Co-Kinetic Journal Issue 76 - April 2018 by Co-Kinetic

ISSUE 76 APRIL 2018 ISSN 2397-138X

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32-40 EFFICACY OF MANUAL THERAPY FOR CHRONIC MUSCULOSKELETAL PAIN

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

ISSUE 76 APRIL 2018 ISSN 2397-138X

Formerly published as....

medicine & dynamics

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DISCLAIMER While every effort has been made to ensure that all information and data in this magazine is correct and compatible with national standards generally accepted at the time of publication, this magazine and any articles published in it are intended as general guidance and information for use by healthcare professionals only, and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. To the extent permissible by law, the publisher, editors and contributors to this magazine accept no liability to any person for any loss, injury or damage howsoever incurred (including by negligence) as a consequence, whether directly or indirectly, of the use by any person of any of the contents of the magazine. Copyright subsists in all material in the publication. Centor Publishing Limited consents to certain features contained in this magazine marked (*) being copied for personal use or information only (including distribution to appropriate patients) provided a full reference to the source is shown. No other unauthorised reproduction, transmission or storage in any electronic retrieval system is permitted of any material contained in this publication in any form. The publishers give no endorsement for and accept no liability (howsoever arising) in connection with the supply or use of any goods or services purchased as a result of any advertisement appearing in this magazine.

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT This was a retrospective study on 60 male and female patients aged from 18 to 65 years with a Colles’ fracture who had been managed surgically. They were divided in two groups, those who received Maitland mobilisation or those who received conventional mobilisation. For the latter group this comprised active and passive wrist flexion and extension exercises daily for 15 days. The Maitland group received grade 1 and 2 mobilisations of flexion and extension at the wrist joint for the first 7 days of treatment and grade 3 and 4 for the next 8 days. The mobilisations were 15 sets of oscillation lasting 20 to 30 seconds, (1 or 2 oscillations/second) followed by slow stretch. For wrist flexion, the patient starting position was with the forearm supine in the middle of the plinth with elbow flexed to 90°. The therapist used to stand at the affected side of the patient just beyond the flexed elbow. The medial border of the patient’s hand was grasped by the

EFFECTIVENESS OF MAITLAND MOBILISATION TECHNIQUE ON PAIN AND HAND FUNCTIONS IN THE POSTOPERATIVE MANAGEMENT OF COLLES FRACTURE. Mahakul B, Singh H, Sahoo J et al. International Journal of Orthopaedic Sciences 2017;3(3):397–399 same-side hand of the therapist. The thumb was placed against the dorsum of the patient’s metacarpals. The fingers were placed by the palm of the patient’s hand. The opposite hand of the therapist stabilised the forearm of the patient midway just proximal to the wrist joint. Then the therapist’s thumb flexes the patient’s wrist and hand to the limit of its range; followed by the therapist’s finger returning the patient’s wrist to its starting position. The return movements were controlled by placing the index finger near the patient’s metacarpophalangeal joint. Similarly the extension exercises were carried out. Both groups exhibited significant decreases in pain postintervention. Hand functions increased significantly post-intervention in both groups. However, there was significant difference between groups with better

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results observed in the Maitland group with respect to pain improvement and hand functions.

Co-Kinetic comment The idea behind this study is sound but try following the mobilisation protocol above. First, we are not sure whether the mobilisations were physiological or posterior–anterior. Second, the mobilisation group seemed to get much more treatment than the other group. Hence, the although the overall improvement in each group is welcomed, the difference between the two is suspect. - can you change it to: So, although the overall improvement in each group is welcomed, the difference between the two is suspect.

FUNCTIONAL AND SPORTS-SPECIFIC OUTCOME AFTER SURGICAL REPAIR OF ROTATOR CUFF TEARS IN ROCK CLIMBERS. Simon M, Popp D, Lutter C et al. Wilderness & Environmental Medicine 2017;28(4):342–347 This was a retrospective study of 12 rock climbers (10 men, 2 women; average age 55 years; range 28–66 years) with rotator cuff lesions. They were re-evaluated at between 12 and 72 months after arthroscopic surgical repair of the rotator cuff of the shoulder. The postoperative general outcome, including the Constant–Murley score, was assessed with a standardised questionnaire and clinical examination. The postoperative sports-specific outcome was analysed using the UIAA (International Union of Alpine Associations) metric scale. There was an equal mix of chronic and acute tears at surgery. The results revealed that the Constant–Murely scores ranged from 80 to 98. All participants had already started climbing again; 11 of 12 climbers regained a climbing level within ±1.33 UIAA metric grades of their initial capability.

Co-Kinetic comment Arthroscopic repair can get climbers back on the rocks, so surgery is an option they shouldn’t worry too much about. 4

Co-Kinetic Journal 2018;76(April):4-9

RESEARCH INTO PRACTICE

Journal Watch ECCENTRIC HAMSTRING STRENGTH DEFICIT AND POOR HAMSTRING-TOQUADRICEPS RATIO ARE RISK FACTORS FOR HAMSTRING STRAIN INJURY IN FOOTBALL: A PROSPECTIVE STUDY OF 146 PROFESSIONAL PLAYERS. Lee JW, Mok K-M, Chan HCK et al. Journal of Science and Medicine in Sport 2017;doi:10.1016/j.jsams.2017.11.017 A total of 169 professional players participated in a preseason isokinetic strength screening, followed by a 10-month competitive season. The testing protocol included the concentric performance of both knee flexion and extension at 60°/s and 240°/s and the eccentric performance of the knee flexor at 30°/s. Strength deficits, bilateral differences and hamstring-toquadriceps (H/Q) strength ratios were computed. Univariate and multivariate logistic regressions were used to identify potential risk factors of hamstring injury (HSIs). Forty-one acute HSIs were sustained, and 12% (n=5) reoccurred within the study period. In the multivariate analysis, there was an

association between the injury risk and eccentric hamstring peak torque below 2.4Nm/kg; concentric H/Q ratio below 50.5%; and players with previous injury of HSI.

Co-Kinetic comment Players with significantly lower isokinetic hamstring strength, lower H/Q strength ratio, and a previous hamstring injury were linked to an increased risk of acute HSI. Those strengthening exercises really do work.

MULTIFIDUS MUSCLE SIZE CHANGES AT DIFFERENT DIRECTIONS OF HEAD AND NECK MOVEMENTS IN FEMALES WITH UNILATERAL CHRONIC NON-SPECIFIC NECK PAIN AND HEALTHY SUBJECTS USING ULTRASONOGRAPHY. Arimi SA, Bandpei MAM, Rezasoltan A et al. Journal of Bodywork and Movement Therapies 2017;doi:http://dx.doi.org/10.1016/j.jbmt.2017.09.011 Twenty-five women with neck pain and 25 healthy subjects participated in this study. All worked for at least 4 hours a day on a computer. Using ultrasonography, the dimensions of their cervical multifidus muscle (CMM) were measured at rest, and at 50% and 100% maximum isometric voluntary contraction (MIVC) at six directions of neck movements. The size of multifidus was smaller in patients than healthy individuals in the at-rest state. A significantly smaller CMM dimension was found in the affected side compared with the unaffected side in the patients’ group. The multiplied linear dimensions (MLD) showed a significant difference for contraction levels and

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neck movements in both groups. The MLD of the CMM was significantly different between CMM at rest and 50% and 100% MIVC. No significant differences were found between the groups at 50% and 100% MIVC in both instances. The most prominent CMM size change was observed during neck extension, flexion, ipsilateral lateral-flexion and ipsilateral rotation, respectively.

Co-Kinetic comment Apparently, 67–71% of people will experience neck pain during their lifetime, which is not surprising when you consider that 80% of the weight of your head is carried by the muscles not the bone structure. The question is if the muscles are smaller on the painful side what are you going to do about it?

A RANDOMISED CROSSOVER TRIAL COMPARING THAI AND SWEDISH MASSAGE FOR FATIGUE AND DEPLETED ENERGY. MacSween A, Lorrimer S, van Schaik P et al. Journal of Bodywork and Movement Therapies 2017;doi:https:// doi.org/10.1016/j.jbmt.2017.09.014 Twenty participants were randomised to receive three once-weekly Thai (TM) treatments and three onceweekly Swedish (SM) treatments, with crossover after three massages. Symptom checklists were administered at three time points and included the Activation-Deactivation Adjective Check List and VAS Scale. Qualitative data were collected through semi-structured interviews and participants’ diary entries. Both massage types enhanced physical, emotional and mental wellbeing through improved sleep, relaxation, relief of stress and relief of muscular tension. TM alone showed specific energising and psychological stimulation results, along with carryover effect and longer lasting benefits. Ninety-five percent of participants found relief from their initial reason presenting symptoms.

Co-Kinetic comment Massage works, whatever its type. 5

Injury rates of the distal biceps tendon are 1.2 in 100,000 with an average age of 47. Injury usually occurs in a weak tendon during eccentric loading with the elbow at 90° and in full supination. Weakening of the tendon can be from many causes but steroids and smoking increase the risk as does being male and a body builder. Recent advances in anatomy suggest that rather than combining at around the level of the deltoid tuberosity the tendons of the two heads continue in line with their respective heads and can be separated into their separate bundles. Patients usually describe a sudden severe pain. A snap or pop may be heard. There may be bruising over the medial aspect of the elbow but not always. A ‘hook’ test for tendon rupture is simply to hook a finger from

DISTAL BICEPS AND TRICEPS INJURIES. Beazley JC, Lawrence TM, Drew SJ et al. The Open Orthopaedics Journal 2017;11:1364 the lateral side under the tendon. If you can get hold of the cord-like structure it is intact. If there is no structure to hook the tendon is completely avulsed. Hooks and pain may suggest a partial tear. You can also palpate the attachment at the bicipital aponeurosis. Total rupture can be treated non-operatively but there is a reported reduction of up to 40% supination strength and 31% in flexion. There are a variety of surgical fixation techniques with up to a 40% complication rate reported for some. The paper has some nice pictures of surgical repair. Delaying presentation beyond 3 weeks leads to musculotendinous retraction which makes repair difficulty. For partial tears of

less than 50%, conservative treatment is recommended. At more than 50%, some authors recommend complete division and reattachment. Triceps tendon rupture is extremely rare and usually occurs as a result of a fall on an outstretched hand. Full rupture requires similar surgery to the biceps. Partial tear treatment is more controversial with studies reporting good results even in patients with a high functional demand.

Co-Kinetic comment The sort of paper we really like. All you need to know about a particular condition and it’s free to access. More of these please.

IS MULLIGAN MOVEMENT WITH MOBILIZATION EFFECTIVE IN ORTHOPAEDIC REHABILITATION? Çelik D, Canan GD, Ödevoğlu P. Physical Therapy in Sport 2017;28:e1–e25 The usual databases were searched for studies using Mulligan movement with mobilisation (MWM) for musculoskeletal pathologies and dizziness due to cervical spine problems. The Quality Assessment Tool for Quantitative Studies was used to evaluate the quality of evidence. The initial search returned 311 articles. After screening, 25 were included. Twelve studies were rated weak evidence and excluded. MWM was compared either with placebo, placebo laser,

According to earlier work, up to 20% of sporting injuries are hip related and hip muscle pain, fatigue and tightness may affect exercise performance. Hence, this article is a practical review of the available evidence about hips and squats – both single- and doublelegged. The key hip muscles used for performing a squat are the following. The gluteal maximus, which extends the hip during the assent phase and eccentrically controls the loweringdescent phase. The hamstrings assist with hip extension with the biceps femoris being more active during the ascent (concentric phase) and 6

steroid injection, different mobilisation techniques, taping or exercises. There were five studies about shoulder pathologies; three of them resulted in strong evidence, the other two were moderate. There were four studies regarding dizziness, one of them showed strong evidence. For ankle sprain, mechanical cervical pain and lateral epicondylitis one study each was found. Studies about ankle sprain, mechanical cervical pain resulted in

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strong evidence. In these studies, MWM was found superior in shoulder pathologies, dizziness and ankle sprain.

Co-Kinetic comment This is actually a report on a conference presentation. If you use MWM, you know already that it works in some patients. It’s nice to have a bit of research to quote to the manual therapy deniers.

THE INFLUENCE OF HIP MUSCLE IMPAIRMENTS ON SQUAT PERFORMANCE. Kolber MJ, Stull K, Cheatham S et al. Strength and Conditioning Journal 2017;39(3):66–73 the semitendinosus more active controlling descent (eccentric phase). The gluteus medius functions primarily as a hip abductor and controls pelvic position especially during a singleleg squat. Other muscles may have relevance when considering abnormal movements. For example, the iliopsoas functions primarily as a hip flexor, and when tight, may limit hip-extension range of motion and potentially alter motor recruitment patterns of the gluteals. If any of these are not working to full range and potential, pelvic

stability and performance may be affected. The article goes on to quote a number of papers looking at the influence on the squat of hip pain, hip muscle dysfunction, fatigue and tension and to conclude that although there is some evidence that hip impairments affect squat performance, the evidence is limited.

Co-Kinetic comment Even if the literature evidence is limited, in practical terms it’s obvious that if the hip musculature is not working optimally or there is pain inhibition, then both movement quality and, therefore, performance will be affected. Co-Kinetic Journal 2018;76(April):4-9

RESEARCH INTO PRACTICE

For this study, undertaken in a university rehabilitation clinic, 45 male volleyball players (aged 22–28 years) were selected and divided into three groups: shoulder impingement (group I), tennis elbow (group II), and control (group III). The experimental groups performed the ‘gyroscopic device’ mediated resistance training, three sessions per week over 8 weeks. These were basically active range-of-movement (ROM) exercises for shoulder, wrist and elbow completed while holding the device. Grip strength, wrist and shoulder strength and proprioception, and upper extremity performance were measured before and after implementation of the intervention (8-week resistance training using a ‘gyroscopic device’) using a hand-held dynamometer, isokinetic dynamometer, and Y balance test respectively. Improvement in the shoulder, wrist and grip strength, shoulder and wrist proprioception and performance

EFFECTS OF EIGHT-WEEK “GYROSCOPIC DEVICE” MEDIATED RESISTANCE TRAINING EXERCISE ON PARTICIPANTS WITH IMPINGEMENT SYNDROME OR TENNIS ELBOW. Babaei-Mobarakeh M, Letafatkar A, Barati AH et al. Journal of Bodywork and Movement Therapies 2017;doi:https://doi.org/10.1016/j.jbmt.2017.12.002 scores of both experimental groups was significant. There were no significant differences between study groups I and II. However, both groups I and II demonstrated significant differences when compared to the control group, but between group I and the control group, and between group II and the control group, the difference was significant. However, no significant change was seen in the control group.

Co-Kinetic comment The device is a tennis-ball sized contraption with a solid outside case holding a free spinning mass inside it generating a centrifugal force. You can buy them for between £25–40 or over £100 for flasher versions with a rev

EFFECTIVENESS OF MYOFASCIAL RELEASE IN TREATMENT OF CHRONIC MUSCULOSKELETAL PAIN: A SYSTEMATIC REVIEW. Laimi K, Mäkilä A, Bärlund E et al. Clinical Rehabilitation 2017;doi:10.11 77/0269215517732820 Randomised controlled trials were systematically gathered from CENTRAL, Medline, Embase, CINAHL, Scopus, and PEDro databases. The methodological quality of articles was assessed according to the Cochrane Collaboration’s domain-based framework. In addition, the effect sizes of main outcomes were calculated based on reported means and variances at baseline and in follow-up. Of 513 identified records, 8 were relevant. Two trials focused on lateral epicondylitis (N=95), two on fibromyalgia (N=145), three on low back pain (N=152), and one on heel pain (N=65). The risk of bias was considered low in three and high in five trials. The duration of therapy was 30–90 minutes, 4 to 24 times during 2–20 weeks. The effect sizes did not reach the minimal clinically important difference for pain and disability in the studies of low back pain or fibromyalgia. In another three studies with high risk of bias, the level of minimal clinically important difference was reached up to two-month follow-up.

Co-Kinetic comment This paper highlights everything that is wrong with research into MSK conditions and treatment techniques. Over 500 promising-looking records were identified but only 8 were really relevant and of those the risk of bias was high in 5 of them. The worst part, however, is the wording of the conclusion that states, “Current evidence on myofascial release therapy is not sufficient to warrant this treatment in chronic musculoskeletal pain”. If we are not careful manual therapists will have no treatments left to do. Absence of evidence is not evidence of absence. Co-Kinetic.com

counter. As you would expect, the sellers make claims about increasing blood flow, stimulating synovial fluid production and muscle activation. The paper’s authors speculate about greater motor recruitment and maybe a change in muscle fibre type to increase strength. Additionally, (although they admit that it is debatable) they speculate that the muscle activation required to counter the centrifugal force is an eccentric contraction which stimulates muscle fibre elongation. They also wonder about improved collagen alignment in tendons. Whatever the reasons behind the effects it seems to have had a positive impact on a couple of conditions that can be difficult to resolve so it’s worth a try.

COMPARISONS OF HIP STRENGTH AND COUNTERMOVEMENT JUMP HEIGHT IN ELITE TENNIS PLAYERS WITH AND WITHOUT ACUTE HISTORY OF GROIN INJURIES. Moreno-Pérez V, Lopez-Valenciano A, Barbado D et al. Musculoskeletal Science and Practice 2017;29:144–149 Seventeen tennis players with a history of a groin injury (GI) and 44 without (NGI) were assessed for isometric adductor and abductor hip strength and for unilateral countermovement jump tests. The isometric adductor strength and adductor/abductor strength ratios were lower in the injured limb (16.4% and 20.1%, respectively) compared with uninjured side within the GI group, and lower than the dominant side in the NGI group. No significant differences were found for unilateral jump heights between sides in the GI, nor isometric abductor strength, when comparing GI to NGI groups.

Co-Kinetic comment The suggestion in the paper is that muscle strength is not fully recovered in the previously injured athletes, therefore increasing their risk of a repeat injury. It is fairly certain that this does not just apply to groin injury. EFFECT OF FOUR WEEKS DETRAINING ON STRENGTH, POWER, AND SENSORIMOTOR ABILITY OF ADOLESCENT SURFERS. Tran TT, Lundgren L, Secomb J et al. The Open Sports Sciences Journal 2017;10(Suppl 1: M6):71–80

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Nineteen adolescent surfers participated in 4 weeks of detraining (surfing participation maintained but resistance training ceased) following 7 weeks of resistance training. Measures taken before and after the 4 weeks of detraining significantly decreased the following variables: vertical jump height by 5.26%, vertical jump peak velocity by 3.73%, isometric strength by 5.5%, and relative isometric strength by 7.27%. Plus, sensorimotor ability worsened, with a significant increase of 61.36%, indicating that athletes took longer to stabilise from a dynamic landing task.

Co-Kinetic comment Don’t stop the lifting. 7

This useful study has two parts. The first is a discussion on the merits of various imaging methods. MRI comes out on top but ultrasound is cheaper and more accessible. The second is about injury classification systems. For most MSK therapists muscle injury grading systems are simple, mild, moderate, complete or 1, 2, 3 but this does not really give relevant prognostic information. Radiologists reporting on MRI scans, however, start at: grade 0 with no pathological findings; grade 1 with a muscle oedema only but without tissue damage; grade 2 as partial muscle tear; and grade 3 with a complete muscle tear. The Munich consensus proposed classification as either in ‘functional’ (fatigue-induced, delayed onset muscle soreness, spine-related neuromuscular dysfunction, or musclerelated neuromuscular dysfunction) or ‘structural’ muscle pathologies. The latter still divides into subgroups of minor, mild, moderate, complete. However, a further report by the Munich group concluded that the ‘structural’ part of the Munich categorisation was

DIAGNOSTIC IMAGING OF MUSCLE INJURIES IN SPORTS MEDICINE: NEW CONCEPTS AND RADIOLOGICAL APPROACH. Yamada AF, Godoy IRB, Pecci Neto L et al. Current Radiological Reports 2017;5:27 helpful prognostically, but the ‘functional’ aspect of the system was not because the significance of site of the lesion, length, tendon involvement and crosssectional size of the muscle injury was missing. The British Athletics Muscle Injury Classification proposes five grades of muscle injury. Grade 1 injuries are small tears in a limited part of the muscle, not greater than 10% of its cross-sectional area (CSA) and less than 5cm in extension. Grade 2 lesions are moderate tears with signal changes/oedema affecting between 10 and 50% of the muscle’s CSA and with extension between 5 and 15cm. Grade 3 injuries are extensive tears affecting more than 50% of the muscle’s CSA and greater than 15cm of extension. Grade 4 injuries are complete tears of the muscle or its tendon, often with a palpable gap. The grades 1–4 are subdivided into ‘a’, a myofascial injury at the muscle–fascia

interface at the peripheral aspect of the muscle; ‘b’ is mostly within the muscle belly or the muscle–tendon junction with no intratendinous involvement; ‘c’ denotes extension of an injury into the tendon. There is also the Peetrons grading system, which uses four scores (0, no abnormality; 1, muscle oedema with no architectural distortion; 2, oedema with architectural distortion of muscle fibres; and 3, full-thickness tear.

