Co-Kinetic Journal Issue 74 - October 2017 by Co-Kinetic

ISSUE 74 OCTOBER 2017 ISSN 2397-138X

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medicine & dynamics

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MANUAL THERAPY & SPORTS MEDICINE RESEARCH INFOGRAPHICS

39-45 ENTREPRENEUR THERAPIST

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25-32 FASCIA-RELATED 48-50

THERAPIES

ENTREPRENEUR THERAPIST WATCH 08-1 1 JOURNAL MANUAL THERAPY

REVIEW OF SHOULDER 18-24 AIMPINGEMENT CARE

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JOURNAL WATCH PHYSICAL THERAPY

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LONG OCTOBER 2017 ISSUE 74 ISSN 2397-138X

Publisher/Founder TOR DAVIES tor@co-kinetic.com Business Support SHEENA MOUNTFORD sheena@co-kinetic.com Technical Editor KATHRYN TOMAS BSC MPhil Art Editor DEBBIE ASHER Sub-Editor ALISON SLEIGH PHD Journal Watch Editor BOB BRAMAH MCSP Subscriptions & Advertising info@co-kinetic.com

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

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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 A RARE VARIATION IN THE DISTAL ATTACHMENT OF AN EXTRA HEAD OF BICEPS BRACHI MUSCLE. Alex AM, Gopal UB. International Journal of Anatomy and Research 2017;5(1):3461–3463

The foot balance for both feet was measured during treadmill running at the fastest possible 5,000m running pace in 79 healthy recreational male runners. Foot balance was calculated by dividing the average of medial pressure with the average of lateral pressure. Foot balance was categorised into those who presented a higher lateral shod pressure (LP) than medial pressure, and those who presented a higher

This paper presents and highlights the anatomical variation in the insertion of supernumerary heads of biceps brachii muscle. The variation was noted during routine dissection of a male cadaver (65 years of age). In the anterior compartment of the arms bilaterally, extra heads were noticed for the biceps brachii muscle with a separate insertion just below the ‘V’ shaped deltoid tuberosity into which the deltoid muscle is inserted. The extra head was innervated by a separate branch from the musculocutaneous nerve. The insertion of the extra head was also by an aponeurosis and a separate tendon. The extra tendon lay lateral to the original biceps tendon and it is the most lateral content of the cubital fossa. The aponeurosis joins with the bicipital aponeurosis and is attached

to the upper part of the subcutaneous posterior border of the ulna by way of deep fascia of the forearm. The separate tendon goes medially and downwards and expanded to blend with the interosseous membrane between the radius and ulna.

Co-Kinetic comment Don’t believe what you read in the anatomy textbooks. Apparently, approximately 10% of the population have a third biceps head. Also, sometimes a fourth head may arise from the lateral side of the humerus or from the intertubercular sulcus. If you think about it, the upper limb mirrors the lower: we have four quadriceps and three hamstrings so a few extra arm muscles shouldn’t be a surprise.

MEDIAL SHOE-GROUND PRESSURE AND SPECIFIC RUNNING INJURIES: A 1-YEAR PROSPECTIVE COHORT STUDY. Brund RBK, Rasmussen S, Nielsen RO et al. Journal of Science and Medicine in Sport 2017;20(9):830–834 medial shod pressure (MP) than lateral pressure during the stance phase. They were then given a pair of neutral trainers to use and recorded their running distances and injury status. Compared with the LP group (n=59), the proportion of Achilles tendinitis, plantar fasciopathy and medial tibial stress syndrome injuries (APM injuries)

was greater in the MP group (n=99) after 1500km of running, resulting in a cumulative risk difference of 16 percentage points.

Co-Kinetic comment The raw data from the runners was collected using uploads from their smart phones or GPS watches direct to the researchers website. Using that sort of technology could make large cohort studies much easier. The authors speculate that the medial pressure group has more injuries because this puts more strain on the plantar fascia, Achilles tendon or tibia bone compared to lateral pressure. More importantly, they speculate that for runners in the initial phases of APM pain, the risk of injury in these locations might be reduced by moving shoe pressure more laterally. It’s worth getting your athletes/patients checked by a sports podiatrist. Co-Kinetic Journal 2017;74(October):4-7

RESEARCH INTO PRACTICE

Physical Therapy

Journal Watch Twenty-five healthy subjects who ran at least 30km a week had their Achilles tendon blood flow measured before and after a 10min barefoot run at a self-selected speed. This was immediately followed by a similar run wearing neutral Pearl Izumi© shoes. Blood flow was measured using a noninvasive device capable of measuring the perfusion and oxygenation of the subcutaneous tissue up to a depth of 8mm. The device uses an optical fibre probe which incorporates white light spectroscopy and a laser Doppler technique. In addition eight reflective 2D markers were placed on anatomical reference points to obtain kinematic measurements, principally ankle angle in the sagittal plane and the Achilles tendon angle in the frontal plane.

IS ACHILLES TENDON BLOOD FLOW RELATED TO FOOT PRONATION? Wezenbeek E, Willems TM, Mahieu N et al. Scandinavian Journal of Medicine & Science in Sports 2017;doi:10.1111/ sms.12834 [Epub ahead of print] Sex, running speed, age and limb dominance did not have an effect on the outcome parameters. The blood flow showed an increase of 42.6% after barefoot running and 61.7% with the shoes. In the shod running the greater the observed eversion excursion, the lower the increase in blood flow.

Co-Kinetic comment The answer to the question in the title is, therefore, yes. The theory is that excessive pronation causes rotation of the Achilles tendon, which

SPORT SPECIFIC PREVALENCE OF CHONDRAL INJURIES IN THE HIP. Briggs K, Philippon M, Trinidade C et al. British Journal of Sports Medicine 2017;51(4):302–303 The patients in the study were 769 recreational/amateur and 268 professional athletes aged between 18 and 50 years old who underwent hip arthroscopy for femoroacetabular impingement (FAI) and were found to have a joint space of more than 2mm. Chondral defects were seen in 822 of 1037 hips. Chondral defects were found in 86% of professional athletes and 77% of recreational athletes. Grade III/IV defects were seen in 476 of 1037 hips. In professional athletes, 50% had grade III/ IV defects compared to 45% in recreational athletes. The prevalence of chondral defects was different by sport for both amateur and professional groups. Grade III/IV defects in professionals were most commonly seen in soccer, football and hockey. Grades III/IV defects in recreational/amateur athletes were most commonly seen in football, hockey and skiing. Significant differences between professional and recreational athletes were seen in hockey, rotational sports and running.

Co-Kinetic comment If your athlete with hip pain is not getting better with whatever treatment you are trying, there is a pretty good chance there is a chondral defect in there somewhere. The Outerbridge classification is: n Grade 0, normal cartilage. n Grade I, cartilage with softening and swelling. n Grade II, a partial-thickness defect with fissures on the surface that do not reach subchondral bone or exceed 1.5cm in diameter. n Grade III, fissuring to the level of subchondral bone in an area with a diameter more than 1.5cm. n Grade IV, exposed subchondral bone.

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then undergoes a ‘whipping’ action. This causes a decrease in blood flow which, in turn, may lead to injury. Time for a visit to the podiatrist.

ASSOCIATION OF POLYMORPHISMS RS1800012 IN COL1A1 WITH SPORTS-RELATED TENDON AND LIGAMENT INJURIES: A META-ANALYSIS. Wang C, Li H, Chen K et al. Oncotarget 2017;8(16):27627–27634 This was a meta-analysis of 1,200 studies to determine the evidence for a particular gene being associated with the susceptibility to sports-related tendon and ligament injuries such as anterior cruciate ligament (ACL) injuries, Achilles tendon injuries, shoulder dislocations and tennis elbow. From the original search six eligible studies including 933 cases and 1,381 controls were acquired from PubMed, Web Of Science and Cochrane library databases. There were three ACL injuries studies, one Achilles tendon injuries study, one tennis elbow study and one shoulder dislocations and cruciate ligament injuries study. The gene under consideration (COL1A1) is responsible for providing instructions for making type 1 collagen. The polymorphism is when part of the DNA sequence differs between members of the same species or in the paired chromosomes of an individual. The results of the study were that a particular change in this gene may be associated with the reduced risk of sportsrelated ligament and tendon injuries.

Co-Kinetic comment So as the poet Phillip Larkin nearly said, “They mess you up, your mum and dad”. For a fuller and more graphic quote, see ‘This be the verse’ in Collected Poems by P. Larkin (Farrar Straus and Giroux 2004). Buy from Amazon (£15.93). http://amzn.to/2wWJg5L. 5

Eighty-seven healthy sedentary individuals (52F, 35M) aged 19–58 years (34 ± 11) had their body mass index (BMI) and the thickness and stiffness of their plantar fascia (PF) and heel pads (HP) measured. Overweight and obese individuals had higher HP and PF thickness, HP microchamber layer stiffness and HP macrochamber layer stiffness, whereas they had lower PF stiffness compared with the individuals with normal weight. BMI had a moderate correlation with HP thickness, PF thickness, microchamber

EFFECTS OF BODY MASS INDEX ON MECHANICAL PROPERTIES OF THE PLANTAR FASCIA AND HEEL PAD IN ASYMPTOMATIC PARTICIPANTS. Taş S, Bek N, Ruhi Onur M et al. Foot & Ankle International 2017;38(7):779–784 and macrochamber stiffness. A negative and moderate correlation was found between BMI and PF stiffness.

Co-Kinetic comment The fact that carrying more bulk affects the properties of the base you are standing on is not much of a surprise. The decrease of PF stiffness perhaps is. The authors speculate that as the PF is one of the primary structures supporting the foot arches,

REST AND TREATMENT/REHABILITATION FOLLOWING SPORT-RELATED CONCUSSION: A SYSTEMATIC REVIEW. Schneider KJ, Leddy JJ, Guskiewicz KM et al. British Journal of Sports Medicine 2017;51(12):930–934 This was a literature search of the usual databases with the eligibility criteria of: (1) original research; (2) reported sportrelated concussion as the diagnosis; and (3) evaluated the effect of rest or active treatment/rehabilitation. Twentyeight studies met the inclusion criteria. However, only five randomised controlled trials (RCTs) met the eligibility criteria for methodological quality. Those RCTs included rest, cervical and vestibular rehabilitation, subsymptom threshold aerobic exercise and multifaceted collaborative care. The authors’ summary is that the papers indicate that a brief period (24–48h) of cognitive and physical rest is appropriate for most patients. Following this, patients should be encouraged to gradually increase

activity. The exact amount and duration of rest is not yet well defined and requires further investigation. The data support interventions including cervical and vestibular rehabilitation and multifaceted collaborative care. Closely monitored subsymptom threshold, submaximal exercise may be of benefit.

Co-Kinetic comment Interesting though this is, it is somewhat conservative in its recommendations compared with the governing bodies of football and rugby who recommend a rest period of 14 days. The bottom line on concussion is that it can be a killer; the English Football Association tagline of ‘If in doubt, sit them out’ is a good maxim to follow.

CURRENT MANAGEMENT STRATEGIES FOR PATELLOFEMORAL PAIN: AN ONLINE SURVEY OF 99 PRACTISING UK PHYSIOTHERAPISTS. Smith BE, Hendrick P, Bateman M et al. a. 2017;18(1):181 An anonymous survey was completed by 99 members of the Chartered Society of Physiotherapy. Responders reported a wide range of management strategies, including a broad selection of type and dose of exercise prescription. The five most common management strategies chosen were: closed chain strengthening exercises (98%); education and advice (96%); open chain strengthening exercises (76%); taping (70%) and stretches (65%). Physiotherapists with a special interest in treating patellofemoral pain were statistically more likely to manage patients with orthoses and bracing compared 6

to physiotherapists without a special interest. Approximately 55% would not prescribe an exercise if it was painful. Thirty-one percent of physiotherapists would advise patients not to continue with leisure and/or sporting activity if they experienced any pain.

Co-Kinetic comment There is no consensus. A follow-up study is needed on the effectiveness of this range of interventions, especially the group advised to give up exercise, which won’t be an option for some people either because it is their job or their life.

a decrease in stiffness could result in degenerative changes by causing a decrease in mid-tarsal joint stabilisation and joint laxity, as well as an increase in foot pronation. In other words, the bigger you are the more vulnerable you are to injury. What would be really good would be to repeat this stuff on recreational athletes rather than the sedentary population used here to see if there is a difference.

ASSESSING THE QUALITY OF MOBILE EXERCISE APPS BASED ON THE AMERICAN COLLEGE OF SPORTS MEDICINE GUIDELINES: A RELIABLE AND VALID SCORING INSTRUMENT. Guo Y, Bian J, Leavitt T et al. Journal of Medical Internet Research 2017;19(3):e67 The goal of this study was to develop and test an instrument that was designed to score the content quality of exercise programme apps with respect to the exercise guidelines set forth by the American College of Sports Medicine (ACSM). Two focus groups (N=14) were formed to elicit input for developing a preliminary 27-item scoring instrument based on the ACSM exercise prescription guidelines. Three reviewers (who were not sports medicine experts) independently scored 28 exercise programme apps using the instrument. An expert reviewer, a Fellow of the ACSM, also scored the 28 apps to create criterion scores. Criterion validity was assessed by comparing the non-expert reviewers’ scores to the criterion scores. Criterion validity was found to be excellent, indicating a substantial agreement between the scores of expert and non-expert reviewers. Finally, all apps scored poorly against the ACSM exercise prescription guidelines. None of the apps received a score greater than 35, out of a possible maximal score of 70.

Co-Kinetic comment The internet and its accompanying apps is perhaps the invention with the greatest benefit to mankind since the wheel but it drowns in its own success. There is a lot of it and wading through the dross to get to the good stuff is one of the hardest skills to master. This may help. Here is a scary statistic for our USA readers. According to this study only approximately 20% of Americans currently meet the physical activity guidelines recommended by the US Department of Health and Human Services. You can get the instrument at http://spxj.nl/2wLJwDY. Co-Kinetic Journal 2017;74(October):4-7

RESEARCH INTO PRACTICE

COMPARISON OF THE SHOCK ABSORPTION CAPACITIES OF DIFFERENT MOUTHGUARDS. Bochnig MS, Oh MJ, Nagel T et al. Dental Traumatology 2017;33(3):205–213 This study took a maxillary jaw model full of sensors and hit it with a pendulum testing device. Impacts of different energies were used to simulate being hit in the mouth with a baseball, a puck, a football, a tennis ball and a number of other sporting projectiles. Five different mouthguards with a labial thickness between 2mm and 11mm made of materials of varying stiffness were investigated. The same experiments were performed without a mouthguard and with guards of different combinations of labial inserts, nylon mesh and air space. Tooth deflection was reduced up to 99.7% compared to no mouthguard, and the braking acceleration was reduced up to 72.2% by increasing the mouthguards’ labial thickness, in combination with labial inserts of different stiffness and a built-in air space between the front teeth and the mouthguard. The mouthguards made of soft materials [ethylene-vinyl acetate (EVA) with nylon mesh] showed slightly better protection qualities than the more rigid mouthguards of similar thickness. However, with increasing impact energy, the protective capacities of the softer mouthguards decreased to a greater extent than the stiffer mouthguards.

Co-Kinetic comment Have you seen the cost of decent dental work? Any mouthguard will give you protection but the thicker ones with an air space seem to top the list. If you hit Google (other search engines are available) you will find one called ‘Dentist Nightmare’. We make no recommendations here, but that is a great name.

QUANTIFYING THE EFFECTS OF WATER TEMPERATURE, SOAP VOLUME, LATHER TIME, AND ANTIMICROBIAL SOAP AS VARIABLES IN THE REMOVAL OF ESCHERICHIA COLI ATCC 11229 FROM HANDS. Jensen DA, Macinga DR, Shumaker DJ et al. Journal of Food Protection 2017;80(6):1022–1031 Washing your hands is a simple task, eh? Apparently not. This study, among other things, looked at such variables as soap volume, lather time, water temperature and product formulation on hand washing efficacy. Baseline conditions were 1ml of a bland (non-antimicrobial) soap, a 5s lather time and 38°C (100°F) water temperature. A non-pathogenic strain of Escherichia coli (ATCC 11229) was the challenge microorganism. Twenty volunteers (10 men and 10 women) participated in the study, and each test condition had 20 replicates. An antimicrobial soap formulation (1% chloroxylenol) was not significantly more effective than the bland soap for removing E. coli under a variety of test conditions. Overall, lather time significantly influenced efficacy in one scenario, in which a greater reduction was observed after 20s with bland soap compared with the baseline wash. Water temperature as high as 38°C (100°F) and as low as 15°C (60°F) did not have a significant effect on the reduction of bacteria during hand washing; however, the energy usage differed between these temperatures. No significant differences were observed between men and women.

Co-Kinetic comment This is a classic example of needing to look behind the headlines. Numerous daily newspapers carried the story that scientists found no difference in bacteria reduction between washing in warm or cold water. However, when you read the paper it turns out that they were talking about one non-harmful strain of one germ. So before you start saving on your water heating bills wait for the results from a few more strains, or viruses, or fungi or any of the other nasty things on your mucky paws.

EAGLE SYNDROME: A COMPREHENSIVE REVIEW. Badhey A, Jategaonkar A, Anglin Kovacs AJ et al. Clinical Neurology and Neurosurgery 2017;1598:34–38 Eagle syndrome, also known as styloid syndrome or sometimes styloid–carotid artery syndrome, is a rare and poorly understood clinical condition. It presents with myriad symptoms that typically include pain in the anterolateral neck, or in the jaw bone, or the back of the throat. The symptoms are often triggered by swallowing, moving the jaw or turning the neck. The condition is caused by an elongated or misshapen styloid process which juts out just behind the ear or occasionally by a calcification of the styloid ligament. Apparently it is present in about 4% of the population and of these about 4% get the syndrome. This study is a literature review following a search of the usual medical databases. Unfortunately it doesn’t say how many papers were found and reviewed but there are 50 references. Six of these are authored by the Dr Watt Eagle, after whom the syndrome was named in 1937, despite its first being recognised by Vesalius in 1543. Once recognised and confirmed by X-ray or CT scan, conservative treatment consists of analgesics such as NSAIDs, but surgery is a more long-lasting option.

Co-Kinetic comment This is a rare condition but one of those that you might start to suspect if all else fails. In fact, the authors note that there seem to be a growing number of cases, probably owing to the fact that more people are aware of it. Hats off to those authors because they have produced the sort of ‘all you need to know about something’ paper that we like.

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CLICK ON RESEARCH TITLES TO GO TO ABSTRACT IMMEDIATE EFFECTS OF MIRROR THERAPY IN PATIENTS WITH SHOULDER PAIN AND DECREASED RANGE OF MOTION. Louw A, Peutendura EJ, Reese D et al. Archives of Physical Medicine and Rehabilitation 2017;doi:10.1016/j.apmr.2017.03.031 [Epub ahead of print] Pain, pain catastrophisation, fear avoidance and active range of motion (ROM) were measured in 69 consecutive patients with shoulder pain at a physical therapy outpatient clinic. They were then set up with a mirror placed in the sagittal plane in front of them. Their affected arm was behind the mirror so they couldn’t see it and their ‘good’ arm was reflected in the mirror. Next, the patient was asked to perform active flexion of their uninvolved arm from a resting position (arm by the side) to full active flexion ROM. Patients were encouraged to move slowly and easily, breathing comfortably and focusing on the movement of the uninvolved arm. The intervention allowed patients to move the uninvolved arm giving the ‘illusion’ that their involved arm was moving through full active shoulder flexion in a pain-free manner. On remeasurement there were significant differences in self-reported pain, pain catastrophisation, and the Tampa

Scale of Kinesiophobia immediately after mirror therapy; however, the means did not meet or exceed the minimal detectable change (MDC) for each outcome measure. There was a significant increase in affected active shoulder flexion immediately postmirror therapy, which did exceed the MDC of 8°.

Co-Kinetic comment What a great idea. Or to be more precise, a great idea ‘borrowed’ from neurophysiotherapy and applied to MSK. One of the big barriers to rehabilitation is patients giving themselves permission to move. In many people there is a genuine fear that they are going to do themselves more damage by doing so. If mirror therapy gets greater range, other modalities such as exercise can maintain or hopefully increase the new range and the road to full recovery is a step or two closer.

THE IMPACT OF CLASSICAL MASSAGE ON SPINE MOBILITY. Radzimińska A, Weber-Rajek M, Lulińska-Kuklik E et al. Pedagogics, Psychology, Medical-Biological Problems of Physical Training and Sports 2017;2:82–86T Thirty-six healthy volunteers (20F, 16M) aged 21 to 27 years old (average age 23.8) received five classical massages. Treatment time was 25–30 minutes. Before and after treatment measurements were taken of a fingers-floor test; the Otto-Wurna test, which measures mobility of the thoracic spine; the straightening of the spine (done by measuring the distance from the xiphoid process to the pubic tubercles; lateral flexion of the spine; and twist of the spine. The results showed that a statistically important increase was found in all tested variables before and after the last massage.

Co-Kinetic comment Do you ever wonder what the purpose of research is? If your answer is something along the lines of creating a body of knowledge to guide therapists in their treatment and ultimately to help patients, then this paper will have you screaming with frustration. It appears to prove that massage is very useful for increasing spinal mobility without actually saying what was done in the way of massage. It’s like saying ultrasound works but without giving a dosage, or that exercise works but without giving sets and reps. A completely useless endeavour.

EFFECTS OF FRICTION MASSAGE OF THE POPLITEAL FOSSA ON BLOOD FLOW VELOCITY OF THE POPLITEAL VEIN. Iwamoto K, Mizukami M, Asakawa Y et al. Journal of Physical Therapy Science 2017;29(3):511–514 Fifteen healthy male university students participated in the study. Doppler ultrasonography was used to measure the blood flow velocity of the popliteal vein. Before reporting to the laboratory, subjects were asked to fast and refrain from caffeine, tobacco, alcohol and strenuous physical activity for at least 12h before the experiment. Friction massage was performed on the intermediate point between the medial and lateral heads of the gastrocnemius muscle using the thumbs and moving

them in small circles (2–3 cm2) at a frequency of 3Hz, at a pressure level of 2 (on a scale of 1–5 on the Massage Therapy Pressure Scale by Tracy Walton). There was a significant increase in popliteal blood flow after friction.

Co-Kinetic comment Massage increases blood flow. We knew that anyway but it is nice to have a bit of scientific proof.

Co-Kinetic Journal 2017;74(October):8-11

RESEARCH INTO PRACTICE

Manual Therapy

Journal Watch Twelve asymptomatic adult male amateur softball position players exhibiting glenohumeral internal rotation deficit (GIRD) were studied. None of them were pitchers. Three were lefties. None had been diagnosed with previous injury. They all performed self-myofascial release (SMR), static stretching or a combination of both 1 week apart. The SMR was performed by the participants in a side-lying position on the side of the throwing shoulder with the throwing shoulder and elbow both flexed to 90°. A lacrosse ball was used owing to its density, firmness and intensity, as opposed to a softer ball, such as a tennis ball. The lacrosse ball was positioned in the area of the infraspinatus muscle on the posterior side of the throwing shoulder’s scapula. The participants were instructed to

ACUTE EFFECTS OF SELF-MYOFASCIAL RELEASE AND STRETCHING IN OVERHEAD ATHLETES WITH GIRD. Fairall RR, Cabell L, Boergers RJ et al. Journal of Bodywork and Movement Therapies 2017;21(3):648–652 locate the ‘most tender area’ along the posterior aspect of the scapula with the lacrosse ball and were then instructed to ‘stick’ in that location and keep constant pressure on the tender area for 60s. The participants performed two sets of 60s with 30s rest between. Static stretches (SS) were a sleeper stretch and a crossbody stretch held for 3×30s with a 30s rest between. All three methods significantly improved glenohumeral internal rotation range. SS alone and SMR+SS improved it significantly more than SMR alone. However, there were no significant differences between SS alone and SMR+SS.

