Co-Kinetic Journal Issue 73 - July 2017 by Co-Kinetic

ISSUE 73 JULY 2017 ISSN 2397-138X

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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 EPIDEMIOLOGY OF INJURIES IN POLE SPORTS: EMERGING CHALLENGES IN A NEW TREND. Mitrousias V, Halatsis G, Bampis I et al. British Journal of Sports Medicine 2017;51(4):363 The data for this study came from the records of a Greek hospital collected between December 2015 and July 2016. The 34 participants were all recreational athletes who presented to the emergency department owing to injuries that occurred while performing pole dancing. Overall, 29.4% of patients suffered from low back and hip strains and contusions, 20.6% suffered from knee sprains and contusions, 17.7% suffered from wrist sprains, 14.7% suffered from ankle sprains, 5.9% suffered from neck (cervical spine) strains, 5.9% suffered from concussion, 1 patient (2.9%) presented with a sizable disc herniation and 1 patient (2.9%)

presented with a fracture of the fifth metatarsal bone.

Co-Kinetic comment According to the International Pole Dance Fitness Association the sport can trace its origins back to 12th century China and India where it is known as ‘Pole Mallakhamb’ and is performed predominately by men. In the West there is a strong association with the exotic, but the fitness aspects started as early as the late 1960s and early 1970s in the USA and Canada. They are trying to get it into the Olympics.

MINIMIZING INJURY AND MAXIMIZING RETURN TO PLAY: LESSONS FROM ENGINEERED LIGAMENTS. Baar K. Sports Medicine 2017;22:1–7 This starts with the stunning statistic that musculoskeletal injuries account for more than 70% of time away from sports. It goes on to state that in youth sport, 50% of all injuries are sprains. In professional sports, the incidence of soft-tissue injury for players reaches 60% for the English Premier League and nearly 70% in the National Football League. Then it notes that for research purposes. What these researchers did, therefore, was to engineer three-dimensional tissues in the laboratory, treated them with agents thought to affect sinew physiology, and then mechanically test them to determine their function. They learnt that sinews, like bone, quickly become refractory to an exercise stimulus, suggesting that short (<10 minutes) periods of activity with relatively long (6 hours) periods of rest are best to train these tissues. The engineered sinews have also shown how oestrogen decreases sinew function and that a factor released following intense exercise increases sinew collagen synthesis and function. Finally, engineered sinews are being used to screen possible nutritional interventions that may benefit tendon or ligament function. The relevance of this to most of us is that they recommend incorporating a connective 4

tissue health session into training. This type of session would involve <10 minutes of activity targeted to a tendon/ligament that is prone to injury. For example, runners would do a session to target the hamstrings, patellar and Achilles tendons, whereas baseball players would target the throwing arm. These exercises could be performed with a light weight and using a limited range of motion if necessary. The connective tissue health session should be performed either 6 hours before or after any other training. Players returning from injury should begin training as soon as possible using range-of-motion and limited weight supported exercises because the amplitude of the load is not important for stimulating collagen production. The time scales of <10 minutes of activity followed by 6 hours therefore suggest three sessions a day to optimise recovery. They also suggest consuming leucine-rich protein as part of training. Thirty to sixty minutes before training, athletes should be encouraged to consume 15g of gelatin in either a liquid or gel form.

Co-Kinetic comment Coaches, are you listening? Target the potential injury sites. Rehab teams: little and often is the order of the day. Co-Kinetic Journal 2017;73(July):4-7

RESEARCH INTO PRACTICE

Physical Therapy

Journal Watch We hear a lot about fascia these days but which tissue are we actually talking about? The Fascia Research Society acted to address this issue by establishing a Fascia Nomenclature Committee whose purpose was to clarify the terminology relating to fascia. This paper details some of the academic controversy but ends with these two proposed definitions and an explanation for how they got there. ‘The fascial system consists of the three-dimensional continuum of soft, collagen containing, loose and dense fibrous connective tissues that permeate the body. It incorporates

DEFINING THE FASCIAL SYSTEM. Adstruma S, Hedley G, Schleip R et al. Journal of Bodywork and Movement Therapies 2017;21(1):173–177 elements such as adipose tissue, adventitiae and neurovascular sheaths, aponeuroses, deep and superficial fasciae, epineurium, joint capsules, ligaments, membranes, meninges, myofascial expansions, periostea, retinacula, septa, tendons, visceral fasciae, and all the intramuscular and intermuscular connective tissues including endo-/peri-/epimysium’. ‘The fascial system interpenetrates and surrounds all organs, muscles, bones and nerve fibres, endowing the

body with a functional structure, and providing an environment that enables all body systems to operate in an integrated manner’.

Co-Kinetic comment We need to ensure that there is a clear and unambiguous international, interdisciplinary, and interprofessional communication about fascia. Why? Look at the definition; fascia is all over the human body. It is involved in all structures and function, so we need to study and understand it and, most importantly, treat its dysfunction.

AN INJURY PREVENTION PYRAMID FOR ELITE SPORTS TEAMS. Coles PA. British Journal of Sports Medicine 2017;doi:10.1136/bjsports-2016-096697 In this educational review the inter-related factors of injury prevention are discussed. It starts with the controversial topic of player recruitment and discusses the fact that some athletes are more durable than others. It also discusses considering if your player is actually suited and able to do what you want him/her to do. The next consideration is load management. There is a maximum level of load that each individual player will be able to tolerate, at any given point in time. If they are pushed beyond that level, they will break down. Next up is an athletic development programme. It involves quality strength and conditioning programmes, which lead to an overall improvement in the athletic qualities of the individuals in your squad. Ultimately, individuals who are not strong enough, or not fit enough, to cope with the demands of their sport will eventually break down. Efficient movement patterns go hand-in-hand with strength and conditioning. Time should be spent to improve each player’s individual movement efficiency, and teaching that is a skill that many physical therapists and strength coaches possess. Co-Kinetic.com

There is evidence that some structured injury prevention programmes can decrease the time loss to ‘preventable injuries’ by around 30%. For example, proprioception training decreases risk of ankle sprains, and eccentric hamstring exercises decrease the risk of hamstring strains; but only if your athletes comply with the programme and they are done consistently enough to achieve the adaptations required. The last thing on the pyramid that you can control is injury assessment and rehabilitation. Deciding if a player can manage to play on with an injury, or when a player returns to play post-injury, is one of the most difficult questions in sports medicine. There is always an element of risk that must be accepted. There are time frames for physiological healing but individual psycho-social influences, team culture, and coaching philosophies should also be considered. Coaching and medical staff have to work together to create a shared responsibility for the management path, and an accepted level of risk in each individual case. The final decision on return to play should be reached after significant

consultation between the medical experts, the players themselves, and the coaches, who each have a role to play in those discussions. The final element is luck. Not everything is under control. If you are pushing athletes hard to achieve elite physical goals, injuries can still occur, even in the best of systems. In the longerterm, however, better systems implemented by an integrated staff will reduce the number of injuries and increase the consistency of your team’s success.

Co-Kinetic comment They are quite right to mention luck, but as Gary Player said, “The more I practise the luckier I get”. Fate is no excuse. This review is great and its concepts are applicable to all sports and teams, not just the elite. 5

This is unusual for Journal Watch as it is a summary of a dissertation submitted to the University of Heidelberg rather than something published in a journal. ln two separate series of experiments, fascia and muscle were stimulated with injections of hypertonic saline and electrical stimuli applied through bipolar concentric needle electrodes. ln both experiments, needle placement inside the fascia was verified by ultrasound. For comparison, the skin was also stimulated. Chemical stimulation of fascia with hypertonic saline caused higher pain intensity with a higher magnitude of affective pain descriptors, and wider pain radiation compared to muscle stimulation. Furthermore, chemical stimulation of the muscle, not of the fascia, led to a sensitisation to blunt

PAIN SENSITIVITY OF HUMAN FASCIA AND MUSCLE SENSORY FINDINGS AFTER CHEMICAL AND ELECTRICAL STIMULATION. Schilder A. Dissertation. University of Heidelberg 2016

pressure. Stimulation of the fascia with electrical high-frequency pulses (HFS) revealed higher pain intensity than muscle stimulation, but pain radiation was similar. Only HFS of the fascia, not of the muscle, induced a Iong-term potentiation of pain at the site of stimulation. HFS of the muscle, however, reduced pain sensitivity of the overlying fascia. Neither HFS of the fascia nor of the muscle changed the somatosensory profile of the skin or the sensitivity to blunt pressure.

Sensory descriptors for fascia pain were similar to those for cutaneous pain, while descriptors for muscle pain were those usually associated with deep tissues.

Co-Kinetic comment We don’t have the full details of the experiments but there is enough information here to suggest that fascia is a major source of pain. Can someone follow this up, please?

SPECIFIC OR GENERAL EXERCISE STRATEGY FOR SUBACROMIAL IMPINGEMENT SYNDROME–DOES IT MATTER? A SYSTEMATIC LITERATURE REVIEW AND META ANALYSIS. Shire AR, Stæhr TAB, Overby JB et al. BMC Musculoskeletal Disorders 2017;18(1):158 Randomised controlled trials (RCTs) were identified through an electronic search of the usual databases. In addition, article reference lists and the website Clinicaltrials.gov (https://clinicaltrials. gov/) were searched. Studies were considered eligible if they included subjects over 18 with subacromial impingement and interventions with resistive specific exercises

as compared to general resistance exercise. Six RCTs were included with 231 participants. Four studies evaluated the effectiveness of specific scapular exercise strategy and two studies evaluated the effectiveness of specific proprioceptive strategy. Five studies were of moderate quality and one study was of low quality. No consistent statistical significant differences in outcomes between treatment groups

were reported in the studies.

Co-Kinetic comment This started by asking the question of whether or not specific or general exercise was better at solving the problem. The answer is ‘Don’t know’. However, looking at the four studies highlighted, whichever exercise programme was prescribed significant improvements were shown. So what this research does indicate is that exercise works for subacromial impingement.

EFFECTS OF CARDIO-PILATES EXERCISE PROGRAM ON PHYSICAL CHARACTERISTICS OF FEMALES. Sevimli D, Sanri M. Universal Journal of Educational Research 2017;5(4):677–680 Forty female participants between the ages of 25 and 41 were tested before and after four weeks of a Pilates exercise programme which lasted 60 minutes three times a week. They did a 10 minute warmup, consisting of 5 minutes general warm-up for major muscle groups and 5 minutes of stretching and strength. Then, the main phase consisted of 20 minutes of aerobics exercises in standing that included mostly leg and arm activities accompanied by music. During this phase, pulse rate was kept between 100 and 120bpm. This was followed by 20 minutes of Pilates-mat exercises including repeated 3-set (1×10; 1×12; 1×15) exercises aimed at 6

major muscles of the abdomen, hip, waist, leg, back, chest and arm. Finally there was a 10 minute cool-down consisting of 5 minutes of general cooling exercises and 5 minutes of stretching and breathing exercises. The results showed significant decreases in body fat percent, body fat weight, waist and hip circumferences.

Co-Kinetic comment Dig out your old celebrity work out DVDs: they work! (In the editor’s office they are still on VHS videos). This does come with a warning, however, that there was no overall loss in weight or BMI and the authors do point out that the effect of an exercise programme depends not only on its duration, intensity, and type but also on the participants’ exercising background and diet. Co-Kinetic Journal 2017;73(July):4-7

RESEARCH INTO PRACTICE

The data came from a search of PubMed (500 titles) and Scopus (272) using the search terms: “nasal bone fracture” AND “etiology OR cause”. When duplicates were taken out and abstracts read for relevance, 26 papers remained. The causes of nasal bone fractures were different between adults and children. In adults, the most frequent causes were fights (36.3%), traffic accidents (20.8%), sports (15.3%) and falls (13.4%). In children, the most frequent causes were sports (59.3%), fights (10.8%), traffic accidents (8.3%), collisions (5.0%) and falls (3.3%). Fights were the most frequent cause in Asia (36.7%), South America (46.5%) and Europe (40.8%). In North America, however, traffic accidents were the most frequent cause (33.6%), followed by fights (20.7%) and sports (17.3%). Among the sports injuries, ballrelated sports were the most frequent

EFFECTS OF SMOKING ON HAND TENDON REPAIR: SCIENTIFIC STUDY & LITERATURE REVIEW. Samona J, Samona S, Gillin M et al. International Journal of Surgery and Research 2017;4(2):70–74

ETIOLOGY OF NASAL BONE FRACTURES. Hwang K, Ki SJ, Ko SH. The Journal of Craniofacial Surgery 2017;28(3):785–788 cause (84.2%). Fighting-related sports (6.4%) contributed to relatively small proportion

Co-Kinetic comment What sort of society do we live in where the major cause of a broken nose in adults is a punch in the face? Leave it to the kids to fly the flag for sports injuries! Fights are still second, though, so maybe that is where society is going wrong.

TREATMENT OF ACROMIOCLAVICULAR JOINT INJURIES IN ATHLETES AND IN YOUNG ACTIVE PATIENTS. Ulucay C, Ozler T, Akman B et al. Journal of Trauma & Treatment 2016;5(5):344 Approximately 9% of shoulder girdle injuries involve the acromioclavicular (AC) joint. Patients commonly complain of pain around the antero-superior part of the AC joint after a trauma. The Rockwood and Green classification has six types depending on the severity of the injury. This paper details injury and treatment for each grade ranging from basic exercise to surgery. It highlights treatment controversies such as to inject or not to inject.

Co-Kinetic comment We normally quote abstracts in Journal Watch but this one loses something in the translation given that it starts, “The latter generation of mankind is somehow evolved. The ordinary people under 50 years old are trying to live as professional sports guys”. However, the body of it has been through a better language app and is one of those ‘all you need to know about’ papers that we love. Well worth finding if you are involved in post-trauma injury rehab.

This was a retrospective review of patients treated by one orthopaedic surgeon and three occupational therapists. It included 56 patients (20 smokers and 36 nonsmokers) with acute traumatic tendon lacerations, fixed via direct (end-to-end) method, within 3 weeks from date of injury. Total active motion (TAM) was measured via American Society for Surgery of the Hand protocol. The overall percentage of TAM regained in smokers was 70% vs 75% of TAM by non-smokers but this was not a significant difference. Flexor tendon TAM was significantly higher in both the smoking and non-smoking groups vs extensor tendon TAM, displaying a larger effect of smoking on flexor vs extensor tendons. There was no significant dose-dependent effect in ‘heavy’ vs ‘light’ smokers on numerous parameters. ‘Surgical wound complications’, were exceptionally low, 1 in the smokers, 2 in the non-smokers.

Co-Kinetic comment What a strange topic for a research paper. We can only think that the author thought that it would be another nail in the smoker’s coffin. Just in case any of our readers are daft enough to light up, the paper quotes a static that male smokers lose an average of 13.2 years of their life and females 14.5 years.

THE EFFECT OF EXERCISE PRESCRIPTION ON FORCE OUTPUT AND MUSCLE ACTIVATION DURING THE NORDIC HAMSTRING EXERCISE. Buhmann R, Shield A, Sims C. British Journal of Sports Medicine 2017;51(4):304 Thirteen healthy recreationally trained and sub-elite male athletes (age 23±4 years, stature 178±6.5cm and weight 75±17kg) performed 3×10 and 5×6 repetitions of the Nordic Hamstring Exercise on separate occasions, with 3 minutes rest between sets. Load cells were used to record knee flexor force, electromyography (EMG) was used to measure hamstring activation and a goniometer was used to measure knee flexion angles during each repetition. The average force (666.44N during 3×10 vs 697.95N during 5×6) and force drop per set (−54.48N during Co-Kinetic.com

3×10 and −51.73N during 5×6) was not different between protocols. Additionally, normalised biceps femoris (87 vs 79% of max isometric EMG during 3×10 and 5×6 respectively) and medial hamstring (111 vs 98% of max isometric EMG during 3×10 and 5×6 respectively) EMG per set was not different between protocols. For both protocols a significant difference between the angle of peak torque and angle of peak biceps femoris EMG was observed.

Co-Kinetic comment This was all about trying to decide which was the better prescription for an exercise extensively used to increase eccentric strength and reduce the risk of recurrent hamstring strain injury. Err … 3×10 and 5×6 both add up to 30; hence, the overall load isn’t much different so it all seems a bit pointless. There was a side bar that perhaps warrants further investigation: peak activation of the biceps femoris appears to occur at shorter muscle lengths than peak force, suggesting inhibition of this muscle at long lengths. 7

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

What is the difference between acupuncture and dry needling? Very little apparently. According to this essay dry needling (DN) is a synonym of acupuncture. It’s just a translation of the original Chinese. In fact in China DN is a name for acupuncture. The term was popularised in the west towards the end of the last century as a way for acupuncturists and medical doctors to help get acupuncture accepted by the medical profession. Consequently some DN course educators have covered up their acupuncture background, and intentionally denied the fact that DN is acupuncture. However, the ‘Mother of DN’, Dr Janet Travell, admitted DN is acupuncture when she stated in a newspaper interview, “[DN is] the medical way of saying it is ‘acupuncture’. In our language that means sticking a needle into somebody”. Nowadays, DN is supported by mainstream physical therapy organisations as a treatment

EVIDENCE AND EXPERT OPINIONS: DRY NEEDLING VERSUS ACUPUNCTURE (II). Fan AY, Xu J, Li Y-M. Chinese Journal of Integrative Medicine 2017;23(2):83–90 modality for muscle pain and related ‘myofascial’ pain syndrome and trigger points. However, according to the authors of this paper DN is an oversimplified acupuncture using biomedical language in treating ‘myofascial’ pain, a contemporary development of a portion of Ashi point acupuncture. It seeks to redefine acupuncture by reframing its theoretical principles in a Western manner. They argue that DN is not merely a technique but a medical therapy and a form of Ac practice, an invasive procedure that should not be in the practice scope of physical therapists on the grounds of training requirements. In most states of America licensed acupuncturists are required to attain an average of 3,000 educational hours via an accredited school or programme before they can apply for a license. The physician or medical acupuncturist is required to get a minimum of an additional 300 educational hours in a board-approved acupuncture training

institution and have 500 cases of clinical acupuncture treatments in order to be certified in medical acupuncture. However, a typical DN education course runs only 20–30 hours, often one weekend, and the participants may receive a ‘DN certificate’ without any examination. For patients’ safety and professional integrity, they strongly suggest that all DN practitioners and educators should have met the minimal standards required for licensed acupuncturists or physicians.

Co-Kinetic comment This article might upset both acupuncturists who don’t like the argument that dry needling is acupuncture, as well as dry needle course providers who get a bit of a kicking. However, don’t shoot us we are only the messenger, but it is a fair point.

EFFECTS OF MANUAL THERAPY AND EXERCISE TARGETING THE HIPS IN PATIENTS WITH LOW-BACK PAIN – A RANDOMIZED CONTROLLED TRIAL. Bade M, Cobo-Estevez M, Neeley D et al. Journal of Evaluation in Clinical Practice 2017;doi:10.1111/jep.12705 Eighty-four subjects (50 M, 34 F, 46.1±16.2 years) were randomised to one of two groups: pragmatic treatment of the lumbar spine only (LBP) (n=39) or pragmatic treatment of the lumbar spine and prescriptive treatment of bilateral hips (LBP + HIP) (n=45). The term ‘pragmatic’ means that the clinician selected treatment interventions that best suited the patient’s needs. Guidelines for this were: (1) manual therapy; (2) trunk coordination, strengthening and endurance exercises; (3) centralisation and directional preference exercises and procedures; (4) flexion exercises; (5) lower-quarter nerve mobilisation 8

procedures; (6) traction; (7) patient education and counselling; and (8) progressive endurance exercise and fitness activities. The only constraint to treatment in the LBP group was that therapists were not to perform isolated hip strengthening exercises or provide hip manual therapy treatment for these patients. Lumbar stabilisation exercises that involved hip motion were allowed. Prescriptive treatment of the hips involved the use of three hip exercises targeting the gluteal musculature and three mobilisation techniques targeting the hips. Subjects were assessed at baseline, 2 weeks, and at discharge with the following measures: Modified Oswestry Disability Index, Numeric Pain

Rating Scale, a Global Rating of Change (GRoC) Score, the Patient Acceptable Symptom State (PASS), and patient satisfaction. At 2 weeks, significant differences were found in GRoC and patient satisfaction favouring the LBP + HIP group. At discharge, there were significant differences on the Modified Oswestry Disability Index, Numeric Pain Rating Scale, GRoC and patient satisfaction favouring the LBP + HIP group (P<0.05).

Co-Kinetic comment Proof, if anyone really needs it, that parts of the body do not work in isolation and shouldn’t be treated in isolation. Co-Kinetic Journal 2017;73(July):8-11

RESEARCH INTO PRACTICE

Manual Therapy

Journal Watch ACUTE EFFECTS OF KINESIO TAPING ON MUSCLE FUNCTION AND SELF-PERCEIVED FATIGUE LEVEL IN HEALTHY ADULTS. Lee NH, Jung HC, Ok G et al. European Journal of Sport Science 2017;17(6):757–764 Eighteen healthy adults, 7 males (23.86±1.68 years) and 11 females (24.82±3.71 years), were enrolled in this study. All subjects underwent three different trials which included: (1) no taping (NT); (2) placebo tape with 3M tape; and (3) Kinesio taping (KT). Subjects were taped with I-shaped and Y-shaped Kinesio tapes according to the Kenzo Kase’s KT manual (1996) by the same specialist who was trained for KT therapy. All subjects wore an eye mask and the taped leg was covered by an elastic band to prevent subjects and researchers from identifying different tapings and to ensure double-blinding. Each test session consisted of the following: application (or not) of the KT and PT on the rectus femoris of the legs and around the patella ligament. Peak power and mean power were measured using an automatic power cycle, isometric muscular strengths of knee extension and flexion using a hand-held dynamometer with the knee at 90°. Muscular endurance was evaluated using a half-squat test with repetitions during a 60-second session being recorded. Self-perceived fatigue was evaluated on a Visual Analogue Scale before and after the tests. The results revealed no significant differences in all variables except muscular endurance. Muscular endurance in the NT condition was significantly higher than that in the KT.