Co-Kinetic comment All of this is really about predicting the future. Realistically how long will it take to get an athlete back to playing? The more you know about the position and extent of a muscle injury the more chance you have of a reasonable guesstimate. At elite level knowing this may have a huge impact on future results and maybe financial implications if you have to buy a new striker or a starting pitcher. We can’t help thinking, however, that rather than attempting catch-all grading systems (of which there seem to be a few and all are subject to various pros and cons) just work on the whatever the radiologist’s report actually says.

COLLATERAL LIGAMENT KNEE INJURIES IN PEDIATRIC AND ADOLESCENT ATHLETES. Kramer DE, Miller P, Berrahou IK et al. Journal of Pediatric Orthopaedics 2017;doi:10.1097/BPO.0000000000001112 The rationale behind this study was that the majority of research on medial collateral (MCL) and lateral collateral ligament (LCL) injuries has focused on adults and combined collateral/cruciate injuries so it was time to look at younger ones. Electronic medical records at Boston Children’s Hospital were queried to identify patients aged below 17 years who sustained an MRIconfirmed isolated MCL or LCL injury over an 8-year period. Injuries to 51 knees (33 in males, 65%), mean age 13.8 years (range 5–17 years), were identified, of which 40 (78%) had MCL injuries. Over half (29,

57%) of knees had an open distal femoral physis including all five bony avulsion injuries. Eleven (22%) had LCL injuries of which three (6%) had concurrent posterolateral corner injuries. Forty-two (82%) knees had injuries that occurred during sports. Eleven knees (28%) with MCL tears had a simultaneous patellar instability episode. Knee injuries that occurred during sports had 37% shorter recovery time. Eight knees (16%) experienced a reinjury and 12 (24%) were followed over an extended period of time for various knee issues. Football (American) injuries were more likely to be grade 3, and football and soccer accounted for all grade 3 injuries. The mean return to sports was 2.2 months, with grade 3 patients returning at 2.4 months, and 95% of patients within 4 months. Isolated collateral ligament injuries are rare in adolescent athletes.

Co-Kinetic comment The MCL vs LCL comparison is a bit less than in adults where around 29% are MCL and LCL around 2% (Bollen S. Epidemiology of knee injuries: diagnosis and triage. Br J Sports Med. 2000;34(3):227–228). 8

Co-Kinetic Journal 2018;76(April):4-9

RESEARCH INTO PRACTICE

CLINICAL FACTORS THAT PREDICT A SECOND ACL INJURY AFTER ACL RECONSTRUCTION AND RETURN TO SPORT: PRELIMINARY DEVELOPMENT OF A CLINICAL DECISION ALGORITHM. Paterno OPEN MV, Huang B, Thomas S et al. Orthopaedic Journal of Sports Medicine 2017;5(12):doi:10.1177/2325967117745279 A total of 163 participants (mean age, 16.7±3.0 years) who underwent primary anterior cruciate ligament reconstruction (ACLR) and were able to return to sport (RTS) were evaluated. All participants completed an assessment of isokinetic strength, hop testing, balance, and the Knee Injury and Osteoarthritis Outcome Score (KOOS). Participants were tracked for a minimum of 24 months to identify occurrences of a second ACL injury. The initial 120 participants enrolled were used to develop a clinical prediction model that utilised classification and regression tree (CART) analysis, and the remaining 43 participants enrolled were used as a validation data set. Additional analyses were performed in all 163 participants using Kaplan–Meier analysis and Cox proportional hazards modelling. Approximately 20% (23/114) of the initial subset of the cohort suffered a second ACL injury. CART analysis identified age, sex, knee-related confidence, and performance on the triple hop for distance at the time of RTS as the primary predictors of a second ACL injury. Using these variables, a model was generated from which high-risk (n=53) and low-risk groups (n=61) were identified. A total of 22 participants in the high-risk group and 1 participant in the low-risk group suffered a second

A total of 60 male amateur athletes (age 21.1 years, height 176.7cm and mass 77.55kg) were randomly assigned to four equal groups (N=15) receiving either (a) an aggressive sports massage (N=15), (b) a cold water immersion (N=15), (c) a combination of previous techniques (N=15) or served as control group (N=15). They all performed a plyometric exercise protocol consisting of consecutive drop jumps (5 sets of 20 drop jumps), aiming at the creation of delayed onset muscle soreness (DOMS). The examination and evaluation of DOMS were based on variables such as exercise intensity (BORG) and muscle pain (VAS), Co-Kinetic.com

ACL injury. High-risk participants fitting one of two profiles are five times more likely to suffer a second ACL injury. Profile 1: age <19 years, triple hop for distance between 1.34 and 1.90 times body height, and triple hop for distance limb symmetry index (LSI) <98.5% (n=43). The LSI was determined by 100% representing perfect symmetry between limbs on the measure and less than 100% representing a deficit in the involved limb. Profile 2: age <19 years, triple hop for distance >1.34 times body height, triple hop for distance LSI >98.5%, female sex, and high knee-related confidence (how much the individual is troubled by lack of confidence in his or her knee) (n=10). The validation step identified the high-risk group as being five times more likely to suffer a second ACL injury, with a sensitivity of 66.7% and specificity of 72.0%.

THE ASSOCIATION OF RECREATIONAL AND COMPETITIVE RUNNING WITH HIP AND KNEE OSTEOARTHRITIS: A SYSTEMATIC REVIEW AND META-ANALYSIS. Alentorn-Geli E, Samuelsson K, Musahl V et al. Journal of Orthopaedic & Sports Physical Therapy 2017:47(6):373–390 The usual databases were searched to identify studies investigating the occurrence of osteoarthritis (OA) of the hip and/or knee among runners. A meta-analysis of studies comparing this occurrence between runners and controls (sedentary, non-running individuals) was conducted. Runners were regarded as ‘competitive’ if they were reported as professional/elite athletes or participated in international competitions. Recreational runners were individuals running in a non-professional context. Twenty-five studies (n=125,810 individuals) were included and 17 (n=114,829 individuals) were subjected to meta-analysis. The overall prevalence of hip and knee OA was 13.3% in competitive runners, 3.5% in recreational runners and 10.2% in controls. Exposure to running of less than 15 years had a lower association with hip and/or knee OA compared with controls.

Co-Kinetic comment Let’s be honest, if we live long enough we are all going to get OA somewhere. Don’t let the fear of that put you off the exercise. Sign up for that park run now, just don’t turn pro!

Co-Kinetic comment OK, we have the identifying factors for a second rupture risk. Now can we have the follow-up for what we do for the high-risk group to minimise the risk, please?

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THE EFFECT OF COLD WATER IMMERSION, AGGRESSIVE SPORTS MASSAGE AND THEIR COMBINATION ON DELAYED ONSET MUSCLE SORENESS SYMPTOMS IN AMATEUR ATHLETES: A RANDOMIZED CONTROL STUDY. Angelopoulos P, Diakoronas A, Panagiotopoulos D et al. Physical Therapy in Sport 2017;28:doi:https://doi.org/10.1016/j.ptsp.2017.08.019 knee flexion range of motion (ROM), quadriceps isometric strength (QIS) and serum creatine phosphokinase (CPK) levels. The above variables were assessed at baseline, immediately after plyometric exercise, 24, 48 and 72 hours after the exercise. The results were that all three interventions significantly reduced the pain sensation (VAS), compared to the control group. No significant statistical differences were found between the groups as regards CPK levels and knee flexion

ROM. Cold water immersion helped to restore muscle strength (QIS) compared with the other interventions, whereas aggressive sports massage led to an improved sense of fatigue (BORG) compared with the other treatments.

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Co-Kinetic comment Do the combination and you cover all the bases, but remember the often mentioned caveat that males do not like cold water immersion above the waist! 9

THE 10 MOST DISCUSSED PIECES OF RESEARCH IN PHYSICAL THERAPY (JAN-MAR 2018)

STATIN WARS: HAVE WE BEEN MISLED ABOUT THE EVIDENCE? A NARRATIVE REVIEW British Journal of Sports Medicine

ENERGY DRINKS: A CONTEMPORARY ISSUES PAPER Current Sports Medicine Reports

EXERCISE ALTERS GUT MICROBIOTA COMPOSITION AND FUNCTION IN LEAN AND OBESE HUMANS

Medicine & Science in Sports & Exercise

EFFECTS OF STRENGTH TRAINING ON THE PHYSIOLOGICAL DETERMINANTS OF MIDDLEAND LONG-DISTANCE RUNNING PERFORMANCE: A SYSTEMATIC REVIEW

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27 13

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ARE WE LEADING BY EXAMPLE? PHYSICAL ACTIVITY GUIDELINES AND PHYSICAL THERAPY All references marked with an asterisk are open access and links are provided in the reference list.

According to research, 88% of physiotherapists are aware of the current Chief Medical Officer’s Physical Activity Guidelines, but only 16% answered the three specific components correctly in a study published in the Lancet in 2016. And yet as healthcare providers, and this isn’t limited to just physiotherapists but includes all physical and manual therapists, we are perfectly positioned to promote the benefits of physical activity, and better still to use it to develop trust and build on relationships with new prospective clients. Physical activity is, in fact, a huge marketing opportunity. This article will review the current guidelines and explore how we can make best use of this knowledge to add value to the lives of our patients and clients. Read this article online http://spxj.nl/2oOgOgK Physical therapy is a profession that involves just that – being physical! Usually on your feet for hours during the day; improving or restoring physical function in patients through mechanical force and movements, manual and exercise therapy. The description of our occupation suggests we are physically active professionals, but are we really? Although our work often involves a lot of physical effort in terms of strength, it is also important to incorporate moderate or vigorousintensity physical activity (PA) in order to gain the health benefits that come with good cardiovascular fitness. And there’s no question that as healthcare providers, we play a critical

EXERCISE AS MEDICINE | 18-04-COKINETIC FORMATS WEB MOBILE PRINT

BY KATHRYN THOMAS BSC MPHIL role in encouraging, educating and empowering our patients to realise the same health benefits. Whether or not it’s fair for us to preach what we don’t practise is a valid question (and let’s face it we’re not alone in the healthcare industry at doing that), but at the very least, we must be up to date with the current guidelines. A recent survey (1*) of UK physiotherapists showed three main findings: 1. The proportion of physiotherapists who achieved the recommended 5×30min of moderate-intensity PA over a week was only 38%.

The median number of sufficiently active days was 4 instead of the recommended 5 per week. 2. Knowledge of all three elements of the PA guidelines was poor. 3. 68% of physiotherapists report that they routinely deliver brief interventions for PA to their patients. Physical inactivity (PI) is defined as achieving less than 30min PA per week (2*). Research has shown that PI has a significant impact on morbidity and mortality; inactive people spend 38% more days in hospital and use significantly more healthcare resources than active people. Apart from the economic burden on healthcare systems and wider society, we know

MEDIA CONTENTS Physical Activity Infographic from the UK Chief Medical Officers. UK Department of Health

and Social Care http://spxj.nl/2ofyQIi NHS General Practice Physical Activity Questionnaire (GPPAQ). UK Department of Health, The National Archives http://spxj.nl/2EI3EIb GPPAQ Screening Tool: Report and How to Use Guide. UK Department of Health, The National Archives http://spxj.nl/2EI3EIb

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the many lifesaving benefits of being physically active. Accordingly, there are national and international guidelines on PA (1*,3). The question is, are we as physical therapists taking advantage of the facetime we have with patients to promote these benefits and, importantly, are we endorsing these benefits ourselves by implementing them into our weekly routines? This article aims to look at where we, as physical therapists are, how we are placed to facilitate PA promotion and to review any updates on the guidelines.

WHERE DO WE CURRENTLY STAND (OR RUN)? As stated above, in a recent study of UK physiotherapists most respondents did not themselves do sufficient PA to confer optimal health benefits (1*). This is unlike other countries where studies have shown physiotherapists to sufficiently meet the PA guidelines; with those in public practice reporting and participating in more physical activity than those in private practice (4*). Interestingly, research has shown that the frequency with which physiotherapists delivered brief interventions (BIs) was not associated with years of experience nor was it associated with physiotherapists’ own PA habits (1*). So do we need to revisit the guidelines ourselves? It seems that may be the case, given that the knowledge of the three different components of the PA guidelines is reported as poor (1*). Physiotherapists, 88% of them, may be aware of the current Chief Medical Officer’s PA guidelines; however, only 16% answered the three specific components correctly (5). We are not alone, in Ireland a survey of physiotherapists reported

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only 51% of participants were able to accurately state the guidelines (6). Other healthcare professions have also highlighted a lack of curriculum content and PA knowledge (1*). This all adds weight to the recent claim by Reid et al. (7) that basic knowledge of the PA guidelines, and their components, remains consistently low across all health professionals.

WHAT IS EXPECTED OF US? There are many factors that may influence PA across a population. To make meaningful change, sustained effort across multiple systems of education, awareness, campaigns, community outreach programmes, to name a few, are required. The healthcare system is clearly one of the best placed to integrate PA promotion and reduce PI (1*). Making Every Contact Count (MECC) is an approach to behaviour change that utilises day-to-day interactions that organisations and individuals have with other people to support them in making positive changes to their physical and mental health and wellbeing. This principal is now embedded within the National Health Service (NHS) and clinical guidance recommends the use of BIs during routine clinical contacts (8*). BIs like these have the potential to reach a large proportion of the adult population and have been shown to be cost-effective (1*). They can increase short-term, self-reported physical activity; however, there is uncertainty about the long-term impact of BIs on PA. Definitions of BIs include interventions that may not be feasible in primary care owing to practitioners reporting lengthy time-consuming discussions or the opposite, BIs that are too brief (less than 5min), owing to

IT IS IMPORTANT THAT PHYSICAL AND MANUAL THERAPISTS ARE UP TO DATE WITH CURRENT GUIDELINES ON PHYSICAL ACTIVITY time constraints, raising questions on effectiveness (9*). Physical and manual therapists are well-placed to deliver and promote PA during their patient appointments through BIs. In the UK alone there are over 51,000 physiotherapists working across health and social care (1*). In 2015–2016, there were over 5 million physiotherapy outpatient contacts (1*); giving huge potential to use BIs to promote PA. Within those appointments, a large proportion of patients may have been overweight or obese, have multiple co-morbid health conditions or be physically inactive (1*) where they could have profited from education on the health benefits of PA. In addition to this, children receiving treatments or parents of children with weight issues may have been enlightened about the negative effects of a sedentary lifestyle. General PA, not just therapeutic exercises, compliments many musculoskeletal conditions treated by physical and manual therapists, again emphasising our role and responsibility in the healthcare system. It is encouraging that, in the UK, it has been reported that 68% of physiotherapists routinely deliver BIs for PA. This is not necessarily the case in other countries where several international studies suggest that levels of PA promotion in physical therapy

Figure 1: Physical activity infographic from the UK Chief Medical Officers. Available to download from the UK Department of Health and Social Care (http://spxj.nl/2ofyQIi)

and physiotherapy practice is low (5,6,10,11*,12*,13*). So, although seemingly better than others, what about the remaining 32% of physical therapists who reported no promotion of PA during patient consultations? Literature suggests that barriers may include: (i) lack of time, (ii) lack of belief in the effectiveness of BIs, (iii) perceived lack of knowledge, and (iv) a sense that it is not acceptable to patients (1*,6,13*). Research has shown that almost all physical therapists thought it would be feasible to incorporate brief PA

counselling into regular treatment sessions (13*). Separate one-onone and group PA consultations were thought to be less feasible. As treatment by a physical therapist is usually spread out over several sessions, and many weeks, this duration will allow time for the provision of sequential PA advice that has previously been shown to be important for effective PA promotion (13*). Ninety percent of physical therapists also thought it would be feasible to distribute PA promotion resources (13*). As many as 56% of physiotherapists did not routinely direct patients to further sources of support for PA, even when there was a clear indication to do so (1*). Uptake of further support has been shown to be enhanced when onward referral is facilitated following a BI. An example may include making an appointment at that time, rather than leaving it to patients to initiate further action themselves (1*).

NEW RESEARCH ON PHYSICAL ACTIVITY BENEFITS AND THE GUIDELINES Delivering BIs for PA requires healthcare professionals to have knowledge of the PA guidelines. The first UK-wide PA guidelines were published in 2011 (Links 1 and 2) (14*); these were updated and formatted into an infographic in 2015 (Fig. 1) (15*). Although there have been no changes to the guidelines since then, it is expected there will be an amendment to them which is due to be released in March 2018. The Department of Public Health England did, however, recently (August 2017) publish and promote a campaign ‘10 minutes brisk walking each day in mid-life for health benefits and towards achieving physical activity recommendations’ (Link 3). A quick search on any medical database for ‘physical activity/exercise is medicine/health benefits’ results in an overwhelming number of published articles, upward of 90,000. Therefore, discussing this topic in totality would be outside the realm of this article. However, highlighting areas of new

research and benefit will be mentioned below; in addition, a recent paper published by Rhodes et al. gives a highlevel comprehensive overview of the literature on PA benefits and may be a good reference (16).

Reducing Premature Mortality The ability for routine PA to simultaneously reduce the risk for varied chronic conditions and premature mortality is remarkable. ‘Exercise is Medicine’, the wonder drug – if only they could bottle it! Well, to date, it still seems the precise mechanisms by which routine PA positively affects multiple conditions remains difficult to independently determine. However, studies show that PA participation leads to various physiological and psychological adaptations that work in a coordinated and additive fashion to improve health status and reduce risk (16). Research has shown that routine PA participation results in: 1. improved healthrelated physical fitness 2. increased exercise tolerance and functional status 3. improved body composition (eg. protect against obesity, reduce abdominal obesity and/or improve weight control) 4. enhanced lipid lipoprotein profiles (eg. reduced triglycerides, higher HDL cholesterol, lower LDL to HDL ratios) 5. improved glucose homeostasis and insulin sensitivity 6. reduced blood pressure 7. improved autonomic tone 8. decreased blood coagulation 9. improved coronary blood flow 10. augmented cardiac function 11. enhanced endothelial function 12. reduced systemic inflammation 13. improved psychological well-being (eg. reduced stress, anxiety and depression) (16). These adaptations may explain (at least in part) the ability for PA to be an effective primary and secondary preventative strategy for at least 25 chronic medical conditions and premature mortality. Virtually everyone

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can benefit from being more physically active. Even small changes in PA [eg. less than half of the current 150min moderate-to-vigorous physical activity (MVPA) recommendation] can lead to marked and clinically relevant changes in health status (particularly in inactive and/or clinical populations) (16). Overwhelming epidemiological evidence shows a 31% lower risk for all-cause mortality in the most active individuals in comparison to the least active. Like several other reviews, a clear dose–response relationship is observed with relatively small changes in PA/fitness leading to significant reductions in the risk for all-cause mortality. The optimal health benefit (39%) is seen following the recommended PA guidelines, however recent studies have revealed that any level of PA participation [eg. 6 to <450 metabolic equivalent (MET)min/week] was associated with a significantly lower risk of mortality (20%) (16).

Sedentary Lifestyle Research has shown that the population risk of heart disease attributable to inactivity is greater than other risk factors such as obesity, smoking and high blood pressure. The relative risk for cardiovascular disease (CVD)-related mortality associated with PI has been shown to be like that of other risk factors, such as hypertension, hypercholesterolemia and obesity; even moderate cigarette smoking (16,17). Metabolic syndrome (a consequence of the association of overweight, hypertension and diabetes) is a high risk for coronary events. Regular physical training has been recently promoted to reduce cardiovascular risks factors in these patients through improved lifestyle and by the ‘anti-inflammatory effectiveness’ (18). A recent publication is calling for a paradigm shift away from the historic belief that saturated fats clog your arteries and contribute to atherosclerosis and CVD, stating that studies have shown there is no association between saturated fat consumption and all-cause mortality. Yes, atherosclerosis is a real killer, but the mechanism is based on an

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THE ABILITY FOR ROUTINE PHYSICAL ACTIVITY TO SIMULTANEOUSLY REDUCE THE RISK FOR VARIED CHRONIC CONDITIONS AND PREMATURE MORTALITY IS REMARKABLE inflammatory process that contributes to cholesterol deposition within the arterial wall and subsequent plaque formation (atherosclerosis). The simple way to combat coronary artery disease, a chronic inflammatory disease, is through regular PA, a minimum of 22min/day. Walking briskly at or above 150min/week can increase life expectancy by 3.4–4.5 years independent of body weight (19*). Studies have demonstrated clear associations of PA (and sedentary behaviour), energy expenditure, adiposity and appetite control. The relationship is likely to be bidirectional, but data indicates strong links between physical inactivity and obesity (20). Compared to normal weight-fit individuals, unfit individuals had twice the risk of mortality regardless of body mass index (BMI). Overweight and obese-fit individuals had similar mortality risks as normal weight-fit individuals. So, the obesity paradox may not influence fit individuals; meaning research seems to show that the protective benefits of PA may be independent of weight or weight loss. Researchers, clinicians and public health officials should focus on PA and fitness-based interventions rather than weight-loss driven approaches to reduce mortality risk (21*).