Co-Kinetic comment OK, all of this works but one problem with this paper is the nomenclature. The SMR described sounds more like a self-trigger pointing than other myofascial release methods described elsewhere. Another is the same problem that is faced by far too many research papers: the subjects may have had the problem but they were asymptomatic and, therefore, not likely to be darkening the therapist’s door. We need research on how to fix people with problems for it to be really worthwhile. Plus GIRD is often associated with scapular control problems, so these are only a short-term fix to get the players through the game rather than a longer-term solution.

EFFECTIVENESS OF MANUAL THERAPY AND STRETCHING FOR BASEBALL PLAYERS WITH SHOULDER RANGE OF MOTION DEFICITS. Bailey LB, Thigpen CA, Hawkins RJ et al. Sports Health: A Multidisciplinary Approach 2017;9(3):230–237 Shoulder range of motion (ROM) and humeral torsion were assessed in 60 active baseball players (mean age, 19 ± 2 years) with ROM deficits. Athletes were randomly assigned to receive a single treatment of instrumented manual therapy plus self-stretching (n=30) or self-stretching only (n =30). The stretches were sleeper and crossbody adduction stretches held for 1min and performed twice with a 30s rest between. The instrumented manual therapy was applied to the infraspinatus and teres minor using a soundassisted soft tissue mobilisation tool. Deficits in internal rotation, horizontal adduction and total arc of motion were compared between groups immediately before and after a single treatment session. Treatment effectiveness was determined by mean comparison data, and a number-needed-to-treat (NNT) analysis. Before intervention, players displayed significant dominantCo-Kinetic.com

sided deficits in internal rotation (−26°), total arc of motion (−18°), and horizontal adduction (−17°). After the intervention, both groups displayed significant improvements in ROM, with the instrumented manual therapy plus self-stretching group displaying greater increases in internal rotation (+5°), total arc of motion (+6°), and horizontal adduction (+7°) compared with self-stretching alone. For horizontal adduction deficits, the added use of instrumented manual therapy with selfstretching decreased the NNT.

Co-Kinetic comment The bottom line is that throwing athletes who display reduced ROM are at a greater risk of injury, so anything that can increase that ROM has to be good. Prices of the gadgets range from 750 to 2,495 USD. Now we need a few studies comparing these tools against what can be achieved using your hands or exercise, which is, of course, free.

EFFICACY OF MANUAL THERAPY INCLUDING NEURODYNAMIC TECHNIQUES FOR THE TREATMENT OF CARPAL TUNNEL SYNDROME: A RANDOMIZED CONTROLLED TRIAL. Wolny T, Saulicz E, Linek P et al. Journal of Manipulative and Physiological Therapeutics 2017;40(4):263–272 One hundred and forty patients with carpal tunnel syndrome (CTS) were randomly assigned to a 10week programme of manual therapy (MT) or to the electrophysical modalities (EM) group. The MT programme included the use of neurodynamic techniques, functional massage of the descending part of the trapezius, and carpal bone mobilisation techniques. The EM group had laser and ultrasound therapy. In the MT group, median nerve sensory conduction velocity increased by 34% and motor conduction velocity by 6%. There was no change in median nerve sensory and motor conduction velocities in the EM. Distal motor latency was decreased in both groups. A baseline assessment revealed no group differences in pain severity, symptom severity or functional status. Immediately after therapy, analysis of variance revealed group differences in pain severity with a reduction in pain in both groups. There were group differences in symptom severity and function on the Boston Carpal Tunnel Questionnaire. Both groups had an improvement in functional status and a reduction in subjective CTS symptoms.

Co-Kinetic comment Both interventions improved the condition, but patients in the MT group scored better for pain reduction, subjective symptoms and functional status. The bottom line is that it is worth trying either or both of these approaches before you let the surgeons loose on it. The neurodynamic techniques are taken from Clinical Neurodynamics:. A New System of Musculoskeletal Treatment by M. Shacklock, Elsevier 2005 (£53.09. Buy from Amazon) http://amzn.to/2f4XqGR. Fifty females and 15 males aged between 18 and 35 years with plantar fasciitis were recruited for the study. They were treated for a period of 7 days using the technique of strain-counterstrain. Specifically, the technique was as follows: with the patient supine and with a bent knee, the tender point of the plantar fascia insertion was palpated and the ankle and toes brought into plantarflexion. Sometimes supination or pronation was added to get to a position of ease. After 90s or so, there was a relaxation of the tissues under the palpation point and the foot was returned to a 10

THE IMMEDIATE EFFECT OF SPORTS MASSAGE ON PROPRIOCEPTION OF KNEE AND ANKLE JOINTS IN COLLEGIATE MALE ATHLETES. Poorbarzegar M, Minoonejad H, Seidi F et al. Scientific Journal of Kurdistan University of Medical Sciences 2017;21(6):72–82 Thirty athletes of Tehran University, aged 18–28 years, were randomly divided into experimental and control groups (n=15). Using gyroscopes, measurement of proprioception was performed by method of knee and ankle joint repositioning error. The experimental group received 10min of massage. The results of the study showed that the use of massage decreased the repositioning error in the knee joint by 0.94° and in the ankle joint

by 0.86° at plantarflexion and 0.79° at dorsiflexion.

Co-Kinetic comment We can’t tell you the details of the protocols because only the abstract of this paper is in English. This is a pity because the subject is promising and suggests that regular massage may be of benefit to the athletic population.

THE EFFECTIVENESS OF PHYSIOTHERAPY AND COMPLEMENTARY THERAPIES ON VOICE DISORDERS: A SYSTEMATIC REVIEW OF RANDOMIZED CONTROLLED TRIALS. Cardoso R, Meneses RF, Lumini-Oliveira J. Frontiers in Medicine 2017;4:45 You may not have considered voice disorders as a subject for physical therapy but postural changes and muscle tension have been reported in association with voice production and increased muscle tension around the shoulders, neck and thorax may compromise the quality of the singing voice. This paper is based on a literature search using key words combination of ‘voice AND (treatment OR intervention)’. After the application of its inclusion and exclusion criteria, it came up with eight relevant papers using 286 subjects. The results were that there is evidence that massage works as a treatment modality to improve fundamental frequency, sound pressure level, global dysphonia level. One of the reported studies used transcutaneous electrical nerve stimulation (TENS) to reduce the intensity and frequency of pain in shoulders, upper back and neck. In the TENS group of this study, 60% of the participants significantly improved the ‘tension’ parameter in voice. A further study reported that acupuncture improved vocal function.

Co-Kinetic comment The initial search came up with over 15,000 papers and according to a 2012 article in the Independent newspaper there are over 25,000 singers in the UK. That is a lot of voices raised and a lot of potential work for therapists. Laryngeal massage is basically the application of standard massage techniques to the anterior neck muscles and especially those attached to the hyoid bone.

A STUDY ON EFFECT OF STRAIN-COUNTERSTRAIN IN PLANTAR FASCIITIS. Pawar AP, Tople RU, Yeole UL et al. International Journal of Advances in Medicine 2017;4(2):551–555 neutral position. Pre-intervention and post-intervention scores of Plantar Fasciitis Pain and Disability scale were assessed and were analysed using unpaired t-test and repeated ANOVA. There was not much difference between pre-intervention and after the third-day intervention scores. However, after the fifth day a considerable difference was noted. It was further noted that limited dorsiflexion improved after one week.

Co-Kinetic comment In reality the success of straincounterstrain techniques depends on the palpation skills of the therapist. You need to be able to monitor the state of the tissues under your hands. The only way to learn this skill is to do it. This paper may give you the evidence you need to try. In the right hands the technique works. Co-Kinetic Journal 2017;74(October):8-11

RESEARCH INTO PRACTICE

THE PREVALENCE OF OSTEOARTHRITIC SYMPTOMS OF THE HANDS AMONGST FEMALE MASSAGE THERAPISTS. Kruger H, Khumalo V, Houreld NN. Health SA Gesondheid 2017;22:184–193

This was a survey of South African massage therapists. It was restricted to females on the grounds that the majority of the practitioners there are female. Participants were required to complete a self-administered questionnaire that evaluated age, self-reported symptomatic presence of and family history of osteoarthritis, and body mass index. Participants also completed the AUSCAN™ Hand Osteoarthritis Index LK3.1 (Australian/Canadian Hand Osteoarthritis Index), which assesses pain, disability and joint stiffness of the hands. The sample was divided into two groups based on the presence or absence of self-reported symptoms. The mean age of symptomatic presentation was 43 years. The AUSCAN™ Index found that more than half of the total sample reported osteoarthritic symptoms in their hands. Participants in the non-symptomatic group also indicated a positive response to symptoms on the AUSCAN™ Index

Co-Kinetic comment Ouch. If you are not a full-time massage therapist do not think for a second that this does not apply to you. Training in massage and other manual therapy should be about looking after yourself. If you go on a course and the instructor wants you to use unsupported thumbs, fingers or whole hands for anything, ask for your money back. This includes doing spinal and peripheral joint mobilisation. There are other ways of working. You have to look after yourself or your career will be short.

EFFECTIVENESS OF INCLUSION OF DRY NEEDLING IN A MULTIMODAL THERAPY PROGRAM FOR PATELLOFEMORAL PAIN: A RANDOMIZED PARALLEL-GROUP TRIAL. Espí-López GV, Serra-Añó P, VicentFerrando J et al. Journal of Orthopaedic & Sports Physical Therapy 2017;47(6):392–401 Sixty patients with patellofemoral pain were randomly allocated to manual therapy and exercises (n=30) or manual therapy and exercise plus trigger-point dry needling (TrP DN) (n =30). Both groups received the same manual therapy and strengthening exercise programme for three sessions (once a week for 3 weeks), and one group also received TrP DN to active TrPs within the vastus medialis and vastus lateralis muscles. The pain subscale of the Knee injury and Osteoarthritis Outcome Score (KOOS; 0–100 scale) was used as the primary outcome. Secondary outcomes included other subscales of the KOOS, the Knee Society Score, the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC), and the numeric pain-rating scale. Patients were assessed at baseline, and at followups at 15 days and 3 months posttreatment. At 3 months, 58 subjects (97%) completed the follow-up. No significant between-group differences

were observed for any outcome but both groups experienced similar moderate-to-large within-group improvements in all outcomes. However, only the KOOS function in sport and recreation subscale surpassed the pre-specified minimum important change.

Co-Kinetic comment So the needles don’t seem to make much difference. On the other hand, the manual therapy worked. It was basically a lumbo-pelvic thrust manipulation; an anterior– posterior mobilisation of the hip and stretching of the external rotators; posterior–anterior and lateral-to-medial mobilisations of the knee and fascial mobilisation of the knee area; as well as rear-foot distraction thrust manipulation. A big shout-out to the authors because not only do they describe these techniques in detail there are pictures so that the reader can reproduce the treatment.

TEAM SPORT ATHLETES’ PERCEPTIONS AND USE OF RECOVERY STRATEGIES: A MIXED-METHODS SURVEY STUDY. Crowther F, Sealey R, Crowe M et al. BMC Sports Science, Medicine and Rehabilitation 2017;9(1):6 Three hundred and thirty-one athletes were surveyed. They were from a range of team sports across a variety of senior competition levels from five cities/towns in Queensland, Australia. They completed the survey after a game or training session over a 14-month period. They were asked to answer either ‘yes’ or ‘no’ separately to whether they performed a recovery strategy after competition, and/or after pre-season training and/ or after in-season training. Those who did not partake in recovery were invited to explain in free text why not. Those who did partake were invited to select from a pre-determined list the recovery methods that they use after competition, pre-season and/or in-season training; and then in free text Co-Kinetic.com

to nominate which recovery method they believed to be the most effective. Fifty-seven percent were found to use one or more recovery strategies including, active land-based recovery (ALB), active pool-based recovery (AWB), active stretching cool down (STR), cold/ice bath/shower (CWI), contrast bath/shower (CWT), massage, sleep/nap, food and/or fluid replacement, ice pack/vest application, heat pack application, liniment or gel application, progressive muscle relaxation or imagery, prayer or music, reflexology or acupuncture, supplement use, medication use and other (participants were asked to specify). STR was rated the most effective recovery strategy with ALB considered the least effective. The water

immersion strategies were considered effective/ineffective mainly owing to psychological reasons; in contrast STR and ALB were considered to be effective/ineffective mainly for physical reasons.

Co-Kinetic comment What would have been really interesting would have been subjecting the same group to a more objective measure of recovery and then comparing it to their perception. As it is, the authors’ thoughts are that athletes may not be aware of the specific effects that a recovery strategy has upon their physical recovery and education is what is needed. It could be worse, the paper cites an earlier study which reports that a similar survey with elite South African team-sport athletes reported sleep, fluid replacement and socialising with friends as the most popular recovery strategies.

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EXPLORING THE DEFINITION OF “ACUTE” NECK PAIN: A PROSPECTIVE COHORT OBSERVATIONAL STUDY COMPARING THE OUTCOMES OF CHIROPRACTIC PATIENTS WITH 0-2 WEEKS, 2-4 WEEKS AND 4-12 WEEKS OF SYMPTOMS Chiropractic & Manual Therapies

EFFECT OF LIGHT PRESSURE STROKING MASSAGE WITH SESAME (SESAMUM INDICUM L.) OIL ON ALLEVIATING ACUTE TRAUMATIC LIMBS PAIN: A TRIPLE-BLIND CONTROLLED TRIAL IN EMERGENCY DEPARTMENT Complementary Therapies in Medicine

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MANUAL THERAPY FOR PLANTAR HEEL PAIN The Foot

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TO RUN SHOD OR NOT SHOD: Are we Asking the Right Question? RUNNING | LOWER LIMB | 17-10-COKINETIC FORMATS WEB MOBILE PRINT

BY PETER FRANCIS PHD, IAPT STO

DOES BAREFOOT RUNNING PREVENT INJURY? WHY HASN’T IT TAKEN OFF?

There is a lot of confusion about the benefits and risks of barefoot running. By discussing the most prominent running injuries and their associated risk factors, this article allows you to understand why they occur, as well as how barefoot running may alter load to the tissues most commonly affected. The article will show you how to identify the patients who will be most likely to benefit from barefoot running, which can be used to initiate gait retraining. Practical recommendations for transitioning to barefoot running are provided, which will help you to create a safe barefoot running training programme for your clients. Read this article online http://spxj.nl/2haaHyu

These are some of the questions I get asked on a regular basis by researchers, clinicians and coaches. The questions themselves perhaps highlight the error in our thinking – or lack thereof – when we attempt to follow an evidence-based model. Follow the right individuals on social media and it is not uncommon to find clinicians waving research articles at one another in the midst of a heated exchange. One paper says it works, the other says it doesn’t. What is the clinician to do? I try to use a concept-based logic rather than seek out a definitive answer.

THE PROBLEM WITH RUNNING INJURY Running is a demanding and repetitive movement activity and, therefore, it is low in the movement variability needed to offset repetitive strain injury (1). Added to this, 75% of runners use a rearfoot strike (2), which is associated with an extended lower leg and greater loading rates (3). It appears that these running mechanics do not allow our muscles to decelerate our bodies effectively and instead, we rely on passive structures, which are not designed and are poorly equipped, to be the primary load bearers. It is, therefore, unsurprising that the primary running injuries are to passive tissues (eg. patellofemoral, medial tibial stress syndrome, plantar fasciitis) and not to their active counterpart (muscle) (4). At this point, it is interesting to draw parallels with our work in professional football. Muscle injury is the most prevalent injury in football

(5). Football is a sport requiring running, jumping, kicking and heading; and, therefore, it is much higher in movement variability. Furthermore, repeated sprint activity is the most common form of running undertaken by footballers. In athletics, sprinters – like footballers – have more muscle-tendon injuries compared to passive tissue injuries (6). Footballers and sprinters appear to be using the eccentric function of their muscles quite well (even if overloading them) to decelerate their body, whereas runners, clearly, are not.

HOW MIGHT BAREFOOT RUNNING HELP REDUCE LOAD TO PASSIVE TISSUES? Barefoot running leads to a reduction in stride length and an increase in knee and ankle angles. In other words, less of an extended leg and rearfoot strike and more of a bent knee and midfoot to forefoot strike. We have recently shown that this effect is particularly pronounced at lower speeds, the predominant speed the endurance runner is exposed to (7,8). At faster speeds, runners behave more like sprinters, which is to naturally flex the hip, knee and ankle (9). The advantage of these mechanics during repetitive movement activities such as running is that they create more-favourable conditions for muscle contributions to deceleration. The flexion of the joints allows muscles to operate closer toward their mid-range on foot contact. This is in contrast to the outstretched and extended leg, which increases load transference toward the joints.

WHY NOT JUST USE GAIT RETRAINING? Gait retraining can be used to encourage favourable running mechanics.

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RUNNING IS A REPETITIVE ACTIVITY AND DOES NOT HAVE THE MOVEMENT VARIABILITY TO OFFSET REPETITIVE STRAIN INJURY The joint-position changes that occur naturally (owing to stimulation of the sensory cutaneous nerves of the foot) during barefoot running can be trained in likeness when wearing shoes. This may assist muscles in making a greater contribution to deceleration in runners prone to passive tissue injury (10,11). However, part two of the runner’s injury conundrum is the absence of variability. A runner’s stride tends to be regular (relative to football for example), as is the interior of a shoe and the pavement the runner is exposed to. By contrast, barefoot running on an appropriate surface, such as pliable grass, creates the greatest net state of variability. The multiple joints of the foot and the medial longitudinal arch can use various combinations of deformation and stiffening in the absence of the regular shoe interior (12–15). In addition, the ground also deforms, with a subtle degree of unpredictability, to create a highly variable surface. Interestingly, changes in joint positions that occur on a variable surface mimic those changes seen with barefoot running. Running on a variable surface leads to an increase in knee angle and a more plantarflexed ankle. A more fixed ankle is adopted on a variable surface to avoid ankle sprain, allowing greater use of the spring-like function of the foot and greater load absorption from the muscles around the knee (15). Proprioceptive training is recommended for the prevention and treatment of most musculoskeletal injuries in the active population (16,17). In fact, great time and expense is spent on designing programmes and purchasing equipment in order to create unstable conditions underfoot. Barefoot running, in the way we describe above, is rich in sensory input. During initial foot contact, passive tissue components deform and the sensory reflex system is stimulated (14). The combined input from these two

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sub-systems influence the response of the motor nerve system and subsequently, our muscle actions. We suggest that rather than comparing barefoot running to shod running, clinicians should seek to understand an athlete’s current mechanics, the degree of variability and proprioceptive input in their training plans and then assess whether barefoot running (on an appropriate surface) may be useful to that individual.

WHY IS BAREFOOT RUNNING UNCOMMON? There are two main reasons: science and society.

muscle exercise, could lead to runners developing muscles more adapted to absorb load and sparing their passive tissues from overload. The second issue from a scientific standpoint is that we do not know what the chronic adaptations to barefoot running are. It appears acutely that favourable changes in stride length and joint positions occur but we do not know what changes occur when barefoot running is performed for an extended period of time. Some of our PhD students in the Musculoskeletal Health Research Group at Leeds Beckett University will be tackling these and other issues as part of our research related to barefoot running.

Science At present, we do not have the longitudinal injury audits to understand potential differences in injury risk between shod and barefoot running. Of the limited data that is available (often in which surface is not controlled for) there appears to be no difference in the number of running injuries between groups. That said, it does appear that barefoot runners suffer more muscle injuries and fewer passive tissue injuries than their shod counterparts who demonstrate the reverse trend (18). We view this as an exciting hypothesis to explore. A greater number of muscle injuries may indicate that muscles have been exposed to unaccustomed exercise. There is the potential that careful progression of barefoot running, as is the case with any new eccentric

Society Variable knowledge among societies about the risks and benefits of eccentric muscle exercise leads to varying outcomes. A sudden transition to unaccustomed eccentric muscle exercise, such as that seen with circuit training, plyometrics or in this case barefoot running, carries an injury risk. As a result, there are individuals who will have good outcomes using barefoot running, particularly if done progressively, over time and on a forgiving surface. Equally, there are individuals who will have poor outcomes using barefoot running, particularly if done suddenly and on an unforgiving surface. The second societal issue relates to social acceptability. In New Zealand, where I have spent the last 6-months

IN RUNNING, A REARFOOT STRIKE IS ASSOCIATED WITH AN EXTENDED LOWER LEG AND GREATER LOADING RATES, RISKING INJURY TO PASSIVE TISSUES 15

GUIDELINES FOR CLINICIANS WHEN IMPLEMENTING BAREFOOT RUNNING

Figure 1: New Zealand schools athletics, March 2017

at the Sports Performance Research Institute New Zealand (SPRINZ) (https://sprinz.aut.ac.nz/), it is socially acceptable not to wear shoes in supermarkets, on public transport or even when running on hard surfaces (Fig. 1). In the UK and Ireland, we would observe this behaviour as rather strange (19) and, therefore, this may also act as a barrier to participation. Finally, the availability of an appropriate surface is a potential barrier to using barefoot running effectively. We did not evolve to run on concrete. We suggest a pliable grass or sand surface is most appropriate. A surface too firm mimics concrete and risks promoting an overly cautious stride pattern. Conversely, grass that is too wet or sand that is too soft can make running feel more like strength and conditioning. Somewhere between those two scenarios resides a surface pliable enough to run on without fear of injury and firm enough to maintain running cadence. For example, over a period of 4 months in preparation for a half-marathon, we trained recreational runners (Fig. 2) to run for up to 80

1. Identify the patient’s injury history. The changes in running mechanics that arise from barefoot running may be most useful to runners with a history of passive tissue injury such as medial tibial stress syndrome or plantar fasciitis. Conversely, caution may be needed in runners with a history of calf strain due to the significant increase in muscle work that may arise from this type of running. 2. Observe the patient running (~20m) in their normal shoes on a firm (indoor if possible) surface. Look at, but also listen to, their mechanics. Repeat the process without shoes and notice any differences. 3. Identify an area suitable for barefoot running such as playing fields. Caution may be needed during summer when surfaces can become particularly firm. 4. Start small and progress slowly. A sufficient start point can be 10–15 minutes on alternate days. 5. Encourage the transfer of favourable running mechanics from the barefoot condition on grass to firmer surfaces in shoes. A lighter pair of shoes can be useful for some people undergoing gait retraining as there is greater proprioceptive feedback. minutes in bare feet on a 2km grass perimeter around playing fields. The advantage of surfaces such as playing fields or golf courses is that it is easier to screen for threats that may cause cuts or bruises to the foot. Surfaces in which runners are uncertain about the presence of such threats may require a minimalist foot covering. Although this dampens the sensory cutaneous input, the removal of the cushioned heel and arch support appears to encourage more-favourable running mechanics when compared to standard running shoes or cushioned minimalist shoes (20). If you are interested in our work on this subject or would like to collaborate on our research projects in this area please email Dr Peter Francis, director of the Musculoskeletal Health Research Group, Leeds Beckett University, peter.francis@leedsbeckett.ac.uk.