Co-Kinetic comment You can’t win them all. Kinesiology tape may assist in some injury conditions but it won’t give you superpowers.

EFFECTS OF KINESIO TAPING® ON KNEE FUNCTION AND PAIN IN ATHLETES WITH PATELLOFEMORAL PAIN SYNDROME. Aghapour E, Kamali F, Sinaei E. Journal of Bodywork and Movement Therapies 2017;doi:http://dx.doi.org/10.1016/j.jbmt.2017.01.012 Fifteen participants (10 F, 5 M) with unilateral patellofemoral pain syndrome (PFPS) were examined and compared under taped and untaped conditions. The vastus medialis obliquus (VMO) of the involved leg was taped from origin at the patella border to insertion on the upper thigh, with 75% of the Kinesio Tape® (KT)’s maximal length tension. The leg was shaved and cleaned with an alcohol-based cleanser. Maximal eccentric and concentric peak torques of quadriceps were measured at 60 and 180°/s angular velocities by an isokinetic dynamometer. Functional performance and pain were evaluated by functional tests (step-

down and bilateral squat) and Visual Analogue Scale, respectively. Paired t-test showed statistically significant increases in VMO peak torque and also repetitions of the step-down test and bilateral squat after using KT. Pain intensity was also decreased significantly following KT application.

Co-Kinetic comment You hardly ever see an elite athlete without tape stuck on somewhere. There is a good reason for this. In the short term, at least, it works. It gets them through the game.

ADVERSE EFFECTS AS A CONSEQUENCE OF BEING THE SUBJECT OF ORTHOPAEDIC MANUAL THERAPY TRAINING, A WORLDWIDE RETROSPECTIVE SURVEY. Thoomes-de Graafa M, Thoomes E, Carlesso L et al. Musculoskeletal Science and Practice 2017;29:20–27 A descriptive online survey was completed by 1,640 current students and recent graduates (≤5 years) across 22 Member Organisations of the International Federation of Orthopaedic Manipulative Physical Therapists (1,263 graduates, 377 students). Sixty percent

of respondents reported never having experienced adverse effects during their manual therapy training. Of the 40% who did, 66.4% reported neck pain, 50.9% headache and 32% low back pain. Most reports of neck pain started after a manipulation and/or mobilisation,

of which 53.4% lasted ≤24 hours, 38.1% >24 hours but <3 months and 13.7% still experienced neck pain to date. A small percentage of respondents (3.3%) reported knowing of a fellow student experiencing a major adverse effect.

Co-Kinetic comment We report lots of studies that prove the effectiveness of manual therapy. However, some of the techniques can be dangerous if applied to unsuitable candidates or are not applied properly. Everybody has to train and you are going to be cack-handed when you start. Students and teachers need to take care. Co-Kinetic.com

THE IMMEDIATE EFFECT OF TALOCRURAL JOINT MANIPULATION ON FUNCTIONAL PERFORMANCE OF 15–40 YEARS OLD ATHLETES WITH CHRONIC ANKLE INSTABILITY: A DOUBLEBLIND RANDOMIZED CLINICAL TRIAL. Kamali F, Sinae E, Bahadorian S. Journal of Bodywork and Movement Therapies 2017:doi:http://dx.doi.org/10.1016/j. jbmt.2017.01.010 Forty athletes (18 M, 22 F) with chronic ankle instability (CAI) were divided into a talocrural joint manipulation (TCJM) group (n=20) and a sham manipulation group (n=20). The participants were semi-elite soccer (n=11), volleyball (n=16), and basketball (n=9) players and martial arts athletes (n=4) who had been exercising at least three times per week. TCJM was performed as a quick thrust on the involved talus, in the posterior direction. Sham manipulation was maintaining the same position, without any thrust. Functional performance of athletes was assessed with single-leg hop; speed and Y balance tests, before and after the interventions. All tests improved significantly after TCJM. These findings were not seen in the control group. Betweengroup comparisons also showed significant changes for all the measurements after the interventions (P<0.05).

Co-Kinetic comment It’s good to have these results but anterior–posterior mobilisations should be standard treatment for ankle injuries.

THE EFFECT OF SHOULDER POSITION ON INFERIOR GLENOHUMERAL MOBILISATION. Witt DW, Talbott NR. Journal of Hand Therapy 2017;doi:http://dx.doi.org/10.1016/j.jht.2017.02.006 This starts with the assumption that inferior mobilisations of the humerus are an effective technique to restore full glenohumeral abduction in individuals with restrictions in overhead movement. They can, of course, be performed with the humeral head in a number of positions. This study looked at three positions: (1) an open-packed position of 55° of abduction and 30° of horizontal adduction; (2) a neutral position with the arm at the side; and (3) an abducted position in which the shoulder is abducted to 90°. Twenty-three subjects (15 F, 8 M) with a mean age of 23 years (range: 22–30) were recruited from a population of convenience. One therapist placed a hand-held dynamometer over the proximal forearm and used their opposite hand to stabilise the contralateral shoulder and trunk. Another therapist positioned an ultrasound scanner head so that the lateral end of the acromion and

THE EFFECTS OF CLINICAL PILATES EXERCISES ON PATIENTS WITH SHOULDER PAIN: A RANDOMIZED CLINICAL TRIAL. Atılgan E, Aytar A, Çağlar A et al. Journal of Bodywork and Movement Therapies 2017;doi:http://dx.doi.org/10.1016/j.jbmt.2017.02.003

Thirty-three patients, experiencing shoulder pain continuously for at least 4 weeks were randomly divided into two groups. A clinical Pilates exercise group (n=17) and conventional exercise group (n=16). They were treated for 5 days a week, for 2 weeks. The assessment of pain and disability among the patients was done at baseline and at the end of the treatment sessions, using the Visual Analogue Scale (VAS) and the Shoulder Pain and Disability Index (SPADI). The clinical Pilates exercises included scapular stabilisation and glenohumeral joint mobilisation in the direction of flexion, abduction and internal-external rotation and was repeated ten times. Imagery and breathing techniques were also used. The conventional 10

exercises were pendulum exercise, wall flexion and abduction stretch and active range of motion exercises in the flexion, abduction, and internal and external rotation direction. The clinical Pilates exercise group showed a significant improvement in all scores used for assessment, whereas the conventional exercise group demonstrated a significant improvement only in the SPADI-Total score. A comparison of scores for the VAS, SPADI-Pain and SPADI-Total between the two groups revealed a significant improvement in the clinical Pilates exercise group.

Co-Kinetic comment Big shout out for clinical Pilates.

the superior aspect of the humerus were visible on the ultrasound image. A third individual silently recorded the magnitude of the force from the hand-held dynamometer as grade 1 then 2 and 3 Kaltenborn mobilisations were applied three times for each of the three arm positions of both arms. The distance of the humeral head from the acromion and force values during each grade of mobilisation was recorded. Maximal inferior translation with minimal force was found when a grade 3 mobilisation was performed in the open-packed position.

Co-Kinetic comment The downside of this, and the majority of manual therapy research, is that it is done on subjects who don’t have a problem. What we need is this study repeated on those who do. In the meantime we know that the theory of creating inferior translation with a mobilisation is true.

SHOULDER PAIN IN ADOLESCENT ATHLETES: PREVALENCE, ASSOCIATED FACTORS AND ITS INFLUENCE ON UPPER LIMB FUNCTION. de Oliveira VMA, Pitangui ACR, Gomes MRA et al. Brazilian Journal of Physical Therapy 2017;21(2):107–113 A Quick-DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire was completed by 310 athletes of both sexes aged between 10 and 19 who participated in overhead sports. Height, body mass, shoulder rotation range and stability of the upper limb were evaluated using the Closed Kinetic Chain Upper Extremity Stability Test (CKCUES-test). The association between pain and the variables was analysed. The prevalence of shoulder pain was 43.5%. Athletes between 15 and 19 years were 1.86 times more likely to report pain. Judo (61.8%), followed by handball (48.7%), and basketball (41.4%), presented the highest frequency of complaints of shoulder pain. Training and competition were most commonly related to the onset of pain (68.8%), and an indirect mechanism (overuse injuries) prevailed in 63.8% of cases. Shoulder pain reduced function scores and increased changes in the range of motion, especially glenohumeral joint internal rotation.

Co-Kinetic comment The bottom line here is that there is a lot of shoulder pain about. It affects levels of upper limb function, reflecting negatively on daily activity and sports skills. The big question is what causes the pain? Co-Kinetic Journal 2017;73(July):8-11

RESEARCH INTO PRACTICE

THERAPEUTIC EFFECTS OF MASSAGE AND ELECTROTHERAPY ON MUSCLE TONE, STIFFNESS AND MUSCLE CONTRACTION FOLLOWING GASTROCNEMIUS MUSCLE FATIGUE. Wang JS. Journal of Physical Therapy Science 2017;29:144–147

Twenty healthy males were equally divided into a transcutaneous electrical nerve stimulation (TENS) group and a combined therapy group that received a combination of massage therapy and transcutaneous electrical nerve stimulation. Muscle fatigue was triggered on the gastrocnemius muscle using deep calf raises to exhaustion. Lateral and medial gastrocnemius muscle tone and stiffness significantly increased and gastrocnemius muscle contraction significantly decreased in each group immediately after fatigue was triggered. Both interventions were applied once a day for 2 days for 15 minutes. In the combined group the massage lasted 7 minutes. Muscle tone and stiffness were measured in a prone position using Myoton®PRO (MyotonAS, Estonia). There was no difference in the effects of the two

intervention methods over time but for both groups muscle tone and stiffness decreased and muscle contraction increased but lateral gastrocnemius muscle tone and stiffness significantly decreased only in the TENS group.

Co-Kinetic comment Parts of this paper show a great attention to detail: the TENS settings are discussed and the temperature is

KINESIOLOGY TAPE DOES NOT AFFECT SERUM CREATINE KINASE LEVEL AND QUADRICEPS ACTIVITY DURING RECOVERY FROM DELAYEDONSET MUSCLE SORENESS. Aminaka N, Fohey T, Kovacs A et al. International Journal of Kinesiology & Sports Science 2017;5(1):doi:10.7575/aiac.ijkss.v.5n.1p.17 Fifty-eight healthy college-age participants were randomly assigned to a kinesiology tape (KT) group (n=15), a placebo group (n=19) who had non-woven retention tape applied to the same area or a control group (n=24). Serum creatine kinase (CK) level and quadriceps EMG activity and performance during countermovement jump and triple singleleg hop for distance were collected at baseline, immediately after repetitive eccentric quadriceps exercise, 48 hours, and 72 hours post-exercise. There was a significant main effect of time on the serum CK level, EMG activity, and performance was observed. However, there were no group differences on the serum CK level, EMG activity, or performance.

Co-Kinetic comment So whatever kinesiology tape does, and there are other studies that suggest it does something, it is not this. The conclusion is that it is not going to make any difference to recovery from DOMS. Co-Kinetic.com

regulated. However, there is no mention of what the massage protocol was other than to say that all interventions were done by a therapist who has completed a Maitland Level IIa, which doesn’t seem to have much, if anything, to do with massage. The biggest fault, however, is that there is no control group; so we don’t know if the stiffness and contractions wouldn’t have returned to pre-fatigue levels anyway.

PLANTAR FASCIITIS: WILL PHYSICAL THERAPY HELP MY FOOT PAIN? Journal of Orthopaedic & Sports Physical Therapy 2017;47(2):56 ‘Yes’ is this answer. This is a patient information leaflet published free. It cites Fraser et al, ‘Utilization of physical therapy intervention among patients with plantar fasciitis in the United States’ (J Orthop Sports Phys Ther 2017;47(2):49–55; doi:10.2519/jospt.2017.6999), which states that in a database study of 819,963 USA patients diagnosed with plantar fasciitis only 7.1% of them were prescribed physical therapy. However, patients sent to physical therapy received manual therapy 87% of the time and supervised rehabilitative exercises 90% of the time. The researchers found that patients who received manual therapy as part of their treatment averaged fewer visits and had a lower cost of care.

Co-Kinetic comment There is a series of these information leaflets available at http://spxj.nl/2qEKYBM; they are well worth a look. 11

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PATELLOFEMORAL PAIN SYNDROME: This article discusses the incidence, presentation, anatomy and biomechanics of patellofemoral pain syndrome (PFPS) before delving deeper into patient examination, the practical application of patellar taping, the use of orthoses and exercise rehabilitation therapy. The article is supported by a series of videos which can also be used as part of a patient education programme, as well as printable patient information leaflets. It is also included within our Patellofemoral Pain Toolkit http://spxj.nl/2so6S0Z. Read this article online http://spxj.nl/2s6sWwA

LOWER-LIMB | KNEE | 17-07-COKINETIC FORMATS WEB MOBILE PRINT

MEDIA CONTENTS Stretching and strengthening exercises for the knee (5 parts) - http://spxj.nl/2s6sWwA Video: Patellar taping for PFPS - http://spxj.nl/2s6sWwA Patient Information Leaflet: Proximal Muscle Rehabilitation for Patellofemoral Pain (phases 1–4) http://spxj.nl/2spGDqV Patient Information Leaflet: Patellar Tendon Pain http://spxj.nl/2suLp5T

A Practical Treatment Approach BY DR CHRISTOPHER NORRIS PHD, MCSP

BACKGROUND Patellofemoral pain (PFP) accounts for up to 17% of knee pain seen generally, and up to 40% of knee problems seen in the sporting population (1), with up to 7% of adolescents between the ages of 15 and 19 years suffering with the condition (2). The condition is more common in young adolescents, especially those active in sport, and is also seen in military recruits. In addition to active individuals, inactive adolescents who are subjected to a sudden increase in walking and/or stair climbing may also suffer. In both groups the condition represents an inability of tissue to adapt to increased loading. PFP is variously described as anterior knee pain, chondromalacia patellae, patella malalignment syndrome and patellofemoral pain syndrome. The condition typically presents as a dull ache over the anterior aspect of the knee, worse following prolonged sitting and when descending stairs. Although more common in youth, the condition can occur at any age and is typically associated with patellofemoral osteoarthritis (OA) in seniors.

STRUCTURE AND FUNCTION OF THE PATELLOFEMORAL JOINT The patella is the largest sesamoid bone (bone lying within a tendon) in the body, attached above to the quadriceps tendon and below to the

patellar tendon. Medially and laterally the patellar retinacula (fibrous tissue to the side of the patella) offer support. The breadth of the pelvis and close proximity of the knee creates an outward (valgus) angle of the tibia compared to the femur. Coupled with this, the direction of pull of the quadriceps is along the shaft of the femur and that of the patellar tendon is almost vertical. The difference between the two lines of pull is known as the Q angle and is often considered an important determinant of knee health. Normal values for the Q angle are in the region of 15–20°. In full extension, the patella does not contact the femur, but lies in a slightly outward (lateral) position. As knee flexion progresses, the patella should move inwards (medially). If it moves laterally it will butt against the prominent lateral femoral condyle and the lateral edge of the patellar groove of the femur. Throughout flexion, different areas of the patellar undersurface are compressed onto the femur below. At 20° flexion, the inferior pole of the patella is compressed, and by 45° the middle section is affected. At 90° flexion, compression has moved to the superior aspect of the knee. In a full squatting position, with the knee reaching 135° flexion, only the medial and lateral areas of the patella are compressed. Patellofemoral loads may be as

EXERCISE THERAPY THAT COMBINES HIP AND KNEE ACTIONS (RATHER THAN KNEE MOVEMENT IN ISOLATION) IS A MAINSTAY OF TREATMENT FOR THIS CONDITION Co-Kinetic Journal 2017;73(July):14-17

PHYSICAL THERAPY

PATELLOFEMORAL PAIN ACCOUNTS FOR UP TO 40% OF KNEE PROBLEMS SEEN IN THE SPORTING POPULATION

high as three or four times body weight as the knee flexes in walking, and nine times body weight when descending stairs or walking down a slope. Changes in patellar contact area and contact force make knee angle an important consideration in the selection of exercise during rehabilitation, together with applied load (weight or resistance band) and muscle contraction type.

of injury. PFP is reproduced in 80% of patients when performing a squatting action, and tenderness to the patellar edges is seen in 71–75% (3), making these two clinical tests important in objective examination. Traditional grinding tests (patellar compression during quadriceps contraction) have low sensitivity and diagnostic accuracy in PFP (1).

PATIENT EXAMINATION AND DIAGNOSIS

SHORT-TERM PAIN RELIEF Patellar Taping

Foot Biomechanics and Orthoses

On subjective examination, PFP typically presents as a diffuse dull ache over the anterior aspect of the knee. The pain may be worse with loading in a bent knee position with pain onset on rising from prolonged sitting or with stair climbing. Typically, descending stairs is worse than ascending. There is rarely a history of specific injury, rather a history of symptom exacerbation when loading is increased for example through training increase, competition, or an increase in knee-loading activity during daily living. PFP must be differentiated from patellar tendinopathy, Osgood–Schlatter syndrome, and Sinding-Larsen and Johansson (SLJ) syndrome. Patellar tendinopathy is more common with jumping actions and commonly presents with pain localised to the inferior pole of the patella (insertion) or patella tendon proper (body). In Osgood–Schlatter syndrome pain is normally restricted to the tibial tubercle. In SLJ syndrome there is normally point tenderness to the inferior pole of the patella, as with insertional tendinopathy, but X-radiography reveals subtle changes with calcification over the longer term. The condition must be distinguished from traumatic avulsion fracture, which shows a definite history

Short-term (3 months or less) pain relief may often be provided by temporarily changing the position of the patella through taping. Exercising with the taping in place can modify symptoms, and may re-educate muscle sequencing to change patellar alignment. Initially, open web adhesive taping is applied to protect the skin against excessive tape drag. The pull of the final taping is applied using 5cm zinc oxide tape. Most commonly a medial glide is applied; however, the taping position and applied stress may be varied to provide the best reduction in the patient’s symptoms. Taping of this type is likely to facilitate the patient’s engagement in rehabilitation (4). Where taping cannot be tolerated because of skin irritation, bracing to limit lateral tracking may be used as an alternative for short-term relief. Fat pad impingement (Hoffa’s syndrome) may coexist with PFP. When in a standing position, the patella rests on the fat pads, and changes to the patella alignment can occur if the pad is enlarged. Relief of fat-pad-related pain may often be given using ‘V’ taping attached from the tibial tubercle to run either side of the patella. The action is to draw the taping upwards so the patella is cradled in the base of

During normal running gait, the subtalar joint (STJ) is slightly supinated (high arch) at heel strike. As the foot moves into ground contact, the joint pronates (low arch), pulling the lower limb into internal rotation and unlocking the knee. As the gait cycle progresses, the STJ moves into supination again, externally rotating the leg as the knee extends (locks) to push the body forward. This biomechanical action combines mobility and shock absorption (STJ pronation and knee flexion) with rigidity and power transmission (STJ supination and knee extension), and shows the intricate link between foot and knee function. If STJ pronation is excessive or prolonged, external rotation of the lower limb will be delayed. At the beginning of the stance phase, STJ pronation should have finished but if it continues the tibia will remain externally rotated, stopping the knee from locking. The leg must compensate to prevent excessive strain on its structures, and so the femur rotates instead of the tibia and the knee is able to lock once more. As the femur rotates internally in this manner, the patella is forced to track laterally. In many circumstances the patella can cope with this extra stress, but if

Video 1: Patellar taping for PFPS (C. Norris, 2017)

Co-Kinetic.com

Video 2: Strengthening exercises for the knee Part 1 (C. Norris, 2017)

the ‘V’. Video 1 demonstrates how to apply patellofemoral taping as well as taping for Hoffa’s syndrome.

Video 3: Strengthening exercises for the knee Part 2 (C. Norris, 2017)

REPRODUCTION OF SYMPTOMS DURING A SQUAT AND TENDERNESS TO THE PATELLAR EDGES ARE IMPORTANT CLINICAL TESTS FOR PFP additional malalignment factors exist, such as anteversion of the femur (internal rotation), vastus medialis oblique (VMO) weakness or tightness of the lateral retinaculum, the lateral patellar tracking may cause symptoms. Biomechanical assessment of the lower limb is useful as part of an objective examination in the management of this condition. If hyperpronation is present, it may be corrected using changes in footwear, patient education and/or orthosis prescription to reduce knee symptoms to give short-term benefits of symptom modification. Not all patients with PFP benefit from foot orthoses. Benefit can be predicted by greater midfoot mobility, reduced dorsiflexion motion range, and immediate PFP improvement when performing a single-leg squat while wearing an orthosis (5).

