to describe the effects of decreased movement on cortical representations in the brain, explain the role mirror neurons play in observation (as well as describe the

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Cortical representations of the body in the adult brain are highly dynamic and plastic in nature http://spxj.nl/1UOcEMZ Tweet this: The mirror neuron system transforms visual information into knowledge information used to produce an active movement http://spxj.nl/1UOcEMZ Tweet this: Pain may indirectly alter the topographical representation of the painful body region within the brain http://spxj.nl/1UOcEMZ Tweet this: The neurological process of action observation is extremely similar to that of action execution http://spxj.nl/1UOcEMZ Tweet this: Observing movements before movement execution may result in higher quality movements and faster recovery http://spxj.nl/1UOcEMZ Tweet this: By observing another individual learning to move, observers are able to move more accurately themselves http://spxj.nl/1UOcEMZ

BY MARK POWERS DPT, OCS APTA AND JOSEPH BRENCE DPT, FAAOMPT, COMT, DAC known benefits of observation learning in rehabilitation), and suggest what all of this data means to us as physical therapists.

CORTICAL REPRESENTATIONS OF THE BODY It has been described that cortical representations in the adult brain are highly dynamic and plastic in nature (7). These representations are organised and reorganised due to peripheral and central alterations of input (7). Thus, if a body part becomes less active, the corresponding topographical representation for that body part in the brain decreases in size (8). For example, imagine someone who presents clinically with chronic right ankle pain. Their right ankle may not be topically represented here resulting in difficulty with motor planning and execution of movements. Patients who seek care from a physical therapist often present with complaints of pain, and altered movement (3–5). It is speculated that the result of pain may indirectly alter the topographical representation of the painful body region within the brain (8). Studies have shown that the amount of cortical reorganisation increases with the duration of the pain (7). When patients present clinically, it is important to note that decreased input may affect central reorganisation negatively, and increased input can affect central reorganisation positively (7). According to Mulder, there are five sources of response-related input described in motor learning: 1) proprioceptive information, 2) tactile information, 3) vestibular information, 4) visual information, and 5) auditory information (7). The focus of this article is on the effects of visual input.

THE MIRROR NEURON SYSTEM The principle driver behind observational learning and visual input is likely the mirror neuron system. Mirror neurons are a class of visuomotor neurons originally discovered in area F5 of a primate’s premotor cortex. A group of researchers discovered that mirror neurons discharged not only when a primate performs a particular action, but also when it observes another individual performing that action (9). This suggests that when we observe another individual perform a movement, we attempt to plan or ‘mirror’ the same movement. Currently, it is hypothesised that mirror neurons are mediators of imitation and serve as the basis of action understanding. Mirror neurons are essentially neurons that are activated in the corresponding area in the premotor cortex (9). The motor representation of an action corresponds to what is generated during active action. Therefore, the mirror neuron system can transform visual information into knowledge information used to produce an active movement. Even though the majority of early research on mirror neurons was performed on primates, there is evolving data suggesting that a mirror neuron system is present and active in humans. Multiple studies using electroencephalogram (EEG) and magnetoencephalography (MEG) demonstrate that desynchronisation during action observation includes rhythm origination from the cortex inside the central sulcus (6). For example, Fadiga et al. recorded motor evoked potentials (MEPs) from the right hand and arm

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PHYSICAL THERAPY RESEARCH LITERATURE INTO PRACTICE REVIEW

muscles from observers who watched an experimenter grasping objects (10). They found that observation of both transitive and intransitive actions determined an increase of recorded MEPs. The increase was specific to the muscles that the subjects would use to produce the observed movements (10). In 2001, researchers used fMRI to demonstrate that action observation activates premotor and parietal areas in a somatotopic manner. In this study, they localised brain areas that were active during observation of actions made by the experimenter. They found that observation of actions resulted in a somatotopically organised activation of the premotor cortex; and the somatotopic patterns were similar to that of the originally described homunculus (11). Therefore, the neurological process of action observation was extremely similar to that of action execution. These are just a select few of the numerous studies that directly and indirectly support the existence of a mirror neuron system in the human brain. When considering the role of the mirror neuron system, it is practical to think that observation has the potential to be a key player in the rehabilitation process due to the ability to begin motor planning of a movement before execution of the movement. In addition to live observation, it has also been demonstrated that subjects who observed a video depicting another person performing a reaching task, were able to perform better when later tested and compared to those who did not observe the reaching tasks. It was concluded that by observing another individual learning to move, observers were able to move more accurately themselves. Similarly, it has been demonstrated that areas of the premotor cortex, temporal gyrus, occipital areas, and parietal cortex are activated by observation of movements. As the premotor cortex plays a major role in planning movements, one can suggest

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that observing movements may lay the groundwork for planning and execution (13).

CLINICAL UTILITY: WHAT DOES THIS MEAN TO US? The positive role of observation has been studied in individuals with various diagnoses, including those who have sustained a cerebrovascular accident (CVA, or stroke). In one study, observation of daily actions was combined with concomitant physical training of the observed actions in a rehabilitation programme (9). Using fMRI they analysed the effects of actionobservation therapy on reorganisation of the motor system and found that neural activations between experimental and control groups after training compared to those elicited before training yielded a rise in activity of the ventral premotor cortex, bilateral superior temporal gyrus, supplementary motor area, and the contralateral supramarginal gyrus. They concluded that their results provide evidence that action observation has a positive additional impact on recovery after stroke (14). Although the majority of research shows the positive impact of observation on the recovery of motor control after stroke, it is the author’s opinion that this can be extrapolated to fill a void in the general physical therapy population. As mentioned above, patients often present to physical therapy with complaints of altered movement (often as result of pain), and this altered activity may lead to cortical reorganisation of motor areas within the brain and ‘smudging’ in the homunculus (8). Smudging is a process that occurs when brain areas normally devoted to different body parts for different functions start to overlap; areas of repeated use get larger and areas of decreased use get smaller (15). It is common for patients to receive a high level of therapeutic exercise very early in their rehabilitation programme. Based on the above-mentioned research, this may potentially be detrimental to the patient, if the underlying motor planning in the premotor cortex is absent. It is in the author’s opinion that simple adjustments to a patient’s rehabilitation

protocol can be made to include action observation before action execution. The most cost effective and efficient way is for the patient to simply observe the therapist performing a movement before performing it themselves. Technology is a valuable tool as well, and using video may afford the clinician the ability to pause on certain phases of movement, in which imagery may then be used by the patient in a step-by-step fashion. Based on previous research, having patients observe movements before execution early in the rehabilitation process may result in higher quality movements and faster recovery. As this is speculative at this time, further research is required to test the possible benefits of observational learning in the outpatient setting. Future research may also be beneficial to generate a treatment algorithm to improve clinical utility, for example observational learning followed by motor imagery followed by active exercise. Therapists often report that patients with persistent pain conditions are the most difficult to treat, and observational learning may be a missing link in this process.

ACKNOWLEDGEMENTS Mark Powers would like to thank his fellowship mentors at Sports Medicine of Atlanta for granting him this research opportunity and analysing/editing this paper. He would also like to thank Carty Dunn PT DPT, OCS for grammatical editing early on in the writing process. References 1. Gellhorn AC, Chan L, et al. Management patterns in acute low back pain: the role of Physical Therapy. Spine 2012;37(9):775–782 2. Nijs J, Mannerkorpi K, et al. Primary care Physical Therapy in people with fibromyalgia: opportunities and boundaries within a monodisciplinary setting. Physical Therapy 2010;90(12):1815–1822 3. Morris ME, Martin CL, Schenkman ML. Striding out with Parkinson disease: evidence-based physical therapy for gait disorders. Physical Therapy 2010;90:280–288 4. Radebold A, Cholewicki J, Polzhofer GK, Greene HS. Impaired postural control of the lumbar spine is associated with delayed muscle response times in patients with chronic idiopathic low back pain. Spine 2001;26(7):724–730 5. Nijs J, Roussel N, et al. Fear of movement and avoidance behaviour toward physical activity in chronic-fatigue syndrome and fibromyalgia: state of the art and implications for clinical practice. Clinical Rheumatology 2013;32:1121–1129 6. Hari R, Forss N, et al. Activation of human primary motor cortex during action observation: a neuromagnetic study. Proceedings of the National Academy of Sciences of the United States of America 1998;95(25):15061–15065 7. Mulder T. Motor imagery and action observation: cognitive tools

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for rehabilitation. Journal of Neural Transmission 2007;114(10):1265–1278 8. Merzenich MM, Kaas JH, et al. Topographical reorganization of somatosensory cortical areas 3b and 1 in adult monkeys following restricted deafferentation. Neuroscience 1983;8(1):33–55 9. Rizzolatti G, Criaghero L. The mirror-neuron system. Annual Reviews of Neuroscience 2004;27:169–192 10. Fadiga L, Fogassi L, et al. Motor facilitation during action observation: a magnetic stimulation study. Journal of Neurophysiology 1995;73(6):2608–2611 11. Buccino G, Binkofski F, et al. Action observation activates premotor and parietal areas in a somatotopic manner: an fMRI study. European Journal of Neuroscience 2001;13(2):400–404 12. Mattar AA, Gribble PL. Motor learning by observing. Neuron 2005;46(1):53–160 13. Grèzes J, Decety J. Functional anatomy of execution, mental simulation, observation, and verb generation of actions: a meta-analysis. Human Brain Mapping 2001;12(1):1–19 14. Ertelt D, Small S, et al. Action observation has a positive impact on rehabilitation of motor deficits after stroke. NeuroImage 2007;36(Suppl 2):T164– 173 15. Butler D, Moseley L. Explain pain, 2nd edn. Noigroup 2013. ASIN B00GGY23A4 (£49.50). Buy from Amazon. http://amzn.to/1XrttRo.

THE AUTHORS Mark Powers DPT, OCS APTA is a Massachusetts native currently residing in Savannah, GA, USA. He is employed with Candler Hospital Outpatient Rehab. His clinical interests include treatment of patients with persistent pain states and learning more regarding the role of observation and clinician language choice in rehabilitation. He’s an avid runner and is currently training for his first triathlon. Email: markspowers@gmail.com Joseph Brence DPT, 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 of pain, the effects of mobilising vs 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

BY JOSEPH BRENCE DPT, FAAOMPT, COMT, DAC

eurodynamics involves the evaluation (and treatment) of the length and mobility of various components of the nervous system. Neurodynamics is also known as ‘neural tension’, and these tests assess the mechanosensitivity of major nerve trunks and their central connections. Although the concept was once theoretical, there is evidence that using precise and sequential positioning of the limb can apply tension on selected neural components (1,2). Even though the concept is introduced in many entrylevel physical therapy programmes, often little is discussed regarding the clinical relevance of the individual tests.

WHAT CONSTITUTES A ‘TRUE POSITIVE’ NEURODYNAMIC TEST? At the Nxt Gen Institute (http://nxtgenpt.com/), we instruct our postdoctoral residents and fellows, that three criteria need to be present to indicate a true positive neurodynamic test: 1. Reproduction of the chief complaint 2. Sensitises signs or symptoms with distal movement 3. Difference side-to-side. We recommend that all three of these criteria be present secondary to high false positive rates when assessing for provocation alone. For example, in a 2007 study, 97.6% of asymptomatic subjects reported a sensory response during the slump test (3).

NEURODYNAMICS OF THE UPPER EXTREMITY There are four neurodynamics tests for the upper extremity. These tests include three of the five peripheral nerves that arise from the cords of the brachial plexus.

Median nerve Originating from the lateral and medial cords of the brachial plexus,

the median nerve is likely the most studied peripheral nerve of the upper extremity. Unlike the other two tested peripheral nerves, there are two tests for the median nerve, upper limb neurodynamic test (ULNT)-1 and ULNT-2A. ULNT-1 With the patient lying supine, the following movements are performed on the tested upper extremity in the following order: 1. Scapular depression 2. Shoulder: 90° of abduction 3. Wrist (and fingers): full extension 4. Forearm: full supination 5. Shoulder: full external rotation 6. Elbow: extension 7. Sensitise with cervical side-bending or rotation. Notes about ULNT-1 The ULNT-1 is sensitive and specific for producing tension in the median nerve with minimal tension in the ulnar and radial nerve (4). It is a valid test (5) and has excellent intra and interrater reliability (6). ULNT-2a With the patient lying supine, the following movements are performed on the tested upper extremity in the following order: a. Scapular depression b. Shoulder is slightly abducted away from side of body c. Elbow: full extension d. Forearm: full supination e. Wrist and fingers: full extension f. Slowly abduct the arm until experience of symptoms g. Sensitise with cervical side-bending or rotation. Notes about ULNT-2a Preferred test for the median nerve if shoulder abduction at or above 90° may be contraindicated or impossible (such as adhesive capsulitis). Excellent intrarater reliability but poor interrater reliability (7). Consider for conditions such as

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PHYSICAL THERAPY RESEARCH LITERATURE INTO PRACTICE REVIEW

MEDICAL SCREENING IN PHYSICAL THERAPY: UNDERSTANDING NEURODYNAMICS Our regular research reviewer, physical therapist Joseph Brence, reviews the role of neurodynamics in medical screening: why it’s useful, how to do it and the clinical relevance of the tests. Read this online http://spxj.nl/1iISS9d carpal tunnel syndrome and cervical radiculopathy.

Radial nerve Originating from the posterior cord of the plexus, the radial nerve passes through the axilla and runs down the posterior arm. It runs along the radial groove of the humerus and passes anteriorly to the lateral epicondyle of the forearm. It crosses the wrist and then supplies cutaneous distribution of the dorsum of the hand. ULNT-2b With the patient lying supine, the following movements are performed on the tested upper extremity in the following order: 1. Scapular depression 2. Elbow extension 3. Shoulder internal rotation 4. Wrist and thumb flexion 5. Shoulder abduction with slight extension 6. Abduct the shoulder until onset of symptoms 7. Sensitize with cervical side-bending or rotation. Notes about ULNT-2b In individuals with confirmed, symptomatic, radial nerve pathology, a ULNT-2b test will be more provocative than if they were asymptomatic or did not have pathology (4). Not very sensitive or specific in determining pathology of the radial nerve (8). Consider for conditions such as lateral epicondylitis.

Ulnar nerve The ulnar nerve is considered to be the largest unprotected nerve in the body and is often injured at the

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medial aspect of the elbow, when the elbow is flexed. Descending down the posteromedial humerus, it enters the anterior compartment of the forearm and supplies the flexor carpi ulnaris and flexor digitorum profundus. It then travels into the hand through Guyon’s canal and passes over the flexor retinaculum. ULNT-3 With the patient lying supine, the following movements are performed on the tested upper extremity in the following order: 1. Scapular depression 2. Shoulder abduction to approximately 45° 3. Wrist and finger extension 4. Shoulder external rotation 5. Elbow flexion 6. Slowly abduct the shoulder past the starting position, while further flexing the elbow 7. Sensitise with cervical side-bending or rotation. Notes about ULNT-3: Consider for conditions such as medial epicondylitis, cubital tunnel syndrome and Guyon’s tunnel syndrome.

WHERE DOES THIS FIT INTO A CLINICAL DECISION MAKING MODEL? We recommend that for any patient presenting to your clinic, you should follow this basic algorithm for clinical decision making: 1. Rule out sinister/medical pathology 2. Rule out the spine 3. Rule out neurodynamics 4. Rule in the peripheral joint/tissues. References 1. Jaberzadeh S, Scutter S, Nazeran H.

Mechanosensitivity of the median nerve and mechanically produced motor responses during Upper Limb Neurodynamic Test 1. Physiotherapy 2005;91(2):94–100 2. Boyd BS, Wanek L, et al. Mechanosensitivity of the lower extremity nervous system during straight-leg raise neurodynamic testing in healthy individuals. Journal of Orthopaedic & Sports Physical Therapy 2009;39(11):780–790 3. Walsh J, Flatley M, et al. Slump test: sensory responses in asymptomatic subjects. The Journal of Manual & Manipulative Therapy 2007; 15(4):231-238 4. Ekstrom RA, Holden K. Examination of and intervention for a patient with chronic lateral elbow pain with signs of nerve entrapment. Physical Therapy 2002;82(11):1077–1086 5. Kleinrensink GJ, Stoeckart R, et al. Upper limb tension test as tools in the diagnosis of nerve and plexus lesions. Anatomical and biomechanical aspects. Clinical Biomechanics 2000;15(1):9–14 6. Coppieters M, Stappaerts K, et al. Reliability of detecting ‘onset of pain’ and ‘submaximal pain’ during neural provocation testing of the upper quadrant. Physiotherapy Research International 2002;7(3):146–156 7. Reisch RK, Williams K, et al. ULNT2 – median nerve bias: examiner reliability and sensory responses in Asymptomatic subjects. The Journal of Manual & Manipulative Therapy 2005;13(1):44–55 8. Peterson CM, Zimmermann CL, et al. Upper limb neurodynamic test of the radial nerve: a study of responses in symptomatic and asymptomatic subjects. Journal of Hand Therapy 2009;22:344–354.

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LOW BACK PAIN ASSESSMENT: THE 10 MINUTE CONSULTATION Every therapist experiences times where they are under pressure to perform a quick and effective musculoskeletal assessment and low back pain (LBP) is a very common ailment seen by clinicians and therapists in a primary care setting. In this article we describe the exact process for how to perform a 10-minute LBP musculoskeletal assessment. A structured approach to history and examination and with some investigations, if necessary, means a diagnosis can be made that can lead to effective management and appropriate referral where necessary. Early mobilisation is key to a successful outcome. This article covers LBP pathologies, a flow chart for determining whether the back pain needs immediate or urgent management, examination tests, investigations, management and suggested stretching exercises. Read this online http://spxj.nl/2bRhtZL

BY DR ROBIN CHATTERJEE MBCHB MSC SEM MSC MED SCI MRCGP DIPSEM MFSEM

INTRODUCTION Low back pain (LBP) is a common ailment seen in the primary care setting (1). Twenty-five percent of episodes result in absenteeism from work and, thus, it causes a huge strain on the economy (2,3). Point prevalence of LBP has been reported as 15–30%, with a lifetime prevalence of 60–80% and an annual incidence of 50% (4). Despite it being such a common presentation, it is often not dealt with as well as it should be by practitioners (5). This is because of a combination of reasons, such as only having 10 minutes to see a patient, having to deal with the myriad of other problems a patient may have and sometimes because of a lack of appropriate training in this particular subject. This article aims to provide

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/2bRhtZL

NOMENCLATURE One of the issues clinicians experience with the diagnosis and management of lower back problems is knowing how to interpret and communicate their findings (5). There are numerous terms, many of which sound quite similar but mean different things, with regards to back pain. Often an umbrella term of ‘sciatica’ is used incorrectly to describe a different type of LBP. Table 1 shows a list of various LBP pathologies with their respective clinical features. It would be prudent to keep these in mind LBP

History Perianal numbness Perianal paraesthes paraesthesia Faecal incontinence Urinary incontinence Unexplained fever History of osteoporosis Pain following trauma On examination Foot may be flail with loss of dorsiflexion of foot or toes or loss of eversion and plantar flexion Ankle jerks may be absent

LOW BACK PAIN | 16-10-COKINETIC | FORMATS WEB MOBILE PRINT

MEDIA CONTENTS

clinicians with a basic framework on how to investigate, examine and manage LBP in 10 minutes. It is by no means a comprehensive guide but should provide some insight into what is often a daunting clinical presentation.

History Unexplained weight loss Bleeding Night pain Loss of appetite Pain temporarily relieved by aspirin or other non-steroidal antiinflammatories (NSAIDS) Age >50 years Failure to improve after 6 weeks of conservative management Past history of cancer

Consider malignancy Consider Cauda Equina Syndrome or infection or spinal fracture

Immediate referral to Accidents & Emergency required

Urgent referral to orthopaedics required (via 2-week wait rule)

Figure 1: Determination of whether the cause of back pain needs immediate or urgent management (R. Chatterjee, 2016)

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PHYSICAL THERAPY MSK DIAGNOSIS, TREATMENT, REHABILITATION

TABLE 1: LOW BACK PAIN PATHOLOGIES (R. Chatterjee, 2016) DISORDER

DESCRIPTION

CLINICAL FEATURES

Spinal stenosis [Lurie & Tomkins. BMJ 2016:352:h6234 (6)]

Abnormal narrowing of spinal canal, causing restriction to canal which may cause neurological deficit.