FURTHER RESOURCES YouTube video ‘The Barefoot Professor’. Courtesy of YouTube user Nature Video. http://spxj.nl/2ewWXNv References

Figure 2: Barefoot running was part of the training for this group of half-marathon runners

1. Dufek JS. exercise variability: a prescription for overuse injury prevention. ACSM’s Health & Fitness Journal 2002;6(4):18–23 2. Hasegawa H, Yamauchi T, Kraemer WJ. Foot strike patterns of runners at the 15-km point

during an elite-level half marathon. Journal of Strength and Conditioning Research 2007;21(3):888–893 3. Pohl MB, Hamill J, Davis IS. Biomechanical and anatomic factors associated with a history of plantar fasciitis in female runners. Clinical Journal of Sport Medicine 2009;19(5):372– 376 4. Taunton JE, Ryan MB, Clement DB et al. A retrospective case-control analysis of 2002 running injuries. British Journal of Sports Medicine 2002;36(2):95–101 5. Fitzharris N, Jones G, Jones A et al. The first prospective injury audit of league of Ireland footballers. BMJ Open Sport & Exercise Medicine 2017;In press 6. Askling CM, Tengvar M, Saartok T et al. Acute first-time hamstring strains during high-speed running: a longitudinal study including clinical and magnetic resonance imaging findings. American Journal of Sports Medicine 2007;35(2):197–206 7. Francis P, Ledingham J, Clarke S et al. A comparison of stride length and lower extremity kinematics during barefoot and shod running in well trained distance runners. Journal of Sports Science & Medicine 2016;15(3):417–423 8. Thompson MA, Lee SS, Seegmiller J et al. Kinematic and kinetic comparison of barefoot and shod running in mid/forefoot and rearfoot strike runners. Gait & Posture 2015;41(4):957–959 9. Novacheck TF. The biomechanics of running. Gait & Posture 1998;7(1):77–95 10. Crowell HP, Davis IS. Gait retraining to reduce lower extremity loading in runners. Clinical Biomechanics 2011;26(1):78–83 11. Noehren B, Scholz J, Davis I. The effect of real-time gait retraining on hip kinematics, pain and function in subjects with patellofemoral pain syndrome. British Journal of Sports

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Medicine 2011;45(9):691–696 12. Moritz CT, Farley CT. Passive dynamics change leg mechanics for an unexpected surface during human hopping. Journal of Applied Physiology 2004;97(4):1313–1322 13. van der Krogt MM, de Graaf WW, Farley CT et al. Robust passive dynamics of the musculoskeletal system compensate for unexpected surface changes during human hopping. Journal of Applied Physiology 2009;107(3):801–808 14. Daley MA, Felix G, Biewener AA. Running stability is enhanced by a proximo-distal gradient in joint neuromechanical control. Journal of Experimental Biology 2007;210(Pt 3):383–394 15. Thomas JM, Derrick TR. Effects of step uncertainty on impact peaks, shock

attenuation, and knee/subtalar synchrony in treadmill running. Journal of Applied Biomechanics 2003;19(1):60–70 16. Riva D, Bianchi R, Rocca F et al. Proprioceptive training and injury prevention in a professional men’s basketball team: a six-year prospective study. Journal of Strength and Conditioning Research 2016;30(2):461–475 17. Steffen K, Emery CA, Romiti M et al. High adherence to a neuromuscular injury prevention programme (FIFA 11+) improves functional balance and reduces injury risk in Canadian youth female football players: a cluster randomised trial. British Journal of Sports Medicine 2013;47(12):794–802 18. Altman AR, Davis IS. Prospective comparison of running injuries between shod and barefoot runners. British Journal of

KEY POINTS nT he predominant running injuries are to passive tissues. n Muscle appears to make insufficient contributions to deceleration leading to passive tissue overload. n 75% of runners use a rearfoot strike which is associated with an extended lower limb and leads to greater loading rates and sub-optimal joint positions for muscles to contribute to deceleration. n Removal of shoes encourages a more mid-forefoot strike in many runners. n An increase in sensory input to the foot allows for greater use of the spring-like function of the foot, sensory reflex mechanisms and optimised motor output. n Humans did not evolve to run barefoot on concrete. n A medium-soft grass or sand surface is appropriate for the gradual implementation of barefoot running. n Implementation of novel eccentric exercise (ie. barefoot running) must be done slowly.

DISCUSSIONS hy are passive tissues overloaded in runners but not sprinters? W What other training strategies could a runner use to increase demand on muscle work? What other techniques could the runner use to maximise variability in training and lower overuse injury risk?

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Barefoot running leads to a reduction in stride length and an increase in knee and ankle angles. http://spxj.nl/2haaHyu Tweet this: Gait retraining can be used to encourage favourable running mechanics. http://spxj.nl/2liVOyS Tweet this: Joint-position changes seen when running on a variable surface mimic those seen in barefoot running. http://spxj.nl/2liVOyS Tweet this: Careful barefoot-running training could help develop muscles and prevent passive tissue overload. http://spxj.nl/2liVOyS Tweet this: Barefoot running may be most useful to runners with a history of passive tissue injury. http://spxj.nl/2liVOyS

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Sports Medicine 2016;50(8):476–480 19. Walton PD, French DP. What do people think about running barefoot/with minimalist footwear? A thematic analysis. British Journal of Health Psychology 2016;21(2):451–468 20. Hollander K, Argubi-Wollesen A, Reer R et al. Comparison of minimalist footwear strategies for simulating barefoot running: a randomized crossover study. PLoS One 2015;10(5):e0125880.

THE AUTHOR Dr Peter Francis PhD, IAPT STO is the director of the Musculoskeletal Health Research Group at Leeds Beckett University. Following his PhD investigating age-related change in muscle quality, Peter’s research broadly focuses on muscle function. This includes several areas of interest. The measurement of age-related change in muscle quality contributes toward developing diagnostic criteria for sarcopenia as well as assessing the muscular health of retired rugby players. Peter’s work on injuryrelated change in muscle function and responses to therapeutic intervention focuses on footballers and endurance athletes. He is aiming to chart muscle function pre-, during and post-injury, as it is becoming increasingly clear that deficits in muscle function can remain even when MRI imaging appears clear, suggesting that imaging alone cannot govern returnto-play criteria. With a background in sport and exercise science from the University of Limerick, Republic of Ireland, Peter became interested in overuse injuries from his own experiences as an endurance runner and completed a BSc Physical Therapy. As a result he has been involved in the treatment and rehabilitation of a number of European, World and Olympic athletes in the sport of athletics. Peter is also an IAAF level 4 endurance coach and ran the endurance programme at the University of Limerick from 2010 to 2013. Peter uses his combined knowledge of exercise science and rehabilitation to provide athlete training camp support and coach education for the Athletics Association of Ireland. Most recently, Peter was team manager for the Irish athletics team at the European Junior Championships in Sweden. Website: http://www.leedsbeckett.ac.uk/ staff/dr-peter-francis/ Email: peter.francis@leedsbeckett.ac.uk LinkedIn: https://uk.linkedin.com/in/ dr-peter-francis-40750338 Twitter: @peterfrancis_ie

RELATED CONTENT ther running-related content on Co-Kinetic O https://www.co-kinetic.com/tag/running

MANAGING THE PINCH: A REVIEW OF SHOULDER IMPINGEMENT CARE This article consolidates current knowledge on the diagnosis, treatment and rehabilitation of shoulder impingement. It is packed full of practical implementation resources including videos of assessment tests, printable quick-reference algorithms and a set of three phased patient exercise rehabilitation leaflets. It is also accompanied by an education-based marketing campaign for patients (available through the marketing or full site subscriptions). Read this article online http://spxj.nl/2h8S3L6 n All references marked with an * are open access and links are provided in the reference list.

INTRODUCTION Several articles have been published recently, both original work and reviews, bringing with them new ideas and questions to the assessment and management of shoulder impingement. This article brings together evidence and best practice from these key studies [Steuri R et al. (1*); Lange et al. (2); Wright A et al, (3); Andersson SH, et al. (4); Kolber MJ et al. (5); Smith BE et al. (6)] endeavouring to curate a comprehensive, up-to-date guide for you. We are hoping that you find this not only informative but practical too, by providing tools and resources to help you implement this best practice with your patients. These include: n quality of life (QoL) questionnaires; n a quick-reference review of the traditional impingement tests; n handy algorithms to decipher and diagnose shoulder pain and guide rehabilitation; n exercise sheets for your patient; and n videos for a visual explanation of shoulder assessment. Shoulder complaints are the third most common musculoskeletal presentation after back and neck disorders. The highest incidence and prevalence of shoulder disorders is in women and

UPPER LIMB | SHOULDER | 17-10-COKINETIC FORMATS

WEB

MOBILE

MEDIA CONTENTS 7 videos showing key shoulder pain assessments http://spxj.nl/2h8S3L6 3 patient rehabilitation leaflets - phased exercises http://spxj.nl/2h8S3L6

BY KATHRYN THOMAS BSC MPHIL persons aged 45–64 years. Among people with shoulder pain, shoulder impingement syndrome (SIS) has the highest prevalence and accounts for 36% of all shoulder problems (1*). SIS is a generic term for injury of structures in the subacromial space, such as rotator cuff tendinosis, partial thickness tears of the rotator cuff, and bursitis. The aetiology of rotator cuff injury and its relationship to subacromial impingement, the encroachment of the involved structures, are still a matter of debate (1*). Historically, labelling of non-traumatic shoulder pain, shoulder diagnoses and exploring theories about underlying shoulder pain are interrelated. Many authors use the phrase ‘syndrome’ to describe a combination of findings, often occurring together, with an unknown or heterogeneous underlying pathogenesis (7). However, the label of SIS is still controversial, as recent evidence suggests that this concept does not fully explain the mechanism (8–10). Until a few years ago, SIS was a widely accepted ‘umbrella’ term for several possible underlying structural or biomechanical causes. Throughout the

years, the description progressed from SIS to ‘impingement-related shoulder pain’ with the growing opinion that ‘impingement’ represents a cluster of symptoms and a possible mechanism for the pain, rather than a pathoanatomic diagnosis itself (7). Perhaps the important thing to note is not the ‘name’ that you give the condition but, rather, that each patient may present differently with varying degrees of involvement of any one or more subacromial structures. Generally, SIS is caused by repeated, overhead movement of the arm into the ‘impingement zone’. The condition is frequently called ‘swimmer’s shoulder’ or ‘thrower’s shoulder’, since the injury occurs from repetitive overhead activities. Injury could also stem from simple home chores, like hanging washing on the line or a repetitive activity at work. Shoulder impingement has primary (structural) and secondary (posture and movement-related) causes. Primary rotator cuff impingement is due to a structural narrowing in the space where the tendons glide. This may be caused by bony spurs or osteoarthritis. Co-Kinetic Journal 2017;74(October):18-24

PHYSICAL THERAPY

SHOULDER IMPINGEMENT SYNDROME (SIS) IS A GENERIC TERM FOR INJURY OF STRUCTURES IN THE SUBACROMIAL SPACE Secondary rotator cuff impingement is due to an instability in the shoulder girdle; normally from a combination of excessive joint movement, ligament laxity and muscle weakness around the shoulder. Muscle imbalances surrounding the scapula can result in changes in the physical position of the acromion, which, in turn, increase the risk of impingement. Failure to properly treat an underlying instability or imbalance causes the injury to recur. Poor technique, posture and bad training habits can compound the injury. The common consequences of SIS are pain and disability, loss of quality of life and sleep disturbances. Over time, pain can cause further dysfunction by altering shoulder movement patterns which may lead to adhesive capsulitis or frozen shoulder. An ongoing impingement process with serious rotator cuff damage can lead to complete joint destruction. Tears in the rotator cuff tendons are common in symptomatic shoulders, whereas up to 17% of asymptomatic shoulders also demonstrate tears in the rotator cuff (1*). The injury may have profound effects on the patients sporting ability as well as work performance.

ASSESSMENT Diagnostic labels are intended to guide treatment and rehabilitation protocols, and to facilitate communication between health professionals. For that reason, clinicians attempt to classify patients into subgroups underneath the umbrella of common shoulder symptoms. Referring to the subacromial conflict, terminology continues to shift from SIS to subacromial pain syndrome (SPS), rotator cuff disease, rotator cuff-related shoulder pain – not one label will satisfy everyone and everything (7). So, with that in mind how best can one assess and diagnose a patient? The purpose of any examination is to allow the clinician to establish the anatomical, pathological and functional conditions of a patient. The examination should be able to determine the underlying causes of the presenting problem with confidence and assuredness. Manual tests should Co-Kinetic.com

BOX 1: KEY STEPS WHEN ASSESSING SHOULDER IMPINGEMENT SYNDROME (SIS) 1. O btain a description of the symptoms. 2. G ive the patient a Quality of Life (QoL) questionnaire. 3. D o clinical tests, observation of posture and scapular dyskinesis (11*). 4. Do functional tests, ie. the action that elicits the symptoms, be that a sporting action, work or activity of daily living (ADL). help specify anatomical structures, and define the structural integrity of the tissue and its function. The diagnosis of impingement aims to isolate the pathological process to the subacromial space; it does not, however, define the cause. See Box 1 for a summary of the key steps needed for assessing SIS. Impingement syndrome is characterised by pain experienced through an arc of elevation as the shoulder abducts. It should be appreciated that this is a condition that is associated with active movement of the shoulder (after all, the patient never functionally lifts the arm passively), so it occurs when the subacromial structures are actively brought into contact with the acromion and coracoacromial ligament during the act of elevating the arm. See Box 2 for a list of the common symptoms associated with SIS.

QoL Questionnaire The effective evaluation and management of orthopaedic conditions including shoulder disorders relies upon understanding the level of disability created by the disease process. Validated outcome measures are critical to the evaluation process. Traditionally, outcome measures have been physician-derived objective evaluations; however, these measures can marginalise a patient’s perception of their disability or outcome. As a result, patient self-reported outcomes measures have become popular recently and are currently primary

BOX 2: COMMON SIS SYMPTOMS Common symptoms associated with SIS can include: n an arc of shoulder pain approximately when your arm is at shoulder height and/or when your arm is overhead n shoulder pain that can extend from the top of the shoulder down the arm to the elbow n pain when lying on the sore shoulder, night pain and disturbed sleep n s houlder pain at rest as the condition worsens n muscle weakness or pain when attempting to reach or lift n p ain when putting your hand behind your back or head: pain combing or blow drying hair, pain attaching bra strap n pain reaching for the seat-belt, or out of the car window for a parking ticket.

BOX 3: QUESTIONNAIRES FOR ASSESSING SHOULDER FUNCTION 1. Constant Score The Constant–Murley Score was developed by Constant and Murley in 1987 and was one of the first outcome measures developed to assess shoulder function. Although it is relatively old, it is easy to administer with clear instructions and is therefore extensively used. It comprises both clinician-assessed physical examination findings and subjective patient-reported assessments. The Constant Score is not effective in the evaluation of shoulder instability, in which case another test should be used, such as the Oxford Score. n PDF download of the Constant Shoulder Score (Link 3) n How to measure using the Constant Shoulder Score Technique (Link 4) nO nline web form of the Constant Shoulder Score with downloadable CSV file (Link 5) 2. Oxford Score The Oxford Shoulder Score and Oxford Shoulder Instability Score are widely used shoulder scores in the UK that were developed as patient-reported outcome measures for patients undergoing shoulder operations other than stabilisation, and for patients undergoing surgery for shoulder stabilisation, respectively. The Oxford Outcome Scores require a licence from ISIS to use – this may incur a fee. n Online web form of the Oxford Shoulder Score with downloadable CSV file (Link 6) n Online web form of the Oxford Shoulder Instability Score with downloadable CSV file (Link 7)

SIS IS GENERALLY CAUSED BY REPEATED, OVERHEAD MOVEMENT OF THE ARM INTO THE ‘IMPINGEMENT ZONE’ tools used to evaluate outcomes of treatment. Health-related quality of life (HRQoL) evaluation includes general health measures, health utility measures, general shoulder measures (Link 1) and condition-specific shoulder measures (Link 2). A combination of HRQoL with a shoulder measure or condition-specific measure is needed to fully capture outcomes in the treatment of shoulder conditions (12*,13*,14*,15*).

Clinical Tests and Observations (16*,17*) The tests that aim to diagnose SIS and rotator cuff disease are numerous. The clinician should attempt to separate out the individual tendons that comprise the cuff to determine the integrity of the tendon. True isolation of the individual tendons is almost impossible because of the coupling effects across the rotator cuff complex. Pain elicited from these tests may be a result of either tendinitis/tear or subacromial impingement. Differentiation

Jobe − Neer + ant Hawkins − apprehension + (pain) ant

IMPINGEMENT SYMPTOMS

External subacromial impingement

Relocation −

Full can +

Rotator cuff pathology

between tendinitis and a small tear (partial thickness or full thickness) is often difficult and an ultrasound scan may be beneficial in these cases. Tears that involve a significant proportion of a tendon will tend to show signs of weakness, although the clinician must be aware that, even in the presence of a large or massive rotator cuff defect, the patient may still only demonstrate mild or subtle signs. This is a result of the ability of the shoulder to compensate for the absence of part of the rotator cuff with residual intact cuff and surrounding intact muscles. Figure 1 shows an algorithm for clinical reasoning in the examination of impingementrelated shoulder pain. There are three commonly used tests for shoulder impingement and they are described below. There are also a number of other tests that can be used to diagnose shoulder impingement issues and all of these can be found in the full online version of this article as well as being available as a handy,

Jobe − Neer + ant Hawkins − apprehension + (pain) post

Internal posteriosuperior glenoid impingement

Relocation + release + (pain)

Primary impingement

downloadable leaflet, ‘Shoulder Impingement Assessments’ http://spxj.nl/2h8S3L6

Relocation + release + (pain)

Secondary impingement

SAT + SRT +

Scapular dyskinesis

Neer’s Sign This test allows demonstration of a pain during passive abduction of the arm with the scapula stabilised, the examiner lifting the arm in the scapular plane with the arm internally rotated (Video 1). Hawkins–Kennedy Test This test is again a passive test, with the examiner positioning the patient’s arm at 90° in the scapular plane, the elbow bent to 90°, and the arm taken passively into internal rotation. Creation of pain during this manoeuvre is indicative of a positive test (Video 2). Jobe’s Empty Can Test This sets out to preferentially test supraspinatus (complete isolation of supraspinatus from the deltoid is difficult), the most commonly affected tendon when considering degenerative cuff disease. It positions the arm such that the supraspinatus tendon is placed under maximal stress as the arm is pushed down, attempting to invoke pain, weakness, or both, from the examination. It does not, however, completely isolate supraspinatus, and some fibres from the anterior part of infraspinatus are also tested (Video 3). The tests described in the Shoulder Impingement Assessment guide, above, are far from exhaustive when aiming to examine the shoulder for

Laxity tests + Apprehension + (appr) relocation + (appr)

Instability

The Most Commonly Used Tests for Shoulder Impingement The three most commonly used clinical tests for impingement are Neer’s Sign, the Hawkins–Kennedy test and Jobe’s empty can test.

O’Brien + Speed’s + biceps load II +

Biceps–SLAP pathology

IR ROM i

GIRD

Video 1: The Neer Test by Physiotutors http://spxj.nl/2xZEUrG

+, Positive; –, negative; IR, internal rotation; GIRD, glenohumeral internal rotation deficit; ROM, range of motion; SLAP, superior labrum from anterior to posterior tear; SAT, scapular assistance test; SRT, scapular retraction test. Figure 1: Algorithm for clinical reasoning in the examination of impingement-related shoulder pain [Reproduced with permission from the British Journal of Sports Medicine (29)]

Co-Kinetic Journal 2017;74(October):18-24

PHYSICAL THERAPY

any suspected rotator cuff pathology but, as with all musculoskeletal assessments, the findings are to be considered against the background of a full and detailed clinical history, especially noting the activity-related symptoms that a patient reports. This should ultimately allow the examiner to focus on the likely causes of the ongoing complaint with increased accuracy, allowing greater specificity in the use of diagnostics and a greater confidence in the prescription of appropriate forms of treatment for the patient and their condition. Isolating the examination to the shoulder and rotator cuff would be short-sighted. It is essential to evaluate the patient’s entire kinetic chain; observing scapula movement patterns, posture, assessing weakness in the mid and lower trapezius muscles or tightness in the pectorals – to name a few. All these could be contributing factors to malalignment within the shoulder girdle. Differences in internal rotation (IR) and external rotation (ER) strength ratios appear to be related to injury in almost all players whose sports involve overhead activities – handball, baseball, swimming, waterpolo, tennis, volleyball (18*,19). It is important to remember the eccentric strength of these muscles in shoulder stabilisation. Eccentric strength of the internal rotators is essential during the arm cocking phase during a volleyball spike or baseball pitching (18*,20). Whereas, the eccentric strength of the external rotators is crucial during the arm-deceleration phase (19*,20*). A higher injury risk has been shown to be associated with IR/ER muscle strength imbalance profiles (21). A paucity of evidence exists to describe intrinsic risk factors of SIS. Studies in weight-training individuals Video 2: The Hawkins– Kennedy test by Physiotutors http://spxj.nl/2wkedMz

Co-Kinetic.com

with SIS have shown significant differences with decreased IR and ER, and decreased body-weight-adjusted strength values of the external rotator and lower trapezius musculature when compared with individuals without SIS (5). Select strength ratios were greater in the SIS group implying agonist to antagonist muscle imbalances (5). Practical applications for these findings may reside in exercise prescription that addresses IR mobility, mitigates training bias, and favours muscles responsible for stabilisation, such as the external rotators and lower trapezius (5).

EXERCISES THAT WORK INTO AN ACCEPTABLE LEVEL OF PAIN PRODUCE SUPERIOR SHORT-TERM OUTCOMES

TREATMENT The integration of key examination techniques with evidence-based rehabilitation concepts to restore optimal range of motion (ROM), rotator cuff and scapular strength, and stabilisation forms the basis of rehabilitation for the individual or athlete with SIS (22). The main treatment goals would include pain reduction and improved upper extremity function. In a recently published review (1*), it was demonstrated that there is little significant evidence to show the efficacy of conservative treatment in managing patients with SIS. Although the review only provided very low quality evidence (because of the lack of randomised controlled trials with sufficient subject numbers and adequate follow-up periods), it suggested that exercise may be considered as the core conservative treatment for shoulder impingement. Furthermore, manual therapy, laser and tape may provide additional benefit. Surgery may be a valid alternative after unsuccessful conservative treatments, of which most surgeons in the UK used a minimum period of 12 weeks of conservative treatment and at least two steroid injections prior to theatre (1*). Video 3: Jobe’s empty can test by Physiotutors http://spxj.nl/2wUnqzb

MANUAL SIS TESTS HELP SPECIFY ANATOMICAL STRUCTURES, AND DEFINE THE STRUCTURAL INTEGRITY OF THE TISSUE AND ITS FUNCTION Current advice regarding exercise prescription for overhead athletes with shoulder injuries is reported mostly as clinical commentaries or general topical review articles by field experts without strong research-based evidence. There is a predominance of evidence focused on individual muscle activation patterns while performing specific exercises, but these studies are limited because they lack transference of specific exercises as part of a rehabilitation programme to functional outcomes or improvements. The strongest available evidence supports the use of single-plane, upper extremity exercises performed below the 90° horizontal (eg. shoulder ER in neutral, prone extension) with some incorporation of elastic resistance for exercise prescription in the overhead athlete with shoulder pathology. Expert opinion however includes a wider variety of exercises with greater attention to the kinetic chain. Exercises identified by clinical experts had a stronger focus on kinetic chain/core/lower extremity and plyometric exercises, and sport-specific training programmes for basketball,

throwers baseball, tennis and swimming. There is a gap between clinical practice and research, with clinical experts using more complex exercises that have yet to undergo rigorous research trials to support their use (3,22). A systematic review by Smith et al. (6*) compared painful and non-painful exercise in a variety of musculoskeletal conditions. This review concluded that exercise approaches that worked into pain demonstrated superior short-term outcomes over pain-free exercises (6*). Exercise should aim to push the patients’ boundaries and challenge their beliefs. Knowledge of exercise within the general population may be limited. Thus, a key role of physiotherapy is to educate patients about their shoulder condition and underlying issues; such that their belief in exercise therapy grows, and with that improve compliance. Within the clinical environment, physical therapists should work with their patients to identify exercises that produce acceptable levels of pain during and after. Avoid prescribing low-level exercises that take

LACK OF SOFT-TISSUE FLEXIBILITY

Scapular muscles

Glenohumeral muscles/capsule

n pectoralis minor n levator scapulae n rhomboids

n posterior capsule n infraspinatus n latissimus dorsi

Stretching and mobilisation

n manual stretching n home stretching n soft-tissue techniques n manual mobilisations (accessory movements) n mobilisation with movement

a long time to progress. Biomechanical and clinical knowledge regarding the role of the scapula in shoulder function and dysfunction is growing, and concepts regarding how to evaluate and treat scapular dyskinesis are evolving, this a statement form the latest ‘Scapular Summit’ in 2013 (23*). This consensus conference revealed that scapular involvement in almost all types of shoulder pathology may play an important, but as yet, not completely understood role in creating or exacerbating the shoulder dysfunction. Shoulder impingement symptoms appear to be affected by scapular position and motion. Scapular dyskinesis is probably most aptly viewed as a potential impairment to optimum shoulder function and should be evaluated and treated as part of a comprehensive treatment protocol (23*). ‘Shoulder Examination of Scapular Control’ from BJSM is a simple straightforward video showing how to assess and spot shoulder dyskinesis (Link 8).