REHABILITATION Exercise therapy that combines hip and knee actions (rather than knee movement in isolation) is a mainstay of treatment for this condition both to Video 4: Strengthening exercises for the knee Part 3 (C. Norris, 2017)

reduce pain and increase function in the short, medium and long term (1). Where individuals get pain on assessment of a single-leg squat, lower limb alignment may be addressed as part of motor control training in the short term to modify symptoms. If patients show a Trendelenburg sign (hip adduction, tibial medial rotation and foot pronation) this movement should be modified using a temporary orthotic and patient re-education to determine if symptoms reduce. Enhancing hip strength can be achieved by both open and closed chain actions. Closed kinetic chain (CKC) actions are more functional, mimicking the weight-bearing actions that load the leg. However, leg loading in the early stages of the condition may exacerbate symptoms and so open chain actions may be used until pain settles. Additionally, CKC actions will work the hip and knee together, which may not be required in the presence of irritable knee structures. Open chain gluteal actions, such as the traditional clam shell in crook side lying, and the fire hydrant and donkey kick in kneeling, together with hip scissor actions, are useful starting points. Motion range and resistance is progressed with the aim of reducing pain intensity and frequency during daily living actions, and enhancing tissue load tolerance. CKC actions can be begun partial weight-bearing progressing to full weight-bearing. Single-leg squat, step-down (eccentric) and full step (concentric-eccentric)

exercises may all be performed initially holding a wall bar in the gym or chair back/pole at home. Focusing on lower limb alignment to avoid excessive hip adduction may reduce symptoms, and the symptom-free movement range and type should initially be chosen. As tissue tolerance is enhanced, both range and alignment should be varied to increase movement variability. Varying training in this way may avoid building fear of certain movement types and encouraging behaviours that avoid actions out of fear of symptom reproduction (hypervigilance). Resistance should be increased to build lower limb strength, and specific motor control actions may give way to more traditional gym-based lower limb exercises such as leg-press, squat variations, deadlift (bent leg and straight leg), and lunge actions with increasing weight and varying motion ranges and speed. Sport- or task-specific movement should also be incorporated to regain confidence in the limb. Videos 2–6 demonstrate a progression of knee strengthening exercises. References 1. Crossley KM, Callaghan MJ, Linschoten R. Patellofemoral pain. British Journal of Sports Medicine 2016;50:247–250 2. Rathleff MS. Patellofemoral pain during adolescence: much more prevalent than appreciated. British Journal of Sports Medicine 2016;50(14):831–832 3. Nunes GS, Stapait EL, Kirsten MH et al. Clinical test for diagnosis of patellofemoral pain syndrome: systematic review with meta-analysis. Physical Therapy in Sport 2013;14:54–59

PATELLOFEMORAL PAIN RARELY HAS A HISTORY OF SPECIFIC INJURY Video 5: Strengthening exercises for the knee Part 4 (C. Norris, 2017)

Video 6: Proprioceptive and functional strengthening exercises for the knee (C. Norris, 2017)

Co-Kinetic Journal 2017;73(July):14-17

PHYSICAL THERAPY

4. Barton CJ, Lack S, Hemmings S et al. The ‘Best practice guide to conservative management of patellofemoral pain’: incorporating level 1 evidence with expert clinical reasoning. British Journal of Sports Medicine 2015;49:923–934 5. Crossley, Stefanik KM, Selfe J et al. 2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 1: terminology, definitions, clinical examination, natural history, patellofemoral osteoarthritis and patient-reported outcome measures. British Journal of Sports Medicine 2016;50:839–843.

THE AUTHOR Dr Chris Norris PhD, MCSP is a physiotherapist with over 35 years’ experience. He has an MSc in Exercise Science and a PhD in Backpain Rehabilitation, together with clinical qualifications in manual therapy, orthopaedic medicine, acupuncture, and medical education. Chris is the author of 12 books on physiotherapy, exercise, and acupuncture and lectures widely in the UK and abroad. He is a visiting lecturer and external examiner to several universities at postgraduate level. He runs private clinics in Cheshire and Manchester and his postgraduate courses for therapists are on his website: http://www.norrishealth.co.uk/. Email: cmn@norrishealth.co.uk Twitter: http://twitter.com/NorrisHealth LinkedIn: http://spxj.nl/2qLAhjV Facebook: https://www.facebook.com/NorrisAssociates/

RELATED CONTENT atellofemoral Pain P Syndrome Toolkit http://spxj.nl/2so6S0Z e have published more W than 14 articles and video presentations on Patellofemoral Pain Syndrome, which can be found at this link - http://spxj.nl/2rsORJT

DISCUSSIONS hat is the Q angle W and why is it useful? If a patient presents with knee pain, which tests would you perform to diagnose patellofemoral pain (PFP) and how would you rule out other related syndromes? What can be done to provide short-term relief from PFP? Create a progressive series of exercises for rehabilitation from PFP.

KEY POINTS nP atellofemoral pain (PFP) is a common knee problem in sport. n PFP typically presents as a dull ache over the anterior aspect of the knee, which is worse after prolonged sitting or when descending stairs. n The Q angle is a measurement of the angle between the line of the quadriceps muscle and the line of the patellar tendon: a normal Q angle is 15–20°. n Patellofemoral loads can be as high as nine times body weight when descending stairs. n Differential diagnoses include patellar tendinopathy, Osgood– Schlatter syndrome, and Sinding-Larsen and Johansson syndrome. n Two important diagnostic tests are the reproduction of PFP during performance of a squat and tenderness to the patellar edges. n Taping can often provide short-term pain relief and allow rehabilitation. n Patients with greater midfoot mobility and reduced dorsiflexion motion range are more likely to benefit from foot orthotics. n Rehabilitation involves exercise therapy to increase hip strength. n Rehabilitation can begin with open chain exercises with subsequent progression to closed chain and then sport- or task-specific movements.

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Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: The patella is the largest sesamoid bone in the body http://spxj.nl/2s6sWwA Tweet this: Patellofemoral loads may be 9× body weight when descending stairs or walking down a slope http://spxj.nl/2s6sWwA Tweet this: Patellofemoral pain typically presents as a diffuse dull ache over the anterior aspect of the knee http://spxj.nl/2s6sWwA Tweet this: Traditional grinding tests have low sensitivity and diagnostic accuracy in patellofemoral pain http://spxj.nl/2s6sWwA Tweet this: Taping can provide short-term relief from patellofemoral pain by moving the position of the patella http://spxj.nl/2s6sWwA Tweet this: Rehab from patellofemoral pain involves exercise therapy that combines hip and knee actions http://spxj.nl/2s6sWwA

Elbow pain is a common presentation seen in the primary care setting by general practitioners, physiotherapists, personal trainers and musculoskeletal physicians. Although tendinopathy accounts for most of these cases, there are many causes of elbow pain (1). Sick days due to elbow pain have resulted in significant financial implications for the individual and society in general (1,2). It is important that clinicians are able to quickly and accurately identify the reason behind any elbow issues and also understand management pathways.

NOMENCLATURE The term â&#x20AC;&#x2DC;tennis elbowâ&#x20AC;&#x2122; is sometimes used to generalise any cause of elbow pain. Determining the underlying aetiology of elbow pain can be difficult because of the complex anatomy. However, fundamental knowledge of the structure and function of the elbow is key in the process of coming to an accurate diagnosis, which in turn will lead to appropriate management (Fig. 1). The elbow joint is made of three articulations: 1. Radiohumeral: capitellum of the humerus with the radial head 2. Humeroulnar: trochlea of the humerus with the ulna 3. Radioulnar: radial head with the ulna. Although the elbow is a hinge joint, it is able to rotate the distal arm in pronation and supination (3). The radiohumeral joint is a combined hinge and pivot joint that allows flexion and extension together with rotation of the radial head on the capitellum. The humeroulnar joint is a hinge joint that allows flexion and extension and the radioulnar joint allows rotation during supination and pronation. Stability of the elbow is provided by the medial and lateral ligament complexes. The ulnar collateral ligament (UCL) is part of the medial (or ulnar) ligament complex, which provides valgus stability. The radial collateral ligament is part of the lateral ligament complex, which provides varus stability. The three main flexor muscles 18

ELBOW PAIN:

THE 10 MINUTE ASSESSMENT This article describes a quick and effective assessment process for elbow pain that can be carried out in just 10 minutes. Although tendinopathy accounts for the elbow pain of most patients seen in the primary care setting, there are many other possible causes. This article covers the causes of pain at the different areas of the elbow, the mechanical injuries associated with certain sports as well as history taking, examination, investigations and management. It is accompanied by 14 tables and figures that will help you to make a detailed and accurate diagnosis for your patient. Read this online http://spxj.nl/2s76MKv BY DR ROBIN CHATTERJEE MBCHB MSC SEM MSC MED SCI MRCGP DIPSEM MFSEM at the elbow are the brachialis, brachioradialis and biceps brachii. The main extensors are the triceps brachii and anconeus. The biceps brachii and supinator muscles supinate the elbow joint, and the pronator quadratus, pronator teres and flexor carpi radialis muscles pronate the joint. The common flexor tendon is a tendon that attaches to the medial epicondyle of the humerus and is an attachment point for the superficial muscles of the anterior forearm (pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, flexor carpi ulnaris). The common extensor tendon is a tendon that attaches to the lateral epicondyle of the humerus and is an attachment for the superficial muscles of the posterior aspect of the forearm (extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris). The three nerves that are found within the elbow complex are the median, radial and ulnar nerve. The median nerve crosses the elbow medially and passes through the two heads of the pronator teres. The radial nerve proceeds down the elbow and arm laterally, where it splits into a deep posterior interosseous nerve and superficial sensory branch. The deep branch passes through the arcade of Frohse. Knowledge of the pathways of these nerves allows us to understand

ELBOW | 17-07-COKINETIC FORMATS WEB MOBILE PRINT

MEDIA CONTENTS TABLE 1: Causes of elbow pain (R. Chatterjee, 2016) - http://spxj.nl/2s76MKv

where they may be compressed. Before taking a history from a patient with elbow pain it is imperative that the clinician has a framework in mind to help guide them as to what may be causing the problem. The elbow should be thought of as four areas: the anterior,

PRIMAL PICTURE 2011

BACKGROUND

Radiohumeral joint

Humerus

Radioulnar joint

Ulna Humeroulnar joint

Radius

Figure 1: Anatomy of the elbow

Co-Kinetic Journal 2017;73(July):18-25

PHYSICAL THERAPY

posterior, lateral and medial parts (Table 1; available online http://spxj.nl/2s76MKv). The interviewer should also be aware as to what problems may occur with which sports (Table 2). With this knowledge, more specific, guided questioning may take place.

HISTORY At the start of a consultation with an individual with elbow pain, it must first be established if the pain will need urgent or immediate treatment. Those who are suspected of having infection, fracture or cancer as the cause of elbow pain must be referred and seen promptly by the appropriate services. History and examination must be focused to determine the severity of the cause of pain (Fig. 2). Only once these ‘red flags’ have been excluded can the clinician move on and determine the cause of pain. Initially the pathological process behind the cause of pain must be established, eg. mechanical, arthritic,

congenital (Table 1). Asking pertinent questions regarding the nature of the pain is crucial in this process (Fig. 3). Some questions are specific to elbow pain and they must be asked in every instance (Fig. 4). Once a thorough history has been obtained the aetiology of the pain can be deduced and this will lead to appropriate investigations to confirm the diagnosis (Fig. 4 and Tables 4 and 5).

EXAMINATION Before any examination, consent must be obtained and the clinician should wash their hands. The next stage is to stand directly in front of the patient and carefully inspect the individual. Eagle-eyed observation can often produce several clues that can lead to the diagnosis (Fig. 5). In order to inspect the patient appropriately, the patient should ideally expose their upper body and then stand in the anatomical neutral position. Asymmetry should be

ELBOW PAIN

History: n History of artificial joint n Recent feverish symptoms n Loss of range of movement n Irritability n Fatigue n Inappropriate progress from treatment made post-surgery On examination: n Red, hot tender joint n Patient may be holding joint rigidly n High temperature n Skin may be red with irregular edges

History: n Night pain n Weight loss n Past history of cancer n Family history of cancer n Possible recent feverish symptoms On examination: n Hard, irregular mass on elbow n Cachexia

Consider malignancy Consider infection, fracture or heterotropic ossification

Immediate referral to Accident & Emergency required

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

Fig. 2: Determine whether cause of elbow pain needs immediate or urgent management (R. Chatterjee, 2017)

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noted as well as any bruising, rashes, scars, muscle wasting and winging of scapulae. The olecranon process should be looked at in particular in case of an obvious bursitis. The olecranon tip, lateral epicondyle and radial head form the posterior–lateral triangle. The olecranon bursa may bulge into this posterior triangle. Joint effusions may consequently be visible in the antecubital fossa. The carrying angle should also be noted. This is the angle of the elbow and forearm when the patient is stood in the anatomical neutral position with forearms supinated. The angle is 5–10° in males and 10–15° in females. Injury

TABLE 2: MECHANICAL ELBOW INJURIES ASSOCIATED WITH CERTAIN SPORTS (R. Chatterjee, 2017) SPORT

ASSOCIATED INJURY

Golf

n Medial epicondylitis n Radial tunnel syndrome

Tennis, badminton, squash

n n n n n n

Swimming

n Radial tunnel syndrome

Skiing

n UCL* injury n Cubital tunnel syndrome

Lawn bowls or ten pin bowling

n Biceps tendinopathy n Radial tunnel syndrome

Boxing

n Triceps tendinopathy

Gymnastics

n Biceps tendinopathy n Triceps tendinopathy

Rowing

n Radial tunnel syndrome

Weightlifting

n n n n n

Biceps tendinopathy Triceps tendinopathy Radial tunnel syndrome Cubital tunnel syndrome UCL* injury

Cricket (bowling), javelin, shot put, discus, baseball (pitching), softball (pitching)

n n n n n n n n

Little league syndrome UCL* injury Cubital tunnel syndrome Pronator syndrome Triceps tendinopathy Olecranon stress fracture Medial epicondylitis Osteochondral defect

Lateral epicondylitis Olecranon stress fracture Medial epicondylitis Triceps tendinopathy Pronator syndrome Radial tunnel syndrome

* UCL – ulnar collateral ligament 19

or infection may change the angle. An increased angle is found in cubitus valgus and a decreased angle is seen in cubitus varus (gunstock deformity). After the initial inspection, the neck and shoulder should be crudely examined to rule out radiculopathy, shoulder weakness or referred pain (21). n Onset: did the pain start gradually or suddenly? n Radiation: does the pain move anywhere and if so then where and how? n Description: is it burning, stabbing, sharp or dull? n Is there any associated numbness or paraesthesia? n Has the individual had this kind of pain before and if so then what caused it? n What are the relieving and exacerbating factors, eg. occupational pain, throwing etc? n Where in the elbow is the pain? n Is the pain continuous or intermittent? n At what time of day does it get better or worse? n Is there pain at rest? Fig. 3: Questions that need to be addressed regarding the nature of pain in an elbow pain consultation (R. Chatterjee, 2017)

nD oes throwing ever exacerbate your symptoms and do you think your symptoms are related to throwing? n Does the pain change with gripping activities? n Do you feel as though your elbow is unstable and may slip out of place? n Was your elbow fully or over-extended when you sustained your injury? n Does movement of the neck or shoulders affect the elbow pain? n Do you have associated numbness or paraesthesia of the hand? Fig. 4: Specific questions that should be asked in cases of mechanical elbow pain (R. Chatterjee, 2017)

nG eneral posture of upper body and upper limbs: consider proximal factors which may cause elbow symptoms n Winging of scapulae n Swelling, deformities, bruising or scarring n Muscle wasting n Carrying angle: normally 5–10° in males and 10–15° in females Fig. 5: Observations to note during inspection of the elbow (R. Chatterjee, 2017)

n n n n

Flexion: 150° Extension: 180° Pronation: 180° Supination: 90°

Fig. 6: Normal range of motion of the elbow (R. Chatterjee, 2017) 20

Spurling’s test (pain when extending and rotating the head to the affected side while pressing down on the head) may be performed to exclude cervical nerve root compression (21). Following this, range of movement of the elbow joint is assessed (Fig. 6). Should the individual have full range of motion, any elbow fracture would be unlikely. Resisted flexion, extension, supination and pronation will allow the examiner to determine the strength of the elbow joint. The elbow joint should be palpated in order to find any pain or swelling. Specifically, the distal biceps tendon, triceps tendon, lateral and medial epicondyles, olecranon process and radial head should be felt. There are a number of special tests that can be performed to further help to diagnose the cause of elbow pain (Table 3).

INVESTIGATIONS Many of the causes of elbow pain can be diagnosed by history and examination alone. However, sometimes further investigations may be required to confirm the diagnosis. Blood tests are performed first, before any imaging, to rule out many conditions that may cause bone or joint pain (Table 4). Anticyclic citrullinated (anti-CCP) antibodies can be looked for if rheumatoid arthritis is thought to be causing the symptoms. Acute and chronic inflammatory markers [C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), respectively] will be raised in most cases of elbow pain and so will not help with determining the reason behind the pain. Vitamin D levels should also be checked as hypovitaminosis D is known to cause bony pain especially in areas with low sunlight and in the Asian and Afro-Caribbean communities (30). There are several modes of imaging that can be used to help to identify the cause of elbow pain (Table 5). The clinician must decide which form is most appropriate based on the information gathered from the patient.

TABLE 3: SPECIAL TESTS CONDUCTED TEST Cozen’s test [Physiotutors 2015. YouTube video: https://www.youtube. com/watch?v=8K7jzDIUpLI (22)] Mill’s test [Geoffroy. Can Fam Physician 1994;40:73 (23)] Maudsley’s test [Physiotutors 2015. YouTube video: https://www.youtube. com/watch?v=BaxgmHT_2eQ (24)] Varus stress test [Dutton. Orthopaedic examination, evaluation, and intervention. McGraw-Hill Education 2016 (25)] Valgus stress test [Dutton. Orthopaedic examination, evaluation, and intervention. McGraw-Hill Education 2016 (25)] Moving valgus stress test [Dutton. Orthopaedic examination, evaluation, and intervention. McGraw-Hill Education 2016 (25)] Milk manoeuvre [Kane. Am Fam Physician 2014;89(8):649 (26)]

Golfer’s elbow test [Kane. Am Fam Physician 2014;89(8):649 (26)]

Reverse Mill’s test [MediSavvy 2017. https://medisavvy.com/reversemills-test/ (27)] Hook test [Vidal. Clin Sports Med 2004;23(4):707 (28)] Tinel test [Shapiro. Med Clin North Am 2009;93(2):285 (29)]

Middle finger test [Kane. Am Fam Physician 2014;89(8):649 (26)] Elbow extension test [Kane. Am Fam Physician 2014;89(8):649 (26)]

MANAGEMENT Appropriate management of elbow pain in a primary care setting often results in the elbow returning to its

pre-morbid state without requiring any invasive or surgical measures. Having knowledge of the ideas, concerns and Co-Kinetic Journal 2017;73(July):18-25

PHYSICAL THERAPY

IN EXAMINATION OF ELBOW PAIN (R. Chatterjee, 2017) WHY

HOW

Test for lateral epicondylitis

n E xaminer stabilises patient’s elbow with his/her thumb while palpating lateral epicondyle. n Patient actively makes a fist while pronating forearm and radially deviating and extending wrist against resistance being applied by examiner. n Test is positive if pain reproduced at lateral epicondyle.

Test for lateral epicondylitis

n L ateral epicondyle is palpated while passively pronating forearm, flexing wrist and extending elbow. n Positive test is reproduction of lateral elbow pain.

Test for lateral epicondylitis

nR esisted extension of 3rd digit of hand, stressing the extensor digitorum muscle and tendon, whilst palpating the lateral epicondyle. n Positive test is reproduction of lateral elbow pain.

Test for integrity of lateral collateral ligament (LCL)

nW ith patient standing, the examiner places the patient’s elbow in 20° of flexion while palpating the humeroulnar joint line. n Varus force is then applied to the elbow. n If pain or excess laxity in comparison to the contralateral side is experienced then test is positive.

Test for integrity of medial collateral ligament (MCL)

nW ith the patient standing, the examiner places the elbow in 20° of flexion whilst palpating the medial joint line. n Distal humerus is stabilised with one hand while valgus stress to elbow is applied with other hand. n If pain or excess laxity in comparison to the contralateral side is experienced then test is positive.

Test for integrity of medial collateral ligament (MCL)

nW ith the patient seated, the shoulder is abducted to 90° and then externally rotated with the palm facing upwards. n While the examiner applies and maintains valgus stress to the elbow, the elbow is quickly flexed and extended. n The test is positive if pain occurs between 70 and 120° of elbow flexion.

Test for integrity of medial collateral ligament (MCL)

n n n n

T he patient is seated. Shoulder is flexed at 90° abduction with the elbow flexed to greater than 90° and the forearm supinated. The examiner pulls the patient’s thumb posteriorly causing increased valgus stress at the elbow. If pain or excess laxity in comparison to the contralateral side is experienced then test is positive.

Test for medial epicondylitis

n n n n

hile seated, the patient should flex their fingers into a fist position. W The examiner palpates the medial epicondyle with one hand and grasps the wrist with the other hand. The examiner then passively supinates the forearm and extends the elbow and wrist. The test is positive if the patient has pain around the medial epicondyle.

Test for medial epicondylitis

nW hile the patient is seated, the examiner extends the patient’s elbow, wrist and fingers. n This stretches the common flexor tendon at the medial epicondyle. n The test is positive if there is any pain around the medial epicondyle.