Standing discomfort Heaviness of legs with walking which causes patient to come to rest (neurogenic claudication) Bilateral symptoms Numbness

Weakness Buttock/thigh pain Below knee pain Symptoms exacerbated by extension of spine and relieved with spine flexion

Spondylosis [Chiba et al. J Orthop Sci 2016:21(3):366–372 (7)]

Degeneration of spinal column from any cause. Osteoarthritis is a common cause of degeneration. This may result in compression of nerve root at level of spine.

Often asymptomatic Lower back pain

Radiation down either or both legs

Spondylolysis/pars interarticularis defect [Standaert.Clin J Sport Med 2002:12(2):119–122 (8)]

The pars interarticularis is a part of the lumbar spine that joins the upper and lower joints. Fracture of this joint may be due to repetitive hyperextension of spine.

Unilateral low back pain Often at L5 Pain may radiate into buttocks or legs Pain exacerbated with activity Pain exacerbated by lumbar hyperextension

Unilateral tenderness on palpation Pain during stork test (hyperextension and rotation of lower back) May have excessive lordosis of lumbar region at rest

Spondylolisthesis [Matz et al. Spine J 2016:16(3):439–448 (9)]

Forward movement of vertebra (commonly 5th lumbar vertebra). May occur due to instability from pars defect.

May see stiff lower back with tight or painful hamstrings Patient may lean forward at rest May have waddle gait May have gluteal muscle wasting May have radiation down buttocks or legs

Coughing and sneezing may exacerbate pain Classically a ‘slipping sensation’ is described by patients when they try to stand from a sitting position or sit from a lying position

Prolapsed intervertebral disc/ spinal disc herniation/ slipped disc [Camp et al. Am J Orthop 2016:45(3):137– 143 (10)]

Tear in outer ring of an intervertebral disc allowing soft central part to bulge out past the outer ring. May be due to trauma, repetitive motion of lower back, age related degeneration, lifting or straining. Pain may be due to either compression of nerve root or release of inflammatory mediators from damaged outer ring.

Asymptomatic Mild, moderate or severe low back pain that may or may not radiate down both or either buttock or leg

In severe disc prolapse, cauda equina syndrome may occur where patient experiences saddle anaesthesia and change in bowel and bladder control. This is a medical emergency.

Sciatica [Spijker-Huiges.Sc J Prim Health care 2015:33(1):27–32 (11)]

This describes a symptom rather than a disease. It is caused by irritation of the sciatic nerve. This can be due to spinal disc herniation, spinal stenosis or anything else that may impinge on the nerve. Sciatica is often used loosely, but incorrectly, as any back pain radiating down the leg.

May or may not have low back pain Pain may radiate down one or both buttocks or legs Pain worse on sitting

Leg pain may be described as burning, tingling (as opposed to dull ache) Possible weakness or difficulty in moving leg or foot

Lumbar spondylitis [Weisman.Rheum Dis Clin North Am 2012:38 (3):501–512 (12)]

This is inflammation of the lumbar vertebra. If one or more vertebral joints are involved then it is referred to as spondylarthritis.

Lower back pain Lower back stiffness Pain on twisting and turning of lower back

Deformity or abnormal spinal curvature

Ankylosing spondylitis [Weisman.Rheum Dis Clin North Am 2012:38 (3):501–512 (12)]

A form of spondylitis which is a chronic, inflammatory autoimmune disease that involves joints including those of the lower back.

Gradual onset Common between age of 20–30 years Chronic dull lower back pain with associated stiffness

Pain is worse in mornings and may awake patient from sleep As disease progresses, many other parts of body may be affected

Pott’s disease [Garg & Somvanshi.J Spinal Cord Med 2011:34(5):440–454 (13)]

Another form of spondylitis, which is a tuberculous disease of the vertebra.

Lower thoracic and upper lumbar vertebrae commonly affected May occur if patient has recently

travelled to country that is high risk for tuberculosis or has been exposed to tuberculosis

Is it acute (< 6 weeks), sub-acute (6-12 weeks) or chronic (>12 weeks)?

Heavy physical work

Muscle wasting

Frequent bending

Asymmetry

Sudden onset or gradual onset?

Vibrations

Winging of scapulae

Radiation down one, both or neither leg?

Static posture

Relieving and exacerbating factors? (Eg. bending, running, sitting etc.)

Repetitive motion

Excessive lordosis of lower back

Continuous or intermittent? Pain score on a scale of 1 to 10? How does the patient describe the pain? (Eg. sharp, dull, burning etc.) Have they had it before and if so then what is the history behind that? How have activities of daily life been affected?

Twisting Poor lifting technique Obesity or recent weight gain

Excessive kyphosis of upper back Scarring Bruising Pelvic tilt

Figure 3: Risk factors an individual may have to make them susceptible to chronic low back pain (R. Chatterjee, 2016)

Figure 4: Inspection of back and chest wall in examination of patient with low back pain (R. Chatterjee, 2016)

What medication have they taken for the pain? Figure 2: Questions that need to be addressed regarding the nature of pain in a low back pain consultation (R. Chatterjee, 2016)

when taking a history and examining a patient with LBP.

HISTORY The first thing a practitioner must determine is if the LBP needs immediate, urgent or more long-term care. This can be elicited by asking very specific questions and following the flow chart in Figure 1. Once it has been determined that the patient does not need immediate or urgent management, further questioning is required to determine what may be causing the LBP (Fig. 2). Specific risk factors related to LBP must be investigated during the course of the consultation (Fig. 3)

EXAMINATION Before any examination, consent must be obtained and the clinician should wash their hands. Initially any garments

TABLE 2: LOWER LIMB MOVEMENTS THAT CORRESPOND TO THE NERVE ROOT BEING TESTED (R. Chatterjee, 2016) Nerve Root Being Tested

Movement Elicited

Hip flexion

Knee extension

Heel walking

Extension of big toe

Tip-toe

EARLY MOBILISATION IS KEY TO A SUCCESSFUL OUTCOME that the individual is wearing on their upper body must be removed. This is because the first stage in examination of the lower back is inspection of the back and the upper body (Fig. 4). After inspecting the back, ask the patient to walk up and down your consulting room so that you can crudely analyse their gait. This will allow you to see how the back changes on movement and also if the pain affects the way in which the patient walks, which in turn may cause other problems. After gait analysis, a basic test of lower limb myotomes is conducted (Table 2). Inability to perform a specific movement can help to identify a particular nerve root impingement. The lower back must next be palpated. This will allow the clinician to determine exactly where the pain is. It is important to note at which dermatomal level the pain is felt and whether the back is painful to touch at the level of the vertebral body, the facet joint or along a part of the dermatome. The patient is then asked to actively forward flex, extend, hyperextend and laterally flex to both the right and left sides. The degree of each movement and any alteration to back pain should be recorded. While the patient is standing, the stork test is then performed to see if the patient may have a pars defect or any evidence of spondylolysis (Table 3).

The slump test and straight leg raise tests are then performed to check for nerve root irritation. However, if one or both tests are negative, this does not necessarily exclude any pathology (Table 3). The history and examination should be enough to provisionally diagnose what the cause of the LBP is. However, sometimes further investigations may be needed to diagnose the cause of the problem.

INVESTIGATIONS Some medical illnesses may cause lower back pain and if this is suspected as the cause of the LBP then it is advisable to obtain some blood tests from the patient. The tests needed are calcium, alkaline phosphatase (ALP) and phosphate. Table 4 shows a list of ailments that may cause LBP and their corresponding blood results. Generally inflammatory markers such as C reactive protein (CRP) or erythrocyte sedimentation rate (ESR) are not needed as they tend to be elevated in most cases anyway and unless serial measurements are taken their absolute value will not affect management. It may be worthwhile measuring vitamin D levels too as recent evidence shows a correlation between low vitamin D levels and chronic LBP (17â&#x20AC;&#x201C;19). Sometimes imaging may also be necessary. It is important to know exactly why imaging is being requested as the risks of the actual imaging Co-Kinetic Journal 2016;70(October):16-22

PHYSICAL THERAPY MSK DIAGNOSIS, TREATMENT, REHABILITATION

TABLE 3: SPECIAL TESTS CONDUCTED IN EXAMINATION OF LOW BACK PAIN (R. Chatterjee, 2016) TEST

WHY

HOW

Straight leg raise test [Boyd & Villa. BMC Musc Dis 2012:13:245 (14)]

To test for lumbosacral nerve root irritation. This can occur with many disorders such as prolapsed intervertebral disc.

Lie patient on back. Raise one leg with knee completely extended, until pain is experienced in buttock, thigh or calf area. Document angle at which pain occurs. Normal value is 80–90°. Dorsiflex foot at point that pain is elicited (sciatic stretch test). Test is positive if additional pain occurs. Flex the knee joint to relieve buttock pain. Extension of foot will also relieve pain.

Slump test [Majlesi et al. J Clin Rheum 2008:14(2):87– 91 (15)]

To determine if lower back pain is due to herniated disc, neural tension or altered neurodynamics.

Patient sat upright on edge of bed with hands held behind back. Patient is asked to slump forwards and then flex neck. Clinician then places hand on top of patient’s head and then asks patient to fully extend knee and dorsiflex foot. Patient asked to look up to ceiling. Test is positive if pain in lower back in slumped position but relieved when neck is moved out of flexion.

Stork test [Sung et al. Spine 2010:35(16): E753–760 (16)]

To identify spondylolysis/ pars interarticularis defect.

Stand behind the patient for support. Ask patient to balance on one leg and then hyperextend back. Test is positive if pain occurs at lumbar vertebrae.

MANAGEMENT

modality may outweigh the benefits (Table 5). As stated earlier, most pathologies can be determined from the history and examination alone and so imaging should only be considered if the patient is not responding to 4–6 weeks of conservative management or if diagnosis is still uncertain.

LBP is a complex problem that affects many people and can be a challenge to deal with. The ideas, concerns and expectations of the patient play a huge part in how the treatment plan is formulated. For many years the advice for back pain was to have complete rest. It is now acknowledged that absolute rest is actually counter-

TABLE 4. BLOOD TEST RESULTS IN CERTAIN AILMENTS THAT MAY CAUSE LOW BACK PAIN (R. Chatterjee, 2016) ALKALINE PHOSPHATASE Osteoporosis

CALCIUM

PHOSPHATE

Paget’s disease

Osteosarcoma

Sarcoidosis

–

Myeloma

–

Osteomalacia

Primary hyperthyroidism

Secondary hyperthyroidism

Tertiary hyperthyroidism Hypoparathyroidism N: Normal

Raised

Co-Kinetic.com

N Lowered

productive and that movement is better for the back than rest. Unfortunately the outdated notion that rest is good has cultivated an atmosphere of fear or avoidance of movement among some patients with LBP. Other attitudinal problems that need to be overcome are that back pain is harmful and potentially disabling, the feeling of depression and isolationism and finally the expectation that passive rather than active treatment is all that is needed to make the pain go away. This is where an individual believes that visiting a doctor or physiotherapist is enough to make the pain better and that no extra exercise outside of the consultation is needed. It is imperative that these false beliefs and negative thoughts are addressed at the outset of treatment. In order to allow the patient to move, analgesia must be optimised (Table 6). A step-up approach is preferable with first-line treatment usually a simple analgesic such as paracetamol together with a nonsteroidal anti-inflammatory (NSAID). It may be advisable to offer a proton pump inhibitor (such as omeprazole) in addition to the NSAID, as some individuals may suffer gastro-intestinal (GI) disturbances with NSAIDs. This class of drug should be avoided in any patient who suffers with asthma or heartburn. Incidentally, paracetamol and capsaicin may be used together, as well as with an NSAID also. Cyclooxygenase-2 inhibitors (COX-2 i) carry a lower risk of peptic ulceration and GI disturbances than other NSAIDs and so may be considered as an alternate drug. If the patient is still in pain a weak opioid may be added. Constipation is a common problem with weak and strong opioids and so addition of a laxative can be useful. If the patient complains of radicular pain even after administration of these analgesics then a GABA receptor inhibitor or tricyclic antidepressant may be added as they are useful in the remedy of neuropathic pain. Other classes of drugs may be used to relieve LBP but these should not be administered in a primary care setting due to potential side effects such as respiratory depression. 19

Benzodiazepines are an example of such drugs. They are sometimes used by Sports & Exercise Medicine (SEM) physicians both as a muscle relaxant and as an anxiolytic to allow optimum conditions for exercise. Hot and cold therapies are both useful conservative measures that should be encouraged in addition to pharmacological treatment in the primary care setting (Table 7). This is because although there is limited evidence regarding efficacy, these therapies are non-invasive, cheap, readily available and have relatively few side effects (23). Even before adequate pain relief is established, physical exercise must be encouraged. The FITT (frequency, intensity, time, type) principle should be used to offer a structured exercise programme tailored to the individual. Exercise programmes should consist of aerobic activity, movement instruction,

muscle strengthening, postural control and stretching. Eight sessions of exercise over a 12-week period is an appropriate start for an ‘exercise-naïve’ patient (24). Group supervised exercise is preferable as this will maintain patient motivation and enthusiasm for exercise as well as provide a support network for the individual (See ‘Related content’ panel for various patient information leaflets for low back pain). A multidisciplinary team (MDT) consisting of physiotherapists, chiropractors, osteopaths and SEM physicians should be involved from an early stage. Spinal manipulation (joint movement within the normal range of movement), massage (manual mobilisation of soft tissues) and acupuncture can all be offered and provided by a number of different clinicians to aid in the management of LBP (24). Referral to a psychologist or counsellor should also be considered

TABLE 5: IMAGING THAT MAY BE USED IN THE INVESTIGATION FOR LOW BACK PAIN (R. Chatterjee, 2016) MODE OF IMAGING

ADVANTAGES

DISADVANTAGES

X-ray (plain radiographs) [Kerry et al. Br J Gen Pract 2002:52(479):469–474 (20)]

Low cost Readily available May help identify fractures of vertebrae and bony deformities including degenerative changes

Rarely indicated as part of initial workup Exposure to radiation Discs cannot be visualised Abnormalities that are identified by X-ray may be unrelated to cause of pain, eg. scoliosis Soft tissue damage not identifiable

Magnetic resonance imaging (MRI) [Jarvik & Deyo. Ann Intern Med2002:137(7):586– 597 (21)]

No radiation exposure Preferred over CT if soft tissue or spinal canal needs to be identified Needed if patient has persistent radicular symptoms after initial conservative management

Expensive Often long waiting time to get MRI Not to be used to identify herniated disc, as it can be an incidental finding and not the source of pain

Computed tomography (CT) [Jarvik & Deyo. Ann Intern Med2002:137(7):586– 597 (21)]

Preferred over MRI if bony anatomy needs to be identified Used to identify fracture if radiograph normal but fracture still suspected

High exposure to radiation

Bone scan [Lateef & Patel. Curr Rev Musculoskelet Med 2009:2(2):69–73 (22]

Used to identify stress fractures, bony metastases, infections or occult fractures Can differentiate between acute or healed compression fracture

Not usually used in LBP as is generally non-specific in identifying cause of pain

as some patients may benefit from cognitive behavioural therapy (CBT) or other forms of emotional and psychological support. Pilates and yoga should be encouraged as they can improve strength and proprioception of core, trunk and back muscles. If after an extensive period of rehabilitation LBP still persists, an SEM physician may consider alternate therapies such as prolotherapy, transcutaneous nerve stimulation (TENS), extracorporeal shockwave therapy (ESWT), platelet rich plasma (PRP) injections or epidural analgesia. As there is limited evidence available on the efficacies of these new techniques, the decision to treat the patient should not be made at a primary care level and only after all other therapies have been exhausted. Finally if all conservative and medical methods of management have been attempted and the patient is still symptomatic, referral to an orthopaedic surgeon should be considered for possible spinal fusion.

CONCLUSION LBP is a very common ailment seen by clinicians in a primary care setting and it is often difficult to manage in a 10-minute consultation. However, with a structured approach to history and examination and with some investigations if necessary, a diagnosis can be made which can lead to effective management and appropriate referral. Early mobilisation is key to a successful outcome. Addressing the fears and concerns of the patient will help to create a positive mind-set for the patient to allow them to mobilise effectively. Early involvement of the MDT provides the patient with a support network of professionals who can provide different expertise. LBP is a condition which should not be feared by practitioners but instead with sufficient knowledge of both the condition and management options available, should lead to effective and satisfactory treatment for patients. References 1. Deyo RA, Weinstein JN. Low Back Pain. New England Journal of Medicine

Co-Kinetic Journal 2016;70(October):16-22

PHYSICAL THERAPY MSK DIAGNOSIS, TREATMENT, REHABILITATION

TABLE 6: LIST OF MEDICATIONS THAT CAN BE USED FOR ANALGESIA IN LOW BACK PAIN (R. Chatterjee, 2016) TYPE OF ANALGESIC

NAME OF DRUG

MODE OF ADMINISTRATION

Simple analgesics

Paracetamol Capsaicin

Oral Topical gel

NSAIDs

Ibuprofen Diclofenac Naproxen

Oral or topical gel Oral or topical gel Oral

COX-2 inhibitors

Celecoxib Valdecoxib Etoricoxib

Oral Oral Oral

GABA inhibitors

Gabapentin Pregabalin

Oral Oral

TCA

Amitriptyline

Oral

Weak opioids

Codeine Co-codamol Co-dydramol

Oral Oral Oral

Strong opioids

Tramadol Buprenorphine Fentanyl Oxycodone

Oral Topical patch Topical patch Oral or topical patch

Benzodiazepines

Diazepam

Oral

ADDRESSING THE FEARS AND CONCERNS OF THE PATIENT WILL HELP TO CREATE A POSITIVE MIND-SET FOR THE PATIENT TO ALLOW THEM TO MOBILISE EFFECTIVELY

TABLE 7: HEAT AND COLD THERAPY AS ANALGESIA (R. Chatterjee, 2016) TEST

WHY

HOW

Mechanism of action

Opens up blood vessels which increases blood flow and therefore oxygen, nutrients and natural anti-inflammatories to area of pain Decreases muscle spasms

Reduces speed of blood flow to area where cold is applied This results in reduced pain and swelling

Mechanism of action

Hot water bottle Heat pack/pad Hot shower Hot bath Sauna/steam room Heat should not be so hot that it burns skin Moist heat tends to penetrate area better than dry heat

Ice cubes Bag of peas Frozen bag of food Ice pack Gel pack

Frequency of application

As many episodes as possible with each episode lasting up to 20 minutes. Should be minimum 10 minute intervals between episodes of application.

As many episodes as possible with each episode lasting up to 20 minutes Should be minimum 10 minute intervals between episodes of application.