Efficacy of PA Compared to Medication PA can, potentially, be more effective than widely used pharmaceutical interventions. Although metformin reduces the incidence of diabetes by 31% (as compared with a placebo) in both men and women across different racial and ethnic groups, lifestyle intervention (including exercise) reduces the incidence by 58% (22*). A lack of understanding of the interactions between pharmaceuticals and exercise could lead doctors to prescribe treatments that are not only

less effective than exercise, but which might also serve to blunt its therapeutic effect. A recent study suggests that metformin may attenuate the effects of exercise on certain cardiovascular risk factors and the severity of metabolic syndrome in patients with impaired glucose tolerance (23*). In this context even more startling is that some statins may attenuate the exercise-mediated increases in cardiorespiratory fitness in obese or overweight patients (24*).

Cancer and Other Diseases A positive impact has been shown in the case of cancer-survived patients, with or without co-morbidities, and especially in those subjects where the inflammatory process is globally represented. The American College of Sports Medicine (ACSM) guidelines and, more recently, a new Italian model both support the role of ‘exercise as therapy’ at a moderate level of energy expenditure in cancer patients (18). Breast cancer is the most the frequently diagnosed cancer and the leading cause of cancer deaths in women worldwide. Many studies show a relationship between exercise behaviour and breast cancer prognosis. Additionally, more recently, research reports a relationship between fitness and disease-free survival in women with breast cancer. Exercise is safe and beneficial after breast cancer, reversing sequelae such as weakness and fatigue (25). Research has again shown that exercise training minimised carcinogenic mechanisms related to inflammation (25). This may also be a mechanism by which exercise training improves overall survival in this population (25). Among men with overweight and obesity, higher cardiorespiratory fitness (CRF) was associated with lower cancer mortality. Eliminating low CRF as a risk factor could potentially prevent a considerable number of cancer deaths (26*). Systemic hypertension is one of

the most important risk factors for CVD, and has been ranked as the leading cause for death and disability worldwide: therefore, adequate control of blood pressure is important for public health. Lowering of blood pressure and prevention of hypertension is, in the first instance, preferable by lifestyle changes. These include weight loss, moderation of alcohol intake, a diet with increased fresh fruit and vegetables, reduced saturated fat, reduced salt intake, reduced stress, and, finally, increased PA. Historically, exercise training in pulmonary hypertension has not been recommended because of safety concerns. However, an increasing number of studies have demonstrated the benefit of exercise training on exercise capacity, peak oxygen consumption and quality of life (27*). Diseases of the cardiovascular system, cancer (both colon and breast), and type 2 diabetes have had considerable research focus. However, important emerging evidence has demonstrated the remarkable health benefits for cognition and mental wellbeing in people who are regularly active.

Cognitive Function From midlife to old age, greater PA is associated with better mental health and vice versa. Research suggests persistent longitudinal and bidirectional associations

A SIMPLE WAY TO COMBAT CORONARY ARTERY DISEASE IS THROUGH REGULAR PHYSICAL ACTIVITY

between PA and mental health (28*). The number of patients suffering from dementia is expected to be more than triple by the year 2040. One of the most effective prevention mechanisms against dementia lies in increasing brain- and cognitive-reserve capacity, which has been found to reduce the behavioural severity of dementia symptoms as neurological degeneration progresses. Most factors known to enhance this are historical or non-modifiable; however, regular exercise has been associated with decreased risk of dementia (29*). Questions remain unanswered around this topic including the amount of training required to receive any cognitive benefit from these activities and the extent to which this benefit continues following cessation. Future research is warranted on what the potential for exercise and other lifestyle activities serve as both a prophylactic and therapeutic treatment for dementia (30*). Current evidence suggests positive effects of exercise on post-traumatic stress disorder (PTSD) symptoms; however, knowledge about how these effects are achieved is limited (31*). Clinically significant reductions in PTSD severity after two-weeks of aerobic exercise intervention has been shown, suggesting aerobic exercise can improve PTSD symptoms (32).

Active Ageing â&#x20AC;&#x2DC;Active ageingâ&#x20AC;&#x2122; is also a new area of focus regarding PA and the elderly; there is huge importance, and complexity, in promoting PA among older adults. The inverse association between PA and the risk of CVD is significant in the elderly and comparable with middle-aged individuals (33*). PA is vital, and beneficial, in not only managing noncommunicable diseases (NCD) in this population, but also preserving functional capacity, neuromotor abilities, balance coordination, reaction time and neurological or cognitive health (34*).

Strength Training and Sport It is important to note that numerous chronic conditions (eg. type 1 diabetes and various psychological conditions) that are not the result

of physical inactivity can show marked improvement from exercise rehabilitation and/or routine PA participation. Research has demonstrated that remarkably small volumes of activity (or exercise) can lead to clinically relevant risk reductions in persons living with chronic medical conditions. It highlights the importance of individualised exercise prescriptions to positively influence life with chronic medical conditions (16). As stated in the guidelines, it is not just cardiovascular fitness that provides health benefits. Strength training, performed two or more days a week, is also recommended. Research has shown that musculoskeletal fitness positively correlates with glucose homeostasis, functional status, bone health, mobility, psychological well-being and overall quality of life, and negatively associated with fall risk, morbidity and premature mortality (16). Sport is one way to prescribe or achieve exercise for health. Research showed that among many sports swimming, aerobics and racquet sports showed the largest reductions in mortality risk (as indicated by the HR value) (35). Following this research, discussions on the aetiology of the beneficial associations that participation in certain sports conferred suggested that the lower mortality did not reflect the health attributes of the sport but, instead, was related to socioeconomic characteristics of the participants of certain sports. For example, as football is perceived to be lower social status sports, the smaller association with mortality could be an indication of participantâ&#x20AC;&#x2122;s socioeconomic status and affluence. Racquet sports, aerobics and swimming usually involve paying for participation and/or equipment and as such may indicate membership of a higher socioeconomic group. Adjustments were subsequently made for educational attainment and occupation (as is generally considered a better indicator of current socioeconomic circumstances) and the results confirmed that sport or vocational PA or just about any form of recreational activity has a strong protective role. The re-analysis of the

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data showed that it was the sport, not the socioeconomic status that provided the protective effect (35). The key results remained that (a) we need to develop and promote healthenhancing sport programmes to reach more people from all ages across all socioeconomic groups and (b) when sports participation is not a possibility, to support opportunities to adopt new active choices both in everyday life and during recreation (35). Interestingly, a large, statistically powerful study by O’Donovan et al. has suggested that different leisure time PA patterns are associated with reduced risks for all-cause, CVD and cancer mortality (36). Although not adhering to the PA guidelines it appears that the ‘weekend warrior’ and other PA patterns characterised by 1 or 2 sessions per week of moderate- or vigorous-intensity PA may be sufficient to reduce risks for all-cause, CVD and cancer mortality (36).

ASSESSMENT FOR PHYSICAL ACTIVITY An abundance of data unequivocally demonstrates that exercise can be an effective tool in the fight against NCDs. Despite the well-established long-term beneficial effects of exercise, the risk of an acute cardiovascular event may be transiently elevated during and just after vigorous physical exertion for susceptible individuals. This is the so-called ‘paradox of exercise’ (22*). This paradox does not mean doctors should refrain from prescribing exercise; the long-term benefits of exercise far outweigh the acute risks (22*). Indeed, low levels of PA are a significant contributing factor to whether an individual is susceptible to the elevated risk of sudden death during exercise. This risk is dramatically lower in regular exercisers and dramatically higher in habitually sedentary individuals who undertake a sudden bout of unaccustomed vigorous exercise (22*). Doctors have a moral reason, grounded in the duty of non-maleficence (ie. the duty to not harm patients), to refrain from: 1. preventing patients from undergoing beneficial treatment without good reason

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2. exposing patients to unreasonable risks (reasonable risk is defined below) 3. reducing the therapeutic effect of an effective medical intervention (22*).

Determining the Risks In determining whether the risks of participation in exercise are reasonable, the following factors are relevant: 1. Is there a known risk to participants before commencing exercise and what is its magnitude, based on evidence available at the time? Are there relevant evidence-based professional guidelines (eg. ACSM guidelines) to categorise the risk to this participant? 2. Should any further research (eg. systematic overview or computer modelling) be performed before the exercise to better estimate the risk to participants? 3. Could the risk be reduced in any other way? Is it as small as possible? 4. Are the potential benefits (in terms of health and global well-being) of exercise worth the risks? (22*)

FORMAL ASSESSMENT OF PHYSICAL FITNESS SHOULD INVOLVE USE OF A MEASUREMENT TOOL as individuals become more physically active/fit. The recently updated ACSM preparticipation guidelines (Link 4) (37*) proposed a new evidence-informed model for exercise pre-participation health screening based on three variables that have been identified as risk modulators of exercise-related cardiovascular events: 1. the individuals current level of PA 2. presence of signs or symptoms and/or known cardiovascular, metabolic, or renal disease 3. desired exercise intensity (37*). Identifying CVD risk factors remains an important objective of overall disease prevention and management, but risk factor profiling is no longer included in the exercise pre-participation health screening process. The new ACSM

A lack of understanding of the physical impact of exercise may lead doctors to overemphasise the risk factors for a cardiac event during exercise. This can result in an under-prescription of exercise for patients with known cardiovascular, metabolic or renal disease, or dissuade them from exercise by insisting on tests before activity, tests that the scientific community have agreed are unnecessary (37*).

Screening Tools Studies have suggested that using the old ACSM exercise pre-participation health screening guidelines can result in excessive physician referrals, possibly creating a barrier to exercise participation. In addition, there is considerable evidence that exercise is safe for most people and has many associated health and fitness benefits; exercise-related cardiovascular events are often preceded by warning signs/ symptoms; and the cardiovascular risks associated with exercise lessen

Figure 2: NHS General Practice Physical Activity Questionnaire. Available to download from the UK Department of Health, The National Archives

(http://spxj.nl/2EI3EIb)

exercise pre-participation health screening recommendations reduce possible unnecessary barriers to adopting and maintaining a regular exercise programme, a lifestyle of habitual PA, or both, and thereby emphasise the important public health message that regular PA is important for all individuals (37*). Within the article is a summarised flowchart (Link 5) on the screening process and may be beneficial to have in your practice for quick reference regarding which patients needs further tests/referrals to a physician before starting a PA routine. Formal assessment of physical fitness should involve use of a measurement tool. Current clinical guidance recommends the use of the General Practice Physical Activity Questionnaire (GPPAQ) (Fig. 2) to assess PA levels in routine practice (See Link 6 for full details including the downloadable report and how to use guide as well as GPPAQ) (38*). These measures take time to complete and interpret and, therefore, may not be practical in a busy clinical setting, especially if the appointment is not specifically dedicated to PA promotion. In addition to this, none of the assessment tools [GPPAQ, Brief Physical Activity Assessment Tool (BPAAT) or Physical Activity Vital Sign (PAVS)] have shown high reliability and validity (39). The alternative is to use informal approaches which, although quicker, are likely to be insufficient to accurately measure PA levels and inadequate as a baseline from which to measure change.

The Two Question Assessment (2Q) has been reported to be preferred by clinicians and may be most appropriate for dissemination (Table 1) (40).

HOW CAN WE STRIDE AHEAD IN PHYSICAL ACTIVITY PROMOTION? Physical and manual therapists are ideally placed to contribute to the global efforts to reduce PI. However, support is required to ensure that effective and feasible PA interventions are integrated into routine care to maximise potential impact. Physical and manual therapists have the advantage of exercise knowledge, repeated facetime with patients, counselling skills and trusted relationships to potentially make meaningful change to patients’ lives. Exercise prescription can be a powerful weapon in preventing NCD and premature death. To maximise the therapeutic benefits of exercise and to avoid unnecessary harm, it must be implemented by professionals with an adequate understanding of the guidelines, both the recommended weekly PA and pre-participation screening guidelines. Most discussions around PA focus upon modes considered to be traditionally ‘aerobic’ (eg. running, cycling, rowing, swimming, etc). Current guidelines do include recommendations to engage in ‘muscle strengthening activities’ though there has been very little emphasis upon these modes in either research or public health effort (41*). Greater emphasis needs to be placed upon resistance training as a beneficial component of PA.

TABLE 1: TWO QUESTION ASSESSMENT OF PHYSICAL ACTIVITY 1. How many times a week do you usually do 20min or more of vigorous-intensity physical activity that makes you sweat or puff and pant? (eg. heavy lifting, digging, jogging, aerobics or fast bicycling?) 3 or more 1–2 None times a week times a week 2. How many times a week do you usually do 30min or more of moderate-intensity physical activity or walking that increases your heart rate or makes you breathe harder than normal? (eg. carrying light loads, bicycling at a regular pace, or doubles tennis) 5 or more 3–4 1–2 None times a week times a week times a week (Sourced Smith BJ et al. Screening for physical activity in family practice: evaluation of two brief assessment tools. Am J Prev Med 2005;29(4):256–264)

Higher recreational and nonrecreational PA has been associated with a lower risk of mortality and CVD events in individuals from lowincome, middle-income, and highincome countries (42*). Encouraging an increase in PA through sport, recreation, structured exercise routines or during daily activities and chores is a simple, widely applicable, lowcost global strategy that could reduce deaths and CVD.

WHAT CAN YOU DO TODAY TO START PUTTING THE INFORMATION IN THIS ARTICLE INTO PRACTICE? n Education is key – every Co-Kinetic subscription includes access to 38 printable, downloadable client advice handouts covering physical activity advice for a whole range of different health conditions (http://spxj.nl/2EFBgud). n Send regular email updates on different aspects of physical activity promotion (use content from the Co-Kinetic leaflets if you want to). n Give short evening or lunchtime presentations on the benefits of physical activity for specific health conditions – this is a great valueadded opportunity to get together with existing clients and if you give them the option to bring a friend, that’s more new leads and prospective customers.

DISCUSSIONS Having read this article, would your approach to physical activity promotion and participation differ now, and if so how? Is there scope for brief interventions on physical activity in your practice and would you be confident incorporating it into your patients’ sessions? What tools and assessments would you use to aid promotion of physical activity with your patients?

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LINKS Link 1: UK physical activity guidelines (http://spxj.nl/2omb0Kh) UK Department of Health and Social Care Link 2: UK guidance on physical activity http://spxj.nl/2EKakcV National Institute for Health and Care Excellence (NICE) Link 3: 10 minutes brisk walking each day in mid-life for health benefits and towards achieving physical activity recommendations. Evidence summary. (http://spxj.nl/2olflNS) Public Health England Link 4: Riebe D et al. Updating ACSM’s recommendations for exercise preparticipation health screening. Med Sci Sports Exerc 2015;47:2473–2479 http://spxj.nl/2EI64Gs Link 5: The new exercise preparticipation health screening process algorithm. http://spxj.nl/2EI64Gs Figure 2 from Riebe D et al. (37) Link 6: The General Practice Physical Activity Questionnaire (GPPAQ): all information and templates (http://spxj.nl/2EI3EIb) UK Department of Health, The National Archives

THE AUTHOR Kathryn Thomas BSc Physio, MPhil Sports Physiotherapy is a physiotherapist with a master’s 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. Email: kittyjoythomas@gmail.com

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/2Il1mRo

RELATED CONTENT Exercise is medicine and the role of sports physician – Fisic Conference Presentation 2015 http://spxj.nl/2Cmf3eJ Physical Activity for Health Advice Handouts http://spxj.nl/2EFBgud

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Therapists are well-placed to deliver and promote physical activity through brief interventions http://spxj.nl/2oOgOgK Tweet this: Physical activity results in various, coordinated adaptations that improve health http://spxj.nl/2oOgOgK Tweet this: Small changes in physical activity lead to significant reductions in risk for all-cause mortality http://spxj.nl/2oOgOgK Tweet this: The protective benefits of physical activity may be independent of weight or weight loss http://spxj.nl/2oOgOgK Tweet this: Formal assessment of physical fitness should involve use of a measurement tool http://spxj.nl/2oOgOgK

KEY POINTS n Regular physical activity leads to various physiological and psychological adaptations that improve health status and reduce disease risk in over 25 chronic illnesses. n A clear dose–response relationship is observed with relatively small changes in physical activity leading to significant reductions in the risk for all-cause mortality. n Sitting for over 8 hours a day with no additional physical activity, is equivalent to smoking and obesity in terms of mortality risk. n Physical activity can potentially be more effective than many widely used pharmacological medications in chronic disease. n ‘Active ageing’ is a new area of focus where physical activity not only benefits elderly with chronic disease, but can preserve functional capacity, neuromotor abilities, balance, coordination, reaction time, and neurological or cognitive health. n 1 hour of moderate-intensity physical activity per day seems to eliminate the increased mortality risks of prolonged inactivity. n Not all physical therapists have thorough knowledge of the physical activity guidelines. n Physical therapists should lead by example, incorporating the physical activity guidelines into their weekly schedules. n Brief interventions have been shown to be effective, in both time and cost, in educating patients about the benefits of physical activity. n Physical therapists are ideally positioned within the healthcare system to use their facetime with patients to promote physical activity and circulate additional information to them.

Co-Kinetic.com

THE RAPID RETURN HAMSTRING TO SPORT HUSTLE: VERSUS RECURRENCE BY KATHRYN THOMAS BSC MPHIL

Isn’t this the pressure that you, as a physical therapist, are put under every day? “How soon, how quickly, when, why, how come?”; “This is costing me money and time, I’m losing my place in the team, I have a race coming up…” Making that call of when a patient can return to full sport can be challenging; especially when there are coaches, sponsors, parents and the athlete all adding to the ‘drama’, as well as social media or the internet giving their own ‘advice’. There is a plethora of information out there regarding hamstring injuries, often confounding. You are not alone, even the research can be confusing and ill-defined. This article will look at the most recent research available regarding return-to-sport prerequisites following a hamstring strain injury and enable you to get your patient to that point of readiness through the most current, and successful, rehabilitation protocols. Read this article online http://spxj.nl/2oPxO6m All references marked with an asterisk are open access and links are provided in the reference list.

LOWER LIMB | 18-04-COKINETIC FORMATS

WEB

MOBILE

MEDIA CONTENTS Video 1: Assessment – At Return to Sport, Include Dynamic Flexibility H-test by Askling. Courtesy of YouTube user Aspetar https://youtu.be/VYnMnb7AlKE Video 2: Nordic Hamstring Curl Variations | Hamstring Training. Courtesy of YouTube user Physiotutors https://youtu.be/ihTUvs997b4 Video 3: The 4 Best Hamstring Exercises | Hamstring Training. Courtesy of YouTube user Physiotutors https://youtu.be/2PGC_gmgj30 Video 4: Askling Protocol | Hamstring Strain Rehabilitation. Courtesy of YouTube user Physiotutors https://youtu.be/D6bGLfCk4QU Video 5: Hamstring Rehab for Football Players. Courtesy of YouTube user Hamstring Rehab https://youtu.be/MdzA6vwz9hA

INCIDENCE OF HAMSTRING STRAIN INJURY Hamstring strain injuries (HSIs) are most prevalent in team sports, accounting for 12–26% of injuries in Australian rules football, American football, football (soccer), rugby and track and field (1). Hamstring muscle strains are associated with significant time loss and high financial costs for the player and clubs. The predominant hamstring injury mechanisms in football occur during high-speed running and/ or acceleration efforts, or during movements with large joint excursions (ie. stretching-type injury) such as high-kicking, split positions and glide tackling (2*). Hamstring injuries in football most commonly involve the Co-Kinetic Journal 2018;76(April):20-31

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proximal musclulotendinous junction (MTJ) of the biceps femoris long head (BFl), accounting for approximately 60–85% of all hamstrings injuries (2*). The occurrence of HSI is generally believed to be related to the presence of repetitive high-force eccentric actions (3), such as the ones observed during high-speed running, where the lengthening demands placed on the muscle could exceed the mechanical limits of the tissue. Increasing the eccentric strength of the hamstring muscles has, therefore, been proposed as a method to prevent hamstring injuries (3). Hamstring injuries are a heterogeneous group consisting of different injury types, locations and sizes, which makes recommendations regarding rehabilitation and prognosis about healing time difficult (4,5,6). The reinjury rate in football is high (7,8), which in most cases, may indicate inadequate rehabilitation programmes and/or premature return to sport.