Test for distal biceps tendon rupture

nS houlder is abducted to 90° with the elbow in 90° of flexion. n The examiner attempts to use his or hers index finger to hook behind the distal biceps tendon. n The test is positive if finger does not hook onto the biceps tendon

Test for either cubital tunnel syndrome or radial tunnel syndrome

n E lbow flexed to 20°. n Examiner gently taps over the course of the superficial nerve (ulnar nerve: groove between olecranon and medial epicondyle; radial nerve: anterior to the lateral epicondyle and then through the cubital fossa, where the nerve divides into a deep branch and superficial branch) n Positive test if paraesthesia is elicited over the distal course of the nerve.

Radial tunnel syndrome (posterior interrosseous nerve syndrome)

nP atient attempts to extend middle finger against resistance while arm is outstretched. n Positive test if patient demonstrates weakness or inability to resist force.

Test to determine if patient has elbow trauma

nP atient is asked to fully extend elbow. n Test is positive if patient unable to fully extend elbow. n May need X-ray or further investigations.

MANY OF THE CAUSES OF ELBOW PAIN CAN BE DIAGNOSED BY HISTORY AND EXAMINATION ALONE Co-Kinetic.com

APPROPRIATE MANAGEMENT OF ELBOW PAIN IN A PRIMARY CARE SETTING IS OFTEN SUCCESSFUL WITHOUT REQUIRING ANY INVASIVE OR SURGICAL MEASURES TABLE 4: BLOOD TEST RESULTS IN CERTAIN AILMENTS THAT MAY CAUSE ELBOW PAIN (R. Chatterjee, 2016)

Alkaline phosphatase Calcium Phosphate

Osteoporosis N

N N

Paget’s disease

N N

Osteosarcoma

N N

Sarcoidosis N – Myeloma N – Osteomalacia

Primary hyperthyroidism

Secondary hyperthyroidism

Tertiary hyperthyroidism

Hypoparathyroidism N N, Normal;

Raised;

Lowered.

ESWT, extracorporeal shockwave therapy; GTN, glyceryl trinitrate; MDT, multidisciplinary team; NSAIDs, non-steroidal anti-inflammatory drugs; PRICE (protection of joint, rest, ice, compression, elevation); POLICE (protect, offload, ice, compress, elevate) PRP (plateletrich plasma); SEM (sports and exercise medicine).

STEP 2: STEP 1: n PRICE/POLICE n For 48 hours

n Referral to MDT n Lifestyle modifications eg. workplace modifications n Oral analgesics n NSAIDs n Hot/cold therapy n Eccentric stretches n Psychological support n Bracing n Cock-up wrist splints n For 6 weeks

expectations of the patient is paramount in achieving a satisfactory outcome. Each individual will have a different idea as to what constitutes an acceptable result. For some, an early return to sport or activity is considered a successful outcome whereas for others, merely a reduction in pain is an acceptable goal. By addressing any preconceptions or misinformation that the patient may have, compliance with rehabilitation or analgesic programmes is far more likely. For those with non-mechanical causes of elbow pain, early referral to an appropriate discipline is required. Once the source of pain has been determined to be mechanical, a stepwise approach to management is needed (Fig. 7). Step 1 is application of the PRICE (protection of joint, rest, ice, compression, elevation)/POLICE (protect, offload, ice, compress, elevate) protocol for a period of 48 hours. As overuse of the joint is a major factor in most of the

STEP 4: STEP 3:

n Referral to orthopaedics for surgery

n Referral to SEM n Supervised eccentric stretches n ESWT n Intra-articular corticosteroid injection n GTN patches n Autologous PRP injection n Hyaluronon gel injection n Botulinum toxin A injection n For 6 months

Fig. 7: Stepwise management of tennis elbow in particular, but also mechanical, non-fracture elbow pain in general (R. Chatterjee, 2017)

mechanical pathologies, it makes sense to rest the joint, ie. offload it. In step 2, the multidisciplinary team (MDT) should be involved as soon as possible. This includes physiotherapists, GP, dieticians, occupational therapists, psychologists and counsellors. The first issues that need to be addressed are lifestyle modifications that may provide symptomatic relief. Measures such as weight loss, change in training regime, improved diet or workplace modifications are sometimes enough to significantly reduce the elbow pain. If the patient plays sport, then changing technique involving the elbow would be advisable. Overload and underload are both bad for tendons (14). The underlying principle in management of overuse injury of the elbow should be to load (ie. exercise) the tendon to as close to its limits as possible, without exceeding them (14). Eccentric exercises are the mainstay of rehabilitation of elbow (and other) tendinopathies. The partial loading provided by the eccentric exercises aid in the repair of a degenerative tendon and prepares it for future load (14). The MDT will be able to provide advice on padding and strapping of the joint if needed, home physical therapy, appropriate use of oral analgesics and anti-inflammatories, stretching exercises and psychological support. The FITT (frequency, intensity, time, type) principle is used to specifically prescribe exercise. Counterforce bracing and cock-up wrist splints provide symptomatic relief by reducing extensor muscle activity (19,31). Optimisation of analgesia will allow the patient to actually perform the stretches and exercises prescribed at home. A step-up method of analgesia is preferred where weaker topical agents are initially prescribed with stronger oral medications only being given if pain persists (Table 6). There is some debate as to whether non-steroidal antiinflammatory drugs (NSAIDs) should be given in bony pain. Studies have shown that there may be delayed bone healing or non-unions associated with NSAID exposure. However, a recent systematic review on this topic has advocated its use, as withholding NSAIDs does not have any proven scientific benefit to patients and may even cause harm by increasing the requirement for stronger, more addictive medications (32). Co-Kinetic Journal 2017;73(July):18-25

PHYSICAL THERAPY

TABLE 5: IMAGING THAT MAY BE USED IN THE INVESTIGATION OF ELBOW PAIN (R. Chatterjee, 2017) Mode of imaging

Advantages

Disadvantages

X-ray (plain radiographs)

n Low cost n Readily available n May help identify fractures or bony deformities including degenerative changes n Osteophytes, joint space narrowing, soft tissue swelling, osteochondral defects, enthesophytes and joint effusions can also be identified

n E xposure to radiation nA bnormalities that are identified by X-ray may be unrelated to cause of pain, eg. incidental osteophyte n E xtent of soft tissue swelling may not be visible on X-ray

Magnetic resonance imaging (MRI)

n No radiation exposure n Preferred over CT if soft tissue needs to be identified n Often the investigation of choice as can identify pathological conditions such as tendinopathy, inflammation, nerve entrapment, joint effusion and bone marrow oedema n Can identify ligament tears, osteochondral defects or loose bodies in those without joint effusion

n Expensive nO ften long waiting time to get MRI n Tissue calcification cannot be identified on MRI as bone and calcium do not show up

Computed tomography (CT)

n Preferred over MRI if bony anatomy needs to be identified n Used to identify fracture if radiograph normal but fracture still suspected n Can detect soft tissue calcification, eg. myositis ossificans or intra-articular loose bodies

nH igh exposure to radiation nM ore incidences of allergic reaction to CT contrast than MRI contrast

Ultrasonography

n n n n

Bone scan

n Used to identify stress fractures, bony metastases, infections or occult fractures

Inexpensive Can be done in clinic Allows dynamic evaluation Can identify medial and lateral elbow tendinopathy

TABLE 6: MEDICATIONS FOR ANALGESIA IN ELBOW 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

Tricyclic antidepressant (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

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nO perator dependent

nG enerally non-specific in identifying cause of pain

Heat 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 its efficacy, these therapies are non-invasive, cheap, readily available and have relatively few side effects (33). Should the patient still be symptomatic then step 3 commences with referral to a sports and exercise medicine (SEM) specialist. In conjunction with the other members of the MDT as well as the patient, further supervised eccentric stretches and physical therapy is offered. Alternate therapies

STABILITY OF THE ELBOW IS PROVIDED BY THE MEDIAL AND LATERAL LIGAMENT COMPLEXES 23

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

Cold therapy

Mechanism of action

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

nR educes speed of blood flow to area where cold is applied. n This results in reduced pain and swelling.

Method of application

n n n n n n

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

n n n n n

Frequency of application

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

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

When and how to use it

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

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

may be offered at this point. These include: extracorporeal shockwave therapy (ESWT), corticosteroid joint injection and platelet-rich plasma (PRP) injections. There is limited evidence of the efficacies of these procedures and so they should only be offered after all other avenues have been exhausted (34). Non-operative management of tennis elbow and other tendinous elbow injuries will result in successful resolution of symptoms in 90% of patients (35). Finally, if after step 3 there is still no improvement, referral to an orthopaedic surgeon is made. Surgical options include percutaneous, open and arthroscopic techniques (36). Stages 1 to 3 should be attempted for at least 6–12 months before surgical intervention.

CONCLUSION Elbow pain is commonly seen in the primary care setting. A systematic framework can help the clinician to investigate and diagnose the cause of pain. Mechanical causes of elbow pain 24

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

are managed in a stepwise fashion. Patient education and addressing the ideas, concerns and expectations of the individual are key concepts in ensuring good compliance with a treatment regimen and thus an optimal outcome. References 1. Walker-Bone K, Palmer KT, Reading I et al. Occupation and epicondylitis: a population based study. Rheumatology (Oxford) 2012;51(2):305–310 2. Silverstein B, Welp E, Nelson N et al. Claims incidence of work-related disorders of the upper extremities: Washington state, 1987 through 1995. American Journal of Public Health 1998;88(12):1827–1833 3. Chumbley EM, O’Connor FG, Nirschl RP. Evaluation of overuse elbow injuries. American Family Physician 2000;61(3):691–700 4. Bain GI, Durrant AW. Sports-related injuries of the biceps and triceps. Clinics in Sports Medicine 2010;29(4):555–576 5. Dogramji PP. Hot topics in primary care: update on the recognition and management of gout: more than the great toe. The Journal of Family Practice 2015;64(12 Suppl):S31–36 6. van den Broek M, van Riet R. Intraarticular

capacity of the elbow joint. Clinical Anatomy 2017;doi:10.1002/ca.22915 7. Sanchez-Sotelo J. Elbow rheumatoid elbow: surgical treatment options. Current Reviews in Musculoskeletal Medicine 2016;9(2):224–231 8. Strohl AB, Zelouf DS. Ulnar tunnel syndrome, radial tunnel syndrome, anterior interrosseous nerve syndrome and pronator syndrome. The Journal of the American Academy of Orthopaedic Surgeons 2017;25(1):e1-e10 9. Ligon CB, Gelber AC. Elbow loose bodies. The Journal of Rheumatology 2014;41(7):1426–1427 10. Bell S. Elbow and arm pain. In: Brukner P, Khan K eds. Clinical Sports Medicine, 3rd edn. McGraw-Hill 2006, pp302–303. ISBN 13-978-0070278998 (£34.98). Buy from Amazon http://spxj.nl/2rE00uE 11. Herrera FA, Meals RA. Chronic olecranon bursitis. The Journal of Hand Surgery 2011;36(4):708–709 12. Brucker J, Sahu N, Sandella B. Olecranon stress injury in an adolescent overhand pitcher: a case report and analysis of the literature. Sports Health 2015;7(4):308–311 13. Laratta J, Caldwell JM, Lombardi J et al. Evaluation of common elbow pathologies: a focus on physical examination. The Physician and Sportsmedicine 2017;45(2):184–190 14. Orchard J, Kountoris A. The management of tennis elbow. BMJ 2011;342:d2687 15. Slabaugh MA. Elbow injuries. In: Seidenberg PH, Beutler AI, eds. The Sports Medicine Resource Manual. Saunders Elsevier 2008, pp226– 232. ISBN 978–1416031970 (£98.99). Buy from Amazon http://spxj. nl/2siGSng 16. Conti Mica M, Caekebeke P, van Riet R. Lateral collateral ligament injuries of the elbow- chronic posterolateral rotatory instability (PLRI). EFORT Open Reviews 2017;1(12):461–468 17. Meyers AB, Kim HK, Emery KH. Elbow plica syndrome: presenting with elbow locking in a pediatric patient. Pediatric Radiology 2012;42(10):1263–1266 18. Claessen FM, Louwerens JK, Doornberg JN et al. Panner’s disease: literature review and treatment recommendations. Journal of Children’s Orthopaedics 2015;9(1):9–17 19. Taylor SA, Hannafin JA. Evaluation and management of elbow tendinopathy. Sports Health 2012;4(5):384–393 20. Smucny M, Kolmodin J, Saluan P. Shoulder and elbow injuries in the adolescent athlete. Sports Medicine and Arthroscopy Review 2016;24(4):188–194 21. Javed M, Mustafa S, Boyle S et al. Elbow pain: a guide to assessment and management in primary care. The British Journal of General Practice 2015;65:610–612 22. Physiotutors 2015. Cozen’s test. Lateral epicondylitis “Tennis Elbow”. YouTube video http://spxj.nl/2rOQxip Co-Kinetic Journal 2017;73(July):18-25

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23. Geoffroy P, Yaffe MJ, Rohan I et al. Diagnosing and treating lateral epicondylitis. Canadian Family Physician 1994; 40:73–78 24. Physiotutors 2015. Maudsley’s lateral epicondylitis test. Lateral epicondylitis or tennis elbow. YouTube video http://spxj.nl/2sWyLtg 25. Dutton M. Orthopaedic examination, evaluation, and intervention, 4 th edn. McGrawHill Education 2016. ISBN 9781259583100 (Kindle £77.47 Print £103.17). Buy from Amazon http://spxj.nl/2rP9TUR 26. Kane SF, Lynch JH, Taylor JC. Evaluation of elbow pain in adults. American Family Physician 2014;89(8):649–657 27. Reverse Mill’s test. MediSavvy 2017 https://medisavvy.com/reverse-mills-test/

28. Vidal AF, Drakos MC, Allen AA. Biceps tendon and triceps tendon injuries. Clinics in Sports Medicine 2004;23(4):707–722, xi 29. Shapiro BE, Preston DC. Entrapment and compressive neuropathies. The Medical Clinics of North America 2009;93(2):285–315, vii. 30. Shah SK, Taufiq I, Najjad MK et al. Vitamin D deficiency and possible link with bony pain and onset of osteoporosis. The Journal of the Pakistan Medical Association 2014;64(12 Suppl 2):S100– 103 31. Burton AK. Grip strength and forearm strength straps in tennis elbow. British Journal of Sports Medicine 1985;19(1):37– 38 32. Marquez-Lara A, Hutchinson ID, Nunez F Jr et al. Nonsteroidal anti-inflammatory drugs and bone healing: A systematic review of research quality. Journal of Bone and Joint

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KEY POINTS nA lthough tendinopathy accounts for many instances of elbow pain, there are many other causes. n The elbow is a hinge joint but is also capable of rotation, which allows pronation and supination of the distal arm. n When making a diagnosis, it is helpful to think of the elbow as four areas: the anterior, posterior, lateral and medial parts. n The first stage of assessment is a detailed visual examination of the elbow as well as a crude examination of the neck and shoulder area. n Be aware of the mechanical elbow injuries that are associated with certain sports. n If the patient has full range of motion in the elbow, fracture is unlikely. n There are a number of special tests that can be used to help diagnose the cause of elbow pain. n Good communication with the patient about their expectations and concerns is crucial to achieving a successful treatment outcome. n Mechanical elbow pain is managed in a stepwise approach. n Non-operative management of elbow tendinopathies is successful in 90% of patients.

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Surgery Reviews 2016;4(3):pii:01874474201603000-00005 33. Malanga GA, Yan N, Stark J. Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury. Postgraduate Medicine 2015;127(1):57– 65 34. Ahmad ZA, Siddiqui N, Malik SS et al. Lateral epicondylitis: a review of pathology and management. The Bone & Joint Journal 2013;95-B(9):1158–1164 35. Hay EM, Paterson SM, Lewis M et al. Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. BMJ 1999;319(7215):964– 968 36. Grundberg AB, Dobson JF. Percutaneous release of the common extensor origin for tennis elbow. Clinical Orthopaedics and Related Research 2000;376:137–140.

THE AUTHOR Dr Chatterjee is a specialist registrar (ST4) in sports and exercise medicine (SEM) and also a GP with a special interest (GPwSI) in SEM. He first became interested in SEM when he gained experience in hyperbaric medicine, cardiopulmonary exercise testing and chronic musculoskeletal pain management while working as an anaesthetist in Australia. He currently works as a medical officer at the Defence Medical Rehabilitation Centre at Headley Court, London Broncos Rugby League and Musculoskeletal Interface Clinical Assessment Service (MICAS) at Battersea Health Centre. He has recently received the Dr Vivien Lane Foundation Scholarship for his research investigating the effects of low vitamin D on chronic non-specific low back pain and has been appointed on the research committee for European College for Sports & Exercise Physicians (ECOSEP). Email: robinchatterjee1@yahoo.co.uk Twitter: http://twitter.com/sportsdocrob

DISCUSSIONS ow have you been dealing with patients with elbow H pain and, after reading this article, is there anything that you would change? If so, what? What symptoms indicate the need for urgent or immediate treatment? How would you decide what constitutes a good treatment outcome?

RELATED CONTENT ow Back Pain Assessment: The 10 Minute L Assessment [Article] - http://spxj.nl/2bRhtZL eel Pain: The 10 Minute Assessment [Article] H http://spxj.nl/2gy8fUd ssessment and Treatment of the Elbow [Article] A http://spxj.nl/1PXHgb1

17-07-COKINETIC FORMATS WEB MOBILE

BY RANDALL COOPER B.PHYSIO M.PHYSIO, APAM FACP

THE STUDY If there was one sport you had to pick to test what recovery techniques work, what sport would it be? Ironman Triathlon of course! Researchers from Brazil (1) recruited 74 Ironman Brazil athletes who presented to the physiotherapy clinic complaining of anterior thigh (quadriceps) soreness immediately following the event. Thirty-seven athletes were randomised to the massage group; the other 37 were the controls. The massage group received 7 minutes of Swedish massage to the quadriceps, whereas people in the control group just rested in a sitting position for 7 minutes.

OUTCOME MEASURES Two outcome measures were used to gauge any effectiveness of the massage therapy: 1. Pain and perceived fatigue Athletes were asked to rate their pain and fatigue on a visual analogue scale (VAS). 2. Pain pressure threshold A digital pressure algometer was used to apply pressure on three sites on the anterior thigh. Participants had to tell the researchers when the increasing pressure of the algometer changed from ‘pressure’ to ‘pain’, with the highest pressure reading being recorded as their pain threshold. Measurements were taken before and after intervention (or control) and the assessors were blinded to whether the athletes had received massage or not. Only one participant was lost in the study, owing to nausea.

TRIAL RESULTS The results showed a statistically significant difference between groups for pain and perceived fatigue – put another way, the massage group felt less discomfort and fatigue after the 7-minute massage than the control group. There were no differences between the groups for pain pressure threshold.

IS MASSAGE AN EFFECTIVE SPORTS RECOVERY STRATEGY? Optimal recovery from an intense training session or event is of the highest importance to an athlete, and massage has for a long time been an integral part of the recovery process. But is massage therapy an effective recovery tool? We review a recent study which sheds some light on the topic. Read this online http://spxj.nl/2s7halA DISCUSSION This research raises some interesting issues. The first issue is that (only) a 7-minute massage resulted in a modest but notable improvement in pain and perceived fatigue (7mm and 15mm respectively on a 0–100mm VAS). Would a longer massage session result in a greater magnitude of effect/benefit? Obviously the current study can’t answer the question, but it would be nice to know at what point in time the effect/ benefit tapers off or reverses: 10, 15, 20 minutes? The second issue, and probably the most interesting is that the massage group improved regarding perceived pain and fatigue, but not pressure pain threshold. There are a number of different theories and studies on how massage ‘works’ in the recovery process with psychological, physiological and neurological responses being postulated. The current study suggests that a neurological response (gate control theory – where massage stimulates the neural input back to the central nervous system suppressing the original pain) can’t explain the perceived reduction in pain. If it did, pressure pain and perceived pain should both improve. A physiological response such as endorphin release and/or removal of ‘waste’ (catabolic) molecules could be an explanation, as could a psychological response (personal touch and attention resulting in a sense of relaxation and well-being).

CONCLUSIONS It’s an interesting study; however, the (very) short follow-up on the participants is a major limitation. Whereas for most triathletes their next Ironman event is going to be months away, for people who play ‘tournament’ sports (such as tennis,

football, or basketball) optimising a quick recovery is super important. It would have been nice to see whether the massage group maintained their better pain and fatigue perception over a few days or more. The study on the effectiveness of massage therapy on recovery following an Ironman Triathlon adds to a growing body of evidence that massage is an important component of optimising athletic performance.