When and how to use it

Do not apply directly to skin. Wrap heat device in cloth or towel first Do not use on open wounds Do not lie down on hot device as patient may fall asleep and burn themselves Avoid in first 48 hours after trauma or injury

Do not apply directly to skin. Wrap cold device in cloth or towel first Should be used in first 48 hours after trauma or injury

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2001:344(5):363–730 2. Ekman M, Jonhagen S, et al. Burden of illness of chronic low back pain in Sweden: a cross-sectional, retrospective study in primary care setting. Spine 2005:30(15):1777–1785 3. Burdorf A, Jansen JP. Predicting the long-term course of low back pain and its consequences for sickness absence and associated work disability. Occupational and Environmental Medicine 2006:63(8):522–529 4. Nachemson A, Waddell G, Norlund A. Epidemiology of neck and low back pain. In: Nachemson A, Jonsson E (eds) Neck and back pain: the scientific evidence of causes, diagnosis and treatment, pp.165–188. Lippincott Williams and Wilkins 2000. ISBN 978-0781727600 (Print £55.31). Buy from Amazon http://amzn.to/2bF4CGj 5. Darlow B, Dean S, Perry M et al. Acute low back pain management in general practice: uncertainty and conflicting certainties. Family Practice 2014:31(6):723–732 6. Lurie J, Tomkins-Lane C. Management of lumbar spinal stenosis. BMJ 2016:352:h6234 7. Chiba D, Tsuda E, et al. Lumbar spondylosis, lumbar spinal stenosis, knee pain, back muscle strength are associated with the locomotive syndrome: rural population study in Japan. Journal of Orthopaedic Science 2016:21(3):366–372 8. Standaert CJ. Sponylolysis in the adolescent athlete. Clinical Journal of Sport Medicine 2002:12(2):119–122 9. Matz PG, Meagher RJ, et al. Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis. Spine Journal 2016:16(3):439–448 10. Camp CL, Conti MS, et al. Epidemiology, treatment and prevention of lumbar spine in major league baseball players. American Journal of Orthopedics 2016:45(3):137–143 11. Spijker-Huiges A, Groenhof F, et al Radiating low back pain in general practice: incidence, prevalence, diagnosis, and long term clinical course of illness. Scandinavian Journal of Primary Health Care 2015:33(1):27–32 12. Weisman MH. Inflammatory back pain. Rheumatic Disease Clinics of North America 2012:38 (3):501–512 13. Garg RK, Somvanshi DS. Spinal tuberculosis: a review. Journal of Spinal Cord Medicine 2011:34(5):440–454 14. Boyd BS, Villa PS. Normal inter-limb 21

differences during the straight leg raise neurodynamic test: a cross sectional study. BMC Musculoskeletal Disorders 2012:13:245 15. Majlesi J, Togay H, et al. The sensitivity and specificity of the slump and straight leg raised tests in patients with lumbar disc herniation. Journal of Clinical Rheumatology 2008:14(2):87–91 16. Sung PS, Yoon B, Lee DC. Lumbar spine stability for subjects with and without low back pain during one-leg standing test. Spine 2010:35(16):E753–760 17. Lofti A, Abdel-Nasser AM, et al. Hypovitaminosis D in female patients with chronic low back pain. Clinical Rheumatology 2007:26 (11):1895–1901 18. Ghai B, Bansal D, et al. High prevalence of hypovitaminosis D in Indian chronic low back patients. Pain Physician 2015:18(5):E853– 862 19. Al Faraj S, Al Mutairi. Vitamin D deficiency

and chronic low back pain in Saudi Arabia. Spine 2003:28 (2):177–179 20. Kerry S, Hilton S, et al. Radiography for low back pain: a randomised controlled trial and observational study in primary care. British Journal of General Practice 2002:52(479):469–474 21. Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Annals of Internal Medicine 2002:137(7):586–597 22. Lateef H, Patel D. What is the role of imaging in acute low back pain? Current Reviews in Musculoskeletal Medicine 2009:2(2):69–73 23. Malanga GA, Yan N, Stark J. Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury. Postgraduate Medicine 2015:127(1):57– 65 24. NICE Guidelines CG88. Low back pain in adults: early management. NICE 2009.

KEY POINTS Low back pain (LBP) is a very common condition seen in a primary care setting but often not managed as well as it should be. Red flags to look out for include change in bowel habit, unexplained weight loss, night pain, saddle anaesthesia, unexplained fever, pain following trauma and failure to improve after 6 weeks of conservative management. These all require immediate or urgent management. There are many different causes of LBP. Appropriate history and examination is required to accurately diagnose the cause. Imaging is rarely required to diagnose the cause of LBP but may be used in certain cases. Patient education and involvement will improve overall outcome. It is imperative that the ideas, concerns and expectations of the patient are addressed. Early movement is key in the management of LBP. Analgesia must be optimised to allow movement. The multidisciplinary team must be involved from as early as possible. Clinicians should consider referral of such cases to the new specialty of Sports & Exercise Medicine. An extensive period of rehabilitation is often needed to improve LBP, and patients should be made aware of this.

RELATED CONTENT Low Back Pain: The really important things to exclude - Fisic Conference Presentation 2015 http://spxj.nl/1S7NcEh Physical therapy or advanced medical imaging: how should low back pain be first managed? http://spxj.nl/1MmbWnl Patient Information Leaflet: Exercises and Advice for Sporting Back - http://spxj.nl/1lwtB33 Patient Information Leaflet: Exercises and Advice Chronic Low Back Pain - http://spxj.nl/1lwstg2 Patient Information Leaflet: Back Pain During Pregnancy - http://spxj.nl/2c1bK3K More articles on low back pain - http://spxj.nl/2cb92bQ

THE AUTHOR Dr Robin Chatterjee is a specialist registrar in Sports & Exercise Medicine at the Charing Cross and Hammersmith Hospitals in London and also a qualified general practitioner with a special interest in Sports & Exercise Medicine. After graduating in 2003 from the University of Liverpool with an Honours degree in Medicine, he went on to pursue a wide and varied career. Highlights include practising as an anaesthetist in the outback in Australia, gaining experience in dive and altitude medicine, working at the London Marathon and World Triathlon Championships. In 2008, Dr Chatterjee happened to be in Thailand during a terrorist attack, where he fulfilled the role of a trauma medic in the field, as well as a regional correspondent for the BBC World Service. He currently works as a medical officer for Brentford FC Academy and West Ham United FC Academy and has a particular interest in low back pain. He has obtained an MSc in Sports & Exercise Medicine at Queen Mary University of London in 2015 has also obtained the Diploma in Sports & Exercise Medicine and has subsequently been awarded full membership to the UK Faculty of Sports & Exercise Medicine of the joint Royal Colleges of Physicians and Surgeons. Outside of work Dr Chatterjee is a PADI certified diver, avid football fan and a doting father to his newborn son! Email: robinchatterjee1@yahoo.co.uk

DISCUSSIONS How have you been dealing with chronic low back pain (LBP) in your consultations? It is often thought by patients that absolute rest is required for this ailment. How will you address this false notion and persuade the patient to move? It is vital to know what services are available in your locality to aid in the treatment of LBP. NHS Sports & Exercise departments are becoming more common, and should be used in such cases.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: The term ‘sciatica’ is used incorrectly to describe a different type of low back pain http://spxj.nl/2bRhtZL Tweet this: A practitioner must first determine if the LBP needs immediate, urgent or more long-term care http://spxj.nl/2bRhtZL Tweet this: On palpation of the lower back, it is important to note at which dermatomal level the pain is felt http://spxj.nl/2bRhtZL Tweet this: If illness is the suspected LBP cause, calcium, alkaline phosphatase and phosphate tests are needed http://spxj.nl/2bRhtZL Tweet this: Imaging for LBP is only considered if the patient is not responding to conservative management http://spxj.nl/2bRhtZL Tweet this: Absolute rest is counter-productive for LBP and movement is actually better for the back than rest http://spxj.nl/2bRhtZL

Co-Kinetic Journal 2016;70(October):16-22

PHYSICAL THERAPY MSK DIAGNOSIS, TREATMENT, REHABILITATION

Low back pain (LBP) is a common complaint amongst women during pregnancy and has a huge impact on their quality of life. It has been estimated that about 50% of pregnant women will suffer from some kind of LBP at some point during their pregnancies or during the postpartum period, although some research suggests this percentage is much higher. Pregnancy-related LBP seems to be a result of several factors including mechanical, hormonal and psychological ones. This article outlines the distinction between physiological and pathological back pain, the difference between pelvic girdle pain and low back pain and outlines diagnostic strategies and treatment options for each. It is accompanied by three printable patient information leaflets: Back Pain During Pregnancy; Physical Activity During Pregnancy; and Physical Activity After Pregnancy. There is also a downloadable and printable poster of good and bad posture while seated. Read this online http://spxj.nl/2b9tqr0

LOW BACK PAIN (LBP) AND PELVIC GIRDLE PAIN (PGP) ARE COMMON IN PREGNANCY LOW BACK PAIN | HANDOUT | 16-10-COKINETIC | FORMATS WEB MOBILE PRINT

MEDIA CONTENTS Patient information leaflet: Back Pain During Pregnancy http://spxj.nl/2b9tqr0 Patient information leaflet: Physical Activity During Pregnancy http://spxj.nl/2b9tqr0 Patient information leaflet: Physical Activity After Pregnancy http://spxj.nl/2b9tqr0 Printable poster: Optimal Desk Posture http://spxj.nl/2b9tqr0

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LOW BACK PAIN DURING PREGNANCY PHYSIOLOGICAL VERSUS PATHOLOGICAL BACK PAIN BY MR DAMIEN FAHY BSC MBBS FRCS (TR & ORTH) DIP ORTH ENG AND DR GLYN TOWLERTON BSC MBBS MRCP FRCA FIPP FFMRCA

INTRODUCTION Low back pain (LBP) and pelvic girdle pain (PGP) are common in pregnancy. The mean and median prevalence of LBP in pregnancy is 45.3% and 49%, respectively (1,2). The true incidence is almost certainly higher with some form of mechanical pain being almost universal. Distinction must be drawn between pain that is almost a ‘normal’ physiological experience in pregnancy and ‘pathological’ pain.

‘PHYSIOLOGICAL’ PREGNANCY-ASSOCIATED PAIN Non-Specific Low Back Pain (NSLBP) NSLBP is defined as pain below the costal margin and above the inferior gluteal folds. NSLBP is the most common form of LBP in the general population, and is also the most common in the pregnant population. The prevalence is thought to be higher in the pregnant population due to a variety of theoretical causes as well as hormonal, biomechanical and even vascular alterations (3). The risk factors associated with NSLBP may include previous history of LBP, smoking, obesity, age, depression and anxiety, exercise habits, maternal habitus. Obstetric considerations may not be relevant to LBP. Interestingly, previous lumbar surgery has been identified as protective, which is counter-intuitive and the exact mechanism of this effect is unclear. Younger mothers report more LBP. The stage of gestation does not affect reporting of LBP. Length of time spent in bed, but not mattress characteristics,

has been shown to be important (3).

Pelvic Girdle Pain (PGP) PGP is defined as pain in the symphysis and/or between the posterior iliac crest and the gluteal fold, which may refer to the posterolateral thigh. This is a symptom complex which is more closely linked to the progress of the pregnancy, presentation, foetal size and previous obstetric history including increasing parity (4). Mechanisms including increasing mechanical load, relative pelvic ligamentous instability and muscular dysfunction have been proposed (4). The differentiation of LBP and PGP is based on description of the pain, especially its distribution, stage of pregnancy and examination findings. LBP is characterised by restriction of flexion, paraspinal tenderness and pain on lumbar flexion. PGP is diagnosed by pain induced by the posterior pelvic provocation test. For this test, the hip and knee are flexed to 90°, the pelvis is stabilised at the contralateral iliac crest and a posterior-directed force along the femur produces ipsilateral gluteal pain (5). It is useful to differentiate the two conditions as treatment differs. Evidence supports the use of a nonelastic pelvic support belt placed at the level of the greater trochanters in PGP but not in LBP. There is variable evidence to support pelvic and gluteal strengthening exercises in PGP. Weight-bearing exercise may be painful, and cycling is often not possible especially in an upright position. LBP is best managed by an active functional core and a gluteal

THAT ‘EPIDURALS CAN LEAD TO PERSISTENT BACK PAIN FOLLOWING PREGNANCY’ IS A MYTH STILL TOLD TO WOMEN IN LABOUR strengthening exercise programme designed specifically for the pregnant woman. General weight-bearing nonimpact exercise such as walking, cycling and the use of an elliptical cross trainer will be beneficial. Swimming, particularly freestyle and backstroke, is also to be encouraged.

PATHOLOGICAL SPINAL PAIN Pregnant women are susceptible to the same pathologies as the general population. As with all patients presenting with back pain, quick consideration should be given to the ‘red flags’. Clearly the extremes of age and trauma are not relevant but past medical history, systemic symptoms, deformity and the distribution and character of pain are important. Conditions unusually presenting in pregnancy include aortic dissection, spontaneous epidural haematoma, lumbar or sacral osteoporotic insufficiency fractures, tumours, infection including tuberculosis, inflammatory spondyloarthropathies and symptomatic vertebral haemangiomata.

Cauda Equina Symptoms of cauda equina compromise must be specifically sought and examination including perianal sensory disturbance and anal tone documented. Changes in sphincter function can easily be attributed to pregnancy and if not considered properly may lead to serious delay in diagnosis and essential intervention. One in 10,000 pregnant women will suffer disc prolapse and/or cauda equina syndrome (CES). Often the only symptom on presentation is back pain, and it is not uncommon for there to be no leg symptoms and no abnormal leg neurological findings on examination. In the majority of cases initial rest (48 hours maximum) followed by gentle mobilisation with appropriate analgesia and physical therapy will suffice. Pain usually settles within 4 to 6 weeks. If pain is unmanageable with safe analgesia or there is objective evidence of progressive neurological loss especially CES (which necessitates immediate intervention), investigation is indicated. MRI is the modality of choice. Current advice is to avoid MRI in the first trimester due to theoretical harmful effects on the foetus, although no harmful effects have been demonstrated. However, if benefit outweighs risk after discussion with a radiologist, MRI can be undertaken at any stage of pregnancy with adjustments to the protocols used (6).

Sciatica Disc Pathology Disc pathology is the most common pathological condition presenting in pregnancy. Pain referring below the knee is unlikely to be PGP and raises the possibility of neural compromise. Disc prolapse is most common in the over 30-year-old age group which is becoming increasingly a larger proportion of the pregnant population. Diagnosis is made on the description of the pain, its distribution and neurological symptoms. Physical findings, such as limited straight leg raise, sciatic and femoral stretch tests, may be misleading in the pregnant. Objective evidence of motor or sensory disturbance is key.

Treatment of refractory sciatica in pregnancy follows the same algorithm as in the general population with a conservative approach being foremost. In the presence of deteriorating neurology or CES, surgical discectomy is the preferred course of action. Non-obstetric surgery in pregnancy is associated with premature delivery and low birth weight but not congenital defects (7). LBP and PGP do not alter indications for mode of delivery.

Birth Plan Pathological back pain in pregnancy should be taken into account when planning confinement; known symptomatic disc prolapse or recent

spinal disc surgery would be a relative indication for consideration of elective Caesarean section in conjunction with maternal and foetal imperatives. The incidence of radicular pain during pregnancy after microdiscectomy is 18%, but the need for revision surgery is not higher than the general post-discectomy population (8).

THERAPIES Pregnancy is a pro analgesic state with changes in endogenous opioids and increased pain thresholds. The usual advice is that analgesics should be avoided in the first trimester if at all possible. Thereafter, paracetamol is usually considered safe and benzodiazepines can be used for spasm. Non-steroidal anti-inflammatory drugs (NSAIDs) have been associated with an increase in miscarriage, potentially lead to vascular comprise of the placenta and are best avoided. Codeine and other opioids can be taken but if taken just before delivery may have an impact on the foetus’s breathing when delivered, although anecdotal reports have suggested these can be tolerated well by mother and foetus. Non-pharmacological options are gentle physiotherapy, TENS machines and acupuncture, which we have done on many occasions with good results. We have undertaken epidural injections under ultrasound for disc prolapse and sciatica to avoid surgery on several occasions with good results. It is often said by midwives that epidurals can lead to persistent back pain following pregnancy. A large prospective trial has shown this not to be true but unfortunately it is still a myth told to women in labour. Epidurals and spinal injections for pain during labour are usually safe if you have suffered back pain during pregnancy. If the mother is considered to have had significant disc pathology they should check with the obstetric and anaesthetic team in a prenatal visit about a plan for this at the time of labour.

CONCLUSIONS It is not possible to prevent all spinal pain in pregnancy, but the risks may be mitigated by pre-conception attention

Co-Kinetic Journal 2016;70(October):23-27

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to BMI, smoking and exercise. Most cases can be dealt with in a conservative manner with advice, reassurance and exercise with simple appropriate analgesia as required. Serious pathology is rare but must be excluded. Investigation with MRI and treatment with therapeutic epidural injections or, in extremis, surgery is not absolutely contraindicated. References 1. Wu WH, Meijer OG, et al. Pregnancyrelated pelvic girdle pain (PPP), I: terminology, clinical presentation, and prevalence. European Spine Journal 2004;13(7):575–589 2. Bastiaanssen JM, de Bie RA, et al. A historical perspective on pregnancyrelated low back and/or pelvic girdle pain. European Journal of Obstetrics, Gynecololgy, and Reproductive Biology 2005;120(1):3–14

3. Kovacs FM, Garcia E, et al. Prevalance and factors associated with low back pain and pelvic girdle pain during pregnancy: a multicenter study conducted in the Spanish National Health Service. Spine 2012;37(17):1516–1533 4. Mogren IM, Pohjanen AI. Low back pain and pelvic pain during pregnancy: prevalence and risk factors. Spine 2005;30(8):983–991 5. Smith MW, Marcus PS, Wurtz LD. Orthopaedic issues in pregnancy. Obstetrical & Gynecological Survey 2008;63(2):103–111 6. Wang PI, Chong ST, et al. Imaging of pregnant and lactating patients: part 1, evidence-based review and recommendations. American Journal of Roentgenology 2012;198(4):778–784 7. Brown MD, Levi AD. Surgery for lumbar disc herniation during pregnancy. Spine 2001;26(4):440–443 8. Berkmann S, Fandino J. Pregnancy and childbirth after microsurgery for lumbar disc herniation. Acta Neurochirurgica 2012;154(2):329–334.

KEY POINTS n Low back pain (LBP) and pelvic girdle pain (PGP) are common in pregnancy. n Non-specific low back pain (NSLBP) is defined as pain below the costal margin and above the inferior gluteal folds. n Pelvic girdle pain (PGP) is defined as pain in the symphysis and/ or between the posterior iliac crest and the gluteal fold, which may refer to the posterolateral thigh. n Differentiation between NSLBP and PGP is useful as treatment differs. n Be aware of the ‘red flags’ when pregnant women present with back pain: past medical history, systemic symptoms, deformity and the distribution and character of pain are important. n Watch out for disc pathologies, cauda equina syndrome and refractory sciatica. n Epidurals do not lead to persistent back pain after pregnancy. n Analgesics should be avoided in the first trimester if at all possible. n Paracetamol is usually safe, but NSAIDs have been associated with miscarriage and should be avoided. n The risk of spinal pain in pregnancy can be reduced by attention to BMI, smoking and exercise before conception.

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THE AUTHORS Mr Damien Fahy BSc MBBS FRCS (Tr & Orth) Dip Orth Eng is a consultant spinal surgeon specialising in spinal pain, including neck, lower back pain and sciatica. Mr Fahy has a wide practice in sports-related spinal problems, treating many professional and world-class sportsmen and women from athletics, swimming, rugby, cricket and professional football, working closely with teams and clubs, as well as other disciplines. His training in spinal surgery took place at Charing Cross Hospital and The Royal National Orthopaedic Hospital. He also trained in Sweden and Switzerland, with a short time spent in the United States. Email: fahy@fortiusclinic.com Website: https://www.fortiusclinic.com/specialists/ mr-damian-fahy Twitter: @fortiusclinicUK LinkedIn: https://www.linkedin.com/company/fortius-clinic Facebook: https://www.facebook.com/fortiusclinic/ Dr Glyn Towlerton BSc MBBS MRCP FRCA FIPP FFMRCA specialises in non-surgical treatments for the back, neck and leg, particularly for treating lumbar, sciatica, neck and shoulder pain. He has treated many elite athletes from a wide range of sports for over a decade. His special interests include spinal interventional procedures and injections, and spinal cord stimulation. Email: towlerton@fortiusclinic.com Website: https://www.fortiusclinic.com/specialists/dr-glyntowlerton Twitter: @fortiusclinicUK LinkedIn: https://www.linkedin.com/company/fortius-clinic Facebook: https://www.facebook.com/fortiusclinic

DISCUSSIONS Create a flow chart of how you would assess and treat a pregnant woman presenting with low back pain. What treatments are safe for a pregnant woman and which should be avoided? What are the ‘red flags’ to watch out for in pregnant women presenting with low back pain and what are the conditions that are not a ‘normal’ part of pregnancy?