RETURN TO SPORT Early return to sport (3 weeks) is often proposed for hamstring injuries, even though basic research clearly shows that ongoing muscle regeneration still occurs, and the risk of recurrence is dramatically increased at this point. Recurrence includes possible additional injury and non-optimal healing of the hamstring musculotendinous complex. Such an injury can cause an athlete severe hamstring problems for up to a year. Therefore, to manage hamstring injuries properly, it is important to address one of the main problems – the extremely high recurrence rate – which includes everything from exacerbation to reinjury. The acute hamstring injury and its recovery can be difficult for most lay people (including athletes and coaches) to comprehend, as jogging and moderatepaced running is often possible early after the injury, which suggests that full recovery is close. However, because the eccentric capacity (the ability to dissipate forces through lengthening contractions) of the hamstring musculotendinous complex is not challenged until the introduction of highpaced running, full recovery can still be weeks or months away. Co-Kinetic.com

THE OCCURRENCE OF HAMSTRING STRAIN INJURY IS GENERALLY BELIEVED TO BE RELATED TO THE PRESENCE OF REPETITIVE HIGH-FORCE ECCENTRIC ACTIONS Askling et al.’s important work also highlights the problem of a very early return to sport (4*). Isometric hamstring muscle strength in sprinters was 70% (2 weeks), 85% (3 weeks) and 90% (6 weeks) of the uninjured limb after an initial hamstring muscle injury. The actual length of time before these injured athletes felt that they were back at their pre-injury level was, however, a median of 16 weeks (range 6–50 weeks). Verrall et al. also showed that coach ratings of player performance were significantly lower immediately upon return to sport when compared with ratings for the entire season, and when compared with ratings from the two games before injury (9). Given that athletes (4*) and coaches (9) report that performance during early return to sport is reduced, it must be prudent to delay return to sport. Not only are athletes at greater risk of recurrence, which would potentially sideline them for an even longer period than the initial injury, they are also physically and mentally functioning at a lower level (4,9); in short, early return to sport has poor odds for success and is likely to fail in a large proportion of cases.The criteria for return to sport should be hamstring-function dependent, not time dependent (10*). Return-to-play (RTP) decisionmaking is a complex process, which is based on the evaluation of the relevant health (medical and injury-specific factors) and activity (performance factors) risks, but is also influenced by contextual factors known as decision modifiers (eg. timing of the season, competitive level, pressure) (11*). Despite the relevance of this issue, there is currently no consensus on RTP assessment following HSI in sports. As reported in a recent qualitative systematic review, numerous criteria are used but none of these have been validated (12,13*,14*). In the absence of scientific evidence, Delvaux et al. explored current practice with a survey of physicians from French and

Belgian elite football clubs (15*). The authors produced a list of RTP criteria but did not investigate the degree of consensus between responders. The paucity of available evidence on such a relevant topic in football medicine can be explained by the intrinsic limitations that research encounters in this field, such as ethics, players’ and clubs’ availabilities, and confidentiality (16). However, there remains the need for validated criteria to facilitate HSI RTP management (12). There are three major questions about RTP after hamstring injuries (13*): 1. How should RTP be defined? 2. Which medical criteria should support the RTP decision? 3. And who should make the RTP decision? A recent consensus statement (Link 1) (13*) aimed to answer these questions, through a systematic review and use of the Delphi procedure (Box 1). Consensus was achieved that RTP

BOX 1: THE DELPHI METHOD The Delphi method is relatively new and is described by Wikipedia as: The Delphi method is a structured communication technique or method, originally developed as a systematic, interactive forecasting method which relies on a panel of experts. The experts answer questionnaires in two or more rounds. After each round, a facilitator or change agent provides an anonymised summary of the experts’ forecasts from the previous round as well as the reasons they provided for their judgments. Thus, experts are encouraged to revise their earlier answers in light of the replies of other members of their panel. It is believed that during this process the range of the answers will decrease and the group will converge towards the “correct” answer. Finally, the process is stopped after a predefined stop criterion (e.g. number of rounds, achievement of consensus, stability of results) and the mean or median scores of the final rounds determine the results. Delphi is based on the principle that forecasts (or decisions) from a structured group of individuals are more accurate than those from unstructured groups.

TABLE 1: SUMMARY OF FINDINGS FOR RETURN-TO-PLAY (RTP) CRITERIA FOLLOWING HAMSTRING STRAIN INJURY (HSI) [Sourced Zambaldi et al., Br J Sports Med 2017;51(6):1221–1226 (12)] Functional performance

The ability to perform maximal sprints and reach maximal linear velocity were consistently considered essential by all participants. These activities require forceful contraction of the hamstrings and constitute the most prevalent mechanism of HSI in professional football. In line with this, participants also agreed that the player must complete a progressive running plan with total high-speed running distance equivalent to match requirements. While contributing to the restoration of the player’s physical condition, high-volume running training and high-speed running also place a considerable eccentric load on the hamstrings that is essential to restore full hamstring function. Another reason to support the completion of a structured running plan encompassing high-speed running is that maximal horizontal force and power while sprinting are reduced at RTP, possibly playing a role in recurrences. Furthermore, recovery of full aerobic and anaerobic fitness as well as achievement of match-based targets of external load also reached consensus. Together with completion of a testing session at maximal effort and under fatigue conditions, these criteria reinforce the need to restore pre-injury physical condition before RTP. The player has to train enough prior to RTP, as sudden peaks in their workload have been demonstrated to increase the risk of reinjury. Moreover, the unfit player is more vulnerable to fatigue, which is perceived as one of the most important risk factors for non-contact injuries and is considered the primary reason for the rise of HSI at the end of each half. Lastly, good lumbopelvic motor control is proposed as an association of lumbopelvic pathology with HSI. However, this has not been prospectively proven, although lumbopelvic stability exercises are widely used as a prevention strategy in professional football. The role of lumbopelvic motor control in HSI remains difficult to establish due to the lack of standardised assessment methods.

Strength and flexibility

All the participants agreed that full hamstring strength and flexibility are necessary for a safe RTP. A significant increased risk of reinjury within 12 months has been documented for incomplete recovery of hamstring muscle strength and flexibility in a cohort consisting of mostly football players. Conversely, another study reported that 35 out of 52 football players with clinically-recovered HSI have residual isokinetic strength deficits when cleared for RTP; no association with reinjury was found but the follow-up only lasted 2 months. Evidence from sufficiently large cohort studies supports the consensus achieved in this Delphi, as lower isokinetic strength and lower passive straight leg raise flexibility were showed to be associated with HSI in professional football players. It should be noted that most isokinetic strength imbalances were revealed in the eccentric contraction phase. This finding is supported by an emerging body of evidence that demonstrates a more significant role of eccentric rather than concentric or isometric strength in HSI, and particularly that the risk of reinjury is reduced with high levels of eccentric strength. Future research will need to determine how to assess hamstring strength and flexibility at the point of RTP after HSI. In particular, different types of muscle contractions would need to be considered separately and more emphasis should be given to eccentric over concentric or isometric strength. The clinical value of isolated strength testing is limited, and its use in musculoskeletal screening to predict future hamstring injury is unfounded.

Pain

Although reaching consensus, surprisingly not all the participants agreed that the player must not feel pain in the muscle before returning to sport. The strict rule of ‘no pain’ has been recommended by a large number of experts and considered the most important criterion in a previous survey; however, this is not unanimous. Further investigations are required to understand whether pain can be accepted at RTP without an increased risk of reinjury.

Player’s confidence

All participants agreed that the player must feel ready and confident to RTP. In line with this, it is important to understand that the player’s confidence before RTP is essential; negative emotions such as anxiety and apprehension are detrimental to performance and are associated with increased risk of reinjury. The successful fulfilment of all functional performance criteria presented in this study can help the player regain full confidence before RTP.

CRITERIA NOT REACHING CONSENSUS Askling H-test and neural function Video 1: Assessment – at return to sport, include dynamic flexibility H-test by Askling (Aspetar) [https://youtu.be/ VYnMnb7AlKE]

One test that specifically evaluates the player’s apprehension is the Askling H-test (Video 1) (16), which has been proposed as a promising tool to assess readiness to RTP as only 1 recurrence among 75 HSIs was reported when used on football players. Surprisingly, the Askling H-test did not reach consensus in this study. Consensus was not achieved on neural function either, although its compromise has been proposed to have a connection with HSI and Brukner et al. recommended to include neurodynamic assessment in the management of HSI (17). It is recognised that the amendments made between rounds 2 and 3 might have impaired the building of consensus for these two criteria. However, it remains difficult to explain the reasons behind their low scoring; particularly for the Askling H-test given the supporting data previously published and that the test is easy to perform in clinical practice and therefore to implement in RTP assessment. For these reasons, future researchers may want to investigate the validity of these RTP criteria despite consensus not being achieved in this study. Co-Kinetic Journal 2018;76(April):20-31

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RTP DECISION MAKERS (multidisplinary decision)

ATHLETE

TEAM COACH

FITNESS TRAINER

PHYSICAL THERAPIST SPORTS PHYSICIAN

RTP CRITERIA TO INCLUDE

DEFINITION OF RTP The moment the player has received criteria-based medical clearance and is mentally ready for full availability for match selection and/or full training

Absence of pain on palpation Absence of pain during flexibility testing

POTENTIAL RTP CRITERION Similar eccentric hamstring strength

MRI Completion of a number of full friendly matches

Absence of pain after functional testing

Psychological readiness/athlete’s confidence Performance on field testing: * Repeated Spring Ability test * Declaration drills * Single leg bridge * Position specific GPS targeted match specific rehabilitation Medical staff clearance

should be defined as ‘the moment a player has received criteria-based medical clearance and is mentally ready for full availability for match selection and/or full training’. The experts reached consensus on the following criteria to support the RTP decision: 1. medical staff clearance 2. absence of pain on palpation 3. absence of pain during strength and flexibility testing 4. absence of pain during/after functional testing 5. similar hamstring flexibility 6. performance on field testing 7. psychological readiness. It was also agreed that RTP decisions Co-Kinetic.com

Similar concentric/isometric hamstring strength Neuromuscular function

Absence of pain during functional performance

Similar hamstring flexibility Both the passive and active straight leg raise test should be assessed

RTP CRITERIA TO EXCLUDE

Completion of a number of full training sessions Figure 1: Return-to-play (RTP) model for hamstring injuries in football [Reproduced with permission from van der Horst N et al. Return to play after hamstring injuries in football (soccer): a worldwide Delphi procedure regarding definition, medical criteria and decision-making. Br J Sports Med 2017;51(22):1583–1591 (13)]

HIGH REINJURY RATES IN FOOTBALL MAY INDICATE INADEQUATE REHABILITATION PROGRAMMES AND/ OR PREMATURE RETURN TO SPORT should be based on shared decisionmaking, primarily via consultation with the athlete, sports physician, physiotherapist, fitness trainer and team coach (Fig. 1). Within the evidence-based practice framework, it is established that where no research has been published on a given subject (or experimental designs are not feasible due to ethical issues), expert opinion and expert clinical practice should be considered. This is the case for RTP assessment after HSI in professional football, where the studies available are limited despite a strong need to standardise RTP criteria. The most recent research, by Zambaldi et al., also used a Delphi method to reach expert consensus on RTP criteria

after HSI in professional football (Table 1), and the results mirrored what was found in the consensus statement mentioned above (12). The study defined a list of consensually agreed RTP criteria for HSI. Further work would Video 1: Assessment – at return to sport, include dynamic flexibility H-test by Askling (Courtesy of Aspetar https://youtu.be/VYnMnb7AlKE)

REHAB RULES

Aims/Goals

Goal C (Weight bearing)

Close element allows progress of another

Goal B (Balance & proprioception)

13 3

4 4

End Stage (15)

RTP (15)

Focus may continue or becomes dormant

8 6

Transfers Transfer

Goal A (ROM) 1

Focus may continue or becomes dormant

Time

Figure 2: A model for exercise progressions in a complex rehabilitation programme [Reproduced with permission from Blanchard S, Glasgow P. A theoretical model for exercise progressions as part of a complex rehabilitation programme design. Br J Sports Med 2017;pii:bjsports-2017-097486 (18)]

THE CRITERIA FOR RETURN TO SPORT SHOULD BE HAMSTRINGFUNCTION DEPENDENT, NOT TIME DEPENDENT be required to determine the validity of the identified criteria (12). Although the focus of the study by Zambaldi et al. was to present criteria reaching consensus, the knowledge of the items excluded during the Delphi

process may be of equal interest for future research and clinical decisions (12). For instance, the value of medical images in the assessment of HSI has been extensively investigated. However, it is noteworthy that in line with the reported poor significance of MRI findings at RTP, none of the participants stated they use medical images to inform their RTP decisions (12). So, what now? There may be clearer outlines for RTP, but how do you get there? Which rehabilitation programme and exercises are best to help your patient progress through the stages of recovery?

Clear clinical reasoning relating to appropriate progression and regression of rehabilitation is essential to achieve positive clinical outcomes. Theoretical models have been designed to assist practitioners. Older models provided a visual means for clinicians to represent modification of rehabilitation stimuli regarding progression of a single exercise (eg. sets, reps, speed). Although useful as a reference for clinicians on progression of single exercises, the original model is limited in its ability to describe progressions within a multidimensional rehabilitation programme. The older models suggest that a patient must be able to fully execute each stage of an exercise progression before the reintroduction of previously learnt components. In practice, rehabilitation is rarely linear with many components often trained concurrently to allow different emphases during different rehabilitation sessions. This is especially applicable for elite athletes who may rehabilitate daily for many hours requiring programmes that have the appropriate variety to reduce boredom, enhance effectiveness and maximise compliance. Rehabilitation progressions should effectively merge previously independent exercise drills to become more complex as part of the larger aim of return to sport. Blanchard and Glasgow present a model that more clearly articulates the complexities of a multifaceted

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rehabilitation programme (Fig. 2) (18). A multidimensional exercise programme of this nature should start with a goal that is safe and achievable for the athlete, yet appropriately challenging. The safest intervention to achieve the specified goal is displayed on the bottom of the vertical axis. This exercise will have progressions that do not alter the desired movement pattern (these include repetitions, sets, speed, load); these are represented by the triangles. The increase in slope of the triangle indicates progress over time. Variables that enhance the motor control challenges of the exercise (change of environment, external stimuli, plane of movement) are represented by the blocks along the horizontal axis (time). Over time, more demanding tasks can be carried out at the same time as the existing exercises, permitting transfer of elements from one task to another (18). This model also demonstrates how discrete components are trained initially and as rehabilitation progresses components are merged into more complex sport-specific drills (18). This model is in agreement with the return-to-sport continuum proposed by the recent international consensus statement on return to sport (11*). The factors underlying hamstring injuries are accepted as multifactorial and complex. It has been suggested that a systematic rehabilitation process (ie. algorithm) consisting of an ordered sequence of steps (criteria phases) could aid in the complicated clinical decision-making procedure of a successful RTP and subsequently decrease reinjury rates (19). With this algorithm approach, each phase of hamstring strain recovery depends on the outcome of the previous step and is based on an individualised response to progress in difficulty. Furthermore, if the algorithm can objectively structure the content and criteria to be met according to (19): 1. biological tissue repair principles (20*), 2. main injury mechanism (ie. sprinting mechanics), and 3. multiple risk factors associated with hamstring strain (19,20*), it could conceivably provide flexible programming accounting for the Co-Kinetic.com

specific weaknesses of each player. This design process is not possible in a pre-established, one-size-fits-all general protocol (2*). In summary, the algorithm constitutes a theoretically objective and individualised multifactorial approach to hamstring injury rehabilitation to build a solid framework (21). The most recent examples of these are from Valle et al. (Links 2–4) (20*) and Mendiguchia et al. (21) and will be discussed further below.

Video 2: Nordic hamstring curl variations | Hamstring training (Courtesy of Physiotutors) (https://youtu.be/ihTUvs997b4)

Eccentric Essentials The popularity of the Nordic hamstring exercise (NHE) may lie in its ease of use, requiring no equipment and being effective at reducing the risk of HSI (Video 2) (2,22,23). It is possible that the intervention was adopted out of necessity to address HSIs in sports such as football (22) that may have only recently embraced more traditional strength training. Although seen by some to be non-functional, the NHE combined with sports-specific training in professional and amateur football players has been shown to reduce both the incidence and recurrence rate of HSI by 60% and 85%, respectively, following a 10-week intervention programme (22). Greater eccentric hamstring strength may also offset the likelihood of injury in older or previously injured athletes. This appears to be an effective intervention, requiring minimal effort when compliance is adequate (24,25). Some NHE Facts (26): n The hamstrings are activated differently during hip-based and knee-based tasks. The NHE may be limited in its effectiveness by only training eccentric knee flexor strength in a knee dominant action. n Hip-extension exercise more evenly activates the three long heads of the hamstrings, and the NHE preferentially recruits the semitendinosus. n Hamstring injury prevention and rehabilitation exercises can potentially be targeted to the site of injury. n Hip-extension exercise may be more useful than the NHE for selectively activating the more commonly injured BFl. n NHE has been thought to be suboptimal in protecting against

running-related strain injury which predominantly effects the BFl. EMG evidence shows a selective activation of the semitendinosus during NHE; however, there is still strong activity in the BFl muscle; implying NHE may infer improved load-bearing capacity of the hamstring muscle in general. Indeed, BFl normalised electromyography (nEMG) activity was higher during the NHE than during the eccentric phase of any other exercise, and the evidence for this exercise’s protective effects (2,22) suggests that eccentric actions alone in a training programme are sufficient to make the hamstrings more resistant to strain injury. These protective benefits might be mediated by the elongation of BFl fascicles, which would be expected to improve the strength of this muscle at long lengths and reduce its susceptibility to exercise-induced damage. High levels of BFl nEMG activity during the NHE are consistent with previous investigations, and are the result of the supramaximal intensity of the exercise, which potentially explains why high levels of BF nEMG are also observed in the eccentric gluteus–hamstring raise (26). The invention of devices such as the ‘NordBord’ allows for quick, easy and reliable measurements of eccentric knee flexor strength (25). These devices may provide a link between testing and training where daily feedback is received and actionable data are generated (25). A low adoption rate and poor adherence to NHE in elite level 25

football (24) may be caused by the initial soreness (delayed onset muscle soreness), experienced by some with this exercise. n Systematic and progressive eccentric strengthening has a large hamstring re-conditioning capability, most likely addressing eccentric strength deficits, musculotendinous atrophy and scar tissue, certainly changing the injury risk profile of the athlete with a previous hamstring strain, even when addressed somewhat later than the initial injury and rehabilitation (22). The physiological adaptation to hamstring lengthening contractions (22), therefore, also seem consistent with the physiological process of mechano-transduction and mechano-therapy. n What the precise preventive injury mechanism related to the eccentric strength training is, remains uncertain, and the debate is ongoing. Although not an exhaustive list, HSI risk factors include age, previous injury, strength imbalance, flexibility, fatigue (1) and low eccentric strength. There is a growing body of evidence on the NHE and its impact on HSI reduction. However, there may be misconceptions (fuelled by social media) that this is the only exercise used to prevent HSI. The NHE is not the ‘silver bullet’ that critics imply practitioners claim it to be, and it is unlikely that experienced practitioners solely rely on the NHE alone when dealing with HSI (25).

eccentric contractions may elongate muscle fascicles which could mediate the protective mechanism of improving muscle strength at longer lengths (26).

prevention tool, there continues to be a high incidence of HSI (25). A greater appreciation for the multifactorial nature of HSI while also addressing the primary injury mechanism – sprinting (1) – is required. A more holistic approach to hamstring health has been proposed (Fig. 3) (25).

High-Speed Running (Sprinting) Exposing athletes to increased weekly sprint distances (90–120m above 95% maximum velocity) and exposures (6–10 efforts) in team-based running sports has also been shown to have a protective effect on lower limb injuries. Importantly, the acute high-speed running load should be progressed gradually, avoiding large sudden increases which may increase the odds of HSI (27). So, the NHE is one method of strengthening, which is important for hamstring health. It would advocate that both hip and knee dominant exercises be included in an injury prevention programme (25). Although the exercises discussed develop eccentric hamstring strength, the contractions occur at a much slower rate than during sprinting and it would be logical to regularly and progressively expose the athlete to high-speed running. Only when all these factors are addressed in a multifaceted approach can one hope to achieve holistic hamstring health (25).

Exercise Selection During the late swing phase of running, the BF and other hamstring muscles function eccentrically to resist hip flexion and decelerate knee extension, where they undergo large ranges of motion and different activation patterns. It would, therefore, be advisable to train the hamstrings with both hip and knee dominant exercises (Video 3). Holistic hamstring health (25) suggests alternative options including the use of other hip and knee dominant exercises reported in elite level football (24). A growing body of evidence exists for the ‘hip-extension exercise’. It has been shown to target the BFl and semitendinosus, whereas the NHE preferentially recruits the semitendinosus but also elicits the greatest absolute activation of BF compared with other hamstring exercises (26). Overloading the

Single Leg Bridge o

45 Hip Extension

Glute Ham Raise

KP Swings

Nordics

SLDL

HOLISTIC HAMSTRING HEALTH: TWO MISSING PARTS OF THE PUZZLE Although the NHE is an effective

Lunge Leg Curls Roman Deadlift

Strength Deadlifts

Video 3: The 4 best hamstring exercises | Hamstring training (Courtesy of Physiotutors) (https://youtu.be/2PGC_gmgj30 https://youtu.be/2PGC_gmgj30) (https://youtu.be/2PGC_gmgj30)

Razor Curls Hip Thrusts Glute Bridge Yo-Yo

Bosch Iso Hold

Squats

Hamstring Slideouts

Slide Board Leg Curls Supine Isometric Leg Exchange

Figure 3: Holistic Hamstring Health [Reproduced with permission from Oakley AJ, Jennings J, Bishop CJ. Holistic hamstring health: not just the Nordic hamstring exercise. Br J Sports Medicine 2017;doi:10.1136/bjsports-2016-097137 (25)]

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REHABILITATION PROTOCOLS Based on the above, you will now find two of the most recent hamstring rehabilitation protocols (21,28*), which include the essential eccentric strengthening; but also address a more holistic approach to the lower limb and core as well as progressive functional and sport-specific drills.

