Co-Kinetic Journal Issue 75 - January 2018 by Co-Kinetic

ISSUE 75 JANUARY 2018 ISSN 2397-138X

Formerly published as....

medicine & dynamics

what’s inside EXERCISE HANDOUT

PRACTICAL

PRODUCED IN ASSOCIATION WITH

EXERCISES FOR LOW BACK PAIN PHASE 1 Optimal strength in the core abdominal muscles is essential for a pain free back and good posture. Strength of the muscles supporting the lower back is also crucial in preventing and managing back pain. That is why so many exercises not only include the abdominals, but also the legs, glutes (buttocks) and hip muscles.

YOUR REHABILITATION PROGRAMME This exercise programme has specific exercises to strengthen muscles around your lower back and core. It is important to ensure

the exercises are performed with good technique. Poor practice may place potential strain on your back. The following leaflet includes some exercises to help in your rehabilitation.

PROGRESSION SPEED Your therapist will advise you on the speed you should progress. Progression is not just about being able to do the exercise but to do it correctly, with appropriate control. If at any time, you feel pain or discomfort stop the exercises and consult your therapist.

EXERCISE HANDOUT

PRODUCED IN ASSOCIATION WITH

PELVIC TILT LYING

FLOOR SUPERMAN OPPOSITE

Lie flat on your back, and engage your deep core muscles by drawing your belly button inwards (towards your spine slightly), while flattening your spine against the floor, then relax. Repeat as required.

Lie on your front, and lift your opposite arm and leg, keeping them straight. Hold this position, and then relax. This exercise helps to arch your lower back (to create what is known as a lumbar Hyperlordosis) while strengtheningOptimal the lower back and buttock muscles. muscles is essential for a pain strength in the core abdominal free back and good posture. Strength of the muscles supporting the

SETS

EXERCISES FOR LOW BACK PAIN PHASE 2

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SETS

Video: http://youtu.be/44D6Xc2Fkek

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lower back is also crucial in preventing and managing back pain. That is Video: why so many exercises not only include the abdominals, but also the http://youtu.be/ViUO_rtbSiA legs, glutes (buttocks) and hip muscles.

YOUR REHABILITATION PROGRAMME

SUPINE BRIDGE BASIC

LUMBAR ROTATION

Lie flat on your back, with your knees bent, squeeze your bottom muscles and lift your body upwards. Keep your arms by your side and use them to help you balance. Make sure you maintain good posture (do not over-arch your lower back) and contract the deep abdominal muscles by squeezing your tummy towards your spine. This exercise helps to strengthen the abdominal, lower back, gluteal and hamstring muscles.

exercise programme Lie on a bed or a floor. Bend yourThis knees, and keeping your has specific exercises to strengthen around feet flat on the bed or floor, rotatemuscles your hips to oneyour sidelower back and core. It is important to ensure creating a rotation through your lower back. Only go as far as feels comfortable, you do not need to get your knees STRAIGHT LEG RAISE to the floor. Return to the oppositeBILATERAL side. This flat on your back, and lift both straight legs as is an excellent lower back mobilityLieexercise, as pain feelsorcomfortable. Hold this position, and especially if you have acute lowerfar back relax. This exercise will stretch the Hamstrings, disc problems. SETS REPS although to get your legs to this position will also use the lower abdominal muscles. Do not worry if you cannot get your legs as high as Katy. Video: http://youtu.be/UxORTXzuU9E

SETS

REPS Video: http://youtu.be/fK_xUE3OKIE

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HORSE-STANCE WEIGHT SHIFT Go on to all fours, and keep good posture. Draw your tummy inwards (towards the ceiling). Shift your weight from one side of your body to the other side. This is a great core control exercise to work the abdominal muscles.

SETS

REPS Video: http://youtu.be/p6t-t1hGtQ8

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LEG SLIDE Video: Lie on your back, with both legs straight, http://youtu.be/BA8-M-AHxx activate your deep abdominal muscles by drawing your tummy towards the floor. Slide one heel towards your bottom. Maintain SUPINE BRIDGE HARD only the slightest contact with your Lieheel flat on your back with your arms by your the ground. Keep the leg slide slow andand controlled. can bent. progress side, with yourYou knees Squeeze the exercise by lifting the oppositeyour leg bottom just a few inchesand off lift theyour ground, muscles back while sliding the other heel towards your bottom. This is aone great upwards and straighten leg.core Make control exercise to work the abdominal muscles. sure you maintain good posture (do not over-arch your lower back) SETS REPS and contract the deep abdominal muscles by squeezing your tummy towards your spine. This exercise helps to strengthen the abdominal, Video: lower back, gluteal and hamstring muscles. http://youtu.be/hi4nb-isyZ8 SETS

REPS

the exercises are performed with good technique. Poor practice may place potential strain on your back. The following leaflet includes some exercises to help in your rehabilitation.

HIP ABDUCTION LYING Lying on your side, flatten your lower back by gently tucking your tummy in. Lift your leg several inches in the air. You can either hold this position, or return your leg down and then repeat the exercise. Ask your therapist which they would prefer you to do. This exercise strengthens the pelvic, gluteal, and lower back areas.

SETS

CLAM ADVANCED

posture. Draw your tummy inwards (towards

Lie on your side, with both knees bent. Squeeze your deep abdominal muscles by drawing the belly button inwards. Keeping your feet together, lift the feet 3-4 inches above the floor. Open your knees, like a clam, hold, and return to the start position. This is a good strengthening exercise for your gluteal (buttock) and outer thigh/ hip muscles. It also works the abdominal core muscles.

control exercise to work the deep abdominal muscles. The exercise will also strengthen the lumbar erector and gluteal muscles.

REPS Video: http://youtu.be/BTaCXKy53wc

OF 30-35 ASSESSMENT THE CERVICAL SPINE

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HORSE-STANCE HORIZONTAL the ceiling). Straighten your arm in front of you, TIME-SAVING RESOURCES FOR PHYSICAL

and your opposite leg behind you. Repeat each journal AND MANUAL THERAPISTS side. This is a great core stability and core

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STRENGTHENING LEAFLETS

Video: http://youtu.be/IjraQMSIGio

Video:

The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical http://youtu.be/x-b9yvFzLqk care or as a substitute for specialist medical advice in each individual case. ©Co-Kinetic 2017

PRODUCED BY:

REPS Video: http://youtu.be/m48WZUmcw5Y

LUMBAR FLEXION WITH ROTATION CONTROL Lie flat on your back, and contract your deep abdominal muscles by drawing your tummy inwards. Bend your hips to 90 degrees, keep your knees together, and rotate the spine. Do not go too far, just a few inches, and keep the movement controlled. This exercise works the lower abdominal muscles, and core control.

19-20 BACK

SETS

REPS Video: http://youtu.be/cQroGjei4B8

The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. ©Co-Kinetic 2017

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PRODUCED BY:

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TIME-SAVING RESOURCES FOR PHYSICAL

journal AND MANUAL THERAPISTS

MANUAL THERAPY & PHYSICAL THERAPY INFOGRAPHICS

MARKETING

36-38 MENTORING FOR SUCCESS 21-25 FASCIA: WHAT IT IS AND WHY IT MATTERS

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THE HIDDEN INFLUENCES OF NURTURE EMAILS

JOURNAL WATCH MANUAL THERAPY

42-44 PATIENT RETENTION REVIEW OF 14-18 ABACK PAIN CARE

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JOURNAL WATCH PHYSICAL THERAPY

THE BRAIN'S 26-29 PAIN: INTERPRETATION OF DANGER

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LONG JANUARY 2018 ISSUE 75 ISSN 2397-138X

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CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

CARDIOVASCULAR RESPONSE TO RECREATIONAL HOCKEY IN MIDDLE-AGED MEN. Goodman A, Thomas SG, Wald RC et al. The American Journal of Cardiology 2017;119(12):2093–2097 A total of 23 men aged 40 to 65 years were recruited for the study from men’s recreational ‘pick-up’ ice hockey games by postings at local rinks and by word of mouth. They were screened by interview to exclude a history or symptoms of cardiovascular disease, hypertension or use of cardiovascular medications. Baseline measures of height, weight, blood pressure (BP) at rest, and maximal exercise testing were taken. Maximal oxygen consumption (VO2 peak) was determined by direct gas exchange using an electronically braked cycle ergometer. Cardiovascular monitoring occurred 20–30min before the game as participants dressed and continued throughout the on-ice warm-up (10min), the game (45–55min), and recovery period in the dressing room (15–20min). Peak heart rate, and systolic and diastolic BP obtained during play were significantly higher than those obtained during graded exercise testing.

Co-Kinetic comment There is a lot more complicated science stuff about recovery rates in this paper if that interests you but the headline attraction is that putting people into a competitive situation results in much higher cardiovascular demands than were observed in graded maximal exercise testing. The authors note that because of the difficulties of measurement during play the BP during skating may actually be higher than reported. They also note that it was not possible to monitor fluid intake so the player’s hydration state may be an influence on individual cardiovascular responses.

This is an essay explaining therapeutic modalities to orthopaedic surgeons. It explains the uses of cryotherapy, thermotherapy, ultrasonography, electrical stimulation, iontophoresis and laser therapy and, more importantly, quotes the evidence base if there is one. In summary: The use of cold therapy is mostly based on anecdotal experience, with limited scientific evidence to support the efficacy. There is evidence that in the acute stage it works for pain relief and whole-body cryotherapy (immersion in water or cold dry air) has an effect on post-exercise muscle soreness. Heat increases the elasticity and decreases the viscosity of

connective tissue. Its chief effects are pain reduction and increased blood flow, tissue metabolism, and elasticity of connective tissues. Most heat modalities only provide superficial penetration, although ultrasound can get deeper than most. Multiple studies have provided evidence that the combination of heat with stretching increases range of motion more than stretching or heat alone does. Therapeutic ultrasonography is used by clinicians for the purposes of raising tissue temperature, stimulating soft tissue repair, and modulating pain. The evidence base is largely anecdotal, and scientific evidence to support its clinical utility is lacking. Electrical stimulation (transcutaneous nerve stimulation (TENS), muscle contraction, nerve stimulation) is usually applied by passing current between

SHALL WE INJECT SUPERFICIAL OR DEEP TO THE PLANTAR FASCIA? AN ULTRASOUND STUDY OF THE TREATMENT OF CHRONIC PLANTAR FASCIITIS. Gurcay E, Kara M, Karaahmet OZ et al. The Journal of Foot and Ankle Surgery 2017;56(4):783–787 Thirty patients (24 females and 6 males) with unilateral chronic plantar fasciitis were divided into two groups according to the corticosteroid injection site: superficial (n =15) or deep (n =15) to the plantar fascia. Patient heel pain was measured using a Likert pain scale and the foot ankle outcome scale (FAOS) for foot disability, evaluated at baseline and repeated in the 1st and 6th weeks. The plantar fascia and heel pad thicknesses were assessed on US scans at baseline and the sixth week. The groups were similar in age, gender and body mass index. Compared with the baseline values, the Likert pain scale and FAOS subscale scores had improved at the 1st- and 6th-week followup visits in both groups. Although the plantar fascia thickness had decreased significantly in both groups at the 6th week, the heel pad thickness remained unchanged. The difference in the FAOS subscales (pain, activities of daily living, sports/recreational activities, quality of life) and plantar fascia thickness showed better improvement in the deep than in the superficial injection group.

Co-Kinetic comment Great, but please try some soft tissue work through the entire posterior fascial line before you start sticking needles and drugs in.

Co-Kinetic Journal 2018;75(January):4-7

RESEARCH INTO PRACTICE

Physical Therapy

Journal Watch external electrodes, although there can be implants. Pain modulation works on the pain gate theory. Evidence for this is limited and inconsistent but try telling that to suffers of low back pain who swear by it. Interferential current (IFC) delivers a low-amplitude current to superficial structures, and a higher-amplitude current to deeper ones producing a pulsing effect. There is evidence of reduced postoperative pain, increased range of motion, and oedema in postoperative ACL patients and in other conditions if used with other treatment modalities. Neuromuscular electrical stimulation (NMES) is an adjunctive therapy for muscle strengthening used in addition to standard strengthening programmes. Electrodes are placed over the location of the peripheral nerve to the muscle

THE ROLE OF THERAPEUTIC MODALITIES IN SURGICAL AND NONSURGICAL MANAGEMENT OF ORTHOPAEDIC INJURIES. Logan CA, Asnis PD, Provencher MT. Journal of the American Academy of Orthopaedic Surgeons 2017;25(8):556–568 being treated. The innervated muscle will contract as the nerve depolarises, mimicking voluntary contractions. There is evidence to support NMES to facilitate postoperative quadriceps strengthening after ACL reconstruction. Iontophoresis uses direct electrical current to deliver drugs to biologic tissue. Although widely used, the evidence as to whether or not it is better than other drug-delivery systems is lacking. For low-level laser therapy, multiple studies in different patient populations (including those with shoulder pain requiring rehabilitation, medial tibia stress syndrome, patellofemoral syndrome, and

INCIDENCE, AETIOLOGY AND PREVENTION OF MUSCULOSKELETAL INJURIES IN VOLLEYBALL: A SYSTEMATIC REVIEW OF THE LITERATURE. Kilic O, Maas M, Verhagen E et al. European Journal of Sport Science 2017;17(6):765–793

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Medline and SPORTDiscus were searched up to May 2016 for relevant articles in Dutch, English, French and German which resulted in 1722 citations that were whittled down to 129 for full review. From these, 28 studies (of which 10 were literature reviews) were included in this work. These gave an incidence of musculoskeletal injury of between 1.7 and 10.7 injuries per 1,000 player hours. Ankle, knee and shoulder injuries were the most often reported. Acute injuries reported were knee 33%, ankle 17%, and shoulder 17%. The main danger area was during contact with other players at the net, with both ankle and finger injuries being reported. For overuse injuries, no ankle injuries were reported but knees were 24% of the injuries and shoulders 12%. Of the studies reporting on injury prevention strategies, one reported an injury decrease of 100% in adolescents following a 26-week supervised individualised resistance training programme. Another reduced anterior knee pain with isometric strength, open kinetic chain exercises in the 1st month, closed chain in the 2nd month, sports-specific skills and plyometrics in the 3rd month and eccentric load in the 4th month. A third study decreased injury rates using 14 basic proprioception exercises, of which the coach picked four as part of a warm-up over a 36-week period. None of the prevention studies covered shoulder injuries.

Co-Kinetic comment Apparently there are 200 million volleyball players in the world, which is a lot of potential injuries. The important part to note is that all the reported injury prevention strategies reduced injuries, so coaches please incorporate them into every session. Co-Kinetic.com

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lateral epicondylitis) have failed to support the use of laser therapy as an effective modality.

Co-Kinetic comment This is a ‘must read’ for anyone interested in post-orthopaedic injury/surgery rehab or athletic performance. It starts by recognising two important aspects. The first is that all of this stuff is adjunct to exercise prescription and manual therapy and should not be used in isolation. Secondly, there is not a ‘one size fits all’ approach. The efficacy of a therapeutic modality is linked to the phases of healing. What is useful at an acute stage may be useless at a later stage. Let’s also not forget that absence of evidence is not evidence of absence of a therapeutic effect on a human subject.

A RARE CASE OF DOUBLE-HEADED PSOAS MINOR MUSCLE WITH REVIEW OF ITS KNOWN VARIANTS. Protas M, Voin V, Wang JMH et al. Cureus 2017;9(6):e1312

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This is a post-mortem report on a routine examination of a 49-year-old male. He was found to have a twoheaded psoas minor. The lateral head arose from the lumbar L1 vertebral body and the medial head originated from the L4/L5 vertebral bodies and intervening intervertebral disc. The genitofemoral nerve exited the psoas major between the two heads of the psoas minor but nearer to the medial edge of the lateral head. The lateral head was innervated by the genitofemoral nerve but a clear branch to the psoas minor was not identified. The two heads of the psoas minor came together at the lower spinal segment (S1) vertebral level and continued as a single tendon to attach onto the iliopectineal eminence.

Co-Kinetic comment Don’t assume everyone is built like the pictures in the text books. There can be anatomic variations. We know nothing about this man’s medical history but what if you were his therapist and he presented with low back pain? Could it have been that the twin headed psoas minor was pulling on the lumbar intervertebral disk it is attached to? Sadly we will never know. 5

TREATMENTS OF MENISCUS LESIONS OF THE KNEE: CURRENT CONCEPTS AND FUTURE PERSPECTIVES. Cengiz IF, Pereira H, Espregueira-Mendes J et al. Regenerative Engineering and Translational Medicine 2017;3(1):1–19

Meniscus injuries are one of the most frequent injuries in the knee, with meniscectomy as the most frequent surgical procedure. This study looks at the options for clinical management concentrating on surgical repair, meniscus substitution and regeneration. The menisci function under compressive, radial tensile and shear stresses. Although injuries can occur in all age groups, age is a relevant pathophysiological factor of meniscus lesions because their characteristics vary according to age, tear pattern and pathological conditions. These include water content, cells, extracellular matrix, collagen and adhesion glycoproteins. A traumatic meniscus tear is typically associated with an acute event capable of creating enough capacity to rupture the meniscus tissue. Degenerative meniscus lesions have a considerably different nature. Some characteristic changes of a degenerative meniscus

include cavitations, softened tissue, fibrillation or complex tear patterns. Even the younger populations can be subject to degenerative change. Repair options have increased with the development of new materials and techniques but the failure rate is around 15%. The key to a successful outcome depends on the type and the location of the lesion, and on the experience of the surgeon. The ideal candidates for meniscus allograft transplantation are young patients with a history of prior meniscectomy in a stable knee with neutral alignment and no severe chondral damage. Obesity and smoking are considered risk factors. There are concerns regarding the graft longevity, prevention of osteoarthritis, and return to high-demand activities. For injuries where the meniscus roots and peripheral rim remain preserved, scaffold implantation is

The data for this study came from a search of the usual databases from 2006 to September 2016, plus ClinicalTrials.gov and the proceedings from the 2015 American College of Rheumatology annual meetings. Search criteria were randomised controlled trials conducted in adults 18 years or over diagnosed with osteoarthritis (OA) of the knee, comparing any of the interventions of interest with placebo (sham) or any other intervention of interest that reported a clinical outcome (including pain, function, and quality of life). Interventions that show beneficial effects on short-term outcomes of interest include TENS for pain; strength and resistance training on Western Ontario and McMaster University Arthritis Index (WOMAC) total scores;

TREATMENT OF OSTEOARTHRITIS OF THE KNEE: AN UPDATE REVIEW. Newberry SJ, FitzGerald J, SooHoo NF et al. Comparative Effectiveness Review No. 190. Agency for Healthcare Research and Quality (US) 2017 tai chi on pain and function; and agility training, home-based programmes, and pulsed electromagnetic field therapy on pain. Interventions that show beneficial effects on medium-term outcomes include weight loss, glucosamine plus chondroitin, general exercise programmes, tai chi, and home-based programmes for pain and function; intra-articular platelet-rich plasma on pain and quality of life; chondroitin sulphate alone on pain; and whole-body vibration on function. Interventions that show beneficial long-term effects include agility training and general exercise programmes for pain and function; and

an option. Two have been approved in Europe. One of them is a collagen meniscus implant or based on type I bovine collagen matrix. The other one is a polycaprolactone-polyurethane scaffold. Both have proven to be safe, without any apparent adverse effects. A more advanced option comes from tissue engineering and regenerative medicine, which typically employs cells, scaffolding biomaterials, and signalling factors, either alone or in combination. Preferably, autologous mesenchymal stem cells are isolated from the patient’s biopsy and added to a 3D printed tissue engineered implant and expanded in vitro.

Co-Kinetic comment. This is the sort of ‘everything you need to know’ paper that we love. 3D printing of new body parts is the stuff of science fiction but it is with us now.

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manual therapy and weight loss for pain. No consistent serious adverse effects were reported for any intervention.

Co-Kinetic comment There is some low-level evidence that participation in sport increases the chances of developing OA in elite participants. It’s less clear for nonelite athletes [see Tran et al. Does sports participation (including level of performance and previous injury) increase risk of osteoarthritis? A systematic review and meta-analysis. Br J Sports Med 2016;50(23):1459– 1466] but the chances are that no matter what branch of the therapy profession you are in you are going to see patients who have it. Sadly the state of the current evidence suffers from lack of quality, which makes pooling results difficult. How often do we have to say this before researchers get their act together?

Co-Kinetic Journal 2018;75(January):4-7

RESEARCH INTO PRACTICE

ANATOMY AND PHYSIOLOGY OF CHRONIC SCROTAL PAIN. Patel AP. Translational Andrology and Urology 2017;6(1):S51–S56

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This article reviews the anatomy and physiology of the scrotum and its contents as it pertains to chronic scrotal pain. Physiology of chronic pain is reviewed, as well as the pathophysiology involved in the development of chronic pain. The main reason the sac is external is to do with facilitating temperature regulation of the testes to ensure optimal spermatogenesis. It is well supplied with blood from both the internal and external iliac arteries with the testes being supplied via the testicular artery, so there can be a potential for major blood loss following trauma. Possible causes of chronic pain are altered or hyper-activated nerve sensation, a heightened immune cell response. There can also be referred pain from structures on the same nerve pathway (mostly L1, L2, and S2–4).