RELATED CONTENT Patient information leaflet: Physical Activity During Pregnancy [Online leaflet for printing] http://spxj.nl/2aJRzX4 Patient information leaflet: Physical Activity After Pregnancy [Online leaflet for printing] http://spxj.nl/29zWQjg Axial/dynamic MRI in sports – Fisic Conference Presentation 2015 - http://spxj.nl/1IQZVZj

BACK PAIN DURING PREGNANCY Back pain during pregnancy affects around 50% of women, and some studies suggest that percentage is even higher. Back pain experienced during pregnancy is normally a result of changes in the body to compensate for the growing foetus. Leg pain during pregnancy is even more common than low back pain (LBP), and is also due to changes in the mechanical stresses on the vertebrae at the bottom of the spine [just above your tailbone (coccyx)]. The following leaflet gives information on why these changes take place, suggests treatment options and gives advice on how to relieve the pain as well as the stresses on the body that are likely to cause pain. It also advises on what you should look for from a therapist, should you want to seek professional help. INTRODUCTION As the foetus develops during pregnancy and becomes heavier, your body posture must compensate in order for you to maintain your balance when you are standing up. This change in weight distribution will put more pressure on the soft tissue structures (muscles and ligaments) in your lower back and may lead to you experiencing either low back pain (LBP) or leg pain during your pregnancy. In addition the stomach muscles become weaker as a result of the increasing stretch of the growing foetus and they lose some of their ability to distribute the increasing weight and maintain a normal neutral posture. As pregnancy continues, the production of the hormone relaxin increases by about ten times its normal amount which increases joint laxity to allow the pelvis to accommodate the growing baby. Unfortunately this also weakens the static supports in the lumbar spine (lower back) to resist shearing forces which then may result in pain from the facet joints of the vertebrae and the associated soft tissues such as muscles and ligaments in the area.

TYPES OF PAIN The most common forms of LBP during pregnancy can be classified into 3 types: 1. LBP in the lumbar spine – around the lower curve (lumbar lordosis) of the back. 2. Leg pain around the back of your buttocks (sacroiliac pain) and potentially down to your hamstrings – this is four times more likely to occur than LBP. 3. Back pain that occurs at night time when you are lying down.

TREATMENT OPTIONS Women who are physically active (engage in 45 minutes or more of physical activity per week) before they become pregnant are less likely to develop LBP during pregnancy; however, this does not seem to reduce the risk of sacroiliac pain. The weight gain and changes in hormone levels will put more stress on your lower back and pelvis at the same time as the ligaments and joints become more lax, so it’s important to minimise and manage mechanical stress to the lower back. This means understanding what good (neutral) posture is, and being very conscious of keeping this neutral posture at all times, particularly

when you are going about your normal daily activities: for example, lifting items, playing sport, moving wet clothes from washing machines, carrying shopping, etc.

A NEUTRAL POSTURE IN STANDING INVOLVES: Equal pressure distributed through both feet Making sure you’re not tipping forward or leaning backwards as you stand Feet hip-width apart (so you can run a straight line down from your hip, through your knee to your foot) Drawing the shoulders back and down Lifting your chin so it’s not tilted down (imagine you have a grapefruit under your chin) Imagining if you were to hold a piece of string with a weight on the end it would cross all the areas shown in the image below.

PATIENT INFORMATION LEAFLET PHYSICAL THERAPY: PAIN, BRAIN AND SPORTS PERFORMANCE

A NEUTRAL POSTURE IN SITTING INVOLVES: Feet on the floor (or footrest) Hips slightly higher than the knees Lumbar area (low back) supported Head / neck / shoulders / elbows / hips aligned Shoulders relaxed Elbows bent at 100° or more Wrists straight Fingers slightly curled and relaxed.

WHAT TO AVOID Heels – shoes with heels accentuate the curve in your lower back and increase the stress on the facets of your vertebrae. Standing for long periods of time – this also increases the lumbar lordosis (curve of your lower back) – placing one foot on a stool can help. Sitting for long periods of time – again resting one foot on a stool can help relax the muscle (iliopsoas) that increases this lumbar lordosis.

SEEKING PROFESSIONAL HELP A programme of exercises is one of the most helpful things you can do but it is important that you know how to perform these exercises correctly so that you don’t increase stress on your back. A therapist can help advise on what exercises would help you most. It may also be helpful for the therapist to watch you doing your usual daily activities, for example using appliances in your house or replicating activities that you do regularly so that they can give you tips on how to keep a neutral spine as you do them. It may also be helpful to use heat or ice for pain relief and this will depend on which application works best for you. You should avoid joint manipulation while you are pregnant and generally non-steroidal anti-inflammatory drugs (NSAIDs) should also not be taken during pregnancy.

Figure 1: Postures to avoid when using a computer: (a) poking chin, (b) excessive lumbar lordosis

A FINAL WORD Unfortunately no known exercise regimen completely protects you against LBP during pregnancy but with advanced planning, exercise and awareness, there are many ways to help prevent or alleviate it.

OTHER RESOURCES If your therapist has access to the Co-Kinetic website we have two other leaflets giving specific physical activity advice during pregnancy as well as after pregnancy. If you’d like to purchase these leaflets individually you can find them at the following links: – Physical Activity During Pregnancy http://spxj.nl/2aJRzX4 – Physical Activity After Pregnancy http://spxj.nl/29zWQjg

Figure 2: Neutral sitting posture

The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or Co-Kinetic.com as a substitute for specialist medical advice in each individual case. To the extent permissible by law, the publisher, editors and contributors accept no liability for any loss, injury or damage howsoever incurred (including negligence) as a consequence, whether directly or indirectly, of the use by any person of the contents of this article. ©Co-Kinetic 2016

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Injury prevention is personal. Generic preventative exercise programmes are likely to modify some risk factors of injury, but the evidence proves that an individualised programme, designed specifically for each player, is considerably more effective. The first article in this series http://spxj.nl/1TEyG2V discussed risk factors of injury and outlined clinical tests that can screen for these risk factors, providing normative data to enable the medical team to identify those players at risk of injury. This article covers the next challenge which is to establish the best method for modifying these risk factors. It outlines the basic principles of designing an injury prevention programme, and examines the current research on the most commonly used methods in the field of injury prevention. Read this online http://spxj.nl/2bHFIK2

5 EVIDENCE-BASED EXERCISE PREVENTION STRATEGIES FOR REDUCING INJURY RATES IN PROFESSIONAL FOOTBALL

BY DAVID HARTLEY GSR FOOTBALL | 16-10-COKINETIC | FORMATS WEB MOBILE PRINT

MEDIA CONTENTS 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/2bHFIK2 Copenhagen hip adduction exercise http://spxj.nl/2bCloJr (Credit YouTube user: BacchusChris) FIFA 11+ warm-up programme http://spxj.nl/2bAm4Oc Downloadable PDF FIFA11+ http://spxj.nl/2bHFIK2 Downloadable resources FIFA11+ further information http://spxj.nl/2bKzINV Downloadable PDF FIFA 11+: an effective programme to prevent football injuries in various player groups worldwide â&#x20AC;&#x201D; a narrative review http://spxj.nl/2bwxVel

INTRODUCTION Injuries have an adverse effect on team performance in male professional football. Over the last two decades, the financial reward for success in football has increased dramatically. Therapists already have an ethical commitment towards playersâ&#x20AC;&#x2122; 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, evidencebased interventions and objective outcome measurements. This article outlines the basic principles of designing an injury

prevention programme, and examines the current research on the most commonly used methods in the field of injury prevention.

1. JOINT MOBILISATION/ MANUAL THERAPY Hip A hip joint restriction will cause compensation elsewhere in the kinetic chain, causing overuse and injury of certain structures. A study has demonstrated that a stretching programme targeting the myofascial structures of the upper body can improve hip range of motion (ROM), particularly in extension and external rotation (1). This can be achieved by performing conventional hip passive stretches and incorporating trunk

A STRENGTH PROGRAMME CAN REDUCE INJURY RATES TO LESS THAN ONE THIRD AND OVERUSE INJURIES BY HALF Co-Kinetic Journal 2016;70(October):28-34

PHYSICAL THERAPY MSK DIAGNOSIS, TREATMENT, REHABILITATION

rotation and elevation of the upper limb to add tension to myofascial structures. The participants in this study were recruited because of their limited hip mobility, so this intervention may be effective in modifying hip ROM to normative parameters. A follow-up study (2) found that these improvements in hip mobility do not transfer into functional movements; individuals’ movement patterns do not automatically improve even if more hip mobility is acquired. In practice, this means that other functional movement interventions should be used to complement mobility exercise. Functional movement exercises will be discussed in greater detail later in this article. Stretching specifically to increase hip ROM, targeting myofascial structures, may be beneficial but this does not imply that routine stretching is an effective modality in an injury prevention programme. A recent systematic review of injury prevention strategies (3) stated that stretching does not reduce injury rates. The success of this intervention is dependent on the source of the joint restriction; if the restriction is not myofascial in nature, then this intervention will not be effective. If the restriction is structural in nature, there is little that exercise interventions can do to modify it. Femoroacetabular impingement (FAI), for example, is associated with decreased ROM (4). Current conservative treatment for symptomatic FAI involves activity modification (5), which is inappropriate for elite athletes. Therefore, athletes with symptomatic FAI will tend to receive surgery to restore deficiencies (6).

A MULTIFACETED NEUROMUSCULAR TRAINING PROGRAMME, INCORPORATING ASPECTS OF STRENGTH, ENDURANCE AND PROPRIOCEPTION, CAN REDUCE INJURIES BY 29–80% IN YOUTH FOOTBALL ankle sprains. Hatcher recently outlined the general principles of mobilisation and manipulation (18). The Maitland Grades of Movement correspond to the amplitude of a mobilisation. Grades three and four go into the resistance range, which is thought to improve ROM. Mulligan proposed the concept of mobilisations with movement (MWMs) for peripheral joints in 1993 (19), whereby a limited movement is performed actively while the therapist applies a sustained accessory glide parallel to the joint (20) in order to improve ROM. Studies have shown MWMs have a mechanical effect on subacute ankle sprains (9). The process by which the Maitland and Mulligan concepts are effective is unclear. Hatcher postulates that movement of the joint capsule decreases the viscoelastic properties or mechanical resistance, thereby reducing stiffness (18). Mulligan suggests that a minor positional fault occurs following injury, and mobilisations correct the resultant mechanical block (20).

(a)

(b)

2. STRENGTHENING A systematic review of exercise interventions to prevent injury found that a strength programme can reduce injury rates to less than one third and overuse injuries by half (3). Strengthening is an essential component of any injury prevention programme. Indeed, the research on common injuries in football advocates strengthening as part of both prevention and rehabilitation programmes.

Hip Adductors A randomised controlled trial (RCT) by Holmich et al. demonstrated the effectiveness of eccentric strength exercises in the treatment of adductorrelated groin pain (21), which continued to have a significant effect at 8–12 year follow-up (22). The long-term effect of this treatment modality suggests a preventative effect. The Copenhagen Research Group demonstrated that a similar protocol could reduce injuries by 30%, although this was statistically insignificant (23). A recent systematic review and meta-analysis of groin injuries

(c)

Ankle The talocrural joint of the ankle is the hinge at which plantarflexion and dorsiflexion occurs. A dorsiflexion restriction at the talocrural joint results in compensation, such as increased inversion, internal rotation and pronation, which can contribute to chronic ankle instability (7). There is a large body of evidence that suggests that manual therapy techniques, particularly anterior-toposterior (AP) mobilisations can aid in restoring dorsiflexion ROM (7–17), which modifies a risk factor of recurrent Co-Kinetic.com

Figure 1: Copenhagen hip adduction exercise (Photo credit: D. Hartley, 2016)

The Copenhagen hip adduction exercise can be performed with a partner or by using a bench for support. The patient lies on the side of their non-dominant leg, using the lower forearm as support on the floor and the other arm is placed along the length of the upper side of the body. The patient raises their body from the floor and adducts the non-dominant leg so the feet touch and the body is in a straight line (a). The non-dominant leg is then lowered so that it touches the floor, but does not use it for support (b) and the patient lowers his body so that his hip touches the floor. The first part of the exercise is repeated to return to the starting position (c).

revealed a 19% reduction of injury (24), but this was also statistically insignificant. To date, studies have been insufficiently powered to detect statistically significant reductions but there appears to be a clinically meaningful reduction of groin injuries using strengthening exercises. Serner et al. investigated various adductor strengthening exercises by electromyography (EMG), which can be used to grade exercises by intensity (25). Eccentric exercises appears to be most effective at improving strength (26), so are likely to be the best exercises for a prevention programme. In the early stages of a prevention programme, however, individuals may not have the capacity to tolerate high eccentric forces so it may be necessary to introduce less demanding exercises and progress as strength improves. The Copenhagen hip adduction exercise induces high eccentric activity of the adductor longus and requires no additional equipment for its performance. It is, therefore, an ideal exercise to perform as part of a prevention programme (Fig. 1a–c and YouTube video in Media Contents) (25).

Hamstrings A 10-week progressive Nordic hamstring exercise protocol (Table 1) has been shown to be effective in reducing acute hamstring strain injuries (HSI) (27,28). The Nordic hamstring exercise does not directly replicate the mechanism of injury (MOI) of HSIs, but is thought to be effective by shifting the angle of peak torque to longer muscle lengths (29),

INDIVIDUALS WHO UNDERTAKE PILATES SESSIONS TWO TIMES PER WEEK HAVE BETTER BODY CONTROL THAN THOSE WHO DO NOT

TABLE 1: 10-WEEK PROGRESSIVE NORDIC HAMSTRING EXERCISE PROTOCOL (Adapted from Mjolsnes R, et al. Sc J Med Sci Sports 2004;15:311–317)

WEEK

NO. OF REPETITIONS SESSIONS

2×5

2×6

3 × 6–8

3 × 8–10

5–10

12–10–8

resulting in greater eccentric strength at terminal swing phase of gait. The exercise relies heavily on the eccentric action of the hamstring, which means delayed onset of muscle soreness (DOMS) is a possibility. The progressive nature of the exercise is designed to overcome DOMS (27) but the presence of DOMS could potentially affect compliance. A systematic review revealed tha t non-compliance is a major issue when prescribing a Nordic hamstring programme (30). Athlete supervision will undoubtedly improve compliance, and emphasising the benefits to the athlete – reduced injury risk – will ensure they are more open to the intervention. Fatigue is also documented as a risk factor for HSI. Athletes demonstrate reduced eccentric strength in the later stage of matches (31), so they will be less effective at decelerating the forward movement of the leg at the terminal swing phase. Traditionally the Nordic hamstring exercise has been performed during a warm-up, in a non-fatigued state, but a study investigating the effect of performing the exercise in a fatigued state found that players were able to maintain their eccentric strength (31), thereby improving their resistance to fatigue. As the majority of HSIs occur towards the end of each half in matches (32), this is an important finding. It is, therefore, worth considering prescribing the Nordic hamstring exercise at the end of training.

3. BALANCE TRAINING/ PROPRIOCEPTION Balance and coordination training has 30

LOAD Load is increased as the subject can withstand the forward fall for longer. When managing to withstand the whole ROM for 12 reps, increase the load by adding speed to the starting phase of the motion. The partner can also slowly increase the load further by pushing at the back of the shoulders. traditionally been used to prevent lateral ankle sprains (LAS), but research suggests that these interventions are not effective in preventing primary occurrences (33,34). A consensus statement on the treatment and prevention of ankle sprains states that balance and coordination training is effective at reducing the risk of recurrent LAS, and these interventions are effective within the first 12 months of primary occurrence (33). Changes in the motor cortex have been demonstrated following LAS (33), which will alter proprioception and movement patterns and leave individuals susceptible to a secondary injury, as discussed in the first article in this series. Balance training modifies impaired proprioception, altered postural control and impaired neuromuscular control (35), which are characteristic of functional ankle instability (7). Modifying the effects of functional ankle instability will, therefore, result in a reduced risk of sustaining a recurrence. This has implications in prevention programmes, as balance training should be reserved for those who have previously sustained a LAS. The current consensus to prevent recurrent ankle injury in athletes is to incorporate balance and coordination exercises into regular training. Balance-board training is a commonly used method to train proprioception and a comprehensive 36-week training programme found a significant reduction in recurrent ankle sprains (34). The first article in this series, discussing the process of screening for risk factors of injury, described the star excursion balance Co-Kinetic Journal 2016;70(October):28-34

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

A COMPREHENSIVE 36-WEEK BALANCE TRAINING PROGRAMME FOUND A SIGNIFICANT REDUCTION IN RECURRENT ANKLE SPRAINS test as an assessment tool. It can also be used as a balance training intervention as it requires high levels of proprioception, neuromuscular control, balance and strength in order to perform correctly (36). If using the same training intervention as a screening method, however, any improvement when retesting should be interpreted with caution, as there is the potential for a learning effect.

4. MOTOR CONTROL INTERVENTIONS Functional Movement Screen (FMS) Corrective Exercise The FMS has been shown to predict injury in athletes (37). It is, therefore, appropriate to assume that modifying issues that are identified in the FMS will reduce the risk of injury. The FMS may identify a side-to-side asymmetry during functional movement, for example, which will increase injury. A corrective exercise programme, incorporating exercises to improve mobility and stability has been shown to rectify asymmetry and improve FMS scores (38), which would suggest a reduced injury risk. The research on corrective exercise has used off-season programmes, suggesting that this is the most effective time to implement a corrective exercise programme. In the professional football setting, where the off-season period is particularly short, it may be more realistic to combine remedial exercise with other aspects of a strength-and-conditioning programme during the in-season. Movement preparation exercises, for example, could be performed prior to a strength training session to encourage correct movement patterns.

Pilates and Yoga Lumbopelvic stability is thought to be key in preventing a variety of musculoskeletal injuries, and has a prominent role within rehabilitation. Exercises aimed at controlling the pelvis enable optimal function of the hamstrings and have been shown to be effective at preventing recurrent Co-Kinetic.com

hamstring injuries (39). Similarly, lumbopelvic exercises are advocated in the treatment of many groin-related conditions (40,41) in order to control shear forces around the pelvis. There is evidence that lumbopelvic stability is altered in those with low back pain (LBP) (42,43), and exercises targeting postural deficits associated with LBP can prevent recurrence (44,45). Yoga is a mind–body centring technique that has a strong emphasis on correct body alignment and body awareness. It is amongst the most effective modalities at enhancing proprioception, and is associated with high degrees of flexibility and strength (46). Case studies document its use in the rehabilitation of recurrent hamstring strains (47), and the British Hernia Society advocates its use in the conservative treatment of inguinal disruption (48). A quick internet search will reveal numerous styles of yoga; the most effective styles for injury prevention, such as Iyengar and Ashtanga, are those that enhance strength and proprioception. The Pilates method was developed by Joseph Pilates, who believed injury is caused by imbalances in the body and habitual patterns of movement. He first proposed this concept in the 1920s, and it is now widely accepted within the fields of physiotherapy and sports medicine. Pilates emphasises the importance of beginning movement from the lumbopelvic region, and interventions targeting the deep abdominal muscles reflect this. Pilates exercises require strength, core stability and muscle control and has a strong emphasis on correct posture (49). Individuals who undertake Pilates sessions two times per week have better body control than those who do not, suggesting that Pilates can reduce the risk of musculoskeletal injury (50).

5. NEUROMUSCULAR TRAINING A multifaceted neuromuscular training programme, incorporating aspects of

strength, endurance and proprioception, can reduce injuries by 29–80% in youth football (51–54). This is clearly a clinically significant reduction so young players should have a neuromuscular training component included in their programme. Compliance is key to obtaining the benefits of a neuromuscular training programme; if a programme is too extensive then compliance is likely to be reduced (3). As with a Nordic hamstring exercise programme, compliance to a neuromuscular training programme can be improved through athlete supervision and education, and incorporating exercises into training sessions will ensure they are delivered appropriately.