LACK OF MUSCLE PERFORMANCE

Muscle control

Muscle strength n lower/middle trapezius n serratus anterior

n co-contraction n force couples

Neuromuscular coordination

Strength training

Conscious muscle control

Advanced control during basic activities

Balance-ratio

Advanced control during sports movements

Endurance/strength

Figure 2: Shoulder impingement rehabilitation algorithm [Reproduced with permission from the British Journal of Sports Medicine (22)] 22

Co-Kinetic Journal 2017;74(October):18-24

PHYSICAL THERAPY

‘How to Cue the Scapula During Shoulder Exercises’ is an excellent video from MikeReinold.com so you can see what you should be looking for during and when teaching your rehab exercises (Link 9). The re-education of spinal posture is an integral part of shoulder impingement management yet supporting evidence is limited. Research shows that flexion ROM was significantly greater in the erect sitting posture, than slouched (24). An erect sitting posture appears to increase active shoulder flexion in subjects with shoulder impingement, although there were no differences in reported pain intensity (24). Neer’s model (25,26) involving acromial irritation of the subacromial tissues has been embraced by physical therapists who have suggested that an alteration in upper body posture, colloquially known as a forward-head posture (FHP), is associated with the impingement process due to changes in the position of the scapula, an increase in the thoracic kyphosis angle, and a concomitant imbalance of the surrounding muscles. These changes are thought to produce a compressive impingement under the acromion, creating a mechanical block to elevation of the humerus and irritation of the subacromial tissues (27*). Research has shown that using tape to change posture, influenced all components of posture measured and these changes were associated with a significant increase in the ROM in shoulder flexion and abduction in the plane of the scapula in SIS patients (27*). Changing posture was not found to have a significant effect on the intensity of pain experienced by the symptomatic patients, although the point in the range of shoulder elevation at which they experienced their pain was significantly higher. The purpose of the postural-change taping was to extend the thoracic spine, and to retract, depress, and posteriorly tilt the scapula, which has shown to have a positive effect on static posture in SIS patients (27*). This may be beneficial in the early stages of rehabilitation. Ultimately good posture, without taping, and good dynamic shoulder positioning should be achieved and maintained actively. Injury and recovery from injury in Co-Kinetic.com

individuals and athletes represents a dynamic system, where there are multiple internal and external factors, such that changing one affects all the others. Rehabilitation should address the complex, dynamic and multidimensional aspects of injury and recovery with exercise prescription that is based on athletic- or work-related movement and performance as well the incorporation of local (joint), regional (trunk and extremity) and global (system-wide and spinal, paraspinal and supraspinal) approaches. In the context of rehabilitation for SIS, it is recommended that one uses single-plane exercises below 90° of shoulder elevation in the early phases of rehabilitation, with a graduated progression that addresses the regional (plyometrics) and global (dynamic, triplanar activities) issues that adequately prepare the individual for return to sport or work (3) (see Further Resources for printable patient leaflets).

PREVENTION Shoulder injuries, predominantly from overuse, have been highlighted as an area warranting preventative efforts, in a wide variety of throwing sports, where the shoulder is exposed to large demands due to repeated overhead motion at high velocity (3). Findings from a recent study (4) showed that a 10-minute exercise programme, the OSTRC Shoulder Injury Prevention Programme, reduced the prevalence of shoulder problems and substantial shoulder problems among elite handball players. The risk of reporting a shoulder injury during the competitive season was reduced by 28% in the intervention group. This is the first randomised controlled trial investigating an exercise programme in the prevention of overuse shoulder injuries (4). As mentioned earlier, finding the cause of the injury, be it postural with underlying muscle imbalances in strength and length, habitual, overuse from sport or work, will be key in treating SIS but also in preventing a recurrence. Figure 2 shows an algorithm for creating a rehabilitation strategy.

CONCLUSION An important point to consider when treating SIS, is that physical therapists focus on movement-related impairments

rather than structural anatomy. Physical therapists are unable to alter the shape of the acromion or remove a spur, repair a labrum; therefore, the influence is on motor control, soft-tissue strength and flexibility and functional osteokinematics and arthrokinematics (7). Rather than relying solely on some inferred structural diagnoses, physical therapy strategies are based on the identified impairments, tissue irritability and patient-related goals and expectations (7). Yes, the underlying structural abnormalities will be relevant for the prognosis and possible limitation of full recovery, but do not primarily determine the treatment strategy. As shoulder pain is often related to abnormal scapulothoracic or glenohumeral kinematics (28), muscle performance deficits or kinetic chain dysfunction (7), the challenge is to identify these postural (static) and movement (dynamic) abnormalities to ensure successful outcomes.

FURTHER RESOURCES n Algorithm for clinical reasoning in the examination of impingement-related shoulder pain (PDF) - http://spxj.nl/2h8S3L6 n Shoulder impingement rehabilitation algorithm (PDF) http://spxj.nl/2h8S3L6 n Shoulder Impingement Assessments (PDF) - http://spxj.nl/2h8S3L6 n This is a brilliant Shoulder Impingement video playlist of 23 by Physiotutors – well worth checking out – very clean and professionally produced videos http://spxj.nl/2wV0lvs n In the online version of this article we’ve included three pre-designed printable and downloadable patient rehabilitation leaflets each featuring 6 rehabilitation exercises with links to videos where applicable and progressing rehabilitation stages. References Owing to space limitations in the print version, the references that accompany this article are available at the following link and are also appended to the end of the article in the online version. Click here to access the references. http://spxj.nl/2ffhyKg 23

THE AUTHOR Kathryn Thomas BSc Physio, MPhil Sports Physiotherapy is a physiotherapist with a Masters degree in Sports Physiotherapy from the Institute of Sports Science and University of Cape Town, South Africa. She graduated both her honours and Masters degrees Cum Laude, and with Deans awards. After graduating in 2000 Kathryn worked in sports practices focusing on musculoskeletal injuries and rehabilitation. She was contracted to work with the Dolphins Cricket team (county/provincial team) and The Sharks rugby teams (Super rugby). Kathryn has also worked and supervised physios at the annual Comrades Marathon and Amashova cycle races for many years. She has worked with elite athletes from different sporting disciplines such as hockey, athletics, swimming and tennis. She was a competitive athlete holding national and provincial colours for swimming, biathlon, athletics, and surf lifesaving, and has a passion for sports and exercise physiology. She has presented research at the annual American College of Sports Medicine congress in Baltimore, and at South African Sports Medicine Association in 2000 and 2011. She is Co-Kinetic’s technical editor and has taken on responsibility for writing our new clinical review updates for practitioners.

RELATED CONTENT void the Pinch: Content Marketing Campaign for A Therapists - http://spxj.nl/2hhcPVe Shoulder Impingement by Dr Chris Norris http://spxj.nl/2w3mxQI Other shoulder content on Co-Kinetic https://www.co-kinetic.com/tag/shoulder

KEY POINTS n Shoulder complaints are the third most common musculoskeletal presentation after back and neck disorders. n Among people with shoulder pain, shoulder impingement syndrome (SIS) has the highest prevalence. n SIS is a generic term for injury of structures in the subacromial space n Each patient may present differently with varying degrees of involvement of any one or more subacromial structures. n Generally, SIS is caused by repeated, overhead movement of the arm into the ‘impingement zone’. n The common consequences of SIS are pain and disability, loss of quality of life and sleep disturbances. n Patient self-reported outcome measures are currently popular primary tools for evaluating treatment outcomes. n Commonly used manual SIS tests (such as Neer’s sign, Hawkins–Kennedy test and Jobe’s empty can test) help specify anatomical structures, and define the structural integrity of the tissue and its function. n Rehabilitation is based on restoring optimal range of motion, rotator cuff and scapular strength, and stabilisation. n Posture correction may be key in rehabilitation and prevention of SIS. n The 10-minute OSTRC Shoulder Injury Prevention Programme has been found to reduce the prevalence of shoulder problems. n Finding the cause of SIS is crucial in preventing recurrence of the injury.

LINKS Link 1: G eneral shoulder measures (http://spxj.nl/2xuZtzc) Table from Wylie et al. (12) Link 2: C ondition-specific shoulder measures (http://spxj.nl/2fg6HMZ) Table from Wylie et al. (12) Link 3: P DF download of the Constant Shoulder Score (http://spxj.nl/2wXnwns) Link 4: H ow to measure using the Constant Shoulder Score Technique (http://spxj.nl/2wY03nF) Link 5: O nline web form of the Constant Shoulder Score with downloadable CSV file (http://spxj.nl/2h07Mfw) Link 6: O nline web form of the Oxford Shoulder Score with downloadable CSV file (http://spxj.nl/2eSa8cd) Link 7: O nline web form of the Oxford Shoulder Instability Score with downloadable CSV file (http://spxj.nl/2gY7RA8) Link 8: S houlder Examination of Scapular Control (http://spxj.nl/2eSKjsd) Video from BJSM – simple straightforward video showing how to assess and spot shoulder dyskinesis Link 9: H ow to Cue the Scapula During Shoulder Exercises (http://spxj.nl/2vRGvyt) Video from MikeReinold.com – excellent so you can see what you should be looking for during and when teaching your rehab exercises.

DISCUSSIONS iscuss whether ‘shoulder impingement syndrome’ D is an appropriate term to use or not. What is the important thing to remember about patients presenting with shoulder pain? Discuss the different methods available for assessing your patient and how would the results affect your treatment plan? Discuss the impact of posture on shoulder impingement. How would you plan to prevent recurrence of your patient’s shoulder problem?

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: SIS is a generic term for injury of structures in the subacromial space. http://spxj.nl/2h8S3L6 Tweet this: Many factors contribute to malalignment within the shoulder girdle. http://spxj.nl/2h8S3L6 Tweet this: Exercises that work into an acceptable level of pain produce superior short-term outcomes. http://spxj.nl/2h8S3L6

Co-Kinetic Journal 2017;74(October):18-24

SHOULDER IMPINGEMENT ASSESSMENTS Video 1: The Neer Test by Physiotutors http://spxj.nl/2xZEUrG

The Most Commonly Used Tests for Shoulder Impingement The three most commonly used clinical tests for impingement are Neer’s Sign, the Hawkins–Kennedy test and Jobe’s empty can test.

Hawkins–Kennedy Test This test is again a passive test, with the examiner positioning the patient’s arm at 90° in the scapular plane, the elbow bent to 90°, and the arm taken passively into internal rotation. Creation of pain during this manoeuvre is indicative of a positive test (Video 2).

Infraspinatus Weakness or ‘External Rotation Lag Sign’ Used to diagnose an infraspinatus tear, this test sets out to examine the posterosuperior and posterior cuff elements. The arm is held in 20° of flexion with the elbow bent to 90°. The forearm is passively externally rotated to its maximal range and released. If the arm drops back towards its starting position, even by a few degrees, it is said to have a lag (‘the lag sign’). The ability of the patient to maintain the arm fully externally rotated implies the effectiveness of the cuff structures, mostly infraspinatus, but, with the element of forward flexion, there is also an element of supraspinatus activity with the test, and so pain may be present even if no lag is recorded (Video 4).

Jobe’s Empty Can Test This sets out to preferentially test supraspinatus (complete isolation of supraspinatus from the deltoid is difficult), the most commonly affected tendon when considering degenerative cuff disease. It positions the arm such that the supraspinatus tendon is placed under maximal stress as the arm is pushed down, attempting to invoke pain, weakness, or both, from the examination. It does not, however, completely isolate supraspinatus, and some fibres from the anterior part of infraspinatus are also tested (Video 3).

Teres Minor The examination of the posterior cuff is the hornblower sign. The arm is placed passively by the examiner in 90° of abduction and maximal external rotation. The patient is instructed to attempt to maintain the hand in space when the examiner releases the hold on the wrist. If the patient’s arm falls forward, this is a positive test, and indicates significant weakness of the infraspinatus and usually the teres minor. If the patient can maintain the position of the arm, gentle forward pressure on the forearm may cause pain, and indicate the presence of a

Video 3: Jobe’s empty can test by Physiotutors http://spxj.nl/2wUnqzb

Other Tests Often Used to Diagnose Shoulder Impingement Issues

PHYSICAL THERAPY

Video 4: Lateral rotation lag sign/infraspinatus weakness by Physiotutors http://spxj.nl/2wntyMg

small tear involving the infraspinatus (Video 4). Subscapularis Testing the subscapularis involves the evaluation of the patient’s ability to forcibly internally rotate the humerus. This can be achieved either in front (the belly-press test and bear-hug test) or behind (Gerber’s lift-off test) the body. Belly-press Test (Napoleon Sign) This involves the hand (or hands if done bilaterally) being placed flat on the abdomen, and the patient is requested to press the hand onto the stomach. If the patient is unable to maintain the elbow forward, so extending the shoulder and flexing the wrist to achieve the desired pressure, this indicates a positive test (Video 5). Bear-hug Test This test was described by Burkhart and De Beer, and involves the arm reaching across the body to hold the opposite latissimus dorsi and, with the elbow held forward of the body, the strength of the resistance to the hand being pulled away from the body is evaluated. Some examiners modify this slightly, asking the patient to simply place the hand on the opposite chest wall, with the examiner’s hand between the patient’s and their chest wall, and ask them to resist a pull-off (Video 6).

Gerber’s Lift-off Test The dorsum of the hand is placed on the sacrum and the patient is asked to take the hand off the back, when the examiner maintains a fixed angle of elbow flexion. If the elbow is allowed to extend, the test is false because there is recruitment of the triceps to the manoeuvre and so any determination of the strength of the lift-off is inaccurate. In addition to this test, a lag sign may be looked for, with the arm held away from the sacrum by the examiner, so maximising the internal rotation of the humerus, and the patient is then asked to maintain that position as the hand is released. If the hand falls back onto the sacrum, it indicates a weakness of the subscapularis (Video 7). One important difference between testing the subscapularis anteriorly or posteriorly is the fundamental ability of the patient to position their hand in the correct place. Although this is rarely (if ever) a problem for the belly-press or bear-hug positions, any significant degree of restriction of internal rotation of the shoulder, or a body shape with big hips and buttocks, may prevent the patient being able to reach sufficiently far around their back to allow comfortable positioning of the hand, meaning an accurate and consistent assessment may be impossible to achieve.

Video 5: Belly-press test/subscapularis tear by Physiotutors http://spxj.nl/2jkOEtn

Video 6: Bear-hug test/subscapularis tear by Physiotutors http://spxj.nl/2f32cZj

Video 7: Lift-off sign/subscapularis weakness by Physiotutors http://spxj.nl/2h1gyWN

PHYSICAL THERAPY

MANAGING THE PINCH: A REVIEW OF SHOULDER IMPINGEMENT CARE References

BY KATHRYN THOMAS BSC MPHIL

1. Steuri R, Sattelmayer M, Elsig S et al. Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs. British Journal of Sports Medicine 2017;51(18):1340–1347 Open Access article (http://spxj.nl/2w3XpOD) 2. Lange T, Matthijs O, Jain NB et al. Reliability of specific physical examination tests for the diagnosis of shoulder pathologies: a systematic review and meta-analysis. British Journal of Sports Medicine 2017;51(6):511–518 3. Wright AA, Hegedus EJ, Tarara DT et al. Exercise prescription for overhead athletes with shoulder pathology: a systematic review with best evidence synthesis. British Journal of Sports Medicine 2017;doi:10.1136/bjsports-2016-096915 4. Andersson SH, Bahr R, Clarsen B et al. Preventing overuse shoulder injuries among throwing athletes: a cluster-randomised controlled trial in 660 elite handball players. British Journal of Sports Medicine 2017;51:1073–1080 5. Kolber MJ, Hanney WJ, Cheatham SW et al. Shoulder joint and muscle characteristics among weight-training participants with and without impingement syndrome. Journal of Strength and Conditioning Research 2017;31(4):1024–1032 6. Smith BE, Hendrick P, Smith TO et al. Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. British Journal of Sports Medicine 2017;doi:10.1136/ bjsports-2016-097383 Open Access article (http://spxj.nl/2xX2MLJ) 7. Cools AM, Michener LA. Shoulder pain: can one label satisfy everyone and everything? British Journal of Sports Medicine 2017;51:416–417 8. Papadonikolakis A, McKenna M, Warme W et al. Published evidence relevant to the diagnosis of impingement syndrome of the shoulder. The Journal of Bone & Joint Surgery (Am) 2011;93(19):1827–1832 9. de Witte PB, de Groot JH, van Zwet EW et al. Communication breakdown: clinicians disagree on subacromial impingement. Medical & Biological Engineering & Computing 2014;52(3):221–231 10. Ludewig PM, Lawrence RL, Braman JP.

What’s in a name? Using movement system diagnoses versus pathoanatomic diagnoses. Journal of Orthopaedic & Sports Physical Therapy 2013;43(5):280–283 11. Vind M, Bogh SB, Larsen CM et al. Interexaminer reproducibility of clinical tests and criteria used to identify subacromial impingement syndrome. BMJ Open 2011;1(1):e000042 Open Access article (http://spxj.nl/2eS30fP) 12. Wylie JD, Beckmann JT, Granger E et al. Functional outcomes assessment in shoulder surgery. World Journal of Orthopedics 2014;5(5):623–633 Open Access article (http://spxj.nl/2xi1Jc9/) 13. Dawson J, Fitzpatrick R, Carr A. Questionnaire on the perceptions of patients about shoulder surgery. The Journal of Bone & Joint Surgery (Br) 1996;78(4):593-600 Open Access article (http://spxj.nl/2vRcu1M) 14. Dawson J, Hill G, Fitzpatrick R, Carr A. The benefits of using patient-based methods of assessment. Medium-term results of an observational study of shoulder surgery. The Journal of Bone & Joint Surgery (Br) 2001;83(6):877–882 Open Access article (http://spxj.nl/2xhIJdV) 15. Dawson J, Fitzpatrick R, Carr A. The assessment of shoulder instability. The development and validation of a questionnaire. The Journal of Bone & Joint Surgery (Br) 1999;81(3):420–426 Open Access article (http://spxj.nl/2h0B5uA) 16. Phillips N. Tests for diagnosing subacromial impingement syndrome and rotator cuff disease. Shoulder & Elbow 2014;6(3):215–221 Open Access article (http://spxj.nl/2jk0yDL) 17. Hanchard NCA, Lenza M, Handoll HHG et al. Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement. Cochrane Database of Systematic Reviews 2013,30;(4):CD007427 Open Access article (http://spxj.nl/2gZIj5H) 18. Hadzic V, Sattler T, Veselko M et al. Strength asymmetry of the shoulders in elite volleyball players Journal of Athletic Training 2014;49(3):338–344 Open Access article (http://spxj.nl/2h14Lbf) 19. Batalha NM, Raimundo AM, TomasCarus P et al. Shoulder rotator cuff balance, strength, and endurance in young swimmers during a competitive season. Journal of

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Strength and Conditioning Research 2013;27(9):2562–2568 20. Stickley CD, Hetzler RK, Freemyer BG, et al. Isokinetic peak torque ratios and shoulder injury history in adolescent female volleyball athletes. Journal of Athletic Training 2008;43(6):571–577 Open Access article (http://spxj.nl/2ffvLUg) 21. Edouard P, Degache F, Oullion R et al. Shoulder strength imbalances as injury risk in handball. International Journal of Sports Medicine 2013;34(7):654–660 22. Ellenbecker TS, Cools A. Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: an evidence-based review. British Journal of Sports Medicine 2010;44:319–327 23. Kibler WB, Sciascia AD. Introduction to the Second International Conference on Scapular Dyskinesis in Shoulder Injury – the ‘Scapular Summit’ report of 2013. British Journal of Sports Medicine September 2013;47(14):874 Open Access article (http://spxj.nl/2y27HvY) 24. Bullock MP, Foster NE, Wright CC. Shoulder impingement: the effect of sitting posture on shoulder pain and range of motion. Manual Therapy 2005;10(1):28–37 25. Neer CS, II. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. The Journal of Bone & Joint Surgery (Am) 1972;54(1):41–50 26. Neer CS, II. Impingement lesions. Clinical Orthopaedics and Related Research 1983;173:70–77 27. Lewis JS, Wright C, Green A. Subacromial impingement syndrome: the effect of changing posture on shoulder range of movement. Journal of Orthopaedic & Sports Physical Therapy 2005;35(2)72–87 Open Access article (http://spxj.nl/2xum1jO) 28. McClure PW, Michener LA, Karduna AR. Shoulder function and 3-dimensional scapular kinematics in people with and without shoulder impingement syndrome. Physical Therapy 2006;86(8):1075–1090 29. Cools AM, Cambier D, Witvrouw EE. Screening the athlete’s shoulder for impingement symptoms: a clinical reasoning algorithm for early detection of shoulder pathology. British Journal of Sports Med 2008;42:628–35 Open Access article (http://spxj.nl/2wTQcjA).

24i

MANUAL THERAPY

CONNECTIVITY: FASCIA-RELATED THERAPIES T

his article presents the basics for a wide range of fascia-related treatment modalities in a user-friendly way. Although it is generally accepted that all of these treatments can positively affect the fascia, inclusion is neither meant as endorsement nor that the therapy has been conclusively proven to work through evidencebased or randomised clinical trials. They are being included because they have a reputation for getting the desired results. To quote Leon Chaitow: ‘Lack of proof of efficacy is not the same as proof of lack of efficacy.’

There are many fascia-related treatment modalities, which are generally accepted to positively affect the fascia. This article describes the origins, methods and practicalities of each method. This allows you to understand the aims behind them and to choose the treatment most appropriate for your patient’s symptoms and needs. Current research on how treatment modalities are thought to affect fascia structure is also discussed. This article has been modified from Chapter 8 ‘Fascia-Oriented Therapies’ from the author’s book Fascia: What it is and Why it Matters. Read this article online http://spxj.nl/2h9ii4i.