Askling Protocol Firstly, the most recent study being that of Mendiguchia et al., which was an equally randomised, double-blind, parallel-group, controlled clinical trial for hamstring rehabilitation starting at day 5 post-injury (therefore excluding the acute phase) (21). This trial used two randomised groups of football players, one following a daily Askling L-Protocol (Video 4 and Link 5) ([2](http://spxj. nl/2otqM76)) and the others using a systematic rehabilitation algorithm (RA) approach designed by Mendiguchia et al. (19,21). In the Mendiguchia group (RA), when one or more of the criteria established for each phase was not achieved, the player remained in the same phase and continued with their individualised training/treatment, adding an additional afternoon session (same

content) to eventually fulfil the required criteria. The programmeâ&#x20AC;&#x2122;s criteria and content were selected and timed according to current knowledge on the biology of muscle injury and repair, the different risk factors associated with the hamstring injury (ie. poor flexibility, diminished strength, altered lumbopelvic control, fatigue), and the main mechanisms causing the injury (sprinting or stretching). The players progressed through the regeneration and functional phases as they met each criteria, with a concurrent running programme (21). Video 5 shows the exercises in the rehab programme. The main findings of the study were that players allocated to the Mendiguchia Algorithm (RA) group experienced (21): 1. substantially fewer reinjuries, specifically in the early recurrences period - In this way at RTP, the player who followed the RA presented a lower risk (4%) compared with a typical footballer with no history of previous injury (12â&#x20AC;&#x201C;16%). 2. substantially more time (small effect) in returning to sport after injury 3. substantially greater performance (ie. 10m and top speed) and mechanical Progressive Speed Exposure Volume at Max Speed

Progressive Overload

Max Speed Exposure

Running

The second hamstring rehabilitation protocol has not been conducted (as yet) under a randomised control trial; however, there have been reports of the success of the programme in preventing and managing athletes following HSI (28*). This is the Aspetar Hamstring Rehabilitation Protocol (Link 6), and was developed following comprehensive, evidence-based research and compiled

Video 4: Askling protocol | Hamstring strain rehabilitation (Courtesy of Physiotutors) (https://youtu.be/D6bGLfCk4QU)

Speed Drills

Change of Direction

Glutes

Calf

Flexibility

Hamstring

Injury Risk Factor

Co-Kinetic.com

Aspetar Hamstring Rehabilitation Protocol

Straight Leg Runs

Decelerations

Holistic Hamstring Health

variables related to speed factors (V0 and Pmax) compared with the other group. In summary, male football players who underwent an individualised, multifactorial, criteria-based algorithm, which integrated the temporal sequencing of the different and multiple risk factors potentially related to hamstring injury with a performance and primary risk factor-oriented training programme from the early stages of the process, markedly decreased the risk of reinjury, improved sprint performance and mechanical properties, but resulted in a possibly slower (small effect) RTP compared with a general protocol where long-length strength training exercises were prioritised (21).

Hip Flexor

Video 5: Hamstring rehab for football players (Courtesy of Hamstring Rehab) (https://youtu.be/MdzA6vwz9hA)

Quadriceps

Restore Post Injury

Emerging Pattern (Injury or adaptation)

Recursive loop

Recursive loop Regularities

(Risk or protective Profile)

Web of Determinants The group of variables at the bottom makes up the web of determinants, which is composed of contributing units with different weights. Variables circled by darker lines have more interactions than variables circled by lighter lines and exert a greater influence on the outcome. Dotted lines represent a weak interaction and thick lines represent a strong interaction between variables. Arrows indicate the relationship between the observable regularities, which captures the risk/protective profile, and the emerging outcome. Figure 4: Complex Model for Sports Injury [Reproduced with permission from Bittencourt NFN et al. Complex systems approach for sports injuries: moving from risk factor identification to injury pattern recognition—narrative review and new concept. Br J Sports Med 2016;50:1309–1314 (32)]

by Nicol van Dyk (Box 2) and the team from Aspetar Orthopaedic and Sports Medicine Hospital. Extensive research conducted by the Aspetar Sports Injury and Illness Prevention Programme (ASPREV) during the last three years on football players at Aspetar identified roughly 100 hamstring injuries per year – one for every 1,000 hours of participation in matches and training. Indeed, since using this protocol, Aspetar has recorded an average return-to-sport time of 23 days, with a low rate of reinjury among athletes treated with it. In an effort to share skills and knowledge with colleagues across the globe, the International Olympic Committee (IOC) accredited research centre has made the protocol publicly available through a series of 34 videos on its YouTube channel, detailing the stages of the innovative approach to hamstring injury treatment and rehabilitation (Link 7). In the Aspetar protocol, the athlete is assessed daily by the physiotherapist to determine progress of the rehabilitation programme. In a recently published paper (29), by the same authors of the Aspetar protocol, one subjective measure and three objective findings tracked well with the progress of rehabilitation in a cohort of athletes with acute hamstring

BOX 2: NICOL VAN DYK Nicol van Dyk is a physiotherapist in the Rehabilitation Department at Aspetar Sports Medicine and Orthopaedic Hospital in Doha, Qatar. Originally from South Africa, he graduated with a BSc in Physiotherapy from Stellenbosch University in 2005, and completed his MSc in Orthopaedic Manipulative Therapy in 2010. During the 2010 FIFA® World Cup in South Africa, he worked at the Sport Science Institute of South Africa. He currently occupies a role as coordinator for the musculoskeletal component of the periodic health evaluation at Aspetar as well as treating athletes. Nicol is an associate editor and editorial board member of BJSM, and is currently completing his PhD in injury prevention studying risk factors for hamstring injuries in elite football players.

Recent publications include: 1. van Dyk N, Bahr R, Whiteley R et al. Hamstring and quadriceps isokinetic strength deficits are weak risk factors for hamstring strain injuries: a 4-year cohort study. The American Journal of Sports Medicine 2016;44(7):1789– 1795 2. van Dyk N, Bahr R, Burnett AF et al. A comprehensive strength testing protocol offers no clinical value in predicting risk of hamstring injury: a prospective cohort study of 413 professional football players. British Journal of Sports Medicine 2017;51(23):1695–1702 3. Dijkstra HP, van Dyk N, Schumacher YO. Can I tell you something? I’m doping… British Journal of Sports Medicine 2016;50(9):510–511 4. van Dyk N, Clarsen B. Prevention forecast: cloudy with a chance of injury. British Journal of Sports Medicine 2017;51(23):1646–1647 5. van Dyk N, van der Made AD, Timmins R et al. There is strength in numbers for muscle injuries: it is time to establish an international collaborative registry. British Journal of Sports Medicine 2017;doi:10.1136/bjsports-2016-097318

injury. These clinical measures can be meaningful to inform the progression of loading during the rehabilitation stages through to return to participation, and is suggested that the practitioner invest the time into a daily assessment including the following (29): n Palpate length of pain, measure outer range strength, then ask about pain, and measure maximum hip flexion with active knee extension (MHFAKE) for your daily examination of hamstring-injured athletes. n Pain should likely resolve by about a third the way through rehab, so asking about this will be of less use in the second half of rehabilitation unless the pain worsens. n The MHFAKE seems a better flexibility measure than the SLR to track rehabilitation progress. n Outer range strength seems better than mid-range, which in turn is better than inner range as a strength test measure. n Athletes can estimate their running effort in a meaningful way, but only above approximately 40% of their perceived maximum. The central tenets of the Aspetar rehabilitation protocol (28*) are as follows: 1. A requirement for set criteria (specific physical testing) to be proven before allowing progression to the next stage. 2. Daily measurements of subjective pain, pain with palpation, range of movement or flexibility and strength allows the clinician to adapt the protocol for the player on that particular day depending on the presentation of the individual, as well as identify the response to the previous day’s treatment. 3. Although specific exercises and progressions within each stage are suggested, clinical reasoning is continuously required from the clinician to execute the protocol optimally for each session. 4. In the clinical reasoning process, the clinician will consider factors such as the presumed mechanism (swingphase injury versus stance-phase, active- versus passive-stretch-type injury), sport-specific hamstring demands and presumed individual Co-Kinetic Journal 2018;76(April):20-31

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risk factors, such as trunk stability and lumbo-pelvic control. The rehabilitation protocol consists of six stages, three ‘physiotherapy’ stages and three sport-specific stages. An overlap of exercises between the stages is allowed, recognising the fluidity of the rehabilitation process and reflecting an integrated protocol with set criteria for progression. The main feature of the protocol repeated in each stage is the early but safe resumption of repeated high-speed running and direction change movements. All hamstring injuries (grade 0–3) are treated with the same protocol. Since the protocol is criteria based, it implies that usually a grade 3 injury would remain for a longer time period in stage 1. In general: n All exercises should be performed close to the pain-free limit. If the exercise/movement provokes pain (2 VAS) from the injured area, the exercise is immediately adjusted or terminated. n The patients should be instructed to perform the exercises with adequate control/stabilisation of the hip and trunk. n Variations: depending on the localisation of the injury (medial/ lateral), tibial internal rotation or external rotation is applied when appropriate during exercises with knee flexion movements.

PREVENTION PARADIGMS Are you able to predict the weather next winter with 100% accuracy? Impossible, right? Yet the belief that one can predict which athletes will get injured based on some form of screening test is not uncommon. Roald Bahr’s paradigmshifting British Journal of Sports Medicine publication suggests the reason why prediction is impossible is quite simple: current screening tests do not pass standard tests for utility (30*). Although sports injury prediction may not be perfectly accurate, it nevertheless provides us with useful information. Screening athletes for risk factors does not predict which individual will suffer injury, but it can direct effective prevention efforts (31). Co-Kinetic.com

Injury Prediction Injury prediction is one of the most challenging issues in sports and a key component for injury prevention. Aetiology investigations of sports injuries have assumed a reductionist view in which a phenomenon has been simplified into units and analysed as the sum of its basic parts and causality has been seen in a linear and unidirectional way. Much of human health conditions are complex. In this sense, the multifactorial complex nature of sports injuries arises not from the linear interaction between isolated and predictive factors, but from the complex interaction among a web of determinants (Fig. 4) (32*): n Sports injury prevention relies on the identification of risk profiles, which means moving from risk factors to risk pattern recognition. This approach considers an interconnected and multidirectional interaction between all factors, which embrace the complex nature of the sports injury (32*). n Improvements in sports injuries prediction, as well as in prevention, depend on coherence among the phenomena of interest (sports injuries as an emergent event), philosophical paradigm (complexity) and methods of analysis. In this sense, non-linear and complex system approaches should be explored (32*). How might injury prediction impact on clinical practice in the future? n Clinicians should be aware of how risk factors may interact, rather than list several isolated risk factors, to plan effective preventive intervention (32*). n Risk profiles may include non-linear interaction between risk factors from different scales, such as biomechanical, training characteristics, psychological and physiological. Additionally, risk profiles should be continuously assessed throughout preseason and in season (32*). n The recognition of the web of determinants in clinical practice might include risk factors that strongly influence the outcome and interact in many ways with several variables (32*).

Injury Prevention Training Programmes In a recent systematic review and meta-analysis (3) to investigate the effectiveness of the injury prevention programmes, there was strong evidence that training programmes that include the NHE decrease the risk of hamstring injuries by up to 51% in the long term compared with usual warmup or training programmes. The current evidence suggests that the NHE alone or in combination with injury prevention programmes is effective for preventing hamstring injury (3). We know that a reduction in hamstring injury incidence, up to 70%, can be achieved by eccentric training following the NHE programme. Although NHE compliance was high in studies, the NHE programme has not been adopted in amateur soccer and the number of hamstring injuries has not diminished yet. Arguments for non-compliance are lack of time, delayed onset muscle soreness, the need to sit on the ground or a mat, and that it is not sportspecific enough to incorporate into the warm-up. The bounding exercise programme (BEP) is another potentially effective training programme that can be done after warming up. It consists of singleleg jump exercises characterised by a stretch-shortening cycle: eccentric pre-stretch phase, amortisation phase, and concentric shortening phase. This stretch-shortening cycle strengthens the elastic properties of connective tissue, thereby improving (eccentric and concentric) strength and power by allowing the muscle to accumulate (prestretch/eccentric phase) and release (concentric phase) energy. Plyometric training is already used widely in intermittent team sports to enhance sprinting and jumping performance and might reduce sprint-type hamstring injuries. Efforts now must focus on developing more easily implementable group interventions to prevent injury. Programmes such as the FIFA 11+ exercise programme reduce injury rates at various levels of sport in a range of populations (33*); professionals need to get compliance from athletes in performing the programmes.

MULTIDIMENSIONAL REHAB PROGRAMMES WITH THE APPROPRIATE VARIETY OF ACTIVITIES HELP TO REDUCE BOREDOM, ENHANCE EFFECTIVENESS AND MAXIMISE COMPLIANCE What is known of the FIFA 11+ Programme? The key points of the FIFA 11+ programme are listed below (Link 8) (33*). n FIFA 11+ is a simple exercise programme completed as part of warm-up can decrease the incidence of injuries in amateur football players. Considerable reductions in the number of injured players, ranging between 30% and 70%. n Performing the FIFA 11+ as a standard warm-up reduces the injury risk in young female football players. n The efficacy of FIFA 11+ to prevent non-contact injuries has been proven in young male amateur football players. n ‘The FIFA 11’ programme reduced the incidence of hamstring (the programme includes NHE), lateral ankle ligament (LAL) injuries and anterior cruciate ligament (ACL) injuries in amateur players. n Compliance with the programme (at least twice a week) is key to successful injury prevention. n Players with high compliance to the FIFA 11+ programme had an estimated risk reduction of all injuries by 35% and show significant improvements in components of neuromuscular and motor performance when participating in structured warm-up sessions at least 1.5 times/week. n The coach is the key person to promote FIFA 11+ to his/her players. n Warm-up and performance effects of FIFA 11+ have been evaluated in detail. n The strong commitment of the national football governing bodies 30

(Member Associations of FIFA) is necessary to implement FIFA 11+ at the country amateur football level. n The FIFA 11+ can be considered as a fundamental tool to minimise the risks of participation in a sport with substantial health benefits. In a prospective observational study of the FIFA11+ programme, it was identified that fitness coaches and physiotherapists were the main injury prevention exercise programme (IPEP) deliverers, while football coaches decided on the number and length of IPEPs within each training week (34). Programmes are delivered in a range of training locations (eg. outdoor/ indoor pitch and gym) and formats (eg. warm-up, cool-down and separate athletic sessions). IPEPs were structured around the same basic components found in established evidence-based programmes (strength, balance, core stability, jumping and landing), but staff frequently modify the programmes to add variation, progression and individualisation and to harmonise the IPEPs with athletic and cognitive goals. In general, a broad range of barriers/facilitators affecting the implementation of injury prevention programmes have been identified. These were related to the player (eg. motivation and absences), team staff (eg. planning and communication), club (eg. acceptance and culture), governing bodies (eg. game schedules) and the environment (eg. weather). What are the Most Important Practical Applications? (35) 1. To enhance the real-world impact of IPEPs, implementation strategies should have multiple targets, including players (the health beneficiaries), team staff members (the program deliverers) and club officials (the policy makers). 2. Key individuals from all target levels should be engaged when designing IPEPs. Understanding their goals, perceptions and specific environment can help to identify potential implementation barriers and find appropriate solutions. 3. In professional football settings, IPEPs require adequate variation, progression, individualisation and

football specificity. Potential strategies to achieve this include tailoring programs to individual player profiles, providing adequate staffing, including ball exercises and incorporating a range of training equipment.

CLOSING THOUGHTS There is a lot of information out there regarding HSIs, and is often hard to see the wood for the trees. This article hopefully consolidates some of the most recent research and practice protocols for hamstring injuries and has enlightened you to a more holistic and practical approach to rehabilitation and return to sport.

LINKS Link 1: Consensus statement. van der Horst N et al. Return to play after hamstring injuries in football (soccer): a worldwide Delphi procedure regarding definition, medical criteria and decision-making. British Journal of Sports Medicine 2017;51(16):1221–1226. (http://spxj.nl/2EWbEZb) Link 2: Rehabilitation protocol design basis (https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC4691307/) Figure 1 from Valle X et al. (20) Link 3: Therapeutic exercises combination, and progression during phases (http://spxj.nl/2FmczQC) Figure 2 from Valle X et al. (20) Link 4: Exercise progression examples (http://spxj.nl/2FmczQC) Figure 3 from Valle X et al. (20) Link 5: Askling L-protocol (http://spxj.nl/2CzNcHP) In Askling CM et al. (2) Link 6: van Dyk N. Aspetar Hamstring Protocol [PDF]. (http://spxj.nl/2EVQCKi) Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar, 2017 Link 7: Aspetar Hamstring Protocol and exercises [34 videos] (http://spxj.nl/2sLvS39) Aspetar YouTube channel Link 8: FIFA 11+ Warm-Up exercise programmes [22 videos]. YouTube user Timothy Kozakevich (http://spxj.nl/2CeKs79)

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KEY POINTS n Hamstring strain injury (HSI) seems to be related to repetitive highforce eccentric actions. n The heterogenous nature of HSI makes diagnosis and rehabilitation difficult; a high reinjury rates suggest inadequate rehab/premature return to sport. n Early return to sport following HSI increases the risk of recurrence. n There is currently no consensus on return-to-play (RTP) assessment following HSI. n The Delphi method is being used to try to achieve consensus on RTP criteria. n Older rehab models involved mainly linear exercise progressions; nowadays rehab programmes are often multidimensional and progression involves merging independent drills to create more complex, sport-specific activities. n The Nordic hamstring exercise is an effective preventative tool, but is best used in combination with sport-specific training. n The most recent hamstring rehabilitation protocols include eccentric strengthening and a holistic approach to the lower limb and core. n The identification of ‘risk profiles’ is useful for directing injury prevention and involves appreciating the multidirectional interaction between individual risk factors. n Injury prevention is key: injury prevention exercise programmes, such as the FIFA11+, need to be incorporated into training routines and warm-up.

DISCUSSIONS Having read this article, would your approach to hamstring injury rehabilitation be different now and if so, how? What criteria and assessments would you use to aid decisions about your patient’s fitness for return to play? Is there scope for injury prevention in your practice and what would you recommend for your clients?

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EFFICACY OF MANUAL THERAPY FOR CHRONIC MUSCULOSKELETAL PAIN BY DR PHILIP AUSTIN BSC MSC PHD 18-04-COKINETIC FORMATS WEB MOBILE

EFFICACY AND EVIDENCE FOR PHYSICAL THERAPIES A number of physical treatments are used to manage chronic musculoskeletal pain. These include manual therapies, exercise, acupuncture, electrotherapy and thermal modalities. However, although different therapies are advocated by different groups of practitioners, it is increasingly evident that many physical and manual therapists are adopting more evidence-based approaches to chronic pain management (10). Thus, the aim of this article is to provide current evidence for the efficacy for each of the above therapeutic categories. Additionally, given the variation in quality of evidence, the following sections will focus on results mainly from systematic reviews and meta-analyses. It should also be noted that many different pain and disability measures are used between studies, thus showing an apparent lack of homogeneity in findings between studies. This article reviews studies discussing or using only validated outcome measures. A review of the multitude of therapeutic approaches used by physical therapists is beyond

THERE IS GOOD EVIDENCE FROM EXPERIMENTAL STUDIES TO SUGGEST THAT MANUAL THERAPY, THERAPEUTIC EXERCISE AND ACUPUNCTURE CAN BE EFFECTIVE IN THE TREATMENT OF CHRONIC MUSCULOSKELETAL PAIN 32

Chronic pain can be treated in a number of ways and each method has its proponents, making it difficult to know which method to choose. Turning to the literature to make evidence-based decisions reveals a bewildering array of studies reporting different levels of quality of evidence and outcomes. This article discusses the current evidence for the use of different treatment modalities for different chronic pain conditions allowing you to make evidence-based decisions when you are putting together a treatment package for your chronic pain patients. A table summarising the information is available to download, providing you with a handy, quickreference guide. Additionally, this article will enable you to understand what is required for high-quality evidence, what is lacking in low-quality evidence and, therefore, how to assess for yourself the quality of evidence described in studies and reports in the literature. This article has been adapted from chapter 7 ‘Efficacy of manual therapy for chronic musculoskeletal pain’ from the author’s book Chronic Pain. A resource for effective manual therapy. Read this article online http://spxj.nl/2oOMCls the scope of this article; thus, here we will focus on manual therapy, therapeutic exercise and acupuncture as these therapeutic approaches are described as the most commonly used within manual therapeutic settings. However, other modalities such as electrotherapy (eg. transcutaneous electrical nerve stimulation, interferential therapies) and thermal treatments (eg. superficial and deep tissue heating, ultrasound, and cryotherapy) may be briefly discussed in the chapters that review pain disorders in the book Chronic Pain. A resource for effective manual therapy, from which this article has been derived. For more in-depth discussion of these treatment modalities, please refer to Wright and Sluka (10) Clar et al. (11) and Chang et al. (12).

MANUAL THERAPY Manual therapy techniques are intended to promote movement and relieve pain in musculoskeletal structures (10). Techniques such as joint manipulation and mobilisation are aimed at moving joints in specific directions and at different speeds in order to restore movement. Active and passive muscle stretching is also used to improve muscle activation and function (13), whereas soft tissue techniques are aimed at mobilising skin, underlying muscle and connective tissue. Within manual therapy, most research has focused on joint mobilisation, manipulation and massage, with studies showing varying degrees of methodological rigor and treatment efficacy. The most common classification of manual therapies is based on the distinction Co-Kinetic Journal 2018;76(April):32-40

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Neutral Exercise Mobilisation & stretching Manipulation

Manipulation

Joint play Active ROM limit Physiological barrier Anatomical barrier

Figure 1: The presumed barriers to joint motion and the position and/or range of motion where manual therapy and exercise are performed

between massage, passive movement, mobilisation and manipulative techniques, as shown in Figure 1.