Treatment time for a dual Winter Olympian (Credit: E. Oswald, 2014)

FURTHER RESOURCES 1. Weerapong P, Hume PA, Kolt GS. The mechanisms of massage and effects on performance, muscle recovery and injury prevention. Sports Medicine 2005;35(3):235–256 2. Best TM, Hunter R, Wilcox A et al. Effectiveness of sports massage for recovery of skeletal muscle from strenuous exercise. Clinical Journal of Sport Medicine 2008;18(5):446–460 3. Bervoets DC, Luijsterburg PA, Alessie JJ et al. Massage therapy has short-term benefits for people with common musculoskeletal disorders compared to no treatment: a systematic review. Journal of Physiotherapy 2015;61(3):106–116. References 1. Nunes GS, Bender PU, de Menezes FS et al. Massage therapy decreases pain and perceived fatigue after long-distance Ironman triathlon: a randomised trial. Journal of Physiotherapy 2016;62(2):83–87. Co-Kinetic Journal 2017;73(July):26-27

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THE AUTHOR Randall Cooper B.Physio M.Physio, APAM FACP is an experienced sports physiotherapist who has worked with some of Australia’s most notable sporting organisations and has consulted from the internationally renowned Olympic Park Sports Medicine Centre in Melbourne, Australia. In 2008 Randall also attained the title of Specialist Sports Physiotherapist, awarded by the Australian College of Physiotherapists. He is the founder and managing director of Premax, an Australian company that manufactures a range of sports skincare and massage creams, and he has also designed the Thermoskin Cooper Knee Alignment Sleeve. As an adjunct lecturer at the La Trobe University Sport and Exercise Medicine Research Centre, Randall advocates sport and exercise medicine, physical activity, health and well-being for all. He provides support to the Centre, actively assisting in translating research findings to key stake holders including the international research community, health practitioners and the general public. Email: randall@premax.co Twitter: http://twitter.com/RL_Cooper, http://twitter.com/ premax LinkedIn: https://au.linkedin.com/in/randallcooper-68172854 Facebook: https://www.facebook.com/premaxaustralia/

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KEY POINTS n Pain and fatigue are common after intense exercise. n Massage improved athlete pain and perceived fatigue after an Ironman Triathlon. n Only 7 minutes of massage was administered. n The effectiveness was likely to be physiological or psychological, not neurological. n The amount of pressure needed over the quads to elicit pain was not improved with massage. n Massage appears to be more effective for the recovery from pain and perceived fatigue than no intervention after intense exercise. n This study adds to a growing body of evidence supporting the use of massage therapy after intense exercise. n Further research is required to assess the longevity of improved outcomes and the optimum duration of treatment.

DISCUSSIONS

ould a longer massage result in further improvement W in pain and perceived fatigue? The follow-up of the athletes in the study was very short. Would people expect to see athletes maintain benefits for 24 to 48 hours or longer? The following techniques were used by the therapists in the study: n 1 minute of superficial effleurage, in which the therapist slid both hands in the direction of the muscle fibres from distal to proximal with a gentle pressure on the thigh; n 2 minutes of deep effleurage, in which the therapist performed the same movement but applied more pressure to the thigh; n 2 minutes of petrissage, in which the therapist used the entire surface of the palm of the hands to compress and lift the tissue sequentially; n 1 minute of tapotement, in which the therapist agitated the tissues of the thigh with cupped hands; n and 1 minute of superficial effleurage to finish the intervention. Would you use a different protocol, and if so why? What should researchers investigate next?

RELATED CONTENT eries of massage videos published on the Premax S YouTube channel - http://spxj.nl/2s44Y1j Sports massage articles on Co-Kinetic - http://spxj.nl/2slFbET

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17-07-COKINETIC FORMATS WEB MOBILE

BY LEON CHAITOW ND DO (RETIRED), HON FELLOW UNIV. WESTMINSTER

THE MORPHOLOGY OF REFLEX AND ACUPUNCTURE POINTS Pain researchers have demonstrated that approximately 75% of trigger points are located where acupuncture points are shown on traditional meridian maps (1,2). The remainder may be thought of as ‘honorary’ acupuncture points since, according to Traditional Chinese Medicine (TCM), all spontaneously tender areas (whether or not they are on the meridian maps) are suitable for acupuncture (or acupressure) treatment – and a trigger point is nothing if it is not spontaneously tender! Using delicate measuring techniques, Ward (3) examined 12 acupuncture sites that are also common trigger point sites, in the trapezius and infraspinatus muscles. He found precisely the ‘spike’ of electrical activity characteristic of an active trigger point in all of these. Mense and Simons (4) are less definite: “Frequently the acupuncture point selected for the treatment of pain is also a trigger point, but sometimes it is not.” However, if they usually lie in the same place as acupuncture points, what tissues are involved? Bossy (5) examined the associated tissues extensively and reported that all motor points of medical electrology are also acupuncture points (which he calls “privileged loci of the organism that allow exchanges between the inner body and the environment”). The skin manifestation is, he says, “easier

ADDING LESSONS FROM TCM TO YOUR MANUAL THERAPY TOOLBOX Although Traditional Chinese Medicine (TCM) has been used for over 5,000 years, Western practitioners can struggle with its ideas and conclusions. In this article you will discover that there are perhaps more similarities between TCM and Western practices than you might first imagine. Use the exercises described to test and improve your palpation and perception skills. Incorporating the learnings of TCM into your manual therapy toolbox will improve your sensitivity to and awareness of your patient. This article has extracted from the new edition of the author’s book Palpation and Assessment in Manual Therapy. Read this online http://spxj.nl/2s6Tk9n to feel than to see. The most superficial morphological expression is a cupule.” Under the skin (which is a little thinner than the surrounding areas) covering these ‘privileged loci’ there are common features: n Neurovascular bundles are commonly found. n Connective tissue is always a feature. n Fatty tissue is sometimes present. n Vessels and nerves seem to be important common features, although their stimulation during treatment is usually indirect, as the result of deformation of connective tissue and consequent traction.

PAIN RESEARCHERS HAVE DEMONSTRATED THAT APPROXIMATELY 75% OF TRIGGER POINTS ARE LOCATED WHERE ACUPUNCTURE POINTS ARE SHOWN ON TRADITIONAL MERIDIAN MAPS 28

n I n some instances, tendons, periarticular structures, or muscle tissues are involved, as part of the acupuncture/trigger point morphology. After extensive dissection, Bossy states, “fat and connective tissue are determinants for the appearance of the acupuncture sensation.” Bossy’s research has been validated by subsequent investigation – most notably by Langevin and Yandow (6), as described below.

Acupuncture Points and Fascia Staubesand and Li (7) studied human fascia using electron microscopy and found smooth muscle cells embedded within collagen fibres. This research also showed that there are a great many perforations of the superficial fascial layer, characterised by penetration through the fascia of venous, arterial and neural structures (mainly unmyelinated vegetative nerves). Heine (8), who also Co-Kinetic Journal 2017;73(July):28-33

MANUAL THERAPY

FAT AND CONNECTIVE TISSUE ARE DETERMINANTS FOR THE APPEARANCE OF THE ACUPUNCTURE SENSATION (BOSSY, 1984) documented the existence of these perforations in the superficial fascia, was additionally involved in the study of acupuncture, and established that the majority (82%) of these perforation points are topographically identical with traditional Chinese acupuncture points. Langevin and Yandow (6) noted that acupuncture meridians were traditionally believed to constitute channels, connecting the surface of the body to internal organs. Langevin and colleagues hypothesised that the network of acupuncture points and meridians can be viewed as a representation of the network formed by interstitial connective tissue. This hypothesis is supported by ultrasound images showing connective tissue cleavage planes at acupuncture points in normal human subjects. She mapped acupuncture points in serial gross anatomical sections through the human arm, and found “an 80% correspondence between the sites of acupuncture points and the location of intermuscular or intramuscular connective tissue planes in postmortem tissue sections.” This sort of research into the behaviour and morphology of acupuncture (and other reflex) points helps to explain some of the common findings noted on palpation. For example, a slight ‘cupule’ or depression, overlaid with slightly thinner skin tissue, can usually be felt, indicating the presence of an acupuncture point (which if sensitive is ‘active’ and quite likely to be also a trigger point). Shang (9) explains the ‘cupule’ phenomenon as follows: Many acupuncture points are located at transition points, or boundaries, between different body domains or muscles, coinciding with the fascia and connective tissue planes. Other palpatory signs exist: skin ‘drag’ and loss of elastic qualities being the most important palpatory indications.

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PALPATING THE TRADITIONAL CHINESE PULSES A method of diagnosis that has existed and been refined over a period of 5,000 years deserves to be taken seriously, even if its precepts and conclusions seem to fly in the face of current Western medical thinking. Not surprisingly, there are different versions and interpretations of pulse diagnosis; however, the basic methodology is similar in all schools. As an exercise in palpation, the methods of pulse diagnosis have much to commend them, even if the interpretations of what is being palpated are not generally accepted by Western medicine or if the language in which these findings are expressed is difficult to follow in the West. Precisely the same can be said for cranial palpation, in which there is little dispute that ‘something’ is being felt when ‘cranial impulses’ are being palpated, although there is a great deal of debate as to what ‘it’ is, and what ‘it’ may mean, in health terms. It should be remembered that the TCM practitioner who is using pulse diagnosis incorporates the impressions gained in this way with other methods of assessment, including the presenting signs, symptoms, and history, as well as methods such as tongue diagnosis (where descriptors such as ‘pale’, ‘fat’, ‘moist’, ‘dry’, ‘yellow’, and so on, are used to discriminate one pathophysiological state of the tongue from another, each indicating an imbalance of one sort or another) (10).

History Austin (11) pointed out that in Western medicine, taking the pulse is an important part of the diagnostic process: nH ow many beats to each breath? n I s the pulse strong or weak, even or irregular? n I s blood flow full or thin, strong or weak, hard or soft, regular or intermittent, etc?

TCM Pulses The Chinese pulse is, however, quite a different story. In TCM it is considered that through the pulse it is possible to read not merely the health of the organism as a whole, but that of each inner organ separately: nw hether it has too much or too little energy nw hether it is congested, over-full, or deficient nw hether it is hyperactive or hypoactive nw hether the polarity predominance and polarity changes are in proper order … and so on (11). The Chinese identified 12 (some say 14) positions on the radial pulse that could be used to indicate the status of specific organs and functions. How is this possible? Austin (11) explains: TCM identifies 12 points on the radial pulse that indicate the status of specific organs/functions. If you have fluid flowing through a resilient tube, a rubber or plastic tube attached to a water tap, and very lightly touch the tube with a finger, the flow of water can be felt. The tube need hardly be compressed at all for us to feel the flow quite distinctly. Let the fingertip linger a while, so that the kind of sensation of flow registers in you; now steadily compress the tube by increasing the pressure until you have stopped the flow, then lift ever so slightly – maintain this pressure and note what you are feeling. The kind of sensation you now experience in your fingertip is different from that of the first light touch. You may, for example, be more aware of the resilience of the tube itself, at one pressure level rather than another; or of volume, water pressure, speed of flow, etc. Continue your experiment by varying the surface on which the tube rests. A tube resting on a hard surface will feel different from when it is resting 29

upon a soft surface (folded towel, for example). This will apply to both levels of palpation. There will also be a difference if one places a layer of material between finger and tube. See if you can detect these sensations yourself by trying Exercise 1. If, instead of the tube described by Austin (11), we think of an artery, and of the hard surface as an underlying bone, and of the gauze as soft tissues, we can see that it may indeed be quite possible for palpation to detect variations in flow, depending upon what lies between the palpating finger and the artery, and what lies below the artery. Some of the many descriptors used in TCM to describe the different sensations imparted by the various pulses include, ‘wiry’, ‘bounding’, ‘full’,

‘rapid’, ‘empty’, ‘thin’, ‘thready’. Each of these descriptors is thought to represent the current state of energy balance relative to the organ and its functions that are being assessed in this way. Use Exercise 2 to learn to assess your own pulses and those of patients, friends or volunteers and see how many different descriptors you can contrive (10). For a more recent evolution of this method of palpation see the paper by Shu and Sun (12), who describe a quantitative approach that complements the qualitative nature of traditional pulse diagnosis. They note: Chinese pulses can be recognized quantitatively by the newlydeveloped four classification indices, that is, the wave length, the relative phase difference, the rate parameter,

LANGEVIN FOUND ‘AN 80% CORRESPONDENCE BETWEEN THE SITES OF ACUPUNCTURE POINTS AND THE LOCATION OF INTERMUSCULAR OR INTRAMUSCULAR CONNECTIVE TISSUE PLANES IN POST-MORTEM TISSUE SECTIONS’ EXERCISE 1: PALPATING WATER FLOW THROUGH A TUBE (Chaitow, 2017) As described by Austin [(Acupuncture therapy, ASI 1978 (11)], only a very light touch to a tube is needed to feel the flow of a fluid through it. Method n C onnect a plastic or rubber tube to a bath or kitchen tap and turn the tap on. n Touch the tube very lightly with a finger and feel the flow of the liquid within it. - Leave your finger there and acknowledge the sensation of the liquid flow. n Now press harder on the tube until you have stopped the flow of water, then lift the finger very slightly. - Maintain this pressure and register what you are feeling. - The sensation in your fingertip will be different from the first light touch. n At the different levels of pressure, note how your awareness of the following aspects changes. - The resilience of the tube itself. - Fluid volume, pressure, speed of flow, etc. n P lace the tube on different kinds of surfaces and note how this changes what you feel. Note how the sensations change when: - the tube is resting on a hard surface or a soft surface (eg. a folded towel) - a layer of material is placed between the tube and your finger.

and the peak ratio. The new quantitative classification not only reduces the dependency of pulse diagnosis on Chinese physician’s experience, but also is able to interpret pathological wrist-pulse waveforms more precisely.

Pulse Evaluation For pulse evaluation, Oshawa (13) states: The extreme end of the finger, the pulp, which is the most sensitive part, should be used to evaluate the pulses. The last phalanges should be perpendicular to the plane of the wrist. The nails must be cut short. The superficial yin pulse corresponds to the hollow organs; the deep yang pulse corresponds to the full yang organs. You judge the superficial pulse by feeling the position lightly and then gradually increasing the pressure of the finger. To determine the deep pulse, one compresses the artery completely at the beginning and then releases it little by little. The deep pulse corresponds to the blood pressure, to the fundamental composition of blood; the superficial pulse to the variable blood pressure. TCM Interpretations Figures 1 and 2 show the locations of pulse positions 1, 2 and 3. Left wrist nP osition 1 light pressure (superficial) is said to relate to the small intestine meridian and deep pressure detects the heart meridian status. n Position 2 light pressure (superficial) relates to gall bladder and deep pressure detects liver meridian status. n Position 3 light pressure (superficial) relates to bladder meridian and deep detects the kidney meridian. Right wrist n Position 1 light pressure (superficial) is for large intestine and deep is for lungs. n Position 2 light pressure (superficial) is for stomach and deep is for spleen. nP osition 3 light pressure (superficial) Co-Kinetic Journal 2017;73(July):28-33

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AS AN EXERCISE IN PALPATION, THE METHODS OF PULSE DIAGNOSIS HAVE MUCH TO COMMEND THEM is triple heater and deep is circulation. Notes Oshawa states that the allocation of organs to pulses on the right and left hand, as described above, relates to men only. The pulse allocations are said

by him to be reversed in women. This sort of controversial statement helps to explain why so many Western-trained therapists find difficulty in accepting the conclusions drawn from TCM pulse diagnosis.

EXERCISE 2: PULSE PALPATION ON YOURSELF AND OTHERS (Chaitow, 2017) According to Oshawa [Acupuncture and the philosophy of the Far East, Tao Books 1973 (13)], for pulse evaluation: n The most sensitive part of the finger, the extreme end, should be used. n The assessor’s fingernails must be cut short and the distal phalanges should be perpendicular to the plane of the patient’s wrist. n The superficial yin pulse corresponds to the hollow organs and the deep yang pulse corresponds to the full yang organs. Method (Figs 1 and 2) n Sit in a relaxed manner and with your right hand feel the (TCM) pulses of the left wrist. n Resting the back of your, or your patient’s, left hand on the palm of your right hand, curl your fingers so that they rest on the radial artery. n Place the middle finger at the level of the radial styloid prominence, just below the wrist crease. Your forefinger will then rest naturally on the crease, near the thenar eminence, and the ring finger will fall naturally onto the third pulse position. n Position 1 is where your index finger rests, position 2 is where the middle finger rests, and position 3 is where the ring finger rests. n Adopt the palpation position as described, right hand palpating the left radial pulse. - Evaluate the superficial pulse by feeling the position lightly and then gradually increasing the pressure of the finger. This pulse corresponds to the variable blood pressure. - Evaluate the deep pulse by compressing the artery completely and then releasing it a little at a time. This pulse corresponds to the blood pressure as a whole: the fundamental composition of the blood. How many descriptors can you think of for the different sensations that you are detecting? 1

2 3

Figure 1: Location of pulses (right hand only illustrated) for assessment in Traditional Chinese Medicine (Copyright Handspring 2017, reproduced here with permission).

Figure 2: Taking the pulse in Traditional Chinese Medicine (Copyright Handspring 2017, reproduced here with permission). One finger at a time would apply suitable degrees of pressure to make an assessment, superficially or at depth.

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A Simpler View Stiefvater (14) gives the following simplified break-down of what pulse readings may indicate: n Small, thin, and fine indicates insufficiency. n Full and hard indicates hypertension and hyperfunction. n Soft and strong indicates inflammation. n Small, hard and pointed indicates spasticity, contracture, and the associated organ will usually be painful. n Overflowing and large indicates excess, usually with inflammation and pain. n Very weak, scarcely perceptible indicates energy depletion. Giving a Numerical Value to the Palpated Pulse As you palpate, try to gain a sense of normal (score of 4), excess (score of 5–8) or deficiency (score of 0–3). Lawson-Wood (15) states that a score of 0 is applicable to someone who is ‘almost dead’ and a score of 8 represents a patient ‘in extremis’. When feeling the pulses the practitioner ‘listens’ to them much as one listens to an orchestra – each pulse representing one of the instrumentalists. Taken together the ‘melody’ should be a happy and harmonious one. If the melody is not joyous and harmonious at least one of the players is out of tune. You need to locate which is the discordant player. You must be relaxed and receptive and when you palpate each level quite deliberately say to yourself, “I am now listening to the pulse of (name of meridian) to hear and understand what it has to say to me.”

Making Use of What You Feel The exercises described above should help you to sense the difference in what you feel in the various indicated pulse positions. You are not meant to make a diagnosis 31

THE TCM PRACTITIONER WHO IS USING PULSE DIAGNOSIS INCORPORATES THE IMPRESSIONS GAINED IN THIS WAY WITH OTHER METHODS OF ASSESSMENT on this basis or to necessarily accept the interpretations of TCM offered above, merely to gain an awareness of what is being suggested by TCM. References 1. Melzack R, Wall P. The challenge of pain, revised edn. Penguin 1996. ISBN 978-0140256703 (£20.57). Buy from Amazon http://amzn.to/2qCB0A5 2. Wall P, Melzack R. Textbook of pain, 6th edn. Saunders 2013. ISBN 9780702040597 (Kindle £160.74 Print £169.20). Buy from Amazon http://amzn.to/2sak71X 3. Ward A. Spontaneous electrical activity at combined acupuncture and myofascial trigger point sites. Acupuncture Medicine 1996;14(2):75–79 4. Mense S, Simons D. Muscle pain: understanding its nature, diagnosis and treatment. Lippincott Williams and Wilkins 2000. ISBN 978-

THE AUTHOR Leon Chaitow, ND DO (retired), Hon fellow Univ. Westminster, is wellknown internationally as the author of over 60 books on natural heath and complementary medicine. He has also co-edited and contributed to numerous other important publications in the field of fascial dysfunction and its treatment, notably as co-editor of Fascia: The Tensional Network of the Human Body http://spxj.nl/2rBwt6c edited by Robert Schleip et al. Leon is Editorin-Chief of the Journal of Bodywork and Movement Therapies http://www. bodyworkmovementtherapies.com. Website: http://leonchaitow.com/ Email: chaitow1@gmail.com LinkedIn: https://uk.linkedin.com/in/ leon-chaitow-40a91027 Facebook: https://www.facebook. com/leon.chaitow

0683059281 (£69.67). Buy from Amazon http://amzn.to/2qwlbQA 5. Bossy J. Morphological data concerning acupuncture points and channel networks. Acupuncture and Electro-Therapeutics Research 1984;9(2):79–106 6. Langevin H, Yandow J. Relationship of acupuncture points and meridians to connective tissue planes. Anatomical Record 2002;269:257–265 7. Staubesand J, Li Y. Begriff und substrat der faziensklerose bei chronisch venöser insuffizienz. Phlebologie 1997;26:72–79 (in German) 8. Heine H. Functional anatomy of traditional Chinese acupuncture points. Acta Anatomica 1995;152:293 9. Shang C. Prospective tests on biological models of acupuncture. Evidence-based Complementary and Alternative Medicine 2009;6(1):31–39 10. Ryan M, Shattuck A. Treating AIDS with Chinese medicine. Pacific View Press 1995. ISBN 978-1881896074

(£1.72). Buy from Amazon http://amzn.to/2qCxc1T 11. Austin M. Acupuncture therapy, 2nd edn. ASI 1978. ISBN 9780882310039 (£8.97). Buy from Amazon http://amzn.to/2si2Qmo 12. Shu JJ, Sun Y. Developing classification indices for Chinese pulse diagnosis. Complementary Therapies in Medicine 2007;15(3):190–198 13. Oshawa G. Acupuncture and the philosophy of the Far East. Tao Books 1973. ASIN B0006WK3D6 (£3.23). Buy from Amazon http://amzn.to/2saSipZ 14. Stiefvater EW. Akupunktur als neuraltherapie. Karl F 1956. ASIN: B000HGHKFK (in German) (£40). Buy from Amazon http://amzn.to/2rB1oj4 15. Lawson-Wood D. Five elements of acupuncture and Chinese massage, 2nd edn. The Book Service 1973. ISBN 978-0850321067 (£9.99). Buy from Amazon http://amzn.to/2qCooZK.