ACUPUNCTURE

Methods

Origins

In acupuncture, very fine needles, about the width of a human hair, are inserted into the skin. The insertion is not at random: the acupuncture points occur along 20 specific lines throughout the body called meridians. These meridians are the conveyors of qi, pronounced, and often spelled, ‘chi.’ In traditional Chinese medicine, qi is the essential energy of the human body. Qi maintains all the vital and functional activities of tissues and organs. The meridians themselves seem to have a deeper connection to the fascia, as they appear to be preferentially located along fascial planes. More than 80% of the acupuncture points in the arm are located along fascial planes (6).

According to archaeological evidence, acupuncture dates back to the Neolithic Age, somewhere between 10,000– 2,000 BCE, and the original needles were made of stone (1) . From there, and to suit our purpose, we need to time-travel considerably into the future to 2001 and the laboratory of Helene Langevin. Professor Langevin has long been intrigued by the ‘grasping’ sensation often associated with acupuncture. This is the physiologic sensation felt by the fingers of the practitioner of the acupuncture needle being sucked into the body by the tissue. It has no biological explanation, or at least none until very recently (2). What was observed under the microscope was loose connective tissue wrapping itself around the acupuncture needle. Every time the needle was twisted, the loose connective tissue would further entwine itself, like ‘spaghetti around a fork’ (3). Furthermore, this phenomenon also occurs in living tissue (4). It is precisely this kind of stretch that activates mechanotransduction and has an effect on the shape of nearby fibroblasts (5).

BY DAVID LESONDAK BCSI KMI FFT LMT FASCIA | 17-10-COKINETIC FORMATS WEB MOBILE PRINT The pulse at the wrist is felt for various qualities that indicate excesses and deficiencies in the meridians. A visual examination of the tongue is also quite common. This information will be correlated with presenting symptoms to determine which meridians and acupuncture points will be stimulated. Upon insertion, the patient may not

In Practice Acupuncture treatment is usually goal-oriented, centred around achieving sustained results for a wide variety of autoimmune, systemic and musculoskeletal pains. It has been shown to be quite effective for chemotherapyrelated vomiting and idiopathic headaches (7).

FASCIA TREATMENT MODALITIES HAVE NOT BEEN CONCLUSIVELY PROVEN TO WORK BUT, CONVERSELY, THERE IS NO PROOF THAT THEY DO NOT WORK Co-Kinetic.com

even feel the needles; they may elicit the briefest of jabs but that sensation passes within seconds. Many people report warm or heavy sensations at the insertion point. The needles are then left in for a period of 15–30 minutes. The number of treatments required to achieve a sustained result varies with the condition. LEARN MORE: International Academy of Medical Acupuncture, Inc. http://iama.edu/

Elastic Recoil Elastic recoil requires an adequate preparatory countermovement. Like a bowstring needing the right amount of tension in order for the arrow to meet its mark, the preparatory countermovement tenses the fascia in the opposite direction of the desired movement for a springier, more energyefficient movement. These exercises often employ kettle bells, weights and rhythmic bouncing.

FASCIAL FITNESS®

Fascial Stretch Fascial stretch involves engaging in flowing, rather than static, full-body stretches that engage long myofascial chains. In many ways these stretches are similar to what animals do instinctively, and those of you with pets see this all the time. Stretches of this nature are known as pandiculations (11).

Origins Fascial Fitness® (FF) began as a collaboration between continuum movement teacher Divo Müller and Robert Schleip as a way to directly apply the research on fascia to the world of sports and exercise (8). For example, correlations between the high kinetic storage capacity of kangaroo tendons as the reason for their high jumping abilities (9) and ultrasound examinations showing a similar elastic catapult capacity in the human Achilles tendon and associated aponeuroses (10). The goal of FF is to increase resilience throughout the entire fascial net and minimise injuries.

Methods FF has four key components. These are elastic recoil, fascial stretch, fascial release and proprioceptive refinement.

Fascial Release Using rollers of different viscosity and very slow movement, fascial release is used to relax and rehydrate fascial tissues. Conversely, more rapid rolling could be used before an athletic endeavour to stimulate proprioception and improve performance. Proprioceptive Refinement This is induced by both slow and fast micromovements. Sometimes these are lightly loaded. Key to this component is

an exploratory mind-set and focusing attention on the quality of movement.

In Practice FF classes are structured like any good exercise class, proceeding from warm-up to maximum effort, followed by gentle cool-down. Because of stimulating the fascia in this manner and the cycle of collagen turn-over (12,13), too much fascial training could have the exact opposite effect, so it is recommended that this kind of training be done only twice a week. Furthermore, once the principles of FF are sufficiently understood, they may be applied to any exercise routine or sports endeavour. LEARN MORE: Fascial Fitness http://fascial-fitness.de/en/ welcome-to-fascial-fitness/

FASCIAL MANIPULATION® Origins Fascial Manipulation® (FM) was developed by Italian physiotherapist Luigi Stecco. It takes into account the role of fascia in motor control and also the control of posture. Luigi’s children, Carla and Antonio, have followed in their father’s footsteps by going into the family business. They have both furthered the field of fascia science by virtue of their meticulous research into the histology, innervation and anatomy of fascia.

Methods CP

CA: carpus

CL TH

SC HU

HU: humerus

SC: scapula CA

CL: collum TH: thorax LU: lumbi PV: pelvis

TH LU

CP: caput

CU: cubitus

SC HU

DI: digiti

PV DI

CX: coxa TA

GE: genu

TA: talus PE

PE: pes

Figure 1: The 14 functional segments used in Fascial Manipulation® with associated Latin names and abbreviations [Reproduced from Chaitow L. (24) with permission]

FM divides the body into 14 functional segments (Fig. 1). Each functional segment is governed by six myofascial units (MFUs). MFUs are functional units responsible for controlling the movement of that segment. MFUs are composed of: n motor units innervating monoarticular and biarticular muscle fibres; n a joint that moves unilaterally when those fibres contract; n f ascia that connect the fibres to ligament, tendon, joint capsules, and menisci; and n n erves involved in the contraction. Each MFU is further parsed into two different areas. The first is called the centre of coordination (CC) and is the active component of the MFU. The CC is located in a small area in the deep fascia of the muscle belly where Co-Kinetic Journal 2017;74(October):25-32

MANUAL THERAPY

muscle fibre contraction takes place. The passive element of the MCU is called the centre of perception (CP). The CP is where traction from the contractile fibres is perceived and is found in the joint capsule, ligament, or tendon. The CP almost always correlates to where the patient is describing symptoms. This method also has unique nomenclature for describing natural movement. This was created to streamline and simplify the terminology for both patient and practitioner.

In Practice Assessment involves taking a symptomatic history, with detailed chronology to best understand the sequelae of injury and compensation leading to the presenting symptom(s). Then, both movement and palpation assessments are used to determine which functional segments and CCs are involved in the pathology. Treatment consists of deep crossfibre friction applied to the densified CCs. The goal is to restore elasticity and proper sliding (via local increase of hyaluronan). The immediate goal is to relieve the pain, with the longer-term aim being to resolve the dysfunction in as few treatments as possible. LEARN MORE: Fascial Manipulation http://www.fascialmanipulation.com/en/

STRETCH TO WIN® FASCIAL STRETCH THERAPY Origins Stretch to Win® Fascial Stretch Therapy (FST) is the co-creation of Ann and Chris Frederick. Ann credits her education in kinesiology to having grown up in her mother’s dance studio from the age of four. A professional dancer and dance teacher, Ann started developing FST in 1995 at Arizona State University. In 1996 she created FST for the US men’s Olympic wrestling team. Coming from the world of physical therapy, and a professional ballet dancer in his own right, Chris began studying FST with Ann in 1998, and he liked it so much that he married her! Together they evolved FST into the sophisticated neuromyofascial manual Co-Kinetic.com

THE BASIS FOR VISCERAL MANIPULATION IS THAT THE NATURAL, INHERENT PHYSIOLOGIC MOTION OF THE ORGANS IS BASIC TO THEIR HEALTHY FUNCTIONING therapy and movement re-education system that it is today.

JOHN F. BARNES’ MYOFASCIAL RELEASE APPROACH®

Methods

Origins

The basis for FST involves stretch with sustained traction of the joint capsule and myofascia combined with slow oscillations and circumductions in multiple planes of movement. Often the lower limb is comfortably secured under a series of soft straps to better increase leverage and more accurately target the specific joint or neuromyofascial unit. ‘No pain, no pain’ is a mantra of FST, as the positive gains need to be made by finesse not by force. One of the other keys to the method is the metaphor of the stretch wave. The stretch wave concept is to help practitioners and patients to understand stretch as a series of undulations of movement coordinated with proper breathing. Proper breathing is essential in the FST model for both practitioner and patient.

John Barnes was working as a young physical therapist when, via a weightlifting accident, he crushed several discs in his lumbar spine. He underwent lumbar fusion surgery to remedy the situation with subsequent physical therapy to address the problem, but the therapy did not work – at least not fully. John still came home from work in pain every day. The only thing that would give him relief was lying on the floor and using his own body weight and leverage to apply pressure to the affected areas. He found that maintaining sustained pressure over a period of several minutes would relieve the pain, and with repeat applications, the pain continued to be relieved for longer and longer cumulative durations. As he began to see the benefits in himself, he began to create manual methods to apply these same compressive principles to his physical therapy patients.

In Practice Assessment begins with the usual medical history followed by a number objective tests involving both dynamic and static palpation. Other measures include, but are not limited to, posture, gait, observation of activities of daily living and other movement patterns. In a nutshell, the FST practitioner is looking for what can be shortened or lengthened or stabilised to achieve the goals of the session. FST sessions can last anywhere from 15 to 120 minutes. FST is used both to resolve longstanding pain and functional issues as well as specific protocols for enhancing the performance of professional athletes. FST adjusts the parameters to fit the needs of the client and can be used in rehabilitation and recovery to correct imbalances or to prepare for imminent athletic activity. LEARN MORE: Stretch to Win® Fascial Stretch Therapy http://stretchtowin.com/

Methods The Barnes Approach has three distinct facets: structural, unwinding and rebounding. Structural The structural part of the approach involves the more compressive, handson techniques applied to areas of fascial restrictions. Therapists take up the slack of the muscular component, then feel for the collagenous barrier (densification). They then apply steady continuous pressure at that level for anywhere for at least three to five minutes, and often longer, to facilitate a thorough release via increasing both depth into the body and elongation of the tissue. Unwinding Unwinding, or myofascial movement facilitation, involves fully supporting 27

a limb or area of the body in order to nullify the effects of gravity upon it. This often returns the body to the original position and/or tensile state experienced during the trauma. Unwinding often happens spontaneously. The therapist follows the inherent movement along the path of least resistance until it stops. This is called the still point, as all physiologic motion ceases. Often at the still point there can be accompanying somatoemotional release. Rebounding Myofascial rebounding involves working with the fluid dynamics and elastic recoil properties of fascia to induce an oscillation through the fascial net that helps to reset the nervous system component through distraction and confusion. In this respect it could be said to be somewhat analogous to eye movement desensitisation and reprocessing (EMDR) therapy, which is used to treat aspects of post-traumatic stress disorder (PTSD) (14) by changing the way the nervous system processes stressful information.

In Practice This approach always starts with an array of assessments: postural, range of motion, gait, etc. A treatment plan is then devised that involves two sessions of 30–60 minutes per week. Regular reassessments occur throughout the sessions. Every third treatment has a strong self-care focus, using balls, rollers and long pandiculating stretches (to simulate unwinding), so that the patient can become better empowered, with the ultimate goal being independence from the therapist. LEARN MORE: John F. Barnes’ Myofascial Release https://myofascialrelease.com/

MELT METHOD® Origins Necessity is often the mother of invention and no less so for Sue Hitzmann, who is the creator of the Myofascial Energetic Length Technique Method or MELT® Method (MM). A group exercise instructor, fitness maven and manual therapist, Hitzmann was looking for solutions to her own chronic pain issues, predominantly plantar 28

fasciitis. She was also looking for more specifically targeted ‘homework’ for her clients than the usual stretches, and strength and stability exercises. Many years of in-the-field research and development followed and eventually Hitzmann was able to achieve both aims.

Methods An MM practitioner uses both soft foam rollers and a variety of balls of different sizes and viscosities to mimic the techniques and results of hands-on manual therapies. The individual is taught how to identify where dehydration has occurred in the fascial tissues and how to appropriately use the rollers and balls to facilitate effective changes. The overall goal is to restore fluid flow and improve stability to the fascial system. MM is considered appropriate for both chronic pain issues and performance enhancement.

In Practice MM occurs in small classes and individual sessions. People who use MM are encouraged to do it themselves as part of a regular self-care routine. Likewise, MM is suggested as a proactive treatment, and practitioners are encouraged not to wait until they have a problem to employ MM, but rather to use MM to keep pain and dysfunctions from happening in the first place. A recently completed study on MM and low back pain (15) studied 22 people using MM for chronic low back pain. They were compared to a control group not using MM. Significant decreases in pain, thickness of the lumbar fascia and increased flexibility were all reported in the group using MM. LEARN MORE: Melt https://www.meltmethod.com/

MERRITHEW™ FASCIAL MOVEMENT Origins PJ O’Clair has been involved in the fitness industry since the mid-1980s. She got her first appreciation for fascia in the early 2000s, working in the dissection labs at Tufts Medical Center, Boston, USA, with Gil Headley and Todd Garcia. Intrigued by the sliding

and gliding layers under her hands and scalpel, she began to conceive of the idea of creating a movement class to accentuate that fascial aspect of the body. Already a well-respected Pilates and yoga teacher, PJ knew she would need to incorporate aspects of both of those systems into the new technique, and that it would not look like either of them. She also knew that music with mindful movement would play a role. This led her to collaborate with multiple Latin Grammy-winning composer Kike Santander. Santander’s vision was to bring his Zen-like music to the fitness industry with choreographed sequences written by PJ and her programming team. This collaboration evolved into the mindful movement programme known as ZEN·GA®. Merrithew™ Fascial Movement (MFM) is the next evolution. Whereas ZEN·GA® focuses more on softer, more relaxing qualities of fascial-based protocols, MFM combines the latest research to create more resilience, as well as awareness, in the fascial body. MFM can strengthen and tone the fascia as well as restore it.

Methods The basis for MFM involves four fascia movement variables: bounce, sense, expand and hydrate. Bounce Bounce seeks to develop springlike, effortless actions in rhythmic movements. Pre-tension, recoil, and the stretch-shortening cycle are all used to foster this capability within the fascia, from superficial to the deepest visceral layer. Music, of course, plays a key role. There are both strengthening and restorative applications. Sense Using props and tools with various textures, vibrations, and FlexBands of differing viscoelasticity, Sense has a more neurological component and stimulates both proprioception and interoception. Breathing awareness also plays a key role. Expand Expand actively explores force transmission and promotes better Co-Kinetic Journal 2017;74(October):25-32

MANUAL THERAPY

tissue glide and fluid flow. Breathing awareness again has a key role, particularly through using hydraulic expansion to activate better core stability. Pandiculations (whole-body stretches) are used throughout. Hydrate Hydrate assists optimal force transmission by enhancing glide and hydration for greater ease in movement. Hydrate uses soft and firm rollers and balls to ‘soak and squeeze’ the fascial tissues. Hydrate seeks also to promote capillary flow, thereby improving arterial flow and venous return.

In Practice MFM is taught both in groups and oneon-one. From an instructor standpoint, MFM training allows for specific classes with a myriad of programming options. Once the core concepts of MFM are understood, they can be easily integrated into any movement, fitness or sports endeavour at any level. LEARN MORE: Merrithew™ https://merrithew.com/

MYOFASCIAL TRIGGER POINT THERAPY Origins Myofascial Trigger Point Therapy was developed by Dr Janet Travell. As a young doctor, many of her patients with pulmonary disease complained of terrible shoulder and arm pain. Methodical palpation of the chest, arms and shoulders revealed to Dr Travell the presence of trigger zones (16). She would trace these painful areas to trigger points – hyperirritable nodules located within a taut band of skeletal muscle (17), colloquially referred to as muscle knots. Dr Travell would soon abandon cardiology to focus on the aetiology of these muscle knots. Partnering with Dr David Simons, the two of them produced a thorough topographic documentation of trigger points and their patterns of referred pain (pain felt in areas adjacent to the trigger point). This information can be found in their two-volume, 2,000-plus page treatise Myofascial Pain and Dysfunction (17,18). Trigger points can be latent; that is, someone can have them and not experience pain (rather like the segment Co-Kinetic.com

of the population with disc issues but no pain). It has been shown that biochemicals associated with pain, inflammation and intercellular signalling are present near active trigger points (19).

Methods The basic method for Myofascial Trigger Point Therapy is ischemic compression performed by the finger(s), hand, arm, or even elbow of the therapist. Pressure is applied to the point where initial resistance is felt, then sustained until the trigger point begins to soften. This melting sensation is often felt both by the patient and the therapist. Trigger points may also be treated in a manner similar to acupuncture, which is called dry needling.

In Practice Although many trigger point therapists often use other adjunct therapies, they typically have excellent palpation skills. This is a must for finding the exact location of the taut bands and tender nodules and also for being able to provide just the right amount of pressure to elicit the desired effect without causing more pain in the process. Various stretch-based protocols are also part of the rehab process. LEARN MORE: National Association of Myofascial Trigger Point Therapists http://myofascialtherapy.org/

STRUCTURAL INTEGRATION Origins Structural Integration (SI) was created by Ida Rolf. When Ida was a child, she contracted pneumonia and a raging fever after a nearly fatal kick from a horse. Her health and vitality were restored after having her spine manipulated by an osteopath from Montana (20). Ida graduated from Columbia University with a PhD in organic chemistry in 1921 – just one year after women in the USA were given the right to vote. She went on to become the first woman to hold a research post at the Rockefeller Foundation (21). Ida discovered Hatha yoga at the Clarkstown Country Club in Nyack, New York, USA, and would remain a lifelong devotee. She studied homeopathy in

Europe and was also strongly influenced by somatic pioneers Alfred Korzybski and Hubert Godard, as well as a number of osteopaths, including William Sutherland. In the 1950s she would begin teaching her first hands-on classes in structural dynamics at the European College of Osteopathy at Maidstone, England. Later she would rename this process ‘Structural Integration’.

Methods The SI process centres on reorganising the human being in the field of gravity to achieve better balance, proper alignment, and ease of motion. In other words, restoring the body to a state where gravity lifts you up rather than wears you down. Fundamental to this process is recognising fascia as the primary organ of structure. Static postural examinations are routine. SI is based on a repeatable sequence known as ‘the recipe’ – a series of 10 sessions designed by Ida Rolf that have specific physiological goals. The exact sequence of each session is modified by virtue of the individual, idiosyncratic asymmetries of the patient. The over-arching goal of the 10 sessions is to achieve a balanced tone, or palintonicity, throughout the biotensegrity of the body. Rolf would also develop a movementbased practice to complement SI in collaboration with Dorothy Nolte and Judith Aston. The fascial changes are produced by slow, hands-on fascial and myofascial releases that also involve slow stretches and guided movements on the part of the patient.

In Practice Actual mileage varies. Some practitioners treat SI as a step-bystep realignment and fundamental movement re-education process for the human body. Others use the basic recipe as a jumping-off point to treat a variety of chronic pain and musculoskeletal disorders. Different schools have different approaches. For example, Hellerwork® has a paradigm that is designed to address the psychoemotional, as well as biomechanical, aspects of the patient. Anatomy Trains Structural 29

Integration (KMI) takes an anatomically rigorous approach via the Anatomy Trains model of force transmission. It should also be noted that ‘Structural Integration’ is a generic term. Names such as Rolfing®, Hellerwork® or KMI denote a particular brand of SI-influenced therapy. Although the fundamentals are similar, the individual expressions can be different. LEARN MORE: International Association of Structural Integrators® http://www.theiasi.net/

VISCERAL MANIPULATION

for Barral it was wide-open territory. His attention to thoroughly documenting his methods and their results resulted in a gradual consistency in treating conditions like chronic indigestion, incontinence, migraines, reflux, IBS and more. The techniques Barral pioneered and refined are now part of the standard curriculum at all osteopathic colleges in Europe.

Methods The basis for VM is that the natural, inherent physiologic motion of the organs is basic to their healthy functioning.

Origins Visceral mobility Visceral mobility refers to the motion of the viscera in response to voluntary movements: walking, running, bending over, the up-and-down motion of the diaphragm during respiration, and so on. If the ligaments of the organs are compromised or the organs are not sliding in the serous membranes (as can happen with scar tissue after

Visceral Manipulation (VM) was developed by French osteopath and physical therapist Jean-Pierre Barral. While working as a young physician, Barral found that he could relieve certain aches and pains simply by kneading the organs (22). At that time, practitioners of osteopathy were not interested in manipulating the organs so much as manipulating the spine, so

abdominal surgeries), function will be compromised. Visceral restrictions can also manifest as neuromuscular pain, as in the case of chronic right-sideonly shoulder pain having a relationship to the falciform ligament of the liver (23). Visceral motility Visceral motility refers to the intrinsic, active motion of the organs. The movement cycle has two phases: toward and away from the midline of the body. Motility is a slow, low amplitude movement that is assessed solely through very sensitive palpation. Barral admits to motility as having no scientific explanation, but he is aware of it from palpatory observations over four decades of clinical experience. He speculates that it may have a relationship with the craniosacral rhythm. VM is performed with the hands using soft pressure. Often, slow, guided stretching is part of the technique.

In Practice Control

RMS

MFR

YIN YOGA RMS+MFR

(A) The control group shows healthy fibroblast and actin architecture. (B) RMS is the repetitive motion strain group. (C) MFR is the healthy group that received myofascial release. (D) The image shows a culture that had induced RMS and then MFR. Reproduced with permission from Meltzer et al. 2010. Figure 2: Results of experiment attempting to model myofascial release at the cellular level [Reproduced with permission from Meltzer et al. 2010 (27)]

VM sessions are usually very gentle, as befits the delicacy of the tissues involved. They are usually 45–60 minutes in duration and spaced several weeks apart. Highly chronic situations may involve greater frequency, and sometimes teaching the patient selfcare may be warranted. LEARN MORE: The Barral Institute http://barralinstitute.com/

Origins The introduction of Yin yoga to the West happened in the late 1970s and is credited to yogi and martial artist, Paulie Zink. It has its roots in Taoist yoga where asanas (yoga poses) are held for longer periods of time than traditional Hatha styles of yoga. This form of yoga has been further popularised in the US by Paul Grilley and Sarah Powers. Paul has infused the style with a stronger anatomical foundation. Sarah has brought more traditional Chinese medicine concepts to it, including sequences designed to enhance the flow of qi through the meridians.

Methods Co-Kinetic Journal 2017;74(October):25-32

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Although most forms of yoga do work the fascia (how can they not?), they tend to be more energetic and thus considered yang – Yin yoga has a slower, more contemplative pace. The slower pace is thought to foster an inner stillness, among other spiritual goals. Although the asanas are similar to other forms of yoga, they often have different names and are modified to use as little muscular exertion as possible. It is this quality along with the duration of the poses that is thought to produce a beneficial effect on the connective tissue and also serve to rehydrate the fascia.

In Practice Yin yoga classes function much like any other yoga class; however, the asanas are typically held for 5 minutes or longer, depending on the pose. As such, there are fewer poses in a Yin class than in more Hatha-oriented styles of yoga. The goal is to passively create length and flexibility. Learn More: See Clark B, The Complete Guide to Yin Yoga: The Philosophy and Practice of Yin. White Cloud Press 2012 (25) and Grilley P, Yin Yoga: Principles & Practice (26).