Chronic Low Back Pain Mobilisation and manipulative techniques are most commonly applied to people complaining of low back pain and thus this is the most extensively researched. Studies show that manipulation techniques reduce pain intensity, decrease functional disability and increase spinal mobility (14–17). However, although these improvements are generally observed at 1-month follow-up, there is virtually no difference when compared to sham therapies or continued improvement at 1-year follow-up. Concerning mobilisation techniques, studies show similar findings. For example, muscle energy technique (18,19) and posteroanterior mobilisation (20) are shown to significantly improve lumbar range of motion (ROM) over the short term while also increasing function and decreasing disability in patients with acute low back pain (21). Overall, evidence suggests that multidisciplinary treatments involving both manipulation and mobilisation techniques are more effective than general physical therapy, home exercise and general practice medical care alone for reducing long-term disability (22). However, although these individual techniques are effective for improvements in objective functional measurement of chronic low back pain, exercise still provides the longest interval of relief (23). Currently, systematic review data show a mixture of findings. First, there is moderateCo-Kinetic.com

to-strong evidence for the benefit of manipulation over sham treatments for pain, function and quality of life in the short term. Second, moderate evidence shows combinations of manipulation, mobilisation, soft tissue techniques and exercise for pain, function and quality of life both short and long term are more beneficial than exercise alone, ‘back school’ or usual medical care. Third, there is limited evidence showing the benefit of mobilisation and soft tissue techniques combined with exercise compared to usual medical care (24). Meta-analyses generally show moderate efficacy for a range of techniques including high-velocity low-amplitude (HLVA) manipulation, low-velocity low-amplitude (LVLA) oscillation, and massage techniques. However, an overall lack of studies with a low risk of bias prevents any strong recommendations regarding AUSTIN spinal manipulation (25).Figure Additionally, No. 7.1 van Middelkoop and co-workers state Draft stage 1 that most randomised controlled Draft stage 2 trials (RCTs) show methodological Draft stage 3 deficiencies mostly owing Draftto stage 4 Draftpopulations, stage heterogeneity of sampled interventions outcome measures, and comparison groups (26). More encouragingly, in a recent metaanalysis, Franke and colleagues show moderate-quality evidence that osteopathic manipulative treatment improves pain and functional status in patients with non-specific low back pain (26a). These meta-analyses also show manual techniques to be mostly effective in the short term for chronic non-specific low back pain (less than 3 weeks).

Concerning soft tissue technique, systematic reviews also show shortterm benefits for the treatment of chronic low back pain (27). However, as with mobilisation and manipulative techniques, the qualities of studies reviewed are again poor. For example, two systematic reviews identified trials that focused on the efficacy of massage for chronic low back pain. Here, results showed that although massage showed similar short-term benefits compared to mobilisation techniques, there was significant heterogeneity owing to differences in interventions, differences in control groups, and duration of intervention (28,29).

Chronic Neck Pain The effects of manipulative and mobilisation techniques for neck pain have also been examined using systematic reviews and meta-analysis. Similar to chronic low back pain, these techniques have been shown to provide short-term relief for both chronic neck and shoulder pain, especially in combination with advice and exercise (30,31). Interestingly, in a smaller study, Gemmell and Miller compared the effectiveness of (i) specific segmental HVLA, (ii) segmental mobilisation, and (iii) the Activator® instrument that delivered an HVLA within normal physiological ranges of the segments manipulated (32). Although all treatments showed reduced disability and improved quality of life at 12-month follow-up, sample sizes were small and thus it is uncertain if these treatment BH true or simply due to Artistwere effects Date 06 06 17 chance. In two Cochrane reviews, moderate-quality evidence also suggests that multiple sessions of cervical manipulation and mobilisation show similar effects on pain, function, and patient satisfaction at immediate follow-up (33,34). The same reviews located only a few low-quality studies that support thoracic manipulation for pain reduction and increased function in chronic neck pain. Given the paucity and quality of studies relating to the manual treatment of neck and shoulder pain and the potential for positive outcomes, there is a need for better quality studies that should address: (i) 33

WITHIN MANUAL THERAPY, MOST RESEARCH HAS FOCUSED ON JOINT MOBILISATION, MANIPULATION AND MASSAGE treatment dose comparisons between manipulation and mobilisation; (ii) intermediate and long-term follow-up changes in pain severity, functional disability and quality of life; and (iii) the effectiveness of manipulative and mobilisation techniques in the thoracic spine for chronic neck and shoulder pain. The efficacy of soft tissue massage techniques for neck pain remains uncertain. Although Chinese massage, strain/counterstrain techniques when compared to no treatment (35), and placebo (36) show significant improvement in subjects with chronic neck pain, levels of evidence are low (37). Given these findings and the fact that assessed outcomes immediately post-treatment are not adequate to assess clinical change, currently no recommendations can be made concerning the effectiveness of soft tissue massage techniques for chronic neck pain.

such as spinal manipulation, classic massage, soft tissue massage, Cyriax mobilisation, manual traction and craniosacral techniques. Although there is limited evidence for the effectiveness of soft tissue techniques, overall, results showed no rigorous evidence for other manual therapy techniques for reducing pain intensity in tension-type headaches. The authors in their discussion suggest that the aim of soft tissue techniques is to correct mechanical stress caused by myofascial tissue conditions, and thus they may be the effective choice. However, given that systematic reviews identify so few RCTs, and the potential for the use of manual therapy techniques, there is a clear need for well-designed RCTs evaluating the effectiveness of specific types of manual therapy techniques for both cervicogenic and tension-type headaches.

Chronic Shoulder Pain Chronic Headaches Despite the common occurrence of chronic cervicogenic and tension-type headaches, there are surprisingly very few recommendations concerning the efficacy of manual therapy techniques. This is mainly because of the lack of randomisation, the lack of blinded evaluators and inadequate statistical analysis (38). However, although inconclusive, data show that spinal manipulation relieves cervicogenic and tension-type headaches. One systematic review found that of nine RCTs accepted for review, six suggested that spinal manipulation was more effective than physical therapy, gentle massage, drug therapy, or no intervention (39). However, the remaining three studies show no differences in pain relief compared to placebo manipulation, physical therapy, massage or waiting list controls. Owing to a lack of methodological rigor, a similar review accepted only six studies from 55 potentially relevant articles (40). Selected studies assessed different techniques 34

Generally, studies investigating the effect of manual therapy in painful shoulder conditions examine a variety of techniques including manipulation, joint mobilisation with and without other modes of passive therapy, and exercise (11). Concerning rotator cuff disorders, there is moderate evidence from existing systematic reviews to suggest that manipulation and mobilisation in conjunction with multimodal exercise show positive treatment outcomes compared to manipulation and mobilisation alone (41,42). However, the use of manipulation and mobilisation alone only shows better outcomes when compared to no treatment. Furthermore, a recent Cochrane database study reviewing over 60 studies shows manual therapy and exercise to be similar in effect to glucocorticoid injection and subacromial decompression surgery (43). These findings are substantiated by Dickens and colleagues, who showed that 26% of patients diagnosed with subacromial impingement who had failed three steroid injections into the subacromial

space avoided surgery using mobilisation techniques and exercises (44). Regarding soft tissue techniques for painful shoulder conditions only a few studies exist. However, a systematic review of manual therapy for rotator cuff tendinopathy showed only one study investigating the effect of deep friction massage compared to therapeutic ultrasound. In this RCT, the authors reported patients receiving massage therapy showed lower pain at rest and greater active abduction ROM. Unfortunately, however, they further state that these changes were not clinically significant (45). Some authors suggest that mobilisation and manipulation techniques in combination with exercise including proprioceptive retraining are shown to be beneficial for adhesive capsulitis (41,46). Studies have investigated a number of manual techniques that include HVLA, end-of-range mobilisation, and mid-range mobilisation in conjunction with or without movement of the shoulder girdle (41). However, two recent systematic reviews show that these treatments are less effective than glucocorticoid injection in the short term while also showing a number of adverse reactions (43,47). Encouragingly, however, Page and colleagues, in their Cochrane review of 32 studies, suggest that manual therapy and exercise do provide greater patient-reported treatment success in active ROM. Nevertheless, because of low standards of methodological rigor, they go on to suggest that high-quality RCTs are required to (i) compare combinations of manual therapy and exercise versus placebo or no intervention and (ii) establish the benefits and harms of these forms of rehabilitation that reflect actual practice (48).

Temporomandibular Disorders Temporomandibular disorders (TMD) are conditions that affect the temporomandibular joint, the masticatory muscles and related structures (49). Manual therapy has been used for many years for the treatment of such conditions; however, evidence regarding their effectiveness is outdated. Recently, two Co-Kinetic Journal 2018;76(April):32-40

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systematic reviews (same research group) examined the quality of RCTs investigating the effectiveness of manual therapy and exercise compared to more standard treatments (50,51). The first review investigated the effectiveness of manual therapy for the management of pain and limited ROM in people with signs and symptoms of TMD where seven of the eight RCTs included were of high methodological quality. Results encouragingly showed that myofascial release and massage techniques to the masticatory muscles were equally as effective as botulinum toxin injections (52) and more effective than controls. Equally, although upper cervical manipulation and mobilisation techniques (53) were more effective than controls, thoracic manipulative techniques were not (54). The same group later reviewed the effectiveness of manual therapy and therapeutic exercise for TMD. Although they included 48 studies, evidence was considered low because many RCTs showed unclear or high risk of bias (51). Examples of the studies included in this review examined the effectiveness of posture correction and TMDs (55), general jaw exercises combined with neck exercises (56), intraoral myofascial therapy (57), and jaw and neck exercises alone (58). Overall, their results showed that manual therapy alone or in combination with both active and passive exercises of the jaw or cervical spine showed favourable outcomes.

Fibromyalgia Clar and colleagues identified three systematic reviews evaluating manual therapy in patients with fibromyalgia (11). Although all three reviews showed significant improvement in most of the recognised tender points, these improvements were not maintained over time. In the same year, another systematic review identified 10 quantitative and qualitative studies assessing the effectiveness of different styles of massage therapy in fibromyalgia. Overall, they found that most styles of massage consistently improved quality of life. Although of low-level evidence, narrative review data results nevertheless show that the effects of manual lymphatic drainage Co-Kinetic.com

may be superior to connective tissue massage, while Swedish massage is shown to have little or no effect (59). Additionally, although evidence is limited, results are favourable for the effectiveness of chiropractic manipulation (60), craniosacral therapy (61), and massage therapies (62) for fibromyalgia.

Summary Although manual therapies for musculoskeletal disorders appear to be effective, the effect of these treatments on musculoskeletal pain generally

THERE IS A NEED FOR BETTER QUALITY STUDIES RELATING TO THE MANUAL TREATMENT OF NECK AND SHOULDER PAIN TABLE 1: EVIDENCE SUMMARY FOR MANUAL THERAPY AND CHRONIC PAIN EVIDENCE LEVEL

OUTCOME

Spinal mobilisation alone

Moderate to high

Positive

Spinal manipulation alone

Moderate

Positive in short term

Soft tissue techniques alone

Poor to moderate

Positive in short term

Manual therapy–exercise combination

Moderate

Positive in short and long term

Cervical mobilisation and manipulation combination

Moderate

Positive in short term

Thoracic manipulation

Poor to moderate

Positive in short term

Soft tissue techniques alone

Poor

Positive in short term

Spinal manipulation

Poor

Unclear

Soft tissue technique

Poor

Positive

Mobilisation

Poor

Unclear

MANUAL THERAPY Chronic low back pain

Chronic neck pain

Chronic cervicogenic/tension Headache

Chronic shoulder pain (rotator cuff disorders) Mobilisation and manipulation

Poor to moderate

Positive

Manual therapy–exercise combination

Moderate

Positive

Soft tissue technique

Poor

Unclear

Chronic shoulder pain (adhesive capsulitis) Mobilisation and mobilisation (mid and end ROM)

Moderate

Unclear to positive

Manual therapy–exercise combination

Moderate

Positive

Massage and myofascial release

Moderate to high

Positive

Manual therapy–exercise combination

Moderate

Positive

Poor to moderate

Positive

Temporomandibular disorders

Fibromyalgia Massage and myofascial release

Reduced physical impairment ↑ strength and flexibility

Figure 2: Mechanisms underlying the effect of therapeutic exercise for chronic pain conditions

Positive effect on cognitive appraisal ↑ self-efficacy, body awareness ↓ fear-avoidance, catastrophising

Exercise Positive effect on stress and affect ↓ emotional distress ↑ perceived affect

↓ pain severity ↓ pain-related disability

Improves endogenous pain modulatory pathways ↑ release of endogenous opioids ↓ release of proinflammatory mediators ↑ effect of descending pain inhibitory pathways

neurotransmitters associated with descending inhibitory pain pathways (68–71). Many different forms of exercise have been used in the management of chronic musculoskeletal pain conditions. These include varying levels of aerobic exercise, strengthening exercise, mobility training, and specific re-activation and re-education exercise programmes (10). Types of aerobic exercise studied include stationary running, cycling and step exercises. Strengthening exercises involve both isometric resistance in which the angle of the joint does not change (static contraction) and dynamic resistance, where muscle contraction does produce joint movement (68). Mobility training includes yoga and various stretching exercises while reactivation training includes disciplines such as Pilates exercises. The following sections review the evidence for the above types of exercise.

Aerobic Exercise lack methodical rigor and mostly show short-acting positive effects. Given the findings reviewed in this section, the efficacy of manual therapy would greatly benefit from studies that investigate single interventions on homogenous subject groups, for example the sampling of age- and gender-matched subject. Moreover, methodological rigor can be further increased by sampling subject groups with the same pain condition from the same population. Unhelpfully, previous studies have also used a wide range of self-reporting measures to gain data regarding levels of pain and disability, producing potentially different findings. Table 1 summarises evidence

MANUAL THERAPY ALONE OR IN COMBINATION WITH BOTH ACTIVE AND PASSIVE EXERCISES OF THE JAW OR CERVICAL SPINE SHOWED FAVOURABLE OUTCOMES FOR TEMPOROMANDIBULAR DISORDERS 36

for manual therapy and chronic low back pain, chronic neck pain, chronic headaches, chronic shoulder pain, temporomandibular disorders and fibromyalgia.

THERAPEUTIC EXERCISE Therapeutic exercise is used extensively in the management of a wide range of musculoskeletal disorders. Clinical trials and systematic reviews repeatedly show high levels of evidence for the effectiveness of exercise for people with chronic pain (63–65). As described throughout this book, chronic pain conditions are strongly associated with altered pain modulation, with research further showing that exercise helps to modulate pain perception and suppression, resulting in hyperalgesic effects (63,66). Here, evidence suggests that exercise stimulates the release of endogenous opioids (endorphins) that are associated with changes in both mood and pain sensitivity (Fig. 2) (67). Research also shows that the effect of exercise on muscle fibres, the cardiovascular system and the suppression of inflammatory mediators all influence similar brain mechanisms and

Aerobic exercise is shown to reduce pain severity in both healthy and older adults in experimental conditions (29,68,69,72). Meta-analysis of the general hypoalgesic effects of exercise show that the overall effect of aerobic exercise moderately correlates with improvements in pain reduction (68). However, these changes in pain perception generally last only up to 30 minutes (73,74). Generally, analyses from the review show that the strongest reductions in pain perception were gained using moderate-tohigh intensity exercises, whereas experimental studies using pressure pain stimuli show consistently more hyperalgesic effects compared to those using thermal stimulation. Unfortunately, nearly all studies investigating aerobic exercise AUSTIN use either healthy adults or subjects who 7.2 are active or inactive Figure No. rather than using people suffering BH Artistfrom chronic pain. 1Surprisingly, thereDate have 12 05 17 Draft stage been very Draft stagefew 2 studies investigating the Draft stage effects of aerobic exercise on chronic 3 stage 4 Of the studies located, painDraft subjects. stage twoDraft trials found that submaximal bicycle exercise had pain-reducing effects on pressure pain thresholds in multiple body regions (75,76). Thus, while at present evidence is weak, Co-Kinetic Journal 2018;76(April):32-40

MANUAL THERAPY

there is much potential for further research in this area.

Isometric Exercise Decreased muscle strength in patients with chronic pain may be related to pain-induced inhibition of motor systems in addition to structural changes in muscle mass (77,78). Such findings suggest that strengthening exercises should encourage morphological changes in muscles. In healthy adults, the effect of isometric exercise on the perception of pain is strong for both thresholds and intensity taken during and/or after exercise, regardless of site, intensity or duration of muscle contraction (68). Interestingly, studies also show that hypoalgesic effects are increased with low-to-moderate intensity muscle contractions that are held for a longer duration. For example, the greatest changes in pain threshold and intensity follow low-intensity contraction to failure (between 5 and 9 minutes) compared to high-intensity contractions held for 3 to 5 seconds (79). Mechanisms for this response are thought to be because of the fact that when active motor units fatigue, higher threshold motor units become progressively recruited to maintain the necessary force. Concerning studies in chronic pain patients, local isometric exercises are shown to be of benefit for people with chronic low back pain (80), neck pain (81), and cervicogenic headaches (82), with increased levels of muscle activity being correlated with the degree of pain relief. Interestingly there are differences in the effect of isometric exercise between subjects with specific pain disorders (shoulder myalgia) and those with widespread pain (fibromyalgia) (83). Here, Lannersten and colleagues showed that distal (quadriceps) but not local (infraspinatus) contractions decreased shoulder pain intensities, whereas subjects with fibromyalgia showed no changes in levels of pain for all contractions. These results suggest that exercising non-painful areas of the body will have beneficial effects. However, these findings interestingly Co-Kinetic.com

STUDIES SHOW THAT FOR LOW BACK PAIN MOBILISATION AND MANIPULATION TECHNIQUES REDUCE PAIN INTENSITY AND INCREASE FUNCTION AND MOBILITY IN THE SHORT TERM highlight the lack of endogenous pain inhibition in people suffering widespread pain conditions.

Stretching Exercise Most studies investigate stretching not as a single treatment, but as part of a general exercise therapy routine (84). Here, stretching has been shown to be most beneficial for chronic low back pain when incorporated into supervised exercise programmes that also involve muscle strengthening exercises (12,85). Only one systematic review examining the efficacy of stretching for people with chronic pain was found. Here, Barros and colleagues investigated the effects of muscle stretching exercises for people with fibromyalgia. Although only four studies were accepted, they all showed that stretching exercises, regardless of type, reduced levels of pain (86). However, as with many other studies, methodological rigor, interventions, parameters used and follow-up varied widely. Several studies investigate the effects of yoga on chronic pain conditions. Recently, a systematic review evaluating the use of yoga for chronic low back pain found that yoga is effective in reducing pain as well as improving physical and mental function, with benefits lasting several months (87). However, one of the studies included shows that although yoga is more effective than a self-care book, it is no more effective than general stretching (88). These results are corroborated by Holtzman and Beggs who, in their meta-analysis of RCTs, found yoga to be consistently beneficial for people suffering chronic low back pain, but only in the short term (89). Additionally, the authors also warn of methodological concerns that need to be addressed, especially the need for an active control group such as general stretching.

Concerning chronic neck pain, results from low-evidence articles generally suggest that stretching alone and/or with other exercise modalities may not change pain intensity or improve function immediately or at short-term follow-up (82). However, HĂ¤kkinen and colleagues compared the effectiveness of a 12-month home-based combined strength and stretching programme against stretching alone, randomised in two groups (90). Although there were no significant differences in improvements in both neck pain and disability between programmes, they did find effects on neck pain to be encouraging. However, as with many programmebased regimens, there was low adherence to training in both groups.

Dynamic Resistance Exercise Dynamic strengthening exercises are aimed at improving neuromuscular control, strength and endurance of muscles that are key to maintaining spinal and trunk stability (91). Although lumbar spinal stability relies in part on passive support such as ligaments and connective tissues of skeletal muscles, active contractions of muscles play a leading role. The central nervous system also has a significant role in spinal and trunk stability. By responding to sensations produced by muscles and passive soft tissue structures, the central nervous system controls motor coordination and thus governs physical actions to maintain stability (92). These muscles include the transverse abdominis, lumbar multifidus, internal oblique and quadratus lumborum (93). First, the lumbar multifidus attach to each lumbar vertebral segment and the transverse abdominis and thus initiate a co-contraction mechanism (94). Subsequent abdominal draw-in provides spinal segmental stability. Second, other more shallow core 37

IN MOST CASES, CLINICAL TRIALS LACK THE RIGOR TO SHOW STRONG EVIDENCE OF EFFICACY OF TREATMENT muscles (rectus abdominis, internal/ external oblique muscles, erector spinae, quadratus lumborum and hip muscle groups) also enable spinal control owing to their attachments to the spine and thoracic ribs and legs (95). Very few studies have examined the effectiveness of dynamic resistance exercise in people with chronic pain. Of these, only one has systematically reviewed their efficacy among chronic low back pain patients. Chang and colleagues identified only four articles suitable for review, each of which examined four core strength training exercises (trunk balance, stabilisation and motor control exercises), all of which were compared to more common resistance training such as straight leg-raises, push-ups, and sit-ups (94). They found that although all core strength training exercises alleviated chronic low back pain, those focusing on the deep core muscles (transverse abdominis and lumbar multifidus) were most effective. Importantly, such programmes have also been shown to have a positive effect on patients with low back pain due to spondylolisthesis and spondylolysis (96). Interestingly,

Ekstrom and colleagues aimed to determine which muscles were activated by dynamic resistance exercises so practitioners can have a better idea about the effect specific exercises have on muscle stabilisation. Using surface electromyography analysis they showed that dynamic resistance exercises such as unilateral bridge and quadruped extremity lifts significantly activate gluteus medius, gluteus maximus and external oblique muscles (95).