Co-Kinetic comment Half of our readers will be wondering what all the fuss is about but the other will know that there is nothing – nothing – as excruciatingly, mind-numbingly painful as a blow to the male nether regions. That does not, however, stop other males giggling at their colleague’s misfortune. It can, however, be serious. This paper is all you need to know about the injured bits. It starts with the suggestion that most chronic scrotal pain is a result of trauma and that is not unusual in sport. There is a companion piece on treatment: Williams DH. How to manage testicular/groin pain: medical and surgical ladder. Urology Times 2014 (http://spxj.nl/2iZaU9q). The purpose of this article was to summarise the anatomy, aetiology and incidence of nasal fractures, and to evaluate the current body of literature regarding immediate on-field and subsequent outpatient management. Two nasal bones form the ‘bridge’ of the nose and this framework supports a combination of cartilaginous structures (septal, greater and lesser alar, accessory, lateral, vomeronasal). Overlying this cartilaginous surface is a network of nerves, blood vessels, mucous glands, muscle and fatty tissue which are particularly susceptible to bleeding (epistaxis) following minor trauma. Following injury, the first principle is the ABC of

ECHOCARDIOGRAPHIC ASSESSMENT OF YOUNG MALE DRAFTELIGIBLE ELITE HOCKEY PLAYERS INVITED TO THE MEDICAL AND FITNESS COMBINE BY THE NATIONAL HOCKEY LEAGUE. Ong G, Connelly KA, Goodman J et al. American Journal of Cardiology 2017;119:2088–2092 This is a report on screening done by the National Hockey League in North America on the top draft-eligible elite ice hockey players to determine the frequency of occult cardiac anomalies in this cohort of athletes. They took 2-dimensional (2DE) and 3-dimensional (3DE) echocardiographic measurements which gave information on cardiac structure and function at rest, which were compared with non-athlete controls. A total of 592 athletes were evaluated (mean age 18 ± 0.5 years) from 2009 to 2014. Ventricular and atrial dimensions, and left ventricular mass were significantly greater in the athletes compared with controls. Abnormalities were identified in 15 hockey players (2.5%) consisting of a bicuspid aortic valve in 10 (1.7%), patent ductus arteriosus in 1 (0.2%), low normal left ventricular systolic function in 2 (0.3%), an idiopathic pericardial effusion in 1 (0.2%), and posterior mitral valve prolapse in 1 (0.2%).

Co-Kinetic comment Top marks to the NHL for doing this screening. Our British readers only have to know two words to illustrate the importance of this: Fabrice Muamba, the Premier League footballer who ‘died’ on the pitch and was revived. Others, such as Marc-Vivien Foe, were not so lucky. Screening saves lives. Note the accompanying research we have reported on the cardiac output of non-elite ice hockey players from the same publication (Goodman et al. Cardiovascular response to recreational hockey in middle-aged men. Am J Cardiol 2017;119(12):2093–2097).

basic first aid so establish that the athlete’s airway is not compromised. After that, are there other severe concomitant injuries, such as a cervical spine injury, concussion, ocular injury or leakage of cerebrospinal fluid (CSF)? There are a few critical findings that should not be missed and require an immediate trip to hospital. The presence of a sunken eye globe, depression of the zygomatic arch, or gross facial asymmetry suggest a more complex injury, and potentially multiple facial fractures, has occurred. Altered vision suggests ocular injury or can be a symptom of concussion, which itself should always be a consideration following facial injury. Persistent mucus fluid (rhinorrhoea) that is clear and watery in nature should raise suspicion of potential cribriform plate damage and CSF leak.

MANAGEMENT OF NASAL FRACTURES IN SPORTS. Patel Y, Goljan P, Pierce TP et al. Sports Medicine 2017;47:1919 Bleeding can be stopped via ice, pinching of the bridge of the nose or intranasal packing. Topical vasoconstrictive agents such as oxymetazoline and phenylephrine hydrochloride may also be used. If this doesn’t work it suggests artery damage, so again it’s hospital A.S.A.P. This is the care limit for most of us but the paper continues with intranasal inspection and closed reduction of fractures for those adequately trained.

Co-Kinetic comment Nasal fractures make up approximately 60% of all maxillofacial injuries occurring in sporting activities so having an idea about immediate and longer-term treatment is a must. Return to play is discussed. The first decision will be whether or not the player returns immediately or not. After that there is no consensus on timelines.

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CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

EFFECTS OF DRY NEEDLING TRIGGER POINT THERAPY IN THE SHOULDER REGION ON PATIENTS WITH UPPER EXTREMITY PAIN AND DYSFUNCTION: A SYSTEMATIC REVIEW AND META-ANALYSIS. Hall ML, Mackie AC, Ribeiro DC. Physiotherapy 2017;doi:http://dx.doi. org/10.1016/j.physio.2017.08.001

ACUTE CHANGES OF HIP JOINT RANGE OF MOTION USING SELECTED CLINICAL STRETCHING PROCEDURES: A RANDOMIZED CROSSOVER STUDY. Hammer AM, Hammer RL, Lomond V et al. Musculoskeletal Science and Practice 2017;32:70–77 Forty participants (20 male and 20 female) who had reduced hip adductor muscle length attended a familiarisation session and five testing sessions on nonconsecutive days using a randomised crossover study design. There was a 5min warm-up on an upright cycle and pre-intervention measures of ROM and maximal voluntary contraction (MVC) before they were assigned to one of three clinical stretching procedures (modified lunge, multidirectional, and joint mobilisation) or a static stretch or control condition. Each stretch was maintained for 60s. The multidirectional stretch was done in a TrueStretch cage (model 800SS Pro, True Fitness Technology) while standing on one leg and abducting and externally rotating the other leg when placing it in the trough. Participants were then told to use their hands and head as ‘drivers’ to cause rotation in the pelvis in the sagittal, frontal and transverse planes. An examiner manually applied overpressure and assisted in moving hips for 20s in each of the planes to dynamically stretch the hips at about one movement/sec

for a total of 60s then repeating on the other side. The mobilisations were performed by having the participant stand and abduct the leg with the knee flexed onto a platform to a stretch sensation of a 6 with a foam pad for comfort. A therapist then provided an oscillating pressure near the hip socket to achieve a 7 on the authors’ own stretch sensation scale. This is a 0–10 scale, where 0 = resting, 10 = muscle tearing scale. 7 = the point of discomfort. Not enough stretch to make you wince. Post-intervention measures of ROM and MVC were taken immediately following completion of the assigned condition. All interventions resulted in small but statistically significant increases in ROM of only 1.0–1.7° with no intercondition differences except one, which was that multidirectional stretching was greater than control. None of the stretching procedures induced a significant decrement in force output.

Co-Kinetic comment Once is not enough!

CUPPING THERAPY: AN ALTERNATIVE METHOD OF TREATING PAIN. Dalton EL, Velasquez BJ. Public Health 2017;2(2):59–63 This paper contains everything you want to know about cupping and its uses. It was originally a form of Chinese medicine that is believed to act by correcting imbalances in the internal biofield. It involves applying a heated or suction type cup to generate a partial vacuum that mobilises blood flow to promote healing. In theory this encourages blood flow to the area by causing rupture of capillaries on the skin surface, which in turn is thought help in the healing process by bringing oxygenated blood and nutrients to the damaged tissue. A couple of papers are quoted to prove this, as is another that states that cupping produces pain relief from musculoskeletal conditions such as low back, neck and shoulder pain. 8

Co-Kinetic comment You may have seen athletes with distinct circles on their backs that look like they have a series of love bites (hickies for our American cousins or Knutschflecke in German, which sounds much more medical). It’s been around for thousands of years so it’s probably more than a passing fad. If you are thinking of using cups, Google it and look at some of the pictures from when it went wrong. Co-Kinetic Journal 2018;75(January):8-11

RESEARCH INTO PRACTICE

Manual Therapy

Journal Watch CHANGES IN MUSCLE ACTIVITY OF THE ABDOMINAL MUSCLES ACCORDING TO EXERCISE METHOD AND SPEED DURING DEAD BUG EXERCISE. Yun BG, Lee SJ, So HJ et al. Physical Therapy Rehabilitation Science 2017;6(1):1–6 The subjects were 30 healthy adults (13 males and 17 females). They performed three different speeds of dead bug exercises: 60bpm, 90bpm and 120bpm, timed using a metronome. The electromyography (EMG) assessment was percentage of maximal voluntary isometric contraction on the rectus abdominis, external oblique, and internal oblique. The results were that EMG activation of all three muscles was significantly greater at the higher speed. There was a significant increase in abdominal muscle activity during the dead bug exercise performed with both the upper and lower extremities compared to that with only the upper extremities or the lower extremities.

The purpose of this study was to produce the best evidence synthesis of exercise prescription for treating shoulder pathology. The data came from a search of the usual databases up to July 2016. One hundred and thirty unique exercises were identified. Most of the evidence is at the level of expert opinion. The strongest evidence supports the use of single-plane, open chain, upper

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Co-Kinetic comment Try doing this at 120bpm. In the interest of research we tried. It activates the core muscle but it is **** hard work. In future we will believe the research without trying it!

EXERCISE PRESCRIPTION FOR OVERHEAD ATHLETES WITH SHOULDER PATHOLOGY: A SYSTEMATIC REVIEW WITH BEST EVIDENCE SYNTHESIS. Wright AA, Hegedus EJ, Tarara DT et al. British Journal of Sports Medicine 2017;doi:10.1136/bjsports-2016-096915 [Epub ahead of print] extremity exercises performed below 90° of elevation and closed chain exercises. Clinical expert pieces support a more advanced, global treatment approach.

Co-Kinetic comment Best evidence for shoulder injury exercises was always going to be a big ask. There are just too many options in both the variation of people and their needs and the number of exercises that have been dreamt up. Note, however, that the real experts don’t just focus on the shoulder. Think globally.

EFFECTIVENESS OF CONSERVATIVE INTERVENTIONS INCLUDING EXERCISE, MANUAL THERAPY AND MEDICAL MANAGEMENT IN ADULTS WITH SHOULDER IMPINGEMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RCTS. Steuri R, Sattelmayer M, Elsig S et al. British Journal of Sports Medicine 2017;51(18):1340–1347 This was a search of the ‘usual suspect’ databases looking for randomised controlled trials which included participants with shoulder impingement and evaluating at least one conservative intervention against sham or other treatments. The headline results were that for pain, exercise was superior to non-exercise control interventions. Specific exercises were superior to generic exercises. Corticosteroid injections were superior to no treatment, and ultrasoundguided injections were superior to non-guided injections. Non-steroidal anti-inflammatory drugs had a small Co-Kinetic.com

to moderate effect compared with placebo. Manual therapy was superior to placebo. When combined with exercise, manual therapy was superior to exercise alone, but only at the shortest follow-up. Laser was superior to sham laser. Extracorporeal shockwave therapy was superior to sham and tape was superior to sham.

Co-Kinetic comment There is no magic pill. There is not much high-quality evidence for any of it but something is better than nothing. Try the lot but here’s a thought: shoulder impingement is a clinical sign not a diagnosis. Find what’s causing the impingement and you may have a better result with the treatment. 9

IMPAIRMENT BASED EXAMINATION AND TREATMENT OF COSTOCHONDRITIS: A CASE SERIES. Zaruba RA, Wilson E. International Journal of Sports Physical Therapy 2017;12(3):458 Eight subjects were referred to physical therapy for costochondritis (mean duration of condition 6.3 ± 1.3 months) and reported that their condition restricted their ability to participate in occupational and fitness activities. They were evaluated for cervicothoracic conditions, including restricted ROM at spine, reproduction of symptoms during anterior posterior glides of the costovertebral joint, relevant muscle lengths and upper limb tension tests. They also completed a numerical pain rating scale (NPRS), a patient-specific functional scale (PSFS) before and after intervention and the global rating of change (GROC) scale on discharge. All subjects received treatment directed at the cervicothoracic spine and ribcage consisting of manual therapy and exercise. Identified cervicothoracic junction and upper thoracic vertebral

region received manipulations, followed by first and second rib issues which were treated with manipulation. They were given home exercises to target the dysfunction and some selfmanipulations with a belt. Tight muscles, including the pectoralis major/minor, latissimus dorsi, upper trapezius and scalenes, were treated with contract/relax soft tissue-release techniques. On each visit the subjects were reassessed and manual therapy for specific impairments was discontinued if impairment was no longer present, but the specific exercises for the impairment were continued three times per day at home and/or in clinic for a minimum of 2 weeks after manual therapy intervention for specific impairment was discontinued. The subjects were seen 4.8 (± 0.9)

THE FEMALE ATHLETE: KEY DIFFERENCES BETWEEN GIRLS AND BOYS. Franklin CCD. NASN School Nurse 2017;35(2):318–321 This article was generated because over the last few years there has been a tenfold increase in female sports participation in US high schools and a fivefold increase at university. Hence, the US National Association of School Nurses is quite rightly concerned that when caring for female athletes, it is important to understand what risk factors and injury patterns are most common. One injury that is highlighted is ACL rupture with referenced studies suggesting an eightfold higher incidence in females. Reasons for this are speculative but include biologic and hormonal factors, as well as other factors where the risk can be reduced by coaching. These include an apparent tendency for female athletes in general to land with their knees in a more valgus position and with less hip and knee flexion, and to have quadriceps that are much stronger than their hamstrings. In addition, female athletes are more likely to sustain stress fractures, particularly in sports that require repetitive running

or jumping, such as long-distance running, basketball, volleyball, and soccer (football to the rest of the English speaking world). The female athlete triad (energy deficiency with or without disordered eating, menstrual disturbances/amenorrhoea and bone loss/osteoporosis) is mentioned, where athletes participating in activities requiring a thin body type (such as distance running, ballet and gymnastics) are at particular risk. For reasons that are not fully understood females are more prone to concussions.

Co-Kinetic comment We always thought that the difference was that boys are made of “Snips and snails and puppy dogs’ tails” and that girls were “Sugar and spice and all things nice”, no? This article is a bit basic (remember that it’s aimed at school nurses) but it makes a good point. There are differences and those involved in sport should not only be aware of them but be proactive in addressing some of the differences to lessen the risk.

times. All showed clinically meaningful changes at discharge. The mean NPRS decreased by 5.1 ± 1.7 points; the mean PSFS increased by 5.3 ± 1.4 points; and the mean GROC was 5.9 ± 1.1 points. All subjects were able to return to participation in previous activities without restrictions at discharge.

Co-Kinetic comment On the scales of how good evidence is supposed to be, RCTs are said to be the best and reports like this one not so good. Sadly far too many RCTs set unrealistic situations or use healthy subjects and are consequently of little use to working therapists. Case studies like this, however, are the real ‘gold standard’. Take a group of patients with a condition, tell us what you did and if it worked or not. More of these please. EFFECTIVENESS OF EXERCISE AND LOCAL STEROID INJECTIONS FOR THE THORACOLUMBAR JUNCTION SYNDROME (THE MAIGNE’S SYNDROME) TREATMENT. Alptekin K, Örnek NI, Aydın T et al. The Open Orthopaedics Journal 2017;11:467–477 Thirty patients (average age 23.43 ± 3.75 years; 1 female) were divided into three groups of 10. Group 1 received exercise, group 2 received a local steroid injection, and group 3 received the injection and exercise. All three groups improved on Oswestry and VAS scales but the best result was in the injection and exercise group. Although there were variations between patients, the exercises started with simple pelvic tilt exercises and built up so that firstly pelvic muscles, then back extensors, then neck flexors and extensors were added. They were also given ‘hip-bearing exercises’ although these were not further described.

Co-Kinetic comment Maigne’s syndrome (also known by other names) is sometimes called ‘does not exist syndrome’ but if you have a patient with pain in the lower abdominals, groin, around the pubic bone or the lumbo-sacral region and you can’t find out why, it is worth considering. Co-Kinetic Journal 2018;75(January):8-11

RESEARCH INTO PRACTICE

INTERNAL IMPINGEMENT OPEN OF THE SHOULDER: A RISK OF FALSE POSITIVE TEST OUTCOMES IN EXTERNAL IMPINGEMENT TESTS? Leschinger T, Wallraff C, Müller D et al. BioMed Research International 2017;2017:2941238 Nineteen males and 18 females (average age 24 years; range 20–30 years), and all right-handed, had an MRI of their dominant shoulders while in a plaster splint that placed them in the following positions: (i) Neutral position; (ii) Hawkins–Kennedy test position (90° forward flexion of the shoulder with internal rotation of 15° and 90° flexion of the elbow); (iii) Neer test position (170° elevation of the shoulder with a stabilised patient’s scapula); and (iv) horizontal impingement test position (90° abduction with 15° internal rotation of the shoulder). Following the MRI, internal impingement was classified according to the extent of contact between the rotator cuff and glenoid: grade 0, no contact; grade 1, contact without deformation of the rotator cuff; and grade 2, rotator cuff deformation was present. The Neer and Hawkins–Kennedy tests resulted in significant narrowing of the minimum distance from the greater tuberosity to the glenoid. The lesser tuberosity was significantly closer to the glenoid when performing both tests.

Co-Kinetic comment Yes, you read that right. They put the victims (sorry, subjects) in a plaster of Paris cast from the waist up. There are pictures. The bottom line is that the two tests did what they were supposed to do in most subjects. Why do we get so bogged down in this stuff? A simple active shoulder abduction/elevation will tell you all you need to know. If there is a painful arc there is an impingement. If you want to add the fancy tests like the Neer, Hawkins–Kennedy and empty can, fine – but they are only telling you what you already know. If so, according to the leading physio textbooks and web sites, the treatment is the same for most of us. Sort out posture, sort out scapular humeral rhythm, get the range back and strengthen it. If none of that is working send them to a specialist. Co-Kinetic.com

MANUAL THERAPY FOR PLANTAR HEEL PAIN. Pollack Y, Shashua A, Kalichman L. The Foot 2017;34:11–16 The ‘usual suspect’ databases were searched for keywords relating to plantar heel pain, joint and soft tissue mobilisations. There were no search limitations or language restrictions. The PEDro score was used to assess the quality of the reviewed papers. This discovered six relevant randomised controlled trials. Two examined the effectiveness of joint mobilisation on plantar heel pain and four, the

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effectiveness of soft tissue techniques. Five studies showed a positive short-term effect after manual therapy treatment, mostly soft tissue mobilisations, with or without stretching exercises for patients with plantar heel pain, compared to other treatments. One study observed that adding joint mobilisation to the treatment of plantar heel pain was not effective. The quality of all studies was moderate to high.

Co-Kinetic comment Does what it says on the tin. Mobilisation works.

ACUTE EFFECTS OF QUICK SHORT DURATION MASSAGE ON VERTICAL JUMP; A CROSSOVER RANDOMISED CONTROLLED TRIAL. Mine K. HSOA Journal of Physical Medicine Rehabilitation & Disabilities 2017;3:019 Fifteen young healthy male individuals (age 21.07 ± 0.25 years, body mass index 22.29 ± 2.39kgm−2) were recruited. All subjects received both massage and control interventions on separate days. The massage was 10s of effleurage and 10s of tapotement for quadriceps and gastrocnemius muscles on both legs. In the control group, subjects were asked to lie down for the same duration as the massage group. Vertical jump height was assessed before and after interventions. The results were that there was no significant difference

between the two groups in changes in vertical jump performance. Both groups showed no change after interventions compared to the baselines.

Co-Kinetic comment The result is probably correct but the fault of this experiment is that there is little attention to the actual dose of the treatment. It says that the massage was quick, superficial and stimulatory for 2min in total, including the time for the therapist to move around the bed and for subjects to change lying positions. That doesn’t really say how much actual treatment there was or how deep it was and, therefore, how much load was going into the tissue.

FRICTION MASSAGE VERSUS KINESIOTAPING FOR SHORT-TERM MANAGEMENT OF LATENT TRIGGER POINTS IN THE UPPER TRAPEZIUS: A RANDOMIZED CONTROLLED TRIAL. Mohamadi M, Piroozi S, Rashidi I et al. Chiropractic & Manual Therapies 2017;25:25 Fifty-eight male students (aged 18–30 years), participated in this single-blind randomised clinical. Inclusion criteria for this study were the presence of a latent trigger point in the proximal third of the upper trapezius muscle. The pressure pain threshold was recorded with a pressure algometer and grip strength was recorded with a Collin dynamometer. The participants were randomly assigned to two different treatment groups: kinesiology tape (K-tape) or friction massage. Friction massage was performed daily for three sessions and K-tape was used for 72h. One hour after the last session of friction massage or removal of the

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K-tape, pressure pain threshold and grip strength were evaluated again. Pressure pain thresholds decreased significantly after both interventions. Grip strength increased significantly after friction massage; however, there was no significant change in the K-tape group. There were no significant differences in pressure pain threshold or grip strength between the two study groups.