FASCIAL RELEASE: HOW DOES IT WORK? Fascia has a two-dimensional lattice structure (like the warp and weft in nylon hosiery), which gives it both stretch and strength. The more regular the lattice, the better the crimp of the individual collagen fibres. Crimp is the wavy springiness of the individual collagen fibres that allow for their proper flexion–extension along the stress–strain curve. Immobility promotes crosslinks in the fascial tissues, essentially making them stuck and matted together. Tissues in this state lose their ability to glide. It is thought that the proper stimulation of the fibroblasts through movement can promote restoration of healthy crimp and glide. I would also speculate the same is true in our manual therapies. An intriguing experiment attempting to model the effects of myofascial release (MFR) at the cellular level was carried out by Meltzer et al. (27). The monofilaments, intermediate filaments and microtubules that make up the Co-Kinetic.com

cytoskeleton are mechanically active and will respond to stress. In Meltzer’s simulation, active cell cultures of human fibroblasts were subjected to 8 hours of repetitive motion strain (RMS) using a vacuum-driven, flexible petri dish apparatus. That same apparatus was then reconfigured to approximate MFR by simulating compression (load) with strain (uniaxial stretch) over a sustained period of 60 seconds (time). The fibroblasts subjected to RMS exhibited elongated lamellipodia, cellular decentralisation, cytoplasmic condensation, and reduced cell-to-cell contact area. Most significant was a 30% increase in fibroblast apoptosis (cell death) among the RMS group when compared to the non-stressed control and other groups (Fig. 2).

ACKNOWLEDGMENT The figure has been taken from the author’s book Fascia: What it is and Why it Matters ©Handspring Publishing 2017, and is reproduced here with permission. References 1. Deng LY, Cheng X. Chinese Acupuncture and Moxibustion, 4th printing. Foreign Language Press 1996. ISBN 978-7119003788 (£41.95). Buy revised edition on Amazon http://amzn.to/2h10hF1 2. Langevin HM, Churchill DL, Cipolla MJ. Mechanical signaling through connective ect of acupuncture. FASEB Journal 2001;15(12):2275–2282 3. Langevin HM. The science of stretch. The Scientist 2013 http://spxj.nl/2xZ3VCt 4. Langevin HM, Konofagou EE, Badger GJ et al. Tissue displacements during acupuncture using ultrasound elastography techniques. Ultrasound in Medicine & Biology 2004;30(9):1173–1183 5. Langevin HM, Bouffard NA, Fox JR et al. Fibroblast cytoskeletal remodeling contributes to connective tissue tension. Journal of Cellular Physiololgy 2011;226(5):1166–1175 6. Langevin HM, Yandow JA. Relationship of acupuncture points and meridians to connective tissue planes. The Anatomical Record 2002;269(6):257–265 7. Ernst E. Acupuncture: what does the most reliable evidence tell us? Journal of Pain and Symptom Management 2009;37(4):709– 714 8. Schleip R, Müller DG. Training principles for fascial connective tissues: Scientific foundation and suggested practical application. Journal of Bodywork and Movement Therapies 2013;17(1):103–111 9. Kram R, Dawson TJ. Energetics and biomechanics of locomotion in red kangaroos

(Macropus rufus). Comparative Biochemistry Physiology - Part B 1998;120:41–49 10. Sawicki GS, Lewis CL, Ferris DP. It pays to have a spring in your step. Exercise and Sport Sciences Reviews 2009;37(3):130– 138 11. Bertolucci LF. Pandiculation: nature’s way of maintaining the functional integrity of the myofascial system? Journal of Bodywork and Movement Therapies 2011;15(3):268–280 12. Kjaer M, Langberg H, Heinemeier K et al. From mechanical loading to collagen synthesis, structural changes and function in human tendon. Scandinavian Journal of Medicine & Science in Sports 2009;19(4):500–510 13. Magnusson SP, Langberg H, Kjaer M. The pathogenesis of tendinopathy: Balancing the response to loading. Nature Reviews Rheumatology 2010;6(5):262–268 14. Servan-Schreiber D. The instinct to heal: curing depression, anxiety and stress without drugs and without talk therapy. Rodale Books 2005. ISBN 978-1594861581 (Print £9.10 Kindle £7.12). Buy from Amazon http://amzn.to/2w8bE4E 15. Sanjana F, Chaudhry H, Findley T. Effect of MELT method on thoracolumbar connective tissue: The full study. Journal of Bodywork and Movement Therapies 2016;21(1):179– 185 16. Travell JG. Office hours: day and night: the autobiography of Janet Travell, M.D. World Publishing Co 1968. ASIN B0014KJM5Y (£10.69) Buy from Amazon http://amzn.to/2fioQd2 17. Travell JG, Simons DG. Myofascial pain and dysfunction. The trigger point manual, volume 1. Upper half of body. Lippincott, Williams & Wilkins 1999. ISBN 978-0683083637 (£73). Buy from Amazon http://amzn.to/2w8gu23 18. Travell JG, Simons DG. Myofascial pain and dysfunction. The trigger point manual, volume 2. The lower extremities. Lippincott, Williams & Wilkins 1992. ISBN 978-0683083675 (£84.26) Buy from Amazon http://amzn.to/2xZ69ls 19. Shah JP, Gilliams EA. Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis: An application of muscle pain concepts to myofascial pain syndrome. Journal of Bodywork and Movement Therapies 2008;12(4):371–384 20. Love R. The Great OOM: the mysterious origins of America’s first yogi. Penguin Books 2011, pp.286–287. ISBN 978-0143119173 (£13.26) Buy from Amazon http://amzn.to/2wYoIGZ 21. Jacobson E. Structural integration: origins and development. Journal of Alternative and Complementary Medicine 2011;17(9):775–780 22. Levine M. Visceral manipulation: has your liver been liberated? TIME Magazine 2008, May 16 http://spxj.nl/2h2Vseu 23. Barral J-P. The Thorax. Eastland Press

1991. ISBN 978-0939616121 (£44.63). Buy from Amazon http://amzn.to/2fia6uE 24. Chaitow L. Fascial dysfunction: manual therapy approaches. Handspring Publishing 2014. ISBN 978-1909141100 (print £27.85 Kindle £28.20). Buy from Amazon http://amzn.to/2f6qwJD 25. Clark B. The complete guide to yin yoga: the philosophy and practice of Yin. White

Cloud Press 2012. ISBN 9781935952503 (Print £12.38 Kindle £11.27) Buy from Amazon http:// amzn.to/2h15AEv 26. Grilley P. Yin yoga: principles & practice, 10th anniversary edn. White Cloud Press 2012. ISBN 978-1935952701 (Print £10.99 Kindle £10.44). Buy from Amazon http://amzn.to/2vTaJRP.

THE AUTHOR David Lesondak BCSI KMI FFT LMT is an allied health member in the Department of Family and Community Medicine at the University of Pittsburgh Medical Center (UPMC), where he maintains a clinical practice in structural integration, visceral manipulation and other fascial modalities at UPMC’s Center for Integrative Medicine. He has been a clinical bodyworker/structural integrator for over 25 years. Certified in kinesis myofascial therapy by Thomas Myers, he is also a board certified structural integrator, fascial fitness trainer, visceral manipulator via the Barral Institute and also certified by Ann and Chris Frederick as a fascial stretch therapist, level one. David is also a keen communicator, having produced Anatomy Trains Revealed, a 3-DVD companion to the best-selling book, has recorded and edited 88 individual scientific presentations from the most forward-thinking researchers in the field of fascia, as well as running the Fascial Connections (http://fascialconnections.com/) blog. He also a busy lecturer and presents internationally on the topic of fascia and fascia-based therapies. Website: http://www.davidlesondak.com/ Email: david.lesondak@gmail.com Blog: Fascial Connections http://fascialconnections.com LinkedIn: linkedin.com/in/david-lesondak-a9026a6

Fascia: What it is and Why it Matters by David Lesondak Handspring Publishing 2017; ISBN: 978-1-909141-55-1 Buy it from Handspring - http://handspringpublishing.com/product/fascia-what-it-is-and-why-it-matters/ In the introduction, the author, David Lesondak, explains his purpose for writing this book: “My quest to find more reliable outcomes for my patients, those who entrusted me with being the custodian and way finder for the way out of their chronic pain, led me to the world of fascia – and that world turned out to be a whole inner universe.”

CONTENTS Introduction Chapter 1. Fascia, The Living Tissue Chapter 2. Fascia in the Cellular Level Chapter 3. Fascia in the Musculoskeletal System Chapter 4. Fascia in the Organs Chapter 5. Fascia and the Nervous System Chapter 6. Fascia and the Brain Chapter 7. Diagnosing Fascial Conditions Chapter 8. Fascial Modalities Chapter 9. Summary 32

DISCUSSIONS ll of the treatment modalities aim to affect the A fascia. However, are some more similar to each other than others? Can they be placed into groups of similar treatments? How would you decide which modality to use for a patient? Some common ideas seem to run through most of the modalities; discuss what you think they are.

KEY POINTS nT here are many fascia-related treatment modalities, which are generally accepted to positively affect fascia. n They have not been conclusively proven to work but, conversely, there is no proof that they do not work. n Fascial therapies are thought to activate mechanotransduction and affect the shape of nearby fibroblasts. n Fascial Fitness® has four key components: elastic recoil, fascial stretch, fascial release and proprioceptive refinement. n Fascial Manipulation® divides the body into functional segments, which, in turn, are divided into myofascial units. n The Stretch to Win® Fascial Stretch Therapy mantra is ‘no pain, no pain’: gain is made by finesse, not force. n The Barnes Myofascial Release Approach® has three distinct facets: structural, unwinding and rebounding. n The MELT Method® uses rollers and balls to restore fluid flow and improve stability to the fascial system. n Myofascial Trigger Point Therapy involves ischemic compression of the trigger point (or muscle knot) by the finger(s), hand, arm, or even elbow of the therapist. n The goal Structural Integration is to reach a balanced tone throughout the biotensegrity of the body.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Acupuncture dates back to the Neolithic Age and the original needles were made of stone. http://spxj.nl/2h9ii4i Tweet this: Acupuncture points occur along 20 specific lines throughout the body called meridians. http://spxj.nl/2h9ii4i Tweet this: To avoid affects detrimental to the collagen, Fascial Fitness training is done only twice a week. http://spxj.nl/2h9ii4i Tweet this: The Fascial Stretch Therapy mantra is ‘no pain, no pain’. http:// spxj.nl/2h9ii4i Tweet this: The concepts of the Merrithew modality can be used for any movement, fitness or sports endeavour. http://spxj.nl/2h9ii4i Tweet this: The slower pace of Yin yoga is thought to benefit connective tissue and to rehydrate the fascia http://spxj.nl/2h9ii4i

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MANUAL THERAPY STUDENT HANDBOOK Assessment and treatment of the wrist and hand BY JULIAN HATCHER GRAD DIP PHYS MPHIL, MCSP FOM Video 1: Surface marking of the wrist region (Video with captions but no sound)

Video 2: Assessment of the wrist (Video with captions but no sound)

Video 3: Assessment of the fingers (Video with captions but no sound)

This article is the tenth from our Manual Therapy Student Handbook (see the ‘Contents panel’ for further details) and it describes how to assess and treat common wrist and hand 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. All videos can be accessed online at http://spxj.nl/1S5oOUh 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.

WRIST | HAND | 17-10-COKINETIC FORMATS WEB MOBILE PRINT

MEDIA CONTENTS Videos 1-13: Techniques for wrist and hand assessment. J. Hatcher, 2013

THE CAPSULAR PATTERN OF MOVEMENT LIMITATION AT THE WRIST IS DEFINED BY: Assessment of EQUAL LOSS OF FLEXION the wrist and hand AND EXTENSION; AND LEAST For a full assessment of the wrist and LOSS OF RADIAL AND hand, the therapist must be familiar with the anatomy of the area and perform ULNAR DEVIATION the observations and examinations detailed in Table 1 and Videos 2–4.

Video 4: Assessment of the thumb (Video with captions but no sound)

Treatment of the wrist and hand

Video 5: Mobilisation of the wrist: extension (Video with captions but no sound)

CAPSULAR PATTERN – WRIST The capsular pattern of movement limitation at the wrist is defined by: n Equal loss of flexion and extension n Least loss of radial and ulnar deviation.

CAUSES OF Co-Kinetic.com

TABLE 1: ASSESSMENT OF THE WRIST AND HAND OBSERVATION/ EXAMINATION DETAILS 1. Anatomy n Wrist joint derived from C6/C7/C8 segments n Dermatomes C5: radial aspect of forearm to thumb C6: thumb and index finger C7: middle three fingers; C8 ring and little fingers n Myotomes C6: wrist extensors C7: wrist flexors, finger extensors C8: thumb adductors, extensors and flexors, finger flexors T1: finger abduction and adduction 2. Initial observation n Face and posture and gait 3. History n Age and occupation n Site and spread n Onset and duration n Behaviour and symptoms n Past medical history (P.M.H.) 4. Inspection

n n n n

Bony deformity Colour changes Wasting Swelling

CAPSULAR PATTERN Typical causes of capsular pattern movement limitation at the wrist and hand are shown in Table 2. Treatment choice for the radiocarpal joint n Mobilisations of the radiocarpal joint. Extension mobilisation (Video 5) Directions: 1. Patient lying supine, stand at side of bed facing slightly toward patient’s head. 2. Place outer hand around distal aspect of radius and ulna, holding forearm in supinated position, and place inner hand over the palmar aspect of the patient’s hand. 3. Take wrist into extension while Video 6: Mobilisation of the wrist: flexion (Video with captions but no sound)

5. Objective n Observe/examine state at rest examination n Palpate for heat, swelling and synovial thickening (and pulses if necessary) 6.

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

n n n n n n

Pronation – inferior radio-ulnar joint Supination – inferior radio-ulnar joint W rist flexion Wrist extension Radial deviation Ulnar deviation

ideo 7: Mobilisation of V the wrist: radial and ulnar deviations (Video with captions but no sound)

7. Resisted tests n Flexion – flexor carpi radialis (FCR), flexor carpi (for pain and ulnaris (FCU) power) n Extension – extensor carpi radialis longus (ECRL), extensor carpi radialis brevis (ECRB), extensor carpi ulnaris (ECU) n Radial deviation – ECRL, ECRB, FCR n Ulnar deviation – FCU, ECU 8. Thumb n Passive extension with adduction – carpo metacarpal joint between trapezium and first metacarpal n Resisted flexion – flexor pollicis longus (FPL), flexor pollicis brevis (FPB) n Resisted extension – extensor pollicis longus (EPL), extensor pollicis brevis (EPB) n Resisted abduction – abductor pollicis longus (APL), abductor pollicis brevis (APB) n Resisted adduction – adductor pollicis

9. Fingers

n Resisted abduction – dorsal interossei n Resisted adduction – palmer interossei

10. Additional specific tests

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

ideo 8: Mobilisation of the V wrist: anterior–posterior accessory glide on carpus (Video with captions but no sound)

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stabilising the forearm with the opposite hand. 4. Grade according to your findings on assessment. Flexion mobilisation (Video 6) Directions: 1. Patient lying supine, stand at side of bed facing slightly toward patient’s head. 2. Place outer hand around distal aspect of radius and ulna, holding forearm in supinated position, and place inner hand over the palmar aspect of the patient’s hand. 3. Take wrist into flexion while stabilising the forearm with the opposite hand. 4. Again, grade according to your findings on assessment. Radial deviation mobilisation (Video 7) Directions: 1. Patient lying supine, stand at side of bed facing slightly toward patient’s head. 2. Place outer hand around distal aspect of radius and ulna, holding forearm in mid-prone position, and place inner hand over the ulnar border of the patient’s hand, with your fingers in their palm and your thumb on the dorsum. 3. Take wrist into radial deviation while stabilising the forearm with the opposite hand. 4. Grade according to your clinical assessment. Ulnar deviation mobilisation (Video 7) Directions: 1. Again, patient lying supine, stand at side of bed facing slightly toward patient’s head. 2. Place outer hand around distal aspect of radius and ulna, holding forearm in mid-prone position, and place inner hand over the radial border of the patient’s hand (excluding the thumb), with your fingers in their palm and your thumb on the dorsum. 3. Take wrist into ulnar deviation while stabilising the forearm with the opposite hand. 4. Again, grade according to your clinical assessment. Anterior–posterior carpus mobilisation

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TABLE 2: CAUSES OF CAPSULAR PATTERN AT THE WRIST AND HAND TYPICAL FEATURES CAUSE Osteoarthritis (OA) n Wear and tear to the joint, may be primary, or possibly secondary to previous lesion such as fracture, or repetitive use of vibratory tools. n Mild capsulitis, possible crepitus. Rheumatoid arthritis (RA) and other systemic arthropathies

Traumatic arthritis (TA)

n Systemic autoimmune disease, causing degeneration and possible joint disruption. nO ften severe capsulitis, may lead to joint laxity and deformity. n T rauma from fall on outstretched arm.

(Video 8) Directions: 1. Again, patient lying supine, stand at side of bed facing slightly toward patient’s head. 2. Place outer hand around distal aspect of radius and ulna, holding forearm in supinated position, and place the index finger and thumb of you inner hand around the proximal row of carpus bones as close to the radiocarpal joint line as possible, with your fingers resting around your Video 9: Mobilisation of the wrist: posterior–anterior accessory glide on carpus (Video with captions but no sound)

TREATMENT n Warm the capsule using appropriate electrotherapy and use Grade B (Maitland Grade III and IV) mobilisation and self-help exercises to end of range. nR efer to GP for Rheumatology opinion. n If not in acute flareup, may use Grade A (Maitland Grade I and II) mobilisations and progress to Grade B (III and IV). nM ay require mobilisation as pain allows, Grade A–B (I–IV). n May require electrotherapy and Grade A and B mobilisations.

other hand. 3. Gently pull towards you while stabilising the radius and ulna with the opposite hand. 4. Again, grade according to your clinical assessment. Posterior–anterior carpus mobilisation (Video 9) Directions: 1. Again, patient lying supine, stand at side of bed facing slightly toward patient’s head. 2. Place outer hand around distal aspect of radius and ulna, holding forearm in supinated position, and place the index finger and thumb of you inner hand around the proximal row of carpus bones as close to the radiocarpal joint line as possible, with your fingers resting around your other hand. 3. Gently push away from you while stabilising the radius and ulna with the opposite hand. 4. As always, grade according to your assessment.

Figure 1: Anterior–posterior mobilisation of the first carpo-metacarpal joint

Finger flexion mobilisation (Video 11) Directions: 1. Again, patient lying supine, stand at side of bed facing slightly toward patient’s head. 2. Using index fingers and thumbs of both hands, gently grasp around the joint to be treated (could be interphalangeal joint or metacarpo-phalangeal joint). 3. Gently push the distal bone into flexion while stabilising the proximal bone with the opposite hand. 4. As always, grade according to your assessment. Treatment choice for the thumb joints n Mobilisations of the fingers.

Figure 2: Posterior–anterior mobilisation of the first carpometacarpal joint

Treatment choice for the finger joints n Mobilisations of the fingers. Finger extension mobilisation (Video 10) Directions: 1. Again, patient lying supine, stand at side of bed facing slightly toward patient’s head. 2. Using index fingers and thumbs of both hands, gently grasp around the joint to be treated (could be interphalangeal joint or metacarpophalangeal joint). 3. Gently pull the distal bone back into extension while stabilising the proximal bone with the opposite hand. 4. As always, grade according to your assessment. Video 10: Mobilisation of the fingers: extension (Video with captions but no sound)

Anterior–posterior first carpometacarpal mobilisation (Fig. 1) Directions: 1. Again, patient lying supine, stand at side of bed facing slightly toward patient’s head. 2. Using index fingers and thumbs of both hands, gently grasp around the joint to be treated (either trapezio-metacarpal joint, or metacarpo-phalangeal joint). 3. Gently pull towards you with the proximal end of the distal bone while stabilising the proximal bone with the opposite hand. 4. As always, grade according to your assessment.

treated (either trapezio-metacarpal joint, or metacarpo-phalangeal joint). 3. Gently push away from you with the proximal end of the distal bone while stabilising the proximal bone with the opposite hand. 4. As always, grade according to your assessment.

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

CAUSES OF NONCAPSULAR PATTERN Common causes of non-capsular patterns of movement limitations in the wrist and hand include articular disc tear and subluxed capitate.

Articular disc tear The key clinical features are: n Intermittent sharp episodes of pain nM ay click or crack with accompanying pain nP ain on at least one passive movement nM ay have painful springy end-feel either in extension or flexion, or either deviation nR ather like meniscal injury in knee, may require surgical removal.

Subluxed capitate Posterior–anterior first carpo-metacarpal mobilisation (Fig. 2) Directions: 1. Again, patient lying supine, stand at side of bed facing slightly toward patient’s head. 2. Using index fingers and thumbs of both hands, gently grasp around the joint to be Video 11: Mobilisation of the fingers: flexion (Video with captions but no sound)

The key clinical features are: nO ften traumatic onset – eg. fall on outstretched hand nP ainful flexion, with occasional springy end-feel n L imited extension with hard end-feel nR esponds well to manipulative procedure: Grade C manoeuvre Video 12: Manipulation for subluxed capitate in the wrist (Video with captions but no sound)

Co-Kinetic Journal 2017;74(October):33-38

SUBJECT AREA MANUAL LINK THERAPY WHOLE REFERENCE STUDENT TO HANDBOOK ARTICLE

under traction nM ay require addition deep transverse frictions to interosseous ligaments around margins of capitate. Treatment choice for subluxed capitate n Capitate Grade C amanoeuvre under traction. Manipulation under traction for subluxed capitate (Video 12) Directions: 1. Have patient standing across a high plinth from you, with their forearm resting across the width of the plinth. 2. The patient’s affected wrist needs to just overhand the plinth edge; patient can support their weight by leaning on the plinth with the other arm. 3. Place an assistant’s hand around the proximal row of carpus bones immediately distal to the styloid processes of both the radius and ulna. 4. With both your hands, grasp around the distal row of carpal bones placing your thumbs (one over the other) directly over the capitate bone on its dorsal surface (immediately proximal to base of 3rd metacarpal). 5. Keeping your arms reasonably straight, apply traction using bodyweight standing on back leg (stride stance). 6. Quickly push in a downward direction, forcing the capitate to relocate while simultaneously maintaining the traction. 7. The movement should be quick and brisk (biscuit-like, not marshmallow-like!)

CONTRACTILE LESIONS Video 13: Deep transverse frictions for De Quervain’s tenosynovitis: abductor pollicis longus and extensor pollicis brevis tendons (Video with captions but no sound)

Common contractile lesions of the wrist and hand include tendinitis and tenosynovitis, such as De Quervain’s tenosynovitis.

Tendinitis and tenosynovitis (eg. De Quervain’s tenosynovitis) The key clinical features are: n Overuse or repetitive strain injury usually n Often associated with excessive use of computers games consoles, and or texting n May also be associated with racquet sports, and use of handheld tools n Pain on movements involving specifically affected tendons n Several key tendons and their associated sheaths areas may be affected: extensor indicis (following Colles fracture); De Quervain’s (APL and EPB where they share the same sheath); although could affect any tendon n Often responds well to accurate deep transverse frictions or injection therapy n Use electrotherapy – ultrasound may also be helpful n All tendons require rest from aggravating activity while under treatment. Treatment choice for De Quervain’s tenosynovitis n Deep transverse frictions for tendons APL and EPB. Deep transverse frictions for De

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Quervain’s tenosynovitis (Video 13) Directions: 1. Have patient sitting at a plinth opposite from you, with their forearm resting over a pillow. 2. The patient’s affected wrist needs to be in an ulnar deviated position, with the thumb completely flexed at all joints so that the tendons are on stretch. 3. Place one of your hands around the patient’s to maintain this stretched position and as support for the limb. 4. With the index finger of your other hand, palpate the painful area of the tendons. 5. Maintain a firm pressure using your index finger, supported by your middle finger placed on top, and your thumb around the patient’s wrist to oppose the pressure. 6. The movement should be made with your arm, not just your fingers, and the tendon should ‘flick’ back and forth underneath your finger.