Summary Currently, exercise therapy has been demonstrated to be effective at moderately decreasing levels of pain and levels of disability in people with chronic pain. Hayden and colleagues in their meta-analysis suggest the supervised, individually designed programmes are the most effective, with stretching and muscle strengthening exercises being the most effective, especially for chronic low back pain (84). Currently, it is thought that exercise in all forms is sufficient to activate endogenous pain inhibitory mechanisms in both animals and humans, especially opioid systems via the pituitary and hypothalamus (10). For example, both swimming and running produce opioidinduced analgesia that is reversed by the administration of naloxone (an opioid receptor antagonist) (97,98). Interestingly, increases in betaendorphins in peripheral circulation are associated with both increased

TABLE 2: EVIDENCE SUMMARY FOR THERAPEUTIC EXERCISES IN PEOPLE WITH CHRONIC PAIN Therapeutic exercise

Evidence level

Outcome

Aerobic exercise High intensity Moderate intensity

None Weak

None Unclear

Isometric exercise Moderate intensity â&#x20AC;&#x201C; long duration High intensity â&#x20AC;&#x201C; short duration

Moderate Moderate

Positive (CLBP, CNP, CH) Unclear

Stretching exercise General muscle stretches Yoga

Moderate Moderate

Positive (FMS) Positive in short term

Moderate

Positive (CLBP, spondylolisthesis, spondylolysis)

Dynamic resistance exercise Motor control/stabilisation

CLBP, chronic low back pain; CNP, chronic neck pain; CH, chronic headache; FMS, fibromyalgia

lactate concentrations and duration of exercise (99). However, while evidence is strong, mechanisms of endogenous analgesia are relatively complex, with the exact type of analgesic mechanism possibly depending on the type of exercise stressor. Table 2 summarises evidence for aerobic, isometric, stretching and dynamic resistance exercises in people with chronic pain.

ACUPUNCTURE Acupuncture is a treatment based on the theories of Traditional Chinese Medicine, in which its effect on painrelated disorders has been recognised from the earliest texts right up to present-day research (100). A recent review estimated that 3.5 million American adults receive acupuncture treatment each year, with the number increasing each year over a recent 10-year period (101). Currently, people receive acupuncture for chronic pain conditions because the effectiveness of conventional medical treatments is perceived to be low (102,103). However, although acupuncture is considered to have physiological effects relevant to analgesia (104), there is no accepted mechanism by which it could produce long-lasting effects on chronic pain. There are a number of methods of stimulating anatomical points in acupuncture, such as needle insertion, with or without manipulation, and the application of surface pressure and electrical stimulation of inserted needles (105). Of these, the use of thin metal needles that penetrate the skin and which are manually manipulated is by far the most extensively researched. Like other forms of nonpharmacological treatment approaches to musculoskeletal pain, acupuncture is thought to activate endogenous opioid analgesia in humans and animals. Blockade of opioid receptors in the limbic system and descending pain pathway nuclei with naloxone in animals is shown to prevent analgesia (10). Interestingly, animals made tolerant to mu- and delta-opioid agonists are only tolerant to 2Hz but not 100Hz electroacupuncture, whereas animals made tolerant to kappa-opioid are also tolerant to 100Hz (106). These results suggest Co-Kinetic Journal 2018;76(April):32-40

MANUAL THERAPY

that manual acupuncture and lowfrequency and high-frequency types of electroacupuncture stimulation activate different analgesic opioid mechanisms. Although systematic reviews consistently show acupuncture to be effective for short-term pain relief in several chronic pain conditions, such as low back pain, osteoarthritis and chronic headache (107), the long-term effects of acupuncture are less certain. For example, studies show decreases in pain at between 6- and 12-month follow-up for chronic headache (108) and osteoarthritis of the knee (109). Concerning meta-analysis of chronic headaches across eight RCTs, Davis and colleagues found that subjects showed 1.34 fewer headache days per month and a 3.74 point decrease in pain intensity (VAS) (110). However, these findings were not significantly different to reports from subjects in sham groups. Generally, the effect of acupuncture on chronic low back pain is less conclusive, with some studies showing significant pain relief in the short term (111) and others showing it to be only more effective than no or sham treatment (112). However, as for nearly all therapies reviewed in this chapter, more effort is needed to improve both internal and external validity of primary studies. Concerning neck pain and neck pain with radicular symptoms, meta-analyses also show mixed results, with moderate evidence suggesting that acupuncture is more effective than sham treatments immediately and at short-term followup (113).

Issues Surrounding Sham Acupuncture Typically, RCTs set sham treatments as a control to investigate the specific effects of a test treatment. However, ‘sham acupuncture’ is more difficult and expensive to set up. Sham acupuncture uses needles with blunt tips without skin penetration or ‘minimal acupuncture’ where needles are inserted either superficially or away from studied acupuncture points (111). Non-penetrating needles retract into the clinician’s hand rather than penetrating the skin. Here, the pressure of the needle felt by the patient is very similar. Additionally, RCTs also use Co-Kinetic.com

non-needle sham controls, including inactivated laser and transcutaneous electrical nerve stimulation devices (114). However, findings from research using sham acupuncture show that neither non-penetration nor minimal penetration models are physiologically inert because ‘touching’ the skin may also elicit an emotional or hormonal response, and activate afferent nerve fibres and changes in limbic system function (111). Thus, these sham treatments may partially or fully represent the effects of actual needles.

SUMMARY There is good evidence from experimental studies to suggest that manual therapy, therapeutic exercise and acupuncture can be effective in the treatment of chronic musculoskeletal pain. However, findings from this area of research so far have not been acceptably replicated in clinical studies. Importantly, the effectiveness of treatments may show changes in endogenous analgesia; however, these changes are most often short-lasting and modest, in part because of other exogenous and endogenous confounding factors, such as altered mood and cognition also associated with the maintenance of chronic pain. Additionally, clinical trials in most cases lack the rigor to show strong evidence concerning the efficacy of treatment, resulting in part from the heterogeneity of sampling, investigated treatments and multiple outcome measures, as well as inadequate randomisation and blinding procedures. Currently, therapeutic exercise stands out as a form of therapy best suited to the treatment of chronic pain, not because of stronger research methods but to homogeneity in the prescription of exercises. However, it should also be recognised that by tightening homogeneity in sample selection, outcome measures and intervention-type, manual therapy and acupuncture have a significant role in the treatment of chronic pain. Thus, by sampling subject groups with the same pain disorder, from the same population, at the same time point in the condition, applying the same treatments and using the same outcome measures, evidence

will become much clearer as to how and what we can best use to manage people suffering chronic pain.

Acknowledgement All figures and tables have been taken from the author’s book Chronic Pain. A resource for effective manual therapy ©Handspring Publishing 2017, and are reproduced here with permission. 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/2F1eM7a THE AUTHOR Dr Philip Austin BSc MSc PhD is a UK-trained osteopath and researcher who holds a PhD in pain medicine. Phil’s clinical areas of interest include the treatment of computer-related musculoskeletal pain conditions and the effects of work-related stress on the severity and duration of persistent pain. Phil graduated from the European School of Osteopathy in 1997. Following the completion of his degree Phil worked in New Zealand, UK and Sweden and is now permanently located in Sydney where he combines his clinical work with research. This includes the investigation of clinical methods of predicting the extent and severity of pain in people with chronic pain conditions such as fibromyalgia and in cancer patients receiving chemotherapy. He is also a member of the Australian Osteopathic Accreditation Council and a leader in the Chronic Pain Practice Group. Phil began his postgraduate studies at the University of Edinburgh gaining an MSc in pain management and a PhD investigating the potential for multi-dimensional assessment of functional gastrointestinal disorders such as irritable bowel syndrome and functional dyspepsia. Phil works as a clinical tutor for the MSc in Clinical Management of Pain at the University of Edinburgh while also being involved in various areas of palliative care research at Greenwich Hospital in Sydney. Phil practices osteopathy at the Elevate Sydney Clinic, Sydney, Australia. Email: paustin@hammond.com.au Website: https://elevate.com.au/practitioners/ dr-philip-austin-osteopath/ Twitter: https://twitter.com/PhilipAustin18 LinkedIn: https://www.linkedin.com/in/philaustin-70021017/ Facebook: https://www.facebook.com/Phil-AustinPhD-498288083650045/

Chronic Pain. A resource for effective manual therapy By Dr Philip Austin Handspring Publishing 2017; ISBN-13: 9781909141513 Buy it from Handspring https://handspringpublishing.com/product/ chronic-pain-management

RELATED CONTENT More Content on Manual Therapy - http://spxj.nl/2sYQk0t

DISCUSSIONS There are many studies on the effect of manual therapy – why are so few included in meta-analyses and systematic reviews? Discuss the reasons why therapeutic exercise seems to be the most effective for the treatment of chronic pain; does this mean that exercise is more effective than manual therapy? Devise an evidence-based treatment programme for a patient with chronic pain.

KEY POINTS n A number of therapies are used to manage chronic musculoskeletal pain, including manual therapies, exercise and acupuncture (among others). n Practitioners are increasingly keen to adopt evidence-based approaches. n Within manual therapy most research has focused on joint mobilisation, manipulation and massage. n The evidence level for the use of manual therapies for chronic low back pain and neck pain is generally moderate and the outcomes are largely positive in the short term. n The evidence level for the use of manual therapies for temporomandibular disorders is moderate to high and the outcomes are positive. n The evidence levels for the use of manual therapies for chronic tension headache, chronic shoulder pain and fibromyalgia are generally poor to moderate and the outcomes are either unclear or positive depending on the precise therapy used. n Exercise therapy is effective at causing moderate decreases in pain levels in people suffering chronic pain. n Dynamic resistance exercises for developing core strength, particularly those aimed at the deep core muscles, were effective for alleviating chronic low back pain. n Acupuncture seems to be consistently effective in the short term but long-term effects are less certain. n Meta-analyses and systematic reviews are hampered by the lack of rigor of clinical trial design, resulting from heterogeneity of sampling and treatments investigated, as well as the use of multiple outcome measures.

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The effective management of pain is a problem which confronts all manual therapists. This book provides a clear picture of our current understanding of pain mechanisms and shows how that knowledge should inform approaches to treatment. The knowledge of pain science that the book conveys will help the therapist select the best approach to the clinical management of each patient. Different types of pain disorder may require different management strategies which may involve only one discipline or, at other times, a multidisciplinary team which may also include medical clinicians, psychologists, occupational therapists, nurses and other healthcare practitioners as well as manual therapists. The book is divided into three parts: n An introduction to the concept of pain and its neurophysiological mechanisms. n A review and discussion of current and potential evidence-based evaluation methods. n A review and discussion of common types of functional pain disorders. This approach provides readers with a comprehensive reference to evidence-based information that should enable them to manage their clients’ pain as effectively as possible. CONTENTS SECTION 1. Chapter 1. Chapter 2. Chapter 3.

Basic pain mechanisms Peripheral nociceptive mechanisms Spinal nociceptive mechanisms Supraspinal pain mechanisms

SECTION 2. Epidemiology, psychology, evaluation and treatment Chapter 4. Epidemiology of chronic pain Chapter 5. Psychological features of chronic pain Chapter 6. Evaluation of chronic pain Chapter 7. Efficacy of manual therapy for chronic musculoskeletal pain SECTION Chapter Chapter Chapter Chapter Chapter

3. Clinical presentations of chronic pain 8. Chronic musculoskeletal pain 9. Neuropathic pain 10. Chronic visceral pain 11. Primary headaches and orofacial pain 12. Pain in the elderly

Co-Kinetic Journal 2018;76(April):32-40

Latest Books from Handspring Publishing CHRONIC PAIN

http://spxj.nl/2oJ9piP £32.95 The effective management of pain is a problem which confronts all manual therapists. This book provides a clear picture of our current understanding of pain mechanisms and shows how that knowledge should inform approaches to treatment.

FASCIA IN MOTION

http://spxj.nl/2FTGU9b £45 Fascia in Motion is a comprehensive guide to fascia oriented training in original and contemporary Pilates mat, reformer, and studio applications.

FASCIA - WHAT IT IS AND WHY IT MATTERS

http://spxj.nl/2FlSCvJ £24.95 This book gives the reader an understanding of fascia as a tissue, its role in the various systems of the body and its clinical significance. By the end of the book the reader will have a solid working knowledge of fascia.

PALPATION AND ASSESSMENT IN MANUAL THERAPY

http://spxj.nl/2CZFS8Q £39.95 As the title suggests this book has been written to assist manual therapists to understand and hone the palpatory skills which are essential to their effectiveness as practitioners.

SPINE AND JOINT ARTICULATION FOR MANUAL THERAPISTS

http://spxj.nl/2oIyDxI £34.95 The book focuses on the practical application of articulation and mobilisation techniques with clear explanations and visual support of the techniques. Techniques are described for all body regions.

TEMPOROMANDIBULAR DISORDERS MANUAL THERAPY, EXERCISE AND NEEDLING

http://spxj.nl/2FVmNI2 £39.50 An authoritative and comprehensive account of the assessment and conservative management of temporomandibular disorders.

MEDICAL THERAPEUTIC YOGA

http://spxj.nl/2FrxPqo £37.50 For yoga to be used safely as medicine and to meet the needs of today’s society, yoga postures should evolve by embracing the current evidence base. Medical Therapeutic Yoga provides this evolution by including the evidence base to facilitate the development of integrative health care practices and protocols.

t: +44(0)1875 341 859 e: info@handspringpublishing.com w: handspringpublishing.com

18-04-COKINETIC FORMATS

WEB

MOBILE

MEDIA CONTENTS Step-by-Step Guide to Using Co-Kinetic’s Marketing Content and Publishing Tools http://spxj.nl/2rhx0X1 A Social Media and Lead Collection Campaign Set Up in Less Than 3 Minutes. http://spxj.nl/2FKNMFP

BY TOR DAVIES, CO-KINETIC FOUNDER

OVERVIEW If you follow the marketing strategy that is outlined in detail at this link http://spxj.nl/2haSVyW you will grow your business, there’s no two ways about it. In a nutshell, it all begins with generating new prospective customer leads, moves on to nurturing your relationship with these prospective customers, and then the final stage is to offer these leads opportunities to get in front of you, so you can convert them to a paid ‘product’. But thanks to Facebook’s algorithm changes over the last 4–5 years, and particularly in January this year, dramatically reducing the number of page posts that people actually get to see, (which I’ve written more about here http://spxj.nl/2GXwFjE), if you think you can stick a few sexy looking pieces of social media on your social networks and sit back and wait for it to generate you stacks of new email leads, you’re going to be waiting a looooooooooong time. Yes, social media can absolutely play a powerful part in your marketing (a topic I’ll present on at the COPA Show 2018 (www.copashow.co.uk)), but realistically these days, only if you’re prepared to pay to promote your posts, and if you do pay to promote those posts, you must make sure you’re doing it properly (however, I’ll also help you with that!). Let’s start at the beginning. As I’ve described, there are basically three stages in this marketing 42

HOW TO RUN A MONTHLY MARKETING CAMPAIGN USING CONTENT FROM CO-KINETIC As a physical or manual therapist, your main role is to treat patients. However, you must never forget that you are also running a business and that part of your time needs to be spent on activities that will help you to develop your business. Perhaps you already have ideas of what you want your business to become but you are not sure how to get there? This article describes some of the marketing tools and activities that CoKinetic has already created for you and shows you how to run a monthly marketing campaign that will take up very little of your time but will bring your business big rewards. Read this article online http://spxj.nl/2HK9k62 strategy, and it’s a proven strategy that’s working for 1000s of practitioners across the world, but you have to follow it through. You can’t just do one part and then sit back and wait. To make it as quick and easy for you as I can, each Co-Kinetic marketing campaign contains everything you need to implement this strategy from start to finish. But if you want new clients, you’ve got to cross the finish line with Level 3. If you just want to generate a few new email leads, and keep your existing contacts happy, you can get away with doing just Level 1 and Level

2 but be prepared that it’s not going to have a significant impact on your bottom line. Here’s how it works.

SOCIAL MEDIA CAN PLAY A POWERFUL PART IN YOUR MARKETING BUT REALISTICALLY ONLY IF YOU PAY TO PROMOTE YOUR POSTS Co-Kinetic Journal 2018;76(April):42-46

ENTREPRENEUR THERAPIST

LEVEL

LEAD GENERATION

CO NT

n You’ll be collecting new leads from all these activities. n Your social networks will be more engaging and authoritative. n The blog post and the videos will improve the search engine optimisation of your website, making it more findable and more likely to rank higher in search results.

Here are the benefits you’ll get from doing the activities above:

Note: Obviously, any activities you undertake at Level 3 will also generate new leads if you promote them to people outside your own contact list by using the promotional material we create for you but I left it out of this level so we can keep them in distinct phases.

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1. Ready-made social media which you can post directly to your social networks through Co-Kinetic 2. Pre-written blog-post content and images (copyright free) 3. Professionally designed newsletter/ guide/cheat sheet/patient handouts (lead magnet) 4. A personalised hosted lead collection page which delivers the lead magnet when the viewer completes the form 5. Ad artwork for Facebook.

LEAD C OLLEC

SO Co-Kinetic.com

This is the content that a subscription to Co-Kinetic includes for lead generation purposes:

1. Post the social media provided to your social networks (you can do this in just 3 minutes through the Co-Kinetic site) – here’s how http://spxj.nl/2FKNMFP. 2. Upload the videos we provide, to your YouTube/Vimeo channels and onto your website. 3. Publish the pre-written blog post we provide, on your website or blog. 4. Offer the blog post as a guest post on someone else’s blog (eg. If the post is about cycling injuries, offer it to cycling clubs or cycling shops). 5. Print out the newsletter/lead magnet and distribute in your clinic/local area/clubs/businesses/help groups. 6. Run Facebook ads which link to your lead magnet/lead capture page – to get highly targeted leads of people who live locally with an interest in the topic you’re promoting.

n Posting guest blog posts on other people’s websites raises your profile and helps get you in front of new people (and can also contribute to improving your search rankings). n Printing out the professionally designed lead magnets and newsletters builds strong authority and reputation and if rebranded are very effective brand awareness tools (all our public facing content can be rebranded). n Facebook ads help you target very specific groups of people and can be a very powerful generator of new email leads.

(collecting leads of new prospective customers) Before we start, remember that everything you do at this level must link to your lead collection page and lead magnet – that’s the most important thing. Without that, you won’t be able to collect new leads. That whole aspect of lead collection is taken care of if you use the Co-Kinetic platform. Every campaign has a Personal Campaign URL (you can learn more here http://spxj.nl/2i3aSvX) which takes people to your own personal lead collection page, that we’ve created for you. When that page visitor enters their email details, they will receive the lead magnet that they’ve signed up for. We collect the leads and store them against that campaign, in your account. If you have a Mailchimp account, we’ll also send them there. You don’t have to worry about anything. The whole point and priority of this level is to collect new leads, period. But remember you’re offering something of value, in exchange for these new leads, so let your imagination run riot on how you let people know the content exists.

This is what I suggest you do with that content:

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All I’d say is, don’t be tempted to try and make any sales in this email (and if you do, keep it small and understated), it should just be a genuinely informative, educational email, offering value. The one exception is that if you choose to run a free session (ie. take it to Level 3), then you absolutely should use this email to promote that free session with a Call to Action telling them how to book onto the session. Every campaign kit also contains a professionally designed two-page A4 article which you could print (or have professionally printed) and post to clients who you don’t have email addresses for. This would be a great activity if you knew for, example, that they were particularly interested in the topic in question and it gives you an opportunity to re-establish contact with them, by providing value-added information, which also helps build reciprocity and further builds your professional authority and reputation.

NURTURE YOUR EXISTING CONTACTS This is a really simple level because it can just involve sending your existing email contacts a regular monthly nurture email, which we write for you. If you use Mailchimp we give you a pre-designed template including text and images, just one click and it appears in your own Mailchimp account, ready for you to edit and send, which should take no more than 5–10 minutes. If you use another email platform, we give you some sample text and images to copy and paste in a new email. You can edit whatever you like.