Co-Kinetic comment Neither of the treatments alleviated the latent trigger points. In fact, poking them seems to have made them worse. That’s what happens with latent trigger points, so no surprise there. Also, you can write off cross-fibre frictions and K-tape. There are other ways of dealing with latent trigger points.

TIME-SAVING RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

Produced by:

American Journal of Sports Medicine

IS THERE A CORRELATION BETWEEN COACHESÕ LEADERSHIP STYLES AND INJURIES IN ELITE FOOTBALL TEAMS? A STUDY OF 36 ELITE TEAMS IN 17 COUNTRIE

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SUDDEN CARDIAC ARREST DURING PARTICIPATION IN COMPETITIVE SPORTS

British Journal of Sports Medicine

WHY WE SHOULD FOCUS ON THE BURDEN OF INJURIES AND ILLNESSES, NOT JUST THEIR INCIDENCE

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MUSCLE INJURY RATE IN PROFESSIONAL FOOTBALL IS HIGHER IN MATCHES PLAYED WITHIN 5 DAYS SINCE THE PREVIOUS MATCH: A 14-YEAR PROSPECTIVE STUDY WITH MORE THAN 130 000 MATCH OBSERVATION

BMJ Open Sport & Exercise Medicine

PHYSIOTHERAPY AND PHYSICAL ACTIVITY: A CROSS-SECTIONAL SURVEY EXPLORING PHYSICAL ACTIVITY PROMOTION, KNOWLEDGE OF PHYSICAL ACTIVITY GUIDELINES AND THE PHYSICAL ACTIVITY HABITS OF UK PHYSIOTHERAPISTS

For other Co-kinetic infographics go to https://www.co-kinetic.com/tag/infographic

THE 10 MOST DISCUSSED PIECES OF RESEARCH IN SPORTS MEDICINE (OCT-DEC 2017)

Chiropractic & Manual Therapies

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THE EFFECTIVENESS AND SAFETY OF MANUAL THERAPY ON PAIN AND DISABILITY WHAT IS IN OLDER PERSONS CHIROPRACTIC? WITH CHRONIC Chiropractic & LOW BACK PAIN: A Manual Therapies SYSTEMATIC REVIEW

0 19 6 5

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FRICTION MASSAGE VERSUS KINESIOTAPING FOR SHORT-TERM MANAGEMENT OF LATENT TRIGGER POINTS IN THE UPPER TRAPEZIUS: A RANDOMIZED CONTROLLED TRIAL

For other Co-kinetic infographics go to https://www.co-kinetic.com/tag/infographic

0 27 2 2

Chiropractic & Manual Therapies

THE CHIROPRACTIC PROFESSION: A SCOPING REVIEW OF UTILIZATION RATES, REASONS FOR SEEKING CARE, PATIENT PROFILES, AND CARE PROVIDED

THE 10 MOST DISCUSSED PIECES OF RESEARCH IN MANUAL THERAPY (OCT-DEC 2017)

0 25 4 5

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UNRAVELING THE MECHANISMS OF MANUAL THERAPY: MODELING AN APPROACH

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THORACIC MANUAL THERAPY IS NOT MORE EFFECTIVE THAN PLACEBO THORACIC MANUAL THERAPY IN PATIENTS WITH SHOULDER DYSFUNCTIONS: A SYSTEMATIC REVIEW WITH METAANALYSIS

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0 109 2 46 14 4 4

Produced by:

3 73 3 5

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MASSAGE THERAPY DECREASES CANCERRELATED FATIGUE: RESULTS FROM A RANDOMIZED EARLY PHASE TRIAL

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CLASSIFICATION SYSTEMS:

A REVIEW OF LOW BACK PAIN CARE LOWER BACK | 18-01-COKINETIC FORMATS WEB MOBILE PRINT

MEDIA CONTENTS Video 1: When to manipulate the lumbar spine/Flynn Clinical Prediction Rule. Courtesy of YouTube user Physiotutors https://youtu.be/vky_6Nv0KK0 Video 2: Luomajoki lumbar movement control dysfunction screening. Courtesy of YouTube user Physiotutors https://youtu.be/A4gU0YD6HS4 Video 3: Lumbar movement control exercises/ Motor control impairment. Courtesy of YouTube user Physiotutors https://youtu.be/x6mRy22eYkA 3 patient information leaflets on posture, exercises and stretches for LBP http://spxj.nl/2BSZKKn Low Back Pain and Sleep: A Content Marketing Campaign for Therapists http://spxj.nl/2ludLuL

THE CHAIN OF COMMAND According to Wikipedia:

‘A chain is a serial assembly of connected pieces, called links, typically made of metal, with an overall character like that of a rope, in that it is flexible and curved in compression but linear, rigid and load-bearing in tension.’ n All references marked with an * are open access and links are provided in the reference list.

Management of the lower back is no longer viewed in its isolation at any specific lumbar level or inter-vertebral joint but within a much wider scope of interactions along the kinematic chain. Movement patterns and muscle slings, dynamic and static posture, habits and side dominance as well as work and sport demands are all contributors to the complex workings of the spine. Commanding the chain through neuromuscular facilitation and

LBP REMAINS THE MOST COMMON INJURY WORLDWIDE, YET STRONG CLEAR EVIDENCE DEFINING EFFECTIVE TREATMENT PROTOCOLS FOR LBP IS LACKING 14

Low back pain (LBP) is one of the most common presentations in primary healthcare. It is a complex condition with a multifactorial aetiology, which perhaps explains why there is a lack of strong clear evidence for effective treatment protocols. The treatment-based classification (TBC) system is one of several models that classify LBP patients into subgroups in order to tailor treatment more appropriately, which seems to yield improved outcomes. This article reviews the evidence available, the TBC system and treatment recommendations. With explanatory videos, links to current research results and patient exercise leaflets, this article will allow you to better understand and more effectively treat your LBP patients. Read this article online http://spxj.nl/2BSZKKn BY KATHRYN THOMAS BSC MPHIL motor control rehabilitation appears to be an effective treatment modality for low back pain (LBP). LBP remains the most common injury worldwide, yet strong clear evidence defining effective treatment protocols for LBP is lacking. Recent reviews of the literature have highlighted this, yet endeavoured to propose best-practice protocols based on the existing evidence or lack thereof. This article will aid in consolidating the reviews and guide your management of LBP.

EVOLUTION OF TREATMENT-BASED CLASSIFICATION FOR LBP LBP is among the most common symptoms seen in primary healthcare (1*). The management of LBP depends on aetiology, duration, presence of radiculopathy, and radiologic and physical examination findings. Most episodes of LBP are acute, lasting less than 4 weeks with no clear identification of the underlying cause. LBP is considered subacute it if lasts 4–12 weeks and chronic when pain persists for longer than 12 weeks (2*). Although much research has been

done on LBP, no definitive evidence has emerged from clinical trials to suggest which interventions are best (1*,2*). It is often suggested that this discrepancy arises because most clinical trials study the application of a single therapy to a mixed group of LBP patients. This lack of patient selection tends to reduce the apparent effectiveness of a treatment. The effect of a treatment is best seen when it is matched to a classified subgroup of patients; an approach that has shown improved treatment outcomes when compared to non-matched approaches (3–6). It is now important that studies are planned with therapies matched to LBP-classified patient subgroups (7*). In physical therapy, the following four basic LBP classification systems have been described that use a clinical decision-making process to ascribe therapies to patient subgroups: n the McKenzie mechanical diagnosis and therapy classification model [Hefford (3)]; n t he movement system impairment syndromes model [Sahrmann (4)]; n t he mechanism-based classification [O’Sullivan (5)]; and Co-Kinetic Journal 2018;75(January):14-18

PHYSICAL THERAPY

n t he treatment-based classification (TBC) system [Delitto et al. (6)]. These systems have considerably improved the ability of clinicians to analyse their patients’ LBP symptoms and to assign interventions. However, the generally inadequate quality of evidence on which these systems are based means that they will inevitably have weaknesses. As better quality evidence emerges from better designed studies and our understanding of LBP improves, we will be more likely to be able to move toward one well-defined model. Over the years, however, there has been repeated work and modification of the TBC system (6,7*,8). Most recently, Alrwaily et al. once again revised the classification system in 2015 (9*). This new system breaks the initial triage process into the level of the first healthcare provider contact (direct access) and, secondly, the rehabilitation provider. At the level of the first provider, the patient is directed either toward medical management, rehabilitation management or self-management. This determination is based on the presence/ absence of red flags and neurological deficits. See Glyn Towlerton’s session from the Fisic 2015 conference ‘Low Back Pain: The really important things to exclude’ for further details of the red flags (Further Resources 1). Once the patient has been transitioned to rehabilitation management, the classification categories have been broadened to direct patients toward the correct treatment approaches (Links 1–5). Instead of breaking the categories into specific interventions, the updated TBC categories involve logical groups of interventions: symptom modulation, movement control, and functional optimisation. This alteration will prevent patients from being categorised into multiple groups or not being classified at all. TBC seems to yield better outcomes (10,11,12,13*). Additionally, this updated TBC embraces the biopsychosocial model of back pain management, including the importance for risk assessment and the need to address psychological factors, regardless of the rehabilitation approach. Currently, this is the most Co-Kinetic.com

consistent and effective evidencebased tool to evaluate and treat LBP and should be considered a viable option for any therapist (Link 6) (9*). During clinical practice, not every patient will fit nicely into a specific subgroup, but having this framework aids clinicians in making more informed, evidence-based treatment decisions.

COMPARATIVE BENEFITS OF PHYSICAL THERAPY RELATED THERAPIES The purpose of these LBP clinical practice guidelines and reviews (2*,13*,14,15*,16*,17*,18*,19*) is to describe the peer-reviewed literature and make recommendations and updates related to: 1. treatments matched to LBP subgroup responder categories; 2. treatments that have evidence to prevent recurrence of LBP; and 3. treatments that have evidence to influence the progression from acute to chronic low back pain and disability. A summary of major recommendations from the most recent reviews of Qaseem et al., 2017 (2*); Wenger et al., 2017 (14); Hong et al., 2017 (15*); and NICE, 2016 (16*) includes: n For acute or subacute LBP (LBP lasting less than 4 weeks or 4–12 weeks) superficial heat, massage, acupuncture or spinal manipulation are recommended as first-line therapy (strong recommendation, low-to-medium quality evidence). n Non-steroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxants can be offered if patients request pharmacologic treatment for acute or subacute LBP (strong recommendation, moderate-quality evidence). n For chronic LBP, lasting more than 12 weeks, a range of nonpharmacological therapies should be used initially, including exercise, psychological therapies, multidisciplinary rehabilitation, acupuncture, massage, spinal manipulation and low-level laser therapy had small-to-moderate effects (low-to-medium quality evidence).

n I f non-pharmacological therapy is ineffective for chronic LBP, NSAID (first-line) or tramadol or duloxetine (second-line) should be considered (weak recommendation, moderatequality evidence). n Clinicians should consider opioids only when the aforementioned treatments have failed and after consideration of their risks and benefits (weak recommendation, moderate-quality evidence). Greater detail of the studies and evidence behind this summary can be seen in Table 1 (available online) or refer to the full text articles (2*,14,15*,16).

Recommendation 1 (2*,14) Given that most patients with acute or subacute LBP improve over time regardless of treatment, clinicians and patients should select non-pharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select NSAIDs or skeletal muscle relaxants (moderate-quality evidence; grade: strong recommendation). Clinicians should inform all patients of the generally favourable prognosis of acute LBP with or without sciatica, including a high likelihood for substantial improvement in the first month. Clinicians should also provide patients with evidence-based information regarding their expected course, advise them to remain active as tolerated, and provide information about effective self-care options (Further Resources 2). Clinicians and patients should use a shared decision-making approach to select the most appropriate treatment based on patient preferences, availability, harms and costs of the interventions. Non-pharmacologic interventions shown to be effective for improving pain and function in patients with acute or subacute LBP include superficial heat (moderate-quality evidence and moderate improvement in pain and function) and massage (low-quality evidence and small-to-moderate improvement in pain and function). Low-quality evidence (17*) showed 15

that acupuncture had a small effect on improving pain and spinal manipulation had a small effect on improving function compared with sham manipulation but not inert treatment. Regarding spinal manipulation, McCarthy et al. have developed a model suggesting that a transient, mechanical stimulus (spinal manipulation) to the tissue produces a chain of neurophysiological (and psychological) effects (20). A clinical prediction rule (CPR) has been devised (21) and validated (22*) that accurately identifies patients with LBP, who are likely to respond with rapid and prolonged reductions in pain and disability following spinal manipulation. Table 2 shows the five variables that were identified to form a CPR for patients with LBP likely to respond favourably to spinal manipulation and is discussed in Video 1. Based on the number of these variables present, the study calculated the probabilities of the manipulation being successful. It concluded that a patient presenting with four out of the five variables would have a probability of 95%, but even if one out of the five variables were present the likelihood of the manipulation being successful is 46% [See Table 7 in Flynn et al. (21)]. Studies (21,22*,23*) have shown a favourable response to lumbopelvic manipulation defined as a 50% or greater reduction in self-reported disability occurring over two treatment sessions. In these studies (21,22*,23*), over 90% of patients with LBP who satisfied four of the five criteria in the CPR experienced a successful outcome within 1 week.

Harms of non-pharmacologic interventions for LBP were sparsely reported, and no serious adverse events were reported. Superficial heat was associated with increased risk for skin flushing, and massage and spinal manipulation were associated with muscle soreness.

Recommendation 2 (2*,14) For patients with chronic LBP, clinicians and patients should initially select non-pharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, lowlevel laser therapy, operant therapy, cognitive behavioural therapy, or spinal manipulation (low-quality evidence; grade: strong recommendation). Non-pharmacologic interventions are considered as first-line options in patients with chronic LBP because fewer harms are associated with these types of therapies than with pharmacologic options. It is important that physical therapies be administered by providers with appropriate training. Moderate-quality evidence showed that exercise therapy resulted in small improvements in pain and function. Specific components associated with greater effects on pain included individually designed programmes, supervised home exercise, and group exercise; regimens that included stretching and strength training were most effective (Further Resources 2). Recent studies (24,25) have shown that improved fitness and targeted training in muscle strength, endurance

TABLE 1: THE FIVE CRITERIA IN THE PROBABILITY RULE DEVELOPED BY FLYNN ET AL. (21) Criteria

Definition of positive

Symptom location

No symptoms distal to knee

Duration of current episode

Less than 16 days

FABQ work subscale

Less than 19

Segmental mobility testing in a postero-anterior direction

At least 1 hypomobile segment in the lumbar spine

Hip internal rotation range of motion

At least 1 hip with greater than 35° of internal rotation

FABQ, fear avoidance beliefs questionnaire

and lumbar proprioception can aid in reducing chronic LBP. Moderate-quality evidence showed that, compared with usual care, multidisciplinary rehabilitation resulted in moderate pain improvement in the short term (<3 months), small pain improvement in the long term, and small improvement in function in both the short and long term. Low-quality evidence showed that multidisciplinary rehabilitation resulted in a moderate improvement in pain and a small improvement in function compared with no multidisciplinary rehabilitation. Acupuncture had a moderate effect on pain and function compared with no acupuncture (moderate-quality evidence) and a moderate effect on pain with no clear effect on function compared with sham acupuncture (low-quality evidence). Acupressure has been shown to reduce LBP in terms of pain scores, functional status and disability. These effects were not only seen in the short term but also lasted up to 6 months (26*). Recent data has also shown a benefit of integrating acupressure into physical therapy treatment for chronic LBP (27*). There are similarities between acupressure and some manual therapy techniques, for example the significant overlap of trigger points with acupoints (28). Ischemic pressure manipulates the skin in a similar manner to acupressure (29*). This may be something to include in future research and clinical trials for the benefit of managing LBP. Moderate-quality evidence showed that mindfulness-based stress reduction resulted in small improvements in pain and function (small effect), and one study showed that it was equivalent to cognitive behavioural therapy (CBT) for improving back pain and function. A more recent follow-up of that study showed benefits over a 2-year period (Link 7) (32*). Low-quality evidence showed that tai chi had a moderate effect on pain and a small effect on function. Tai chi sessions in included studies lasted 40–45 minutes and were done 2 to 5 times per week for 10 to 24 weeks. Low-quality evidence showed that yoga (Further Resources 2) improved pain and function by a moderate amount compared with usual care Co-Kinetic Journal 2018;75(January):14-18

PHYSICAL THERAPY

and by a small amount compared with education. Low-quality evidence showed that motor control exercises had a moderate effect on pain and a small effect on function. Motor control exercise, tai chi, and yoga were favoured over general exercise (lowquality evidence). According to Panjabi (33), the segmental movements of the spine are controlled through three systems: passive, active and neural systems (33,34,35). The disc, the joint surfaces and the ligaments passively restrict the movement. The myofascial system causes the active movements and the neural system controls and coordinates the movements (Fig. 1). From this theory, ‘motor control exercises’ or ‘movement control exercises and dysfunction’ arose and studies have shown the benefit of this rehabilitation principle (33,36,37 *]38,39*,40*,41*,42*,43*). Luomajoki et al. illustrate the basic principles for assessment (Video 2) (42*,43*) and implementation into an exercise programme (Video 3). Low-quality evidence showed that progressive relaxation had a moderate effect on pain and function, electromyography biofeedback and CBT each had a moderate effect on pain and no effect on function, and operant therapy had a small effect on pain and no effect on function. Low-quality evidence showed that low-level laser therapy had a small effect on pain and function. Low-quality evidence showed that spinal manipulation had a small effect on pain compared with inert treatment but no effect compared with sham manipulation. There were no clear differences between spinal manipulation and other active interventions (moderate-quality evidence). Harms were poorly reported for non-pharmacologic therapies, although no serious harms were reported for any of the recommended interventions. Muscle soreness was reported for exercise, massage and spinal manipulation. Ultrasound, TENS and Kinesio taping had no effect on pain or function compared with control treatments (low-quality evidence).

Recommendation 3 (2*) In patients with chronic LBP who Co-Kinetic.com

Neural control system Ascending and descending pathways, coordination, proprioception, higher level processing (brain and brainstem)

Passive control system Discs, ligaments, joints and their capsules

Active control system Muscles, fascia and tendons

Figure 1: The stability system of the spine [adapted from Panjabi, 1992 (33)]

have had an inadequate response to non-pharmacologic therapy, clinicians and patients should consider pharmacologic treatment with NSAIDs as first-line therapy, or tramadol or duloxetine as secondline therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients (grade: weak recommendation, moderatequality evidence).

AREAS OF INCONCLUSIVE EVIDENCE Evidence is insufficient or lacking to determine treatments for radicular LBP. Most randomised controlled trials enrolled a mixture of patients with acute, subacute and chronic LBP, so it is difficult to extrapolate the benefits of treatment compared with its duration. Use of opioids for chronic pain is an important area that requires further research to compare benefits and harms of therapy. The evidence is also insufficient for most physical modalities. Evidence is insufficient on which patients are likely to benefit from which specific therapy. Evidence on patient-important outcomes, such as disability or return to work, was largely unavailable, and available evidence showed no clear connection with improvements in pain (2*).

CONCLUSION The guidelines provide a pragmatic approach to treating LBP, stratified by symptom duration. Among the many

non-invasive treatments considered, no option shows a large benefit for pain and back-specific function. Even less can be said for other therapeutic outcomes, such as disability and quality of life. It remains the professional judgment of the therapist to tailor a treatment protocol best suited to the individual patient based on the above evidence.

Further Resources 1. Glyn Towlerton. Low back pain: the really important things to exclude. Video of presentation at Fisic 2015 conference, London, UK http://spxj.nl/2iP8pXw. 2. In the online version of this article we’ve included printable and downloadable patient information leaflets and a ready-made content marketing campaign for low back pain: n Why Posture Matters http://spxj.nl/2BjcScv n Exercises and Advice for Chronic Low Back Pain http://spxj.nl/2BfXNs1 n Exercises and Advice for Sporting Back - http://spxj.nl/2iNF2ol n Low Back Pain and Sleep: A Content Marketing Campaign for Therapists - http://spxj.nl/2ludLuL. References Owing to space limitations in the print version, the references that accompany this article are available at the following link and are also appended to the end of the article in the web and mobile versions. Click here to access the references http://spxj.nl/2jRBjGW

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.

LINKS Link 1: Triage by the first-contact health care provider (http://spxj.nl/2i1jXcK) Figure 1 from Alrwaily et al. (9) Link 2: Triage Process and Matching Criteria for the Rehabilitation Provider (http://spxj.nl/2i1jXcK) Table from Alrwaily et al. (9) Link 3: Low back pain triage process (http://spxj.nl/2i1jXcK) Figure 3 from Alrwaily et al. (9) Link 4: Example of hierarchical exercise progression for patients matched to symptom modulation approach (http://spxj.nl/2i1jXcK) Figure 4 from Alrwaily et al. (9) Link 5: Example of hierarchical exercise progression for patients matched to movement control approach (http://spxj.nl/2i1jXcK) Figure 5 from Alrwaily et al. (9) Link 6: TBC detailed tables assessment and management (http://spxj.nl/2i1jXcK) Tables 1–3 from Alrwaily et al. (9) Link 7: Cognitive behavioural therapy and mindfulness for low back pain (http://spxj.nl/2i2oJqK) Figure from Cherkin et al. (32)

Email: kittyjoythomas@gmail.com

DISCUSSIONS evise the red flag signs for LBP. There are also flags of R other colours – which would be the next most useful? Discuss what is useful about the treatment-based classification system of LBP. Are there any weaknesses of this system? Discuss the use of pharmacologic versus nonpharmacologic interventions for LBP: which drugs would you advise your patient to discuss with their doctor and when?