FURTHER RESOURCES 1. KhanM, Lim WY, Resnick D. Carpal instability (http://spxj.nl/2wNbgax). MRI Web Clinic 2012. 2. Richie CA III, Briner WW Jr. Corticosteroid injection for treatment of de Quervain’s tenosynovitis: a pooled quantitative literature evaluation. Journal of the American Board of Family Practice 2003;16(2):102–106.

RECOMMENDED READING

1. Anderson MK, Parr GP. Fundamentals of Sports Injury Management. Lippincott, Williams & Wilkins 2011. ISBN 978-1451109764 (Print £64.80 Kindle £61.56). 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 (£39.03). 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 (£89.99). Buy from Amazon http://amzn.to/1mwohwt 4. Higgs J, Jones A, et al. Clinical reasoning in the health professions, 3rd ed. Butterworth-Heinemann 2008. ISBN 978-0750688857 (Print £49.49 Kindle £52.99). 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 (Print £47.69 Kindle £43.48). Buy from Amazon http://amzn.to/1mwomR2 6. Magee DJ. Orthopaedic physical assessment, 6th ed. Saunders 2014. ISBN 9781455709779 (Print £64.99 Kindle £51.35). 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 (Print £61.19 Kindle £58.13). Buy from Amazon http://amzn.to/1Qbf7NB 8. Hengeveld E, Banks K. Maitland’s Peripheral manipulation: management of neuromusculoskeletal disorders – volume 2, 5th ed. Churchill Livingstone 2013. ISBN 978-0702040672 (Print £67.99 Kindle £46.55). 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 (£357.70). Buy from Amazon http://amzn.to/1KfpnbK.

KEY POINTS n The 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 wrist is defined by: equal loss of flexion and extension; and least loss of radial and ulnar deviation. n Causes of capsular pattern at the wrist are often osteoarthritis, rheumatoid arthritis and other systemic arthropathies, as well as traumatic arthritis. n The treatment for capsular pattern at the radiocarpal joint, fingers and thumb are mobilisations. n A common cause of non-capsular pattern of movement limitation in the wrist and hand include articular disc tear and subluxed capitate. n Common contractile lesions of the wrist and hand include: tendinitis and tenosynovitis, such as De Quervain’s tenosynovitis.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Articular disc tear and subluxed capitate are common causes of wrist/hand non-capsular patterns of movement limitation. http://spxj.nl/1S5oOUh Tweet this: Common contractile lesions of the wrist/hand include tendinitis and tenosynovitis, such as De Quervain’s tenosynovitis. http://spxj.nl/1S5oOUh

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 hy is the thumb the most important W digit in the hand? Why is there a hard end-feel to wrist extension with a subluxed capitate? Who is De Quervain? What is a mallet finger injury?

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

Co-Kinetic Journal 2017;74(October):33-38

ENTREPRENEUR THERAPIST

17-10-COKINETIC FORMATS WEB MOBILE

INTRODUCTION John Jantsch, founder of the brilliant Duct Tape Marketing blog and podcast, coined the phrase “Marketing without strategy is like noise before failure”. He adapted this from a Sun Tzu quote, from the book Art of War, which is just as relevant:

“Strategy without tactics is the slowest route to victory. Tactics without strategy is the noise before defeat.” I found John’s quote when I Googled ‘marketing without strategy’ … because that is exactly the purpose of writing this article, to help you avoid doing it. Does the following scenario sound at all familiar? Something, somewhere gives us a kick up the back side: it might be a slowing down of appointment bookings; a dip in the cash flow; an increase in business costs; the desire to buy a new car; or the arrival of a new family member; or on the flip side you’ve read a business or motivational book or seen an inspirational talk and you’re suddenly filled with a surge of enthusiasm to give your business and your career an injection of growth. Driven by this stimulation we get busy on our social media networks, we spend valuable hours writing blog posts, we email all our customers and prospective customers telling them about all the brilliant things we’re doing, we may even run some sort of offer, and persuade the local newspaper to run an article for us, and then we sit back and wait for the bookings to come flooding in. But to our disappointment nothing much happens. And we collapse with the exhaustion of this frenzied activity, concluding that marketing is just a pointless waste of time. So we trundle on, as before, working long hours, without ever feeling like we’re reaching our business potential.

A MARKETING STRATEGY FOR THERAPISTS In this article we explain why you’re doomed to failure if you don’t have a marketing strategy, why most marketing efforts fail and why narrowing your focus can give you the much-needed advantage as well as help you save time and resources. We explain how to identify patients who are most likely to ‘convert’ and become paying customers, and we outline a triedand-tested strategy that you can copy – there’s no need to recreate the wheel or figure it out yourself. This, combined with use of the Co-Kinetic content and unique, state-of the-art marketing platform, means you can run a new monthly campaign that takes just 15–20 minutes of your time to set up, requires no technical know-how and is fully automated. As a result you will be generating new leads for your email list, keeping your website fresh with new content and SEO-optimised, your social networks will be active, engaging and growing, and you’ll be keeping in touch with, and offering useful, helpful content to help all your email prospects, keeping you at the forefront of their minds. Read this article online http://spxj.nl/2haSVyW BY TOR DAVIES, CO-KINETIC FOUNDER his sales style may not necessarily suit everyone, he knows exactly how to use marketing to build physiotherapy clinics. I’ve copied the following quote from a recent customer nurture email I received from Paul. Today I’d like to share with you the 4 reasons that I believe Luke [the subject of Paul’s case study he’s been discussing earlier in the email] is now loving having a long-wait list… 1. Create a Plan: everyone is obsessed with ‘start with why’. In reality, that is a complete load of crap. Start with a PLAN and you’ll figure out the rest as you become more successful.

SO WHAT’S THE SOLUTION?

2. Focus: most business owners are ‘tired’ because they lack focus. And without focus, you work hard on the wrong things for longer than is needed.

I’d like to quote directly from Paul Gough, who is not only a very successful physio and multi-clinic owner, but also an excellent marketer. Although

3. Action: Vision without Action is just a dream. Action without a PLAN, that is a nightmare.

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4. ‘Omnipresence Marketing’: it’s taken me a couple of months to earn Luke’s trust that to be successful with direct marketing is not about running a ‘workshop’ once every so often – it’s about OMNIPRESENCE. Running 4 or 5 ads concurrently (Facebook, Newspapers, Email, Social Media, Google, etc), talking to a very specific pocket of people (ie. 50+) about a problem they are living with (ie. back pain) that you can help them solve (with PT). And, it’s the latter that I want to KEEP bringing to your attention…

Paul Gough, physio, multi-clinic owner and ninja marketer

“Marketing – and business success – is about the slow, rhythmical acquisition of new leads turned into clients – sustained over a period of time. Like 12 months. The last sentence is key: “the slow, rhythmical acquisition of new leads turned into clients – sustained over a period of time.” So how do we rhythmically acquire new leads?

THE VALUE OF YOU Before we look at that in detail I’m going to take a short diversion to make an important point here, because there’s one major cost-trap that most people running a small business fall into at some point in the business life cycle, and that is miscalculating the real cost of you. How many of us at some point have said: “Oh, it’s not worth getting someone else to do that job, by the time I’ve explained it to them, I could have done it myself (and better)?” How often do you remind yourself that if you’re a physical therapist your time is worth £60+ an hour and if you’re a manual therapist then £30–40+? How often do you honestly look at what you spend time on, and calculate whether that time spent away from treating patients, doing other business admin and marketing tasks, actually delivers a return on your investment (ie. you get more back than it cost you to do)? Your time is not free. This is a subject I’ll cover in more detail in one of my Therapy Expo 2017 presentations in November, so all I’ll say now is, make sure to factor the cost of yourself into every business activity you

LEADS

EXPLORE & EDUCATE

ARE LOOKING FOR INFORMATION

NURTURE

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Figure 1: A basic customer acquisition funnel

spend time on, and endeavour to find opportunities to get tasks, particularly those you don’t enjoy doing, done for less cost, and/or for better results, while at the same time giving yourself more time to spend on the things you really enjoy about your business, like treating patients (hopefully!). This will categorically improve your quality of life, make your business more sustainable and ultimately be more profitable. My first choice out of preference is to automate whatever I can, ie. get a computer to do it for me, even if you have to pay for a subscription to that software platform, if it saves you time and lets you do more of what you love, then you’re quids in. Also it’s likely to be more reliable and things won’t slip when times get busy. If a computer can’t do the whole job, see if you can find ways it can do some of the job, so there’s less left for a human to do. Then with the rest of it, do the task once, write a ‘standard operating procedure (SOP)’ for that task, basically a step-by-step guide that someone else could pick up and follow, and hand off the task to someone else. It may take slightly longer to write that SOP but then it’s done, and anyone else can pick it up in future. Plus there’s a huge peace of mind that comes with having all your processes documented. It’s

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excellent business practice. If you’re a one-man band and you don’t have anyone else available to outsource to, you could use the online freelance site, Upwork. We use Upwork at Co-Kinetic for a bunch of small jobs. Or recruit someone locally who could work a few hours a week from home. Bundle all those admin tasks together, with clear SOPs for each, and it won’t take very long at all for someone to relieve you of those stresses. You could even give interviewees one or two of the tasks with the SOPs as part of the interview process. Ninety-nine percent of the time it’s cheaper to pay someone (or something, ie. software) to do jobs you don’t like, and probably aren’t that well suited to, than to do it yourself and the chances are if you pick the right someone or something, then you’ll get better, more consistent, more reliable results.

A CUSTOMER ACQUISITION STRATEGY So coming back to Paul’s quote: “Marketing – and business success – is about the slow, rhythmical acquisition of new leads turned into clients – sustained over a period of time.” Very simply, customer acquisition means gaining new leads (contacts) and turning these into paying customers, and to do this, you must have a strategy. It’s not a one-step activity, it’s a process – which is why sustaining it over time is so important. A strategy is defined as a plan of action designed to achieve an overall aim. It is the sequence of steps you need to take from gaining new potential customer leads to converting them into paying customers. The marketing world has developed this concept of a sales funnel, or customer acquisition funnel, which is a more visual example of what a strategy might look like (Fig. 1). A customer acquisition funnel – irrespective of the market, industry or the service being offered, at the most basic level consists of three key stages: Level 1: Acquire leads Level 2: Nurture or ‘activate’ those leads Level 3: Convert them into paying customers. Co-Kinetic Journal 2017;74(October):39-45

ENTREPRENEUR THERAPIST

are prepared to part with their contact There are lots of sub-elements within page’ or lead collection page. When the details to obtain (usually an email those three top levels, just as there interested person arrives at the ‘landing address but sometimes telephone are lots of different methods you can page’, they will be asked to enter their number). The more valuable the ‘lead use within that funnel (if you Google contact details to download the ‘lead magnet’ the more effective a lead ‘customer acquisition funnel’ you’ll magnet’. This is an example of one of generator it is. see what I mean). But most models our landing pages we create for you centre first on bringing yourself to the to use: attention of potential new clients, then The ‘Landing Page’ offering value-added education that This ‘lead magnet’ sits behind a ‘landing The ‘Bait’ helps solve the problems of those In order to get people to the landing potential clients, and in turn builds page, you need to sprinkle the bait. EX ER C IS E HA ND O UT trust, and finally deepening that This could come in several S H OULDE rome inch? R IMPIN g TheldPer Impingement Synd customer’s engagement with you forms, or ideally GEMEN Feelinbo ou T PHAS rn Sh E1 The Stub and your ‘brand’ (Fig. 1). multiple forms. Social D The next stage is to move media is an obvious them to a point where they’re one. Feed various tweets, prepared to take some sort of more posts, images, cartoons, ‘committed’ action, such as engaging animations, facts and face-to-face with you, and this doesn’t necessarily mean booking a paid appointment, it could be attending a free workshop or assessment with Engaging, viral, you. social media posts Social At this point, if you do your job well, media posts THE LEAD MAGNET and you concentrate on building that trust and developing the relationship you have with that client, the chances of converting them to a paying customer are significantly increased. Animations Animations It may not be immediate but if you & Cartoons continue to nurture that relationship and add value, when that customer does need that appointment, you’re LANDING PAGE going to be right at the forefront of their mind. The great thing is that everything THE BAIT up until you get face-to-face with prospective clients, can be done online and can be automated, and you can continue the nurture process simply and easily through regular emails with your leads. We’ve built both the content and the platform that will allow you to do this in as little as 15–20 minutes of your time each month. Social Media Posts The goal is to make the process as quick, efficient and as effective as Engaging, viral it can be in terms of delivering the social media posts optimal customer at the most costeffective price possible. PRODUC

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A CUSTOMER ACQUISITION STRATEGY FOR THERAPISTS? Level 1 – Acquire Leads The ‘Lead Magnet’ It starts with what’s called a ‘lead magnet’. This is something desirable, helpful, valuable and useful that people Co-Kinetic.com

Explainer Videos

Videos 41

YOU ARE LOOKING FOR CLIENTS WITH A HIGH PROBABILITY THAT THEY’LL REQUIRE YOUR SERVICES, (AND SOON) THE MOTIVATION TO SEEK YOUR SERVICES AND THE MEANS TO PAY FOR THEM figures, and videos out through your social networks, all of which lead back to the landing page and lead magnet. Other ways to publicise your lead magnet and get people to visit that landing page to download it could include: n writing/publishing an article on your website and then offering the lead magnet as a value-added extra; n writing an article in the local press and including a mention of the added extra lead magnet (with a link to the landing page);

n g etting promo postcards printed with a link to the article on your website OR to the landing page (or both), which you can distribute locally (through businesses you have good contacts with, or businesses on theme with the topic, eg. cycling clubs if the topic of the lead magnet is cycling); and n r unning Facebook ads to promote your article and your lead magnet (more about this later as this has HUGE potential for therapy businesses).

However you can think of publicising either your article or your lead magnet (and landing page link), goes. Remember Paul Gough’s comment about ‘omnipresence marketing’, the key is being seen everywhere. 1. In its simplest form, you could just use social media to send people to the landing page, and you would acquire new leads (as well as growing your social networks). 2. To add authority to your website and boost your search engine optimisation (SEO), then publish an article on your website (with calls to action to visit your landing page and download the bonus lead magnet). 3. To target customers very specifically to your locality, run some Facebook ads. 4. If you have a good local network of contacts, get yourself published in the local press and circulate promotional material leading back to

Figure 2: The Co-Kinetic patient acquisition strategy

Co-Kinetic Journal 2017;74(October):39-45

ENTREPRENEUR THERAPIST

these resources through business partners (preferably make it worth their while like offering their clients a discount on first bookings or some other benefit to make it mutually beneficial). Just make sure there’s ALWAYS a ‘call to action’ on all your material, sending people either to the article on your website (within which you have buttons sending people to your landing page/ lead magnet). Note: If this all sounds either too much like hard work or technically intimidating, don’t worry, we create ALL this content for you AND if you use the Co-Kinetic platform, we also set up the landing page and collect your leads for you as well as publish the social media posts to your own social networks (Fig. 2).

Level 2 – Nurture and Activate Leads Level 1 is all about acquiring new leads (well, and growing your social network following and increasing engagement among existing followers). Level 2 is all about nurturing and converting the leads you have, this could be an existing email database of past, current and potential clients that you already have email addresses for as well as the new leads you’re now collecting. The goal of Level 2 is to build trust and develop relationships with your leads by delivering regular value-added information that helps them solve their problems (Fig.3). Email is a great way of doing this. At the very basic level it realistically only requires one email a month (and we write a new one for you every month in our marketing kits) to keep you at the forefront of your clients’ minds. One good quality, high-value email is better than lots of low-quality, low-value emails. For your new sign-ups, you could perhaps include a short introductory sequence, either a general sequence about you and your clinic, etc, or alternatively a short sequence based on the topic they signed up for (we also write these for you). All of this can be automated so it doesn’t even need to take you time. If you use Mailchimp, we even Co-Kinetic.com

design a ready-made template for you. You simply click on a link and that template is automatically imported into your Mailchimp account, ready to be sent. Our marketing platform also integrates with Mailchimp so every new lead you collect through the CoKinetic landing pages, is passed directly through to Mailchimp. There’s no need to worry about downloading CSV files and uploading them into Mailchimp. It’s all automated. In addition to Level 2 being about nurturing your leads, it’s also about activating them to move into the next funnel level, Level 3. The point of the emails at 2, while providing high-value content, is also to encourage your leads to take that extra step and actually get in front of you, face-toface.

Level 3 – Convert Activation could involve attending a free workshop you’re running (yes, guess what, we even create a ready-to-go PowerPoint presentation for you so you can organise this quickly and easily) or you could offer the opportunity to attend a free (or very low-cost) assessment. What you offer, to get them to this next level, is completely your choice. As we move down the levels of the funnel, each level grows more and more dependent on you as a practitioner. At this workshop or assessment, you still need to focus on adding value, this could be by providing them with additional information, patient leaflets or advice about their next steps. It is at this point you want to work out who the people are that you can genuinely help and explain to them honestly what you can offer that will solve their problem. A lot of marketing advice on the web revolves around selling things like software. The process is very different for someone with a musculoskeletal issue. Most of the time people won’t make the leap and see a therapist until they are worried enough about the consequences of not getting help, or the issue has become too difficult to manage without help. Reasons might include: 1. experiencing a specific injury such

Figure 3: The Email Nurture Cycle

as a car accident, sports injury, accident etc. 2. noticeable or visible physical changes to limbs or soft tissues 3. the pain becomes so bad that other treatments and medications are no longer enough 4. it becomes too difficult to do things that are important to them, ie. work, lifting, playing with grandchildren, or other activities of daily living 5. concern about long-term implications 6. pre- or more commonly postoperatively 7. a chronic condition or neurological disease.

CHOOSE YOUR CLIENTS CAREFULLY Now we get to 80 : 20 part. The Pareto Principle (or 80 : 20 law) states that 80% of your results come from 20% of your actions, or equally 80% of your revenue comes from 20% of your customers. What you have to do is find the 20% of customers or 20% of actions that make 80% of the results. In other words, you need a way of identifying and targeting the set of customers that are going to give you the best profits. You may think this sounds too commercial but it’s just good business sense. It doesn’t stop you taking other clients, but your marketing focus should be on the clients who will be most profitable. 43

And for this you have to address their fears and show them a way in which your service, be it physical or manual therapy, can help solve these problems. I come back to Paul Gough again. He offers three downloads on his website covering the four main issues people book a physiotherapy appointment for. Those ‘ebook’ covers immediately seek to allay a specific fear which is usually the reason why patients make the decision that it’s time to visit their physio (Fig. 4). His ‘ebooks’ offer to address that person’s fears and solve their problems and explain how physiotherapy can help in that process. There’s too much on this topic to cover in this article but look at your local competitors, see if there’s a niche that’s not being catered for that your services can particularly help with. Then make sure that your potential target group has the right ‘motivation’, ie. they’re close to ‘buying’ or booking point. And lastly make sure they are a demographic with the disposable income to afford your services. There’s no point finding the perfect target market, if they can’t afford you. This is why golfers and cyclists are often such good target customers, they frequently get injured, they want to get back to participating as quickly as possible and given both sports are not for the financially light-hearted, they have the disposable income to commit to making that happen.

Figure 4: Answering patients’ fears

“In a nutshell, you’re looking for clients with a high probability that they’ll require your services, (and soon) the motivation to seek your services and the means to pay for them” Oh yes, and they ideally need to live within 5–10 miles of your clinic! Does the eye of the needle feel like it’s shrinking rather too much?

The Therapist’s Secret Weapon: Facebook Ads This will be a subject that we cover in much more detail in future but it’s important to make a couple of points here. Facebook advertising for local business offers massive opportunities mainly because of the ability to target so specifically multiple demographics such as aged 50+, a locality (ie. within 5–10 miles), a ‘lookalike’ audience that matches your existing customer profile, education levels, income etc. The target opportunities are almost endless. The upshot of it is that if you were offering a tennis elbow resource for example – you could specifically target anyone with an interest in tennis, anyone who has liked the pages of local tennis clubs, is the right age group to match those most frequently suffering from tennis elbow and who lives within your catchment area (you can specify down to one mile), which means that the leads coming in from your landing page, requesting

information about a condition, are very likely to be super-targeted potential clients. You could advertise your article on your website and, once they visit, you could then re-target with ads on Facebook offering them access to your free assessment or workshop. It’s all about ‘racking the shotgun’ and narrowing down and filtering your audience to give you the best opportunity to solve real problems that they are looking for a solution for today. More of this will follow, much more! However, for the time-being, if there’s one thing you should do NOW, it’s get the Facebook Pixel installed on your website. There’s some more info at this link about what’s important about the Facebook pixel (https://www.jonloomer. com/2017/02/09/importancefacebook-pixel/) but the key thing is that if the pixel isn’t installed, you’re not gathering important data about your website visitors. Even if you have no intention of advertising on Facebook yet, the more data you can collect through the Facebook Pixel about the people visiting your site, the more accurately you can target if and when you do decide to use Facebook ads.

CONCLUSION This article outlines a patient acquisition strategy which any physical or manual therapist can adopt to generate new leads and nurture these and existing leads through the sales funnel, with the ultimate goal of converting them to a paying customer. The process may seem intimidating, but it’s not as bad as it seems if you use the resources we provide through Co-Kinetic. We’ve designed them specifically to achieve your patient acquisition goals. The ingredients for Levels 1 and 2 are: 1. a lead magnet (highly desirable download) 2. a landing page (to collect emails) 3. social media material (which point to the landing page/lead magnet) 4. a follow-up nurture email 5. a blog post/article (optional). And you could potentially stop there. If you did that each month, you would be generating new leads on your email list, keeping your website fresh with new content and SEO-optimised, your social Co-Kinetic Journal 2017;74(October):39-45

ENTREPRENEUR THERAPIST

networks would be active, engaging and growing, and you’d be keeping in touch with, and offering useful, helpful content to help all your email leads (current and potential customers), keeping you at the forefront of their minds. That’s more than what 97% of practitioners are doing, so it’s an excellent place to start. And if you have a Co-Kinetic subscription, we create all that content for you, every month, covering a new topic so all you need to do is log in, choose your start and end dates, decide which social networks you want to post to and click go. Connect it to your Mailchimp account and you could do all that work, complete both marketing levels 1 AND 2, in just 15–20 minutes a month, with absolutely NO technical know-how. To take it into Level 3 you have the option of running workshops, seminars or free assessments to encourage prospective leads to get more engaged. Maybe you focus those assessments to narrow the focus on people who are most likely to need your help, and soon. And maybe you only choose to

run them every few months, rather than every month. It all depends on your desire and need for new clients. If you’re interested in finding out more about the Co-Kinetic marketing kits and the marketing platform visit this link http://landing. co-kinetic.com/marketing. If want to know where you can get your biggest marketing gains then try out the Entrepreneur Therapist Marketing Grader. Answer just 20 yes/no questions and we’ll follow up with personalised advice on the areas you can get most gains, most quickly, including step-by-step guidance on how to implement each one. You can find the Marketing Grader at http://landing.co-kinetic.com/ marketinggrader.