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THE FACE-TO-FACE CONVERSION ACTIVITY: THE KEY TO IT ALL This is the conversion stage. If you do well at this level, the sky is the limit for your business! The goal of this level is to get someone face-to-face with you, ideally by offering a free (or mostly free) session allowing you the opportunity to further establish your expertise and create an opportunity for attendees to become paying customers. It gets harder for us to create the content for you at this stage, because what you do at this level will come down to your own skills and preferences but we do suggest ideas specific to each campaign and, where relevant, provide you with promotional material including Facebook ads (images and text), posters, leaflets and postcards that you can print out (or have professionally printed). The sorts of things that work well could include: n educational workshop/presentation n free assessments, eg. posture, gait, muscle balance n equipment assessment, eg. bike fitting, running shoes n free treatment/exercise class/ massage.

This is the content that a subscription to Co-Kinetic includes for this Level 3 face-toface conversion activity n Off-the-shelf PowerPoint presentation for running an educational workshop n Promotional material promoting two or three recommended free sessions/events (ie. promotional themes).

IF YOU WANT NEW CLIENTS, YOU HAVE TO IMPLEMENT ALL THREE LEVELS OF THIS MARKETING STRATEGY 44

Co-Kinetic Journal 2018;76(April):42-46

ENTREPRENEUR THERAPIST

Each promotional theme comes with the following artwork both with bleeds (for professional printing) and without bleeds (for a normal home/office printer): n Postcard (A6 size) n Posters (A1, A3, A4 sizes) n Leaflet (A5 size) n Facebook ad artwork and suggested text (1200×627 pixels).

This is what I suggest you do with that content: n Use the PowerPoint presentation to run an educational workshop. You can edit whatever you like, we recommend you add your logo and we provide blank slides so you can add additional content where desired. n Have the postcards professionally printed (it costs just £20 to print 100 double-sided postcards through Solopress) which you can then distribute locally or through your clinic/affiliate partners and post them to customers you don’t have email contact details for. n Print out the posters and leaflets and distribute them on local notice boards, clinic signage if you have any and on your clinic walls. n Use the Facebook ad artwork to run Facebook ads promoting your free sessions. Once you get people to the session, make sure you have ‘products’ to sell. I’ve included a bunch of ideas at this link http://spxj.nl/2F7GAXx. This could be an additional moredetailed assessment, packages of treatments, even packages of stock products, all depending on the type of session you’re running. If it’s marathon season, why not offer a special 10 for the price of 9 pre- and post-run massages, or gait assessments at key training stages. Pick things you can do well, that demonstrate your skills and play to your strengths, and more importantly that you enjoy!

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the ‘mirror revention is essentially of injuries. image’ of risks or causes then you If you understand those, know where to start. Overloading 1 TRAINING ERRORS: repetition of tissues due to constant your mileage, the running action. Watch your weekly you should aim to increase 5-10%. Include mileage by no more than train. Run on recovery days and cross (including different routes and surfaces nature and grass) to vary the repetitive should also load on your body. You of different rotate between 2-3 pairs are great for running shoes. Group runs but ensure motivation, fun and company within the group you can run at your pace off on long, or and don’t get dragged ready hilly, runs if you are not

on prevention injuries makes focusing The high rate of running to run more injuries, you’ll be able key. If you can prevent challenging weekly mileage, do more consistently, reach a higher race a lot faster for longer. workouts – and ultimately,

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for some time rehabilitation treatment glycogen is an glycogen stores. Muscle after the injury has ‘healed’. exercise, Weak essential fuel during strenuous THE STRENGTH TRAINING: fatigue and INJURY 7 to injury and less the depletion of it causes muscles are more prone Runner’s stores glycogen knee, moreresilient to the impact forces of running. inhibits performance. If patellofemo will start scientifically you strength exercises. are not effectively replaced, condition ral pain Focus on fundamental called Research syndrome state, which is key. shows single leg strength the next run in a semi-depleted (PFPS) affects For runners, buttock on therefore andunderside the cartilage is a never muscles, that strengtheni causing potential fatigue you’re running, you are structures of the kneeWhen ng the and the cap (patella) on the time. Each same may which hip/ leggluteus specifically the the same increased injury risk. The and hip both feet atand muscles, PFPS. 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Worn BY: exacerbate Achilles case. ©Co-Kinetic periods, so it’s best as a basis can THE PREVENTION Achilles tendinopathy, for planning inadequate cushioning 2017 in earliest point possible. individual they add no benefit When people experience stiffness medical tendon issues as increase a simple feeling of heel strike. Rapid it often starts as absorbing load during can have THE SYMPTOMS which is often sharp, take steps to increase intensity or training in the tendon. If you the heel, muscles in volume and/or so it’s n Pain close to the ankle and calf much more quickly, flexibility, strengthen the first the same effect poking and incapacitating. your feet and on the tendon at the back of attention to both and decrease stress Achilles tendon, at the important to pay n Pain along the when you’re training it’s possible to prevent sign of stiffness, your sessions—especially instability, a legthe lower leg. at foot can be mild swelling problem from escalating. Achilles hard. 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CONCLUSION Follow this process through each month and you will never be short of new clients and you will build your business. But as I’ve said before, and I’ll no doubt say again, if you want more clients, you have to follow the strategy all the way through and you have to do it regularly and consistently. Do not expect to just post the social media posts to your social networks and for your life and business to suddenly change. It’s not going to, even though so many people still believe it will! Spoiler alert … most people don’t even see most of the posts you post to your Facebook pages, here’s why http://spxj.nl/2CQqcc5. If you want new leads, it’s very likely that you’re going to have to pay for them (just like we used to in the newspaperss ooldd days by running unn ng ads inn newspape sending out letters and send ng ou e e s and leaflets ea e s too peoples’ homes). Paying to get in front of prospective clients, is not new and running ads on Facebook is an incredibly powerful nc ed b y powe u way too target a ge very ve y specific groups of people, but you’re going go ng too have too pay too pplay. ay If you just us expect your unpaid (organic) posts to deliver you’ree go going de ve loads oads oof new leads, eads you ng to be very disappointed.

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And if you need new clients, you can’t just stop at Level 1 and Level 2 because that alone is not going to convert for you. You have to take it to Level 3. If, however, you’re in that enviable position of not needing or wanting new clients and you just want to maintain the status quo, build your brand and authority, increase your findability on Google and keep your current contacts happy, Levels 1 and 2 will take less than an hour a month, and will work perfectly for you.

I look forward to helping you use the Co-Kinetic content to turn your business into what you always dreamed it could be.

Further Resources n A step-by-step practical hands-on guide to accessing, downloading and using our content to implement this strategy - http://spxj.nl/2rhx0X1 n View all the campaigns available as part of a subscription http://spxj.nl/2s5cRq8

THE AUTHOR Tor Davies 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. Twitter: @CoKinetic Facebook: https://www.facebook.com/sportex.tor

KEY POINTS n The number of page posts on Facebook that people actually get to see has been dramatically reduced. n Realistically you have to pay to promote your posts in order to generate new email leads. n For this marketing strategy to be successful you have to do all three parts of it. n Level 1 is to generate new leads (email addresses of prospective new customers). n Level 2 is to strengthen your relationship with your existing contacts. n Level 3 is to get your new leads to meet you faceto-face. n Co-Kinetic has already created marketing content that is ready for you to use. n Co-Kinetic has lots of good suggestions for how you can use this marketing content.

RELATED CONTENT A Ready-To-Go Marketing Strategy for Therapists http://spxj.nl/2haSVyW Why Nobody Ever Engages With Your Facebook Posts, Why It’s Impossible to Bombard Your Page Fans and What the January 2018 Facebook Algorithm Changes Mean to Your Business Facebook Page http://spxj.nl/2CQqcc5 How to Sell Without Being Salesy - http://spxj.nl/2sRgRvr

DISCUSSIONS Think about your own marketing strategy – what are you trying to achieve with it? Which of the three levels described here are you at? What would be the best thing for you to do next to achieve the aims of your marketing? 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;76(April):42-46

ENTREPRENEUR THERAPIST

18-04-COKINETIC FORMATS WEB MOBILE

BY CLARE CARRICK BSC, MCSP

THE GIFT HORSE Last month I wrote about how most physical therapy businesses lose perfectly ethical earning opportunities every single day. One of those ways to boost earnings ethically is to enhance and follow through on what we all do best – giving advice and exercise for the patient to follow at home, so they improve their strength, range of motion and reduce their pain levels as soon as possible. Clients are very motivated and engaged on their initial visit to see you, so this is an ideal time to suggest selfhelp measures. By stocking key items of equipment that you like to recommend, and having these attractively displayed in a designated area of your reception, will prime your client, making them open to a potential purchase for either themselves or someone they’re close to. If you recommend a potential solution to a client that will help them get better, it is crazy not to be able to provide that product then and there. People lead busy lives, which means they may not get the opportunity to source the product immediately. If they remember, they will most probably choose to order from Amazon, which may also incur postage. And once it does arrive, will they know what to do with it? If you have the product in stock, it’s very simple to give a demonstration at the same time that you’re talking about the benefits which means you get better client engagement and you’re very likely to get a better clinical outcome, which is, after all, what everybody wants. It’s all about offering a better, more professional service to your customers. I guarantee very few customers will begrudge you a couple of quid in commission if you can provide a valueadded service, that also saves them time.

BOOST YOUR BOTTOM LINE WITH STOCK SALES Really good businesses are built from an aggregation of marginal gains, a concept that was made famous by Sir Dave Brailsford, general manager of the GB Cycling Team. All too often we focus on one part of the ‘sale’, ie. the appointment, and miss other opportunities to generate additional earnings, frequently for very little extra effort. Stock sales is one of those marginal gains that can end up making you thousands in extra revenue, every year. This article details how this opportunity can be put into practice by any therapist or practice. Read this article online http://spxj.nl/2oP33OU be time-consuming to source the right products at the right price to make it financially worth my while. Often the time invested in ordering and sourcing is outweighed by the monetary gain. Added to which, most products have to be bought in bulk to make any significant profit and many of us don’t have either the cash flow to do this, particularly when you’re starting out, or the space to physically store the products. My other challenges have been the time it takes to place orders and the packaging quality of the products, because let’s face it, an unattractive package doesn’t look good on display at reception.

CLIENTS ARE VERY MOTIVATED AND ENGAGED ON THEIR INITIAL VISIT TO SEE YOU, SO THIS IS AN IDEAL TIME TO SUGGEST SELF-HELP MEASURES Recently I’ve discovered a company called Eureka Physiocare that ticks all these boxes, so much so that I felt they deserved a mention. The products are great quality and they look really stunning on display. Remember this is all about

What to look for You need products that: n are good quality; n that look good on display; n that give you a good profit margin; n that you can order quickly and easily online; n that you don’t need to buy in huge numbers; and n a provider that stocks most (or ideally all) of the stock sale products you need.

The downsides While there are obvious benefits to being able to offer value-add stock sales, I’ve worked in private practice for over 14 years, and I know it can

Co-Kinetic.com

adding value and offering convenience. An added bonus is that it can also boost your bottom line. You save your clients the time of having to order the products online, or find a shop that stocks them. And, more to the point, they can feel confident that the product is good quality, instead of having to try and work out for themselves which product out of the huge range offered by Amazon, for example, would be best for them. I have road tested these products in my clinics for the last 6 months now. The clients love the products, and the staff feel confident about selling them. This is because of the care and attention that Eureka Physiocare puts into sourcing all the products they sell. They really understand what we need to get out of it as a practitioner, while also offering a great quality product to our clients. Eureka have put together a Profit Calculator, which you can download at the following link, that will help you to simply and easily calculate the profit that you could add to your business, both weekly and annually, by selling stock. You can download the Profit Calculator at this link http://spxj.nl/2Gj1XSO. Better still, Eureka Physiocare will

also produce a custom display for you with your branding on, which you can use to display the products you sell and most of the products also come with a leaflet detailing how to use them, which saves you time explaining everything. Remember, patients don’t know what they need in order to get better. That’s why they come to you in the first place. If you stock a product that can help them get better, more quickly, not only will they be grateful, but they’re also more likely to refer you to their friends and family. It’s win, win for everyone. If you want to ask me any questions about my experience with these products specifically or advice about stock sales in general, you can contact me via email at clare@back-in-motion.co.uk To find out more about Eureka Physiocare visit https://eurekaphysiocare.co.uk/

RELATED CONTENT Use our Marketing Grader Quiz to discover the 13 simple things you must have in place in order to run a thriving therapy business – www.marketinggrader.guru Read more Business Growth articles at this link http://spxj.nl/2z1V3j6

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, she moved to New Zealand where she worked in a variety of settings, from public to private health environments, as well as elite sport. Driven by the desire to have the flexibility to travel, Clare developed her own vision for physiotherapy delivery, creating the successful Back in Motion franchise model, which now has seven clinics in East Anglia, UK. Clare enjoys sharing her experience and knowledge and has supported the therapists that she works with to develop their own business, allowing them to maximise their earning potential, choosing the hours they want to work and working on a business that will also be saleable in the future. Email: franchising@back-in-motion.co.uk Website: http://back-in-motion.co.uk/ 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 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)

FORTRESS SPIKEY BALLS Trade price (exc. VAT) = £2.50 Trade price (inc. VAT) = £3.00 RRP = £5.99 Profit per item = £2.99

4 OZ BIOFREEZE SPRAY Trade price (exc. VAT) = £6.49 Trade price (inc. VAT) = £7.79 RRP = £9.99 Profit per item = £2.20

FORTRESS® EXERCISE BANDS (1.5m pre-cut packs) Trade price (exc. VAT) = £1.50 Trade price (inc. VAT) = £1.80 RRP = £3.99 Profit per item = £2.19

FORTRESS SHOULDER PULLEY Trade price (exc. VAT) = £7.99 Trade price (inc. VAT) = £9.59 RRP = £9.99 Profit per item = £0.40

ECONOMY FOAM ROLLERLARGE Trade price (exc. VAT) = £14.99 Trade price (inc. VAT) = £17.99

RRP = £18.99 Profit per item = £1.00 NEUROPEX TENS UNITS Trade price (exc. VAT) = £19.99 Trade price (inc. VAT) = £23.99 RRP = £29.99 Profit per item = £6.00

Co-Kinetic Journal 2018;76(April):47-48

ENTREPRENEUR THERAPIST

OFFICIALLY DEAD 18-04-COKINETIC | COMMUNICATION FORMATS WEB MOBILE PRINT BY TOR DAVIES, CO-KINETIC FOUNDER January’s announcement sent shockwaves through many in the digital marketing community; however, it shouldn’t have come as a surprise. As far back as 2012, Facebook started cutting back on the number of organic posts (unpaid posts) it was showing on the news feeds of page fans and followers. In fact, in 2012 they throttled it right back to only showing about 16% of the posts that were published on your Facebook pages (if you posted 10 new posts only 1.5 of them would be seen by your page followers). By 2016 it was down to less than 2% and in 2017, well basically it pretty much fizzled out. So while the reality of what that means settles in, hopefully it will at least help to answer a couple of questions that I’m asked frequently: n “Why can’t I ever get people to react or engage with my Facebook posts?” n “I’m worried about bombarding my page followers with too many posts” Answer = Very few people ever even see what you’re posting, which explains why engagement is so low, and why you will never be able to bombard your page followers with too much stuff. This might make you feel better about why it’s so hard to get engagement. The average engagement (ie. like, comment, share) of a post on Facebook in 2017 was 0.14–0.17%. In other words, it’s extremely hard, virtually impossible in fact, to get anyone to engage with anything on your Facebook page.

WHY IS THIS HAPPENING? Money – as always! Facebook’s business model relies on people having a great user experience. They want people to spend as much time as possible on the site. However, as business owners began to realise how much potential Facebook had as a marketing tool, it Co-Kinetic.com

In January this year, Facebook made a supposedly huge announcement, telling us that pretty much all business page Facebook posts will stop appearing on people’s news feeds, and instead posts which involved discussions between people, would be prioritised. This article explains what the changes are to Facebook pages, why they’ve happened and what you should be doing through your Facebook page to harness the huge marketing and business growth potential it still offers your business. Read this article online http://spxj.nl/2oQeTs5 became flooded with low quality content that people either weren’t interested in, or content that’s commonly known as ‘clickbait’, the attention grabbing stuff that leads you away from Facebook to an outside web page. The low quality content wasn’t good for the user experience, and meant people began disengaging and spending less time on Facebook, and the clickbait usually took people off Facebook altogether. As you can appreciate, both outcomes were bad news for Facebook because the only way they can sell ads is if they have highly engaged, active users spending more and more time on the site.

SO SHOULD YOU JUST DITCH YOUR FACEBOOK PAGE? On the contrary! Here are five reasons why your Facebook page is still very valuable internet ‘real estate’.

Reason 1 People are on Facebook, over 2 billion of them as it happens, including 70% of the UK population, so unless most of your work involves people at either end of the age spectrum, your customers are most likely to be on there.

Reason 2 Think of your website as an online brochure, it’s glossy, formal and functional, answering commonly asked questions (and ideally also providing value-added information that help build your authority and reputation (among other things)). Your Facebook page is more like dropping in for a coffee and a chat, but not in real time (thankfully). It gives you the opportunity to add personality to your business, and let people get to know you and your business in a less formal setting, which can be a great help in building relationships, particularly when you’re moving cold ‘leads’ ie. people who know little or nothing about you, towards becoming paying customers.

Reason 3 Customer testimonials is one of the most important search engine ranking factors, as well as one of the most powerful reasons people will choose to do business with you. The more Facebook and Google reviews you have, the higher you are likely to rank in search rankings and the greater the

FACEBOOK ADVERTISING IS, WITHOUT EXCEPTION, THE MOST POWERFUL MARKETING TOOL THAT WE HAVE EVER HAD AT OUR DISPOSAL 49

YOUR FACEBOOK PAGE GIVES YOU THE OPPORTUNITY TO ADD PERSONALITY TO YOUR BUSINESS chance that people will choose your business over a local competitor.

Reason 4 These days people are just as likely to check your Facebook page as they are your website, if only to try and get a feel for your business. If your Facebook page is either inactive, or full of dull, uninspiring posts … well there’s a good chance that visitor is going to look elsewhere for a business with a more dynamic presence, irrespective of how good you or your team’s clinical skills are.

Reason 5 Facebook advertising is, without exception, the most powerful marketing tool that we have ever had at our disposal, and that’s likely to last at least for the foreseeable future (as far as one can foresee technology that is!). Disregard Facebook advertising and you’re quite literally opening your doors to business decline and possibly even failure, because you can bet your bottom dollar that at least some of your competitors won’t disregard it, meaning they will be scooping up prospective clients instead of you. Never before have we had the opportunity to get as targeted with our marketing, as it’s possible to do on Facebook. Once upon a time (in my business life anyway) we paid for adverts in local magazines and newspapers and we did leaflet promotions, but never could we get so finely targeted as we can using Facebook ads, both in terms of geographical location, but also in terms of interests and demographics. For obvious reasons you would link your Facebook adverts with your Facebook page. 50

OK, SO WHAT SHOULD I BE DOING ON FACEBOOK, THEN? Here are three things you should absolutely start doing now, to use Facebook effectively for your business. 1. Use paid ads on Facebook to build your prospective customer lists and collect data that you can use outside Facebook to grow your business. Be mindful that you are building a house on rented property (ie. you don’t own or have control of it) so just because you have fans and followers now, doesn’t mean you will have in a year’s time. What does that mean in real terms? Use Facebook to target people and collect things of real value that you can use in your everyday business. For example offer (and pay to promote) value-added resources for download in exchange for an email address. 2. Use Facebook to build relationships and move cold ‘leads’ of people who don’t know you, to becoming familiar ‘warm’ leads. Practically, that could mean using your Facebook page to start conversations around topics of concern or doing live question-and-answer events on a regular basis, or on a specific topic where people can visit your page and get advice. If you have a team, get them involved too. It doesn’t have to take long, and it’s a valuable chance to build relationships and establish authority. 3. Use it to support existing customers and build a community that’s wider than just your own clients. Think of turning it into a digital version of a pub or church. It’s all about community. This is your chance to shine and take a lead in your local community. You could set up Facebook groups (posts from which do appear on people’s news feeds) around certain topics and encourage people who are active on social media to contribute and help support the group. The groups could get as niche as you like, for example a low back pain group, or pregnant mothers, or any groups where you have a significant number of patients, and particularly those who are socially active. Facebook groups is a great opportunity, that I’ve written more about (see Related Content). Use your groups to encourage discussion and participation, but again without being spammy, turn those contacts into real email leads by adding the occasional document that people will give their email address in return for downloading.

RELATED CONTENT How to Harness the Power of Facebook to Grow Your Business in 2018 - http://spxj.nl/2I9O0HF The Facebook Pixel: Your Secret Weapon to Applying the 80:20 Principle for Building Your Physical Therapy Business - http://spxj.nl/2gfXtnB Co-Kinetic Journal 2018;76(April):49-50

TIME-SAVING RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

Practice Growth Hub at COPA 2018

T H U R S D AY 1 0 T H M AY

Overview of the day

A full day of presentations focused specifically on giving you practical advice to help you grow your business. Each session represents part of a bigger picture strategy taking you from the top of a sales funnel where the focus is on building awareness of your business and collecting new email leads, through to converting those email leads into paying customers.

Session 1:

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Session 4:

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Session 7:

Awesome! How do I attend? Just sign up for your COPA ticket completely free of charge at this link http://bit.ly/2p0iC5t and then put Thursday 10th May in your diary. We look forward to seeing you there.