RELATED CONTENT L ow Back Pain: The 10 Minute Assessment [Article] - http://spxj.nl/2u6lAad L ow Back Pain During Pregnancy: Physiological versus Pathological Back Pain [Article] - http://spxj.nl/2umiDCI O ther low back pain content on Co-Kinetic - http://spxj.nl/2kYEHTw

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Tweet this: Strong clear evidence defining effective treatment protocols for LBP is lacking http://spxj.nl/2BSZKKn Tweet this: Flynn’s clinical prediction rule identifies LBP patients likely to respond to spinal manipulation http://spxj.nl/2BSZKKn Tweet this: Rehab programmes specifically tailored to the LBP patient have greater effects on pain http://spxj.nl/2BSZKKn

KEY POINTS n Low back pain (LBP) is considered as acute (lasting <4 weeks), subacute (lasting 4–12 weeks) or chronic (persisting >12 weeks). n LBP treatment matched to homogeneous patient subgroups yields improved outcomes. n Know and check for the LBP red flag signs. n The first level of treatment-based classification (TBC) of LBP groups patients according to what sort of management is needed: medical; physical therapy; or self-care. n The second level of TBC of LBP groups patients assigned to physical therapy according to the aim of the physical therapy: symptom modulation; movement control; or functional optimisation. n TBC of LBP now also addresses the importance of psychological factors in LBP. n A clinical prediction rule has been devised and validated that identifies which patients are likely to respond well to spinal manipulation. n Individually tailored exercise programmes and regimens including stretching and strength training are most effective for chronic LBP. n For chronic LBP, pharmacologic treatment should only be considered for patients with a poor response to non-pharmacologic therapy. n No single treatment option shows a large benefit for LBP pain and function: the therapist needs to use their judgment to create a treatment plan tailored to the needs of the individual.

Co-Kinetic Journal 2018;75(January):14-18

EXERCISE HANDOUT

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the exercises are performed with good technique. Poor practice may place potential strain on your back. The following leaflet includes some exercises to help in your rehabilitation.

PROGRESSION SPEED

This exercise programme has specific exercises to strengthen muscles around your lower back and core. It is important to ensure

Your therapist will advise you on the speed you should progress. Progression is not just about being able to do the exercise but to do it correctly, with appropriate control. If at any time, you feel pain or discomfort stop the exercises and consult your therapist.

PELVIC TILT LYING

FLOOR SUPERMAN OPPOSITE

YOUR REHABILITATION PROGRAMME

SETS

REPS

SETS

REPS Video: http://youtu.be/ViUO_rtbSiA

Video: http://youtu.be/44D6Xc2Fkek

SUPINE BRIDGE BASIC

LUMBAR ROTATION

Lie on a bed or a floor. Bend your knees, and keeping your feet flat on the bed or floor, rotate your hips to one side creating a rotation through your lower back. Only go as far as feels comfortable, you do not need to get your knees to the floor. Return to the opposite side. This is an excellent lower back mobility exercise, especially if you have acute lower back pain or disc problems.

SETS

REPS

SETS

Video: http://youtu.be/fK_xUE3OKIE

REPS Video: http://youtu.be/UxORTXzuU9E

HORSE-STANCE WEIGHT SHIFT

LEG SLIDE

Go on to all fours, and keep good posture. Draw your tummy inwards (towards the ceiling). Shift your weight from one side of your body to the other side. This is a great core control exercise to work the abdominal muscles.

Lie on your back, with both legs straight, activate your deep abdominal muscles by drawing your tummy towards the floor. Slide one heel towards your bottom. Maintain only the slightest contact with your heel on the ground. Keep the leg slide slow and controlled. You can progress the exercise by lifting the opposite leg just a few inches off the ground, while sliding the other heel towards your bottom. This is a great core control exercise to work the abdominal muscles.

SETS

REPS Video: http://youtu.be/p6t-t1hGtQ8

SETS

REPS Video: http://youtu.be/hi4nb-isyZ8

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EXERCISE HANDOUT

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EXERCISES FOR LOW BACK PAIN PHASE 2 Optimal strength in the core abdominal muscles is essential for a pain free back and good posture. Strength of the muscles supporting the lower back is also crucial in preventing and managing back pain. That is why so many exercises not only include the abdominals, but also the legs, glutes (buttocks) and hip muscles.

the exercises are performed with good technique. Poor practice may place potential strain on your back. The following leaflet includes some exercises to help in your rehabilitation.

PROGRESSION SPEED

This exercise programme has specific exercises to strengthen muscles around your lower back and core. It is important to ensure

BILATERAL STRAIGHT LEG RAISE

HIP ABDUCTION LYING

Lie flat on your back, and lift both straight legs as far as feels comfortable. Hold this position, and relax. This exercise will stretch the Hamstrings, although to get your legs to this position will also use the lower abdominal muscles. Do not worry if you cannot get your legs as high as Katy.

Lying on your side, flatten your lower back by gently tucking your tummy in. Lift your leg several inches in the air. You can either hold this position, or return your leg down and then repeat the exercise. Ask your therapist which they would prefer you to do. This exercise strengthens the pelvic, gluteal, and lower back areas.

YOUR REHABILITATION PROGRAMME

SETS

REPS Video: http://youtu.be/BA8-M-AHxx

Video: http://youtu.be/m48WZUmcw5Y

SUPINE BRIDGE HARD Lie flat on your back with your arms by your side, and with your knees bent. Squeeze your bottom muscles and lift your back upwards and straighten one leg. Make sure you maintain good posture (do not over-arch your lower back) and contract the deep abdominal muscles by squeezing your tummy towards your spine. This exercise helps to strengthen the abdominal, lower back, gluteal and hamstring muscles.

SETS

REPS

SETS

REPS

REPS Video: http://youtu.be/IjraQMSIGio

Video: http://youtu.be/x-b9yvFzLqk

HORSE-STANCE HORIZONTAL

CLAM ADVANCED

posture. Draw your tummy inwards (towards the ceiling). Straighten your arm in front of you, and your opposite leg behind you. Repeat each side. This is a great core stability and core control exercise to work the deep abdominal muscles. The exercise will also strengthen the lumbar erector and gluteal muscles.

SETS

REPS Video: http://youtu.be/BTaCXKy53wc

SETS

REPS Video: http://youtu.be/cQroGjei4B8

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MANUAL THERAPY

FASCIA: WHAT IT IS AND WHY IT MATTERS FASCIA | 18-01-C0KINETIC FORMATS WEB MOBILE PRINT

A NOT-SO-SIMPLE DEFINITION OF FASCIA On September 17, 2015, the Nomenclature Committee of the Fascia Research Congress came to consensus on the anatomical definition of fascia. This was at the request of the IFAA – the International Federation of Associations of Anatomists. This was a big deal. The IFAA is responsible for maintaining the Terminologia Anatomica, which sets the international standard for terminology in human anatomy. Although that might seem overly obvious, there was a time when the 5,000 structures in the body were referred to by approximately 50,000 different terms (1). In this capacity the IFAA performs a vital function. Given that the term ‘fascia’ can and has been used rather broadly, the IFAA recognised the need for a new standard definition of fascia and went to the world experts in the field. So, on September 18, 2015, at the Fourth International Fascia Research Congress, Carla Stecco MD presented the new, medical definition of fascia to the 700-plus attendees:

Fascia. The word seems to crop up all the time, but what actually is it and what does it do? If you are not sure, don’t worry – you‘re not alone. For a tissue (or is it a system?) that is so ubiquitous in the body, its structure and function has been difficult to pin down. Even the attempts at defining the term have been controversial. This article will introduce you to an understanding of the different types of fascia, its structure and what it is composed of, as well as, most importantly, what it does and why it is important to you as DAVID a clinician. ThisBCSI article hasLMT been modifed from Chapter BY LESONDAK KMI FFT 1 ‘Fascia: The Living Tissue and System’ from the author’s book Fascia: What it is and Why it Matters. Read this article online http://spxj.nl/2BSph6F. BY DAVID LESONDAK BCSI KMI FFT LMT Congress, Robert Schleip and Thomas Findley defined fascia as follows:

‘Fascia,’ she declared, ‘is a sheath, a sheet, or any number of other dissectible aggregations of connective tissue that forms beneath the skin to attach, enclose, and separate muscles and other internal organs’ (2).

‘Fascia is the soft tissue component of the connective tissue system that permeates the human body, forming a whole-body continuous threedimensional matrix of structural support. It interpenetrates and surrounds all organs, muscles, bones, and nerve fibres, creating a unique environment for body systems functioning. The scope of our definition [my emphasis] and interest in fascia extends to all fibrous connective tissues including aponeurosis, ligaments, tendons, retinacula, joint capsules, organ and vessel tunics...’ (3).

To some this was a let-down, to some it was a great moment and to others it actually felt controversial. In a world where consensus is so hard to come by, why wasn’t this breakthrough being unanimously celebrated? Perhaps it is because in 2007 at the First International Fascia Research

Now you know why some attendees were disappointed. How could such an integral tissue – some call fascia the ‘the organ of form’ (4,5) – be limited by such a narrow definition? If one’s interest in fascia is coming from a purely histological or morphological tissue-and-structure

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perspective then it makes sense to have a very narrow definition. However, if one’s interest is more functional or sensory and if one is curious about the way fascia behaves, then a much broader definition is necessary. Fascia is both a tissue and a system, and as such it has certain properties and functions that were not even hinted at in the new definition for the IFAA. It has been announced that a second definition – a definition of the fascial system – will be forthcoming (6). This definition will be distinct from the definition of ‘a fascia’ and I suspect that will be much more pleasing, and exciting, for those underwhelmed by the 2015 announcement. In the meantime, we have to start somewhere. So let us begin to comprehend fascia – the most universal, and perhaps most misunderstood, tissue in the body.

FASCIA 101: THE BASICS The most important thing to keep foremost in mind, at all times, is that the fascial net is one continuous structure throughout the body. Anatomy and rehabilitation professor 21

Figure 1: Close-up of the fascia surrounding a muscle in an unembalmed cadaver. [Photo by author. Reproduced with kind permission from Thomas Myers] Figure 2: Rendering of the full body fascial ‘catsuit’ [Illustration courtesy of fascialnet.com]

FASCIA IS BOTH A TISSUE AND A SYSTEM

Abdominal aponeurosis or rectus sheath

Figure 3: The abdominal aponeurosis – a fascial envelope for the ‘six pack’ of the rectus abdominis

Andry Vleeming once said: ‘Fascia is your soft skeleton’ (7); however, the most important thing to remember, as mentioned above, is that the fascial net is one continuous structure throughout the body. Specific terminologies for clearly identified structures (ie. the mesentery, the deltoid, etc.) are certainly needed, but it is useful if they are used topographically, so we know where we are on the map. As far as the body is concerned, the fascia is all one – one complex, holistic, self-regulating organ. It is capable of being dissected out in pieces to study, obviously, but it is no less a singular unit in nature than the organ known as the skin. How many pieces or parts does the skin have? It is the same with the fascia. The ubiquity of fascia – it is literally everywhere in the body – has made it very difficult to image in any useful way. Recent innovations in ultrasound and computer-assisted imaging, up to and including 3D printing, however, point to a moment in the not too distant future when we may have a fully realised image of the fascial net in all of its complicated splendour. The ‘everywhereness’ of fascia also implies that, indeed, it is all connected, and thus is ‘connective tissue,’ which is a term often used interchangeably with ‘fascia.’ There is also the quite evocative German word for connective tissue Bindgewebe, which makes me think of ‘binding web,’ and from this we get ‘fascial web.’ Please note that the terms ‘fascial net,’ ‘fascial web,’ and ‘fascial system’ will be used interchangeably to prevent jargon fatigue. So, imagine a silvery-white material (Fig. 1), flexible and sturdy in equal measure – a substance that surrounds and penetrates every muscle, coats every bone, covers every organ and envelops every nerve. Fascia keeps everything separate yet interconnected at the same time. It is a tissue that, up until recently, was thought to be inert and lifeless (8,9). Welcome to the fascia and the fascial web. So now that we have the unity of fascia clearly in our minds, let’s do what humans love to do: take it apart to see how it all works! Don’t worry – we will be putting it back together and

hopefully there will be no parts left over. There have been many attempts to categorise fascia in the broader sense. A common categorisation is to make the fascia of the limbs appendicular and distinct from the fascia of the back and torso. Another well-meaning attempt (10) suggested organising fascia into four functional categories: linking, fascicular, compression and separating. As interesting as that idea is, it quickly gets so complicated that you might want to turn around and head back when we have only just begun our journey. So to keep things relatable, we will make four distinctions for fascia based on location.

Superficial Fascia The superficial layer is often described as a fibrous layer of loose connective tissue. Loose because there is not a strong, regular pattern to its organisation. This layer is also often described as ‘areolar,’ which can be confusing until one realises that ‘areolar’ comes from the Latin ‘area,’ meaning ‘open place.’ Superficial fascia is also called pannicular fascia. Superficial fascia is the fascial layer directly underneath a slightly more superficial layer of adipose tissue under the skin. It is fibrous yet highly elastic with variable fat content. It separates the skin from the muscles to allow for normal sliding action on each other. The superficial fascia is involved with thermoregulation, circulation and lymphatic flow. It is also connected to the deep fascia.

Deep Fascia Deep fascia is a dense, well-organised fibrous layer that covers the muscles. This is the layer that butchers and hunters refer to as the ‘silver skin,’ and for good reason (Fig. 2). The deep fascia is the body stocking or catsuit layer, with the innermost aspect peeling away to form a discrete pocket around each muscle. This serves to keep everything separate yet interconnected and, in healthy fascia, sliding on each other. Deep fascia includes both the individual muscle pockets, or epimysium, and also the broad, flat sheaths called aponeuroses, that cover muscle groups (Fig. 3). Co-Kinetic Journal 2018;75(January):21-25

MANUAL THERAPY

Use the Force Transmission It is in this layer that myofascial force transmission takes place (11). It is well known that a muscle transmits force longitudinally across a joint, via the myotendinous junction, to create an action. So pick up your coffee or tea and have a sip. There is a whole sequence of force transmission occurring at the shoulder, elbow, wrist joints and fingers. And the fascia is right there along with it, transmitting that force via the epimysium (12,13). This fascial force transmission between muscles occurs in neighbouring muscles, even antagonistic muscles. It is estimated that about 30% of muscular tension may be transmitted in this way (14). Understanding more about how these interactions work should lead us to a better understanding of the pathology of chronic muscle problems, repetitive use syndromes, and more. It also explains the common phenomenon where muscle contracting in one area can sometimes be felt very far away. As such, it is proposed that this relationship fosters reciprocal feedback between the muscles and the fascia to better regulate tension and expansion (15).

Meningeal Fascia Meningeal fascia surrounds the nervous system and the brain.

Visceral Fascia Visceral fascia includes the fascia surrounding the lungs, heart, and abdominal organs. Visceral fascia suspends the organs within their cavities and includes visceral ligaments that serve to both affix the organs to the body wall and allow for physiological motion.

shape after an outside force is applied to them. This is similar to pulling on a rubber band and then letting go, or, as an example of a bigger elastic deformation, similar to what one would experience after finishing a melting yoga stretch. Viscosity is a measure of a liquid’s resistance to flow. Materials with high viscosity, such as honey, move very slowly compared to something with low viscosity like water. High-viscosity materials seldom return to their original shape; this is called a ‘plastic deformation.’ Ever play with a piece of wet chewing gum? That is plastic deformation. Synthetic viscoelastic materials are used in industrial applications for absorbing shock and dissipating heat. It has been shown that heating fascia decreases its viscosity, making it more fluid and moveable (16). So there is good science behind warming up before working out, or applying heat to a stiff area of the body. The ability of fascia to slowly deform under load is called ‘creep’. If the load is manageable, the fascia will gradually adapt to it in appropriate ways. Once that load is removed it will gradually return back to its original shape, or creep back. This is why, after sitting through a 2-hour movie, your buttocks do not look like the chair when you stand up. However, if the load is excessive or repeated excessively over a long period of time with no counterbalancing intervention, the fascia can become damaged. So, fascia displays the qualities of both a solid and a liquid.

Fascia

Cells

Fibroblasts Extracellular matrix (ECM)

ECM

Other cells

Mast cells

Nerves and vessels Fibers Ground substance

Mostly collagen, some elastin

Figure 4: Components of fascia. The basic constituents are cells (mostly fibroblasts) and extracellular matrix (ECM), the latter of which consists of fibres plus the watery ground substance. [Illustration courtesy of fascialnet.com]

WHAT IS FASCIA MADE OF? At a basic level, fascia consists of mostly extracellular matrix (ECM) as well as some cells. ECM is composed of watery ground substance and fibres, such as collagen and elastin. The cells are mostly fibroblasts, with mast cells, nerves and vessels as well as others also present (Fig. 4). The higher-level structure of fascia has been elucidated by Dr Jean-Claude Guimberteau, a tendon-transplant surgeon from L’Institut Aquitain de la Main (The Aquitaine Institute of the Hand), France. He has produced the first in vivo pictures of the living fascial

Viscoelasticity and the Concept of ‘Both/And’ Fascia is a colloid. Gels and emulsions are colloids. A colloid is a substance that contains particles of solid material suspended in a liquid. So, basically, a colloid is both fibre and fluid. As a colloid, fascia exhibits a quality known as viscoelasticity. Viscoelastic materials exhibit both viscous and elastic properties when under pressure. Elasticity is the quality of solid materials to return to their original Co-Kinetic.com

Figure 5: The microvacuole: the intersection of fibrils in three dimensions that form an irregular polyhedral unit of volume (x130). [Reproduced with the kind permission of Endovivo Productions and J.-C. Guimberteau MD]

FASCIA SEEMS TO BE FORMED OF A NETWORK OF MICROVACUOLES THAT ALLOW FOR THE EFFICIENT MOVING AND GLIDING OF THE ADJACENT STRUCTURES

system as part of his quest to better understand how tendons slide on each other. The fascia, which initially appears disorganised and chaotic, seems to consist of a network of microvacuoles that allow for the efficient moving and gliding of the adjacent structures. Dr Guimberteau named this sliding system the Multimicrovacular Collagen Absorbing System (17). The microvacuoles are formed by microfibrils that create polyhedral shapes, which enclose the microvacuole (Fig. 5). The microvacuole is filled with glycosaminoglycan gel. For greater detail see Chapter 1 of the author’s book, Fascia: What it is and Why it Matters.

SUMMARY As we have seen, the most important thing to keep foremost in mind, at all times, is that the fascial net is one continuous structure throughout the body. It keeps everything separate yet interconnected at the same time. With this in mind, it is perhaps possible to start reworking the way we think the human body is structured.

Acknowledgment All figures have been taken from the author’s book Fascia: What it is and Why it Matters ©Handspring Publishing 2017, and are reproduced here with permission. References 1. Adstrum S. Fascial eponyms may help elucidate terminological and nomenclatural development. Journal of Bodywork and Movement Therapies 2014;19(3):516–525 2. Stecco C. Anatomy consensus in nomenclature. Presented at the Fourth International Fascia Research Congress 2015, Washington DC, USA. Video content available online http://spxj.nl/2j5CFNZ 3. Findley TW, Schleip R. Introduction. In: Findley TW, Schleip R (eds) Fascia Research III: basic science and implications for conventional and complementary health care. 24

Elsevier Urban & Fischer 2012, p2. ASIN: B01A68TC9U (£166.58). Buy from Amazon http://amzn.to/2kca2BU. View excerpt from 2007 edn online http://spxj.nl/2AsooES 4. Varela FJ, Frenk S. The organ of form: towards a theory of biological shape. Journal of Social Biology and Structure 1987;10(1):73–83 5. Garfin SR, Tipton CM, Mubarak SJ et al. Role of fascia in maintenance of muscle tension and pressure. Journal of Applied Physiology: Respiratory, Environmental and Exercise Physiology 1981;51(2):317– 320 6. Stecco C, Schleip R. A fascia and the fascial system. Journal of Bodywork and Movement Therapies 2016;20(1):139–140 7. Vleeming A. Comment made by Vleeming at a conference panel discussion. International Myofascial Pain Conference, 2011, Manchester, UK. 8. Schleip R. Active fascial contractility: fascia may be able to contract in a smooth muscle-like manner and thereby influence musculoskeletal dynamics. Medical Hypotheses 2005;65(2):273–277 9. Schleip R, Klingler W, Lehmann-Horn F. Fascia is able to contract in a smooth muscle-like manner and thereby influence musculoskeletal mechanics. Journal of Biomechanics 2006;39(Suppl 1):S488 10. Kumka M, Bonar J. Fascia: a morphological description and classification system based on literature review. Journal of the Canadian Chiropractic Association 2012;56(3):179–191 11. Huijing PA. Epimuscular myofascial force transmission: a historical review and implications for new research. International Society of Biomechanics Muybridge Award Lecture, Taipei 2007. Journal of Biomechanics 2009;42(1):9 12. Maas H, Sandercock TG. Force transmission between synergistic skeletal muscles through connective tissue linkages. Journal of Biomedicine and Biotechnology 2010;2010:575672 13. Yucesoy CA. Epimuscular myofascial force transmission implies novel principles for muscular mechanics. Exercise and Sport Sciences Reviews 2010;38(3):128–134 14. Huijing PA, Maas H, Baan GC. Compartmental fasciotomy and isolating a muscle from neighboring muscles interfere with myofascial force transmission within the rat anterior crural compartment. Journal of Morphology 2003;256(3):306–321 15. Kwong EH, Findley TW. Fascia—current knowledge and future directions in physiatry: narrative review. Journal of Rehabilitation Research and Development 2014;51(6):875–884 16. Matteini P, Dei L, Carretti E et al. Structural behavior of highly concentrated hyaluronan. Biomacromolecules 2009;10(6):1516–1522 17. Guimberteau JC. An interview with Dr Jean-Claude Guimberteau 2016 http://spxj.nl/2jldG9b.