FIFA 11+ Programme The FIFA 11+ programme is an injury prevention programme developed on behalf of FIFA (55), incorporating 15 exercises to be performed as part of a warm-up before training and matches. The exercises include progressive

Figure 2: FIFA11+ Warm-Up Programme – taken from the 11+ manual

PROGRAMMES SHOULD NOT BE TOO EXTENSIVE; ATHLETES ARE LIKELY TO FAVOUR A PROGRAMME WITH A FEW KEY EXERCISES THAT ARE NOT TOO TIME CONSUMING running, stability, balance and strength exercises, with emphasis placed on correct technique, posture and control and can be progressed based on each player’s competency (Fig. 2). A recent systematic review on injury prevention strategies in professional football revealed that the most commonly used preventative exercises are components of the FIFA 11+ programme (56). The programme has been validated to reduce non-contact injuries in male and female athletes (57–59). The effectiveness of this programme is probably because the exercises target accepted risk factors of injury,

so modifying these factors will reduce injury risk. The most benefit is seen in those aged 14–19 years (57), which is possibly because this population is still developing physically, which makes it easier to modify physical characteristics. Indeed, research has demonstrated that the programme has no effect on those aged over 40 years old (60), when individuals have physically matured. The programme has been shown to improve neuromuscular control (58,61,62) and results in a better hamstrings : quadriceps strength ratio as well as improved jumping and agility skills (58,63,64). The programme takes 20 minutes to complete, with most studies advocating that it is performed three times per week. This equates to 1 hour each week dedicated to injury prevention, which is a significant amount of time taken away from tactical and technical aspects of training. The coach is the leader of any football team, so it is important to discuss the importance of the FIFA 11+ and how it can complement other aspects of a football player’s development (58). Indeed, a review of the FIFA 11+ identified the coach as being key to its successful introduction, and several European football associations include the programme in its coaching workshops

(65,66). Most of the research has been conducted on amateur players, so it is unknown if findings can be generalised to elite athletes who are highly trained. There is limited research on neuromuscular programmes in physically mature football players (58), so this is an area that should be studied further. Bizzini and Dvorak have written an open access article reviewing the FIFA 11+ (‘FIFA 11+: an effective programme to prevent football injuries in various player groups worldwide—a narrative review’ http://spxj.nl/2bwxVel) (55) and the videos for the FIFA 11+ warm-up programme can be found at this link: http://spxj.nl/2bAm4Oc. This website also provides downloads (http://spxj.nl/2bKzINV) of scientific papers validating the FIFA 11+ approach, posters, field set-up information and videos for iPhone and PowerPoint presentations.

LIMITATIONS TO THE CURRENT RESEARCH Injury prevention is a relatively new concept within sport medicine and as a result the current research is not of the highest quality, nor does it definitively state that current modalities are effective. A recent systematic review on injury prevention strategies by McCall et

TABLE 2: DOCUMENTED RISK FACTORS OF INJURY, CLINICAL TESTS, NORMATIVE DATA AND PREVENTATIVE EXERCISE (D. Hartley, 2016) Risk Factor for Injury

Screening Test

Normative Data/Threshold

Preventative Exercise

Reduced hip ROM

Goniometer testing

Internal rotation 38° External rotation 41°

Stretching with myofascial component and additional functional movement exercises

Weak adductors

Dynamometer testing

Adduction strength equal to contralateral side Adduction : abduction ratio >90%

Adductor strengthening

Hamstring : quadriceps (H/Q) strength imbalance

Isokinetic testing

Side-to-side imbalance <10% Conventional H/Q ratio 0.6 Functional H/Q ratio 0.75

Progressive Nordic hamstring exercise programme

Reduced ankle ROM

Weight bearing lunge (knee-to-wall test)

11–14cm 9.5cm Equal bilaterally

Mobilisation

Ankle instability

Star excursion balance test

Equal maximal reach bilaterally

Star excursion training

Poor motor control

Functional movement screen

>14/21

Corrective exercise Movement prep. Yoga Pilates

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PHYSICAL THERAPY MSK DIAGNOSIS, TREATMENT, REHABILITATION

EACH PLAYER’S INJURY PREVENTION PROGRAMME SHOULD BE INDIVIDUALISED BASED ON THEIR SCREENING RESULTS PERSONALISED INJURY PREVENTION: CASE STUDIES

(D. Hartley, 2016) Injury prevention exercise programmes are most effective when tailored to the individual. The Table shows some hypothetical results from the preseason screening of players by a football club’s medical team. HYPOTHETICAL RESULTS OF PRESEASON MEDICAL SCREENING OF FOOTBALLERS (D. Hartley, 2016) Player A

Player B

Player C

Injury history

Left adductor-related groin pain at the end of the season, which eased over the summer

Recurrent left hamstring injuries

Right grade Iateral ankle sprain 3 months ago

Hip internal rotation

Left 39° Right 39°

Left 39° Right 40°

Left 40° Right 48°

Hip external rotation

Left 44° Right 45°

Left 36° Right 46°

Left 40° Right 40°

Adduction : abduction strength ratio

Left 0.8 Right 1.1

Left 0.9 Right 1.0

Left 1.2 Right 1.1

Functional H/Q ratio

Left 0.75 Right 0.7

Left 0.5 Right 0.79

Left 0.76 Right 0.77

Knee-to-wall test

Left 8 Right 8

Left 4 Right 4

Left 7 Right 3

Star excursion balance test

No reach deficits

Right-sided reach deficits in all directions

Functional movement screen

17/21

16/21

14/21

H/Q ratio, hamstrings : quadriceps ratio These players all have different requirements from an injuryprevention programme, as indicated by their injury history and predisposing risk factors identified on screening. Player A, for example, has a left-sided adduction: abduction strength imbalance, which is the underlying cause of his adductorrelated groin pain. These symptoms can be modified with adduction strengthening programme. Player B’s low left-sided functional H/Q ratio indicates weak left hamstrings that are unable to tolerate the high eccentric forces associated with high-intensity running and sprinting, and this is likely to be the predominant underlying cause of his recurrent hamstring injuries. A hamstring-strengthening programme will reduce the risk of hamstring injury (note, Player B would also require a multifaceted approach to

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injury prevention, possibly including neural interventions and an intensive period of conditioning). Player C presents with chronic ankle instability, secondary to a LAS. This is indicated by reduced right-ankle ROM and right-sided reach deficits on the star excursion balance test. Player C would require ankle mobilisations and proprioception interventions to improve their performance on these tasks, thereby reducing their risk of future injury. They would also require ankle strapping or a brace for games and training sessions. Although a generic injury-prevention programme would mitigate some of these factors, an individualised programme – focusing on the most relevant risk factors of injury – would be more appropriate. The injury history and screening results of Players A and B do not identify a risk of ankle injury, so spending time on proprioception would essentially be time wasted, especially

as these interventions appear to be effective only for those who have sustained previous ankle injury. Likewise, Players B and C have no adductor-related issues, and their screening scores for adduction : abduction strength are within acceptable parameters. Therefore, only Player A would truly benefit from adductor strengthening in this scenario. It is essential that the screening programme is repeated at regular intervals; a player’s risk factors are likely to improve when addressed with appropriate interventions, whilst other factors may become more relevant later in the season (for example, if a player sustains an acute injury during the season or an overuse injury in response to a heavy schedule). Continuous monitoring is essential to ensure that the interventions used with athletes are the most appropriate to their presentation.

al. state that most of the preventative exercises used in professional football “have a low level of evidence and low graded recommendation (56).” The article goes on to state: “This does not imply that these perceptions and practices are not important or not valid, as it may simply be that they are yet to be sufficiently validated or refuted by research.” In short, higher quality research is required on the most commonly used methods of modifying risk factors for injury. Therapists must use their clinical reasoning skills to implement preventative programmes. Although interventions should be evidence-based, clinical experience will also form part of the decision-making process.

CONCLUSION Each player’s injury prevention programme should be individualised based on their screening results. This article discusses methods for modifying the most common risk factors for injury. Once the risk factors are identified for each player, a prevention programme

can be designed to target specific elements that will predispose each individual to injury. Table 2 outlines which modalities are most effective at modifying each risk factor for injury. Programmes should not be too extensive, as this can adversely affect compliance; athletes are likely to favour a programme with a few key exercises that are not significantly time consuming. Some interventions, such as the FIFA 11+ programme, can be delivered during training sessions to ensure players undertake it sufficiently. Other interventions can be combined in a strength-and-conditioning programme. The medical team can use their imagination to incorporate evidencebased interventions to reduce injury rates into conditioning programmes, ensuring the delivery is both challenging and stimulating for the athletes. 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/2bBlgpL.

DISCUSSIONS Why is general stretching not an effective modality to prevent injury? Current practices to prevent injury in football have a low level of recommendation due to a lack of high quality research. Is it appropriate to use research from other sports, such as American football or ice hockey, to justify interventions? Is there one intervention that is more effective than others to prevent injury in football?

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KEY POINTS Stretching with an emphasis on myofascial structures is effective at improving ROM, but routine stretching is not effective at reducing injury rates. Anterior-to-posterior ankle mobilisations can increase ankle dorsiflexion. Adductor strengthening exercise results in a clinically meaningful reduction in adductor injury. A 10-week progressive Nordic hamstring exercise protocol is effective in reducing hamstring strain injuries. Performing injury prevention exercises in a fatigued state can improve athletes’ resistance to fatigue. Balance training is effective at preventing recurrent lateral ankle sprains. Functional movement may improve using corrective exercise as part of a strength-andconditioning programme. The FIFA 11+ can be used as a warm-up and is effective in reducing non-contact injuries in players aged 14–19. Ensuring compliance is key to the success of an injury prevention programme.

THE AUTHOR David 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

HERE ARE SOME SUGGESTIONS Tweet this: Strengthening is an essential component of any injury prevention programme http://spxj.nl/2bHFIK2 Tweet this: Research on common injuries in football advocates strengthening for both prevention and rehab http://spxj.nl/2bHFIK2 Tweet this: Eccentric exercises for hip adductors are one of the best hamstring injury prevention exercises. http://spxj.nl/2bHFIK2 Tweet this: Performing the Nordic hamstring exercise in a fatigued state improves resistance to fatigue http://spxj.nl/2bHFIK2 Tweet this: Each player’s injury prevention programme should be individualised based on their screening results http://spxj.nl/2bHFIK2

RELATED CONTENT How to Reduce Injury Rates in Professional Football using Surveillance and Screening http://spxj.nl/1TEyG2V Injury Prevention Strategies – Do They Work? Fisic Conference Presentation 2015 http://spxj.nl/1RbR6Md Hamstring Injuries in Football Part 2: Prevention http://spxj.nl/1Hdnbfg Other football-related content Search results http://spxj.nl/1Tj08sM

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5 EVIDENCE-BASED EXERCISE PREVENTION STRATEGIES FOR REDUCING INJURY RATES IN PROFESSIONAL FOOTBALL References 1. Moreside JM, McGill SM. Hip joint range of motion improvement using three different interventions. Journal of Strength and Conditioning Research 2012;26(5):1265– 1273 2. Moreside JM, McGill SM. Improvements in hip flexibility do not transfer to mobility in functional movement patterns. Journal of Strength and Conditioning Research 2013;27(10):2635–2643 3. Lauersen JB, Bertelsen DM, Andersen LB. The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis. British Journal of Sports Medicine 2014;48:871–877 4. Diamond LE, Dobson FL, et al. Physical impairments and activity limitations in people with femoroacetabular impingement: a systematic review. British Journal of Sports Medicine 2015;49:230–242 5. Emara K, Samir W, et al. Conservative treatment for mild femoroacetabular impingement. Journal of Orthopaedic Surgery 2011;19(1):41–45 6. Cakic J, Patricios J. Femoroacetabular impingement: prevention or intervention? The sports physician quandary. British Journal of Sports Medicine 2014;48(14):1073–1074 7. Hertel J. Functional anatomy, pathomechanics and pathophysiology of lateral ankle instability. Journal of Athletic Training 2002;37(4):364–375 8. Vicenzino B, Branjerdporn M, et al. Initial changes in posterior talar glide and dorsiflexion of the ankle after mobilization with movement in individuals with recurrent ankle sprain. Journal of Orthopaedic & Sports Physical Therapy 2006;36(7):464–471 9. Collins N, Teys P, Vicenzino B. The initial effects of a Mulligan’s mobilization with movement technique on dorsiflexion and pain in subacute ankle sprains. Manual Therapy 2002;9(2):77–82 10. Green T, Refshauge K, et al. A randomized controlled trial of a passive accessory joint mobilization on acute ankle inversion sprains. Physical Therapy 2001;81(4):984–994 11. Landrum EL, Kelln BM, et al. Immediate effects of anterior-to-posterior talocrural joint mobilization after prolonged ankle immobilization: a preliminary study. Journal of Manual and Manipulative Therapy 2008;16(2):100–105 12. Reid A, Birmingham TB, Alcock G. Efficacy of mobilization with movement for patients with limited dorsiflexion after ankle sprain: Co-Kinetic.com

a crossover trial. Physiotherapy Canada 2007;59(3):166–172 13. Hoch MC, McKeon PO. Joint mobilization improves spatiotemporal postural control and range of motion in those with chronic ankle instability. Journal of Orthopaedic Research 2011;29(3):326–332 14. Hoch MC, Andreatta RD, et al. Two-week joint mobilization intervention improves self-reported function, range of motion, and dynamic balance in those with chronic ankle instability. Journal of Orthopedic Research 2012;30(11):1798–1804 15. de Souza MVS, Ventunni CA, et al. Force-displacement relationship during anteroposterior mobilization of the ankle joint. Journal of Manipulative and Physiological Therapeutics 2008;31(4):285–292 16. Venturini C, Penedo MM, et al. Study of the force applied during anteroposterior articular mobilization of the talus and its effect on the dorsiflexion range of motion. Journal of Manipulative and Physiological Therapeutics 2007;30(8):593–597 17. Harkey M, McLeod M, et al. The immediate effects of an anterior-to-posterior talar mobilization on neural excitability, dorsiflexion range of motion, and dynamic balance in patients with chronic ankle instability. Journal of Sport Rehabilitation 2014;23(4):351–359 18. Hatcher J. Manual therapy: definitions – mobilisation, manipulation and massage. sportEX journal 2015;66(October):44–47 19. Mulligan BR. Mobilisations with movement. Journal of Manual and Manipulative Therapy 1993;1(4):154–156 20. Exelby L. Peripheral mobilisations with movement. Manual Therapy 1996;1:118–126 21. Holmich P, Uhrskou P, et al. Effectiveness of active physical training as treatment for

long-standing adductor-related groin pain. The Lancet 1999;353:439–443 22. Holmich P, Nyvold P, Larsen K. Continued significant effect of physical training as treatment for overuse injury. American Journal of Sports Medicine 2001;39(11):2447–2451 23. Holmich P, Larsen K, et al. Exercise program for prevention of groin pain in soccer players: a cluster-randomised controlled trial. Journal of Medicine and Science in Sports 2010;20:814–821 24. Esteve E, Rathleff MS, et al. Prevention of groin injuries in sports: a systematic review with meta-analysis of randomised controlled trials. British Journal of Sports Medicine 2015;49(12):785–791 25. Serner A, Jakobsen MD, et al. EMG evaluation of hip adduction exercises for soccer players: implications for exercise selection in prevention and treatment of groin injuries. British Journal of Sports Medicine 2014;48(14):1108–1114 26. Jensen J, Holmich P, et al. Eccentric strengthening effect of hip-adductor training with elastic bands in soccer players: a randomised controlled trial. British Journal of Sports Medicine 2014;48(4):332–338 27. Mjolsnes R, Arnason A, et al. A 10-week randomised trial comparing eccentric vs concentric hamstring strength training in well-trained soccer players. Scandinavian Journal of Medicine & Science in Sports 2004;14:311–317 28. Petersen J, Thorborg K, et al. Preventive effect of eccentric training on acute hamstring injuries in men’s soccer. American Journal of Sports Medicine 2011;39(11):2296–2303 29. Thorborg K. Why hamstring eccentrics are hamstring essentials. British Journal of Sports Medicine 2012;46(7):463–465 34i

30. Goode A, Reiman M, et al. Eccentric training for prevention of hamstring injuries may depend on intervention compliance: a systematic review and meta-analysis. British Journal of Sports Medicine 2014;49(6):349–356 31. Small K. McNaughton L, et al. Effect of timing of eccentric hamstring strengthening exercises during soccer training: implications for muscle fatigability. Journal of Strength and Conditioning Research 2009;23(4):1077–10837 32. Ekstrand J, Hagglund M, Walden M. Injury incidence and injury patterns in professional football: the UEFA injury study. British Journal of Sports Medicine 2011;45:553– 558 33. Kerkhoffs GM, van den Bekerom, et al. Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. British Journal of Sports Medicine 2012;46:854–860 34. Verhagen E, van der Beek A, et al. The effect of proprioceptive balance board training program for the prevention of ankle sprains: a prospective controlled trial. American Journal of Sports Medicine 2004;32:1385–1393 35. Chaowanichsiri D, Lorprayoon E, Noomanoch L. Star excursion balance training: effects on functional stability after ankle sprain. Journal of the Medical Association of Thailand 2005;88(Suppl 4):S90–S94 36. 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 37. Kiesel K, Plisky PJ, Voight ML. Can serious injury in professional football be predicted by a preseason function movement screen? North American Journal of Sports Physical Therapy 2007;2(3):147–158 38. Kiesel K, Plisky P, Butler R. Functional movement test scores improve following a standardized off-season intervention program in professional football players. Scandinavian Journal of Medicine & Science in Sports 2011;21(2):287–292 39. Sherry MA, Best TM. A comparison of 2 rehabilitation programs in the treatment of acute hamstring strain. Journal of Orthopaedic & Sports Physical Therapy 2004;34(3):116–125 40. Jardi J, Rodas G, et al. Osteitis pubis: can early return to elite competition be contemplated? Translational Medicine @ UniSa 2014;10:52–58 41. Marshall PW, Murphy BA. Core stability exercises on and off a Swiss ball. Archives of Physical Medicine and Rehabilitation 2005;86(2):242–249 42. Grosdent S, Demoulin C, et al. Lumbopelvic motor control and low back pain in elite soccer players: a crosssectional study. Journal of Sports Sciences 2016;34(11):1021–1029

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43. Teyhen DS, Bluemle LN, et al. Changes in lateral abdominal muscle thickness during the abdominal drawing-in maneuver in those with lumbopelvic pain. Journal of Orthopaedic & Sports Physical Therapy 2009;39(11):791–798 44. Hides JA, Jull GA, Richardson CA. Longterm effects of specific stabilising exercises for first-episode low back pain. Spine 2001;26(11):E243–E248 45. Macedo LG, Maher CG, et al. Motor control exercise for persistent, nonspecific low back pain: a systematic review. Physical Therapy 2009;89(1):9–25 46. Norris C. Yoga as therapy. sportEX dynamics 2015;43(January):20–28 47. 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 48. Sheen AJ, Stephenson BM, et al. Treatment of the sportsman’s groin: British Hernia Society’s 2014 position statement based on the Manchester Consensus Conference. British Journal of Sports Medicine 2014;48:1079–1087 49. Wells C, Kolt GS, Bialocerkowski A. Defining Pilates exercises: a systematic review. Complementary Therapies in Medicine 2012;20:253–262 50. Phrompaet S, Paungmali A, et al. Effects of Pilates training on lumbo-pelvic stability and flexibility. Asian Journal of Sports Medicine2011;2(1):16–22 51. Bergeron MF, Mountjoy M, et al. International Olympic Committee consensus statement on youth athletic development. British Journal of Sports Medicine 2015;49:843–851 52. Olsen OE, Myklebust G, et al. Exercises to prevent lower limb injuries in youth sports: cluster randomised controlled trial. BMJ 2005;330:449 53. Emery CA, Cassidy JD, et al. Effectiveness of a home-based balancetraining program in reducing sports-related injuries among healthy adolescents: a cluster randomized controlled trial. Canadian Medical Association Journal 2005;172:749–54 54. Emery CA, Meeuwisse WH. The effectiveness of a neuromuscular prevention strategy to reduce injuries in youth soccer: a cluster-randomised controlled trial. British Journal of Sports Medicine 2010;44:555–62 55. Bizzini M, Junge A, Dvorak J. Implementation of the FIFA 11+ football warm up program: How to approach and convince the football associations to invest in prevention. British Journal of Sports Medicine 2013;47:803–806 56. McCall A, Carling C, et al. Injury risk factors, screening tests and preventative strategies: a 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;49:583–589 57. Owoeye OBA, Akinbo SRA, et al. Efficacy of the FIFA 11+ warm-up programme in male youth football: a cluster randomised controlled trial. Journal of Sports Science and Medicine 2014;13:321–328 58. Bizzini M, Dvorak J. FIFA 11+: an effective programme to prevent football injuries in various player groups worldwide: a narrative review. British Journal of Sports Medicine 2015;49:577–579 59. Soligard T, Myklebust G, et al. Comprehensive warm-up programme to prevent injuries in young female footballers: a cluster-randomised controlled trial. BMJ 2008;337:a2469 60. Hammes D, Aus der Fünten K, et al. Injury prevention in male veteran football players: a randomised controlled trial using FIFA 11+. Journal of Sports Sciences 2015;33(9):873–881 61. Nakase J, Inaki A, et al. Whole body muscle activity during the FIFA 11+ program evaluated by positron emission tomography. PLoS ONE 2013;8:e73898 62. Whittacker JL, Emery CA. Impact of the FIFA 11+ on the structure of selected muscle in adolescent female soccer players. Physical Therapy in Sport 2015;16(3):228–235 63. Brito J, Figuerido P, Fernandes L. Isokinetic strength effects of FIFA’s “The 11+” injury prevention training programme. Isokinetics Exercise Science 2010;18:211– 215 64. Ris I, Rebelo A, et al. Performance enhancement effects of Federation International de Football Association’s “The 11+” injury prevention training program in youth futsal players. Clinical Journal of Sports Medicine 2013;23:318–320 65. Junge A, Lamprecht M, et al. Countrywide campaign to prevent soccer injuries in Swiss amateur players. American Journal of Sports Medicine 2011;39:57– 63 66. Bollars P, Claes S, et al. The effectiveness of preventive programs in decreasing the risk of soccer injuries in Belgium: national trends over a decade. American Journal of Sports Medicine 2014;42:577–582.