KEY POINTS nM any trigger points are also acupuncture points. nT he body tissue at acupuncture points has certain common features, most notably including connective tissue and fat. n There is a marked coincidence of acupuncture points with perforations of the superficial fascia and connective tissue cleavage planes. n Acupuncture points can often be detected by palpation as a ‘cupule’ or slight depression in the tissue which is overlaid with slightly thinner skin. n Taking note of a patient’s pulse is an important part of both Western and Traditional Chinese Medicine (TCM). n In TCM more attention is paid to the sensations gained from different layers (superficial pulse and deep pulse) by using different pressures of the fingertips at the pulse point. n In TCM the three fingers used to take a pulse sit on three specific positions. n In TCM the superficial pulse and the deep pulse detected at the three pulse positions provides information about different parts of the body. n I n TCM the pulse positions on the left wrist provide different information to the pulse positions on the right wrist. nD iagnoses are not made by pulse alone, but paying more attention to what you feel at the pulse points will put you more in tune with your patient.

ACUPUNCTURE MERIDIANS WERE TRADITIONALLY BELIEVED TO CONSTITUTE CHANNELS, CONNECTING THE SURFACE OF THE BODY TO INTERNAL ORGANS 32

Co-Kinetic Journal 2017;73(July):28-33

MANUAL THERAPY

DISCUSSIONS o you think that acupuncture points in Traditional Chinese Medicine D (TCM) are similar to the trigger points described in Western medicine? Justify your answer. Even if the language used about pulse points in TCM seems a little unusual, do you think that it is possible that sensations detected at these points could reflect conditions at different parts of the body? Discuss the reasons for your answer. Perform Exercises 1 and 2 and discuss the sensations that you can feel. How would you plan to incorporate some of the ideas from TCM into your manual therapy practice?

Palpation and Assessment in Manual Therapy (4th edn) by Leon Chaitow Handspring Publishing 2017; ISBN: 978-1-909141-34-6 Buy it from Handspring - http://handspringpublishing.com/ product/palpation-assessment-manual-therapy/ The 4th edition of Leon Chaitow’s well established and much loved book, Palpation and Assessment in Manual Therapy has been updated by Leon himself with valuable contributions from six notable musculoskeletal specialists, Sasha Chaitow, Whitney Lowe, Warrick McNeill, Sarah Mottram, Tom Myers and Michael Seffinger. CONTENTS: Chapter 1. Objective: Palpatory literacy Leon Chaitow Chapter 2. Palpation reliability and validity Michael Seffinger Chapter 3. Fundamentals of palpation Leon Chaitow Chapter 4. Palpating and assessing the skin Leon Chaitow Chapter 5. Palpating for changes in muscle structure Leon Chaitow Chapter 6. Fascial palpation Thomas W. Myers and Leon Chaitow Chapter 7. Assessment of abnormal mechanical tension in the nervous system Leon Chaitow Chapter 8. Palpation and assessment of joints (including spine and pelvis) Leon Chaitow Chapter 9. Accurately identifying musculoskeletal dysfunction Whitney Lowe Chapter 10. Evaluating movement Warrick McNeill and Sarah Mottram Chapter 11. Palpating for functional ‘ease’ Leon Chaitow Chapter 12. Visceral palpation and respiratory function assessment Leon Chaitow Chapter 13. Understanding and using intuitive faculties Sasha Chaitow Chapter 14. Subtle palpation Leon Chaitow Chapter 15. Palpation and emotional states Leon Chaitow.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: The majority of fascia perforation points are identical with TCM acupuncture points. http://spxj.nl/2s6Tk9n Tweet this: Acupuncture points can often be detected by palpation as a slight ‘cupule’ or depression under thinner skin. http://spxj.nl/2s6Tk9n Tweet this: As an exercise in palpation, the methods of TCM pulse diagnosis have much to commend them. http://spxj.nl/2s6Tk9n Tweet this: TCM identifies 12 points on the radial pulse that indicate the status of specific organs/functions. http://spxj.nl/2s6Tk9n Co-Kinetic.com

THERAPY EXPO 2017 CONFER PROGRAMME PREVIEW Theatre 11 Theatre

Theatre 2 1 Theatre

Theatre 3

Wednesday 22nd

Time

09:30 10:15

10:45 11:45 12:00 12:45 13:45 14:30

15:00 15:45

16:50 17:30

Topic

Time 09:45 10:30

Is there a role for taping in neurological conditions? Becky Duncan, Practice Principal, Neurological Physiotherapy Practice

11:00 11:45

Chris McCarthy, Consultant Physiotherapist, Manchester Metropolitan University

11:00 11:45

Embodying mindfulness in physical therapy practice Dr Hilary Abbey, Head of Research, British School of Osteopathy

12:00 12:45

Social Media for Therapists Celia Champion, Director Painless Practice

13:45 14:30

Infrapatellar fat pad of the knee - the source of all evil? Sanjay Anand, Consultant Orthopaedic Surgeon, BMI Hospitals & OrthTeam

15:00 15:45

14:55 15:40

Session delivered by Kieser

16:30 17:15

15:50 16:35

Exercise in Parkinsonâ&#x20AC;&#x2122;s Disease Julie Jones, Senior Lecturer, Physiotherapy, Robert Gordon University

16:45 17:30

Giving them wings: global integration for sustainable shoulders Joanne Elphinston, Physiotherapist, Performance Consultant & International Lecturer, JEMS Movement

11:00 11:45

Thursday 23rd

13:45 14:30

Hand & Wrist Injuries in Sport Mike Hayton, Consultant Orthopaedic Surgeon, Wrightington Hospital Session delivered by Mentholatum Shoulder Instability Jo Gibson, Shoulder Rehabilitation Specialist, Liverpool Upper Limb Unit The importance and effects of Movement Re-Education after injury Mike Antoniades, Performance & Rehabilitation Director, The Running School Anterior Knee Pain John Rogers, Consultant Orthopaedic Surgeon, OrthTeam

Time

10:45 11:45

Time

Combined movement treatment for back and neck pain: a rational approach to treating severe spinal pain

Thursday 23rd

09:30 10:15

Topic

Topic Giving them wings: global integration for sustainable shoulders Joanne Elphinston, Physiotherapist, Performance Consultant & International Lecturer, JEMS Movement ITB friction syndrome - Asses then treat or treat then assess. The journey to understanding the severity of the problem and how to keep runners running

Time 09:45 10:30

11:00 11:45

Celia Champion, Director, Painless Practice Patellofemoral Pain where are we up to on subgrouping?

12:00 12:45

13:45 14:30

14:45 15:30

Dr Claire Minshull, Rehabilitation & Conditioning Specialist, Get Back to Sport

Session delivered by Capita

Mind your language - words matter in manual therapy Dr Oliver Thomson, Senior Lecturer & Research Unit Leader, British School of Osteopathy

12:00 12:45

14:45 15:30 15:45 16:25

James Selfe, DSc, PhD, MA, GDPhys, FCSP, Professor of Physiotherapy, Department of Health Professions, Manchester Metropolitan University

14:35 15:15

Shockwave therapy for tendon injury rehabilitation Christoph Schmitz, EMS

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Julian Baker, Owner, Functional Fascia How to assess & manage patients within a Biopshychosocial context Dr Jerry Draper-Rodi, Draper-Rodi, British School of Osteopathy Session delivered by Mammoth Stop Plodding & Start Rocking Celia Champion, Director Painless Practice

Topic Session delivered by Mammoth Returning to Work, A taboo topic we should get to grips with in fully rehabilitating our patients? Heather Watson, Clinical Director & Consultant Physiotherapist, Designed2Move A new anatomy Julian Baker, Owner, Functional Fascia Improving Patient Buy-In & Retention Ethically Celia Champion, Director, Painless Practice

Demo Zone Wednesday 22nd

Biomechanics and the Sports Injury profile - what are we looking for? John Gibbons, Osteopath, Author & International Lecturer, Oxford University Sport

A new anatomy

Time

Paul Horbrough The cross education effect; a novel approach to rehabilitating the immobilised limb

Neuroplasticity - how it differs in a variety of neurological rehab settings

Thursday 23rd

Topic Stop Plodding & Start Rocking

Topic

Time 10:45 11:15 11:30 12:00

Topic Session delivered by Dynamic Tape Running assessment demonstration Mike Antoniades, Performance & Rehabilitation Director, The Running School

13:15 13:45

Session delviered by EMS

14:00 14:30

Session deliverd by BTL Industries

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RENCE

Education streams MSK

NEURO REHABILITATION

SPORTS INJURIES & BIOMECHANICS ACUTE CARE

BUSINESS WORKSHOPS

22nd and 23rd November 2017 NEC Birmingham

CPR & ANAPHYLAXIS

14:45 15:15 16:00 16:45

Spinal injury management demonstration Matthew Smale, Senior Training Manager, Lubas Medical

Wednesday 22nd

Session delivered by Keiser

Thursday 23rd Time

Therapy Update Theatre

Topic

Time 09:45 10:15 10:30 11:00

Topic Session delivered by Ergolet Spinal injury management in sport

09:45 10:30

Session delivered by Dynamic Tape

12:15 12:45

Session delivered by Keiser

11:15 11:45

Session delivered by DP Medimaging

13:15 13:45

Session delivered by BTL Industries

12:00 12:30

Session delivered by Venn Healthcare

14:00 14:30

Running assessment demonstration Mike Antoniades, Performance & Rehabilitation Director, The Running School

12:45 13:15

Session delivered by Wandis Ltd

14:45 15:15

Session delivered by EMS

16:00 16:30

Biomechanics in action - a demonstration John Gibbons, Osteopath, Author & International Lecturer, Oxford University Sport

Time

Topic

09:30 10:00

Kinesiology taping top tips Paul Coker, Medical Director

10:15 10:45

Introduction to Rockblades and modern instrument assisted techniques Dr Robert Crowley BSc DC, RockTape Instructor

11:00 11:30

Integrated treatment of Achilles and Patellar Tendinopathy Dan Lawrence, Education Director

11:45 12:15

Chiropractic techniques every therapist should know Dr Robert Crowley BSc DC, RockTape Instructor

13:30 14:00

Rocktape, Manual therapy and Exercise for knee pain Paul Coker, Medical Director

Neuro Demo Zone

12:00 12:30

Session delivered by Venn Healthcare

14:15 14:45

Self myofascial release techniques to teach your patients Dan Lawrence, Education Director

Wednesday 22nd

12:45 13:15

Session delivered by Ergolet

15:00 15:30

Combined treatment approach for improving thoracic mobility and function Paul Coker, Medical Director

15:45 16:15

Managing and Treating CrossFit and Power Athletes Dr Robert Crowley BSc DC, RockTape Instructor

16:30 17:00

Rocktape for common running injuries Paul Coker, Medical Director

17:15 17:30

Clinical Case study and open floor discussion Team Rocktape

Topic

11:30 12:00

Session delivered by Mindmaze

13:15 13:45

Virtual rehabilitation in the neurological setting - a practical demonstration

Thursday 23rd Topic

09:45 10:30

Session delivered by Mindmaze

10:45 11:15

Neurological taping demonstration Becky Duncan, Practice Principal Neurological Physiotherapy Practice

11:30 12:00

Session delivered by Ottobock

13:15 13:45

Therapeutic foot drop assessment and intervention in stroke patients Becky Duncan, Practice Principal Neurological Physiotherapy Practice

7 348 1868

Thursday 23rd

Time

Session delivered by DP Medimaging

Session delivered by Ottobock

14:45 15:15

Wednesday 22nd

Paul Lubas, Managing Director, Lubas Medical

11:15 11:45

10:45 11:15

Time

RockTape Movement Summit

The stroke shoulder - assessment and intervention Becky Duncan, Practice Principal Neurological Physiotherapy Practice

STA Conference Wednesday 22nd Topic

Time

Thursday 23rd

14:30 15:00

The STA moving forwards Gary Benson

15:30 16:00

‘Dealing with the stinger’ Rugby injury workshop Keith Burnett

16:15 16:45

The role of Strength and Conditioning in the injury rehab continuum Brendan Chaplin

17:00 17:30

Don’t under estimate the power of the mind in Rehab Nicola Elwood

Thursday 23rd Time

Topic

Time

Topic

09:30 10:00

Introduction to Rockblades and modern instrument assisted techniques Paul Coker, Medical Director

10:15 10:45

Kinesiology taping top tips Dan Lawrence, Education Director

11:15 11:45

Strength training for running athletes Andrew Caldwell and Paul Coker, Medical Director

12:00 12:30

Rocktape for Shoulders, addressing source and symptoms Dan Lawrence, Education Director

13:30 14:00

Clinical Case studies and open floor discussion Team Rocktape

14:15 14:45

Getting golfers better Andrew Caldwell

14:00 14:30

The STA moving forwards Gary Benson

14:45 15:15

Sports Science and its influence on Rehabilitiation Ryan Spencer

15:00 15:30

5 brilliant Mobilisations with movement Paul Coker, Medical Director

15:30 16:00

Primal Movement Solutions; The way we move

15:45 16:15

Stop rubbing tendons (and what to do instead) Dan Lawrence, Education Director

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MANUAL THERAPY STUDENT HANDBOOK Assessment and treatment of the elbow This article is the ninth from our Manual Therapy Student Handbook (see the ‘Contents panel’ for further details) and it describes how to assess and treat common elbow complaints. As well as listing a comprehensive assessment procedure, the treatments are described in full and have accompanying videos, which provides a great practical resource for the clinician. Read this online http://spxj.nl/1PXHgb1 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 elbow

For a full assessment of the elbow, the therapist must be familiar with the Video 1: Surface marking of the elbow region (Video with captions but no sound; J. Hatcher, 2013)

anatomy of the area and perform the observations and examinations detailed in Table 1 and Video 2.

Treatment around the elbow CAPSULAR PATTERN The capsular pattern of movement limitation at the elbow is defined by: n Most loss of flexion n Least loss of extension n May have equal loss in pronation and supination if severe.

CAUSES OF CAPSULAR PATTERN Typical causes of capsular pattern Video 2: Assessment of the elbow region (Video with captions but no sound; J. Hatcher, 2013)

ELBOW | 17-07-COKINETIC FORMATS WEB MOBILE PRINT

MEDIA CONTENTS Videos 1-8: Techniques for elbow assessment. J. Hatcher, 2013

Co-Kinetic Journal 2017;73(July):36-40

MANUAL THERAPY STUDENT HANDBOOK

LATERAL EPICONDYLITIS IS USUALLY AN OVERUSE INJURY BUT CAN BE INITIATED BY POOR TECHNIQUE IN RACKET SPORTS TABLE 1: ASSESSMENT OF THE ELBOW (J. Hatcher, 2013)

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

OBSERVATION/ EXAMINATION DETAILS 1. Anatomy

CAUSE Osteoarthritis (OA)

2. Initial observation n Face and posture and gait

Rheumatoid arthritis (RA) and other systemic arthropathies

3. History n Age and occupation n Site and spread n Onset and duration n Behaviour and symptoms n Past medical history (P.M.H.)

n Refer to GP for nS ystemic autoimmune Rheumatology opinion. disease, causing degeneration and possible n If not in acute flare-up, may use Grade A joint disruption. (Maitland Grade I and n Often severe capsulitis, II) mobilisations and may lead to joint laxity progress to Grade B and deformity. (III and IV).

Traumatic arthritis (TA)

n T rauma often not remembered. n Slow onset in the over 40s, time varies. n Pain may be severe enough to radiate towards wrist, and have night pain.

n E lbow joint derived from C5/C6 segments n Dermatomes C5/6: anterior aspect of elbow C7: posterior aspect of elbow n Myotomes C5/6: biceps/brachialis C6: pronator teres, supinator C7: triceps

4. Inspection

n n n n

Bony deformity Colour changes Wasting Swelling

5. Objective n Observe/examine state at examination rest n Palpate for heat, swelling and synovial thickening 6. Passive tests n Flexion – elbow joint (for pain, range n Extension – elbow joint and end-feel) n Pronation – superior radioulnar joint n Supination – superior radioulnar joint 7. Resisted tests n Flexion – biceps, brachialis, (for pain and brachioradialis power) n Extension – triceps, anconeus n Pronation – pronator teres (and quadratus) n Supination – biceps, supinator n Wrist extension – common extensors n Wrist flexion – common flexors 8. Additional specific tests

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

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

nM ay require mobilisation as pain allows, Grade A–B (I–IV). n May require electrotherapy and Grade A and B mobilisations.

Extension mobilisation (Video 3) Directions: 1. Patient lying supine, stand at side of bed

facing slightly toward patient’s feet. 2. Place inner hand around elbow and support patient’s upper arm between your forearm and body, place outer hand around anterior aspect of wrist. 3. Take forearm into extension while stabilising the upper arm with the opposite hand.

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

Video 4: Mobilisation of the elbow: flexion (Video with captions but no sound; J. Hatcher, 2013)

movement limitation at the elbow are shown in Table 2. Treatment choice n Mobilisations of the elbow.

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

Flexion mobilisation (Video 4) Directions: 1. Patient lying supine, stand at side of bed facing patient’s head. 2. Place inner (caudad) hand around posterior aspect of elbow, place outer hand around wrist. 3. Take forearm into flexion while stabilising the elbow with the opposite hand. 4. It may be helpful to place a pillow below the patient’s forearm as a comfortable block to movement depending on the required grade of mobilisation. Pronation mobilisation (Video 5) Directions: 1. Similar stance position to extension mobilisation but with outer hand placed around posterior aspect of the elbow joint. 2. Place inner (cephalad) hand around distal radius. 3. Mobilise by taking radius into pronation depending on grade required. 4. Grade according to clinical assessment findings. Supination mobilisation (Video 5) Directions: 1. Similar stance position as in pronation mobilisation. 2. Again, place inner (cephalad) hand around distal radius. 3. Mobilise by taking radius into supination depending on grade required. 4. Grade according to clinical assessment findings.

Video 5: Mobilisation of the elbow: pronation and supination (Video with captions but no sound; J. Hatcher, 2013)

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

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

Loose body The key clinical features are: n Intermittent twinges of pain n Painful springy end-feel either in extension or flexion n Responds well to manipulative procedure: Grade A manoeuvre under traction n May require arthroscopic removal especially in children/adolescents. Treatment choice nG rade A manoeuvre under traction. Manipulation under traction for loose body (Video 6) Directions: 1. Have patient sitting sideways on high plinth, attempting to place their chest against the raised back of the bed. 2. Place patient’s affected shoulder into abduction and place crook of elbow around edge of bed padded using a blanket or towel. 3. Place one hand over the lower forearm above wrist, and one beneath it interlocking the fingers of each hand. 4. Keep forearm in mid prone position and decide whether to go into supination of pronation (whichever is least painful). Video 6: Manipulation for loose body in the elbow (Video with captions but no sound; J. Hatcher, 2013)

5. If supinating, face opposite direction of patient; apply traction using body weight standing on one leg only (nearest the head). 6. Move arm through small range of extension using your body weight to maintain traction through range and swing forwards around the fulcrum of the elbow, simultaneously flicking into supination as you go. Maintain traction at all times. 7. If pronating, face same direction as patient, again applying traction using body weight on opposite leg (again nearest the head). 8. Move arm through small range of extension using your body weight to maintain traction through range and swing backwards around the fulcrum of the elbow, simultaneously flicking into supination as you go. Maintain traction at all times.

CONTRACTILE LESIONS Common contractile lesions of the elbow include: lateral epicondylitis (tennis elbow), medial epicondylitis (golfer’s elbow), bicipital tendonitis and bicipital rupture).

Lateral epicondylitis (tennis elbow) The key clinical features are: nO veruse injury usually, although can be initiated by poor technique in racket sports nD isplays pain on resisted extension of wrist nP ain on full passive flexion of wrist particularly when accompanied with extension of elbow nP ain on gripping, screwing or Video 7: Deep transverse frictions to the common extensor origin for tennis elbow (Video with captions but no sound; J. Hatcher, 2013)

Co-Kinetic Journal 2017;73(July):36-40

MANUAL THERAPY STUDENT HANDBOOK

using manual tools, often affecting dominant hand of manual workers such as plumbers and joiners n Potentially four areas may be affected: extensor carpi radialis longus origin; extensor carpi radialis brevis (ECRB) origin (most common); ECRB body of tendon; ECRB musculotendinous junction n Often responds well to accurate deep transverse frictions or injection, also use electrotherapy n All require rest post-treatment n Also use of Mill’s manipulation if full ROM into extension. Treatment choice n Deep transverse frictions for lateral epicondylitis. Deep transverse frictions to common extensor origin (Video 7) Directions: 1. Have patient in long sitting with arm resting on lap. 2. Place cephalad hand underneath patient’s arm and hold just above wrist, to control amount of pronation/ supination. 3. Keep forearm in mid prone position. 4. Locate the lateral epicondyle and immediately above is the lateral supracondylar ridge. 5. Place caudad thumb over tenoosseous junction so that friction occurs using the lateral border of your thumb against the supracondylar ridge, maintaining downward pressure on the common extensor origin. 6. Move your arm to cause friction transverse to the fibres of the extensor carpi radialis longus. Video 8: Deep transverse frictions to the common flexor origin for golfer’s elbow (Video with captions but no sound; J. Hatcher, 2013)

Mill’s manipulation (Video 7) Directions: 1. Have patient sitting on chair in front and below you. 2. Place your thumb of outer hand in patient’s palm with their arm fully medially rotated at the shoulder and forearm in full pronation. 3. This hand can then flex the patient’s wrist, maintaining full pronation. 4. Place your inner hand on posterior arm immediately above the elbow, and support patient’s upper arm using your forearm. 5. Slowly extend patient’s elbow to virtually full extension, then keeping your outer arm extended, perform slight side flexion of your body away from the patient’s elbow. 6. This causes overpressure on the elbow joint, and particularly on the wrist extensors. 7. Please note: this should only be performed on chronic tennis elbow lesion, and only if patient can achieve virtually full range of extension in the manipulative position!