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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 is 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

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DISCUSSIONS iscuss the advantages and disadvantages of the D different definitions for ‘fascia’. Describe the properties of a colloid and discuss how they are related to the properties exhibited by fascia. How is deep fascia involved with myofascial force transmission and what does this mean for our understanding and treatment of chronic muscle problems?

HERE ARE SOME SUGGESTIONS Tweet this: The fascial net is one continuous structure throughout the body http://spxj.nl/2BSph6F Tweet this: Fascia keeps everything separate yet interconnected at the same time http://spxj.nl/2BSph6F Tweet this: Deep fascia covers the muscles like a catsuit layer http://spxj.nl/2BSph6F Tweet this: Fascia is viscoelastic displaying the qualities of both a solid and a liquid http://spxj.nl/2BSph6F

KEY POINTS n Fascia is both a tissue and a system. n The fascial net is one continuous structure throughout the body. n Fascia is a silvery-white material that is flexible and sturdy in equal measure. n Fascia surrounds and penetrates every muscle, coats every bone, covers every organ and envelops every nerve. n We will make four distinctions for fascia based on location: superficial, deep, meningeal and visceral. n Superficial fascia separates the skin from the muscles to allow for normal sliding action on each other. n Deep is a dense, well-organised fibrous layer that covers the muscles. n Myofascial force transmission takes place in the deep fascia. n Fascia is a colloid and so is viscoelastic: it displays the qualities of both a solid and a liquid. n Fascia seems to be a network of microvacuoles enclosed by microfibrillar polyhedral shapes.

Fascia: What it is and Why it Matters by David Lesondak Handspring Publishing 2017; ISBN: 978-1909141-55-1 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

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PAIN: THE BRAIN’S INTERPRETATION OF DANGER LOWER LIMB | HIP 18-01-COKINETIC FORMATS WEB MOBILE PRINT

This article explores the wider perspective of pain and how this can mean different things to different people, in different contexts, and based on different experiences. It gives a good clear overview of the physiology and mechanics of physical versus psychogenic pain, and discusses how every individual will experience pain differently based on a whole host of variables. Discover how you, as a therapist, can play a unique role in helping your clients to manage their pain. Read this article online http://spxj.nl/2C0oEc BY RUTH DUNCAN DIPSRMT, MFR UK

INTRODUCTION Pain is an experience we all would rather not have, yet pain prevalence is enormous. The process of pain experience has been researched for centuries, but why and how we feel pain is still challenging pain researchers. Pain is often explained as a physiological sequence of events involving the central and peripheral nervous systems. However, our perception or awareness of pain is not limited to the presence or intensity of physical injury. Instead, pain can be perceived as unpleasant feelings coinciding with physical trauma, or as psychogenic pain such as emotion or empathy. Pain also occurs when the nervous system is compromised, causing conditions such as phantom limb pain and neuropathic pain. Pain does not live or exist in the body. Manual therapists cannot release their client’s pain. In our anatomy and physiology training, we are taught about nociceptors, the nerves which transmit pain. We are taught about synapses, the ‘Pain Gate Theory’ and myelinated and unmyelinated fibres. However, recent research suggests, and actually states, that there are no such things as pain nerves. The experience of pain is not about pain to, or in, the body. Rather, the sensory input is a protective mechanism 26

notifying us of actual or potential danger (1). The role of manual therapy is to reduce the noxious sensory input or danger in the tissues by means of alleviating tissue dysfunction which, in turn, changes the perception of pain in the brain. Pain experience is constructed in the brain as a protective mechanism advising us that something is potentially harmful to, or in, the body. Pain is a response dependent on which and how many neurons in the brain are being activated. Pain also depends on actual or perceived tissue damage, life experiences, memory and the biopsychosocial model according to Professor Lorimer Moseley, Professor of Clinical Neurosciences and Chair in Physiotherapy School of Health Sciences at The University of South Australia (1). Pain, defined as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’, is experienced by everyone (2). However, how individuals perceive pain, to what intensity and their resultant behaviour, is entirely subjective. Physical injury is detected as a sensation when the body meets something potentially injurious called noxious stimuli. Noxious stimuli are processed by sensory neurons called nociceptors, which receive information Co-Kinetic Journal 2018;75(January):26-29

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from sensory nerve endings all over the body. Nociceptors detect both internal and external danger from pressure, chemical and thermal means. However, nociceptors are simply transmitting sensory information, they are not specifically transmitting pain to the brain.

PHYSICAL PAIN Physical injury or a danger sensation is communicated by the spinothalamic pathway from the sensory nerve endings and nociceptors to transmission cells via the spinal cord and finally to the thalamus and somatosensory cortex. Here, the sensation triggers what Moseley calls neuro tags and this complex neural communication in the brain will determine what type of danger, how much danger there is and what action should be taken (1). As manual therapy practitioners, we all know that people experience, describe and express pain in an individualistic manner. You will probably have treated many clients with back pain, yet their descriptions, expressions and limitations from their pain experience will be different. Our interpretation of pain, previous experience, belief and even the experience of people around us, living with or discussing their pain can influence the neuro tags in our brain, determining the intensity and frequency of the pain we experience. Communication of a danger sensation in the spinothalamic pathway is initiated by the release of an excitatory neurotransmitter, glutamate, and the movement of sodium and potassium ions across the neuron membrane. These chemicals generate an electrical charge, called an action potential. However, this pathway doesn’t provide an explanation of how individuals can modulate or ‘gate’ pain perception. Research has discovered that besides nociceptors, other neurons, called interneurons, are involved in the suppression of danger signals. It is this ability to modulate pain perception, and how this ability is conducted, that has facilitated the understanding that pain is not transmitted by the nociceptors, but is determined by the brain. Pain perception was highlighted by the work of Ronald Melzack and Patrick Wall who hypothesised that the human body had a ‘gate control’ where the interneurons in the spinal cord suppress pain or danger sensations (3). This supports previous research Co-Kinetic.com

where studies explored the correlation of thought with the extent of physical injury and the use of medication. This phenomenon of being able to control, or ‘gate’ (as according to Melzack and Wall), the intensity and even existence of perceived pain, was discovered by Dr Henry Beecher in 1956. Beecher observed that soldiers who had horrific injuries from World War II, were able to modulate their perceived pain by thought, negating the requirement for pain medication. Beecher concluded that pain perception was subjective and could be influenced by attitude regardless of the extent of the physical injury. The ability to modulate pain perception is the responsibility of an area in the brain called the periaqueductal grey. Ordinarily, the danger sensation is communicated from the nociceptor by an action potential generated by the excitatory mechanoreceptor glutamate, to the transmission cell. However, the periaqueductal grey generates the release of the neurotransmitter gammaaminobutyric acid (GABA), inhibiting action potentials at the interneuron while the natural pain killer (danger killer) encephalin, blocks the release of glutamate from the nociceptor in the spinothalamic pathway closing the ‘gate’ to pain experience. The ability of an individual to modulate pain can also explain why the reduction of pain perception is possible by religious belief (4) as well as a distraction (5). Manual therapy is an effective method of closing the ‘gate’ by stimulation of other sensory nerve endings responsive to touch. The automatic response of rubbing an injury generates an action potential where glutamate is released by the touch neurons exciting the interneurons in the spinal cord which, in turn, closes the ‘gate’. However, cognition can also work in reverse. Learned behaviours, past experiences and pain experiences adopted from others can trigger pain perception in the absence of a physical injury.

PSYCHOGENIC PAIN Psychogenic pain, also described as mental and emotional pain, can exist without any physical injury and is detected by metabolic activity in the brain by fMRI (functional magnetic resonance imaging) scans. An fMRI study carried out on individuals who had experienced grief from the loss of a close relative showed activation in the parts of the brain associated with physical pain,

yet no other pain pathway was activated (6). Moreover, psychogenic pain includes pain from social isolation, divorce and other emotional life experiences, all of which stimulate the pain mechanisms in the brain. However, sometimes the nervous system itself is injured, sending incorrect signals to the brain. This system dysfunction is called neuroplasticity. Once tissue has healed from injury, many clients still experience pain. Neuroplasticity results in central sensitisation where the nervous system has become hypersensitive triggering pain perception. Moseley highlights this with the analogy of the gear box light on the dashboard of your car coming on resulting in you taking the car to the garage to get fixed. After three attempts to repair the gear box, the light is still engaged on the dashboard. The result is that it’s not actually the gear box that’s the problem, but the electrical wiring to the light. It’s the same for the person in pain. Once the tissue has repaired, some people still experience pain because the wrong signals are being interpreted as pain in the brain when there is no actual tissue danger or damage (1). Evidence also suggests that neuroplasticity is the plausible explanation for phantom limb pain where the transmission cells and the brain become hypersensitive in the absence of correct nociceptive input from the amputation or removed tissue, continually firing pain sensations (7). Additionally, damaged nerves from an underlying pathology, such as shingles or diabetes, cause neuropathic pain stimulating the overproduction of action potentials sending ‘danger’ sensations to the brain. These are situations where the ‘gate’ is not able to close. Besides neuroplasticity, pain experience in the absence of any physical injury and how we express pain perception is highly subjective. Moseley’s research suggests many clients develop habitual belief patterns about their pain and that certain movements or activities will ‘bring on their pain’ and that they believe that they will be in pain for the rest of their lives. This belief stems in part from the biopsychosocial model, that of inherited traits, personality, attitude, behavioural, cultural and socioeconomic factors and also unfortunately, by the lack of help and understanding of traditional healthcare (1).

THE ROLE OF THE MANUAL THERAPIST Moseley promotes that all manual therapy (cont on p.29) 27

BOX 1: MYOFASCIAL RELEASE AND CROSS-HAND RELEASE TECHNIQUES FOR PAIN RELIEF Myofascial release is a hands-on manual therapy used as part of a rehabilitation programme for both acute and persistent pain. It has become a popular therapy in recent years owing to increased research and understanding of the role and function of the fascial system. Myofascial release is the governing term for the therapy which encompasses many different fascial orientated approaches and techniques. Fascial research has provided information about how the fascial system is involved in force transmission, fluid dynamics, viscoplasticity and mechanotransduction, among others. This knowledge has encouraged practitioners to refine techniques that can effectively treat fascial dysfunction. One of the most popular myofascial release techniques is the ‘cross-hand release’ technique; so-called because the practitioner crosses their hands to apply the technique. This technique is an excellent approach for both acute and chronic pain conditions and can also be used immediately after an injury, such as a hamstring tear, to regulate tissue repair (8). This technique, like most myofascial techniques, is applied without lubrication to avoid slippage in the skin. The application is gentle and sustained making it a very useful technique for the majority of pain conditions. The pressure applied by the practitioner is a light to moderate pressure leaning into the tissue without force. Fascia is highly mechanosensitive. Too much pressure will cause the fascial system to bind down to protect, making the technique ineffective. Cross-hand release techniques can be performed anywhere on the body using the whole hand or fingers for smaller areas. They can be performed over an area of dense restricted tissue or above and below surgery or injury sites and can be applied in all directions. Apply cross-hand release techniques in the following way: n With hands crossed, gently contact the tissue. n Allow your hands to sink slowly and gently down into the tissues until you meet resistance (barrier or end feel) –

Figure 1: Crosshand release of the anterior hip

this is the first dimension. nW ait at this barrier until you feel a yielding or melting sensation allowing you to lean a little more to the floor. There may be numerous sensations of tissue melting, which feel soft and somewhat bouncy. nC ontinue with your downward pressure following each tissue change until you feel that your hands have met a firmer resistance, this will be the deeper layers of fascia. nM aintaining your pressure to the floor, slowly separate your hands until you meet resistance – this is the second dimension. Wait at these two barriers for the tissue to yield under and between your hands. nA s the fascia yields to your touch, you will feel motion under your hands – this is the third dimension. nG o with the motion to the next barrier which may feel like a twist, shear or unwinding. nC ontinue to hold these three components for at least 5 minutes or longer. n Always be subtle and sensitive with your hands and never force the barrier. nA llow the tissue to reorganise without force. Disengage from the tissues by gently reducing pressure and removing your hands. Cross-hand release techniques form the main component of a myofascial release treatment session. The pressure used to apply the technique varies from person to person as everyone’s tissue tension is different. The skill of the technique is not how much pressure is used, but how much resistance is felt in the patient’s body. The practitioner applies the technique to tissue tension and waits for the myofascial tissue and ground substance (gel fascia) to reorganise, which can be felt as a yielding or ‘release’ of tissue tension under their hands. Figures 1–5 show the use of a of cross-hand release techniques for a variety of applications. This technique, along with many others, is taught by Myofascial Release UK (MFR UK) on workshops around the UK and internationally.

Figure 2: Crosshand release of the pectoral area

Figure 3: Extraoccular release

Figure 4: Sidelying cross-hand release of the lateral lumbar spine

Figure 5: Crosshand release of the anterior leg

Further information can be found at: Website: Myofascial Release UK http://www.myofascialrelease.co.uk/ Email : info@myofascialrelease.co.uk Tel : 0333 006 4555

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practitioners learn the processes of pain perception to allow them to pass that information to clients and patients. Being able to accurately describe the process of pain will help the client understand why and how they experience pain. There is a huge difference between advising a client that they have no tissue damage and that their pain is all in their head to accurately describing how pain is experienced and interpreted by the brain, and that sometimes it’s the nerves and brain that have faulty wiring opposed to having actual tissue damage. The role of the manual therapist is more than just treating the tissue. We can help to re-educate clients about what pain is and that pain perception is a signal for danger opposed to damage. Moseley promotes that

reframing negative beliefs about pain is essential for correct communication and comprehension and pain experience. Many clients feel controlled by their pain. If we can educate them about what pain really is, it can only help them to learn how to deal with and resolve pain perception leading to an enhanced quality of life. Box 1 describes the cross-hand release technique used in myofascial release for pain relief by manual therapists.

Further Resources 1. R. Duncan. Myofascial Release (Hands-on Guides for Therapists). Human Kinetics 2014. ISBN 978-1450444576 (Print £21.99 Kindle £15..07). Buy from Amazon http://amzn.to/2hVbDLB

References 1. Moseley L, Butler D. Explain pain supercharged. The clinician’s handbook. NOI 2017. ISBN 978-0648022701 (£89). Buy from Amazon http://amzn.to/2hUO1Xo 2. International Association for the Study of Pain (IASP) https://www.iasp-pain.org 3. Melzack R, Wall PD. The challenge of pain, revised edn. Penguin 1996. ISBN 978-0140256703 (£20.99). Buy from Amazon http://amzn.to/2hUPsVM 4. Wiecha K, Fariasc M, Kahane G, et al. An fMRI study measuring analgesia enhanced by religion as a belief system. Pain 2008;139(2):467–476 5. Bantick SJ, Wise RG, Ploghaus A et aI. Imaging how attention modulates pain in humans using functional MRI. Brain 2002;125(2):310–319 6. Eisenberger NI. The neural bases of social pain: evidence for shared representations with physical pain. Psychosomatic Medicine 2012;74(2):126–135 7. Keefe FJ, Abernathy AP, Campbell LC. Psychological approaches to understanding and treating disease-related pain. Annual Review of Psychology 2005;9:389–393 8. Meltzer KR, Standley PR. Modeled repetitive motion strain and indirect osteopathic manipulation techniques in regulation of human fibroblast proliferation and interleukin secretion. Journal of the American Osteopathic Association 2007;107:527–536.

KEY POINTS nP ain is a perception in the brain, there are no ‘pain nerves’. n The pain response depends on which and how many neurons in the brain are activated. n The pain experience is constructed in the brain as a protective mechanism. n How individuals perceive pain is entirely subjective. n Physical injury or danger is communicated by the spinothalamic pathway. n Melzack and Wall formed the ‘gate control’ hypothesis, where interneurons in the spinal cord suppress pain. n It is possible to modulate perceived pain by thought. n Psychogenic pain can exist without any physical injury. n Changes in the function of the nervous system itself, neuroplasticity, can result in the sensation of pain after the original injury has healed. n Myofascial release is a valuable therapy for the treatment of pain and dysfunction.

DISCUSSIONS hy do we all respond to pain in different ways? W How do we experience pain from an emotion? Can a belief such as religion help us moderate our pain experience? Is fascia more than just the myofascia?

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Research states that there are no such things as pain nerves http://spxj.nl/2C0oEc7 Tweet this: Manual therapy is an effective method of closing the ‘pain gate’ by stimulating other nerve endings http://spxj.nl/2C0oEc7 Tweet this: Psychogenic pain, also described as mental and emotional pain, can exist without physical injury http://spxj.nl/2C0oEc7

THE AUTHOR Ruth Duncan, DipSRMT, is an advanced myofascial release therapist, proprietor, instructor, guest lecturer, speaker, national committee member and writer with extensive training in a variety of approaches. She completed her advanced postgraduate training in 2004 with John F. Barnes, the world’s leading authority on myofascial release, and has assisted with his seminars in the United States. Ruth also has explored other direct and non-direct fascial approaches, including Thomas Myers anatomy trains and myofascial meridians, Erik Dalton’s myoskeletal alignment techniques and Jean Pierre Barral’s visceral manipulation. She has studied with experts on a myriad of topics to learn more about human anatomy, function and dysfunction and the emotional aspects of chronic pain and healing. Ruth is director of Myofascial Release UK, and author of Myofascial Release (Hands-on Guides for Therapists). Email: Ruth@myofascialrelease.co.uk Twitter: https://twitter.com/MyofascialUK Website: https://myofascialrelease.wordpress.com Facebook: https://www.facebook.com/MyofascialReleaseUK

RELATED CONTENT ideo - Breaking the Pain Cycle: How Brain and Body V Communication Changes when Pain Persists http://spxj.nl/2wjr2dT Novel bedside tests to explore bodily perception in pain and rehabilitation - http://spxj.nl/2Aaf7Oe The Brain, Movement and Pain: Parts 1 + 2 - http://spxj.nl/2julmtj More pain-related content - http://spxj.nl/2BC5E6P

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MANUAL THERAPY STUDENT HANDBOOK Assessment and treatment of the cervical spine BY JULIAN HATCHER GRAD DIP PHYS MPHIL, MCSP FOM SPINE | 18-01-COKINETIC FORMATS WEB MOBILE

MEDIA CONTENTS Videos 1-7: Techniques for cervical spine assessment. J. Hatcher, 2013

This article is the eleventh from our Manual Therapy Student Handbook (see the ‘Contents panel’ for further details) and it describes how to assess and treat common complaints involving the cervical spine. 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/1PXHLSr FUNCTIONAL ANATOMY A sound knowledge of anatomy is a necessary skill for the competent manual therapist. As a result, the functional anatomy of the region should be revised before continuing with assessment and treatment techniques. Video 1 shows surface marking of the anatomical area and will help you with the key structures encountered in this article.

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

Treatment of the cervical spine CAPSULAR PATTERN The capsular pattern of movement limitation of the cervical spine is defined by: n Greatest loss of extension n E qual loss of both side flexions and rotations n Least loss of flexion.

CAUSES OF CAPSULAR PATTERN Osteoarthrosis (OA) Typically: n Elderly people (50+) n Wear and tear to the joint; may be primary, or possibly secondary to a previous lesion, such as whiplash. The key clinical features are: n Displays capsular pattern

Video 1: Surface marking of the spine region (Video with captions but no sound)

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

Co-Kinetic Journal 2018;75(January):30-35

MANUAL THERAPY STUDENT HANDBOOK

TABLE 1: ASSESSMENT OF THE CERVICAL SPINE OBSERVATION/ EXAMINATION DETAILS

Figure 1: Vertebral artery testing in lying position

Figure 2: Vertebral artery testing in sitting position

n Affects the bilateral zygoapophyseal joints n Pain is movement and posture dependent n May be central pain, unilateral or bilateral pain n Occasional inclusion of paraesthesia if severe. 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.