KEY POINTS n “Marketing without strategy is like noise before failure.” n F ocus – most business owners are ‘tired’ because they lack focus. And without focus, you work hard on the wrong things for longer than is needed. n Action – Vision without Action is just a dream. Action without a PLAN, that is a nightmare. n Your goal is omnipresence marketing – don’t just target one channel, be seen everywhere. n Marketing – and business success– is about the slow, rhythmical acquisition of new leads turned into clients, sustained over a period of time. n A strategy is the sequence of steps you need to take from gaining new potential customer leads to converting them into paying customers. n Every customer acquisition funnel consists of three key stages: acquire leads; nurture or ‘activate’ those leads; and convert them into paying customers. n Don’t underestimate the value of you. n All you need to run an effective customer acquisition process is a lead magnet, a lead capture landing page, some promotional social media and a nurture email and you’ll be doing better marketing than 97% of therapists. n Focus on targeting patients with a high probability that they’ll require your services, (and soon) the motivation to seek your services and the means to pay for them. n Try out the Marketing Grader to get a personalised list of marketing priorities and step-by-step advice on implementing them http://landing.co-kinetic.com/marketinggrader

Co-Kinetic.com

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 WTA international 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 on at global conferences.

RELATED CONTENT 1 3 Steps to Building a Thriving Therapy Business [Article] - http://spxj.nl/2sFEiaV E ntrepreneur Therapist Marketing Grader http://spxj.nl/2vxhPxC ow to Get More Clients Without Being Salesy [Article] H http://spxj.nl/2sRgRvr

DISCUSSIONS L ist out some of the most common administration and marketing jobs you do and write down how much time each one takes. Multiple this by your hourly rate. Now prioritise the ones that take the longest and cost the most and discuss with your colleagues how you can automate, outsource or reduce this time/cost outlay. Discuss which groups of prospective clients will have a high probability that they’ll require your services, (and soon) the motivation to seek your services and the means to pay for them.

THERAPY EXPO 2017 CONFERENCE PROGRAMME PREVIEW Education streams MSK

Time

09:30 10:15

NEURO REHABILITATION

SPORTS INJURIES & BIOMECHANICS

ACUTE CARE

Theatre 2 1 Theatre

Theatre 3

Wednesday 22nd

Topic Combined movement treatment for back and neck pain: a rational approach to treating severe spinal pain Chris McCarthy, Consultant Physiotherapist, Manchester Metropolitan University Hand & wrist injuries in sport Mike Hayton, Consultant Orthopaedic Surgeon, Wrightington Hospital

12:00 12:45

Topical pain relief – when to use heat, cold or NSAIDs Colin Brown, Director of Research & Quality Development, The Mentholatum Co Ltd

Time

09:45 10:30

Topic A new approach to neuro-rehabilitation: Intensive training to optimise plasticity in practice Sarah Daniel, Clinical Director & Consultant Neurological Physiotherapist, MOTIONrehab Becky Duncan, Practice Principal, Neurological Physiotherapy Practice

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

Accelerated rehabilitation after shoulder stabilisation surgery: A case of the tortoise and the hare? Jo Gibson, Shoulder Rehabilitation Specialist, Liverpool Upper Limb Unit

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

The importance and effects of Movement Re-Education after injury Mike Antoniades, Performance & Rehabilitation Director, The Running School

14:55 15:40

Patellofemoral pain where are we up to on subgrouping? Dr James Selfe, Professor of Physiotherapy Department of Health Professions, Manchester Metropolitan University

16:50 17:30

Anterior Knee Pain John Rogers, Consultant Orthopaedic Surgeon, OrthTeam How to execute the perfect 80/20 patient acquisition funnel Tor Davies, Founder, Co-Kinetic

15:50 16:35

Exercise in Parkinson’s: indications, implications and intensity 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

Thursday 23rd Time

Topic

09:30 10:15

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

10:45 11:45

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 Paul Horbrough, Owner, published author (Running free of injuries) and Runners World columnist, Ex international athlete, sports scientist and physiotherapist, Physio&Therapy UK

12:00 12:45

The cross education effect; a novel approach to rehabilitating the immobilised limb Dr Claire Minshull, Rehabilitation & Conditioning Specialist, Get Back to Sport

13:45 14:30

Topical pain relief – when to use heat, cold or NSAIDs Colin Brown, Director of Research & Quality Development, Director of Research & Quality Development

15:45 16:30

BUSINESS WORKSHOPS

Theatre 11 Theatre

10:45 11:45

16:00 16:45

CPR & ANAPHYLAXIS

Session sponsored by Capita Dr Oliver Thomson, Senior Lecturer & Research Unit Leader, British School of Osteopathy

Thursday 23rd Time

Topic

09:45 10:30

Stop plodding & start rocking Celia Champion, Director, Painless Practice

11:00 11:45

Patellofemoral Pain where are we up to on subgrouping? James Selfe, DSc, PhD, MA, GDPhys, FCSP, Professor of Physiotherapy, Department of Health Professions, Manchester Metropolitan University

12:00 12:45

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

14:35 15:15

Extracorporeal shock wave therapy on the musculoskeletal system in sports medicine and evidence-based medicine Dr Christoph Schmitz, MD Full Professor and Head, Extracorporeal Shock Wave Research Unit , Department of Neuroanatomy Ludwig-MaximiliansUniversity of Munich, Germany

15:40 16:20

Clinical evaluation of the ‘problem ankle’ Benoy Matthew, ESP Physiotherapist and Lower Limb MSK Specialist

Book your ticket for just £149 +VAT before 27th October (full price £299 +VAT)

Time

Topic

10:00 10:45

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

12:00 12:45

A new anatomy Julian Baker, Owner, Functional Fascia

13:45 14:30

How to assess & manage patients within a Biopshychosocial context Dr Jerry Draper-Rodi, Draper-Rodi, British School of Osteopathy

15:00 15:45

Fatigue: the enemy of human performance Dr Jonathan Bloomfield, Chief Scientific Officer, Mammoth

16:30 17:15

Increase your referrals painlessly Celia Champion, Director, Painless Practice

Thursday 23rd Time

Topic

10:00 10:45

Comparative review of available Exoskeleton devices and update on current Exoskeleton research Jon Graham, Medical Director, PhysioFunction

11:00 11:45

Fatigue: the enemy of human performance Dr Jonathan Bloomfield, Chief Scientific Officer, Mammoth

13:45 14:30

Injury associated with CrossFit ™, what does the evidence say? Dale Walker, Physiotherapy Lecturer, Practitioner, Researcher, Bulletproofbodies

12:00 12:45

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

14:45 15:30

Chronic back pain - options & interventions David McDowell, Consultant in Pain Management, OrthTeam

15:45 16:25

Improving Patient Buy-In & Retention Ethically Celia Champion, Director, Painless Practice

Demo Zone Wednesday 22nd Time

Topic

09:45 10:15

Fascial dysfunction master class Ruth Duncan, Lecturer and Owner, Myofascial Release UK

10:45 11:15

An introduction to biomechanical taping for the management of load, movement and function Melanie Betts, Musculoskeletal & Sports Physiotherapist, Dynamic Tape & PosturePals

11:30 12:00

Movement Re-Patterning for Rehabilitation & Performance Mike Antoniades, Performance & Rehabilitation Director, The Running School

12:15 12:45

Session sponsored by Pontemed

www.therapyexpo.co.uk /cokinetic

Thursday 23rd

13:00 13:30

Shockwave therapy: the facts Jonathan Wride, Physiotherapist, ElectroMedicalSystems

13:45 14:15

Session deliverd by BTL Industries

14:45 15:15

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

16:00 16:30

The use of pneumatic resistance technology for patients with patellofemoral pain Pat Viroux, Sports Rehab Specialist, Consulting sport physical therapist for the Chinese Olympic Committee Rob Swire, Physiotherapist, Professional Jockeys Association

Time

Thursday 23rd Time

Topic

10:45 11:15

Neurological taping demonstration Becky Duncan, Practice Principal Neurological Physiotherapy Practice

11:30 12:00

Session delivered by Ottobock

Time

12:15 12:45

Session sponsored by Remotion

14:00 14:30

Working for ParalympicsGB Stan Marveridis

13:00 13:30

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

14:45 15:15

Myofasical bodywork Stan Marveridis

14:00 14:30

Eliciting an energy-efficient gait pattern in the Neurologically impaired population Nechama Kerman, Chief Clinical Educator, Mobility Research

15:30 16:00

The STA moving forwards Gary Benson Director/Founder Sports Therapy Association

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

09:45 10:30

An introduction to biomechanical taping for the management of load, movement and function Melanie Betts, Musculoskeletal & Sports Physiotherapist, Dynamic Tape & PosturePals

14:45 15:15

11:30 12:00

Myofascial shoulder master class Ruth Duncan, Lecturer and Owner, Myofascial Release UK

Therapy Update Theatre

12:15 12:45

13:00 13:30

Session delivered by BTL Industries

14:00 14:30

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

14:45 15:15

Shockwave therapy: the facts Jonathan Wride, Physiotherapist, ElectroMedicalSystems

15:30 16:00

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

Neuro Demo Zone Wednesday 22nd Time

Wednesday 22nd Time

Spinal injury management in sport Paul Lubas, Managing Director, Lubas Medical

11:15 11:45

Session delivered by Imaging Firsting

12:00 12:30

An introduction to shockwave therapy and itâ&#x20AC;&#x2122;s use in clinical practice Paul Hobrough, Physiotherapist, Venn Healthcare

12:45 13:15

Magnesium massage therapy TamĂĄs KĂĄlmĂĄn, Managing Director, Wanadis Kft

Thursday 23rd Time

Topic

09:45 10:15

â&#x20AC;?We can all rehab a shoulder rightâ&#x20AC;&#x153; How do you create a robust and durable shoulder for recreational climbers? Uzo Ehiogu Specialist Musculoskeletal Physiotherapist (Medical Education), Research and Education Department Royal Orthopaedic Hospital NHS Foundation Trust

10:00 10:30

Session sponsored by Remotion

10:30 11:00

The False Economy of You: 10 Strategies for Getting The Biggest Bang for Your Buck out of You Tor Davies Founder Co-Kinetic

10:45 11:15

Session delivered by Ottobock

11:15 11:45

Session delivered by DP Medimaging

11:30 12:00

The role of virtual realitytechnologies in neurorehabilitation Tia Nott Clinical Specialist Neuro Physiotherapist MindMaze SA

12:00 12:30

An introduction to shockwave therapy and itâ&#x20AC;&#x2122;s use in clinical practice Paul Hobrough, Physiotherapist, Venn Healthcare

12:15 12:45

Demonstration of the new L300 GO drop foot device - wireless and potentially foot switch free Matt Dale, Bioness

13:00 13:30

Session sponsored by Summit Medical & Scientific Session sponsored by Medimotion

14:45 15:15

Neurofit boot camp demonstration Jon Graham Medical Director PhysioFunction

15:30 16:00

Eliciting an energy-efficient gait pattern in the Neurologically impaired population Nechama Kerman Chief Clinical Educator Mobility Research

16:15 16:45

High intensity rehab augmented by technology Sarah Daniel Clinical Director & Consultant Neurological Physiotherapist MOTIONrehab

0207 013 4998

Topic

RockTape Movement Summit Wednesday 22nd 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

14:15 14:45

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

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

Thursday 23rd Time

Topic

STA Conference

09:30 10:00

Introduction to Rockblades and modern instrument assisted techniques Andrew Caldwell, RockTape Tutor

Wednesday 22nd

10:15 10:45

Introducing stick mobility Paul Coker, Medical Director

11:00 11:30

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

11:45 12:15

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

13:30 14:00

Clinical Case studies and open floor discussion Team Rocktape

14:15 14:45

Getting golfers better Andrew Caldwell, RockTape Tutor

15:00 15:30

5 brilliant Mobilisations with movement Paul Coker, Medical Director

15:45 16:15

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

14:00 14:30

Thursday 23rd

Topic

10:30 11:00

Topic

22nd and 23rd November 2017 NEC Birmingham

10:00 10:30

The role of virtual reality technologies in neurorehabilitation Tia Nott, Clinical Specialist Neuro Physiotherapist, MindMaze SA

Topic

Time 14:30 15:00

Nutrition for rehabilitation Ben Coomber

15:15 15:45

A â&#x20AC;&#x2DC;stingerâ&#x20AC;&#x2122; in Rugby: a transient episode or something more sinister? â&#x20AC;&#x201C; A case study Keith Burnett Lecturer and Practitioner in Sports Therapy

16:00 16:30

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

16:45 17:15

New thinking = new behaviour = new outcomes. The secrets to unlocking performance and rehab Nicola Ellwood Master Performance Coach & Master NLP Practitioner Performance & Mastery

d.earl@closerstillmedia.com

TherapyExpo

@TherapyExpo

Therapy Expo

DO YOU HAVE WHAT IT TAKES TO RUN A SUCCESSFUL THERAPY BUSINESS? BY CLARE CARRICK BSC, MCSP

OVERVIEW Many of us give little thought to our future when we start out in our careers or even when we set up our therapy businesses. When you started out, did you ask yourself what you wanted your life to look like in 5 or 10 years? In this series of articles we’re going to take you on a journey seeking to answer questions about what defines success and what represents a successful business, as well as discussing the challenges you may meet along the way, and what skills you’ll need to overcome them. We’ll then delve deeper into the key measurements, performance indicators and business processes that you’ll need to track to give both yourself and your business the best chance of success.

WHAT IS SUCCESS? People often think that success is defined by the amount of turnover or profitability of your company, and although this is important if you want to make your business grow, a more important measure is how happy you 17-10-COKINETIC FORMATS WEB MOBILE

MEDIA CONTENTS YouTube video ‘Tony Robbins, Why we do what we do’. Courtesy of YouTube user Ted Talks 2007. http://spxj.nl/2f85LNM ouTube video ‘Asher Z. Trust your struggle’ Y Courtesy of YouTube user Ted Talks 2015. http://spxj.nl/2wYw7IR Book ‘Gerber ME. The e-myth revisited: why most small businesses don’t work and what to do about it’. 3rd edn. HarperBusiness 2001. ISBN 978-0887307287 Buy from Amazon http://amzn.to/2y1sqQm Book ‘Covey SR. The 7 habits of highly effective people’. Simon and Schuster 2004. Buy from Amazon http://amzn.to/2h0qkwl

In this article, we look at what it takes to run a successful therapy business and what success actually means to you, both personally and professionally. We look at what defines a successful, well-run business, discuss the importance of learning how to be effective with your time, and how to avoid some of the most common traps that new therapists (as well as more experienced ones) often fall into when starting a business. The article includes some recommendations for resources that will help you programme your mind for success, avoid the risk of procrastination, and develop a highly effective approach to your work life. Read this article online http://spxj.nl/2hb95Z3 are in your life, and particularly your professional life. I feel that success is more to do with whether you wake up and are excited to go to work. Keeping your life and work stimulating requires good planning, setting yourself tasks and making sure you keep on track with your own goals and aspirations. Times can be tough, keeping up with the daily demands of your business as well as keeping clients and staff retained, is hard work. It’s during those times that resilience and strategy are vital to ensure that you can steadily progress through the challenges of business growth as swiftly and securely as possible, without prolonging any periods of increased stress, or letting that impact on you or your family. If you’re starting out, I’d definitely recommend that you write down what this success looks like to you, get as specific as you want to. This forms a future reference point against which you can monitor your journey. That end-point may change with time as you develop both professionally and personally, and that’s fine, but the important thing is that any change to

your end goal is a conscious decision and not one of circumstances out of your control. Progressive business growth, which comes through good systems and processes in your business, will lead to financial security that, in turn, is likely to make you more successful. It will provide you with the means to take the holidays you need, or get married, or pay for a house move or just afford to retire. Michael Gerber’s book E-Myth (1) states, “Begin with the end in mind.” I’d highly recommend it. It explores the concept of ‘start with how you wish to be remembered’. Are you doing the things you want to be remembered for? Do you want a business that is not reliant on you and drives a passive income for you? If so, develop a strong brand that can stand alone without you. Avoid the desire to call your business John Smith Physiotherapy from the outset and the model will be much more saleable in the future. If, on the other hand, you are happy and successful having a smaller operation where you are the lead clinician, and don’t mind working hands on with Co-Kinetic Journal 2017;74(October):48-50

ENTREPRENEUR THERAPIST

clients into the future, then this can be equally ‘successful’. If you’re not sure, give yourself options and flexibility.

THE IMPORTANCE OF KNOWING YOU Any business of any size starts and ends with you and your ability to lead yourself and possibly also a team of individuals to group success, so starting with a reflection of your own ‘skill set’ is a good place to start. Business owners are all hard working, but some are more successful than others. Why? It comes down to who is more effective with their time, and if you’re leading a team, who has the best leadership skills? If it’s not you, then delegate. Play to your strengths and passions. We all have the same number of hours in a day, what makes the difference is how we choose to use them. And this starts by knowing what you want to achieve, knowing why you want to achieve it, knowing the kind of person you need to become to make it happen and programming the mind to turn it into reality. Carrie Green (2) speaks about programming your own mind for success. In business there are always unknowns and many of us are don’t make decisions because we’re not sure what the future holds, nor do we want to miss out on future opportunities. Both choices can be self-limiting for your business. Identify the obstacles that may be preventing you from making a decision and recognise the power your mind can impact on the actions you take. Success is no accident, living an incredible life is no accident – you have to do it on purpose. To quote Tony Robbins, world-renowned author, speaker and entrepreneur, in his 2007 Ted Talk (3), “Your destiny is determined by the choices you make. Choose now. Choose well.”

improve your service, rather than what you can’t control in your business. A good example of this might be using systems and processes to educate patients about how you can help them to improve. Patients generally have very little knowledge about the skills of a therapist and it’s your job to educate them. If you can achieve this each and every time you see a patient, you’re likely to achieve improved compliance as well as improved clinical outcomes. It’s disappointing to hear of practitioners letting their clients leave the building with the send-off, “See how you go and call me if you feel another appointment is needed.” We are the experts, we should we making the call on whether they need to come back for more than one or two sessions, surely. One of the biggest concerns for physiotherapists currently, both in the UK as well as internationally, is private medical insurance and how larger companies are ‘controlling’ the industry by driving down price and limiting the number of sessions they will pay for. Therapists today are receiving less money per consultation than we were 10 years ago. This is a great example of the need to learn to be proactive, rather than reactive. It’s easy for all of us to complain about the changes in the industry but you can’t change it, so find ways of working around it. Develop your service and find ways to convert your referred client to a private paying client, for life if you can (and we’ll be exploring ways in which you can do this in future articles).

BOX 1: OCTOBER’S ACTION PLAN nR ead more about self-leadership skills and reflect on your own skills. nS tart with the end in mind and consider your life purpose. nS et some personal and business objectives and ensure these are coordinated and complementary. nW e all have the same number of hours in a day, it’s just how we choose to use them, take a look at how you use your time. nC reate a great brand for your business so that it’s able to stand alone from you as an individual and have saleable value. nS tart analysing your retention of clients by looking at the average number of follow-up appointments to the initial consultation in your diary and your other therapists.

YOU ARE YOUR MOST VALUABLE ASSET Most people, when asked, what is most important to them, will answer ‘wellbeing’ and ‘relationships’; however, the reality is that we spend less time on that, than we do working. We spend much more time doing things that aren’t even important to us like social media browsing and checking emails. When you get involved in running a business, your time becomes even more important. It’s very easy to just throw more and more time into it, while neglecting the things that give you a sense of wellbeing, like going to the gym or spending time with family and friends, which can be a problem as you get involved in running a business. This makes it all the more important

FOCUS ON WHAT YOU CAN CONTROL, NOT WHAT YOU CAN’T Stephen Covey wrote a best-selling book, The 7 Habits of Highly Effective People (4), and one strand focuses on the importance of being proactive rather than reactive. Focus on what you can control and how you can Co-Kinetic.com

to use your time effectively and focus on putting the things that matter to you, first.

CONCLUSION Running a business is a very difficult path to take but with good support, a clear vision, resilience and robust systems and processes, the journey can also be an extremely rewarding one which gives you the complete personal freedom to be who you want to be, to do what you love, and to be successful and happy. Zain Asher speaks about trusting your struggle (5). There will be tough times but it’s about keeping up the momentum and having enough fuel in your tank to keep giving. If your systems are good, the more you give to your business and those who work for you, the more you will get THE AUTHOR After graduating from Manchester university in 1998, Clare Carrick BSc, MSCP worked as a physiotherapist in an NHS trust for a year. After this, Clare worked in New Zealand in a variety of settings, from public to private health environments, as well as elite sport. Keen to travel further and have the flexibility with work to do so meant that working for herself was the best option. This led Clare to develop her own vision for physiotherapy deliverance, creating the successful Back in Motion franchise model, which now has seven clinics in East Anglia, UK. This process has given Clare invaluable insight into running a successful health business. Clare is happy to share her experience and knowledge: she has supported therapists she has worked with to develop their own business, allowing them to maximise their earning potential, choosing the hours they want to work and working on something they can call their own which will be saleable and have value too. Email: franchising@back-in-motion.co.uk Website: Back in Motion http://www.back-inmotion.co.uk/about/the-team.html LinkedIn: linkedin.com/in/clare-carrick-79aa0036 Facebook: https://www.facebook.com/clare. carrick.3

back. Box 1 gives you some activities for this month to help you start to analyse your business plans. References 1. Gerber ME. The e-myth revisited: why most small businesses don’t work and what to do about it, 3rd edn. Harper Business 2001. ISBN 978-0887307287 Buy from Amazon http://amzn.to/2y1sqQm 2. Carrie Green. Female Entrepreneur

Association http://femaleentrepreneurassociation.com 3. Robbins T. Why we do what we do. Ted Talks 2007. View on YouTube http://spxj.nl/2f85LNM 4. Covey SR. The 7 habits of highly effective people. Simon and Schuster 2004 (Print £11.04). ISBN 978-0684858395 Buy from Amazon http://amzn.to/2h0qkwl 5. Asher Z. Trust your struggle. Ted Talks 2015. View on YouTube http://spxj.nl/2wYw7IR.

CLARE CARRICK AND BACK IN MOTION Clare Carrick Bsc, MCSP established the Back in Motion franchise model of healthcare in the UK in 2009. She has supported therapists in developing their businesses, allowing them to maximise their earning potential, choosing the hours they want to work and working on something they can call their own which will be saleable and have value. Building a business that is scalable, replicable and sustainable in a changing healthcare marketplace is invaluable, so over the next few months Clare is working in conjunction with us at Co-Kinetic to help you get the best out of you and your therapy business. If you are curious about what a Back in Motion franchise model may mean to your business, or how Clare can help you launch into running your own health and fitness business model or enhance the model you have currently then please contact Clare: franchising@back-in-motion.co.uk or call 0845 4741193 or come and see us at Therapy Expo on November 22/23 2017.

KEY POINTS n Read more about self-leadership skills and reflect on your own skills. nS tart with the end in mind and consider your life purpose. n Set some personal and business objectives and ensure these are coordinated and complementary. n We all have the same number of hours in a day, it’s just how we choose to use them. You may need to reflect on how you use your time. n Create a great brand for your business should you want your future business not reliant on you and have saleable value. n Start analysing your retention of clients by looking at the average number of follow-up appointments to the initial consultation in your diary and your other therapists. n Success is not just defined by turnover and profit, but also by how happy you are with your life. n You are your business’s most valuable asset.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: An important measure of success is how happy you are with your life. http://spxj.nl/2hb95Z3 Tweet this: Progressive business growth will lead to financial security. http://spxj.nl/2hb95Z3 Tweet this: “Your destiny is determined by the choices you make. Choose now. Choose well. http://spxj.nl/2hb95Z3 Tweet this: Know what you want to achieve with your business and programme your mind to turn it into reality. http://spxj.nl/2hb95Z3

Co-Kinetic Journal 2017;74(October):48-50

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