Medial epicondylitis (golfer’s elbow) The key clinical features are: n Overuse injury n Displays pain on resisted extension of wrist n Pain on full passive flexion of wrist with extension of elbow n Pain on gripping, screwing n Potentially two areas may be affected: common flexor origin; common flexor musculotendinous junction n Often responds well to accurate deep transverse frictions or injection, also use electrotherapy n All require rest post-treatment. Treatment choice n Deep transverse frictions for medial epicondylitis (teno-osseous junction) n Deep transverse frictions for medial epicondylitis (musculotendinous junction). Deep transverse frictions to common flexor origin (Video 8) Directions: 1. Have patient in long sitting with arm

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resting in extension over pillow. 2. Support limb using caudad hand. 3. Locate the medial epicondyle and teno-osseous junction is immediately distal and slightly anterior to this point. 4. Place index finger (reinforced by middle finger) over lesion and apply counter pressure with thumb. 5. Apply friction using your arm, so that massage is transverse to the fibres of the common flexor tendon.

Bicipital tendonitis The key clinical features are: nA t distal attachment, often overuse nM aybe musculotendinous or tenoosseous junction nP ain on resisted elbow flexion and supination of forearm nR equires deep transverse frictions, or injection, and rest.

Bicipital rupture The key clinical features are: nO ften traumatic and sudden onset nC haracteristic bulge appears halfway down upper arm n E xtensive bruising is apparent nP ain on resisted elbow flexion and supination of forearm nR equires RICE (rest, ice, compression, elevation) then gentle deep transverse frictions, effleurage and stretching, use of electrotherapy.

FURTHER RESOURCES 1. Tennis elbow http://spxj.nl/2r1hmla Canadian Centre for Occupational Health and Safety 2. Jindal N, Gaury Y, et al. Comparison of short term results of single injection of autologous blood and steroid injection in tennis elbow: a prospective study. Journal of Orthopaedic Surgery and Research 2013;8:10 doi: 10.1186/1749-799X-8-10 http://spxj.nl/2rZihQz.

RECOMMENDED READING 1. Anderson MK, Parr GP. Fundamentals of Sports Injury Management. Lippincott, Williams & Wilkins 2011. ISBN 978-1451109764 (Kindle £61.56 Print £64.80). Buy from Amazon http://amzn.to/1QbemUV 2. Cyriax J. Textbook of orthopaedic medicine, vol. 1: diagnosis of soft tissue

lesions, 8th ed. Balliere Tindall 1982. ISBN 978-0702009358 (£136.44). Buy from Amazon http://amzn.to/1QbeC6o 3. Boyling J, Jull G. Grieve’s modern manual therapy: the vertebral column, 3rd ed. Churchill Livingstone 2005. ISBN 978-0443071553 (£76.62). 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 (Kindle £52.99 Print £48.17). 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. Mosby 2013. ISBN 978-0723436973 (Kindle £43.38 Print £47.69). Buy from Amazon http://amzn.to/1mwomR2 6. Magee DJ. Orthopaedic physical assessment, 6th ed. Saunders 2014. ISBN 978-1455709779

(Kindle £51.35 Print £61.99). Buy from Amazon http://amzn.to/1Kfpjsn 7. Hengeveld E, Banks K. Maitland’s Vertebral Manipulation: management of neuromusculoskeletal disorders – volume 1, 8th ed. Churchill Livingstone 2013. ISBN 978-0702040665 (£54.90 Print £57.79). 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 9780702040672 (Kindle £46.55 Print £56.99). 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. ISBN 978-0702029592 (£470.91). Buy from Amazon http://amzn.to/1KfpnbK

KEY POINTS nT he therapist must be familiar with the anatomy of the area in order to perform a full assessment. n The capsular pattern of movement limitation at the elbow is defined by: most loss of flexion; least loss of extension; may have equal loss in pronation and supination if severe. n Causes of capsular pattern at the elbow are often osteoarthritis, rheumatoid arthritis and other systemic arthropathies, as well as traumatic arthritis. n The treatment for capsular pattern is mobilisations of the elbow. n A common cause of non-capsular pattern of movement limitation in the elbow is loose bodies and the treatment is the loose body manoeuvre. n Common contractile lesions of the elbow include: lateral epicondylitis (tennis elbow), medial epicondylitis (golfer’s elbow), bicipital tendonitis and bicipital rupture.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: A common cause of non-capsular patterns of movement limitation in the elbow is the presence of a loose body. http://spxj.nl/1PXHgb1 Tweet this: Common contractile lesions of the elbow include lateral and medial epicondylitis, and bicipital tendonitis and rupture. http://spxj.nl/1PXHgb1

THE AUTHOR Julian Hatcher Grad Dip Phys MPhil, MCSP FOM is a senior lecturer at the University of Salford and the programme leader for BSc Hons Sport Rehabilitation programme, having created it 1997. Previously he was senior physiotherapist in Orthopaedic Medicine at Warrington Hospital Trust from 1987–1997. He also worked in Rugby League (including Great Britain BARLA Rugby League) for 7 years as well running his own Sports Injuries Clinic in Warrington up until 1997. Julian became a Fellow of Orthopaedic Medicine (FOM) in 2000, and Certified Strength & Conditioning Specialist in 2005. After starting with a Graduate Diploma in Physiotherapy (Grad Dip Phys), he gained his Master of Philosophy (MPhil) from the University of Salford in 2007 and has several publications around the knee particularly concerning topics such as ‘ACL deficiency: detection, diagnosis and proprioceptive acuity’ and ‘Osteoarthritis long-term outcomes’. Julian is also an Honorary Member of British Association of Sport Rehabilitators and Trainers (BASRaT). Email: J.Hatcher@salford.ac.uk

DISCUSSIONS hat is the purpose of performing bilateral elbow W movements during the assessment of the elbow? hat is the common site of lesion for tennis W elbow? Under what circumstances may it be appropriate to perform Mill’s manipulation? What are the consequences of having steroid injections for tennis elbow?

RELATED CONTENT Other Co-Kinetic content for students http://spxj.nl/1QXQkOx

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

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INTRODUCTION This article discusses 13 steps that are crucial for developing your business. The tasks are listed in priority order, with task 1 being the most important, but as you get the fundamentals in place, the tasks grow in their ability to have impact. It is important, however, to get the fundamentals in place first. Over the last few months, I’ve been working with my Done For You Marketing clients and during this process I’ve been drilling down to find the 20% of marketing activities you can do, that will give you 80% of the marketing rewards. It turns out that it’s much easier to see the wood for the trees when it’s not your forest, and I get a massive kick out of helping you guys to save time while also building a thriving business, so this article is particularly exciting for me. If somebody had come along to me when I was starting out as a green inexperienced entrepreneur and totally novice publisher all those 19 years ago, and said, “Hey, you know, if you do these 13 things well your business is going to fly”, I would have bitten their arm off for that list. And you know the best part of all? Every one of these tasks is totally achievable even for the most technophobic luddite. And if you’re still not convinced you’re up to the challenge, I’ll point you in the direction of people who can help you.

YOUR MARKETING MISSION SHOULD YOU CHOOSE TO ACCEPT IT Work from the top of the list down, they’re listed in priority order, and if you’re really pushed for time, set yourself the task of doing one job each week and keeping on track. If you’re a shit-or-bust kind of person like me, set aside a day and go at it full on. Most of the time I don’t manage to everything I set out to do, mainly because I’m hopelessly over-optimistic, but you know the saying, ‘if you shoot for the moon even if you miss you’ll land among the stars’. Focus on each task as if your life depends on it, because the success and health of your business literally Co-Kinetic.com

13 STEPS TO BUILDING A THRIVING THERAPY BUSINESS If you do these 13 tasks well, I guarantee that you will build a thriving therapy business, with a constant stream of fresh, new, cash-paying clients, as well increasing loyalty among your existing clientele. Sound too good to be true? Well it isn’t – we’ve put it into practice and it works. For each task I will explain the rationale behind why each task appears in the list and, wherever possible, give you links to practical resources to enable you to implement them. Most of the tasks you should be able to do yourself, or with very minimal help. Read this online http://spxj.nl/2sFEiaV BY TOR DAVIES, CO-KINETIC FOUNDER does! Some of the tasks on this list are one-off set-up jobs which you should be able to clear off quickly and once they’re done, they’re done. Then you have time to concentrate on the ones that need ongoing attention. Don’t be put off by the thought of having to create all the content we talk about in Part 2 of the article because we’ve got that covered, just focus on getting the foundations and infrastructure in place so that it can allow the magic to happen.

17-07-COKINETIC FORMATS WEB MOBILE

MEDIA CONTENTS ‘10 Website Home Page Essentials for Winning New Clients’ http://spxj.nl/2seLPuS ‘Optimising Your Physical Therapy Website to Generate New Leads’ http://spxj.nl/2qiQsSM ‘5 Things You Can Do in An Hour to Increase Your Google Search Profile’ http://spxj.nl/2sCSHVy PDF version of the presentation 13 Mission Critical Steps (see online version of this article) Google Review Handout PDF (see online version of this article) 30 Day Free Trial to Lynda.com http://spxj.nl/2rzcGj6

PART All 1: ONE-OFF Access SET-UP JOBS

a la carte ACTIVITY #1 GET A WEBSITE IN PLACE AND MAKE SURE IT’S MOBILE-FRIENDLY Why Do I Need a Website for my Therapy Business? Having a website shows legitimacy. It helps you establish credibility and gives people a reason to trust you as well as a way of contacting you and reading more about the services you offer. It’s your online shop front. It helps you promote offers, establish expertise, offer social proof from other users of your services (more about that later), provide useful, value-added information to help solve the needs and problems of your website visitors and build trust, and very importantly it also offers you a way to collect email leads which you

THE

STEPS TO BUILDING A THRIVING THERAPY BUSINESS

ONE-OFF SET UP JOBS

1 Make sure your website is fit for purpose 2 Make sure Google Analytics is installed on your website 3 Set up a free Google My Business listing 4 Get your Business onto Facebook – set up a Business Page or Profile 5 Set up a YouTube channel for your business 6 Set up an email collection/lead generation process 7 Install Google Tag Manager (and then add the Google Retargeting Remarketing and Facebook Pixel) on your website

ONGOING JOBS

8 Build up your Google and Facebook Reviews and Testimonials 9 Run regular programmes of ‘free’ education, advice sessions

or assessments marketing & business 10 Create lead generation (lead magnet) resources that you give development advice away in return for email addresses 11 P ublish regular social media images, posts and videos on Facebook that leads onto either a downloadable lead magnet or one of the education/assessment sessions mentioned above

12 Publish regular videos on YouTube as well as Facebook and your website 13 P ublish great quality content on your website/blog/Facebook that helps solve the problems of your ideal patient

can nurture through your ‘customer acquisition funnel’. It’s important that your site is mobile-friendly (known as responsive) for two reasons: the first is that Google ranks mobile-friendly websites more highly than non-mobile-friendly sites; the second reason is that mobile traffic is on a massive ascendency thanks to the increasing size and use of mobile devices (if you’re in doubt about whether you need a responsive site have a look at your Google Analytics visitor data for mobile users).

How Do I Build a Website Without it Costing a Fortune? If you haven’t already got a one, there is one particularly great solution, WordPress. WordPress.com is a website and blogging platform used by literally millions of people, many with little or no technology skills, as well as many with very advanced technology skills and it works for everyone. There are simple ready-made themes that you can use as the basis of your site and it can grow with you. You don’t need to install anything, you just need to choose your website domain name (http://www.yourwebsitename.com/) and build your site (or get someone else to do it for you). There are loads of free beginner tutorials on the internet about building WordPress websites from scratch but I’m a big advocate of Lynda.com, which provides very well structured courses on just about anything, and for the cost of £12.95 a month, a month’s subscription will be worth its weight in gold and even better you can get a 30 day free trial (links and info below). The best bit about WordPress is that there are literally hundreds of thousands of ‘plugins’ (ready-made bits of software that you can install in a couple of clicks of a button) that let you add just about any functionality you could dream of. It is such a hugely popular platform, nothing else comes close to it. It can cope with the smallest and the biggest jobs. In fact, I very nearly used it as the basis of the CoKinetic publishing platform, and I’ve built three web publishing platforms over the last 20 years, so I like think that I know my stuff when it comes to content platforms. Co-Kinetic Journal 2017;73(July):41-48

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If you don’t know where to start why not use our favourite outsourcing tool, Fiverr, and search for ‘build a WordPress site’. There are plenty of people out there to help you, and cheaply, but make sure you go for quality. You don’t want your site looking cheap and nasty and make sure all text on the site is accurately spelt. Read our article (see Helpful Resources) on the 10 elements you must include on your home page.

Already Got a Website in Place? Excellent. Make sure it’s mobile-friendly, and make sure to read our article ‘10 Website Home Page Essentials for Winning New Clients’ (http://spxj.nl/2seLPuS) to make sure you have everything you need, if not on the home page, then easily accessible elsewhere on the website. We also give you loads of useful resources that will literally help you write your website as you work through it. Helpful Resources n For more info on WordPress visit https://wordpress.com/ n For beginner level WordPress training sign up to Lynda.com and follow the course WordPress.com Essential Training http://spxj.nl/2sJiXxP) n Use our article on ‘10 Website Home Page Essentials for Winning New Clients’ (http://spxj.nl/2seLPuS) n We published a follow-up article to the one referenced above on ‘Optimising Your Physical Therapy Website to Generate New Leads’ (http://spxj.nl/2qiQsSM) which unsurprisingly includes some of the components mentioned in this article n And don’t forget our most popular marketing article to date: ‘5 Things You Can Do in An Hour to Increase Your Google Search Profile’ (http://spxj.nl/2sCSHVy)

ACTIVITY #2 MAKE SURE GOOGLE ANALYTICS IS INSTALLED ON YOUR WEBSITE What is Google Analytics? Google Analytics is a phenomenally powerful FREE service provided by Google! It is the de facto internet standard in web analytics and although Co-Kinetic.com

there are many other analytics programmes that offer lots of bells and whistles and some really great additional functionality, to be honest it’s unlikely you’ll outstretch Google Analytics unless you start moving into really advanced analytics.

Why is Google Analytics So Important to My Business? Google Analytics provides you with all sorts of critical information around what pages are generating the most leads for you, which pages are the most widely read, or the most underperforming, how much time people spend on all the pages on your site, whether they are new or returning users, what devices people are accessing your site on … and so on. The level of detail you can drill down to is almost overwhelming. Again Lynda. com has lots of really good Google Analytics courses pitched at all levels, I’ve done many of them. Links below. Marketing is all about numbers. To get great results, you’ve got to know your numbers and if you have no means of tracking or measuring what you’re doing how can you see what works or how to improve? Your time is the most valuable thing you have. If you’re going to spend time on marketing activities, taking you away from seeing paying clients, you have to be able to measure impact and return on investment (ROI). Online marketing and social media marketing should NEVER be done without a strategy and strategies require SMART targets (specific, measurable, achievable, realistic, time-based) to establish what is and isn’t working. Google Analytics gives you pretty much everything you need, it costs nothing and it’s easy to install so there’s no good reason not to use it.

installed, fire your web developers now. I mean it! A web developer that didn’t install Google Analytics when they built your website, doesn’t deserve to call themselves a web developer and any excuses they offer as to why it’s not installed … well, as I say, fire them! There’s absolutely no good excuse. Installing Google Analytics is incredibly easy for any web developer, even an amateur with access to the administration end of the website could do it. If your web developers want to charge you (and you still haven’t fired them) it takes no more than a few minutes to do, 10 minutes at the most, so don’t let them take you for a ride! And if you are asking them to install it then why not kill two birds with one stone and knock out task 7 at the same time by asking them to install Google Tag Manager along with Google Analytics. Both installations require small pieces of code to be added to each page of your website (both can be done at the same time and it takes no time at all). For more information about Google Tag Manager read Goal 7 below – it’s well worth doing and will save you having to ask your web developers for help in the future. And if you have fired your website designer, good on you. Instead why not use someone like this guy (http://spxj.nl/2szlTgi) to do it for you for less than £20. I’m a big fan of Fiverr. We use it for all sorts of things and it’s a great way to get very specific jobs done very cheaply. You’d be amazed at the level of detail of jobs you can get done for very low fixed costs.

Marketing kits

marketing & business development advice

How Do I Get Google Analytics Installed on my Website? First things first, if you’re not sure whether Google Analytics is installed on your website, go to the GAchecker. com (http://gachecker.com/) site, enter your website address and you’re looking for lots of nice ticks in the third column of the results. If you’ve had a website built by web developers who you still employ, and Google Analytics is not already

Client Materials

Helpful Resources n Lynda.com course Google Analytics Essential Training (http://spxj.nl/2ssAEAN) n See Activity 7 for more information on Google Tag Manager and Google Retargeting

ACTIVITY #3 SET UP A GOOGLE MY BUSINESS LISTING As we all know, Google dominates 80% of all web search traffic. It has been number 1 on the list of most visited websites for a while now. In the past, its nearest competitor has been Facebook but as of 3 April 2017 YouTube jumped up to position 2 sending Facebook down to position 3. As Google owns YouTube, that should just about say it all. If we want traffic, we have to play nicely with Google. Setting up a Google My Business listing is a no brainer and it’s free to set up (Fig. 1).

Why is a Google My Business Listing So Important to your Business? Very simply it helps your business appear in search results when people search for local businesses providing the services you provide. It also provides a very quick route through to calling you, visiting your website or getting directions to your place of work (assuming you’ve added these details into your listing). It’s a must do, hence the reason it is so far up the list. Put a

Figure 1: The Co-Kinetic Google My Business listing Figure 2: Three Ways to tell how good a Fiverr seller is 44

check in your diary to keep the details updated. It also provides an easy way for people to review you. More about that in Activity 8.

Having a Facebook page brings a whole host of benefits, ten very good ones are outlined in the article below under Helpful Resources.

How Do I Set Up a Google My Business Listing?

How Do I set up a Facebook Business Page?

To get started, visit www.google.co.uk/ business (https://www.google.co.uk/ business/) and click ‘Get onto Google’, enter your business name and address and click search. If you don’t find a match, click ‘Add your business’. You’ll be asked to verify your information and then taken on a tour of Google My Business! Easy!

The main thing you need is a profile cover image along with a picture of you or your logo. If you don’t know where to start with that, don’t let it put you off, this is a perfect job for Fiverr. There are literally hundreds of people who can create profile images for you for less than a pint of beer! You can also use your own pictures if you have them. Jobs on Fiverr are called ‘Gigs’. There are three great ways to quickly and easily establish how good a ‘seller’ on Fiverr is. Look at their star rating with the number of gigs they’ve done and how many times people have favourited that seller (Fig. 2). The higher the number of all those, the better your chance of having a great experience.

Helpful Resources nW e give more information in our article ‘5 Things You can Do in Less than an Hour to Increase your Google Search Profile’ (http://spxj.nl/2sCSHVy)

ACTIVITY #4 GET YOUR BUSINESS ONTO FACEBOOK Even if you hate Facebook (and you won’t be alone), as of April 2017 1.2 billion people are logging in every day and the odds are very good that a chunk of these will include many of your existing clients, as well as lots of potential new ones. Better still over the last 12 months Facebook have made some MAJOR improvements to the advertising opportunities available through the Facebook Ads platform, allowing you to target with the most amazing accuracy, people who match the profiles of your own clients and visitors to your website. So at the very least you should have your Facebook Pixel installed on your website (see Activity 7) even if you don’t want to do any Facebook advertising just yet. We’ll come back to the Facebook Pixel later.

Helpful Resources n T op 10 Benefits to Having a Facebook Business Page (http://spxj.nl/2ruEQkp) n F iverr search results for Facebook Profile Image design (http://spxj. nl/2seL5pB) n2 2 Facebook Post Ideas for Businesses (http://spxj.nl/2swipeK) n 1 7 Killer Facebook Post Ideas for Small Business Owners (http://spxj.nl/2sDCxLr)

ACTIVITY #5 SET UP A BUSINESS YOUTUBE CHANNEL If your first concern is what on earth you’re going to put on your channel, don’t worry, we have a solution to that, but why bother with a YouTube channel in the first place? YouTube is the second most visited website in the world and the second biggest search engine, it’s also owned by Google so given it requires very little effort, and we can provide you with regular video footage to keep your channel fresh, you’ve got nothing to lose. It may also have an impact on the findability of your business.