OA-related disorders 1. Cervical spondylosis - Degenerative disease of intervertebral joints. - Osteophytosis, often painless, may require surgery to remove. - When advanced, can cause palsy. 2. Spinal stenosis - Paraesthesia in hands/feet particularly on exertion. - Due to a narrowing of spinal canal. - Requires surgery. 3. Matutinal headache - Often elderly men with morning headache, often referred from C1 and C2. - Manual/mechanical traction, DTF to capsule. 4. Drop attack/sudden onset dizziness

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1. Anatomy n Dermatomes C1: superior head (cap area) C2: face, lateral and posterior head C3: posterior and side neck, lower jaw C4: lateral neck, superior shoulders C5: lateral arm to wrist C6: lateral forearm to thumb and index finger C7: posterior forearm to middle 3 fingers C8: medial forearm to medial 3 fingers T1: medial arm to wrist T2: sternum, axilla and medial upper arm n Myotomes C1: rotators of neck C2: extensors of neck C3,4: trapezius C5: shoulder abductors, lateral rotators C6 Medial rotators of shoulder, elbow flexors, wrist extensors C7: shoulder adductors, elbow extensors, wrist flexors C8: thumb adductors and extensors T1: finger adductors and abductors 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 Bony deformity n Wasting

n Colour changes n Swelling

5. Objective n Observe/examine state at rest examination 6. Active tests (for willingness, pain and range)

n E xtension nR ight rotation n Right side flexion

n Left rotation n Left side flexion n Flexion

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

As ‘Active tests’ but performed as overpressure at end of active ranges.

8. Neurological n Root signs (myotomes – resisted tests for strength) examination C2,3,4 C5 C6 C7 C8 T1 n Sensation C5, C6, C7, C8, T1 n Reflexes C5, C6, C7, Babinski? 9. Additional specific tests

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

10. Vertebral Directions: artery testing 1. Have patient supine lying with knees resting over pillow, head supported (Figs 1,2) by your hand but resting over top edge of plinth. 2. Crouch at head of patient and take weight of patient’s head. 3. Hold patient’s head in extension first. 4. After approximately 10 seconds, add in some side flexion. 5. After another 10 seconds, add in some rotation to the same side (could rotate away instead). 6. At each stage, ask patient to keep eyes open, and observe them looking for signs of dizziness or fainting (pupils dilating) 7. If at any stage patient feels affected by this (not pain though!), this may indicate some insufficiency, and manipulations should not be considered.

- L ax ligaments/odontoid fracture/ RA/osteophytosis - Never manipulate.

Rheumatoid arthritis (RA) and other systemic arthropathies Typically: n Systemic autoimmune disease, causing degeneration and possible joint disruption n Often severe capsulitis, may lead to joint laxity and deformity. The key clinical features are: n Displays capsular pattern n Often affects people aged between 30 and 70 n Complains mainly of pain, often intermittent n Often other joints are also affected n Often have large amount of joint degeneration, and may have loose ligaments n Never manipulate. Treatment: n Refer to GP for Rheumatology opinion. n If not in acute flare-up, may use Grade A (Maitland Grade I and II) mobilisations and progress to Grade B (III and IV).

Traumatic arthritis Typically: n Trauma from whiplash injury. The key clinical features are: n Displays capsular pattern n Affects the bilateral zygoapophyseal joints n Pain is movement and posture dependant n Pain may be severe enough to radiate n May be central pain, unilateral or bilateral pain n Occasional inclusion of paraesthesia if severe n Be aware to look out for laxity/drop attacks, etc. n Consider legalities.

Grade A and B mobilisations nM ay require manipulation at later stage if has underlying non-capsular pattern.

Ankylosing spondylitis (AS) nG radual fusing of intervertebral joints. The key clinical features are: nO ften young men in 20s/30s nA lways insidious onset nC omplain of severe morning stiffness n May have had previous thoracic or lumbar back pain n May also have had hip/shoulder stiffness first nO ccasionally may have problem with eyes – iritis nA ssociated with predisposing factor in blood – HBLA27, although this is sometimes absent. Treatment: n Relieved by regular exercise and Grade B mobilisations – often needing to be self-performed nH ydrotherapy is also good option. Treatment choice for the cervical spine – non-manipulative: nM obilisations of the cervical spine. Cervical posterior–anterior (PA) mobilisation (Video 3) Directions: 1. Have patient prone lying with feet resting over pillow. 2. Have hands overlapped and forehead resting on hands. 3. Have the bed level with your superior aspect of patella; palpate using thumbs placed back-to-back over spinous ideo 3: Cervical posterior– V anterior (PA) mobilisations (Video with captions but no sound)

processes, fingers spread and resting gently on patient’s back. 4. Locate either C2 or C7 spinous process, and count up or down accordingly. 5. Apply posterior/anterior movement using bodyweight over vertical arms and grade accordingly. Cervical rotation mobilisation (Video 4) Directions: 1. Have patient supine lying with knees resting over pillow. 2. Have one hand around chin, with forearm of same arm supporting underneath patient’s head (need to have small amount of rotation at head to do this – occurs at atlanto-axial joint). 3. Have bed level with your top of thigh, so that you can slightly flex your knees to get underneath patient. 4. Locate either C2 or C7 spinous process, and count up or down accordingly until you reach desired level. 5. Slide finger underneath back of neck until the spinous process is situated in your 1st web-space. 6. Push anteriorly into neck and gently pull back the slack in the skin so that the spinous process is now situated just proximal to the metacarpophalangeal joint of your index finger. 7. Firmly (but gently) grip the head between both hands and your body and allow yourself to side flex. This causes rotation at the cervical spine. Effort should be made to focus the movement at the level by the underneath hand. 8. The direction of rotation is opposite Video 4: Cervical Grade III rotation mobilisation (Video with captions but no sound)

Treatment: n May require mobilisation as pain allows, Grade A–B (I–IV) n May require electrotherapy and

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to the hand placed under the neck – ie. right neck rotation is produced by the left hand of the manual therapist (see Video 4). 9. Grade the movement as appropriate to the patient’s signs and symptoms. (NB always perform a vertebro-basilar artery insufficiency test before using Grade V techniques). Cervical oblique glide mobilisation (Video 5) Directions: 1. Have patient supine lying with knees resting over pillow. 2. Have one hand around chin, with forearm of same arm supporting underneath patient’s head (need to have small amount of rotation at head to do this - occurs at Atlanto-axial Joint). 3. Have bed level with your top of thigh, so that you can slightly flex your knees to get underneath patient. 4. Locate either C2 or C7 spinous process, and count up or down accordingly until you reach desired level. 5. Slide finger underneath back of neck until the spinous process is situated in Video 5: Cervical Grade III oblique mobilisations (Video with captions but no sound)

Video 6: Cervical manual traction (Video with captions but no sound)

Co-Kinetic.com

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

CAUSES OF NON-CAPSULAR PATTERN Figure 3: Cervical posterior mobilisation

your 1st web-space. 6. Push anteriorly into neck and gently pull back the slack in the skin so that the spinous process is now situated just distal to the metacarpo-phalangeal joint of your index finger. 7. Firmly (but gently) grip the head between both hands and your body and translate the neck into oblique glide (following the line of the patient’s nose). Effort should be made to focus the movement at the level by the underneath hand almost acting as a fulcrum. 8. The direction of movement is opposite to the hand placed under the neck – ie. oblique gliding to the right is produced by the left hand of the manual therapist (see Video 5). 9. Grade the movement as appropriate to the patient’s signs and symptoms. (NB always perform a vertebro-basilar artery insufficiency test prior to using Grade V techniques). Cervical posterior mobilisation (Fig. 3) Directions: 1. Have patient supine lying with knees resting over pillow. 2. Stand side on to patient and have cephalad hand underneath occiput, and caudad hand placed directly over lower mandible keeping 3rd, 4th and 5th fingers flexed under chin. 3. Have bed level with your top of thigh, so that you can slightly flex your knees. 4. Keep elbow directly above chin and move patient’s head and your body simultaneously, by flexing and extending your knees. This causes the head to move in an AP direction. Again, you can focus the movement to a specific level by using the underneath hand (cephalad) as a fulcrum. 5. Grade the movement as appropriate to the patient’s signs and symptoms.

Common causes of non-capsular patterns of movement limitation in the cervical spine include: disc lesions, facet joint lesions, and thoracic outlet syndrome.

Disc Lesions The key clinical features are: n May have referred pain n Referred pain is usually unilateral nM ainly articular signs, ie. pain on movements nM ay have root signs, ie. myotomes/ dermatomes/reflexes affected n May have central pressure on spine n needs referral! Treatment: nR elieved by manipulation if articular signs, pain relief and advice if root signs nC areful manipulation in over 50s and/or cervical traction (mechanical) nM ay even try electrotherapy or sustained natural apophyseal glides (SNAGS)/natural apopyseal glides (NAGS).

Facet joint lesions The key clinical features are: nO ften traumatic onset – although sometimes insidious but sudden nU nilateral irritation with little or scapular reference of pain nA rticular signs only – no root signs nA symmetrical pattern of restricted neck movements. Treatment: nR elieved by mobilisation or manipulation as appropriate nC areful manipulation in over 50s and/or cervical traction (mechanical) nM ay even try electrotherapy or SNAGS/ NAGS.

Thoracic outlet syndrome The key clinical features are: nO ften affects middle-aged females nP ain or pins and needles often at night nP ain usually unilateral nC heck for cervical rib.

Treatment: n Usually requires posture correction and shoulder elevation before going to bed or in bed n May need mobilisation of 1st rib.

CONTRACTILE LESIONS A common contractile lesion of the cervical spine is muscle strain.

Muscle strain The key clinical features are: n Rare, but often traumatic onset n Difficult to distinguish from muscle spasm which is far more common n Pain on specific resisted movements. Treatment: n Treat with deep transverse frictions, electrotherapy and stretching/end of range exercises. Treatment choice for the cervical spine – manipulative: n Manipulations of the cervical spine. Cervical manual traction manipulation (Video 6) Directions: 1. Have patient supine lying with knees resting over pillow. 2. Stand at end of bed with feet together placed directly underneath patient’s head. Place one hand underneath occiput, the other hand under chin, being careful not to place fingers too near the trachea. 3. Have bed level with your top of thigh; so that you can lean you weight back to apply traction. 4. Keep knees extended, and slowly pay your arms out so that they are straight, hold for very small amount of time (<1s) and return to original position. 5. Grade the movement as appropriate to the patient’s signs and symptoms. (NB always perform a vertebro-basilar artery insufficiency test before using Grade C techniques). Longitudinal manipulation to atlantooccipital joint (C0–C1) (Fig. 4) Directions: 1. Have patient supine lying with knees resting over pillow. 2. Stand at side of patient with slightly flexed knees.

3. Hold patient’s head using cephalad arm by holding under chin and supporting using forearm and body. 4. Extend head slightly at C0/C1 and rotate chin away at C1/C2 by 30°, and side flex slightly towards. This produces a small ‘ledge’ of occiput around the atlanto-occipital joint. 5. Place caudad hand underneath occiput, using metacarpo-phalangeal joint to apply traction to occiput. 6. Movement is to apply full traction first, followed by small high velocity thrust, of short amplitude, in cephalad direction. 7. NB always perform a vertebro-basilar artery insufficiency test before using Grade V techniques. Longitudinal manipulation to the first rib (Video 7) Directions: 1. Have patient prone lying with feet resting over pillow, head rotated to affected side. 2. Stand at head of patient in walk standing. 3. Hold patient’s upper fibres of trapezius in ‘outer’ hand, gently pulling slack tissue up. This allows the flat palmar surface of the thumb to lie against the 1st rib. 4. Reinforce thumb with heel of ‘inner’ hand and apply pressure in caudad direction. 5. Technique is usually applied as Grade V manipulation (small high velocity thrust, of short amplitude, in caudad direction), but can be applied as a graded movement (I–IV). Contra-indications to manipulation 1. Neurological - drop attacks, UMN signs: increased reflexes/positive Babinski reflex 2. Osseous - traumatic or pathological fracture suspected, disease of spine (osteomyelitis/osteoporosis/TB, etc) 3. Vascular - basilar insufficiency, anticoagulant or long-term steroid usage, spinal claudication 4. Suspicious history or unusual unexplainable objective findings (not likely to be from musculoskeletal origin).

Figure 4: Longitudinal manipulation to atlanto-occipital joint (C0–C1)

Video 7: Manipulation to the first rib (Video with captions but no sound)

FURTHER RESOURCES 1. Spine-health. Whiplash video http://spxj.nl/2BgIqPZ. 2. Symons BP, Leonard T, Herzog W. Internal forces sustained by the vertebral artery during spinal manipulative therapy. Journal of Manipulative and Physiological Therapeutics 2002;25(8):504–510.

RECOMMENDED READING 1. Anderson MK, Parr GP. Fundamentals of Sports Injury Management. Lippincott, Williams & Wilkins 2011 (Print £64.80, Kindle £61.56). ISBN 978-1451109764. Buy from on Amazon http://amzn.to/1QbemUV 2. Cyriax J. Textbook of orthopaedic medicine, vol. 1: diagnosis of soft tissue lesions, 8th ed. Balliere Tindall 1982 (£33.72). ISBN 978-0702009358. 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 (£80.43). ISBN 978-0443071553. Buy from Amazon http://amzn.to/1mwohwt 4. Higgs J, Jones A, et al. Clinical

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reasoning in the health professions, 3rd ed. Butterworth-Heinemann 2008 (Print £49.49 Kindle £52.99). ISBN 978-0750688857. Buy from Amazon http://amzn.to/1mwokZb 5. Abrahams PH, McMinn RMH. McMinn and Abrahams’ Clinical atlas of human anatomy, 7th ed. Mosby 2013 (Print £52.99 Kindle £50.34). ISBN 9780723436973. Buy from Amazon http://amzn.to/1mwomR2 6. Magee DJ. Orthopaedic physical assessment, 6th ed. Saunders 2014 (Print £74.99 Kindle £51.35). ISBN 9781455709779. 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 (£61.19). ISBN 9780702040665. 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 (Print £67.99 Kindle £46.55). ISBN 978-0702040672. 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 (£402.54). ISBN 978-0702029592. Buy from Amazon http://amzn.to/1KfpnbK.

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

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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 cervical spine is defined by: greatest loss of extension; equal loss of both side flexions and rotations; and least loss of flexion. n Causes of capsular pattern at the cervical spine include osteoarthrosis and related disorders such as spondylosis and stenosis, traumatic arthrosis such as whiplash injury and ankylosing spondylitis. n The treatment for capsular pattern is mobilisations and, in some cases, hydrotherapy and/or electrotherapy. n Common causes of non-capsular pattern of movement limitation in the cervical spine include disc lesions, facet joint lesions and thoracic outlet syndrome. n There are several contra-indications for mobilisation of the cervical spine.

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DISCUSSIONS hy are the myotomes of C6 and C7 tested W multiple times? At which joint does the vast majority of rotation of the neck occur? Why is it important to consider doing a test for vertebral artery insufficiency before doing cervical manipulations? Whiplash in most cases is just DOMS (delayed onset muscle soreness). Is this statement true?

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

18-01-COKINETIC FORMATS WEB MOBILE

INTRODUCTION Some of the biggest problems we face as therapists, is that we often work in isolation, we have to build our businesses from scratch, we get little or no training in business or marketing and we only earn money when we treat clients. But there’s so much to do to run the business, and find a regular supply of clients, that more often than not, we end up spending much more time than we want to on the “business of business”, instead of on our passion for helping people. Often we have an idea that we think will work, so we spend time (and sometimes also money) trying to implement that idea, only to find that it doesn’t give us the results we wanted. We have all the day-to-day worries about taking payments, keeping our accounts up to date, ordering equipment and supplies, paying rent and bills, getting our branding designed, and website built, not to mention marketing and promoting ourselves, locally and on social media. Oh yes, and then we need to treat our clients and actually earn some money! By the time you’ve done all these tasks, and paid all your bills, it frequently seems like there’s very little left in the bank account for us, in return for all those efforts. So what’s the solution? Well, one very simple one is mentoring.

THE BENEFITS OF MENTORING Here’s a list of just some of the benefits of mentoring: n It saves you money n It saves you time n It brings focus to what’s truly important – and even more importantly stops you getting distracted with (or spending money on) things that are not important n You learn from other people’s mistakes n You learn from other people’s successes n You have improved confidence in what you’re doing n It helps you solve problems 36

ARGUABLY THE BEST SHORTCUT TO BUSINESS SUCCESS BY TOR DAVIES, CO-KINETIC FOUNDER

One of the biggest problems we face as therapists, is that we often work in isolation, we get little or no training in business or marketing and we only earn money when we treat clients. But running a business, as you’ve probably discovered by now, is not for the faint-hearted. This article explores how you can use mentoring to help you avoid costly mistakes, save you time, save you money, ensure you’re focusing on what’s important and outsourcing the things you don’t enjoy or don’t do well. Equally importantly it can significantly reduce your sense of professional isolation and offer a supportive and nurturing network that will help you to thrive and dramatically increase your chance of achieving your professional (and possibly also personal) goals. Read this article online http://spxj.nl/2BTXGBV supported to stay on track n I t offers you new ideas and ways of n You can share what you learn with thinking other people who work for you. n I t expands your network of contacts n I t provides encouragement and support, and helps you feel less isolated nY ou get immediate access to business processes and marketing strategies that actually work in practice n I t usually qualifies for continuing professional development credit or time nY ou are held accountable and Jim Rohn

MY MENTOR SAID, ‘LET’S GO DO IT,’ NOT ‘YOU GO DO IT.’ HOW POWERFUL WHEN SOMEONE SAYS, ‘LET’S!’ Co-Kinetic Journal 2018;75(January):36-38

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KEY OBJECTIONS TO MENTORING Despite the overwhelming list of benefits, sadly most people often don’t consider mentoring because they think it’s too expensive, or that they don’t have enough time. Some are even nervous about being held accountable and kept on track and if that’s how you feel, read no further because the chances are you have too many mental barriers in the way to benefit from mentoring, or to justify the effort or time commitment a mentor would need to invest, to see a result. It requires energy and passion to mentor. A good and effective mentor, in addition to having the appropriate business skills and experience, also needs to understand you, your business, and in the case of healthcare, also your industry. Healthcare professionals have a bias towards certain drivers and motivations, and to further complicate the situation, usually a new client or patient needs to reach a ‘clinical tipping point’, before they are willing to take action and book an appointment, and this is different to many other sectors of business. It’s important for the mentor to understand this, and ensure that their advice is congruent with these motivations and industry ‘quirks’. Without it, the mentor, and mentee (individual being mentored) may find it hard to gel and progress won’t be as effective as it could be. Regarding the argument about mentoring costing too much money, or taking up too much time, well consider the following: n Mentors save you time AND money because they’ve been there before and know the shortcuts. They know the answers to questions that you will have to learn through trial and error. n Mentors will give you focus on the things that work, and stop you going down blind alleys that often take up both time and money. n Mentors will hold you accountable. n Mentors have tested out strategies, and know which ones are the most profitable and most effective. n They can help you work out which jobs you should outsource, and how to do it. Co-Kinetic.com

n They can save you from spending money on the wrong things and make sure you only spend it on the things that work.

SO WHAT IS MENTORING AND WHAT DOES IT USUALLY COST? “Mentoring is most often defined as a professional relationship in which an experienced person (the mentor) supports and encourages people to develop specific skills and knowledge that will maximise their business potential and improve their performance. In short, it is the transfer of knowledge, skills and experience.” Mentoring can sometimes be pricey. The Rockstar Group, which is a well-known UK mentoring organisation, charges £95 an hour for 1-to-1 mentoring and this is good value. But, I have teamed up with Clare Carrick who established the Back in Motion franchise model, to make a unique offer to just 12 people. Clare has supported therapists since 2009, in building businesses that are scalable, replicable and sustainable in an ever-changing healthcare marketplace. She currently runs 4 of her own clinics and supports another 4 under her franchise model. She brings both her clinical experience as a physiotherapist, as well as her business experience in running clinics and establishing market-leading business processes to ensure the clinics run both efficiently and profitably. I bring marketing experience from helping more than 100 clinics and individual physical and manual therapists in marketing their own businesses both utilising the Co-Kinetic marketing platform, as well as the more hands-on approach I take through my marketing company, Done For You Marketing Ltd. As many of you know, I also frequently give presentations and seminars, and write articles, on a range of digital marketing topics from setting up websites, ensuring all the right marketing foundations for growth are in place, how to get a return on investment from your social media activities, and on specific marketing strategies that are working most effectively for therapists in the current digital environment.