MANUAL THERAPY STUDENT HANDBOOK

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 Assessment the ‘Contents and panel’ for further details) and it describes how to assess and treat common hip complaints. As well as listing a comprehensive assessment procedure, the treatment of the knee treatments are described in full and have accompanying videos, which provides a great TABLE 1: ASSESSMENT OF THE KNEE (J. Hatcher, 2013) OBSERVATION/ EXAMINATION

DETAILS

1. Anatomy

Joint derived from L3 segment Dermatomes L2,3: front S1,2: back Myotomes L2,3,4: quadriceps http://spxj.nl/1QhBT6P L5, S1,2: hamstrings

This article is practical the sixth resource in a series our Manual forfrom the clinician. Read this online Therapy Student Handbook (see the ‘Contents panel’ BY JULIAN HATCHER GRAD DIPobservation PHYS MPHIL, Face MCSP FOM 2. Initial and posture and gait for further details) and it describes how to assess and 3. History Age and occupation treat common knee complaints. As well as listing a Site and spread Onset and duration comprehensive assessment procedure, the treatments Behaviour and symptoms are described in full and have accompanying videos, Past medical history (P.M.H.) which provides a great practical resource for the 4. Inspection Bony deformity Colour changes clinician. Read this online http://spxj.nl/23NmIfu Wasting Swelling

BY JULIAN HATCHER GRAD DIP PHYS MPHIL, MCSP FOM

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 knee For a full assessment of the knee, the therapist should perform the Video 1: Surface marking of the knee region (Video with captions but no sound; J. Hatcher, 2013)

KNEE | 16-10-COKINETIC FORMATS WEB MOBILE

5. Objective examination

Observe/examine state at rest and eliminate hip joint Palpate for heat, swelling and synovial thickening

6. Passive tests (for pain, range and end-feel)

Flexion Extension

a. Ligaments (for pain, range and end-feel)

Medial collateral – valgus strain Lateral collateral – varus strain Medial coronary – lateral rotation Lateral coronary – medial rotation Anterior cruciate – anterior drawer (plus Lachman’s test) Posterior cruciate – posterior drawer (observe flexed position also)

b. Menisci (for pain and apprehension)

Flexion, lateral rotation and adduction scoop Flexion, lateral rotation and abduction scoop Flexion, medial rotation and adduction scoop Flexion, medial rotation and abduction scoop

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

observations and examinations detailed in Table 1 and Video 2.

Treatment around the knee CAPSULAR PATTERN The capsular pattern of movement limitation at the knee is defined by: Most loss of flexion than extension. Video 2: Assessment of the knee (Video with captions but no sound; J. Hatcher, 2013)

8. Additional specific tests

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

CAUSES OF CAPSULAR PATTERN Typical causes of capsular pattern movement limitation at the knee are shown in Table 2. Treatment choice Mobilisations of the knee. Flexion mobilisation (Video 3) Directions: 1. Stride standing with cephalad hand

on patient’s knee keeping hip in some degree of flexion. 2. Firmly hold above ankle with caudad hand. 3. Take lower leg into flexion. 4. Grade according to assessment findings. Also try the use of accessory glide mobilisation to improve physiological range of flexion (Video 4).

TABLE 2: CAUSES OF CAPSULAR PATTERN AT THE KNEE (J. Hatcher, 2013) TYPICAL FEATURES CAUSE Wear and tear to the Osteoarthritis (OA) joint, may be primary, or possibly secondary to previous lesion. Mild capsulitis, possible crepitus.

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

Systemic autoimmune disease, causing degeneration and possible joint disruption. Often severe capsulitis, may lead to joint laxity and deformity.

Refer to GP for Rheumatology opinion. If not in acute flareup, may use Grade A (Maitland Grade I and II) mobilisations and progress to Grade B (III and IV).

Common in the knee joint.

Need to treat for swelling first (exercises and/or electrotherapy) – may require aspiration. Treatment to ligaments as necessary and mobilise as pain allows, Grade A–B (I–IV).

Rheumatoid arthritis (RA) and other systemic arthropathies

Traumatic arthritis (TA)

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

Video 4: Mobilisations of the knee: accessory glides (Video with captions but no sound; J. Hatcher, 2013)

Extension mobilisation (Video 5) Directions: 1. Stand side on to patient placing cephalad hand on lower anterior aspect of thigh, above the patella. 2. Place the caudad hand under the calcaneus posteriorly, approaching from the inside. 3. Maintain downward pressure on the femur while simultaneously lifting lower leg in superior direction. 4. Again, grade according to clinical assessment. Also try use of accessory glide mobilisation to improve physiological range of flexion (Video 4).

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

CAUSES OF NONCAPSULAR PATTERN Common causes of non-capsular patterns movement limitations in the knee are loose bodies, meniscal tears, medial ligament sprain and coronary ligament injuries.

Loose body The key clinical features are: Intermittent twinges of pain May have sense of locking, or more likely giving way May have springy end-feel to flexion or extension May have mild capsular pattern if degeneration involved. Treatment choice Loose body manoeuvre.

Video 5: Mobilisations of the knee: extension (Video with captions but no sound; J. Hatcher, 2013)

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MANUAL THERAPY STUDENT HANDBOOK

Loose body manoeuvre to the knee joint (Video 6) Directions: 1. Have patient lying on several pillows on flat bed first. 2. Using end of bed, flex hip and knee so the latter is resting over the edge of the bed (keep the bed up relatively high). 3. Place one hand directly over dorsum of foot, the other around back of ankle. 4. Apply traction to knee by squatting using your body weight (helps to have one leg up on bed frame). 5. Maintain traction with body weight and swing backwards and upwards taking leg through short range of extension, simultaneously rotating lower leg into 3 flicks of motion. (Direction of rotation is into least painful direction).

Meniscal tear The key clinical features are: Intermittent twinges of pain Similar to loose body Often complains of giving way, and sudden locking Pain on meniscal tests (and may have pain on coronary ligament tests). Treatment choice Usually requires surgery to remove, if cannot be manipulated as above.

Medial ligament sprain The key clinical features are: Pain on valgus stress and lateral rotation of knee May have slight additional capsular pattern (due to attachment to capsule). Treatment choice Initially RICE (rest, ice, compression, elevation), then deep transverse Video 6: Manipulation for loose body in the knee (Video with captions but no sound; J. Hatcher, 2013)

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frictions in maximum extension then maximum flexion Additional Grade C manipulation if chronic lesion. Deep transverse frictions to acute medial collateral ligament sprain (Video 7) Directions: 1. Have the patient’s flexed knee supported in maximum available extension (using your leg or pillow). 2. Place index finger of caudad hand directly over site of lesion (often along knee joint line). 3. Reinforce with middle finger of same hand and place thumb around the postero-lateral side of the knee (to offer counter pressure). 4. Firmly squeeze and apply transverse frictional massage using arm. 5. Follow this with DTF in full available flexion. For chronic sprain of medial collateral ligament, it is possible to combine the use of deep transverse frictions, with the addition of a manipulation at end of range of both extension, and flexion. See below... Deep transverse frictions (followed by manipulation) to chronic medial collateral ligament into extension (Video 8) Directions: 1. Perform DTF to the point of analgesia in full available extension as above. 2. Place cephalad hand above knee joint, caudad hand cupped under heel and foot. 3. Stand towards the patient’s thigh and extend both your arms fully taking leg into full extension. 4. Manipulation technique is short, quick Video 7: Deep transverse frictional massage to the knee MCL (Video with captions but no sound; J. Hatcher, 2013)

side flexion movement of your body towards your cephalad side. This should then be followed by repeating the procedure in full flexion too. Deep transverse frictions (followed by manipulation) to chronic medial collateral ligament into flexion (Video 9) Directions: 1. Perform DTF to the point of analgesia in full available flexion. 2. Place cephalad hand over knee joint, caudad hand cupped around heel laterally rotating foot with forearm at same time. 3. Stand towards the patient’s pelvis, facing their head and fully flex and laterally rotate the leg. 4. Manipulation technique is short, quick adduction movement of your elbow towards your side (combined movement of flexion and lateral rotation).

Coronary ligaments The key clinical features are: Often medial. Pain on lateral rotation only Treatment choice Treatment by deep transverse frictions. Deep transverse frictions to medial coronary ligament (Video 10) Directions: 1. Have patient with fully flexed and laterally rotated knee supported using your leg over the patient’s foot. 2. Place index finger of caudad hand directly over the upper medial tibial border, and roll hand over the edge into the joint space. Video 8: Manipulation of the knee: MCL in extension (Video with captions but no sound; J. Hatcher, 2013)

CAUSES OF NONCAPSULAR MOVEMENT LIMITATIONS IN THE KNEE ARE LOOSE BODIES, MENISCAL TEARS, MEDIAL LIGAMENT SPRAIN AND CORONARY LIGAMENT INJURIES 3. Place thumb in postero-lateral aspect of knee to apply counter pressure. 4. Reinforce with middle finger of same hand and squeeze, and apply transverse frictional massage.

CONTRACTILE LESIONS Common contractile lesions of the knee include: quadriceps strain or contusion, hamstring strain and bursitis.

Quadriceps strain or contusion The key clinical features are: Often eccentric forces or direct blow to muscle Pain on resisted knee extension May have pain on resisted hip flexion (rectus femoris) Pain on passive knee flexion. Treatment choice Responds well to deep transverse frictions. Deep transverse frictions to quadriceps (Video 11) Directions: 1. Have patient’s flexed knee over pillow. 2. Place heel of hand directly over site of lesion (usually musculotendinous junction of rectus femoris if muscle strain, or site of direct trauma if vastus lateralis contusion). 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.

Some pain on passive hip flexion when combined with extended knee (straight leg raise). Treatment choice Responds well to deep transverse frictions applied to musculotendinous or teno-osseous junctions. Deep transverse frictions to hamstrings – MT junction (Video 12) Directions: 1. Have patient with flexed knee, pillow under foot. 2. Place heel of hand directly over site of lesion (usually musculotendinous junction of biceps femoris if muscle strain, or site of direct trauma if contusion). 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. 5. Can use back of elbow instead of heel of hand to apply friction if necessary.

Bursitis The key clinical features are: Often affects the following bursae: – Suprapatellar, – Infrapatellar, or – Pes anserine bursae). Treatment choice These often require injection, although various modalities of electrotherapy may be helpful.

FURTHER RESOURCES 1. Falah M, Nierenberg G, et al. Treatment of articular cartilage lesions of the knee. International Orthopaedics 2010;34(5):621–630 2. Heiderscheidt BC, Sherry MA, Video 9: Manipulation of the knee: MCL in flexion (Video with captions but no sound; J. Hatcher, 2013)

et al. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. Journal of Orthopaedic & Sports Physical Therapy 2010;40(2):67–81.

RECOMMENDED READING 1. Anderson MK, Parr GP. Fundamentals of Sports Injury Management. Lippincott, Williams & Wilkins 2011. 2011 ISBN 978-1451109764 (print £58.39, Kindle £55.47). Buy from Amazon http://amzn.to/1QbemUV 2. Cyriax J. Textbook of orthopaedic medicine, vol. 1: diagnosis of soft tissue lesions, 8th ed. 1982. ISBN 978Balliere Tindall 198 0702009358 (£6.00). Buy from Amazon http://amzn.to/1QbeC6o 3. Boyling J, Jull G. Grieve’s modern manual therapy: the vertebral column, 3rd ed. 2005. ISBN Churchill Livingstone 2005 978-0443071553 (£76.33). Buy from Amazon http://amzn.to/1mwohwt 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/1mwokZb 5. Abrahams PH, McMinn RMH. McMinn and Abrahams’ Clinical atlas of human anatomy, 7th ed. 2013. ISBN 978-0723436973 Mosby 2013 (Print £45.52, Kindle £43.24). Buy from Amazon http://amzn.to/1mwomR2 6. Magee DJ. Orthopaedic physical assessment, 6th ed. Saunders 2014. ISBN 978-1455709779 2014 (Print £51.86, Kindle £49.27). Buy from Amazon http://amzn.to/1Kfpjsn 7. Hengeveld E, Banks K. Maitland’s Video 10: Deep transverse frictions to the medial coronary ligaments of the knee (Video with captions but no sound; J. Hatcher, 2013)

Hamstring strain The key clinical features are: Often strained through eccentric activity Pain on resisted knee flexion and hip extension

Co-Kinetic Journal 2016;70(October):35-39

MANUAL THERAPY STUDENT HANDBOOK

Vertebral Manipulation: management of neuromusculoskeletal disorders – volume 1, 8th ed. Churchill Livingstone 2013. ISBN 978-0702040665 (Print £61.19, Kindle £58.13). Buy from Amazon http://amzn.to/1Qbf7NB 8. Hengeveld E, Banks K. Maitland’s Peripheral manipulation: management of

neuromusculoskeletal disorders – volume 2, 5th ed. Churchill Livingstone 2013. ISBN 978-0702040672 (Print £56.79, Kindle £53.95). Buy from Amazon http:// amzn.to/1KfplAC 9. Kapandji IA. The physiology of the joints, volume 3: the spinal column, pelvic girdle and head. Churchill Livingstone 2008 2008. ISBN 978-0702029592 (£288.60). Buy from Amazon http://amzn.to/1KfpnbK.

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 2000, and Certified Strength BY JULIAN HATCHER(FOM) GRADinDIP PHYS MPHIL, MCSP FOM & Conditioning KEY POINTS Specialist in 2005. After starting with a Graduate n The therapist must be familiar with the anatomy of the area in order to Diploma in Physiotherapy (Grad Dip Phys), he gained perform a full assessment. his Master of Philosophy (MPhil) from the University n The capsular pattern of movement limitation at the knee is defined by: of Salford in 2007 and has several publications most loss of flexion than extension. around the knee particularly concerning topics n Causes of capsular pattern at the knee include osteoarthritis, such as ‘ACL deficiency: detection, diagnosis and rheumatoid arthritis and other systemic arthropathies, as well as proprioceptive acuity’ and ‘Osteoarthritis long-term traumatic arthritis. outcomes’. Julian is also an Honorary Member n Treatment for capsular pattern is mobilisation of the knee. of British Association of Sport Rehabilitators and n Causes of non-capsular movement limitations in the knee are loose Trainers (BASRaT). bodies, meniscal tears, medial ligament sprain and coronary ligament Email: J.Hatcher@salford.ac.uk injuries. Website: Julian Hatcher, University of Salford, UK n Common contractile lesions of the knee are quadriceps strain or http://www.seek.salford.ac.uk/profiles/JHATCHER.jsp contusion, hamstring strain and bursitis.

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DISCUSSIONS Why is it usual to test for ACL deficiency in both 90° of flexion (anterior drawer test) and 30° of flexion (Lachman’s test)? There are several methods of testing for meniscal damage; the scoop test plus two others – what are they? Intermittent sharp episodes of pain, sudden locking or giving way are often symptoms of meniscal damage; what differential diagnoses are there? Why is the biceps femoris the most commonly injured out of the three hamstrings?

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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Tweet this: Key features of knee coronary ligament injury are often medial, with pain on lateral rotation only http://spxj.nl/23NmIfu Tweet this: Bursitis of the knee often affects the suprapatellar, infrapatellar of pes anserine bursae http://spxj.nl/23NmIfu

CONTENTS PANEL

RELATED CONTENT

Video 11: Deep transverse frictions to the quadriceps (Video with captions but no sound; J. Hatcher, 2013

HERE ARE SOME SUGGESTIONS

Video 12: Deep transverse frictions to the hamstrings (Video with captions but no sound; J. Hatcher, 2013

ARTICLES IN THIS SERIES ON MANUAL THERAPY INCLUDE: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Introduction to manual therapy Definitions: mobilisation, manipulation and massage Musculoskeletal assessment Musculoskeletal diagnosis Assessment and treatment of the hip Assessment and treatment of the knee Assessment and treatment of the ankle and foot Assessment and treatment of the shoulder Assessment and treatment of the elbow Assessment and treatment of the wrist and hand Assessment and treatment of the cervical spine Assessment and treatment of the lumbar spine Assessment and treatment of the thoracic spine

CO-KINETIC NEW ONLINE CONTENT

NEW CONTENT ON THE CO-KINETIC SITE NEW CON TENT PAR TNER

11 THOUGHT-LEADERS PRESENT AT THE BRITISH FASCIA SYMPOSIUM Fascia is a hot topic in the world of manual therapy and The British Fascia Symposium, which takes place every two years in the UK, brought together some of the world’s cutting-edge fascia researchers and practitioners. Co-Kinetic have teamed up with Whole Being Films, who filmed the event, and all the main keynote presentations are now available through the Co-Kinetic site. Presentations include: n Why did we stand up? A Myofascial Perspective by James Earls n Fascia: Healthy Movement in

Relationship by Gil Hedley n Fascial Anatomy: From Basic Science to Clinical Practice by Carla Stecco n Breaking the Pain Cycle: What is it that makes our brain produce pain and why does it persist long after trauma or injury has healed? by Sue Hitzmann

THE ZIKA VIRUS AND THE RIO OLYMPICS 2016

To view all the presentations from the British Fascia Symposium 2016 visit http://spxj. nl/2b6xPfE

To coincide with the Rio Olympics we published a short medical brief reviewing the potential issue of the Zika virus affecting athletes and staff. In this short article we outline key points for medical professionals, with some links to live updating documents. To read more visit http://spxj.nl/2bukYoU

WHOLE BEING FILMS Whole Being Films exists to support health in all it’s forms through inspirational teaching in a variety of media. Their work is crafted to a high standard based on professional broadcast level production values and experience from within the therapeutic field over many years.