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How Do I set up a YouTube Business Channel? Again this is a perfect solution for Fiverr. A link to potential providers is included in the Helpful Resources below. The main requirement again is a channel banner so it doesn’t take much to tick this one off the list. Don’t procrastinate by thinking you’ll save the money and do it yourself, it’s so low cost, your time is more valuable spent elsewhere and it’s probably not your expertise either, so let someone else do it who can do it in their sleep! Once it’s set up, if nothing else, post the videos from our ready-made social media kits to your channel. We produce 4–5 new videos a month, so they soon stack up and all of them contain useful injury prevention tips that your visitors will enjoy. Helpful Resources n Search Results for Setting up a YouTube Channel (http://spxj.nl/2rkHqVT)

ACTIVITY #6 EMAIL COLLECTION Being able to collect email addresses in exchange for offering a useful value-added downloadable resource (also known as a lead magnet) is probably the most valuable marketing tool in your collection. Lead generation, as it’s known, should be a key purpose of your website. It involves creating a web page that includes a simple form asking for first name and email address. Generally, the more fields you include, the less likely a visitor is to complete the form so keep them to a minimum; we’d suggest just fields for just a first name and an email address. If the thought of creating a web page and adding a form sounds intimidating, don’t worry it’s not, and there are lots of tools out there to help. We’ve used three landing page tools, Leadpages, Unbounce and Instapage (my current choice). They all charge for the service (between £25 and £30 a month for the basic package). I love how easy Instapage Co-Kinetic.com

is with its drag and drop editing but Leadpages has also just introduced the same functionality and is a very widely used landing page tool. If you have a WordPress website there are lots of plugins that allow you to add landing pages to your WordPress site. I’ve included a link in the resources at the end of this section. You can also use Instapage to publish directly to Wordpress sites and Facebook pages. You can also link these tools to the more widely used email platforms such as Mailchimp and Constant Contact so new leads are automatically added to your email list. There are other ways of offering downloads without paying for the software. You could ask them to sign up to a Mailchimp list directly, or use a very simple SurveyMonkey page (which has a free plan) but these landing pages have to drive conversions, ie. sign-ups, so if they look cheap and shoddy, it’s likely to compromise their success. Here’s an example of one of our latest landing pages (http://spxj.nl/2swIQQi). Click the ‘Learn More’ button and you’ll see a nice simple pop-up box containing a form. In our content marketing kits we even give you the text and images for a landing page for each resource we create. All you have to do is add your logo and contact details and and you’re off. Here’s a recent lead collection landing page we created for one of our Done For You Marketing clients (http://spxj.nl/2rDnQ6t). We also provide a ready-to-go Instapage template as part of our own marketing kits. You could also use Fiverr to commission someone to build a page for you. Helpful Resources n Instapage (http://spxj.nl/2rvAY2j) – Co-Kinetic’s landing page tool of choice n L anding page Wordpress plugins discussed by Blogging Wizard (http://spxj.nl/2rAemsy) and WPKUBE (http://spxj.nl/2rkCpMN)

ACTIVITY #7 INSTALL GOOGLE TAG MANAGER (AND THEN INSTALL THE GOOGLE REMARKETING TAG AND THE FACEBOOK PIXEL) This is the last task in our list of set-up jobs and one that you probably want to ask your web developer to do for you, OR you could use Fiverr again. Just type into the Fiverr search box ‘install google tag manager’ and then sort by Average Customer Review and you’ll get a bunch of people who can help you do this, if you don’t have a web developer on hand. It is very simple to do. It involves logging into Google Tag Manager with your Google account, and following the step-by-step instructions to generate a small piece of code that needs to be added to each page on your website (or the style sheet). Google Tag Manager allows you to quickly and easily update and install other tags on your website without involving a web developer each time. This means you can then install the Google Remarketing tag and the Facebook Pixel on your website (or you can ask your Fiverr person to do that at the same time – it’s commonly done together).

What is the Google Remarketing Tag and the Facebook Pixel? Basically when someone visits your site the pixel (a bit of code on your site) triggers a cookie (a piece of code on a third party site such as Facebook or Google), to start tracking what people do on your site. You can then use this information to ‘remarket’ to that person once they leave your site. Remarketing or retargeting is what happens when you visit big websites like Amazon and you look at a product. Then all of a sudden you see Amazon ads of that very same product, popping up all over other web pages you visit. At the very simplest level, you could just use a visit to your website, to deliver simple ads for your business to remind them of you and prompt them to take an action you want like download a resource or book a free assessment. At a more sophisticated level you could target them based 45

on which pages they visited. If you’ve published an article on tennis injuries for example, you could have a set of remarketing ads that offered a downloadable rehabilitation leaflet for tennis elbow. When they click the link, they go to a landing page (as described in Activity 6) and enter their email address in return for downloading the leaflet. Remember that until you capture a client’s email address, have no direct access to that individual. Google Remarketing is also very cheap, which makes it a no brainer even if you do it at the very simplest level. The Facebook Pixel is a similar

concept. It can be used as part of an advertising strategy on Facebook; however, it also allows you to build lookalike audiences on Facebook based on a wide range of characteristics that you can define, including geographic location. This makes it a very powerful tool for attracting new customers. Even if you don’t want to start using Facebook advertising any time soon, the sooner you install the Facebook Pixel on your site, the sooner Facebook starts collecting data that can help you later, if you do decide to venture into Facebook advertising (and there is a lot to be said for it, but that’s a topic for another day).

Helpful Resources n About Google Tag Manager (http:// spxj.nl/2rzFJ6m) n About Google Remarketing (http://spxj.nl/2s56vXD) n The Facebook Pixel: What It Is and How to Use It (http://spxj.nl/2tqrGBm) n Fiverr results for people who can help you install Google Tag Manager (http://spxj.nl/2s59NKw) (remember to sort by Average Customer Review)

PART 2: ONGOING JOBS OK this is where the fun starts and where you’re probably starting to feel a bit nervous but don’t worry, help is at hand.

ACTIVITY #8

Figure 3: Review ratings and Google My Business

BUILD UPYOUR GOOGLE AND FACEBOOK REVIEWS AND TESTIMONIALS So the first 7 activities have been super-critical for giving you a rocksolid foundation, but task number 8 comes right at the top of Part 2 of this article. Assuming the first 7 setup tasks are completed, this activity

Figure 4: The Google 3 Pack Results

is possibly the single biggest game changer to you, in the current climate of digital marketing.

Why are Customer Reviews So Important for Health Professionals? Social proof as it’s also known, is MASSIVE right now. After direct word of mouth referrals, testimonials are one of the most powerful customer conversion tools. Customer reviews build trust, they talk to each of us on the basis of one-to-one, they aren’t salesy and they resonate with us better than any other type of web copy.

Figure 5: How do Users Pick a Business from Google’s 3 Pack? (BrightLocal)

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Why Google Reviews Trump Most Other Reviews Google’s mission is to give searchers the best, most relevant results. That equals a happy searcher, great click-through rates and a happy Google. In fact reviews are becoming one of the main ways that Google is using to rank it’s results, particularly the Google 3 Pack results (Figs 3 & 4) The three listings that Google chooses to display are the results of algorithm that few understand but three factors that have a significant impact on those results include: 1. Continuity and consistency of business listings across the web 2. The existence and mobile friendliness of the associated website 3. The number and quality of reviews and testimonials If you have these three pieces in place, you’re likely to rank higher and, as Figure 5 shows, earn a lot more click-throughs. As you can see from Figure 5, 65% of choices come down to reviews or being top of the list. According to the well-respected SEO software company Moz, traffic generated by reviews accounts for 10% of all web traffic and this is growing every day with Google’s increasing focus on reviews as a means of establishing credibility. Helpful Resources n How Online Reviews Impact Search and Consumer Attitudes (http://spxj.nl/2tqBnj6) n Understanding Google’s Local 3 Pack (http://spxj.nl/2swC5z7) n Six Innovative Testimonial Trends for Your Business in 2017 (http://spxj.nl/2swslEI) n Why Google Reviews Might Just Be More Important Than Other Reviews (http://spxj.nl/2swAJEj) n Why not use our Google Reviews Handout to give to clients which tells them not only how to post a review but also offers tips on how to give a good quality review – see the Media Contents panel.

Co-Kinetic.com

Figure 6: Simple Lead Generation Process

LEADS W

LEAD GENERATION

EXPLORE & EDUCATE

LEAD MAGNETS

Injury on nti abilitation Articles Preve ce Workshops/ Reh ﬂets & Lea Downloa Adv Presentation ds s Exercise Screening Videos Biomechanical Ass Free essme Analysis Tests nts

NURTURE CONVERT ENGAGE

EMAIL NURTURE SEQUENCE FACE TO FACE ENGAGEMENT (CONVERT) APPOINTMENT BOOKING (ENGAGE)

cards Posters Post ailings Emails to & M Social Media Your Clients Posts & Videos cal Media Atte nd or Articles in Lo Pad aids Sponsor Ev ents

Offer Advic e Add Value Lead to next step

Worksho Free p/ P t resentat en sm Asses ion

Biomechanical Analysis

Figure 7: The Ultimate Lead Conversion Model for Therapists

ACTIVITIES #9–12 ENGAGE IN SOME HIGHQUALITY CONTENT MARKETING OK so this is where the magic really happens. Assuming you have Google Analytics installed, your Facebook and YouTube business pages up and running, and the ability to collect email address leads in exchange for offering high-value ‘lead magnet’ content downloads, this next part is the element that will convert your business from one that survives, to one that thrives, and thrives consistently over time. All this requires is a simple sequence of events. Each month, choose and run a content promotion campaign. This could just involve generating online leads by running a fairly simple social media promotion with social media posts and videos, which leads to a landing page, which offers a ‘lead magnet’ (high-value download) in exchange for an email address and then ushers that client into a simple email nurture campaign where you build your relationship with those leads over time by regularly sending them high-value, relevant, useful resources (Fig. 6). Or you could take things one step further and combine both online and

THE AUTHOR Tor began her professional life training as a physiotherapist at Addenbrookes Hospital, Cambridge, UK. She went on to complete a BSc in Sport & Exercise Science at the University of Birmingham while also achieving a tennis ranking. After graduation she worked in marketing with a London agency and then moved into medical journalism where her passion for publishing was born. At 27 she established sportEX medicine, a quarterly journal for physical and manual therapists. With a passion for technology as well as publishing, Tor’s leadership grew sportEX into the Co-Kinetic journal and website which included a more collaborative, royalty-based form of publishing as well as a wider content remit. Tor’s focus is on providing resources to help therapists develop their professional authority and brand, and grow their own businesses while working more efficiently and effectively, a topic that she speaks regularly about at global conferences.

offline promotions that lead again to a high-value lead magnet, but which then goes the extra step entering that individual into an email nurture sequence focused specifically on the topic at hand, which is designed to generate sign-ups to some sort of free or cheap/low risk face-to-face assessment, seminar or presentation (Fig. 7). While this may require you to invest a little more time at the on-site assessment or face-to-face interaction, the conversion rates to appointment bookings is likely to be much better. It is exactly these campaigns that we develop through the Co-Kinetic Marketing Kits. We document the entire campaign, offer suggestions of the potential on-site assessments you can run and even give you Facebook ad material and guidelines to help you promote the events. We also create all the other resources you need including the social media posts, videos and lead magnet downloadable resources. Helpful Resources n For more information about our marketing resources please visit https://co-kinetic.com

ACTIVITY #13 PUBLISH HIGH-QUALITY ARTICLES ON YOUR WEBSITE OR BLOG Unfortunately, we are unable to help with this very last task because Google severely punishes the publication of the same content on multiple website pages. This means we’re unable to write the articles for you to publish, but we do give you a set of bullet points around which you can write a short article to publish on your website which leads to the lead magnet/downloadable asset. Remember not to give away all the information from your lead magnet resource, otherwise there is no reason for them to give you their email in exchange for the download.

CONCLUSION In conclusion this article identifies the 13 key activities that you can undertake to create a strong marketing infrastructure, promote your business in a non-salesy way and create a regular stream of fresh, enthusiastic new customers by providing value-added services that help solve the problems and needs of your customers.

KEY POINTS n Working on the marketing aspect of your business is vital. nT here are certain marketing activities that will offer the best reward for effort. nD one well, these activities will give you new clients and increase loyalty in existing patients. nT he activities are straightforward to achieve, even if you really hate technology. n F ocusing on one of the tasks at a time will let you get through the list even if you think you don’t have time to do them. nB uilding a website doesn’t have to be difficult or expensive. n L ead generation (collecting potential clients’ email addresses) is crucial. nO nce the basics are in place, the next aim is to publish high-quality content on your website as well as Facebook and YouTube.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: A website is your online shop front http://spxj.nl/2sFEiaV Tweet this: Google Analytics is the de facto internet standard in web analytics http://spxj.nl/2sFEiaV Tweet this: Marketing activities need measurable targets to establish what is and isn’t working http://spxj.nl/2sFEiaV Tweet this: Reviews and testimonials (‘social proof’) are one of the most powerful customer conversion tools http://spxj.nl/2sFEiaV

Co-Kinetic Journal 2017;73(July):41-48

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. @BJSM.BMJ

ACL injury mechanisms - a key issue in #SportsMedicine http://spxj.nl/2s64n00

THE BEST OF FACEBOOK

@sportsmedicineaustralia

An Australian invention will aim to improve concussion diagnosis to help combat concussion in sport. A mouthguard containing a microchip which can measure the force a player receives in game will be trialled in a local Victorian football league. Read more here; http://spxj.nl/2s7BGCO

THE BEST OF TWITTER

TWEETS

3,230

FOLLOWING

1,170

@SamDBrodie

FOLLOWERS

63 Actionable #ContentMarketing Insights from @neilpatel - don’t miss the “effective outreach” section! http://spxj.nl/2sjzt6V

CO-KINETIC ON SOCIAL MEDIA https://www.facebook.com/CoKinetic https://twitter.com/sportexjournals https://www.linkedin.com/groups/4048152 https://pinterest.com/co_kinetic

5,064

Join in!

@docandrewmurray

Are these companies chiefly concerned about a balanced lifestyle or selling you their product? Via @BJSM_BMJ http://spxj.nl/2snWp5A

https://www.instagram.com/co_kinetic/ Co-Kinetic.com

@KineticRev

What is The Windlass Mechanism of The Foot? http://spxj.nl/2rQ0MDt

@RobertLustigMD

A fresh perspective on the prevention and treatment of #CoronaryDisease. http://spxj.nl/2rTCjgy

@NHSMillion

@mickwhughes

50% of ACL injuries AND 20% LL injuries can be prevented with NMTs. They cost little & ↑performance measures #WinWin http://spxj.nl/2s88741

THIS

TS HIGHLIGH ’S R E T R QUA

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 Scientific Art - http://spxj.nl/2sXuzta l H uman Kinetics - http://spxj.nl/2rPWdJg l Massage Therapy Training - http://spxj.nl/2qZZPac

The NHS is not perfect, but staff do extraordinary things every minute of every day and we have a lot to be proud of - pls RT if you agree http://spxj.nl/2t1yNQt

CHECK OUT ON YOUTUBE: l l l l

Physiotutors - http://spxj.nl/2rPJhTr Modern Manual Therapy - http://spxj.nl/2sHe6K9 Physical Therapy Nation - http://spxj.nl/2r01OeI Kinetic Sports Rehab - http://spxj.nl/2sXKTKt

CHECK OUT ON INSTAGRAM: l l l l

mskrehab - http://spxj.nl/2qZSSpJ muscleandmotion - http://spxj.nl/2sju2F4/ anatomianatomy - http://spxj.nl/2rVTcsu anatomia.repost - http://spxj.nl/2sj2Mq0

Co-Kinetic Journal 2017;73(July):49-50

Done For You Marketing

Let Us Help You Do the Following: lB ook more appointments through our non-salesy email promotions lB ring more visitors to your website using our client-facing newsletter lO pen communication with prospective new customers through your social networks l Expand your marketing reach by collecting email prospects lD evelop loyalty and trust with your current customers l Build authority and credibility in your industry lG row your social media followers and influence l Strengthen relationships with existing and new customers by providing value with no strings attached lS ave yourself valuable time, hassle and stress

How?

Every month we will create, brand and implement the following marketing for you: l 2 x customer emails - one content-rich ‘nurture’ email and one appointment-driving email (we’ll even send the emails out for you) l 1 x professionally designed and branded lead generation resource designed to help you collect new leads and strengthen relationships with existing and prospective customers l 15 x branded social media posts including images to grow your follower base and build authority (we post them to your social networks too) l 5 x animated branded video posts to really grab attention on your website or social networks l 1 x trackable telephone number to monitor campaign success and return on investment l Google Remarketing - branded ads which we create for you, and which will “follow” your prospective customers around the internet on some of the biggest websites in the world l We’ll encourage customer reviews and with it boost your Google search ranking as well as your reputation.

But there’s a catch! Only 49 licences remain Because we don’t want to end up working for two people in the same area, we’ve segmented the country into just 100 available licences and over 50% of these have gone since we launched on the 1st March.

The facts l I t costs £299+vat per month lY our area remains exclusive to you while your subscription is live l T here’s no contract - you can cancel at any time

TIME-SAVING RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

For more information and to check if your geographical region is available visit https://doneforyou.co-kinetic.com/

2017 Conference

Saturday 16th September 2017 Venue: De Vere Beaumont Estate, Burfield Road, OLD WINDSOR, Berkshire SL4 2JJ Registration: Opens at 08.30 Conference welcome with Paul Medlicott at 09.15 Emma Holly - Presentation

Tor Davies - Presentation

How many of your clients have had surgery? Probably more than you think, many even fail to mention surgeries or scars in consultations. The impact of scar tissue and adhesions on mobility and function is often overlooked, even minimal scars of endoscopic surgery can leave lasting damage in the tissues. Emma is a leading ScarWork practitioner using a fresh approach to improve scarring. Learn more in this talk on scars and adhesions. Different from myofascial scar release, ScarWork is a dry manual therapy. Treatment stays within comfort levels to encourage healing, encompassing not only the scar, but the surrounding area, where congestion in tissues has often been created during healing. ScarWork benefits the client, but the gentle techniques, minimise strain on the therapist. Emma’s afternoon workshops will develop her morning presentation starting with a demonstration of scar tissue assessment using a volunteer and develop into group work. Please note, volunteer(s) will be needed.

Tor will demonstrate a simple formula to guarantee an evergreen supply of new clients. Practical advice on how to implement the steps will be included plus access to a free massage marketing kit so you can test the formula. The kit will include all you need to run the campaign along with step by step execution instructions covered in the session. Tor began professional life training as a physiotherapist at Addenbrookes Hospital. A Sport & Exercise Science BSc followed whilst achieving a WTA international tennis ranking. She later trained as a marketeer and moving into medical journalism where a publishing passion blossomed. She established sportEX medicine, a journal on sport and exercise medicine. Tor continues the Co-Kinetic journal but has launched a marketing agency. The focus is helping therapists develop their business and work more effectively.

Investigating scars, adhesions and consequent dysfunction

Shane Kelly - Presentation

We are also very pleased that Shane Kelly, Head of Physical Therapy at British Athletics, will be presenting. British Athletics oversees the development and management of the nation’s favourite Olympic and Paralympic sport, from grassroots through to podium. Shane recently worked with us on the British Athletics/SMA initiative to create 10 positions for SMA members to work within the British Athletics Track & Field Therapists Programme and will be giving an insight into the process and the opportunities this initiative presents for the SMA members.

A 5 Step Online Marketing Plan for Growing Your Massage Business

Kelly Sotherton - Presentation

Our keynote speaker at the 2017 Conference will be Olympic Heptathlete Kelly Sotherton. She is famously a multiple Olympic medallist and a leading spokesperson for the athletic community. Kelly has recently been instrumental in creating the UK Athletics Athletes’ Commission giving, for the first time, a voice to athletes in decisions that directly affect their careers. She is also a powerful advocate for our profession having been a user of Soft Tissue Therapy throughout her sporting career. Kelly has also agreed to be our first sporting SMA Ambassador and will be working to promote the benefits of Soft Tissue Therapy within athletics and the wider sporting community. Following the presentations there could be the opportunity to ask either Kelly or Shane questions around the inside track or almost anything else that takes your fancy!

Dan Buchanan – Workshop

Owen Lewis - Workshop

Dan is a Soft Tissue and Performance Therapist in professional sport. He runs a Sports Injury and Performance clinic and works part time with Derby County. Dan is an SMA regional director interested in developing Soft Tissue Therapy standards amongst those working in professional sport. Much Soft Tissue Therapy focuses on the parasympathetic system, reducing tone, quietening, and promoting recovery and healing. How about the sympathetic/pre-performance side? What do you do about a footballer’s groin pain before a Cup Final or a sprinter feeling a reduction in power warming up? How can you facilitate their performance in those moments? Dan will demonstrate a simple protocol for application to attenuate pain and overcome inhibition prior to performance, an approach that he uses alongside his colleagues working in professional football.

Following completion of a sports science degree Owen spent a year as a fitness instructor and personal trainer. He returned to university for a master’s diploma in sports psychology. A year in San Antonio Texas saw him playing and coaching basketball at a high level. Owen has a sports massage qualification, has lectured in anatomy and physiology with an enthusiasm and insight that is infectious. He is a certified structural integration practitioner from the KMI school and teacher of Anatomy Trains. Owen will demonstrate use of the Anatomy Trains map to maximise running performance and minimise injuries taking an integrated Anatomy Trains approach to tackling common running injuries. Change your perception of running in this exciting and informative session, gaining a detailed understanding of the interplay between structure and function.

The Sympathetic nervous system. Facilitating performance in a stressful situation

Demonstrating use of the Anatomy Trains map to maximise performance and minimise injury in running

TICKETS www.thesma.org Early bird rate to 12th July: Student £80. Full member £110. Non member £140 From 13th July: Student £100. Full member £130. Non member £160

Should non members join as full members within 3 months of the conference date the usual joining fee of £25 will be waived.