MENTORING IS A BRAIN TO PICK, AN EAR TO LISTEN, AND A PUSH IN THE RIGHT DIRECTION. John Crosby

THE CO-KINETIC/BACK IN MOTION MENTORING PROGRAMME What does the programme involve? We’re offering this first programme on a cost-covering basis only, and we have just 12 spots available. The programme is a year-long programme, and costs just £85 a month (£1020 over the year) with a £170 deposit required at the time of booking (followed by a further 10 monthly payments of £85 starting on the day of the first mastermind event). What does this price include: n 4 Mastermind one-day events per year on set dates n Each day will include marketing and operational strategies for securing your business growth n A mastermind group session aimed at providing solutions to 2-3 of your most-pressing issues or concerns n A plan for your own 90 day goals to implement and walk away with new knowledge you can use practically to change your business n A follow up call with either Clare or Tor, after each Mastermind event to assist you with implementation of the plan

Who are we looking for? Each applicant will need to complete an application survey and those shortlisted to join the programme will be asked for a telephone interview by either myself or Clare. It is important for this group to be the most effective it can be, for everyone involved. So we are looking for applicants who are motivated, open-minded, and have a strong desire to learn and to become a better person, both professionally and personally. Common to all candidates must be the desire to grow your business and take on other staff to support your work and build a professional 37

commercial outfit to provide therapy services from. We want you to build a business and not just a job. If you have a more established business, under 250K turnover and want help to continue to grow but iron out existing glitches or stresses and strains you experience on daily basis, this course is for you.

How do you apply? The first step is to fill out the Survey at this link https://cokinetic1.typeform. com/to/MNS8Hi. Applications for this programme end on the 30th January 2018. We’re unable to accept applications completed after this date. We will then review the applications and contact you to either to offer you a place, or give feedback on other options if your application is not accepted on this occasion.

Frequently Asked Questions

locations, we will try and find a good central point that’s as convenient as possible to everyone. If there is no obvious central point, we are most likely to opt for London as our main Mastermind destination.

How does payment work? We will take an initial upfront deposit of £170, if you decide you would like to accept your invitation to join the programme. This will be deducted from the annual payment of £1020. The remaining 10 payments of £85 will start the week the first mastermind event takes place. If you are unable to complete the 12 month programme, the £170 will not be refundable, as you will have taken a space that could have been given to someone else. However, you won’t be charged for any of the additional monthly fees once you’ve cancelled.

THE LAST WORD

Where will the Mastermind days take place? At this point we’re open to being flexible about this until we have confirmed the 12 successful applicants. Then based on your combined

We look forward to working with you to grow your business in 2018 and if you have any other questions please don’t hesitate to contact us at mentoring@co-kinetic.com or start a chat using the chat icon on the Co-Kinetic website.

On what dates will the Mastermind days take place? Once we have confirmed our 12 successful applicants we will offer you a selection of 2-3 dates for each Mastermind event and we will select the one that most people can attend.

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.

CLARE CARRICK 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-in-motion.co.uk/about/the-team.html LinkedIn: http://linkedin.com/in/clare-carrick-79aa0036 Facebook: https://www.facebook.com/clare.carrick.3 Co-Kinetic Journal 2018;75(January):36-38

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18-01-COKINETIC FORMATS WEB MOBILE

BY CLARE CARRICK BSC, MCSP

OVERVIEW There is no point spending time and money on the ‘external’ marketing of establishing your brand, building your authority and bringing new clients through the door, if you just haemorrhage patients and underservice them once they’re in your care. A successful business is ultimately built by raving fans. As the customer service platform Zendesk quotes: ‘The goal is to create raving fans that can’t stop talking to their friends, family, peers, and co-workers about the amazing customer service and overall experience they had with your business’. If the internal systems and processes in your business aren’t primed to deliver this experience, it doesn’t matter how many new clients you bring in, you’ll under-deliver to all of them, and you certainly won’t be generating raving fans (you’re also unlikely to be getting the best clinical outcomes you could achieve). These internal systems and processes are often referred to as ‘internal’ marketing which is a relatively new concept to most practitioners. Interestingly, in my experience, the level of client satisfaction is not proportional to the number of years in practice, or the clinical skills of the practitioner themselves. In fact, many patients receive exceptional service from less experienced practitioners and admin staff, because it comes down to the ability to communicate. If you have an admin team, the patient experience starts and finishes there. Otherwise it starts with and ends with you. Communication processes will dictate the ‘feel’ the client gets about your service, even before their first session and establishes that allimportant first impression. So how do you get your ‘internal’ marketing right? Understanding and planning the ideal scenario of how your client will transition from being a prospective client, converting them into a booking Co-Kinetic.com

CUSTOMER EXPERIENCE IS ALL ABOUT ‘INTERNAL’ MARKETING Spending money on marketing is great for generating new customers. But what if there were a few simple and perfectly ethical things you could do right now, to make more out of your existing clients, while at the same time providing a better service? In this article, we outline 5 key performance indicators you should be tracking to ensure you’re getting the most out of your business, as well as 5 simple but surprisingly effective ways you can plug unnecessarily lost revenue, and add more profit to the bottom line. Read this article online http://spxj.nl/2C20XQq and then ensuring they have a great clinical experience, is a skilled process that needs to be firstly defined and then managed and replicated well. Think about what would make an outstanding customer experience for you, and then think about how you can offer that, in a cost-effective and time-effective way. What are the small, thoughtful touches, that can make an experience? This customer-journey process is greatly aided by establishing a simple set of key performance indicators (KPIs), particularly if you have team members. As a business owner working alongside other staff, can you be sure they are attending to the client in the same way as you would? How are you going to monitor and measure this to achieve a consistent experience for the client time after time and ensure repeat custom. As your business grows this is a challenging concept and fundamental to why some practices grow and others remain the same size. If you work for yourself this

process is just as relevant. You need to establish a simple workflow of what needs to happen, step-by-step, to give that patient an outstanding experience. As you become more successful, it is much easier to hire someone to help with administration if you have these processes established right from the word go.

TOP 5 INTERNAL MARKETING KPIS These KPIs are important regardless of whether you are a sole practitioner, or whether you work as part of a team. A good business will know their numbers for every therapist in their team, including themselves.

Number of new client assessments (per practitioner) and referral source

Some practitioners are always busy, but busy is not always good. If you (or other therapists) are churning through patient assessments, you could be missing out on potential revenue. Therapists with high retention rates of their clients

and fewer new client assessments per month are likely to be significantly more profitable. Understanding these trends in your business, applied both to yourself, as other therapists who work with you, will help you identify missed earning potential. Knowing the source of the referral means you can thank an individual or company for making the referral to you. A thank you could be a simple telephone call, email, thank you card or even better some sort of small gift, such as an offer of a free massage, a bottle of wine, or a small bunch of flowers. The beauty of this sort of gesture is that it costs very little, but is likely to have a huge impact. It also helps you understand rises or falls in referral levels so you can adapt your external marketing efforts, or even recruitment strategies.

Know the average number of sessions each client will attend, after the initial consultation, for every therapist you work with (including yourself)

This gives you a treatment series value and helps you to understand the bigger picture value of a client, particularly for your external marketing budget. It also helps you build a picture of your ‘average lifetime customer value’. Some clients will end up coming back regularly which means the average lifetime value of your customers as a whole, will be higher than just the treatment series value. A therapist may be under-servicing a client by only seeing them once. A minimum of two appointments should be necessary to check that the advice and exercises you may have given at the first treatment have worked (or not). Depending on the

clinical indications, you want to aim for a higher number. Regardless of the number of appointments, you need to know the outcome of every person that either you, or any other practitioners in your team, have assessed and treated.

Identify which patients received no follow-up after the initial consultation

Asking your client to fix a date for a new appointment immediately after, or as soon as you can following a treatment, is crucial. If it’s left to the client to re-book, there’s a good chance the opportunity will be lost in the busyness of life. Every therapist in your team should do the same thing and there should be a process in place to insure this happens. Occasionally there is a genuine reason why a client may only attend once but spotting this and taking action can make you hundreds of pounds or more each year.

Utilisation rate of a therapist’s time

This is the time spent face-to-face with a client, making money, as opposed to down-time due to a cancellation, or for general day-to-day administration tasks. This is particularly important if you are contracting the services of other therapists, but also very important where employed staff are concerned, and critical if you’re a sole practitioner. You only generally earn money when you are seeing clients, so you need to optimise your time by getting people cheaper than your hourly value, to do the jobs that take you away from seeing clients. Most clinics will look for a utilisation rate of 85% to 90% of a therapist’s time, dependent on their job responsibilities.

If the utilisation rate increases then this should tell you its time to start looking for that new staff member, in fact if your business is growing quickly, arguably you should do this even earlier, otherwise other team members will start to feel frantic and stressed, and the quality of service being provided will drop.

Therapist earnings as a percentage of the gross amount taken from the client

This is the amount the clinic makes on the employee or contractor (gross). Ideally this should not rise above 40%, otherwise running a profitable health business gets challenging. Contractor staff demand increasingly higher percentage splits of the takings and in my experience this is just not sustainable in order for the business owner to cover the costs of rents and rates and make any kind of profit themselves. Which makes the reason for absorbing all the stress of the business futile. Many business owners end up with a situation where contractors ‘piggy back’ off the clinic referral streams and earn as much (if not more than the owner) on an hourly basis. To operate a successful therapy model, the costs of the therapists in the team need to come in at no more than 40%. Changing to an employee model is the only sustainable way to grow a business and make a profit as a business owner.

THE TOP 5 LOST EARNING OPPORTUNITIES IN MOST THERAPY BUSINESSES Leaving the booking of the client’s next appointment open and to chance by saying ‘see how you go and give me a call if you need another session’. Block-booking the proposed treatments ahead of time, after the initial consultation, and scheduling all sessions in advance is a much better approach. The client gets the dates and times they want and you can forecast and be more sure where your money is coming from in a few weeks time.

Cancelled appointments and DNAs (did not attends) are not followed up in a systematic way, which means cases remain open and uncompleted, missing earning

Co-Kinetic Journal 2018;75(January):39-41

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opportunity and vital days or weeks since the patient last attended to re-contact them. Patients who do attend for treatment need to get onto their own self help management strategies at home and perhaps need an item of small equipment to assist them in their quest to reduce pain and improve their range of motion and strength. Make sure to hold stock of core items that clients can purchase to help them achieve this. It adds a few extra pounds to the bottom line and you could incentivise your staff to sell them, including the administration staff.

You and your staff are not encouraging your existing clients to refer their friends and family. Be active and forward in mentioning to a client that you rely on word of mouth. Even better run a ‘refer a friend’ scheme. Co-Kinetic has written a detailed article explaining how to do this, as well as created all the material you need to do it (https://www. co-kinetic.com/content/refer-a-friendmarketing-campaign-kit).

Consider selling packages of treatment up front, offering small discounts for these bundles of treatment. This can help you manage cashflow and predict future spend in your clinic. Remember you may want to review your daily sessional prices prior to implementing a package strategy.

HOW TO PUT THIS INTO PRACTICE Reflect on, and evaluate, these two Top 5 lists. Think through and write out step-by-step what your ideal patient pathway would be and observe what is happening and where the patients may be leaking from your pathway. Put processes in place to make sure that you (and any team members) follow the same pathway you’ve settled on. Once your systems are established and you are practising the vision for the patient pathway in your business then its time to think about adding further value for the patient with their clinic experience. Obtaining feedback from clients and taking the time to analyse this data will help you align a client’s wishes with your own vision and help you develop further. The more you know about your customer and what they want to receive the better customer service you will provide.

FURTHER RESOURCES n 1 5 Steps to Great Customer Service video http://spxj.nl/2ADmnDy n How to create loyal customers video http://spxj.nl/2k7PneF n Raving Fans: A Revolutionary Approach to Customer Service Book http://amzn.to/2iZC8Qv n How to Run a One Minute Practice by Paul Wright Book http://spxj.nl/2BSturB

KEY POINTS nY our internal systems and processes need to deliver great customer service so you don’t lose clients. n Exceptional service comes from good communication. n A set of simple key performance indicators (KPIs) will help you improve your customer-journey process. n Know the source of your patient’s referral and thank them for it. n Patients need at least two appointments to check that the advice and exercises are working. n Know the outcome of every patient. n Encourage patients to book their next appointment before they leave. n Contract staff can be expensive – an employee model is a more sustainable way to grow your business. n Encourage clients to refer friends and family – run a ‘refer a friend’ scheme. n Consider selling ‘treatment bundles’ at a small discount.

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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-in-motion.co.uk/about/the-team.html LinkedIn: https://www.linkedin.com/in/clare-carrick-79aa0036/ Facebook: https://www.facebook.com/clare.carrick.3

RELATED CONTENT o You Have What it Takes to Run a Successful Therapy D Business? Article - http://spxj.nl/2hb95Z3 Other marketing-related content - http://spxj.nl/2z1V3j6

DISCUSSIONS onsider the points in the two Top 5 lists. Do you C know this information or can you identify gaps in your knowledge? Which processes would benefit your business the most? Think about the stock items you hold for purchase by clients – should you instigate this or revise your stock?

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Communication processes will dictate the ‘feel’ the client gets about your service http://spxj.nl/2C20XQq Tweet this: Key performance indicators help ensure a consistent, high-quality patient experience http://spxj.nl/2C20XQq WANT TO SEE MORE OR LESS OF THIS KIND OF CONTENT? Vote and rate this article online at http://spxj.nl/2jz0d0W All voters will be entered in the prize draw to win a month’s free Full Site subscription (worth £75)

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DON’T WASTE YOUR MARKETING: How to ethically boost patient retention BY ANDREW BYRNE MCSP HCPC

Finding new customers is key to any business but properly retaining existing customers is arguably even more important otherwise all the marketing money spent on finding new customers is wasted. But what if we focused on really delivering the service our patients actually expected from us, which is frequently something we under-deliver on in the belief we’re doing the patient a favour? We could not only boost our retention and get better outcomes for our clients but we would also build an army of fans who will go out and spread the word locally. This article explains how to make this happen, and it turns out it’s much simpler than you’d expect, it just requires us to ask the right questions, at the right time. Read this article online http://spxj.nl/2C1UANI

INTRODUCTION Everyone knows that it costs considerably more to find a new customer, than it does to retain an existing one. The scenario is a little different however, for healthcare professionals (at least the ethical ones), because our job is to fix a problem, and then send our customers on their way. However, we also owe it to our clients to deliver what is expected of us, and all too often, we don’t get right to the bottom of that. This means we often discharge our patients prematurely, believing we’ve done them a favour, and we fail to deliver on what they really entrusted us to deliver. All of which means we’ve lost the opportunity to get real patient buy-in, their engagement in their treatment is substantially lower than it should be, the outcome isn’t as good as it could be, and we’ve lost a potential ‘raving fan’, which is (or should be) the ultimate goal of any business and the key to word of mouth referrals.

BY DISCHARGING PATIENTS TOO QUICKLY, YOU ARE NOT DOING THEM A FAVOUR, YOU ARE STOPPING THEM FROM ACHIEVING THEIR MAXIMUM BENEFIT 42

THE ‘NEW’ VERSUS ‘EXISTING’ CUSTOMER DEBATE Most of us will have been annoyed at some time by a company that seems to value getting new customers much more than it values its existing ones! However the most successful companies excel at both aspects. They consistently attract new customers with great marketing and by building a brilliant reputation, but they also give exceptional service to their existing customers to make sure they retain them. As a business owner, you have to juggle so many different hats on a daily basis. But the hat that often gets dropped is the patient experience, and in particular, the patient retention hat. If you’re reading this then I’m hoping you’re committed to great marketing and will have spent time, thought and effort in getting new patients into your service, but how do you get on with retaining those patients and giving them an engaging and exceptional service? In my experience, most therapists do a good job at this, but most are not exceptional, which means that some of the efforts in attracting new patients end up being wasted. What makes an exceptional patient experience? Co-Kinetic Journal 2018;75(January):42-44

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I want to discuss one of the keys to exceptional patient experience, and particularly focus on one aspect of patient retention that most therapists don’t do as well as they could do. That topic is how to set goals with your patients. There is a fundamental flaw in how most therapists set goals. It is not our fault, it’s simply a result of our training. During our training, we are taught to focus on the features of the treatment that we give. Things like reducing pain, or reducing muscle tightness. The issue is that people don’t buy into features. To make sense of this, I want to give you a very quick marketing lesson. Marketer people often talk about features and benefits. Features are the things or qualities that a service or product will give, for example leather seats, or high definition screens, or reduced pain. Benefits are exactly what their name suggests, the beneficial results of the features. People buy benefits, they don’t generally buy features. However, practically every therapist I have ever met focusses almost entirely on the features of their treatments, rather than the benefits. The result? Unengaged patients with poor compliance and less than perfect retention.

FIND THE RIGHT GOAL AND PATIENT RETENTION WILL ROCKET A fundamental change is how you set goals with your patients to make sure that you are totally benefits-based. Let me give you an example. A few months ago, I was treating a patient who had torn his hamstring. Answering the standard question that therapists ask about what he wanted to achieve with treatment, he told me that he wanted to get back to running. How many of us have used “return to running” as a goal in the past? I know I have. However, I now know, that this does little to engage my patients so I wanted to know more. I asked why he ran. It turned out he was training for a marathon. Brilliant! Some therapists would have got to this stage and made his goal “be able to run a marathon”. But not me (or you soon). I wanted to know why he was running the marathon. In this instance, he was Co-Kinetic.com

running for charity. You can probably guess the next question. “Which charity are you running for and why is that important to you?”. He told me he was raising money for the hospital that had looked after his son when he was born prematurely. Now that’s a goal! So rather than “return to running”, his deeper goal was “to know he will complete the marathon so that he can raise money in good conscience for the hospital that looked after his son”. Yes, it’s a bit of a mouthful, but can you see how much more engaging and motivating that is? From that point on, every treatment I did with him, every exercise I gave to him to complete, along with every bit of advice I offered about training was linked to that goal. My treatments were no longer just removing pain or improving movement (features), they were doing that so that he could return to running, so that he could complete the marathon, so that he could raise money for the hospital that looked after his son (all benefits). It may seem time-consuming trying to reach a goal like this, but when you have an emotive and passion-filled goal, your patients will almost always follow your advice.

PEOPLE BUY BENEFITS, THEY DON’T GENERALLY BUY FEATURES “return to running”-type goals, you will supercharge your patient retention, but there are a couple more steps to go from doing a good job of retention to doing a great job.

SO HOW DO YOU GET TO THESE DEEPER GOALS? Right at the start of my assessment, I explain that I will be asking some slightly unusual questions so that I can get a real understanding of exactly what that person wants to achieve, so that we’re both focussed on working towards the same thing. Later in the assessment, I will ask them exactly what it is that they want to gain from treatment and then I’ll keep asking them “why?” and “so what?”-type questions (obviously phrased a little more delicately) to find out why that is so important to them. Patients will often struggle to answer these questions as they’re generally not used to healthcare practitioners taking this level of interest in them. To combat this, my all time favourite question is “How would your life be better if I got rid of your pain right now?”. This will generally open up a conversation of exactly how their pain is affecting them. It takes some practice, but if you can move away from “reduce pain” or 43

ASK FOR THE PATIENT’S HELP Use something like, “That’s a great goal and I’d love to work on that with you, but I’ll need your help” works well. If you ask someone for their help they will nearly always agree, and they won’t want to let you down. It’s human nature. People like to help. You’re also making it clear it’s a team effort, it’s not going to be solely up to you, which is important for compliance.

TELL YOUR PATIENTS WHEN TO COME BACK AND WHY Therapists struggle with this conversation as they often see it as selling to their patients, but you owe it to them to give them this information. After all, they have come to see you because they haven’t been able to reach their goal by themselves. They are investing their time, money and trust in you to help them get there. Part of this helping process is to give them the advice they need. See it as helping, NOT selling. If you can give that patient any extra benefit by getting them back again, then you owe it to them to inform them of that. Too

many Therapists try to discharge their patients too quickly as a favour to them. You are NOT doing them a favour, you’re stopping them from achieving their maximum benefit. Patient experience and retention is a huge topic, and goal setting makes up a small but important part of it. I have launched an online course for therapists who want to ethically grow their business through engagement and retention called “Why don’t my patients listen?”. I know how hard it can be to find time to complete courses. The beauty of this course is that you can take it in your own time, and at your own pace. The course will teach you lessons from sales and marketing, customer services, motivational interviewing, personal development and psychology that will transform your practice and help you stand out as the go-to therapist in your area. Co-Kinetic readers can get a special discount on the “Ultimate” version of the course until 10th February and save 25% off the normal price. For more information and to get your discount, go to: http://spxj.nl/2AjSQlj

KEY POINTS nM arketing is vital, but it can be a waste if you don’t then retain the patients. n Therapists are not very good at setting goals because of how we’re trained. n Goals should be emotive and passion-filled. n You have to ask more of the right questions to reach goals like this. n Patients buy benefits and not features of treatment. Therapists nearly always focus on features. n Asking for the patient’s help is very powerful. n You owe it to your patients to give them advice on when and how often they need to come back. n You are not doing your patients a favour by discharging them early. You are robbing them of maximum benefit.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: It costs considerably more to find a new customer than it does to retain an existing one http://spxj.nl/2C1UANl Tweet this: Setting goals with your patients is one of the keys to an exceptional patient experience http://spxj.nl/2C1UANl

RELATED CONTENT Other articles on marketing http://spxj.nl/2z1V3j6

DISCUSSIONS hat are your favourite goals that you’ve ever W worked on with a patient? Do you find it hard telling patients to come back? Do you try to do them a favour by discharging them early? THE AUTHOR Andy Byrne MCSP HCPC has over 10 years’ experience in private practice, the last 4 of which were spent as area manager for one of the largest physiotherapy providers in the UK. He managed 15 clinics simultaneously with over 100 staff. He launched Triad Health in September 2017 to help therapists from around the world to learn and help them get great results for their patients and themselves. He has mentored hundreds of therapists particularly in the nonclinical skills that create exceptional patient experiences and allow for rapid, sustainable and ethical business growth within therapy businesses. Email: info@triadhealth.co.uk Twitter: https://twitter.com/AndyThePhysio Website: https://www.triadhealth.co.uk/ WANT TO SEE MORE OR LESS OF THIS KIND OF CONTENT? Vote and rate this article online at http://spxj.nl/2jz0d0W All voters will be entered in the prize draw to win a month’s free Full Site subscription (worth £75)

Co-Kinetic Journal 2018;75(January):42-44

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TURNING EMAIL LEADS INTO PAYING CUSTOMERS USING THE POWERFUL HIDDEN INFLUENCES OF NURTURE EMAILS INTRODUCTION

BY TOR DAVIES, CO-KINETIC FOUNDER

If you’re not already collecting leads from your social media efforts, you absolutely should be, because it’s one of the most obvious ways of getting a return on investment from time spent on social media. The article ‘A “Ready-to-go” Marketing Strategy for Therapists’ explains why it’s so important to be doing this, and also shows it can be achieved simply and easily [http://spxj.nl/2haSVyW].