INSPIRING LEARNING EXPERIENCES, CUTTING-EDGE ONLINE SEMINARS, WEBINARS AND PODCASTS FROM eHEALTH LEARNING The interdisciplinary field of fascia research is a very dynamic field, so the technology to understand its characteristics and behaviours in our moving bodies is becoming more refined. eHealth Learning and Co-Kinetic have joined forces to gain insight into this hot topic with the release of two webinars now available through the Co-Kinetic site. There are more in the series to come. Webinars include: n Biotensegrity: A Balance of Forces by Joanne Avison n Latest News from Fascia Research: Implications for Manual and Movement Therapy by Robert Schleip To view the trailer or full webinar for each presentation visit http://spxj.nl/2bUjt08 ALL THE NEW CO-KINETIC CONTENT OUTLINED ABOVE IS AVAILABLE FREE OF CHARGE TO ALL OUR FULL SITE SUBSCRIBERS.

eHEALTH LEARNING With a catalogue of over 50 inspiring webinars covering a wide range of health topics, eHealth Learning provide online education accessible worldwide in the comfort of your own home.

PATIENT INFORMATION LEAFLETS All our patient information leaflets are now available to print or download either in A4 or A5 format. There are 60 leaflets in total (with new ones being added each month) covering physical activity and medical conditions, injury rehabilitation and sports first aid. For more information visit http://spxj.nl/2aOP4QV Co-Kinetic Journal 2016;70(October):40

ENTREPRENEUR THERAPIST WEBSITE DEVELOPMENT

10 WEBSITE HOME PAGE ESSENTIALS FOR WINNING NEW CLIENTS BY TOR DAVIES, CO-KINETIC FOUNDER

THIS ARTICLE ANSWERS THE FOLLOWING QUESTIONS: What are the 10 essential elements I must have on my business home page? How do I create a brand for my business? How can I get low cost help designing a new logo or spring-cleaning an old one? How do I sum up my business in one succinct sentence? How do I capture leads for potential new clients through my website? Where can I find good quality free stock photography for my website? “Features tell, but benefits sell”. What’s what, and how to find yours! How do I make sure I’m getting found on Google? Testimonials, reviews and ‘social proofing’ are key Don’t miss opportunities to let clients connect with you. Connect your website to your social networks and vice versa What kind of resources can I provide that my clients will find useful? Hate blowing your own trumpet? Here are some ways of doing it without actually having to do it yourself. The online version includes additional information and resources on all the sections in the article as well as additional details on the following: How do I know what lead generation tools are working on my website? How can I add a Google Map to my website? How do I make my contact number on my website clickable on a mobile device? How do I add my social networks to my site? How do I set up article downloads? Co-Kinetic.com

“You never get a second chance to make a first impression”. It’s true. It doesn’t matter how much money you spend on designers, if you want to use your site to get new clients then you need the following 10 elements on your website home page. Wherever possible we’ve not only explained the importance of each key element but also how to practically apply the advice we’ve given you so that you can build a website which not only brings you new clients but builds trust with your existing ones and all in the most cost-effective way possible. In order to fit this article into the print journal we’ve had to reduce it in size. For the full open access version visit: http://spxj.nl/1sx8y42. INTRODUCTION Welcome to the first article in our Entrepreneur Therapist series. We will be publishing regular short helpful tips and tricks on our Facebook (http:// spxj.nl/2c8tCGG) and LinkedIn pages (http://spxj.nl/1H0fdtR) and our longer more detailed articles on the Co-Kinetic website.

YOUR THERAPY PRACTICE HOME PAGE We’re big fans of the Hubspot marketing blog (http://www.hubspot.com/). It features some of the best, most useful resources covering a whole range of marketing topics. Sadly I can’t afford to sign up to their platform as much as I’d love to, but it’s not going to stop me ranting and raving about their awesome resources! The article “12 Critical Elements Every Website Homepage Must Have” by Lindsay Kolowich (http://spxj.nl/2bjbMp6), served as the foundation of this article which we’ve then adapted specifically with the physical and manual therapist

BUSINESS GROWTH | 16-10-COKINETIC | FORMATS WEB MOBILE PRINT

MEDIA CONTENTS Downloadable checklist for 10 Website Home Page Essentials for Winning New Clients http://spxj.nl/1sx8y42 in mind. Wherever possible we’ve tried to include practical advice on how to bring to life each of the sections in the most cost-effective and practical way possible and included links to useful related resources, such as this one (again from Hubspot), which is a free workbook download on “The ultimate guide to redesigning your website” (http://spxj. nl/2bU0fYP). The 10 key components of a webpage for a physical therapy practice are as follows: 1. Logo/company name 2. Headline 3. One or more calls to action 4. Navigation to other areas of the website 41

1. CHOOSING A NAME AND CREATING A BRAND

started without it costing an arm and a leg. Alternatively if you have a bit of design flare and fancy creating your own logo or you already have a logo and want to modernise it, but lack the software to do so, try sites like Canva (https://www.canva.com/) or Relay (https://www.relaythat.com/).

How do I choose a name for my therapy business?

2. HEADLINE/SUB-HEADING

5. 6. 7. 8. 9. 10.

Supporting image or video Benefits (not features) Testimonials/reviews/social proof Social network links Resources/blog Success indicators.

If you haven’t already got a brand or business name, here’s some help on how you can go about creating one: I’m a Small Business – why do I need a brand? http://spxj.nl/2cdkSnn 8 Steps to Creating a Brand http://spxj.nl/2bTFSMd Branding Guide – practical guide including worksheets on creating a brand http://spxj.nl/2bC6L8M How to Name your Business: 10 things you need to know http://spxj. nl/2bEpxJD 8 Mistakes To Avoid When Naming Your Business http://spxj.nl/2c0IURf The Anatomy of a Strong Company Name http://spxj.nl/2bM2bE4 Choosing a name for your company, partnership or business: what you can and can’t use http://spxj.nl/2bn0Ghy Co-Kinetic Case Study. This is the process that I went through at CoKinetic to transition from sportEX to our new brand Co-Kinetic http://spxj. nl/1HQJDYY.

OK I have a name for my business, now how do I create a logo? Remember this advice applies to people who have an existing logo and want to spring-clean it, as much as it does to someone creating a new logo. Fiverr (https://uk.fiverr.com/) describes itself as the marketplace for creative and professional services. It’s basically a way to link up with a whole range of designers who can very cost-effectively help in the creation of all sorts of artwork including branding and logo development. Designs basically start from £5 (hence the name). It’s a great resource for small businesses and the self-employed. A couple of friends of mine have had logos designed by people on Fiverr and they’ve been very happy with the results. If you’re starting up in business, this is a great way to get 42

Next to your headline or sub-heading/ brand statement. This is how you sum up what you do in one concise phrase. For Co-Kinetic it’s “Practical resources for physical and manual therapists”. Here’s how you find yours… We found a great blog post at WebsitesInWP (http://spxj.nl/2bFjTvr) which outlines a fun 2-step process to help you sum up your business in one sentence. There’s also a good post on LinkedIn on how to describe your business in two sentences (http://spxj.nl/2bM1zhB). Make sure your headline/business statement is right up there on your website, near your logo so that it’s the first thing you see. After you’ve got your logo and your brand statement the next thing to ensure you have on your home page is one or more calls to action.

3. CALLS TO ACTION – THE KEY TO IT ALL So your potential client is on your home page, now what? You need a call to action or CTA. To take things further you want them to interact with your website. A commonly used phrase in modern marketing is the ‘Know, Like, Trust, Convert’ factor. First someone has to get to know you, whether that’s through your website, or your social media profiles. The second step is that you then want them to learn to like you by giving them useful information or resources that help them. The third step is for them to transfer that like to trust, at which point the chances are that you’ve got yourself a new customer and you hit the conversion point. We already know as therapists that trust is a particularly important part of what we do, so you need to move through this process responsibly, carefully and considerately, ie. no spamming or hard selling. That’s a bit like walking up to

someone you don’t know, saying hi, and then asking them out for dinner. It might work for the quirky types who like that style but the majority are likely to run! So don’t do it online. According to Wikipedia: Your call to action needs to be persuasive but resist the temptation to go for the hard sell. Remember your website visitor doesn’t really know you yet and certainly hasn’t moved to the stage of ‘like’, so it’s way too early to get them to trust you just yet. Your visitor may be an existing client who has just jumped on your site to get your phone number, address or find a map of how to get to your clinic for their next appointment (so make sure these are easy to find from the home page – more tips below). The visitor you’re wanting to catch the attention of through your call to action is the new customer who may have found you through a recommendation or through your online or offline marketing efforts (although there’s definitely no harm in offering your existing clients added value if they spot a CTA they like while visiting your site, it all contributes to building the relationship). The holy grail of the call to action at this point is to get your potential client to give you an email address. Try and get into their heads and figure out what it is that they really want information about or help with. If you can’t come up with anything then try asking your current clients what questions they would ask. Then set about creating or sourcing something that will ‘serve’ these prospective new clients. Some ideas might be: answers to frequently asked questions patient-friendly information on commonly occurring conditions or patient handouts (more details follow) a short discussion of newsworthy topics if something has taken the news by storm recently advice about seasonal sports injuries like tennis elbow around Wimbledon or preventing ACL injuries before the start of the ski season. What’s worked for you? I’d love to hear. Please either comment in the discussion area online or email me tor@co-kinetic.com Co-Kinetic Journal 2016;70(October):41-44

ENTREPRENEUR THERAPIST WEBSITE DEVELOPMENT

Ideally you want to provide some nice helpful information on your site which is freely accessible and the odd one or two ‘call to action’ buttons which offer your clients something worth giving their email address up for. If you’re a Co-Kinetic subscriber why not use our Patient Information PDF leaflets which are included as part of your full-site subscription. Just log into your account and go to the following link: http://spxj.nl/2aOP4QV. There are about 60 leaflets on various topics available to you. Even if you’re not a full-site subscriber you can still purchase the leaflets individually for £1 . 92 a leaflet which you can then download and print off to your heart’s content or offer as a download on your site. However you must make sure you’re measuring what you’re doing…

Measure, analyse, adapt and repeat The only way to see if what you’re doing is working is to measure it and this leads me to another point … the mighty Google Analytics! It might sound boring but actually if you know what you’re looking for, it’s incredibly useful. If you haven’t got it installed, it should be your first priority! This link gives step-by-step guidance: http://spxj.nl/2c0MvyA. If you’ve used a web developer on your site then you should already have it installed (if not then ask your web developer to do it and then consider finding a new web developer because no self-respecting web developer should ever create a website without at least installing Google Analytics!). If your site is hosted on one of the popular website platforms such as Wordpress, Squarespace, Moonfruit, Wix, Weebly or 1&1 then it should be pretty easy to install. Just Google “install Google Analytics on (insert platform name)” for instructions. If you want more on Google Analytics, using our patient information leaflets as calls to action or setting up document downloads in general then please refer to the online version of this article at the article link in the introduction.

Co-Kinetic.com

4. EASY WEBSITE NAVIGATION The next point on our home page essentials is to make sure that it’s as easy as possible for people to find their way around your website. This means simple/clear headings and keeping headings to around seven headings or fewer. A search box is also a useful feature for visitors to find what they’re looking for. When your service is healthcarebased, establishing trust is key so make sure to include details in an About Us/ Staff/Meet the Team/Our People section. Wherever possible include pictures and biogs and keep these up to date. It’s also a good idea to include links to your social media profiles but only if they are professionally orientated. This is a time for reputation building, not a diary of your personal life lived through Twitter! At the very least include LinkedIn if you have a LinkedIn profile (and if not, it’s worth setting one up!). Video is growing rapidly in popularity and live video is social media’s golden child of the moment as we write this article (July 2016) so if you (or someone else you work with) loves being in front of a camera then get your camera out and start filming! It doesn’t have to be of a super-professional quality but do some reading up on the basics of video filming to make sure you’ve got the simple stuff covered. Remember this is all about developing your reputation as a therapist and building trust. Why not answer your frequently asked questions by video, or talk about a topic in the news, or talk about a certain injury or condition. Interview staff members, maybe even ask current customers for a testimonial by video (this adds to your social proofing – discussed in more detail further down the article).

Your contact details are essential The other thing that patients will frequently look for is location information so make sure a Contact Us page or Find Us page are … easy to find! Two top tips are to make sure you have a Google Map embedded on your page and make sure your telephone number is clickable on a mobile phone. Information on how to do both is included in the web version of this article.

5. IMAGES AND VIDEO Most people are visual, so you want to make your home page looks as inviting as possible with the use of a graphic/image and/or video, while making sure to use media that is relevant, illustrates what it is you offer and is also in keeping with your ‘brand’. If your budget or photography skills are less than adequate, we’ve found some useful media resources below.

Royalty free stock photography sources librestock.com (http://librestock.com/) is a website that searches 40+ other free stock photos and delivers the search results to you through their site 18 top stock photo libraries (http://spxj.nl/2bnAeo5).

6. WHY SHOULD POTENTIAL CLIENTS CHOOSE YOU? FEATURES VERSUS BENEFITS “Features tell, but benefits sell!” Gregory Ciotti from Help Scout (http://spxj.nl/2bCaYsO) put together this excellent article on how benefits, not features, sell products and services. A great exercise for any business is to create a list of your business’ features, and for each feature ask yourself: (a) what the benefit is, and (b) what problem it solves. Trust me, it’s harder than you think.

7. GETTING FOUND ON GOOGLE: TESTIMONIALS, REVIEWS AND ‘SOCIAL PROOFING’ ARE KEY I was listening to a podcast the other day on the best ways to get your business found on Google and the single one thing that stood out was making sure you had reviews on Google (those are the yellow stars you see under the company name). In fact the guy being interviewed said if he only had time to do one thing of all the things he’d discussed in the podcast, it would be to make sure your Google Business page was set up and that you were collecting reviews (http://spxj. nl/2bhkxg1). Go to the web version of this article to find out how to make sure you’re set up on Google Business and how to get reviews.

8. SOCIAL MEDIA ICONS Over 75% of home pages have social media links, with Facebook and Twitter 43

being the top platforms of choice (assuming of course you have professionally-orientated Facebook or Twitter pages – if not, don’t add them!)

9. RESOURCES Hubspot’s advice about resources is very sound. “Again, most visitors to your website won’t be ready to buy … yet. For folks who are looking for more information, offer a link to a resource centre where they can browse relevant information. Not only does this keep them on your webpage for longer, but it also helps you establish your credibility as a thought leader in your industry.” If you haven’t got time to create the resources yourself (or need a helping hand) why not use our printable, downloadable patient information leaflets mentioned earlier.

10. SUCCESS INDICATORS: BLOWING YOUR OWN TRUMPET (DISCREETLY)! If you’re anything like most of the therapists I speak to, you hate showing

off and you’ll be your own worst salesperson. I get it and I empathise 100%! I hate it too. I want to put the journal and website in front of people and just let them make their own minds up on whether it works for them. So why not let others speak for you instead – here are some ideas: Customer success stories (this is a great way of adding video to your site too). The Putney Chiropractic Centre (http://spxj.nl/2bn91BY) is a fantastic example of how to do this. Have you won any awards or received any letters of recognition or commendation? If so, they should be on your site and preferably on your home page. Do you work with any sports teams, organisations, groups or businesses with recognisable brands? If so, why not add a strip of logos on your home page. (Note: Want to know how to create a strip of logos? Ask us using the discussion forum online and we’ll put some step-by-step instructions together for you using free tools).

5 SIMPLE THINGS YOU CAN DO BOTH ON AND OFF YOUR WEBSITE TO GET MORE PATIENTS In 1. 2. 3. 4.

order of priority here are 5 things you should do next: Make sure Google Analytics is installed on your website Set up a Google Business page Ask your customers for reviews on your Google Business Page Make sure the telephone number on your website is ‘clickable’ so that if someone is visiting your site on a mobile device they can call you just by clicking the link 5. Insert an embeddable Google Map on your Contact Us page

If you’d like practical step-by-step guidance on accomplishing each of the actions above, follow the link below and we’ll send you an email per action point with a new one triggered only when you’re ready. Each action point we send will take between 5–10 minutes so you can implement them easily. Follow this link to sign up http://spxj.nl/2bR5NCO

RELATED CONTENT Optimising your physical therapy website to generate new leads and get new clients - http://spxj.nl/28KG6kY Business Development for Physical Therapists: An introduction to the LEAN Therapist - http://spxj.nl/1s5o5aP Financial health check-up for the self-employed physical therapist http://spxj.nl/1P9XKvS

THE AUTHOR Tor Davies Having started my professional life training as a physiotherapist at Addenbrookes Hospital, Cambridge, UK, I then went on to complete a BSc in Sport and Exercise Science at Birmingham University. After graduation and a relatively short-lived attempt at a job in marketing, I became a medical journalist with Reed Business Publishing where my passion for publishing was born. When the publisher I worked for wouldn’t agree to publish a sports medicine magazine for GPs, I thought I’d give it a go myself. Sixteen years later I reckon I’ve just about figured it out how to do it! I’m incredibly lucky that with more than a little help from the friends I’ve met along the way, and in particular a man I have huge respect for and who in fact wrote an article in our very first issue in July 1999, Dr Dylan Morrissey, we’ve managed to put together an amazing commissioning team. My job is just to nudge, prod and generally organise a fantastic editorial team and create a publishing infrastructure that does our readers, editors and authors justice.

KEY POINTS The Hubspot marketing blog (http://www.hubspot.com) is very useful. The right business name will make sense immediately to your customers and will communicate what your business is about. A ‘call to action’ on your home page will help prospective clients move along the ‘Know, Like, Trust, Convert’ pathway. Offer prospective clients something that will be useful to them so that they will give you their email address. Use Google Analytics to measure what you are doing with your website to see if it is working for you. Make sure your website is easy for people to find their way around. Your contact details must be easy to find. Having reviews on Google will help your website to be found by the search engine. Use customer success stories/testimonials to indicate your success.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Work out your brand statement: how to sum up your business in one concise phrase. http://spxj.nl/1sx8y42 Tweet this: The holy grail of the call to action at this point is to get your potential client’s email address. http://spxj.nl/1sx8y42 Tweet this: The only way to see if what you’re doing is working is to measure it: install Google Analytics! http://spxj.nl/1sx8y42 Tweet this: Use customer success stories to blow your own trumpet discreetly. http://spxj.nl/1sx8y42

Co-Kinetic Journal 2016;70(October):41-44

ENTREPRENEUR THERAPIST WEBSITE DEVELOPMENT

10 WEBSITE HOME PAGE ESSENTIALS FOR WINNING NEW CLIENTS THIS ARTICLE ANSWERS THE FOLLOWING QUESTIONS How do you create a brand for your business? How do you get low cost help designing a new logo or spring-cleaning an old one? How do you sum up your business in one succinct sentence? How do you capture leads for potential new clients through your website? Where can you find good quality free stock photography for your website? “Features tell, but benefits sell”. What’s what, and how to find yours! How do you make sure you’re getting found on Google? Testimonials, reviews and ‘social proofing’ are key Don’t miss opportunities to let clients connect with you. Connect your website to your social networks and vice versa What kind of resources can you provide that your clients will find useful? Hate blowing your own trumpet? Here are some ways of doing it without actually having to do it yourself.

CHECKLIST 1. Logo/company name 2. Headline 3. One or more calls to action 4. Navigation to other areas of the website 5. Supporting image or video 6. Benefits (not features) 7. Testimonials/reviews/social proof 8. Social network links 9. Resources/blog 10.Success indicators

ADDITIONAL RESOURCES

Open access to full version of article at http://spxj.nl/1sx8y42 Hubspot marketing blog http://www.hubspot.com/ Free workbook download on “The ultimate guide to redesigning your website” http://spxj.nl/2bU0fYP Choosing a name for your company, partnership or business: what you can and can’t use - http://spxj.nl/2bn0Ghy Branding design with Fiverr https://uk.fiverr.com/ Create your own logo with Canva https://www.canva.com/ or Relay https://www.relaythat.com/ Sum up your business in one sentence with WebsitesInWP http://spxj.nl/2bFjTvr How to get started with Google Analytics y Logo - White/light background http://spxj.nl/2c0MvyA 18 top stock photo libraries http://spxj.nl/2bnAeo5 “Features tell, but benefits sell!” by Gregory Ciotti from Help Scout http://spxj.nl/2bCaYsO.

on Facebook https://www.facebook.com/sportEX.net/

on Twitter https://twitter.com/sportexjournals

on LinkedIn https://www.linkedin.com/company/sportex-net

on Google+ https://plus.google.com/+Cokinetic/about

PRACTICAL RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

Co-Kinetic.com

CYAN

MAGENTA

YELLOW

BLACK

ENTREPRENEUR THERAPIST FINANCIAL HEALTH

FINANCIAL HEALTH CHECK-UP FOR THE SELF-EMPLOYED THERAPIST This article, along with the checklist provided, will help you to diagnose the state of your financial health. The suggested resources, as well as the basic budget spreadsheet and key points will enable you to design a personalised financial rehabilitation plan, allowing you to realise your business aims, maximise your financial potential and complete your tax return with time efficiency and confidence. The article has been written specifically with the physical and manual therapist in mind by a fellow manual therapist who is also a qualified accountant and holds a Masters degree in commerce. Read this online http://spxj.nl/1P9XKvS BY DIRK BENADE MCOM CA(SA) MSMA

TABLE 2: HOW DOES YOUR BUSINESS FITNESS SCORE?

(D. Benade, 2016)

s physical therapists we are considered experts in what we do, but sometimes when it comes to the financial part of our business, we need some help. We often don’t have a financial background and this can make it difficult for us to judge whether our business finances are in good shape, or in need of some serious attention. This article is a starting point in which I’d like to offer my perspective as an accountant of some common mistakes to avoid, and a few good habits worth adopting, to keep your business finances healthy. The information is presented in the form of a checklist (Table 1 on the next page). Your score suggests if the health of your business is more towards the elite athlete or couch potato ends of a financial fitness spectrum. Suggested resources for further information are provided in italics. If you review these, please exercise your own judgement as to whether you should rely on them. Score 1 point for each question in bold (Table 1) to which you can fully or mostly answer ‘Yes’. Then sum your score and match

Co-Kinetic.com

Score 1 2 3 4 5 6 7 8 9 10

BUSINESS GROWTH | 16-10-COKINETIC | FORMATS WEB MOBILE PRINT

MEDIA CONTENTS

Level of financial fitness Couch potato Muffin top Weekend warrior Club athlete

Semi-professional

Downloadable resources Basic Budget Spreadsheet for a Physical Therapy Business http://spxj.nl/2bTeheR

Elite

The Pensions Advisory Service http://spxj.nl/2bFDV4l

the result to those in Table 2. Because each business is unique your checklist result can only offer an indication. If you haven’t scored as well as you would have liked, consider making improvements. Being in good health, whether physically or financially, requires discipline. I think the results are worth it.

Acknowledgements Ian Baker, FCCA CTA (Utterly Tax Limited, chartered certified accountants and chartered tax advisors), is 46, (continued on p48)

The Money Advice Service. Emergency Savings – How much is enough? http://spxj.nl/2bpmsfH HMRC. Expenses and Benefits A to Z: Homeworking http://spxj.nl/2bmfRGg Performance Accountancy. A Therapist’s Guide to Business Expenses and Self Assessment in the UK http://spxj.nl/2ceOdxE Balens Ltd http://spxj.nl/2blyRS8 HMRC. Keeping your Pay and Tax Records http://spxj.nl/2bmgLCl Sports Massage Association http://www.thesma.org/ North London School of Sports Massage http://www.nlssm.com/ Co-Kinetic/sportEX https://co-kinetic.com/ 45

TABLE 1: FINANCIAL HEALTH CHECKLIST (D. Benade, 2016). NO 1

CHECKLIST ITEM

YES

Accept card/PayPal/etc. payments to make it easier for customers to pay you? Consider keeping surplus cash that you want to use later in the business in a high interest deposit account?

Where relevant do you also: Ensure your net profit covers all of your living costs, savings plans and pension contributions? Identify trends to ensure they are moving in the right direction? For example, is your income from work stable for an established practice, or otherwise increasing over time if you’re just starting out?

Resource: Your own bank should be able to advise you of options. Ask about any costs or fees before deciding, and consider shopping around to ensure what’s on offer is competitive.

Chase up your debtors? Ensure your P&L includes all relevant business expenses? Minimise use of debt, especially expensive credit cards and overdrafts, unless it’s part of your strategic investment plan, and you clearly understand the risks? Monitor your time spent travelling if this isn’t paid for? If you travel an hour each way to do two hours work for example, your actual hourly rate of pay is only half as good as it seems. Resource: Some accountants as part of their service offer templates for monthly accounts tailored to your business to make life easier, so it can be worth checking.

2 BUDGET Do you prepare a budget annually of how much you expect to earn and spend? Where relevant do you also: Ensure you are charging a suitable market rate for your services relative to competitors? Adjust your pricing for inflation periodically? At least quarterly (ie. every 3 months), compare your actual results to budget and understand the reasons for any differences, taking corrective action where appropriate? For example, if income was less than planned, say through unintended time off, you may seek more work in the next quarter. Take considerable care before making any medium- to long-term financial commitments, such signing as a lease agreement for a studio? I’d suggest between 6 and 12 months is medium term, and more than a year would be long term. Resource: If you don’t already have a budget, you may wish to try the basic budget spreadsheet in the Resources section to get you started.

SEPARATE BANK ACCOUNT. Do you maintain a separate bank account for all your workrelated income and expenses? This should make control and reconciliation of your monthly accounts considerably easier. Where relevant do you also: Encourage customers to pay direct to your work bank account?

PENSION AND SAVINGS If it is your plan to retire one day, are you saving an appropriate amount of your income for your pension? Do you have savings for a rainy day? Pensions are a complex area with many considerations, so seeking independent advice may be worthwhile. A point to watch out for is fees – anything more than 1% (the UK limit for stakeholder pensions) might be expensive.

Check that money owing to or by you has been paid?

YES

MONTHLY ACCOUNTS. At least monthly, do you prepare management figures showing your income and expenses (Profit and Loss/P&L), and what your business owns and owes (Balance Sheet)?

CHECKLIST ITEM

It can be sensible to set aside sufficient funds for 3 months of essential personal outgoings in the event you are unable to work for a short period of time. Resources: The Pensions Advisory Service. The Money Advice Service – Emergency Savings – how much is enough?

TAXES Do you declare all your income to HMRC, and avoid the temptation of slipping personal expenses into your tax return? Where relevant have you also taken into consideration: Allowable business expenses? If necessary to earn income, you may be able to include rental charges; consumables; protective clothing (and cleaning) if you are expected to wear a uniform; mobile phone costs; advertising; workrelated travel (in some cases related subsistence such as meals and accommodation costs when staying at a temporary workplace); professional memberships; certain training; fixed assets (although the amount you can claim is restricted if there is an element of private use); professional journal subscriptions; and working from home and travel costs discussed in more detail below. Working from home allowance? HMRC allows £10, £18 or £26 per month (home working 25–50/51–100/101+ hours monthly); or an apportionment of home expenses if part of your home is set aside specifically for business. Home expenses include: rent/mortgage interest, council tax, contents insurance, business assets, repairs, cleaning, electricity, gas, water (telephone and broadband form separate claims). The percentage can be calculated on the number of rooms and the amount of time spent working in each room. Travel costs allowances? You may claim the rate of 45p per mile (first 10,000 business miles per annum dropping to 25p/24p/20p per mile for cars/motorbikes/bicycles respectively). VAT? You are aware that if you are making VATable

Co-Kinetic Journal 2016;70(October):45-48

ENTREPRENEUR THERAPIST FINANCIAL HEALTH

CHECKLIST ITEM

YES

supplies and total revenue exceeds the threshold (currently £82k) over 12 months, you must register for VAT and charge your customers this at 20%. Resources: HMRC – Expenses and benefits: A to Z. How do I calculate my working from home expenses? A Therapists Guide to Business Expenses and Self Assessment in the UK.

CHECKLIST ITEM

YES

Become a member of an appropriate industry body which lends credibility to your business? Subscribed to at least one quality industry journal, reading relevant articles? Resources: CPD events are organised through a variety of service providers. Some options or massage therapists include the Sports Massage Association and NLSSM. I subscribe to Co-Kinetic.

6 INSURANCE Do you have adequate comprehensive professional liability, public liability and professional indemnity insurance? Where relevant, have you also: Considered whether disability and critical illness insurance are appropriate for you? These can be important where your work has a physical component, if you are the sole breadwinner, or your family needs your income to make ends meet. If you work from home, have you checked that your home insurance and mortgage/rental terms permit you to do so? Resource: For indicative cover, one option you may wish to review is Balens.

7 RECORD KEEPING Do you keep your business records for at least 6 years for tax purposes? Can you produce an invoice, receipt or other suitable documentary evidence to support every expense claim? Where relevant do you also: Check that your time spent (eg. time sheets/calendar/ treatment notes) reconciles to your invoices proving that you have reported your all your business income correctly? File your paperwork monthly at the same time as you produce your monthly accounts (for example bills, bank statements and work-related correspondence)? If you keep your records electronically, ensure that you backup regularly and preferably in a different location to where your computer is for safety? If you update your software, ensure your old files remain readable? Resource: HMRC – Keeping your pay and tax records.

8 STAYING CURRENT Do you update your knowledge through continuing professional development (CPD)? Where relevant have you also: Embraced technology to make business life easier, for example using email and SMS to send booking confirmations and bank payment details? Created a website allowing customers to book appointments online with automated email reminders to them a day or two before?

Co-Kinetic.com

9 APPROPRIATE BUSINESS FORM Do you periodically (at least every 3 years, or when your circumstances change) assess whether you’re better off as a sole trader or limited company? Some indicators that a limited company may be more suitable for your business include: If in addition to your self-employment income you have other employment/ investment income which is significant. Your total income is higher than £18,000. Potential customers prefer to deal with limited companies. You are concerned about being personally liable for debts and potential claims against your business. Your business is being developed in order to later sell on and/or pass along to the next generation. You are intending to build up funds within the business, rather than draw it all immediately. You are comfortable with the additional administration limited companies require, such as recording dividends, preparing minutes of board meetings, and filing annual returns (this is likely to require at least a couple of hours monthly, and considerably more at quarter and year ends). Resource: I suggest it’s worth speaking to a practising accountant regarding this matter, as they can advise specifically to your circumstances and future plans. Although I’m a chartered accountant myself, I prefer to save time by engaging a fellow professional to handle some of these elements for me using their software and experience. That allows me to spend time generating revenue rather than keeping updated with tax rules for example.

10 YOUR OWN HEALTH Do you take excellent care of your health, recognising your ability to earn income depends on it? Where relevant do you also: Exercise regularly, have a suitable body weight, don’t smoke, and eat sensibly? Adopt suitable biomechanics while working (power from the legs, avoiding using your fingers where possible) to extend your professional longevity? Resources: Your student training notes should cover biomechanics, so consider revising these from time to time. Treatment swaps with other therapists, giving honest feedback on elements such as technique, can help identify areas for improvement.

PREPARE MANAGEMENT FIGURES MONTHLY, AND ENSURE YOUR NET PROFIT COVERS ALL OF YOUR LIVING COSTS, SAVINGS PLANS AND PENSION CONTRIBUTIONS qualified at 21 and advises many clients in both the holistic health and freelance sectors on a fixed fee basis. Ian is available by email: Ian.Baker@utterlytax.com, or by telephone: 0333 123 4884. Susan Findlay, BSc RGN, Dip SMRT, MSMA, MLCSP, Board Member of GCMT, is the author of Sports Massage for Therapists (Human

Kinetics, 2010), a feature writer for Massage World and sportEX, and director of NLSSM The School of Sport & Remedial Massage. For more information please see Susan’s website http://www.susanfindlay.co.uk/. Susan is available by email: susan@nlssm.com.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Being in good financial health requires discipline but the results are worth it. http://spxj.nl/1P9XKvS

RELATED CONTENT Business Development for Physical Therapists: An introduction to the LEAN Therapist - http://spxj.nl/1s5o5aP Physical Therapy Website Design: 10 Home Page Essentials for Getting New Clients - http://spxj.nl/1sx8y42 Optimising your physical therapy website to generate new leads and get new clients - http://spxj.nl/28KG6kY

DISCUSSIONS If you had to pick a single word of your own to describe the health of your business, what would that word be? How many hours per month, on average, are you investing on keeping on top of your business finances? Do you think this is sufficient? For the checklist questions to which you answered ‘No’, what things could go wrong as a consequence? What top three things could you do differently for your business from having read this article? When will you do these by? Consider diarising them to ensure they happen.

KEY POINTS An important part of being self-employed is ensuring your business finances are under control. That goes beyond the (hopefully) obvious points of maximising your revenue and controlling costs. You should also be doing the following: Preparing and reviewing accounts every month showing how your business has performed. Have an annual budget which you compare against your actual accounts every 3 months. Maintain a separate bank account for your business and use it for all your business income and expenses; don’t mingle these with your personal finances. Save an appropriate amount of your income for your pension, and have at least 3 months’ savings as a rainy day fund. Declare all your income for tax, and ensure you only claim deductions for things you are entitled to. Maintain adequate professional indemnity insurance. Keep your business records for at least 6 years, and be able to produce documentary evidence supporting every expense claim. Stay current to protect your ability to earn income in the future. Assess whether you are better off as a sole trader or limited company periodically. Look after your own health: your ability to earn a living depends on it.

HAVING A SEPARATE BUSINESS BANK ACCOUNT SHOULD MAKE CONTROL AND RECONCILIATION OF YOUR MONTHLY ACCOUNTS CONSIDERABLY EASIER THE AUTHOR Dirk Benade MCom CA(SA) MSMA holds a Master’s degree in commerce from the University of the Witwatersrand, and qualified as a chartered accountant (South Africa) with KPMG. He is also a chartered management accountant. For the past 15 years Dirk has worked as a contractor in the financial services sector, and has operated his business through a limited company since 2005. Dirk also qualified as a yoga teacher with Triyoga, and sports massage therapist with NLSSM. Dirk is a member of the SMA and holds his insurance with Balens. His own accountant is Ian Baker.

Co-Kinetic Journal 2016;70(October):45-48

SOCIAL WATCH

SOCIAL

WATCH

In line with our goal of saving you both time and money, here’s our pick of some of the best resources on social media published over the last couple of months.

@DigitalChiro

@YLMSportScience

How to Increase Authority Using Google+ http://spxj.nl/2bP3mSJ

If U are interested by sport science & working with athletes, this infographic is key to understand #stats http://spxj.nl/2bNwAjM @JingMassage

Steven Goldstein’s ‘Fibromyalgia: Continued Perspectives for the Manual-Massage Therapist’ http://spxj.nl/2bgsnE6

@Peter_Gettings

@PrestonsHealth @ tomgoom Interesting paper here on hormones and tendinopathy too... http://spxj. nl/2bFSLek

TWEETS

2,927

FOLLOWING

1,127

@SCCAthTrng

FOLLOWERS

4,882

@injurypics @concussionblog http://spxj.nl/2bgmvxH

Join in!

@Moz @sportexjournals

Good advice from @HubSpot Q: Which social networks should you focus on? A: Follow your customers http://spxj.nl/2bOZcdB

Co-Kinetic.com

Tag Length Guidelines: 2016 Edition By @dr_pete http://spxj.nl/2bBFaGe

@Jlstein19

Excellent presentation on ACL care for adolescent patients by Dr Micheli @SportsMedBoston #ACSM2016 #legend #ToughDecisions http://spxj.nl/2bi4xYi @DrChrisBarton

Key treatment options in Patellofemoral Pain A Best Practice Guide Screencast http://spxj.nl/2bVGa7m

THE BEST OF FACEBOOK

@techinsider New knee repair surgery. This revolutionary surgery could change the way doctors treat knee injuries. http://spxj.nl/2bBMCkN

@susanatnlssm

How can you use #compression in combination with shearing and rotational movements? #MassageMondays #SportsMassage http://spxj.nl/2bibF6W

@topphysios Understanding the Psoas Muscle Anatomy masters Stu Girling and David Keil speak about the significance of the Psoas Muscle and how its understanding helps ones practice. http://spxj.nl/2bgyyLd

@massagetherapy

The invited review - a not so subtle critique http://spxj.nl/2bNz8ii

RTER’S THIS QUA

HIGHLIGH

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 PINTEREST l l l l

Sarah Oliver Osteopathy - http://spxj.nl/2c9QIRU Primal Pictures 3D Anatomy - http://spxj.nl/2c9Rr5k AnatomyStock - http://spxj.nl/2bIwFqC Anatomy Physiotherapy - http://spxj.nl/2bQuu2y

CHECK OUT ON YOUTUBE l l l l

Kenhub - http://spxj.nl/2bpRMwW AnatomyTutorials - http://spxj.nl/2bijqds Jing TV! Advanced Massage Training - http://spxj.nl/2bDor5E The Running School - http://spxj.nl/2bhU7y2

CHECK OUT ON INSTAGRAM l l l l

physiofitnessaus - http://spxj.nl/2bIa9iZ abmpmassage - http://spxj.nl/2bkohPN trustmephysiotherapist - http://spxj.nl/2bPvBQl physiotutors - http://spxj.nl/2byNvZU

CO-KINETIC ON SOCIAL MEDIA https://www.facebook.com/sportEX.net/ @physioedgepodcast Infographic on Recommendations for assessing runners, with takehome messages from the Physio Edge podcast 048 with Dr Rich Willy “Running from injury”. http://spxj.nl/2bnh4M4

https://twitter.com/sportexjournals https://www.linkedin.com/groups/4048152 https://pinterest.com/co_kinetic https://www.instagram.com/co_kinetic/ Co-Kinetic Journal 2016;70(October):49-50

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PRACTICE GROWTH SESSIONS AT THERAPY EXPO 2016

4 SESSIONS

2 SPEAKERS

WARREN CASS

USING SOCIAL MEDIA TO FILL YOUR DIARY – WARREN CASS Most people understand they need to have a social media presence but very few practitioners have turned this into appointments. Why? Well simply put they don’t have a strategy and don’t understand how to leverage this powerful medium. Warren Cass has been working with businesses internationally on their Social strategy and he has created this talk specifically for therapists and practitioners.

FIVE STRATEGIES TO ATTRACT MORE PATIENTS – WARREN CASS So you have set up your practice. I bet you are really good at what you do. But do you know how to market your services and build the processes which ensure your diary is full? In this talk Warren will share 5 simple strategies you can implement right away which will help create a flow of new patients and more importantly keep them coming back.

Warren Cass is founder of Business Scene and Champions of Small Business, both supporting entrepreneurs and business owners across the UK with their growth. He is a key influencer in UK Small Business with a huge network and consults with major brands & SME’s alike helping them to engage & add value to their target audience. Warren is an international speaker who has been entertaining audiences for over 10 years providing clarity and strategy. His speaking style is fun and engaging and definitely one not to miss.

HOW TO CREATE REPEAT BOOKINGS AND ABUNDANT REFERRALS – TOR DAVIES A strong practice is one with a core of loyal clients who visit regularly, but more importantly they become such strong advocates it’s like having an army of salespeople. In this talk Tor will share some simple ideas for increasing loyalty, incentivising clients and explain how you can make it easier for people to recommend you. One not to miss!

TOR DAVIES THE KEY INGREDIENTS FOR A SUCCESSFUL PRACTICE – TOR DAVIES Setting up a practice is the easy part. Making it successful takes effort and know how. In this talk Tor will share the key strategies for establishing your business, building your reputation and growing your client base.

For more information about Therapy Expo 2016 or to book your tickets visit http://www.therapyexpo.co.uk/co-kinetic/

Tor Davies is founder of the sportEX journals and more recently Co-Kinetic, a website and journal which focuses on providing practical resources to help physical therapists and massage therapists grow their practices as well as keep up to date with changing clinical practice. This includes a new section called the Entrepreneur Therapist which focuses on giving practitioners practical guidance on using technology and social media to build their business.