So, you’re publishing some great social media content onto your social networks, some of which (hopefully) are designed specifically to collect email leads in return for the downloading of a value-added piece of content. Everyone reading this article, will probably have a bunch of email leads of past and prospective customers, that aren’t currently being tapped to grow your business. Depending on the size of your list, this is potentially a big opportunity that can be mobilised quickly and easily. The question is how to convert these email leads into paying customers, a topic that I’ll explore in this article. I’ll explain a quick and easy way of doing this, and reveal why nurture emails have some hidden influences that make them such a powerful tool when you have this objective in mind. Read this article online http://spxj.nl/2BU2UO3

“Lead nurture is the process of developing relationships with buyers at every stage of the sales funnel, and through every step of the buyer’s journey. It focuses marketing and communication efforts on listening to the needs of prospects, and providing the information and answers they need.” However, regardless of whether you are collecting leads from your social media efforts or not, everyone probably has at least some email leads of past or prospective customers that you could be warming up to become a newly paying client. The question is how you can do this quickly and easily, without it taking up unnecessary time or money. The process is called lead nurture and this is defined as follows: “lead nurture is the process of developing relationships with buyers at every stage of the sales Co-Kinetic.com

funnel, and through every step of the buyer’s journey. It focuses marketing and communication efforts on listening to the needs of prospects, and providing the information and answers they need.” That process sounds complicated, but we’re going to break it down and show that it can be made very simple. This article is specifically about ‘nurturing’ leads, as opposed to selling appointments. It’s about strategies and techniques for moving email leads from initially cold contacts who have little or no awareness of you, to the point of becoming a paying client. This process is achieved by building trust, rather than trying to ‘close the deal’ ie. taking a paid booking there and then (we’ll talk more about that aspect in a future article).

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WEB

MOBILE

MEDIA CONTENTS Video 1: The Science of Persuasion (Courtesy of YouTube user Influence at Work) http://spxj.nl/2keW2Up

LEAD NURTURING IS ALL ABOUT PROVIDING VALUE, AND DOING IT CONSISTENTLY, IN A WAY THAT BUILDS TRUST AND DEVELOPS THE RELATIONSHIP BETWEEN YOU AND EACH EMAIL LEAD 45

THE ALL IMPORTANT LEADS So, you may already have a database of email leads from previous business activities, and you are hopefully also collecting new leads all the time using your website and social media at the very least. But the very first time someone visits your website, or sees your social media, they probably know relatively little, or maybe even nothing about you. They may or may not have an existing relationship with you or your business. In this case, your first job is to offer them something that’s worth it to them, to give you their email address. For example, someone may have stumbled across a helpful blog post on your website while searching for a solution to a problem, or seen one of your social media posts shared by one of their friends on Facebook. If your marketing strategy is good, these blog posts and social media posts will offer the viewer the chance to download a document such as a cheat sheet, article, or patient handout, that they’re really keen to get hold of (we call this document a ‘lead magnet’). In order to receive this lead magnet, they need to give you their email address in return using the lead collection form which your social media post or blog links to. This way you’re constantly collecting new prospective

customer leads. Your job is then to warm these contacts up, by giving them the chance to get to ‘know’ you. So that at some point down the line, when they need your help, you’re the first person they think of calling. But obviously, it’s impractical to call each new lead, have a chat and share life stories, so we need to find a way of building that relationship practically, with an ever-growing number of leads (if you’re doing your marketing well). So how do we do this?

It’s All About Building Trust To convert a cold lead who doesn’t know much about you, into a paying customer who is prepared to put their ‘pain’ in your hands (literally), you need to build trust, and this is specifically important within a healthcare setting, in fact it’s arguably more important than in pretty much any other industry or business. And this is the start of why email, and specifically nurture emails, can be so powerful for healthcare professionals. Remember our initial definition of lead nurturing: “It focuses marketing and communication efforts on listening to the needs of prospects, and providing the information and answers they need.”

Lead nurturing is all about providing value, and doing it consistently, in a way that builds trust and develops the relationship between you and each email lead. What does this look like in practical terms? It means emails that help to answer questions or solve problems that your leads are commonly likely to encounter. Depending on your ideal customer demographic, this could be common musculoskeletal issues, or sports injuries, nutritional information or advice about the role of exercise for medical conditions like diabetes or heart disease. Unfortunately, we rarely, if ever, take the time to send these nurture emails, because we’re just too busy and it takes too much time (I have a solution to that later). Instead, we resort to sales email Band-Aid syndrome to do the job.

SALES EMAIL BAND-AID SYNDROME We have too little time as it is to dedicate ourselves to marketing, so the temptation to go for the hard sell in what are probably fairly sporadic, impulsive customer emails, is too great. That’s the trouble with most marketing done by small business owners. Something sudden, and usually specific, stimulates the need or desire for new business, which results in a one-off flurry of marketing activity, that nearly always contributes little, and more usually nothing, to the bottom line of the business. It’s the classic sign of a lack of strategy behind your marketing. That email will probably be an exception, rather than a regular activity, in which you’re looking for a ‘quick fix’ to try and fill out the appointment diary for the next week or month, often by offering some crazy discount deal you can’t really afford to offer. All in a usually vain attempt to patch a hole in your business, which usually just keeps getting bigger with time, unless a proper marketing strategy is put in place. As I’ve said so many times before in articles and presentations on the same topic, flurries of marketing activity, are at best a waste of time, and at worst, a waste of time, money, passion AND energy. Co-Kinetic Journal 2018;75(January):45-50

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And I know from experience, that nearly all of you reading this article, will desperately hate going for the hard sell anyway, so not only is it costing you in both time and money, now it’s emotionally draining you too. And when you do send the email, and after a couple of hours with little response to your offer, it probably leaves you feeling disillusioned and maybe even a little dirty, because fundamentally you HATE sales pitches. And so does everyone else!

Why the Sales Pitch Never Works So why will you get little or no response from your hastily crafted sales email? Well the number one rule of any copywriting or sales course is that “people absolutely hate to feel sold to”. Imagine you were thinking of buying a new car and you quite liked the thought of an Audi. So you walk into a local Audi dealership to check out the shiny new Audis. Within seconds you sense that car sales person walking towards you, and you feel your body tensing with resistance to the sales pitch you know is coming. But what if that sales person did nothing more than say hi, and ask you what had brought you to his/her garage today, and what you were looking for in a car? They listened closely to your response and then gave you some useful information which specifically answered your questions or concerns. Wow, no sales pitch in the ear. So far so good. Your resistance slowly starts to wane and you see the car you had your eye on, the Q5. It looks stunning. You engage in more conversation, asking questions about whatever aspect is important to you, and begin to get a better sense of your salesperson. You receive honest, informative, non-salesy replies. Maybe you’re even starting to quite like them, so you ask to take the car for a test drive. OK, now you’re engaged in the experience. Now you have the combination of the immersive experience of the car playing into the situation, the smell of new leather, the beautiful design touches, the acceleration power, the breaking Co-Kinetic.com

sensitivity. Buying tipping points are nearly always emotional, which we then back up with logic, usually in the process of, or even after the purchase. And yes, maybe you walk away that day because you haven’t quite hit the buying tipping point, you’re a significant way further down the line than you were when you walked into that garage. You’ll also have a good feeling about the sales person and all your senses will be stimulated when you recall the feeling of the test drive. If that experience has been good and ticked all the boxes, and you’ve reached your buying tipping point, how long is it going to be before you go back and sign the paperwork? However, there is a key reason why the healthcare situation differs from the scenario above. Booking a physical therapy or massage treatment is rarely an impulsive, walk-in-off-thestreet type of action. For someone to get to that point, they need to have reached what I’ve come to refer to as their ‘clinical tipping point’.

TIPPING POINTS AND DECISION-MAKING CRITERIA So, when is a lead ready to become a customer? Let’s think about the reasons someone would decide to make an appointment to see a physical therapist or massage therapist for that matter. Clinical tipping points might include: n Experiencing a specific injury such as a car accident, sports injury, accident n Noticeable or visible physical changes to limbs or soft tissues

How to acquire and nurture leads

IF YOUR EMAILS ARE CONSISTENTLY HELPFUL THEY ARE MORE LIKELY TO BE READ nW hen the pain becomes so bad that other treatments and medications that have worked before, are no longer enough n It becomes too difficult to do things that are important to someone like working, carrying things, playing with grandchildren, or other activities of daily living n Concern about long-term implications of leaving things without treatment n Pre- or more commonly postoperatively n A chronic condition or neurological disease n During or after pregnancy. Very often your prospective new client might have been living in pain for months, maybe even years, before they hit this clinical tipping point. This is exactly why the gentle, non-invasive, approach of sending value-added emails is a perfect nurture tool. It’s supportive and helpful without getting in people’s faces. It’s also easy to delete if it’s not relevant and it’s easy to share with friends and family if it is relevant. There are lots of reasons 47

why nurture emails have an advantage over many other marketing approaches, particularly for warming up leads, which I’ll cover in more detail shortly. But let’s first look at the reasons why a lead might not be ready to become a paying customer.

When a Lead is NOT Ready to Become a Customer and What You Can Do About It Here are some key reasons why someone might not be ready to book an appointment with you yet, in fact it could be more than one of the following reasons, but they’re ranked in a general order of importance. 1. It’s not the right time – they’re not at that ‘clinical’ tipping point yet. 2. Trust – this is a major deal, not only do they need to know you, and like you, but do they trust you? 3. Confidence – are you the right solution for them, will it work, is it worth spending money on? 4. Authority and reputation – are you and your business credible? 5. Location convenience – can they get to you easily, but also can they park and get into your clinic with their given needs? 6. Price – many people wrongly think this factor is more important than it actually is. In reality it’s likely to be the very last objection (assuming all the boxes above it have been ticked). And frankly if someone does want to

The Email Nurture Cycle

prioritise on price, let them go, they’re not the kind of customer you want. You can’t influence the clinical tipping point, well you might be able to accelerate it slightly by making them aware of the consequences of delaying on treatment, but generally that requires you to get face to face with the prospective lead to do it, rather than via email. However, you can influence points 2, 3, 4 and 5 through nurture emails (and 6 as I’ve mentioned, in my view, you should actively avoid considering, because your skills and expertise are worth more than that). Location you may not be able to do much about immediately, if you’re already committed to somewhere, but it is a consideration you should revisit if needs be, when the opportunity arises. Trust, confidence, authority and reputation are all things you can start to influence now and in fact can be greatly benefited through the email nurture process; however, before we get to the anatomy of the nurture email that will help you do this, here are some quick wins that can give you get a head start: nB uild up customer testimonials on Google and Facebook – this is probably the single most important thing you can do right now. nM ake sure to feature these customer testimonials on your website. nA dd social proofing and reputation to your website by featuring logos of associations you are a member of and businesses or sports teams that you have worked for (they must be genuine and it’s courteous and highly advisable to ask for approval prior to featuring them on your website). n I nclude a frequently asked questions area on your website – this gives people a chance to start building trust. nG ive people a way of getting to know you – make sure your website features biogs of you and any fellow practitioners, photos, and videos if you can. n Use your social networks (particularly Facebook but also Twitter) to introduce Facebook fans to aspects of your business that can help enhance your reputation but

remember, avoid the sales push approach! n Develop a USP so that you become the ‘go to’ person for that niche. n Define your ideal client ‘persona’ so you can be more targeted with your marketing. n Get involved with local Facebook groups in the areas you want to attract clients, and offer value and free advice – become known for your area of expertise.

THE HIDDEN POWERS OF THE NURTURE EMAIL This is where we get to the secret sauce. Here are 10 reasons that regular, valueadd nurture emails are brilliant relationship building, non-salesy sales tools. Nurture emails: 1. allow you to help people 2. add value to people’s lives 3. build likeability 4. build trust 5. develop a relationship 6. are easy to share and forward 7. generate reciprocity 8. build authority 9. are non-intrusive 10. increase brand awareness

The Anatomy of a Perfect Nurture Email 1. Use it to help people You went into this business to help people; to help fix their pains, and ease their suffering, and nurture emails give you the perfect opportunity to do that. It’s what you do well, and it’s likely to fit well with your ethos and your internal drivers, which in turn will make you feel good too. I frequently quote Albert Einstein in my presentations because it encapsulates a perfect marketing strategy for those of us who have chosen a career in helping people: “Try not to become a person of success, but rather try to become a person of value.” When you look at words that go with the noun nurture, they include encouraging, cultivating, boosting, advancing – these are all perfect descriptors for your nurture emails. The important thing is to keep this in mind when you’re writing your emails (or editing the ones we provide in the Co-Kinetic subscriptions). Co-Kinetic Journal 2018;75(January):45-50

ENTREPRENEUR THERAPIST

2. Make sure it adds value It’s hard to reject someone who is offering helpful advice, which is appropriate and relevant and has no strings attached. This is one reason why email is such a great way of offering value. Some helpful advice in an email about a problem that is commonly experienced, along with a link to a more detailed resource, is unlikely to be regarded as rude. If that person suffered from back pain and you sent them details about tips on getting a better night’s sleep if you suffer from back pain, it’s very likely to be appreciated. Better still they may even forward it to a fellow sufferer. 3, 4, 5. Use it to build likeability, trust and to develop the relationship Trust is the single most important element in purchase decisions, whether that’s trust of a brand name or in your case as a provider of healthcare, of you and your business. When you combine someone’s concerns about whether your solution is the right solution for their problem, along with whether you’re the right person for the job, AND the additional trust required to submit to physical hands-on-treatment, you can start to understand why this element is so key. Through regular, consistent, helpful emails offering advice about problems they may be experiencing, as well as opportunities to get to know you (and your business) through clinic updates on your social networks, email offers the perfect opportunity to help nurture and build this trust and develop the relationship you have with that prospective client. It also helps nurture the ‘know, like, trust’ sequence. People want to buy from people who they like and trust. Email nurture is an ideal medium for you to develop this relationship and let your reader get to know and relate to you. 6. Make it easy to share and forward This doesn’t require much explanation except to say that it’s excellent practice to include somewhere in the email a call to action asking the reader to forward the email to someone who may benefit from it. It’s surprising how small things like this can make a big Co-Kinetic.com

difference. People are busy, they have a million things on their mind. Just a quick “PS. if this isn’t relevant to you, but you know someone suffering from shoulder pain, please feel free to share this email with them”.

Video 1: The Science of Persuasion (Courtesy of YouTube user Influence at Work)

7. Use it to generate reciprocity This is a really awesome benefit of nurture emails! Robert Cialdini, in the HIGHLY recommended book Influence: The Psychology of Persuasion (http://amzn. to/2B0Zf4x), identifies reciprocity as one of the six most powerful forms of influence. It’s a rule that’s been fundamental to human evolution and is therefore deeply embedded in human society. Simply put, if someone does us a favour, we’re predisposed to finding a way to repay them, and feel more obliged to them. Hence, if you’re providing helpful solutions to real life problems experienced by your readers and email leads, this can stimulate powerful feelings of reciprocity. In fact, all the power influencers indentified by Cialdini, are very relevant to your work. If you want a fun and fascinating 11-minute overview of the book watch the animated explainer video, ‘The Science of Persuasion’ (Video 1), and you’ll pick up some valuable tricks too. I’d also personally highly recommend the book as well. The other five power-influencers identified by Cialdini are authority, liking, scarcity, consistency and consensus. Watch the video for more information. 8. Use it to establish authority This is based on the principle that people follow the lead of credible, knowledgeable experts. As the Cialdini book (and explainer video) describes, physiotherapists, for example, are able to persuade more of their patients to comply with recommended exercise programmes if they display their medical diplomas on the walls of their consulting rooms. Just as people are more likely to give change for a parking meter to a complete stranger, if that requester wears a uniform rather than casual clothes. What this means is that it’s important to signal to others what

makes you a credible, knowledgeable authority before you make your influence attempt. One of the best ways of doing this is through social proof and testimonials as well as case studies, all of which can be shared easily through your nurture emails, on your website and on your social networks. This is why association logos and the logos of the businesses and teams you work with can be so influential, you could even include them as a banner at the bottom of your email. 9. Email is relatively unobtrusive, don’t be offended if it’s not always opened If you deliver consistently helpful, value added information, the chances are that your email open rates will increase

AS EINSTEIN SAYS, ‘TRY NOT TO BECOME A PERSON OF SUCCESS, BUT RATHER TRY TO BECOME A PERSON OF VALUE 49

over time (which means click rates are also likely to). And if your emails are generally helpful, it’s less likely that anyone will choose to spam it. They may not ALWAYS open the email, depending on what’s going on in their life at that time, but that’s OK. As the saying goes: “You can please some of the people all of the time, you can please all of the people some of the time, but you can’t please all of the people, all of the time.” It is a good idea however to delete people from your email list if they haven’t opened an email for a long period of time. This will help you increase your open rates and is likely to mean your emails get better deliverability because they’re considered more relevant. 10. Use your emails to increase brand awareness It won’t cost more than £5–£10 to have someone on the freelance services marketplace, Fiverr, create you a standard email header banner ideally in html (so the elements are linked and clickable) or alternatively as a static graphic if that’s easier. The graphic should be between 600 and 800 pixels wide which is a standard email width. For the header make sure you include as many of the following as possible

(without it becoming too cluttered): n Your logo n Your company name (but only if it’s not included in the logo) n Your contact telephone number n Your website address n Social media logos linked to your active social networks You can then add this banner or html to each nurture email you send out. Ideally make sure that visually in terms of colours it ties in with the look of your website, so the brand recognition is consistent across all touch points. The most important thing is to make it easy for people to get hold of you.

CONCLUSION Hopefully this article has demonstrated just how powerful nurture emails can be when used as part of a marketing strategy. It is incredibly effective both consciously and sub-consciously at achieving not just one, but several very core components in the lead to paying customer conversion process. One of the problems with nurture emails is that they require you to find the time to write them, which is why we include a new nurture email in every monthly campaign that we create. We write the content, provide you with

KEY POINTS n L ead nurture is the process of creating potential clients from initial cold contacts by getting them to know, like and trust you. n Create a lead by offering something that makes it worth someone giving you their email address (this is called a lead magnet). n Listen to your prospective client’s needs and provide the information and answers that they need. n Don’t be tempted by the sporadic, impulsive hard sell as a ‘quick fix’. n Make sure you are doing the easy basics on your website and social media, with testimonials, biogs and photos of you, logos of professional associations, etc. n Email is an ideal way to nurture leads as it is relatively unobtrusive. n Use regular, consistent and helpful emails to create trust. n Make your emails easy to forward and share. n Use an email header banner to enhance recognition of your brand.

copyright-free images, and if you use Mailchimp, we even create the readyto-go email. You just click a link and it pops straight into your Mailchimp account, ready for you to edit as you need, and then send. If you’d like more information visit https://co-kinetic.com/marketing I hope this article has been useful and if you have any feedback or would like more information on any parts of the article, please post your comments in the discussion panel below.

DISCUSSIONS ssess your ‘brand’. Do you have a consistent ‘look’ A across all your touch points, with the necessary contact information? Think about your current email leads – how often/ regularly do you send out emails and do they contain information that is helpful to the potential client? After reading this article, would you change your approach to your nurture emails and what would you change

RELATED CONTENT Ready-to-go Marketing Strategy for Therapists A http://spxj.nl/2haSVyW ow to Get More Clients Without Being Salesy H http://spxj.nl/2sRgRvr Ways to Build a Thriving Therapy Business 13 http://spxj.nl/2sFEiaV 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.

Co-Kinetic Journal 2018;75(January):45-50

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